Uganda

In the early 1980s, when the first cases of HIV/AIDS emerged in the South Western district of Masaka—now known as Rakai—the government did not shy away from addressing the then-mysterious virus. Estimates by the U.S. Census Bureau and UNAIDS suggest that national HIV prevalence peaked at around 15 percent in 1991 and had fallen to 5 percent as of 2001 (Hogle et al., 2002). Still, from two cases in 1982, the epidemic grew to a cumulative 2 million cases by 2000 (Okware et al., 2001).

President Yoweri Museveni started talking openly about AIDS as early as 1985–1986. At that time, a prominent Ugandan musician, Philly Bongole Lutaaya, who tested positive for HIV, actively spoke out about HIV/AIDS before his death in 1989. Soon after, President Museveni established the National AIDS Commission, and NGOs, including faith-based organizations (FBOs) and local community groups, began to play an important role in confronting AIDS.

Uganda’s first program to address AIDS in 1986 consisted of epidemiological surveillance, ensuring a safe blood supply, provision of AIDS Information, Education and Communication (IEC) and control of Sexually Transmitted Diseases (STDs). The government’s early message was “love carefully” or “love faithfully” to protect people and their families from the disease. Another message was “live faithfully.” Social marketing of condoms was added to the program in the early 1990s and a multisectoral strategy was implemented with the establishment of AIDS control programs in other ministries. “Raising awareness was the mainstay of our initial programme. At first we focused on instilling fear in the population, but it soon became apparent that many people were insensitive and refractory to calls for behaviour change. Fear could only be effective for a short time. Widening the range of prevention options to include condom use as well as avoidance of casual sexual contacts helped our programme to gain wider acceptance” (Okware et al., 2001).

One of the early NGOs dedicated to HIV was The AIDS Service Organization, known as TASO. Mukasa Monico, then head of TASO, said that she drew on what was known about the sexual transmission of HIV and the messages that were used in the late 1980s to promote healthy behaviors. Abstinence referred to “delaying sexual debut for the youth, or refraining from having casual sex”—a mixed message of both postponement and avoidance (Monico, 2003). Fidelity meant that those people who were already sexually active should have only one partner. Given that polygamy is practiced in much of Africa, TASO intentionally avoided the word monogamous. Similarly, TASO avoided referring to people’s marital status because of the prevalence of extramarital sex. The message about condom use was directed toward those people who were already sexually active, but who were not sure of the sexual behaviors of their partners. The condom message was extended to HIV-positive individuals and serodiscordant couples (in which one partner is HIV-positive, while the other is HIV-negative) to prevent transmission to uninfected partners. Mukasa Monico also noted that UNAIDS introduced another acronym into the program in Uganda—FACT, which stood for Faithfulness, Abstinence, Condom use and Training (Mukasa Monico, 2003).

During the late 1980s and early 1990s, the growing awareness of HIV and AIDS led to a very active response that involved many players and messages. Promotion of condom use became a more central part of the HIV prevention strategy. However, early messages and activities frequently avoided talking directly about condoms. Participants from Uganda attending a workshop on reproductive health for youth¹  and HIV policy recalled that around 1988 there was a massive HIV prevention campaign that reached even primary school students. Later, in 1990, the government sponsored a campaign that highlighted two phrases—“Don’t forget to carry your ‘coat [condom]’” and “zero grazing.” The campaign warned against sugar daddies - a particularly high-risk group of older men going out with young girls. The campaign also provided information about the ways HIV could be transmitted and the ways it is not. “In the 1980s, even though there were other messages, the message that caught young people’s minds was use condoms, because that was new,” recalled one of the workshop participants, thinking back on the early days of the epidemic.

In many countries, people in leadership positions were hesitant to talk openly about condoms. However, in the late 1980s, one Ugandan religious leader took a stand in favor of openly supporting condom use for HIV prevention. The late Bishop Karuma of the Anglican Church of Uganda was willing to come out in favor of condom use, according to Reverend Simon Mwesigwa (2004). Bishop Kawuma was the first religious leader to link the B and C messages—being faithful and condom use—saying that “If you are foolish enough to have sex outside, don’t be stupid enough not to use a condom.” The Bishop’s reason for supporting condom use to prevent HIV resonated with the country: His son had died of AIDS.

In the early 1990s, “ABC” still did not appear in public sector HIV prevention programs (Slutkin et al., 2006). Donna Flanagan (2004), who worked as the GPA advisor on IEC in Uganda between 1990 and 1994, indicated that the term “ABC” was not used in any of the IEC materials developed by the AIDS Control Program or the Ugandan Ministry of Health (MOH). “The approach in those days was to talk about how the virus could be transmitted and then discuss how it could be prevented” (Flanagan, 2004). Before her arrival, she recalls, the materials used illustrated “zero-grazing.” Flanagan recalled an evaluation of IEC messages that found target audiences were not at all sure what “zero grazing” had to do with AIDS. On the other hand, “zero grazing” appeared to be a comfortable concept from the perspective of the MOH because it avoided the need to talk directly about sexual behavior. In the early years of her tenure in Uganda, Flanagan observed that MOH staff were also hesitant to talk about condoms, and as a result, condoms were not advocated as the first line of protection. However, during community-based HIV education sessions, the public was eager to learn and not afraid to talk about condoms, although they were not commonly available through the MOH.

Image 8: Poster stating, "Sexually transmitted diseases. How to prevent STDs: It's easy: Abstain from sex, be faithful to each other, prevent STDs with a condom." Courtesy of JHU/CCP.

By all accounts, President Museveni played an enormous role in publicizing and de-stigmatizing AIDS and in promoting a program that includes a wide range of organizations (Sensendo and Sekatawa, 1999; Okware et al., 2001; Hogle, 2002; Low-Beer and Stoneburner, 2003; Garbus and Mareilee, 2003; Putzel, 2004; Green 2004). Reflecting on the importance of Museveni’s actions at a critical time, Parkhurst (2001: 75) wrote, “The President has taken on HIV/AIDS as an issue of importance, speaking out throughout the country and internationally as well, to highlight the problem AIDS represents. Not a stated policy initiative at the time, many officials in Uganda see this as one of, if not the most important aspects of what the government has done in the fight against AIDS.” Part of the success of Museveni’s actions may be due to timing: After years of civil strife, Uganda was at war with a disease that struck indiscriminately. From the beginning, he promoted behavior change—most notably partner reduction, which he referred to as “zero grazing.” His messages also favored abstinence for young people. Even as the government was increasing promotion of condoms in HIV prevention programs in the 1990s, Museveni has never considered condoms to be the sole answer to HIV/AIDS (Tebere 1991; Green, 2003b; Museveni, quoted in Schuettler 2004). The government of Uganda “did not push for condoms very strongly, instead pursuing a ‘quiet promotion of condoms,’ and inviting religious leaders to take part in discussions of condoms as a state policy” (Parkhurst, 2001: 78).

Uganda’s nascent ABC strategy emerged in stages. The government and churches tended to focus on the risk avoidance behaviors of abstinence and being faithful. The messages associated with A and B created a link between them that resulted in their being promoted in tandem. Bishop Karuma contributed to the much more sensitive link between B and C,²  in an effort to promote safety. The connections between A, B, and C represent programmatic attempts to focus on sexual transmission of HIV. Although they were not tied into a specific strategy in the early years of the epidemic in Uganda, the country’s national plans have included both risk reduction and avoidance.