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PROJECT 

LESSONS 

LEARNED 

CASE • STUDY 

What Happened 

in Uganda? 

Declining HIV Prevalence, Behavior 

Change, and the National Response 

U.S. Agency for 

International 

Development 

Photo by:


Rich Marchewka, ©2000.


WHAT HAPPENED 

IN UGANDA? 

Declining HIV Prevalence, Behavior Change, 

and the National Response 

This document is not intended to provide a definitive explanation for Uganda’s 

AIDS prevention successes during the 1980s and 1990s. Rather, it is a synthesis 

of presentations made in February 2002 at the U.S. Agency for International 

Development (USAID) by four individuals with long-term experience in HIV 

prevention in Africa. USAID’s Office of HIV/AIDS decided to commission a 

summary document synthesizing the ideas presented by these researchers. The 

following pages do not include all the various statistical and other details that 

were presented; however, it is hoped that the main points described here provide 

MEDIAN HIV PREVALENCE AMONG PREGNANT WOMEN IN UGANDA 

(Interpolated for one-year gaps in site data) 

35 

30 

25 

20 

15 

10 

5 

0 

1986 1988 1990 1992 1994 1996 1998 2000 

Other Sites 

Kampala 

Source: HIV/AIDS Surveillance Report, STD/AIDS Control Programme, Ministry of Health, 

Uganda, June 2001. 

PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 1 
some insight into how Uganda has managed to control its HIV epidemic during 

the past 15 years. 

HIV prevalence has declined significantly in Uganda: Now considered to be 

one of the world’s earliest and best success stories in overcoming HIV, Uganda 

has experienced substantial declines in prevalence, and evidently incidence, during at least the past decade, especially among younger age cohorts. According to 

Ministry of Health (MOH) data, prevalence among pregnant women has 

declined consistently since the early 1990s at all of the country’s sentinel sites 

(except Tororo, near the Kenyan border, where prevalence increased a little during the mid-to-late 1990s, but declined significantly again by 2000). While it is 

more difficult to find reliable data on trends in incidence (or the rate of new 

infections), seroincidence also appears to have fallen significantly. In one site, 

Masaka, incidence fell from 7.6 per thousand per year in 1990 to 3.2 per thousand per year by 1998. As with prevalence, the decline was more pronounced 

among younger women. 

Seroprevalence among 15-19-year-old pregnant women, which is believed to be 

reflective of HIV incidence, fell sharply from the early 1990s, when this data was 

first collected, until 1995 or 1996, and since then has remained low. Based on 

this trend, as well as the fact that national seroprevalence peaked in 1991 and 

from some other indications (e.g., syphilis rates in Rakai plummeted in 1988), it is 

probable that incidence in Uganda would have peaked sometime in the late 1980s. 

Regarding prevalence, estimates by the U.S. Census Bureau/Joint United Nations 

Programme on HIV/AIDS (UNAIDS) are that national HIV prevalence peaked at 

around 15 percent in 1991, and had fallen to 5 percent as of 2001. This dramatic 

decline in prevalence is unique worldwide, and has been the subject of curiosity 

since the mid-1990s, and recently of even more intense scientific scrutiny. 

Observed consistently over time and across many different geographic and 

demographic populations, Uganda’s falling HIV prevalence is likely not due 

merely to measurement bias or a “natural die-off syndrome,” but rather mainly 

to a number of behavioral changes that have been identified in several surveys 

and qualitative studies. Some have postulated that the decline in seroprevalence 

was primarily a result of so many people succumbing to the disease that the rate 

of new infections was simply outweighed by the numbers of AIDS deaths. 

However, a number of other African regions (e.g., Zambia, Zimbabwe, western 

Kenya) have experienced nearly as old—and at least as severe—epidemics as 

Uganda’s, yet prevalence has yet to decline at the population level. Furthermore, 

2 PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 
HIV PREVALENCE AMONG 15-19-YEAR-OLD PREGNANT WOMEN


40 

35 

30 

25 

20 

15 

10 

5 

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 

Gulu 

Mbarara 

Fort Portal 

Jinja 

Nsambya 

Rubaga Hospital 

Source: HIV/AIDS Surveillance Report, STD/AIDS Control Programme, Ministry of Health, 

Uganda, June 2000. 

the large decline in prevalence among younger age cohorts in Uganda argues 

against this as a primary explanation. 

