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

(Green, Halperin, Nantulya, & Hogle, 2006)


–       Researchers and policymakers have debated the meaning of Uganda’s unprecedented HIV prevalence decline. While some researchers believe that the decline in prevalence rates is due to a decrease in casual/multiple sexual partner behavior, others believe it is rather than mainly condom use or increases in mortality. Finally some believe that the prevention approach that has centered on condom usage and HIV testing.

–       Prevention focused on ABC factors (Abstinence, Being faithful and Condom use).

–       UNAIDS (2004) reports Uganda as a compelling national success story in combating the spread of HIV.

–       What exactly decreased HIV rates in Uganda?

  • According to the Ministry of Health, prevalence among pregnant women attending antenatal clinics has declined consistently since the early 1990s and has remained low until recently for the first time in a decade.
  • Behavior change in young men and the subsequent prevalence decline in pregnet women.
  • HIV peaked in late 1980s in Uganda around 15% and fell to 4% in 2003.

–       National Response: although the decline in HIV is complex due to the relationships between various behavior changes, mortality and prevention efforts play a role (decline in age of premarital sex, condom use)

–       High level of political and National Support as well as multi-sectoral response. President Yoweri Museveni responded in face to face interactions with Ugandans and emphasizing that fighting AIDS was a “patriotic duty” requiring openness, communication and strong leadership from the village level to the State House. Immediately Museveni put HIV/AIDS on the development agenda and encouraged consistent and honest updates with the media.

–       In 1986 Uganda established a National AIDS Control Program (ACP) and the national sentinel surveillance system, which has tracked the epidemic since 1987. By 1992 the Uganda AIDS Commission (UAC) was created to closely coordinate and monitor the national AIDS strategy. The UAC prepared a National Operation Plan implementing agencies, sponsored task forces and encouraged AIDS programs within other ministries including Defense, Education, Gender and Social Affairs. In 2001, there were at least 700 agencies both governmental and non governmental working on HIV/AIDS issues across Uganda.

– (Ministry of Health Uganda) AIDS was first recognized in 1983 with 900 cases reported in 1986 which increased to 6000 by 1988. Uganda was one of the first African countries to establish a national AIDS control program and national committee for the prevention of AIDS.

–       (new) While some have postulated that the prevalence decline was primarily a result of so many people succumbing to the disease that AIDS deaths outweighed the rate of new infections. The decline in prevalence rates among younger age cohorts in Uganda cannot be explained by AIDS mortality as very few people under 20 die of AIDS.

–       Tend #1: Declining Casual / multiple sexual partners

  •  (WHOs Global Program on AIDS) surveys from 1988/9 and 1995 although not fully nationally representative did sample a large number of people in the most affected  HIV parts of the country. This study found that in 1989 60% of single males 15-24 reported having premarital sex which decreased to 23% in 1995 (although these statistics should be taken with caution as the number of respondents also decreased from 35% to 15% among males).



–       National Response: changes in age of sexual debut, casual and commercial sex trends, partner reduction and condom use all appear to have played key roles in the continuing declines. Although it is believed that HIV knowledge, risk perception and risk avoidance/risk reduction options can ultimately lead to reduced HIV incidence, there is a complex set of epidemiological, socio-cultural, political and other elements that likely affected the course of the epidemic in Uganda. In countries that have yet to experience a decline in HIV these elements appear to be absent or less evident in those African countries that have not yet experienced significant national prevalence declines, such as South Africa and Malawi.

–       High-Level Political Support and Multi-Sectoral Response: see about about president

–       Decentralized Planning and Implementation for Behavior Change Communication: in 1986 Ugandas ACP program which later was known as STD/AIDS Control program (in 1994) launched an aggressive public media campaign that included print materials, radio, billboards, and community mobilization for a grass-roots offensive against HIV and has since then trained thousands of community-based AIDS counselors, health educators, peer educators and other types of specialists. Rural and urban communities become involved with spreading the word that involved not just information and education but rather a fundamental behavior change-based approach to communicating and motivating which become empowering for local communities.

–       Uganda’s approach to behavioral change relied on primarily community-based and face-to-face communication. Strong support from NGOs and community-based support led to flexible, creative and culturally appropriate interventions that helped facilitate individual behavior change as well as changes in community norms despite extreme levels of poverty. Involvement of all groups in society in AIDS education of not only health professions, traditional healers and traditional birth attendants but also non health sectors such as political, community religious leaders, teachers, leaders in woman and youth groups and grass roots community groups. Key target groups were addressed without creating high stigmatizing climate (female sex workers and clients, soldiers, fisherman, long distance truck drivers, bar girls, police and students.)

–       Addressing Women, Youth and Stigma and Discrimination: Linked to high-level political support and grassroots-level communication for behavior change was a strong emphasis on greater empowerment of women and girls: targeting youth both in and out of school: and aggressively fighting stigma and discrimination against people living with HIV/AIDS. Politically the government tried to empower women by giving them more of a voice in Parliament where by law women make up a minimum one-thired of the members (in addition to four members elected by youth caucuses). Grassroots organizations have fought to empower women socially, economically, and legally. Womens empowerment organizations aimed programs at male behavior, particularly older men with disposable incomes who were likely the principal “core transmitters”.

–       Youth friendly approach such as Straight Talk promoted behavior change through promotion of delaying sexual intercourse and remaining faithful to one partner and using condoms if you “move around”.

–       Political support in terms of the president and other government and community leaders and prominent activist has led, relatively speaking, to a remarkably accepting and non-discriminatory response to AIDS.

–       Condom Promotion: Prior to 1990s there was resistance among President Museveni and some religious leaders about promoting condom usage. In a 1988 Uganda report the, “government does not recommend using condoms as a way to fight AIDS.” This was later rewritten as “one can still get AIDS even if a condom is used”. Condoms sales did not reach substantial levels until the later 1990s. Mid 1990s the Ministry of Health though health centers and NGO projects purchased  and distributed condoms. Stats: in  1989, 1% 1995, 6% of sexually active Uganda’s reported using a condom with some regularity while this rose to 40% in 2000.

–       Among sex workers condom usage is nearly 100% in Kampala.

–       Lower Levels of Multiple Partnerships and Reduced Sexual Networks: by the mid-1990s Ugandans had fewer non-regular sexual partners across all age groups. Males in 1995 were less likely to have ever had sex (in the 15-19 year old age range), more likely to be married and to keep sex within marriage and much less likely to have multiple partners, particularly if never married. GPA surveys reported a drop from 15-3% for men reporting three or more non-regular sexual partners.

–       Behavioral changes are consistent with dominate AIDs prevention messages of early Uganda response (1986-1991), specifically: “stick to one partner”, “love faithfully” and “zero-grazing” (grazing:…..)

–       Sum up: Many of the elements of Uganda’s response, such as high-level political support, decentralized planning and multi-sectoral organization, do not affect HIV infection rates directly. Rather, sexual behavior itself must change in order for seroincidence to change.  See pg342.