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 abducted tens of thousands of adults and children and forced them to work as porters and cooks, serve as sex slaves, and become rebel soldiers.[94]
The Government of Uganda acknowledges that internal trafficking of children for labor and commercial sexual exploitation is a growing problem. Street children and child domestics work long hours, are frequently denied food, endure physical and sexual abuse, and are isolated from their families and friends. The government is making significant efforts to fully comply with minimum standards for the elimination of trafficking; severe resource constraints are among the factors impeding progress.[94]
Health System

See also the accompanying table of indicators.

Health Status

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.[95] 

In its 2002 Poverty Reduction Strategy Paper progress report, the government noted that:

"Perhaps the issue of most concern raised in the Progress Report is the persistence of high mortality in Uganda, especially among infants, young children and mothers."[55] 

It also noted that ill health was the most frequent cause and consequence of poverty cited in the 1999 Uganda Participatory Poverty Assessment Project.[55]

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. Infant mortality fell from 133 in 1960 to 79 in 2001.[3] Despite these declines, however, infant and under-five mortality rates stagnated during the 1990s; factors include high fertility, low birth spacing, adolescent pregnancies, unsupervised deliveries, declining immunization coverage, increased malaria prevalence, and malnutrition.[51] Between 1995 and 2000, immunization coverage declined significantly. Overall, the share of fully immunized children fell from 47 to 37 percent, mainly attributed to a significant decline (from 61 to 46 percent) in diphtheria-tetanus-pertussis (DPT) immunizations. Coverage for measles, TB, and polio also decreased. Tetanus toxoid vaccination for pregnant women also fell during this period, from 54 to 42 percent.[55]

Uganda's Ministry of Finance, Planning, and Economic Development has found that the infant mortality gap between the rich and the poor has been widening. Infant mortality is almost 80 percent higher among the poorest 20 percent of the population compared with the richest.[55]

Another critical health indicator is the maternal mortality ratio (MMR). As mentioned above, 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]

(AIDS mortality is discussed in the Impact section below.)

Health System

In the mid-1960s, Uganda's health care system was one of the finest in Africa. However, war and economic decline severely weakened it.[78] Only 42 percent of Uganda's 5,152 parishes have any form of health facility.[61] 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. For example, between 1996 and 2000-01, average distance to the nearest health facility increased from 4.0 to 4.8 km.[55] 

In 2001, the government reported 1,156 public health units across the country (hospitals, health centers, dispensaries, and maternity units).[78] 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.[61] 

Health Expenditures

In 2000, public expenditure on health was 1.5 percent of GDP; private health expenditure was 2.4 percent of GDP.[64] Whereas the MOH estimates that at least US$28 per person is required to fund the minimum package of essential health services outlined in its Health Sector Strategic Plan, health expenditure per capita in 2001-02 was US$15. According to Uganda's Global Fund for AIDS TB & Malaria country coordinating mechanism, of this amount, public expenditure accounted for US$8 and private expenditure for US$7; external donors accounted for US$3.60 of the US$15 total.[61]

Decentralization and Abolition of User Fees

The government's overarching policy framework for the health sector is the Health Sector Strategic Plan, launched in August 2000. The plan targets cost-effective interventions for the heaviest disease burdens with a minimum health care package of essential services. The health plan is also based on decentralization; however, this process is proving to be extremely costly.[55]

In February 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. If quality declines, usage of public facilities may also fall.[55] (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.[55])

The government has released extra funds to close the gap left by user fee abolition, but health districts still have highly inadequate resources. One reason is administrative delays between the Ministry of Health and the Ministry of Public Service, which leave districts with little operational cash. Consequently, some districts have failed to pay health worker's salaries for months. Another factor is that all government health facilities must purchase drugs through the National Medical Stores and on cash terms; thus, cash-strapped health districts are unable to obtain drugs.[55]

Despite abolition of user fees, numerous financial barriers to health care utilization remain. Very few drugs are free (and the drug formulary remains severely limited), and patients must still pay for diagnostic services.[96] 

Tuberculosis

According to WHO, Uganda is a "high TB burden country." In 2001, it 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 in 2001. Among adult (15-49) TB cases, 35 percent are infected with HIV. An estimated 0.5 percent of new cases are multidrug-resistant.[97] According to WHO, constraints to achieving TB targets include:

* limited staffing at central level
* weak central-level laboratory quality control and insufficient training of staff
* poor TB control in urban settings
* increasing prevalence of HIV infection in TB patients

Malaria 

During the 1990s, malaria prevalence increased. In response, the government abolished taxes and tariffs on bednets.[51] 

Researchers from Rome's Istituto Superiore di Sanità; the University of Milan; Lacor Hospital in Gulu District, Uganda; and Circolo di Busto Arsizio Hospital in Varese examined the association between HIV and malaria in northern Uganda. From 1996 to 2000, they conducted epidemiologic and immunologic studies at Lacor Hospital in Gulu: an HIV serosurvey among 699 adult patients admitted to the medical ward and an unmatched hospital-based case-control study involving 36 clinical malaria cases and 134 controls. The serosurvey found very high HIV prevalence among patients admitted for malaria at Lacor Hospital (48.8 percent; 95 percent CI: 32.9-64.9) compared to that estimated for the general population living in the hospital's catchment area (17.8 percent in 1996-1997), suggesting an association between HIV and malaria. To test this hypothesis, the researchers undertook a case control study, which showed a significant association between HIV and clinical malaria (OR=3.61, 95 percent CI: 1.04-12.52).[98]

Hepatitis C

In a retrospective study conducted by the Joint Clinical Research Center in Kampala involving 102 HIV-positive patients admitted between January and December 2000, the prevalence of hepatitis C among HIV-positive patients was 2.9 percent. HCV/HIV coinfection was confined to patients ages 25-50. In addition, 8.8 percent of patients had abnormal aminotransferase (ALT) levels.[99]

Sexual & Reproductive Health

See also the accompanying indicator table.

UNFPA ranks Uganda a Category "A" Country, meaning that it is furthest from achieving the goals of the International Conference on Population and Development (ICPD), held in Cairo in 1994, and has low levels of development. Group A countries have the greatest need for external assistance and the lowest capabilities for mobilizing domestic resources to close this gap.[100]

Maternal Health

As mentioned above, Uganda's MMR is extremely high: 880 deaths per 100,000 live births. In 2000, Uganda had the world's 13th-highest number of maternal deaths. A Ugandan woman's lifetime risk of maternal death is 1 in 13.[72] Obstetric fistula are a major cause of maternal morbidity.[101] A 1986 study found that 35 percent of maternal deaths were linked to complications from unsafe abortion. In the country's main referral hospital, induced abortion has been ranked as the second-leading cause of maternal mortality.[102] Another factor is anemia: three out of 10 women ages 15-49 are anemic. Anemia is more prevalent among women living in rural areas, women who have given birth, women with no education, and women living in the eastern part of the country.[41]

According to the 2000-01 UDHS, antenatal care is almost universal in Uganda (92 percent). Women in urban areas are three and a half times more likely than rural mothers to receive ANC from a doctor (26 percent and 7 percent, respectively). Rural women are more likely than urban women to receive ANC from a nurse or a midwife (85 percent and 71 percent, respectively). Seventy percent of women use a public facility for ANC, of which the most common are government health centers (38 percent) and government hospitals (28 percent).[41]

About 62 percent of births are delivered at home. Delivery in a health facility is more common in urban than in rural areas (79 percent and 32 percent, respectively). Mothers with secondary education are over three times more likely to deliver at a health facility than women with no education (72 percent and 21 percent, respectively).[41]

Fertility

Fertility levels in Uganda are high; the total fertility rate (TFR) for 2000-05 is 7.1 (the average number of children a woman would have assuming that current age-specific birth rates remain constant throughout her childbearing years, usually considered to be ages 15 to 49). By comparison, the median TFR for sub-Saharan Africa is 5.6 and for the least-developed countries, it is 5.3.[103] According to the U.N. Population Division, Uganda's TFR is the fifth-highest in the world. The division projects that the TFR will decline to 6.37 during 2010-2015, to 5.43 during 2020-2025, and to 2.90 during 2045-2050.[31]

Contraception

Awareness of family planning is nearly universal: 96 percent of women ages 15-49 and 98 percent of men ages 15-54 know of at least one method of contraception.[41] However, use of contraception remains low. During the 1990s, contraceptive prevalence was estimated at 23 percent for all methods and 18 percent for modern methods.[71]Among currently married women, 35 percent have an unmet need for family planning services (21 percent for spacing births and 14 percent for limiting them).[41]

Researchers from the Rakai Project assessed the association between hormonal contraception use and HIV acquisition. Between 1994 and 1999, a group of 5,117 sexually active HIV-negative women were surveyed at 10-month intervals. Information on demographic and sociobehavioral characteristics, use of hormonal contraception (pill and injectable methods), condoms, and the number of sexual partners was obtained through home-based interview. A total of 960 women used some hormonal contraception, either oral or injectable, during the period of observation. Participants ages 20-24 and 25-34 showed the highest use of hormonal contraceptives (19.9 percent and 23.5 percent, respectively). Hormonal contraceptive use was lowest in adolescents and older women (roughly 10 percent each). The proportion of women using hormonal contraceptives increased with higher levels of education and number of sex partners. HIV incidence was 2.3 per 100 person-years in hormonal contraceptive users compared with 1.5 per 100 person-years in nonhormonal contraceptive users (unadjusted IRR, 1.56; 95 percent CI, 1.00-2.33). After multivariate adjustment, the IRR associated with hormonal contraceptives was reduced to 0.94 (95 percent CI, 0.53-1.64). The adjusted IRR was 1.12 (95 percent CI, 0.48-2.56) with oral contraceptive use and 0.84 (95 percent CI, 0.41-1.72) with injectable methods. Use of hormonal contraception was not associated with HIV acquisition after adjustment for behavioral confounding.[27]

Abortion

In Uganda, abortion is permitted only to save the life of the woman, preserve physical health, or preserve mental health (it is not permitted in cases of rape or incest). Although the law does not require the approval of a committee, the consent of two physicians is usually sought before a legal abortion can be performed. Illegal abortions are common and are more prevalent among young women. A survey carried out in 1988 among women ages 15-24 found that 23 percent of those who had ever been pregnant had had one or more abortions.[102] (See also the Maternal Health section above.)

Young Women

Adolescent pregnancy and motherhood are major concerns, as they are associated with higher morbidity and mortality for both the mother and the child. Moreover, adolescent pregnancy often ends the education of the mother. According to the 2000-2001 UDHS, 31 percent of teenagers have begun childbearing, 26 percent are mothers, and 6 percent are pregnant with their first child. These figures represent a dramatic decline from the 43 percent of teenagers who had begun childbearing observed in the 1995 UDHS.[41] However, the number of births to young women (ages 15 to 19) remains very high, 211 per 1,000 women; by comparison, the median figure for sub-Saharan Africa is 117.[71] 

Sexually Transmitted Infections

Effect of STI Treatment on HIV Infection
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. Researchers randomly allocated all adults living in 18 communities in Masaka to receive behavioral interventions alone (group A), behavioral and STI interventions (group B), or routine government health services and community development activities (group C). Compared with group C, the incidence rate ratio of HIV was 0.94 (0.60-1.45, p=0.72) in group A and 1.00 (0.63-1.58, p=0.98) in group B, and the prevalence ratio of use of condoms with last casual partner was 1.12 (95 percent CI 0.99-1.25) in group A and 1.27 (1.02-1.56) in group B. Incidence of HSV-2 was lower in group A than in group C (IRR 0.65, 0.53-0.80) and incidence of active syphilis and prevalence of gonorrhea were both lower in group B than in group C (active syphilis IRR, 0.52, 0.27-0.98; gonorrhea prevalence ratio, 0.25, 0.10-0.64). The researchers 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.[57]
The Rakai Project used a randomized, controlled, single-masked, community-based trial of intensive STI control through home-based mass antibiotic treatment. Ten community clusters were randomly assigned to intervention or control groups. All consenting residents ages 15-59 years were enrolled; visited in the home every 10 months; interviewed; asked to provide biologic samples for assessment of HIV and other STI infection; and were provided with mass treatment (azithromycin, ciprofloxacin, metronidazole in the intervention group, vitamins/anthelmintic drug in the control). Intention-to-treat analyses used multivariate, paired, cluster-adjusted rate ratios. The baseline prevalence of HIV was 15.9 percent. Seventy-five percent of intervention-group and 72.6 percent of control-group participants provided at least one follow-up sample for HIV testing. At enrollment, the two treatment groups were similar in STI prevalence. At 20-month follow-up, the prevalences of syphilis (352/6238 [5.6 percent] versus 359/5284 [6.8 percent], rate ratio 0.80 [95 percent CI, 0.71-0.89]) and trichomoniasis (182/1968 [9.3 percent] versus 261/1815 [14.4 percent], rate ratio 0.59 [0.38-0.91]) were significantly lower in the intervention group than in the control group. The incidence of HIV was 1.5 per 100 person-years in both groups (rate ratio 0.97 [0.81-1.16]). No effect of the intervention on HIV incidence was observed. The researchers concluded that a substantial proportion of HIV acquisition in Rakai appears to occur independently of treatable STI cofactors.[104]
Whereas the two trials above did not find that STI interventions affected HIV incidence, a trial conducted as part of Tanzania's Mwanza Cohort Study found that improved syndromic management of STIs reduced HIV incidence by 38 percent in intervention compared to control communities in Mwanza.[105] Various hypotheses have been offered to explain the Masaka and Rakai (Uganda) and Mwanza (Tanzania) findings, including differences in the epidemic's maturity, STI patterns, and effectiveness of the interventions assessed.[57] 
In April 2003, researchers from LSHTM published an analysis of these three trials. Age and sex stratified prevalences of gonorrhea, chlamydia, syphilis, HSV-2, and trichomoniasis observed at baseline in the three trials were adjusted for sensitivity and specificity of diagnostic tests and for sample selection criteria. The researchers found that limited sensitivity of diagnostic and screening tests led to underestimation of STI prevalence in all three trials, particularly in Mwanza. Adjusted prevalences of curable STIs were higher in Mwanza than in Rakai and Masaka. After adjustment, gonorrhea prevalence was higher in men and women in Mwanza (2.8 percent and 2.3 percent) compared to Rakai (1.1 percent and 1.9 percent) and Masaka (0.9 percent and 1.8 percent). Chlamydia prevalence was higher in women in Mwanza (13.0 percent) compared to Rakai (3.2 percent) and Masaka (1.6 percent) but similar in men (2.3 percent in Mwanza, 2.7 percent in Rakai, and 2.2 percent in Masaka). Prevalence of trichomoniasis was higher in women in Mwanza compared to women in Rakai (41.9 percent versus 30.8 percent). Although HSV-2 prevalence and prevalence of serological syphilis (TPHA+/RPR+) were similar in the three populations, the prevalence of high titer syphilis (TPHA+/RPR >/=1:8) in men and women was higher in Mwanza (5.6 percent  and 6.3 percent) than in Rakai (2.3 percent and 1.4 percent) and Masaka (1.2 percent and 0.7 percent).[106]
Relationship between STI and HIV Infection

