HIV/AIDS in Uganda
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Uganda has been hailed as a rare success story in the fight against HIV and AIDS, widely being viewed as the most effective national response to the pandemic in sub-Saharan Africa. President Yoweri Museveni established the AIDS Control Program (ACP) within the Ministry of Health (MOH) to create policy guidelines for Uganda’s fight against HIV/AIDS. Uganda quickly realized that HIV/AIDS was more than a ‘health’ issue and in 1992 created a “Multi-sectoral AIDS Control Approach.” In addition, the Uganda AIDS Commission, also founded in 1992, has been instrumental in developing a national HIV/AIDS policy. A variety of approaches to AIDS education have been employed, ranging from the promotion of condom use to 'abstinence only' programmes. There is suggestion, however, that the HIV infection rate in Uganda is on the rise, perhaps linked to over-emphasis on abstinence at the expense of condom use.
To further Uganda's efforts in establishing a comprehensive HIV/AIDS program, in 2000 the MOH implemented birth practices and safe infant feeding counseling. According to the WHO, around 41,000 women received Preventing Mother To child Transmission (PMTCT) services in 2001. Uganda was the first country to open a Voluntary Counselling and Testing (VCT) clinic in Africa called AIDS Information Centre and pioneered the concept of voluntary HIV testing centers in Sub-Saharan Africa.
The very high rate of HIV infection experienced in Uganda during the 80's and early 90's created an urgent need for people to know their HIV status. The only option available to them was offered by the National Blood Transfusion Service, which carries out routine HIV tests on all the blood that is donated for transfusion purposes. Because the need for testing and counseling was great, a group of local NGOs together with the Ministry of Health established the AIDS Information Centre in 1990 to provide HIV testing and counseling services with the knowledge and consent of the client involved.
There are striking similarities with the history of HIV/AIDS response in Senegal, where an equally high-level political response was encouraged by the fact that the HIV-2 strain of the disease was discovered by the Senegalese scientist Dr Mboup.
Uganda's Success Story
Abstinence, monogamy and contraception helped to curb the spread of AIDS in Uganda, where HIV infections reached epidemic proportions in the 1980s. The prevalence of HIV began to decline in the late 1980s and continued throughout the 1990s. In fact, between 1991 and 2000, HIV infection rates declined dramatically. Various claims have been made on the extent of these declines, but mathematical modelling estimates typically predict falls from around 15 to 6 percent.
Shortly after he came into office in 1986, President Museveni of Uganda spearheaded a mass education campaign promoting a three-pronged AIDS prevention message: abstinence from sexual activity until marriage; monogamy within marriage; and condoms as a last resort. The message became commonly known as ABC: Abstain, Be faithful, and use Condoms if A and B fail.
The government used a multi-sector approach to spread its AIDS prevention message: it developed strong relationships with government, community and religious leaders who worked with the grassroots to teach ABC. Schools incorporated the ABC message into curricula, while faith-based communities, including Christians, Muslims, and Jews, trained leaders and community workers in ABC. The government also launched an aggressive media campaign using print, billboards, radio, and television to promote abstinence, monogamy and condom use.
Condoms were not the main element of the AIDS prevention message in the early years. President Museveni said, "We are being told that only a thin piece of rubber stands between us and the death of our Continent ... they (condoms) cannot become the main means of stemming the tide of AIDS." He emphasized that condoms should be used, "if you cannot manage A and B ... as a fallback position, as a means of last resort."
Some reports suggest that the decline in AIDS prevalence in Uganda was due to monogamy and abstinence, rather than condom use. According to Dr. Edward Green, an anthropologist at Harvard University, fidelity to one's partner was the most important factor in Uganda's success, followed by abstinence. A 2004 Science study also concluded that abstinence among young people and monogamy, rather than condom use, contributed to the decline of AIDS in Uganda.
However, a field-study conducted in Rakai, a region in southern Uganda, showed that abstinence and fidelity rates had been declining during 1995-2002, but without the expected rise in HIV/AIDS rates, suggesting a greater role for condoms than acknowledged by Museveni.
The scope of Uganda's success has come under scrutiny from new research. Research published in The Lancet medical journal in 2002 questions the dramatic decline reported. It is claimed statistics have been distorted through the inaccurate extrapolation of data from small urban clinics to the entire population, nearly 90 per cent of whom live in rural areas. Also, recent trials of the HIV drug nevirapine have come under intense scrutiny and criticism.
US-sponsored abstinence promotions have received recent criticism from observers for denying young people information about any method of HIV prevention other than sexual abstinence until marriage. Human Rights Watch says that such programmes "leave Uganda’s children at risk of HIV". Alternatively, the Roman Catholic organization Human Life International says that "condoms are adding to the problem, not solving it" and that "The government of Uganda believes its people have the human capacity to change their risky behaviors."
It is feared that HIV prevalence in Uganda may be rising again; at best it has reached a plateau where the number of new HIV infections matches the number of AIDS-related deaths. There are many theories as to why this may be happening, including the government’s shift towards abstinence-based prevention programmes, and a general complacency or 'AIDs fatigue'.It has been suggested that antiretroviral drugs have changed the perception of AIDS from a death sentence to a treatable, manageable disease; this may have reduced the fear surrounding HIV, and in turn have led to an increase in risky behaviour.
