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AIDS in Africa - Uganda
Why is Uganda interesting?
Background
Timeline
What do HIV prevalence and incidence
mean?
How accurate are the prevalence
figures?
Why might HIV prevalence have
declined?
Why was Uganda's response so
effective?
Antiretroviral treatment
What needs to happen now?
What can we learn that will help
elsewhere?
TOP
Uganda is one of the few African countries where HIV
prevalence rates have declined, and it is seen as a rare example of
success in a continent which is facing a severe AIDS crisis.
Uganda's policies are credited with having brought the prevalence
rate down from 15% in the early 1990s to 5% in 2001. At the end of
2003, the government and the UN say that only 4.1% of adults had the
virus. The country is seen as having implemented a well-timed and
successful public education campaign.
More and more money is being channelled to Africa,
especially by the US which has pledged $15 billion to fight HIV/AIDS
in resource-poor countries. Uganda is lucky enough to be one of the
countries on President Bush's list and many other countries are
being urged to follow its example.
But the results seen in Uganda don't have a simple
recipe, and with so many lives and such large sums of money at
stake, it is important to look carefully at what has been done
there.
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Uganda is estimated to have a population of about
23-30 million. The extreme mortality of AIDS has had an effect on
this figure, which would otherwise be higher. As another consequence
of AIDS, healthy life expectancy in Uganda is only around 42 years.
It was estimated in a UNDP report that 51% of the population did not
have access to healthcare facilities in 2001. Uganda achieved
independence from the UK in 1962.
Uganda contains over 18 distinct ethnic groups, a
similar number of languages, and several religions. Most newspapers
and television broadcasts use English as a common language. Over 80%
of the working population is employed in agriculture, and the
population growth is about 2.9% annually.
Today, much of Uganda remains mired in a conflict
between the Lords Resistance Army rebels fighting against
government-backed militia. The conflict has claimed many civilian
victims, with both sides targeting civilian populations, and
atrocities such as the mass amputation of limbs reportedly not being
uncommon. There have been recent indications that the conflict may
be ending, but much of the North of Uganda is still considered too
dangerous to visit .
During the conflict LRA, rebels have abducted
thousands of children - conservative estimates place the number of
children abducted at a minimum of 20,0005. About 20% 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 50% have
some type of STD. Among children who have been in captivity for
longer, this rate rises to 85%.
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/AIDS
testing to children in their centres in recent years, and have found
13 out of 83 children tested to be HIV+. The youngest was thirteen.
Three of the girls had children of their own, and at least one has
since died of AIDS.
HIV prevalence levels amongst the LRA troops are
worrying for another reason - thee 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 vulnerable to
sexual exploitation. The war has now continued for 19 years.
HIV has not only a social but an economic cost. HIV
/ AIDS related expenses in Uganda cost the public services over
sh3billion in 1999, and the country's GDP has fallen. Of this
sh3billion, sh192m was for burial expenses. AIDS is known to hamper
efforts to reduce poverty, and indeed, often increases the numbers
of people living in extreme poverty. As AIDS usually kills
sexually-active adults, it tends to strike hardest against a
country's labour-force. The impact this has on economic revenues
negatively affects the educational and health services and leaves
behind orphaned children and grand-parents, an additional burden on
the community or the state.
During the early 1990s, national adult HIV
prevalence peaked at around 15% and exceeded 30% among pregnant
women in the cities. At the end of 2003, adult prevalence was
estimated at 4.1%, and an estimated 530,000 people were living with
HIV/AIDS, according to UNAIDS/WHO.8 This reduction in HIV prevalence
has not been seen in countries neighbouring Uganda, so seems
unlikely to be a natural decline. But with other countries suffering
under a high burden of HIV prevalence, the drop is one that many
people would like to imitate. The debate is - why did HIV prevalence
in Uganda decline? And how can this decline be replicated?
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The data in the timeline below are taken from a
number of different studies. The graphed data shows UNAIDS/WHO
median HIV prevalence rates by year amongst antenatal clinic
attendees in major urban areas.
AIDS in Uganda was initially known as 'slim' due to
its physically wasting characteristics. It began to spread in Uganda
on the shores of Lake Victoria in the late 1970s.10 It is from here
that many theories suggest HIV spread to the rest of the world. If
the HIV epidemic did indeed start in Uganda before it did in other
countries, then Uganda's HIV epidemic might be said to have had
something of a 'head start' on other national epidemics.
