Abstinence Education in Uganda
The potential of abstinence-centered, character-based sexuality education to directly reduce the spread of HIV/AIDS infection among adolescents and adults is highlighted by a case study published by the U.S. Agency for International Development (2002), “What Happened in Uganda? Declining HIV Prevalence, Behavior Change, and the National Response.”
Green, Hogle, Nantulya, Stoneburner, and Stover (2002) state that “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.”
Regarding HIV prevalence in Uganda, estimates by the U.S. Census Bureau/Joint United Nations Programme on HIV/AIDS (UNAIDS) are that “national HIV prevalence peaked at around 15 percent in 1991, and has fallen to 5 percent as of 2001.This dramatic decline in prevalence is unique worldwide” (p.2). (See Figure 1.)
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| Figure 1: HIV Prevalence among 15-19 Year-old Women in Selected Sites in Uganda, 1991 - 2000 |
Green et al. (2002) state that
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 countries (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” (p.2-3) (see Figure 2).
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| Figure 2: Non-regular sex partners in unmarried by age in Uganda, Kenya, Zambia, Malawi |
Hogle et al. (2002) describe the Ugandan approach in this way: “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,’ [also called] ‘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, among youth ages 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” (p.6). (See Figure 3.)
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| Figure 3: Sexual debut among 13-16 year-olds in Soroti District, Uganda, 1994 – 2001 |
Regarding the role of condom use, Green et al. (2002) state that “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” (p.7-8). In the opinion of the authors, “the most important determinant of the reduction in HIV incidence in Uganda appears to be a decrease in multiple sexual partnerships and networks. In comparison with men in Kenya, Zambia, and Malawi, 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 to keep sex within marriage, and less likely to have multiple sex partners, particularly if never married” (p.9). (See Figure 4) This focus on eliminating risk through changing sexual behaviors has also been described as “primary behavior change”(Green, E.C., 2003, p.9)
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| Figure 4: Urban and rural males and females reporting casual sex in Uganda, 1989 – 1995 |
Serwadda and Makumbi (2002) reported on trends in HIV prevalence, 1994-2000 in Rakai-Southwestern Uganda. They reported that the odds ratio, compared with those who had had no sex in the previous six months, for HIV infection was higher for the sexually active reporting condom use during the last six months than for the sexually active who reported never using condoms in the last six months. Serwadda et al. offer no explanation for this trend, but Kirby (2003) observed that while sexually active Ugandans are more likely to use condoms with new casual partners, sexually intimate couples who continue their relationship are less likely to continue using condoms. This is an example of “disinhibition” where an increase in one health behavior leads to a reduction in another. Apparently the reduction in the number of partners provides greater risk reduction than does higher levels of condom use with higher numbers of partners.
Green et al.(2002) also state that the sexual abstinence message in Uganda was framed in the context of “a strong emphasis on empowerment of women and girls; and aggressively fighting stigma and discrimination against people living with HIV/AIDS (PLWHAs)” (p.5). As discussed earlier, the strong message of the Ugandan campaign was framed as a “‘war’ against the decimating disease known as ‘Slim’” (p. 4 ) with stark choices presented as the weapons of choice to fight this war. Some might describe this as a “fear-based” message, but here it can be seen how a message that contains strong elements of fear can also contain elements of compassion for people already infected with the disease and of empowerment for women.
Green et al. (2002) ask if this success can be replicated. They point out that 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. Allen and Heald (2004) also analyzed the reasons for the success of the Ugandan approach in contrast with the estimated 40% national HIV prevalence among adults ages 15-49 in Botswana (UNAIDS), where condom use has been the main health education message. They argue that “the promotion of condoms at an early stage proved to be counter-productive in Botswana, whereas the lack of condom promotion during the 1980s and early 1990s contributed to the relative success of behavior change strategies in Uganda. Other important factors included national and local-level leadership, the engagement (or alienation) of religious groups and local healers and, most controversially, procedures of social compliance. (p.1)”
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 (Agha, 2002), the main factor behind the large decline in prevalence among Zambian youth during the 1990s was a significant reduction in multiple partner trends.
References
Agha, S. (2002). Declines in casual sex in Lusaka, Zambia: 1996-1999. AIDS 2002, 16, 291-93.
Allen, T. & Heald, S. (2004). HIV/AIDS policy in Africa: what has worked in Uganda and what has failed in Botswana. Journal of International Development 16, 1141-1154.
Green, E., Hogle, J., Nantulya, V., Stoneburner, R., Stover, J. (2002). What happened in Uganda? Declining HIV prevalence, behavior change, and the national response. U.S. Agency for International Development-Washington and The Synergy Project, TvT Asociates, Washington, D.C., September, 2002.
Green, E.C. (2003). Rethinking AIDS prevention: Learning from successes in developing countries. Westport, CT: Praeger.
Serwadda, D., & Makumbi, F. (2002). Rakai Project Presentation: Trends in HIV-prevalence, and the association of delayed first sexual intercourse and HIV prevalence. Paper presented on August 6, 2002.
