FROM COFFINS TO ABCS: AIDS PREVENTION IN UGANDA
Blinking my eyes to adjust to the bright African sun as we made our way
through traffic from the Entebbe airport to the Ugandan capital,
Kampala, I looked out the window and asked, “What are those?”
“Coffins,” the driver replied. “Because of AIDS,” he added, in case it
wasn't obvious why the wooden boxes were displayed along the roadside
with other goods for sale, things I recognized, like furniture, iron
gates, tiny bananas, and the reddest tomatoes I had ever seen. The year
was 1995, I was a naïve American grad student, and this was my first
introduction to Africa.
The HIV/AIDS epidemic had hit Uganda with a vengeance. The infection
rate peaked in the early 1990s, with a national prevalence rate of
about 15% in 1991 and more than 30% of the population in some urban
areas infected in 1992. It is now estimated that a million Ugandans
have died from HIV/AIDS, leaving twice as many orphans behind, and more
than one million are currently living with the disease. The wrath of
the disease dealt a devastating blow to the country and its development
efforts. But there was a growing market for coffins.
Yet, already by 1995, Uganda had distinguished itself as the first
country to deal with the epidemic head on. A high level political
commitment to action, constructive involvement of civil society
including religious authorities, and excellent public information
campaigns - among many other factors - all contributed to help the
country stem the flow of the epidemic. In 1995, when coffins lined the
road, the national prevalence rate was 18.5%. Within a few years, the
rate dropped to one third of that number.
One element of Uganda's success in preventing infection has been a
public information strategy known as ABC - Abstinence, Be faithful, and
use Condoms. The key to the ABC strategy was to promote all three
together, recognizing that no one type of behaviour change could work
perfectly. The ABC model has been widely recognized internationally,
and adapted for use in other countries around the world. The journal
Science recently reported that it has been almost as successful as a
vaccine in Uganda.
This is not to say that the battle is over. Few people living with
HIV/AIDS have adequate access to anti-retroviral therapy that could
prolong their lives, permitting them to participate in the workforce
and care for their families. An estimated 25,000 babies are born HIV
positive each year in Uganda. The situation of children orphaned by
AIDS remains dire. Stigma and discrimination are still prevalent
despite the best efforts of the government and AIDS advocates. And
discrimination continues to make women most vulnerable to the disease.
While Ugandan activists agree that more must be done to treat people
living with HIV/AIDS, they continue to stress the importance of
prevention. Many analysts caution that it would be ill-advised to rely
too heavily on the success of the public information campaign. Some
even query whether the ABC strategy was really responsible for the
decline in prevalence. A 2003 baseline study on knowledge, attitudes,
and behavioural practices found that high-risk behaviour is still very
common in Kampala. And recent data indicate that rates of infection
could be back on the rise.
There can be no disputing that the scale of the problem in Uganda
remains alarming, and that urgent action is required to save lives and
prevent the epidemic from further eroding the country's development
efforts. Thus, perhaps the most difficult challenge facing Uganda now
is to build on the success of the past decade. Even if Uganda and its
donors meet their target of providing ARVs to 100,000 people in the
next five years, Dr. Coutinho of The Aids Support Organisation predicts
twice that number could be newly infected. This is no time for
Many hope that the US$15 billion President Bush pledged last year for
AIDS in Africa and the Caribbean might go a long way towards solving
the problem. The money (known as “Bush money” in Ugandan parlance)
finally started to reach 14 countries including Uganda last month, from
the President's Emergency Fund for HIV/AIDS Relief. But it is not that
In fact, while grateful for all the money available from international
donors, many Ugandans I spoke to on a recent visit to the country were
already skeptical as the Bush money took so long to start trickling in,
and they were not convinced that it would necessarily be put to most
Organisations such as the US-based Centre for Health and Gender Equity
and Physicians for Human Rights have expressed numerous concerns about
the Bush administration's strategy for using the money, as spelled out
in the President's Emergency Plan for AIDS Relief: US Five-Year Global
For starters, the process of developing the strategy was a closed one
and key stakeholders were excluded. What's more, the administration has
been widely criticized for following ideological and fundamentalist
religious beliefs rather than evidence-based recommendations.