1982 The first AIDS case in Uganda was diagnosed.
Between 1982 and 1986 there was little understanding of what AIDS
was, and it was not known that it was caused by HIV. During this
period the epidemic was largely addressed at local levels with
communities caring for those infected and affected by deaths.
1986 President Yoweri Museveni responded to the
emerging HIV crisis in Uganda swiftly, embarking on a nationwide
tour to tell people that avoiding AIDS was a patriotic duty, and
that they should abstain from sex before marriage and then go on to
remain faithful to their partners and to use condoms. Uganda's
Health Minister announced to the World Health Assembly that there
was HIV in Uganda, and the first AIDS control program in Uganda was
established. It focused on providing safe blood products, and
educating people about risks.
1987 16 volunteers who had been personally affected
by HIV/AIDS came together to found the community organisation TASO.
A program was established to control the spread of HIV in the
military.
1988 The first national survey to assess the extent
of the epidemic was conducted and found the average prevalence in
the population to be 9%
1990 The AIDS Information Centre was formed to
provide voluntary counselling and testing.
1991 Prevalence among pregnant women aged 15-24
peaked in this year at 21%. UNAIDS estimated data indicates that
national prevalence peaked at 15% in 1991.
1992 The government adopted a multisectoral approach
to addressing the epidemic and coordinating the response to it. HIV
prevalence in young pregnant women in Uganda began to decrease
between 1991 and 1993.
1994 Various governmental departments - for example,
Agriculture, Internal Affairs, Justice, etc - established individual
AIDS control Program Units. The government borrowed $50million from
the World Bank to fight the epidemic, with the Ugandan government
and other donors making this up to a total of $75million to set up
the Sexually Transmitted Infections Project.
1995 Uganda announced that it had observed what
appeared to be declining trends in HIV prevalence.
1997 Ugandans participated in a study of using
anti-retroviral drugs to prevent mother-to-child transmission of
HIV.
1998 Prevalence among pregnant women aged 15-24 had
fallen to 9.7%. The Drug Access Initiative was established to lobby
for reduced prices for antiretroviral (ARV) medication which can
improve the health of an infected person, and the establishment of
the infrastructure necessary to allow these drugs to be generally
accessible.
1999 The Ugandan ministry of Health started a
voluntary door-to-door HIV testing programme using rapid tests.
2000 The government began to 'mainstream' HIV / AIDS
issues in Uganda's Poverty Eradication Action Plan.
2001 The World Bank agreed to spend $47.5 million
over the next five years on Uganda's AIDS prevention and treatment
programs. UNAIDS estimated data indicates that national HIV
prevalence had fallen to around 5% in 2001.
2004 The non-governmental organisation National
Guidance and Empowerment Network released a report saying that
Uganda's HIV prevalence rate is actually 17% - more than four times
the official rate. Experts have claimed that the study is
inaccurate, but admit that the HIV problem in Uganda may still be
much worse than official statistics indicate.18 In the same year,
the Foreign Minister was 'outed' by a national tabloid newspaper as
having died from an AIDS-related disease. His family and government
denied this, showing that some stigma is still attached to the
disease.
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When talking about HIV and AIDS figures, the terms
'incidence' and 'prevalence' are used.
HIV 'incidence' is the number of new cases of HIV in
the population during a certain time period. People who were already
infected before that time period are not included in that figure -
not even if they are still alive and HIV+ during the time period.
Due to limited data-collection, incidence data for Uganda is
difficult to find, but one example is that USAID said that in one
site, Masaka, incidence fell from 7.6 per thousand per year in 1990
to 3.2 per thousand per year by 1998.
HIV 'prevalence' is given as a percentage of a
population. If a thousand truck drivers, for example, are tested for
HIV and 30 of them are found to be positive, then the results of a
study might say that HIV prevalence amongst truck drivers is 3%.
This does not mean that all the truck drivers in a country have been
tested, and it gives only a very limited hint of what the prevalence
might be in another group - for example, old people.
HIV prevalence in developing countries is often
difficult to measure - partly because much of the population, as in
Uganda, does not have access to healthcare facilities and relies on
traditional medicine. Therefore, HIV prevalence tends to be measured
at whatever points the people do have contact with health staff.
This is often at antenatal clinics or STD treatment centres.
