Abstinence: Uganda HIV Rates Suggest Failure

Abstinence: Uganda HIV Rates Suggest Failure


My name is Daniel DiRito and I have been blogging at www.thoughttheater.com since March. While I have been a frequent commenter here at Donklephant, this is my first posting. I want to thank Justin for the invitation and the opportunity. Hopefully, my diverse curiosities will offer you, the readers, some additional perspectives on prior topics as well as exposure to other lesser discussed subjects.

Perhaps I am best described as a contradiction in that I’ve spent a lifetime searching for an affiliation that I could accept and maintain…one that would, for the most part, define me like a word in the dictionary…and yet I have come to the realization that my identity is always evolving and I am better explained by my inability to be characterized. I see this conundrum in simplistic terms as my own commitment to finding more “truth”. Rest assured that remark by no means is intended to assert that I know the truth or always live the truth…rather, what I know is that I enjoy the search for truth and that is a quintessential distinction.

Consequently, it’s been my practice to write primarily about the human condition and all of its components. I see life as a constant voyage towards the truth and in order to uncover more truth, one must be willing to deconstruct that which seems incontrovertible. Ultimately, I believe the answers will be found in the questions. Here’s hoping the journey is the genesis.

I look forward to posting here at Donklephant as well as my continued blogging at Thought Theater. I also hope you will take the opportunity to check out my postings at www.thoughttheater.com…it will provide a more comprehensive view of my interests. I welcome your comments and observations and hope the dialogue will lead each of us to more truth. Thank you in advance for reading and sharing.

Abstinence: Uganda HIV Rates Suggest Failure

The latest HIV infection information from Uganda seems to indicate that the abstinence approach may be a disaster in the making. Uganda, long viewed as a model for HIV prevention success in Africa, appears to have taken a wrong turn in promoting the program described as ABC…A: abstinence first…B: be faithful in a committed relationship…C: use condoms if A and B fail. The Bush administration appears to be complicit in these alarming new infection rates by virtue of its push towards programs that emphasize abstinence while moving away from the promotion of condom usage.

From allAfrica.com:

Speaking at the ceremony, the Uganda Aids Commission (UAC) Director General, Dr Kihumuro Apuuli, said despite financial support from the donor community, the rate of people acquiring HIV/Aids is still increasing.

He said, in 2005 130,000 Ugandans got infected compared to 70,000 in 2003.

One must understand a little of the history of Uganda’s AIDS prevention efforts in order to draw any conclusions. Uganda was one of the first African nations to openly discuss HIV and to direct energy and money towards awareness. In 1986, President Museveni toured the country with a message that HIV prevention was a patriotic endeavor and basically introduced the above described program that has come to be called the ABC’s of AIDS prevention. There is little dispute about these basic facts. However, since that time the interpretation of the resulting data has been widely divergent and controversial.

When the Bush administration announced its five year, 15 billion dollar effort to combat HIV in Africa in early 2003, it immediately embraced the Ugandan ABC program as a model for the rest of Africa. Since that time, two opposing views have emerged with regard to an effective plan to combat HIV in Africa.

The administration and numerous religious groups (most of these groups have limited HIV experience) believe that abstinence should be the primarly prevention message. Those with significant HIV prevention experience caution that abstinence can be an adjunct to condom promotion and distribution, but it is not a method that ought to be singularly enbraced and endorsed. They cite abundant research and data to support this contention.

From talk2action.org:

Uganda was once an HIV prevention success story, where an ambitious government-sponsored prevention campaign, including massive condom distribution and messages about delaying sex and reducing numbers of partners, pushed HIV rates down from 15 percent in the early 1990s to 5 percent in 2001. But conservative evangelicals rewrote this history–with the full-throated cooperation of Uganda’s evangelical first family, the Musevenis. As one Family Research Council paper put it:

“Both abstinence and monogamy helped to curb the spread of AIDS in Uganda…How did this happen? Shortly after he came into office in 1986, President Museveni of Uganda spearheaded a mass education campaign promoting a three-pronged AIDS prevention message: abstinence from sexual activity until marriage; monogamy within marriage; and condoms as a last resort. The message became commonly known as ABC: Abstain, Be faithful, and use Condoms if A and B fail.”

