HIV/AIDS in Uganda


Lisa Garbus, MPP
Elliot Marseille, DrPH, MPP

AIDS Policy Research Center, University of California San Francisco


Published November 2003
(c) 2003 Regents of the University of California. All Rights Reserved. 

Table of Contents

TABLE OF CONTENTS	2
PREFACE	4
ACKNOWLEDGMENTS	4
CONTACT INFORMATION	5
EXECUTIVE SUMMARY	6
EPIDEMIOLOGY	6
POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT	6
IMPACT	10
RESPONSE	11
EPIDEMIOLOGY	16
AT A GLANCE	16
HIV SENTINEL SURVEILLANCE	18
OTHER HIV PREVALENCE DATA	20
HIV INCIDENCE	21
TRANSMISSION PATTERNS	22
UGANDAN GOVERNMENT ESTIMATES	22
U.N. ESTIMATES	22
AIDS CASES	22
AIDS MORTALITY	23
DATA QUALITY ISSUES	23
EXAMINING DETERMINANTS OF DECLINE IN HIV PREVALENCE, 1985-2001	25
CHALLENGES	29
POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT	33
AT A GLANCE	33
POLITICAL OVERVIEW	40
POPULATION DYNAMICS	41
HUMAN DEVELOPMENT	41
EDUCATION	42
PUBLIC EXPENDITURES	43
GOVERNANCE	43
ECONOMY	46
POVERTY	46
DEBT	47
MOBILE AND DISPLACED POPULATIONS	49
HEALTH SYSTEM	51
SEXUAL & REPRODUCTIVE HEALTH	54
SEXUALLY TRANSMITTED INFECTIONS	56
STIGMA AND DISCRIMINATION	59
GENDER	60
AWARENESS AND KNOWLEDGE OF HIV/AIDS	64
SEXUAL BEHAVIOR	65
MALE CIRCUMCISION	69
ALCOHOL AND DRUG USE	70
IMPACT	72
AT A GLANCE	72
DEMOGRAPHIC	73
MACROECONOMIC	75
WELFARE	76
HEALTH	76
HOUSEHOLDS	76
ORPHANS AND OTHER VULNERABLE CHILDREN	78
EDUCATION	79
AGRICULTURE	79
RESPONSE	81
AT A GLANCE	81
GOVERNMENT OF UGANDA	88
DONORS	94
HUMAN RIGHTS	97
CIVIL SOCIETY	97
ORPHANS	103
HIV PREVENTION TRIALS NETWORK	104
VCT	104
CARE AND SUPPORT	106
PMTCT	108
TREATMENT OF OPPORTUNISTIC INFECTIONS	110
ANTIRETROVIRAL THERAPY	110
FEMALE-CONTROLLED PREVENTION TECHNOLOGIES	114
VACCINE TRIALS	114
ASSESSMENT OF NATIONAL RESPONSE	115
LINKS	119
REFERENCES	119




Preface

The Country AIDS Policy Analysis Project is managed by the AIDS Policy Research Center at the University of California San Francisco. The project is funded by the U.S. Agency for International Development, Cooperative Agreement PHN-A-00-01-00001-00. Stephen F. Morin, PhD, is the project's principal investigator. The project receives additional support from the International Training and Education Center on HIV (I-TECH), a collaboration of the University of Washington and UCSF funded through a cooperative agreement with the HIV/AIDS Bureau of the U.S. Health Resources and Services Administration. The views expressed in the outputs of the Country AIDS Policy Analysis Project do not necessarily reflect those of USAID or I-TECH.
The Country AIDS Policy Analysis Project is designed to inform planning and prioritizing of effective and equitable HIV/AIDS prevention and treatment interventions through multidisciplinary research on HIV/AIDS. The project evolved from the acute need for analysis of the epidemiology of HIV/AIDS in tandem with analysis of countries' political economy and sociobehavioral context¾at household, sectoral, and macro levels. This multidisciplinary analysis aims to: 
* help inform national HIV/AIDS policies 
* strengthen ability to plan, prioritize, and implement effective interventions 
* highlight the range of sectoral interventions that may affect or be affected by HIV/AIDS 
* facilitate multisectoral/interministerial coordination 
* facilitate intercountry information sharing 
* increase national and subregional capacity for effective partnerships 

The project develops and disseminates online, fast-download, continually updated analyses of HIV/AIDS in 12 USAID priority countries: Ethiopia, Kenya, Malawi, Senegal, South Africa, Uganda, Tanzania, Zambia, Zimbabwe, Brazil, Cambodia, and India <http://ari.ucsf.edu/ARI/policy/countries.htm> Each analysis is linked with national strategic plans for HIV/AIDS prevention, care, and support. Analyses also include a comparative table of 70 key HIV/AIDS and socioeconomic indicators. 

The primary audience for the country analyses is in-country HIV/AIDS planners, including those from government ministries and agencies, multi- and bilateral donors, international and local NGOs, health care institutions, prevention programs, academia, affected communities, and the private sector. International investigators and policymakers also report using the analyses in their work.

All country analyses undergo peer review at the AIDS Research Institute of the University of California San Francisco. In addition, two in-country experts from each profiled country serve as peer reviewers. A scientific advisory board also reviews all analyses.

Acknowledgments

The following individuals served as peer reviewers and provided valuable inputs to this paper:  Dr. David Bangsberg, associate professor, and Dr. Cheryl Liechty, clinical fellow, AIDS Research Institute, University of California San Francisco; Professor Nelson Sewankambo, dean, Makerere University Faculty of Medicine, cochair, Academic Alliance for AIDS Care and Prevention in Africa, and principal investigator, Rakai Project, Uganda Virus Research Institute; and Dr. Moses Kamya, senior lecturer, Makerere University Department of Medicine, and head, Mulago Hospital AIDS Clinic. They are not responsible for any errors of fact or judgment.

Contact Information

Because this analysis is continually updated, comments and suggested sources of new data are welcome and may be sent to the coinvestigator/project director at UCSF's AIDS Policy Research Center: Lgarbus@psg.ucsf.edu




Executive Summary

Epidemiology

The first AIDS cases in Uganda were identified in 1982. HSS began in 1985 in Kampala among women attending ANCs. Overall HIV prevalence increased rapidly through the 1980s and early 1990s. Since the mid-1990s, overall HIV prevalence among ANCs attendees has been declining. The most consistent HIV prevalence declines are among the youngest age groups. HIV prevalence appears to be declining in major urban areas and stabilizing in rural areas. 

The findings from the 2001 HSS, indicated that among women attending ANCs, overall HIV prevalence was 6.5 percent, an increase from 6.1 percent in 2000. ANC prevalence in urban areas was 8.8 percent and 4.2 percent in rural areas. According to the MOH, the increase in ANC prevalence was not statistically significant.

Most new HIV infections (84 percent) in Uganda occur through heterosexual transmission. MTCT accounts for about 15 percent of cases. Unsafe blood/blood products account for up to 5 percent of all HIV cases. The portion of HIV transmission attributable to MSM and IDU is not known.

In December 2001, 1.05 million Ugandans were living with HIV/AIDS. Among them, 945,500 were adults, of whom 56.3 percent were women. Nearly 80 percent of those infected with HIV were between ages 15-45. Since the beginning of the epidemic through 2001, 2 million Ugandan children had been orphaned by AIDS.

Among reported AIDS cases through December 2001, 92.6 percent were adults. The overall mean age for adults with AIDS was 30.9 years; for men, this figure was 33.0, for women, 29.1. 
AIDS is responsible for 12 percent of annual deaths and is the leading cause of death among those ages15-49. By 2000, there had been 1.3 million AIDS deaths in Uganda. 

There are several reasons why reports of declining HIV prevalence could be misleading or inaccurate, including

* weaker HSS in rural areas
* changes in age at first pregnancy
* HIV-related subfertility
* AIDS mortality

Against the backdrop of these data quality issues, there is consensus in the global HIV/AIDS community that there has been a robust decline in HIV prevalence in Uganda. Factors related to this decline are discussed below.

Political Economy and Sociobehavioral Context

Uganda's general stabilization in 1986, after about 20 years of civil strife, helped engender a political environment conducive to focusing attention and resources on AIDS. 

Uganda's has the world's youngest population and 10th-highest population growth rate. High population growth is likely to slow economic performance and put substantial pressure on already inadequate health service delivery. 

During the late 1990s, Uganda's annual public expenditure on education was 2.3 percent of GDP, up from 1.5 percent in 1990. In 2001, Uganda spent 2.1 percent of GDP on military expenditures, down from 3.0 in 1990. However, military spending as a percentage of GDP continues to exceed public expenditures on health (1.5 percent of GDP). Moreover, President Museveni recently announced plans to increase the Ugandan defense budget, in part to attempt to defeat the rebels in the north. 

Two decades of armed conflict severely damaged the country's law enforcement infrastructure. Ineffective enforcement of laws and contracts, as well as excessive red tape, hinder foreign investment. Uganda ranks as the 17th-most corrupt country in the world. 

In the Rwenzori region in western Uganda, intensified cross-border armed activity by the insurgency group Allied Democratic Forces began in 1996, causing the displacement of between 150,000 and 180,000 people. Since the mid-1990s, the northern districts of Uganda have been plagued by high levels of insecurity resulting from the insurgency group the Lord's Resistance Army. In November 2003, the U.N. Office for the Coordination of Humanitarian Affairs described the situation in northern Uganda as the "world's biggest, neglected, ignored" humanitarian crisis.

Since 1987 the government, with the support of donors, has pursued macroeconomic stabilization. During the 1990s, average GDP growth was close to 7 percent and inflation reduced to about 5 percent. More recently, however, economic growth has slowed, given drought and adverse trade shocks (e.g., decline in world coffee prices). The World Bank has noted that potential for growth from macroeconomic reforms has now been largely exploited, and therefore further economic growth requires a broader reform agenda. Moreover, insecurity in the north, growing corruption within the government, and weakened government determination to press reforms could all constrain continuation of strong growth.

Despite macroeconomic reforms and relatively high growth rates, Uganda remains one of the poorest countries in the world. In 2001, GNI per capita was US$260. Using international poverty measures, 82.2 percent of the population lives below US$1 a day; 96.4 percent lives below US$2 a day. 

Uganda became the first country to benefit from debt relief under the Heavily Indebted Poor Countries (HIPC) Initiative, which is managed by the IMF and World Bank. Part of the debt relief from the World Bank was in the form of a US$75 million grant allocated to the Universal Primary Education Program. However, Uganda is and will continue to be heavily dependent on external donors and foreign creditors. According to the World Bank and IMF, the long-run debt sustainability prospects for Uganda are poor.

Mobile and displaced populations include:

* internally displaced persons and refugees
* people affected by drought and other natural disasters
* migrant workers
* military personnel
* transport workers 
* tourism workers
* sex workers 
* individuals emigrating from Uganda 
* merchants/traders/vendors
* orphans and vulnerable children (e.g., street children)
* humanitarian and relief workers
* prisoners 

In the mid-1960s, Uganda's health care system was one of the finest in Africa. However, war and economic decline severely weakened it. In 2001, the government reported 1,156 public health units across the country. Most do not have adequate supplies and clinical equipment. Moreover, only 57 percent of health workers are qualified. Of them, most serve in hospitals or urban areas; thus, unqualified health personnel serve the vast majority of Ugandans.

In 2000, public expenditure on health was 1.5 percent of GDP; private health expenditure was 2.4 percent of GDP. Whereas the MOH estimates that at least US$28 per person is required to fund the minimum package of essential health services, health expenditure (public and private) per capita in 2001-02 was US$15. 

In 2001, Uganda had the world's 20th-highest burden of TB, in terms of new cases. Among adult TB cases, at least 35 percent are infected with HIV. 

Uganda has conducted two landmark community-based, randomized trials assessing the effect of STI treatment on HIV. The Masaka Study examined whether behavioral interventions alone or in combination with improved management of STIs were effective in reducing HIV incidence and occurrence of other STIs. It found that the interventions used were insufficient to reduce HIV incidence. The Rakai Project's intervention was intensive STI control through home-based mass antibiotic treatment. No effect of the intervention on HIV incidence was observed. 

In the early to mid-1990s, HIV/AIDS-related discrimination, stigma, and denial (DSD) were serious problems. In the late 1990s, although DSD was declining, it was still high, particularly in relation to family and community attitudes toward PLWHA. One of the most severe forms of HIV/AIDS-related discrimination experienced by Ugandan women is in relation to inheritance, particularly in terms of remaining in the marital home after the husband dies.

Ugandan women are vulnerable to HIV given their low status, lower educational attainment, higher unemployment, and weaker negotiating skills within relationships. About 32 percent of married women in Uganda are in a polygynous union. The government has implemented a far-reaching affirmative action program to promote women's political participation. However, many customary and statutory laws discriminate against women in areas of marriage, divorce, and inheritance. 

Property "grabbing" is a phenomenon wherein relatives forcefully take possession of the deceased's household goods, land, livestock, clothes, and other assets. This scenario exacerbates the already precarious economic (and social) situation of widows and their children. Property grabbing in Uganda is widespread. 

The Rakai Project found that 30 percent of women had experienced physical threats or physical abuse from their current partner. Ninety percent of women viewed beating of the wife or female partner as justifiable in some circumstances. The Rakai researchers underscored the strength of the association between alcohol consumption and domestic violence: women whose partner frequently or always consumed alcohol before sex faced risks of domestic violence almost five times higher than those whose partners never drank before sex.

Although awareness of HIV/AIDS is universal in Uganda, the level of awareness about the disease is not matched by knowledge of how to avoid contracting it. For example, 13.4 percent of women and 4.7 percent of men either do not know whether AIDS can be avoided or believe that there is no way to avoid AIDS. Misinformation persists; for instance, 12.4 percent of men and 22.8 percent of women do not know that a healthy looking person can be HIV-positive. 