Researchers from the Masaka Study found a strong association between HIV and HSV-2 infection. Prevalence at baseline was 9.6 percent for HIV, 27.7 percent for HSV-2, and 13.0 percent for active syphilis. The incidence rates per 100 person-years (events/person-years) were 0.74 (304/41060) for HIV, 3.1 (428/13607) for HSV-2, and 2.6 (961/36676) for active syphilis. Both HSV-2 and active syphilis prevalence were higher among HIV-positive than HIV-negative adults (80 versus 23 percent for HSV-2, p<0.001; 19 versus 12 percent for active syphilis, p<0.001). HSV-2 and active syphilis prevalence were associated with HIV incidence; age/sex adjusted rate ratios were 6.17 (95 percent CI, 4.46-8.55) and 1.42 (95 percent CI, 1.00-2.04), respectively. HSV-2 incidence per 100 person-years was significantly higher among those who were HIV-positive (15.7) than among those HIV-negative (3.0) (p<0.001). However, active syphilis incidence per 100 person-years was similar in those HIV-positive (2.7) and HIV-negative (2.6) (p=0.72).[107]
Another MRC study in Masaka used a cross-sectional survey to assess whether STIs and sexual behavior are independently associated with HIV among adults and adolescents. Researchers found that women reporting genital ulcers in the last 12 months were over twice as likely to be HIV-positive after adjustment for sociodemographic factors and number of lifetime sex partners (OR, 2.5; 95 percent CI, 1.9-3.4). Equivalent associations were stronger for men (OR, 3.2; 95 percent CI, 2.2-4.7) but weaker for adolescents (OR, 2.0, 95 percent CI, 0.5-8.7). Number of lifetime sex partners was associated (p<.05) with HIV status for women, men, and adolescents independent of reported genital ulcers. The strongest independent association observed between HIV prevalence and measures of sexual behavior among adolescents was reporting ever having had a casual sex partner (OR, 4.5, p< .001). Men reporting ever having used condoms had 70 percent higher adjusted odds of being HIV-positive than HIV-negative (p = .001). This factor was the only one, in addition to lifetime sex partners, to remain significantly associated with HIV prevalence after adjustment.[108]
Other STI Data

To determine STI prevalence in rural STI clinic attendees, researchers from Case Western Reserve University and Mulago Hospital undertook a cross-sectional study at two rural clinics from June to August 2001. A total of 394 patients (mean age 28), of which 77 percent were female, were seen. One-quarter reported lower abdominal pain, 44 percent abnormal vaginal discharge, 6 percent urethral discharge syndrome, and 11 percent genital ulcers. Prevalence of gonorrhea was 8 percent; trichomoniasis: 9.0 percent; and chlamydia: 1 percent. Fifteen percent of patients tested HIV-positive and 3 percent RPR positive. Of 25 people tested for HSV-2, 30 percent were positive. The sensitivity, specificity and PPV of vaginal discharge or lower abdominal pain diagnosis, compared to PCR diagnosis for gonorrhea, trichomoniasis, or chlamydia, was 80, 24, and 21 percent, respectively. In men sensitivity, specificity and PPV for urethral discharge syndrome compared to PCR for gonorrhea or chlamydia was 91, 83, and 43 percent, respectively.[109]

Makerere and Case Western Reserve universities are conducting a cohort study examining the relationship between hormonal contraception use and risk of HIV acquisition (the study also includes researchers working in Thailand and Zimbabwe). Since November 1999, 2,856 non-HIV-infected women ages 18-35 have been enrolled from family planning and STI clinics and community settings. At baseline, HIV prevalence was 18.6 percent. Syphilis prevalence at screening was 2.4 percent and correlated with HIV prevalence (p<0.05). Prevalence of infection due to C. trachomatis was 3.0 percent. Bacterial vaginosis prevalence was 9.3 percent and not related to age and yearly number of sex partners at baseline.[110]

Stigma and Discrimination

One of the key players in the response to the HIV/AIDS epidemic in Uganda has been the AIDS Support Organization (TASO), established in 1986 to provide care and support to and fight discrimination against PLWHA.[32, 58]A 2001 analysis of HIV/AIDS-related stigma and discrimination undertaken by TASO for UNAIDS found that in the early to mid-1990s, despite the efforts of TASO and others, HIV/AIDS-related discrimination, stigma, and denial (DSD) were serious problems. TASO found that community members were sometimes unwilling to provide care and social support to PLWHA because of fears of HIV transmission, the stigma associated with AIDS, and judgmental attitudes. Another concern was attitudes of family members, particularly towards widows of men who had died of AIDS-related conditions. Ostracism of children and lack of familial care (including being denied food) threatened the survival of widows and their children, particularly in rural communities. HIV/AIDS was viewed as causing insecurity in employment and discrimination in the workplace. Some organizations terminated the contracts of PLWHA when they become ill. Those who were HIV-positive and unemployed found it difficult to find work; those who did find work were likely to encounter discrimination because of their HIV status. Many Ugandans blamed others for the epidemic; one research project reported that Tanzanians were blamed for bringing AIDS across the border during the liberation war of 1979, after Amin was overthrown and fled the country. Women, particularly female sex workers, were also blamed. Moreover, many communities in Uganda viewed the epidemic as a disease of rich urbanites and not a concern for rural communities.[58]

In the late 1990s, TASO and UNAIDS found declining though still high levels of DSD, particularly in relation to family and community attitudes toward PLWHA. DSD were also found
in health care and workplace environments, although in both these settings there was
evidence of some of "normalization" of response, whereby at least some PLWHA were receiving better treatment. Despite progress in these areas, however, the importance of self-stigmatization was highlighted repeatedly throughout the study.[58]

In the 2000-01 DHS, respondents were asked, "If a person learns that she/he is infected with the
virus that causes AIDS, should the person be allowed to keep this fact private or should this
information be available to the community?" Among women, 47.4 percent responded that an HIV-positive person should be allowed to keep this fact confidential; however, among men, this figure was only 28.2 percent. Ten percent of women and 8.9 percent of men were not willing to care for a relative with AIDS in their home. Respondents were also asked, "If a female teacher has the AIDS virus, should she be allowed to continue teaching in the school?" About half of women and men (49.6 and 53.0 percent, respectively) did not believe that an HIV-infected female teacher should be allowed to continue teaching.[41]

The Ugandan Government has been and continues to be supportive of a general climate to combat DSD.[58] However, much work remains to be done, particularly in terms of a legislative framework. Although the Ugandan government has excellent guidelines in place, these have not yet been translated into enforceable laws to protect PLWHA from the kinds of DSD documented in the TASO/UNAIDS report.[58]

The TASO/UNAIDS study also found that influential religious leaders were providing mixed messages about routes of HIV transmission and appropriate attitudes toward PLWHA (see the Religious Organizations section below). The study also highlighted DSD regarding the inheritance and succession rights of women (see Gender section below).[58]

Uganda's Third National AIDS Conference, held in October 2002, also found that HIV/AIDS-related stigma remains high.[28] Dr. Daphne Topouzis of FAO also notes that "AIDS is rarely acknowledged as a cause of death even in countries that are 'open' about the epidemic, such as Uganda."[111]

See also the Human Rights section below.

Gender

Ugandan women are vulnerable to HIV given their low status, lower educational attainment, higher unemployment, and weaker negotiating skills within relationships.[27] The TASO/UNAIDS study discussed above found that although the majority of married women were aware of HIV transmission issues, they felt unable to control the risk behavior of their male partners or to negotiate safer sex.[58]

UNDP measures gender inequality by using the unweighted average of three component indices: life expectancy, education, and income. Its Gender-related Development Index (GDI) value ranges from 0 (lowest gender equality) to 1 (highest gender equality). In 2001, UNDP calculated Uganda's GDI value at 0.483, ranking it 117 out of 144 countries for which UNDP calculated a GDI.[64] The country's high MMR (see above) is also an indication not only of poor reproductive health, but of women's low status and poor access to basic health services. 

The government has implemented a far-reaching affirmative action program to promote women's political participation. National and local elective offices have been reserved for women, and the number of women holding seats in Parliament has risen.[59] By law, women must constitute one-third of the members of Parliament, and four individuals are elected by youth caucuses to represent youth in Parliament.[32]  In 2001, 27.3 percent of seats in Parliament were held by women.[64] Civil society has also been very active in women's issues, with numerous women's rights groups working in the country (see the Links section). 
According to a July 2003 Human Rights Watch report:
"The Ugandan government has been widely credited with emphasizing the empowerment of women and girls in recent policy-making....The government adopted a National Gender Policy in 1997 and formulated a National Action Plan on Women. The 1995 constitution provides for affirmative action through the provision of reserved seats for women in Parliament and in local government, women are now in Local Council positions, and women hold influential posts including...deputy chief justice, deputy speaker of parliament and deputy inspector-general of police. The government established a Ministry of Gender, Labor and Social Development in 1988 and a Directorate of Gender and Community Development to integrate gender within the development process. Women's Councils have been established under the National Women's Council Act 1993....Despite this progress, many customary and statutory laws discriminate against women in areas of marriage, divorce, and inheritance."[78]
Poverty

According to Uganda's Poverty Reduction Strategy Paper:

"At the level of the household, poverty is related to rural residence (specifically to living in the north or the east), to land shortage, to low levels of education, to being headed by a female widow or by someone old, and to limited access to markets. Unequal sharing of resources within the household reflects not only cultural factors but unequal access to education and physical assets such as land, in which women are disadvantaged."[74]

Across Ugandan households, 27.5 percent are headed by women (30.8 percent in urban areas versus 27.0 percent in rural areas).[41] 

Land Tenure

The subsistence food crop farmers that constitute the largest group of the poor in Uganda are predominantly women. Women provide 75 percent of total agricultural labor and over 80 percent of labor in food crop and nontraditional export sectors. However, the current legal framework constrains women's access to land; when husbands die, the wife often loses rights to the land she has been cultivating. The HIV/AIDS epidemic, by increasing adult mortality rates, has rendered this problem particularly acute.[59] According to Human Rights Watch:

"A 1998 Land Act, intended to decentralize land administration, strengthen security of tenure, and address historical gender imbalances in land ownership, failed to provide for spousal co-ownership of land despite extensive lobbying. In June 2003, the Ugandan parliament passed the Land Act (Amendment) Bill, which provides for a spouse's 'security of occupancy' on family land. Although the bill would provide women with greater security of tenure, it still fails to provide women with equal rights of ownership."[78]

Property Grabbing

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. A study by the Horizons Project of the Population Council and Makerere University's Department of Sociology found that property grabbing in Uganda is widespread. Among widows (n = 204) in the study, 29 percent reported that property was taken from them when their husbands died, rendering them four times more likely than widowers to have experienced property grabbing.[112] 

Daphne Topouzis of FAO has also reported that Ugandan widows and their children often have great difficulties in retaining family land and other assets, which tend to revert to the late husband's family after he has died because of AIDS.[111] According to the TASO/UNAIDS study mentioned above, 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. Moreover, denial of one's inheritance or succession rights is not necessarily related to the death of a husband; the TASO/UNAIDS report found that some fathers and other relatives appeared unwilling to bestow bequests of any kind upon women with HIV and their children.[58] 

Human Rights Watch has also found numerous examples of property grabbing, wherein widows were evicted from the marital home and their assets seized by in-laws. HRW goes on to report that:

"The enactment of the 1972 Succession (Amendment) Decree was intended to rationalize the law of inheritance and make it applicable to all Ugandans. The decree restricts the application of customary law, recognizes women's right to inherit from their husbands and fathers, and preserves the right of widows to remain in the matrimonial home until remarriage or death. However, customary law continues to be applicable with regard to the appointment of a 'customary heir' and in polygynous marriages....In reality, the succession laws are largely ignored. The court procedures for administering estates are arduous and costly, and unless grants of probate or letters of administration are required for formal matters (such as for banking purposes), or property disputes are referred to the courts, customary practices are commonly followed."[78]

Education

According to the 2000-01 UDHS, 27 percent of females age six and above have never been to school, compared with only 15 percent of males. In all age groups except the youngest, males are less likely to have no education and more likely to have attained some secondary education than females.[41] (See also the accompanying indicator table for gender-disaggregated enrollment ratios and literacy rates.) 

Employment

Among Ugandan women who are currently employed, 77 percent work in the agriculture sector. Twenty-seven percent of employed women receive payment in cash only, 35 percent receive both cash and kind, 9 percent receive only payment in kind, and 29 percent receive no payment for their work.[41]

Polygyny

The 2000-2001 UDHS found that 32.2 percent of married women in Uganda are in a polygynous union. This percentage is slightly higher than that recorded in the 1995 UDHS (30.0 percent). In the 2000-2001 UDHS, two in three women in a polygynous union had only one cowife. The prevalence of polygynous unions increases with age; young women are more likely to be in a monogamous marriage than older women.[41]

Sexual Violence
To examine domestic violence, the Rakai Project surveyed 5,109 women of reproductive age. The findings, published in 2003, indicated 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. Age of woman, pregnancy status, use of modern contraception, religion, and occupation of the male partner were not statistically significant predictors of violence. An exception was women's education: women with secondary schooling experience (>8 years) had significantly lower risks of violence (OR 0.66) than those with no education. Women in consensual unions¾i.e., not formally married¾faced significantly higher risks of violence (OR 1.32) than married women. (NB: Twenty-two percent of Ugandan women are in consensual unions.[41]).[113]
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 (OR 4.62). The risk of violence to women whose partners sometimes consumed alcohol before sex was also significantly higher than those with partners in the nondrinking reference group (OR 1.62). Women's own consumption of alcohol before sex was also modestly, though significantly, related to the risk of violence (OR 1.22).[113]
According to a 2003 report from the African Network for Prevention and Protection against Child Abuse and Neglect, 5,868 cases of child abuse and neglect were reported across Uganda's police stations in 2002. Girls accounted for 85.8 percent of cases reported. Of all cases reported, 4,495 were rape cases. The 2003 report notes that these figures are likely gross underestimates, as most cases of child abuse go unreported to the police. Many cases of child abuse, particularly rape, are handled by customary courts at village level.[114]
According to the July 2003 report from Human Rights Watch, Ugandan women:
"[C]onfront an environment that sustains unequal power relations, contend with persistent societal pressure to tolerate violence, and whose husbands and extended family routinely subject them to coercion and emotional abuse....A discriminatory legal framework is just one of the many obstacles that Ugandan women face in trying to escape abusive relationships. Women remain without adequate recourse to state protection whether through the police or the local courts, and contend with social stigma when attempting to prosecute their abusers. Biased officials, convoluted legal processes, and the imposition of official and unofficial 'fees' hinder women at every step. The belief that domestic violence is a private concern that should not involve the state permeates all levels of the justice system, ensuring that perpetrators of domestic violence go largely unpunished."[78]
Bride Price and Widow Inheritance

According to Human Rights Watch, the payment of bride price (dowry) is a major factor related to domestic violence and women's economic subordination in Uganda. Economic vulnerability also plays a role in widow inheritance, wherein when a man dies, his brother is appointed to marry the widow.[78] 

Female Genital Mutilation
Uganda's demographic and health surveys from 1988-89, 1995, and 2000-01 did not collect data on female circumcision. According to Amnesty International, 5 percent of women and girls in Uganda have undergone FGM (clitoridectomy and excision). (This figure should be viewed with caution, as it is presumably from the early to mid-1990s). No law specifically prohibits FGM, though the government publicly condemns it.[115]
FGM has mainly been practiced within the Sabiny ethnic group in eastern Uganda's Kapchorwa District. The Sabiny Elders Association has worked to find cultural alternatives/rituals to FGM. In 1996, the association partnered with UNFPA to address this issue and has since become a model of global best practice.[116] 

