“The fight against HIV/AIDS requires leadership from all parts of government – and it needs to go right to the top. AIDS is far more than a health crisis. It is a threat to development itself” – Kofi Annan

Part 2: HIV Prevention Programs before the introduction ehealth in Zambia and Uganda

Ehealth provides innovative solutions to tackle increasingly complex health issues while offering creative solutions for HIV prevention in resource poor countries. Before ehealth initiatives were introduced in Uganda and Zambia, preventative strategies were derived from national policies advocating behavioral change. Uganda presents a compelling success story in HIV/AIDS reduction, while Zambia has seen minimal reductions in HIV prevalence rates.

Uganda
In Uganda, HIV peaked at approximately 15% in 1991 and fell to 4% in 2003 (Cohen, 2003; Green, Halperin, Nantulya, & Hogle, 2006). Uganda’s success can be attributed to a combination of government support and behavioral changes through the ABC approach; abstinence, being faithful and condoms. There is some skepticism surrounding how much trust can be placed upon behavioral changes as a significant factor in HIV reductions. Some research suggests that the decline in HIV within Uganda is due to large numbers of people succumbing to the virus and therefore death rates outweigh the rate of new infections. However, the decline in infection rates among young populations under 20 cannot be due to high death rates because few individuals in this demographic have died from the virus (Green, Halperin, Nantulya, & Hogle, 2006).

In 1986 Uganda’s National response included President Yoweri Museveni recognizing and responding to the importance of fighting AIDS in Uganda. Immediately Museveni placed HIV/AIDS on the development agenda while acknowledging the importance of good communication and strong leadership from local villages to state house (Tumushabe, 2006). In 1986 Uganda established a National AIDS Control Program (ACP) and the national sentinel surveillance system, which has tracked the AIDS epidemic since 1987. In 1992 Uganda established the AIDS Commission (UAC) to closely monitor and coordinate the national AIDS strategy (Green, Halperin, Nantulya, & Hogle, 2006).

Major International Actors
Since 1987 donor funding has remained a consistent factor in both state and non-state actors in the management of the HIV/AIDS epidemic. The bulk of donor funds used in government run programs comes from the World Bank Multi-Country HIV/AIDS Program for Africa, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Great lake Initiative on AIDS, the US President’s Emergency Plan for AIDS Relief (PEPFAR), UN agencies, and bilateral organizations (Tumushabe, 2006). Non Governmental Organizations (NGOs) and faith-based organizations are also present in local initiatives. In 2001 there were more than 700 governmental and non-governmental organizations working on HIV/AIDS issues in Uganda (Green, Halperin, Nantulya, & Hogle, 2006).

Prevention Efforts
The ACP in 1986 launched an aggressive mass media campaign, which allowed Uganda’s government to provide accurate updates about the HIV/AIDS situation. Throughout the early to mid 1990s, political support was shown through mass media prevention campaigns supported by the Government and NGOs.  Public awareness of issues related to HIV/AIDS were broadcasted on private radio and television for the public to discuss freely (Green, Halperin, Nantulya, & Hogle, 2006). During the late 1980’s and early 1990s, HIV/AIDS prevention and anti-stigma messages were displayed on billboards and promoted in health, education and administrative departments within Uganda. Stigma attached to HIV/AIDS was addressed in these media campaigns to educate the Ugandans on the transmission of AIDS. Straight talk, a newsletter, was also included in Uganda’s prevention efforts. It communicated information on HIV/AIDS including sex and relationship advice to 15 000 secondary and primary school students as well as 600 community groups (Tumushabe, 2006).

 

The ABC Approach
Uganda’s method for behavioral change used the ABC approach that sought to change conduct around sex and sexual partners while encouraging abstinence until marriage, being faithful, and promoting condom usage. The National government relied primarily on community-based organizations to provide flexible, creative and culturally appropriate interventions to facilitate behavioral change. The involvement of a variety of groups in society was not typical for the health sector in AIDS education and awareness, however they were now incorporated into behavioral change initiatives. These included political, community and religious leaders, teachers, women and youth groups leaders. Key target groups were involved in AIDS education without creating an environment that stigmatized sex workers and their clients, soldiers, fisherman, long distance truckers, bar girls, police and students (Green, Halperin, Nantulya, & Hogle, 2006). Grassroots organizations emphasized the empowerment of women, while aiming efforts at older men with disposable incomes who were likely core transmitters of HIV. Politically the government made efforts to empower women by giving them more of a voice in parliament, where by law women only held one third of the positions (Green, Halperin, Nantulya, & Hogle, 2006).

