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89–197 PDF 2003

S. HRG. 108–106

FIGHTING AIDS IN UGANDA: WHAT WENT RIGHT?

HEARING

BEFORE THE

SUBCOMMITTEE ON AFRICAN AFFAIRS

OF THE

COMMITTEE ON FOREIGN RELATIONS

UNITED STATES SENATE

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

MAY 19, 2003

Printed for the use of the Committee on Foreign Relations

(

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate

COMMITTEE ON FOREIGN RELATIONS

RICHARD G. LUGAR, Indiana, Chairman

CHUCK HAGEL, Nebraska

LINCOLN CHAFEE, Rhode Island

GEORGE ALLEN, Virginia

SAM BROWNBACK, Kansas

MICHAEL B. ENZI, Wyoming

GEORGE V. VOINOVICH, Ohio

LAMAR ALEXANDER, Tennessee

NORM COLEMAN, Minnesota

JOHN E. SUNUNU, New Hampshire

JOSEPH R. BIDEN, JR., Delaware

PAUL S. SARBANES, Maryland

CHRISTOPHER J. DODD, Connecticut

JOHN F. KERRY, Massachusetts

RUSSELL D. FEINGOLD, Wisconsin

BARBARA BOXER, California

BILL NELSON, Florida

JOHN D. ROCKEFELLER IV, West Virginia

JON S. CORZINE, New Jersey

KENNETH A. MYERS, JR., Staff Director

ANTONY J. BLINKEN, Democratic Staff Director

SUBCOMMITTEE ON AFRICAN AFFAIRS

LAMAR ALEXANDER, Tennessee, Chairman

SAM BROWNBACK, Kansas

NORM COLEMAN, Minnesota

JOHN E. SUNUNU, New Hampshire

RUSSELL D. FEINGOLD, Wisconsin

CHRISTOPHER J. DODD, Connecticut

BILL NELSON, Florida

(II)

CONTENTS

Page

Alexander, Hon. Lamar, U.S. Senator from Tennessee, opening statement ...... 3

Letter from Mrs. Janet K. Museveni, First Lady of Uganda, to Chairman

Richard G. Lugar, pertaining to the ‘‘Uganda ABC model’’ ...................... 25

Biden, Hon. Joseph R., Jr., U.S. Senator from Delaware, prepared statement . 5

Busch, Jeffrey, chairman and CEO, SafeBlood for Africa, statement submitted

for the record entitled ‘‘Blood Safety: An Important Tool in AIDS Prevention,’’ ...................................................................................................................... 5

Feingold, Hon. Russell D., U.S. Senator from Wisconsin, prepared statement .. 6

Green, Edward C., Ph.D., senior research scientist, Harvard Center for Population and Development Studies, Cambridge, MA ............................................ 32

Prepared statement .......................................................................................... 35

Mukasa Monico, Sophia, senior AIDS officer, Global Health Council, Washington, DC ............................................................................................................. 40

Prepared statement .......................................................................................... 43

Uganda AIDS Commission Status Report ...................................................... 46

Peterson, Dr. Anne, Assistant Administrator for Global Health, U.S. Agency

for International Development, Washington, DC .............................................. 7

Prepared statement .......................................................................................... 10

‘‘What Happened in Uganda?’’ a synthesis of presentations made in February 2002 at USAID by four individuals with long-term experience

in HIV prevention in Africa ......................................................................... 15

(III)

(1)

FIGHTING AIDS IN UGANDA: WHAT WENT

RIGHT?

MONDAY, MAY 19, 2003

U.S. SENATE, SUBCOMMITTEE ON AFRICAN AFFAIRS, COMMITTEE ON FOREIGN RELATIONS, Washington, DC.

The subcommittee met, pursuant to notice, at 2:31 p.m. in room

SD–419, Dirksen Senate Office Building, Hon. Lamar Alexander

(chairman of the subcommittee), presiding.

Present: Senators Alexander and Feingold.

Senator ALEXANDER. The hearing will come to order. I would like

to welcome everyone here. Senator Feingold is here and we will

begin.

Here is how we will proceed. I will make a very brief opening

statement and I will invite Senator Feingold to do the same, and

then we will begin with Dr. Peterson from USAID; and then we

will go to our second panel, Dr. Green and Ms. Mukasa Monico,

and we will have some questions for the two of you at that time.

After we have completed the hearing, we will immediately move

to the nomination hearing of Steven Browning, nominated to be

Ambassador to Malawi, and we will hear from him. At that time,

since he is here, we will ask him to reflect on what he has heard.

In the midst of the AIDS pandemic, a beacon of hope shines out

from Uganda. The rate of infection has declined from about 15 percent in 1991 to about 5 percent in 2001. Uganda did this largely

through a nationwide campaign focused on the ABC model: Abstain, Be faithful, use a Condom.

Today we will look at how that model works in practice and what

that implies for U.S. policy in combating AIDS. It is especially relevant because Senator Feingold and I and almost all Senators were

up until about 2:30 in the morning on Thursday night expressing

the agenda of both political parties as well as the President to do

what this country can to help with this worldwide epidemic.

The crisis posed by the AIDS pandemic is growing worse every

day and the statistics are becoming all too familiar. Over 40 million

people are now infected by HIV-AIDS. Thirty million of those are

in sub-Saharan Africa, nearly 5 percent of the overall population

of sub-Saharan Africa. The scope of the problem in some countries

is overwhelming. Eleven million African children have lost their

parents to AIDS. In Zambia 30 percent of all children are AIDS orphans. In Botswana nearly 40 percent of the adult population is

HIV-positive. When I visited Botswana a year-and-a-half ago, at

one hospital the nurse there told me that 97 percent, virtually all,

2

of the women, the pregnant women she sees there are infected with

HIV-AIDS.

The disease also affects other sectors of African society. Seven

million agricultural workers have succumbed to AIDS. The agricultural work force has been depleted by more than 20 percent in several African countries, resulting in production declines that are a

contributing factor to hunger and even famine. Young adults are

the hardest hit by the virus, leaving not only millions of orphans

but also ever-increasing numbers of households headed by grandparents.

But in the midst of this human tragedy there is hope. Something

different has been happening in Uganda. Despite the lack of a cure

or vaccine, HIV infection rates are declining. As I mentioned, in

1991, 21 percent of pregnant women in Uganda were HIV-positive.

Ten years later that number declined to 6 percent. By comparison,

34 percent of pregnant women in Botswana were HIV-positive in

the year 2000.

What is Uganda doing differently? Led by President Museveni,

Ugandan society has mobilized to combat HIV-AIDS with vigor and

over a long period of time. Uganda has taken a comprehensive approach to combating the challenge. Religious and military leaders,

many of whom are HIV-positive themselves, have led the way in

creating an open dialog that has to a large extent de-stigmatized

the disease. With the help of groups like the AIDS Support Organization of Uganda, the country has sought to provide treatment and

care to those infected.

But the heart of the story in Uganda is behavior change promoted by the ABC model. The campaign has had great success. In

one area of the country, for example, 60 percent of youth age 13

to 16 reported being sexually active in 1994. By 2001 the number

had fallen to 5 percent. Similarly, the number of Ugandan men

with two or more sexual partners per year dropped from over 70

percent in 1989 to less than 20 percent in 1995.

So how does the Ugandan model work in practice? How can that

model be replicated or adjusted to work in other countries and cultures, or can it be? What does that imply for United States policy

and foreign assistance in combating this pandemic around the

world? That is what we are here to find out and we have a distinguished panel to help us do that.

I also hope we will explore with the witnesses this afternoon the

idea of having what I would call an AIDS Corps, where American

health professionals can volunteer to go to Africa or other hard-hit

countries and help train professionals in country how to provide

care and treatment for those who are infected and affected by HIVAIDS.

I introduced a bill for that purpose last week. There are provisions for that purpose in the legislation that passed on Thursday

night. Many Senators of both parties, the President himself, have

all talked about this idea and I thought this might be a good time

to gain some additional advice about how we could help an AIDS

Corps work if one were to be formed.

But before I introduce our first panelist, I would like to comment

that the AIDS subject is not new to this committee or to this subcommittee. The former chairman of this subcommittee, Senator

3

Frist, now the majority leader, spoke about AIDS early on and vigorously and I believe helped to persuade this administration to

take a more active role. He was joined in that by his partner on

this committee Senator Feingold from Wisconsin, who has also

been an early and active advocate for AIDS, has been to Africa

many times. I welcome Senator Feingold for his opening statement.

[The prepared statement of Senator Alexander follows:]

OPENING STATEMENT OF SENATOR LAMAR ALEXANDER

In the midst of the AIDS pandemic, a beacon of hope shines out from Uganda.

The rate of infection has declined from about 15 percent in 1991 to about 5 percent

in 2001. Uganda did this largely through a nationwide campaign focused on the

ABC model: Abstain, Be faithful, use a Condom. Today, we will look at how that

model works in practice and what that implies for U.S. policy in combating AIDS.

The worldwide crisis posed by the AIDS pandemic is growing worse everyday.

Over 40 million people are now infected by HIV/AIDS. Thirty million of those are

in sub-Saharan Africa—nearly 5 percent of the overall population. The scope of the

problem is overwhelming. Eleven million African children have lost their parents to

AIDS. In Zambia, 30 percent of all children are AIDS orphans. In Botswana, nearly

40 percent of the adult population is HIV-positive.

The disease also affects other sectors of African society. Seven million agricultural

workers have succumbed to AIDS. The agricultural workforce has been depleted by

more than 20 percent in several African countries, resulting in production declines

that are a contributing factor to hunger and even famine. Young adults are the

hardest hit by the virus, leaving not only millions of orphans, but also ever-increasing numbers of households headed by grandparents.

But in the midst of this human tragedy, there is a glimmer of hope. Something

different is happening in Uganda. Despite the lack of a cure or vaccine, HIV infection rates are declining. For example, in 1991 21 percent of pregnant women in

Uganda were HIV-positive; ten years later that number had declined to 6 percent.

(By comparison, 43 percent of pregnant women in Botswana were HIV-positive in

2000.)

What is Uganda doing differently? Led by President Museveni, Ugandan society

has mobilized to combat HIV/AIDS with vigor. Uganda has taken a comprehensive

approach to combating the challenge.

Religious and military leaders, some of whom are HIV-positive themselves, have

led the way in creating an open dialogue that has to a large extent de-stigmatized

the disease. With the help of groups like The AIDS Support Organization of Uganda, the country has sought to provide treatment and care to those infected.

But the heart of the Ugandan story is behavior change, promoted by the ABC

model—Abstain, Be faithful, use a Condom. The campaign has had great success.

In one area of the country, for example, 60 percent of youth aged 13-16 reported

being sexually active in 1994; by 2001 the number had fallen to 5 percent. Similarly,

the number of Ugandan men with two or more sexual partners per year dropped

from over 70 percent in 1989 to less than 20 percent in 1995.

So how does the Uganda model work in practice? How can that model be replicated or adjusted to work in other countries and cultures? What does that imply

for U.S. policy and foreign assistance in combating this pandemic around the world?

That’s what we’re here to find out, and we have a distinguished panel to help us

do that this afternoon. I also hope to explore with the witnesses the idea of having

an AIDS Corps—where American health professionals could volunteer to go to African or other hard-hit countries and help train professionals in-country how to provide care and treatment for those infected and affected by HIV/AIDS. I introduced

a bill for that purpose last week.

Senator FEINGOLD. Thank you very much, Mr. Chairman, and I

would like to thank you for convening this hearing, for your willingness to work in such a cooperative way in putting it together.

I genuinely appreciate your approach and frankly, Mr. Chairman,

think that this is the perfect medicine for a recent minor outbreak

of what I might call politicization when it comes to this issue.

It is a little bit of a shame, really, that this hearing is coming

after, rather than before, the floor action on the AIDS authorizaVerDate 11-MAY-2000 15:10 Sep 16, 2003 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6602 89197 SFORELA1 PsN: SFORELA1
4

tion bill, which, as you mentioned, occurred late Thursday night

when people were pretty tired, although there was one good thing

about it. Everybody had to be there to listen, and that does not

happen a lot in the Senate.

Let me compliment you on introducing and authoring, particularly so early in your tenure here in the Senate, Senate bill 1067,

which is the AIDS Corps bill. It is interesting that in Botswana,

a country that you and I have both visited and looked at the AIDS

issue, that they had graduated, if you will, from the Peace Corps,

did not have it any more, but because of the very severe problem

with HIV-AIDS, the President, President Mogae of Botswana,

asked if the Peace Corps would come back, and the Peace Corps

there is exclusively working on the HIV-AIDS problem. So there is

in a way a precedent, at least in one sense, for this very good idea

that you have put forward, and I compliment you on it.

Lately we have heard many different perspectives on the ABC

approach in Uganda, which of course refers to awareness raising

and educational campaigns urging people to abstain, to be faithful

to one partner, and to use condoms. I think common sense tells us

that all of these elements are important parts of combating this

horrifying pandemic.

Ugandan efforts have also been characterized by other things, by

strong and visible political leadership, by grassroots involvement

on a massive scale, and by concerted efforts to destigmatize the disease. The story is not a simple one.

The bottom line is that Uganda’s multifaceted approach to combating AIDS was successful. Ugandan AIDS prevalence rates have

declined markedly over the 1990s. Mr. Chairman, I had a chance

to sort of see this in the middle when I visited the country in late

1999, met with President Museveni and others to see what they

were trying to do. And today, several years later, as you have indicated, the country continues vigorously addressing the crisis.

This is a tremendously important example and Uganda deserves

the acclaim that has come to the country in the wake of this

achievement. But I must raise for a moment one other issue briefly

because I think that it would be a mistake for this subcommittee

to be convening today and discussing Uganda in any context without at least mentioning the ongoing crisis in Ituri province in the

Democratic Republic of the Congo, a crisis that has involved Uganda and a crisis that will require international commitment to solve,

including real commitment from Uganda and Rwanda to use their

influence with Ituri’s ethnic militia forces.

Obviously, this serious situation is not the focus of today’s hearing, but I did want to use this opportunity to go on record about

my deep concern and my hope that the United States will play a

constructive role in defusing this crisis rather than being an obstacle to urgently needed action.

Turning back to the subject at hand, I think it is important that

we recognize both the value in learning from the Ugandan experience and the fact that one country’s model is not necessarily precisely the right model for every other AIDS-affected society. So this

subcommittee is diving into this discussion with an understanding

that Uganda is not Senegal, which is not South Africa.

5

That said, Uganda’s success has played an important role in convincing people here in Washington and around the world that it is

possible to fight AIDS and win. That is a tremendous contribution

and it deserves to be celebrated and studied closely.

Mr. Chairman, I would ask that the statement of Senator Biden,

the ranking member of the full committee, be added to the record.

[The prepared statement of Senator Biden follows:]

PREPARED STATEMENT OF SENATOR JOSEPH R. BIDEN, JR.

Mr. Chairman, I would like to submit a statement for the hearing record from

Jeffrey Busch, Chief Executive Officer of SafeBlood for Africa. SafeBlood for Africa

is a not for profit organization whose objective is to improve the national blood supply of African countries where few or no mechanisms exist to test blood for infectious diseases such as HIV before tranfusion.

Lately we have been hearing a lot about the importance of prevention in halting

the transmission of HIV/AIDS. There has been a singular focus on what’s know as

the ABC model—Abstinence, Be faithful and use Condoms as the key to prevention.

This model is very important, however as Mr. Busch’s statement indicates, it is only

one part of an overall prevention model which includes voluntary testing and counseling, prevention of mother-to-child transmission, and safety of the national blood

supply.

