The very high rate of human immunodeficiency virus infection experienced in Uganda during the 1980s and early 1990s 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. The great need for testing and counseling resulted in a group of local non-governmental organizations such as The AIDS Support Organisation, Uganda Red Cross, Nsambya Home Care, the National Blood Bank, the Uganda Virus Research Institute[1] together with the Ministry of Health establishing the AIDS Information Centre in 1990. This organization worked to provide HIV testing and counseling services with the knowledge and consent of the client involved.
In Uganda, HIV/AIDS has been approached as more than a health issue and in 1992 a Multi-sectoral AIDS Control Approach was adopted. In addition, the Uganda AIDS Commission, also founded in 1992, has helped develop 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' programs.[2]
To further Uganda's efforts in establishing a comprehensive HIV/AIDS program, in 2000 the Ugandan Ministry of Health 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.[3] Uganda was the first country to open a Voluntary Counseling and Testing (VCT) clinic in Africa called AIDS Information Centre and pioneered the concept of voluntary HIV testing centers in Sub-Saharan Africa.
The Ugandan government, through President Yoweri Museveni, has promoted this as a success story in the fight against HIV and AIDS, arguing it has been the most effective national response to the pandemic insub-Saharan Africa. Though equally there has in recent years been growing criticism that these claims are exaggerated, and that the HIV infection rate in Uganda is on the rise.[4]
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 has experienced the sharpest decrease in HIV/AIDS-related death rate in the world between 1990 and 2017, with an 88 percent decrease a timespanespan of twenty seven years.[5] Other awareness programs are arranged annually Nation wide by the Uganda Network of AIDs Support Organizations to provide HIV Training, the exercises involve community members, health workers, musicians, partners and community activists such as Canadian Lanie Banks who led musician participants in the 2023 HIV Training awareness campaign. These trainings are aimed at equipping ugandans with HIV, TB and AIDs knowledge[6][7]
History
Some residents in southern Uganda believe that Tanzanian soldiers introduced HIV/AIDS into the region during the 1979 Uganda–Tanzania War, spreading the disease by having sex with civilians.[8]
An overarching policy known as "ABC", which consisted of abstinence, monogamy, and condoms, was set up with the aim of helping to curb the spread of AIDS in Uganda, where HIV infections reached epidemic proportions in the 1980s.[9] The prevalence of HIV began to decline in the late 1980s and continued throughout the 1990s. Between 1991 and 2007, HIV prevalence rates declined dramatically. Various claims have been made on the extent of these declines, but mathematical models estimated falls from about 15 percent in 1991 to about 6 percent in 2007.[10]
Shortly after he came into office in 1986, President Museveni 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: Abstinence, be faithful, use a condom if A and B fail. This message also addressed the high rates of concurrency in Uganda, which refers to the widespread cultural practice of maintaining two or more sexual partners at a time. Mass media campaigns also targeting this practice including the "Zero-Grazing" and "Love Carefully" public health messages in the 1990s[11]
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 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.[citation needed]
Condoms were not the main element of the AIDS prevention message in the early years.[12] 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."[13] He emphasized that condoms should be used, "if you cannot manage A and B ... as a fallback position, as a means of last resort."[14]
Some reports suggest that the decline in AIDS prevalence in Uganda was due to monogamy and abstinence, rather than condom use. According to Edward C. Green, a medical anthropologist at the Harvard School of Public Health, the promotion of fidelity to one's partner and abstinence were the most important factors in Uganda's success because they disrupted the widespread practice of having multiple concurrent sexual partners.[15] Research found that in rural Uganda, the educational messaging regarding condom use was often not effective. In fact, it was found that twenty-three percent of adolescents surveyed did not even know about condoms.[16] A 2004 study published in the journal Science also concluded that abstinence among young people and monogamy, rather than condom use, contributed to the decline of AIDS in Uganda.[17]
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 other central finding of the Rakai study was that, due to Uganda's focus on prevention of the spread of HIV-AIDS, rather than treatment for those who had already contracted the disease, a large part of the decline in prevalence of HIV-AIDS is due to the premature death of those who have contracted it. This led to the popular play on the ABC campaign, 'A-B-C-D', with the D standing for Death. Because only prevalence is measured, incidence can actually increase while prevalence decreases if those who contract HIV are not treated for the disease, thereby dying younger. Later studies have seriously questioned the veracity of Uganda's miraculous HIV-AIDS claims [citation needed].
