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close this bookThe Courier N 184 - Jan - Feb 2001 - Dossier: Press and Democracy - Country Reports: St Kitts and Nevis (EC Courier, 2001, 96 p.)
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AIDS in Uganda

by Ruth Evans

With an estimated 34 million people worldwide now living with HIV/AIDS, two thirds of them in sub-Saharan Africa, the need for effective action against this devastating epidemic becomes even more pressing. One of the first countries to be open about the extent of the epidemic, Uganda, has now amassed a great deal of experience in preventing infection, caring for those infected and mitigating the socio-economic effects of the epidemic. A few of the lessons learned there might usefully be applied elsewhere.

In the shade of the mango tree, Yudis feeds scraps to a litter of piglets that squeal and shove excitedly as they try to get to the food. Here in the Ugandan village of Katalemura, the pigs are part of an income-generating project set up to help HIV-positive women like Yudis.

Yudis tells me she doesn't know exactly when she became HIV positive, but only four of the nine children she's given birth to have survived. Three of them are thought to have died because they too were HIV positive, and two died of measles. She has now separated from her husband, and supports herself by frying fish and selling it to the community and helping to feed the pigs. When they are sold, she will have her share of the women's profits.

Stories like this are all too common. Since the first case was reported in Uganda in the early 1980s, at least half a million people have died from AIDS and about seven per cent of the population are currently living with HIV/AIDS, according to Ministry of Health statistics.

Impact among women

The socio-economic impact of HIV/AIDS has been enormous, especially amongst women in Uganda, who have been disproportionately affected by the epidemic. Women constitute 51% of the total population in Uganda, but the demographic figures indicate that women get exposed to HIV infection much earlier than men. The spread of the infection is facilitated by gender and social inequalities and, in turn, reflects and reinforces these inequalities. As wives and mothers, women are at higher risk of sexual transmission and as mothers they are left to deal with the implications of HIV infection for unborn babies and children. As primary carers, women bear the main burden of caring for the sick and dying while trying to hold the family unit together.

Making an impact on the disease

Despite the enormity of the problems, there is no doubt that Uganda has made an impact against the AIDS epidemic since it was first detected in the 1980s. There is now evidence of increased awareness and knowledge about HIV/AIDS in the entire country among adults, even though awareness doesn't always lead to behavioural change. However, here in Uganda the demand for and use of condoms and preventative control services has also risen. There has also been a reported decline in casual sexual relationships. More strikingly, HIV prevalence in pregnant women has declined in five areas surveyed between 1992 and 1998.

These are major achievements in the face of apparently insurmountable odds. From early on in the epidemic, one of the most striking things about Uganda's approach was a high degree of political commitment, with President Museveni working alongside religious leaders, traditional elders, the private sector and community initiatives to try and ensure maximum success. This, says Janat Mukwaya, Uganda's Minister for Gender, Labour and Social Development, has been the main lesson learned. “One of the things that has made Uganda a success story in handling HIV/AIDS has been the high level of political commitment from early on, especially from our President. So one of the strategies effective for other countries would entail being really open about this disease.”

New help for AIDS sufferers, no longer shunned by society

“We must be open”

It was a strategy that initially came at a price. Uganda became known as the epicentre of the AIDS epidemic and initially suffered from a certain degree of stigma because of this openness. Tourism suffered. But Mrs Mukwaya is absolutely convinced that it was still the right strategy for the government to adopt.

“Whatever we do we must be open,” she says. “Because we have been open, AIDS in Uganda is now considered just like any other disease such as malaria and typhoid. And for your information, malaria in Uganda kills far more people than AIDS. But being open has helped us break down the culture of silence.”

That culture of silence means that in many other countries, especially in southern Africa where the rates of infection are now much higher than in Uganda, people with HIV/AIDS suffer isolation, stigma and trauma as well as the disease. That was true in Uganda too in the early days, so I asked Janat Mukwaya how they tackled breaking down that stigma.