Although abstinence has always been part of the country’s prevention strategy it has come under scrutiny since 2003 following significant investment of money for abstinence-only programmes from PEPFAR, the American government’s initiative to combat the global HIV/AIDS epidemic. It is felt that PEPFAR has shifted the focus of prevention in Uganda from the comprehensive ABC approach of earlier years. PEPFAR is channelling large sums of money through pro-abstinence and even anti-condom organisations that are faith-based, and believe sexual abstinence should be the central pillar of the fight against HIV. Abstinence-only is also being encouraged by evangelical churches within Uganda, and by the First Lady, Janet Museveni.
This money is making a difference - some Ugandan teachers report being instructed by US contractors not to discuss condoms in schools because the new policy is 'abstinence only'. Dozens of billboards around the country have sprung up promoting only abstinence to prevent HIV infection and sometimes discouraging condom use. Some leaders of small community-based organisations also report they are aware that they are more likely to receive money from PEPFAR (which is the largest HIV-related donor to the country) if they mention abstinence in their funding proposal.
There have been calls for a more nuanced view of Uganda's response to HIV/AIDS. There is no doubt that there has been sustained, long term political commitment at the highest levels of government on this issue. In other countries such as Zimbabwe or South Africa, inept leadership has led to a serious crisis; some such as former President Thabo Mbeki deny the link between HIV and AIDS.
Structure of health provision
The provision of all health services in Uganda is shared between three groups: the government staffed and funded medical facilities; private for profit or self-employed medics including midwives and traditional birth attendants; and, NGO or philanthropic medical services. The international health funding and research community, such as the Global Fund for Aids, TB and Malaria, or bilateral donors are very active in Uganda. Part of the success in managing HIV/AIDS in Uganda has been due to the cooperation between the government and the non-government service providers and these international bodies. Public Private Partnerships in Health are often mentioned in Europe and North America to fund construction or research. In Uganda, it is more practical being the recognition by the (public) government and (public) donor that a (private) philanthropic health facility can receive free test kits for HIV screening, free mosquito nets and water purification to reduce opportunistic infections and free testing and treatment for basic infections of great danger to PLHA.
Several studies, conducted in Uganda and its neighbors, indicate that adult male circumcision may be a cost-effective means of reducing HIV infection. A review on the acceptability of adult male circumcision  indicated Across studies, the median proportion of uncircumcised men willing to become circumcised was 65% (range 29-87%). Sixty nine percent (47-79%) of women favored circumcision for their partners, and 71% (50-90%) of men and 81% (70-90%) of women were willing to circumcise their sons.
An economic analysis by Bertran Auvert, MD, from the INSERM U687, Saint-Maurive, France, and colleagues estimated the cost of a roll-out over an initial 5-year period would be $1036 million ($748 – $1319 million) and $965 million ($763 – $1301 million) for private and public health sectors, respectively. The cumulative net cost over the first 10 years was estimated at $1271 million and $173 million for the private and public sectors, respectively . After adjustment for averted HIV medical costs, the researchers determined that the program would result in a net savings of about $2 per adult per year over the first 20 years of the program.
Notes and references
- ^ http://www.jaids.org/. Using HIV Voluntary Counseling and Testing Data for Monitoring the Uganda HIV Epidemic, 1992-2000 Journal of Acquired Immune Deficiency Syndromes:Volume 37(1)1 September 2004pp 1180-1186
- ^ [UNAIDS] 2008 Epidemiological Fact Sheet on Uganda.
- ^ Address by Janet K. Museveni, First Lady of Uganda at the Medical Institute for Sexual Health's "Common Ground: A Shared Vision for Health" Conference, Washington, D.C., June 17-19, 2004.
- ^ President Museveni of Uganda, Interview with Jackie Judd, Kaiser Family Foundation, June 14, 2004.
- ^ Green, ibid.
- ^ Rand L. Stoneburner and Daniel Low-Beer, "Population-Level HIV Declines and Behavioral Risk Avoidance in Uganda," Science 304 (April 2004): 714-718.
- ^ http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/02/24/MNG2PBG3VF1.DTL
- ^ Parkhurst, J. O. (2002). "The Ugandan success story? Evidence and claims of HIV-1 prevention," The Lancet, 360: 78-80 PubMed
- ^ Harper's Magazine, Out of Control.
- ^ "Uganda: 'Abstinence-Only' Programs Hijack AIDS Success Story", Human Rights Watch, 30 March, 2005
- ^ "An open letter to Melinda Gates", [Human Life International], 29 August, 2006
- ^ http://www.avert.org/aids-uganda.htm
- ^ http://povertynewsblog.blogspot.com/2008/05/hope-clinic-gives-hope-to-hopeless.html
- ^ Acceptability of Male Circumcision for Prevention of HIV/AIDS in Sub-Saharan Africa: A Review,N. Westercamp & R. C. Bailey, AIDS Behav.,11(3):341-355.2--8.
- ^ Economic Analysis Supports Adult Male Circumcision for HIV Prevention in Sub-Saharan Africa, E. Hitt, Medscape Medical News, July 25, 2007