In the 1990s there had been limited access to treatment in the form of anti-retrovirals for those who are HIV positive. As access to anti-retrovirals increased in Uganda, however, studies began to investigate the conflicting social influences on a woman's desire to continue having children. It was found that while some women felt social obligated to continue reproducing in order to meet a respectable number of offspring, others felt societal taboo and pressure as parents with HIV were thought to be bearing orphans.[18] Through the combined effort of US PEPFAR, the government of Uganda, and international agencies (Clinton HIV/AIDS Initiative, the Global Fund, UNITAID) this has improved.[19] The country's HIV-AIDS campaign focuses solely on prevention rather than cure, and that prevention is of questionable success.[20]
Criticism
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% of whom live in rural areas.[21] Also, recent trials of the HIV drug nevirapine have come under intense scrutiny and criticism.[22]
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 programs "leave Uganda’s children at risk of HIV".[23] 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."[24]
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.[citation needed] There are many theories as to why this may be happening, including the government’s shift from abstinence-based prevention programs, and a general complacency or 'AIDS fatigue'. It has been suggested that anti-retroviral 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 behavior. Although prevention interventions, like safe male circumcision, have been shown to effectively reduce HIV transmission, studies in Uganda have shown delayed uptake of these interventions and attributed this to debate over evidence by high-level leaders.[25]
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 programs 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 channeling large sums of money through pro-abstinence and even anti-condom organizations 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 organizations 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.[26]
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.
One aspect of the response to HIV in Uganda bridges the Millennium Development Goals and prevention—that is vertical transmission or Prevention of Mother To Child Transmission (PMTCT). Through the Global Fund's Born HIV Free campaign BornHIVFree the need and impact of PMTCT is made clear. Funding is encouraged by UNITAID and MassiveGood[permanent dead link]
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.[27]
Alternative proposals
Several studies, conducted in Uganda and its neighbors, indicate that adult male circumcision may be a cost-effective means of reducing HIV infection. A 2007 review of studies about the acceptability of adult male circumcision[28] indicated the median proportion of uncircumcised men willing to become circumcised was 65 percent (range 29–87 percent). Sixty nine percent (range 47–79 percent) of women favored circumcision for their partners, and 71 percent (range 50–90 percent) of men and 81 percent (range 70–90 percent) of women were willing to circumcise their sons. The national AIDS Indicator survey in 2011 also indicated that over 48 percent of adult men were willing to be circumcised, generating a critical mass of demand for male circumcision.[29]
An economic analysis by Bertran Auvert, a physician 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.[30]
↑ 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., 17–19 June 2004.
↑ Konde-Lule, Joseph K.; Sewankambo, N.; Morris, Martina (1997). "Adolescent sexual networking and HIV transmission in rural Uganda". Health Transition Review. 7: 89–100. ISSN1036-4005. JSTOR40652295. PMID10184747.
HIV/AIDS originated in Africa during the early 20th century and has been a major public health concern and cause of death in many African countries. AIDS rates varies significantly between countries, though the majority of cases are concentrated in Southern Africa. Although the continent is home to about 15.2 percent of the world's population, more than two-thirds of the total population infected worldwide – some 35 million people – were Africans, of whom 15 million have already died. Eastern and Southern Africa alone accounted for an estimate of 60 percent of all people living with HIV and 70 percent of all AIDS deaths in 2011. The countries of Eastern and Southern Africa are most affected, AIDS has raised death rates and lowered life expectancy among adults between the ages of 20 and 49 by about twenty years. Furthermore, the life expectancy in many parts of Africa is declining, largely as a result of the HIV/AIDS epidemic with life-expectancy in some countries reaching as low as thirty-nine years.
The United States President's Emergency Plan For AIDS Relief (PEPFAR) is a United States governmental initiative to address the global HIV/AIDS epidemic and help save the lives of those suffering from the disease. Launched by U.S. President George W. Bush in 2003, as of May 2020, PEPFAR has provided about $90 billion in cumulative funding for HIV/AIDS treatment, prevention, and research since its inception, making it the largest global health program focused on a single disease in history until the COVID-19 pandemic. PEPFAR is implemented by a combination of U.S. government agencies in over 50 countries and overseen by the Global AIDS Coordinator at the United States Department of State. As of 2023, PEPFAR has saved over 25 million lives, primarily in Sub-Saharan Africa.
Male circumcision reduces the risk of human immunodeficiency virus (HIV) transmission from HIV positive women to men in high risk populations.