Awareness and Knowledge of HIV/AIDS

Uganda conducted national demographic and health surveys in 1988-89, 1995, and 2000-01. The 1988-89 DHS did not include any items on sexual behavior or HIV/AIDS. A 2003-04 DHS is currently under way.[48]

The 2000-01 UDHS asked respondents whether they had ever heard of HIV/AIDS; no description of the disease or its symptoms was provided. One hundred percent of men and 99.7 percent women reported that they have heard of HIV/AIDS. However, 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. A sizeable proportion of respondents (13.5 percent of women and 5.2 percent of men) know that AIDS can be avoided but do not know a particular method to avoid contracting it.[41] In the 1995 UDHS, these last figures were 13.6 and 8.7 percent, respectively.[117]  

In 2000-01, when respondents were asked to spontaneously name methods to avoid HIV infection, the top methods named were using condoms (mentioned by 54.4 percent of women and 72.3 percent of men), abstaining from sexual relations (49.7 percent of women and 65.4 percent of men), and limiting sex to one partner/staying faithful to one partner (49.0 percent of women and 43.0 percent of men).[41] These figures represent substantial increases from the 1995 UDHS, when 21.4 percent of women and 32.0 percent of men mentioned condoms; 34.2 percent of women and 36.5 percent of men mentioned abstinence.[117]

In the 2000-01, 88.8 percent of women and 89.1 percent of men knew that HIV can be transmitted from mother to child. However, among them, only 46.3 percent of women and 43.3 percent of men know that HIV can be transmitted during breastfeeding.[41] Nevertheless, these figures represent substantial increases in knowledge since 1995. In the 1995 UDHS, 85.8 percent of women knew that HIV can be transmitted from mother to child; only 0.6 percent knew that HIV can be transmitted during breastfeeding. Among men, these figures were 84.4 and 0.5 percent, respectively.[117]

Misconceptions about HIV/AIDS

Despite the universal awareness of HIV/AIDS, misinformation still persists. For example, the 2000-01 UDHS found that 12.4 percent of men and 22.8 percent of women do not know that a healthy looking person can be HIV-positive. Among those ages 15-19, these figures are 19.9 and 28.0 percent, respectively.[41] 

Among all women, the 2000-01 figure represents an increase from the 1995 UDHS (i.e., a decline in knowledge), when 16.7 percent did not know that a healthy looking person can be HIV-positive. Similarly, among women and men ages 15-19, the 2000-01 figures represent increases from the 1995 UDHS (i.e., a decline in knowledge), when 18.8 percent of men and 21.5 percent of women did not know that a healthy looking person may be infected with HIV.[117] (NB: 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])

Sexual Behavior

As discussed above, 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]

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 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])

Age at First Sexual Intercourse

In the 2000-2001 UDHS, respondents were asked to report their age at first sexual intercourse. The 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.[41] 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.[117] 

In 2000-01, there were no variation in median age at first sex between women and men with no formal education and those with primary education. For women with at least some secondary education, first sex occurs 1.8 years later for than less-educated women. However, among men, there is no difference in the initiation of sexual intercourse by educational attainment. The median age at first sex was slightly higher among rural men than among men living in urban areas (ages 25-54): 18.9 versus 18.6 years (in 1995, these figures were 17.6 and 17.2, respectively). However, among women ages 20-49, urban women had a slightly higher median age at first sex (17.0) compared to rural women (16.6) (in 1995, these figures were 16.4 and 16.1, respectively).[41, 117]

Age at First Marriage

Although the minimum legal age for a woman to marry is 18 years in Uganda, the 2000-2001 UDHS results show that the median age at first marriage among women ages 20-49 is 17.8 years, a figure that has been fairly stable for the past 30 years. Among women ages 20-49, 16.9 percent
were married by age 15 and 53.2 percent were married by age 18. Fewer women are marrying at very young ages; for example, among women ages 15-19, only 6.6 were married before age 15, compared to 22.2 percent of women ages 45-49. Among men ages 25-54, the median age at first marriage is 22.3. By age 20, 26.4 percent of men have been married, compared with 73.0 percent of women.[41] 

Recent Sexual Activity

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.[117] 

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.[41] 

Among never-married men, 13.3 percent reported sexual activity in the four weeks prior to the 1995 UDHS. Among all men ages 15-19, 18.9 reported sexual activity in the four weeks before the survey, and 52.4 percent reported never having had sex. Among men ages 20-24, these figures were 52.5 and 11.2 percent, respectively.[117] (NB: The 2000-01 UDHS did not publish data on these items for men.[41])

In 2000-01, 57.9 percent of rural women ages 15-49 reported sexual activity in the four weeks prior to the survey; among urban women, this figure was 48.8 percent.[41] (In 1995, these figures were 61.3 and 52.9 percent, respectively. Among men ages 15-54, 58.5 percent in rural areas and 57.6 in urban areas reported sexual activity in the four weeks prior to the survey)[117]

Multiple Partners

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.[41] 

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. Extramarital partners were more common among younger men (ages 15-30), men living in urban areas, and better-educated men.[41] 

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.[41] (NB: There was no item in the 1995 UDHS on number of sex partners.[117])

Condom Use

Overall, use of condoms is low, with wide gender differentials: 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.[41]

There are also wide residence differentials; with regard to a spouse or cohabiting partner, 1.9 percent of rural women and 3.3 percent of rural men report condom use at last sex; among urban residents, these figures 6.9 and 7.9 percent, respectively. For noncohabiting partners, 29.7 percent of rural women and 50.2 percent of rural men report condom use at last sex; for urban residents, these figures are 58.4 and 80.7 percent, respectively.[41]

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.[41]

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.[41] (NB: There were no items on condom use in the 1995 UDHS.[117])

Age Mixing

The Rakai Project examined whether differences in age between sexual partners affect the risk of HIV infection in female adolescents and young adults. A total of 6,177 ever-sexually active women ages 15-29 completed a sociodemographic and sexual behavior questionnaire and provided a blood sample for HIV serology. The age difference between partners was categorized as men 0 to 4 years older (referent group), 5 to 9 years older, and 10 or more years older. HIV infection in female participants increased with older male sexual partners. Among women ages 15-19, the adjusted risk of HIV infection doubled (RR = 2.04; 95 percent CI, 1.29-3.22) among those reporting male partners 10 or more years older compared with those with male partners 0 to 4 years older; among women ages 20-24, the RR was 1.24 (95 percent CI, 0.96-1.60). The attributable fraction (exposed) of prevalent HIV infection in women ages 15-24 years associated with partners 10 or more years older was 9.7 percent (95 percent CI, 5.2-14.0). HIV incidence did not increase with differences in age of partners. The researchers concluded that higher HIV prevalence in younger women is caused in part by transmission from older male partners.[118]

Sex Work

Between 2000 and 2001, Makerere University and the Center For Peace Research conducted a cross-sectional study among female sex workers in urban Kampala. A total of 500 SWs were enrolled from the major strata of SWs in Kampala: slum-based, 41.4 percent; bar-based, 30.4 percent; and street-based, 28.2 percent. Median age was 23, and 51.6 percent had ever contracted an STI. Major STI syndromes reported included vaginal discharge (70.5 percent), genital sores and swellings (57.4 percent), and lower abdominal pain and dysuria (57 percent). Almost 40 percent continued sex work while infected with an STI, and 9.4 percent had an STI at the time of the interviews. Among other findings: relative prevalence of sex with over three clients per day was 1.37, p=0.0006; RP of history of abortion was 1.6, p= 0.00007; RP of addictive drugs and substance abuse was 1.5, p=0.0002; and RP of insertion of astringents to tighten the vagina was 1.25, p=0.001.[119]

Male Circumcision
Researchers from the Rakai Project found that male circumcision is associated with reduced HIV acquisition. Using a cross-sectional study, they surveyed 6,821 men ages 15-59. Age at circumcision was divided into men who were circumcised before or at age 12 (prepubertal) and men circumcised after age 12 (postpubertal). Postpubertal circumcised men were also subdivided into those reporting circumcision at ages 13-20 and at 21 years. The study found that HIV prevalence was 14.1 percent in uncircumcised men, compared with 16.2 percent among men circumcised at age 21, 10.0 percent in men circumcised at ages 13-20, and 6.9 percent in men circumcised at age 12. Circumcision was significantly associated with reduced HIV acquisition in the cohort as a whole (RR 0.53, CI 0.33-0.87), but not among non-Muslim men. On bivariate analysis, lower prevalence of HIV associated with prepubertal circumcision was observed in all age, education, ethnic, and religious groups. The multivariate adjusted odds ratio of prevalent HIV infection associated with prepubertal circumcision was 0.39 (95 percent CI, 0.29-0.53). In the postpubertal group, the adjusted odds ratio for men circumcised at ages 13-20 was 0.46 (95 percent CI, 0.28-0.77), and 0.78 (95 percent CI, 0.43-1.43) for men circumcised after age 20. Prepubertal circumcision was associated with reduced HIV risk, whereas circumcision after age 20 was not significantly protective against HIV infection.[120]
Researchers from the Rakai Project also examined male circumcision and HIV-discordant couples. Prevalence of circumcision was 16.5 percent for all men; 99.1 percent in Muslims, and 3.7 percent in non-Muslims. In discordant couples with HIV-negative men, no serconversions occurred in 50 circumcised men, whereas HIV acquisition was 16.7 per 100 person-years in uncircumcised men (P = 0.004). In couples with HIV-positive men, HIV transmission was significantly reduced in circumcised men with HIV viral loads less than 50,000 copies/ml (P = 0.02).[121] (For a response to this study, see Halperin D.T., et al. "Response to Ronald Gray, male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda (2000, 14:2371-2381)." AIDS 2002;16(5):810-12.)

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.[45]

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. There are several local forms of home-brewed alcohol in Uganda, including  malwa, tonto, and enguli.[40] As part of the Masaka Study, researchers examined the association between alcohol consumption and HIV seropositivity. At the eighth annual survey, all respondents were asked about history of alcohol consumption, sale of alcohol in their household, and other sociodemographic information. Of the total adult population, 3,279 (60 percent) were interviewed; 48 percent were male. Among the 3,279 interviewees, 905 (27 percent) had not started sexual activity and were excluded from further analysis. Of the remaining 2,374, 8 percent were HIV-positive, 57 percent had ever drunk alcohol, and 4 percent lived in households where alcohol was sold. Living in a household where alcohol was sold was associated with a history of having ever drunk alcohol (OR 2.9, 95 percent CI, 1.7-4.8). HIV prevalence among adults living in households selling alcohol was 15 percent, compared with 8 percent among those living in households not selling alcohol (OR 2.0, 95 percent CI, 1.1-3.6). Individuals who had ever drunk alcohol had an HIV prevalence twice that of those who had never drunk alcohol, 10 versus 5 percent (OR 2.0, 95 percent CI, 1.5-2.8). This association remained after adjusting for potential confounders including sale of alcohol in the household and Muslim religion (OR 1.8, 95 percent CI, 1.2-2.7). Only age, marital status, and having ever drunk alcohol independently predicted HIV seropositivity in a logistic regression model.[122]

The Rakai Project data on domestic violence cited above 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 (OR 4.62). The risk of violence to women whose partners sometimes consumed alcohol before sex was also significantly higher than those with partners in the non-drinking reference group (OR 1.62). Women's own consumption of alcohol before sex was also modestly, though significantly, related to the risk of violence (OR 1.22).[113]

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.[77]

The Narcotic and Psychotropic Substances (Control) Bill 1999 has not yet been passed by Parliament. In the interim, a national coordination committee has been formed to oversee drug-related matters. The Ministry of Internal Affairs coordinates activities in the supply reduction sector. The country's newly drafted mental health policy includes the formation of a demand reduction committee; however, until the policy is approved, an interim demand reduction committee has been formed with the MOH.[77]

Uganda has no public or private treatment clinics for drug addicts. Butabika Hospital in Kampala, however, does have a weekly outpatient clinic for drug addicts. Most drug addicts seeking treatment end up in the mental health system.[77]



Impact

At a Glance Summary Bullets

Demographic

* 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.

Health

* Uganda's health care system is under extreme strain because of HIV/AIDS. 

Households

* 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.

Orphans and Other Vulnerable Children

* About 2 million Ugandan children have been orphaned by AIDS. The percent of Uganda's orphans that could be attributed to AIDS rose from 17.4 percent in 1990 to 42.4 percent in 1995 to 51.1 percent in 2001. This percentage is projected to decline to 47.2 percent in 2005 and to 38.9 percent in 2010.

* 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.

Education

* HIV/AIDS will substantially reduce Uganda's school-age population, compared to a "no AIDS scenario." However, given continuing high fertility, absolute cohort sizes will continue to increase. 

* Studies have not found a major impact of HIV/AIDS on teachers. However, there are numerous impacts on students; for example, absenteeism and dropout rates are increasing. 

Agriculture

* Between 1985 and 2020, Uganda will have lost 14 percent of its agricultural labor force because of AIDS.[123]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. 


Demographic

Uganda's 2003 population is 25.8 million; 50.3 percent of the population is female. The U.N. Population Division examined population under a "no-AIDS" scenario. 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 (tables 1 and 2).[31] Factors include AIDS deaths, as well as reduction in fertility due to condom use to prevent infection, fewer births because of a smaller reproductive age population, and fertility reduction associated with HIV infection

Table 1. Projected Population with and without AIDS, 2000, 2015, and 2050 (Thousands)
Period
2000
2015
2050
With AIDS

Without AIDS
With AIDS
Without AIDS
With AIDS
Without AIDS
23,487 

25,214 
39,335 
43,367 
103,248 
115,754
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 <http://www.un.org/esa/population/publications/wpp2002/wpp2002annextables.PDF>



Table 2. Projected Population Reductions, 2000, 2015, and 2050
Period
2000
2015
2050
Population
Reduction
(Thousands)
Percentage Reduction
Population
Reduction
(Thousands)
Percentage Reduction
Population
Reduction
(Thousands)
Percentage Reduction
1,727   

7
4, 032 
9
12,505 
11
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 <http://www.un.org/esa/population/publications/wpp2002/wpp2002annextables.PDF>


Life Expectancy

Table 3 indicates that 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. 