Many experts postulate that behavior change is an important determinant of the decline in HIV prevalence in Uganda. Some researchers posit that the greatest changes in sexual behavior in Uganda occurred between the late 1980s and mid-1990s. To support this assertion, they draw heavily on data from sexual behavior surveys conducted in 1989 and 1995 by WHO's then Global Program on AIDS (GPA). Yet these two surveys differed considerably in terms of samples and questionnaires; in addition, both surveys had a strong urban bias (the first involved eight districts, the second involved four). Thus, claims regarding sexual behavior trends between 1989 and 1995 should be viewed with caution, as should comparison of findings from the subnational GPA surveys with nationally representative demographic and health survey (DHS) data. 

In the 2000-2001 UDHS, among men ages 25-29, the median age at first sex was 19.4; among women in the same age group, it was 16.8. These figures are higher than those reported in the 1995 UDHS, when the median age at first sex among men ages 25-29 was 17.5 years and among women ages 25-29, it was 16.0 years.

In the 1995 UDHS, among all women ages 15-19, 40.9 reported sexual activity in the four weeks before the survey, and 38.4 percent reported never having had sex. In the 2000-01 UDHS, among those ages 15-19, 30.0 reported sexual activity in the four weeks before the survey, and 47.9 percent reported never having had sex, representing steep declines since 1995.

Overall, use of condoms is low, with wide gender differentials: the 2000-01 UDHS found that 6.9 percent of women who had sex in the past year used a condom at last sex with any partner (spouse, cohabiting partner, noncohabiting partner); for men, this figure is 14.7 percent. With regard to a spouse or cohabiting partner, 2.5 percent of women and 3.9 percent report condom use at last sex. However, for noncohabiting partners, these figures are 37.8 and 58.9 percent, respectively. Among those ages 15-19, 49.6 percent of women and 51.5 percent of men report condom use at last sex with a noncohabiting partner. In the 20-24 age group, these figures are 36.9 and 71.0 percent, respectively. Only 53.3 percent of Ugandan women know a source for male condoms, and only 36.2 percent report that they could obtain a condom. 

Researchers from the Rakai Project found that male prepubertal circumcision was associated with reduced HIV risk, whereas circumcision after age 20 was not significantly protective against HIV infection. The Rakai Project and Uganda Virus Research Institute have begun a large, randomized trial to test the efficacy of male circumcision to prevent HIV/STIs.

Researchers from the Masaka Study found that HIV prevalence among adults living in households selling alcohol was almost twice as high as among those living in households not selling alcohol. Individuals who had ever drunk alcohol had an HIV prevalence twice that of those who had never drunk alcohol.

Limited information is available on the drug control situation in Uganda. However, according to the U.N. Office on Drugs and Crime, recent seizures show that illicit trafficking is increasing, as is illicit drug abuse. Cannabis, heroin, and methaqualone are the most available and consumed illicit drugs.

Impact

Because of continued high fertility, Uganda's population will continue to increase substantially, to over 115 million by 2050. However, the population will be up to 11 percent smaller than it would have been in a "no-AIDS" scenario. Although Uganda's life expectancy is projected to increase, AIDS will reduce life expectancy by 17 percent during 2000-05, by 8 percent for 2010-15, and by 3 percent for 2045-50. AIDS has already increased the number of deaths in Uganda by 23 percent. By 2000, there had been 1.3 million AIDS deaths in Uganda. The U.N. projects an additional 1.4 million AIDS deaths by 2050.

Uganda's health care system is under extreme strain because of HIV/AIDS. Ugandan households are likely bearing the largest share of the HIV/AIDS burden. The additional cost of illness associated with AIDS is devastating for already impoverished Ugandan families. The household cost of AIDS treatment (which must be paid in cash, out-of-pocket) competes with other crucial expenditures, such as food, shelter, and educational expenses. The burden of AIDS care falls heavily on girls and women, including elderly women.

About 2 million Ugandan children have been orphaned by AIDS. The impact of HIV/AIDS on children begins with parental diagnosis or onset of illness.  There are a growing number of child-headed households as a result of AIDS-related orphanhood, and such families are particularly vulnerable, as are children living in conflict areas. Because they have been overstretched, extended family and community structures can no longer offer adequate support to orphans. Orphan guardians are under considerable strain, and many households do not have sufficient resources to take in more children. Many guardians are in poor health; some are HIV-positive. Although standby guardians appointed by parents are predominantly male, women ultimately assume much of the responsibility for orphaned children.

Orphans often face increased malnutrition, lack of immunization and health care, lack of schooling, and early entry into paid or unpaid labor. Some orphans may be vulnerable to sexual abuse, thereby increasing their vulnerability to HIV. As orphans often witness the prolonged illness or death of family members, they are more prone to depression and psychosocial distress.

Between 1985 and 2020, Uganda will have lost 14 percent of its agricultural labor force because of AIDS. In districts severely affected by HIV/AIDS, up to 25 percent of households are cultivating less land as a result of HIV/AIDS. A decline in cash crop production¾particularly coffee, which is labor-intensive¾is also being observed. 

Response

The first AIDS cases in Uganda were identified in 1982. In 1985, the government established the National Committee for the Prevention of AIDS. In 1986, the new head of state, President Yoweri Museveni, immediately recognized HIV/AIDS as a problem. His government moved quickly by establishing the Uganda National AIDS Control Project (NACP) in 1986. NACP focused on blood safety, prevention of HIV infection in health care settings, and education and communication. The government also created AIDS control projects in 12 line ministries. In 1992, the government adopted the Multisectoral Approach to the Control of AIDS. To coordinate this approach, the Uganda AIDS Commission (UAC) was established in 1992 by Statute of Parliament with the mandate of coordinating the activities of the various actors nationwide. UAC, located in the Office of the President, was also mandated to mobilize resources.

Uganda's National Strategic Framework for HIV/AIDS Activities, first developed in 1997 and revised in 2000, is a key document that positions HIV/AIDS as part of the country's broader national development. In 1997, Uganda enacted a policy of decentralization. As part of this policy, local governments are encouraged to help implement the strategic framework and develop HIV/AIDS interventions specific to their local context. However, most districts have not yet developed HIV/AIDS workplans. National policy guidelines were developed in 1993 in a process led by UAC; they were revised in 1996. Currently, UAC is reviewing and updating these guidelines, with the aim of producing a national HIV/AIDS policy that will ultimately be sent to Parliament for approval.

In the late 1980s, the Uganda Blood Transfusion Service was strengthened to screen all blood received through the central and regional blood banks. Voluntary, nonremunerated blood collection has increased in all regional blood banks, from 60 percent in 1998 to 96 percent in 2001. 

In the early 1990s, President Museveni and some religious leaders opposed promoting condom use. However, by the mid-1990s, they had generally abandoned their opposition. 

In 1987, the Ministry of Defense developed an HIV/AIDS program. Soon after he became president, Yoweri Museveni sent Ugandan army officers to Cuba for military training. In Cuba, they were screened for HIV before beginning their training. Many were infected with HIV, and Cuban President Fidel Castro contacted Museveni to alert him of these findings. This scenario appears to have heavily influenced Museveni's decision to take significant action on HIV/AIDS shortly after assuming the presidency; moreover, it led to the military's early and substantial involvement in HIV/AIDS activities. Among its interventions are posttest clubs, mobile health clinics that serve both armed forces and nearby populations, and awareness-raising activities at all levels of the chain of command.

All government ministries have HIV/AIDS workplans. Although ministries have been implementing their workplans to varying degrees, many need financial, technical, and logistical support to reach full implementation. 

Uganda qualified for the World Bank's Multicountry HIV/AIDS Program (MAP). Uganda's MAP project was funded at US$47.5 million for 2001-06. In the first round of the Global Fund to Fight AIDS, TB & Malaria, Uganda's proposal to scale up the national response to HIV/AIDS was approved for US$36.3 million over two years. In the third GFATM round, Uganda's proposal to scale up ART and support to orphans and OVC was approved for US$70.4 million over two years. 

Although the Ugandan government has promoted excellent principles of nondiscrimination in the strategic framework, the country has no specific laws regarding HIV/AIDS, including the rights of PLWHA. Laws regarding custody of children and inheritance are also inadequate. 

Early on, Uganda's NACP enlisted community leaders, civil society, and religious groups in its activities. The involvement of prominent personalities such as the archbishop of the Church of Uganda and the late musician Philly Lutaaya, who in 1988 became the first well-known Ugandan to speak openly about his infection, also made a significant contribution. NGOs, CBOs, households, and traditional healers have played a crucial role in Uganda's HIV/AIDS efforts. Some have become global models of best practice. In September 2003, there were 2,500 NGOs working on HIV/AIDS in Uganda. Civil society was providing 80 percent of VCT and 90 percent of posttest counseling and care. Among constraints reported by NGOs and CBOs, inadequate financial, human, institutional, and capacity resources are the most commonly cited.

Numerous research institutions within and outside Uganda are involved in HIV/AIDS efforts. These include the Uganda Virus Research Institute, which manages the Rakai Project and collaborates with the CDC, among many others; the Academic Alliance for AIDS Care and Prevention in Africa; Makerere University; Uganda Medical Research Council Program on AIDS; Joint Clinical Research Center; Mulago, Nsambya, and Mengo hospitals; and Mildmay Center. These institutions collaborate with a wide array of international partners. HIV/AIDS interventions undertaken by private industry have thus far been limited. 

There is no national policy regarding orphans. The Ministry of Labor and Social Affairs has principal responsibility for the welfare of orphans. However, its capacity is very limited. Numerous NGOs, CBOs, religious organizations, and households are providing critical care and support to orphans and OVC. Although NGO and CBO support for orphans expanded rapidly during the 1990s, assistance remains concentrated in urban and periurban areas. NGO and CBO orphan assistance is also impeded by financial and human resource constraints. 

During the 1980s, there were few HIV testing services in Uganda outside research-related programs and almost none with related counseling programs. Uganda established Africa's first confidential VCT service, launching the AIDS Information Center (AIC) in Kampala in 1990. AIC pioneered provision of same-day results using rapid HIV tests, as well as creation of posttest clubs. Uganda was fairly unique in Africa in the emphasis it placed on VCT, at a time when the WHO's then Global Program on AIDS and other international organizations were not yet recommending it as a prevention strategy. 

By 2002, AIC had about 70 sites across the country serving a total of 55,000 clients. VCT services were available in 34 of 56 districts. However, even in districts where VCT services are available, coverage may be sparsely distributed. Using funds from the GFATM, the government plans to scale-up VCT services to include all 56 districts, as well as strengthen VCT capacity to provide information on ART. 

Uganda's 2000-01 DHS found that 8.4 percent of women and 12.0 percent of men reported having been tested for HIV. Among those not tested for HIV, 63.7 percent of women and 65.4 percent of men would like an HIV test.

Home-based care (HBC) has been a major component of the response to HIV/AIDS in Uganda, given scarce health care facilities, difficulty in accessing the available care facilities by the very ill, and the preference for terminal care and death in the home setting. There is no government policy on nor direct participation in HBC. The cost of HBC is borne by the private sector, often religious or charitable, with financing largely from external donors. The demand for HBC is far in excess of available resources. Rural areas tend to be underserved with regard to care and support. 

In the late 1990s, Uganda undertook a landmark clinical trial on PMTCT that found that nevirapine was associated with a 41 percent reduction in relative risk of HIV transmission through age 18 months. The government is working with UNICEF and other key partners to scale up PMTCT. 

In 1996, the MOH created the National Committee on Access to ARV Therapy. In 1998, Uganda established the Drug Access Initiative (DAI) to advocate for reduced prices for ARVs and support the establishment of necessary infrastructure for administering them. The DAI was succeeded by the Accelerated Access Initiative (AAI), a partnership between the U.N. and five pharmaceutical companies. A breakthrough in ARV prices occurred in October 2000 when the Joint Clinical Research Center (JCRC) began importing low-cost generic ARVs manufactured by the Indian pharmaceutical company Cipla. JCRC was founded in 1990 as a joint project of the MOH, MOD, and Makerere University; currently, 70 percent of Ugandans on ART receive their ARVs and treatment services from JCRC.

ART is not yet routinely available in government hospitals but is administered in health facilities accredited by the MOH, private health facilities, specialized HIV/AIDS care clinics, pharmacies, and research institutions. In addition, some access ART through their employers. There are over 20 private and public facilities offering ART nationwide. In addition to JCRC, major facilities/projects include:

* Mulago Hospital Infectious Disease Clinic, in partnership with the Academic Alliance for AIDS Care and Prevention in Africa
* Mildmay Center
* Médecins sans Frontières 
* Uganda Cares 

Currently, about 10,000 Ugandans are receiving ART. However, at least 150,000 are in immediate need of it. In December 2002, the retail price for a generic, three-drug combination of stavudine, lamivudine, and nevirapine was about US$28 per month. In late 2003, the monthly price of generic ARVs in Uganda fell to US$24. In fall 2003, the Ugandan government announced that, in light of the Doha 2001 international trade agreement permitting importation of generics during health emergencies, it would now purchase generic ARVs. Although ARVs are now available at significantly reduced prices, the government provides no subsidy to those using them. Most patients on ART live in urban areas and pay for ART entirely out-of-pocket or share the cost with their employers. 

Uganda was the site of the first AIDS vaccine trial in Africa (1999). In February 2003, researchers at the Uganda Virus Research Institute, in partnership with the International AIDS Vaccine Initiative, began enrolling participants for a phase 1 trial testing the safety and immunogenicity of a clade A HIV-DNA/MVA prime-boost combination.