Abstinence-only sex education is a form of sex education that teaches not having sex outside of marriage. It often excludes other types of sexual and reproductive health education, such as birth control and safe sex. Comprehensive sex education, by contrast, covers the use of birth control and sexual abstinence.
Abstinence, be faithful, use a condom, also known as the ABC strategy or abstinence-plus sex education, also known as abstinence-based sex education, is a sex education policy based on a combination of "risk avoidance" and harm reduction which modifies the approach of abstinence-only sex education by including education about the value of partner reduction safe sex and birth control methods. Abstinence-only sex education is strictly to promote the sexual abstinence until marriage, and does not teach about safe sex or contraceptives. The abstinence-based sex education program is meant to stress abstinence and include information on safe sex practices. In general terms, this strategy of sex education is a compromise between abstinence-only education and comprehensive sex education. The ABC approach was developed in response to the growing epidemic of HIV/AIDS in Africa, and to prevent the spread of other sexually transmitted diseases. This approach has been credited by some with the falling numbers of those infected with AIDS in Uganda, Kenya and Zimbabwe, among others. From 1990 to 2001 the percentage of Ugandans living with AIDS fell from 15% to between 5 and 6%. This fall is believed to result from the employment of the ABC approach, especially reduction in the number of sex partners, called "Zero-Grazing" in Uganda.
Angola has a large HIV/AIDS infected population, however, it has one of the lowest prevalence rates in the Southern Africa zone. The status of the HIV/AIDS epidemic in Angola is expected to change within the near future due to several forms of behavioral, cultural, and economic characteristics within the country such as lack of knowledge and education, low levels of condom use, the frequency of sex and number of sex partners, economic disparities and migration. There is a significant amount of work being done in Angola to combat the epidemic, but most aid is coming from outside of the country.
Kenya has a severe, generalized HIV epidemic, but in recent years, the country has experienced a notable decline in HIV prevalence, attributed in part to significant behavioral change and increased access to ARV. Adult HIV prevalence is estimated to have fallen from 10 percent in the late 1990s to about 4.8 percent in 2017. Women face considerably higher risk of HIV infection than men but have longer life expectancies than men when on ART. The 7th edition of AIDS in Kenya reports an HIV prevalence rate of eight percent in adult women and four percent in adult men. Populations in Kenya that are especially at risk include injecting drug users and people in prostitution, whose prevalence rates are estimated at 53 percent and 27 percent, respectively. Men who have sex with men (MSM) are also at risk at a prevalence of 18.2%. Other groups also include discordant couples however successful ARV-treatment will prevent transmission. Other groups at risk are prison communities, uniformed forces, and truck drivers.
HIV/AIDS in Lesotho constitutes a very serious threat to Basotho and to Lesotho's economic development. Since its initial detection in 1986, HIV/AIDS has spread at alarming rates in Lesotho. In 2000, King Letsie III declared HIV/AIDS a natural disaster. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2016, Lesotho's adult prevalence rate of 25% is the second highest in the world, following Eswatini.
HIV/AIDS in Eswatini was first reported in 1986 but has since reached epidemic proportions. As of 2016, Eswatini had the highest prevalence of HIV among adults aged 15 to 49 in the world (27.2%).
Mozambique is a country particularly hard-hit by the HIV/AIDS epidemic. According to 2008 UNAIDS estimates, this southeast African nation has the 8th highest HIV rate in the world. With 1,600,000 Mozambicans living with HIV, 990,000 of which are women and children, Mozambique's government realizes that much work must be done to eradicate this infectious disease. To reduce HIV/AIDS within the country, Mozambique has partnered with numerous global organizations to provide its citizens with augmented access to antiretroviral therapy and prevention techniques, such as condom use. A surge toward the treatment and prevention of HIV/AIDS in women and children has additionally aided in Mozambique's aim to fulfill its Millennium Development Goals (MDGs). Nevertheless, HIV/AIDS has made a drastic impact on Mozambique; individual risk behaviors are still greatly influenced by social norms, and much still needs to be done to address the epidemic and provide care and treatment to those in need.
