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In 1983, Uganda recognized its first cases of AIDS, and following, there was an extremely high rate of HIV infection. 900 cases were reported by 1986, and by 1988, there were over 6,000. [1] Uganda is located in the Lake Victoria region of Central and Eastern Africa, the region in which scientists now believe is the area where humans were first infected with HIV.[2] Since this time, Uganda has been included in headlines globally concerning HIV/AIDS, initially as one of the countries hit hardest by the disease, but later as one of the only countries in Sub-Saharan Africa, and the world, able to reverse the epidemic.[3]

In Uganda, HIV/AIDS has been approached as more than a health issue, and in 1992, a Multi-sectoral AIDS Control Approach was adopted. In addition, the Uganda AIDS Commission, also founded in 1992, has helped develop a national HIV/AIDS policy. A variety of approaches to AIDS education have been employed, ranging from the promotion of condom use to 'abstinence only' programs.

To further Uganda's efforts in establishing a comprehensive HIV/AIDS program, in 2000 the MOH implemented birth practices and safe infant feeding counseling. According to the WHO, around 41,000 women received Preventing Mother To child Transmission (PMTCT) services in 2001.^[3] Uganda was the first country to open a Voluntary Counselling and Testing (VCT) clinic in Africa called AIDS Information Centre and pioneered the concept of voluntary HIV testing centers in Sub-Saharan Africa.

The Ugandan government, through President Yoweri Museveni, has promoted this as a success story in the fight against HIV and AIDS, arguing it has been the most effective national response to the pandemic in sub-Saharan Africa. However, in recent years, there have been many obstacles both cultural and political that have obstructed effective HIV prevention programming in Uganda, causing the projections for HIV prevalence and infection rates to rise in the coming years.[4]

Prevalence

As of 2016, there are an estimated 1.4 million people in Africa living with HIV, with an infection rate of 6.5% in adults. There have been 52,000 new HIV infections and 28,000 AIDS-related deaths. As there continue to be disparities in who has access to treatment for HIV/AIDS, only 67% of adults and 47% of children are on antiretroviral treatment.

The key affected populations at the highest risk for HIV infection in Uganda are men who have sex with men (MSM), sex workers, adolescent girls and young women, and people who inject drugs.

In 2013, HIV prevalence for MSM was at 13%, prevalence among sex workers was 36%, them and their clients accounting for 16% of new infections in 2014, prevalence among young women was at 3.8%, and prevalence among people who inject drugs was at 16.7%.

History

Museveni became president in 1986 after overthrowing 15 years of dictatorships. He learned of his country's AIDS problem from Cuba's president, Fidel Castro. At the September 1986 meeting of Non-Aligned Heads of State, Castro pulled Museveni aside. "He ... told me that of the 60 soldiers we had sent to Cuba for training, 18 of them had the virus of AIDS," Museveni tells FRONTLINE. "He was therefore worried that it may reflect what [level of prevalence] is in the population."

Museveni and his government acted quickly, airing television and radio ads and speaking about HIV/AIDS at political rallies. "I could not keep quiet on this," Museveni says. "There was no other option. Any other option would have been murder."

Shortly after he came into office in 1986, President Museveni spearheaded a mass education campaign promoting a three-pronged AIDS prevention message, the overarching policy known as "ABC", which stands for Abstain, Be Faithful, or, if A and B fail, use a Condom, was set up with the aim of helping to curb the spread of AIDS in Uganda, where HIV infections reached epidemic proportions in the 1980s. This message also addressed the high rates of concurrency in Uganda, which refers to the widespread cultural practice of maintaining two or more sexual partners at a time. The government used a multi-sector approach to spread its AIDS prevention message: it developed strong relationships with government, community, and religious leaders who worked with the grassroots to teach ABC. Schools incorporated the ABC message into curricula, while faith-based communities trained leaders and community workers in ABC. The government also launched an aggressive media campaign using print, billboards, radio, and television to promote abstinence, monogamy, and condom use.^{[citation needed]} The prevalence of HIV began to decline in the late 1980s and continued throughout the 1990s. Between 1991 and 2007, HIV prevalence rates declined dramatically. Various claims have been made on the extent of these declines, but mathematical models estimated falls from about 15 percent in 1991 to about 6 percent in 2007.