I think it is important to understand the need to focus on a comprehensive strategy of prevention which includes more than just the ABC’s.

[Attachment.]

BLOOD SAFETY: AN IMPORTANT TOOL IN AIDS PREVENTION

STATEMENT SUBMITTED BY JEFFREY BUSCH, CHAIRMAN AND CEO, SAFEBLOOD FOR

AFRICA

PREVENTION IN UGANDA

Uganda is one of a few African countries to achieve a reduction in the prevalence

of HIV in its population. While much has been made about the ABC approach in

Uganda—Abstinence, Be faithful, use Condoms as a prevention strategy, I would

like to point out that the ‘‘ABC’s’’ are only a part of Uganda’s overall prevention

strategy. Other elements of the prevention strategy include prevention of motherto-child transmissions, voluntary testing and counseling, and ensuring a safe national blood supply. According to a European Union report, the creation of a successful Uganda Blood Transfusion Service (UBTS) has been a major contributor to that

success. (From 2nd Edition European Community Official Publication, Safe Blood in

Developing Countries, www.tve.org/ho/doc.cfm?aid=413.)

The UBTS has saved countless lives through:

• Intensive HIV/AIDS education drives for blood donors. This has resulted in

many Ugandans taking an HIV test. The knowledge of one’s HIV status has encouraged those who are negative to stay negative, and those who are positive

to avoid passing on the infection.

• Provision of infection free blood for those in need of blood transfusions through

recruitment of volunteer, non-remunerated, repeat blood donors.

• Systematic training of staff. Central coordination and organization of all transfusion services including standard operating procedures and quality control.

The Ugandan experience stands in stark contrast to the rest of the African continent where unsafe blood is estimated to cause up to 10% of all new HIV infections.

This is due to the fact that on much of the continent, blood transfusions occur with

little or no pre-transfusion testing. Dr. Harvey Klein, Chief of Transfusion Medicine

at the National Institute of Health, states, ‘‘In the last century, transfusions have

saved more lives than any therapy except antibiotics.’’ It is unfortunate that in subSaharan Africa transfusions meant to save lives carry a significant risk of having

a negative effect on the health of African patients.

OTHER EXPERIENCES

At the XIV International Conference on AIDS held in Barcelona in 2002, the Global HIV Prevention Working Group, composed of nearly 40 of the world’s leading HIV

prevention experts, stated that that an effective global HIV prevention strategy

6

should consist of several different approaches. One of the experts, Dr. Helene Gayle

of the Bill and Melinda Gates Foundation, emphasized this point by stating that

‘‘Just as combination therapy attacks HIV from different angles, prevention requires

a combination of approaches. There is no single magic bullet. ‘Combination prevention,’ however, has proven very effective.’’

Supporting a multidimensional approach to HIV prevention, the United Nations

Special Session on HIV/AIDS in June 2001 indicated that ‘‘Prevention programmes

must concentrate on [all] the main routes along which HIV spreads [that is] by addressing blood safety, mother-to-child transmission, injecting drug use and sexual

transmission.’’

SAFE BLOOD FOR AFRICA FOUNDATION

Our organization is a 501(c)(3) not-for-profit corporation whose purpose is to help

prevent the spread of HIV/AIDS by blood transfusion in sub-Saharan Africa. We will

achieve this goal by working with the 34 countries in sub-Saharan Africa where

blood contaminated with infectious diseases—including HIV, Hepatitis B and Hepatitis C—is most prevalent to develop national blood screening and safety systems.

When our programs are fully implemented, we estimate that we will save between

10 and 20 million lives over the next 10 years.

Senator ALEXANDER. It will be done.

Senator FEINGOLD. Thank you very much, Mr. Chairman.

[The prepared statement of Senator Feingold follows:]

PREPARED STATEMENT OF SENATOR RUSSELL D. FEINGOLD

Mr. Chairman, I want to thank you for convening this hearing and for your willingness to work in such a cooperative way in putting this together. I genuinely appreciate your approach and frankly think that it is the perfect medicine for a recent

minor outbreak of politicization when it comes to this issue. It is a shame that this

hearing is coming after, rather than before, floor action on the AIDS authorization

bill.

Lately we have heard many different perspectives on the ABC approach in Uganda, which of course refers to awareness-raising and educational campaigns urging

people to abstain, to be faithful to one partner, and to use condoms. And I think

common sense tells us that of these elements are important parts of combating this

horrifying pandemic. But Ugandan efforts have also been characterized by strong

and visible political leadership, by grassroots involvement on a massive scale, and

by concerted efforts to destigmatize the disease. The story is not a simple one.

The bottom line is that Uganda’s multi-faceted approach to combating AIDS was

successful. Ugandan AIDS prevalence rates have declined markedly over 1990s, and

the country continues vigorously addressing the crisis today. This is a tremendously

important example and Uganda deserves the acclaim that has come to the country

in the wake of this achievement.

But I must raise one different issue, just briefly, Mr. Chairman, because I think

that it would be a mistake for this subcommittee to be convening today and discussing Uganda in any context without mentioning the ongoing crisis in Ituri province in the Democratic Republic of the Congo—a crisis that has involved Uganda,

and a crisis that will require international commitment to solve, including real commitment from Uganda and Rwanda to use their influence with Ituri’s ethnic militia

forces. Obviously this serious situation is not the focus of today’s hearing, but I do

want to use this opportunity to go on the record about my deep concern and my

hope that the United State will play a constructive role in defusing this crisis rather

than being an obstacle to urgently-needed action.

Turning back to the subject at hand, I think it is important that we recognize

both the value in learning from the Ugandan experience, and the fact that one country’s model is not necessarily precisely the right model for every other AIDS-affected

society. So this subcommittee is diving into this discussion with an understanding

that Uganda is not Senegal, which is not South Africa. That said, Uganda’s success

has played an important role in convincing people here in Washington and around

the world that it is possible to fight AIDS and win. That is a tremendous contribution, and it deserves to be both celebrated and studied closely.

Senator ALEXANDER. Thank you, Senator Feingold.

We are delighted to have Dr. Anne Peterson testifying on behalf

of the administration. She is currently Assistant Administrator of

7

the Bureau for Global Health at USAID. Something like our majority leader, she is a medical doctor. She has done volunteer work in

Africa, I guess may still do; formerly worked on the front lines in

African countries as a volunteer doctor and in many nonprofit organizations.

Dr. Peterson, we are delighted to have you. We look forward to

your comments. I would suggest to you and the other witnesses

perhaps you could keep your comments to within 10 minutes or

less and then that will leave more time for questions and discussion.

STATEMENT OF ANNE PETERSON, M.D., ASSISTANT ADMINISTRATOR, BUREAU FOR GLOBAL HEALTH, U.S. AGENCY FOR

INTERNATIONAL DEVELOPMENT, WASHINGTON, DC

Dr. PETERSON. Thank you, Mr. Chairman. It is an honor to be

here today and thank you for holding this hearing on the grave

public health crisis of HIV-AIDS. I would like to submit my written

testimony for the record and then summarize it. I will try to be

brief.

You have already spoken about the devastation that HIV-AIDS

has wrought on the developing world. Every hour 350 people

around the world die of AIDS and, as President Bush said last

month at the White House, ‘‘time is not on our side.’’ I am really

thrilled with the urgency that is now really moving this epidemic

and its response, our response to this epidemic.

President Bush called for a massive U.S. Government response

to the crisis, the $15 billion over 5 years, and Thursday you voted

to support that call to action. It has ambitious goals, to prevent 7

million infections, treat 2 million people with life-extending drugs,

and provide care for millions.

Mr. Chairman, I am a public health physician and my career has

been focused on both domestic public health and health development in Africa. My very first time in Africa was in the Bunia area

of Congo that is now in such difficult circumstances, but most of

my time was in Kenya and Zimbabwe, very close to the border of

Uganda. I believe that the work that I have done in Africa and my

American public health work has given me a good grasp of what

is going on in Africa and the programmatic realities that we need

to be dealing with now.

As you have recognized, Uganda is not only important because

it is a success, but because there are many elements of that success

that can be replicated. The Ugandan epidemic peaked in 1991 and

has fallen to about 5 percent in 2001. I would like to quote again

President Bush, who cited the example of Uganda in his call to action: ‘‘This is a terrible disease, but it is not a hopeless disease. We

know that AIDS can be prevented. In Uganda President Museveni

began a comprehensive program in 1986 with a prevention strategy

emphasizing abstinence and marital fidelity, as well as condoms to

prevent HIV transmission. The results are encouraging. Congress

should make the Ugandan approach the model for our prevention

efforts under the emergency plan.’’

The dramatic decline is unique to Uganda. What can we learn

from it? I would like to enter for the record, Mr. Chairman, a study

that was published last fall by USAID on Uganda’s successful batVerDate 11-MAY-2000 15:10 Sep 16, 2003 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6602 89197 SFORELA1 PsN: SFORELA1
8

1Dr. Peterson’s written testimony and the report referred to can be found beginning on page

10.

tle against HIV-AIDS. That report and my written testimony 1 contain a great deal of other information.

The Ugandan story is a story about prevention. As you said, before terrorism or vaccine was available, when President Museveni

came to power in 1986, his country was already being decimated

by AIDS. Under his leadership, every sector of society responded to

the crisis by sending a unified and forceful message. Their message

was as simple as ABC: ‘‘abstain, be faithful, and if necessary use

a condom.’’ This message was disseminated widely through all sectors of society during the 1980s.

The first is abstinence. By 1990 the percentage of youth age 15

to 19 in Uganda ever having had sex decreased noticeably. In 1989,

32 percent of males and 28 percent of females age 15 to 19 reported

being virgins, while by 1995 these numbers had increased to 55

percent of males and 45 percent of females. As you can see in your

handout, the decline is even more dramatic for 13- to 16-year-olds

in an after-school educational program.

We can also measure abstinence in the trend toward delayed age

of sexual debut among youth. In the 1990s, sexual debut among

girls in Uganda increased from 16.5 to 17.3 years. This does not

look like much, but it has profound impact on the prevalence of

HIV-AIDS and it also demonstrates huge cultural changes that

young girls were able to abstain. For boys it rose from 17.6 to 18.3

years in the second half of the decade. For youth the A of the ABC

message, abstinence, is probably the most important single message.

The second message is B. The ABC message of Uganda is not

just abstinence. Many people, including Uganda’s first lady, acknowledged that the B, be faithful, which includes partner reduction, may be overall the most important factor. Also known as ‘‘zero

grazing,’’ being faithful is a strong cultural norm that resonated

strongly in Uganda and, from my own experience, I know it resonates also in many other African countries.

In general, Ugandans of all ages now have considerably fewer

non-regular sex partners. Surveys conducted in 1989 to 1995 show

that men with one or more casual partners declined from almost

40 percent to 15 percent, and for women the decline was from 16

percent to 6 percent. The number of men reporting three or more

non-regular partners in a year fell from 50 percent to 3 percent.

The 1995 survey also revealed an amazing statistic: 89 percent

of men reported that they had changed some behavior relative to

HIV-AIDS, with most of them adopting faithfulness as the behavior

change. In the second data slide, you can see that for all ages

Ugandans now reports significantly fewer non-regular partnerships

than compared to other African countries.

The third message is C. While condom promotion was not a dominant element in Uganda’s early response to AIDS, in more recent

years, there has been increased condom use. The beneficial role of

condoms is clear when one spouse is HIV-positive and the other is

not, but it is also an important prevention tool for people who have

sex with non-regular partners.

9

Again, in the condom use slide, the third one, Uganda is a model.

They are responding to the A and B message by having fewer partners, but when they do stray outside of marriage they are also

leading the way on condom use.

We know that these ABCs have played key roles in the decline

of HIV prevalence in Uganda, but there is more to learn about the

relative contributions of each and the other factors that contribute

to the decline of AIDS and the success of the ABC message. These

include: the political commitment to fighting AIDS from President

Museveni and his wife; the important role of faith-based organizations and churches in changing behavior; communicating a consistent message with credible messengers, such as Ugandan pop

star Philly Lutaaya; fighting stigma that clouds the attitude toward HIV and AIDS and, as you are seeing in Botswana, this has

been an incredible limiting factor. There were also important policy

and law changes and the bringing in of voluntary counseling and

testing.

I am pleased, Mr. Chairman, that USAID was able to play an

important role in Uganda’s success. Seventy percent of Uganda’s

prevention and care activities are funded by donor nations. USAID

funded nearly half of that donor support. Last year we provided

$20 million to Uganda for HIV-AIDS programs, and this year our

budget will be over $27 million in Uganda.

The program includes a spectrum of activities from prevention to

care, support, and treatment. I would like to mention just a couple

examples. The AIDS Support Organization, or TASO, is world-renowned and has provided care and support to more than 60,000 individuals and their families, as well as supporting 200,000 children

affected by AIDS. USAID has been a long-time supporter of TASO

and today provides TASO with approximately $2 million a year.

The former head of that organization, Sophia Mukasa Monico, will

testify before you in a few minutes and is one of the many heros

of Uganda’s war on AIDS. Since 1995, we have also been supporting the First Lady Museveni’s orphan and microcredit work

and have been working with faith-based organizations since 1991.

USAID will continue strong support of the Uganda success and

support of both the implementation and research into ABC programs. But the real question, days after the passage of the emergency AIDS bill—and again I thank you—is not only what happened in Uganda, but can we replicate Uganda’s success? The short

answer is emphatically yes. Uganda is unique, and it is hard to

imagine the amazing leadership role of the President and his wife

will be repeated, but many elements of Uganda’s success can be recreated elsewhere.

In Uganda we have learned that a comprehensive behavior strategy, ideally involving high-level political commitment and a diverse

spectrum of community and faith-based participation, building on

cultural norms, can change the course of the epidemic.

The Uganda model is also a flexible model. It takes into account

the epidemiological, the demographic, and the cultural norms, and

can be balanced between the A, B, and C components as well as

all of the other supporting elements.

Every country will be different, but we can learn from the successful elements of the action in Uganda. In some countries we are

10

beginning to hear the voices of Presidents and other political leaders take on new roles. In other countries we see strong leadership

from the faith community and civil society. In South Africa the engagement of the business community is remarkable and likely to be

a significant factor in future successes.

And we are seeing signs that other countries are beginning to

turn epidemics around. Recent studies among youth in Zambia indicate that a similar success story there may be in the making.

Clear and positive changes in all three of the ABC behaviors have

been reported in surveys, and a significant decline in casual sex

has occurred among both men and women between 1996 and 1999.

Mr. Chairman, as you noted, I spent 6 years in Africa as a missionary doctor. I worked with communities, children in school,

street children, AIDS patients, and families in the most desperate

of circumstances. I helped develop and teach abstinence programs

to African youth. I have seen the light in young people’s eyes when

they realize they can take control of their own lives. The data

shows this as well. It is as simple as ABC.

But we need that simple message, together with all the supporting elements involved that made the ABC success in Uganda,

to save lives. We cannot ignore the moral issues involved in finding

a solution to the HIV-AIDS crisis. To protect the next generation

of African youth, we cannot step aside from difficult dilemmas of

abstinence and faithfulness.

Uganda’s First Lady Museveni last Tuesday in a speech said:

‘‘How are we going to teach children to be law-abiding citizens if

we do not train them to exercise self-control and to learn to police

themselves while they are still young and teachable? Not to guide

our young in this way implies that we as adults and leaders have

no faith in human nature and in our ability as beings to exercise

self-control. If this is the case, then we are surely a doomed species.’’