HIV/AIDS in Namibia is a critical public health issue. HIV has been the leading cause of death in Namibia since 1996, but its prevalence has dropped by over 70 percent in the years from 2006 to 2015. While the disease has declined in prevalence, Namibia still has some of the highest rates of HIV of any country in the world. In 2016, 13.8 percent of the adult population between the ages of 15 and 49 are infected with HIV. Namibia had been able to recover slightly from the peak of the AIDS epidemic in 2002. At the heart of the epidemic, AIDS caused the country's live expectancy to decline from 61 years in 1991 to 49 years in 2001. Since then, the life expectancy has rebounded with men living an average of 60 years and women living an average of 69 years
Rwanda faces a generalized epidemic, with an HIV prevalence rate of 3.1 percent among adults ages 15 to 49. The prevalence rate has remained relatively stable, with an overall decline since the late 1990s, partly due to improved HIV surveillance methodology. In general, HIV prevalence is higher in urban areas than in rural areas, and women are at higher risk of HIV infection than men. Young women ages 15 to 24 are twice as likely to be infected with HIV as young men in the same age group. Populations at higher risk of HIV infection include people in prostitution and men attending clinics for sexually transmitted infections.
HIV and AIDS is a major public health issue in Zimbabwe. The country is reported to hold one of the largest recorded numbers of cases in Sub-Saharan Africa. According to reports, the virus has been present in the country since roughly 40 years ago. However, evidence suggests that the spread of the virus may have occurred earlier. In recent years, the government has agreed to take action and implement treatment target strategies in order to address the prevalence of cases in the epidemic. Notable progress has been made as increasingly more individuals are being made aware of their HIV/AIDS status, receiving treatment, and reporting high rates of viral suppression. As a result of this, country progress reports show that the epidemic is on the decline and is beginning to reach a plateau. International organizations and the national government have connected this impact to the result of increased condom usage in the population, a reduced number of sexual partners, as well as an increased knowledge and support system through successful implementation of treatment strategies by the government. Vulnerable populations disproportionately impacted by HIV/AIDS in Zimbabwe include women and children, sex workers, and the LGBTQ+ population.
UNAIDS has said that HIV/AIDS in Indonesia is one of Asia's fastest growing epidemics. In 2010, it is expected that 5 million Indonesians will have HIV/AIDS. In 2007, Indonesia was ranked 99th in the world by prevalence rate, but because of low understanding of the symptoms of the disease and high social stigma attached to it, only 5-10% of HIV/AIDS sufferers actually get diagnosed and treated. According to the a census conducted in 2019, it is counted that 640,443 people in the country are living with HIV. The adult prevalence for HIV/ AIDS in the country is 0.4%. Indonesia is the country is Southeast Asia to have the most number of recorded people living with HIV while Thailand has the highest adult prevalence.
The southeast-Asian nation of East Timor has dealt with HIV/AIDS since its first documented case in 2001. It has one of the lowest HIV/AIDS-prevalence rates in the world.
Since HIV/AIDS was first reported in Thailand in 1984, 1,115,415 adults had been infected as of 2008, with 585,830 having died since 1984. 532,522 Thais were living with HIV/AIDS in 2008. In 2009 the adult prevalence of HIV was 1.3%. As of 2016, Thailand had the highest prevalence of HIV in Southeast Asia at 1.1 percent, the 40th highest prevalence of 109 nations.
Cases of HIV/AIDS in Peru are considered to have reached the level of a concentrated epidemic.
The Dominican Republic has a 0.7 percent prevalence rate of HIV/AIDS, among the lowest percentage-wise in the Caribbean region. However, it has the second most cases in the Caribbean region in total, with an estimated 46,000 HIV/AIDS-positive Dominicans as of 2013.
Uganda is one of the few Sub-Saharan African countries that has adopted abstinence-only sex education as an approach of sexual education that emphasizes abstinence from sexual intercourse until marriage as the only option. Abstinence-only sex education does not include joint curriculum covering other options including safe sex practices, family planning, and is espoused as the only sure way to avoid pregnancy and sexually transmitted infections. Uganda is commonly recognized as an exemplary case of lowering the rate of HIV prevalence. Prevalence figures may have also been distorted by the lack of treatment, meaning that the percentage of infected is decreased by disproportionately early deaths. Abstinence-only sex education has been implemented and supported for this cause to a large degree in Uganda, to some controversy. Critics have questioned its effectiveness in lowering HIV/AIDS transmission. They have also highlighted discrimination, gender inequality and social stigma as the outcomes of the program in Uganda.
Joseph Konde-Lule is a retired Ugandan medical sociologist and epidemiologist who conducted extensive work regarding HIV risk behaviors in rural Uganda.
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