The relationships between the large variety of interventions in Uganda and the 

decline in incidence and prevalence are complex and not yet completely understood. This is especially true regarding the earlier years (i.e., there is little HIVrelated Demographic and Health Surveys (DHS) data prior to 1995). However, 

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 we know that HIV knowledge, risk perception, and risk 

avoidance 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. Many of these elements 

appear to be absent or less significant in other African countries that have not 

yet seen significant seroprevalence declines, such as Zimbabwe, South Africa, 

Botswana, Kenya, and Malawi. These key elements are summarized in roughly 

chronological order in the following pages. 

1. High-level political support with multi-sectoral response set the tone: 

In 1986, after 15 years of civil strife, Uganda’s new head of state, President 

Yoweri Museveni, responded to evidence of a serious emerging epidemic with a 

proactive commitment to prevention that has continued to the present. In faceto-face interactions with Ugandans at all levels, he emphasized that fighting 

PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 3 
AIDS was a patriotic duty requiring openness, communication, and strong leadership from the village level to the State House. His charismatic directness in 

addressing the threat placed HIV/AIDS on the development agenda, and 

encouraged constant and candid national media coverage of all aspects of the 

epidemic. This early high-level support fostered a multi-sectoral response, prioritizing HIV/AIDS and enlisting a wide variety of national participants in the 

“war” against the decimating disease known as “Slim.” In 1992, the multi-sectoral Uganda AIDS Commission (UAC) was created to coordinate and monitor 

the national AIDS strategy. The UAC prepared a National Operational Plan to 

guide implementing agencies, sponsored Task Forces, and encouraged the establishment of AIDS Control Programmes in other ministries including Defense, 

Education, Gender and Social Affairs. As of 2001, there were also reportedly at 

least 700 agencies—governmental and nongovernmental—working on 

HIV/AIDS issues across all districts in Uganda. 

2. Decentralized planning and implementation for behavior change communication (BCC) reached both general populations and key target 

groups: In 1986, Uganda established a National AIDS Control Program (ACP), 

which launched an aggressive public media campaign that included print materials, radio, billboards, and community mobilization for a grass-roots offensive 

against HIV. A national sentinel surveillance system, which has tracked the epidemic since 1987, began with four sites and by 2000 included 15; also of importance, there has been surveillance of AIDS cases since 1986. The ACP became 

the STD/AIDS Control Programme in 1994 and has since trained thousands of 

community-based AIDS counselors, health educators, peer educators, and other 

types of specialists. Led by their leaders’ examples, the general population in 

both urban and rural areas eagerly joined the fight against AIDS, so that it 

became a “patriotic duty” to support the effort. Spreading the word involved not 

just “information and education” but rather a fundamental behavior changebased approach to communicating and motivating. Decentralization itself was 

actually a type of local empowerment that involved local allocation of 

resources—in itself a motivating force. 

Notably, Uganda’s approach to BCC has relied more on “non-electronic” mass 

communication—which was community-based, face-to-face, and culturally 

appropriate. Strong nongovernmental organizations (NGO) and communitybased support led to flexible, creative, and culturally appropriate interventions 

that worked to change behavior despite extreme levels of post-civil war house4 PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 
hold poverty. As Edward Green observed, “low-tech” approaches also led to the 

sensitization and subsequent involvement in AIDS awareness and education of 

not only health personnel, traditional healers, and traditional birth attendants 

(TBAs), but influential people normally not involved in health issues such as 

political, community, and religious leaders, teachers and administrators, traders, 

leaders of women’s and youth associations, and other representatives of key 

stakeholder groups. BCC interventions reached not only the general population, 

but also key target groups including female sex workers and their clients, soldiers, fishermen, long-distance drivers, traders, bar girls, police, and students, 

without creating a highly stigmatizing climate. 