My own experience tells me that Mrs. Museveni’s words are directly on point. Our mission at USAID is to learn from the successes that we have before us and bring similar successes to other

devastated countries around the world.

Thank you for letting me testify before you today.

[The prepared statement of Dr. Peterson follows:]

PREPARED STATEMENT OF DR. ANNE PETERSON, ASSISTANT ADMINISTRATOR FOR

GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT

Good afternoon. Thank you for inviting me to testify on the important topic of

Uganda’s successful battle against HIV/AIDS. This issue could not be timelier or

more urgent. The HIV/AIDS pandemic is currently claiming 350 lives per hour

worldwide. President Bush announced an unprecedented five-year, $15 billion program to fight the disease. It is crucial that we take the right lessons from Uganda’s

experience and apply them effectively elsewhere.

We are at a turning point in the battle against HIV. While HIV infection rates

are still increasing and the disease is raging in many places, we now have success

stories. We know what works and soon will have sufficient resources to implement

those successful strategies much more broadly. It is important that we highlight the

successful interventions in Uganda so we can better apply them to other countries.

The new Emergency Plan for AIDS Relief that President Bush announced in January in the State of the Union Address is based on one of these successful models.

I have been serving as the Assistant Administrator of USAID for Global Health

for 18 months. I came to the agency with a long history of service in medicine and

public health. I spent six years in Africa, working with AIDS patients and their

11

families. My work in both Zimbabwe and in Kenya, near the Ugandan border, included similar interventions to ones we’ll be examining today from Uganda.

I have seen first-hand the devastation that AIDS has wreaked on individuals,

families and communities. While we often hear of the hopelessness of HIV/AIDS,

today there are many signs that give us hope of winning the war against this deadly

disease.

WHAT HAPPENED IN UGANDA?

Despite all my African experience, it is humbling to be here talking about what

happened in Uganda. This is a Ugandan story and should be told by Ugandans. The

saving grace is that I know many of you heard from Mrs. Janet Museveni, the First

Lady of Uganda last week. Her passion and depth of insight are vital elements of

the political leadership from her and her husband, President Yoweri Museveni,

which has made, and continues to make, such a difference in Uganda.

Today, I would like to focus on four areas: first, the data on HIV/AIDS from Uganda; second, the data and cultural support for the ABC approach to AIDS prevention;

third, USAID’s past role in Uganda; and fourth, what the U.S. government can do

to replicate Uganda’s success elsewhere.

With your permission, Mr. Chairman, I would like to enter, for the record, a study

published by USAID last fall on Uganda’s successful battle against HIV/AIDS.

In Uganda, according to estimates by UNAIDS, HIV prevalence among adults

peaked at around 15 percent in 1991, and fell to 5 percent as of 2001. While some

quibble on the numbers, we know this dramatic decline is unique to Uganda, which

is why it is important that we examine what led to the turnaround.

The Uganda success story is about prevention. When President Museveni came

to power in January 1986, his country was already being decimated by AIDS. Under

President Museveni’s leadership, leaders at every level of society responded to this

crisis by sending a unified and forceful message. They urged people to prevent the

spread of HIV. Their message was as simple as ABC: Abstain, Be faithful, and, if

necessary, use a Condom. This message was disseminated widely through all sectors

of society during the late 1980s.

‘‘A’’: By the 1990s, the percentage of youth aged 15-19 in Uganda reporting ever

having had sex decreased noticeably. In 1989, 32 percent of males and 28 percent

of females age 15-19 reported being virgins, while by 1995 these numbers had increased to 55 percent of males and 45 percent of females. In addition, there was

a clear trend towards delayed age of sexual debut among youth. In the 1990s, sexual

debut among girls in Uganda increased from 16.5 to 17.3 years. For boys, it rose

from 17.6 to 18.3 years in the second half of the decade. For youth—I agree with

Mrs. Museveni—the A of ABC, abstinence, is the most important single message.

USAID will be funding additional studies to verify that our current body of evidence

is in fact correct as to the contribution of abstinence to AIDS education.

‘‘B’’: But the ABC message of Uganda is not just A. Many people, including Uganda’s First Lady, acknowledged that ‘‘B’’, Be faithful, may be overall the most important factor. Also known as ‘‘Zero grazing’’—being faithful is a strong cultural norm

that resonated strongly in Uganda. The rise in couples that are mutually faithful

is striking.

In general, Ugandans of all ages now have considerably fewer non-regular sex

partners. In surveys conducted in 1989 and 1995, men with one or more casual partners declined from 35 percent to 15 percent, and for women the decline was from

16 percent to 6 percent. Also significant, the number of men reporting three or more

non-regular partners fell from 15 percent to 3 percent. A 1995 survey found that

89 percent of men reported they had changed their behavior to avoid AIDS, with

most of them adopting faithfulness to one partner, and other partner-related

changes.

‘‘C’’: While condom promotion was not a dominant element in Uganda’s early response to AIDS, in more recent years, increased condom use has contributed to the

continuing decline in prevalence. The beneficial role of condoms is clear when one

spouse is HIV positive and the other is not. But it is also a particularly important

prevention tool for people who have sex with a ‘‘non-regular’’ partner. In Uganda,

condom use by women with non-regular partners rose from 20 to 38 percent, and

for men rose from 36 to 59 percent, over the last five years of the 1990s.

We know that these ‘‘ABCs’’ have played key roles in the decline of HIV prevalence in Uganda, but there is much more to be learned about the relative contributions of each. There are still many unanswered questions about how Uganda has

moved so many people to make such significant changes in behavior. Some of the

critical elements we know contributed to the adoption of the ABC message were:

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Political commitment: Uganda in 1986 was just emerging from 15 years of civil

unrest. When he had just assumed office, President Museveni received evidence of

an emerging epidemic and immediately began a proactive prevention campaign that

continues to this day. In meetings and speeches, he emphasized that fighting AIDS

was a patriotic duty requiring openness, communication and strong leadership at all

levels. This early support from the President enlisted a wide variety of national participants in the war against the new disease.

Role of faith-based organizations: Religious leaders are uniquely positioned to influence the behavior of large numbers of people. Early and significant mobilization

of Ugandan Christian and Muslim leaders and organizations resulted in their active

participation in AIDS education and prevention activities. For example, the Catholic

Church and mission hospitals provided leadership in designing AIDS home care

projects and special programs for AIDS widows and orphans. The Church of Uganda

and the Islamic Medical Association of Uganda used their extensive networks to

train more than 1800 religious leaders and 5000 peer educators.

Communicating a consistent message: Along with elected and faith-leaders, other

influential people who did not normally work on health issues, like First Lady Janet

Museveni and pop music star Philly Lutaya, became involved in AIDS awareness

and education. An aggressive media campaign, including print, radio and billboards,

educated people to change their behavior. This was reinforced by old-fashioned,

interpersonal communication, with Uganda training thousands of community-based

AIDS counselors and educators, who in turn motivated people to change their behavior.

Fighting stigma: The stigma attached with HIV and AIDS often serves as a barrier to effective prevention measures. Openness on the part of President Museveni

led to openness from every level of society down to local community leaders, producing an accepting and non-discriminatory response to AIDS. In addition, The

AIDS Support Organization, known as TASO, advocated effectively against discrimination and stigma. TASO is recognized around the world as a leader and innovator

in the field of HIV/AIDS care and support. The former head of that organization,

Sophia Mukasa Monico, will join us in a later panel.

Policy and law change: ‘‘Gender vulnerability’’ refers to the problem of wives exposed to HIV through the indiscretions of their husbands or young girls put at risk

through intergenerational sex. This is a deeply cultural and sensitive part of the

problem in many African countries. When I asked Mrs. Museveni how Uganda overcame these problems, she talked about policy and law change. Women could prosecute for rape, wives would not lose their homes if they refused to have sex without

protection with their HIV+ husband. And these weren’t just verbal promises; free

legal support, including from women lawyers, was made available so that this was

a real hope. While not completely overcoming this problem and not reaching all

parts of Uganda with legal support, these policy and legal changes make it possible

for women to abstain when in other circumstances their exposure to AIDS would

be out of their control.

Confidential voluntary counseling and testing: In 1990, the first confidential voluntary counseling and testing center opened in Kampala. The AIDS Information

Center was the first to provide same-day results using rapid HIV tests. The Center

also started ‘‘post-test clubs’’ to provide long-term support for those who have been

tested, whether they are HIV-positive or negative. The availability of these services,

and the lack of stigma associated with getting tested, were important assets in

Uganda’s prevention efforts.

USAID’S ROLE IN UGANDA

I am pleased to be able to report that USAID was a strong supporter of Uganda’s

approach and the largest financial supporter to its success story. Donor countries,

particularly the United States, played important roles during those critical years by

complementing Uganda’s energy and initiative with financial and technical support.

Donor support covered 70 percent of Uganda’s prevention and care activities,

amounting to $180 million from 1989 to 1998. USAID has provided more than $83

million in AIDS funding since 1988. I will now describe the activities of USAID in

Uganda, though I note that other federal agencies have also participated in the fight

against AIDS in Uganda.

Last year, USAID provided $20 million to Uganda for HIV/AIDS programs, and

this year’s budget will be over $27 million. Our program includes prevention, care

and support, voluntary counseling and testing, and programs for children affected

by AIDS. Let me mention a few highlights of our past and present programs:

USAID has a long history of supporting Uganda’s two largest local non-governmental organizations dedicated to the fight against AIDS. TASO, as I mentioned

13

earlier, is world-renowned, and has provided care and support services to more than

60,000 individuals and their families, as well as supporting 200,000 children affected by AIDS. Today, USAID provides TASO with approximately $2 million a

year.

The AIDS Information Center, which provides HIV counseling and testing, has

served over half a million Ugandans. USAID was the first donor to support the

AIDS Information Center, and currently funds more than 80 percent of its annual

budget.

USAID/Uganda’s partnerships with faith-based organizations began early in 1991,

with a project designed to mobilize civil-society organizations, including those that

are faith-based. These institutions, especially the Church of Uganda and the Islamic

Medical Association, were able to utilize their extensive networks to educate and influence people’s behavior. Today, USAID funds World Vision to reinvigorate and

strengthen the role of faith-based organizations in their response to HIV/AIDS. This

initiative is strengthening the Interreligious Council of Uganda, as well as providing

sub-grants.

USAID, working with Catholic Relief Services, World Vision and others, currently

has a five-year, $30-million project in Uganda to provide food aid to over 60,000 individuals. Good nutrition plays an important role in the quality—and we believe

also length—of life of people living with AIDS. In addition, since it is not uncommon

for economically disadvantaged women to trade food for sex, food aid can play an

important role in decreasing this risky behavior that can drive the epidemic.

The Uganda Women’s Effort to Save Orphans, founded by First Lady Janet

Museveni, has more than 7500 members, most of whom provide direct care for orphans. Since 1995, with support from USAID, this group’s small-scale credit program has provided income generation activities for orphan households. Their programs have assisted over 25,000 orphans and 2,600 micro-entrepreneurs.

USAID provided the leadership and technical expertise for a planning meeting for

representatives from the major religious communities in Uganda: Anglican, Roman

Catholic, Orthodox Christian, and Muslim. Out of this meeting, the Interreligious

Council of Uganda HIV/AIDS Task Force was established.

Currently, USAID and the Centers for Disease Control are funding a program to

develop comprehensive, integrated HIV/AIDS prevention and care services in 16 of

Uganda’s 56 districts. These integrated programs will create a model for serving

Uganda’s rural poor.

Preventing mother-to-child transmission of HIV is one of the aspects of this program. USAID/Uganda is also supporting a private sector initiative designed to increase utilization of services to prevent mother-to-child transmission through a program for midwives. These programs will be scaled-up significantly thanks to President Bush’s International Mother and Child HIV Prevention initiative and the

President’s Emergency Plan for AIDS Relief.

USAID’S BALANCED APPROACH TO AIDS PREVENTION TODAY

Although USAID has always acknowledged a balanced ABC approach to the HIV/

AIDS pandemic is needed, it is true that in the past, the agency’s programs tended

to skew towards those that are easier to measure such as the social marketing of

condoms. Uganda is leading the way in helping to provide data on the contribution

of the abstinence and be faithful messages to successful AIDS prevention. There is

supporting evidence from abstinence and teen pregnancy prevention programs in

the United States and evidence is accumulating from a variety of international programs that these messages are successful.

Rarely do we have a controlled study environment in international programs that

would allow interventions to definitely prove cause and effect. This is also true for

the assessment of the ABC approach. But we do have a growing body of evidence

of ecological, programmatic and time oriented associations that is very strong. Based

on this body of evidence, USAID’s policy since last fall has been modified to follow

a more balanced approach to the ABC’s of HIV prevention. The balance is set for

an individual country based on culture, epidemiology, and the stage of the epidemic.

The ABCs of HIV prevention reinforce one another, and the appropriate message

must reach the appropriate audience. These messages and target audiences can be

segmented without denigrating any one message.

In Zambia, we have seen evidence of a program that successfully applies a balanced approach. It is also a program that we think can be replicated in other similar

situations. The HEART program—or Helping Each Other Act Responsibly Together—was designed by youth for youth and uses the mass media to promote AIDS

prevention through abstinence, being faithful to one partner, and, when necessary,

correct and consistent condom use.

14

According to a survey of Zambian youth, girls in particular said they want concrete messages with reasons to stay virgins or return to abstinence. The decision

to abstain was frequently reported as a direct result of exposure to the HEART program. Respondents were also more likely to say they chose ‘‘to abstain’’ rather than

to use condoms—a finding that counters the common argument that television and

radio spots about safe sexual behavior encourage promiscuity. The study clearly

shows we can promote abstinence as ‘‘cool’’ and reinstitute it as a social norm among

Zambian youth, whether they are still virgins or for those wanting to return to abstinence.

In Jamaica, a USAID-funded program promotes abstinence with the slogans such

as ‘‘go real slow, take the time to know.’’ This message is promoted through popular

rap songs, with lyrics like, ‘‘Now I don’t want to complicate this life of mine, so right

now sex is out, and that’s just fine.’’ An evaluation of this campaign found that more

than half the youth who recalled the ads said they had influenced the way they handle relationships.

In Namibia, past surveys show that girls begin sex at a young age, and 12 percent

of 15-19 year aids are HIV positive. USAID began a campaign last year that works

with churches, including the Catholic Church and the Evangelical Lutheran Church,

to encourage church leaders to use their pulpits to speak about the importance of

educating children about HIV prevention, with an emphasis on delaying first sexual

intercourse. Another component of the program will adapt the Christian Family Life

Education to be implemented as part of Sunday School lessons. The program will

also seek to form partnerships between churches and parenting organizations.

Similarly the B component of ABC is vitally important (Be faithful or Behavior

change—partner reduction) to a comprehensive approach. B is a bridge between A

and C and preliminary data suggests it may be the most important element of all.

USAID will continue to support a strong B emphasis and continue to study to validate the data evidence for its contribution.

Condom promotion is also an important tool to stem the spread of the disease

among high-risk populations. While messages of abstinence and faithfulness are key

to young and married adults, it is important to provide information on condoms to

those who have sex outside or before marriage. Prostitutes and their clients, longdistance truck drivers, and migrant populations, like miners and fishermen, are audiences that are appropriate for a condom promotion message. Social marketing is

designed to tailor messages to a target audience. It is used successfully for hygiene

initiatives, oral rehydration therapy, malaria control, and HIV prevention. Social

marketing of condoms can provide appropriate and effective messages targeted to

specific at-risk groups.

USAID uses indicators developed with UNAIDS to measure the success of A, B

and C. We are analyzing the data we collect to make sure our programs are as effective as possible.

