Behavioral Change Is the Only Way To Fight AIDS
HIV/AIDS is the biggest challenge to mankind in the 21st century, comparable to the Bubonic plague of the Middle Ages. In order to avert more deaths and suffering from this insidious viral infection leaders of nations must stand resolute with total commitment to lead the fight and galvanize the entire efforts of communities and nations to face the challenge.
Although a global problem, more than 90% of HIV infections occur in developing countries like Uganda. The morbidity and mortality figures due to HIV/AIDS are well known; they are indeed staggering and the world is nowhere near controlling this rampaging infection.
Eighteen years ago, as we emerged from a two decades protracted peoples' war of liberation against the dictatorial regimes of [Idi] Amin and [Milton] Obote, Uganda was once again under the shroud of a devastating mysterious ailment called "Slim," later to be known as AIDS. Two decades of civil war, state mismanagement and inappropriate monetary policies had left the Ugandan economy and social infrastructure in tatters with extreme levels of household poverty. The medical infrastructure, especially the hospitals, were in a sorry state with many of the medical profession living in exile, and the total per capita expenditure on health at less than $1 per annum. By 1985, Uganda was among the ten poorest countries in the world.
We had to transmit to our people the conviction that behavior change and therefore control of the epidemic was an individual responsibility and a patriotic duty and within their individual means. In our fighting corner was a resilient population and a committed leadership with years of fire-tested experience in mobilizing our people to overcome obstacles at great odds and with minimal resources.
Our only weapon at the time [was] the message: "Abstain from sex or delay having sex if you are young and not married, Be faithful to your sexual partner (zero-grazing), after testing, or use a Condom properly and consistently if you are going to move around. This has now been globally popularized as the ABC strategy." With no medical vaccine in sight, behavioral change had to be our social vaccine and this was within our modest means.
Starting with the highest level of government, we made HIV/AIDS a development issue, mainstreaming it into the public sector. We brought on board other partners and fostered a multi-sectoral response, prioritizing it in all government programs, enlisting a wide variety of national participants in the "war" against the decimating disease. We have encouraged and enlisted the support of civil society, especially the faith-based organizations. As of 2001, there were 1,117 agencies, governmental and nongovernmental, working on HIV/AIDS issues across all districts of Uganda.
With the help of the international community, we embarked on a vigorous program of making blood transfusion and injections safe. We also instituted comprehensive diagnosis and treatment of sexually transmitted infections having been convinced that it is these that have fueled the early epidemics in resource-poor countries, especially sub-Saharan Africa, the Asian subcontinent and Caribbean countries.
Twenty years down the road, we have had some modest success, learnt some valuable lessons but overall, AIDS has had a devastating impact on our society and nation, an effect that will be felt for generations to come.
During the course of 1993 came the first signs of hope that HIV prevalence in Uganda might be stabilizing or even beginning to fall. The decline continued in six surveillance sites in 1994, with the greatest decline among women under the age of 24.
According to Ministry of Health data, prevalence among pregnant mothers has declined consistently at least over the last decade at all the country's sentinel sites. The national sero-prevalence having peaked at around 18% in 1991, had fallen to 6% as of 2001. This dramatic decline in prevalence is unique world-wide, and has been the subject of curiosity since the mid-1990s, and recently of even more intense scientific scrutiny.
In addition to these biological/medical indicators of change, the AIDS Control Program carried out a study of the sexual behavior of men and women aged 15-49 in Kampala and Jinja. The study compared the sexual behavior of people in this age group in 1995 with the result of a similar study in 1989. Published in 1997 in the international journal AIDS, the results were striking in particular:
? A two-year delay in the onset of sexual intercourse among youths aged 15-24 years. Among girls, the median age increased to 16.6 years; among boys to 17.4 years.
? A 9% decrease in casual sex in the previous year among male youths aged 15-24 years.
? A drop of nearly 50% in the proportion of men and women exchanging sex for money.
? Sharp increases in condom use: from 15.4% to 55.2% among men, and from 5.8% to 38.8% among women.
These researchers also concluded that these changes in behavior could help to account for the previously reported decline in HIV prevalence among young pregnant women at several antenatal clinics in Uganda. Further studies in many countries have found antenatal prevalence data to correlate well with the general adult population.
We are grateful to the international community especially the U.N. family and our other development partners who over the last few years have risen to the occasion by going a long way in raising the necessary funds. International spending on HIV/AIDS over the past years has risen well above $165 million as was documented in 1998. As of mid-2002, aggregate spending for HIV/AIDS was projected to approach $3 billion.
We are grateful to U.S. President George W. Bush who, in his State of the Union address on January 28, 2003, launched the Presidential Emergency Plan for AIDS Relief, asking the U.S. Congress to commit $15 billion over the next five years, including $10 billion in new money, to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean. This is a work of mercy beyond all current international efforts to help the people of Africa. Of this money Uganda has been allocated for fiscal year 2004/05, $94 million -- $54 million in new money and $40 million for ongoing programs.
AIDS has been like no other pestilence in human history. Other serious disease epidemics kill or immobilize the victims quite early thereby limiting transmission and burning themselves out. With AIDS it is different as the long incubation it allows the carrier to remain in good health so as to spread it over many years. Once disease sets in, it attacks our defenses, not giving us a chance to fight back. At the societal level, its impact makes it self perpetuating in that the weaker and poorer the society becomes, the more vulnerable to HIV infection it becomes. AIDS so far has written all the rules of the game and when we get near to understanding them so as to score, it changes the goal posts.
Ultimately the world needs an AIDS vaccine to control this epidemic as we did with small pox and polio soon. The scientific consensus is that an AIDS vaccine is possible. Non-human primates have been protected by experimental AIDS vaccines and some people repeatedly exposed to HIV resist infection and mount HIV specific immune responses, providing important clues for the design of an effective AIDS vaccine.
When all is said, even if an effective drug and vaccine were announced at this conference, the legacy of AIDS will be with us for generations to come as we still have the orphans to care for. Looking at the world's past experience with diseases like tuberculosis, which have had effective treatments for ages, or gonorrhea and syphilis, which one shot of penicillin used to cure, we have hundreds of thousands with the infections around the world today. Drugs as a magic bullet will never be the only solution.
Individual behavior and personal responsibility, based on knowledge, will be our best protection against AIDS and other future epidemics. In Uganda we managed to bring the HIV sero-prevalence from 18.6% to 6.1% using just a social vaccine, a reduction close to 70%. I am told by the medical scientists that a medical vaccine with 80% efficacy is considered a very good vaccine.
Mr. Museveni is the president of Uganda. This is an edited extract from his speech to the international conference on AIDS in Bangkok on Monday.
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