From Coffins to ABCs: AIDS Prevention in Uganda

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

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

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

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

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

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

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

There can be no disputing that the scale of the problem in Uganda remains alarming, and that urgent action is required to save lives and prevent the epidemic from further eroding the country's development efforts. Thus, perhaps the most difficult challenge facing Uganda now is to build on the success of the past decade. Even if Uganda and its donors meet their target of providing ARVs to 100,000 people in the next five years, Dr. Coutinho of The Aids Support Organisation predicts twice that number could be newly infected. This is no time for 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 including 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 international donors, many Ugandans I spoke to on a recent visit to the country were already skeptical as the Bush money took so long to start trickling in, and they were not convinced that it would necessarily be put to most 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 ideological and fundamentalist religious beliefs rather than evidence-based recommendations.

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

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

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

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

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

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

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

I recently took the Entebbe-Kampala road again on one of my frequent trips to Africa. My heart sank as soon as we drove out of the airport parking lot, quickly dashing the excitement I felt about returning to Uganda that had peaked during the breathtaking landing on the shores of 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 merchants and their wares. Together, we breathed a sigh of relief when we didn't see any coffins.

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

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

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