[Senate Hearing 108-106]
[From the U.S. Government Publishing Office]
S. Hrg. 108-106
FIGHTING AIDS IN UGANDA: WHAT WENT RIGHT?
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON AFRICAN AFFAIRS
OF THE
COMMITTEE ON FOREIGN RELATIONS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
MAY 19, 2003
__________
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COMMITTEE ON FOREIGN RELATIONS
RICHARD G. LUGAR, Indiana, Chairman
CHUCK HAGEL, Nebraska JOSEPH R. BIDEN, Jr., Delaware
LINCOLN CHAFEE, Rhode Island PAUL S. SARBANES, Maryland
GEORGE ALLEN, Virginia CHRISTOPHER J. DODD, Connecticut
SAM BROWNBACK, Kansas JOHN F. KERRY, Massachusetts
MICHAEL B. ENZI, Wyoming RUSSELL D. FEINGOLD, Wisconsin
GEORGE V. VOINOVICH, Ohio BARBARA BOXER, California
LAMAR ALEXANDER, Tennessee BILL NELSON, Florida
NORM COLEMAN, Minnesota JOHN D. ROCKEFELLER IV, West
JOHN E. SUNUNU, New Hampshire Virginia
JON S. CORZINE, New Jersey
Kenneth A. Myers, Jr., Staff Director
Antony J. Blinken, Democratic Staff Director
------
SUBCOMMITTEE ON AFRICAN AFFAIRS
LAMAR ALEXANDER, Tennessee, Chairman
SAM BROWNBACK, Kansas RUSSELL D. FEINGOLD, Wisconsin
NORM COLEMAN, Minnesota CHRISTOPHER J. DODD, Connecticut
JOHN E. SUNUNU, New Hampshire BILL NELSON, Florida
(ii)
C O N T E N T S
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Page
Alexander, Hon. Lamar, U.S. Senator from Tennessee, opening
statement...................................................... 3
Letter from Mrs. Janet K. Museveni, First Lady of Uganda, to
Chairman Richard G. Lugar, pertaining to the ``Uganda ABC
model''.................................................... 25
Biden, Hon. Joseph R., Jr., U.S. Senator from Delaware, prepared
statement...................................................... 5
Busch, Jeffrey, chairman and CEO, SafeBlood for Africa, statement
submitted for the record entitled ``Blood Safety: An Important
Tool in AIDS Prevention,''..................................... 5
Feingold, Hon. Russell D., U.S. Senator from Wisconsin, prepared
statement...................................................... 6
Green, Edward C., Ph.D., senior research scientist, Harvard
Center for Population and Development Studies, Cambridge, MA... 32
Prepared statement........................................... 35
Mukasa Monico, Sophia, senior AIDS officer, Global Health
Council, Washington, DC........................................ 40
Prepared statement........................................... 43
Uganda AIDS Commission Status Report......................... 46
Peterson, Dr. Anne, Assistant Administrator for Global Health,
U.S. Agency for International Development, Washington, DC...... 7
Prepared statement........................................... 10
``What Happened in Uganda?'' a synthesis of presentations
made in February 2002 at USAID by four individuals with
long-term experience in HIV prevention in Africa........... 15
(iii)
FIGHTING AIDS IN UGANDA: WHAT WENT RIGHT?
----------
MONDAY, MAY 19, 2003
U.S. Senate,
Subcommittee on African Affairs,
Committee on Foreign Relations,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:31 p.m. in
room SD-419, Dirksen Senate Office Building, Hon. Lamar
Alexander (chairman of the subcommittee), presiding.
Present: Senators Alexander and Feingold.
Senator Alexander. The hearing will come to order. I would
like to welcome everyone here. Senator Feingold is here and we
will begin.
Here is how we will proceed. I will make a very brief
opening statement and I will invite Senator Feingold to do the
same, and then we will begin with Dr. Peterson from USAID; and
then we will go to our second panel, Dr. Green and Ms. Mukasa
Monico, and we will have some questions for the two of you at
that time.
After we have completed the hearing, we will immediately
move to the nomination hearing of Steven Browning, nominated to
be Ambassador to Malawi, and we will hear from him. At that
time, since he is here, we will ask him to reflect on what he
has heard.
In the midst of the AIDS pandemic, a beacon of hope shines
out from Uganda. The rate of infection has declined from about
15 percent in 1991 to about 5 percent in 2001. Uganda did this
largely through a nationwide campaign focused on the ABC model:
Abstain, Be faithful, use a Condom.
Today we will look at how that model works in practice and
what that implies for U.S. policy in combating AIDS. It is
especially relevant because Senator Feingold and I and almost
all Senators were up until about 2:30 in the morning on
Thursday night expressing the agenda of both political parties
as well as the President to do what this country can to help
with this worldwide epidemic.
The crisis posed by the AIDS pandemic is growing worse
every day and the statistics are becoming all too familiar.
Over 40 million people are now infected by HIV-AIDS. Thirty
million of those are in sub-Saharan Africa, nearly 5 percent of
the overall population of sub-Saharan Africa. The scope of the
problem in some countries is overwhelming. Eleven million
African children have lost their parents to AIDS. In Zambia 30
percent of all children are AIDS orphans. In Botswana nearly 40
percent of the adult population is HIV-positive. When I visited
Botswana a year-and-a-half ago, at one hospital the nurse there
told me that 97 percent, virtually all, of the women, the
pregnant women she sees there are infected with HIV-AIDS.
The disease also affects other sectors of African society.
Seven million agricultural workers have succumbed to AIDS. The
agricultural work force has been depleted by more than 20
percent in several African countries, resulting in production
declines that are a contributing factor to hunger and even
famine. Young adults are the hardest hit by the virus, leaving
not only millions of orphans but also ever-increasing numbers
of households headed by grandparents.
But in the midst of this human tragedy there is hope.
Something different has been happening in Uganda. Despite the
lack of a cure or vaccine, HIV infection rates are declining.
As I mentioned, in 1991, 21 percent of pregnant women in Uganda
were HIV-positive. Ten years later that number declined to 6
percent. By comparison, 34 percent of pregnant women in
Botswana were HIV-positive in the year 2000.
What is Uganda doing differently? Led by President
Museveni, Ugandan society has mobilized to combat HIV-AIDS with
vigor and over a long period of time. Uganda has taken a
comprehensive approach to combating the challenge. Religious
and military leaders, many of whom are HIV-positive themselves,
have led the way in creating an open dialog that has to a large
extent de-stigmatized the disease. With the help of groups like
the AIDS Support Organization of Uganda, the country has sought
to provide treatment and care to those infected.
But the heart of the story in Uganda is behavior change
promoted by the ABC model. The campaign has had great success.
In one area of the country, for example, 60 percent of youth
age 13 to 16 reported being sexually active in 1994. By 2001
the number had fallen to 5 percent. Similarly, the number of
Ugandan men with two or more sexual partners per year dropped
from over 70 percent in 1989 to less than 20 percent in 1995.
So how does the Ugandan model work in practice? How can
that model be replicated or adjusted to work in other countries
and cultures, or can it be? What does that imply for United
States policy and foreign assistance in combating this pandemic
around the world? That is what we are here to find out and we
have a distinguished panel to help us do that.
I also hope we will explore with the witnesses this
afternoon the idea of having what I would call an AIDS Corps,
where American health professionals can volunteer to go to
Africa or other hard-hit countries and help train professionals
in country how to provide care and treatment for those who are
infected and affected by HIV-AIDS.
I introduced a bill for that purpose last week. There are
provisions for that purpose in the legislation that passed on
Thursday night. Many Senators of both parties, the President
himself, have all talked about this idea and I thought this
might be a good time to gain some additional advice about how
we could help an AIDS Corps work if one were to be formed.
But before I introduce our first panelist, I would like to
comment that the AIDS subject is not new to this committee or
to this subcommittee. The former chairman of this subcommittee,
Senator Frist, now the majority leader, spoke about AIDS early
on and vigorously and I believe helped to persuade this
administration to take a more active role. He was joined in
that by his partner on this committee Senator Feingold from
Wisconsin, who has also been an early and active advocate for
AIDS, has been to Africa many times. I welcome Senator Feingold
for his opening statement.
[The prepared statement of Senator Alexander follows:]
Opening Statement of Senator Lamar Alexander
In the midst of the AIDS pandemic, a beacon of hope shines out from
Uganda. The rate of infection has declined from about 15 percent in
1991 to about 5 percent in 2001. Uganda did this largely through a
nationwide campaign focused on the ABC model: Abstain, Be faithful, use
a Condom. Today, we will look at how that model works in practice and
what that implies for U.S. policy in combating AIDS.
The worldwide crisis posed by the AIDS pandemic is growing worse
everyday. Over 40 million people are now infected by HIV/AIDS. Thirty
million of those are in sub-Saharan Africa--nearly 5 percent of the
overall population. The scope of the problem is overwhelming. Eleven
million African children have lost their parents to AIDS. In Zambia, 30
percent of all children are AIDS orphans. In Botswana, nearly 40
percent of the adult population is HIV-positive.
The disease also affects other sectors of African society. Seven
million agricultural workers have succumbed to AIDS. The agricultural
workforce has been depleted by more than 20 percent in several African
countries, resulting in production declines that are a contributing
factor to hunger and even famine. Young adults are the hardest hit by
the virus, leaving not only millions of orphans, but also ever-
increasing numbers of households headed by grandparents.
But in the midst of this human tragedy, there is a glimmer of hope.
Something different is happening in Uganda. Despite the lack of a cure
or vaccine, HIV infection rates are declining. For example, in 1991 21
percent of pregnant women in Uganda were HIV-positive; ten years later
that number had declined to 6 percent. (By comparison, 43 percent of
pregnant women in Botswana were HIV-positive in 2000.)
What is Uganda doing differently? Led by President Museveni,
Ugandan society has mobilized to combat HIV/AIDS with vigor. Uganda has
taken a comprehensive approach to combating the challenge.
Religious and military leaders, some of whom are HIV-positive
themselves, have led the way in creating an open dialogue that has to a
large extent de-stigmatized the disease. With the help of groups like
The AIDS Support Organization of Uganda, the country has sought to
provide treatment and care to those infected.
But the heart of the Ugandan story is behavior change, promoted by
the ABC model--Abstain, Be faithful, use a Condom. The campaign has had
great success. In one area of the country, for example, 60 percent of
youth aged 13-16 reported being sexually active in 1994; by 2001 the
number had fallen to 5 percent. Similarly, the number of Ugandan men
with two or more sexual partners per year dropped from over 70 percent
in 1989 to less than 20 percent in 1995.
So how does the Uganda model work in practice? How can that model
be replicated or adjusted to work in other countries and cultures? What
does that imply for U.S. policy and foreign assistance in combating
this pandemic around the world?
That's what we're here to find out, and we have a distinguished
panel to help us do that this afternoon. I also hope to explore with
the witnesses the idea of having an AIDS Corps--where American health
professionals could volunteer to go to African or other hard-hit
countries and help train professionals in-country how to provide care
and treatment for those infected and affected by HIV/AIDS. I introduced
a bill for that purpose last week.
Senator Feingold. Thank you very much, Mr. Chairman, and I
would like to thank you for convening this hearing, for your
willingness to work in such a cooperative way in putting it
together. I genuinely appreciate your approach and frankly, Mr.
Chairman, think that this is the perfect medicine for a recent
minor outbreak of what I might call politicization when it
comes to this issue.
It is a little bit of a shame, really, that this hearing is
coming after, rather than before, the floor action on the AIDS
authorization bill, which, as you mentioned, occurred late
Thursday night when people were pretty tired, although there
was one good thing about it. Everybody had to be there to
listen, and that does not happen a lot in the Senate.
Let me compliment you on introducing and authoring,
particularly so early in your tenure here in the Senate, Senate
bill 1067, which is the AIDS Corps bill. It is interesting that
in Botswana, a country that you and I have both visited and
looked at the AIDS issue, that they had graduated, if you will,
from the Peace Corps, did not have it any more, but because of
the very severe problem with HIV-AIDS, the President, President
Mogae of Botswana, asked if the Peace Corps would come back,
and the Peace Corps there is exclusively working on the HIV-
AIDS problem. So there is in a way a precedent, at least in one
sense, for this very good idea that you have put forward, and I
compliment you on it.
Lately we have heard many different perspectives on the ABC
approach in Uganda, which of course refers to awareness raising
and educational campaigns urging people to abstain, to be
faithful to one partner, and to use condoms. I think common
sense tells us that all of these elements are important parts
of combating this horrifying pandemic.
Ugandan efforts have also been characterized by other
things, by strong and visible political leadership, by
grassroots involvement on a massive scale, and by concerted
efforts to destigmatize the disease. The story is not a simple
one.
The bottom line is that Uganda's multifaceted approach to
combating AIDS was successful. Ugandan AIDS prevalence rates
have declined markedly over the 1990s. Mr. Chairman, I had a
chance to sort of see this in the middle when I visited the
country in late 1999, met with President Museveni and others to
see what they were trying to do. And today, several years
later, as you have indicated, the country continues vigorously
addressing the crisis.
This is a tremendously important example and Uganda
deserves the acclaim that has come to the country in the wake
of this achievement. But I must raise for a moment one other
issue briefly because I think that it would be a mistake for
this subcommittee to be convening today and discussing Uganda
in any context without at least mentioning the ongoing crisis
in Ituri province in the Democratic Republic of the Congo, a
crisis that has involved Uganda and a crisis that will require
international commitment to solve, including real commitment
from Uganda and Rwanda to use their influence with Ituri's
ethnic militia forces.
Obviously, this serious situation is not the focus of
today's hearing, but I did want to use this opportunity to go
on record about my deep concern and my hope that the United
States will play a constructive role in defusing this crisis
rather than being an obstacle to urgently needed action.
Turning back to the subject at hand, I think it is
important that we recognize both the value in learning from the
Ugandan experience and the fact that one country's model is not
necessarily precisely the right model for every other AIDS-
affected society. So this subcommittee is diving into this
discussion with an understanding that Uganda is not Senegal,
which is not South Africa.
That said, Uganda's success has played an important role in
convincing people here in Washington and around the world that
it is possible to fight AIDS and win. That is a tremendous
contribution and it deserves to be celebrated and studied
closely.
Mr. Chairman, I would ask that the statement of Senator
Biden, the ranking member of the full committee, be added to
the record.
[The prepared statement of Senator Biden follows:]
Prepared Statement of Senator Joseph R. Biden, Jr.
Mr. Chairman, I would like to submit a statement for the hearing
record from Jeffrey Busch, Chief Executive Officer of SafeBlood for
Africa. SafeBlood for Africa is a not for profit organization whose
objective is to improve the national blood supply of African countries
where few or no mechanisms exist to test blood for infectious diseases
such as HIV before tranfusion.
Lately we have been hearing a lot about the importance of
prevention in halting the transmission of HIV/AIDS. There has been a
singular focus on what's know as the ABC model--Abstinence, Be faithful
and use Condoms as the key to prevention. This model is very important,
however as Mr. Busch's statement indicates, it is only one part of an
overall prevention model which includes voluntary testing and
counseling, prevention of mother-to-child transmission, and safety of
the national blood supply.
I think it is important to understand the need to focus on a
comprehensive strategy of prevention which includes more than just the
ABC's.
[Attachment.]
Blood Safety: An Important Tool in AIDS Prevention
Statement Submitted by Jeffrey Busch, Chairman and CEO, SafeBlood for
Africa
PREVENTION IN UGANDA
Uganda is one of a few African countries to achieve a reduction in
the prevalence of HIV in its population. While much has been made about
the ABC approach in Uganda--Abstinence, Be faithful, use Condoms as a
prevention strategy, I would like to point out that the ``ABC's'' are
only a part of Uganda's overall prevention strategy. Other elements of
the prevention strategy include prevention of mother-to-child
transmissions, voluntary testing and counseling, and ensuring a safe
national blood supply. According to a European Union report, the
creation of a successful Uganda Blood Transfusion Service (UBTS) has
been a major contributor to that success. (From 2nd Edition European
Community Official Publication, Safe Blood in Developing Countries,
www.tve.org/ho/doc.cfm?aid=413.)
The UBTS has saved countless lives through:
Intensive HIV/AIDS education drives for blood donors. This
has resulted in many Ugandans taking an HIV test. The knowledge
of one's HIV status has encouraged those who are negative to
stay negative, and those who are positive to avoid passing on
the infection.
Provision of infection free blood for those in need of blood
transfusions through recruitment of volunteer, non-remunerated,
repeat blood donors.
Systematic training of staff. Central coordination and
organization of all transfusion services including standard
operating procedures and quality control.
The Ugandan experience stands in stark contrast to the rest of the
African continent where unsafe blood is estimated to cause up to 10% of
all new HIV infections. This is due to the fact that on much of the
continent, blood transfusions occur with little or no pre-transfusion
testing. Dr. Harvey Klein, Chief of Transfusion Medicine at the
National Institute of Health, states, ``In the last century,
transfusions have saved more lives than any therapy except
antibiotics.'' It is unfortunate that in sub-Saharan Africa
transfusions meant to save lives carry a significant risk of having a
negative effect on the health of African patients.
OTHER EXPERIENCES
At the XIV International Conference on AIDS held in Barcelona in
2002, the Global HIV Prevention Working Group, composed of nearly 40 of
the world's leading HIV prevention experts, stated that that an
effective global HIV prevention strategy should consist of several
different approaches. One of the experts, Dr. Helene Gayle of the Bill
and Melinda Gates Foundation, emphasized this point by stating that
``Just as combination therapy attacks HIV from different angles,
prevention requires a combination of approaches. There is no single
magic bullet. `Combination prevention,' however, has proven very
effective.''