CAN UGANDA’S SUCCESS BE REPLICATED?

Uganda’s experience was unique in many ways, particularly in the early and

strong voice of the President and his wife. Many elements of Uganda’s response, including the political and community action that supported the ABC approach and

led to real changes in sexual behavior, worked together in order for HIV rates to

fall so dramatically. However, many elements of Uganda’s success can be and are

being replicated elsewhere.

Every country will be different, but we learn successful elements of action from

Uganda. For instance, in some countries, we are seeing political leaders, including

and in addition to the head of state, take on a leadership role. In other countries,

we see strong leadership from the faith community or civil society. In South Africa,

the engagement of the business community is remarkable and likely to be a significant factor in future successes.

We are seeing strong signs that other countries are beginning to turn their epidemic around. Recent studies among youth in Zambia indicate that a similar success story there may be in the making. Clear and positive changes in all three of

the ‘‘ABC’’ behaviors have been reported in surveys, and a significant decline in casual sex occurred among both men and women between 1996 and 1999.

Senegal, Thailand and Cambodia have also had successes, and their stories also

suggest that a balanced ABC approach should be promoted.

In Uganda, we have learned that a comprehensive behavior change strategy—

ideally involving high-level political commitment and a diverse spectrum of community and faithbased participation, building on cultural norms—can change the

course of an epidemic.

Mr. Chairman, let me again thank you for holding this important hearing today.

15

1This document was developed with support from the Office of HIV/AIDS, Bureau for Global

Health, U.S. Agency for International Development under contract number HRN-C-00-99-00005-

00. The opinions expressed herein are those of the contributors and do not necessarily reflect

those of USAID. 2 Editor: Janice A. Hogle, Ph.D. Contributors: Edward Green, Ph.D., Vinand Nantulya, M.D.,

Ph.D., Rand Stoneburner, M.D., M.P.H., John Stover, Ph.D.

[Attachment.]

Project Lessons Learned Case Study—September 2002

WHAT HAPPENED IN UGANDA? 1

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 2 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 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 he 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

16

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, 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 HIV-related

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 face-to-face interactions with Ugandans at all levels, he emphasized that fighting 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

17

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

change-based 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 community-based support

led to flexible, creative, and culturally appropriate interventions that worked to

change behavior despite extreme levels of post-civil war house-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.

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

18

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 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,’’ ‘‘zero-grazing,’’ 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 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 eastern 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

19

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 nonregular partner in the past 12 months, 59 percent of men and 38 percent of women

reported using a condom with their last non-regular 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.

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 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.)

20

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.

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).

21

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 AIDS-related 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.

22

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 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.

23

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 ms., 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.

Senator ALEXANDER. Thank you, Dr. Peterson, and thank you for

your service. It is helpful to have someone with as much on the

ground experience as you have had with this.

I have a few questions and I know Senator Feingold will have

some and then I may have a couple more on a little different subject. I would like to talk with you for a moment about—and you

referred to both of these—will the ABC approach work in other African countries? And then, then the more practical question of just

how you go about implementing the model.

Let me begin with the ‘‘will it work’’ point. You referred to several factors, but Mrs. Museveni last week here referred often to

self-control in the remarks I heard her make. You mentioned that.

24

And she said that, what you also said, which is the abstinence part,

the A part, which she starts with and gives more emphasis to, although she does encourage strongly the B and the C, she says that

fits the Ugandan culture. She basically said, in not so impolite

words, that until the foreigners came in and began messing up behavioral patterns in Uganda, things were better in this respect.

No. 1, how true is that? In your own experience, how much does

abstinence fit the Ugandan culture for children? And No. 2, is

Uganda unique in that respect among African countries and does

that mean that this model does not fit other countries quite so

neatly?

Dr. PETERSON. Thank you. I think there has been a change in African cultures, and I am sure Sophia can say many more things

about that. But most of the cultures do very highly regard abstinence in their cultural traditions. There are a few examples that

are slightly different than that in sort of exceptional cases or with

the Masai coming-of-age rites. But for the most part, abstinence

and faithfulness is a cultural norm and, just as our own society

went through a revolution and a sort of loosening of morals, African culture did as well.

So when the call came for abstinence and ‘‘zero grazing,’’ it was

very much based on coming back to your African roots. Zero grazing is where you put a stake in the ground and you tie your cow

to it and he grazes just around that stake. That zero grazing in

their agricultural society means to them the same thing: Put your

stake in the ground for your marriage and you graze only within

that household. So it resonated very much with the cultural norms

and bringing them back to their cultural roots.

As far as whether it is appropriate for other countries, I would

say, in all of the other countries that I have been in, yes, that they

have that same cultural norm. It will be pulling them back to that

cultural norm.

The other thing we need to remember is that most of the new

infections, 50 to 69 percent of new infections, are with the young

people, 15- to 24-year-olds, where abstinence is a very appropriate

message to bring and the delay of onset of sexual activity. So if we

are truly going to turn the epidemic around in a country, we do

need to focus on what is best for the youth of that country. Uganda

has really found a good balance and that is, as she said, abstinence

was No. 1. Once you are married, be faithful, but they have also

been very good at reducing the number of partners if they were

outside of the A and B norms. But then using condoms also in the

casual sex.

So they have heard all three parts and Uganda has done an

amazing job of implementing all three parts.

Senator ALEXANDER. In a letter that Mrs. Museveni wrote to

Senator Lugar, the chairman of our committee, April 2, which I

will put in the record and share with Senator Feingold, although

he may have seen it, she says: ‘‘My experience has led me to conclude that when dealing with young people especially, it is vitally

important to emphasize abstinence as the first line of defense, so

to speak.’’ She also points out in her letter the importance of B and

C in the ABC formula.

[The letter referred to follows:]

25

THE REPUBLIC OF UGANDA

STATE HOUSE, P.O. BOX 25497

KAMPALA, UGANDA, 2ND APRIL, 2003

The Honorable RICHARD G. LUGAR,

Chair

Senate Foreign Relations

United States Senate

Washington, DC 20510

DEAR HONORABLE LUGAR,

Re: GLOBAL AIDS SENATE BILL

We in Uganda are very pleased and grateful for the leadership that the United

States of America has shown as far as the struggle against HIV/AIDS, Tuberculosis

and Malaria is concerned. We believe that the commitment of the Bush Administration to this cause is genuine, as proven by the sizeable funding it has recently made

available for the purpose of supporting developing nations hit by those killer diseases.

I have been made to understand that the Global AIDS Bill is soon coming before

the Senate, and that the important issue of preferred methods of prevention of HIV

is likely to be a point of contention. I note that one of the approaches to prevention

is now being referred to as the ‘‘Uganda ABC model,’’ namely ‘‘Abstain, Be Faithful,

Use Condoms,’’ in that order of preference.

I feel that I should shed some light on the issue of preventive measures against

HIV/AIDS, since I have had first hand experience in activities of behaviour change

in Uganda for over a decade. My experience has led me to conclude that, when dealing with young people especially, it is vitally important to emphasize Abstinence as

the first line of defence, so to speak.

I believe that we humans have an innate mechanism called conscience, which convicts us concerning what is wrong and what is right, or what is good for our survival

and what is harmful. It is this mechanism that society builds on to form certain

norms and value systems to ensure the survival and continuity of it’s people. When

dealing with a disease such as HIV/AIDS which has no known cure, it is important

to tap into this in-built sense of right and wrong and encourage it, particularly in

young people who have not yet become set in their habits or behaviour patterns.

I cannot help but recall the verse in the Bible which says, ‘‘Train a child in the way

that he should go, and when he is old he will not turn away from it.’’ (Proverbs 22:6)

And so, for the young, I believe it is our obligation to try to form their character

by teaching them the benefits of abstaining from sex until they are ready to engage

in it in the right context and with the right partner. Not to do this, to me, implies

that we as adults and leaders have no faith in human nature and in our ability as

human beings to control ourselves. How then are we going to prevent our young

people from indulging in other practices such as excessive intake of alcohol, substance abuse, stealing, and killing other human beings? How are we going to teach

them to be law-abiding citizens if we do not train them to exercise self-control while

they are still young? Human beings must learn to police themselves internally; this

is the first safeguard of civilization. This is the wisdom of the ages, and we ignore

it at our own peril. Incidentally, I must mention that even before Christianity came

to Uganda, promiscuity, specifically sex before marriage was severly punished;

therefore in teaching abstinence to our children, we are also reinstating our cultural

practices and traditions. A culture of promiscuity is, literally, a culture of death to

the human race.

The practice of being faithful in marriage relationships then follows quite naturally when you have been practicing abstinence, and there is no need to elaborate

on this.

We in Uganda have not advocated against the use of condoms as a method of prevention against HIV/AIDS. Condoms are freely available in all appropriate public

places, freely and continuously advertised in our electronic and print media. Indeed

they are even to be found in the remotest of our villages.

However, my husband and I belong to the school of thought that maintains that

our preferred method of prevention for certain catagories of our population, particularly the young, is Abstinence and Faithfulness in sexual matters. We have seen it

work in Uganda, and I would strongly advocate that it be considered as the method

that, in the long run, is likely to be the most beneficial.

This is my humble opinion, based on 15 years of hands-on-experience in combating the killer disease, HIV/AIDS. I hope it can be transmitted to the august asVerDate 11-MAY-2000 15:10 Sep 16, 2003 Jkt 000000 PO 00000 Frm 00029 Fmt 6633 Sfmt 6621 89197 SFORELA1 PsN: SFORELA1
26

sembly of the Senate of the United States of America as they deliberate these

issues, which are critically important to our populations.

Sincerely,

JANET K. MUSEVENI (MRS)

Senator ALEXANDER. As I understand USAID policy, the emphasis has shifted somewhat from a focus, more of a focus on condoms,

to more of a primary focus on abstinence, still recognizing the importance of the B and C part of the formula. Can you describe that

shift of policy, if indeed there has been a shift?

Dr. PETERSON. I think this is part of the balanced approach and

being able to shift the balance based on what you know, what you

have learned, and on the specific country. For a long time we did

not have data on abstinence, and within the public health community it was extraordinarily controversial. Senator Feingold pointed

out that many of these issues have become very political at times.

What I hope is to find the middle ground that everyone can agree

to.

What has happened in the last few years is we are getting more

and more data that supports abstinence as a public health intervention, not just as a philosophy or a moral mandate, but as a

data-based public health intervention. The question initially, everyone said was: Yes, if you could get people to abstain, of course that

would help reduce transmission of disease, but would youth ever do

that? Would they ever wait?

What we are seeing, and I have seen it on the domestic front in

teen pregnancy prevention programs as well as in Uganda and now

in a number of other countries, is that with full education and really understanding the issues, you can wait, and they will wait. They

will choose to wait, and therefore it is truly a public health intervention that can be used in HIV-AIDS programs successfully.

Senator ALEXANDER. My last question in this round is: After we

get beyond the model and the talk and the legislation, somebody

has to spend the money and make things work. How do you take

a model like this into some country other than Uganda and make

it work? What exactly do you do? What steps do you take? How do

you go about that?

Dr. PETERSON. First certainly is to know the situation in that

country, both the distribution of AIDS, the age groups at risk,

whether it is what we call a concentrated epidemic, which would

be more like the Cambodia/Thailand, or, as in the Presidential initiative countries, a more generalized epidemic. Look at the age

spectrums and the routes of exposure.

Then you really need people and partners who are in the country

who then can look at how much abstinence: Are we reaching a

youth group or are we reaching married families with too many

partners? Or is it really being primarily moved along by high-risk

sexual activity of prostitutes and their clients?

Once you have done that, then you go to the partners who know

how to work with those groups, with the in-country experts. We

have examples of programs in many different countries, both on abstinence—our Zambia program is social marketing of abstinence.

We have worked in policy change, quality assurance, voluntary

counseling and testing.

27

The elements are all there. What you have to do is take all of

those elements that have been supportive to the ABC message, find

the political leaders, the faith-based leaders, and engage as many

different sectors of society as possible to address the issues in their

own cultural and epidemiological priorities.

Senator ALEXANDER. Thank you.

Senator Feingold.

Senator FEINGOLD. Thank you, Mr. Chairman. I found your line

of questioning there to be very helpful and very much along the

lines I want to pursue.

I would like to ask you a little bit more about this point that

Senator Alexander was just asking you about, the differences from

country to country. I noticed your answer essentially talked about

looking at the same factors in each country and trying to adapt it

to the country, but it is my sense, having visited 14 or 15 African

countries and having tried to talk about AIDS or visiting an AIDS

program in each of those countries, that each of those countries is

not the same culturally. I am not suggesting you said that, but I

think there are significant differences within the traditional cultures. There are also significant differences because of the different

religious and colonial influences that occurred in the countries.

In fact, I have been struck by, for example, the difference in the

willingness to talk about the disease in different places. So I guess

I would like to pursue a little more specifically: How do you account for the differences between countries? Are there religious differences? For example, there was a very successful program in Senegal to prevent AIDS from ever getting out of control. That is a

largely Islamic country and Uganda of course is a country that has

a significant Christian population and traditional religions.

I am just wondering if you are able to take that into account and

if it affects people’s willingness to address A, B, and C.

Dr. PETERSON. Yes, I think there are significant differences. In

Botswana it is utterly amazing that they have both some political

leadership speaking about AIDS, they have a good health system

for Africa, they have been making treatment available, and yet

stigma has been an incredible stumbling block, and they are still

not getting people to come in. In South Africa violence is an underlying factor that is dominating a lot of the response there.

What we have to do is talk to the people who have been working

and how they have tried to overcome some of the problems. In

Haiti, which traditionally is one of those countries that does not do

very well and has never had the political voice, I went to an area,

Jeremie on the South Peninsula. There was a physician who had

mobilized the political leaders, the religious leaders, and the civil

leaders. It is the only place that I have been to recently—and I

have not been to Uganda in the last few years—where there was

no stigma.

At least one of the unifying factors seems to be that political or

social voice that allows the disease to be talked about that says: We

will care for you. And Uganda was really remarkable about this.

Mrs. Museveni talks a lot about responsibility and self-control,

which sometimes is seen as negative, but immediately following

that call to responsibility she says: But if you are HIV-positive, we

28

will take care of you and we will take care of your children. And

they have overcome stigma there.

We have seen it in Haiti.

So I think we need to be very specific in our analysis of the problems. There are unifying factors. We know that we need to get all

sectors involved. We know we need to deal with stigma. We know

we need to deal with youth. And we put relatively different

amounts of effort into the problems that are the biggest barriers

in that particular country.

But all of the elements were there in Uganda, and they are there

in other countries as well. We are going to learn new responses in

some other countries. The business sector is new in South Africa.

In some place or another, we are going to have to learn how do we

overcome the violence that is a problem?

South Africa is beginning to overcome some stigma by providing

grants that are disability grants, and suddenly people are willing

to come in to be tested who were not before. That is a novel way

of overcoming stigma. So we need to keep learning lessons, but we

can also use what we have learned in Uganda and apply the pieces

that fit for each country.

Senator FEINGOLD. I appreciate that answer, because on a recent

trip to Botswana and South Africa there was so much conversation

about situations involving older men and younger women. Essentially younger women were being put in a position where—I do not

know if it was completely involuntary. Certainly in some cases it

was. But you know, that is not an abstinence issue.

So I would suggest that as the policy tries to create the proper

balance between A, B, and C—I think you are already aware of

this—that the places in which the shift to focusing more on abstinence would be a certain number of places, but not necessarily

every place, given the very points that you just made about, for example, violence in South Africa. I am not at all sure that abstinence is as relevant to that as it is to some of the issues that occur

in other places.

