Twenty years after the first clinical evidence of Acquired Immune Deficiency Syndrome (AIDS) was reported, it has become one of the most devastating diseases humankind has ever faced. The Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organisation (WHO) estimate that over 60 million people have been infected with the virus since the epidemic began. Worldwide, HIV/AIDS is reported to be the fourth major cause of mortality. The majority of new infections occur among young adults living in the developing world, most of whom do not know that they are infected. About one third of the HIV infected are aged between 15-24 years.
HIV marks a severe development crisis in Sub-Saharan Africa, which remains by far the worst affected region in the world. It is reported that the estimated total number of people living with HIV/AIDS in Sub-Saharan Africa is now 28.1 million. Furthermore, by the end of 1999 the region had 12.1 million orphaned children from AIDS related deaths.
It is hard to underestimate the impact of the AIDS pandemic to development. Badly affected countries are losing highly trained expertise, which is difficult to replace, and often the disease is spreading against a setting of deteriorating public services, poor employment prospects and endemic poverty. Even if effective prevention and treatment and care programmes take hold immediately, the scale of the crisis means that the human and socioeconomic toll will remain significant for many generations.
Nevertheless, there are some signs of hope. Perhaps the most important of all being the case of Uganda, one of the countries in which AIDS was first diagnosed.
Uganda's AIDS crisis
The first cases of clinical AIDS in Uganda were diagnosed in 1982 in Rakai district in the south west of the country. At that time the disease was locally called "slim". It is estimated that today 1.1 million people living in Uganda have HIV/AIDS, with nearly 80% between the ages of 15 to 45 years (UAC, 2002). It has become the leading cause of death for adults, and it is possible that the population of Uganda will plunge from 30 to 20 million by the year 2010 as a result of the epidemic.
Uganda records the highest proportion of AIDS orphans in the world. Many have been forced to drop out of school to start earning money or because their caretakers cannot afford school fees. Furthermore, a recent UNAIDS report estimated that 110,000 children were living with HIV/AIDS in Uganda at the end of 2001. This high number is evidence that mother to children transmission is a challenge. The demographic structure in Uganda is undergoing considerable transformation. Families commonly comprise of a grandparent surrounded by grandchildren. There are also large numbers of children-headed families and communities of children without any caring adults at all.
Uganda's response to the epidemic
The situation is very serious, but it could be even worse. In fact, Uganda is often cited as Sub-Saharan Africa's leading "success" story in the fight to reduce the prevalence of AIDS. This is because Uganda has succeeded in lowering its very high infection rates at a time when the rate of new infections continues to increase in most other countries in the region.
In Rakai district, probably the AIDS epicentre in the country, a British Medical Research Council study reported in 1996 that there had been a decline in prevalence (particularly amongst young males) from 12 per cent to 3 per cent over a five year period. Other studies have shown that since 1993 HIV infection rates among pregnant women, a key indicator of the progress of the epidemic, have been more than halved in some areas.
In Kampala, the major urban area, it has been reported that sex workers studied in the early 1980s had an infection rate of about 80 per cent, but in 2000 sex workers tested in Kampala had a rate of 28 per cent (UNAIDS/WHO, 2002). It has also been reported that infection rates among men seeking treatment for sexually transmitted infections have dropped by over a third. Summarizing findings from all over the country, a recent article in the Lancet noted an overall downward trend in HIV prevalence in rural and urban populations since the late 1990s - from about 28 per cent to 8 per cent.
What exactly has been the cause of the decrease in prevalence rates is still not known, but it is generally agreed that a significant part of the success in reducing the prevalence of HIV in Uganda is the result of a broad-based national effort backed up by firm political commitment, including the personal involvement of the head of state, President Yoweri Museveni.
A structured Government response to the HIV/AIDS epidemic dates back to the late 1980s when an AIDS Control Programme (ACP) was created in the Ministry of Health. This was the result of the work of a committee constituted in 1985 to promote resource mobilisation. In recognition of the fact that HIV/AIDS has causes and consequences far beyond the health sector, the Uganda AIDS Commission (UAC) was constituted in 1992 by Statute of Parliament and placed under the Office of the President.