Supporting a multidimensional approach to HIV prevention, the
United Nations Special Session on HIV/AIDS in June 2001 indicated that
``Prevention programmes must concentrate on [all] the main routes along
which HIV spreads [that is] by addressing blood safety, mother-to-child
transmission, injecting drug use and sexual transmission.''
SAFE BLOOD FOR AFRICA FOUNDATION
Our organization is a 501(c)(3) not-for-profit corporation whose
purpose is to help prevent the spread of HIV/AIDS by blood transfusion
in sub-Saharan Africa. We will achieve this goal by working with the 34
countries in sub-Saharan Africa where blood contaminated with
infectious diseases--including HIV, Hepatitis B and Hepatitis C--is
most prevalent to develop national blood screening and safety systems.
When our programs are fully implemented, we estimate that we will save
between 10 and 20 million lives over the next 10 years.
Senator Alexander. It will be done.
Senator Feingold. Thank you very much, Mr. Chairman.
[The prepared statement of Senator Feingold follows:]
Prepared Statement of Senator Russell D. Feingold
Mr. Chairman, I want to thank you for convening this hearing and
for your willingness to work in such a cooperative way in putting this
together. I genuinely appreciate your approach and frankly think that
it is the perfect medicine for a recent minor outbreak of
politicization when it comes to this issue. It is a shame that this
hearing is coming after, rather than before, floor action on the AIDS
authorization bill.
Lately we have heard many different perspectives on the ABC
approach in Uganda, which of course refers to awareness-raising and
educational campaigns urging people to abstain, to be faithful to one
partner, and to use condoms. And I think common sense tells us that of
these elements are important parts of combating this horrifying
pandemic. But Ugandan efforts have also been characterized by strong
and visible political leadership, by grassroots involvement on a
massive scale, and by concerted efforts to destigmatize the disease.
The story is not a simple one.
The bottom line is that Uganda's multi-faceted approach to
combating AIDS was successful. Ugandan AIDS prevalence rates have
declined markedly over 1990s, and the country continues vigorously
addressing the crisis today. This is a tremendously important example
and Uganda deserves the acclaim that has come to the country in the
wake of this achievement.
But I must raise one different issue, just briefly, Mr. Chairman,
because I think that it would be a mistake for this subcommittee to be
convening today and discussing Uganda in any context without mentioning
the ongoing crisis in Ituri province in the Democratic Republic of the
Congo--a crisis that has involved Uganda, and a crisis that will
require international commitment to solve, including real commitment
from Uganda and Rwanda to use their influence with Ituri's ethnic
militia forces. Obviously this serious situation is not the focus of
today's hearing, but I do want to use this opportunity to go on the
record about my deep concern and my hope that the United State will
play a constructive role in defusing this crisis rather than being an
obstacle to urgently-needed action.
Turning back to the subject at hand, I think it is important that
we recognize both the value in learning from the Ugandan experience,
and the fact that one country's model is not necessarily precisely the
right model for every other AIDS-affected society. So this subcommittee
is diving into this discussion with an understanding that Uganda is not
Senegal, which is not South Africa. That said, Uganda's success has
played an important role in convincing people here in Washington and
around the world that it is possible to fight AIDS and win. That is a
tremendous contribution, and it deserves to be both celebrated and
studied closely.
Senator Alexander. Thank you, Senator Feingold.
We are delighted to have Dr. Anne Peterson testifying on
behalf of the administration. She is currently Assistant
Administrator of the Bureau for Global Health at USAID.
Something like our majority leader, she is a medical doctor.
She has done volunteer work in Africa, I guess may still do;
formerly worked on the front lines in African countries as a
volunteer doctor and in many nonprofit organizations.
Dr. Peterson, we are delighted to have you. We look forward
to your comments. I would suggest to you and the other
witnesses perhaps you could keep your comments to within 10
minutes or less and then that will leave more time for
questions and discussion.
STATEMENT OF ANNE PETERSON, M.D., ASSISTANT ADMINISTRATOR,
BUREAU FOR GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL
DEVELOPMENT, WASHINGTON, DC
Dr. Peterson. Thank you, Mr. Chairman. It is an honor to be
here today and thank you for holding this hearing on the grave
public health crisis of HIV-AIDS. I would like to submit my
written testimony for the record and then summarize it. I will
try to be brief.
You have already spoken about the devastation that HIV-AIDS
has wrought on the developing world. Every hour 350 people
around the world die of AIDS and, as President Bush said last
month at the White House, ``time is not on our side.'' I am
really thrilled with the urgency that is now really moving this
epidemic and its response, our response to this epidemic.
President Bush called for a massive U.S. Government
response to the crisis, the $15 billion over 5 years, and
Thursday you voted to support that call to action. It has
ambitious goals, to prevent 7 million infections, treat 2
million people with life-extending drugs, and provide care for
millions.
Mr. Chairman, I am a public health physician and my career
has been focused on both domestic public health and health
development in Africa. My very first time in Africa was in the
Bunia area of Congo that is now in such difficult
circumstances, but most of my time was in Kenya and Zimbabwe,
very close to the border of Uganda. I believe that the work
that I have done in Africa and my American public health work
has given me a good grasp of what is going on in Africa and the
programmatic realities that we need to be dealing with now.
As you have recognized, Uganda is not only important
because it is a success, but because there are many elements of
that success that can be replicated. The Ugandan epidemic
peaked in 1991 and has fallen to about 5 percent in 2001. I
would like to quote again President Bush, who cited the example
of Uganda in his call to action: ``This is a terrible disease,
but it is not a hopeless disease. We know that AIDS can be
prevented. In Uganda President Museveni began a comprehensive
program in 1986 with a prevention strategy emphasizing
abstinence and marital fidelity, as well as condoms to prevent
HIV transmission. The results are encouraging. Congress should
make the Ugandan approach the model for our prevention efforts
under the emergency plan.''
The dramatic decline is unique to Uganda. What can we learn
from it? I would like to enter for the record, Mr. Chairman, a
study that was published last fall by USAID on Uganda's
successful battle against HIV-AIDS. That report and my written
testimony \1\ contain a great deal of other information.
---------------------------------------------------------------------------
\1\ Dr. Peterson's written testimony and the report referred to can
be found beginning on page 10.
---------------------------------------------------------------------------
The Ugandan story is a story about prevention. As you said,
before terrorism or vaccine was available, when President
Museveni came to power in 1986, his country was already being
decimated by AIDS. Under his leadership, every sector of
society responded to the crisis by sending a unified and
forceful message. Their message was as simple as ABC:
``abstain, be faithful, and if necessary use a condom.'' This
message was disseminated widely through all sectors of society
during the 1980s.
The first is abstinence. By 1990 the percentage of youth
age 15 to 19 in Uganda ever having had sex decreased
noticeably. In 1989, 32 percent of males and 28 percent of
females age 15 to 19 reported being virgins, while by 1995
these numbers had increased to 55 percent of males and 45
percent of females. As you can see in your handout, the decline
is even more dramatic for 13- to 16-year-olds in an after-
school educational program.
We can also measure abstinence in the trend toward delayed
age of sexual debut among youth. In the 1990s, sexual debut
among girls in Uganda increased from 16.5 to 17.3 years. This
does not look like much, but it has profound impact on the
prevalence of HIV-AIDS and it also demonstrates huge cultural
changes that young girls were able to abstain. For boys it rose
from 17.6 to 18.3 years in the second half of the decade. For
youth the A of the ABC message, abstinence, is probably the
most important single message.
The second message is B. The ABC message of Uganda is not
just abstinence. Many people, including Uganda's first lady,
acknowledged that the B, be faithful, which includes partner
reduction, may be overall the most important factor. Also known
as ``zero grazing,'' being faithful is a strong cultural norm
that resonated strongly in Uganda and, from my own experience,
I know it resonates also in many other African countries.
In general, Ugandans of all ages now have considerably
fewer non-regular sex partners. Surveys conducted in 1989 to
1995 show that men with one or more casual partners declined
from almost 40 percent to 15 percent, and for women the decline
was from 16 percent to 6 percent. The number of men reporting
three or more non-regular partners in a year fell from 50
percent to 3 percent.
The 1995 survey also revealed an amazing statistic: 89
percent of men reported that they had changed some behavior
relative to HIV-AIDS, with most of them adopting faithfulness
as the behavior change. In the second data slide, you can see
that for all ages Ugandans now reports significantly fewer non-
regular partnerships than compared to other African countries.
The third message is C. While condom promotion was not a
dominant element in Uganda's early response to AIDS, in more
recent years, there has been increased condom use. The
beneficial role of condoms is clear when one spouse is HIV-
positive and the other is not, but it is also an important
prevention tool for people who have sex with non-regular
partners.
Again, in the condom use slide, the third one, Uganda is a
model. They are responding to the A and B message by having
fewer partners, but when they do stray outside of marriage they
are also leading the way on condom use.
We know that these ABCs have played key roles in the
decline of HIV prevalence in Uganda, but there is more to learn
about the relative contributions of each and the other factors
that contribute to the decline of AIDS and the success of the
ABC message. These include: the political commitment to
fighting AIDS from President Museveni and his wife; the
important role of faith-based organizations and churches in
changing behavior; communicating a consistent message with
credible messengers, such as Ugandan pop star Philly Lutaaya;
fighting stigma that clouds the attitude toward HIV and AIDS
and, as you are seeing in Botswana, this has been an incredible
limiting factor. There were also important policy and law
changes and the bringing in of voluntary counseling and
testing.
I am pleased, Mr. Chairman, that USAID was able to play an
important role in Uganda's success. Seventy percent of Uganda's
prevention and care activities are funded by donor nations.
USAID funded nearly half of that donor support. Last year we
provided $20 million to Uganda for HIV-AIDS programs, and this
year our budget will be over $27 million in Uganda.
The program includes a spectrum of activities from
prevention to care, support, and treatment. I would like to
mention just a couple examples. The AIDS Support Organization,
or TASO, is world-renowned and has provided care and support to
more than 60,000 individuals and their families, as well as
supporting 200,000 children affected by AIDS. USAID has been a
long-time supporter of TASO and today provides TASO with
approximately $2 million a year. The former head of that
organization, Sophia Mukasa Monico, will testify before you in
a few minutes and is one of the many heros of Uganda's war on
AIDS. Since 1995, we have also been supporting the First Lady
Museveni's orphan and microcredit work and have been working
with faith-based organizations since 1991.
USAID will continue strong support of the Uganda success
and support of both the implementation and research into ABC
programs. But the real question, days after the passage of the
emergency AIDS bill--and again I thank you--is not only what
happened in Uganda, but can we replicate Uganda's success? The
short answer is emphatically yes. Uganda is unique, and it is
hard to imagine the amazing leadership role of the President
and his wife will be repeated, but many elements of Uganda's
success can be recreated elsewhere.
In Uganda we have learned that a comprehensive behavior
strategy, ideally involving high-level political commitment and
a diverse spectrum of community and faith-based participation,
building on cultural norms, can change the course of the
epidemic.
The Uganda model is also a flexible model. It takes into
account the epidemiological, the demographic, and the cultural
norms, and can be balanced between the A, B, and C components
as well as all of the other supporting elements.
Every country will be different, but we can learn from the
successful elements of the action in Uganda. In some countries
we are beginning to hear the voices of Presidents and other
political leaders take on new roles. In other countries we see
strong leadership from the faith community and civil society.
In South Africa the engagement of the business community is
remarkable and likely to be a significant factor in future
successes.
And we are seeing signs that other countries are beginning
to turn epidemics around. Recent studies among youth in Zambia
indicate that a similar success story there may be in the
making. Clear and positive changes in all three of the ABC
behaviors have been reported in surveys, and a significant
decline in casual sex has occurred among both men and women
between 1996 and 1999.
Mr. Chairman, as you noted, I spent 6 years in Africa as a
missionary doctor. I worked with communities, children in
school, street children, AIDS patients, and families in the
most desperate of circumstances. I helped develop and teach
abstinence programs to African youth. I have seen the light in
young people's eyes when they realize they can take control of
their own lives. The data shows this as well. It is as simple
as ABC.
But we need that simple message, together with all the
supporting elements involved that made the ABC success in
Uganda, to save lives. We cannot ignore the moral issues
involved in finding a solution to the HIV-AIDS crisis. To
protect the next generation of African youth, we cannot step
aside from difficult dilemmas of abstinence and faithfulness.
Uganda's First Lady Museveni last Tuesday in a speech said:
``How are we going to teach children to be law-abiding citizens
if we do not train them to exercise self-control and to learn
to police themselves while they are still young and teachable?
Not to guide our young in this way implies that we as adults
and leaders have no faith in human nature and in our ability as
beings to exercise self-control. If this is the case, then we
are surely a doomed species.''
My own experience tells me that Mrs. Museveni's words are
directly on point. Our mission at USAID is to learn from the
successes that we have before us and bring similar successes to
other devastated countries around the world.
Thank you for letting me testify before you today.
[The prepared statement of Dr. Peterson follows:]
Prepared Statement of Dr. Anne Peterson, Assistant Administrator for
Global Health, U.S. Agency for International Development
Good afternoon. Thank you for inviting me to testify on the
important topic of Uganda's successful battle against HIV/AIDS. This
issue could not be timelier or more urgent. The HIV/AIDS pandemic is
currently claiming 350 lives per hour worldwide. President Bush
announced an unprecedented five-year, $15 billion program to fight the
disease. It is crucial that we take the right lessons from Uganda's
experience and apply them effectively elsewhere.
We are at a turning point in the battle against HIV. While HIV
infection rates are still increasing and the disease is raging in many
places, we now have success stories. We know what works and soon will
have sufficient resources to implement those successful strategies much
more broadly. It is important that we highlight the successful
interventions in Uganda so we can better apply them to other countries.
The new Emergency Plan for AIDS Relief that President Bush announced in
January in the State of the Union Address is based on one of these
successful models.
I have been serving as the Assistant Administrator of USAID for
Global Health for 18 months. I came to the agency with a long history
of service in medicine and public health. I spent six years in Africa,
working with AIDS patients and their families. My work in both Zimbabwe
and in Kenya, near the Ugandan border, included similar interventions
to ones we'll be examining today from Uganda.
I have seen first-hand the devastation that AIDS has wreaked on
individuals, families and communities. While we often hear of the
hopelessness of HIV/AIDS, today there are many signs that give us hope
of winning the war against this deadly disease.
WHAT HAPPENED IN UGANDA?
Despite all my African experience, it is humbling to be here
talking about what happened in Uganda. This is a Ugandan story and
should be told by Ugandans. The saving grace is that I know many of you
heard from Mrs. Janet Museveni, the First Lady of Uganda last week. Her
passion and depth of insight are vital elements of the political
leadership from her and her husband, President Yoweri Museveni, which
has made, and continues to make, such a difference in Uganda.
Today, I would like to focus on four areas: first, the data on HIV/
AIDS from Uganda; second, the data and cultural support for the ABC
approach to AIDS prevention; third, USAID's past role in Uganda; and
fourth, what the U.S. government can do to replicate Uganda's success
elsewhere.
With your permission, Mr. Chairman, I would like to enter, for the
record, a study published by USAID last fall on Uganda's successful
battle against HIV/AIDS.
In Uganda, according to estimates by UNAIDS, HIV prevalence among
adults peaked at around 15 percent in 1991, and fell to 5 percent as of
2001. While some quibble on the numbers, we know this dramatic decline
is unique to Uganda, which is why it is important that we examine what
led to the turnaround.
The Uganda success story is about prevention. When President
Museveni came to power in January 1986, his country was already being
decimated by AIDS. Under President Museveni's leadership, leaders at
every level of society responded to this crisis by sending a unified
and forceful message. They urged people to prevent the spread of HIV.
Their message was as simple as ABC: Abstain, Be faithful, and, if
necessary, use a Condom. This message was disseminated widely through
all sectors of society during the late 1980s.
``A'': By the 1990s, the percentage of youth aged 15-19 in Uganda
reporting ever having had sex decreased noticeably. In 1989, 32 percent
of males and 28 percent of females age 15-19 reported being virgins,
while by 1995 these numbers had increased to 55 percent of males and 45
percent of females. In addition, there was a clear trend towards
delayed age of sexual debut among youth. In the 1990s, sexual debut
among girls in Uganda increased from 16.5 to 17.3 years. For boys, it
rose from 17.6 to 18.3 years in the second half of the decade. For
youth--I agree with Mrs. Museveni--the A of ABC, abstinence, is the
most important single message. USAID will be funding additional studies
to verify that our current body of evidence is in fact correct as to
the contribution of abstinence to AIDS education.
``B'': But the ABC message of Uganda is not just A. Many people,
including Uganda's First Lady, acknowledged that ``B'', Be faithful,
may be overall the most important factor. Also known as ``Zero
grazing''--being faithful is a strong cultural norm that resonated
strongly in Uganda. The rise in couples that are mutually faithful is
striking.
In general, Ugandans of all ages now have considerably fewer non-
regular sex partners. In surveys conducted in 1989 and 1995, men with
one or more casual partners declined from 35 percent to 15 percent, and
for women the decline was from 16 percent to 6 percent. Also
significant, the number of men reporting three or more non-regular
partners fell from 15 percent to 3 percent. A 1995 survey found that 89
percent of men reported they had changed their behavior to avoid AIDS,
with most of them adopting faithfulness to one partner, and other
partner-related changes.
``C'': While condom promotion was not a dominant element in
Uganda's early response to AIDS, in more recent years, increased condom
use has contributed to the continuing decline in prevalence. The
beneficial role of condoms is clear when one spouse is HIV positive and
the other is not. But it is also a particularly important prevention
tool for people who have sex with a ``non-regular'' partner. In Uganda,
condom use by women with non-regular partners rose from 20 to 38
percent, and for men rose from 36 to 59 percent, over the last five
years of the 1990s.