Obviously, this is what you do, but that is just a point I would

like to make.

What kind of information should be available at a voluntary

counseling and testing center? For example, what if a man comes

in and gets tested and tests positive? What would he learn? And

if he returns bringing his spouse and she tests negative, what kind

of counseling and information will the couple get?

Dr. PETERSON. Very good questions. Before he tests positive, he

should have had pre-test counseling which should have covered the

disease, the test itself, and the likelihood of testing positive, the

windows where it might test negative, how it is transmitted, and

what it might mean if he tests positive for himself.

After the test comes back, we actually do a lot of counseling for

those who are HIV-negative, not just for those who are HIV-positive, and it has been shown that post-test counseling for HIV-negative has also been very helpful in behavior change. Presumably

they are coming in because they have put themselves at risk. So

we are seeing changes in behavior post-counseling even if they are

negative.

29

If they are HIV-positive, then certainly they will learn about the

disease, the progression of the disease, how they can keep themselves healthy as long as possible, and their responsibility to not

pass the disease on.

If you have what we call a discordant couple—HIV-positive, usually husband, and then an HIV-negative spouse—then certainly

they have two options. They either abstain, which some couples actually do, or use condoms. We have studies in an African setting

that show correct, consistent, every single time use can protect the

uninfected partner, and they would be recommended to do that

very diligently.

I would like to go back to the gender issue, the young girls, and

say that I agree completely. You have in your handout my favorite

slide that I used for teaching in schools in Zimbabwe with the older

man and the younger girl. I think this is an element we really need

to again delve deep into the Uganda story. The fact that the young

girls in Uganda did have a delay in onset of sexual activity, that

they were able to stay virgins longer, means there has been a

change in this situation. Either the girls have been given the power

to say no or the men’s activities have changed, probably both.

But we need to know how that very deep cultural change has

happened. So those are the kinds of issues we will continue to look

at very strongly. I see it as the backdrop to the ABC. It is one of

those elements that supports the AB—you cannot just say abstain.

What we have to do, especially for youth that are so critical, is say

how can you abstain, how are you going to have the ability, the authority, to protect yourself?

That is true for wives as well. I used to have Kenyan wives come

and say: My husband is coming home from Nairobi, I know he has

that disease; what can I do to protect myself? And in 1986, 1987

in Kenya, I did not have anything that I could do for her.

Senator FEINGOLD. Well, I appreciate that as well, because in a

sense, at least in some contexts, the abstinence is really a good consequence of empowering women or young girls to protect themselves. It is not actually the solution. It is the result of allowing

women to make their own choices and to have the legal power and

other powers to avoid something they may not want or may not be

ready for.

So I think that needs to be a part of the analysis. I have found

an awful lot of women talking about that element of it. That is

really the driving force, giving women the power to protect themselves.

One of the concerns that has been voiced about abstinence-only

programming is the concern that unless that programming is supplemented with other information when abstinence fails, individuals have no information about how to protect themselves. Other

concerns center on the possibility that some may seek to discourage

promiscuity by arguing that condoms do not work, thereby discouraging people from bothering to use them when they do actually

begin a sexual relationship.

Will USAID work to ensure that to the extent possible communities have access to complete and accurate information about prevention strategies?

30

Dr. PETERSON. The short answer is yes, very strongly. I worked

in an abstinence-only program in Zimbabwe in the schools, but we

gave youth full information about their sexual development, about

the disease, about how they could protect themselves. Many of the

faith-based organizations have said, can we talk about condoms,

and this is in an abstinence-only kind of setting, and give the data

on how effective condoms are.

So there are some that are uncomfortable talking about it at all

and there are others—and what I have said would be our policy— if they are to talk about condoms then they must be absolutely scientifically accurate. With a group that we are working with actually on either side of the debate, what we would want to have is

accuracy in what they teach the children. And we have good data

that condoms are protective. Is it perfect? No. But we have good

data that condoms are protective and therefore that they play a

role. We are very comfortable having all of our partners do that.

Senator FEINGOLD. Well, I appreciate your very reasonable answers and your willingness to get into some depth on them.

Thank you, Mr. Chairman.

Senator ALEXANDER. I have a couple of questions and then I will

go back to Senator Feingold, and then we will go to our second

panel.

My first question is to go back to this AIDS Corps idea. What

I am really trying to do here is understand the idea well enough

to move it on down the path, recognizing, as Senator Feingold

pointed out, that a lot of people have this idea. The President in

his speech in the East Room a couple of weeks ago turned around

to the Peace Corps Director at the end of the speech and said:

‘‘Now, Mr. Peace Corps Director, I want you to go to work on this

idea.’’

As I looked at the House bill that we passed last Thursday night,

I saw three things about it that if I were in a magical world I

would have changed with a sweep of the wand, and I wonder what

you might think about this. One is I like the name ‘‘AIDS Corps’’ because I would like to focus. I think it gives a focus to the idea.

Two is I would like to put training for treatment ahead of treatment. In other words, my sense of things is that there is a real demand for volunteers or employees from this country who can go to

African countries, as an example, and train people to treat people.

A third point is I would like to see the time limitation for that

more flexible. I believe the legislation we enacted said 3 years.

There are organizations in this country of health professionals and

physicians who regularly go to other parts of the world for shorter

periods of time and do a lot of good. They go all over the world.

I am wondering whether if we could not make it easier for health

professionals and doctors to go to Uganda, Botswana, wherever, for

a month or 2 months or 3 months and fit into a program where

they could train people to treat people and then come home, whether that is a practical idea.

Then the last change I would make would be to try to avoid the

medical malpractice issues that might arise with any sort of treatment, to put these, these persons, these health professionals from

the United States, say, who might go to an African country to train

people, if they do incidental treatment and incur some sort of liabilVerDate 11-MAY-2000 15:10 Sep 16, 2003 Jkt 000000 PO 00000 Frm 00034 Fmt 6633 Sfmt 6602 89197 SFORELA1 PsN: SFORELA1
31

ity that they would be under the same set of circumstances that

a Federal employee would be under the Tort Claims Liability Act.

Now, anything you might say about this general idea would be

useful to me and the committee, I think, as we look ahead to take

an idea of many Senators and the President and push it forward.

Dr. PETERSON. Clearly, especially with the passage of the emergency AIDS bill and the Global Fund, we are getting to the point

where we have got a fair amount of dollar resources. It is very soon

that we are going to have what we call human capacity, the people

as the limiting factor. We have an expanding epidemic, with more

people at risk. We have a contracting number of health personnel

because, frankly, they are as devastated by the disease as others.

When I was in Zimbabwe, my husband trained the higher level

Ministry of Health people, and a third of the 20 or so people he

trained are now dead. So human capacity is going to be one of the

biggest limiting factors. Before you can just go and do, you truly

should be training. So I agree with you completely that training

needs to be first.

The Peace Corps is absolutely marvelous. They are more likely

to be the ones to do this, and in fact are doing really wonderful,

community-based training in many places, but that is going to be

mostly on the prevention end. When you get to the clinical and

treatment piece, then, as you said, there are many groups that are

already experienced medical professionals. The only thing that I

would have liked is experience, international experience, as one of

the criteria, because that is what would lead us to being able to

be more flexible about how long they went.

If they already had experience in similar countries, then they

would be much more able to get up to speed quickly and make sure

that they were training appropriate for that country, and not just

trying to transfer our technology.

As we have been looking at this problem, both within the agency

overall, but also together with HHS and other USG agencies on the

mother-to-child transmission, we have been looking at this idea of

a medical volunteer corps. At least initially, we were going to try

and embed that volunteer medical corps within a twinning program

where a U.S. institution is twinned with an African or Caribbean

institution so they have an ongoing relationship and the volunteers

are within those institutions and go back and forth.

So we are very supportive. We have been working very hard on

this. I think this is one part of how we begin to deal with the

human capacity issue. But we also need to do lots more training,

as well as deal with systems issues like brain drain that are causing this to be such a difficult problem in many of the countries

hardest hit by AIDS.

Senator ALEXANDER. Senator Feingold, do you have more questions?

Senator FEINGOLD. No, thank you.

Senator ALEXANDER. Dr. Peterson, thank you very much.

May I invite our next two witnesses to come forward while I introduce them.

I would like to welcome to the hearing Dr. Edward Green and

Ms. Sophia Mukasa Monico. Dr. Green is the senior research scientist at the Harvard Center for Population and Development

32

Studies. He is a medical anthropologist with 30 years experience in

developing countries, one of the leading authorities in academia on

the Ugandan success story in the application of the ABC model.

Ms. Mukasa Monico is a Uganda. She is currently the senior

AIDS program officer with the Global Health Council here in

Washington, DC. She is a leading human rights and AIDS activist

from Uganda. She has formerly led the AIDS Support Organization

of Uganda, a leading civil society organization.

May I suggest Dr. Green first and Ms. Monico second, if you

could keep your remarks to about 10 minutes or less, and then I

and Senator Feingold will have questions for both of you. Thank

you for coming.

STATEMENT OF EDWARD C. GREEN, PH.D., SENIOR RESEARCH

SCIENTIST, HARVARD CENTER FOR POPULATION AND DEVELOPMENT STUDIES, CAMBRIDGE, MA

Dr. GREEN. Thank you, Senator Alexander, distinguished members of the Africa Subcommittee. I am an anthropologist working

at the Harvard School of Public Health. For most of my professional career I have worked in less developed countries as a behavioral science researcher and as a designer and evaluator of public

health programs. I have worked extensively in Africa and other resource-poor parts of the world. A good deal of my work has focused

on reproductive health, some of this including the social marketing

of contraceptives.

I applaud the President’s initiative to commit major U.S. funding

to address HIV-AIDS in the parts of the world with the highest infection rates. I am also glad that notice has been taken of Uganda’s

success in AIDS prevention since there is much to be learned from

the country that has had the greatest amount of AIDS prevalence

decline. Infection rates have declined from 21 percent to 6 percent.

We have also heard the figure 15 to 5 percent. It depends on

whether you do a weighting for rural-urban residents.

The Government of Uganda, led by President Museveni, developed a distinctive approach to AIDS prevention known as the ABC

approach: abstain, be faithful, or use a condom. The abstinence

message for the most part took the form of urging youth to delay

having sex until they were older, preferably married. Many of us

in the AIDS and public health communities did not believe that abstinence and faithfulness were realistic goals. It seems now that we

were wrong.

Uganda’s ABC AIDS program began in 1986, the year Museveni

became head of state. Since the rate of new infections began to decline in the late 1980s, incidence rates, it becomes important to

know what programs were in place at that time and what behaviors changed in order to account for the decline of infection rates.

None of the standard programs we associate with AIDS prevention—condoms, social marketing, voluntary counseling and testing,

treatment of sexually transmitted diseases, and most recently prevention of mother to child transmission based on the drug

nevirapine—were in place in the 1980s. I am certainly not saying

that these standard biomedical interventions are not useful, only

that we need to look at what interventions were actually in place

when infection rates began to decline.

33

It is also important to work backward from the epidemiological

and behavioral data. We know that prevalence decline and changes

in sexual behavior were most pronounced in youth age 15 to 19.

These findings took many of us by surprise since we believed that

teenagers are driven by raging hormones, therefore abstinence is

an unrealistic or impossible objective. In fact, many of us also believed that women had no power to negotiate sex or to refuse unwanted sex or to insist upon condom use because African societies

are male-dominated.

In spite of these legitimate concerns, based on real cultural patterns, Uganda designed interventions aimed at fundamentally

changing sexual behavior, something the standard interventions

just listed do not attempt. The primary target audience was youth.

Let me provide two examples of interventions that were among the

first developed by Uganda. One is the youth program which was

and is national in scope. The second example involves faith-based

organizations.

The program to introduce AIDS education in Ugandan primary

schools began in 1987, starting with the School Health Education

Program, or SHEP, of the Ministry of Education. The aim of this

program was to teach youth with AIDS prevention information,

reach youth with this information, before they became sexually active. It was also known that the dropout rates after primary school

were high.

AIDS was not the only component of SHEP, but it was an important one. The behavior change emphasis was on delay of age of

first sex, but education about condoms was also part of the program.

To implement the new program there was a training of trainers

approach that went from the district level down to sub-districts,

then to teachers, who were the ones who taught students. Students

themselves were trained as peer educators and they were expected

to teach their parents and friends about AIDS. This was all done

in a relatively short time. The basic facts about AIDS and how to

prevent it were taught.

So-called life skills education also has been taught in Ugandan

schools for a number of years beginning in about 1987. Life skills

might be regarded as AIDS Education 102, which comes after the

basic course in what AIDS is and how it is transmitted and prevented. Life skills refers to training youth in skills such as interpersonal relationships, self-awareness and self-esteem, problemsolving, effective communications, decisionmaking, negotiating sex

or not having sex, resisting peer pressure, critically thinking, formation of friendships, and empathy. These are referred to as cognitive skills and they seem to help youth make healthy and indeed

life-saving decisions.

Did this and similar programs have impact? According to studies

by the World Health Organization, the proportions of young males

age 15 to 24 reporting premarital sex decreased from 60 percent in

1989 to 23 percent in 1995. For females the decline was from 53

percent to 16 percent.

The take-home message for the U.S. Senate is that, while

condoms were part of the education for youth, the emphasis was

34

on persuading children to postpone sexual activity until they were

older, until they were married.

In addition to the national statistics already cited, we have some

findings concerning the impact of a school-based AIDS education

program in Soroti District, a program that benefited from additional inputs from an East African nongovernmental organization

called AMREF. Baseline and followup studies of primary 7 students, which is age 13 through 16, but mostly around age 14,

showed that as an apparent result of the school AIDS prevention

program self-reported sexual activity among boys dropped from 61

percent for the class of 1994 to 5 percent for the class of 2001,

while in girls the change was of similar magnitude, from 24 percent in 1994 to 2 percent in 2001. Some evidence other than selfreported findings corroborate these remarkable data, and I have

some figures in the paper that has been handed out.

Now to the faith-based example. Some other early efforts involve

faith-based organizations or FBOs. In 1992 USAID allocated funds

for three major religious groups in Uganda—Catholic, Anglican,

and Muslim. Each developed an AIDS prevention project and each

received roughly a third of a million dollars from USAID. The

FBOs said at first that they wished to promote fidelity and abstinence rather than condoms. At the time many working in AIDS

prevention thought that fidelity and abstinence promotion would

lead to few, if any, measurable results. Nevertheless, USAID made

the grants and only asked that the FBOs not criticize condom promotion by other groups. This was agreed to and adhered to.

In the months to follow there were few, if any, problems over

condoms. In fact, before long there was some condom promotion by

two of the projects.

All three projects were found to be successful. The experience of

the Muslim project, IMAL, has been published as a U.N. AIDS socalled best practices paper. So I will say a little bit more about the

Anglican church project because it is less well known. This program was implemented in 10 out of 40 districts in Uganda at the

time, meaning that the project had relatively large coverage. Clergy

and laity were trained in AIDS prevention using the peer education

approach. AIDS education messages were delivered from the pulpit

in sermons as well as at funerals, weddings, and other occasions.

A USAID-funded evaluation of sexual behavior change among

those reached by this project was conducted in 1995. It found that

those reporting two or more sexual partners declined from 86 percent to 29 percent for men and from 75 percent to 7 percent for

women. Ever-use of condoms rose from 9 percent to 12 percent in

the same period.

