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Uganda Reduces HIV
ABC Model in Uganda Reduces HIV by Two Thirds
The
potential of abstinence-centered, character-based sexuality education
to directly reduce the spread of HIV/AIDS infection among adolescents
and adults is highlighted by a case study published by the U.S. Agency
for International Development (2002), “What Happened in Uganda?
Declining HIV Prevalence, Behavior Change, and the National Response.”
Green,
Hogle, Nantulya, Stoneburner, and Stover (2002) state that “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.”
Regarding HIV prevalence in Uganda,
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 has fallen to 5 percent as of 2001.This dramatic
decline in prevalence is unique worldwide” (p.2). (See Figure 1.)
Figure 1: HIV Prevalence among 15-19 Year-old Women in Selected Sites in Uganda, 1991 - 2000
Green et al. (2002) state that
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 countries (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” (p.2-3) (see Figure 2).
Figure 2: Non-regular sex partners in unmarried by age in Uganda, Kenya, Zambia, Malawi
Hogle
et al. (2002) describe the Ugandan approach in this way:
“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,’ [also called]
‘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, among youth ages 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” (p.6). (See Figure 3.)
Figure 3: Sexual debut among 13-16 year-olds in Soroti District, Uganda, 1994 – 2001
Regarding
the role of condom use, Green et al. (2002) state that “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” (p.7-8). In the opinion of the authors,
“the most important determinant of the reduction in HIV incidence in
Uganda appears to be a decrease in multiple sexual partnerships and
networks. In comparison with men in Kenya, Zambia, and Malawi, 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 to keep sex within
marriage, and less likely to have multiple sex partners, particularly
if never married” (p.9). (See Figure 4) This focus on eliminating risk
through changing sexual behaviors has also been described as “primary
behavior change”(Green, E.C., 2003, p.9)
Figure 4: Urban and rural males and females reporting casual sex in Uganda, 1989 – 1995
Serwadda
and Makumbi (2002) reported on trends in HIV prevalence, 1994-2000 in
Rakai-Southwestern Uganda. They reported that the odds ratio, compared
with those who had had no sex in the previous six months, for HIV
infection was higher for the sexually active reporting condom use
during the last six months than for the sexually active who reported
never using condoms in the last six months. Serwadda et al. offer no
explanation for this trend, but Kirby (2003) observed that while
sexually active Ugandans are more likely to use condoms with new casual
partners, sexually intimate couples who continue their relationship are
less likely to continue using condoms. This is an example of
“disinhibition” where an increase in one health behavior leads to a
reduction in another. Apparently the reduction in the number of
partners provides greater risk reduction than does higher levels of
condom use with higher numbers of partners.
Green et al.(2002)
also state that the sexual abstinence message in Uganda was framed in
the context of “a strong emphasis on empowerment of women and girls;
and aggressively fighting stigma and discrimination against people
living with HIV/AIDS (PLWHAs)” (p.5). As discussed earlier, the strong
message of the Ugandan campaign was framed as a “‘war’ against the
decimating disease known as ‘Slim’” (p. 4 ) with stark choices
presented as the weapons of choice to fight this war. Some might
describe this as a “fear-based” message, but here it can be seen how a
message that contains strong elements of fear can also contain elements
of compassion for people already infected with the disease and of
empowerment for women.
Green et al. (2002) ask if this success
can be replicated. They point out that 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. Allen and Heald (2004) also analyzed
the reasons for the success of the Ugandan approach in contrast with
the estimated 40% national HIV prevalence among adults ages 15-49 in
Botswana (UNAIDS), where condom use has been the main health education
message. They argue that “the promotion of condoms at an early stage
proved to be counter-productive in Botswana, whereas the lack of condom
promotion during the 1980s and early 1990s contributed to the relative
success of behavior change strategies in Uganda. Other important
factors included national and local-level leadership, the engagement
(or alienation) of religious groups and local healers and, most
controversially, procedures of social compliance. (p.1)”
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
(Agha, 2002), the main factor behind the large decline in prevalence
among Zambian youth during the 1990s was a significant reduction in
multiple partner trends.
References
Agha, S. (2002). Declines in casual sex in Lusaka, Zambia: 1996-1999. AIDS 2002, 16, 291-93.
Allen,
T. & Heald, S. (2004). HIV/AIDS policy in Africa: what has worked
in Uganda and what has failed in Botswana. Journal of International
Development 16, 1141-1154.
Green, E., Hogle, J., Nantulya, V.,
Stoneburner, R., Stover, J. (2002). What happened in Uganda? Declining
HIV prevalence, behavior change, and the national response. U.S. Agency
for International Development-Washington and The Synergy Project, TvT
Asociates, Washington, D.C., September, 2002.
Green, E.C. (2003). Rethinking AIDS prevention: Learning from successes in developing countries. Westport, CT: Praeger.
Serwadda,
D., & Makumbi, F. (2002). Rakai Project Presentation: Trends in
HIV-prevalence, and the association of delayed first sexual intercourse
and HIV prevalence. Paper presented on August 6, 2002.
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