There is consensus in the global HIV/AIDS community that there has been a robust decline in HIV prevalence in Uganda, related to several factors. Among them:

* high-level commitment to awareness and prevention
* community mobilization: involvement of key national stakeholders and pioneering NGO projects
* behavior change
* multisectoral response
* institutional capacity building
* blood safety
* condom distribution 
* VCT
* involvement of marginalized populations
* targeted interventions
* care, support, and recognition of the rights of PLWHA 

The results of the 2001 HSS indicated that national ANC prevalence had increased to 6.5 percent, up from 6.1 percent in 2000. Although this increase was not significant, it may signal that HIV prevalence is stabilizing and that further declines will not be possible without major new prevention efforts (and concomitant resources). Uganda's main HIV/AIDS challenges are related to:

* surveillance, knowledge, and prevention gaps
* rural populations
* youth
* mobile populations and conflict areas
* STI treatment 
* human rights
* increasing care and support burden
* local-level coordination
* sustainability of interventions

Despite strong political support, Uganda has limited resources to spend on prevention and mitigation of the epidemic. It is one of the world's poorest countries and its economic prospects are threatened by a variety of factors. Uganda¾and its HIV/AIDS program¾remains heavily dependent on external donors. Military spending continues to exceed public expenditure on health. The country faces the enormous task of concurrently mobilizing resources, meeting donor/lender conditions, expanding and sustaining prevention interventions, providing ART, and reaching underserved populations to maintain prevalence declines as well as achieve future targets. 




Epidemiology

At a Glance Summary Bullets

HIV Sentinel Surveillance

* The first AIDS cases in Uganda were identified in 1982. HSS began in 1985 in Kampala among women attending ANCs.

* Overall, HIV prevalence increased rapidly through the 1980s and early 1990s. Since the mid-1990s, HIV prevalence among ANCs attendees has been declining.

* The most consistent HIV prevalence declines are among the youngest age groups.

* HIV prevalence appears to be declining in major urban areas and stabilizing in rural areas. 

* The findings from the 2001 HSS, indicated that among women attending ANCs, overall HIV prevalence was 6.5 percent, an increase from 6.1 percent in 2000. ANC prevalence in urban areas was 8.8 percent and 4.2 percent in rural areas. According to the MOH, the increase in ANC prevalence was not statistically significant.

Transmission Patterns

* Most new HIV infections (84 percent) in Uganda occur through heterosexual transmission. MTCT accounts for about 15 percent of cases. Unsafe blood/blood products account for up to 5 percent of all HIV cases. The portion of HIV transmission attributable to MSM and IDU is not known.

Ugandan Government Estimates

* At the end of 1999, an estimated 1.44 million Ugandans were living with HIV/AIDS; at the end of 2000, this figure was 1.12 million. In December 2001, 1.05 million Ugandans were living with HIV/AIDS; of them, about 120,000 had developed AIDS. 

* Among Ugandans with HIV/AIDS during 2001, 945,500 were adults, of whom 56.3 percent were women. Nearly 80 percent of those infected with HIV were between ages 15-45. 

* Since the beginning of the epidemic through 2001, 2 million Ugandan children had been orphaned by AIDS.

U.N. Estimates

* At the end of 2001, UNAIDS estimated that 600,000 Ugandans were living with HIV/AIDS (estimate range: 480,000 to 720,000). Of those, 500,000 were adults (ages 15-49), and adult HIV prevalence was 5 percent. (At the end of 1999, UNAIDS estimated that adult HIV prevalence was 8.3 percent.)

* Of adults living with HIV/AIDS, UNAIDS estimated that 280,000 (or 56 percent) were women. HIV prevalence among women ages 15 to 24 was 5.65 to 9.99 percent at the end of 2001; among men in the same age group, the range was 3.17 to 5.62 percent. 

* According to the U.N. Population Division, adult HIV prevalence in Uganda peaked in 1989 at 13.3 percent. By 2050, the division projects that adult prevalence will be 0.7 percent.

AIDS Cases

Through December 2001, a cumulative total of 60,173 AIDS cases (child and adults) had been reported to the NACP, an increase from 58,165 in 1999 (NB: these figures represent reported cases only). Among reported AIDS cases, 55,707 (92.6 percent) were adults. Of total AIDS cases for which sex was recorded, 29,879 (55.1 percent) were female. The overall mean age for adults with AIDS was 30.9 years; for men, this figure was 33.0, for women, 29.1.

AIDS Mortality

* AIDS is responsible for 12 percent of annual deaths and is the leading cause of death among those ages15-49. UAC estimates that through December 2001, the cumulative number of AIDS deaths was 947,552. Of these, 852,797 were adults and 94,755 children. Adult female deaths were estimated at 427,153 and males at 425,644.

* According to the U.N. Population Division, AIDS has already increased the number of deaths in Uganda by 23 percent. The division estimates that by 2000, there had been 1.3 million AIDS deaths in Uganda. The division projects an additional 1.4 million AIDS deaths by 2050.

* UNAIDS estimated that there were 110,000 AIDS deaths in Uganda during 1999. During 2001, it estimated that there were 84,000 deaths due to AIDS.

Data Quality Issues 

* There are several reasons why reports of declining HIV prevalence could be misleading or inaccurate: 

? weaker HSS in rural areas
? changes in age at first pregnancy
? HIV-related subfertility
? AIDS mortality

Examining Determinants of Decline in HIV Prevalence, 1985-2001

* Against the backdrop of these data quality issues, there is consensus in the global HIV/AIDS community that there has been a robust decline in HIV prevalence in Uganda, related to several factors, including:

? high-level commitment to awareness and prevention
? community mobilization: involvement of key national stakeholders and pioneering NGO projects
? behavior change
? multisectoral response
? institutional capacity building
? blood safety
? condom distribution 
? VCT
? involvement of marginalized populations
? targeted interventions
? care, support, and recognition of the rights of PLWHA 

Challenges

Although the increase in ANC prevalence recorded in 2001 was not significant, it may signal that HIV prevalence is stabilizing and that further declines will not be possible without major new prevention efforts (and concomitant resources). Uganda's HIV/AIDS challenges are related to:

* surveillance, knowledge, and prevention gaps
* rural populations
* youth
* mobile populations and conflict areas
* STI treatment 
* human rights
* increasing care and support burden
* local-level coordination
* sustainability of interventions


HIV Sentinel Surveillance

The first AIDS cases in Uganda were identified in 1982 in the Rakai district. HIV sentinel surveillance began in 1985 in Kampala among women attending antenatal clinics (ANCs).[1] 

In 1989, the government launched HIV sentinel surveillance at ANC sites outside Kampala and among male patients at the Mulago STI clinic in Kampala.[1-3] In 1989, there were six HSS sites, located primarily in urban areas. This figure rose to 13 in 1993 and to 19 in 1995. By the end of 2001, there were 20 HSS sites throughout the country, mainly in urban areas.[4] However, over the last four years, only 17 sites have consistently participated in HSS.[5]

HSS is conducted annually.[5] Four times during the year, HSS is conducted over a 6- to 8-week period.[6] A minimum sample of 250 women is obtained from each site; at four sites in large urban areas, 500 women from each site are enrolled.[5] Annual surveillance reports based on these data are published by the National AIDS Control Program (NACP) of Uganda's Ministry of Health. Blood is collected anonymously from women on their first ANC visit for a particular pregnancy; it is then tested for HIV antibodies using the ELISA system.[6] In 1994 and 1995, WHO evaluated six HSS sites and concluded that they complied with the recommended procedures for selection and quality control.[7]

Several donors have contributed to the development of HSS surveillance in Uganda, including WHO, USAID, and the U.S. Centers for Disease Control and Prevention (CDC).[8-10]

HIV Sentinel Surveillance Findings through 2000

* Overall HIV prevalence increased rapidly through the 1980s and early 1990s. Since the mid-1990s, HIV prevalence among ANCs attendees has been declining.

In 1992, national ANC prevalence was 18 percent.[11] In 1992, prevalence at some ANC sites reached 30 percent (Mbarara: 30.2 percent, Nsambya: 29.5 percent, Rubaga: 29.4 percent). By 2000, prevalence at these sites had declined steeply: Mbarara: 10.0 percent, Nsambya: 11.8 percent, Rubaga: 10.7 percent.[12] In 2000, national ANC prevalence was 6.1 percent.[13] 

* The most consistent HIV prevalence declines are among the youngest age groups.

Since 1992, the largest and most consistent declines have been observed among the youngest age groups, particularly those ages 15-19.[6] For example, at Nsambya Hospital in Kampala, HIV prevalence among women 15-19 fell from 28.5 percent in 1991 to 8.8 percent in 1998 (and to 8.2 percent in 2001).[5]

* HIV prevalence appears to be declining in major urban areas and stabilizing in rural areas. 

In 1992, HIV prevalence among women attending ANCs was 30 percent in urban areas and 3 percent in rural areas. [6] In 2000, HIV prevalence in urban areas was 8.7 percent and 4.2 percent in rural areas.[14]

In 1985, HIV prevalence among ANCs in Kampala was 11 percent.[15] This figure rose to 25 percent in 1990 and to 29.4 percent in 1992. In 1996, prevalence had fallen to 15 percent.  In 1998, it had declined to 13.8 percent and to 11.3 percent in 2000.[16, 17]  

In most rural areas, the NACP has only recently begun to collect HSS data (see Data Quality Issues section below). Many rural areas have seen declines in prevalence; for example, between 1998 and 2000, prevalence declined from 11.5 to 10.5 percent in Kagando, from 3.2 to 2.7 percent in Moyo, and from 2.5 to 2.1 percent in Mutolere. In other rural areas, prevalence has been relatively stable.[12] 

Researchers from the Istituto Superiore di Sanità in Rome note that HIV prevalence in Gulu ANC, Lacor Hospital (northern Uganda) increased in 1997, which could be partly explained by the resurgence of violence in the region in 1996; the conflict has led to a dramatic reduction in social service activities as well as massive population dislocation.[18]  (See the Governance and Population Mobility sections below.) Although overall, HIV prevalence at Gulu has fallen (from 27.1 percent in 1991 to 13.1 percent in 2000 to 11.3 percent in 2001), it remains the highest prevalence of all HSS sites.[5, 19] 

2001 HSS

The findings from the 2001 HSS, released by the MOH in October 2002, indicated that among women attending ANCs, overall HIV prevalence was 6.5 percent, an increase from 6.1 percent in 2000. ANC prevalence in urban areas was 8.8 percent and 4.2 percent in rural areas. According to the MOH, the increase in ANC prevalence was not statistically significant, as the 2001 HSS figures overlapped with the confidence intervals of the 2000 figures.[14]

Other HIV Prevalence Data

* In 1988, a national seroprevalence survey was conducted and found that adult HIV prevalence was 9 percent.[2] (NB: Detail on this study is not available.) In 2003, Uganda announced that it would conduct a second nationwide seroprevalence survey. The National HIV/AIDS Serosurvey will involve about 30,000 participants nationwide; it will also test for syphilis, herpes simplex virus-2, and hepatitis B. The MOH will implement the survey with the support of the Uganda National Bureau of Statistics, CDC, WHO, UNAIDS, UNICEF, and UNFPA.[20]

* Between 1989 and 1999, the Masaka cohort study (more detail below) found that HIV prevalence fell significantly among young women, from 2.8 to 0.9 percent among those ages 13-19 and from 19.3 to 10.1 percent among those ages 20-24. During the same period, a significant decline was observed among men ages 20-24 (from 6.5 to 2.2 percent) and ages 25-29 (from 15.2 to 10.9 percent).[21]

* The Masaka cohort study found increasing prevalence among women ages 30-34 years (from 10.7 to 20.6 percent) and ages 35-39 (from 8.3 to 14.7 percent), which researchers attributed to a cohort effect caused by infected women moving into these age groups. Over the course of the study, the median age of HIV-positive men had risen from 32 to 35 years, and of women from 26 to 30 years.[21]

* Researchers from CDC and Uganda's AIDS Information Center (AIC) analyzed data from clients tested between 1992 and 2000 at four AIC VCT sites (NB: Individuals who test at VCT sites are self-selected and are more likely to include high-risk persons.) Repeat testers and clients reporting possible HIV-related morbidity were excluded. Data from 203,299 clients were analyzed. Overall, HIV prevalence declined from 23 percent to 13 percent (men: 17 to 9 percent; women: 30 to 17 percent). Among men, declines were observed within all age groups except those above age 40. Among women, large declines were observed in the younger age groups, though not in women over 30. For both males and females, the highest HIV incidence was among those born before 1967.[22]

* Researchers from the MOH examined annual HIV prevalence data from 250-300 clients from each of the 20 sentinel sites (1989-2000) as well as data on sexual behavior from about 1,500 adults resident in the catchment areas of the sites based on repeated cross-sectional behavioral surveys. In three areas where HIV prevalence data are available along with behavioral data from the catchment area, HIV prevalence fell from 30.2, 29.4, and 19.8 percent in 1992 to 11.8, 10.0, and 8.3 percent, respectively, in 2000.[23]

* According to data from patients attending the Mulago STI Clinic in Kampala, HIV prevalence has declined from 44.6 percent in 1990 to 29.4 percent in 1997, and to 23.7 percent in 2001.[4, 5]

* In the 1980s, HIV prevalence among sex workers in Kampala was about 80 percent; in 2000, sex workers tested in Kampala had an HIV prevalence of 28 percent. [5, 24]

HIV Incidence

According to the Uganda AIDS Commission, in 2001, there were 99,031 new HIV cases; of them, 89,128 were adults. Among adults, 49,092 (55.1 percent) were female.[14]

Some researchers have posited that HIV incidence in Uganda peaked in the 1980s, and that declines in HIV prevalence during the 1990s reflect declines in HIV incidence that occurred during the late 1980s.[4, 25]

Reductions in HIV prevalence, especially among young adults, may indicate concomitant declines in HIV incidence. However, other factors, such as mortality, migration, and survey coverage, also contribute to prevalence trends.[26] Thus, incidence trends cannot be estimated directly from prevalence trends. Reductions in HIV incidence would provide the most convincing evidence of a decrease in the size of the epidemic, but large, long-term, longitudinal studies (cohort studies, which indicate both incidence as well as prevalence) are needed to obtain such evidence.[21]

In Uganda, two such cohorts have been established:

1. The Rakai Project: a community-based cohort established in 1988 and expanded in 1994 for the Rakai STI Control for AIDS Prevention Project; partners: Uganda Virus Research Institute, Makerere University (Institute of Public Health and Clinical Epidemiology Unit), Columbia University School of Public Health, and Johns Hopkins University.