These findings underscore that in Uganda reduction in the number of sexual partners was probably the single most important behavior change that resulted in prevalence decline. Abstinence was

probably the second most important change. Why do I say this? We

measured both behavior and HIV prevalence through surveys of

people age 15 through 49. Most people in these age groups are

married, especially in Africa, where the age of marriage is relatively young, and therefore sexually active. This is why Uganda’s

main message directed at the majority population was ‘‘zero grazing,’’ meaning being faithful to one partner. Fidelity to one partner

35

also seems to have been the main response to the epidemic, if not

to Uganda’s prevention program.

When Ugandans were and are asked in surveys what is the main

thing they have done to avoid AIDS, faithfulness to one partner is

the first and overwhelming response in all age groups except 15 to

19, among whom the first answer is abstaining or delaying, closely

followed by fidelity to one partner.

Unfortunately, the American political debate over abstinence

versus condoms has contributed to monogamy or partner reduction

being somewhat overlooked. It is very good that the United States

through USAID has adopted the new ABC policy for those countries with generalized epidemics, that is epidemics where most HIV

is found in the general population rather than in distinct high-risk

groups. This policy should guide the development of programs in

Africa and the Caribbean funded under the President’s initiative.

Indeed, there are other countries in these regions that have implemented ABC approaches and they have achieved measures of

success—Senegal, Zambia, Jamaica, and the Dominican Republic.

My concern is that the ABC from Uganda be recognized for what

it actually is, a comprehensive approach to AIDS prevention that

recognizes that people are different and therefore a range of behavioral options for AIDS prevention needs to be presented, not just

one or two. It should be remembered that ‘‘zero grazing’’ or remaining faithful to one partner was the main message for the majority

of Uganda’s population.

The reason I must say ‘‘was’’ is that Uganda’s AIDS prevention

program has gradually changed, perhaps due to the funding priorities of foreign donor organizations. Since the mid-1990s there has

been less emphasis on sexual behavior and more on medical solutions. In recent years there has been a small but disturbing trend

toward riskier sexual behavior and for the first time in a decade

there has been a slight up tick in national infection rates. The distinctive Ugandan ABC model of the earlier period, the one developed primarily by Ugandans for Ugandans, is the one that seems

to have worked the best and the one that probably has the most

to teach the rest of the world. Thank you, Senators.

[The prepared statement of Dr. Green follows:]

PREPARED STATEMENT OF EDWARD C. GREEN, PH.D., SENIOR RESEARCH SCIENTIST,

HARVARD CENTER FOR POPULATION AND DEVELOPMENT STUDIES, CAMBRIDGE, MA

Thank you, Senator Alexander and distinguished members of the Africa subcommittee. I am an anthropologist working at the Harvard School of Public Health.

For most of my professional career, I have worked in less developed countries as

a behavioral science researcher and as a designer and evaluator of public health

programs. I have worked extensively in Africa and other resource-poor parts of the

world. A good deal of my work has focused on reproductive health, some of this including the social marketing of contraceptives.

I applaud the President’s Initiative to commit major U.S. funding to address HIV/

AIDS in the parts of the world with the highest infection rates. I am also glad that

notice has been taken of Uganda’s success in AIDS prevention, since there is much

to be learned from the country that has had the greatest amount of HIV prevalence

decline.

Infection rates have declined from 21% to 6% since 1991 [Fig. 1]. The Government

of Uganda, led by President Museveni, developed a distinctive approach to AIDS

prevention known as the ABC approach: Abstain, Be faithful, or use Condoms if A

and B are not practiced. The abstinence message for the most part took the form

of urging youth to delay having sex until they were older, and preferably married.

36

Many of us in the AIDS and public health communities didn’t believe that abstinence and faithfulness were realistic goals. It now seems we were wrong.

FIG. 1.

Uganda’s ABC AIDS program began in 1986, the year Museveni became head of

state. Since the rate of new infections began to decline in the late 1980s, it becomes

important to know what programs were in place at that time and what behaviors

changed in order to account for the decline of infection rates. None of the standard

programs we associate with AIDS prevention:

Condom social marketing;

Voluntary counseling and testing (VCT)

Treatment of STDs

And most recently, prevention of mother-to-child transmission (PMTCT, based on

the drug nevirapine)

were in place in the 1980s.

I am certainly not saying that these standard, biomedical interventions are not

useful, only that we need to look at what interventions were actually in place when

infection rates began to decline. It is also important to work backwards from the

epidemiological and behavioral data. We know that prevalence decline and changes

in sexual behavior were most pronounced in youth age 15-19. These findings took

many of us by surprise, since we believed that teenagers are driven by ‘‘raging hormones,’’ therefore abstinence is an unrealistic or impossible objective. In fact, many

of us also believed that women had no power to negotiate sex, or to refuse unwanted

sex, or to insist upon condom use, because African societies are male-dominated. In

spite of these legitimate concerns based on real cultural patterns, Uganda designed

interventions aimed at fundamentally changing sexual behavior, something the

standard interventions just listed do not attempt. The primary target audience was

youth.

Let me provide two examples of interventions that were among the first developed

by Uganda. One is a youth program which was and is national in scope. The second

example involves faith-based organizations.

THE SHEP PROGRAM

A program to introduce AIDS education in Ugandan primary schools began in

1987, starting with the School Health Education Program (SHEP) of the Ministry

of Education. The aim of this program was to reach youth with AIDS prevention

37

information before they become sexually active. It was also known that dropout

rates after primary school were high. AIDS was not the only component of SHEP,

but it was an important one. The behavior change emphasis was on delay of age

of first sex, but education about condoms was also part of the program.

To implement the new program, there was a ‘‘training of trainers’’ approach that

went from the district level, down to sub-districts, and then to teachers, who were

the ones to taught students. Students themselves were trained as peer educators,

and they were expected to teach their parents and friends about AIDS. This was

all done in a relatively short time. The basic facts about AIDS and how to prevent

it were taught.

So-called Life Skills education has also been taught in Ugandan schools for a

number of years, beginning in about 1987. Life Skills might be regarded as AIDS

Education 102, which comes after the basic course in what AIDS is and how it is

transmitted and prevented.

Life Skills refers to training youth in such skills as interpersonal relationships,

self awareness and self esteem, problem solving, effective communication, decisionmaking, negotiating sex or NOT having sex, resisting peer pressure, critical thinking, formation of friendships, and empathy. These are referred to as cognitive skills

and they seem to help youth make healthy and indeed life-saving decisions.

Did this and similar programs have impact? According to studies by the World

Health Organization, the proportion of young males age 15-24 reporting premarital

sex decreased from 60% in 1989 to 23% in 1995. For females, the decline was from

53% to 16%.

The take-home message for the U.S. Senate is that while condoms were part of

AIDS education for youth, the emphasis was on persuading children to postpone

sexual activity until they were older, until they were married. In addition to the national statistics already cited, we have some findings concerning the impact of a

school-based AIDS education program in Soroti District, a program that benefited

from additional inputs from an East African NGO called AMREF. Baseline and follow-up studies of Primary 7 pupils (age 13-16) showed that as an apparent result

of the school AIDS prevention program, self-reported sexual activity among boys

dropped from 61% for the class of 1994 to 5% for the class of 2001, while in girls

the change was of similar magnitude, from 24% in 1994 to 2% in 2001 [Fig. 2]. Some

evidence other than self-reported findings corroborate these remarkable data. [Fig.

3] (AMREF/Uganda. (2001; Nantulya 2002).

38

THE ANGLICAN CHURCH PROJECT

Some other early efforts involved faith-based organizations (FBOs). In 1992,

USAID allocated funds for three major religious groups in Uganda: Catholic, Anglican and Muslim. Each developed an AIDS prevention project and each received

39

roughly $350,000 from USAID. The FBOs said at first that they wished to promote

‘‘fidelity’’ and ‘‘abstinence’’ rather than condoms. At the time, many working in AIDS

prevention thought that fidelity and abstinence promotion would lead to few if any

measurable results. Nevertheless, USAID made the grants and only asked the FBOs

to not criticize condom promotion by other groups. This was agreed to and adhered

to. In the months to follow there were few if any problems over condoms, in fact

before long, there was some condom promotion by two of the projects.

All three projects were found to be successful. The experience of the Muslim

project has been published as a UNAIDS so-called Best Practices paper. I will say

a bit more about the Anglican project since it is less well known. This program was

implemented in 10 out of 40 districts of Uganda, meaning the project had relatively

large coverage. Clergy and laity were trained in AIDS prevention, using the peer

education approach. AIDS education messages were delivered from the pulpit in sermons, as well as at funerals, weddings, and other occasions.

A USAID-funded evaluation of sexual behavior change among those reached by

this project was conducted in 1995. It found that those reporting two or more sexual

partners declined from 86% to 29% for men, and from 75% to 7% for women (Lyons

1996:8-9). Ever-use of condoms rose from 9% to 12% in the same period [Fig. 4].

These findings underscore that fact that in Uganda, reduction in the number of

sexual partners (mutual monogamy, also reduction in partners among the minority

of core transmitters reporting 3 or more partners) was probably the single most important behavioral change that resulted in prevalence decline. Abstinence was probably the second most important change (see Green 2003 and Hogle et al 2002 for

more supporting data).

Why do I say this? We measure both behavior and HIV prevalence through surveys of people age 15-49. Most people in these age groups are married (especially

in Africa, where age of marriage is relatively young) and sexually active. This is

why Uganda’s main message, directed at the majority population, was ‘‘zero grazing,’’ meaning being faithful to one partner. Fidelity to one partner also seems to

have been the main response to the epidemic, if not to Uganda’s prevention program. When Ugandans were (and are) asked in surveys what is the main thing they

have done to avoid AIDS, faithfulness to one partner is the first and overwhelming

response in all age groups except 15-19, among whom the first answer is abstaining

or delaying, closely followed by fidelity to one partner.

Unfortunately, the American political debate over abstinence versus condoms has

contributed to monogamy or partner reduction being overlooked. It is very good that

40

the United States through USAID has adopted a new ABC policy for those countries

with generalized epidemics, that is, epidemics where most HIV is found in the general population rather than in distinct, high-risk groups. This policy should guide

the development of programs in Africa and the Caribbean funded under the President’s Initiative. Indeed, there are other countries in these regions that have implemented ABC approaches, and they have also achieved measures of success: Senegal,

Zambia, Jamaica, and the Dominican Republic.

My concern is that the ABC model from Uganda be recognized for what it actually

is: a comprehensive approach to AIDS prevention that recognizes that people are

different and therefore a range of behavioral options for AIDS prevention needs to

be presented, not just one or two. And it should be remembered that ‘‘zero grazing,’’ or remaining faithful to one partner, was the main message for the majority of

Uganda’s population.

The reason I must say ‘‘was’’ is that Uganda’s AIDS prevention program has

gradually changed, perhaps due to the funding priorities of foreign donor organizations. Since the mid-1990’s, there has been less emphasis on sexual behavior and

more on medical solutions. In recent years, there has been a small but disturbing

trend toward riskier sexual behavior, and for the first time in a decade there has

been a slight uptick in national infection rates. The distinctive Uganda ABC model

of the earlier period, the one developed primarily by Ugandans for Ugandans, is the

one that seems to have worked best, and is the one that has most to teach the rest

of the world.

REFERENCES

AMREF/Uganda. (2001, August). The effects of the Katakwi/Soroti school health and

Aids prevention project. Kampala, Uganda: African Medical and Research Foundation (AMREF).

Green, E.C., ‘‘Rethinking AIDS Prevention.’’ Westport, Ct.: Praeger Press, Greenwood Publishers, (2003, in press).

Hogle, J. (editor), Green, E.C., V. Nantulya, R. Stoneburner, J. Stover, ‘‘What Happened in Uganda? Declining HIV Prevalence, Behavior Change and the National Response.’’ USAID/Washington and The Synergy Project, TvT Associates,

Washington, D.C. September 2002. Available online: http://www.usaid.gov/pop—

health/aids/Countries/africa/uganda—report.pdf

Lyons, M. (1996, January 20). Summative evaluation: AIDS prevention and control

project. Kampala: USAID/Uganda.

Nantulya, V. (2002, February). HIV/AIDS prevention: Policy and program context

of Uganda’s success story. Presentation to USAID, Washington, D.C.

Senator ALEXANDER. Thank you, Dr. Green.

Ms. Sophia Mukasa Monico, welcome.

STATEMENT OF SOPHIA MUKASA MONICO, SENIOR AIDS PROGRAM OFFICER, GLOBAL HEALTH COUNCIL, WASHINGTON,

DC

Ms. MUKASA MONICO. Thank you, Mr. Chairman. My name is

Mukasa Monico.

Senator ALEXANDER. Mukasa, I am sorry. Mukasa.

Ms. MUKASA MONICO. Mr. Chairman, subcommittee members, ladies and gentlemen: Thank you for giving me this opportunity to

be here with you this afternoon. I think you all agree with me that

this is a historic moment. On behalf of the thousands of health

practitioners what are members of the Global Health Council and

the communities they care for around the world, I want to thank

you and your colleagues in the Senate for the speed with which you

passed the President’s emergency plan for AIDS relief.

From 1995 to 2001, Mr. Chairman, I was the chief executive officer of The AIDS Support Organization, TASO. TASO is an indigenous nongovernment organization in Uganda which was founded in

1987 to contribute to the process of restoring hope and improving

the quality of life for people and communities infected and affected

41

by HIV and AIDS. TASO is now recognized around the world as

a leader and innovator in the field of AIDS care, prevention, and

support and, like what Anne said, the real heroes of TASO are the

people living with HIV and AIDS and the founders who have

passed away in the past years.

Mr. Chairman, ladies and gentlemen, my task this afternoon is

to share with you some key elements that constitute Uganda’s relatively small but significant success story, and I refer you to my

testimony for more detailed information and statistics around this

success story.

As we have all heard, as early as 1986 the then new Ugandan

President Yoweri Museveni learned through his army that his nation was confronting an epidemic threatening to decimate his nation. The President has made it his personal and governmental priority to speak out about HIV and AIDS and is an advocate for reducing HIV-AIDS-related stigma and denial.

Mr. Chairman, reduction in stigma and denial is an indispensable element in the positive response to HIV and AIDS. It enables

individuals to proactively take steps to avoid infecting others or

being infected, as well as promote access to services that add to the

overall success of prevention efforts. Additionally, it improves people’s attitudes, making them more accepting of the infected and

willing to provide compassionate care and support.

Ladies and gentlemen, reduction in stigma and denial is not

enough to halt HIV transmission. Individuals must take action to

change their own behavior and take precautions to avoid getting

infected. Accordingly, President Museveni’s personal commitment

was quickly followed by a national policy and strategy, a strategy

which is embedded in the conviction that HIV and AIDS affects

every level of the population and poses a serious threat to the socioeconomic strata and development of our country.

The national policy charges all Ugandans individually and collectively with the responsibility of being actively involved in AIDS

control activities within their mandates and capacities in a coordinated way at the various administrative and political levels down

to the grassroots level. Ownership of the response is critical to an

effective response to HIV and AIDS, Mr. Chairman.

Working with a nongovernmental faith-based, tradition, and community-based organizations, President Museveni has promoted prevention and care interventions that are relevant and culturally appropriate and sensitive. For some he promotes a message of delaying sexual relations, for others he urges them to be faithful to each

other and promotes the use of condoms as an effective barrier. It

is this three-part message that has made it possible for Ugandans

to respond effectively to the devastating epidemic. I cannot stress

strongly enough that all these program elements need to be in

place for prevention to work.