Table 3. Life Expectancy with and without AIDS, 2000-2005, 2010-2015, and 2045-2050
Period
2000-2005
2010-2015
2045-2050
With AIDS
Without AIDS
Reduction in Life Expectancy
Percentage Reduction
With AIDS
Without AIDS
Reduction in Life Expectancy
Percentage Reduction
With AIDS
Without AIDS
Reduction in Life Expectancy
Percentage Reduction
46.2 



55.5 
9 
17 
55.0 
59.5 
5
 8 
69.3 
71.4
2 
3
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 <http://www.un.org/esa/population/publications/wpp2002/wpp2002annextables.PDF>

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. By 2000, there had been 1.3 million AIDS deaths in Uganda. The division projects an additional 1.4 million AIDS deaths by 2050 (tables 4 and 5).[31] 


Table 4. Projected Number of Deaths with and without AIDS, 1980-2000, 2000-2015, and 2015-2050 (Thousands)
Period
1980-2000
2000-2015
2015-2050
With AIDS
Without AIDS
With AIDS
Without AIDS
With AIDS
Without AIDS
6,874  


5,583 
6,296
5,489 
16,445 
15,825
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 <http://www.un.org/esa/population/publications/wpp2002/wpp2002annextables.PDF>



Table 5. Excess Deaths Because of AIDS, 1980-2000, 2000-2015, and 2015-2050
Period
1980-2000
2000-2015
2015-2050
Excess
Deaths
(Thousands)

Percentage
Increase
Excess
Deaths
(Thousands)
Percentage
Increase
Excess
Deaths
(Thousands)
Percentage
Increase
1,290     

23
807
15
620
4
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 <http://www.un.org/esa/population/publications/wpp2002/wpp2002annextables.PDF>

Research undertaken by UNAIDS and WHO found that for Uganda, the HIV-attributable under-5 mortality rate (per 1,000 and corrected for competing causes of mortality) was 19.9 during the 1990s. (Rates among the 39 countries studies ranged from Madagascar [0.2] to Botswana [57.7].) The HIV-related population proportional attributable risk of dying before age 5 (i.e., the proportion of all-cause under-5 mortality attributable to HIV) was 11 percent; the average for the 39 sub-Saharan African countries studied was 7.7 percent, ranging from 0.1 percent in Madagascar to 42.4 percent in Botswana.[124]

Macroeconomic

Uganda's Ministry of Finance, Planning, and Economic Development notes that despite declining HIV prevalence, Uganda has lost and will continue to lose a substantial portion of the most productive segment of the labor force.[55]According to a June 2003 report from the World Bank, previous studies have grossly underestimated the economic impact of AIDS, failing to factor in the impact of education and parenting on the economy. The authors underscore that by killing primarily young adults, AIDS does more than destroy the human capital embodied in them; it also deprives their children of the requirements (parents' care, knowledge, and capacity to finance education) to become economically productive adults. The Bank study notes that this weakening of the mechanism through which human capital is transmitted and accumulated across generations becomes apparent only after a long time lag, and it is progressively cumulative in its effects.[125]

At a November 2002 Commonwealth meeting, President Museveni reported that HIV/AIDS costs the country about US$702 million annually; malaria costs the nation approximately US$348 million each year. Contributing to these costs are loss of skilled workers, lost productivity, and the cost of medications and funerals.[126]

Welfare

Crafts and Haacker of the IMF have sought to quantify the welfare losses associated with HIV/AIDS. They used estimates and projections of the impact of the epidemic on mortality and life expectancy, as well as existing studies on the value of statistical life. They estimated welfare loss as the loss in per capita income that would have the same effect on lifetime utility as the increase in mortality, expressed as a percentage of GDP. (They do note numerous limitations of their study.) For Uganda, they found that HIV/AIDS has already resulted in welfare losses equivalent to 48.6 percent of GDP.[127]

Health

Uganda's health care system is under extreme strain because of HIV/AIDS. AIDS increases the number of people seeking services, and care for AIDS patients is more expensive than for most other conditions. The government faces the multiple challenges of securing the resources needed to treat those already infected, preventing further transmission, and treating other diseases such as TB and malaria. UNAIDS notes that the public health care sector urgently requires additional resources to accommodate the burden of the AIDS epidemic.[62]

Health professionals must attend to an increasing number of AIDS patients; as mentioned, the MOH estimates that there are about 100,000 new AIDS cases each year.[12] The health care sector has been affected by an increase in the number of OIs associated with AIDS, including TB, pneumonia, Kaposi's sarcoma, and diarrheal disease.[128]  

Researchers from the Istituto Superiore di Sanità in Rome, who work with the Lacor Hospital in Gulu in northern Uganda, estimated the impact of HIV/AIDS on hospital services. They conducted an HIV serosurvey and analyzed routinely compiled hospital records. The serosurvey was conducted among all 352 patients admitted to the medical ward in March 1999 (this ward comprises three units: general medicine, TB, and cancer). The impact on hospital services was estimated using the hospital discharge records for all 3,447 patients admitted in 1999, in combination with serosurvey data, and was expressed as the percentage of bed-days attributable to HIV-positive patients. In the medical ward, overall HIV prevalence was 42.0 percent (52.6, 44.6, and 13.2 percent in the general medicine, TB, and cancer units, respectively). The disease-specific prevalence ranged from 45-65 percent for patients with TB, pneumonia, malaria, and enteritis. Compared with HIV-negative patients, HIV-positive patients had a higher in-hospital mortality (14.6 versus 3.0 percent) and a lower average length of stay (41.4 versus 48.9 days). AIDS cases accounted for 5.0 percent of hospital admissions, 4.1 percent of bed-days, and 11.5 percent of deaths. When considering all HIV-positive patients, these accounted for 37.2 percent of bed-days.[129]

Households

See also the Gender and Stigma and Discrimination sections above.

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. David Bangsberg of UCSF posits that this intrahousehold competition for expenditures may be the single most important factor regarding who receives HIV/AIDS treatment and survives, with survival (staying healthy and employed) vital to one's ability to pay for ARVs, OI drugs, physician fees, diagnostics tests, etc.[40] 

As a result of increased AIDS-related morbidity and mortality, Ugandan household expenditure on health care has increased. To meet health costs, households are likely to deplete their savings and sell productive assets.[28] A 2003 study by Daphne Topouzis of FAO found that in the Rakai district, households are spending up to one-third of their annual cash income on monthly medical care or on a single funeral.[111] Across the country, many AIDS-affected households sell their food crops to cover hospital expenses. Some households also sell their land to raise money for medical care. In some instances, hospitals and clinics encourage terminally ill patients to surrender land titles as security for medical bills.[111] Food insecurity among AIDS-affected households is a major constraint to care and support.[28] 

Topouzis also cites a World Bank study that found that asset ownership declines when a household member with AIDS dies, but remains stable when the death is not related to AIDS. This erosion of the household resource base deprives families of the essential means of survival. Dramatic reductions in income and productivity occur just as household medical expenses are increasing. Moreover, as discussed in the Gender and Stigma and Discrimination sections above, surviving widows and their children often have great difficulty in retaining family land and other assets, which tend to revert to the late husband's family.[111] 

As previously mentioned, household poverty in Uganda 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 an elderly person, and limited access to markets.[74] Thus, these households are likely to be even more vulnerable to AIDS-related impacts. 

The burden of AIDS care falls heavily on women and girls.[58, 59] This scenario has numerous consequences in terms of girls' curtailed education and thus limited opportunities for employment in the formal labor force, which may be related to vulnerability to acquiring HIV.[130]

A study by the Research Triangle Institute found that the responsibility for day-to-day patient care is borne primarily by elderly females. Using focus group discussions, case studies, and semistructured interviews with elderly respondents (50 years and above) and community leaders in 10 rural and urban communities within two Ugandan districts, the study also found:

1. The elderly tend to help at the terminal stage of the illness when patients require the most constant care. This demanding care level leads to ailments in caregivers such as chest pains, backache, and hypertension.
2. Most elderly caregivers report limited knowledge of optimal care for ailing relatives. 
3. The elderly bear a financial burden to care for sick relatives despite being at the least economically productive stage of their lives. 
4. Although elderly persons constitute a significant proportion of HIV/AIDS caregivers, their views on how to design better interventions are rarely sought.[131]

Orphans and Other Vulnerable Children

In Uganda, an orphan is defined as a child under 18 who has lost one or both of his/her biological parents. According to the 2000-01 UDHS, 14 percent of children under age 18 are orphans. Among them, 3 percent have lost both parents, 8 percent have lost their father only, and 3 percent have lost their mother only. Among children under age 15, 12 percent have been orphaned.[41] The 1995 UDHS found that among children under age 15, 10 percent had lost their fathers and 5 percent had lost their mothers; 2 percent had lost both parents.[117]

The Uganda AIDS Commission estimates that 2 million children had been orphaned by AIDS through the end of 2001.[14] According to UNAIDS, there were 880,000 AIDS orphans (under age 15) in Uganda at the end of 2001.[132] Children on the Brink 2002, a report on AIDS orphans undertaken by USAID, UNAIDS, and UNICEF, estimated that the percent of Uganda's orphans that could be attributed to AIDS rose from 17.4 percent in 1990 to 42.4 percent in 1995 to 51.1 percent in 2001. This percentage is projected to decline to 47.2 percent in 2005 and to 38.9 percent in 2010.[133]

The study by the Horizons Project of the Population Council and Makerere University's Department of Sociology mentioned above found that property grabbing is widespread, with women and children particularly vulnerable. Among older orphans (ages 13-18, n = 105), 21 percent reported experiencing property grabbing. Despite concerns about property grabbing, only 10 percent of parents in the study had prepared written wills.[112] 

The study also assessed the impact of an orphan support program on the physical, educational, and emotional well-being of children. Using a baseline sample of 353 parents who are HIV-positive, 495 children of PLWHA, 233 orphans, and 326 current and standby guardians, the study found that:

* The impact of HIV/AIDS on children begins with parental diagnosis or onset of illness. 
* Many guardians are in poor health; some are HIV-positive. 
* Material support was the most frequently cited need of all study participants.[112]

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.[28] Orphan guardians are under considerable strain, and many households do not have sufficient resources to take in more children.[134] Although standby guardians appointed by parents are predominantly male, women ultimately assume much of the responsibility for orphaned children.[135] 

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.[112] In a 2002 World Bank study, orphans reported feeling lonely, unloved, and financially deprived. They also expressed much anxiety about their future and their prospects for further education and employment. Some reported anxiety about being vulnerable to HIV infection through sex work. Many orphans reported being subject to excessive labor demands from their guardians.[136]

A 1996 study by the Ministry of Gender, Labor, and Social Development indicated that many street children in Uganda were orphans who left home in search of new survival strategies or the company of other orphans. Overall, these children had little education, often took part in risky or criminal behavior, and were more likely to abuse alcohol or marijuana. They had low levels of knowledge about HIV/AIDS and limited access to health services.[137]

Education

According to researchers from the Department of Geography at the University of Liverpool, HIV/AIDS will substantially reduce Uganda's school-age population, compared to a "no AIDS scenario." Under the most optimistic HIV/AIDS projections, the epidemic will reduce the school-age population by 8 percent. However, given continuing high fertility, absolute cohort sizes will continue to grow at over 2 percent annually.[138]

According to researchers from the Center for International Education at the University of Sussex, mortality for both primary and secondary school teachers in Uganda peaked at less than one percent during 1995-97. About half of this mortality was AIDS-related. Both in absolute terms and in relation to high rates of attrition from other causes (resignations, retirements, etc.), the researchers did not believe that this level of mortality posed a serious threat to the education sector.[134] A 2002 World Bank study also did not find a major impact of HIV/AIDS on teachers; mortality in general was a relatively insignificant cause of teacher attrition.[136]

Neither study found high rates of absenteeism among teachers. However, both did find that absenteeism among students is high. The Sussex researchers found that absenteeism is very high among all primary school children, primarily as a result of poverty. Although student absenteeism tended to be higher among orphans than nonorphans, the differences were much lower than expected. Illness in the family was not a major reason for absence, except for maternal and double orphans. Generally, the poorest orphans had the most difficulty attending school.[134] In the Bank study, teachers identified increased levels of absenteeism and dropout rates as the principal negative effects of HIV/AIDS on students. Approximately 37 percent of students interviewed reported having lost at least one parent; 10 percent had lost both parents.[136]

Agriculture

According to FAO, between 1985 and 2020, Uganda will have lost 14 percent of its agricultural labor force because of AIDS.[123]  The 2003 Topouzis study mentioned above found that in  districts severely affected by HIV/AIDS, such as Rakai and Masaka, 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. In addition, AIDS is contributing to food scarcity in areas previously known for food availability and surplus.[111]

According to Uganda's Ministry of Agriculture, Animal Industry, and Fisheries (MAAIF), loss of senior administrators to AIDS mortality has often left significant gaps in the ministry's structure. AIDS mortality has also contributed to the elimination of the post of county extension coordinator (officers in charge of counties and district subject matter specialists who provide technical back-up and support supervision to extension workers). In the mid-1990s, one FAO study found that up to half of agricultural extension staff time in one district in Uganda was lost because of HIV/AIDS. Staff members were frequently absent from work caring for sick relatives or attending funerals. In addition, some staff members had fallen ill themselves. In 2003, MAAIF reports that increased and prolonged morbidity renders the "implementation of certain key activities impossible."[111]



Response

At a Glance Summary Bullets

Government of Uganda

* 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. 

* 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 1997, Uganda enacted a policy of decentralization. As part of this policy, local governments are encouraged to help implement the National Strategic Framework for HIV/AIDS Activities and develop HIV/AIDS interventions specific to their local context. However, most districts have not yet developed HIV/AIDS workplans.

* 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 post-test 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. 

Donors

* Total donor support for HIV/AIDS-related interventions during 1989-1998 was approximately US$180 million, representing about 70 percent of total expenditures on HIV/AIDS prevention and care in Uganda. During 2000-01, external donors spent US$43.7 million on HIV/AIDS in Uganda. Donors financing HIV/AIDS activities in Uganda include the World Bank, USAID, DFID, SIDA, CDC, EU, French Cooperation, JICA, AusAID, GTZ, NORAD, DANIDA, Italian Cooperation, and Ireland Aid. Various international NGOs also fund HIV/AIDS projects. 

* Uganda qualified for the 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$36,314,892 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$70,357,632 over two years. 

Human Rights

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

Civil Society

* 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, and households 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. 

* Key NGOs include the AIDS Support Organization, National Community of Women Living with HIV/AIDS, National Guidance and Empowerment Network of People Living with HIV/AIDS in Uganda, AIDS Information Center, Hospice Uganda, Uganda Network of AIDS Service Organizations, National Forum of PWHA Networks in Uganda, Uganda Youth Anti-AIDS Association, and Uganda Women's Effort to Save Orphans. 

* 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 Palliative Care Center. These institutions collaborate with a wide array of international partners.

* Religious organizations have a long history of providing health services in Uganda and are highly influential. The early and significant involvement of Protestant, Catholic, and Muslim leaders was crucial to HIV/AIDS efforts. Particularly critical were Uganda's bishops, who issued a statement on AIDS in 1989 that highlighted care for and compassion toward PLWHA. 

* In 1989, the Islamic Medical Association of Uganda held a national AIDS education workshop. The workshop included a declaration of support from the highest level of Uganda's Muslim community.

* IMAU manages several projects, including Community Action for AIDS Prevention, Madarasa AIDS Education and Prevention, and Family AIDS Education & Prevention through Imams,

* Studies have found that some religious organizations have a somewhat "contradictory attitude" towards PLWHA. Some influential religious leaders are providing mixed messages about routes of HIV transmission and appropriate attitudes toward PLWHA. 

* In 1992, Traditional Healers and Modern Practitioners Together Against AIDS (THETA) piloted a training project in Kampala to equip traditional healers to become HIV/AIDS/STI educators and counselors. In 1995, given requests from the Uganda AIDS Commission and various NGOs, THETA extended this training program to rural districts. 

* Following a 1999 study by the International Transport Workers' Federation (ITF), two Ugandan transport workers unions affiliated with the ITF¾the Amalgamated Transport and General Workers Union and the Uganda Railway Workers Union¾established an HIV/AIDS program. In August 2001, the program launched an HIV/AIDS/STI project targeting long-distance truck drivers and their assistants; sex workers; lodge and restaurant/bar workers; and other communities in three truckstop towns in eastern Uganda. 

* HIV/AIDS interventions undertaken by private industry have thus far been limited. 

* In May 2001, the Ugandan Business Council on HIV/AIDS was launched, with the aim of persuading large and small businesses to adopt policies to educate staff on HIV/AIDS and to support HIV-positive individuals in the workplace. In mid-2003, the council was supplying a small quantity of ARVs in Masaka.