This warped version of the true Uganda story became the mantra in Bush’s Washington, with the “C” reduced more and more to an afterthought as time went by. For example, in piling on against a 2002 pro-condom comment by then Secretary of State Colin Powell, Focus on the Family’s James Dobson wrote condoms out of the story entirely: “Secretary Powell seems to be ignorant of the fact the Uganda has made great progress against AIDS by emphasizing abstinence, not condoms.”

To see more about this shifting Bush administration emphasis on abstinence and faith based programs, please see the prior Thought Theater posting on the topic here. Questions about the Ugandan effort and their reports of successful results began to surface in 2004.

From BBC News:

An organisation helping people living with HIV/Aids in Uganda has questioned the authenticity of the government’s statistics on the disease.

Uganda is often held up as a success story and the government lauded for the progress it has made with the official prevalence rate put at only 6%.

But after conducting research in districts across Uganda, an NGO suggests the real picture is far worse.

They found prevalence rates as high as 30% and bad access to anti-retrovirals.

Major Rubaramira Ruranga, the executive director of the National Guidance and Empowerment Network of people living with HIV/Aids in Uganda (NGEN), said he believed the HIV prevalence rate could be more than three times higher than previously thought.

“We have found the prevalence rate at this time is 17%,” he told a news conference.

Additional data was reported in early 2005 in the San Francisco Chronicle. Take particular note that researchers seem to be confounded by the information they were gathering when they compared it to the reported declines in infection rates. Not only were they finding that abstinence was waning, they were puzzled that infection rates appeared to be declining. They point out that condom use seemed to be on the increase…possibly providing an explanation to the confusing data.

Research from the heavily studied Rakai district in southern Uganda suggests that increased condom use, coupled with premature death among those infected more than a decade ago with the AIDS virus, are primarily responsible for the steady decline in HIV infections in that area.

Uganda’s “ABC” prevention formula — standing for Abstinence, Be Faithful, and use Condoms — has been widely credited with lowering that nation’s infection rate from 30 percent in the early 1990s to below 10 percent today.

In the Rakai district, however, researchers found that abstinence and fidelity have actually been declining, but the expected rise in HIV infections stemming from such behavior has not occurred.

“Condom use may be offsetting other high-risk behaviors,” said Maria Wawer, a professor at Columbia University’s Mailman School of Public Health, who presented the study at a session of the 12th Annual Retrovirus Conference in Boston.

The Rakai findings are based on an extensive and continuing process of interviewing 10,000 adults each year –a so-called population-based survey that is considered the gold standard for this kind of epidemiological research.

Reports of consistent condom use by men rose to more than 50 percent by 2002, compared with 10 percent a decade earlier. Among women, reports of condom use rose from virtually zero to 25 percent.

In order to fully understand all the factors that may explain these new infection statistics, one must also realize what was taking place within the Ugandan condom distribution program. In 2004, the Ugandan government suddenly issued a recall for condoms that were being distributed for free at numerous clinics throughout the country. The President of Uganda indicated concerns about the quality of the condoms.

From Avert.org:

In 2004 the Ugandan government issued a nationwide recall of the condoms distributed free in health clinics, due to concerns about their quality. Although tests showed there was nothing at all wrong with the condoms, the government said that public confidence in the brand had been badly dented, so they would not redistribute them. By mid-2005 there was said to be a severe scarcity of condoms in Uganda, made worse by new taxes which made the remaining stocks too expensive for many people to afford.

Some have said the US is largely to blame for the shortages. According to Stephen Lewis, the UN Special Envoy for HIV/AIDS in Africa, “there is no question that the condom crisis in Uganda is being driven and exacerbated by PEPFAR and by the extreme policies that the administration in the United States is now pursuing”.

Mr Lewis has also said that PEPFAR’s emphasis on abstinence above condom distribution is a “distortion of the preventive apparatus and is resulting in great damage and undoubtedly will cause significant numbers of infections which should never have occurred”.

However, speaking in August 2005, Uganda’s coordinator of condom procurement at the Ministry of Health denied there was any shortage of condoms, and said that new stocks would be distributed soon. She also said the government was committed to promoting all three parts of the “ABC” strategy: Abstinence, Faithfulness and Condoms.

From Kaisernetwork.org:

U.N. Special Envoy for HIV/AIDS in Africa Stephen Lewis and other AIDS advocates in August said the Bush administration’s policy of promoting abstinence prevention programs and cuts in federal funding for condoms have contributed to a condom shortage in Uganda and undermined the country’s HIV/AIDS fight. Uganda needs between 120 million and 150 million condoms annually, but since October 2004 only 32 million have been distributed in the country, according to the U.S.-based Center for Health and Gender Equity, also known as CHANGE.

