Since AIDS first emerged 30 years ago, it has been nearly impossible to divorce the disease from issues of religion, morality, ethnicity, class, race, and gender. These associations and accusations have greatly complicated the policymaking enterprise, as AIDS policy intersects with a host of potentially explosive domestic political concerns. Curiously, though, the effects of these divisions on domestic policymaking on AIDS, especially in developing countries, have received relatively little attention. Seeking to fill this gap, Evan S. Lieberman and Amy S. Patterson each present insightful and thought-provoking volumes. Each book focuses on a fault line that can complicate the crafting of effective AIDS policies—Christian churches in sub-Saharan Africa for Patterson and the strength of ethnic divisions for Lieberman.

Patterson opens her book bluntly: “Churches in sub-Saharan Africa have been maligned, vilified, praised, and ignored for their role in the fight against the Acquired Immunodeficiency Syndrome (AIDS)” (p. 1). She recognizes that churches can stigmatize those with HIV/AIDS, but that they can also be at the front line providing services and education. Patterson wants to complicate the reader's assumptions about both the role of civil society in sub-Saharan African politics and the willingness of Christian churches—often seen as impediments to effective AIDS programming—to address the AIDS epidemic. Churches, she argues, are political actors in their own right in most of sub-Saharan Africa, and their actions are so intertwined with the state that we cannot effectively analyze state responses to AIDS without understanding how churches position themselves. She neither reduces churches to reactionary moralizers nor trumpets them as selfless do-gooders. She offers nuanced frameworks for analyzing whether, how, and when sub-Saharan African churches get involved in addressing HIV/AIDS by focusing on historical experiences, resources, leadership styles, and theology. To maker her argument, she draws heavily on interviews and news reports from Ghana, Kenya, and Zambia.

Lieberman calls attention to the ways in which ethnicity, and the divisions it can introduce into a society, affect the forcefulness of a government's response to AIDS. Going beyond traditional assumptions that ethnic diversity undermines the provision of public goods, he argues that it is not ethnic diversity per se but, rather, the rigidity of ethnic divisions that explain policy commitment. States in which ethnic boundaries are more rigid are less likely to introduce aggressive AIDS responses because policymakers and publics can more easily argue that AIDS is a disease of the “other.” This attitude both discourages action by those who are not part of the stigmatized group and makes members of the stigmatized group less interested in calling attention to the disease. Where ethnic boundaries are more fluid, AIDS is framed as a disease that could affect everyone, not just members of a particular group. This, he asserts, leads to more forceful responses. He builds his argument around the contrasting case studies of Brazil (fluid ethnic boundaries, aggressive AIDS response), South Africa, and India (rigid ethnic boundaries, less aggressive AIDS response). From there, he presents a large-n quantitative analysis of AIDS policy responses in Asia, Africa, Latin America, and the Caribbean.

Patterson's and Lieberman's monographs demonstrate that we cannot reduce domestic AIDS policymaking simply to a series of rational, incremental decisions made solely on the basis of scientific evidence. Instead, they forcefully and rightfully remind us how much existing social structures and institutions complicate the policymaking process. Both incorporate path-dependent explanations, highlighting how contemporary decisions about AIDS policy made by a wide range of actors reflect historical legacies, past experiences, and contextual variables. In this way, they geographically extend Peter Baldwin's approach in his 2005 book on AIDS policymaking in Western states, Disease and Democracy. While celebrating the importance of context, though, Patterson and Lieberman provide frameworks by which we can identify generalized patterns to be used for analyzing additional cases. In this way, they find that sweet spot of acknowledging the unique qualities of their own case studies while simultaneously appreciating the regularities and patterns to which these cases point.

Both volumes also admirably demonstrate that developing states exhibit some measure of agency and policy autonomy in the face of international consensuses about appropriate treatment regimes, financing from donor states, and international scientific opinion. The churches described by Patterson undertake their actions for reasons that appeal to their spiritual nature and to their understanding of their religious mission on earth. They do not simply respond to the changing whims of international donors. Lieberman shows how a state like South Africa or India can challenge international norms of appropriate policy when those norms fail to accord with its conceptualization of risk and the salience of ethnicity within its political system.