2. The Masaka Study; established in 1989, has surveyed an open cohort of all adults (ages 13 years and above) resident in a cluster of 15 neighboring villages using annual censuses, questionnaires, and serological surveys; partners: Uganda Medical Research Council, Medical Research Council of the U.K., London School of Hygiene and Tropical Medicine, Oxford University, WHO, and the PHLS Central Public Health Laboratory (U.K.).

Between 1990 and 1999, the Masaka cohort study found a significant decline in adult HIV incidence. During that period, HIV incidence fell from 8.0 to 5.2 per 1000 PYAR (p=0.002, chi(2) for trend), a 37 percent reduction (p=0.002, t-test). There were significant declining trends by sex (women from 6.4 per 1000 PYAR to 4.4, P=0.03; men from 9.7 to 6.0, P=0.045) and by age group (age less than 35 from 7.2 to 7.0, P=0.04; age greater than 35 from 9.2 to 2.0, P=0.008).[21]

Transmission Patterns

Most new HIV infections (84 percent) in Uganda occur through heterosexual transmission.[14, 27] Mother-to-child transmission accounts for about 15 percent of cases. Unsafe blood/blood products account for up to 5 percent of all HIV cases.[28] According to the Uganda AIDS Commission, more research is needed to determine transmission via MSM and IDU.[24]

Ugandan Government Estimates

According to a June 2003 report from the Uganda AIDS Commission, at the end of 1999, an estimated 1.44 million Ugandans were living with HIV/AIDS; at the end of 2000, this figure was 1.12 million. In December 2001, 1.05 million Ugandans were living with HIV/AIDS; of them, about 120,000 had developed AIDS. Among Ugandans with HIV/AIDS during 2001, 945,500 were adults, of whom 56.3 percent were women. Nearly 80 percent of those infected with HIV were between ages 15-45. Since the beginning of the epidemic through 2001, 2 million Ugandan children had been orphaned by AIDS.[14]

U.N. Estimates

At the end of 2001, UNAIDS estimated that 600,000 Ugandans were living with HIV/AIDS (estimate range: 480,000 to 720,000). Of those, 500,000 were adults (ages 15-49), and adult HIV prevalence was 5 percent.[29] (At the end of 1999, UNAIDS estimated that adult HIV prevalence was 8.3 percent.[30])

Of adults living with HIV/AIDS, UNAIDS estimated that 280,000 (or 56 percent) were women. HIV prevalence among women ages 15 to 24 was 5.65 to 9.99 percent at the end of 2001; among men in the same age group, the range was 3.17 to 5.62 percent. [29]

According to the U.N. Population Division, adult HIV prevalence in Uganda peaked in 1989 at 13.3 percent. By 2050, the division projects that adult prevalence will be 0.7 percent.[31]

AIDS Cases

The first AIDS cases in Uganda were identified in 1982.[32] Through December 2001, a cumulative total of 60,173 AIDS cases (child and adults) had been reported to the NACP, an increase from 58,165 in 1999 (NB: these figures represent reported cases only). Among reported AIDS cases, 55,707 (92.6 percent) were adults. Of total AIDS cases for which sex was recorded, 29,879 (55.1 percent) were female. The overall mean age for adults with AIDS was 30.9 years; for men, this figure was 33.0, for women, 29.1.[14]

AIDS Mortality

AIDS is responsible for 12 percent of annual deaths and is the leading cause of death among those ages15-49.[33] The Uganda AIDS Commission estimates that through December 2001, the cumulative number of AIDS deaths was 947,552. Of these, 852,797 were adults and 94,755 children. Adult female deaths were estimated at 427,153 and males at 425,644.[14]

According to the U.N. Population Division, AIDS has already increased the number of deaths in Uganda by 23 percent. The division estimates that by 2000, there had been 1.3 million AIDS deaths in Uganda. The division projects an additional 1.4 million AIDS deaths by 2050.[31] 

UNAIDS estimated that there were 110,000 AIDS deaths in Uganda during 1999.[30] During 2001, it estimated that there were 84,000 deaths due to AIDS.[29] 

See also the Impact section for detailed mortality data.

Data Quality Issues 

See also box 1.

There are several reasons why reports of declining HIV prevalence could be misleading or inaccurate: selection bias, errors in analysis, or change in the composition of the group surveyed.[32] These factors are discussed below.

Weaker HSS in Rural Areas

HIV sentinel surveillance has been subject to several problems in Uganda. Insecurity in the northern region has hindered data collection at sentinel sites. (See the Governance section below.) Increasing the number of rural sites has been difficult, given insufficient human, technical, and financial resources.[9] Although HSS sites span the country, they are primarily located in urban areas. Moreover, only a few sites have sufficient data available to analyze time trends.[4]

Justin Parkhurst of the London School of Hygiene and Tropical Medicine "believe[s] that Uganda has indeed been successful in slowing the spread of HIV-1, leading to reduced prevalence rates." However, he argues for a more tempered view of the epidemiologic data. He is concerned that claims about Uganda's "success story" have been based largely on data from a few urban ANC sites (whereas 88 percent of Ugandans live in rural areas[34]). Parkhurst also notes that more recent surveillance has included increasingly more data from rural sites, which tend to have lower prevalence rates, which may in turn have exaggerated the decline in national prevalence. (NB: Parkhurst's 2002 Lancet article examined ANC data through 1998.)[35]

Age at First Pregnancy

The profile of women who become pregnant may change over time, leading to errors in the measurement of prevalence. The delays in onset of sexual activity and increased condom use observed in Uganda (see the Sexual Behavior section) would lead to a delay in age of a woman's first pregnancy, rendering the average age of pregnant women older than among previous HSS groups. The difference in age would make it difficult to compare effectively the HSS samples.[7, 8]

Subfertility 

Using data from the Rakai Project, Gray et al. found that pregnancy prevalence was greatly reduced in HIV-infected women because of lower rates of conception and increased rates of pregnancy loss. The multivariate adjusted odds ratio of pregnancy in HIV-infected women was 0.45 (95 percent CI 0.35-0.57); the odds of pregnancy were low both in HIV-infected women without symptoms (0.49 [0.39-0.62]) and in women with symptoms of HIV-associated disease (0.23 [0.11-0.48]). In women with concurrent HIV infection and syphilis, the odds ratio was 0.28 (0.14-0.55). The incidence rate of recognized pregnancy during the prospective follow-up study was lower in HIV-positive than in HIV-negative women (23.5 versus 30.1 per 100 woman-years; adjusted risk ratio: 0.73 [0.57-0.93]). Rates of pregnancy loss were higher among HIV-infected than uninfected women (18.5 versus 12.2 percent; odds ratio: 1.50 [1.01-2.27]). The prevalence of HIV was significantly lower in pregnant than in nonpregnant women (13.9 versus 21.3 percent). Thus, the researchers concluded, HIV surveillance that includes only pregnant women underestimates the magnitude of the HIV epidemic in the general population.[36]

Box 1.  HIV Sentinel Surveillance: Evaluating Data from Antenatal Clinics

In many developing countries, estimates on the magnitude of and trends in the HIV epidemic are obtained through HIV seroprevalence surveys. These surveys are primarily conducted using sentinel populations. The most frequently used sentinel populations are women attending antenatal clinics and persons attending clinics for diagnosis and treatment of sexually transmitted infections. The objectives of sentinel seroprevalence surveys include:

1. obtaining information on the prevalence of HIV infection in the sentinel population
2. monitoring trends in HIV prevalence in the sentinel population
3. providing information for estimating future number of AIDS cases
4. providing information for program planning and evaluation of interventions

Seroprevalence surveys are usually conducted annually at preselected clinics or hospitals. Surveys of women attending antenatal clinics can provide a reasonable estimate of HIV prevalence within the general population. The surveys are conducted among women ages 15 to 49 years attending the antenatal clinic for the first time during a current pregnancy. Surveys are usually conducted in an unlinked manner, in which serum remaining from routine syphilis screening is tested for HIV infection after all personal identifying information is removed from the specimen. Sampling is usually conducted during an 8- to 12-week period, and all eligible women are sampled consecutively until the desired sample size is achieved. In general, samples of 250 and 400 women are usually sufficiently large as to provide reasonable estimates of HIV prevalence over time.

Although these surveys are extremely useful, there are several limitations to consider when interpreting the survey results. The surveys are not based upon a probability sample and therefore may not be representative of the population as a whole. True population-based surveys have found antenatal clinic data may overestimate or underestimate HIV prevalence. 

Moreover, the ANC studies do not provide information on mortality or HIV-associated morbidity. In addition, although monitoring trends in HIV prevalence provide information on the magnitude of the HIV epidemic, trends in prevalence cannot be relied upon to indicate trends in HIV incidence. However, examining trends in HIV prevalence in younger populations, particularly 15- to 19-year-olds, may provide some indication of trends in recently acquired HIV infection , as this group is unlikely to have been infected for a long period of time.

Prepared by Sandy Schwarcz, MD, MPH
Director, HIV/AIDS Statistics and Epidemiology Section, San Francisco Department of Public Health
Adjunct Assistant Professor, Department of Epidemiology and Biostatistics, University of California San Francisco


Population Mobility

Uganda has a large mobile population. The Masaka cohort study found that rural populations experience high mobility.[37] There are 1.3 million internally displaced people in Uganda,[38]  in addition to 190,000 refugees.[39] (See the population Mobility section below.) Repatriation of refugees and resettlement of IDPs may have led (and continues to lead) to a change in the composition of women attending ANCs. In addition, urban-rural migration could play a part in reduced prevalence; HIV-positive women may return to rural areas to receive care from their families, leading to lower prevalence recorded at urban clinics (where HIV testing is more likely to occur, given the higher number of urban HSS sites).[7, 8] Another dynamic may be the influx of HIV-negative, rural migrants into urban areas, thus, again, leading to lower prevalence in urban areas.[40]

AIDS Mortality

Some have argued that the decline in HIV prevalence in Uganda is primarily a result of AIDS-related mortality, such that the rate of new HIV infections is simply outweighed by AIDS deaths.[7, 8, 32] Others highlight the possible role of a natural "burning out" of the epidemic.[40]

UNAIDS posits that although all the above factors may play a role in the decline of HIV prevalence, they are unlikely to cause a serious distortion of the data. UNAIDS argues that it is unlikely that selection bias contributes to inaccurate HIV surveillance in Uganda as 92 percent of Ugandan women attend ANCs at some time during pregnancy.[41] Additionally, UNAIDS argues that errors in analysis are unlikely, as HSS analysis in Uganda is completed at a centralized laboratory.[7, 8] 

Examining Determinants of Decline in HIV Prevalence, 1985-2001

Against the backdrop of the data quality issues discussed above, there is consensus in the global HIV/AIDS community that there has been a robust decline in HIV prevalence in Uganda, related to several factors. In a May 2003 report, the Global HIV Prevention Working Group, convened by the Bill & Melinda Gates and Kaiser Family foundations, referred to Uganda's approach as "combination prevention":

A key finding from Uganda's experience is that no single factor or intervention can adequately explain the country's extraordinary progress in reversing its potentially catastrophic epidemic. Uganda's success underscores the effectiveness of a combination of proven approaches to HIV prevention: AIDS awareness campaigns, community mobilization, targeted behavior change programs-encouraging delayed initiation of sex, mutual monogamy, and condom use-voluntary counseling and testing, and treatment of STDs.[42]

Behavior Change

Many experts postulate that behavior change is an important determinant of the decline in HIV prevalence in Uganda.[5, 23, 32, 35, 42-44] Uganda pioneered the ABC approach to HIV prevention: abstinence/delay of sexual début, being faithful/partner reduction ("zero grazing"), and condom use with nonregular partners.[45, 46] A May 2003 report authored by researchers from USAID, the Global Fund to Fight AIDS, Tuberculosis & Malaria, the University of California at Berkeley, the Gates Foundation, and the University of Washington notes that:

"It is difficult to reconstruct the events that occurred during the late 1980's and early 1990's, when incidence was falling in Uganda, in order to weigh the relative contributions of A, B and C....each component of the 'ABC' approach probably played an important role."[47] 

Another behavioral factor may have been high levels of AIDS-related morbidity and mortality. A study undertaken by Uganda's NACP indicated that by 1995, over 70 percent of urban adults were exposed to the AIDS-related death of relatives or close friends. Together with the high level of knowledge of HIV/AIDS due to prevention efforts, fear and anxiety caused by the death of friends and family may have led to behavior changes and thus to decreased prevalence.[43, 46]

However, there are some crucial caveats with regard to the behavioral data. Some researchers posit that the greatest changes in sexual behavior in Uganda occurred between the late 1980s and mid-1990s. To support this assertion, they draw heavily on data from sexual behavior surveys conducted in 1989 and 1995 by WHO's then Global Program on AIDS (GPA).[3, 46] Yet these two surveys differed considerably in terms of samples and questionnaires; in addition, both surveys had a strong urban bias (the first involved eight districts, the second involved four).[46] Thus, claims regarding sexual behavior trends between 1989 and 1995 should be viewed with caution, as should comparison of findings from the subnational GPA surveys with nationally representative demographic and health survey (DHS) data. (Uganda conducted DHSs in 1988-89, 1995, and 2000-01. The 1988-89 DHS did not include any items on HIV/AIDS. The 2000-01 DHS included more items on HIV/AIDS and sexual behavior than did the 1995 DHS, rendering examination of time trends difficult.[48] Moreover, caution needs to be exercised in analyzing trends on the basis of the 1995 and 2000-01 datasets because of differences in their geographic coverage.[41])

High-Level Commitment to Awareness and Prevention

As discussed in depth in the Response section below, upon assuming office in 1986, President Yoweri Museveni immediately recognized HIV/AIDS as a problem. He argued that effective HIV prevention required openness, communication, and strong leadership, from the village to the highest levels of government. In 1986, the NACP was created and launched a massive awareness and prevention campaign. President Museveni encouraged constant and candid media coverage of all aspects of the HIV/AIDS epidemic.[32] Museveni also openly discussed Uganda's high HIV prevalence at a time when most African presidents were silent about their countries' epidemics.[49]

According to Dr. Alex Coutinho, executive director of Uganda's AIDS Support Organization
(TASO), key components in Uganda's HIV prevalence decline include: 

"The early and sustained political commitment by President Museveni to the fight against HIV/AIDS. The key word here is sustained [author's emphasis]. There is ample evidence that over the 16 years in power President Museveni has kept HIV/AIDS as one of three of his priorities¾peace and security, economic empowerment and HIV/AIDS."[50]

"The liberalization of the media to produce a vibrant and extensive print and radio media throughout the country. The particular contribution of the FM stations in the fight against HIV/AIDS has not been properly acknowledged but these could be the major source of information on health and HIV/AIDS in rural areas of Uganda. We need to protect this freedom."[50]

A related factor is Uganda's general stabilization in 1986, after about 20 years of civil strife.[46] This stabilization helped engender a political environment conducive to focusing attention and resources on AIDS. It may also have entailed a decrease in population dislocation and other phenomena often associated with conflict. (However, northern Uganda remains enmeshed in conflict, as discussed in the Governance and Population Mobility sections below.) 