We know that these ``ABCs'' have played key roles in the decline of
HIV prevalence in Uganda, but there is much more to be learned about
the relative contributions of each. There are still many unanswered
questions about how Uganda has moved so many people to make such
significant changes in behavior. Some of the critical elements we know
contributed to the adoption of the ABC message were:
Political commitment: Uganda in 1986 was just emerging from 15
years of civil unrest. When he had just assumed office, President
Museveni received evidence of an emerging epidemic and immediately
began a proactive prevention campaign that continues to this day. In
meetings and speeches, he emphasized that fighting AIDS was a patriotic
duty requiring openness, communication and strong leadership at all
levels. This early support from the President enlisted a wide variety
of national participants in the war against the new disease.
Role of faith-based organizations: Religious leaders are uniquely
positioned to influence the behavior of large numbers of people. Early
and significant mobilization of Ugandan Christian and Muslim leaders
and organizations resulted in their active participation in AIDS
education and prevention activities. For example, the Catholic Church
and mission hospitals provided leadership in designing AIDS home care
projects and special programs for AIDS widows and orphans. The Church
of Uganda and the Islamic Medical Association of Uganda used their
extensive networks to train more than 1800 religious leaders and 5000
peer educators.
Communicating a consistent message: Along with elected and faith-
leaders, other influential people who did not normally work on health
issues, like First Lady Janet Museveni and pop music star Philly
Lutaya, became involved in AIDS awareness and education. An aggressive
media campaign, including print, radio and billboards, educated people
to change their behavior. This was reinforced by old-fashioned,
interpersonal communication, with Uganda training thousands of
community-based AIDS counselors and educators, who in turn motivated
people to change their behavior.
Fighting stigma: The stigma attached with HIV and AIDS often serves
as a barrier to effective prevention measures. Openness on the part of
President Museveni led to openness from every level of society down to
local community leaders, producing an accepting and non-discriminatory
response to AIDS. In addition, The AIDS Support Organization, known as
TASO, advocated effectively against discrimination and stigma. TASO is
recognized around the world as a leader and innovator in the field of
HIV/AIDS care and support. The former head of that organization, Sophia
Mukasa Monico, will join us in a later panel.
Policy and law change: ``Gender vulnerability'' refers to the
problem of wives exposed to HIV through the indiscretions of their
husbands or young girls put at risk through intergenerational sex. This
is a deeply cultural and sensitive part of the problem in many African
countries. When I asked Mrs. Museveni how Uganda overcame these
problems, she talked about policy and law change. Women could prosecute
for rape, wives would not lose their homes if they refused to have sex
without protection with their HIV+ husband. And these weren't just
verbal promises; free legal support, including from women lawyers, was
made available so that this was a real hope. While not completely
overcoming this problem and not reaching all parts of Uganda with legal
support, these policy and legal changes make it possible for women to
abstain when in other circumstances their exposure to AIDS would be out
of their control.
Confidential voluntary counseling and testing: In 1990, the first
confidential voluntary counseling and testing center opened in Kampala.
The AIDS Information Center was the first to provide same-day results
using rapid HIV tests. The Center also started ``post-test clubs'' to
provide long-term support for those who have been tested, whether they
are HIV-positive or negative. The availability of these services, and
the lack of stigma associated with getting tested, were important
assets in Uganda's prevention efforts.
USAID'S ROLE IN UGANDA
I am pleased to be able to report that USAID was a strong supporter
of Uganda's approach and the largest financial supporter to its success
story. Donor countries, particularly the United States, played
important roles during those critical years by complementing Uganda's
energy and initiative with financial and technical support.
Donor support covered 70 percent of Uganda's prevention and care
activities, amounting to $180 million from 1989 to 1998. USAID has
provided more than $83 million in AIDS funding since 1988. I will now
describe the activities of USAID in Uganda, though I note that other
federal agencies have also participated in the fight against AIDS in
Uganda.
Last year, USAID provided $20 million to Uganda for HIV/AIDS
programs, and this year's budget will be over $27 million. Our program
includes prevention, care and support, voluntary counseling and
testing, and programs for children affected by AIDS. Let me mention a
few highlights of our past and present programs:
USAID has a long history of supporting Uganda's two largest local
non-governmental organizations dedicated to the fight against AIDS.
TASO, as I mentioned earlier, is world-renowned, and has provided care
and support services to more than 60,000 individuals and their
families, as well as supporting 200,000 children affected by AIDS.
Today, USAID provides TASO with approximately $2 million a year.
The AIDS Information Center, which provides HIV counseling and
testing, has served over half a million Ugandans. USAID was the first
donor to support the AIDS Information Center, and currently funds more
than 80 percent of its annual budget.
USAID/Uganda's partnerships with faith-based organizations began
early in 1991, with a project designed to mobilize civil-society
organizations, including those that are faith-based. These
institutions, especially the Church of Uganda and the Islamic Medical
Association, were able to utilize their extensive networks to educate
and influence people's behavior. Today, USAID funds World Vision to
reinvigorate and strengthen the role of faith-based organizations in
their response to HIV/AIDS. This initiative is strengthening the
Interreligious Council of Uganda, as well as providing sub-grants.
USAID, working with Catholic Relief Services, World Vision and
others, currently has a five-year, $30-million project in Uganda to
provide food aid to over 60,000 individuals. Good nutrition plays an
important role in the quality--and we believe also length--of life of
people living with AIDS. In addition, since it is not uncommon for
economically disadvantaged women to trade food for sex, food aid can
play an important role in decreasing this risky behavior that can drive
the epidemic.
The Uganda Women's Effort to Save Orphans, founded by First Lady
Janet Museveni, has more than 7500 members, most of whom provide direct
care for orphans. Since 1995, with support from USAID, this group's
small-scale credit program has provided income generation activities
for orphan households. Their programs have assisted over 25,000 orphans
and 2,600 micro-entrepreneurs.
USAID provided the leadership and technical expertise for a
planning meeting for representatives from the major religious
communities in Uganda: Anglican, Roman Catholic, Orthodox Christian,
and Muslim. Out of this meeting, the Interreligious Council of Uganda
HIV/AIDS Task Force was established.
Currently, USAID and the Centers for Disease Control are funding a
program to develop comprehensive, integrated HIV/AIDS prevention and
care services in 16 of Uganda's 56 districts. These integrated programs
will create a model for serving Uganda's rural poor.
Preventing mother-to-child transmission of HIV is one of the
aspects of this program. USAID/Uganda is also supporting a private
sector initiative designed to increase utilization of services to
prevent mother-to-child transmission through a program for midwives.
These programs will be scaled-up significantly thanks to President
Bush's International Mother and Child HIV Prevention initiative and the
President's Emergency Plan for AIDS Relief.
USAID'S BALANCED APPROACH TO AIDS PREVENTION TODAY
Although USAID has always acknowledged a balanced ABC approach to
the HIV/AIDS pandemic is needed, it is true that in the past, the
agency's programs tended to skew towards those that are easier to
measure such as the social marketing of condoms. Uganda is leading the
way in helping to provide data on the contribution of the abstinence
and be faithful messages to successful AIDS prevention. There is
supporting evidence from abstinence and teen pregnancy prevention
programs in the United States and evidence is accumulating from a
variety of international programs that these messages are successful.
Rarely do we have a controlled study environment in international
programs that would allow interventions to definitely prove cause and
effect. This is also true for the assessment of the ABC approach. But
we do have a growing body of evidence of ecological, programmatic and
time oriented associations that is very strong. Based on this body of
evidence, USAID's policy since last fall has been modified to follow a
more balanced approach to the ABC's of HIV prevention. The balance is
set for an individual country based on culture, epidemiology, and the
stage of the epidemic. The ABCs of HIV prevention reinforce one
another, and the appropriate message must reach the appropriate
audience. These messages and target audiences can be segmented without
denigrating any one message.
In Zambia, we have seen evidence of a program that successfully
applies a balanced approach. It is also a program that we think can be
replicated in other similar situations. The HEART program--or Helping
Each Other Act Responsibly Together--was designed by youth for youth
and uses the mass media to promote AIDS prevention through abstinence,
being faithful to one partner, and, when necessary, correct and
consistent condom use.
According to a survey of Zambian youth, girls in particular said
they want concrete messages with reasons to stay virgins or return to
abstinence. The decision to abstain was frequently reported as a direct
result of exposure to the HEART program. Respondents were also more
likely to say they chose ``to abstain'' rather than to use condoms--a
finding that counters the common argument that television and radio
spots about safe sexual behavior encourage promiscuity. The study
clearly shows we can promote abstinence as ``cool'' and reinstitute it
as a social norm among Zambian youth, whether they are still virgins or
for those wanting to return to abstinence.
In Jamaica, a USAID-funded program promotes abstinence with the
slogans such as ``go real slow, take the time to know.'' This message
is promoted through popular rap songs, with lyrics like, ``Now I don't
want to complicate this life of mine, so right now sex is out, and
that's just fine.'' An evaluation of this campaign found that more than
half the youth who recalled the ads said they had influenced the way
they handle relationships.
In Namibia, past surveys show that girls begin sex at a young age,
and 12 percent of 15-19 year aids are HIV positive. USAID began a
campaign last year that works with churches, including the Catholic
Church and the Evangelical Lutheran Church, to encourage church leaders
to use their pulpits to speak about the importance of educating
children about HIV prevention, with an emphasis on delaying first
sexual intercourse. Another component of the program will adapt the
Christian Family Life Education to be implemented as part of Sunday
School lessons. The program will also seek to form partnerships between
churches and parenting organizations.
Similarly the B component of ABC is vitally important (Be faithful
or Behavior change--partner reduction) to a comprehensive approach. B
is a bridge between A and C and preliminary data suggests it may be the
most important element of all. USAID will continue to support a strong
B emphasis and continue to study to validate the data evidence for its
contribution.
Condom promotion is also an important tool to stem the spread of
the disease among high-risk populations. While messages of abstinence
and faithfulness are key to young and married adults, it is important
to provide information on condoms to those who have sex outside or
before marriage. Prostitutes and their clients, long-distance truck
drivers, and migrant populations, like miners and fishermen, are
audiences that are appropriate for a condom promotion message. Social
marketing is designed to tailor messages to a target audience. It is
used successfully for hygiene initiatives, oral rehydration therapy,
malaria control, and HIV prevention. Social marketing of condoms can
provide appropriate and effective messages targeted to specific at-risk
groups.
USAID uses indicators developed with UNAIDS to measure the success
of A, B and C. We are analyzing the data we collect to make sure our
programs are as effective as possible.
CAN UGANDA'S SUCCESS BE REPLICATED?
Uganda's experience was unique in many ways, particularly in the
early and strong voice of the President and his wife. Many elements of
Uganda's response, including the political and community action that
supported the ABC approach and led to real changes in sexual behavior,
worked together in order for HIV rates to fall so dramatically.
However, many elements of Uganda's success can be and are being
replicated elsewhere.
Every country will be different, but we learn successful elements
of action from Uganda. For instance, in some countries, we are seeing
political leaders, including and in addition to the head of state, take
on a leadership role. In other countries, we see strong leadership from
the faith community or civil society. In South Africa, the engagement
of the business community is remarkable and likely to be a significant
factor in future successes.
We are seeing strong signs that other countries are beginning to
turn their epidemic around. Recent studies among youth in Zambia
indicate that a similar success story there may be in the making. Clear
and positive changes in all three of the ``ABC'' behaviors have been
reported in surveys, and a significant decline in casual sex occurred
among both men and women between 1996 and 1999.
Senegal, Thailand and Cambodia have also had successes, and their
stories also suggest that a balanced ABC approach should be promoted.
In Uganda, we have learned that a comprehensive behavior change
strategy--ideally involving high-level political commitment and a
diverse spectrum of community and faithbased participation, building on
cultural norms--can change the course of an epidemic.
Mr. Chairman, let me again thank you for holding this important
hearing today.
[Attachment.]
Project Lessons Learned Case Study--September 2002
WHAT HAPPENED IN UGANDA? \1\
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\1\ This document was developed with support from the Office of
HIV/AIDS, Bureau for Global Health, U.S. Agency for International
Development under contract number HRN-C-00-99-00005-00. The opinions
expressed herein are those of the contributors and do not necessarily
reflect those of USAID.
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DECLINING HIV PREVALENCE, BEHAVIOR CHANGE, AND THE NATIONAL RESPONSE
This document is not intended to provide a definitive explanation
for Uganda's AIDS prevention successes during the 1980s and 1990s.
Rather, it is a synthesis of presentations made in February 2002 at the
U.S. Agency for International Development (USAID) by four individuals
\2\ with long-term experience in HIV prevention in Africa. USAID's
Office of HIV/AIDS decided to commission a summary document
synthesizing the ideas presented by these researchers. The following
pages do not include all the various statistical and other details that
were presented; however, it is hoped that the main points described
here provide some insight into how Uganda has managed to control its
HIV epidemic during the past 15 years.
---------------------------------------------------------------------------
\2\ Editor: Janice A. Hogle, Ph.D. Contributors: Edward Green,
Ph.D., Vinand Nantulya, M.D., Ph.D., Rand Stoneburner, M.D., M.P.H.,
John Stover, Ph.D.
HIV prevalence has declined significantly in Uganda: Now considered
to be one of the world's earliest and best success stories in
overcoming HIV, Uganda has experienced substantial declines in
prevalence, and evidently incidence, during at least the past decade,
especially among younger age cohorts. According to Ministry of Health
(MOH) data, prevalence among pregnant women has declined consistently
since the early 1990s at all of the country's sentinel sites (except
Tororo, near the Kenyan border, where prevalence increased a little
during the mid-to-late 1990s, but declined significantly again by
2000). While it is more difficult to find reliable data on trends in
incidence (or the rate of new infections), seroincidence also appears
to have fallen significantly. In one site, Masaka, incidence fell from
7.6 per thousand per year in 1990 to 3.2 per thousand per year by 1998.
As with prevalence, the decline was more pronounced among younger
women.
Seroprevalence among 15-19-year-old pregnant women, which is
believed to he reflective of HIV incidence, fell sharply from the early
1990s, when this data was first collected, until 1995 or 1996, and
since then has remained low. Based on this trend, as well as the fact
that national seroprevalence peaked in 1991 and from some other
indications (e.g., syphilis rates in Rakai plummeted in 1988), it is
probable that incidence in Uganda would have peaked sometime in the
late 1980s. Regarding prevalence, estimates by the U.S. Census Bureau/
Joint United Nations Programme on HIV/AIDS UNAIDS) are that national
HIV prevalence peaked at around 15 percent in 1991, and had fallen to 5
percent as of 2001. This dramatic decline in prevalence is unique
worldwide, and has been the subject of curiosity since the mid-1990s,
and recently of even more intense scientific scrutiny.
Observed consistently over time and across many different
geographic and demographic populations, Uganda's falling HIV prevalence
is likely not due merely to measurement bias or a ``natural die-off
syndrome,'' but rather mainly to a number of behavioral changes that
have been identified in several surveys and qualitative studies. Some
have postulated that the decline in seroprevalence was primarily a
result of so many people succumbing to the disease that the rate of new
infections was simply outweighed by the numbers of AIDS deaths.
However, a number of other African regions (e.g., Zambia, Zimbabwe,
western Kenya) have experienced nearly as old--and at least as severe--
epidemics as Uganda's, yet prevalence has yet to decline at the
population level. Furthermore, the large decline in prevalence among
younger age cohorts in Uganda argues against this as a primary
explanation.
The relationships between the large variety of interventions in
Uganda and the decline in incidence and prevalence are complex and not
yet completely understood. This is especially true regarding the
earlier years (i.e., there is little HIV-related Demographic and Health
Surveys (DHS) data prior to 1995). However, changes in age of sexual
debut, casual and commercial sex trends, partner reduction, and condom
use all appear to have played key roles in the continuing declines.
Although we know that HIV knowledge, risk perception, and risk
avoidance options can ultimately lead to reduced HIV incidence, there
is a complex set of epidemiological, socio-cultural, political, and
other elements that likely affected the course of the epidemic in
Uganda. Many of these elements appear to be absent or less significant
in other African countries that have not yet seen significant
seroprevalence declines, such as Zimbabwe, South Africa, Botswana,
Kenya, and Malawi. These key elements are summarized in roughly
chronological order in the following pages.
1. High-level political support with multi-sectoral response set
the tone: In 1986, after 15 years of civil strife, Uganda's new head of
state, President Yoweri Museveni, responded to evidence of a serious
emerging epidemic with a proactive commitment to prevention that has
continued to the present. In face-to-face interactions with Ugandans at
all levels, he emphasized that fighting AIDS was a patriotic duty
requiring openness, communication, and strong leadership from the
village level to the State House. His charismatic directness in
addressing the threat placed HIV/AIDS on the development agenda, and
encouraged constant and candid national media coverage of all aspects
of the epidemic. This early high-level support fostered a multi-
sectoral response, prioritizing HIV/AIDS and enlisting a wide variety
of national participants in the ``war'' against the decimating disease
known as ``Slim.'' In 1992, the multi-sectoral Uganda AIDS Commission
(UAC) was created to coordinate and monitor the national AIDS strategy.
The UAC prepared a National Operational Plan to guide implementing
agencies, sponsored Task Forces, and encouraged the establishment of
AIDS Control Programmes in other ministries including Defense,
Education, Gender and Social Affairs. As of 2001, there were also
reportedly at least 700 agencies--governmental and nongovernmental--
working on HIV/AIDS issues across all districts in Uganda.
