In 1986, not long after his guerrilla force seized power in Uganda, Museveni sent 60 top officers from his bush army to Cuba for training. Several months later Fidel Castro approached Museveni with a staggering bit of news: Medical exams in Cuba had revealed that 18 of the 60 officers were HIV-positive.
Years of war, pillage, displacement, and rape had entrenched HIV in Uganda as early as the late 1970s. Perhaps because his army was threatened, Museveni took Castro’s warning to heart.
Within one year he was leading a nationwide mobilization against AIDS that drew in bishops, imams, and public health experts, as well as thousands of small community groups nationwide.
The program would become known as ABC, for “Abstain, Be Faithful, or wear a Condom”–very much in order of emphasis. Children should abstain from sex until marriage and then practice “zero grazing”–i.e., fidelity. “You tether your animal around a tree, and it can only feed where it is tethered,” Nantulya says with a chuckle.
Billboards with this message are omnipresent in Uganda. By last year the number of pregnant Ugandan women testing positive for HIV antibodies had fallen from 21.2 percent at the height of the epidemic in 1991 to 6.2 percent.
By contrast, in neighboring Kenya the rate is roughly 15 percent; in Zimbabwe it stands at 32 percent; and in Botswana fully 38 percent of mothers-to-be are HIV-positive–with rates continuing to rise in each country.
Senegal has also done well against the plague: HIV rates there have remained low.
By far the most striking epidemiological feature of Uganda’s success is the drastic reduction in multiple partnering by Ugandan adults. Among women aged 15 and above, the number reporting multiple sexual partners fell from 18.4 percent in 1989 to 8.1 percent in 1995 to 2.5% in 2000, according to Harvard study anthropologist E. C. Green. Smaller but similar declines in male promiscuity were reported as well.
At the same time, while the average Ugandan girl becomes sexually active at the age of 17–about one year older than was the case a decade ago–the rate of marriage among girls aged 15 to 19 is 76 percent, compared with 37 percent in neighboring Kenya.
In short, Uganda’s experience suggests that abstinence and fidelity may be the keys to whipping AIDS in Africa.
It’s an idea with dramatic implications. According to a study presented to the USAID by former CDC / WHO epidemiologist R. Stoneburner, Uganda’s prevention model has the potential to reduce the AIDS rate in Africa’s worst-stricken countries by 80 percent. Stoneburner is advising South Africa’s leading prevention program: “According to the modeling we’ve done, 3.2 million lives would be saved between 2000 and 2010.”
Pres Bush hosted Museveni as part of an effort to make abstinence promotion a centerpiece of USA’s development efforts in the Third World. “It’s fortuitous common ground,” says Jeff Spieler, chief of the Research Division in USAIDs Population Office. “We’re not really influenced by the Bush administration’s line on abstinence. It just happens to be where the evidence is pointing.”
Adds Green: “I’m a flaming liberal, don’t go to church, never voted for a Republican in my life. But if you say the things I’ve said… the religious people love you and the people in public health get suspicious.”
A recent study in Uganda led by Ronald Gray, a physician-researcher at Johns Hopkins University, confirmed that while consistent condom use works in slowing HIV transmission, inconsistent use had no effect whatsoever.
Botswana and Zimbabwe provide further evidence that condom use alone is not the answer. The two nations rank first and second worldwide, respectively, in HIV prevalence. In a 1999 survey, more than 70% of adult men in Zimbabwe said they had used condoms in their last high-risk sex act. And while a leading USAID contractor, Population Services International (PSI), has marketed condoms heavily in Zimbabwe and Botswana, they haven’t stemmed the AIDS epidemic. “Both countries are basket cases,” says Green, who is writing a book about failures and successes in the fight against AIDS.
“Condoms are marketed as if they are one hundred percent safe; but there is leakage, breakage, slippage, improper usage…. If condoms fail or aren’t used correctly or consistently just twenty percent of the time, if you don’t change your behavior and keep running around, it may be just a matter of time before you’ll get infected.” All of which helps explain why even PSI, with six billion condoms sold worldwide–has been moving into the “A” and “B” elements of prevention as well.
Recently, PSI joined a USAID-funded study with the Harvard School of Public Health and others to determine how Uganda’s ABC program worked, with an eye toward including more abstinence and zero grazing in its anti-HIV campaigns.
Researchers working in Uganda have suspected that abstinence and fidelity were contributing to declining infection rates for close to a decade. In 1993 Green wrote in a report for World Learning Inc., a USAID contractor: “If a high AIDS-prevalence country like Uganda shows a significant decline in STDs (sexually transmitted diseases) in the absence of a male condom prevalence rate over 5 (percent), it might suggest that other types of behavior change (premarital chastity, ‘zero grazing’ or marital fidelity, abstinence, non-penetrative and other safer sexual practices) can significantly affect STD incidence if not HIV incidence.” Stoneburner, then a WHO official, came to a similar conclusion two years later.
But their message didn’t exactly catch fire. And while it is difficult to separate political differences from scientific ones, both Green and Stoneburner complain of difficulty publishing studies that point to the importance of fidelity and abstinence.
In 1998 Green wrote an article about the apparent success of what he calls “primary behavior change” — more abstinence and fewer partners, as opposed to condom use and STD treatment–in slowing HIV transmission in the Dominican Republic, only to have it turned down by four academic journals. (He eventually published it as a brief letter in the journal Sexually Transmitted Infections.)
Today, however, there is mounting evidence that Uganda’s lesson is catching on. Green notes that USAID has been more receptive to his and Stoneburner’s research since Daniel Halperin–an academic medical anthropologist –joined USAID’s office of HIV-AIDS last year. That office is likely to boost assistance to a $1 million pilot project, begun last year, to provide small grants to African groups that primarily promote abstinence and fidelity. [The New Republic, Arthur Allen, May 27, 2002 http://www.thenewrepublic.com/doc.mhtml?i=20020527&s=allen052702. www.abstinence.net]