The National government of Uganda relied heavily on a pre-marital abstinence approach to HIV prevention while attacking condom use as a form of HIV prevention. By the mid-1990s, Ugandans had fewer non-regular partners across all age groups. Males (aged 15-17 years) in 1995 were less likely to have ever had sex, more likely to be married and to keep sex within marriage and much less likely to have multiple partners, particularly if they had never married (Tumushabe, 2006).

Second to abstinence and being faithful is condom usage, which until 1991 was not a central element of Uganda’s response to AIDS as political and religious support in favour of condom usage was weak. President Museveni and local religious leaders resisted in promoting condoms. In 1988 the first edition government handbook on AIDS prevention prevailed attitudes toward condoms that were resistant, “The government does not recommend using condoms as a way to fight AIDS” (UNICEF/Uganda, 1988: 32). This attitude was reinforced further with, “one can still get AIDS even if a condom is used” (Green, Halperin, Nantulya, & Hogle, 2006). However, by the mid 1990s, the Ministry of Health was distributing condoms in health centers as well as through NGO projects. Condom usage increased among women and men. Women reporting condom use increased from 1% in 1989, to 6% in 1995 and 15% in 2000, while male condom use increased from 16% in 1995 to 40% in 2000 (Green, Halperin, Nantulya, & Hogle, 2006).

President Museveni displayed continued resistance toward condoms and in May 2004 Museveni was quoted as saying, “I am going to review this issue. I will open war on condom sellers. Instead of saving lives, they are promoting promiscuity among young people. When I proposed the use and distribution of condoms, I wanted  them  to  remain  in town for the prostitutes to save their lives” (Green, Halperin, Nantulya, & Hogle, 2006). Current statistics on condom usage by the Uganda AIDS Commission (2012) reveals that rates have dropped to 13.3% for men and 15.7% for women in 2011.

Although there is skepticism as to what specifically resulted in the decrease and stabilization of HIV/AIDS rates in Uganda, indirectly behavioral changes have contributed to a decline in prevalence rates. Uganda witnessed a significant decline in HIV prevalence until this stabilized around 2000, since then it has reduce to 6.7% (Uganda AIDS Commission, 2012). Despite this marked progress, Uganda still continues to struggle with providing consistent health facilities throughout the country between urban and rural areas. Subsequently, ehealth can provide helpful solutions to areas lacking adequate prevention strategies.

Zambia
Zambia unlike Uganda has yet to see dramatic decreases in HIV prevalence, but similar to Uganda, prevalence rates in Zambia have stabilized. Zambia has struggled with lowering prevalence rates since the first case was discovered in the mid 1980s. According to the United Nations General Assembly (UNGA) report (2012) HIV prevention efforts have yet to succeed in reducing infection rates below death rates, and therefore they are not witnessing a decrease in HIV prevalence rates.

Zambia has struggled to minimize HIV transmissions, accomplishing minimal reductions in prevalence rates. Still, Zambia’s has found success with a slight reduction in the adult population infected with HIV from 15.6% in 2001 to 14.3% in 2007 (UNGA, 2012). Children born to mothers infected with HIV reduced from 7.72% in 1997 to 1.99% in 2011 due to the administration of prophylaxes to prevent mother to child transmission. This program has reached national coverage of 80% and continues to strive for universal access. Despite reductions in HIV prevalence, in some rural areas men have seen an increase in HIV from 8.9% in 2001 to 11% in 2007 (UNGA, 2012).

Differences in Rural and Urban rates are noticeable as small reduction in HIV rates for 15-49 year olds.