Obviously, this does not give a full picture of the
spread of the epidemic in the country as a whole - the former will
give an indication of the prevalence rate amongst sexually active
women, the latter generally amongst presumably sexually
non-monogamous adults. As a general rule, however, it seems apparent
that a prevalence rate of anything over 10% in any population
indicates an extremely serious problem.
Given that HIV incidence is the figure which tells
about new infections in a population over a period of time, this is
often more revealing that prevalence figures. A society which shows
regularly declining incidence figures is one which is experiencing
fewer and fewer new infections, something which is certainly
desirable.
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It is hard to be sure about the exact prevalence of
HIV amongst Uganda's population. What UNAIDS/WHO prevalence rates do
exist are taken mainly from women who visit pre-natal clinics.
In a country which has very poor healthcare
infrastructure and many people unable to access what does exist, it
is very difficult to assess HIV levels. Much of northern Uganda is
involved in civil war between the LRA and the army, and efforts
there predominantly focus on caring for refugees and providing food.
Many people in this part of the country have been killed or injured
by the fighting, and at least 1.6 million have been displaced.
Condom availability amongst people in Internally Displaced People's
camps is low.
At least one recent study has challenged Uganda 's
official statistics, saying that the HIV prevalence levels in Uganda
may be much higher than reported. Whilst there have been claims that
the methodology of that study was flawed, it suggests that the
problem might not be accurately reflected in the official
statistics.
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According to the best statistics available, the HIV
prevalence rate in Uganda fell dramatically during the 1990s. A
declining prevalence rate indicates a lower proportion of positive
people in the population. This could result from a fall in the
number of new infections (incidence) or from a rise in the death
rate among HIV-positive people, or from a combination of both
factors.
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It is probable that the number of new infections
peaked in the late 1980s, and then fell sharply until the mid 1990s.
This is generally thought to have been the result of behaviour
change. Increased abstinence, a rise in the average age of first
sex, a reduction in the average number of sexual partners and more
frequent use of condoms are all likely to have contributed.
In the late 80s and early 90s, condom use rose
steeply among unmarried sexually active men and women, and since the
mid 1990s, condom promotion and distribution in Uganda has increased
dramatically. It is thought that this has helped to keep down the
number of new infections in recent years.
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There is no precise data on the number of
AIDS-related deaths which have taken place. The reasons for this are
several - lack of healthcare facilities able to diagnose either HIV
or AIDS cases in patients, and many deaths having gone unrecorded,
or recorded as the results of opportunistic infections.
It has been suggested that an increase in the death
rate may have been largely responsible for the drop in the number of
people living with HIV that occurred in the late 1990s (though not
for earlier declines). In the absence of widespread antiretroviral
treatment, any rise in the number of new infections will almost
inevitably result in an increase in the death rate a few years
later, as people reach the end of their survival period.
It is clear that a huge number of HIV+ people have
died in Uganda since the epidemic began, and a sufficiently high
number of deaths could certainly result in a decrease in HIV
prevalence figures. However, it should be noted that many other
countries in sub-Saharan Africa experienced rapid increases in HIV
incidence at the same time as Uganda, and, although they are
similarly likely to have experienced large numbers of deaths, have
not yet seen any substantial decline in prevalence. This suggests
that the decline seen in Uganda wasn't a natural occurrence, but
rather that it was the result of something that was done differently
in Uganda.
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The approach used in Uganda has since been named the
ABC approach - first, encouraging sexual Abstinence until marriage;
secondly, advising those who are sexually active to Be faithful to a
single partner or to reduce their number of partners; and finally,
especially if you have more than one sexual partner, always use a
Condom. A number of factors helped to encourage people to take up
these strategies.
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It seems that the message about HIV and AIDS has
been effectively communicated to a diverse population by the
government and by word of mouth. Ugandan people have themselves to
thank, in part, for the reduction in the HIV prevalence rate. Much
of the prevention work that has been done in Uganda has occurred at
grass-roots level, with a multitude of tiny organisations educating
their peers, mainly made up of people who are themselves HIV+. There
was considerable effort made towards breaking down the stigma
associated with AIDS, and frank and honest discussion of sexual
subjects that had previously been taboo was encouraged. There is a
high level of AIDS-awareness amongst people generally.
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Very early in the course of the epidemic, the
government recruited the Ugandan people to help themselves in the
fight against HIV/AIDS. One of the first community-based
organisations to be formed was TASO, the AIDS Support Organization
founded in 1987, a time when there was still a great deal of
stigmatisation of people with HIV.
