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Before the Subcommittee on African Affairs
Committee on Foreign Relations
May 19, 2003
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 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:
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 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.
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 olds 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, long-distance 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 faith-based 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.
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