The Bush Admin likes the Ugandan AIDS story. As Jonathan Cohn explained it two years ago:
Although President Bush has pledged $15 billion to fight global AIDS over the next ten years--an impressively generous sum, assuming his tax cuts don't swallow up the money before it's spent--he clings to a very specific idea about how AIDS-prevention money should be spent: on teaching abstinence. That's why he and his supporters constantly talk up the success of Uganda. Ten years ago, 15 percent of the country's population had AIDS. Today, just 5 percent do. And a major reason for the drop is an AIDS program that conforms to White House notions of propriety. As Ari Fleischer explained recently, Uganda puts "an emphasis where emphasis belongs, which is on abstinence."
Yesterday, the Globe and Mail
reported on the recent slew of research reports to come out on Uganda. Unfortunately, the article buries the lede, going on at silly lengths about the "dark" fact that Ugandan HIV prevalance rates have fallen because HIV positive citizens have died of AIDS (how else would they do down? Nobody gets cured of HIV. The point is to slow the rate of incidence) but the nugget is this:
AIDS fighters sometimes call it "the Ugandan miracle." The country's ABC model (Abstain; Be faithful to one partner; and if you can't do that, use a Condom) has been copied around the world.
...
The U.S. study [from Columbia University and Johns Hopkins University] also found that although people reported a growing number of sexual partners, and declining abstinence over the decade, there was no corresponding increase in the number of new HIV infections.
In fact the prevalence rate fell. Participants in the study reported more condom use, which the researchers believe offset their high-risk sexual behaviour. But the researchers said the emphasis on abstinence and fidelity did not appear to have had an impact.
...
Uganda's sexually frank media also contributed, Dr. Coutinho said. Well-financed primary schools produced a population better able to absorb messages on sexual health, and its support for political and economic empowerment of women increased their ability to make sexual choices, he added.
So here are the recent findings on the Ugandan experience: More sex with more partners. More condom use. Better information about how HIV gets transmitted. Helping young women understand their right to say no. Falling incidence of HIV. (By the way, I wrote a Development Economics term paper on a different panel microdata study from the World Bank that reported the exact same patterns for a set of villages in Western Uganda over the 90s: more partners, decline in the age of first intercourse, more condom use, lower incidence.)
Unfortunately, the article also echoes earlier worries from Human Rights Watch. In a report released last November, Human Rights Watch worries that Uganda is working to replace ABC with just AB:
In November 2004, the Uganda AIDS Commission (UAC) released a draft "Abstinence and Being Faithful (AB)" policy to guide the implementation of abstinence-until-marriage programs throughout the country. Intended as a companion to the country's existing strategy on the promotion of condoms, the policy in fact undermines condoms as an HIV prevention measure and suggests that promoting condoms alongside abstinence messages would be "confusing" to youth. The document contains virtually the same definition of "abstinence education" as in legislation governing abstinence-only programs in the United States, suggesting that Uganda's programs will replicate programs that have been proven ineffective in numerous U.S. states.
Human Rights Watch further complains that secondary school textbooks and curriculums are being stripped of valuable information on condoms and other aspects of healthy sex. And even though official Ugandan policy is still to promote condom use among people who are already sexually active, there has been increasing government backlash against condom promotion, completely condoned by the Bush Admin:
With the growth of abstinence-only approaches in Uganda, there are growing indications that condoms will disappear from the country's HIV/AIDS strategy. In October 2004, the Ministry of Health issued a nationwide recall of all free government condoms, allegedly in response to failed quality control tests. The ministry then took the extraordinary step of requiring post-shipment quality control testing on all condoms imported into Uganda, including those that have already been tested. By December 2004, experts were forecasting a national condom shortage. Rather than take steps to address the shortage, however, Uganda's minister of state for primary health care stated, "As a ministry, we have realized that abstinence and being faithful to one's partner are the only sure ways to curb AIDS. From next year, the ministry is going to be less involved in condom importation but more involved in awareness campaigns; abstinence and behavior change."
The Globe article reports that "Uganda's AIDS commission said the country is probably now meeting only half the demand for condoms."
Both Human Rights Watch and Avert.org give good overviews of why abstinence or monogamy-based AIDS prevention programs are likely to be futile endeavours in a war-torn country like Uganda and how vulnerable it leaves women in marriages who have to trust their husbands not to cheat. And now the results of this study directly contradict the idea that abstenance is behind the fall in HIV incidence in Uganda. In fact, it looks like it was the "C". And now the "C" might be dropped.
But the move away from condom-promotion is especially upsetting since recent evidence seems to suggest that Uganda's HIV prevalence rate has actually stopped falling and may even be trending back up. Although everything is still guestiments since there's no official census, UNAIDS now says the rate has been in "stagnation" around 6% since 2001 (after falling from close 20% or more in the early 90s), and as little as six months ago, the number being bandied in the press was 4%. Some agengies, like Avert, think the prevalence rate is really closer to 10%.
And cracking down on condoms sure as hell isn't going to help.