2. Decentralized planning and implementation for behavior change
communication (BCC) reached both general populations and key target
groups: In 1986, Uganda established a National AIDS Control Program
(ACP), which launched an aggressive public media campaign that included
print materials, radio, billboards, and community mobilization for a
grass-roots offensive against HIV. A national sentinel surveillance
system, which has tracked the epidemic since 1987, began with four
sites and by 2000 included 15; also of importance, there has been
surveillance of AIDS cases since 1986. The ACP became the STD/AIDS
Control Programme in 1994 and has since trained thousands of community-
based AIDS counselors, health educators, peer educators, and other
types of specialists. Led by their leaders' examples, the general
population in both urban and rural areas eagerly joined the fight
against AIDS, so that it became a ``patriotic duty'' to support the
effort. Spreading the word involved not just ``information and
education'' but rather a fundamental behavior change-based approach to
communicating and motivating. Decentralization itself was actually a
type of local empowerment that involved local allocation of resources--
in itself a motivating force.
Notably, Uganda's approach to BCC has relied more on ``non-
electronic'' mass communication--which was community-based, face-to-
face, and culturally appropriate. Strong nongovernmental organizations
(NGO) and community-based support led to flexible, creative, and
culturally appropriate interventions that worked to change behavior
despite extreme levels of post-civil war house-hold poverty. As Edward
Green observed, ``low-tech'' approaches also led to the sensitization
and subsequent involvement in AIDS awareness and education of not only
health personnel, traditional healers, and traditional birth attendants
(TBAs), but influential people normally not involved in health issues
such as political, community, and religious leaders, teachers and
administrators, traders, leaders of women's and youth associations, and
other representatives of key stakeholder groups. BCC interventions
reached not only the general population, but also key target groups
including female sex workers and their clients, soldiers, fishermen,
long-distance drivers, traders, bar girls, police, and students,
without creating a highly stigmatizing climate.
3. Interventions addressed women and youth, stigma and
discrimination: Linked to high-level political support and grassroots-
level communication for behavior change was a strong emphasis on
empowerment of women and girls; targeting youth in and also out of
school; and aggressively fighting stigma and discrimination against
people living with HIV/AIDS (PLWHAs). Since at least 1989, teachers
have been trained to integrate HIV education and sexual behavior change
messages into curricula. At the same time, the country's President and
his political party have attempted to empower women and youth by giving
them more political voice, including in Parliament where by law women
make up a minimum one-third of the members. Four members elected by
youth caucuses represent youth in Parliament. Youth-friendly approaches
promoted partner reduction through talking about delaying sexual
debut--remaining abstinent, remaining faithful to one uninfected person
if ``you've already started,'' ``zero-grazing,'' and using condoms if
``you're going to move around.'' Of particular note is the indicator
for the proportion of youth that has not yet begun to have sex. In an
African Medical and Research Foundation (AMREF) study in Soroti
District cited by Vinand Nantulya, among youth age 13-16 nearly 60
percent of boys and girls reported having already ``played sex'' in
1994, but in 2001 that proportion was down to less than 5 percent.
Respecting and protecting the rights of those infected by HIV has
been inspired since 1988 by a number of prominent Ugandan citizens, and
by public events such as candlelight memorials and World AIDS Day
observances. In the late 1980s, a celebrated European-based Ugandan
musician, who went public about his HIV status at the beginning of the
epidemic, returned home and devoted his last days to giving testimonies
in schools, colleges, churches and elsewhere. Of critical importance,
The AIDS Support Organization (TASO) was organized back in 1987, and
has advocated against discrimination and stigma while pioneering a
community-based approach for care of PLWHAs. The work of TASO and other
care organizations has also made important contributions to prevention
efforts, exemplifying the concept of a prevention-to-care continuum.
Other national spokesmen included a Major in the Ugandan army who
talked openly about his infection and how he used condoms to avoid
infecting his wife, and a Protestant minister who disclosed that he
learned of his infection when his first wife died, and talked publicly
about using condoms to avoid infecting his new wife and their children.
Openness on the part of the President, other government and community
leaders, and prominent activists has led in general to a remarkably
accepting and non-discriminatory response to AIDS.
4. Religious leaders and faith-based organizations have been active
on the front lines of the response to the epidemic: Mainstream faith-
based organizations wield enormous influence in Africa. Early and
significant mobilization of Ugandan religious leaders and organizations
resulted in their active participation in AIDS education and prevention
activities. Also, Mission hospitals were among the first to develop
AIDS care and support programs in Uganda. In 1990, the Islamic Medical
Association of Uganda (IMAU) piloted an AIDS education project in rural
Muslim communities that evolved into a larger effort to train local
religious leaders and lay community workers. Documenting increases in
correct knowledge and decreases in risky behaviors, the IMAU project
was selected as a ``Best Practices Case Study'' by UNAIDS. The
Protestant Church of Uganda organized a workshop for bishops and other
religious leaders in 1991, and implemented an extensive AIDS education
project in many dioceses. The Catholic Church and mission hospitals
provided leadership in designing AIDS mobile home care projects and
special programs for AIDS widows and orphans. The three chairpersons of
the Uganda AIDS Commission have included an Anglican and a Catholic
Bishop. (The first leader was President Museveni.)
5. Africa's first confidential voluntary counseling and testing
(VCT) services: In 1990, the first AIDS Information Center (AIC) for
anonymous VCT opened in Kampala. By 1993, AIC was active in four major
urban areas as more and more people became interested in knowing their
sero-status. AIC pioneered providing ``same day results'' using rapid
HIV tests, as well as the concept of ``Post Test Clubs'' to provide
long-term support for behavior change to anyone who has been tested,
regardless of sero-status. Uganda was fairly unique in Africa in the
emphasis it placed on VCT, at a time when the Global Program on AIDS
and other international organizations were not yet recommending it as a
prevention strategy.
6. Condom social marketing has played a key but evidently not the
major role: Condom promotion was not an especially dominant element in
Uganda's earlier response to AIDS, certainly compared to several other
countries in eastern and southern Africa. In Demographic Health
Surveys, ever-use of condoms as reported by women increased from 1
percent in 1989, to 6 percent in 1995 and 16 percent in 2000. Male
ever-use of condoms was 16 percent in 1995 and 40 percent in 2000.
Nearly all of the decline in HIV incidence (and much of the decline in
prevalence) had already occurred by 1995 and, furthermore, modeling
suggests that very high levels of consistent condom use would be
necessary to achieve significant reductions of prevalence in a
generalized-level epidemic. Therefore, it seems unlikely that such
levels of condom ever-use in Uganda (let alone consistent use, which
was presumably much lower) could have played a major role in HIV
reduction at the national level, in the earlier years. However, in more
recent years, increased condom use has arguably contributed to the
continuing decline in prevalence.
In the early 1990s, there was resistance on the part of the
President and some religious leaders to promoting condom use, but by
the mid-1990s the controversy had generally faded. Purchased mainly
with external donor funds, millions of condoms have since then been
distributed by the MOH through health centers and NGO projects. Condom
sales and reported use have increased significantly during the past
half-decade (although still not to the same extent as in other
countries like Zimbabwe, South Africa, Botswana, and Kenya). High
levels of condom use have been reported for commercial sex work (i.e.,
reportedly at near-100 percent levels in Kampala), and according to
Uganda's 2000 DHS, among people reporting a non-regular partner in the
past 12 months, 59 percent of men and 38 percent of women reported
using a condom with their last non-regular partner. Therefore, current
condom use rates with non-regular partners are probably playing a role
in the continued declining seroprevalence. Note that while condom use
with non-regular partners has been increasing, Ugandans are also
reporting significantly fewer non-regular partners. In contrast,
according to John Stover, if condom use in Kenya had not been as
plentiful, seroprevalence might have increased even more than it has.
But without the other, Uganda-like behavior changes (i.e., delay of
sexual debut and ``zero grazing''/partner reduction), prevalence did
not decline.
Sexually transmitted infections (STI) control and prevention
programs have received increased emphasis: Since 1994, after declines
in HIV prevalence began to be documented, two donor-funded projects
addressed improving STI diagnosis and treatment of STIs. Adequate
supplies of STI drugs in the country suffered from considerable delays
in offshore procurement but by the end of the 1990s, drug supplies were
adequate and distribution to rural health facilities was improving.
Donor funding also financed a national reference laboratory at Mulago
Hospital to study drug resistance. Two large randomized trials in
Uganda (Rakai and Masaka) attempted to look at the impact of STI
treatment on reducing HIV prevalence. Although both interventions
reduced the rates of some STIs, there was no significant reduction in
HIV incidence. According to an expert panel at the 2002 World AIDS
Conference in Barcelona, the main reason for the lack of effect on HIV
from STI treatment was the large decrease in risky sex/multiple partner
trends that had occurred in Uganda by the time the STI trials began.
(Most HIV transmission therefore now occurs within monogamous regular
partnerships, where bacterial STIs tend to be rare.)
8. The most important determinant of the reduction in HIV incidence
in Uganda appears to be a decrease in multiple sexual partnerships and
networks: In general, Ugandans now have considerably fewer non-regular
sex partners across all ages. Population-level sexual behavior,
including the proportion of people reporting more than one sexual
partner, in Kenya (1998), Zambia (1996), and Malawi (1996), for
example, appear comparable to those reported in Uganda in 1988-89. In
comparison with men in these countries, Ugandan males in 1995 were less
likely to have ever had sex (in the 15-19-year-old range), more likely
to be married and keep sex within the marriage, and less likely to have
multiple partners, particularly if never married.
According to Rand Stoneburner, such behavioral changes in Uganda
appear related to more open personal communication networks for
acquiring AIDS knowledge, which may more effectively personalize risk
and result in greater actual behavior change. Comparing DHS survey data
with Kenya, Zambia, and Malawi, Ugandans are relatively more likely to
receive AIDS information through friendship and other personal networks
than through mass media or other sources, and are significantly more
likely to know of a friend or relative with AIDS. Social communication
elements, as suggested by these kinds of indicators, may be necessary
to bridge the motivational gap between AIDS prevention activities and
behavior change sufficient to affect HIV incidence. If these elements
are present, the success of prevention activities may be greatly
enhanced. Model simulations suggest that knowledge can diffuse rapidly,
even early in an epidemic, in an environment of ``open'' personal
networks. Uganda's President set the example for the nation with his
matter-of-fact approach to dealing with the HIV threat, and inspired
thousands of community, religious, and government leaders to talk
candidly to people about delaying sexual activity, abstaining, being
faithful, ``zero grazing,'' and using condoms (roughly in that order).
What did all this cost? According to an analysis by Elizabeth
Marum, USAID/Centers for Disease Control and Prevention (CDC) HIV
program director in Kampala throughout the 1990s, total donor support
for all AIDS-related contributions during the period 1989-1998 was
approximately $180 million, or about $1.80 per adult per year over the
10-year period. Donor contributions amount to an estimated 70 percent
of total expenditures on AIDS prevention and care in Uganda. Although
this proportion is clearly significant, Uganda itself (both public and
private sectors) must be credited with developing much of the
successful approach, specifically: involvement of religious
organizations, bold IEC in schools, VCT, and community-based and
culturally appropriate BCC strategies.
A ``social vaccine'' in Africa? (Can this success be replicated?)
It must be remembered that many of the elements of Uganda's response,
such as high-level political support, decentralized planning, and
multi-sectoral responses, do not affect HIV infection rates directly.
Sexual behavior itself must change in order for seroincidence to
change. According to Stoneburner, the effect of HIV prevention
interventions in Uganda (particularly partner reduction) during the
past decade appears to have had a similar impact as a potential medical
vaccine of 80 percent efficacy. The historical and socio-cultural
context, various interventions and other factors are complex and may be
somewhat unique to Uganda, and it is not clear to what extent this
success can exactly be replicated elsewhere, especially in more
cosmopolitan, Westernized settings. However, recent seroprevalence and
behavioral survey data among youth in Zambia indicate that a Uganda-
like success story may be in the making there as well. According to a
recent study by Population Services International, the main factor
behind the large decline in prevalence among Zambian youth during the
1990s was a significant reduction in multiple partner trends.
In conclusion, although we may never fully know ``what really
happened in Uganda,'' the experience there and in other countries that
have achieved some success suggests that a comprehensive behavior
change-based strategy, ideally involving high level political
commitment and a diverse spectrum of community-based participation, may
be the most effective prevention approach.
SOURCES
1. Edward C Green, Ph.D. ``What happened in Uganda?'' [Powerpoint
presentation]; ``What are the lessons from Uganda for AIDS prevention?
[10-page document]. Presentation to USAID, Washington DC, Feb. 5, 2002.
2. Vinand M Nantulya, M.D., Ph.D. ``HIV/AIDS prevention: Policy and
program context of Uganda's success story'' [Powerpoint presentation].
Presentation to USAID, Washington DC, Feb. 5, 2002.
3. John Stover, Ph.D. ``The effects of behavior change on trends in
HIV incidence in Uganda and Kenya'' [Powerpoint Presentation].
Presentation to USAID, Washington DC, Feb. 5, 2002.
4. Rand Stoneburner, Daniel Low-Beer, Tony Barnett, Alan Whiteside.
``Enhancing HIV prevention in Africa: Investigating the role of social
cohesion on knowledge diffusion and behavior change in Uganda.''
Presentation at the World AIDS Conference, Durban, South Africa, July
2000; also presented at the World Bank, October 2000, and at USAID,
Washington DC, February 2002.
5. Elizabeth Marum & E. Madraa. ``A decade of an effective national
response to AIDS: A review of the Ugandan experience.'' Draft ms.,
1999.
6. SM Mbulaiteye, C Mahe, JAG Whitworth, et al. Declining HIV-1
incidence and associated prevalence over 10 years in a rural population
in south-west Uganda: A cohort study. Lancet 2002;360:41-44.
7. S Agha. Declines in casual sex in Lusaka, Zambia: 1996-1999.
AIDS 2002;16:291-93.
Summary produced by Jan Hogle, Ph.D., Synergy Consultant.
Senator Alexander. Thank you, Dr. Peterson, and thank you
for your service. It is helpful to have someone with as much on
the ground experience as you have had with this.
I have a few questions and I know Senator Feingold will
have some and then I may have a couple more on a little
different subject. I would like to talk with you for a moment
about--and you referred to both of these--will the ABC approach
work in other African countries? And then, then the more
practical question of just how you go about implementing the
model.
Let me begin with the ``will it work'' point. You referred
to several factors, but Mrs. Museveni last week here referred
often to self-control in the remarks I heard her make. You
mentioned that. And she said that, what you also said, which is
the abstinence part, the A part, which she starts with and
gives more emphasis to, although she does encourage strongly
the B and the C, she says that fits the Ugandan culture. She
basically said, in not so impolite words, that until the
foreigners came in and began messing up behavioral patterns in
Uganda, things were better in this respect.
No. 1, how true is that? In your own experience, how much
does abstinence fit the Ugandan culture for children? And No.
2, is Uganda unique in that respect among African countries and
does that mean that this model does not fit other countries
quite so neatly?
Dr. Peterson. Thank you. I think there has been a change in
African cultures, and I am sure Sophia can say many more things
about that. But most of the cultures do very highly regard
abstinence in their cultural traditions. There are a few
examples that are slightly different than that in sort of
exceptional cases or with the Masai coming-of-age rites. But
for the most part, abstinence and faithfulness is a cultural
norm and, just as our own society went through a revolution and
a sort of loosening of morals, African culture did as well.
So when the call came for abstinence and ``zero grazing,''
it was very much based on coming back to your African roots.
Zero grazing is where you put a stake in the ground and you tie
your cow to it and he grazes just around that stake. That zero
grazing in their agricultural society means to them the same
thing: Put your stake in the ground for your marriage and you
graze only within that household. So it resonated very much
with the cultural norms and bringing them back to their
cultural roots.
As far as whether it is appropriate for other countries, I
would say, in all of the other countries that I have been in,
yes, that they have that same cultural norm. It will be pulling
them back to that cultural norm.
The other thing we need to remember is that most of the new
infections, 50 to 69 percent of new infections, are with the
young people, 15- to 24-year-olds, where abstinence is a very
appropriate message to bring and the delay of onset of sexual
activity. So if we are truly going to turn the epidemic around
in a country, we do need to focus on what is best for the youth
of that country. Uganda has really found a good balance and
that is, as she said, abstinence was No. 1. Once you are
married, be faithful, but they have also been very good at
reducing the number of partners if they were outside of the A
and B norms. But then using condoms also in the casual sex.
So they have heard all three parts and Uganda has done an
amazing job of implementing all three parts.
Senator Alexander. In a letter that Mrs. Museveni wrote to
Senator Lugar, the chairman of our committee, April 2, which I
will put in the record and share with Senator Feingold,
although he may have seen it, she says: ``My experience has led
me to conclude that when dealing with young people especially,
it is vitally important to emphasize abstinence as the first
line of defense, so to speak.'' She also points out in her
letter the importance of B and C in the ABC formula.
[The letter referred to follows:]
The Republic of Uganda
State House, P.O. Box 25497
Kampala, Uganda, 2nd April, 2003
The Honorable Richard G. Lugar,
Chair
Senate Foreign Relations
United States Senate
Washington, DC 20510
Dear Honorable Lugar,
Re: GLOBAL AIDS SENATE BILL
We in Uganda are very pleased and grateful for the leadership that
the United States of America has shown as far as the struggle against
HIV/AIDS, Tuberculosis and Malaria is concerned. We believe that the
commitment of the Bush Administration to this cause is genuine, as
proven by the sizeable funding it has recently made available for the
purpose of supporting developing nations hit by those killer diseases.
