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Why is Uganda interesting?

Uganda is one of the few African countries where HIV prevalence rates are declining, 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 higher than 30% in the early 90s to 4.3% 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, reducing the numbers of people indulging in casual sex as well as significantly cutting the HIV prevalence rate.¹

More and more money is being channelled to Africa through faith-based organisations, 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.²

Given that a number of other countries with a high HIV prevalence are being urged to examine what has happened there, the policies in Uganda could ultimately effect the spread of HIV across many other parts of the world. 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.

Background

Uganda is estimated to have a population of about 20 - 25 million, although the extreme mortality of AIDS has had an effect on this - the figure would otherwise be higher. Again, due to AIDS, life expectancy in Uganda is 42 years³. 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 1962.⁴

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.

Uganda has had a history of conflict. 300,000 people were killed by the dictator Idi Amin and the situation has not greatly improved since. Much of Northern Uganda remains involved in conflict, with the Lord's Resistance Army (LRA) attacking civilian populations and killing or displacing many thousands of people. Much of this part of the country is considered too dangerous to visit.⁵

The LRA rebels have abducted around 26,000 children to be soldiers, and at least 1,000 deaths have been reported in the past year. About 20 percent of those abducted are female, most of whom will be forced into 'marriages' or given to senior commanders as rewards and incentives. Some manage to escape, and of those who have done so almost 100% suffer from syphilis. Other sexually transmitted infections and HIV are also very common.

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. There have also been reports of the LRA troops - many of them children - deliberately infecting people with HIV. The LRA has waged war against the Ugandan government for 18 years in the north.⁶

During the early 90s, HIV prevalence peaked at over 30% and until recently has been much higher than that in some areas. Uganda is now estimated by UNAIDS to have about 530,000 people living with HIV/AIDS. Uganda's Ministry of Health Surveillance Unit estimated that there were about 1,050,555⁷ people living with HIV/AIDS by end of December 2001 and that there had been over 940,000 HIV/AIDS-related deaths since the onset of the epidemic in the country.

The Foreign Minister has recently been 'outed' by a national tabloid newspaper as having died from an AIDS-related disease. His family and government deny this, showing the stigma that is still attached to the disease.⁸

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, as has the life expectancy of its population - in 2001, only 44.7 years at birth.⁹ 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.¹⁰

Timeline

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 1970s¹¹.

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.¹²

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.¹³

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. ¹⁴

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.¹⁵

1991 Prevalence among pregnant women aged 15 - 24 peaked in this year at 21%.

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.¹⁶

1995 Uganda announced that it had observed what appeared to be declining trends in HIV prevalence.¹⁷

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 has 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 to the infrastructure necessary to allow these drugs to be generally accessible. ¹⁸

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.

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.³¹

What do HIV prevalence and incidence mean?

When talking about HIV and AIDS figures, the terms 'incidence' and 'prevalence' are used.

'Incidence' is the number of new cases of HIV (or AIDS) 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 1998.¹⁹

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 men. 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.

It is possible for HIV incidence to decrease at a time when HIV prevalence is increasing - for example, in a society where both education and treatment are adequately provided. Fewer new infections would occur, lowering HIV incidence, whilst people would live longer, increasing the number of positive people in the population, thus increasing the prevalence figure.

How accurate are the prevalence figures?

It is hard to be sure about the exact prevalence of HIV amongst Uganda's population, as there has been no detailed study since the late 1980s. 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.²⁰

In spite of the problems of war, hunger and poverty Uganda's official prevalence figures have been decreasing since the early 90s. They have now fallen to around 10%, which appears to be fairly constant in both rural and urban areas. A new study, however, has challenged Uganda ’s official statistics which claim huge successes, saying that the HIV prevalence levels in Uganda may be much higher than previously thought. Whilst there have been claims that the methodology of the new study is flawed, it suggests that the problem is perhaps not accurately reflected in the official statistics.

Why might HIV prevalence have declined?

In Uganda, the prevalence rate has been seen to fall since the early '90s. A declining prevalence rate indicates that there is a lower percentage of positive people amongst a population - it does not necessarily mean that there are fewer positive people. The percentage could have declined because there have been a large number of births of negative babies. It could imply some sort of social problem - for example that positive people experience such discrimination that they are reluctant to be tested. It might mean that testing methods have become more accurate, or the decline could also be because there have been a large number of deaths of positive people

Births

An estimated 20,000 - 30,000 HIV+ babies are born to HIV+ mothers each year, a number which is not very significant out of the estimated million HIV+ people in the country. Given that antiretroviral (ARV) medicines are only very recently becoming available in Uganda, these infections are likely to all result in the deaths of the children. Recently, NGOs have begun offering Nevirapine, a drug which can prevent infection in babies born to positive mothers. This indicates that the decline in HIV prevalence is not likely to be due to the birth of a large number of babies who are not positive, since it is only in recent years that Nevirapine has begun to reach pregnant women, and in some rural areas of the country pregnant women are unable to access healthcare facilities.

The Uganda National Operational Plan for HIV/AIDS/STD Prevention, Care and Support, 1994-1998. predicted a cumulative total of 815,507 deaths in 1993 - 1998²¹

New infections

There has also been an apparent fall in the numbers of new infections amongst younger people, suggesting that they are more cautious about indulging in potentially risky activities.

Death

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.

A UN document published in 1994 gives estimated and projected deaths in Uganda per thousand, contrasting the figures with estimates which show how the estimates would have stood were it not for the HIV epidemic in the country.

Based on a population size of 50,000,000 people, this would equate to 245,000 deaths annually by 1995 due to AIDS-related illnesses.

