S

S. Saad Mahmood

MPHP 439

April 10, 2005

Fighting HIV/AIDS in Uganda:

A study of public health management

Uganda – Brief description of a nation

Often called the ‘Pearl of Africa,’ Uganda is situated on the equator and has a population between 20 to 25 million people. The nation is home to over eighteen ethnic groups and a similar number of languages. The official languages are Swahili and English, a remnant of the effects of being a British protectorate. Uganda has had a violent history since achieving independence in 1962. Owing to the activities of the former dictator, Idi Amin, and currently the Lord’s Resistance Army, Uganda has seen its share of civil disorder. However, the last two decades have mostly been peaceful and Uganda is now seen as a poster child for successful public health intervention to reduce prevalence of HIV/AIDS. Uganda is considered an under-developed nation with a per capita GDP of $280 per year.

History of HIV/AIDS in Uganda

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 Uganda” report. As per the national records:

1982 – First reported AIDS case identified in the Rakai District.

· 1988 – By now the infection had spread to most parts of Uganda. A national sero-survey was conducted to assess the magnitude of the epidemic among the adult population. The average prevalence rate was at 9%.

1992 – Peak of infections in hard hit areas with some urban sites registering

a prevalence rate of over 30%.

1995 – Uganda announces confirmed declining HIV prevalence trends

beginning 1992.

2000 – The average national prevalence rates among the adult population

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.

2001 – An estimated cumulative total of 2.2 m people have been infected

with HIV since its onset in the country.

About 800,000 people are estimated to have died of AIDS since the

onset.

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), Uganda was able to successfully implement a public health intervention against the spread of HIV/AIDS owing to the ‘ABC approach’ as explained below:

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 Uganda’s HIV/AIDS prevalence rates, The Alan Guttmacher Institute conducted a study in 2003 on behavioral changes seen in the population of Uganda. The study found that:

• 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 Uganda’s decline in HIV/AIDS prevalence to the successful implementation of the ABC approach. The belief was shared by Jonathan Mermin, M.D. (Country Director for the Centers for Disease Control’s Global AIDS Program in Uganda) who in April 2004 testified before the U.S. Senate’s Committee on Foreign Relations regarding the status of the HIV/AIDS epidemic in Uganda. In his briefing, Dr. Mermin attributed the decline in HIV incidence to many innovative programs, especially the ABC method.

It is felt by many that the ‘Uganda miracle’ was achieved in part due to the positive behavioral changes seen in all three ABC components. In a similar testimony given in May 2003 by Anne Peterson, M.D. (USAID Assistant Administrator for Global Health) it was stated that “USAID has always acknowledged that a balanced ABC approach to the HIV/AIDS pandemic is needed.” Dr. Peterson went on to elaborate that “The balance is set for an individual country based on culture, epidemiology, and the stage of the epidemic. The ABCs of HIV prevention reinforce one another, and the appropriate message must reach the appropriate audience. These messages and target audiences can be segmented without denigrating any one message.”

However, 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 US government towards an abstinence focused model and on October 4, 2004 the USAID announced $100 million were now available for abstinence focused grants. The abstinence focused approach also has the support of the Ugandan First Lady, Mrs. Janet Museveni, who has described safe sex initiatives as being ineffective and irresponsible. Please read the bibliography for links to articles and reports ranging from ones that support abstinence focused approach to ones that support an ABC approach.

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:

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.

Conclusion

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 Uganda miracle was the dedication of non-government agencies, and of organizations such as UNAIDS, USAID, faith based organizations etc. Hence, a successful public health intervention must include adjustments, public engagement and activism on the behalf of the government and also significant amount of efforts on the part of other organizations.

Acknowledgement:

Thanks are due to Jonathan Mermin, M.D. (Country Director for the Centers for Disease Control’s Global AIDS Program in Uganda) for his advice via email on gathering material for writing this paper. Thanks are also due to Ms. Pam Dougherty (Centers for Disease Control, Washington D.C.) for her help in contacting individuals who could provide input on the topic.

Works Cited

Government of Uganda. Uganda AIDS Commission Secretariat. Twenty years of HIV/AIDS in the world: Evolution of the epidemic and response in Uganda. June 2001.

(Access the report at http://www.aidsuganda.org/pdf/20_yrs_of_hiv.pdf)

Government of Uganda. Uganda AIDS Commission. Overview of HIV/AIDS coordination. 2002.

(Access the report at http://www.aidsuganda.org/pdf/overview_of_coordination.pdf)

Government of United States. Centers for Disease Control and Prevention. Fighting HIV/AIDS in Africa: A progress report on the HHS/CDC Efforts. Testimony of Jonathan Mermin, M.D., Public Health Epidemiologist. Country Director for GAP Uganda. Before the Committee on Foreign Relations, Subcommittee on African Affairs. U.S. Senate. April 7, 2004.

(Access the report at http://www.cdc.gov/washington/testimony/HI472004192.htm)

Government of United States. United States Agency for International Development. Testimony of Anne Peterson, M.D., USAID Assistant Administrator for Global Health. Before the Committee on Foreign Relations, Subcommittee on African Affairs. U.S. Senate. May 19, 2003

(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 Uganda: The Roles of Abstinence, Monogamy and Condom Use in HIV Decline, Occasional Report, New York: The Alan Guttmacher Institute, 2003, No. 9.

(Access the report at http://www.guttmacher.org)

Bibliography

(1) The Government of Uganda has an online resource on its activities to tackle the HIV/AIDS epidemic. Uganda’s National AIDS Documentation and Information Center can be accessed at http://www.aidsuganda.org .

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 Uganda. Reports on USAID work in the nation can be accesses at http://www.usaid.gov/locations/sub-saharan_africa/countries/uganda/ .

(3) The Joint United Nations Program on HIV/AIDS (UNAIDS) has been extremely active in Uganda’s fight against HIV/AIDS. Reports on Uganda’s pubic health interventions can be accessed at http://www.unaids.org/EN/Geographical+Area/by+country/uganda.asp .

(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 ‘Uganda’ to access a number of articles.

(5) For those seeking information about the Centers for Disease Control and Prevention’s work in Uganda through the HHS/CDC Global AIDS Program (GAP), access http://www.cdc.gov/nchstp/od/gap/countries/uganda.htm .

(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

http://www.usaid.gov/press/releases/2004/pr041005.html

Report on the First Lady, Mrs. Museveni’s, work ok abstinence only programs

http://www.catholicexchange.com/vm/index.asp?vm_id=90&art_id=27963

Human Rights Watch article on abstinence only approach

http://hrw.org/reports/2005/uganda0305/5.htm

Article criticizing the focus on an abstinence only approach

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2005/02/24/MNG2PBG3VF1.DTL&type=health

(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 .