Condoms were not the main element of the AIDS prevention message in the early years. President Museveni said, "We are being told that only a thin piece of rubber stands between us and the death of our Continent ... they (condoms) cannot become the main means of stemming the tide of AIDS." He emphasized that condoms should be used, "if you cannot manage A and B ... as a fallback position, as a means of last resort."

Some reports suggest that the decline in AIDS prevalence in Uganda was due to monogamy and abstinence, rather than condom use. According to Edward C. Green, a medical anthropologist at the Harvard School of Public Health, the promotion of fidelity to one's partner and abstinence were the most important factors in Uganda's success because they disrupted the widespread practice of having multiple concurrent sexual partners. A 2004 study published in the journal Science also concluded that abstinence among young people and monogamy, rather than condom use, contributed to the decline of AIDS in Uganda.

However, a field-study conducted in Rakai, a region in southern Uganda, showed that abstinence and fidelity rates had been declining during 1995–2002, but without the expected rise in HIV/AIDS rates, suggesting a greater role for condoms than acknowledged by Museveni. The other central finding of the Rakai study was that, due to Uganda's focus on prevention of the spread of HIV-AIDS, rather than treatment for those who had already contracted the disease, a large part of the decline in prevalence of HIV-AIDS is due to the premature death of those who have contracted it. This led to the popular play on the ABC campaign, 'A-B-C-D', with the D standing for Death. Because only prevalence is measured, incidence can actually increase while prevalence decreases if those who contract HIV are not treated for the disease, thereby dying younger. Later studies have seriously questioned the veracity of Uganda's miraculous HIV-AIDS claims^{[citation needed]}.

In the 1990s, there had been limited access to treatment in the form of anti-retrovirals for those who are HIV positive. Through the combined effort of US PEPFAR, the government of Uganda, and international agencies (Clinton HIV/AIDS Initiative, the Global Fund, UNITAID) the prevalence of treatment among those infected has improved. The country's HIV-AIDS campaign focuses solely on prevention rather than cure, a method that is of questionable success.

Reversing the Epidemic

The provision of all health services in Uganda is shared between three groups: the government staffed and funded medical facilities; private for profit or self-employed medics including midwives and traditional birth attendants; and, NGO or philanthropic medical services. The international health funding and research community, such as the Global Fund for AIDS, TB and Malaria, or bilateral donors are very active in Uganda. Part of the success in managing HIV/AIDS in Uganda has been due to the cooperation between the government and the non-government service providers and these international bodies. Public Private Partnerships in Health are often mentioned in Europe and North America to fund construction or research. In Uganda, it is more practical being the recognition by the (public) government and (public) donor that a (private) philanthropic health facility can receive free test kits for HIV screening, free mosquito nets and water purification to reduce opportunistic infections and free testing and treatment for basic infections of great danger to PLHA.

Uganda National AIDS Control Program

Assisted by the World Health Organization, Uganda's government formed the National Committee for the Prevention of AIDS (NCPA) and the National AIDS Control Program (NACP) in 1986 in response to the discovery of a high prevalence of HIV within the country (By 1986, 86% of sex workers, 33% of lorry drivers, and 14% of blood donors were found to be HIV positive). In January of 1987, the first emergency national plan, later followed by a short term and medium term plan in 1988 and 1989, was written. From 1987–1990, AIDS control programs around the world, especially those in Central and Eastern Africa, were progressing; however, Uganda was the first country in which the WHO worked with a single national plan and budget, which all donors agreed to use and give money to in order to focus their aid, in addition to a local multi-donor round table created for the specific purpose of reaching the targeted budget. Uganda was the first country to advance through all of the short-term plan, 3-5 year medium-term plan, joint donor meeting, program review, and reprogramming processes. Uganda was set up to guide the way for all countries in terms of programming, the amount of national staff, WHO support, and global financial support.