When it was first started, the organisation 'met
informally in each other's homes or offices to provide mutual
psychological and social support. Cohesion among these individuals
was strengthened by the fact that they were either directly infected
with HIV or implicitly affected because their very close familial
associates were infected'.25 TASO now provides emotional and medical
support to people who are HIV positive and their families. It also
works with other smaller organisations to educate the public about
discrimination and about the dangers of HIV/AIDS.
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A Cambridge University study in 1995 showed that
91.5% of Ugandan men and 86.4% of women knew someone who was HIV
positive, and that word of mouth was the method by which most people
were informed about HIV prevention. This indicates that one of the
main reasons for people's behaviour change was their alarm about the
risks and the extent of the epidemic. Many villages are experiencing
several deaths each month, houses stand empty, and grandparents are
looking after their orphaned grandchildren. Put simply, people are
more likely to avoid risky behaviour if they know people who have
died of AIDS-related illnesses.
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In the early stages of the epidemic, the government
responded swiftly, giving out simple messages about abstaining from
sex until marriage, staying faithful to one's spouse, and using
condoms. The key message was "Zero Grazing", which instructed people
to avoid casual sex. More complicated messages about risky behaviour
and safer sex were not spread until later, when there had already
begun to be a decline in HIV figures.
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Since 1986, when Uganda's health Minister announced
that there was HIV in the country, there has always been political
openness and honesty about the epidemic, the risks, and how they
might best be avoided. Also in this year, the President toured the
country, telling people that it was their patriotic duty to avoid
contact with HIV. This was a brave approach, as many politicians are
reluctant to talk openly about sexual issues, but the openness paid
off. The president encouraged input from numerous government
ministries, NGOs and faith-based organisations. He relaxed controls
on the media and a diversity of prevention messages - including
'zero-grazing' - spread through Uganda's churches, schools and
villages. This frank and honest discussion of the causes of HIV
infection seems to have been a very important factor behind the
changes in people's behaviour that allowed prevalence levels to
decline.
This contrasts sharply with countries like South
Africa, which have lacked this political leadership in the fight
against the epidemic. Uganda's entire population was mobilised in
the fight against HIV and were made aware of the consequences that
risky behaviour could have for their country. It is largely due to
the Ugandan people that the epidemic appears to have been so well
addressed.
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Antiretroviral (ARV) treatment can extend the
healthy life of someone living with HIV. If other factors remain the
same, and ARV medication helps HIV+ people to survive for longer,
then HIV prevalence will increase. The introduction of ARV
medication, however, can even contribute to reducing prevalence by
presenting people with an incentive to be tested (those who know
their status are more likely to change their behaviour).
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Uganda began one of the first test programs in
Africa distributing life-saving antiretroviral medication. It began
in 1998 and aimed to see how an ARV programme could be set up and
run in a resource-poor country. The patients involved had to pay for
their medication, although at reduced prices. After the study was
complete, the Ugandan Ministry of Health used the lessons it had
learned to set up its National Strategic Framework for HIV/AIDS.
Only very recently, in June 2004, has Uganda begun
to offer free ARV medication to people with AIDS. The initial
consignment was funded by the World Bank, with future drugs to be
paid for by a Global Fund grant of US$70million. Further funds have
come from America's PEPFAR initiative.
Uganda's target was to have 60,000 on treatment by
the end of 2004. According to UNAIDS/WHO estimates, this target was
missed, and between 40,000 and 50,000 people were receiving drugs.
It is estimated that 114,000 people are in need of ARV drug
treatment in Uganda.
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Very little work has been done in the north because
it is so unsafe, despite Gulu province in the north having the
highest prevalence rate of HIV/AIDS. It is feared that rates amongst
the LRA, the army and displaced people are higher still. Due to the
conflict only about a third of young people are enrolled in school,
meaning that many do not receive adequate sexual health education.
There is also an urgent lack of condoms and sexual health education,
and many people in rural areas are unable to access healthcare
facilities.
Many of the organisations which are doing relief
work in the north naturally tend to focus on dealing with the
immediate effects of the conflict - providing medical help and food.
There are groups of American missionaries working in northern
Uganda, but many of these are opposed to condom use, telling
villagers that condoms don't work and to simply wait to have sex
until marriage.