I have been made to understand that the Global AIDS Bill is soon
coming before the Senate, and that the important issue of preferred
methods of prevention of HIV is likely to be a point of contention. I
note that one of the approaches to prevention is now being referred to
as the ``Uganda ABC model,'' namely ``Abstain, Be Faithful, Use
Condoms,'' in that order of preference.
I feel that I should shed some light on the issue of preventive
measures against HIV/AIDS, since I have had first hand experience in
activities of behaviour change in Uganda for over a decade. My
experience has led me to conclude that, when dealing with young people
especially, it is vitally important to emphasize Abstinence as the
first line of defence, so to speak.
I believe that we humans have an innate mechanism called
conscience, which convicts us concerning what is wrong and what is
right, or what is good for our survival and what is harmful. It is this
mechanism that society builds on to form certain norms and value
systems to ensure the survival and continuity of it's people. When
dealing with a disease such as HIV/AIDS which has no known cure, it is
important to tap into this in-built sense of right and wrong and
encourage it, particularly in young people who have not yet become set
in their habits or behaviour patterns. I cannot help but recall the
verse in the Bible which says, ``Train a child in the way that he
should go, and when he is old he will not turn away from it.''
(Proverbs 22:6)
And so, for the young, I believe it is our obligation to try to
form their character by teaching them the benefits of abstaining from
sex until they are ready to engage in it in the right context and with
the right partner. Not to do this, to me, implies that we as adults and
leaders have no faith in human nature and in our ability as human
beings to control ourselves. How then are we going to prevent our young
people from indulging in other practices such as excessive intake of
alcohol, substance abuse, stealing, and killing other human beings? How
are we going to teach them to be law-abiding citizens if we do not
train them to exercise self-control while they are still young? Human
beings must learn to police themselves internally; this is the first
safeguard of civilization. This is the wisdom of the ages, and we
ignore it at our own peril. Incidentally, I must mention that even
before Christianity came to Uganda, promiscuity, specifically sex
before marriage was severly punished; therefore in teaching abstinence
to our children, we are also reinstating our cultural practices and
traditions. A culture of promiscuity is, literally, a culture of death
to the human race.
The practice of being faithful in marriage relationships then
follows quite naturally when you have been practicing abstinence, and
there is no need to elaborate on this.
We in Uganda have not advocated against the use of condoms as a
method of prevention against HIV/AIDS. Condoms are freely available in
all appropriate public places, freely and continuously advertised in
our electronic and print media. Indeed they are even to be found in the
remotest of our villages.
However, my husband and I belong to the school of thought that
maintains that our preferred method of prevention for certain
catagories of our population, particularly the young, is Abstinence and
Faithfulness in sexual matters. We have seen it work in Uganda, and I
would strongly advocate that it be considered as the method that, in
the long run, is likely to be the most beneficial.
This is my humble opinion, based on 15 years of hands-on-experience
in combating the killer disease, HIV/AIDS. I hope it can be transmitted
to the august assembly of the Senate of the United States of America as
they deliberate these issues, which are critically important to our
populations.
Sincerely,
Janet K. Museveni (Mrs)
Senator Alexander. As I understand USAID policy, the
emphasis has shifted somewhat from a focus, more of a focus on
condoms, to more of a primary focus on abstinence, still
recognizing the importance of the B and C part of the formula.
Can you describe that shift of policy, if indeed there has been
a shift?
Dr. Peterson. I think this is part of the balanced approach
and being able to shift the balance based on what you know,
what you have learned, and on the specific country. For a long
time we did not have data on abstinence, and within the public
health community it was extraordinarily controversial. Senator
Feingold pointed out that many of these issues have become very
political at times. What I hope is to find the middle ground
that everyone can agree to.
What has happened in the last few years is we are getting
more and more data that supports abstinence as a public health
intervention, not just as a philosophy or a moral mandate, but
as a data-based public health intervention. The question
initially, everyone said was: Yes, if you could get people to
abstain, of course that would help reduce transmission of
disease, but would youth ever do that? Would they ever wait?
What we are seeing, and I have seen it on the domestic
front in teen pregnancy prevention programs as well as in
Uganda and now in a number of other countries, is that with
full education and really understanding the issues, you can
wait, and they will wait. They will choose to wait, and
therefore it is truly a public health intervention that can be
used in HIV-AIDS programs successfully.
Senator Alexander. My last question in this round is: After
we get beyond the model and the talk and the legislation,
somebody has to spend the money and make things work. How do
you take a model like this into some country other than Uganda
and make it work? What exactly do you do? What steps do you
take? How do you go about that?
Dr. Peterson. First certainly is to know the situation in
that country, both the distribution of AIDS, the age groups at
risk, whether it is what we call a concentrated epidemic, which
would be more like the Cambodia/Thailand, or, as in the
Presidential initiative countries, a more generalized epidemic.
Look at the age spectrums and the routes of exposure.
Then you really need people and partners who are in the
country who then can look at how much abstinence: Are we
reaching a youth group or are we reaching married families with
too many partners? Or is it really being primarily moved along
by high-risk sexual activity of prostitutes and their clients?
Once you have done that, then you go to the partners who
know how to work with those groups, with the in-country
experts. We have examples of programs in many different
countries, both on abstinence--our Zambia program is social
marketing of abstinence. We have worked in policy change,
quality assurance, voluntary counseling and testing.
The elements are all there. What you have to do is take all
of those elements that have been supportive to the ABC message,
find the political leaders, the faith-based leaders, and engage
as many different sectors of society as possible to address the
issues in their own cultural and epidemiological priorities.
Senator Alexander. Thank you.
Senator Feingold.
Senator Feingold. Thank you, Mr. Chairman. I found your
line of questioning there to be very helpful and very much
along the lines I want to pursue.
I would like to ask you a little bit more about this point
that Senator Alexander was just asking you about, the
differences from country to country. I noticed your answer
essentially talked about looking at the same factors in each
country and trying to adapt it to the country, but it is my
sense, having visited 14 or 15 African countries and having
tried to talk about AIDS or visiting an AIDS program in each of
those countries, that each of those countries is not the same
culturally. I am not suggesting you said that, but I think
there are significant differences within the traditional
cultures. There are also significant differences because of the
different religious and colonial influences that occurred in
the countries.
In fact, I have been struck by, for example, the difference
in the willingness to talk about the disease in different
places. So I guess I would like to pursue a little more
specifically: How do you account for the differences between
countries? Are there religious differences? For example, there
was a very successful program in Senegal to prevent AIDS from
ever getting out of control. That is a largely Islamic country
and Uganda of course is a country that has a significant
Christian population and traditional religions.
I am just wondering if you are able to take that into
account and if it affects people's willingness to address A, B,
and C.
Dr. Peterson. Yes, I think there are significant
differences. In Botswana it is utterly amazing that they have
both some political leadership speaking about AIDS, they have a
good health system for Africa, they have been making treatment
available, and yet stigma has been an incredible stumbling
block, and they are still not getting people to come in. In
South Africa violence is an underlying factor that is
dominating a lot of the response there.
What we have to do is talk to the people who have been
working and how they have tried to overcome some of the
problems. In Haiti, which traditionally is one of those
countries that does not do very well and has never had the
political voice, I went to an area, Jeremie on the South
Peninsula. There was a physician who had mobilized the
political leaders, the religious leaders, and the civil
leaders. It is the only place that I have been to recently--and
I have not been to Uganda in the last few years--where there
was no stigma.
At least one of the unifying factors seems to be that
political or social voice that allows the disease to be talked
about that says: We will care for you. And Uganda was really
remarkable about this. Mrs. Museveni talks a lot about
responsibility and self-control, which sometimes is seen as
negative, but immediately following that call to responsibility
she says: But if you are HIV-positive, we will take care of you
and we will take care of your children. And they have overcome
stigma there.
We have seen it in Haiti.
So I think we need to be very specific in our analysis of
the problems. There are unifying factors. We know that we need
to get all sectors involved. We know we need to deal with
stigma. We know we need to deal with youth. And we put
relatively different amounts of effort into the problems that
are the biggest barriers in that particular country.
But all of the elements were there in Uganda, and they are
there in other countries as well. We are going to learn new
responses in some other countries. The business sector is new
in South Africa. In some place or another, we are going to have
to learn how do we overcome the violence that is a problem?
South Africa is beginning to overcome some stigma by
providing grants that are disability grants, and suddenly
people are willing to come in to be tested who were not before.
That is a novel way of overcoming stigma. So we need to keep
learning lessons, but we can also use what we have learned in
Uganda and apply the pieces that fit for each country.
Senator Feingold. I appreciate that answer, because on a
recent trip to Botswana and South Africa there was so much
conversation about situations involving older men and younger
women. Essentially younger women were being put in a position
where--I do not know if it was completely involuntary.
Certainly in some cases it was. But you know, that is not an
abstinence issue.
So I would suggest that as the policy tries to create the
proper balance between A, B, and C--I think you are already
aware of this--that the places in which the shift to focusing
more on abstinence would be a certain number of places, but not
necessarily every place, given the very points that you just
made about, for example, violence in South Africa. I am not at
all sure that abstinence is as relevant to that as it is to
some of the issues that occur in other places.
Obviously, this is what you do, but that is just a point I
would like to make.
What kind of information should be available at a voluntary
counseling and testing center? For example, what if a man comes
in and gets tested and tests positive? What would he learn? And
if he returns bringing his spouse and she tests negative, what
kind of counseling and information will the couple get?
Dr. Peterson. Very good questions. Before he tests
positive, he should have had pre-test counseling which should
have covered the disease, the test itself, and the likelihood
of testing positive, the windows where it might test negative,
how it is transmitted, and what it might mean if he tests
positive for himself.
After the test comes back, we actually do a lot of
counseling for those who are HIV-negative, not just for those
who are HIV-positive, and it has been shown that post-test
counseling for HIV-negative has also been very helpful in
behavior change. Presumably they are coming in because they
have put themselves at risk. So we are seeing changes in
behavior post-counseling even if they are negative.
If they are HIV-positive, then certainly they will learn
about the disease, the progression of the disease, how they can
keep themselves healthy as long as possible, and their
responsibility to not pass the disease on.
If you have what we call a discordant couple--HIV-positive,
usually husband, and then an HIV-negative spouse--then
certainly they have two options. They either abstain, which
some couples actually do, or use condoms. We have studies in an
African setting that show correct, consistent, every single
time use can protect the uninfected partner, and they would be
recommended to do that very diligently.
I would like to go back to the gender issue, the young
girls, and say that I agree completely. You have in your
handout my favorite slide that I used for teaching in schools
in Zimbabwe with the older man and the younger girl. I think
this is an element we really need to again delve deep into the
Uganda story. The fact that the young girls in Uganda did have
a delay in onset of sexual activity, that they were able to
stay virgins longer, means there has been a change in this
situation. Either the girls have been given the power to say no
or the men's activities have changed, probably both.
But we need to know how that very deep cultural change has
happened. So those are the kinds of issues we will continue to
look at very strongly. I see it as the backdrop to the ABC. It
is one of those elements that supports the AB--you cannot just
say abstain. What we have to do, especially for youth that are
so critical, is say how can you abstain, how are you going to
have the ability, the authority, to protect yourself?
That is true for wives as well. I used to have Kenyan wives
come and say: My husband is coming home from Nairobi, I know he
has that disease; what can I do to protect myself? And in 1986,
1987 in Kenya, I did not have anything that I could do for her.
Senator Feingold. Well, I appreciate that as well, because
in a sense, at least in some contexts, the abstinence is really
a good consequence of empowering women or young girls to
protect themselves. It is not actually the solution. It is the
result of allowing women to make their own choices and to have
the legal power and other powers to avoid something they may
not want or may not be ready for.
So I think that needs to be a part of the analysis. I have
found an awful lot of women talking about that element of it.
That is really the driving force, giving women the power to
protect themselves.
One of the concerns that has been voiced about abstinence-
only programming is the concern that unless that programming is
supplemented with other information when abstinence fails,
individuals have no information about how to protect
themselves. Other concerns center on the possibility that some
may seek to discourage promiscuity by arguing that condoms do
not work, thereby discouraging people from bothering to use
them when they do actually begin a sexual relationship.
Will USAID work to ensure that to the extent possible
communities have access to complete and accurate information
about prevention strategies?
Dr. Peterson. The short answer is yes, very strongly. I
worked in an abstinence-only program in Zimbabwe in the
schools, but we gave youth full information about their sexual
development, about the disease, about how they could protect
themselves. Many of the faith-based organizations have said,
can we talk about condoms, and this is in an abstinence-only
kind of setting, and give the data on how effective condoms
are.
So there are some that are uncomfortable talking about it
at all and there are others--and what I have said would be our
policy--if they are to talk about condoms then they must be
absolutely scientifically accurate. With a group that we are
working with actually on either side of the debate, what we
would want to have is accuracy in what they teach the children.
And we have good data that condoms are protective. Is it
perfect? No. But we have good data that condoms are protective
and therefore that they play a role. We are very comfortable
having all of our partners do that.
Senator Feingold. Well, I appreciate your very reasonable
answers and your willingness to get into some depth on them.
Thank you, Mr. Chairman.
Senator Alexander. I have a couple of questions and then I
will go back to Senator Feingold, and then we will go to our
second panel.
My first question is to go back to this AIDS Corps idea.
What I am really trying to do here is understand the idea well
enough to move it on down the path, recognizing, as Senator
Feingold pointed out, that a lot of people have this idea. The
President in his speech in the East Room a couple of weeks ago
turned around to the Peace Corps Director at the end of the
speech and said: ``Now, Mr. Peace Corps Director, I want you to
go to work on this idea.''
As I looked at the House bill that we passed last Thursday
night, I saw three things about it that if I were in a magical
world I would have changed with a sweep of the wand, and I
wonder what you might think about this. One is I like the name
``AIDS Corps'' because I would like to focus. I think it gives
a focus to the idea.
Two is I would like to put training for treatment ahead of
treatment. In other words, my sense of things is that there is
a real demand for volunteers or employees from this country who
can go to African countries, as an example, and train people to
treat people.
A third point is I would like to see the time limitation
for that more flexible. I believe the legislation we enacted
said 3 years. There are organizations in this country of health
professionals and physicians who regularly go to other parts of
the world for shorter periods of time and do a lot of good.
They go all over the world. I am wondering whether if we could
not make it easier for health professionals and doctors to go
to Uganda, Botswana, wherever, for a month or 2 months or 3
months and fit into a program where they could train people to
treat people and then come home, whether that is a practical
idea.
Then the last change I would make would be to try to avoid
the medical malpractice issues that might arise with any sort
of treatment, to put these, these persons, these health
professionals from the United States, say, who might go to an
African country to train people, if they do incidental
treatment and incur some sort of liability that they would be
under the same set of circumstances that a Federal employee
would be under the Tort Claims Liability Act.
Now, anything you might say about this general idea would
be useful to me and the committee, I think, as we look ahead to
take an idea of many Senators and the President and push it
forward.
Dr. Peterson. Clearly, especially with the passage of the
emergency AIDS bill and the Global Fund, we are getting to the
point where we have got a fair amount of dollar resources. It
is very soon that we are going to have what we call human
capacity, the people as the limiting factor. We have an
expanding epidemic, with more people at risk. We have a
contracting number of health personnel because, frankly, they
are as devastated by the disease as others.
When I was in Zimbabwe, my husband trained the higher level
Ministry of Health people, and a third of the 20 or so people
he trained are now dead. So human capacity is going to be one
of the biggest limiting factors. Before you can just go and do,
you truly should be training. So I agree with you completely
that training needs to be first.
The Peace Corps is absolutely marvelous. They are more
likely to be the ones to do this, and in fact are doing really
wonderful, community-based training in many places, but that is
going to be mostly on the prevention end. When you get to the
clinical and treatment piece, then, as you said, there are many
groups that are already experienced medical professionals. The
only thing that I would have liked is experience, international
experience, as one of the criteria, because that is what would
lead us to being able to be more flexible about how long they
went.
If they already had experience in similar countries, then
they would be much more able to get up to speed quickly and
make sure that they were training appropriate for that country,
and not just trying to transfer our technology.
As we have been looking at this problem, both within the
agency overall, but also together with HHS and other USG
agencies on the mother-to-child transmission, we have been
looking at this idea of a medical volunteer corps. At least
initially, we were going to try and embed that volunteer
medical corps within a twinning program where a U.S.
institution is twinned with an African or Caribbean institution
so they have an ongoing relationship and the volunteers are
within those institutions and go back and forth.
So we are very supportive. We have been working very hard
on this. I think this is one part of how we begin to deal with
the human capacity issue. But we also need to do lots more
training, as well as deal with systems issues like brain drain
that are causing this to be such a difficult problem in many of
the countries hardest hit by AIDS.
Senator Alexander. Senator Feingold, do you have more
questions?
Senator Feingold. No, thank you.
Senator Alexander. Dr. Peterson, thank you very much.
May I invite our next two witnesses to come forward while I
introduce them.
I would like to welcome to the hearing Dr. Edward Green and
Ms. Sophia Mukasa Monico. Dr. Green is the senior research
scientist at the Harvard Center for Population and Development
Studies. He is a medical anthropologist with 30 years
experience in developing countries, one of the leading
authorities in academia on the Ugandan success story in the
application of the ABC model.
Ms. Mukasa Monico is a Uganda. She is currently the senior
AIDS program officer with the Global Health Council here in
Washington, DC. She is a leading human rights and AIDS activist
from Uganda. She has formerly led the AIDS Support Organization
of Uganda, a leading civil society organization.
May I suggest Dr. Green first and Ms. Monico second, if you
could keep your remarks to about 10 minutes or less, and then I
and Senator Feingold will have questions for both of you. Thank
you for coming.