* Under the auspices of the UAC, the Private Sector Self-Coordinating Entity brings together representatives from multinationals, local enterprises, employer federations, trade unions, insurance companies, and the informal sector to address HIV/AIDS.

* In 2000, the Bank of Uganda began to offer subsidized ART to its employees. The Bata Shoe Company, New Vision newspaper, U.N. agencies, Standard Chartered Bank, Sheraton Hotel, and British American Tobacco are also subsidizing ART for their employees.

* In October 2003, the U.S. Department of Labor's HIV/AIDS Workplace Education Program announced a US$1 million grant to World Vision and RTI International to fund a workplace HIV/AIDS education program in Uganda. 

Orphans

* 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. 

VCT

* 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 to provide long-term support for behavior change, regardless of serostatus. 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.

* Uganda does not have a comprehensive VCT policy. The MOH is currently drafting new VCT guidelines. 

* 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 through a combination of stationary sites and outreach services. 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.

* When AIC opened in 1990, services were free of charge. Cost-sharing began in January 1994, with US$0.50 charged per client in Kampala. Fees have been increasing almost annually; in mid-2003, the fee was US$2.02.

Care and Support

* 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. 

PMTCT

* The government is working with UNICEF and other key partners from bi- and multilateral agencies and NGOs to scale up PMTCT. Currently, these partners are supporting or have plans to support PMTCT activities in 43 of the country's 56 districts. The aim of Uganda's national PMTCT program is to provide PMTCT services in all 56 districts by 2005. 

* 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.

* Breastfeeding in Uganda is almost universal, with 98 percent of children having been breastfed at some time. 

Treatment of Opportunistic Infections

* Access to treatment for OIs outside Kampala and in rural areas is deemed minimal.

ART

* 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. Founded in 1990 with support from USAID as a joint project of the MOH, MOD, and Makerere University, JCRC is the main supplier of generic ARVs in Uganda; 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. The Ugandan government announced that, in light of the Doha 2001 international trade agreement permitting importation of generic drugs during health emergencies, it would now purchase generic ARVs.

* Although ARVs are now available at significantly reduced prices, the government provides no subsidy to the people 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. 

Female-controlled Prevention Technologies

* Uganda is participating in several microbicide trials. 

Vaccine Trials

* 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.

Assessment of National Response

* 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. 


Government of Uganda

Initial Response

The first AIDS cases in Uganda were identified in 1982. In 1985, the government established the National Committee for the Prevention of AIDS.[33] In 1986, the new head of state, President Yoweri Museveni, immediately recognized HIV/AIDS as a problem. The president emphasized proactive prevention and declared that preventing the spread of HIV was a patriotic duty. He stated that effective prevention required openness, communication, and strong leadership, from the village to the highest levels of government. He encouraged constant and candid media coverage of all aspects of HIV/AIDS and stated that HIV/AIDS must be placed on the development agenda. In addition, he began to assemble a large number of key national stakeholders, including NGOs, community leaders, and religious organizations.[32] Museveni also openly discussed Uganda's high HIV prevalence at a time when most African presidents were silent about their countries' epidemics.[49] And in 1986, at the World Health Assembly, Uganda's minister of health openly declared that AIDS was a problem in Uganda and asked for international support.[59] 

The new government of President Museveni moved quickly by establishing the Uganda National AIDS Control Project (NACP) in 1986, coordinated by the MOH and supported by WHO's then Global Program on AIDS. NACP focused on blood safety, prevention of HIV infection in health care settings, and education and communication. By 1988, a national seroprevalence survey had been conducted to determine the magnitude of the disease.[2, 3] The government also created AIDS control projects in 12 line ministries.[58, 59]

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

"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]

Uganda AIDS Commission 

During 1987-91, the government held consultations on a multisectoral approach to AIDS. In 1992, it adopted the Multisectoral Approach to the Control of AIDS.[2] 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, including government (line ministries), district administrators, local and international NGOs, CBOs, religious organizations, and donors and development partners. UAC, located in the Office of the President,[63] was also mandated to mobilize resources, both locally and internationally, for HIV/AIDS activities.[28] Objectives of UAC include:

* preventing transmission of HIV, with a focus on children and youth, gender issues, the special situation and needs of women, and risky or special situations and sites
* mitigating the health and socioeconomic impact of AIDS
* strengthening national capacity to respond to the epidemic, including the capacity to undertake research
* establishing a national information base on HIV/AIDS[28]  

In 1995, UAC established the National AIDS Documentation and Information Center (NADIC). NADIC acts as a national information clearing house and also provides technical assistance.[139] In late 2002, the Ugandan government established the Uganda HIV/AIDS Partnership Fund to provide a common and transparent mechanism for channeling funding to UAC.[140]

National Strategic Framework for HIV/AIDS Activities for 2000/01-2005/06 

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. The strategy specifies the following goals: 

* reduce HIV/AIDS prevalence by 25 percent by 2005-2006
* mitigate the health and socioeconomic effects of HIV/AIDS at individual, household, and community levels
* strengthen national capacity to respond to the epidemic by emphasizing collaboration and coordination among stakeholders engaged in prevention, care, and availability of affordable antiretroviral drugs
* monitor and evaluate HIV/AIDS interventions to identify replicable good practice
* continue targeting behavior change for youth
* devise effective strategies focused on reducing poverty at the household level
* increase support to assist PLWHA 
* increase care and support to vulnerable children especially orphans
* mobilize sex workers and their clients, including long distance truck drivers and bar maids
* promote gender equity and equality backed by laws to provide enforceable sustainable interventions
* build partnerships with all stakeholders and increase actions at community level
* enhance national capacity and ownership of programs
* reduce mother-to-child transmission
* strengthen research
* scale up the national response[11]
National AIDS Policy 
National policy guidelines were developed in 1993 in a process led by UAC; they were revised in 1996.[141] 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.[142]
Decentralization
In 1997, Uganda enacted a policy of decentralization.[63] As part of this policy, local governments are encouraged to help implement the National Strategic Framework for HIV/AIDS Activities and develop HIV/AIDS interventions specific to their local context.{Uganda AIDS Commission, 2000 #1} The Ministry of Local Government has an AIDS Control Unit and has integrated HIV/AIDS into the ministry's budget and workplan. Activities are being carried out in all 56 districts of the country.[143] However, Uganda's Third National AIDS Conference, held in October 2002, noted that most districts have not yet developed HIV/AIDS plans.[28] 
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] These improved national and regional blood banks currently supply 70 percent of national demand, up from approximately 25 percent in 1986.[6]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] 

Condoms

See also the Sexual Behavior section above. 

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.[24, 32] Parkhurst notes that the government did not push controversial policies such as condom use too strongly, but rather quietly promoted condoms through social marketing channels, keeping religious leaders involved.[35]

In October 2002, the MOH reported that between 1997 and 2000, over 150 million condoms were procured under the Sexually Transmitted Infections Project (STIP), which was funded by a concessional World Bank loan. During 2002, an estimated 50 million condoms were distributed in Uganda; the MOH projects that 80 million condoms will be distributed during 2003. Condom prices average $US0.03 (or UShs54) per unit.[28] With financing from the Global Fund to Fight AIDS, TB & Malaria, Uganda aims to distribute 120 million condoms annually (see below)[52] 

Female Condoms

Through the STIP, the MOH procured 1.2 million female condoms in 1998. Constraints to use include difficulty at first use, discomfort, and cost. The MOH has distributed over 600,000 female condoms and over 400,000 have been sold via social marketing channels.[28]

Multisectoral Response: Ministries outside Health
Line ministries are charged with developing sector-specific HIV/AIDS policies and guidelines.[141] Early on, the ministries of Defense and Internal Affairs developed HIV/AIDS programs. By 1995, HIV/AIDS programs had been established in several other ministries. The Government Ministries Self-Coordinating Entity (GMSCE) brings together HIV/AIDS focal officers in all ministries. During a GMSCE retreat in May 2003, the following issues were noted:[143]
* All government ministries have HIV/AIDS workplans. All but two have strategic plans relating to the National Strategic Framework for HIV/AIDS Activities. 
* Although all ministries have been implementing their workplans to varying degrees, many need financial, technical, and logistical support to reach full implementation. Lack of budget lines for HIV/AIDS constrain access to government funding.
* All ministries have designated HIV/AIDS focal point officers, but their workload is high.
* Common workplace HIV/AIDS components include staff sensitization, counseling, condom distribution, and training in counseling skills. Several ministries are involved in activities that extend beyond the workplace, for example, development of sectoral and thematic policies 
* Monitoring and evaluation components are weak.[143]
Office of the Prime Minister
The office is charged with ensuring effective implementation of HIV/AIDS activities in Uganda and in particular among IDPs, within refugee camps, and in conflict zones.[143]
Defense

As mentioned above, 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] 

In 1987, the Ministry of Defense established an AIDS control program.[2] Among its projects are post-test clubs, created in 1990, and the Network of PLWHA, created in 1997, which aim to improve the quality of life of PLWHA and advocate for their involvement at all levels of HIV/AIDS interventions and program management.[93] In addition, there are mobile health clinics that serve both armed forces and nearby populations, a clinical initiative undertaken with the MOH (the Joint Clinical Research Center, discussed in depth in the ART section below), and awareness-raising activities at all levels of the chain of command.[144] 

In its Summary of Ministerial Policy Statement for Financial Year 2003/04, the MOD states that it aims to mainstream HIV/AIDS into programs of the Uganda Peoples Defense Force (UPDF).[145] Among the challenges identified by the UPDF are institutionalization of the HIV/AIDS response, sensitization of commanders and political commissars, integration of HIV/AIDS in the training syllabus, and support to orphans and widows.[144] 

Education and Sport

The MOES is identified as the lead agency to: 

* promote AIDS education and counseling in schools, colleges, and institutions of higher learning
* develop and distribute materials and messages geared toward life skills and psychosocial development at all levels
* develop standard training curricula on palliative care
* integrate palliative care issues into the preservice training curriculum for health workers and teachers[134]

After a school health education program yielded little progress in attitudes and behavioral
change, a life skills program for primary and secondary schools was piloted in 1994. A
year later no improvement had been realized, primarily because teachers lacked confidence in using new participatory teaching methods; were uneasy and afraid (for social, religious, or work
reasons) to cover topics of sexuality and condom use; and perceived this subject to be
relatively unimportant (given the absence of related examinations).[136]

A new primary education curriculum was introduced during 2000, but coverage of HIV/AIDS was sparse. Moreover, HIV/AIDS was first mentioned in the second term of grade seven, just before students leave primary school.[134]

MOES conducted a sector review in October 2001, highlighting that HIV/AIDS education was not included in the curriculum until grade seven. Given the high dropout rate, many would miss HIV/AIDS education efforts.[146] In late 2002, the ministry launched a primary school HIV/AIDS manual, prepared by MOES in collaboration with the MOH and UAC.[147] 
However, open discussion of sexual matters in many Ugandan schools is still highly constrained.[134] The 2002 World Bank study on education mentioned above found that both teachers and students still found discussion about HIV/AIDS "embarrassing."[136]

In 2002, President Museveni urged teachers to convene general assemblies in their schools every two weeks to discuss HIV/AIDS issues with students.[126]
Justice and Constitutional Affairs 
See also the Human Rights section below.
The ministry is charged with reviewing and incorporating HIV/AIDS issues within the legal sector to manage HIV/AIDS in the workplace; ensuring nondiscrimination and fairness within the legal sector; and reviewing existing laws, policies, and practices in view of HIV/AIDS.[143] However, the country still has no specific laws regarding HIV/AIDS, including the rights of PLWHA. Laws regarding custody of children and inheritance are also inadequate.[58] 
Agriculture, Animal Industry, and Fisheries
MAAIF has been implementing HIV/AIDS activities since 1995. A strategic plan is being implemented, and the ministry is focusing on developing an HIV/AIDS policy for the agriculture sector. As yet, there is no internal funding from the ministry for HIV/AIDS. Current funding comes from the World Bank MAP project (see below).[143]
In the mid-1990s, the Family Life Education (FLE) Unit of MAAIF assumed the role of integrating the ministry into an expanded national response to HIV/AIDS. One of its initiatives was to mainstream HIV prevention and care for affected families into the core activities of the ministry. According to MAAIF, mainstreaming has been largely successful because (a) the manager of the FLE unit has been actively involved in NACP since 1994; (b) several senior MAAIF staff members have also been involved in the development of the ministry's strategic plan for the expanded national response to HIV/AIDS; and (c) each MAAIF department has a focal point officer responsible for the HIV/AIDS program. Key constraints to mainstreaming HIV in the ministry include the absence of commitment and support from some heads of departments and the absence of funds.[111]

Topouzis argues that although focal points for AIDS may be useful instruments for mainstreaming, there has been a tendency to situate these within "soft" units, such as the FLE Unit in MAAIF, rather than within "hard" units (livestock, crop production, fisheries, agricultural extension, etc.). Consequently, Topouzis reports, the FLE exercise was perceived to be an added-on "project" rather than an attempt to integrate HIV in MAAIF programs.[111] 
MAAIF seeks to strengthen HIV/AIDS education among MAAIF staff and the farmers and fishermen they serve; strategies include helping infected and affected persons cope with HIV/AIDS and mitigating the adverse socioeconomic effects of the epidemic through the promotion of profitable agroenterprises that are labor-, energy- and timesaving. It appears, however, that to date, more emphasis has been placed on information, education, and communication initiatives, with less attention on mitigating the adverse effects of HIV/AIDS through core agricultural initiatives.[111]
Public Service
The ministry has an HIV/AIDS strategic plan and workplan. Implementation of activities is supported by the World Bank MAP project. Challenges include mainstreaming and inadequate funding.[143]
Works, Housing, and Communications
With World Bank funding, an HIV/AIDS strategy is being implemented. Challenges include of inadequate funding and lack of tangible support to PLWHA and affected families within the ministerial workforce.[143]
Tourism, Trade, and Industry 
Although an HIV/AIDS strategy and workplan have been created, inadequate funding impedes implementation. Some business partners have supported the ministry's HIV/AIDS activities. A major challenge is reaching rural business communities.[143]
Water, Lands and Environment
Donor-supported projects managed by departmental focal officers incorporate HIV/AIDS activities in their implementation, but there is need for strong coordination among them. Implementation of the HIV/AIDS workplan is constrained by limited funding. The ministry is focusing on the integration of HIV/AIDS into environmental impact assessment tools.[143]

Other Ministries 

AIDS Control Program Units have also been established in the ministries of Gender, Labor, and Social Development; Internal Affairs (Police and Prisons); and Finance.[2] (In November 2003, there was no information on the HIV/AIDS-related activities of these ministries on the UAC website: <http://www.aidsuganda.org/response/govt_sectors/index.htm>. 

Donors

According to a USAID/CDC analysis, total donor support for all AIDS-related interventions during 1989-1998 was approximately US$180 million, representing about 70 percent of total expenditures on HIV/AIDS prevention and care in Uganda.[32] 

A 2001 AMREF-Uganda/UAC report found that during 2000-01, external donors spent US$43.7 million on HIV/AIDS in Uganda. Care and support services accounted for the highest percentage of expenditures (27.7 percent), followed by 18.8 percent on prevention, 16.2 percent on capacity building, 12.1 percent on VCT, and 11.4 percent on HIV testing.[63] (As with any expenditure data, there are numerous caveats attached, including incomplete reporting and difficulty in distinguishing between some HIV/AIDS and sexual & reproductive health expenditures.) (A detailed table entitled "Development Partners' Funds Allocations to HIV/AIDS Activities In Uganda During Year 2001" may be found on pp. 38-42 of the AMREF-Uganda/UAC report: <http://www.aidsuganda.org/pdf/hiv_agencies_inventory.pdf>.)