This is perhaps most evident in the strategy's excessive insistence on
abstinence only, rather than a holistic ABC approach. The strategy
focuses on abstinence for youth and being faithful within marriage, and
emphasizes that condoms are only to be made available to and in the
'vicinity of' so-called high risk populations such as prostitutes.
Potential funding for B and C approaches is further constrained by the
United States Global AIDS Act of 2003, which limits prevention funding
to 20% of the money allocated and mandates that one third of this be
spent on abstinence-until-marriage strategies.
But this approach runs counter to the fundamental premise underlying
the ABC strategy. As Dr. Coutinho explains, even though approximately
60% of his patients do embrace abstinence, they do not always do so
perfectly. For example, someone may well remain abstinent for ten
months, decide to have sex again, and then return to abstinence. For
this and many other reasons, it is crucial to keep the C in the
According to the Centre for Health and Gender Equity, the strategy also
fails to guarantee that those most at risk will be provided access to
comprehensive sex education information such as complete information on
male and female condoms, frank discussions about sexuality, guidance
for negotiating safe sex, etc.
Some NGOs in Uganda say they have sensed a rolling back of the space
available for public information on AIDS prevention and sexuality,
particularly information targeting youth. Though this is not directly
tied to the Bush money, they do see a link. For example, much of the
Bush money is earmarked for faith-based organisations. While all agree
that religious institutions have a crucial role to play, some fear that
this could lead to churches taking over much of the work that secular
NGOs now do. This is especially worrying given that some churches have
strong positions against condoms.
Many Ugandans are also familiar with other Bush administration policies
(including domestic policies focusing exclusively on promoting
abstinence outside marriage and ignoring or even opposing contraceptive
and condom use, as well as the global gag rule). As a result, they fear
there may be 'a change in the winds' towards more conservative public
health policies informed by evangelical interests.
Numerous other serious concerns have also been raised with respect to
the Bush money. One is the failure of the US to contribute its proper
share to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
Another is the fear that funds will only be available for purchase of
name-brand drugs. This will be a decisive factor in how many people
receive treatment, as the funds available are finite and name-brand
drugs can cost four times more than their generic counterparts.
Even beyond the Bush money and public health policy, Christian Aid
recently issued a report decrying a 'dangerous drift' - encouraged by
the US and the UK - of diverting aid funds in Uganda and elsewhere to
the war on terror. Nearly a quarter of Uganda's social services budget
in 2002 went to fund military operations in the North to fight the LRA
(which has been added to the US terrorist list). Yet the report also
found that the war and militarization of the area is actually
contributing to increased spread of HIV in the region.
I recently took the Entebbe-Kampala road again on one of my frequent
trips to Africa. My heart sank as soon as we drove out of the airport
parking lot, quickly dashing the excitement I felt about returning to
Uganda that had peaked during the breathtaking landing on the shores of
I confided in my fellow passenger - a Tanzanian law professor on his
way to the same meeting I would be attending - how this stretch of
road, my first impression of Africa, is branded in my memory together
with coffins. Recalling the devastation that poverty and disease had
wrought on the country in the mid-1990s, he sympathized. But he
reminded me that Uganda had worked hard to slow the impact of the
epidemic, and that things are actually much better today. Together, we
looked anxiously out the window - not at the emerald green landscape,
but at the roadside merchants and their wares. Together, we breathed a
sigh of relief when we didn't see any coffins.
Ugandan AIDS advocates continue to work tirelessly to battle the
epidemic. For example, Dr. Coutinho has suggested an improvement on the
ABC strategy - adding a “D”, for determine and declare, to encourage
people to get tested and be open about their status. The international
community - including the Bush administration - should continue to rely
on evidence, rather than untested strategies motivated by
fundamentalist ideology. This may be the best way to keep the coffins
off the road until we get to V for vaccine, and Z for zero.
* Sara Rakita is a consultant who travels frequently to Africa.
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