DELAYED SEXUAL DEBUT AMONG PRIMARY SCHOOL PUPILS 

(13–16 YEARS) FOLLOWING INFORMATION EDUCATION 

AND COMMUNICATION (IEC) (Soroti District, Uganda) % Reporting Sexual Initiation 

70 

60 

50 

40 

30 

20 

10 

2001 n)=400 

1996 n)=280 

1994 n)=287 

(

(

(

0 

Boys Girls 

Source: The Effects of the Katakwi/Soroti School Health and AIDS Prevention Project, African 

Medical and Research Foundation (AMREF) Report, Kampala, August 2001. 

3. Interventions addressed women and youth, stigma and discrimination: 

Linked to high-level political support and grassroots-level communication for 

behavior change was a strong emphasis on empowerment of women and girls; 

targeting youth in and also out of school; and aggressively fighting stigma and 

discrimination against people living with HIV/AIDS (PLWHAs). Since at least 

1989, teachers have been trained to integrate HIV education and sexual behavior 

change messages into curricula. At the same time, the country’s President and 

his political party have attempted to empower women and youth by giving them 

more political voice, including in Parliament where by law women make up a 

minimum one-third of the members. Four members elected by youth caucuses 

PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 5 
represent youth in Parliament. Youth-friendly approaches promoted partner 

reduction through talking about delaying sexual debut—remaining abstinent, 

remaining faithful to one uninfected person if “you’ve already started,” “zerograzing,” and using condoms if “you’re going to move around.” Of particular 

note is the indicator for the proportion of youth that has not yet begun to 

have sex. In an African Medical and Research Foundation (AMREF) study in 

Soroti District cited by Vinand Nantulya, among youth age 13-16 nearly 60 percent of boys and girls reported having already “played sex” in 1994, but in 2001 

that proportion was down to less than 5 percent. 

Respecting and protecting the rights of those infected by HIV has been inspired 

since 1988 by a number of prominent Ugandan citizens, and by public events 

such as candlelight memorials and World AIDS Day observances. In the late 

1980s, a celebrated European-based Ugandan musician, who went public about 

his HIV status at the beginning of the epidemic, returned home and devoted his 

last days to giving testimonies in schools, colleges, churches and elsewhere. Of 

critical importance, The AIDS Support Organization (TASO) was organized 

back in 1987, and has advocated against discrimination and stigma while pioneering a community-based approach for care of PLWHAs. The work of TASO 

and other care organizations has also made important contributions to prevention efforts, exemplifying the concept of a prevention-to-care continuum. Other 

national spokesmen included a Major in the Ugandan army who talked openly 

about his infection and how he used condoms to avoid infecting his wife, and a 

Protestant minister who disclosed that he learned of his infection when his first 

wife died, and talked publicly about using condoms to avoid infecting his new 

wife and their children. Openness on the part of the President, other government and community leaders, and prominent activists has led in general to a 

remarkably accepting and non-discriminatory response to AIDS. 

4. Religious leaders and faith-based organizations have been active on the 

front lines of the response to the epidemic: Mainstream faith-based organizations wield enormous influence in Africa. Early and significant mobilization of 

Ugandan religious leaders and organizations resulted in their active participation 

in AIDS education and prevention activities. Also, Mission hospitals were among 

the first to develop AIDS care and support programs in Uganda. In 1990, the 

Islamic Medical Association of Uganda (IMAU) piloted an AIDS education project in rural Muslim communities that evolved into a larger effort to train local 

religious leaders and lay community workers. Documenting increases in correct 

6 PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 
knowledge and decreases in risky behaviors, the IMAU project was selected as a 

“Best Practices Case Study” by UNAIDS. The Protestant Church of Uganda 

organized a workshop for bishops and other religious leaders in 1991, and 

implemented an extensive AIDS education project in many dioceses. The 

Catholic Church and mission hospitals provided leadership in designing AIDS 

mobile home care projects and special programs for AIDS widows and orphans. 

