[afro-nets] Has Uganda become Abstinence-only?

[Edward C Green <EGreendc@aol.com>]

Has Uganda become Abstinence-only?
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This story is going all around the world:

'Abstinence-Only' Programs Hijack AIDS Success Story
U.S.-Sponsored HIV Strategy Threatens Youth

(London, March 30, 2005) ­ U.S.-funded "abstinence-only" pro-
grams are jeopardizing Uganda's successful fight against
HIV/AIDS, Human Rights Watch said in a new report today. Absti-
nence-only programs deny young people information about any
method of HIV prevention other than sexual abstinence until mar-
riage.

****************************************************************

I haven't read the full new Human Rights Watch report on Uganda,
which asserts that the Ugandan government is nowadays mostly
promoting abstinence and ignoring condoms. But I was interviewed
by the BBC (live) about this on 3/29.

Here is what I had ready for the interview, and the parts in red
are what I managed to say in the time alloted:

I'm surprised that Human Rights Watch would say such a thing be-
cause it's just not true. I know that Ugandan officials have re-
sponded to this charge, and have said, basically, nonsense, they
promote all three interventions, abstinence, being faithful and
using condoms. The way I look at it, the trend in recent years
has been away from abstinence and being faithful. Why? Because
the major donors have never supported this and they are not com-
fortable with the A and B of ABC. Since the Ugandan government
is heavily dependent on the foreign donors, they naturally have
to develop programs that are in line with the interventions that
the major donors favor. And what the donors favor now is what
they have favored since the beginning of AIDS: risk reduction
only (condoms, treating STDs, getting everyone tested).

The Ugandan Government bought 80 million condoms just a few
weeks ago, even though this same brand (Engabu) was found to be
defective a few months earlier.
http://allafrica.com/stories/200503030920.html

The genius of the Ugandan ABC model is that it includes these
risk intervention models but it also addresses sexual behavior
directly. With A and B interventions, young people are urged to
delay sex until they are married, and sexually active adults are
urged to remain mutually faithful with their partners. This is
something we major donors don't favor or fund (the recent excep-
tion is USAID, which adopted an ABC policy for generalized epi-
demics in Dec 2002, followed by PEPFAR. 1/3 of all prevention
funds are now supposed to go to abstinence programs) - (it's a
great pity that funds were not earmarked for the B of ABC).

If you look at the current national Strategic Framework for
HIV/AIDS, which is a blueprint for all the activities supported
in Uganda to combat AIDS, you will see that there are virtually
no A or B elements there. The document is all about condoms,
STDs, future vaccines, future microbicides, and testing. This
reflects the elements that the major donors like. In fact, the
word abstinence appears only twice in the body of this 77 page
document, but only as being part of a general approach -- there
are no specific objectives or impact measures associated with A
of B interventions.

There's another blueprint document developed in the past year by
the Uganda AIDS Commission, but with major input and funding
from USAID. And this is the 'National Condom Policy and Strat-
egy'. It lays out an elaborate strategy for condom promotion and
it calls for the placing of a condom officer in each of Uganda's
districts. There is no such document for abstinence and fidel-
ity. So I just don't think it's true that Uganda is emphasizing
abstinence only, in fact I know it's not true. If anything, the
donors have influenced Uganda in the direction of not emphasiz-
ing fidelity and abstinence to nearly the same degree that was
the case a few years ago.

By the way, there's a new study of Rakai district that made
headlines all around the world about 2 weeks ago. The popular
interpretation of that study was that condoms work while A and B
do not. If you look more closely you will see that when A and B
levels were higher, prior to 1994, incidence (the rate of new
infections) fell. In the last few years, when there has been
erosion in A and B behaviors, and there's been significantly
higher condom use, the rate of new infections has actually in-
creased. What does that say about the relative impact of A, B
and C interventions?

As for involving FBOs (Faith Based Organizations) in AIDS pre-
vention: I totally agree with President Museveni on this matter.
He said we need everyone-all resources available-to fight the
terrible scourge of AIDS. FBOs are very important in Africa -
Christians and Muslims. In the non-governmental sector, FBOs are
the major players. We MUST involve them. Yes, they might cite
scripture and talk about right and wrong when promoting absti-
nence and fidelity, but hey, it's hard to argue with success!
This approach worked, and, I might add, involving religious
groups did not lead to marginalizing and stigmatizing people, as
many feared.

As for human rights abuses, my colleague Dr Rand Stoneburner has
in fact charged that the great human rights violation of our
time is the fact that evidence for the effectiveness of A&B have
been kept from the public and out of AIDS prevention programs
until very recently. "Data that could save lives is being ig-
nored -- at the cost of millions of lives," he said. "That's a
great abuse of human rights because you would have saved 3 to 5
million lives if the ABC data was recognized and used years ear-
lier."

Re. the Human Rights Watch article itself, it starts: "As an ac-
knowledged leader in HIV prevention, Uganda should be building
on its success, not adopting the United States' failures."

I agree! Objective researchers have published analyses in The
Lancet, Science and BMJ in the last 12-26 months, and they all
conclude that decline in casual sex (the B of ABC) was the sin-
gle most important behavioral change. It was neither condoms nor
abstinence per se. Yet the major donors never supported this "Be
Faithful" intervention. (And the debate is strictly in terms of
the American culture wars: condoms only versus abstinence only).

The failure of the major donors has been to promote only risk
reduction interventions. ABC offers risk reduction plus risk
avoidance. Broader is better than narrower. Let's not perpetuate
this risk reduction only mistake, especially in a generalized
epidemic such as the one we find in Uganda. USAID and PEPFAR
wisely adopted an ABC model for generalized epidemics.

I was reminded later by a Ugandan colleague: "The Recent Stead-
man Report, a survey of media content [in Uganda mass media] re-
lated to AIDS, shows that in the last 3 years, most of the AIDS-
related media expenditure has been on condoms and VCT, and only
about 4% was on abstinence."

So you see, what Human Rights Watch is asserting about Uganda is
just not true.

Edward C Green
mailto:egreendc@aol.com