STATEMENT OF EDWARD C. GREEN, PH.D., SENIOR RESEARCH SCIENTIST,
HARVARD CENTER FOR POPULATION AND DEVELOPMENT STUDIES,
CAMBRIDGE, MA
Dr. Green. Thank you, Senator Alexander, distinguished
members of the Africa Subcommittee. I am an anthropologist
working at the Harvard School of Public Health. For most of my
professional career I have worked in less developed countries
as a behavioral science researcher and as a designer and
evaluator of public health programs. I have worked extensively
in Africa and other resource-poor parts of the world. A good
deal of my work has focused on reproductive health, some of
this including the social marketing of contraceptives.
I applaud the President's initiative to commit major U.S.
funding to address HIV-AIDS in the parts of the world with the
highest infection rates. I am also glad that notice has been
taken of Uganda's success in AIDS prevention since there is
much to be learned from the country that has had the greatest
amount of AIDS prevalence decline. Infection rates have
declined from 21 percent to 6 percent. We have also heard the
figure 15 to 5 percent. It depends on whether you do a
weighting for rural-urban residents.
The Government of Uganda, led by President Museveni,
developed a distinctive approach to AIDS prevention known as
the ABC approach: abstain, be faithful, or use a condom. The
abstinence message for the most part took the form of urging
youth to delay having sex until they were older, preferably
married. Many of us in the AIDS and public health communities
did not believe that abstinence and faithfulness were realistic
goals. It seems now that we were wrong.
Uganda's ABC AIDS program began in 1986, the year Museveni
became head of state. Since the rate of new infections began to
decline in the late 1980s, incidence rates, it becomes
important to know what programs were in place at that time and
what behaviors changed in order to account for the decline of
infection rates.
None of the standard programs we associate with AIDS
prevention--condoms, social marketing, voluntary counseling and
testing, treatment of sexually transmitted diseases, and most
recently prevention of mother to child transmission based on
the drug nevirapine--were in place in the 1980s. I am certainly
not saying that these standard biomedical interventions are not
useful, only that we need to look at what interventions were
actually in place when infection rates began to decline.
It is also important to work backward from the
epidemiological and behavioral data. We know that prevalence
decline and changes in sexual behavior were most pronounced in
youth age 15 to 19. These findings took many of us by surprise
since we believed that teenagers are driven by raging hormones,
therefore abstinence is an unrealistic or impossible objective.
In fact, many of us also believed that women had no power to
negotiate sex or to refuse unwanted sex or to insist upon
condom use because African societies are male-dominated.
In spite of these legitimate concerns, based on real
cultural patterns, Uganda designed interventions aimed at
fundamentally changing sexual behavior, something the standard
interventions just listed do not attempt. The primary target
audience was youth. Let me provide two examples of
interventions that were among the first developed by Uganda.
One is the youth program which was and is national in scope.
The second example involves faith-based organizations.
The program to introduce AIDS education in Ugandan primary
schools began in 1987, starting with the School Health
Education Program, or SHEP, of the Ministry of Education. The
aim of this program was to teach youth with AIDS prevention
information, reach youth with this information, before they
became sexually active. It was also known that the dropout
rates after primary school were high.
AIDS was not the only component of SHEP, but it was an
important one. The behavior change emphasis was on delay of age
of first sex, but education about condoms was also part of the
program.
To implement the new program there was a training of
trainers approach that went from the district level down to
sub-districts, then to teachers, who were the ones who taught
students. Students themselves were trained as peer educators
and they were expected to teach their parents and friends about
AIDS. This was all done in a relatively short time. The basic
facts about AIDS and how to prevent it were taught.
So-called life skills education also has been taught in
Ugandan schools for a number of years beginning in about 1987.
Life skills might be regarded as AIDS Education 102, which
comes after the basic course in what AIDS is and how it is
transmitted and prevented. Life skills refers to training youth
in skills such as interpersonal relationships, self-awareness
and self-esteem, problem-solving, effective communications,
decisionmaking, negotiating sex or not having sex, resisting
peer pressure, critically thinking, formation of friendships,
and empathy. These are referred to as cognitive skills and they
seem to help youth make healthy and indeed life-saving
decisions.
Did this and similar programs have impact? According to
studies by the World Health Organization, the proportions of
young males age 15 to 24 reporting premarital sex decreased
from 60 percent in 1989 to 23 percent in 1995. For females the
decline was from 53 percent to 16 percent.
The take-home message for the U.S. Senate is that, while
condoms were part of the education for youth, the emphasis was
on persuading children to postpone sexual activity until they
were older, until they were married.
In addition to the national statistics already cited, we
have some findings concerning the impact of a school-based AIDS
education program in Soroti District, a program that benefited
from additional inputs from an East African nongovernmental
organization called AMREF. Baseline and followup studies of
primary 7 students, which is age 13 through 16, but mostly
around age 14, showed that as an apparent result of the school
AIDS prevention program self-reported sexual activity among
boys dropped from 61 percent for the class of 1994 to 5 percent
for the class of 2001, while in girls the change was of similar
magnitude, from 24 percent in 1994 to 2 percent in 2001. Some
evidence other than self-reported findings corroborate these
remarkable data, and I have some figures in the paper that has
been handed out.
Now to the faith-based example. Some other early efforts
involve faith-based organizations or FBOs. In 1992 USAID
allocated funds for three major religious groups in Uganda--
Catholic, Anglican, and Muslim. Each developed an AIDS
prevention project and each received roughly a third of a
million dollars from USAID. The FBOs said at first that they
wished to promote fidelity and abstinence rather than condoms.
At the time many working in AIDS prevention thought that
fidelity and abstinence promotion would lead to few, if any,
measurable results. Nevertheless, USAID made the grants and
only asked that the FBOs not criticize condom promotion by
other groups. This was agreed to and adhered to.
In the months to follow there were few, if any, problems
over condoms. In fact, before long there was some condom
promotion by two of the projects.
All three projects were found to be successful. The
experience of the Muslim project, IMAL, has been published as a
U.N. AIDS so-called best practices paper. So I will say a
little bit more about the Anglican church project because it is
less well known. This program was implemented in 10 out of 40
districts in Uganda at the time, meaning that the project had
relatively large coverage. Clergy and laity were trained in
AIDS prevention using the peer education approach. AIDS
education messages were delivered from the pulpit in sermons as
well as at funerals, weddings, and other occasions.
A USAID-funded evaluation of sexual behavior change among
those reached by this project was conducted in 1995. It found
that those reporting two or more sexual partners declined from
86 percent to 29 percent for men and from 75 percent to 7
percent for women. Ever-use of condoms rose from 9 percent to
12 percent in the same period.
These findings underscore that in Uganda reduction in the
number of sexual partners was probably the single most
important behavior change that resulted in prevalence decline.
Abstinence was probably the second most important change. Why
do I say this? We measured both behavior and HIV prevalence
through surveys of people age 15 through 49. Most people in
these age groups are married, especially in Africa, where the
age of marriage is relatively young, and therefore sexually
active. This is why Uganda's main message directed at the
majority population was ``zero grazing,'' meaning being
faithful to one partner. Fidelity to one partner also seems to
have been the main response to the epidemic, if not to Uganda's
prevention program.
When Ugandans were and are asked in surveys what is the
main thing they have done to avoid AIDS, faithfulness to one
partner is the first and overwhelming response in all age
groups except 15 to 19, among whom the first answer is
abstaining or delaying, closely followed by fidelity to one
partner.
Unfortunately, the American political debate over
abstinence versus condoms has contributed to monogamy or
partner reduction being somewhat overlooked. It is very good
that the United States through USAID has adopted the new ABC
policy for those countries with generalized epidemics, that is
epidemics where most HIV is found in the general population
rather than in distinct high-risk groups. This policy should
guide the development of programs in Africa and the Caribbean
funded under the President's initiative.
Indeed, there are other countries in these regions that
have implemented ABC approaches and they have achieved measures
of success--Senegal, Zambia, Jamaica, and the Dominican
Republic.
My concern is that the ABC from Uganda be recognized for
what it actually is, a comprehensive approach to AIDS
prevention that recognizes that people are different and
therefore a range of behavioral options for AIDS prevention
needs to be presented, not just one or two. It should be
remembered that ``zero grazing'' or remaining faithful to one
partner was the main message for the majority of Uganda's
population.
The reason I must say ``was'' is that Uganda's AIDS
prevention program has gradually changed, perhaps due to the
funding priorities of foreign donor organizations. Since the
mid-1990s there has been less emphasis on sexual behavior and
more on medical solutions. In recent years there has been a
small but disturbing trend toward riskier sexual behavior and
for the first time in a decade there has been a slight up tick
in national infection rates. The distinctive Ugandan ABC model
of the earlier period, the one developed primarily by Ugandans
for Ugandans, is the one that seems to have worked the best and
the one that probably has the most to teach the rest of the
world. Thank you, Senators.
[The prepared statement of Dr. Green follows:]
Prepared Statement of Edward C. Green, Ph.D., Senior Research
Scientist, Harvard Center for Population and Development Studies,
Cambridge, MA
Thank you, Senator Alexander and distinguished members of the
Africa subcommittee. I am an anthropologist working at the Harvard
School of Public Health. For most of my professional career, I have
worked in less developed countries as a behavioral science researcher
and as a designer and evaluator of public health programs. I have
worked extensively in Africa and other resource-poor parts of the
world. A good deal of my work has focused on reproductive health, some
of this including the social marketing of contraceptives.
I applaud the President's Initiative to commit major U.S. funding
to address HIV/AIDS in the parts of the world with the highest
infection rates. I am also glad that notice has been taken of Uganda's
success in AIDS prevention, since there is much to be learned from the
country that has had the greatest amount of HIV prevalence decline.
Infection rates have declined from 21% to 6% since 1991 [Fig. 1].
The Government of Uganda, led by President Museveni, developed a
distinctive approach to AIDS prevention known as the ABC approach:
Abstain, Be faithful, or use Condoms if A and B are not practiced. The
abstinence message for the most part took the form of urging youth to
delay having sex until they were older, and preferably married. Many of
us in the AIDS and public health communities didn't believe that
abstinence and faithfulness were realistic goals. It now seems we were
wrong.
Fig. 1.
Uganda's ABC AIDS program began in 1986, the year Museveni became
head of state. Since the rate of new infections began to decline in the
late 1980s, it becomes important to know what programs were in place at
that time and what behaviors changed in order to account for the
decline of infection rates. None of the standard programs we associate
with AIDS prevention:
Condom social marketing;
Voluntary counseling and testing (VCT)
Treatment of STDs
And most recently, prevention of mother-to-child transmission (PMTCT,
based on the drug nevirapine)
were in place in the 1980s.
I am certainly not saying that these standard, biomedical
interventions are not useful, only that we need to look at what
interventions were actually in place when infection rates began to
decline. It is also important to work backwards from the
epidemiological and behavioral data. We know that prevalence decline
and changes in sexual behavior were most pronounced in youth age 15-19.
These findings took many of us by surprise, since we believed that
teenagers are driven by ``raging hormones,'' therefore abstinence is an
unrealistic or impossible objective. In fact, many of us also believed
that women had no power to negotiate sex, or to refuse unwanted sex, or
to insist upon condom use, because African societies are male-
dominated. In spite of these legitimate concerns based on real cultural
patterns, Uganda designed interventions aimed at fundamentally changing
sexual behavior, something the standard interventions just listed do
not attempt. The primary target audience was youth.
Let me provide two examples of interventions that were among the
first developed by Uganda. One is a youth program which was and is
national in scope. The second example involves faith-based
organizations.
THE SHEP PROGRAM
A program to introduce AIDS education in Ugandan primary schools
began in 1987, starting with the School Health Education Program (SHEP)
of the Ministry of Education. The aim of this program was to reach
youth with AIDS prevention information before they become sexually
active. It was also known that dropout rates after primary school were
high. AIDS was not the only component of SHEP, but it was an important
one. The behavior change emphasis was on delay of age of first sex, but
education about condoms was also part of the program.
To implement the new program, there was a ``training of trainers''
approach that went from the district level, down to sub-districts, and
then to teachers, who were the ones to taught students. Students
themselves were trained as peer educators, and they were expected to
teach their parents and friends about AIDS. This was all done in a
relatively short time. The basic facts about AIDS and how to prevent it
were taught.
So-called Life Skills education has also been taught in Ugandan
schools for a number of years, beginning in about 1987. Life Skills
might be regarded as AIDS Education 102, which comes after the basic
course in what AIDS is and how it is transmitted and prevented.
Life Skills refers to training youth in such skills as
interpersonal relationships, self awareness and self esteem, problem
solving, effective communication, decision-making, negotiating sex or
NOT having sex, resisting peer pressure, critical thinking, formation
of friendships, and empathy. These are referred to as cognitive skills
and they seem to help youth make healthy and indeed life-saving
decisions.
Did this and similar programs have impact? According to studies by
the World Health Organization, the proportion of young males age 15-24
reporting premarital sex decreased from 60% in 1989 to 23% in 1995. For
females, the decline was from 53% to 16%.
The take-home message for the U.S. Senate is that while condoms
were part of AIDS education for youth, the emphasis was on persuading
children to postpone sexual activity until they were older, until they
were married. In addition to the national statistics already cited, we
have some findings concerning the impact of a school-based AIDS
education program in Soroti District, a program that benefited from
additional inputs from an East African NGO called AMREF. Baseline and
follow-up studies of Primary 7 pupils (age 13-16) showed that as an
apparent result of the school AIDS prevention program, self-reported
sexual activity among boys dropped from 61% for the class of 1994 to 5%
for the class of 2001, while in girls the change was of similar
magnitude, from 24% in 1994 to 2% in 2001 [Fig. 2]. Some evidence other
than self-reported findings corroborate these remarkable data. [Fig. 3]
(AMREF/Uganda. (2001; Nantulya 2002).
THE ANGLICAN CHURCH PROJECT
Some other early efforts involved faith-based organizations (FBOs).
In 1992, USAID allocated funds for three major religious groups in
Uganda: Catholic, Anglican and Muslim. Each developed an AIDS
prevention project and each received roughly $350,000 from USAID. The
FBOs said at first that they wished to promote ``fidelity'' and
``abstinence'' rather than condoms. At the time, many working in AIDS
prevention thought that fidelity and abstinence promotion would lead to
few if any measurable results. Nevertheless, USAID made the grants and
only asked the FBOs to not criticize condom promotion by other groups.
This was agreed to and adhered to. In the months to follow there were
few if any problems over condoms, in fact before long, there was some
condom promotion by two of the projects.
All three projects were found to be successful. The experience of
the Muslim project has been published as a UNAIDS so-called Best
Practices paper. I will say a bit more about the Anglican project since
it is less well known. This program was implemented in 10 out of 40
districts of Uganda, meaning the project had relatively large coverage.
Clergy and laity were trained in AIDS prevention, using the peer
education approach. AIDS education messages were delivered from the
pulpit in sermons, as well as at funerals, weddings, and other
occasions.
A USAID-funded evaluation of sexual behavior change among those
reached by this project was conducted in 1995. It found that those
reporting two or more sexual partners declined from 86% to 29% for men,
and from 75% to 7% for women (Lyons 1996:8-9). Ever-use of condoms rose
from 9% to 12% in the same period [Fig. 4].
These findings underscore that fact that in Uganda, reduction in
the number of sexual partners (mutual monogamy, also reduction in
partners among the minority of core transmitters reporting 3 or more
partners) was probably the single most important behavioral change that
resulted in prevalence decline. Abstinence was probably the second most
important change (see Green 2003 and Hogle et al 2002 for more
supporting data).
Why do I say this? We measure both behavior and HIV prevalence
through surveys of people age 15-49. Most people in these age groups
are married (especially in Africa, where age of marriage is relatively
young) and sexually active. This is why Uganda's main message, directed
at the majority population, was ``zero grazing,'' meaning being
faithful to one partner. Fidelity to one partner also seems to have
been the main response to the epidemic, if not to Uganda's prevention
program. When Ugandans were (and are) asked in surveys what is the main
thing they have done to avoid AIDS, faithfulness to one partner is the
first and overwhelming response in all age groups except 15-19, among
whom the first answer is abstaining or delaying, closely followed by
fidelity to one partner.
Unfortunately, the American political debate over abstinence versus
condoms has contributed to monogamy or partner reduction being
overlooked. It is very good that the United States through USAID has
adopted a new ABC policy for those countries with generalized
epidemics, that is, epidemics where most HIV is found in the general
population rather than in distinct, high-risk groups. This policy
should guide the development of programs in Africa and the Caribbean
funded under the President's Initiative. Indeed, there are other
countries in these regions that have implemented ABC approaches, and
they have also achieved measures of success: Senegal, Zambia, Jamaica,
and the Dominican Republic.
My concern is that the ABC model from Uganda be recognized for what
it actually is: a comprehensive approach to AIDS prevention that
recognizes that people are different and therefore a range of
behavioral options for AIDS prevention needs to be presented, not just
one or two. And it should be remembered that ``zero grazing,'' or
remaining faithful to one partner, was the main message for the
majority of Uganda's population.
The reason I must say ``was'' is that Uganda's AIDS prevention
program has gradually changed, perhaps due to the funding priorities of
foreign donor organizations. Since the mid-1990's, there has been less
emphasis on sexual behavior and more on medical solutions. In recent
years, there has been a small but disturbing trend toward riskier
sexual behavior, and for the first time in a decade there has been a
slight uptick in national infection rates. The distinctive Uganda ABC
model of the earlier period, the one developed primarily by Ugandans
for Ugandans, is the one that seems to have worked best, and is the one
that has most to teach the rest of the world.