Data from 'AIDS Newsletter' (CAB International) August 1997 quotes Dr Madraa, head of Uganda's STDs/AIDS Control Program at that time, who said that 460,758 of 546,173 Ugandan people who had HIV/AIDS had died since 1988 and that about 1.5 million people there were currently infected with HIV.

Few people living with HIV/AIDS have adequate access to anti-retroviral therapy which means that many people continue to die from AIDS-related diseases. The graph (above) shows a prevalence rate of over 30% in the early 90s. In resource-poor countries such as Uganda, poor nutrition, geographic instability, poor sanitation and water-supplies reduce people's chances of remaining healthy, especially if their immune systems are damaged by AIDS. In such circumstances, progression from HIV infection to death from AIDS-related diseases is likely to take less than 4 years. It can be said with surety that all of the 30% of Uganda's population who were infected with HIV in the early 90s are now dead. This is one very significant explanation for the decline in HIV prevalence.

There have, however, been other factors which have also had an effect on lessening the prevalence rate.

Which factors have contributed?

The approach used in Uganda is often referred to as the ABC approach - first, encouraging sexual Abstinence until marriage, secondly, advising those who are sexually active to Be faithful to a single partner, and, especially if you have more than one sexual partner, always to use a Condom.

Whilst poor monitoring makes is difficult to suggest that one aspect of the ABC strategy was more successful than others, it seems likely that the President's message in 1986 made the most difference, and that 'B' - being faithful - was more effective than condom use or sexual abstinence.

Communication

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 levels, with a multitude of tiny organisations educating their peers, mainly made up of people who were themselves HIV+. There has been a reduction in some types of risky behaviour, and there is a high level of AIDS-awareness amongst people generally.

Community action

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'.²³ 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.

Risky behaviour

There are few surveys to base any conclusions on but it appears that people are engaging in less risky behaviour. The age of sexual debut seems to have increased and people are more likely to remain faithful to one spouse.

Condom use

Similar levels of condom use have been reported in neighbouring countries - Kenya, Malawi, Zambia - but prevalence rates have not followed the same trend as has been seen in Uganda. It is the combination of condom use, sexual abstinence until marriage and the reduction in the number of sexual partners which is credited with being the main reason for the decline in new HIV infections.

Fear

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.

Simple messages

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. 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.

Political openness

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 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.

Treatment

Only very recently, in June 2004, Uganda has begun to offer free ARV medication to people with AIDS. This initial consignment has been funded by the World Bank, with future drugs to be paid for by a Global Fund grant of US$70million. It is also hoped that funding will be forthcoming from President Bush's promised US$15billion which is set aside to fight AIDS in fourteen badly-affected countries, including Uganda.²⁵ This has to be accompanied by education of these HIV+ people since as they will live long enough and remain healthy enough to be sexually active. In October 2004, the Ugandan Ministry of Health claimed 25,000 were being treated out of a minimum estimate of 110,000 in need.

Drug distribution

Uganda began one of the first test programs in Africa distributing life-saving antiretroviral medication (ARVs). 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.

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.²⁶ In June 2004, free ARV distribution began in all areas of Uganda, and the health minister was quoted as saying that at least 2,700 people would be treated by the first batch of medicines. 'Priority' he said, 'would be given to the poor including some civil servants'.²⁷

Funding the fight against HIV/AIDS

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.²⁸ 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.²⁹

The United States Agency for International Development has been one of the largest foreign donor agencies to respond to the HIV epidemic in Uganda, having contributed more than US$80 million since 1988.³⁰

Employers are starting to understand the benefits of having healthy staff, and are starting to fund ARV programs for their employees.

What difficulties are involved in treatment provision?

Conflict

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 at 11.2%. It is feared that rates amongst the LRA, the army and displaced people are much higher. 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.

Inaccurate monitoring

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 preventative education, condom distribution and AIDS medicines.

Another problem of weak monitoring is that it is not possible to say which factor - abstinence, being faithful or condom use - has been most successful at reducing the further spread of HIV.

High prevalence

Although the prevalence rates in Uganda have declined from 30% to about 10% between 1992 and 1996, it seems to have stagnated since then, and the decline has been slower. The current official figure is 4.1%, which does represent some success. The accuracy of this figure, however, has been called into question by a recent study, and even if true, a prevalence rate of 4.1% is still alarmingly high.

What needs to happen now?

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. It needs increased funding for treatment and education programs, and this funding needs to be used effectively.

One of the greatest difficulties, when trying to learn from Uganda, is that lack of monitoring makes it very hard to gain a clear picture of the epidemic there. People talk about the success of Uganda without having a clear how successful it actually has been. As part of addressing its AIDS issues, Uganda needs first to have an accurate picture of them. Basing strategies on the monitoring of those pregnant women who are able to access healthcare is insufficient - Uganda needs to undertake a full study of the HIV epidemic amongst its population, whilst starting to treat it. Too often, treatment programs wait for epidemiological data before beginning to rollout drugs. It is already clear that there is still a serious problem in Uganda, and the drug rollout should not be delayed.

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 fourteen countries which have been listed to receive funding from America's US$15billion HIV/AIDS money. This money, which has only recently begun to be released, should lead to a massive expansion in ARV treatment. 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.

What can we learn that will help elsewhere?

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.

A significant amount of the USA's $15 billion 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. It should, however, be noted that 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 may yet be many more. There is no simple way to reducing a countries HIV prevalence rate - a number of different interventions are required. Foremost amongst them are the ABC approach, political leadership, and the availability of money, trained medical staff and drugs for AIDS treatment.

Last updated January 31, 2005

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