|HIV Prevention Needs and Successes: a tale of three countrie (UNAIDS, 2001, 25 p.)|
Uganda is one of the worlds poorer countries and one of the most severely affected by the epidemic. Uganda has 21 million people, with less than 14% living in cities. The gross national product per capita is equivalent to about US$ 240. Total prevalence among adults is over 8%.
Fortunately, Uganda is also one of the African countries where the HIV epidemic was recognized relatively early and so prevention efforts were started on a national level.1
In 1986, the President publicly acknowledged the countrys HIV/AIDS problem and made a commitment to mobilizing efforts against it. A national budget for the AIDS programme was established early in the epidemic.
The country adopted a multisectoral approach. The Uganda AIDS Commission was set up in the Presidents office, and HIV/AIDS control programmes were established in several government ministries, including the Ministry of Health.
Persons at different levels of society were involved, such as political, community and religious leaders. The Islamic Medical Association of Uganda has supported community education on HIV/AIDS throughout the country, including the distribution of condoms. 2 Radio messages on HIV/AIDS were broadcast very widely.
Condom social marketing services, backed by USAID, were implemented countrywide.
HIV voluntary counselling and testing was made available extensively and out- side the formal health-care service.
1 For more detailed information, see A measure of success in Uganda: the value of monitoring both HIV prevalence and sexual behaviour, Case Study UNAIDS/98.8, Geneva, May 1998.
2 For further information, see AIDS education through Imams: a spiritually motivated community effort in Uganda, Case Study UNAIDS/98.33, Geneva, October 1998.
In Uganda the best option for tracking the epidemic was sentinel surveillance among pregnant women, with samples of blood taken routinely at antenatal clinics. Surveillance started in 1989 at six sites in major cities and has since covered the whole country. The results are shown in Fig.1.
Fig. 1: HIV prevalence among pregnant women. Selected sentinel sites, Uganda, 1990-1996
All these urban sentinel sites showed a significant decline in HIV infection during the first half of the 1990s. In some cases, the percentage of mothers testing HIV-positive almost halved.
This evidence is strengthened when the analysis is focused on the youngest women - those aged 15-19 years. This limits distortions caused by ageing and by infertility, and will actually be much closer to the incidence among the young.
Fig. 2: HIV prevalence by age group, Nsambya
Fig. 2 focuses on Nsambya, a hospital in Kampala. Prevalence among pregnant women aged 15-19 dropped from 22% in 1990 to 10% in 1996, after reaching a peak of 28% in 1991. The steady drop for the youngest women suggests a real fall not just in HIV prevalence but also in incidence.
Uganda conducted two large population-based surveys in 1989 and 1995 that permit comparisons. Both surveys covered two urban areas - Kampala and Jinja - where HIV surveillance was carried out over this period.
Very encouraging data arose from questions about behavioural change among young people in 1995 when compared with their predecessors of the same age in 1989.
Fig. 3: Percentage sexually experienced by current age (1524 years old) in 1989 and 1995
The first finding related to delayed age of first sexual experience, as shown in Fig. 3.
The clearest difference between 1989 and 1995 can be seen at the left of the figure. For the youngest, the 15-year-olds, the proportion of boys or girls reporting that they had never had sex rose from around 20% to around 50%. Overall, age of sexual initiation shifted upward.
Fig. 4: Percentage of sexually active men and women who have ever used a condom. Urban Uganda, 1989 and 1995
The second finding related to the increase in condom use (Fig. 4).
Between 1989 and 1995, the percentage of sexually active men and women who reported using condoms increased significantly. If the numbers are merged, the proportion of men who said that they had ever used a condom rose from 15% to 55%. Among women, the total rose from 6% to 39%.
This steep increase in condom use occurred in all age groups.
In addition to these two large surveys, there have been numerous quantitative and qualitative investigations into behavioural change in recent years, although on a smaller scale.
In rural areas, the number of new infections is still high even among the younger age groups. Obviously, a review of strategies and implementation for rural areas is needed. However, even with this troubling situation a great deal has clearly been accomplished.
Ugandas experience can be summed up as follows:
First, sentinel surveillance indicates that the prevalence, and probably the incidence, of HIV infection has fallen among pregnant women in urban areas. Other studies show falling prevalence for other groups, although not as strongly as this one.
Second, surveys of sexual behaviour suggest that increasing condom use and/or a delay in starting sexual activity play a key role in the decline of incidence.