Uganda beating back AIDS

Leadership, education and openness are keys to progress

By Fred Kirungi in Kampala

Uganda has recorded declining rates of HIV infection since 1993. Although HIV prevalence among pregnant women rose from 24 per cent in 1989 to 30 per cent in 1992, by 1999 it had dropped to 10 per cent, according to the latest figures from the AIDS Control Programme (ACP) in the Ministry of Health. Among patients suffering from sexually transmitted diseases at Uganda's leading hospital, Mulago, HIV infection rates fell from 44.2 per cent in 1989 to 23 per cent in 1999.

This achievement can be attributed to four factors, according to Dr. Joshua Musinguzi, the acting programme manager of ACP: the high level of political commitment to the fight against HIV/AIDS, openness about the epidemic, involvement of all sections of society and the government policy of decentralization. Even President Yoweri Museveni "got engaged in the fight early and encouraged other political leaders to do so," Dr Musinguzi told Africa Recovery.

Profile: AIDS in Uganda
People living with HIV/AIDS (1999)	823,000
of which:
women (15-49 years old)	420,000
men (15-49)	350,000
children	53,000
Adult HIV prevalence rate (%)	8.3
Estimated AIDS deaths to 1999	110,000
Children who have lost one or both parents	1,700,000
Source: UNAIDS, UN Economic Commission for Africa, AIDS in Africa: Country by Country, 2000.

A strong start

In 1986, the same year Mr. Museveni came to power, the government launched the ACP to spearhead the struggle against HIV/AIDS. The programme's objectives, according to Dr. Musinguzi, were to prevent further transmission of HIV, create mechanisms to care for the infected and their families and create the capacity to contain the epidemic. "The backbone of our programme was information, education and communication. We had to make people aware of the problem and translate this awareness into behavioural change," said Dr. Musinguzi.

The core of ACP's anti-AIDS message was abstinence from sex, faithfulness to one's partner and use of condoms. "More people are now using condoms and there has been a decline in casual sex," said Dr. Musinguzi.

The ACP alone distributed 80 mn condoms last year, and the number is expected to rise to 120 mn this year, compared to only 4 mn in 1990. A June 2000 report shows an increase in condom use across the country. In Kampala, 51 per cent of those surveyed used condoms in 1998 compared to 42 per cent in 1995. The report also records a slight decline in non-regular sex partners from 14.1 per cent in 1995 to 13.7 per cent in 1998. However, condom use with non-regular partners increased significantly, from 58 per cent to 76 per cent.

Local councils

Dr Musinguzi said the ACP conducted information campaigns on radio, television and in newspapers, distributed leaflets and posters and put up billboards across the country. However, because of the limited reach of these, especially in the rural areas, the programme also used existing administrative and social institutions.

"We especially used the LC [Local Council] system not only to get our message to every village but also ensure that anti-AIDS activities were initiated and implemented at the lowest level," he said.

The LC system is a hierarchical administrative structure from the village to the district level. At each level, there is a governing committee composed of nine elected members, including secretaries for health, women and youth. The ACP trained LC officials at the district and in some cases, sub-county levels, and they, in turn, trained their counterparts at the lower levels on AIDS-related issues. "Our approach was to encourage them to design and implement their own strategies to cope with the problem," said Dr. Musinguzi.

Although there was no direct funding from the government for AIDS-related activities in the villages, LC committees were given assistance in the form of information leaflets, condoms and, in some cases, HIV testing services. Since 1996 when the government adopted the policy of decentralization, 65 per cent of tax revenues remains at the sub-county level and some of it is committed to AIDS activities.

In addition, the ACP used drama groups, schools, churches, mosques and community-based organizations to help spread the word on AIDS. "Because of our openness about it, the challenge of AIDS became the concern of everybody. Churches, mosques, schools, the army, and even private companies initiated their own programmes to handle the problem," he said.

Combating stigma

Dr. Musinguzi said that openness about AIDS also helped remove the stigma associated with the scourge and encouraged people infected with HIV to join in the fight. One such group is the Buwolomera Development Association (BUDEA), set up in October 2000 in Iganga district, some 120 km east of the capital, Kampala. All 55 members of the group are infected with HIV, and 43 of them are women.