In 2005, Act Up also took up the issue of the reported condom shortage in Uganda and the fears about the shift to abstinence programs that were emerging since the introduction of the Bush administrations efforts to combat the disease in Africa.

From Actupny.org:

(Manhattan) A coalition of AIDS activists held a demonstration in midtown Manhattan outside of the Ugandan Permanent Mission to the United Nations today to bring attention to that nation’s severe condom shortage which is putting people at dangerous risk of HIV infection. The crisis has developed over the past ten months as the government of Uganda has stopped its robust program of public sector condom distribution. These condoms previously accounted for 80% of condoms available in the country.

Since May 2004, new shipments–some 30 million quality-approved condoms–have been sitting in government warehouses. Activists are demanding to know why, nearly a year into the shortage, health clinics are still unsupplied and the government is refusing to state when or how they will distribute the condoms. “This crisis could have been averted by the government long ago. The condoms are there, but what is in woeful shortage is the political will of Ugandan leaders to distribute them and promote condom use,” said Sharonann Lynch of Health GAP.

Now activists in Uganda say the program has been overtaken by abstinence-until-marriage approaches as President Yoweri Museveni and First Lady Janet Museveni are aligning Uganda’s policies with the ideology touted–and financed–by the United States government.

Uganda is a country receiving funds from the President Bush’s Emergency Plan for AIDS Relief (PEPFAR). The program requires a minimum of 33% of its prevention funds to be used for abstinence-only-until-marriage programs, and limits the distribution of condoms to specific high-risk groups. “The strident prevention politics tied to the Bush administration’s AIDS funding are undermining sound prevention in the name of abstinence-only approaches. Scientific studies have shown the inadequacy of such methods, and President Museveni is neglecting the public health of Ugandans by bowing to Bush’s pressure.” said Eustacia Smith of ACT UP.

A comprehensive review of this body of information simply illuminates the misguided efforts of the Bush administration with regard to HIV prevention. The data not only show that the abstinence approach is at best suspect (and more likely, wholly insufficient); it clearly demonstrates that condom availability and usage are the essential tool in combating increasing infection rates.

One is left to wonder about the accuracy of the reported data. While the near doubling of infection rates is sufficiently alarming, it is even more frightening to consider the possibility that the information may be inaccurate. I have no way to verify the data and while I question the motivations of the Ugandan government, it may be several years before it can be determined if the numbers may have been deliberately under reported.

Uganda is a snapshot of a confluence of allegiances and events that will ultimately have led to more pain, suffering, and death. History will likely note that the matching ideologies of those in power in both nations directly led to the unnecessary spread of a deadly disease at a time when money and energy were available to enable the opposite. That is an unmitigated and inexcusable tragedy.

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  • DosPeros

    I don’t know whether you’re right or not, Daniel.

    I just wish I was Ugandan so that I could have all the really smart people in the western world handwringing as to whether to encourage me to have sex or not to have sex or how to have sex if do have sex. I’ve seen some paternalist attitudes before, but this might take the cake or the condom as it is. Let me ask you a blunt question: are they stupid?

    It’s kind of like our fascination with Panda Bear sex, which we can track from satellites. I think the Ugandans get it. And I think that condom availability probably isn’t a huge problem. The west just doesn’t have a spectacular track record of “saving” Africa, maybe we should stop trying and see if that works.

  • http://sethyblog.blogspot.com Pooh


    So now we’re not supposed to care about sex? I get so confused as to when I am and am not obliged to meddle…

  • DosPeros

    Pooh — I am very concerned about sex, but it is primarily limited to when I, as a married man with children, am ever going to have any. The Ugandan’s national sex life could not possibly interest me less! And I do not believe for one second that it is morally, ethically or politically incumbent on us to nanny the Ugandans on how to safely screw or not screw. I tend to support the abstinence program because I believe in marital fidelity, period and I believe other people should to. I think that dumping loads of condoms out of low flying aircrafts into tribal villages is completely demeaning and is treating them like savages that don’t know any better, that we must protect from from themselves.

  • http://sethyblog.blogspot.com Pooh

    How can you “support the absitnece program” and claim not to care about what they do or do not do? You can certainly support abstinence and say that it is a Good Thing, but how is a program encouraging that categorically different from urging condom use? I mean aside from your normative rankings of the two paradigms. Either it’s their sex (or lack thereof) or it isn’t.

