Uganda in the late 1980s was a country suffering the effects of more than two decades of civil war and social upheaval. Against this background, the scourge of AIDS spread rapidly, infecting hundreds of thousands of people. Estimates of the prevalence of the disease at its peak around 1990 have topped 20 per cent of the population, but today the figure is between 6 and 7 per cent. Uganda’s success in preventing AIDS has made it a model for other African countries and has shaped President George Bush’s current $15 billion AIDS relief programme.
What happened in Uganda? And can it still happen? Ugandan paediatrician Angelina Kakooza-Mwesige has every reason to face these questions squarely: she sees the youngest victims of AIDS at her weekly clinics at Mulago Hospital and Complex in Kampala — the largest and the main national, referral hospital in the country. She is also a lecturer at Makerere University Medical School in Kampala. Here she talks to MercatorNet about the current situation in her homeland and why success in fighting AIDS is, ultimately, as simple as ABC.
MercatorNet: Uganda has had remarkable success in fighting AIDS. What are the main factors in this success story?
Dr Kakooza: In the first place we had bold and committed leadership from the President, Yoweri Museveni, whose open discussion about AIDS and sexual behavior sounded the alarm. Then there was a decision to get people to change their behaviour in the direction of avoiding risk, rather than just reducing risk, as is the case with programmes that focus on condoms.
The behaviour change message was very clear and practical: A-Abstain, B-Be faithful and, if you must, use Condoms. For the Uganda Catholic Church, C stands for character formation. The ABC campaign did indeed lead to a behaviour change, with sexually active individuals resorting to being faithful to one partner and the non-sexually active persons delaying their sexual debut. Uganda’s Demographic and Health Survey of 2000-2004 indicated that 93 per cent of Ugandans changed their sexual behaviour to avoid AIDS.
There are many other important aspects of the campaign. AIDS preventive education was begun in primary schools, reaching children before they were sexually active. Involvement of value-based organisations by religious leaders was promoted. People living with HIV and AIDS were organised to take part in AIDS prevention activities. Face-to-face, open discussion about AIDS was fostered with the involvement of community groups like TASO, The AIDS Support Organization.
A basic aim of such activities was to arouse fear of this disease, which truly is fearful, so as to get people to see the risk of certain sexual behaviours and motivate them to change. At the same time we have put up a constant fight against stigmatising people with AIDS, since this robs them of the chance of treatment and care and leads to the spread of the disease. Silence and denial have to be replaced by compassion and understanding, and we are working hard at this. Also very important is the advancement of women in society and, of course, improving access to antiretroviral drugs
MercatorNet: Western experts don’t have much confidence in the ability of young people to be chaste and faithful. Was it very difficult to get young Ugandans to take this message on board?
Dr Kakooza: It is always very difficult initially to spread this message across to the youth. They often think it is impossible. However once they have realised the truth of the message and its goodness they become strong advocates of living chastity and good peer supporters. There are various groups of young people such as Youth Alive and Ma-Play who stand for this principle and go out to schools to share the message and help their peers come on board.
MercatorNet: Does this campaign still have momentum? Are there pressures from within the country, or outside it, to put more emphasis on the C message than on A and B?
Dr Kakooza: There has always been pressure from outside to put more emphasis on the C. However, there are now various non-governmental and religious organisations putting up a heated battle with the A and B. This has also been supported by recent USAID funds advocating more for A and B, and the current President’s wife, Janet Museveni, is a strong advocate for this too.
MercatorNet: How is the African family standing up to the combined effects of AIDS and the infiltration of Western values?
Dr Kakooza: The African family has been greatly threatened by the pandemic; there are a rising number of orphans and child-headed households. The extended family is still doing its best to ameliorate the situation but this occasionally becomes overwhelming. The decadent Western values using the press, radio and television media are slowly eroding some of the strong family values.
MercatorNet: Are there problems arising from the status of women in your country? Is polygamy a special problem?
Dr Kakooza: Yes, there are many problems in this area. There is still an element of gender inequality that subordinates women rights to those of men in sexual issues. Many women are still socially and economically dependent on men., and some women in the home are powerless to say “No” to an unfaithful husband. Polygamy is indeed a special problem. Currently it is reported that 32 per cent of Ugandan women are in polygamous unions.
MercatorNet: How big an obstacle is poverty to changing people’s sexual behaviour?
Dr Kakooza: Poverty plays a pivotal role in changing people’s sexual behaviour. Some adolescents, due to peer pressure, may indulge in sexual activity in order to meet their need for consumer items and activities that mark them as part of the “in group”. A few parents may quickly marry off their daughter to obtain a handsome dowry to assist them cope with their various family needs. Amongst unmarried or widowed women, factors like lack of employment, shelter, school fees, or food drive some of them to exchange sex for income.
MercatorNet: Uganda has suffered many years of insurgency and violence, tearing the social fabric apart. This makes the achievements in AIDS prevention even more impressive. How much of an obstacle is political conflict to further progress?
Dr Kakooza: Political and armed conflict hinders further progress in the fight against HIV/AIDS. The current insurgency in the northern part of the country has led to a large number of displaced persons who reportedly have a higher HIV/AIDS prevalence than the rest of the Ugandan population.
MercatorNet: Religion, and the Catholic Church in particular, is often blamed in the West for the AIDS pandemic in Africa. What is the truth of the matter?
Dr Kakooza: The truth of the matter is that abstinence is the only real protection against HIV/AIDS. It is not merely a risk reduction method but it is 100 per cent risk preventive. The Church prescribes abstinence before marriage and mutually faithful sexual relations within marriage. Misinformed people tend to blame the increase in the number of HIV cases on the Church’s ban on condom use, but it is people’s individual behaviour that’s to blame. A false sense of security often comes with the “trusted” protection of the condom, giving people the liberty to have multiple partners and hence fuelling spread of the epidemic.
MercatorNet: What has your own experience as a paediatrician working with children who have AIDS taught you about this disease?
Dr Kakooza: AIDS is a disease that has no barriers; it affects people of all social classes. Ugandan children are oftentimes infected by their mothers… Some children may be apparently “normal” for many years without showing any effects of the disease. Once they start showing signs of being infected it is always important to look out and control for the many otherwise preventable common childhood illnesses and opportunistic infections such as pneumonia, tuberculosis, persistent diarrhoea, malaria or recurrent blood system infections.
The use of antiretroviral drugs, when appropriate, in treating these children is excellent in stabilising their health. Inability to access antiretroviral therapy treatment is partly responsible for the high mortality rate among children infected with HIV/AIDS in Uganda according to a joint research report carried out by Makerere University and John Hopkins University.
Carolyn Moynihan is Deputy Editor of MercatorNet.