S. Saad Mahmood
April 10, 2005
Fighting HIV/AIDS in
A study of public health management
called the ‘Pearl of Africa,’
In 2001 the
Uganda AIDS Commission Secretariat (Government of Uganda) published the “Twenty
years of HIV/AIDS in the world: Evolution of the epidemic and response in
1988 – By
now the infection had spread to most parts of
a prevalence rate of over 30%.
noted to have declined from around 18.5% in 1995, to 14.7% in
1997, 9.5% in 1998 to 8.3% at the end of 1999.
with HIV since its onset in the country.
About 800,000 people are estimated to have died of AIDS since the
1.4m people are currently estimated to be living with HIV/AIDS.
Over 1.7 million children have been orphaned by AIDS.
The ABC approach
As per the
United States Agency for International Development (USAID),
A for Abstinence (or delayed sexual initiation among youth)
B for Being faithful (or reduction in number of sexual partners)
C for Correct and consistent condom use.
ABC has been
cited to be very effective in a number of developing countries, where each of
the ABC interventions can be targeted and balanced according to the needs of
the nation’s at-risk population or even the specific circumstances of the
epidemic. To study the reasons for the decline in
• Fewer Ugandans were having sex at young ages [abstinence]. The proportion of young men who had ever had sex decreased substantially and the median age at which young women began having sex rose from 15.9 in 1988 to 16.3 in 1995. Importantly, however, among those people who were having sex, overall levels of sexual activity did not decline.
• Levels of monogamy [being faithful] increased. Sexually active men and women of all ages, particularly the unmarried, were less likely to have more than one sexual partner in a 12-month period in 1995 than in 1989. Other research has found that the proportion of men reporting three or more sexual partners also fell during the period.
• Condom use rose steeply among unmarried sexually active men and women. Among unmarried women who had had sex in the last four weeks, the proportion who used condoms at last intercourse rose from 1% in 1989 to 14% in 1995; among unmarried men, condom use rose from 2% to 22%.”
The Alan Guttmacher Institute
study therefore attributed
It is felt by
many that the ‘
United States Government under George W. Bush views the Ugandan intervention to
have been successful due to the abstinence portion of ABC. There is therefore a
move on part of the
Creating organization and infrastructure
In 2002 the Uganda AIDS Commission published the “Overview of HIV/AIDS Coordination” report describing the structuring and nationwide hierarchy the Government of Uganda adapted to coordinate the HIV aimed public health intervention. The report stated its goal to have “coordination with reference to HIV/AIDS,” and have a “harmonized response of the HIV/AIDS program in the country.” As per the 2002 report, the structural organization and description of HIV efforts is visualized and described below:
Hierarchy for policy matters:
(gives technical advice to UAC)
Forum for Development Partners
(makes program and resource decisions)
(gather ideas from international partners such as Great Lakes Initiative on HIV/AIDS)
National level coordination:
Self Coordinating Entities
(international NGOs, Ugandan NGOs, Faith based organizations, Media, Research groups, Unites Nations, Government Ministries)
Partnership Committee – Serves as a forum for dialogue between the Self Coordinating Entities. The Committee meets every month and consists of 13 representatives with the Uganda AIDS Commission as chair.
Partnership Forum – At this annual meeting all members of the Self Coordinating Entities meet to discuss activities and strategy.
Partnership Fund – Covers operational costs of Partnership Committee, Self Coordinating Entities and any other task needing quick national response and funds. The money is from contributions made by various partners.
Technical Resources Networks – Consisting of 15 people with the responsibility of planning and implementing thematic issues. The members are of highly technical expertise and from specialized institutions.
District level coordination:
(organize task forces to mobilize political leadership towards advocacy and overseeing the local government’s HIV/AIDS programs)
Local Government Parliament
(manages, plans, implements, monitors and evaluates HIV/AIDS programs in the district.
Consisting of HIV/AIDS committees, chaired by Chief Technical Executive. Members are allowed access to the local government.
Implementing ABC through the Multi-sectoral AIDS Control Approach
With a national level organizational hierarchy in development, the Government of Uganda launched in July 1991 the Multi-sectoral AIDS Control Approach (MACA). The aim of MACA was to engage all sectors of society against HIV/AIDS. The national public health intervention had to be seen as a collective responsibility. Based on the Government’s experience with AIDS since 1982, the MACA established 5 goals which were to be implemented at all levels of organization described in the previous section of this paper.
Goal 1 – Stop spread of HIV infection
Goal 2 – Mitigate the adverse health socioeconomic impact of HIV/AIDS epidemic
Goal 3 – Strengthen national capacity to respond to HIV/AIDS epidemic
Goal 4 – Establish a National Information Base on HIV/AIDS
Goal 5 – Strengthen national capacity to undertake research relevant to HIV/AIDS
Hence, as mentioned above, the MACA approach has the core features of seeking involvement in AIDS control measure by all sections and levels of society (i.e. coordination at administrative, political and grass root level). The MACA also goes beyond AIDS prevention and into the area of managing the consequences of the epidemic. Finally, the MACA seeks to establish sustainable activities among sectors and organizations, and build capacity.
In a 2003 study by Singh et. al. for The Alan Guttmacher Institute, the authors credit the
Government of Uganda for its ability to organize a hierarchy which provided the
infrastructural support needed to carry out a successful public health
intervention. A “uniquely creative and strategic policy approach [was
implemented] to enable non-state actors in their individually targeted message
about prevention.” This paper has attempted to give an overview of how the
Government restructured its organizational level around the ABC policy and
achieved a coordinated public health intervention. At the same time one must
keep in mind that an essential cofactor for the success of the
Thanks are due
to Jonathan Mermin, M.D. (Country
Director for the Centers for Disease Control’s Global AIDS Program in
(Access the report at http://www.aidsuganda.org/pdf/overview_of_coordination.pdf)
(Access the report at http://www.cdc.gov/washington/testimony/HI472004192.htm)
(Access the report at http://www.usaid.gov/press/speeches/2003/ty030519.html)
Singh S, Darroch
JE and Bankole A, A, B and C in
(Access the report at http://www.guttmacher.org)
(1) The Government of
Also, the Ministry of Health’s (Government of Uganda) ‘STD/HIV/AIDS Surveillance Report’ can be accessed at http://www.health.go.ug/hiv.htm .
(2) United States Agency for
International Development (USAID) has been actively involved in
(3) The Joint United Nations Program on HIV/AIDS
(UNAIDS) has been extremely active in
(4) For an analysis on why
the Uganda HIV/AIDS intervention was a success please read the impressive
studies published by The Alan Guttmacher
Institute at http://www.guttmacher.org
. Browsers should search for ‘
(5) For those seeking
information about the Centers for
Disease Control and Prevention’s work in
(6) If you want to learn about the debate between abstinence vs. being faithful and condom use go to:
USAID press release announcing $100 million dollars for abstinence focused grants
Report on the First Lady, Mrs. Museveni’s, work ok abstinence only programs
Human Rights Watch article on abstinence only approach
Article criticizing the focus on an abstinence only approach
(7) To read more about some community and faith based organizations fighting HIV/AIDS go to http://www.usaid.gov/our_work/global_health/aids/TechAreas/community/index.html .