Mr. Chairman, this is the foundation of the massive social mobilization effort that has given birth to the result that constitutes the

success of Uganda. The interventions that contributed to this success go beyond ABC. They include the implementation of a comprehensive package of services for prevention, care, support, and

treatment which serve overlapping but not identical goals. Prevention, support, and care efforts are not additive, but rather each

42

strategy increases the impact of the other through synergistic effects. Further, prevention and treatment involve different sectors

and constituencies. It is therefore necessary to invest in all three

simultaneously to achieve more than would be accomplished by investing in any one alone.

As a Ugandan, Mr. Chairman, I am deeply concerned when I

hear people taking a single element of our successful national program, like abstinence, out of context and ascribe all our achievements to that one element. All three elements must be implemented together in order for prevention to work.

Ladies and gentlemen, Ugandans were very much cognizant of

their society and as early as 1986 we acknowledged that providing

comprehensive and candid information about HIV and AIDS was

not enough. We had to reinforce those messages by formulating

other policies and creating an environment that enables us to turn

our knowledge into meaningful action. Hence other sectoral

changes were also necessary in order to assure that prevention of

HIV infection is attained in Uganda.

For example, Mr. Chairman, we worked with the existing decentralized political system to ensure that the voices of the most vulnerable populations, especially the girls, women, and the youth, are

heard and acted upon. Through the education for all policy, as we

have heard, and other programs, Ugandans ensure that social alternatives to sex are created for the youth and the children by

keeping them productively busy through formal and informal education.

This policy change is important because schools provide a natural protective environment for the children, putting girls out of

reach of older men and transactional sex. According to Ugandan

data, girls are four to six times more vulnerable to HIV infection

than boys of the same age group. Schools also provide an opportunity to inform, educate, and communicate about HIV and AIDS

to the youth in an appropriately mixed and balanced way that is

not interpreted as inciting the youth into early sex or promiscuity.

From a legal protection point of view, Mr. Chairman, significant

changes have been made to the laws relating to sexual abuse, especially for the youth. For example, the age for consensual sex was

increased from 14 to 18 years. In addition, Uganda has made economic empowerment of women a priority in order to improve their

status in society, turning the rhetoric ‘‘no to risky sexual contacts’’

to meaningful protective actions.

It is worth reiterating, Mr. Chairman, that it was important for

Uganda to have all of these and more programmatic elements in

place for our balanced and comprehensive program to work.

The next step in addressing the epidemic in Uganda and

throughout the developing world is extending anti-retroviral treatment. In his State of the Union Address, President Bush outlined

his vision and commitment for the United States to expand access

to anti-retroviral drugs. These medicines will provide hope to millions of Africans who do not see a future for themselves or their

community today.

In a nutshell, Mr. Chairman, a motivating rather than a

judgmental environment in Uganda made it possible for the community at large to forge ways and means that are both culturally

43

sensitive and relevant to meaningful behavior change, protecting

people from HIV infection, and encouraging compassionate care.

Mr. Chairman, Uganda, just like most countries in the world, is

implementing the universal approaches that are recommended by

public health practitioners. As Ugandans, as Africans, we know

what works. The real issue following the passage of the emergency

plan for AIDS relief is to identify, expand, and replicate those elements that make the HIV-AIDS universal interventions work for

Ugandans.

Mr. Chairman, to answer your question about the AIDS Corps,

but also to move the agenda forward, the Global Health Council

will be sponsoring a summit meeting for those charged with delivering these programs during the International Conference on AIDS

and STDs [sexually transmitted diseases] in Africa this September

in Nairobi, Kenya. At this summit, Mr. Chairman, representatives

from the public, private, and governmental sectors will come together to share lessons learned and strategies that work.

The meeting will also discuss the practicalities needed to effectively and efficiently implement President Bush’s challenge. We

must be ready to put this legislation together—to work, and immediately.

Thank you for the opportunity to share my views with you today

and I am happy to answer any questions you might have.

[The prepared statement of Ms. Mukasa Monico follows:]

PREPARED STATEMENT OF SOPHIA MUKASA MONICO, SENIOR AIDS OFFICER, GLOBAL

HEALTH COUNCIL, WASHINGTON, DC

Mr. Chairman, subcommittee members, ladies and gentlemen, thank you for giving me the opportunity to be with you today. This is a historic moment. On behalf

of the thousands of health practitioners who are members of the Global Health

Council, and the communities they care for around the world, I want to thank you

and your colleagues in the Senate for the speed with which you passed the President’s Emergency Plan for AIDS Relief. As a native Ugandan, I believe that the

onus is now on African and Caribbean people to make it work. I join my colleagues

at the Global Health Council, which is the world’s largest membership alliance dedicated to saving lives by improving health around the world, in looking forward to

working with the Administration and Congress to put this plan into action.

From 1995 to 2001, I was the Chief Executive Officer of The AIDS Support Organization (TASO). TASO, an indigenous Ugandan NGO, was founded in 1987 to contribute to the process of restoring hope and improving the quality of life for persons

and communities infected and affected by HIV/AIDS. TASO is now recognized

around the world as a leader and innovator in the field of AIDS care, prevention

and support.

AIDS IN UGANDA

Uganda is a large country about the size of Oregon, with an estimated population

of 22 million people. AIDS was identified in 1982 in Uganda and early surveillance

data showed that in 1988, the prevalence rate was 9 percent. This quickly escalated

and, by 1992, urban areas were registering a prevalence rate of 30 percent, while

the nationwide average rate was 18.5 percent. With the benefit of a concerted national effort, by the end of 1999 infection rates dropped 50 percent to the current

prevalence rate of 5.7 percent in urban areas.

Children have been hit particularly hard by the epidemic, with two million children under age 18 having lost either one or both parents to the disease. This is detrimental to the development of an entire generation, which have lost their parents

at the moment when parental care, guidance, and socialization are pivotal as a child

develops his or her identity.

The effects are varied. A study carried out in southwest Uganda reported that

school absenteeism in AIDS-affected household is significantly higher among girls

than boys. This is largely due to the fact that girls are often the main care givers

at home when their parents are ill. Not attending school has also had a significant

44

impact on the overall success of Uganda’s prevention strategy. In Uganda, HIV/

AIDS prevention messages have been incorporated into primary school curricula,

with Ugandan boys and girls reporting behavior change as a direct result.

The epidemic has also had a significant impact on the overall health status of

children, wiping out the significant gains we had achieved in child survival over the

past decade. Uganda’s child mortality rates remain high, with 134 out of every 1,000

live births not surviving until their fifth birthday because of AIDS.

WHY WAS UGANDA SUCCESSFUL?

Mr. Chairman, my task this afternoon is to share with you some of the reasons

why Uganda has become a relatively small, but significant, success story. The epidemic is still raging in Uganda, and we have much to do before we can claim victory

over our HIV/AIDS epidemic.

As early as 1986, the new Ugandan president, Yoweri Museveni, learned from his

Army that his nation was confronting an epidemic threatening to decimate his nation. Early on in his presidency, President Museveni both spoke out about HIV/

AIDS and became an advocate for reducing HIV/AIDS-related stigma. Strong political leadership is key to Uganda’s success, and stigma reduction has been critical

on many levels. When stigma is reduced, individuals are more willing to seek counseling and voluntarily seek HIV testing. This enables individuals to proactively take

steps in order to avoid contracting and transmitting the virus to others, and adds

to the overall success of prevention efforts. Additionally, if the stigma of HIV/AIDS

is reduced in communities, people become more accepting of the infected and willing

to provide compassionate care for them. Reducing stigma has benefits for both the

community and the individual.

But, a reduction in stigma alone is not enough to halt HIV transmission individuals must take action to change their own behavior and take precautions. Accordingly, an environment that supports this individual choice must be created and sustained. President Museveni spoke out loudly and often about the need for individual

Ugandans to protect themselves from the virus. Working with non-governmental,

faith-based, traditional and community-based organizations, President Museveni

promoted prevention interventions that were creative, culturally appropriate and

compassionate, for people who were infected and affected by HIV/AIDS.

For some, he promoted a message of delaying sexual relations; for others, he

urged them to be faithful to one partner and to use a condom. It was this threepart message that was effective in Uganda. In my personal experience, I believe

that this comprehensive approach is critical. Different populations require different

messages, and it is essential that people of all ages are educated about how to protect themselves.

I cannot stress strongly enough that all these program elements need to be in

place for prevention to work. As a Ugandan, I am deeply concerned when I hear

people taking a single element of our successful national program like abstinence

out of context, and ascribe all of our achievements to that one element. All three

elements must be implemented together, in order for prevention to work.

Museveni’s personal commitment was quickly echoed by a National Policy and

Strategy, which was embedded with the conviction that HIV/AIDS affects all every

level of the population, and posed a serious threat to the socio-economic development of our country. The National Policy charges all Ugandans, individually and/

or collectively, with the responsibility of being actively involved in AIDS control activities within their mandates and capacities in a coordinated way, at the various

administrative and political levels down to the grassroots level.

This is the foundation of the massive social mobilization that has given birth to

the results that constitute the success of Uganda. The interventions that contributed to this success include the implementation of a comprehensive package of services for prevention, care, support and treatment, which serve overlapping but not

identical goals. Prevention and care efforts are not afterthoughts but, rather, each

strategy increases the impact of the other through synergistic effects. Further, prevention and care involve different sectors and constituencies. It is therefore necessary to invest in all three simultaneously, to achieve more than would be accomplished by investing in any one alone.

We know what works and these interventions are not unique to Uganda. They are

the universally recommended approaches advocated by all public health institutions

and practitioners. Therefore, the issue is not what to do. Rather, we must identify,

expand and replicate what the Ugandans did and are doing, to make the universal

interventions work for everyone.

45

I will take this opportunity, to discuss further an issue that has been pulled out

of context and risks to reverse the prevention gains we have achieved so far: bringing abstinence-only programs into the discussion.

We all know how critically important it is for prevention programs to target youth

before they become sexually active. Uganda has achieved this on a personal and a

societal level. Cognizant of our society, early in the process we acknowledged it was

insufficient to only provide comprehensive and candid information about HIV/AIDS.

We had to reinforce those messages by formulating other policies and creating an

environment that would enable youth to turn their knowledge into meaningful action, which encouraged them to choose to protect themselves. In order to achieve

this objective, the environment and messages had to be motivational rather than

judgmental.

Political Change: We worked with the existing decentralized political system to

ensure that the voices of the most vulnerable populations—especially girls, women

and youth were heard, by:

• Setting a policy that 1⁄3 of members of Parliament had to be women;

• Establishing a seat in Parliament for youth; and

• Ensuring that women and youth were represented at all levels of the political

decision-making apparatus.

Social Change: Ugandans ensured that youth and children were kept busy

through both formal and informal education, which created social alternatives to

sex. Under a policy change that calls for education for all, communities have promoted sending more girls to schools. However, it is not enough to promote only primary education. As education is still not free-of-charge in Uganda, communities are

advocating for a policy that would make high school education free for all as well.

This policy change is important because schools provide a natural protective environment for children, putting girls out of reach of older men and transactional sex.

Schools provide an opportunity to provide information about HIV/AIDS that is appropriately mixed and balanced, so that it is not interpreted as inciting the youth

into early sex or promiscuity. These classes, which have demystified sex, impart sensitive and relevant life skills to youth so that they can make responsible choices.

Legal Change: Significant changes were made to laws in Uganda relating to the

treatment of rape and statutory rape. Female lawyers in Uganda came together to

seek these changes, and continue to work to stiffen the punishments for these

offences. Other laws need to be established that will both serve as a disincentive

to adults who might consider having sex with youth, and will enable enforcement

against those who violate the law.

Economic Change: Uganda has made improving the status of women through economic empowerment a priority. Credit facilities targeted towards women were established, enabling many women to establish small businesses and attain economic

self-sufficiency.

I cannot stress strongly enough how important it was for Uganda to have all of

these programmatic elements in place, for our balanced and comprehensive program

to work. Mr. Chairman, meaningful implementation of abstinence cannot be left

open for interpretation by individuals with differing moral values. Uganda was very

much aware of this, and complemented its ideology and sexual morals with an environment that encourages abstinence and change.

The next step in addressing the epidemic in Uganda and throughout the developing world is extending anti-retroviral treatment. In his State of the Union Address, President Bush outlined his vision and commitment for the United States to

expand access to anti-retroviral drugs. These medicines will provide hope to the millions of Africans who do not see a future for themselves or their communities today.

Pilot projects in Africa offering these life-extending medications have begun to reap

their just results, with people returning to their normal lives as working, self-sufficient members of society, rather than as people waiting for death. Treatment is not

only a humanitarian imperative—treatment supports prevention efforts, because it

provides the requisite hope that will encourage individuals to learn their HIV status

and it will reduce associated stigma.

CONCLUSION

Uganda’s current successes were realized through an effective social mobilization

effort that fostered an environment that was motivational, rather than judgmental.

Uganda’s efforts against HIV/AIDS continue to be substantially, financially and

technically supported both by the government, as well as multilateral organizations

including UNAIDS, the United Nations Development Program, the World Bank, the

European Union and the World Health Organization. In addition, efforts are funded

46

through bilateral mechanisms supported by the U.S., Danish, British, Swedish,

Italian, German, French and Japanese governments. Various international and local

NGOs also fund and implement a variety of programs and activities.

This positive environment makes it possible for the community at large to forge

ways and means that are both culturally sensitive and relevant to meaningful behavior change, protecting people from HIV infection and encourages compassionate

care. In addition, you will note that these interventions represent a multi-sector response. AIDS is not just a medical condition in Africa HIV prevention work is not

carried out by people wearing white coats but it is the responsibility of individuals,

families, schools, media and religious institutions, political leaders and traditional

leaders to ensure that further spread of HIV infection is halted.

NEXT STEPS

The real question following passage of the Emergency Plan for AIDS Relief is how

to replicate the success in Uganda in other countries. It is critical for the U.S. government to remember the importance of working with local partners, which will

guarantee cultural sensitivity and effectiveness.

Toward that end, the Global Health Council will be sponsoring a summit meeting

of those charged with delivering these programs this September in Nairobi, Kenya,

discussing the practicalities needed for effectively and efficiently implementing

President Bush’s challenge. At this summit, representatives from the public, private, and governmental sectors will come together to share lessons learned and

strategies that work. We must be ready to put this legislation to work immediately.

Thank you for the opportunity to present my views here today and I am happy

to answer any questions you might have.

UGANDA AIDS COMMISSION STATUS REPORT

WWW.AIDSUGANDA.ORG

HIGHLIGHTS OF KEY EVENTS AND ACTIVITIES

1982—Uganda medical doctors identify first AIDS cases on the shores of Lake Victoria in Rakai district, Southern Uganda.

1982-86—The epidemic largely handled by the health sector with spontaneous community initiatives to care for the infected and affected.

1986—Uganda’s Health Minister of the new government announces the existence of

HIV/AIDS in the country during the World Health Assembly in Geneva. This

marked the beginning of political openness about the epidemic, creating a

conducive environment for mass campaigns spearheaded by President Y K

Museveni.

1986—The first AIDS Control Program was established in the Ministry of Health.

Its priorities were safe blood, prevention of HIV infection in health care settings, information, education and communication about how to avoid HIV

transmission (beginning of the ABC policy). This marked the first government-structured effort to address the epidemic.

1987—An AIDS Control Program was established in the Ministry of Defense to respond the special needs of the armed forces.

1987-91—Consultations began on a multi-sector approach to controlling AIDS. The

government recognized that the epidemic’s impact went beyond the health

sector, and required planning and implementing relevant activities in other

sectors.

1987—Establishment of The AIDS Support Organization (TASO) to provide much

needed psychosocial support for the infected and affected. Quickly complemented by other initiatives, especially from the missionary hospitals

(Kitovu, Nsambya, Rubaga and Mengo).

