[afro-nets] From coffins to ABS's: AIDS prevention in Uganda

[Patrick Burnett <patrick@fahamu.org.za>]

 From coffins to ABS's: AIDS prevention in Uganda
------------------------------------------------

I thought members of this list might be interested in this arti-
cle from Pambazuka News (http://www.pambazuka.org).

FROM COFFINS TO ABCS: AIDS PREVENTION IN UGANDA

Sara Rakita

Blinking my eyes to adjust to the bright African sun as we made
our way through traffic from the Entebbe airport to the Ugandan
capital, Kampala, I looked out the window and asked, "What are
those?"

"Coffins," the driver replied. "Because of AIDS," he added, in
case it wasn't obvious why the wooden boxes were displayed along
the roadside with other goods for sale, things I recognized,
like furniture, iron gates, tiny bananas, and the reddest toma-
toes I had ever seen. The year was 1995, I was a naïve American
grad student, and this was my first introduction to Africa.

The HIV/AIDS epidemic had hit Uganda with a vengeance. The in-
fection rate peaked in the early 1990s, with a national preva-
lence rate of about 15% in 1991 and more than 30% of the popula-
tion in some urban areas infected in 1992. It is now estimated
that a million Ugandans have died from HIV/AIDS, leaving twice
as many orphans behind, and more than one million are currently
living with the disease. The wrath of the disease dealt a devas-
tating blow to the country and its development efforts. But
there was a growing market for coffins.

Yet, already by 1995, Uganda had distinguished itself as the
first country to deal with the epidemic head on. A high level
political commitment to action, constructive involvement of
civil society including religious authorities, and excellent
public information campaigns - among many other factors - all
contributed to help the country stem the flow of the epidemic.
In 1995, when coffins lined the road, the national prevalence
rate was 18.5%. Within a few years, the rate dropped to one
third of that number.

One element of Uganda's success in preventing infection has been
a public information strategy known as ABC - Abstinence, Be
faithful, and use Condoms. The key to the ABC strategy was to
promote all three together, recognizing that no one type of be-
haviour change could work perfectly. The ABC model has been
widely recognized internationally, and adapted for use in other
countries around the world. The journal Science recently re-
ported that it has been almost as successful as a vaccine in
Uganda.

This is not to say that the battle is over. Few people living
with HIV/AIDS have adequate access to anti-retroviral therapy
that could prolong their lives, permitting them to participate
in the workforce and care for their families. An estimated
25,000 babies are born HIV positive each year in Uganda. The
situation of children orphaned by AIDS remains dire. Stigma and
discrimination are still prevalent despite the best efforts of
the government and AIDS advocates. And discrimination continues
to make women most vulnerable to the disease.

While Ugandan activists agree that more must be done to treat
people living with HIV/AIDS, they continue to stress the impor-
tance of prevention. Many analysts caution that it would be ill-
advised to rely too heavily on the success of the public infor-
mation campaign. Some even query whether the ABC strategy was
really responsible for the decline in prevalence. A 2003 base-
line study on knowledge, attitudes, and behavioural practices
found that high-risk behaviour is still very common in Kampala.
And recent data indicate that rates of infection could be back
on the rise.

There can be no disputing that the scale of the problem in
Uganda remains alarming, and that urgent action is required to
save lives and prevent the epidemic from further eroding the
country's development efforts. Thus, perhaps the most difficult
challenge facing Uganda now is to build on the success of the
past decade. Even if Uganda and its donors meet their target of
providing ARVs to 100,000 people in the next five years, Dr.
Coutinho of The Aids Support Organisation predicts twice that
number could be newly infected. This is no time for complacency.

Many hope that the US$15 billion President Bush pledged last
year for AIDS in Africa and the Caribbean might go a long way
towards solving the problem. The money (known as "Bush money" in
Ugandan parlance) finally started to reach 14 countries includ-
ing Uganda last month, from the President's Emergency Fund for
HIV/AIDS Relief. But it is not that simple.

In fact, while grateful for all the money available from inter-
national donors, many Ugandans I spoke to on a recent visit to
the country were already skeptical as the Bush money took so
long to start trickling in, and they were not convinced that it
would necessarily be put to most effective use.

Organisations such as the US-based Centre for Health and Gender
Equity and Physicians for Human Rights have expressed numerous
concerns about the Bush administration's strategy for using the
money, as spelled out in the President's Emergency Plan for AIDS
Relief: US Five-Year Global HIV/AIDS Strategy.