The three chairpersons of the Uganda AIDS Commission have included an 

Anglican and a Catholic Bishop. (The first leader was President Museveni.) 

5. Africa’s first confidential voluntary counseling and testing (VCT) 

services: In 1990, the first AIDS Information Center (AIC) for anonymous 

VCT opened in Kampala. By 1993, AIC was active in four major urban areas 

as more and more people became interested in knowing their sero-status. AIC 

pioneered providing “same day results” using rapid HIV tests, as well as the concept of “Post Test Clubs” to provide long-term support for behavior change to 

anyone who has been tested, regardless of sero-status. Uganda was fairly unique 

in Africa in the emphasis it placed on VCT, at a time when the Global Program 

on AIDS and other international organizations were not yet recommending it as 

a prevention strategy. 

6. Condom social marketing has played a key but evidently not the major 

role: Condom promotion was not an especially dominant element in Uganda’s 

earlier response to AIDS, certainly compared to several other countries in eastNUMBER OF SOCIALLY MARKETED CONDOMS SOLD IN UGANDA 

25 

20 

15 

10 

5 

0 

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 

Life Guard 

Protector 

Number of Condoms in Millions 

Source: Deloitte Touche Tohmatsu, Commercial Market Strategies, Uganda Report, 2001. 

PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 7 
ern and southern Africa. In Demographic Health Surveys, ever-use of condoms 

as reported by women increased from 1 percent in 1989, to 6 percent in 1995 

and 16 percent in 2000. Male ever-use of condoms was 16 percent in 1995 and 

40 percent in 2000. Nearly all of the decline in HIV incidence (and much of the 

decline in prevalence) had already occurred by 1995 and, furthermore, modeling 

suggests that very high levels of consistent condom use would be necessary to 

achieve significant reductions of prevalence in a generalized-level epidemic. 

Therefore, it seems unlikely that such levels of condom ever-use in Uganda (let 

alone consistent use, which was presumably much lower) could have played a 

major role in HIV reduction at the national level, in the earlier years. However, 

in more recent years, increased condom use has arguably contributed to the 

continuing decline in prevalence. 

In the early 1990s, there was resistance on the part of the President and some 

religious leaders to promoting condom use, but by the mid-1990s the controversy had generally faded. Purchased mainly with external donor funds, millions 

of condoms have since then been distributed by the MOH through health centers and NGO projects. Condom sales and reported use have increased significantly during the past half-decade (although still not to the same extent as in 

other countries like Zimbabwe, South Africa, Botswana, and Kenya). High levels 

of condom use have been reported for commercial sex work (i.e., reportedly at 

near-100 percent levels in Kampala), and according to Uganda’s 2000 DHS, 

among people reporting a non-regular partner in the past 12 months, 59 percent 

of men and 38 percent of women reported using a condom with their last nonregular partner. Therefore, current condom use rates with non-regular partners 

are probably playing a role in the continued declining seroprevalence. Note that 

while condom use with non-regular partners has been increasing, Ugandans are 

also reporting significantly fewer non-regular partners. In contrast, according to 

John Stover, if condom use in Kenya had not been as plentiful, seroprevalence 

might have increased even more than it has. But without the other, Uganda-like 

behavior changes (i.e., delay of sexual debut and “zero grazing”/partner reduction), prevalence did not decline. 

7. Sexually transmitted infections (STI) control and prevention programs 

have received increased emphasis: Since 1994, after declines in HIV prevalence began to be documented, two donor-funded projects addressed improving 

STI diagnosis and treatment of STIs. Adequate supplies of STI drugs in the 

country suffered from considerable delays in offshore procurement but by the 

8 PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 
end of the 1990s, drug supplies were adequate and distribution to rural health 

facilities was improving. Donor funding also financed a national reference laboratory at Mulago Hospital to study drug resistance. Two large randomized trials 

in Uganda (Rakai and Masaka) attempted to look at the impact of STI treatment 

on reducing HIV prevalence. Although both interventions reduced the rates of 

some STIs, there was no significant reduction in HIV incidence. According to 

an expert panel at the 2002 World AIDS Conference in Barcelona, the main reason for the lack of effect on HIV from STI treatment was the large decrease in 

risky sex/multiple partner trends that had occurred in Uganda by the time the 

STI trials began. (Most HIV transmission therefore now occurs within monogamous regular partnerships, where bacterial STIs tend to be rare.) 