Ms. Florence Kumunhyu said they formed the association not only to support each other, but also to help others in the community avoid their fate. "We visit and give each other material and emotional support. Since we are all infected, we appreciate each other's problems and the dangers of this scourge more than anybody else," says Ms. Kumunhyu.

Members of BUDEA visit schools, churches and mosques to preach against the epidemic. They also carry out door-to-door campaigns. "People take an infected person more seriously. Our status is an advantage rather than a weakness in the struggle against the spread of HIV," Ms. Kumunhyu says.

BUDEA receives no external funding, relying solely on the efforts of its members to finance its education and home care activities. "We rear chickens, grow crops and make handicrafts to raise money," explains Ms. Kumunhyu.

Society-wide coordination

The members of BUDEA initially belonged to a larger non-governmental organization, Integrated Development Activities and AIDS Concern (IDAAC). Formed 10 years ago, the NGO operates in the three districts of Eastern Uganda.

Photo: Sean Sprague

"We went to the villages encouraging people to come for HIV testing. We provided our members with home care support and counselling," said Rev. Jackson Muteeba, IDAAC's programme manager. As the numbers grew, however, IDAAC found it difficult to provide these services. "We encouraged them to form local associations so that they could support each other. Intervention measures are more effective and sustainable if they are applied from the lowest level, right from the home," Rev. Muteeba said. The group, with over 4,500 registered HIV patients, provides its member associations with training and advisory services. There now are over 1,500 NGOs and community-based organizations involved in HIV activities in the country.

Dr. Musinguzi noted that it was the involvement of different sectors of society that originally led to the formation of the Uganda AIDS Commission (UAC) in 1992 to coordinate all AIDS activities. The UAC's director

of AIDS research and policy development, Dr. John Rwomushana, explained that under the multi-sectoral approach the commission adopted in 1993, the struggle against AIDS was broadened to include fighting poverty, illiteracy, child abuse and cultural practices like polygamy and wife inheritance, all of which make individuals more vulnerable to HIV infection.

Overall, AIDS-related activities are expected to cost $181 mn over the next five years, according to the UAC. The government will contribute $60-88 mn, with the shortfall expected to be taken up by NGOs and donor agencies.

Cultural sensitivities

"Our education campaigns not only addressed AIDS and health-related issues," said Dr. Rwomushana, "but also risky cultural practices. HIV control was made an integral part of the country's national education and poverty eradication policies."

One of the biggest challenges, according to Dr. Rwomushana, was how to campaign against AIDS and risky behaviour without upsetting cultural and religious sensibilities. "We adopted a policy of inclusiveness that avoids confrontation with the different social and religious groups," he said. "The fact that the chairman of the Uganda AIDS Commission, Halem Imana, is a retired Catholic bishop is a demonstration of this."

One policy that posed particular problems was the promotion and distribution of condoms. Many religious groups were opposed to them, prompting the ACP and UAC to not be very forceful in promoting them in the beginning. That obstacle has now been overcome, according to Dr. Rwomushana.

"We encourage groups that preach morality to promote means of HIV avoidance they are comfortable with, without, however, undermining other agencies that may be promoting methods less acceptable to them," he said.

Big challenges

Despite all these achievements, there are serious challenges to be faced, not least the growing number of AIDS orphans. According to UAC, there are 1.9 million Ugandan children who have lost one or both parents to AIDS. "The challenge is to provide them with housing, food and education," says Dr. Rwomushana, who is in charge of formulating a national strategy to address the problem of orphans.

Another big challenge, according to Dr. Musinguzi, is reducing the comparatively high prevalence of HIV among girls aged 15-19 years. A March 2001 UAC report noted that girls are six times more likely to be infected with HIV than boys the same age. Dr. Musinguzi attributes this to the "sugar daddy" syndrome, referring to older, relatively wealthy men who engage adolescents in sexual relationships. "A broad approach that involves enrolling and keeping girls in school and equipping them with skills to resist such men is needed," he says.

Ms. Anne Akia Sydler, editor of Straight Talk, a free monthly magazine that targets adolescents, agrees. "Girls fall easy prey to sugar daddies because they have no bargaining power. Straight Talk is trying to equip these girls with bargaining and communication skills," she says.

Daunting as these challenges are, Dr. Rwomushana has no doubt that they will be surmounted. "With the involvement of everybody, we have managed to bring the infection rates down. There will be no complacency, and the situation can only improve," he says.

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