Last week, at the ninth International Aids Vaccine Awareness Day, Dr Kihumuro Apuuli, the Uganda Aids Commission (UAC) Director General, gave what appeared to be the standard HIV/AIDS-call-to-action speach. In the middle of it though, he dropped
a bombshell of a statistic:
"In 2005, 130,000 Ugandans got infected compared to 70,000 in 2003."
"Ugandans should know that the issue of HIV/Aids is still alarming in the country," he said.
What makes this near doubling of the incidence rate so particularly shocking is that Uganda has been one of the only countries who has seen it's HIV rates decreasing over the last decade or so. In fact, it has been repeatedly used as a model for the global fight against HIV. You may ask "What has changed in the past few years to cause this deadly resurgance?" ...
That's right Timmy, the answer is Abstinence only education.
Back in the late 80's and early 90's, Uganda, like most of its neighbors, was waking up to a crisis. Luckily for Uganda, it had a President who was willing to tackle the issue head on. Utilizing the help of various organizations, it undertook
a widespread campaign:
President Yoweri Museveni, unlike most other African leaders at the time, recognised the danger and took swift action showing forceful leadership. Uganda's response was powerful and wide-ranging. The government launched an aggressive media campaign involving posters, radio messages and rallies; they trained teachers to begin effective HIV and AIDS education; and - most importantly - they mobilised community leaders, churches and indeed the public in general.
The flagship program that came out of Uganda was the ABC approach, Abstinence, Be faithful, or use Condoms. This harm-reduction tool wroked because it was based in the reality that one method of prevention wouldn't work for everyone. The results? Drastic reductions in new infections, and eventual declines in HIV prevalence in Uganda. Things seemed to be working great, untill 2003.
That year, President Bush introduced, during his SOTU speech, his intention to funnel 15 billion dollars to a plan that would become known as PEPFAR, the President's Emergency Plan for AIDS Relief. The congress reacted quickly, passing H.R. 1298: "The United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003". PEPFAR was fully funded and ready to be unleashed on Uganda.
In the past two years since PEPFAR has come on the scene, some noteable changes have taken place. Right off the bat, the US came in and changed the definition of the ABC method of prevention. Specifically, they changed the definition of the "Abstinence" pillar to read differently from the original:
"Abstinence for youth, including the delay of sexual debut and abstinence until marriage"...
The controversy arises from the differences between these two definitions of ABC, and in particular the fact that with the PEPFAR definition there is no promotion of condoms for young people (or anyone else outside the "high risk groups"), and that with abstinence the emphasis is on abstaining until marriage.
More importantly however, has been the funding restrictions PEPFAR put in place:
HIV prevention money accounts for around 20% of total PEPFAR expenditure, and Congress has specified that at least a third of this money should be spent on abstinence until marriage programs...
(More recently come to light is) A document (subscription only) that first became public when leaked to the Baltimore Sun in December 2005 revealed a new requirement for Federal Year 2006, decreeing that at least two-thirds of all funds for preventing sexual transmission of HIV should be spent on promoting abstinence and being faithful (known as "AB" strategies). If a country does not meet this requirement then they must be able to supply a good excuse. In the case of countries with generalised epidemics (which includes most of Africa), the document says "a very strong justification is required to not meet the 66 percent AB requirement". PEPFAR expects all fifteen of its focus countries to meet the requirement. It says that, without exception, no country should decrease between 2005 and 2006 the proportion of sexual transmission activities that are AB.
The PEPFAR five-year strategy document mentions condom provision and promotion only for those who practice high-risk behaviours. Those who practice high-risk behaviours include "prostitutes, sexually active discordant couples [in which one partner is known to have HIV], substance abusers, and others". Condoms are not mentioned as a strategy for helping young people in general. This approach differs significantly from previous U.S. policy and the policies of other donors including the European Union and the Global Fund.
The results? Well up untill now, the US administration has been happy to claim its program a success, nay even a model for others to follow. Yet with these new rising incidence rates that Dr Kihumuro Apuuli has announced, it may be that the tide is rushing back in on drowning Uganda. You can be sure that the international community will continue to focus a magnifying glass on Uganda's HIV education programs. However, with so much public emphasis having been placed on the "resounding success" of abstinence-only education in Uganda, it is doubtful that the current US administration can be considered unbiased in these matters.
As a caveat, I want to conclude by stating that it is all too early to tell what's going on. There has been some reports recently that actual prevalence rates could be much higher than previously reported. This BBC report in particular questions Uganda's official statistics. So it is possible that these "new numbers" are in reality, just an effort to bring the official figures more in line with reality. It's just too early to tell. What is clear however, is that HIV hasn't gone away. And if we as a nation, are going to be throwing around billions of dollars in aid, we better be sure that we're getting the best value for the investment.
Finally, let me leave you with the words of a full-page editorial (also subscription only, sorry!) in the medical journal, The Lancet:
"Many more lives will be saved if condom use is heavily promoted alongside messages to abstain and be faithful."
That's what I call reality.