Donors financing HIV/AIDS activities in Uganda include the World Bank (see below), USAID, DFID, SIDA, CDC, EU, French Cooperation, JICA, AusAID, GTZ, NORAD, DANIDA, Italian Cooperation, and Ireland Aid. Various international NGOs also fund HIV/AIDS projects. See p. 24 of Uganda's 2003 Global Fund proposal for a table of the main national and international agencies involved in HIV/AIDS in Uganda and their financing levels: <http://www.theglobalfund.org/search/docs/3UGDH_755_0_full.pdf>

U.S.

Uganda is a priority country within USAID's HIV/AIDS program <http://www.usaid.gov/pop_health/aids/Countries/africa/uganda.html>. It is also part of CDC's Global AIDS Program <http://www.cdc.gov/nchstp/od/gap/countries/uganda.htm>. In 2003, President George W. Bush announced that Uganda would be part of the Emergency Plan for AIDS Relief.[49] 

World Bank

In 1994, Uganda borrowed US$75 million from the World Bank (through the International Development Association, which lends money to the world's poorest countries at zero interest with a 10-year grace period and maturities of 35 to 40 years) for the Sexually Transmitted Infections Project (STIP) 1995-2000.[2]

Uganda qualified for the Bank's Multicountry HIV/AIDS Program (MAP). To quality for MAP, Uganda had to meet the following criteria: 
1. satisfactory evidence of a strategic approach to HIV/AIDS, developed in a participatory manner
2. existence of a high-level HIV/AIDS coordinating body, with broad representation of key stakeholders from all sectors, including people living with HIV/AIDS
3. government commitment to quick implementation arrangements, including channeling grant funds for HIV/AIDS activities directly to communities, civil society, and the private sector
4. agreement by the government to use multiple implementation agencies, especially NGOs and CBOs[148]
Uganda's MAP project was funded at US$47.5 million for 2001-06. (This is also a consessional loan from the International Development Association). The project aims to fill financing gaps in implementing the National Strategic Framework for HIV/AIDS Activities for 2000/01-2005/06.[33]
Global Fund to Fight AIDS, TB & Malaria
The Ugandan government has pledged US$2 million to the GFATM.[149] In the first round of GFATM grants, announced in April 2002, Uganda's proposal "The Uganda Comprehensive Country Proposal for Scaling up the National Response to HIV/AIDS" was approved for US$36,314,892 over two years.[150] The proposal addresses gaps in financing the National Strategic Framework for HIV/AIDS Activities for 2000/01-2005/06. Its overarching objectives are to enhance HIV/STI prevention, strengthen care and support for people living with and affected by HIV/AIDS, and build and strengthen capacity at all levels to respond to the burden of HIV/AIDS.[52] Among its strategies:
* intensify and scale up information, education, and communication, and behavior change communication, particularly in rural areas
* support the provision/social marketing of condoms, particularly in rural areas
* strengthen and improve the quality of services for STI and AIDS care
* provide drugs and medical supplies, including increasing access to ART 
* scale up programs and activities for VCT and PMTCT 
* strengthen the capacity for monitoring and evaluation of HIV/AIDS activities and operational research
* support mitigation programs for orphans and other vulnerable children
* strengthen institutional (human resources and infrastructure) capacity for the delivery of prevention, care, and support services[52]
Its anticipated results:
* increase the number of districts with VCT services to 56
* increase the number of regional hospitals with ART services to 11
* increase the number of districts with PMTCT programs to 56
* increase condom availability to 120 million annually
* increase reported condom use with nonregular particulars to 80 percent
* increase the proportion of STI cases that are managed according to national guidelines to 35 percent 
* increase the proportion of STI cases that receive appropriate counseling on preventive measures to 45 percent 
* reduce adult HIV seroprevalence to 5 percent[52]
In March 2003, a grant agreement was signed; by November 2003, only US$287,029 had been disbursed from the round-1 grant. (In the second round of GFATM grants, Uganda's malaria and TB proposals were approved.)[150]
In the third GFATM round (for which approved grants were announced in October 2003), Uganda's proposal entitled "Scaling up of Anti-Retroviral Therapy (ART) and Orphan and Other Vulnerable Children (OVC) Interventions within the Framework of Existing and Proposed National Strategic Frameworks and Plans in Uganda" was approved for US$70,357,632 over two years.[150] Its overarching objectives are to expand equitably the use of ART, reduce overall morbidity and mortality due to AIDS, and reduce HIV seroprevalence.[61]Specific objectives include:
* increase the number of people receiving ART from 10,000 to 30,000 through a public-private partnership in 26 facilities 
* expand national capacity to monitor and supervise ARV drug resistance. 
* expand and strengthen capacity to provide family counseling 
* build on efforts funded through the first GFATM HIV/AIDS grant and further strengthen VCT capacity to provide information on ART
* strengthen logistic systems (including forecasting, procurement, storage, inventory management, information systems, and distribution) to ensure consistent, secure, and timely availability of quality ARV drugs and supplies at service delivery points
* promote behavior change among PLWHA on ART and raise awareness of the public health implications of noncompliance[61]
Anticipated results: 
* improved access to HIV/AIDS care, especially ART; increased counseling; less noncompliance and fewer risks of drug resistance regarding ART; increased community participation in ART; decreased costs of OI care 
* improved access to and utilization of VCT and PMTC
* strengthened health system[61]
Human Rights

See also the Stigma and Discrimination and Industry sections.

Although the Ugandan government has promoted excellent principles of nondiscrimination in its National Strategic Framework on HIV/AIDS, the country has no specific laws regarding HIV/AIDS, including the rights of PLWHA. Laws regarding custody of children and inheritance are also inadequate.[58] The Ministry of Justice and Constitutional Affairs is charged with reviewing and incorporating HIV/AIDS issues within the legal sector to manage HIV/AIDS in the workplace; ensuring nondiscrimination and fairness within the legal sector; and reviewing existing laws, policies, and practices in view of HIV/AIDS.[143] 

According to Uganda's Third National AIDS Conference, held in October 2002, there continues to be a great deal of stigma and discrimination against PLWHA in the workplace.[28] In April 2003, Ugandan member of Parliament and human rights activist Dora Byamukama stated that major legal reforms are urgently needed. She stated that marital rape, wife inheritance, and bride price must be outlawed to stem the spread of AIDS. She called for policy changes to improve protection for health workers and to protect the jobs of HIV-infected workers who take time off for medical appointments.[151]

In Uganda, the work of TASO and other community-based groups has been central to encouraging greater openness about the epidemic and in providing support and care to individuals, families, and communities living with HIV/AIDS.[152] In addition many PLWHA organizations have been established in the country and are playing a major role in advocating for improved care of PLWHA, including increasing access to ART. 

Civil Society

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] 

NGOs, CBOs, and households have played a crucial role in Uganda's HIV/AIDS efforts. Community-level responses have been essential in a variety of initiatives, including home-based care, support for orphans and vulnerable children, and HIV/AIDS prevention and mitigation. Much of this work has been carried out through community-based and religious organizations.[24] 

By 1997, there were at least 1,020 NGOs and CBOs involved in HIV/AIDS work in Uganda.[59] In September 2003, Dr. Alex Coutinho, executive director of TASO, noted that 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. Seventy percent of Ugandans on ART were receiving treatment services from the Joint Clinical Research Center (discussed in more depth in ART section below). NGOs and CBOs were also providing nutritional supplementation to 35,000 PLWHA.[153]

One of the key players in the response to the HIV/AIDS epidemic in Uganda has been TASO, established in 1986. TASO provides care and support to approximately 60,000 AIDS patients and their families, as well support to over 1,000 orphans and OVC. TASO was the first indigenous AIDS organization in Africa and now serves as a global role model. With seven centers across Uganda, TASO continues to play a major role in AIDS care, education, and support.[58] Among its many projects, it is working with the World Food Program to provide food aid support to families affected by HIV/AIDS.[154]

Other key organizations include the Uganda Network of AIDS Service Organizations, National Forum of PWHA Networks in Uganda, National Guidance and Empowerment Network of People Living with HIV/AIDS in Uganda, AIDS Information Center, Hospice Uganda, National Community of Women Living with HIV/AIDS, Uganda Youth Anti-AIDS Association, and Uganda Women's Effort to Save Orphans. See also the membership directory of the Uganda Network of AIDS Service Organizations, which includes information for over 300 organizations: <http://www.unaso.or.ug/members.php> Another useful resource is Inventory of Agencies with HIV/AIDS Activities and HIV/AIDS Interventions in Uganda 2001, prepared by AMREF-Uganda and UAC: <http://www.aidsuganda.org/pdf/hiv_agencies_inventory.pdf> 

Among constraints reported by NGOs and CBOs, inadequate financial, human, institutional, and capacity resources are the most commonly cited.[63] 


Academic and Research Institutions

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 Palliative Care Center (see the sections below for more detailed discussion). These institutions collaborate with a wide array of international partners.

According to Coutinho of TASO:

"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]
Religious Organizations
In Uganda, 66 percent of the population is Christian and 16 percent Muslim; 18 percent follow indigenous and other beliefs.[69] Religious organizations have a long history of providing health services in Uganda[153] and are highly influential. The early and significant involvement of Protestant, Catholic, and Muslim leaders was crucial to HIV/AIDS efforts.[24] 

Particularly critical were Uganda's bishops. In 1989, they issued a statement on AIDS, which included the following sections:

"The AIDS epidemic should be looked at by us Christians, as a phenomenon which constitutes a special time in salvation history, a moment of grace, paradoxical as this might seem. It is a time, when once again, we hear the call to conversion, to turn to faithfulness to God's law, regarding sex and marriage; and to rediscover the value of chastity. We do not believe that this disease, or any other one for that matter, should be looked at, as a punishment from God. Rather than looking with any feeling of condemnation at those who have contracted it, we should reach out to them in love, understanding and compassion."

"All the youth should be given education about AIDS, and Christian values, which should be backed up with efforts to bring about a change in attitudes and behavioral patterns. This education should be geared to making the young people realize that ultimately they alone can be responsible for their health and life. Young Christians should be encouraged to be promoters of a healthy way of living."

"To you who have received the Sacrament of Matrimony, we stress and remind you that the most common mode of transmission of the AIDS virus is through normal heterosexual contact, and that the greatest risk factor is having multiple sexual partners. A stable and continued faithful marital relationship between husband and wife is the most effective protective weapon against catching AIDS."

"By providing direct care to the sick, by visiting them, praying with them, consoling them with the word of God, being supportive and sympathetic listeners, and understanding their many problems and frustrations, we can offer companionship and solidarity to them, along with the refreshment and reconciliation of the Lord. We encourage the formation of Support Groups, within our Christian communities and parishes, which will reach out to the people and families in need, especially the orphans." 

"We urge pastors of souls, catechists, and those who assist in the preparation of the liturgy and other community-prayer, to include the needs of the AIDS patients, with an explicit invitation to the faithful to offer their spiritual as well as temporal assistance. We also encourage liturgies, specially organized for the sick, in which the sick themselves take an active part." (Duncan MacLaren, ed. The Church Responds to HIV/AIDS. Rome: Caritas Internationalis, 1996 <http://www.cafod.org.uk/hivaids/aidschurch.shtml>)

In 1989, the Islamic Medical Association of Uganda (IMAU), comprising over 300 Islamic medical practitioners, held a national AIDS education workshop. The workshop, funded by Uganda's NACP and WHO, included a declaration of support from the highest level of Uganda's Muslim community. Following the workshop, IMAU organized AIDS education workshops for imams in several districts. Discussion between health professionals and religious leaders at these early workshops indicated the need to design an HIV/AIDS education project to reach Muslim families through educators trained with and sanctioned by imams.[155]

IMAU then organized Community Action for AIDS Prevention (CAAP) in Kampala. CAAP workshops train teams from mosques, as well as groups such as bicycle transporters. IMAU also launched the Madarasa AIDS Education and Prevention Project (MAEP). MAEP helps imams and their assistants provide children with AIDS education through a special curriculum designed for informal schools attached to mosques (Madarasa schools).[155]

IMAU's Family AIDS Education & Prevention through Imams Project (FAEPTI) helps imams incorporate accurate information about HIV/AIDS into their spiritual teachings and trains teams of community volunteers to provide education, basic counseling, and motivation for behavior change through individual home visits. FAEPTI was launched in two districts in 1992; within five years, it was operating in 10 districts. The project has worked with leaders at 850 mosques and has trained 6,800 community volunteers who have made personal visits to 102,000 homes.[155]

The 2001 TASO/UNAIDS study mentioned above found that some religious organizations "have a somewhat contradictory attitude towards people with HIV." Respondents stated that influential religious leaders were providing mixed messages about routes of HIV transmission and appropriate attitudes toward PLWHA. As a result, many respondents with HIV felt that they could no longer attend Christian or Islamic services. TASO/UNAIDS also found that attitudes held by some church leaders fostered a false sense of security among married people and others who did not consider themselves "promiscuous." However, the study also found that women, especially widows, used places of worship as a refuge.[58]

The Uganda Protestant Medical Bureau is a member of Uganda's GFATM CCM.[61]

Traditional Healers

In Uganda, there is one traditional health practitioner for every 200 to 400 people[78] (compared to approximately five physicians per 100,000 people[64]). In 1992, with the support of Uganda's NACP, UAC, TASO, and Médecins sans Frontières, Traditional Healers and Modern Practitioners Together Against AIDS (THETA) piloted two projects in Kampala. The first aimed at evaluating traditional herbal treatments for some specific AIDS symptoms. The second tested the effect of empowering traditional healers (n=25) as HIV/AIDS/STI educators and counselors through training. THETA found that traditional healers can be effective community educators and counselors through their ability to deliver preventive messages in unique ways, such as the use of personal testimonies, stories, song, dance, drama, and proverbs. In 1995, given requests from the Uganda AIDS Commission and various NGOs, THETA extended its training program to rural districts. By April 2001, nearly 1,000 healers from seven rural districts had participated in a three-day AIDS awareness workshop, and about 300 traditional healers had undergone an intensive, two-year training and certification program in HIV/STI counseling and education. Traditional healers trained as trainers by THETA have also reported training over 200 other healers in HIV/AIDS prevention and care. In addition, over 100 biomedical health workers have collaborated with THETA.[156]

THETA also demonstrated that symptoms of herpes zoster and chronic diarrhea could be alleviated with local herbal preparations. Two consecutive studies, involving systematic clinical observation and laboratory follow-up of over 500 patients, supported this finding. To facilitate wider use of  these local preparations, THETA has piloted a herbal processing and packaging demonstration lab and has also initiated the growing of useful herbs at a herbal garden near its Kampala offices.[156]

In 1995, THETA launched the Resource Center for Traditional Medicine and AIDS, which includes a library and speakers' bureau. The Center facilitates the exchange of information and networking, both locally and globally. It has also published booklets, training kits, two informational/educational videos, and a newsletter with a readership of over 500.[156]

THETA has become a global model of best practice. In 2000, UNAIDS asked THETA to host a meeting to discuss traditional medicine and HIV/AIDS in Eastern and Southern Africa. During this meeting, at which 17 countries were represented, THETA was chosen as the regional secretariat of a task force aimed at developing collaboration between the traditional and modern health sectors for HIV/AIDS prevention, care, and research.[156]

