HIV and AIDS in Uganda, then and now

Uganda is one of the few African countries where rates of HIV infection have declined substantially, down from around 15 percent in the early 1990s to 5 in 2001. The country's success in fighting AIDS is commonly attributed to a well-timed and successful public education campaign.

When President Yoweri Museveni took over power in 1986, he responded swiftly to the emerging HIV crisis in Uganda, embarking on a nationwide tour to tell people that avoiding AIDS was a patriotic duty. People should abstain from sex before marriage and remain faithful to their partners, and use condoms, he said. The first AIDS control programme in Uganda was established. It focused on providing safe blood products, and educating people about risks.

The current situation

Despite being lower than in the early 1990s, Uganda still has an alarmingly high HIV prevalence. UNAIDS estimated that adults living with the virus rose to 6,7 percent in 2005. Unless a continued effort is made, it is quite possible that prevalence remains at this level or even increases again. There is some evidence that such a rise is already taking place, possibly because people are becoming more complacent about HIV.

High population growth is another factor that may lead to an increase in HIV infections. It is estimated that in 2025 the population will be 50 million people, a very high figure for a country like Uganda. With more people being born, and without an intensive prevention campaign especially the PMTCT programme, more people are likely to get infected at birth and more deaths are likely to occur due to unavailability of sufficient antiretrovirals (ARV).

Knowing your status

In June 2004, twelve members of Parliament made public their decision to undergo a HIV test, demonstrating that it is good to know one's HIV status. Part of the current revived prevention campaign focuses on this, saying "it's better to know". As treatment options grow, this will be increasingly true.

Treatment provision is now seen as being one of the best methods of HIV prevention. People who test HIV positive have two main needs. They need the ARV treatment that can prolong their lives. They also need education to enable them to enjoy a reasonable quality of life whilst not passing the virus on to anyone else. It is unreasonable to expect people to volunteer for HIV testing if there are no facilities in place to provide treatment. As ARV therapy becomes more generally available and affordable, people will hopefully be more willing to know their status and more likely to avoid behaviour that risks HIV transmission.

Funding for HIV and AIDS

Uganda is one of the fifteen countries that receive most funding from America's PEPFAR initiative, currently around US$250 million per year. Part of the aim of this initiative is an expansion of the antiretroviral (ARV) treatment programme. Given that Uganda has around one million people living with HIV, this needs to happen swiftly if a huge number of deaths is to be averted. About US$ 700 million is needed the next year and a half, according to the Uganda AIDS Commission.

Although Uganda's government has been much praised for its early response to AIDS, recently criticism is becoming more frequent. Much of the PEPFAR funding is channelled through pro-abstinence and even anti-condom organisations which are faith-based. Some Ugandan teachers report being instructed by US contractors not to discuss condoms in schools because the new policy is "abstinence only".

Around the country dozens of billboards have sprung up promoting only abstinence to prevent HIV infection. Some of these even carry negative messages about condoms to discourage their use. While prevention interventions are being designed in countries like Uganda, one should keep in mind that multiple partner sex is still high, homosexuality is a reality and concurrent sexual relationships is a common practice.

The condom shortage

In 2004 the Ugandan government recalled condoms that were distributed free in health clinics due to concerns about their quality. Although tests showed there was nothing wrong with the condoms, except for an unpleasant smell, the government said that public confidence in the brand had been badly dented, so they would not redistribute them. Millions of condoms were incinerated, and by mid-2005 there was said to be a severe scarcity of condoms in Uganda. The retail price reportedly rose from 100 shillings to 1,000 shillings.

Two years later the Ministry of Health announced it had with assistance from the World Bank imported 80 million re-branded condoms for free distribution. The brand name, Engabu, was the same as that of the withdrawn condoms, but the new stock would be marked by a yellow sticker as a guarantee of quality. A spokeswoman said Uganda had previously used five million condoms per month, a number set to be doubled. In order to meet this target, the government and others will have to work hard to counter the widespread mistrust of the Engabu brand.

Conflict with the LRA

During the conflict in northern Uganda, LRA rebels have abducted thousands of children - conservative estimates place the number of children abducted at a minimum of 20,000. About 20 percent of those abducted are girls most of whom will be forced into 'marriages' or given to senior commanders as rewards and incentives. Some children manage to escape, and among those who have done so, about half have some type of sexually transmitted disease. Among children who have been in captivity for longer, this rate rises to 85 percent.

The rates of HIV infection among the abductees or the LRA rebels are unknown, but are thought to be very high. Rehabilitation centres for abductees have been offering HIV testing to children in their centres in recent years. HIV prevalence levels amongst the LRA troops are worrying for another reason - there have been many reports of mass-rapes and of deliberate HIV infection, often used against civilian populations. In urban areas there are reports of tens of thousands of people gathering together in city centres every night to sleep in 'safety of numbers', which makes them safe from LRA attacks, yet vulnerable to sexual exploitation.

What can we learn that will help elsewhere?

Uganda's success was based not only on encouraging abstinence until marriage but also on encouraging fidelity thereafter and condom use. It involved pragmatic discussion of risky sexual behaviours, strong governmental leadership, and condom distribution. The open and frank discussion that took place around the sexual means of HIV transmission is certainly not a feature of the pro-abstinence-only agenda.

There is no simple way to reducing the number of new infections - a number of different interventions are required. Foremost among these are a balanced ABC approach, committed political leadership also to address stigma and discrimination, a willingness to discuss openly the ways in which HIV transmission can be prevented, and a vigorous response from communities across the country. Promoting sexual abstinence until marriage without looking at other issues is a recipe for failure, and Uganda's example cannot be allowed to be misused in this way.

Thanks to Olive Bwanika from the Royal Norwegian Embassy in Kampala for this report.