POPULATION-BASED SURVEYS, UGANDA


Males Females 

50 

% Reporting Casual Sex in 

Past 12 Months 40 

30 

20 

10 

1995 

1989 

0 

Urban Rural Urban Rural 

Source: Global Program on AIDS, Geneva. 

8. The most important determinant of the reduction in HIV incidence in 

Uganda appears to be a decrease in multiple sexual partnerships and 

networks: In general, Ugandans now have considerably fewer non-regular sex 

partners across all ages. Population-level sexual behavior, including the proportion of people reporting more than one sexual partner, in Kenya (1998), Zambia 

(1996), and Malawi (1996), for example, appear comparable to those reported in 

Uganda in 1988-89. In comparison with men in these countries, Ugandan males 

in 1995 were less likely to have ever had sex (in the 15-19-year-old range), more 

likely to be married and keep sex within the marriage, and less likely to have 

multiple partners, particularly if never married. 

PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 9 
According to Rand Stoneburner, such behavioral changes in Uganda appear 

related to more open personal communication networks for acquiring AIDS 

knowledge, which may more effectively personalize risk and result in greater 

actual behavior change. Comparing DHS survey data with Kenya, Zambia, and 

Malawi, Ugandans are relatively more likely to receive AIDS information 

through friendship and other personal networks than through mass media or 

other sources, and are significantly more likely to know of a friend or relative 

with AIDS. Social communication elements, as suggested by these kinds of indicators, may be necessary to bridge the motivational gap between AIDS prevention activities and behavior change sufficient to affect HIV incidence. If these 

elements are present, the success of prevention activities may be greatly 

enhanced. Model simulations suggest that knowledge can diffuse rapidly, even 

early in an epidemic, in an environment of “open” personal networks. Uganda’s 

President set the example for the nation with his matter-of-fact approach to 

dealing with the HIV threat, and inspired thousands of community, religious, 

and government leaders to talk candidly to people about delaying sexual activity, 

abstaining, being faithful, “zero grazing,” and using condoms (roughly in that 

order). 

SEXUAL PARTNERSHIPS IN UNMARRIED BY AGE: 

% reporting non-regular partners in last 12 months, (DHS) 

Males Females 

100% 

80% 

60% 

40% 

20% 

0% 

Uganda Kenya Zambia Malawi Uganda Kenya Zambia Malawi 

1995 1998 1996 1996 1995 1998 1996 1996 

15-19 yrs 25-29 yrs 

20-24 yrs 30+ yrs

Source: Demographic Health Surveys. 

10 PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 
What did all this cost? According to an analysis by Elizabeth Marum, 

USAID/Centers for Disease Control and Prevention (CDC) HIV program 

director in Kampala throughout the 1990s, total donor support for all AIDSrelated contributions during the period 1989-1998 was approximately $180 million, or about $1.80 per adult per year over the 10-year period. Donor contributions amount to an estimated 70 percent of total expenditures on AIDS 

prevention and care in Uganda. Although this proportion is clearly significant, 

Uganda itself (both public and private sectors) must be credited with developing 

much of the successful approach, specifically: involvement of religious organizations, bold IEC in schools, VCT, and community-based and culturally appropriate BCC strategies. 