Emergency assistance – first plan in Africa

The strategies of Uganda's first national AIDS control plan of 1987 were described as “to mount an educational campaign to inform the public on the modes of transmission and ways to avoid infection,” “to reduce transmission through blood transfusion by setting up laboratories to test all blood before transfusion and to reduce transfusion to a minimum,” “to advocate careful sterilization of instruments and contaminated hospital areas to assure patient and health worker safety,” and “to measure the extent of the outbreak and possible co-factors by case surveillance, seroprevalence studies and operational research projects” (Uganda, 1989), which were the usual strategies for all early AIDS programs (WHO Global Program on AIDS, 1987–1995).

The plan was supported by WHO through a grant of $400,000, which was made available within week of the signature of the short-term plan, in addition to $1 million that was provided as emergency assistance. There was vast blood testing in major urban areas, along with an immediately initiated health education program and a sentinel surveillance program, which were far more advanced than programs in other countries at this time. This plan acted as the groundwork for Uganda's five-year plan, which had plans to be fully developed in 1989. The first program review occurred in 1988, summarizing the successes of the National AIDS Control Program in Uganda in its first 2.5 years.

The first Uganda program review

The first program review was performed in December of 1988 stately for the purpose of "reviewing accomplishments, adequacy, relevance, progress, and effectiveness of stated activities" and "making recommendations for the next phase", the next phase being the five-year plan scheduled to be developed beginning the following month. WHO's Global Program on AIDS and the Ugandan government were both in emergency mode regarding accelerated program development, cooperation, and assistance at this time.

The Uganda Program Review initially gave ten recommendations regarding what was in process and what was thought to be required by the nation expert review and international teams, in addition to recommendations for the continued political commitment of President Museveni and the Ugandan government as well as contributions from non-governmental organizations. In just weeks, these recommendations were integrated into the 1989-90 strategic plan. The primary recommendations, quoted from the first report, were:

1. Stepwise application of well-conceived and integrated KAP/IEC strategies
2. Making prevention methods (condoms) ... available to all groups
3. More widespread dissemination of factual information
4. Increased emphasis for illiterate people
5. Materials designed for groups at high risk, and for families with AIDS
6. Information that can be used by resistance committees (village level political structures through which the government operationalized new policies) to raise local awareness
7. Effective channels for distributing written and pictorial information
8. The teaching of training and communication skills
9. Financial support ... to enable district, community, and other training groups to run training courses
10. Health educators to be fully equipped and functional within weeks rather than ... several months

In regard to condoms, the co-sponsored review advised the National AIDS Control Program to "review the use of condoms as part of the strategy particularly where transmission rates are high"; however, this recommendation was not embraced by the Ministry of Health, the NACP, or President Museveni, as they argued issues of too much availability, acceptability, disposal, and too much dependence on a singular prevention method. In addition, the review repeatedly noted the urgent need for the rapid spread of information, education, communication, and training regarding HIV.

The 1989–1992 health education campaign

The Health Education campaign, commonly known as IEC, standing for information, education, and communication was the center of the National AIDS Control Program. The primary foals of the campaign were to mobilize all formal and informal sectors of Ugandan society; provide IEC materials to all districts, and; provide decentralized information and training on a district level. Led by the Ministry of Health, the IEC campaign activities included the development of training packages and "training of trainers" program in all sectors, the development and dissemination of public education materials, and district level mass mobilization and "cross fertilization" of education, with training educators from one district to be used in the next. The campaign was made possible by assistance from WHO, UNICEF, and other critical NGOs.

"Training of trainers"

The primary points of the proposed multi-sector training were: destigmatization; correct information on how HIV is transmitted; care and compassion; and condoms. Each sector led specific training activities that included workshops for Ministries and other personnel such as police, teachers, secretaries, parliamentarians, ministers, family planning association workers, and resistance committee members. Then, there was a "center out" cascade of training and information dissemination. Overall, the activities' purposes were to spread correct information and ask that people living with AIDS be treated humanely.