1990—Establishment of the AIDS Information Center (AIC) for voluntary Counseling and testing services (VCT).

1992—The Government adopts the multi-sectoral Approach to the Control of AIDS

(MACA) as a policy and strategy for responding to the epidemic. This approach was aimed at building broad coalitions between the government and

other partners, including community-based organizations and business.

1992—The Uganda AIDS Commission (UAC) is established by Act of Parliament to

coordinate and harmonize the multi-sectoral efforts of the response.

1993—UAC leads and coordinates the development of the first multi-sectoral National Operational Plan (NOP) for HIV/AIDS/STD Activities 1994-1998, reVerDate 11-MAY-2000 15:10 Sep 16, 2003 Jkt 000000 PO 00000 Frm 00050 Fmt 6633 Sfmt 6621 89197 SFORELA1 PsN: SFORELA1
47

flecting the priority need for different sectors to take the lead in addressing

the epidemic.

1994-95—More AIDS Control Program Units are established in the Ministries of

Gender, Education, Agriculture, Internal Affairs (Police and Prisons), Justice,

Finance, Public Service and Local Government.

1994-Government secures a $75m soft loan from the World Bank to fight the epidemic, executed by the Ministry of Health through the Sexually Transmitted

Infections Project (STIP) 1995-2000.

1995—Uganda successfully hosts and organizes the International Conference on

AIDS and STDs in Africa (ICASA). Uganda announces the observed declining

trends in HIV prevalence.

1996—Uganda receives the first UNAIDS Country Program Adviser (CPA).

1996—The country begins preparing for HIV vaccine trials after thorough consultations with all key stakeholders. Actual trial begins 1998.

1997-99—Participation in the study for the prevention of mother-to-child transmission of HIV using anti-retroviral drugs.

1997—With the support of UNAIDS, a comprehensive review of HIV/AIDS activities

in Uganda is conducted by partners to assess coordination and implementation of HIV/AIDS activities.

1997—Uganda shifts from its traditional observance of World AIDS Day (WAD) to

an annual World AIDS Campaign (WAC), culminating in WAD every year.

WAC has since become a major advocacy activity in the country.

1997—Development of the 1998-2002 National Strategic Framework (NSF) for HIV/

AIDS Activities with consensus from partners from various sectors at national

and district levels.

1998—Establishment of the Drug Access Initiative, advocating for reduced prices for

Anti Retroviral (ARV) drugs and supporting the establishment of the proper

infrastructure for administering these drugs.

2000—Revision of the 1998-2002 NSF and development of the 2000/1-2005/6 NSF,

which puts the HIV/AIDS problems into the broader context of national development goals.

2000—Recognizing the impact of HIV/AIDS on development, the Government embarked on the process of mainstreaming HIV/AIDS issues in the country’s

Poverty Eradication Action Plan while targeting integration in the government sector budgeting exercise.

2001—Accomplishment of the preparation of the Uganda AIDS Control Project prepared under the aegis of Multi-country AIDS Project (MAP) of the World

Bank. A $50 million loan has been secured to support HIV/AIDS activities in

all sectors at national, district and community levels.

Senator ALEXANDER. Thank you, Ms. Mukasa Monico. I appreciate your coming.

I have a question and it is one I asked Dr. Peterson earlier. Mrs.

Museveni suggested that the African culture is congenial to the

idea of self-control, of young people delaying sex, of married people

being faithful. One, do you believe that is true? And two, do you

believe that is unique in Uganda? I would be interested. Let me

start with you, Ms. Mukasa Monico.

Ms. MUKASA MONICO. I will start with the last one. I do not

think it is unique to Uganda. I think every human being, especially

every parent, if I can start from that as a parent, will agree with

me that abstaining would be the best solution for every youth in

the world to avoid getting infected. But again, we know that the

youth—or that children become youth and they become adults who

make their own decisions.

So the best alternative to avoid getting infected would be, when

you start getting—when you become sexually active, at least stick

to one partner so that you do not get STDs or even HIV infection

from outside your partnership or your union.

But as we know as human beings, if that were just the answer

to it, Mr. Chairman, we would not be having infections right now.

So we have to get together all the other approaches that will actuVerDate 11-MAY-2000 15:10 Sep 16, 2003 Jkt 000000 PO 00000 Frm 00051 Fmt 6633 Sfmt 6602 89197 SFORELA1 PsN: SFORELA1
48

ally ensure that if A does not work and B does not work, then there

is another way, another practical way to avoid getting infected and

dying of HIV.

So if you find yourself in a situation where you actually cannot

abstain, you are not sticking to your partner, or actually your first

partner, who you do not know what his status is, but you have to

get sexually involved, then you must do everything possible to protect yourself.

Senator ALEXANDER. It seems to me that all the witnesses and

most people agree that part of the genius of the Ugandan proposal

seems to be the combination of things, starting with exceptional

leadership over a long period of time, that includes not just the

government but many other, many other parts of the community,

and that is comprehensive in that it is A, B, and C.

Yet it seems to me the news about it is not just that it worked,

but that A and B worked better than most health care professionals expected. Most of the talk was that condoms were the answer and the news I am hearing is that condoms are a part of the

answer, but that abstinence and faithfulness are more of the answer than many people were willing to admit 5 and 3 years ago.

Would you agree with that or not?

Ms. MUKASA MONICO. My simple answer to that is I do not think

it is A, B, or C. I think it is A, B, and C together that have made

it happen.

Senator ALEXANDER. No, I am not disagreeing with that. But I

am saying I believe—and Dr. Green, let me just go to you. Do I not

hear you saying that, that among health care professionals over the

last several years that most were skeptical of abstinence or faithfulness as contributing much toward prevention of AIDS?

Dr. GREEN. That is right, Senator.

Senator ALEXANDER. And what the data suggests is that they are

important parts of the comprehensive approach?

Dr. GREEN. Part of the genius of Uganda’s response to AIDS, and

it occurred early, is that it treated AIDS as a behavioral issue, not

simply as a medical issue for which there were medical solutions,

such as condoms, male or female condoms, such as drugs for treating standard sexually transmitted diseases, which if you treat them

the idea is that you will have less opportunity for infection.

But I think that you have put your finger on it, Mr. Chairman,

that the real difference between ABC as practiced in Uganda and

elsewhere is there was genuine balance. There was some real emphasis on A and B, not just the occasional nod in the direction of

A and B and the funding goes into condoms and drugs and the program impact indicators are attached to condoms and drugs. It was

truly a balanced program. I think we do not find so much balance

elsewhere.

Senator ALEXANDER. Senator Feingold.

Senator FEINGOLD. Thank you, Mr. Chairman. This is an excellent panel and an extremely important discussion.

I want to say particularly to Ms. Mukasa Monico how important

her message is. I heard your message loud and clear, and that is

that we dare not oversimplify what happened in Uganda. You

know, Uganda was a country that arguably had one of the worst

reputations of any country in the world in the 1970s and 1980s,

49

and somehow miraculously, through incredible effort of the Ugandan people, this country has made great progress. In the whole

world now, if you know anything about HIV-AIDS, if you want to

talk about somewhere where people were able to help bring this

under control, the first place that is discussed is Uganda, which is

a tremendous credit to your country, to your leadership, and to all

the people of your country.

I guess I feel so strongly that we should not mischaracterize or

accidentally portray in a way that is not accurate what was really

done there, and I believe that somebody like you who has devoted

your life to this has a very important message when you tell us to

be sure that we understand the complexity of it, that abstinence

itself certainly is not the only answer and is not sufficient. And I

believe the chairman is saying that and I believe other witnesses

are saying that as well, in fairness.

But your phrase that this needs to be motivational but not

judgmental is very, very important, because there are people who

will take this data and these concepts and this straightforward talk

about what is going on and use it in a way to suggest something

that, frankly, is way too simplistic to be effective and in my view

is extremely unfair to the people of Uganda who have achieved this

success.

So I appreciate your message and believe that we have to continue to tell the story as it has actually occurred in Uganda and

I will strive to be as accurate as I can about it and to avoid the

judgmental aspect that potentially could accompany it.

My questions sort of relate to that aspect for both of you. First,

Dr. Green, do the data show that people who have previously been

sexually active respond meaningfully to the abstinence message or

are the B and C messages typically more effective for this segment

of the population?

Dr. GREEN. The short answer is yes, typically for people who

have experienced sexual debut, as they call it, that the B and C

messages are more appropriate. We have data from, for example,

the demographic and health survey funded by the United States

that shows that a not insignificant proportion of Ugandans who are

widowed or single, but are, say, over 21 and who have had sexual

intercourse are abstaining because they are not currently married.

But most of those who report zero partners in the last year are

those who have not started to have sex yet, yet. But yes, the B and

C messages are probably the most important messages for the sexually active, and it was so recognized by Uganda.

Senator FEINGOLD. With regard to certain specific groups of people within the country, let me ask first Ms. Mukasa Monico: What

kind of steps have been taken in Uganda to work with high-risk

groups like long-haul truck drivers?

Ms. MUKASA MONICO. A comprehensive program, especially a

prevention program and information, education, and communication, but candid communication about HIV and AIDS. But let me

just take you another step up from just truck drivers, because what

we realized in Uganda is the fact that sex workers are very young

girls and mainly girls who have parents or are orphans. And unfortunately the clients of the sex workers are none other than our

husbands, our brothers, and our children. So to ignore them as a

50

population which is at high risk and actually risk to transmit HIV

into our families—we had to target them.

The only way to make sense while working with them was to

promote the use of condoms. Actually, there was a great increase

in the use of condoms among sex workers, from 20 percent in 1991

to 80 percent in 2001, which is a very big contribution to HIV prevention, especially from a high-risk group to a normal group.

But going to the truck drivers, if you go to Uganda you find that

along the highway from Kenya to Rwanda that is where you find

all the TASO programs. You find a program in Jinja, Mulago,

Tororo, and up to Rwanda practically. The one reason why we put

those programs there was to target the truck drivers by, first of all,

demystifying HIV and AIDS; and after demystifying it making sure

that they actually have the right information and devices to protect

themselves from HIV infection. So that was another targeted high

group, high-risk group, in our interventions.

Senator FEINGOLD. Dr. Green, you want to comment on that?

Dr. GREEN. There was an attempt not to stigmatize groups like

commercial sex workers and bar girls and truck drivers and soldiers. So the information, education, and communication was mostly done sort of low-key, through peer educators. And there was a

lot of condom promotion to groups that were known to be at special

risk.

Senator FEINGOLD. What about the military? You point out the

history of this and how President Museveni found out about the

problem through the military. We have heard very similar concerns

in South Africa. What strategies have been targeted to the military, Ms. Mukasa Monico?

Dr. GREEN. I think that that is——

Senator FEINGOLD. Dr. Green?

Dr. GREEN [continuing]. Another high-risk—Sophia was looking

at me, so maybe she wanted me to answer it first.

Senator FEINGOLD. Go ahead.

Dr. GREEN. I think that that was another high-risk group. There

was a lot of peer education in the military. Infection rates fell in

the military in the late eighties, early nineties, quite dramatically.

But this was also true for military recruits. So you just had a lot

of HIV prevalence decline among all groups, but including the military, and there were special programs.

I think maybe the first program in Africa that was directed at

the military was there. I was part of the design of such a program

in Swaziland a year ago, funded by the USAIDs of Defense, and

the question arose what are the—out of A, B, C, what do you promote to soldiers? The answer was B and C.

When you mentioned truck drivers, about 10 years ago I was

working in Tanzania in a project for commercial sex workers and

I was driving to Mulago and our car broke down and we had to

hitchhike, and we hitchhiked with a couple of truck drivers on the

famous highway that you have all heard about, along which HIV

infection spread. We asked the truck drivers what they were doing

about AIDS and one driver said that he was faithful to his

girlfriend that he is living with and the other one said he is getting

married and no longer stopping and having sex along the way the

way they used to.

51

So this was 1993, and it gave me my first clue that something

other than the model that we had in mind as international AIDS

experts might be going on. Then soon after that, I went to Uganda

for the first time and saw that indeed something different was

being promoted and something different seemed to be happening.

Ms. MUKASA MONICO. Maybe just to answer you about the military. One important element that has been incorporated in the

military is voluntary counseling and testing as an entry point to

behavior change and also seeking prompt medical care, which you

find everywhere—not everywhere, like 60 percent in Uganda. But

this is a specific service for the military men.

Senator FEINGOLD. I appreciate both of your answers because obviously I focus on the truck drivers and the military because of the

stories I have heard all over Africa about the way in which HIVAIDS can be spread. I remember hearing on a trip where we went

first to Tanzania, then Mozambique, the concerns about the highways and the travel and the way in which it may have spread

through Tanzania to Mozambique.

I appreciate the candor that realistically the most likely thing to

work here is B and C, although you do express some hope that, it

sounds like, that A has some role in this regard. But I think you

are looking at the type of lifestyle and situation realistically. It is

so important to remember what the role of B and C are in preventing the spread among very mobile people, which by definition

the military and the truck drivers are.

We have even heard this with regard to sometimes troops that

we have helped assist us in various difficult situations in Africa

being sent from one country to another to keep the peace. This is

a potential negative side effect for a country that may not have a

particular high HIV-AIDS rate, when individuals may come and be

involved in those areas. Even though they may be trying to keep

the peace, other things obviously happen. This is a very critical

part of understanding how the problem has spread throughout the

continent.

Where do efforts to increase access to treatment stand in Uganda? Have efforts to increase access to treatment in Uganda encouraged people to participate in voluntary counseling and testing? Ms.

Mukasa Monico?

Ms. MUKASA MONICO. The first targeted initiative to increase access to treatment in Uganda started around 1998 with the drug access initiative from UNAIDS. That is when we negotiated with big

pharma to import drugs with reduced prices. It was not so reduced,

because a person was paying around $1,500 per month just for triple therapy.

But around 2001, through again an increased effort to decrease

prices and through contacting CIPLA India we managed to negotiate for generics and now drugs are costing $300 per year in Uganda, which is a substantial decrease from $1,500 per month. So that

is one step forward.

So what we did was to import generics of anti-retrovirals, but by

importing generics of anti-retrovirals we also managed to bring

down the prices, some of the prices of the brand names for antiretrovirals.

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I think, just like any other incentive, knowing that you have a

support system to fall back on, people are encouraged to go and

test and find out where they are with HIV and AIDS because they

know at the end of the day I can improve my quality of life because

I can get access to anti-retrovirals. So undoubtedly, with more access to anti-retrovirals more people find out about their HIV status,

and by finding out their HIV status they either know that they

have to change their behavior if they are not infected, and if they

are infected at least they know that they can get support.

But it also decreases the stigma around HIV and AIDS, and

again improving access to services.

Senator FEINGOLD. Mr. Chairman, I thank both the witnesses.

Thank you, Mr. Chairman.

Senator ALEXANDER. Thank you very much. I think the Ugandan

experience has done something in the United States that we ourselves could not do. You have those who strongly believe in abstinence talking about condoms, and those who strongly believe in

condoms acknowledging the importance of abstinence. That is a lot

of progress in this country.

So we are grateful to you for the work you have done in Uganda

and in helping us understand the role of that model as we go about

an effort, particularly on this subcommittee, to help make sure the

United States marshals the resources that we are beginning to approve and that we spend them as wisely and effectively as possible

and with as much respect for the countries and the people that we

hope to serve.

Thank you very much for being here.

Dr. GREEN. Thank you.

[Whereupon, at 4:02 p.m., the subcommittee adjourned, to reconvene subject to the call of the Chair.]

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