REFERENCES
AMREF/Uganda. (2001, August). The effects of the Katakwi/Soroti school
health and Aids prevention project. Kampala, Uganda: African
Medical and Research Foundation (AMREF).
Green, E.C., ``Rethinking AIDS Prevention.'' Westport, Ct.: Praeger
Press, Greenwood Publishers, (2003, in press).
Hogle, J. (editor), Green, E.C., V. Nantulya, R. Stoneburner, J.
Stover, ``What Happened in Uganda? Declining HIV Prevalence,
Behavior Change and the National Response.'' USAID/Washington
and The Synergy Project, TvT Associates, Washington, D.C.
September 2002. Available online: http://www.usaid.gov/pop--
health/aids/Countries/africa/uganda--report.pdf
Lyons, M. (1996, January 20). Summative evaluation: AIDS prevention and
control project. Kampala: USAID/Uganda.
Nantulya, V. (2002, February). HIV/AIDS prevention: Policy and program
context of Uganda's success story. Presentation to USAID,
Washington, D.C.
Senator Alexander. Thank you, Dr. Green.
Ms. Sophia Mukasa Monico, welcome.
STATEMENT OF SOPHIA MUKASA MONICO, SENIOR AIDS PROGRAM OFFICER,
GLOBAL HEALTH COUNCIL, WASHINGTON, DC
Ms. Mukasa Monico. Thank you, Mr. Chairman. My name is
Mukasa Monico.
Senator Alexander. Mukasa, I am sorry. Mukasa.
Ms. Mukasa Monico. Mr. Chairman, subcommittee members,
ladies and gentlemen: Thank you for giving me this opportunity
to be here with you this afternoon. I think you all agree with
me that this is a historic moment. On behalf of the thousands
of health practitioners what are members of the Global Health
Council and the communities they care for around the world, I
want to thank you and your colleagues in the Senate for the
speed with which you passed the President's emergency plan for
AIDS relief.
From 1995 to 2001, Mr. Chairman, I was the chief executive
officer of The AIDS Support Organization, TASO. TASO is an
indigenous nongovernment organization in Uganda which was
founded in 1987 to contribute to the process of restoring hope
and improving the quality of life for people and communities
infected and affected by HIV and AIDS. TASO is now recognized
around the world as a leader and innovator in the field of AIDS
care, prevention, and support and, like what Anne said, the
real heroes of TASO are the people living with HIV and AIDS and
the founders who have passed away in the past years.
Mr. Chairman, ladies and gentlemen, my task this afternoon
is to share with you some key elements that constitute Uganda's
relatively small but significant success story, and I refer you
to my testimony for more detailed information and statistics
around this success story.
As we have all heard, as early as 1986 the then new Ugandan
President Yoweri Museveni learned through his army that his
nation was confronting an epidemic threatening to decimate his
nation. The President has made it his personal and governmental
priority to speak out about HIV and AIDS and is an advocate for
reducing HIV-AIDS-related stigma and denial.
Mr. Chairman, reduction in stigma and denial is an
indispensable element in the positive response to HIV and AIDS.
It enables individuals to proactively take steps to avoid
infecting others or being infected, as well as promote access
to services that add to the overall success of prevention
efforts. Additionally, it improves people's attitudes, making
them more accepting of the infected and willing to provide
compassionate care and support.
Ladies and gentlemen, reduction in stigma and denial is not
enough to halt HIV transmission. Individuals must take action
to change their own behavior and take precautions to avoid
getting infected. Accordingly, President Museveni's personal
commitment was quickly followed by a national policy and
strategy, a strategy which is embedded in the conviction that
HIV and AIDS affects every level of the population and poses a
serious threat to the socioeconomic strata and development of
our country.
The national policy charges all Ugandans individually and
collectively with the responsibility of being actively involved
in AIDS control activities within their mandates and capacities
in a coordinated way at the various administrative and
political levels down to the grassroots level. Ownership of the
response is critical to an effective response to HIV and AIDS,
Mr. Chairman.
Working with a nongovernmental faith-based, tradition, and
community-based organizations, President Museveni has promoted
prevention and care interventions that are relevant and
culturally appropriate and sensitive. For some he promotes a
message of delaying sexual relations, for others he urges them
to be faithful to each other and promotes the use of condoms as
an effective barrier. It is this three-part message that has
made it possible for Ugandans to respond effectively to the
devastating epidemic. I cannot stress strongly enough that all
these program elements need to be in place for prevention to
work.
Mr. Chairman, this is the foundation of the massive social
mobilization effort that has given birth to the result that
constitutes the success of Uganda. The interventions that
contributed to this success go beyond ABC. They include the
implementation of a comprehensive package of services for
prevention, care, support, and treatment which serve
overlapping but not identical goals. Prevention, support, and
care efforts are not additive, but rather each strategy
increases the impact of the other through synergistic effects.
Further, prevention and treatment involve different sectors and
constituencies. It is therefore necessary to invest in all
three simultaneously to achieve more than would be accomplished
by investing in any one alone.
As a Ugandan, Mr. Chairman, I am deeply concerned when I
hear people taking a single element of our successful national
program, like abstinence, out of context and ascribe all our
achievements to that one element. All three elements must be
implemented together in order for prevention to work.
Ladies and gentlemen, Ugandans were very much cognizant of
their society and as early as 1986 we acknowledged that
providing comprehensive and candid information about HIV and
AIDS was not enough. We had to reinforce those messages by
formulating other policies and creating an environment that
enables us to turn our knowledge into meaningful action. Hence
other sectoral changes were also necessary in order to assure
that prevention of HIV infection is attained in Uganda.
For example, Mr. Chairman, we worked with the existing
decentralized political system to ensure that the voices of the
most vulnerable populations, especially the girls, women, and
the youth, are heard and acted upon. Through the education for
all policy, as we have heard, and other programs, Ugandans
ensure that social alternatives to sex are created for the
youth and the children by keeping them productively busy
through formal and informal education.
This policy change is important because schools provide a
natural protective environment for the children, putting girls
out of reach of older men and transactional sex. According to
Ugandan data, girls are four to six times more vulnerable to
HIV infection than boys of the same age group. Schools also
provide an opportunity to inform, educate, and communicate
about HIV and AIDS to the youth in an appropriately mixed and
balanced way that is not interpreted as inciting the youth into
early sex or promiscuity.
From a legal protection point of view, Mr. Chairman,
significant changes have been made to the laws relating to
sexual abuse, especially for the youth. For example, the age
for consensual sex was increased from 14 to 18 years. In
addition, Uganda has made economic empowerment of women a
priority in order to improve their status in society, turning
the rhetoric ``no to risky sexual contacts'' to meaningful
protective actions.
It is worth reiterating, Mr. Chairman, that it was
important for Uganda to have all of these and more programmatic
elements in place for our balanced and comprehensive program to
work.
The next step in addressing the epidemic in Uganda and
throughout the developing world is extending anti-retroviral
treatment. In his State of the Union Address, President Bush
outlined his vision and commitment for the United States to
expand access to anti-retroviral drugs. These medicines will
provide hope to millions of Africans who do not see a future
for themselves or their community today.
In a nutshell, Mr. Chairman, a motivating rather than a
judgmental environment in Uganda made it possible for the
community at large to forge ways and means that are both
culturally sensitive and relevant to meaningful behavior
change, protecting people from HIV infection, and encouraging
compassionate care.
Mr. Chairman, Uganda, just like most countries in the
world, is implementing the universal approaches that are
recommended by public health practitioners. As Ugandans, as
Africans, we know what works. The real issue following the
passage of the emergency plan for AIDS relief is to identify,
expand, and replicate those elements that make the HIV-AIDS
universal interventions work for Ugandans.
Mr. Chairman, to answer your question about the AIDS Corps,
but also to move the agenda forward, the Global Health Council
will be sponsoring a summit meeting for those charged with
delivering these programs during the International Conference
on AIDS and STDs [sexually transmitted diseases] in Africa this
September in Nairobi, Kenya. At this summit, Mr. Chairman,
representatives from the public, private, and governmental
sectors will come together to share lessons learned and
strategies that work.
The meeting will also discuss the practicalities needed to
effectively and efficiently implement President Bush's
challenge. We must be ready to put this legislation together--
to work, and immediately.
Thank you for the opportunity to share my views with you
today and I am happy to answer any questions you might have.
[The prepared statement of Ms. Mukasa Monico follows:]
Prepared Statement of Sophia Mukasa Monico, Senior AIDS Officer, Global
Health Council, Washington, DC
Mr. Chairman, subcommittee members, ladies and gentlemen, thank you
for giving me the opportunity to be with you today. This is a historic
moment. On behalf of the thousands of health practitioners who are
members of the Global Health Council, and the communities they care for
around the world, I want to thank you and your colleagues in the Senate
for the speed with which you passed the President's Emergency Plan for
AIDS Relief. As a native Ugandan, I believe that the onus is now on
African and Caribbean people to make it work. I join my colleagues at
the Global Health Council, which is the world's largest membership
alliance dedicated to saving lives by improving health around the
world, in looking forward to working with the Administration and
Congress to put this plan into action.
From 1995 to 2001, I was the Chief Executive Officer of The AIDS
Support Organization (TASO). TASO, an indigenous Ugandan NGO, was
founded in 1987 to contribute to the process of restoring hope and
improving the quality of life for persons and communities infected and
affected by HIV/AIDS. TASO is now recognized around the world as a
leader and innovator in the field of AIDS care, prevention and support.
AIDS IN UGANDA
Uganda is a large country about the size of Oregon, with an
estimated population of 22 million people. AIDS was identified in 1982
in Uganda and early surveillance data showed that in 1988, the
prevalence rate was 9 percent. This quickly escalated and, by 1992,
urban areas were registering a prevalence rate of 30 percent, while the
nationwide average rate was 18.5 percent. With the benefit of a
concerted national effort, by the end of 1999 infection rates dropped
50 percent to the current prevalence rate of 5.7 percent in urban
areas.
Children have been hit particularly hard by the epidemic, with two
million children under age 18 having lost either one or both parents to
the disease. This is detrimental to the development of an entire
generation, which have lost their parents at the moment when parental
care, guidance, and socialization are pivotal as a child develops his
or her identity.
The effects are varied. A study carried out in southwest Uganda
reported that school absenteeism in AIDS-affected household is
significantly higher among girls than boys. This is largely due to the
fact that girls are often the main care givers at home when their
parents are ill. Not attending school has also had a significant impact
on the overall success of Uganda's prevention strategy. In Uganda, HIV/
AIDS prevention messages have been incorporated into primary school
curricula, with Ugandan boys and girls reporting behavior change as a
direct result.
The epidemic has also had a significant impact on the overall
health status of children, wiping out the significant gains we had
achieved in child survival over the past decade. Uganda's child
mortality rates remain high, with 134 out of every 1,000 live births
not surviving until their fifth birthday because of AIDS.
WHY WAS UGANDA SUCCESSFUL?
Mr. Chairman, my task this afternoon is to share with you some of
the reasons why Uganda has become a relatively small, but significant,
success story. The epidemic is still raging in Uganda, and we have much
to do before we can claim victory over our HIV/AIDS epidemic.
As early as 1986, the new Ugandan president, Yoweri Museveni,
learned from his Army that his nation was confronting an epidemic
threatening to decimate his nation. Early on in his presidency,
President Museveni both spoke out about HIV/AIDS and became an advocate
for reducing HIV/AIDS-related stigma. Strong political leadership is
key to Uganda's success, and stigma reduction has been critical on many
levels. When stigma is reduced, individuals are more willing to seek
counseling and voluntarily seek HIV testing. This enables individuals
to proactively take steps in order to avoid contracting and
transmitting the virus to others, and adds to the overall success of
prevention efforts. Additionally, if the stigma of HIV/AIDS is reduced
in communities, people become more accepting of the infected and
willing to provide compassionate care for them. Reducing stigma has
benefits for both the community and the individual.
But, a reduction in stigma alone is not enough to halt HIV
transmission individuals must take action to change their own behavior
and take precautions. Accordingly, an environment that supports this
individual choice must be created and sustained. President Museveni
spoke out loudly and often about the need for individual Ugandans to
protect themselves from the virus. Working with non-governmental,
faith-based, traditional and community-based organizations, President
Museveni promoted prevention interventions that were creative,
culturally appropriate and compassionate, for people who were infected
and affected by HIV/AIDS.
For some, he promoted a message of delaying sexual relations; for
others, he urged them to be faithful to one partner and to use a
condom. It was this three-part message that was effective in Uganda. In
my personal experience, I believe that this comprehensive approach is
critical. Different populations require different messages, and it is
essential that people of all ages are educated about how to protect
themselves.
I cannot stress strongly enough that all these program elements
need to be in place for prevention to work. As a Ugandan, I am deeply
concerned when I hear people taking a single element of our successful
national program like abstinence out of context, and ascribe all of our
achievements to that one element. All three elements must be
implemented together, in order for prevention to work.
Museveni's personal commitment was quickly echoed by a National
Policy and Strategy, which was embedded with the conviction that HIV/
AIDS affects all every level of the population, and posed a serious
threat to the socio-economic development of our country. The National
Policy charges all Ugandans, individually and/or collectively, with the
responsibility of being actively involved in AIDS control activities
within their mandates and capacities in a coordinated way, at the
various administrative and political levels down to the grassroots
level.
This is the foundation of the massive social mobilization that has
given birth to the results that constitute the success of Uganda. The
interventions that contributed to this success include the
implementation of a comprehensive package of services for prevention,
care, support and treatment, which serve overlapping but not identical
goals. Prevention and care efforts are not afterthoughts but, rather,
each strategy increases the impact of the other through synergistic
effects. Further, prevention and care involve different sectors and
constituencies. It is therefore necessary to invest in all three
simultaneously, to achieve more than would be accomplished by investing
in any one alone.
We know what works and these interventions are not unique to
Uganda. They are the universally recommended approaches advocated by
all public health institutions and practitioners. Therefore, the issue
is not what to do. Rather, we must identify, expand and replicate what
the Ugandans did and are doing, to make the universal interventions
work for everyone.
I will take this opportunity, to discuss further an issue that has
been pulled out of context and risks to reverse the prevention gains we
have achieved so far: bringing abstinence-only programs into the
discussion.
We all know how critically important it is for prevention programs
to target youth before they become sexually active. Uganda has achieved
this on a personal and a societal level. Cognizant of our society,
early in the process we acknowledged it was insufficient to only
provide comprehensive and candid information about HIV/AIDS. We had to
reinforce those messages by formulating other policies and creating an
environment that would enable youth to turn their knowledge into
meaningful action, which encouraged them to choose to protect
themselves. In order to achieve this objective, the environment and
messages had to be motivational rather than judgmental.
Political Change: We worked with the existing decentralized
political system to ensure that the voices of the most vulnerable
populations--especially girls, women and youth were heard, by:
Setting a policy that \1/3\ of members of Parliament had to
be women;
Establishing a seat in Parliament for youth; and
Ensuring that women and youth were represented at all levels
of the political decision-making apparatus.
Social Change: Ugandans ensured that youth and children were kept
busy through both formal and informal education, which created social
alternatives to sex. Under a policy change that calls for education for
all, communities have promoted sending more girls to schools. However,
it is not enough to promote only primary education. As education is
still not free-of-charge in Uganda, communities are advocating for a
policy that would make high school education free for all as well.
This policy change is important because schools provide a natural
protective environment for children, putting girls out of reach of
older men and transactional sex. Schools provide an opportunity to
provide information about HIV/AIDS that is appropriately mixed and
balanced, so that it is not interpreted as inciting the youth into
early sex or promiscuity. These classes, which have demystified sex,
impart sensitive and relevant life skills to youth so that they can
make responsible choices.
Legal Change: Significant changes were made to laws in Uganda
relating to the treatment of rape and statutory rape. Female lawyers in
Uganda came together to seek these changes, and continue to work to
stiffen the punishments for these offences. Other laws need to be
established that will both serve as a disincentive to adults who might
consider having sex with youth, and will enable enforcement against
those who violate the law.
Economic Change: Uganda has made improving the status of women
through economic empowerment a priority. Credit facilities targeted
towards women were established, enabling many women to establish small
businesses and attain economic self-sufficiency.
I cannot stress strongly enough how important it was for Uganda to
have all of these programmatic elements in place, for our balanced and
comprehensive program to work. Mr. Chairman, meaningful implementation
of abstinence cannot be left open for interpretation by individuals
with differing moral values. Uganda was very much aware of this, and
complemented its ideology and sexual morals with an environment that
encourages abstinence and change.
The next step in addressing the epidemic in Uganda and throughout
the developing world is extending anti-retroviral treatment. In his
State of the Union Address, President Bush outlined his vision and
commitment for the United States to expand access to anti-retroviral
drugs. These medicines will provide hope to the millions of Africans
who do not see a future for themselves or their communities today.
Pilot projects in Africa offering these life-extending medications have
begun to reap their just results, with people returning to their normal
lives as working, self-sufficient members of society, rather than as
people waiting for death. Treatment is not only a humanitarian
imperative--treatment supports prevention efforts, because it provides
the requisite hope that will encourage individuals to learn their HIV
status and it will reduce associated stigma.
CONCLUSION
Uganda's current successes were realized through an effective
social mobilization effort that fostered an environment that was
motivational, rather than judgmental. Uganda's efforts against HIV/AIDS
continue to be substantially, financially and technically supported
both by the government, as well as multilateral organizations including
UNAIDS, the United Nations Development Program, the World Bank, the
European Union and the World Health Organization. In addition, efforts
are funded through bilateral mechanisms supported by the U.S., Danish,
British, Swedish, Italian, German, French and Japanese governments.
