Global Policy Forum

By Tina Rosenberg

In 1991, 15 percent of Ugandans had the AIDS virus. A decade later, the rate was 5 percent, a drop unmatched anywhere in the world. How this was done is now the focus of a tragically ideological argument about the shape of Washington's programs to fight AIDS overseas. The religious right is convinced that it knows Uganda's secret: abstinence. But only by understanding the entire program can one grasp Uganda's success and build models for other countries. Meanwhile, religious conservatives are opposing the passage of AIDS legislation in Congress because they say the current House bill — written largely by Henry Hyde, a conservative himself — does not sufficiently focus on abstinence. Talking about safe sex and condoms is a failed strategy, Representative Joseph Pitts of Pennsylvania claims.

"When I hear this debate I get very annoyed," said Sophia Mukasa Monico, who until 2001 was the director of TASO, Uganda's premier group helping the infected. "It is so unfair to pull out one element of a bigger picture — a very small percentage of the whole picture — and say, `This is what works.' " Uganda is indeed a model for nations fighting AIDS, but it is not quite the model the religious right would like to believe. Ugandans are responding to a campaign known as ABC, which says: Abstain. If you can't abstain, be faithful. If you can't be faithful, use a condom. Contrary to the assertions of Mr. Pitts and others, there is nothing unusual about this slogan. "ABC came to us from the World Health Organization," said Ms. Mukasa Monico, who now works for the Global Health Council in Washington. "It was the standard public health approach to prevent sexually transmitted diseases."

Why, then, has it worked better in Uganda? Mostly because the government and society are effective at getting out the message. Sex and AIDS are talked about openly, not suppressed. And strong political leadership has been crucial. President Yoweri Museveni's early energetic response — he called fighting AIDS a "patriotic duty" — contrasted with the denial and inaction of other leaders. Prominent figures, including a beloved musician, a minister and an army major, have spoken publicly about being infected. The other key component has been to spread information through word-of-mouth. The national AIDS control program trained thousands of people to be AIDS counselors and educators in their communities. Studies show that Ugandans are more likely than Kenyans and other Africans to get information through personal networks rather than mass media.

The point is to demystify and destigmatize AIDS, breaking down the "couldn't happen to me" barrier and allowing people to consider the possibility that they may become — or may already be — infected. Uganda has been able to do what other nations have not: get the risk to hit home. That's when teenagers decide to postpone sex, people in relationships agree to "zero grazing" (as Ugandans call monogamy), and the unfaithful consent to using condoms. Ugandans have fewer sexual partners and are much more likely to use condoms in casual relationships than they were 10 years ago. Rates of young people's sexual activity have fallen sharply. In one school district in 1994, more than 60 percent of students 13 to 16 years old reported that they had already had sex. In 2001, the figure was fewer than 5 percent.

The government and public interest groups decided that it was important to find ways to inform people about AIDS in ways they were most likely to accept. Since more than 90 percent of those diagnosed with the AIDS virus go to witch doctors, Uganda decided to work with witch doctors. It set up an organization to help traditional healers learn about AIDS so they can give patients accurate information and know when to refer patients to Western medicine.

Uganda's AIDS prevention program resists an ideological label. It does emphasize abstinence and monogamy, and does work closely with religious organizations. But Uganda also promotes condom usage and has been able to make condoms available to those who need them. Uganda also does AIDS education among prostitutes and gay men. Its work with these high-risk groups is nonjudgmental, to avoid driving the epidemic underground. As a result, condom use is around 95 percent among prostitutes in Kampala, the capital — up from virtually zero before the epidemic hit.

Any embrace of the Uganda strategy must include the full spectrum of its anti-AIDS efforts. Perhaps the most essential aspect of Uganda's response is the fact that the country has reacted to the epidemic as if it were World War III, as one academic who studies Uganda put it. Instead of holding up AIDS funds with arguments over religious correctness, politicians in Washington should be tackling the difficult task of promoting the committed leadership and total social mobilization that have been crucial to Uganda's success.

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