Community Mobilization: Involvement of Key National Stakeholders and Pioneering NGO Projects

Early on, Uganda's NACP enlisted community leaders, civil society, and religious groups in its activities.[42] The involvement of prominent personalities such as the archbishop of the Church of Uganda and the late musician Philly Lutaaya, who in 1988 became the first well-known Ugandan to speak openly about his infection[50], also made a significant contribution.[45] TASO was established in 1987 to provide care and support and to fight discrimination against PLWHA[32]; it now serves as a global model. Coutinho of TASO notes Uganda's:

"...acceptability of people living with HIV/AIDS as part of greater society so that the levels of stigma and discrimination in Uganda while still there are much lower than many other African countries. This has not been achieved through legislation but through consistent advocacy for the rights of PLWHA."[50]

He goes on to state that:

"Most important of all in my view has been the acceptance by Ugandans that the focus of control of HIV/AIDS lies with themselves and not with other third parties. Without this emancipation it is difficult if not impossible to scale up HIV/AIDS programs."[50]

(See the Civil Society section below for further discussion.) 

Multisectoral Response

Early on, Uganda adopted a multisectoral response to HIV/AIDS, including the 1992 creation of a national, multisectoral coordinating body, the Uganda AIDS Commission.[50] Numerous nonhealth ministries are involved in significant HIV/AIDS activities. (See the Response section.) 

Institutional Capacity Building

Uganda has focused on establishing and strengthening institutions to provide services, conduct research, and serve as training centers.[6] According to Coutinho:

"The mobilization of national and international research institutions as early as 1985 to carry out research on HIV/AIDS and apply the results to solution generation has enabled Uganda to apply lessons that are relevant to its situation."[50]

(See the Response section for detail.) 

Blood Safety

In the late 1980s, the Uganda Blood Transfusion Service was strengthened to screen all blood received through the central and regional blood banks.[4] Voluntary, nonremunerated blood collection has increased in all regional blood banks, from 60 percent in 1998 to 96 percent in 2001. HIV seroprevalence in blood units collected from schools fell from 5.2 percent in 1989 to 0.5 percent in 2001; in blood units collected from nonschool communities, HIV seroprevalence declined from 14.0 to 1.4 percent. Among relatives/replacement donors, HIV prevalence fell from 24 percent in 1989 to 4.8 percent in 2001.[28] 

Condom Distribution 

Condom distribution and social marketing services have been implemented nationwide.[3] According to Coutinho, critical has been:

"The gradual buildup and social acceptability of interventions like condom promotion in the media and public places without hindrances from religious groups. A key to this acceptance has been the A, B, C campaign where condoms are seen as an alternative to abstinence and faithfulness. Social marketing of condoms has been very successful allowing especially the youth to accept that safe sex can be fun sex."[50]

(See the Condoms section below.) 

Voluntary HIV Counseling and Testing 

Uganda was the first African country to provide VCT services.[42] (See the VCT section below.)

Involvement of Marginalized Populations

Since 1989, President Museveni's government has attempted to increase the political voice of women and youth.[32] (See the Gender section.)

Targeted Interventions

For example, in the early years of the epidemic, young women with a secondary education had higher HIV prevalence than those with no education, possibly because of a lifestyle that was less constrained by traditional norms. For example, from 1991 to 1994, women with a secondary education in Kabarole District were more likely to be infected with HIV than women with no education (adjusted OR, 1.54; 95 percent CI, 1.08-2.19), and the results were even more pronounced among women under 25 (adjusted OR, 2.69; 95 percent CI, 1.4-5.17).  Given this scenario, secondary schools were targeted for interventions, and access to HIV/AIDS information was significantly improved. Sexual behavior among secondary school students in the Kabarole District indicated that the number of students who had ever used condoms increased from 43 percent in 1994 to 58 percent in 1997. By 1997, women with a secondary education were less likely to be infected with HIV than women with no education (adjusted OR, 0.94; 95 percent CI, 0.62-1.42), and women under 25 with a secondary education were even less likely to be infected than women with no education (adjusted OR, 0.61; 95 percent CI, 0.35-1.04).[44]

Coutinho cites: 

"Publications like Straight Talk speak of topics that in other African countries are considered taboo even for adults. The distribution of Straight Talk to all school going children has been further assisted by universal primary education [UPE]....The establishment of UPE has been a success in terms of enabling all children access education including knowledge of human sexuality and HIV/AIDS, and possibly through the delay in sexual activity. As important is that it has allowed AIDS orphans to access the schooling system for at least 7 years throughout Uganda."[50]

(See the Response section, which discusses school-based HIV/AIDS interventions.)

Care and Support for People with HIV/AIDS

Uganda has been a pioneer in provision of care and support to PLWHA. It has also been highly proactive in securing reduced prices for antiretroviral therapy (ART), as well as funding from international agencies to finance treatment, including ART provision. (However, the overwhelming majority of Ugandans with AIDS lack access to ART as well as to treatment for some opportunistic infections; see the OI and ART sections below.)

Challenges

See also the Assessment of Government Response section below.

The results of the 2001 HSS indicated that national ANC prevalence had increased to 6.5 percent, up from 6.1 percent in 2000. Although this increase was not significant[14], it may signal that HIV prevalence is stabilizing and that further declines will not be possible without major new prevention efforts (and concomitant resources). Analysis of the next of round of HSS will be crucial to better understanding epidemic trends in Uganda. 

In May 2003, Uganda's Ministry of Finance, Planning, and Economic Development cautioned:

"Past progress in reducing HIV/AIDS prevalence is to some extent reversible, as the recent increase in prevalence from 6.1 to 6.5 percent suggests, and it is therefore important that efforts continue in this direction."[51]

In June 2003, the Uganda AIDS Commission stated:

"In spite of the declines in HIV prevalence, the infection rates are still high. There is need
for more concerted efforts to further reduce the prevalence and incidence rates and
improve on existing HIV prevention and control strategies with more innovations."[14]

Uganda's 2002 HIV/AIDS proposal to the Global Fund to Fight AIDS, TB & Malaria noted that:

"Uganda has had considerable success in reducing HIV seroprevalence rates, but is still confronted with a serious HIV/AIDS epidemic, including rising numbers of people needing care and support, and orphans."[52]

In February 2003, Coutinho of TASO laid out the following challenges:

* "Maintaining and further reducing the current HIV prevalence
* Protecting the future generations of young people from complacency and infection
* Scaling up best practice, e.g., VCT, PMTCT
* Scaling up ART to all who need it
* Caring for existing and future orphans
* Improving the private and public health care systems
* Producing an HIV vaccine and delivering it to all who need it
* Rebuilding all the skills and knowledge lost through premature death"[50]

Surveillance Gaps

As mentioned above, insecurity in the northern region has hindered HSS data collection. Ensuring that HSS captures the effects of substantial population dislocation is also a challenge. Moreover, as HSS was fairly recently introduced in rural areas, more surveillance data from these sites are needed to examine trends. 

Knowledge Gaps

The 2000-01 Uganda Demographic and Health Survey highlighted that, despite major education campaigns, misconceptions about HIV/AIDS persist. In some cases, knowledge has decreased since 1995. (See the Awareness and Knowledge section below.)

Prevention Needs

These include:

Urban Areas

* Makerere University and the University of North Carolina at Chapel Hill have highlighted gaps in AIDS awareness campaigns and condom distribution in a poor urban district in Kampala.[53]

* In a study of poor young men in Kampala, Makerere University, Johns Hopkins University, the San Francisco Department of Public Health, and the University of California San Francisco found that although there was a substantial increase in condom use with casual partners, the prevalence of sex with casual partners remained high and not all men were consistently using condoms.[54]

Rural Populations

Current services for VCT, STI treatment, and provision of condoms leave rural areas underserved.[33] 

Youth

Uganda's has a very young, fast-growing population.[31] Thus, demand for sexual & reproductive health education and services, including those related to HIV/AIDS, will be great. High population growth is likely to put substantial pressure on already inadequate health service delivery.[55] (See the Health System section below.)

Sex Workers

Although HIV prevalence has fallen among sex workers, it remains very high.[5, 24]

Mobile Populations

Providing Uganda's large mobile populations with HIV/AIDS prevention and care services is crucial. 

Conflict Areas

Delivering HIV/AIDS interventions in the north, which is embroiled in conflict and home to a massive number of internally displaced persons[56], is vital. The north also has the country's highest poverty rate.[51] (See the Governance section below.) 

Sexually Transmitted Infections

More effective STI interventions need to be developed in the context of Uganda's mature HIV/AIDS epidemic.[57] (See the STI section.)

Human Rights

HIV/AIDS-related stigma and discrimination persist.[50] As yet, there are no laws regarding the rights of PLWHA.[58] One of the most severe forms of AIDS-related discrimination is in relation to inheritance, particularly in terms of widows' being permitted to remain in the marital home after their HIV-positive husbands die.[58] (See the Gender and Human Rights sections below.)

Increasing Care and Support Burden

The demand for home-based care is far in excess of available resources.[28] Rural areas tend to be underserved with regard to care and support. The burden of AIDS care falls heavily on women and girls.[58, 59] Overstretched family and community structures can no longer offer adequate support to orphans.[28] (See the Impact section for detail.)

Currently, about 10,000 Ugandans are receiving ART.[49, 60, 61] However, at least 150,000 are in immediate need of it.[49] The MOH estimates that there are about 100,000 new AIDS cases each year.[12] The health care system urgently requires additional resources to accommodate the burden of the AIDS epidemic,[62] including the infrastructure development and support to provide ART and monitor patients.[45] (See the ART section below.)

Local-level Coordination 

Coordination of HIV/AIDS activities at governmental district and subdistrict levels is
very weak.[63] Most of the country's 56 districts have not yet developed HIV/AIDS workplans.[28] 

Sustainability of Interventions

Despite strong political support, Uganda has limited resources to spend on prevention and mitigation of the epidemic.[4] It is one of the world's poorest countries[64] and its economic prospects are threatened by a variety of factors.[65, 66] Uganda¾and its HIV/AIDS program¾remains heavily dependent on external donors. Military spending continues to exceed public expenditure on health.[64] The country faces the enormous task of concurrently mobilizing resources, meeting donor/lender conditions, expanding and sustaining prevention interventions, providing ART, and reaching underserved populations to maintain prevalence declines as well as achieve future targets. 



Political Economy and Sociobehavioral Context

At a Glance Summary Bullets

* Uganda's general stabilization in 1986, after about 20 years of civil strife, helped engender a political environment conducive to focusing attention and resources on AIDS. 

Population Dynamics

* Uganda's has the world's 10th-highest population growth rate. By 2045-50, it will have the world's fourth-highest population growth rate (2.04 percent). As Uganda's Ministry of Finance, Planning, and Economic Development underscores, most population growth is occurring in the poorer segments of society. High population growth is likely to slow economic performance and put substantial pressure on already inadequate health service delivery.

* According to the U.N. Population Division, Uganda has the world's youngest population. In 2000, the median age in the country was 15.1. Fifty-one percent of the population is below age 15.

Public Expenditures

* During the late 1990s, Uganda's annual public expenditure on education was 2.3 percent of GDP, up from 1.5 percent in 1990. In 2001, Uganda spent 2.1 percent of GDP on military expenditures, down from 3.0 in 1990. However, military spending as a percentage of GDP (2.1 percent) continues to exceed public expenditures on health (1.5 percent of GDP). Moreover, President Museveni recently announced plans to increase the Ugandan defense budget, in part to attempt to defeat the rebels in the north. 

Political Participation

* In Uganda, traditional political parties have been banned from operating. 

* A new antiterrorism bill is threatening to redefine criticism of the government as a new form of "terrorism." 

Law Enforcement and Judiciary

* Two decades of armed conflict and lawlessness severely damaged the country's law enforcement infrastructure. Ineffective enforcement of laws and contracts, as well as excessive red tape, hinder foreign investment.