PROMETRA, an NGO that promotes traditional medicine, also has an HIV/AIDS training program for traditional healers. Activities also include income-generating activities for PLWHA.[157]

Trade Unions

Following a 1999 study by the International Transport Workers' Federation (ITF), two Ugandan transport workers unions affiliated with the ITF¾the Amalgamated Transport and General Workers Union (ATGWU) and the Uganda Railway Workers Union (URWU)¾established the ATGWU-URWU HIV/AIDS Program. In August 2001, under a two-year UNAIDS-funded project, the program launched an HIV/AIDS/STI project targeting long-distance truck drivers and their assistants; sex workers; lodge and restaurant/bar workers; and other communities in three truckstop towns (Busia, Malaba, and Naluwerere) in eastern Uganda.[158] Activities include: 

* workplace policy development and negotiation
* workplace and community awareness and sensitization campaigns
* training of HIV/AIDS counselors
* identification of peer educators
* negotiations for improved working conditions
* distribution of male and female condoms[28]

Industry

In 2002, researchers from Axios International published an article on the corporate response to HIV/AIDS in Uganda. They found that:

"While the corporate sector in the country has financially contributed towards the costs of some of the interventions that are currently in place to combat the HIV epidemic, there is largely a paucity of sustained and systematic corporate leadership in providing comprehensive HIV/AIDS programs for their employees. A survey done by the authors of this paper reveals that most programs undertaken in the private sector are of limited scope."[159]

In September 2003, the Uganda AIDS Commission reported:

"Until now, the corporate response to HIV/AIDS in Uganda has been rather limited. With a few exceptions, the private sector has not sought a leadership role in confronting the epidemic. Although some companies pioneered in protecting their workers while others made philanthropic contributions, there is a massive need for the Private Sector to form partnerships with other constituencies in order to maximize resources for scaling up the national response against HIV/AIDS. The greatest immediate responsibility¾and opportunity¾for the private sector is to protect their work forces and their families against the spread of the epidemic, and support employees infected with HIV in remaining healthy and able to contribute to the business for as long as possible."[160]

* In 2000, the Bank of Uganda began to offer ART at subsidized cost to its employees. As of July 2003, the Bank's 82 employees on ART pay 25 percent of drug costs and receive a 100 percent subsidy for laboratory tests. At the African Air Rescue Clinic, the Surgery, and the International Medical Center, about 100 people receive subsidies of up to 50 percent for ART from their employers, including the Bata Shoe Company, New Vision newspaper, U.N. agencies, Standard Chartered Bank, Sheraton Hotel, and British American Tobacco.[60] (See also the ART section below.)

* In May 2001, the Ugandan Business Council on HIV/AIDS was launched, with the aim of persuading large and small businesses to adopt policies to educate staff on HIV/AIDS and to support HIV-positive individuals in the workplace.[161] Among the council's partners are the Global Business Coalition on HIV/AIDS and AMREF.[162] In mid-2003, the council was supplying a small quantity of ARVs in Masaka.[78] 

* Under the auspices of the UAC, the Private Sector Self-Coordinating Entity brings together representatives from multinationals, local enterprises, employer federations, trade unions, insurance companies, and the informal sector to address HIV/AIDS.[160]

* The Ugandan pharmaceutical firm Quality Chemicals, Ltd. is a member of Uganda's GFATM CCM (see the ART section below), as is the Uganda National Chamber of Commerce and Industry.[150]

* In October 2003, the U.S. Department of Labor's HIV/AIDS Workplace Education Program announced a US$1 million grant to World Vision and RTI International to fund a workplace HIV/AIDS education program in Uganda. The program will include workplace prevention education; development of workplace antidiscrimination policies; and capacity building activities for government, trade unions, and employers.[163]

Uganda's Ministry of Gender, Labor and Social Development recommends the following workplace best practices regarding HIV/AIDS:

* making condoms available
* nondiscrimination
* voluntary disclosure of one's serostatus
* availability of nonmandatory HIV tests, encouragement of VCT 
* confidentiality
* educational and training programs 
* minimization of risks for HIV transmission in the workplace[28]

These are recommendations. As mentioned in the Human Rights section above, there is no law to enforce them.

Orphans

There is no national policy regarding orphans. Identification of orphans is also a problem for programmatic staff.[28] The 2002 World Bank study on education and HIV/AIDS in Uganda cited above found that there was no systematic method of identifying orphans or children in need.[136] In July 2003, Elioda Tumwesigye, chair of the Parliamentary Committee on HIV/AIDS, called for a national policy on AIDS orphans.[164]

The Ministry of Labor and Social Affairs has principal responsibility for the welfare of orphans. However, its capacity is very limited.[165] 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.[134] NGO and CBO orphan assistance is also impeded by financial and human resource constraints. Under the World Bank MAP loan mentioned above, funds will be channeled directly to established NGOs as principal implementers of orphan care.[165] 

Schools offer very little targeted support for children most affected by HIV/AIDS; according to the Center for International Education at the University of Sussex, reasons include MOES policy and leadership, perceptions and attitudes of school managers and teachers, acute lack of resources, competing needs of other children in especially difficult circumstances, the school environment, and discrimination and stigma.[134] In 1999, Makerere University and the Population Council's Horizons Project initiated a study in the Luwero and Tororo districts, largely rural districts with small urban and periurban populations. The primary objective was to assess the outcomes of two programs being implemented by the Ugandan office of Plan, an international NGO: (1) succession planning (SP), and (2) orphan support (OS). SP reaches HIV-positive parents, their children, and standby guardians while the family is still in a position to plan for the children's future. OS serves only orphaned children and their guardians. Together, the programs form part of a continuum of care for AIDS-affected children that starts at the time of parental diagnosis or onset of illness and continues through orphanhood.[135] Among the key findings of the study:

* The proportion of HIV-positive parents who appointed a guardian increased significantly after exposure to the SP program.
* After two years in the SP program, parents were significantly more likely to have disclosed their positive serostatus to at least one child.
* Will writing doubled in both groups, but still only a small proportion of parents had written wills.[135]
HIV Prevention Trials Network

Current and planned studies include:
	
* HIVNET 027: A Phase I Study to Evaluate the Safety and Immunogenicity of ALVAC-HIV vCP1521 in Infants Born to HIV-1 Infected Women  

* HPTN 046: Phase III Trial to Determine the Efficacy and Safety of an Extended Regimen of Nevirapine in Infants Born to HIV Infected Women to Prevent Vertical HIV Transmission During Breastfeeding 

* Closed: HIVNET 012: A Phase IIB Trial to Determine the Efficacy of Oral AZT and the Efficacy of Oral Nevirapine for the Prevention of Vertical Transmission of HIV-1 Infection in Pregnant Ugandan Women and Their Neonates[166] The results of this landmark study are discussed in the PMTCT section below. 

VCT

During the 1980s, there were few HIV testing services in Uganda outside research-related programs and almost none with related counseling programs. An enormous burden was placed on the Uganda Blood Transfusion Service, as many Ugandans donated blood to learn their HIV serostatus. In response to the growing demand for testing, several organizations convened to discuss the need for anonymous and VCT services.[167] 

As a result, Uganda established Africa's first confidential VCT service, launching the AIDS Information Center (AIC) in Kampala in 1990. By 1993, AIC was active in four major urban areas. AIC pioneered provision of same-day results using rapid HIV tests, as well as creation of posttest clubs to provide long-term support for behavior change, regardless of serostatus. 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.[32] 

Uganda does not have a comprehensive VCT policy. The MOH is currently drafting new VCT guidelines.[96] Confidentiality remains a major concern.[28] According to a 2001 AMREF-Uganda/UAC report, "Uncontrolled availability of HIV testing kits has led to a mushrooming of testing services provided by untrained people. Hence, a lot of testing is being done without pre- and posttest counseling."[63]

The AIC, Buganda Kingdom Youth Project Center, Kitovu Hospital Mobile Home Care Program, Makerere University, Naguru Teenage Information and Health Center, and TASO worked with the Population Council to examine opportunities for and limitations of providing VCT for youth. They found that:

* Counseling is a valued part of HIV testing.
* Most youth disclose their HIV test results.
* The majority of untested youth would take an HIV test.
* Service providers are not equipped to respond to youth issues.
* More support services are needed for counseled youth.[168]

Based on these findings, service delivery organizations are designing VCT services that are youth friendly. Components include:

* increased training of service providers in counseling skills for youth about HIV
* use of separate and alternative facilities so that youth do not have to risk seeing familiar adults or family members when seeking VCT
* reduced price of testing 
* establishment of a referral system for young clients 
* improved outreach to schools and youth groups
* introduction of VCT at a youth reproductive health center
* a multimedia campaign to inform youth about VCT[168]

Coverage

By the end of the 1990s, AIC had served over half a million clients.[4] According to WHO, during 2001, 20,000 clients received VCT services at Uganda's 45 publicly funded/NGO VCT centers. (There were no VCT services offered in the commercial sector.) During 2001, WHO estimates that 8 percent of the population in need of VCT services in Uganda was receiving them.[169] 
By 2002, AIC had about 70 sites across the country serving a total of 55,000 clients.[28] VCT services were available in 34 of 56 districts through a combination of stationary sites and outreach services. However, even in districts where VCT services are available, coverage may be sparsely distributed.[4] 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.[52, 61]
Uganda's 2000-01 DHS found that 8.4 percent of women and 12.0 percent of men reported having been tested for HIV. Women in their 20s and men ages 25-39 were the most likely to have been tested. Respondents living in urban areas and in Kampala District, as well as respondents with secondary education, were much more likely to have undergone HIV testing. Among those not tested for HIV, 63.7 percent of women and 65.4 percent of men would like an HIV test.[41]
CDC-Uganda and the Uganda Virus Research Institute found that a VCT model concentrating on home-based provision of counseling at the time people receive HIV test results was highly acceptable and greatly increased the proportion who received HIV results compared with other studies. The researchers believed that their findings are related to transport costs, which are often a barrier to access of VCT, even free VCT. Furthermore, participants preferred to receive results within the privacy of their own home.[170]
Cost
When AIC opened in 1990, services were free of charge. Cost-sharing began in January 1994, with UShs1000 (about US$0.50) charged per client in Kampala (outside Kampala, sites charged UShs500). Fees have been increasing almost annually.[167] In mid-2003, the fee was UShs4000 (US$2.02).[60, 78]

According to AIC, over 80 percent of clients are willing and able to pay fees. AIC routinely has "Free Days" for certain groups such as women, youth, or couples. Free Days are widely publicized and enormously popular. AIC has a fee exemption policy for those unable to pay. Counselors forward recommendations for exemption to their supervisor for approval. However, only 1 percent of clients are exempted from paying fees.[167] 

Care and Support

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.[171]

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.[171] Medical visits to the home are very expensive; for example, TASO estimates that it costs on average UShs40,000 (US$20) per patient visit.[45]

The demand for HBC is far in excess of available resources.[28] Rural areas tend to be underserved with regard to care and support. Thus, the burden of AIDS care falls heavily on households, particularly women and girls.[58, 59] 

According to the AfriCASO Directory of 2000, there were 39 registered HBC programs in Uganda, likely an underestimate as many CBOs operate unregistered. An umbrella organization, Joint Home Care, facilitates coordination, networking, and knowledge sharing among HBC programs in Kampala.[171]

In July 2003, the Harvard Center for Population and Development published an assessment of HBC in Uganda. Using a convenience sample of seven HBC programs, the study found that all:

* adhered to the ethical principles involved in HIV/AIDS care
* aimed at improving patients' quality of life
* promoted patients' human dignity and the right to informed choices
* promoted confidentiality while encouraging openness for stigma reduction[171]

The study did not find discrimination on the basis of religion or inability to pay. The longevity of the studied HBC programs attested to their relevance, effectiveness, and sustainability. Comprehensive care and activities for PLWHA, their families, and community addressed various HIV/AIDS issues (e.g., lack of access to health care, poverty, and cultural preference for care and dying at home for the very ill). Essential drugs, other supplies such as traditional remedies, and materials such as food and soap were tailored to the served population's needs. The programs demonstrated their responsiveness and relevance to the community's changing needs by later including community care and, in some instances, palliative terminal cancer care.[171]

Identified constraints to HBC programs included: 

* weak management and financial controls
* deficient records management; lack of defined outcome measures
* heavy reliance on external funding
* weak and informal health facilities linkage
* gap between programs and local political and administrative leaders[171]

The dropout rate of HBC volunteers is also high, given burnout as well as their own AIDS mortality.[28]

The Harvard study concluded that a formal political commitment and policy framework for HBC¾including an appropriate referral system¾would enhance its relevance and enable HBC programs to secure resources from central and district government levels. Moreover the capacity of some HBC programs could be further strengthened to deliver drugs, especially ART, to patients or complement the formal health system in this area, rendering HBC more relevant to patients' needs.[171]

* With support from USAID, NACP is developing national guidelines to serve as the reference document for HIV/AIDS nutritional care and support at district, community, and household levels.[165]

* The Palliative Care Centers at Mildmay and Hospice Uganda have begun training district medical officers, ward nurses, and community nurses in palliative care for PLWHA.[172] 

PMTCT

According to WHO, 41,000 clients received PMTCT services (i.e., basic counseling, testing, and AZT or NVP treatment) at Uganda's 18 public/NGO PMTCT sites during 2001. An estimated 4 percent of the population in need of PMTCT services was receiving them.[169] To move beyond the pilot phase of the PMTCT program, UNICEF assisted the government to develop a phased expansion plan. In addition to UNICEF and other U.N. agencies, about 15 key partners from bi- and multilateral agencies and NGOs work with the government on PMTCT[173]; among them are the Elizabeth Glaser Pediatric AIDS Foundation, German Technical Cooperation,
Médecins sans Frontières (France), Plan International, CDC, and USAID.[61] Currently, these partners are supporting or have plans to support PMTCT activities in 43 of the country's 56 districts.[173] The aim of Uganda's national PMTCT program is to provide PMTCT services in all 56 districts by 2005.[28]  (See also the GFATM section above.) 