Country wide messaging

The dominant message of the Ugandan program, as is well known, and which was well known at the time both throughout Uganda and throughout Africa (as the Uganda message) was “Zero Grazing,” alluding to the traditional way cattle were fenced in, or tied to a stick to limit grazing outside their own pasture. This clearly meant “stick to one partner” which was what was frequently said following the message or by way of explanation. This was a message of “fidelity” although that word was rarely used at the time, as it not only pertained to during marriage, but to during dating as well. One study in1990 supported by WHO/GPA reported higher village recall of the saying or having seen the posters “Love Faithfully” (30%), and “Love Carefully” (25%) than “Zero Grazing.” Over 70% of those aware of “Love faithfully” interpreted this to mean “stick to one partner”; over 50% of those who heard or saw “Love carefully” understood it to meant “choose your partner carefully” (which became a large confusion in Uganda), and over half of those who saw or heard “zero grazing” thought it to mean “stick to one partner.”

The dominant message of the program, which was well known at the time throughout Uganda and Africa, was "Zero Grazing", referring to the way by which cattle were fenced to prevent grazing outside of their own pasture. This during the epidemic spread the message of staying faithful to one's partner, whether within a dating relationship or a marriage. A 1990 study supported by WHO and GPA reported high village recall of sayings and posters stating "Love Faithfully" or "Love Carefully". Many understood "Love Faithfully" and "Zero Grazing" to mean to stick to one partner, but those who saw "Love Carefully" took it to mean that you should choose your partner carefully, causing large confusion in the general population.

All prevention methods including abstinence, delaying sex, fidelity, and to a lesser extent, condoms were also described in distributed materials and included in discussion during trainings. Some posters from the 80s and 90s showed a cow in a pasture surrounded by a fence, while others used the phrasing such as "Thank God I said no to AIDS".

Ugandan "Thank God I said no to AIDS" poster

Mass media

Representatives from Ugandan radio and television stations were included in the program and planning processes using short jingles designed by the National AIDS Control Program to convey information on HIV and AIDS, as both radio (though to reach over 85% of the population) and television were widely used. The daily papers MUNNO and the New Vision ran daily articles or question and answer sections on AIDS, the Q and As later being compiled into booklets used in other countries. The New Vision and the weekly Topic ran a combined 17 articles on AIDS in 1990. Ugandan TV (UTV) regularly broadcasted discussion programs and documentaries. Almost all theater groups wrote plays that incorporated messages about HIV/AIDS. President Museveni, Dr. Okware, the then director of the NACP, and other Ministry officials were spokespersons in the media. This campaign ran daily for three consecutive years.

For about 12%  of the population, church leaders and imams were the primary sources of information, and about 88% of three villages reported that they received messages on HIV and AIDS from the church. Along with abstinence, the church emphasized fidelity and monogamy. 85% of respondents in a study carried out by the NACP stated that abstinence “was not a practical prevention strategy or behavioral option for any or all members in their community”, while 44% felt similarly about monogamy.

Criticism

The scope of Uganda's success has come under scrutiny from new research. Research published in The Lancet medical journal in 2002 questions the dramatic decline reported. It is claimed statistics have been distorted through the inaccurate extrapolation of data from small urban clinics to the entire population, nearly 90% of whom live in rural areas. Also, recent trials of the HIV drug nevirapine have come under intense scrutiny and criticism.

US-sponsored abstinence promotions have received recent criticism from observers for denying young people information about any method of HIV prevention other than sexual abstinence until marriage. Human Rights Watch says that such programs "leave Uganda’s children at risk of HIV". Alternatively, the Roman Catholic organization Human Life International says that "condoms are adding to the problem, not solving it" and that "The government of Uganda believes its people have the human capacity to change their risky behaviors."

It is feared that HIV prevalence in Uganda may be rising again; at best it has reached a plateau where the number of new HIV infections matches the number of AIDS-related deaths.^{[citation needed]} There are many theories as to why this may be happening, including the government’s shift from abstinence-based prevention programs, and a general complacency or 'AIDS fatigue'. It has been suggested that antiretroviral drugs have changed the perception of AIDS from a death sentence to a treatable, manageable disease; this may have reduced the fear surrounding HIV, and in turn have led to an increase in risky behavior. Although prevention interventions, like safe male circumcision, have been shown to effectively reduce HIV transmission, studies in Uganda have shown delayed uptake of these interventions and attributed this to contestations over evidence by high-level leaders.