  • http://www.thoughttheater.com Daniel DiRito

    Dos Peros,

    I understand your sentiment but I think the issue is whether or not the government intentionally withheld condoms from the established distribution system and why (no planes were flying about dumping condoms to savages). Ugandan’s had a long track record of declining infection rates until the condom availability issue arose. I agree that Ugandan’s ought to make their own choices…but they have to have that choice first.

    I’m not sure upon what you’ve based your statement that condom availability wasn’t likely a problem. The data on condom availability and infection rates indicate otherwise. I would encourage you to link to the numerous sources cited in the posting or to further research the situation.

    Meddling can take many forms…when the government gave the population all the choices, infection rates declined…they were doing just fine. When the government limited access to condoms, infection rates increased. I think that is the issue and the problem.

    Your, mine, or anyone elses preference for abstinence or fidelity through the denial of access to condoms should not be allowed to result in higher rates of infection…unless one seeks to equate the prevention of an illness with a moral directive…but that would also be meddling…wouldn’t it?


  • DosPeros

    I agree that the government should not intentionally withhold condoms. That would be stupid. Condoms, like goat milk, should be readily available if there is demand of them. That is quite different than saying the United States should subsidize condoms and condom use. Look, I’m all for Ugandan’s having safe sex if they choose — but as long as we are meddling, why don’t we try to spread a bit of virtue. I know that this an unpopular paradigm among the really smart people, because it involves moral judgement and we shouldn’t do that, (unless it is the moral judgment of the Europeans.) Condoms should not be prohibited and I take you word for it, Daniel, that is what is happening. Uganda needs Griswald. I think that the U.S. had every right to chose how it spends its foreign aid, though.

    Pooh, you are right, I obviously do care what the Ugandans do and it is entirely about my normative ranking of the two paradigms. I think the world is a better place with Ugandans in it. They are part of the human family. We are all children of God. It is because I care about the diginity and respect of the Ugandans that I think they should be encouraged to make moral judgements, rather than simply being diluged with subsidized condoms to facilitate safer sex.

  • T-ron


    Why should the US government take an interest in subsidizing Condoms in Africa? I live and work in East Africa and I can tell you condom price is without a doubt an important contributing factor to condom use. The usubsidized brands that you find anywhere in the world (including Uganda) cost 6 or more times as much as the locally produced subsidized brands. Subsidized brands are generally about $.30 for a pack of three. Unsubsidized brands are as much as $2.00 for the same thing.

    In countries where most people are making less than $2.00 a day, it is rediculous to assume that choosing not to use a condom is simply a matter of personal choice. It can be entirely financial. Not subsidizing condoms is equivalent to banning condom use amongst the poor and the Ugandan presidency and US Administration are fully aware of this. They wish to enforce virture, which is much more paternalistic in nature than simply subsidizing and advertising condoms. They want unvirtuous behavior to be punished with death. The problem is that this death threat doesn’t seem to be enough to enforce virture and that is the same if you are in the US or in Uganda. Abstinence only promotion also costs money and including the B and the C in the ABC education campaign doesn’t cost anymore than just teaching the A. Why not try every approach?

  • Carl

    Debate is great
    Will state up front non religious
    thought this important as DosPeros doesn’t mention how his belief affects his opinion of morality up front.
    Morality is not something that one group controls or dominates or indeed can surplant on others.
    Morality has different meanings across the world
    That is not to say that one sense of morality contains all the answers & the others none
    Sex especially has all kinds of various cultural moralities as well as taboos.
    So northern european based religious driven belief will be diferent from other Christian communities let alone those of other faiths.
    & personally I think any one who believes in promoting ‘A’ alone should be held accoutable for the continued suffering not only from HIV but also other STD’s and unwanted children(bringing in the other big worry of Abortion) and all the emotional, cultural & economic impact of such a disgrace
    Some times people need to be aware that ‘A’ is fine if every body plays(please tell me when & where this happened) but what if you are happen to be infected once in a marriage by an unfaithful partner, or are raped. note all the possibilities mention I know Maybe these don’t matter as they don’t account for the majority of infections!!
    Further I wondered whether DosPeros knows about the religious influences that are all pervasive in Uganda and as such, his concern over morality might should not be any greater than that for the US where religion is important or indeed in Europe, where many might say secular is more influencial than religious constraints
    I know its a rant