SIMULATION OF UGANDA HIV DYNAMICS:


Potential impact of similar behavior change in South Africa by 2000


5,000,000 

HIV Infection 

4,000,000 

3,000,000 

2,000,000 

1,000,000 

0 1990 2000 2010 

Prevalence Baseline Inc. Baseline 

Prevalence Intervention Inc. Intervention 

Deaths Baseline 

Source: Stoneburner, RL, Low-Beer D. Analyses of HIV trend and behavioral data in Uganda, 

Kenya, and Zambia: prevalence declines in Uganda relate more to reduction in sex partners than 

condom use. Abstract ThOrC734. XIII International AIDS Conference, Durban, South Africa, July 

7-14, 2000. 

A “social vaccine” in Africa? (Can this success be replicated?) It must be 

remembered that many of the elements of Uganda’s response, such as high-level 

political support, decentralized planning, and multi-sectoral responses, do not 

affect HIV infection rates directly. Sexual behavior itself must change in order 

for seroincidence to change. According to Stoneburner, the effect of HIV prevention interventions in Uganda (particularly partner reduction) during the past 

decade appears to have had a similar impact as a potential medical vaccine of 80 

PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 11 
percent efficacy. The historical and socio-cultural context, various interventions 

and other factors are complex and may be somewhat unique to Uganda, and it is 

not clear to what extent this success can exactly be replicated elsewhere, especially in more cosmopolitan, Westernized settings. However, recent seroprevalence and behavioral survey data among youth in Zambia indicate that a 

Uganda-like success story may be in the making there as well. According to a 

recent study by Population Services International, the main factor behind the 

large decline in prevalence among Zambian youth during the 1990s was a significant reduction in multiple partner trends. 

In conclusion, although we may never fully know “what really happened in 

Uganda,” the experience there and in other countries that have achieved some 

success suggests that a comprehensive behavior change-based strategy, ideally 

involving high level political commitment and a diverse spectrum of community-based participation, may be the most effective prevention approach. 

35 

30 

25 

20 

15 

10 

5 

0 

HIV PREVALENCE AMONG 15-19-YEAR-OLD 

PREGNANT WOMEN IN LUSAKA, ZAMBIA 

Chelstone Chilenje Kalingalinga Matero 

1993 1994 1998 

Source: U.S. Census Bureau, Population Division, International Program Center, HIV/AIDS 

Surveillance Data Base June 2001. 

12 PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 
Sources: 

1. Edward C Green, Ph.D. “What happened in Uganda?” [Powerpoint presentation]; “What are the lessons from Uganda for AIDS prevention? [10-page 

document]. Presentation to USAID, Washington DC, Feb. 5, 2002. 

2. Vinand M Nantulya, M.D., Ph.D. “HIV/AIDS prevention: Policy and program context of Uganda’s success story” [Powerpoint presentation]. 

Presentation to USAID, Washington DC, Feb. 5, 2002. 

3. John Stover, Ph.D. “The effects of behavior change on trends in HIV incidence in Uganda and Kenya” [Powerpoint Presentation]. Presentation to 

USAID, Washington DC, Feb. 5, 2002. 

4. Rand Stoneburner, Daniel Low-Beer, Tony Barnett, Alan Whiteside. 

“Enhancing HIV prevention in Africa: Investigating the role of social cohesion on knowledge diffusion and behavior change in Uganda.” Presentation at 

the World AIDS Conference, Durban, South Africa, July 2000; also presented 

at the World Bank, October 2000, and at USAID, Washington DC, February 

2002. 

5. Elizabeth Marum & E. Madraa. “A decade of an effective national response to 

AIDS: A review of the Ugandan experience.” Draft m.s., 1999. 

6. SM Mbulaiteye, C Mahe, JAG Whitworth, et al. Declining HIV-1 incidence 

and associated prevalence over 10 years in a rural population in south-west 

Uganda: A cohort study. Lancet 2002;360:41-44. 

7. S Agha. Declines in casual sex in Lusaka, Zambia: 1996–1999. AIDS 

2002;16:291-93. 

Summary produced by Jan Hogle, Ph.D., Synergy Consultant. 

PROJECT LESSONS LEARNED CASE STUDY: What Happened in Uganda? 13 


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