Although abstinence has always been part of the country’s prevention strategy it has come under scrutiny since 2003 following significant investment of money for abstinence-only programs from PEPFAR, the American government’s initiative to combat the global HIV/AIDS epidemic. It is felt that PEPFAR has shifted the focus of prevention in Uganda from the comprehensive ABC approach of earlier years. PEPFAR is channelling large sums of money through pro-abstinence and even anti-condom organizations that are faith-based, and believe sexual abstinence should be the central pillar of the fight against HIV. Abstinence-only is also being encouraged by evangelical churches within Uganda, and by the First Lady, Janet Museveni.

This money is making a difference – some Ugandan teachers report being instructed by US contractors not to discuss condoms in schools because the new policy is 'abstinence only'. Dozens of billboards around the country have sprung up promoting only abstinence to prevent HIV infection and sometimes discouraging condom use. Some leaders of small community-based organizations also report they are aware that they are more likely to receive money from PEPFAR (which is the largest HIV-related donor to the country) if they mention abstinence in their funding proposal.

There have been calls for a more nuanced view of Uganda's response to HIV/AIDS. There is no doubt that there has been sustained, long term political commitment at the highest levels of government on this issue. In other countries such as Zimbabwe or South Africa, inept leadership has led to a serious crisis; some such as former President Thabo Mbeki deny the link between HIV and AIDS.

One aspect of the response to HIV in Uganda bridges the Millennium Development Goals and prevention—that is vertical transmission or Prevention of Mother To Child Transmission (PMTCT). Through the Global Fund's Born HIV Free campaign BornHIVFree the need and impact of PMTCT is made clear. Funding is encouraged by UNITAID and MassiveGood.

Current Barriers to HIV Prevention

Stigma and Discrimination

Some of the primary causes for certain groups within the Ugandan population such as sex workers and men who have sex with men to avoid seeking HIV testing or health care are prejudice and social discrimination. Despite these populations being at the greatest risk of these social consequences, the general population of people living with HIV are still greatly exposed to excessive amounts of negative judgements.

A survey conducted in 2015 by HIV support organizations in partnership with the National Forum of People Living with HIV/AIDS found that internal and external stigma was high against people who are living with or affected by HIV in central and southwestern Uganda. At the beginning of the study, 54% of participants reported to have experienced some form of discrimination as a result of having HIV.

The 2013 People Living with HIV Stigma Index found that the most common forms of external stigma and discrimination directed at those living with HIV were gossip, followed by verbal harassment, insults and threats, and sexual rejection. Experiences of internal stigma were much more common among women than men.

Gender

In recent years, there has been a optimistic decline in gender-based violence (GBV) following the passing of the Domestic Violence and Prohibition of Female Genital Mutilation acts in 2010. Despite these efforts, a large percentage of Ugandan women have been sexually or physically abused by their male partners in their lifetimes.

Taken every five years, the 2011 Uganda Demographic and Health Survey confirms that the prevalence of gender-based violence is still high. 51% of women that have ever been married reported of physical or sexual violence from their spouses in the most recent 12 months.

The Ugandan government and international agencies put numerous programs into place in order to address GBV. For example, in post-conflict Northern Uganda there is USAID's Gender Roles, Equality, and Transformation Project (GREAT), which was created to "improve gender equity and reproductive health in Uganda"*. Through different forms of engagement such as a radio serial drama, group discussions, activities, games, the program encourages adolescents, both married and unmarried, to challenge gender norms and better understand issues regarding sexual and reproductive health.

Legal

There are numerous laws and policies in place in Uganda that restrict the country's response to HIV and AIDS; however, the ability to alter these policies has been improved through the training of law enforcement officers and government officials on HIV, stigma, and discrimination. These strategies helped contribute to the revisions of the Anti-Homosexuality Bill, drastically different from the initial act passed in 2013. Although it is thought that that Anti-Homosexuality Bill has contributed to an increase in anti-gay sentiment, the trainings encouraged Ugandan officials to implement effective policies prohibiting the spread of sexuality- and gender-based violence.