From the outset, the Government involved religious and traditional leaders, community groups, NGOs, and all sectors of society, forging a consensus around the need to contain the escalating spread of HIV and provide care and support for those affected. The reductions in HIV prevalence have been attributed in part to successful intensive behavioural-change campaigns and encouragement of the use of condoms.
Sex education programmes in schools and on the radio focused on the need to negotiate safe sex and encouraged teenagers to delay the age at which they first have sex. The social marketing scheme involved sales of condoms at subsidized prices or free distribution by both the government and the private sector. Another innovation in Uganda was the launch in 1997 of same-day voluntary counselling and testing services. Up until then clients had to wait two weeks for their HIV test results, and it is reported that many failed to return.
Such strategies seem to have had a remarkable impact. Repeated cross-sectional behavioural surveys conducted in Uganda have indicated significant changes in sexual behavior. For example, condom use rates have generally increased, mean age at first sex for girls increased from 15.9 years in 1989 to 16.5 years in 1995, and a joint UNAIDS/WHO survey reported that in 2000 almost 98 per cent of sex workers said they used a condom the last time they had sex.
Does Uganda really show the way forward?
Although there is a consensus that the situation in Uganda is not as bad as it could be and shows signs of improving, there is some debate about what can be learned elsewhere. Some academics have suggested that assertions about Uganda's success have sometimes been based on misinterpretation of data.
There is no evidence, for example, for the claim that overall rates of HIV in Uganda have been reduced from 30 per cent to 10 per cent. This assertion can often be found in aid agency reports and government statements, but a decline on this scale has actually only occurred at one survey site, Mbarara (30.2% to 10.5%, reported in The Lancet, 2002). Moreover, the HIV/AIDS data only comes from particular parts of Uganda - usually ante-natal clinics in predominantly urban areas. It is not known if these data reflect developments in, for example, the north of the country.
It can also be questioned if the decline that has been noted is the consequence of public policy measures. Declines in prevalence in Uganda have been reported since 1992 which, due to the long incubation period of HIV/AIDS, would correspond to a fall in incidence in the mid-1980s. Yet Uganda was in the midst of a civil war at this time and did not have any national HIV programmes in place. Declines in prevalence since the 1990s in Uganda cannot, therefore, be attributed solely to government action and international aid.
Exactly what has led to incidence reductions in the mid-1980s is difficult to say. One argument is that during the civil war there was a great deal of civil disruption, large movements of people and military forces and, as a result, high risk sexual behaviour occurred which may have been largely responsible for the initial explosive spread of HIV. When the war ended there was an immediate reduction in risk behaviour as society returned to normal.
There is consensus that awareness of the disease has increased since the late 1980s and that risk behaviour has continued to decline. The government and aid agencies have certainly played a part in this. But it is not clear whether policy measures have really made the impact that is often claimed for them. It is also likely that, as with other killer epidemics, HIV/AIDS in Uganda has reached a natural peak, and is beginning to decline on its own. This may have occurred even without any intervention.
Despite the criticisms, there appears to be a stabilization of the epidemic in Uganda. It seems reasonable to attribute this to a combination of factors including relative political stability, the response of the Government, the activities of hundreds of non-governmental organizations and community-based organizations, effective promotion of behavioural change and a natural decline in the virulence of the disease.
Clearly, the Ugandan experience can provide valuable information to assist other nations in their prevention efforts. However, before inappropriate recommendations are made, based on poor interpretation of evidence, further research in understanding Uganda's results is needed.
This article was first published in 2003
Prevalance versus incidence
Prevalence tells us the proportion of people who are already affected with HIV at any one point in time. A prevalence of 20% means that one person in five in that community is already infected with HIV.
Incidence tells us about the rate of the occurrence of new infections during any particular year e.g. a 1% incidence rate means that during a particular year 1% of those who were not initially infected will become infected with HIV.