Corruption

* Uganda ranks as the 17th-most corrupt country in the world. 

Security

* In western Uganda's Rwenzori region, intensified cross-border armed activity by the insurgency group Allied Democratic Forces  began in 1996. The ADF has mounted attacks of varying intensity in Kasese, Kabarole, and Bundibugyo districts, causing the displacement of between 150,000 and 180,000 people.

* Since the mid-1990s, the northern districts of Uganda have been plagued by high levels of insecurity resulting from the insurgency group the Lord's Resistance Army (LRA). In November 2003, the U.N. Office for the Coordination of Humanitarian Affairs described the situation in northern Uganda as the "world's biggest, neglected, ignored" humanitarian crisis.
Economy
* Since 1987 the government, with the support of donors, has pursued macroeconomic stabilization. During the 1990s, average GDP growth was close to 7 percent and inflation reduced to about 5 percent.

* More recently, however, economic growth has slowed, given drought and adverse trade shocks (e.g., decline in world coffee prices). The World Bank has noted that potential for growth from macroeconomic reforms has now been largely exploited, and therefore further economic growth requires a broader reform agenda. Moreover, insecurity in the north, growing corruption within the government, and weakened government determination to press reforms could all constrain continuation of strong growth.

Poverty

* Despite macroeconomic reforms and relatively high growth rates, Uganda remains one of the poorest countries in the world. In 2001, GNI per capita was US$260. 

* Using international poverty measures, 82.2 percent of the population lives below US$1 a day; 96.4 percent live below US$2 a day. At household level, poverty is related to rural residence (specifically to living in the north or the east), land shortage, low levels of education, being headed by a female widow or by an elderly person, and limited access to markets. Unequal sharing of resources within households reflects not only cultural factors but unequal access to education and physical assets such as land, in which women are disadvantaged.

Debt

* Uganda became the first country to benefit from debt relief under the Heavily Indebted Poor Countries (HIPC) Initiative, which is managed by the IMF and World Bank

* Part of the debt relief from the World Bank was in the form of a US$75 million grant allocated to the Universal Primary Education Program. 

* HIPC is not debt cancellation; rather it is a restructuring of debt repayment through provision of grants. Uganda is required to continue servicing its debt. Moreover, HIPC does not preclude that a country will have to continue to borrow indefinitely. Uganda, for example, is and will continue to be heavily dependent on external donors and foreign creditors.

* According to the World Bank and IMF, the long-run debt sustainability prospects for Uganda are poor.

Mobile and Displaced Populations

* internally displaced persons and refugees
* people affected by drought and other natural disasters
* migrant workers
* military personnel
* transport workers 
* tourism workers
* sex workers 
* individuals emigrating from Uganda to live/work 
* merchants/traders/vendors
* orphans and vulnerable children (e.g., street children) (See the Impact/Orphans section below)
* humanitarian and relief workers
* prisoners 

Health System

* Major causes of morbidity and mortality in Uganda include AIDS, malaria, acute respiratory infections, tuberculosis, malnutrition, maternal and perinatal conditions, cardiovascular conditions, and trauma/accidents.

* In the mid-1960s, Uganda's health care system was one of the finest in Africa. However, war and economic decline severely weakened it. Only 42 percent of Uganda's 5,152 parishes have any form of health facility. Most Ugandan women report that they have problems seeking medical advice and treatment for themselves. These include distance to health facility, transportation, and negative attitude of health care providers. 

* In 2001, the government reported 1,156 public health units across the country. Most do not have adequate supplies and clinical equipment. Moreover, only 57 percent of health workers are qualified. Of them, most serve in hospitals or urban areas; thus, unqualified health personnel serve the vast majority of Ugandans.

* Since independence, Uganda has made great strides in improving child health. However, infant and under-five mortality rates stagnated during the 1990s. Between 1995 and 2000, immunization coverage declined significantly. 

* In 2000, public expenditure on health was 1.5 percent of GDP; private health expenditure was 2.4 percent of GDP. Whereas the MOH estimates that at least US$28 per person is required to fund the minimum package of essential health services, health expenditure (public and private) per capita in 2001-02 was US$15. 

* In 2001, the Ugandan government, recognizing that user fees were excluding the poor from utilizing health services, abolished them in government health units. (In government hospitals, there are paying and nonpaying lines of service.) An immediate effect of the policy was an increased number of patients seeking treatment in government clinics. Concurrently, the policy has put increased pressure on the health service supply, with a possible decline in quality as an immediate threat. Despite abolition of user fees, some public clinics continue to charge for services, and not all Ugandans are aware that they are no longer required to pay for government health services. Moreover, very few drugs are free (and the drug formulary remains severely limited), and patients must still pay for diagnostic services.

* The government has released extra funds to close the gap left by user fee abolition, but health districts still have highly inadequate resources. 

Tuberculosis

* In 2001, Uganda had the world's 20th-highest burden of TB in terms of new cases. The TB incidence rate was 324 cases per 100,000 population. Among adult (15-49) TB cases, 35 percent are infected with HIV. 

Sexually Transmitted Infections
* Uganda has conducted two landmark community-based, randomized trials assessing the effect of STI treatment on HIV. The Masaka Study examined whether behavioral interventions alone or in combination with improved management of STIs were effective in reducing incidence of HIV and occurrence of other STIs. It found that the interventions used were insufficient to reduce HIV incidence in rural Uganda. They concluded that more effective STI and behavioral interventions need to be developed for HIV prevention in mature epidemics.
* The Rakai Project's intervention was intensive STI control through home-based mass antibiotic treatment. No effect of the intervention on HIV incidence was observed. 

* Researchers from the Masaka Study found a strong association between HIV and HSV-2 infection. HSV-2 incidence per 100 person-years was significantly higher among those who were HIV-positive than among those HIV-negative.

Stigma and Discrimination

* In the early to mid-1990s, HIV/AIDS-related discrimination, stigma, and denial (DSD) were serious problems. In the late 1990s, although DSD was declining, it was still high, particularly in relation to family and community attitudes toward PLWHA. 

* One of the most severe forms of HIV/AIDS-related discrimination experienced by Ugandan women is in relation to inheritance, particularly in terms of remaining in the marital home after the husband dies

Gender

* Ugandan women are vulnerable to HIV given their low status, lower educational attainment, higher unemployment, and weaker negotiating skills within relationships.

* The government has implemented a far-reaching affirmative action program to promote women's political participation. However, many customary and statutory laws discriminate against women in areas of marriage, divorce, and inheritance. 

* Property "grabbing" is a phenomenon wherein relatives forcefully take possession of the deceased's household goods, land, livestock, clothes, and other assets. This scenario exacerbates the already precarious economic (and social) situation of widows and their children. Property grabbing in Uganda is widespread. 

* About 32 percent of married women in Uganda are in a polygynous union. 

* The Rakai Project found that 30 percent of women had experienced physical threats or physical abuse from their current partner; 20 percent of these occurred during the year before the survey. Three of five women who reported recent physical threats or abuse reported three or more specific acts of violence during the preceding year, and just under half reported injuries as a result. Ninety percent of women viewed beating of the wife or female partner as justifiable in some circumstances. 

* The Rakai researchers underscore the strength of the association between alcohol consumption and domestic violence. Women whose partner frequently or always consumed alcohol before sex faced risks of domestic violence almost five times higher than those whose partners never drank before sex.

Awareness and Knowledge of HIV/AIDS

* Although awareness of HIV/AIDS is universal in Uganda, the level of awareness about the disease is not matched by knowledge of how to avoid contracting it. For example, 13.4 percent of women and 4.7 percent of men either do not know whether AIDS can be avoided or believe that there is no way to avoid AIDS. Misinformation persists; for instance, 12.4 percent of men and 22.8 percent of women do not know that a healthy looking person can be HIV-positive. 

Sexual Behavior

* Many experts postulate that behavior change is an important determinant of the decline in HIV prevalence in Uganda. Some researchers posit that the greatest changes in sexual behavior in Uganda occurred between the late 1980s and mid-1990s. To support this assertion, they draw heavily on data from sexual behavior surveys conducted in 1989 and 1995 by WHO's then Global Program on AIDS (GPA). Yet these two surveys differed considerably in terms of samples and questionnaires; in addition, both surveys had a strong urban bias (the first involved eight districts, the second involved four). Thus, claims regarding sexual behavior trends between 1989 and 1995 should be viewed with caution, as should comparison of findings from the subnational GPA surveys with nationally representative DHS data. 

* In the 2000-2001 UDHS, median age at first sex among men ages 25-54 was 18.8 years and among women ages 20-49, 16.7 years. Among men ages 25-29, the median age at first sex was 19.4; among women in the same age group, it was 16.8. These figures are higher than those reported in the 1995 UDHS, when the median age at first sex among men ages 25-54 was 17.6 years and among women ages 20-49, it was 16.1 years. Among those ages 25-29, median age at first sex was 17.5 for men and 16.0 for women. 

* In the 1995 UDHS, 9.2 percent of never-married women reported sexual activity in the four weeks prior to the survey. Among all women ages 15-19, 40.9 reported sexual activity in the four weeks before the survey, and 38.4 percent reported never having had sex. Among women ages 20-24, these figures were 65.5 and 3.2 percent, respectively. In the 2000-01 UDHS, 9.6 percent of never-married women reported sex in the four weeks prior to the survey. However, among ages 15-19, 30.0 reported sexual activity in the four weeks before the survey, and 47.9 percent reported never having had sex, representing steep declines since 1995. Among women ages 20-24, 66.2 percent reported sexual activity in the four weeks before the survey (a slight increase from 1995), whereas 3.7 percent reported never having had sex, a slight increase over 1995.

* Among never-married respondents in the 2000-01 UDHS, 72.5 percent of women reported no sex partner in the 12 months preceding the survey, 25.5 percent had only one partner, and 1.9 percent had two or more partners. Among never-married men, these figures were 66.4, 22.6, and 11.0 percent, respectively. Among all women ages 15-19, these figures were 77.8, 20.5, and 1.7 percent, respectively; among men in the same age group, they were 77.8, 17.2, and 4.8 percent, respectively.

* In the 12 months preceding the 2000-01 UDHS, 97.4 percent of married women reported that they had no sex partner other than their spouse or cohabiting partner; 2.4 percent reported one extramarital sex partner, and 0.1 percent reported two or more partners. Differences by background characteristics were negligible. Among married men, 88.8 percent reported that they had no sex partner other than their spouse or cohabiting partner in the year prior to the survey; 9.7 percent reported one extramarital sex partner, and 2.3 percent reported two or more partners. 

* Among married respondents ages 15-19, 97.0 percent of women reported no other sex partner, 2.9 percent reported one, and 0.1 percent reported two or more; among men in the same age group, these figures were 77.0, 23.0, and 0.0 percent, respectively.

* Overall, use of condoms is low, with wide gender differentials: the 2000-01 UDHS found that 6.9 percent of women who had sexual intercourse in the past year used a condom at last sex with any partner (spouse, cohabiting partner, noncohabiting partner); for men, this figure is 14.7 percent. With regard to a spouse or cohabiting partner, 2.5 percent of women and 3.9 percent report condom use at last sex. However, for noncohabiting partners, these figures are 37.8 and 58.9 percent, respectively.

* Among those ages 15-19, 49.6 percent of women and 51.5 percent of men report condom use at last sex with a noncohabiting partner. In the 20-24 age group, these figures are 36.9 and 71.0 percent, respectively.

* Only 53.3 percent of Ugandan women know a source for male condoms, and only 36.2 percent report that they could obtain a condom. Among women ages 15-19, these figures are 53.1 and 32.3 percent, respectively; among women ages 20-24, they are 62.1 and 47.1 percent, respectively, the highest among all age groups. Among all women, 85.0 percent in urban areas know a source for male condoms and 61.9 percent report that they could obtain one; in rural areas, these figures are 47.0 and 31.1 percent, respectively.

Male Circumcision
* Researchers from the Rakai Project found that male circumcision is associated with reduced HIV acquisition. Prepubertal circumcision was associated with reduced HIV risk, whereas circumcision after age 20 was not significantly protective against HIV infection.
* Researchers from the Rakai Project also examined male circumcision and HIV-discordant couples. In couples with HIV-positive men, HIV transmission was significantly reduced in circumcised men with HIV viral loads less than 50,000 copies/ml.

* The Rakai Project and Uganda Virus Research Institute have begun a large, randomized trial to test the efficacy of male circumcision to prevent HIV/STIs.

Alcohol and Drug Use

* Although commercially prepared alcohol is consumed in Uganda, a substantial amount of alcohol in Uganda is home-brewed, with variable alcohol concentrations and nonstandard consumption quantities. 

* Researchers from the Masaka Study found that HIV prevalence among adults living in households selling alcohol was almost twice as high as among those living in households not selling alcohol. Individuals who had ever drunk alcohol had an HIV prevalence twice that of those who had never drunk alcohol.

* Limited information is available on the drug control situation in Uganda. However, according to the U.N. Office on Drugs and Crime, recent seizures show that illicit trafficking is on the increase, as is illicit drug abuse. Cannabis, heroin, and methaqualone are the most available and consumed illicit drugs.


In a paper prepared for the WHO Commission on Macroeconomics and Health, David Bloom of Harvard and his colleagues note that:

"Existing data provide some indication that the relationship between poverty and HIV is growing stronger over time, both between and within continents. But it is not possible to infer causality from these data. That is, it is difficult to tell whether poverty causes AIDS or vice versa¾or whether another variable, such as war, inadequate health, or poor education, explains the relationship....In sum, the link between economic status and AIDS is complex."[67]

Håkan Björkman, senior adviser on HIV/AIDS to UNDP's Bureau for Development Policy, states that:

"HIV/AIDS is not strictly speaking a "disease of poverty" as it affects people at all income levels. But evidence from some countries at advanced states of the epidemic shows that new HIV infections disproportionately affect poor people, unskilled workers, and those lacking literacy skills¾especially young women in each of these categories. The relationship among poverty, gender, and HIV vulnerability has important policy implications."[68]

This section does not seek to demonstrate causality; rather, it aims to analyze key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. In addition to the comparative table of key HIV/AIDS and socioeconomic indicators that accompanies this analysis, readers may also wish to consult the 2003 indicators related to progress on the Millennium Development Goals, which are published by UNDP <http://www.undp.org/hdr2003/indicator/index_indicators.html>.