One cause for concern was the passing of the HIV Prevention and Control Act in 2014. The bill includes mandatory HIV testing, it only includes such for pregnant women and their partners, and it allows medical providers to disclose a patient's HIV status to others. International agencies such as UNAIDS have discouraged laws like these, as they can disproportionately target women.

The bill also criminalizes HIV transmission, attempted intentional transmission, and behavior that might result in transmission by those who know their HIV status, causing organizations such as Human Rights Watch, HEALTH Global Advocacy Project, and Uganda Network on Law, Ethics, & HIV/AIDS to criticize it. Their main points of criticism are the implementation of mandatory HIV testing and the disclosure of medical information without consent, arguing that they contradict international practices and violate fundamental human rights. They also iterate that the criminalization of HIV transmission is too broad and too difficult to enforce.

Funding

Given Uganda's experience with funding, it has been shown that donor funding is unpredictable, decreasing in availability, and is not a guarantee. In addition, funding often comes along with conditions that may not align with Uganda's national goals.

There is a predicted $3.6 million required to fund Uganda's current National Strategic Plan, stretching from 2016 to 2020. Care and treatment constitutes 55% of funding, prevention interventions account for 23%, leaving system strengthening and social support accounting for 22%. While current domestic funding rests at 11% of the National Strategic Plan, there needs to be a rise to at least 40%. Given these numbers, there have been more efforts made by the Ugandan government to increase their domestic resource mobilization. According to Avert.org, "the concentration of donor funding for HIV among a very small number of donors in Uganda suggests potential vulnerability should the magnitude of their funding commitments change in the future."

The Future of HIV and AIDS in Uganda

Given the current rate of infection, annual new infections are predicted to grow to about 340,500 by 2025.

There were about 1,660 health facilities in operation in Uganda offering antiretroviral treatment (ART) in 2014, and nearly 751,000 people living with HIV were enrolled on treatment. Beginning in 2015, Uganda introduced WHO treatment guidelines that state that all people who test positive for HIV should be enrolled in ART despite their CD4 count; however, in 2016 only 67% of adults and 47% of children living with HIV were enrolled on ART.

Several studies, conducted in Uganda and its neighbors, indicate that adult male circumcision may be a cost-effective means of reducing HIV infection. A 2007 review of studies about the acceptability of adult male circumcision indicated the median proportion of uncircumcised men willing to become circumcised was 65 percent (range 29–87 percent). Sixty nine percent (range 47–79 percent) of women favored circumcision for their partners, and 71 percent (range 50–90 percent) of men and 81 percent (range 70–90 percent) of women were willing to circumcise their sons. The national AIDS Indicator survey in 2011 also indicated that over 48 percent of adult men were willing to be circumcised, generating a critical mass of demand for male circumcision.

In order to continue to curb the severity of Uganda's HIV epidemic, there needs to be enacted a series of comprehensive health, political, and social strategies, in addition to the urgent need to invest in a combination of successful and impactful interventions to more greatly reduce the number of new infections. In order to accomplish this, it is speculated that there will be more government commitment and tough decision-making required at multiple levels, those being political, technical, and operational. This would include domestic funding that would contribute to the national response, which is currently underfunded and heavily dependent on donors. An economic analysis by Bertran Auvert, a physician from the INSERM U687, Saint-Maurive, France, and colleagues estimated the cost of a roll-out over an initial 5-year period would be $1 billion ($748 million – $1.319 billion) and $965 million ($763 million – $1.301 billion) for private and public health sectors, respectively. The cumulative net cost over the first 10 years was estimated at $1271 million and $173 million for the private and public sectors, respectively.

In addition, there have been calls to redesign the political and cultural conditions that stigmatize groups of people living with HIV, more specifically people who inject drugs and men who have sex with men. This would include altering punitive laws that criminalize people from these groups. Regarding this, there arguments that call to make intravenous drug users a graters focus in national HIV prevention strategies, which would result in better health outcomes in not only drug users but also the general population.