Various international and local NGOs also fund and implement a variety
of programs and activities.
This positive environment makes it possible for the community at
large to forge ways and means that are both culturally sensitive and
relevant to meaningful behavior change, protecting people from HIV
infection and encourages compassionate care. In addition, you will note
that these interventions represent a multi-sector response. AIDS is not
just a medical condition in Africa HIV prevention work is not carried
out by people wearing white coats but it is the responsibility of
individuals, families, schools, media and religious institutions,
political leaders and traditional leaders to ensure that further spread
of HIV infection is halted.
NEXT STEPS
The real question following passage of the Emergency Plan for AIDS
Relief is how to replicate the success in Uganda in other countries. It
is critical for the U.S. government to remember the importance of
working with local partners, which will guarantee cultural sensitivity
and effectiveness.
Toward that end, the Global Health Council will be sponsoring a
summit meeting of those charged with delivering these programs this
September in Nairobi, Kenya, discussing the practicalities needed for
effectively and efficiently implementing President Bush's challenge. At
this summit, representatives from the public, private, and governmental
sectors will come together to share lessons learned and strategies that
work. We must be ready to put this legislation to work immediately.
Thank you for the opportunity to present my views here today and I
am happy to answer any questions you might have.
Uganda AIDS Commission Status Report
www.aidsuganda.org
HIGHLIGHTS OF KEY EVENTS AND ACTIVITIES
1982--Uganda medical doctors identify first AIDS cases on the shores of
Lake Victoria in Rakai district, Southern Uganda.
1982-86--The epidemic largely handled by the health sector with
spontaneous community initiatives to care for the infected
and affected.
1986--Uganda's Health Minister of the new government announces the
existence of HIV/AIDS in the country during the World
Health Assembly in Geneva. This marked the beginning of
political openness about the epidemic, creating a conducive
environment for mass campaigns spearheaded by President Y K
Museveni.
1986--The first AIDS Control Program was established in the Ministry of
Health. Its priorities were safe blood, prevention of HIV
infection in health care settings, information, education
and communication about how to avoid HIV transmission
(beginning of the ABC policy). This marked the first
government-structured effort to address the epidemic.
1987--An AIDS Control Program was established in the Ministry of
Defense to respond the special needs of the armed forces.
1987-91--Consultations began on a multi-sector approach to controlling
AIDS. The government recognized that the epidemic's impact
went beyond the health sector, and required planning and
implementing relevant activities in other sectors.
1987--Establishment of The AIDS Support Organization (TASO) to provide
much needed psychosocial support for the infected and
affected. Quickly complemented by other initiatives,
especially from the missionary hospitals (Kitovu, Nsambya,
Rubaga and Mengo).
1990--Establishment of the AIDS Information Center (AIC) for voluntary
Counseling and testing services (VCT).
1992--The Government adopts the multi-sectoral Approach to the Control
of AIDS (MACA) as a policy and strategy for responding to
the epidemic. This approach was aimed at building broad
coalitions between the government and other partners,
including community-based organizations and business.
1992--The Uganda AIDS Commission (UAC) is established by Act of
Parliament to coordinate and harmonize the multi-sectoral
efforts of the response.
1993--UAC leads and coordinates the development of the first multi-
sectoral National Operational Plan (NOP) for HIV/AIDS/STD
Activities 1994-1998, reflecting the priority need for
different sectors to take the lead in addressing the
epidemic.
1994-95--More AIDS Control Program Units are established in the
Ministries of Gender, Education, Agriculture, Internal
Affairs (Police and Prisons), Justice, Finance, Public
Service and Local Government.
1994-Government secures a $75m soft loan from the World Bank to fight
the epidemic, executed by the Ministry of Health through
the Sexually Transmitted Infections Project (STIP) 1995-
2000.
1995--Uganda successfully hosts and organizes the International
Conference on AIDS and STDs in Africa (ICASA). Uganda
announces the observed declining trends in HIV prevalence.
1996--Uganda receives the first UNAIDS Country Program Adviser (CPA).
1996--The country begins preparing for HIV vaccine trials after
thorough consultations with all key stakeholders. Actual
trial begins 1998.
1997-99--Participation in the study for the prevention of mother-to-
child transmission of HIV using anti-retroviral drugs.
1997--With the support of UNAIDS, a comprehensive review of HIV/AIDS
activities in Uganda is conducted by partners to assess
coordination and implementation of HIV/AIDS activities.
1997--Uganda shifts from its traditional observance of World AIDS Day
(WAD) to an annual World AIDS Campaign (WAC), culminating
in WAD every year. WAC has since become a major advocacy
activity in the country.
1997--Development of the 1998-2002 National Strategic Framework (NSF)
for HIV/AIDS Activities with consensus from partners from
various sectors at national and district levels.
1998--Establishment of the Drug Access Initiative, advocating for
reduced prices for Anti Retroviral (ARV) drugs and
supporting the establishment of the proper infrastructure
for administering these drugs.
2000--Revision of the 1998-2002 NSF and development of the 2000/1-2005/
6 NSF, which puts the HIV/AIDS problems into the broader
context of national development goals.
2000--Recognizing the impact of HIV/AIDS on development, the Government
embarked on the process of mainstreaming HIV/AIDS issues in
the country's Poverty Eradication Action Plan while
targeting integration in the government sector budgeting
exercise.
2001--Accomplishment of the preparation of the Uganda AIDS Control
Project prepared under the aegis of Multi-country AIDS
Project (MAP) of the World Bank. A $50 million loan has
been secured to support HIV/AIDS activities in all sectors
at national, district and community levels.
Senator Alexander. Thank you, Ms. Mukasa Monico. I
appreciate your coming.
I have a question and it is one I asked Dr. Peterson
earlier. Mrs. Museveni suggested that the African culture is
congenial to the idea of self-control, of young people delaying
sex, of married people being faithful. One, do you believe that
is true? And two, do you believe that is unique in Uganda? I
would be interested. Let me start with you, Ms. Mukasa Monico.
Ms. Mukasa Monico. I will start with the last one. I do not
think it is unique to Uganda. I think every human being,
especially every parent, if I can start from that as a parent,
will agree with me that abstaining would be the best solution
for every youth in the world to avoid getting infected. But
again, we know that the youth--or that children become youth
and they become adults who make their own decisions.
So the best alternative to avoid getting infected would be,
when you start getting--when you become sexually active, at
least stick to one partner so that you do not get STDs or even
HIV infection from outside your partnership or your union.
But as we know as human beings, if that were just the
answer to it, Mr. Chairman, we would not be having infections
right now. So we have to get together all the other approaches
that will actually ensure that if A does not work and B does
not work, then there is another way, another practical way to
avoid getting infected and dying of HIV.
So if you find yourself in a situation where you actually
cannot abstain, you are not sticking to your partner, or
actually your first partner, who you do not know what his
status is, but you have to get sexually involved, then you must
do everything possible to protect yourself.
Senator Alexander. It seems to me that all the witnesses
and most people agree that part of the genius of the Ugandan
proposal seems to be the combination of things, starting with
exceptional leadership over a long period of time, that
includes not just the government but many other, many other
parts of the community, and that is comprehensive in that it is
A, B, and C.
Yet it seems to me the news about it is not just that it
worked, but that A and B worked better than most health care
professionals expected. Most of the talk was that condoms were
the answer and the news I am hearing is that condoms are a part
of the answer, but that abstinence and faithfulness are more of
the answer than many people were willing to admit 5 and 3 years
ago. Would you agree with that or not?
Ms. Mukasa Monico. My simple answer to that is I do not
think it is A, B, or C. I think it is A, B, and C together that
have made it happen.
Senator Alexander. No, I am not disagreeing with that. But
I am saying I believe--and Dr. Green, let me just go to you. Do
I not hear you saying that, that among health care
professionals over the last several years that most were
skeptical of abstinence or faithfulness as contributing much
toward prevention of AIDS?
Dr. Green. That is right, Senator.
Senator Alexander. And what the data suggests is that they
are important parts of the comprehensive approach?
Dr. Green. Part of the genius of Uganda's response to AIDS,
and it occurred early, is that it treated AIDS as a behavioral
issue, not simply as a medical issue for which there were
medical solutions, such as condoms, male or female condoms,
such as drugs for treating standard sexually transmitted
diseases, which if you treat them the idea is that you will
have less opportunity for infection.
But I think that you have put your finger on it, Mr.
Chairman, that the real difference between ABC as practiced in
Uganda and elsewhere is there was genuine balance. There was
some real emphasis on A and B, not just the occasional nod in
the direction of A and B and the funding goes into condoms and
drugs and the program impact indicators are attached to condoms
and drugs. It was truly a balanced program. I think we do not
find so much balance elsewhere.
Senator Alexander. Senator Feingold.
Senator Feingold. Thank you, Mr. Chairman. This is an
excellent panel and an extremely important discussion.
I want to say particularly to Ms. Mukasa Monico how
important her message is. I heard your message loud and clear,
and that is that we dare not oversimplify what happened in
Uganda. You know, Uganda was a country that arguably had one of
the worst reputations of any country in the world in the 1970s
and 1980s, and somehow miraculously, through incredible effort
of the Ugandan people, this country has made great progress. In
the whole world now, if you know anything about HIV-AIDS, if
you want to talk about somewhere where people were able to help
bring this under control, the first place that is discussed is
Uganda, which is a tremendous credit to your country, to your
leadership, and to all the people of your country.
I guess I feel so strongly that we should not
mischaracterize or accidentally portray in a way that is not
accurate what was really done there, and I believe that
somebody like you who has devoted your life to this has a very
important message when you tell us to be sure that we
understand the complexity of it, that abstinence itself
certainly is not the only answer and is not sufficient. And I
believe the chairman is saying that and I believe other
witnesses are saying that as well, in fairness.
But your phrase that this needs to be motivational but not
judgmental is very, very important, because there are people
who will take this data and these concepts and this
straightforward talk about what is going on and use it in a way
to suggest something that, frankly, is way too simplistic to be
effective and in my view is extremely unfair to the people of
Uganda who have achieved this success.
So I appreciate your message and believe that we have to
continue to tell the story as it has actually occurred in
Uganda and I will strive to be as accurate as I can about it
and to avoid the judgmental aspect that potentially could
accompany it.
My questions sort of relate to that aspect for both of you.
First, Dr. Green, do the data show that people who have
previously been sexually active respond meaningfully to the
abstinence message or are the B and C messages typically more
effective for this segment of the population?
Dr. Green. The short answer is yes, typically for people
who have experienced sexual debut, as they call it, that the B
and C messages are more appropriate. We have data from, for
example, the demographic and health survey funded by the United
States that shows that a not insignificant proportion of
Ugandans who are widowed or single, but are, say, over 21 and
who have had sexual intercourse are abstaining because they are
not currently married.
But most of those who report zero partners in the last year
are those who have not started to have sex yet, yet. But yes,
the B and C messages are probably the most important messages
for the sexually active, and it was so recognized by Uganda.
Senator Feingold. With regard to certain specific groups of
people within the country, let me ask first Ms. Mukasa Monico:
What kind of steps have been taken in Uganda to work with high-
risk groups like long-haul truck drivers?
Ms. Mukasa Monico. A comprehensive program, especially a
prevention program and information, education, and
communication, but candid communication about HIV and AIDS. But
let me just take you another step up from just truck drivers,
because what we realized in Uganda is the fact that sex workers
are very young girls and mainly girls who have parents or are
orphans. And unfortunately the clients of the sex workers are
none other than our husbands, our brothers, and our children.
So to ignore them as a population which is at high risk and
actually risk to transmit HIV into our families--we had to
target them.
The only way to make sense while working with them was to
promote the use of condoms. Actually, there was a great
increase in the use of condoms among sex workers, from 20
percent in 1991 to 80 percent in 2001, which is a very big
contribution to HIV prevention, especially from a high-risk
group to a normal group.
But going to the truck drivers, if you go to Uganda you
find that along the highway from Kenya to Rwanda that is where
you find all the TASO programs. You find a program in Jinja,
Mulago, Tororo, and up to Rwanda practically. The one reason
why we put those programs there was to target the truck drivers
by, first of all, demystifying HIV and AIDS; and after
demystifying it making sure that they actually have the right
information and devices to protect themselves from HIV
infection. So that was another targeted high group, high-risk
group, in our interventions.
Senator Feingold. Dr. Green, you want to comment on that?
Dr. Green. There was an attempt not to stigmatize groups
like commercial sex workers and bar girls and truck drivers and
soldiers. So the information, education, and communication was
mostly done sort of low-key, through peer educators. And there
was a lot of condom promotion to groups that were known to be
at special risk.
Senator Feingold. What about the military? You point out
the history of this and how President Museveni found out about
the problem through the military. We have heard very similar
concerns in South Africa. What strategies have been targeted to
the military, Ms. Mukasa Monico?
Dr. Green. I think that that is----
Senator Feingold. Dr. Green?
Dr. Green [continuing]. Another high-risk--Sophia was
looking at me, so maybe she wanted me to answer it first.
Senator Feingold. Go ahead.
Dr. Green. I think that that was another high-risk group.
There was a lot of peer education in the military. Infection
rates fell in the military in the late eighties, early
nineties, quite dramatically. But this was also true for
military recruits. So you just had a lot of HIV prevalence
decline among all groups, but including the military, and there
were special programs.
I think maybe the first program in Africa that was directed
at the military was there. I was part of the design of such a
program in Swaziland a year ago, funded by the USAIDs of
Defense, and the question arose what are the--out of A, B, C,
what do you promote to soldiers? The answer was B and C.
When you mentioned truck drivers, about 10 years ago I was
working in Tanzania in a project for commercial sex workers and
I was driving to Mulago and our car broke down and we had to
hitchhike, and we hitchhiked with a couple of truck drivers on
the famous highway that you have all heard about, along which
HIV infection spread. We asked the truck drivers what they were
doing about AIDS and one driver said that he was faithful to
his girlfriend that he is living with and the other one said he
is getting married and no longer stopping and having sex along
the way the way they used to.
So this was 1993, and it gave me my first clue that
something other than the model that we had in mind as
international AIDS experts might be going on. Then soon after
that, I went to Uganda for the first time and saw that indeed
something different was being promoted and something different
seemed to be happening.
Ms. Mukasa Monico. Maybe just to answer you about the
military. One important element that has been incorporated in
the military is voluntary counseling and testing as an entry
point to behavior change and also seeking prompt medical care,
which you find everywhere--not everywhere, like 60 percent in
Uganda. But this is a specific service for the military men.
Senator Feingold. I appreciate both of your answers because
obviously I focus on the truck drivers and the military because
of the stories I have heard all over Africa about the way in
which HIV-AIDS can be spread. I remember hearing on a trip
where we went first to Tanzania, then Mozambique, the concerns
about the highways and the travel and the way in which it may
have spread through Tanzania to Mozambique.
I appreciate the candor that realistically the most likely
thing to work here is B and C, although you do express some
hope that, it sounds like, that A has some role in this regard.
But I think you are looking at the type of lifestyle and
situation realistically. It is so important to remember what
the role of B and C are in preventing the spread among very
mobile people, which by definition the military and the truck
drivers are.
We have even heard this with regard to sometimes troops
that we have helped assist us in various difficult situations
in Africa being sent from one country to another to keep the
peace. This is a potential negative side effect for a country
that may not have a particular high HIV-AIDS rate, when
individuals may come and be involved in those areas. Even
though they may be trying to keep the peace, other things
obviously happen. This is a very critical part of understanding
how the problem has spread throughout the continent.
Where do efforts to increase access to treatment stand in
Uganda? Have efforts to increase access to treatment in Uganda
encouraged people to participate in voluntary counseling and
testing? Ms. Mukasa Monico?
Ms. Mukasa Monico. The first targeted initiative to
increase access to treatment in Uganda started around 1998 with
the drug access initiative from UNAIDS. That is when we
negotiated with big pharma to import drugs with reduced prices.
It was not so reduced, because a person was paying around
$1,500 per month just for triple therapy.
But around 2001, through again an increased effort to
decrease prices and through contacting CIPLA India we managed
to negotiate for generics and now drugs are costing $300 per
year in Uganda, which is a substantial decrease from $1,500 per
month. So that is one step forward.
So what we did was to import generics of anti-retrovirals,
but by importing generics of anti-retrovirals we also managed
to bring down the prices, some of the prices of the brand names
for anti-retrovirals.
I think, just like any other incentive, knowing that you
have a support system to fall back on, people are encouraged to
go and test and find out where they are with HIV and AIDS
because they know at the end of the day I can improve my
quality of life because I can get access to anti-retrovirals.
So undoubtedly, with more access to anti-retrovirals more
people find out about their HIV status, and by finding out
their HIV status they either know that they have to change
their behavior if they are not infected, and if they are
infected at least they know that they can get support.
But it also decreases the stigma around HIV and AIDS, and
again improving access to services.
Senator Feingold. Mr. Chairman, I thank both the witnesses.
Thank you, Mr. Chairman.
Senator Alexander. Thank you very much. I think the Ugandan
experience has done something in the United States that we
ourselves could not do. You have those who strongly believe in
abstinence talking about condoms, and those who strongly
believe in condoms acknowledging the importance of abstinence.
That is a lot of progress in this country.
So we are grateful to you for the work you have done in
Uganda and in helping us understand the role of that model as
we go about an effort, particularly on this subcommittee, to
help make sure the United States marshals the resources that we
are beginning to approve and that we spend them as wisely and
effectively as possible and with as much respect for the
countries and the people that we hope to serve.
Thank you very much for being here.
Dr. Green. Thank you.
[Whereupon, at 4:02 p.m., the subcommittee adjourned, to
reconvene subject to the call of the Chair.]