Political Overview
At independence from Britain in 1962, Uganda had rapid agricultural growth, a developing industrial sector, and growing intellectual and cultural leadership.[65] The early years of independence were marked by political instability and social violence, as supporters of a centralized state fought with those in favor of a loose federation and a strong role for ethnically based local kingdoms. In February 1966, Prime Minister Milton Obote suspended the constitution, assumed all government powers, and removed the president and vice president. In September 1967, a new constitution proclaimed Uganda a republic, gave the president greater powers, and abolished the traditional kingdoms.[69]
In January 1971, Obote's government was ousted in a military coup led by armed forces commander Idi Amin. Amin declared himself president, dissolved the parliament, and amended the constitution to give himself absolute power. Amin's eight-year rule produced economic decline, social disintegration, and massive human rights violations. Because Obote and many of his supporters belonged to the Acholi and Langi ethnic groups, these groups were particularly persecuted by Amin. In 1978, the International Commission of Jurists estimated that over 100,000 Ugandans had been murdered during Amin's reign.[69] Other international human rights organizations put the figure closer to 300,000.[70] 
In April 1979, Amin was overthrown and fled the country. Libya and Saudi Arabia offered him asylum; he died in the latter country in August 2003.[70] The Uganda National Liberation Front formed an interim government with Yusuf Lule as president. December 1980 elections returned Obote to power as president. Under Obote, the security forces had one of the world's worst human rights records. In their efforts to stamp out an insurgency led by Yoweri Museveni's National Resistance Army (NRA), they destroyed a substantial portion of the country, especially in the Luwero area north of Kampala.[69]
Obote ruled until July 1985, when an army brigade took Kampala and proclaimed a military government. Obote fled to exile in Zambia. The new regime, headed by former defense force commander Gen. Tito Okello, opened negotiations with Museveni's insurgent forces and pledged to improve respect for human rights, end ethnic rivalry, and conduct free and fair elections. In the meantime, however, massive human rights violations continued as the Okello government murdered civilians and destroyed the countryside to demolish the NRA's support. [69]
Negotiations between the Okello government and the NRA were conducted in Nairobi in fall 1985. Although agreeing in late 1985 to a cease fire, the NRA continued fighting, seized Kampala in late January 1986, and assumed control of the country, forcing Okello to flee north into Sudan. The NRA organized a government with Museveni as president.[69]
Since assuming power, the government dominated by the political group created by Museveni and his followers¾the National Resistance Movement¾has instituted broad economic reforms overseen the efforts of a human rights commission established to investigate previous abuses. A new constitution was adopted in 1995.[69] (See Governance section below.)
Population Dynamics

Uganda's has the world's 10th-highest population growth rate. By 2045-50, it will have the world's fourth-highest population growth rate (2.04 percent).[31] As Uganda's Ministry of Finance, Planning, and Economic Development underscores, most population growth is occurring in the poorer segments of society. High population growth is likely to slow economic performance and put substantial pressure on already inadequate health service delivery.[55]

According to the U.N. Population Division, Uganda has the world's youngest population. In 2000, the median age in the country was 15.1.[31] Fifty-one percent of the population is below age 15 (compared to a median 44 percent in sub-Saharan Africa and 33 percent in all developing countries).[71]

Human Development

One method of tracking human development is to analyze trends in a country's Human Development Index. The HDI was created by UNDP to measures average achievements in life expectancy at birth; adult literacy and combined primary, secondary, and tertiary gross enrollment ratios; and gross national income (which may be thought of as average income). An HDI of 0.800 or above = high human development; 0.500 - 0.799 = medium human development; less than 0.500 = low human development. In 2001, Uganda's HDI value was 0.489. Uganda's HDI value has been increasing since 1985, when it stood at 0.402. Although it is now currently somewhat higher than the median for the sub-Saharan Africa region (0.468), the country's HDI remains below that of all low-income countries (0.561).[2] 

A critical indicator of the well-being of children is the under-five mortality rate. Since independence, Uganda has made great strides in improving child health. In 1960, its under-five mortality rate was 224 per 1,000 live births; in 2001, it had fallen to124, below the median for sub-Saharan Africa (173) and for all least-developed countries (157), though still the world's 36th-highest under-five mortality rate.[3] Infant mortality, another key human development indicator, fell from 133 in 1960 to 79 in 2001, again below the rates for the region (107) and for all least-developed countries (100). [3]

Another critical human development indicator is the maternal mortality ratio (MMR), the number of deaths to women per 100,000 live births that result from conditions related to pregnancy, delivery, and related complications. According to the most recent estimates by WHO, UNICEF and UNFPA, Uganda accounted for 1.9 percent (10,000) of the world's 529,000 maternal deaths in 2000. Uganda had the world's 13th-highest number of maternal deaths during that year. Its MMR was 880 (estimate range: 510-1,200). A Ugandan woman's lifetime risk of maternal death is 1 in 13.[72]

Education

By the time President Museveni assumed power in 1986, Uganda had become one of the world's poorest countries. The education and health systems had collapsed, physical infrastructure had disintegrated, and the civil service had been devastated by low wages and poor morale.[65] 

In 1997, the government initiated a policy of Universal Primary Education (UPE), abolishing user fees for primary education for four children per family.[65, 73] (Though families must still pay school-related costs such as uniforms and books.[28]) UPE has more than doubled the number of children in primary schools.[59] 

As the accompanying indicator table demonstrates, Uganda's gross primary education enrollments are higher than the median for the sub-Saharan African region, although the country's secondary education enrollments lag the regional median.[74] Despite UPE, about one-third of girls and boys ages 6-9 have never been to school. (This finding, from the 2000-01 UDHS, may be related to timing; the UDHS was primarily conducted in the last few months of 2000, and children who turned age six may have been waiting to enter the school year that began in January 2001.[41]) Reasons for nonattendance include poor health, failure to pay extra charges required, and lack of school uniform. In the northern part of the country, lack of security is a major reason for nonattendance. Hygienic facilities in schools have also been highlighted as an important reason for absenteeism and dropouts, especially among girls; for example, over half of all school toilets lack privacy (e.g., doors, shutters).[55]

The top income quintile occupies 63 percent of all secondary school places. Rich Ugandans attend elite boarding schools, whereas the poor resort to low-quality, poorly resourced community schools, when they can afford them. In addition, there are concerns about the relevance and quality of secondary education. Secondary education tends to be theoretical with little practical application of knowledge and skills.[55] Currently, the government is exploring options to broaden access to secondary and tertiary education. [65] (See also the Gender section.)

Public Expenditures

During the late 1990s, Uganda's annual public expenditure on education was 2.3 percent of GDP, up from 1.5 percent in 1990. In 2001, Uganda spent 2.1 percent of GDP on military expenditures, down from 3.0 in 1990.[2] Part of this decrease was due to a reduction in the number of Ugandan troops begun in 1991, which reduced the size of the army from 100,000 to about 50,000.[75] However, the country's military expenditure as a percent of central government expenditure was 13.9 in the late 1990s; the median figures for the sub-Saharan Africa region and world were 9 and 10 percent, respectively.[4] 

President Museveni recently announced plans to increase the Ugandan defense budget, in part to fund an expansion of the army in an attempt to defeat the Lord's Resistance Army (LRA) rebels in the north.[75] A 2002 report by Civil Society Organizations for Peace in Northern Uganda, a coalition of over 40 local and international NGOs, estimated that the conflict in the north has cost the Ugandan economy about US$1.33 billion over the last 16 years, more than the sum spent on health care.[75] (The LRA conflict is discussed in depth below.) Moreover, military spending as a percentage of GDP (2.1 percent) continues to exceed public expenditures on health; in the late 1990s, public expenditure on health was 1.5 percent of GDP.[2]

Governance

Political Participation

In Uganda, candidates compete for election as individuals under the umbrella of the National Resistance Movement; traditional political parties have been banned from operating.[59] According to Transparency International, the activities of opposition political parties in Uganda are "restricted to holding press conferences."[76] Although about 70 percent of Ugandans voted to maintain the NRM system in a March 2000 referendum, the referendum was widely criticized for its "low voter turnout and lack of a level playing field."[69] The traditional political parties, including the Democratic Party and the Uganda People's Congress, boycotted the referendum and do not recognize its results; they have sued the government and are challenging the legitimacy of the 2000 referendum.[59]

Transparency International reports that the events of September 11 are adversely affecting civil society in Uganda. A new antiterrorism bill is threatening to redefine criticism of the government as a new form of "terrorism." Furthermore, the fight against terrorism has justified further increases in military and intelligence agency budgets, increasing the scope for "classified expenditure" and potential abuses.[76] 

Law Enforcement and Judiciary

Two decades of armed conflict and lawlessness severely damaged the country's law enforcement infrastructure.[77] Ineffective enforcement of laws and contracts, as well as excessive red tape, hinder foreign investment.[59]
The judiciary comprises a five-tier system known as the Courts of Judicature, ranging from subordinate magistrates' courts to the Supreme Court. With a predominantly rural population, many Ugandans seek justice at the local level. State-sponsored local tribunals or local council (LC) courts apply customary norms and provide local fora for dispute resolution. LC courts have jurisdiction over limited civil matters and petty criminal offences. They also deal with cases governed by customary law, including property, inheritance, and marital disputes. There are about 4,000 LC courts countrywide. Though once praised as a rapid, inexpensive method of seeking justice, the LC courts are attracting criticism as corrupt institutions. The courts frequently exceed their authority by hearing serious criminal cases, including murder and rape. Although LC court decisions may be appealed to magistrates' courts as well as to the High Court, few defendants are aware of their right of appeal. Women's access to justice is poor, and women's representation in the justice sector, although improved, remains low.[78] (See also the Gender section below.)
Corruption

According to Transparency International's Corruption Perceptions Index 2003, Uganda ranked as the 17th-most corrupt country in the world, scoring 2.2 (on a scale of 0 [highly corrupt] to 10 [highly clean], based on perception of the degree of corruption as viewed by businesspeople, academics, and risk analysts).[79] 

Corruption negatively affects private sector development by raising the cost of doing business. A recent survey of Ugandan firms indicates that the majority of firms pay significant bribes. A household survey found that bribery is most common in the police and judiciary, with two-thirds of users paying a bribe to workers in the judiciary services. Surveys also indicate that corruption has been increasing over the last five years.[59]

Public service delivery is still constrained by the poor pay of civil servants. According to Uganda's Ministry of Finance, Planning, and Economic Development, this scenario is exacerbated by persistent corruption.[55]

Uganda depends on external donors for 52 percent of its public expenditure. Pressure from donors led the government to draft legislation establishing an ethics code for public officials and a national anticorruption body. However, political support for effective anticorruption measures is weak, as are enforcement mechanisms. Moreover, funding is highly inadequate.[76]

In Uganda, civil society organizations were at the forefront of attempts to pressure the government into making its methods of awarding tenders more transparent. Their efforts led, for example, the World Bank to suspend its loan for the Bujagali dam because of corruption allegations.[76]

With Ugandan troops still deployed in both the DRC and Sudan, donors have allowed the Ugandan government to increase defense spending by US$37 million over the next two years. In 2001, a United Nations panel of investigators issued a report accusing Ugandan (and Rwandan) troops occupying parts of DRC of engaging in illicit trade of DRC's natural resources. Uganda appointed its own official commission of inquiry, but, according to Transparency International, its work was largely seen as an attempt to whitewash the accused, who included members of President Museveni's family.[76]

Security
In western Uganda's Rwenzori region, intensified cross-border armed activity by the insurgency group Allied Democratic Forces (ADF) began in 1996. The ADF has mounted attacks of varying intensity in Kasese, Kabarole, and Bundibugyo districts, causing the displacement of between 150,000 and 180,000 people.[80] In 1998, Uganda deployed about 5,000 troops to eastern DRC, ostensibly to prevent attacks from the ADF.[69] 
By May 2002, almost 90 percent of IDPs in Kasese and Kabarole districts had returned to their homes, and most camps had been dismantled. Although district government officials and aid agencies have expressed satisfaction with the progress of internally displaced person (IDP) resettlement in western Uganda, there have been significant constraints to resettlement arising from poor coordination and insufficient resources.[80] Moreover, security concerns still remain in Bundibugyo, from which almost 90 percent of the western IDPs were displaced. The majority of the population in Bundibugyo, which is close to ADF rear bases in the DRC, have not gone home, fearing renewed attacks. Nearly 70 percent of the population of Bundibugyo is still living in camps.[80]
Since the mid-1990s, the northern districts of Uganda have been plagued by high levels of insecurity resulting from the insurgency group the Lord's Resistance Army (LRA). The Acholi people have borne the brunt of the violence; about half (500,000) have been forced to remain in "protected camps" guarded by the Ugandan military.[80] A recent Human Rights Watch report documented that attacks on civilians (including religious leaders, aid providers, and those living in IDP camps)¾abductions, torture, recruitment of child soldiers, and other abuses¾have sharply increased in the past year in northern Uganda because of renewed fighting between Ugandan government forces and the LRA.[81]

In October 2003, Refugees International reported that:

"The news from Uganda is discouraging. In the 11 months since Refugees International last visited northern Uganda, the humanitarian crisis in the country has worsened. The Ugandan government has made no progress in ending the war. The Lord's Resistance Army (LRA) continues to devastate northern Uganda, and the conflict has spread south to the Teso region, displacing up to 300,000 people since June. Peace talks fell apart in March, and there has been no move on either side to restart them. Sudan is reportedly still arming the LRA. The number of Internally Displaced Persons (IDPs) is a staggering 1.1 million. That's double the number of IDPs since Uganda began a military offensive called 'Operation Iron Fist' last year. Due to lack of security, most NGOs are unable to travel to the IDP camps to provide assistance. Each week, the brutal and unsavory LRA abducts more children to replace those who escape or are rescued by the Ugandan military. Although overall emergency funding for the north has increased in the past year, the humanitarian response is inadequate and belies the fact that Uganda has the fourth largest IDP population in Africa."[82]
In November 2003, the U.N. Office for the Coordination of Humanitarian Affairs described the situation in northern Uganda as the "world's biggest, neglected, ignored" humanitarian crisis.[38]
Economy
Uganda has substantial natural resources, including fertile soils, regular rainfall, and sizable mineral deposits of copper and cobalt. Agriculture is the most important sector of the economy, employing over 80 percent of the workforce. Coffee is the major export crop, accounting for over half of export revenues.[65]
When President Museveni assumed power in 1986, the economy was highly regulated with state intervention in nearly all sectors. Real GDP per capita was 42 percent below its level in 1970; the public revenue base had collapsed; inflation was raging; and government expenditure, exports, and investment had all fallen below 10 percent of GDP. [65] 

Since 1987 the government, with the support of donors, has pursued macroeconomic stabilization, including undertaking currency reform, raising producer prices on export crops, and improving civil service wages.[65]
Between 1980 and 1999, Uganda received 20 structural adjustment loans from the World Bank and IMF. In an analysis of structural adjustment loans during this period, Dr. William Easterly of the Center for Global Development found that Uganda's GDP growth was 2.3 percent, the highest among the 12 sub-Saharan African countries that Easterly analyzed.[83] During the 1990s, average GDP growth was close to 7 percent and inflation reduced to about 5 percent. A high level of donor assistance (13 to 14 percent of GDP) played a vital role in supporting policies leading to this growth.[65]
More recently, however, economic growth has slowed, given drought and adverse trade shocks (e.g., decline in world coffee prices).[65] The World Bank has noted that potential for growth from macroeconomic reforms has now been largely exploited, and therefore further economic growth requires a broader reform agenda. [59] Moreover, insecurity in the north, growing corruption within the government, and weakened government determination to press reforms could all constrain continuation of strong growth.[77]

Poverty

Despite macroeconomic reforms and relatively high growth rates, Uganda remains one of the poorest countries in the world. In 2001, gross national income (GNI) per capita (terminology that has replaced GDP per capita) was US$260. This figure is lower than the median for the sub-Saharan Africa region (US$460) and for all low-income countries (US$430). Globally, Uganda's GNI per capita ranks 187 out of 208 countries.[84]

According to Uganda's Ministry of Finance, Planning, and Economic Development, the proportion of the population below the national poverty line fell from 56 percent in 1992 to 44 percent in 1997 and 35 percent in 2000.[51] However, poverty has not fallen in the northern region, where 66 percent of the population remains poor.[51]

Using international poverty measures, 82.2 percent of the population lives below US$1 a day; 96.4 percent live below US$2 a day (i.e., the percentages of the population living on less than US$1.08 a day and US$2.15 a day, respectively, at 1993 international prices [equivalent to US$1 and US$2 in 1985 prices, adjusted for purchasing power parity]).[64] At household level, poverty is related to rural residence (specifically to living in the north or the east), land shortage, low levels of education, being headed by a female widow or by an elderly person, and limited access to markets. Unequal sharing of resources within households reflects not only cultural factors but unequal access to education and physical assets such as land, in which women are disadvantaged.[74]

To continue to qualify for assistance from the World Bank and IMF, Uganda had to develop a Poverty Reduction Strategy Paper (which some critics claim is simply a new name for structural adjustment). Progress on implementing the PRSP determines aid, including debt relief (see below). A 2002 report from the Institute of Development Studies at the University of Sussex highlighted the complexities of the poverty reduction process in Uganda. Although the authors commend past achievements, they question Uganda's capacity to create nationally owned, evidence-based poverty reduction policies. One major constraint is governance, which remains an area of contention between the government and donors.[85]

Debt

Based upon its record of macroeconomic policies, structural adjustment, and development of a comprehensive poverty reduction strategy, Uganda became the first country to benefit from debt relief under both the original and enhanced frameworks of the Heavily Indebted Poor Countries (HIPC) Initiative, which is managed by the IMF and World Bank.[86] However, Easterly of the Center for Global Development states that:

"The IMF and World Bank declaring a country eligible for debt relief is an admission that past loans, including adjustment loans, did not bring enough current account adjustment and export and GDP growth in that country to keep debt ratios within reasonable bounds."[83]

Uganda reached the HIPC completion point under the original framework in April 1998, and under the enhanced framework in May 2000. Assuming full delivery of HIPC assistance, Uganda received debt relief equivalent to US$347 million and US$656 million in net present value (NPV) terms under the original and enhanced frameworks, respectively.[86] 

Part of the debt relief from the World Bank was in the form of a US$75 million grant allocated to the Universal Primary Education Program. The Bank projects that HIPC assistance, in conjunction with comparable action by other creditors, will allow Uganda to redirect resources to priority poverty reduction efforts.[65] Expenditures on health, nontertiary education, basic sanitation, and certain rural and urban development programs have increased, from US$306.0 million in 1999 to US$401.3 million in 2000, and to US$438.2 million in 2001.[87]

HIPC is not debt cancellation; rather it is a restructuring of debt repayment through provision of grants. Uganda is required to continue servicing its debt. Moreover, HIPC does not preclude that a country will have to continue to borrow indefinitely. Uganda, for example, is and will continue to be heavily dependent on external donors and foreign creditors.[87]

Many NGOs have argued that the assumptions underlying HIPC are highly unrealistic. For example, Jubilee Plus, a U.K.-based social justice NGO, notes that HIPC assesses whether a country can afford to pay its debts by looking primarily at its export earnings and often making very optimistic assumptions about them. Countries such as Uganda, heavily dependent on one export commodity (coffee), are vulnerable to external shocks such as changes in the price of and demand for commodities as well as climatic fluctuations.[88] 

Indeed, Ugandan export revenues have declined dramatically because of falling coffee prices. In August 2002, the World Bank and IMF themselves reported that Uganda's debt was no longer sustainable:

"Uganda's external debt sustainability indicators have deteriorated since the time of the  [Debt Sustainability Analysis] for its enhanced HIPC decision and completion points. In particular, the sharp decline in international prices for robusta coffee, Uganda's principal export, has substantially lowered current export earnings and, together with lower projected growth in services exports, total export projections."[86]

"The Government of Uganda has had difficulties securing HIPC debt relief from some creditors, contrary to the principle of comparable burden sharing. With regard to restoring debt sustainability, the authorities are implementing policies to increase export earnings and diversification while containing growth in the debt stock through a gradual fiscal consolidation that does not jeopardize poverty reduction efforts and key programs that support economic growth."[86]

In April 2003, the Bank and IMF projected that Uganda's annual debt service fell to US$9 million in 2001, but will begin to rise in 2002, reaching US$51 million in 2009.[87] A 2003 study by the Bank's Operations Evaluation Department stated that the long-run debt sustainability prospects for Uganda are poor.[89]

In a September 2003 paper, Annalisa Fedelino and Alina Kudina of the IMF presented a model to examine the impact of fiscal policies on debt sustainability in African HIPC countries. Using this model, they found that Uganda's fiscal performance during 1999-2001 was inconsistent with a sustainable debt level; moreover, they projected that Uganda's debt level will remain unsustainable.[66]

Mobile and Displaced Populations

Mobility and displacement can lead to regroupings of family units and exposure to new sexual networks. Uganda's mobile and displaced populations include:

* internally displaced persons and refugees
* people affected by drought and other natural disasters
* migrant workers
* military personnel
* transport workers 
* tourism workers
* sex workers 
* individuals emigrating from Uganda to live/work 
* merchants/traders/vendors
* orphans and vulnerable children (e.g., street children) (See the Impact/Orphans section below)
* humanitarian and relief workers
* prisoners 

Below are data for several of these subpopulations.

Rural Populations

The Masaka cohort study found that rural populations experience high mobility, which is strongly and positively correlated with increased HIV, both as a risk factor and an outcome. Between 1989 and 1999, the study examined residence and mobility patterns. In the first year of follow-up, 73 percent of the cohort stayed in the same house, 5 percent moved within the village, 2 percent moved to another study village, 12 percent joined the study area, 8 percent left the study area, and 1 percent died. Overall HIV prevalence was 4.5 percent (0.7 percent in children and 7.3 percent in adults) and remained stable over the study period. Prevalence was highest among those who died (47.1 percent), followed by leavers (8.8 percent), other migrants (5-6 percent for within village and study movers, and joiners), and lowest in nonmovers (3.5 percent). Data from 10 years of follow-up indicate that HIV prevalence increased steadily from 2.4 percent in nonmovers to 14.7 percent in those moving every year (P<0.001, chi2=361). After controlling for age, sex, and marital status, the odds of HIV infection increased from 1.9 in those who changed residence once to 6.7 in those who never stayed at one place for a year (P<0.001, chi2=181). The 237 seroconverters experienced higher mobility than the rest of the population, both before and after HIV infection.[37]

Internally Displaced Persons 

See also the Governance section above.

In July 2003, the World Food Program reported that there were 820,000 internally displaced persons in Uganda.[90] In October 2003, Refugees International put this figure at 1.1 million.[82] The U.N. Office for the Coordination of Humanitarian Affairs estimated that there were 1.3 million IDPs in Uganda in November 2003.[38] 

In the northern districts most affected by the LRA insurgency (Gulu, Kitgum, Pader, and Lira), increasing insecurity and the consequent disruption of economic activities have severely impeded people's capacity to produce or buy food. IDPs are almost totally dependent on humanitarian assistance for survival.[90, 91] Refugees International reports that because of the lack of security, only Action Against Hunger in Gulu, the World Food Program, and Norwegian Refugee Council are able to travel to IDP camps to provide assistance.[82] 

"The assistance needs in the displaced person camps are overwhelming, especially as few agencies will travel to the camps to provide services. When security worsened in June 2002, government employees providing services in the camps fled, which created a 'service vacuum.' The camps are overcrowded and lack adequate infrastructure to support the large numbers of people living there. Malnutrition is high, sanitation is almost non-existent, water is insufficient, medicine is in perpetually short supply, medical care-particularly reproductive health-is generally unavailable, education is not available or of poor quality, and gender-based violence is believed to be widespread.  Prevalence rates of HIV/AIDS are estimated to be higher than the rest of Uganda outside Kampala, and condoms are unavailable." (Michelle Brown and Larry Thompson. Uganda: With More Than a Million Displaced and Conflict Continuing, Hopes Fade for Peace. Washington, DC: Refugees International, 2003 <http://www.refugeesinternational.org/cgi-bin/ri/bulletin?bc=00667>)
In November 2003, the U.N. Office for the Coordination of Humanitarian Affairs (UNOCHA) acknowledged the general lack of humanitarian access for IDPs in northern Uganda and pledged to help increase the humanitarian presence of UNOCHA and other U.N. agencies in the region.[38]
The Ugandan government has developed a draft national IDP policy, based largely on the U.N. Guiding Principles on Internal Displacement. However, governmental resources have not been forthcoming to implement it.[80]

Refugees

In July 2003, the World Food Program reported that there were 147,000 refugees in Uganda.[90] In October 2003, Refugees International put this figure at 190,000.[39] An increasing number of refugees from Sudan arriving in Uganda's Moyo District has been reported. The upsurge in violence in eastern DRC has also caused several thousand people to cross the border with Uganda into Nebbi District. As of February 2003, at least 11,000 Congolese were living in Nebbi. The security conditions in Nebbi are volatile, as the conflict in DRC tends to spill over into it.[91] 

As of July 2003, there were about 25,000 Rwandan refugees in Uganda. UNHCR has signed a tripartite agreement with the governments of Rwanda and Uganda for their voluntary repatriation.[92]

People Affected by Drought

In July 2003, the World Food Program reported that there were 655,000 Ugandans affected by drought.[90] In the Karamoja Region in eastern Uganda (Kotido, Moroto, and Nakapiripirit districts), a poor 2002 harvest led to low household food stocks and decreased market supplies. Some people have started moving to urban areas in search of work. Pastoralists have also moved in search of food.[91]

Military and Other Uniformed Services

There are approximately 190,000 Ugandans in the uniformed services: military: 50,000; police: 18,000; prison staff: 25,000; and border guards, customs, and national service personnel: 96,000.[93] Given the conflicts discussed above, members of the Ugandan People's Defense Forces (UPDF) are frequently rotating between bases within Uganda and between Uganda and DRC.[28]

Soon after he became president, Yoweri Museveni sent Ugandan army officers to Cuba for military training. In Cuba, they were screened for HIV before beginning their training. Many were infected with HIV, and Cuban President Fidel Castro contacted Museveni to alert him of these findings.[49] This scenario appears to have heavily influenced Museveni's decision to take significant action on HIV/AIDS shortly after assuming the presidency; moreover, it led to the military's early and substantial involvement in HIV/AIDS activities.[93] (See the Response section for details.)
According to a 2002 report from UNAIDS, because of the economic situation, the educational level of applicants to the Ugandan military, police, and other uniformed services is rising. Many have good knowledge of HIV transmission and prevention. However, the longer one remains in the services, the more likely he/she is to become infected with HIV. A significant increase in HIV infection has been reported among those who stay in the services six years or longer.[93]
Trafficking
Uganda is a source country for women and children trafficked to Sudan. Over the past 15 years, the LRA has