For starters, the process of developing the strategy was a
closed one and key stakeholders were excluded. What's more, the
administration has been widely criticized for following ideo-
logical and fundamentalist religious beliefs rather than evi-
dence-based recommendations.

This is perhaps most evident in the strategy's excessive insis-
tence on abstinence only, rather than a holistic ABC approach.
The strategy focuses on abstinence for youth and being faithful
within marriage, and emphasizes that condoms are only to be made
available to and in the 'vicinity of' so-called high risk popu-
lations such as prostitutes. Potential funding for B and C ap-
proaches is further constrained by the United States Global AIDS
Act of 2003, which limits prevention funding to 20% of the money
allocated and mandates that one third of this be spent on absti-
nence-until-marriage strategies.

But this approach runs counter to the fundamental premise under-
lying the ABC strategy. As Dr. Coutinho explains, even though
approximately 60% of his patients do embrace abstinence, they do
not always do so perfectly. For example, someone may well remain
abstinent for ten months, decide to have sex again, and then re-
turn to abstinence. For this and many other reasons, it is cru-
cial to keep the C in the equation.

According to the Centre for Health and Gender Equity, the strat-
egy also fails to guarantee that those most at risk will be pro-
vided access to comprehensive sex education information such as
complete information on male and female condoms, frank discus-
sions about sexuality, guidance for negotiating safe sex, etc.

Some NGOs in Uganda say they have sensed a rolling back of the
space available for public information on AIDS prevention and
sexuality, particularly information targeting youth. Though this
is not directly tied to the Bush money, they do see a link. For
example, much of the Bush money is earmarked for faith-based or-
ganisations. While all agree that religious institutions have a
crucial role to play, some fear that this could lead to churches
taking over much of the work that secular NGOs now do. This is
especially worrying given that some churches have strong posi-
tions against condoms.

Many Ugandans are also familiar with other Bush administration
policies (including domestic policies focusing exclusively on
promoting abstinence outside marriage and ignoring or even op-
posing contraceptive and condom use, as well as the global gag
rule). As a result, they fear there may be 'a change in the
winds' towards more conservative public health policies informed
by evangelical interests.

Numerous other serious concerns have also been raised with re-
spect to the Bush money. One is the failure of the US to con-
tribute its proper share to the Global Fund to Fight AIDS, Tu-
berculosis, and Malaria. Another is the fear that funds will
only be available for purchase of name-brand drugs. This will be
a decisive factor in how many people receive treatment, as the
funds available are finite and name-brand drugs can cost four
times more than their generic counterparts.

Even beyond the Bush money and public health policy, Christian
Aid recently issued a report decrying a 'dangerous drift' - en-
couraged by the US and the UK - of diverting aid funds in Uganda
and elsewhere to the war on terror. Nearly a quarter of Uganda's
social services budget in 2002 went to fund military operations
in the North to fight the LRA (which has been added to the US
terrorist list). Yet the report also found that the war and
militarization of the area is actually contributing to increased
spread of HIV in the region.

I recently took the Entebbe-Kampala road again on one of my fre-
quent trips to Africa. My heart sank as soon as we drove out of
the airport parking lot, quickly dashing the excitement I felt
about returning to Uganda that had peaked during the breathtak-
ing landing on the shores of Lake Victoria.

I confided in my fellow passenger - a Tanzanian law professor on
his way to the same meeting I would be attending - how this
stretch of road, my first impression of Africa, is branded in my
memory together with coffins. Recalling the devastation that
poverty and disease had wrought on the country in the mid-1990s,
he sympathized. But he reminded me that Uganda had worked hard
to slow the impact of the epidemic, and that things are actually
much better today. Together, we looked anxiously out the window
- not at the emerald green landscape, but at the roadside mer-
chants and their wares. Together, we breathed a sigh of relief
when we didn't see any coffins.

Ugandan AIDS advocates continue to work tirelessly to battle the
epidemic. For example, Dr. Coutinho has suggested an improvement
on the ABC strategy - adding a "D", for determine and declare,
to encourage people to get tested and be open about their
status. The international community - including the Bush admini-
stration - should continue to rely on evidence, rather than un-
tested strategies motivated by fundamentalist ideology. This may
be the best way to keep the coffins off the road until we get to
V for vaccine, and Z for zero.

* Sara Rakita is a consultant who travels frequently to Africa.

* Please send comments on this article - and other events in Af-
rica - mailto:editor@pambazuka.org