Patterson does a brilliant job of demonstrating how church involvement in AIDS issues and services is in many ways a response to gaps left by governments and other civil society organizations. Civil society outside the church tends to be fairly weak in most sub-Saharan African states, and few governments possess the resources to adequately address the challenges posed by AIDS. Into this vacuum, churches can bring their “moral extraterritoriality” (p. 106) to prod states to take more useful policy actions, provide a space for AIDS-affected persons to organize, and draw on their perceived links to the spiritual world. At the same time, though, she resists the temptation to analyze “the African church” as a monolithic entity.

Lieberman offers exhaustive case studies that highlight the dynamics that influence AIDS policies. South Africa and Brazil have received a great deal of attention from AIDS scholars, but Lieberman's analyses tie together the political and the societal to give a more holistic picture of the policymaking process. His case study of India is of particular interest. Despite having one of the highest number of HIV-positive citizens, India has not received a commensurate level of attention. He shows how regional, linguistic, caste, and federal divisions in the country have affected both the lack of urgency with which Indian government officials have addressed AIDS and the process of “othering” that has allowed large swaths of the public to assume immunity from the effects of AIDS. Lieberman's analysis of India offers scholars a rich foundation from which to conduct further analyses.

The authors' arguments, while compelling, could benefit from greater specificity in explaining how and why change occurs that upsets the previous balance. Whether we examine churches in Uganda or government policy in South Africa, we see clear elements of change. The South African government has adopted a more proactive response to AIDS in recent years and jettisoned its earlier reliance on AIDS dissidents and disavowal of antiretroviral drugs. Uganda has moved away from promoting condoms to advocating abstinence-only education as the only way to stop the spread of AIDS, as Pastor Martin Ssempa has come to play a larger role in the government's policymaking process. These changes have serious consequences for future policy decisions, but it is not clear from the authors' analyses why these changes would occur. A stronger sense of dynamism within the authors' explanations might provide fuller answers to these questions.

Reading Patterson's book, I found myself wanting an evaluation of the efficacy of these church interventions. Are churches doing better or worse at responding to AIDS than sub-Saharan African governments? Patterson anticipates this reaction by readers and explicitly notes that she is not analyzing the substance of the church activities. Her reasoning makes sense (pp. 38–40), and it points to a larger oversight in the AIDS policy literature (also highlighted by Lieberman) about the lack of robust measures of policy efficacy for cross-national comparisons. That said, if we are to agree with the proposition that churches in sub-Saharan Africa are taking a leading role in addressing AIDS, then it seems important to assess that activity. Action for action's sake is not productive, whether it comes from the state or from the church. That may be better addressed in a future volume, however.

Lieberman presents a fascinating analysis, and one with which I am broadly sympathetic, but his chapter presenting a large-n cross-national quantitative analysis (Chapter 6) raises questions about the overall applicability of his argument. In the previous chapters, he develops useful qualitative case studies that bolster his hypothesis. His initial quantitative analyses in Chapter 6 reinforce this argument, finding that stronger ethnic boundaries depress government AIDS expenditures (pp. 264–66). When he disaggregates this analysis by region and tests a variety of different measures of ethnic division, though, ethnic boundaries lose much of their statistical significance. Table 6.7 (pp. 273–74) shows that ethnic boundaries achieve statistical significance only for sub-Saharan Africa. None of the measures of ethnic division achieve statistical significance in any other region. He explains these results as reflective of problematic measures for Latin America and the Caribbean (p. 284) and of the relatively mild AIDS epidemics in Asia (p. 286), but these leave more questions than they answer. Even if these explanations are accurate, and it is possible that they are, it is curious that ethnic boundaries exhibit statistical significance in only one region of the world. Instead of pointing to the importance of ethnic boundaries around the world, this statistical analysis may instead suggest that there is some other factor in sub-Saharan Africa that gives ethnic boundaries their particular salience there. It also suggests an intractability about ethnic politics in sub-Saharan Africa, which raises an interesting challenge to the work of Daniel Posner on the variability of ethnicity's salience in African politics and expands beyond the realm of AIDS.

Overall, these books help to remedy the paucity of analysis on domestic AIDS policymaking in heavily afflicted countries. Not only do they offer valuable analyses of AIDS policy, but they also speak to larger questions in political science about the role and nature of civil society, the place of ethnicity in policy analysis, and the role of comparative policy analysis. Both prolific and engaging scholars, Patterson and Lieberman make welcome contributions to the literature that will inform the work of additional scholars and foster much-needed discussion and debate.