* The Elizabeth Glaser Pediatric AIDS Foundation is supporting PMTCT activities in:

1. Bushenyi District: 20 health units 
2. Hoima, Kitgum and Pader districts: Hoima Hospital (Hoima District), Kitgum Hospital and St. Joseph's Hospital (Kitgum District) and Kalongo Hospital (Pader District) 
3. Kampala: New Mulago Hospital and Old Mulago Hospital 
4. Mbarara District: Bukanga Clinic, Bwizibwera Clinic, Ibanda Hospital, Isingiro Clinic, Kazo Clinic, Kinoni Health Center, Mbarara University Hospital, Rushere Hospital, and Rwekubo Clinic 
5. National: Arua, Gulu, Iganga, Jinja, Kabale, Masaka, Masindi Mbale, Pallisa, and Tororo health districts 
6. Rakai: The Rakai Project Cohort communities, Kalisizo Hospital, and Kyotera Health subdistrict facilities 
7. Rukungiri, Kasese, and Kumi districts: Kagando, Kisiizi, and Kumi hospitals 
8. Sembabule and Masaka districts: Butenga, Buyoga, Kinoni, Kyazanga, Lwengo, Mateete, Mbirizi Catholic, Ntuusi government, and Ssembabule health centers[174]

* MTCT-Plus is currently being undertaken at two sites in Kampala: St Francis-Nsambya Hospital and Mulago Hospital.[175] 

* In late 2002, UNHCR announced that it would start distributing nevirapine to prevent MTCT in Ugandan refugee camps.[176]
The capacity for national coordination of the PMTCT program has been strengthened through the establishment of three fora: the PMTCT National Technical Committee, the PMTCT Stakeholders Group, and intersite coordination meetings.[173] Challenges to implementing PMTCT include:

* inadequate infrastructure at ANCs
* nonavailability of VCT at some ANCs
* low uptake of VCT by antenatal mothers
* inadequate involvement of male partners
* exclusion of women who neither attend ANC nor accept VCT[28]
* difficulty reaching women with PMTCT services given that about 62 percent of births occur at home[40, 41]

HIVNET 012

From November 1997 to April 1999, HIV-infected pregnant women in Kampala were randomly assigned nevirapine (200 mg at labor onset and 2mg/kg for babies within 72 h of birth; regimen A) or zidovudine (600 mg orally at labor onset and 300 mg every 3 hours until delivery, and 4 mg/kg orally twice daily for babies for 7 days; regimen B). Infant HIV testing was done at birth, age 6-8 weeks, age 14-16 weeks, and age 12 months by HIV RNA PCR, and at age 18 months by HIV antibody testing. The study enrolled 645 mothers: 313 were assigned regimen A, 313 regimen B, and 19 placebo. Eight mothers were lost to follow-up before delivery. Among infants, 99 percent were breastfed (median duration: nine months). Estimated risks of HIV transmission in the zidovudine and nevirapine groups were 10.3 percent and 8.1 percent at birth (p=0.35); 20.0 percent and 11.8 percent by age 6-8 weeks (p=0.0063); 22.1 percent and 13.5 percent by age 14-16 weeks (p=0.0064); and 25.8 percent and 15.7 percent by age 18 months (p=0.0023). Nevirapine was associated with a 41 percent (95 percent CI, 16-59) reduction in relative risk of HIV transmission through age 18 months.[177]

Infant Feeding

Breastfeeding in Uganda is almost universal, with 98 percent of children having been breastfed at some time. The proportion is high across all geographic areas and varies little by subgroups of children. The overall median duration of any breastfeeding is 21.6 months, the median
duration of exclusive breastfeeding is 3.7 months, and the median duration of predominant
breastfeeding is 4.4 months.[41]
In August 2003, The Lancet reported that an increasing number of Ugandan mothers with HIV are breastfeeding their babies after UNICEF ceased donating free infant formula. From 2000-02, UNICEF donated infant formula to babies born to HIV-positive mothers. However, UNICEF stopped the donation because it said that those in need did not have access to it and the donation program was not sustainable. According to UNICEF, only 32 percent of HIV-positive mothers in Uganda opt for formula feeding; the rest chose to breastfeed because of stigma or inability to utilize formula feeding.[178]
At the 2nd IAS Conference on HIV Pathogenesis and Treatment, held in Paris in July 2003, researchers led by the Antiviral Therapy Evaluation Center in Amsterdam presented findings from the SIMBA ("stopping infection from mother-to-child via breastfeeding in Africa") Study, a randomized, open-label trial conducted in Uganda and Rwanda. The 405 mothers enrolled into the study took zidovudine and didanosine from week 36 in their pregnancy until one week after delivery. Then, 397 infants were randomized to receive lamivudine or nevirapine daily until one month after the mothers stopped breastfeeding. Mothers were counseled to breastfeed exclusively but to stop between three and six months. On average, women breastfed for 100 days. The investigators found that HIV transmission occurred in 6.0 percent of infants in the intrauterine period, 1.1 percent of infants on lamivudine, and 0.6 percent of infants on nevirapine. There was no difference between the two drugs and both were well-tolerated. François Dabis of the Unité INSERM 593 in France noted that the results should be interpreted with caution. He stated that he would "rather consider this trial as an element in the direction of the 'proof of concept' of the prevention of postnatal transmission by antiretrovirals, rather than a new and readily usable intervention."[179]
Treatment of Opportunistic Infections

According to WHO, in 2001, cotrimoxazole and isoniazid prophylaxis was provided to an estimated 2 percent of HIV-positive adults in need of it. Access to treatment for OIs outside Kampala and in rural areas was deemed minimal.[169] 

The Fluconazole program began in February 2002 through a Pfizer donation to the Uganda government. Pfizer makes Fluconazole available to government hospitals and public health facilities for use by patients with esophageal candidiasis and cryptococcal meningitis. The drug is distributed to all government referral hospitals, mission hospitals, the police, the armed forces, prisons, and all TASO centers.[28]

Antiretroviral Therapy

Overview

In 1996, the MOH created the National Committee on Access to ARV Therapy.[180] In June 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.[2] The DAI operated through July 2000. During this period, the nonprofit Medical Access Uganda Limited was established and charged with procuring and distributing ARVs at subsidized prices.[181] An evaluation conducted by UNAIDS found that during DAI's existence, 912 patients were provided access to ARVs.[181] They were seen at five accredited centers of excellence in Kampala (Joint Clinical Research Center, Nsambya Hospital, Mildmay Center, Mengo Hospital, and Mulago Hospital.[61].) Although the DAI was judged to have succeeded in several infrastructure building and training goals, it was unable to bring about significant drug price reductions.[181]

The DAI was succeeded by the Accelerated Access Initiative (AAI), a partnership between the U.N. and five pharmaceutical companies designed to accelerate access to ARVs in selected developing countries. The AAI brought technical support and training to a total of 14 accredited centers of excellence, ten in Kampala and four in other major urban areas. With one exception, these centers were supplied with ARVs by Medical Access Uganda Limited.[181] 

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. Founded in 1990 with support from USAID as a joint project of the MOH, Ministry of Defense, and Makerere University, JCRC was the first treatment center to participate in the Drug Access Initiative. Currently, it is the main supplier of generic ARVs in Uganda and services some of the nationally accredited centers of excellence and some private practitioners.[60, 181] (Dr. Alex Coutinho, executive director of TASO, notes that 70 percent of Ugandans on ART receive their ARVs and treatment services from JCRC.[153])

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.[60, 128] In addition, some access ART through their employers. Most patients on ART live in urban areas and pay for ART entirely out-of-pocket or share the cost with their employers.[61]

Key ART Projects

According to Uganda's round-3 GFATM proposal, there are over 20 private and public facilities offering ART nationwide.[61] In addition to the JCRC, major facilities include:

* The Mulago Hospital Infectious Disease Clinic, an extension of the initial HIV clinic at Mulago Hospital founded in 1987. With start-up funding from the Academic Alliance for AIDS Care and Prevention in Africa, the clinic has expanded to three days per week and provides comprehensive clinical care and laboratory management to HIV infected patients.[40] The Academic Alliance for AIDS Care and Prevention in Africa was launched in June 2001 at the Mulago Hospital Campus of Makerere University. A collaboration comprising senior academic physicians from North America, Makerere University, Pangaea Global AIDS Foundation, international and local organizations, and pharmaceutical companies, the alliance trains health care professionals from across Africa in HIV/AIDS prevention, diagnosis, and treatment.[182]

* Mildmay Center, a tertiary care and training facility, was one of Uganda's first accredited centers of excellence for ART.[61] It provides care and support to HIV-infected patients, including ART. It is one of the few centers that treat and monitor children on ART.  In addition, it is involved in training health care workers in comprehensive management of HIV infection.

* Médecins sans Frontières began importing generic ARVs manufactured by Cipla as part of an ART program in Arua, northwestern Uganda. This program enrolls about 20 new patients each month and provides ARVs free of charge.[181] 

* The Uganda Cares program, supported by MOH, Uganda Business Coalition, and AIDS Healthcare Foundation, works with community-based organizations in Masaka to treat PLWHA with ART.[60] TASO and Kitovu mobile units are involved in patient screening, selection, and compliance processes.[61] In February 2003, Uganda Cares, which employs one physician and one nurse, was providing free ARVs to 102 people (including 20 children under age 15).[60, 61] 

* In August 2003, a rural ARV distribution trial began enrolling participants in Tororo District under the auspices of the MOH and CDC. This three-year project features home visits by outreach personnel to monitor and support adherence and will enroll 1,000 individuals.[183]

Other facilities include the regional hospitals of Mbarara, Mbale, Soroti, Kabale, Arua, Masaka, Fort Portal, and Gulu; CASE Medical Center; Victoria Medical Center; KADIC; the Surgery; and Kampala International.[61] 

ART Coverage

The number of people initially enrolled under the Drug Access Initiative rose from 450 at
baseline to 900 by 2000. With generic importation in 2000, enrolment more than tripled to 3,000 by the end of 2001.[128] 

Currently, about 10,000 Ugandans are receiving ART.[49, 60, 61] However, at least 150,000 are in immediate need of it.[49]

Cost

Along with Botswana, Uganda is one of only two African countries that has accepted Boehringer Ingelheim's offer to provide nevirapine free-of-charge for PMTCT.[184] 

Under the DAI, the annual price of a first-line ART regimen in Uganda fell from about US$12,000 in 1997 to about US$7,200 in 1999. In mid-2000, following importation of generic
ARVs by JCRC, as well price reductions by several pharmaceutical companies under the AAI, the annual price of ARVs declined to US$1,000 for first-line, brand-drug regimens and to US$480 for first-line, generic-drug regimens.[60]

As of December 2002, the retail price for a generic, three-drug combination of stavudine, lamivudine, and nevirapine was about US$28 per month; for a generic combination using zidovudine, lamivudine, and efavirenz, the retail price was about US$58.[60]

In late 2003, the monthly price of generic ARVs in Uganda fell to US$24, following the signing of the Doha 2001 international trade agreement, which allowed Cipla to export generic drugs to Uganda through the Kampala-based Quality Chemicals.[185] The Ugandan government also announced that, in light of the Doha 2001 international trade agreement permitting importation of generic drugs in health emergencies, it would now purchase generic ARVs.[186] 

In November 2003, Quality Chemicals announced that, using supplies from Cipla, it planned to establish a factory to manufacture ARVs before the end of 2004. Quality Chemicals stated that the price of the ARVs it manufactures will be less than US$0.50 per day.[185] 

Although ARVs are now available at significantly reduced prices, the government provides no subsidy to the people using them.[60] Thus, they remain out of reach for most Ugandans, who cannot afford to pay for ART out-of-pocket. (And note that the prices above do not include charges for testing and monitoring services; see the Laboratory Monitoring section below.) 

Government Plans to Scale Up ART
See the GFATM section above. In the third GFATM round, Uganda's proposal entitled "Scaling up of Anti-Retroviral Therapy (ART) and Orphan and Other Vulnerable Children (OVC) Interventions within the Framework of Existing and Proposed National Strategic Frameworks and Plans in Uganda" was approved for US$70,357,632 over two years.[150] It aims to increase the number of Ugandans receiving ART from 10,000 to 30,000 through a public-private partnership in 26 facilities; expand national capacity to monitor and supervise ARV drug resistance; and strengthen logistic systems (including forecasting, procurement, storage, inventory management, information systems, and distribution) to ensure consistent, secure, and timely availability of quality ARV drugs and supplies.[61]
Draft ART Policy and Guidelines

As mentioned, in 1996, the MOH created the National Committee on Access to ARV Therapy.[180]In 2000, the MOH reorganized the committee to become a task force for the expansion of comprehensive HIV care whose major task was to develop a strategy for scaling up ARV therapy. As of July 2003, the task force had produced working drafts of the following:

* national policy for ARV therapy
* national ARV treatment and care guidelines for adults and children
* implementation guidelines for ARV therapy
* national training guidelines on ARV therapy
* costing of the national ARV therapy program 
* strategy for ARV therapy advocacy[60]

A recent study by the Mildmay Center in Kampala administered a questionnaire to 11 organizations and 53 private practices within the Kampala area. Only a few of the facilities providing ART have established related protocols or clinical guidelines. With no set protocol on training on ART, the researchers found a variety of training resources used, type of training provided, program content, and methods of assessment.[187]

Laboratory Monitoring

Three institutions currently provide HIV/AIDS reference laboratory services in Uganda: the Uganda Virus Research Institute, the Joint Clinical Research Center, and Makerere University-JHU Research Collaboration Core Lab. The user/patient pays the costs of laboratory tests. The average cost of a CD4 count test is US$30-50, and viral load testing costs about US$100. Tests are usually performed only when clinically necessary. The MOH plans to place a CD4 counter in each of the 11 regional hospitals.[60]

Viral Load  and HIV Transmission

The Rakai Project examined the influence of viral load on heterosexual transmission of HIV in relation to other risk factors. In this rural, community-based study of 15,127 persons, 415 discordant couples were identified and followed prospectively for up to 30 months. The male partner was HIV-positive in 228 couples, and the female partner was HIV-positive in 187 couples. Ninety of the 415 initially HIV-negative partners seroconverted (incidence, 11.8 per 100 person-years). The rate of male-to-female transmission was not significantly different from the rate of female-to-male transmission (12.0 per 100 person-years vs. 11.6 per 100 person-years). The incidence of seroconversion was highest among partners who were ages 15-19 years (15.3 per 100 person-years). The incidence was 16.7 per 100 person-years among 137 uncircumcised male partners, whereas there were no seroconversions among the 50 circumcised male partners (P<0.001). The mean serum HIV RNA level was significantly higher among HIV- positive subjects whose partners seroconverted than among those whose partners did not seroconvert (90,254 copies per milliliter vs. 38,029 copies per milliliter). There were no instances of transmission among the 51 subjects with serum HIV RNA levels of less than 1,500 copies per milliliter; there was a significant dose-response relation of increased transmission with increasing viral load. In multivariate analyses of log-transformed HIV RNA levels, each log increment in the viral load was associated with a rate ratio of 2.45 for seroconversion (95 percent CI, 1.85 to 3.26). The researchers concluded that viral load is the chief predictor of the risk of heterosexual transmission of HIV and that transmission is rare among persons with levels of less than 1,500 copies of HIV RNA per milliliter.[188] These findings suggest (though they do not prove) that ART-induced reductions in viral load might also be associated with lower risks of HIV transmission. If true, the implications for ART policy in Uganda and elsewhere are important as they indicate that, at least under some circumstances, ART may have a preventive dimension.

Female-controlled Prevention Technologies

See also the Condoms section above.

Uganda is participating in several microbicide trials:

* Phase 1 Expanded Safety and Acceptability Study of 6% Cellulose Sulfate Gel
* Safety and Acceptability Study of 10% Polystyrene Sulfonate 
* Phase 1 Expanded Safety and Acceptability Study of Dextrin-2-Sulphate 4% Vaginal Gel 
* Phase 1 Expanded Safety and Acceptability Study of PRO2000 0.5% Vaginal Gel[189]

Vaccine Trials

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 in HIV-uninfected,  healthy volunteers at low risk for HIV infection.[190, 191]

The Walter Reed Project involves the Walter Reed Army Institute of Research (U.S.); Ugandan MOH; and Makerere, Columbia, and Johns Hopkins universities. Based at Makerere University, the project brings together scientists working to develop an AIDS vaccine. The project also helps to strengthen the research capabilities at the university, as well as to develop an infrastructure and database to support ongoing clinical vaccine trials.[192]

Assessment of National Response

Against the backdrop of the data quality issues discussed in the Epidemiology and Sexual Behavior sections 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. Among them:

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

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]

Challenges

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). 

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, 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.

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] 

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] 

Sexually Transmitted Infections

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

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] 

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]

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] 

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 plans.[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.


Links

For queries regarding links, please contact: Lgarbus@psg.ucsf.edu


References


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HIV/AIDS in Uganda