Uganda promotes all three interventions: abstinence, being faithful
and using condoms. Since the Ugandan government is heavily dependent
on the foreign donors, it naturally has to develop programs that are
in line with interventions favored by the major donors. What the donors
favor now is what they have favored since the beginning of AIDS—risk
reduction only: condoms, treating STDs, getting as many people tested
as possible. These are all valid interventions, but recent evidence suggests
that these should not be the only interventions available, or the only
AIDS prevention options promoted to all segments of any national population.
Part of the genius of the Ugandan ABC model is that it includes these
risk intervention models but it also addresses sexual behavior
directly. With A and B interventions, young people are urged to delay
sex until they are married, and sexually active adults are urged to remain
mutually faithful with their partners. This is something major donors
don't favor or fund (the recent exception is USAID, which adopted
an ABC policy for generalized epidemics in December 2002, followed by
PEPFAR. One-third of all prevention funds are now supposed to go to abstinence
programs). It's a great pity that funds were not earmarked for
the B of ABC, since it is increasingly recognized that partner reduction
(or higher levels of fidelity and monogamy) was the major behavioral
change responsible for prevalence decline in Uganda—and more recently,
in Kenya.
In Uganda, the term safer sex previously meant abstinence and fidelity.
Now is means "promotion of safer sex among the young people greatly
depends upon the availability of condoms."
Edward C. Green, co-author of an A-B Policy/Strategy document that
came under the Uganda AIDS Commission, resulted in having his paper demoted
to being considered a "Strategy" and not a "Policy," perhaps
meaning that anything in the document was just a suggestion and not anyone's
policy. Moreover, USAID/Uganda never paid the authors for their time
developing this document, as they did quite lavishly in the case of the
national Condom Policy and Strategy. In the end, a private health foundation
paid the overdue salaries of the authors of the A-B document (Green took
no salary).
A visitor to Uganda today finds an AIDS prevention program that looks
increasingly like programs in any other country in Africa: condom social
marketing, supplemented by treatment of STDs, VCT, and provision of Neveripine
to pregnant mothers. There is little evidence for ABC, especially if
foreign donors are showcasing "What Happened in Uganda." Green
was part of a delegation to Uganda in December 2002. USAID and the CDC
provided nearly two hours of slide presentations to explain "What
Happened in Uganda." There was no mention of the role of abstinence
or faithfulness or even partner reduction or decline of casual sex. The
presentations were exclusively about latex, drugs, and vaccine research.
To discover anything about abstinence or fidelity, one has to consult
religious groups or certain branches of the Ugandan government. As for
involving Faith-Based Organizations (FBOs) in AIDS prevention, Ugandan
President Museveni said, "We need everyone—all resources
available—to fight the terrible scourge of AIDS." FBOs are
very important in Africa—both Christian and Muslim. In the non-governmental
sector, FBOs are the major players. We MUST involve them. Yes, they might
cite Scripture and talk about right and wrong when promoting abstinence
and fidelity, but it's hard to argue with success! This approach
not only worked, but involving religious groups did not lead to marginalizing
and stigmatizing people, as many feared it would.
As for human rights abuses, such as "The exhortation to abstain
until marriage not only ignores the plight of women who contract HIV
in marriage, but also discriminates against lesbians and gay men, who
cannot legally marry in Uganda." Doctor
Rand Stoneburner has in fact charged that the great human rights violation
of our time is the fact that evidence for the effectiveness of A&B
have been kept from the public and out of AIDS prevention programs until
very recently. He said, "Data that could save lives is being ignored—at
the cost of millions of lives. That's a great abuse of human rights
because you would have saved 3 to 5 million lives if the ABC data was
recognized and used years earlier."
The Human Rights Watch report
itself begins: "As an acknowledged leader in HIV prevention, Uganda
should be building on its success, not adopting the United States' failures."
Objective researchers have published analyses in The Lancet, Science
and BMJ, all concluding that decline in casual sex (the B of ABC) was
the single most important behavioral change. It was neither condoms nor
abstinence per se. Yet the major donors never supported this "Be
Faithful" intervention,
nor abstinence or "delay." The debate is strictly in the
terms of the American culture wars of condoms only versus abstinence
only.
^TOP TWO EPIDEMICS >
http://ccih.org/conferences/presentations/2005/uganda-trends.doc
http://ccih.org/conferences/presentations/2005/uganda-trends.doc
http://ccih.org/conferences/presentations/2005/uganda-trends.doc
http://www.globalaidsalliance.org/Lancet_Uganda.cfm
http://ccih.org/conferences/presentations/2005/uganda-trends.doc
"AIDS in Uganda: the Human-Right
Dimension" www.thelancet.com Vol.
365 June 18, 2005
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