The prevalence figures given for Uganda are based on
the results of testing pregnant women. There is little information
about prevalence rates amongst large sectors of the population - for
example children, the elderly, or men. This lack of demographic
knowledge increases the difficulty of addressing the epidemic,
making it harder both to appropriately target treatment provision.
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Uganda needs to build on whatever successes it has
achieved so far. It still has an alarmingly high HIV prevalence
rate, and unless a continued effort is made to keep people aware of
the dangers of HIV then it would be quite possible for the
prevalence rate to remain at this level or even rise again. There is
disagreement over what the prevalence rate in Uganda actually is,
and monitoring clearly needs to be improved - it's hard to treat
people without knowing how many people need treatment.
In June 2004, 12 members of Parliament made public
their decision to undergo a HIV test, encouraging the population
that it is good to know their status. The current campaign focuses
on this, saying 'it's better to know'. As treatment options grow,
this will be increasingly true.
Uganda is one of the fifteen countries that receive
most funding from America's US$15 billion PEPFAR initiative. Part of
the aim of this initiative is an expansion of the ARV treatment
programme. Given that Uganda has over half a million people living
with HIV/AIDS, this needs to happen swiftly if a huge number of
deaths are to be averted.
Treatment provision is now seen as being one of the
best methods of HIV prevention. People who test HIV+ have two main
needs - firstly the antiretroviral treatment that can prolong their
lives, and secondly 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. Hopefully, as
ARV therapy becomes more generally and affordable available, more
people will be willing to know their status, and then to avoid
onward transmission of HIV.
Challenges to funding
The Ugandan government, in spite of its early and
swift action to address the HIV epidemic, has been accused of
placing too high an emphasis on purchasing weapons instead of AIDS
drugs. In May 2004, foreign donors including the European Union
threatened to stop all foreign aid to the Ugandan government unless
it channelled resources away from defence spending which has grown
by 48% over the past two years. Christian Aid has recently noted a
dangerous drift towards channelling money intended for HIV/AIDS
spending in Uganda towards the 'war on terror' - essentially,
military budgets.
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Gradually, more and more countries around the world
are starting to realise that they must take decisive action if they
are to avert a major AIDS crisis. More money is gradually being
channelled to these countries, and, as they try to look for
solutions, Uganda is coming under the spotlight. Given the decline
that has been seen in its prevalence rate, it is increasingly being
held up as an example of good planning and action.
Uganda receives significant amounts of funding from
America, and US$1billion of the US$15billion PEPFAR money is being
channelled through pro-abstinence and even anti-condom organisations
which are faith-based, and which would like sexual abstinence to be
a central pillar of the fight against HIV. This money is making a
difference - teachers report being instructed by US contractors not
to discuss condoms in schools because the new policy is "abstinence
only"28. This is a dangerous change, and one which could easily
reverse the good done in previous years.
Pro-abstinence-only organisations are increasingly
using Uganda as an example to indicate the success of their methods
- this is inappropriate, since the multiplicity of prevention
methods used in Uganda mean that it's fall in HIV prevalence was
certainly not due to abstinence-only HIV prevention methods. Indeed,
abstinence-only HIV prevention methods were not then seen in Uganda,
and the open and frank discussion of the sexual means of HIV
transmission that took place is something that is certainly not a
feature of the pro-abstinence-only agenda. 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.
Randall Tobias, the man leading America's AIDS-money
distribution, accepts that the ABC approach in Uganda involved more
than only abstinence, but a large cut of the money is still being
channelled through Christian organisations. The plans drawn up by
these faith-based groups tend to be ideological rather than
evidence-based and can neglect the other important aspects of HIV
prevention. Promoting sexual abstinence until marriage without
looking at these other issues is a recipe for failure, and Uganda's
example cannot be allowed to be mis-used in this way.
There are now so many people with HIV/AIDS in
Uganda, and Africa as a whole, that their votes are increasingly
being seen as powerful enough to swing elections. Politicians will
have to be able to show that they have a definite plan for
addressing the epidemic and to offer them something more than empty
promises about medication that never arrives.
Unfortunately, there is no easy answer to a high HIV
prevalence rate in a country. Uganda may have decreased its HIV
prevalence but there have been many deaths in the country, and will
yet be many more. There is no simple way to reducing a country's HIV
prevalence rate - a number of different interventions are required.
Foremost among them are a balanced ABC approach, committed political
leadership, a willingness to discuss openly the ways in which HIV
transmission can be prevented, and a vigorous response from
communities across the country.
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