“We have sensitised and educated people and focused on how the disease is transmitted. We have ensured the safety of blood supplies and insist on using a new syringe each time. We are also saying that drinking from the same cup doesn't transmit the disease, neither does shaking hands. How the disease is transmitted must be clear to the people. When you break the culture of silence, infected people will come forward and talk openly about their experiences. They are the best advocates.”

Some countries have not yet seen the full effect of HIV/AIDS on the economy and the community. AIDS is seen as a new emerging concern, and many countries have been slow to identify it. “We are at a different stage,” says Mrs Mukwaya. “In Uganda now it has become a health issue like any other, but recently we had a delegation from South Africa, Zambia and Namibia and one of the delegates asked me what does an AIDS patient look like? So I had to take her to Ward Six of our national hospital, to look AIDS in the face.”

Time the best teacher.

“Southern Africa is now facing a bigger problem, and some countries are still denying there ever was one. By being open we were able to bring in outside partners and money to do research and build a very strong AIDS commission. All blood in our hospitals is now safe. And I think we are proud of our decision. The stigma was short-lived, but in the end we have won.”

Presenting a paper on Uganda's experiences at a Commonwealth Ministerial meeting in Delhi a few months ago, Mrs Mukwaya encountered a degree of political denial amongst other delegates claiming that HIV/AIDS was not a particular problem in their respective countries. To make her point that AIDS is a global epidemic that transcends national and political boundaries, Janat Mukwaya uses a mathematical equation. “Suppose you have one naughty, sadistic man going around with 10 women a day,” she says. “In a month he will have contacted 300 women, and if they each have another contact it comes to 600. And that's just from one man.”

Uganda can rightly be proud of what it has achieved in the past few years, but there's certainly no room for complacency. The achievements are merely scratching the surface of the epidemic, a Band-aid on a gaping wound. The government is now trying to address the issue of the human rights of the people who are infected, and this involves having to deal with those who deliberately or knowingly go out to spread the disease. “The legal framework must be the same for both,” says Minister Mukwaya. “Those who are not infected must be protected, but there must be some way of making people realise it isn't the other person's fault that they are sick.”

Why women?

AIDS has no cure yet in sight. Because levels of transmission remain high, the main strategy will be to continue to emphasise behavioural change. “But it isn't enough to have statistics and know how this disease is transmitted,” says Janat Mukwaya. “We also need to know why women are disproportionately affected. I think what is important is to look at the gender impact of HIV/AIDS in Uganda. Women are more prone to infection...but they also carry the main burden of care even when they are sick themselves. But we have also seen food security being affected because women can no longer tend the fields. Children are also suffering.”

Having an effective gender strategy against AIDS means giving women more control over their lives, says Minister Mukwaya. “In Uganda, we are saying there is a need to popularise the female condom because this strengthens women's control by giving them the tool for HIV/AIDS prevention. But the female condom is neither affordable nor accessible, especially in rural areas. The next strategy is to empower communities economically. Through the National Action Plan we are trying to increase the income of the homestead in order to reduce the dependency of women on men. Poverty is one of the issues facilitating HIV and it's widespread, so addressing homestead incomes is the long-term strategy because that will give women the economic power to make the choice about protection.”

Perhaps Yudis will choose to use some of her share of the profits from the pig project on prophylactic devices such as the female condom. Perhaps it's already too late for her and her children.

Sharing strategies

AIDS is, of course, a global problem and there's only so much any national government can do alone. Until research produces a vaccine or cure, sharing strategies that have worked will be crucial if we are to continue to fight the local battles that make up the global war. In the future, developed nations will need to look at how they can help empower the developing nations who have been affected by this disease and the vacuum it has left, argues Janat Mukwaya. “We are such a small village, but we are also such a big village. The information flow is not readily available, but this is the information age. Let all those people who have information put it on the web. I think that would be a big contribution. But then I also think it's important that we are all open in order to break this culture of silence. HIV/AIDS is a normal disease like any other disease and what people living with HIV/AIDS need most is love, appreciation and assistance. This disease erodes the human resource and that's the saddest thing of all.”