National Response: Achievements and Future Initiatives
Government support in combating HIV in Zambia has included the establishment of National AIDS and Prevention and Control Programs in 1986. In 1987, an emergency short-term plan was established to ensure safe blood and blood products. The 1994-1998 Second Medium Term Plan was the first inclusion of a variety of sectors in Zambia to collaborate in efforts to combat HIV/AIDS. In 2003, Zambia launched its national policy for providing free and universal access to antiretroviral therapy, which in 2005 was expanded to include all related services (UNGA, 2012). In the 2006-2010 National AIDS Strategic Framework (NASF) the main priority was universal access to prevention, treatment, care and support. Coverage within these four sectors was increased to 80% (UNGA, 2012). In 2009, Zambia made male circumcision a priority as HIV transmission could be reduced up to 60%. With a male circumcision rate of only 14% the Ministry of Health recently partnered with local NGOs to establish country wide circumcision clinics aiming to reach 80% by 2020 (Waters et al., 2012). The current HIV/AIDS situation in Zambia is detailed in the 2011-2015 NASF which includes representation from civil society, including those living with HIV/AIDS, governmental institutions, development institutions, the private sectors and local NGOs. Sex workers and vulnerable populations are also included and voiced on behalf of NGOs. NASF has made HIV prevention a priority in order to reduce the number of new cases annually. Main actors currently supporting Zambia’s prevention efforts include; President’s Emergency Plan for AIDS Relief (USA), Global Fund to Fight AIDS, Tuberculosis and Malaria, UK government’s international development department, and the Bill and Melinda Gate Foundation.

Prevention Efforts
Since the early 1990s Zambia’s HIV prevention efforts have been focusing on behavioral changes similarly to Uganda, using the ABC method. The majority of programs were based on abstinence and fidelity with condoms as fall back options if sexual activity took place (Gordon & Mwale, 2006). Abstinence was the emphasis however, and in 2003, the Ministry of Education banned NGOs from distributing condoms at or near school sites (Gordon & Mwale, 2006). Life skills based education is focused upon teaching young people how to deal with the challenges and demands of everyday life, creative and critical thinking, self-awareness, communication and interpersonal awareness. This program was adapted for HIV education, and helps students, assess the individual, social and environmental factors that raise or lower the risk of HIV transmission. The Ministry of Health delivered this program to a total of 7611 primary and secondary schools, however according to the UNGA 2010 report, no evaluation to assess the impact of this prevention program had been undertaken.

During a summer holiday club in the summer 2007, teaching in Mulwani Basic School.

These signs during the summer (June-September) of 2007 were common not only in school yards but also throughout small villages and in the closest large town of Livingstone.

Although prevention efforts are visible through the implementation of NASF policies, little evidence is seen in the reduction of new HIV infections annually. Politically according to the UNGA (2010) report Zambia maintained a poor rating of political support on a scale of 10. In 2005 Zambia scored a 5, in 2007 they scored 7, and it 2009 they scored 6. While the most recent report by the UNGA (2012) reveals improvements in political support, aiming to eliminate rather then reduce HIV transmission from mother to child, and increasing the health budget by 45% in absolute terms. In addition Zambia has increased the antiretroviral budget from 5 million US to 10 million US for 2012. However, the UN reports that Zambia is donor dependent and lacks a local mobilization of resources. The current political support standing in 2011 reported by the UNGA (2012) was 6.

Although Uganda and Zambia have different stories as to what their HIV prevention efforts have comprised of, they are similar in terms of stabilized HIV prevalence rates. Both are now in need of new innovative efforts to jump-start a decline in the annual number of new HIV rates. Thus, preventive ehealth offers creative tools that may benefit both countries in the future as current efforts are lacking success.

 References

Cohen, S. (2003). The ABC Approach to HIV: Prevention: A Policy Analysis. The Guttmacher Report on Public Policy, New York.

Gordon, G., & Mwale, V. (2006). Preventing HIV with Young People: A Case Study from Zambia. Reproductive Health Matters , 14 (28), 68-79.

Green, E., Halperin, D., Nantulya, V., & Hogle, J. (2006). Uganda’s HIV Prevention Success: The Role of Sexual Behavior Change and the National Response. AIDS and Behavior , 10 (4).

Tumushabe, J. (2006). The Politics of HIV/AIDS in Uganda. Programme Paper Number 28, United Nations Research Institute for Social Development, Social Policy and Development.

Uganda AIDS Commission. (2012). Global AIDS Response Progress Report. The Republic of Uganda.

United Nations General Assembly. (2010). Zambia Country Report: Monitoring the Declaration of Commitment on HIV and AIDS and the Universal Access. Biennial Report, United Nations General Assembly Special Session on HIV and AIDS.

United Nations General Assembly. (2012). Zambia Country Report: Monitoring the Declaration of Commitment on HIV and AIDS and the Universal Access. Biennial Report, United Nations General Assembly Special Session on HIV and AIDS.

Waters, E., Stringer, E., Mugisa, B., Bowa, K., & Linyama, D. (2012). Acceptability of neonatal male circumcision in Lusaka, Zambia. AIDS Care , 24 (1), 12-19.

 

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