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10 Months and Counting: The Condom Crisis in Uganda

TRANSCRIPT FROM AUDIO PRESS CONFERENCE

Monday, August 29, 2005 at 10h00 EST

SPEAKERS:

• Stephen Lewis, UN Secretary General’s Special Envoy for HIV/AIDS in Africa
• Zackie Achmat, Chairperson, Treatment Action Campaign (TAC), South Africa
• Beatrice Were, ActionAid Uganda
• Jodi Jacobson (moderator), Center for Health and Gender Equity

Operator: Excuse me everyone, and welcome to the conference call. All lines will be muted during the broadcast. If anyone should need assistance during the conference, simply pick up your handset and press star, and then zero and a coordinator will be standing by to assist you. There will be a question-and-answer session following the presentation and instructions for asking a question will be given at that time.

I would now like to turn the conference over to Jodi Jacobson. Ms. Jacobson, you may begin.

Jodi Jacobson: I want to welcome everyone to the call. My name is Jodi Jacobson and I am Executive Director of the Center for Health and Gender Equity. This call is being co-sponsored by four organizations: Health GAP or Health Global Access Project; Center for Health and Gender Equity; Human Rights Watch; and Advocates for Youth in the United States.

I wanted to again welcome all of you and let you know who will be on the line speaking today and then give you a brief overview of the issues that we're going to be addressing. First up for speaking, after I close, will be, Beatrice Were, who's an HIV-positive activist working for Action Aid International in Uganda. Beatrice is a leader on AIDS issues in Uganda and is also associated with Health Rights Action Group and Positive Women Leaders. We are really excited to have Beatrice on the line with us today.

We also have Zackie Achmat, who most of you probably know as an HIV-positive activist from South Africa and Chairperson of the Treatment Action Campaign in South Africa, which he helped to launch in 1998. He's also co-founder of the Pan-African Treatment Access Movement or PATAM.

Finally, we have also Stephen Lewis, who has been the United Nations Secretary General's Special Envoy for HIV/AIDS in Africa since 2001. Mr. Lewis, who is probably well known to all of you, is one of the most eloquent and forceful spokespeople on global AIDS issues in the world today and probably needs little introduction.

As Judy mentioned, we will have the speakers speak briefly and then we will open up for question and answer, and we welcome any follow up from anyone on the call after the call is over. So I just want to give you a brief overview of what we're going to be talking about today.

There are two important sets of issues here. One is the fact that in Uganda there has been a condom crisis for the past 10 months. As many of you probably know from the background materials that we sent out, the Ugandan government recalled its own brand of condoms, Engabu condoms, in late fall of last year, 2004 and at the time of the recall, had no back-up plan in place for replacing Engabu condoms, which have for about 10 years been provided free in government health clinics on the ground in the country.

At the same time that this shift was happening, there has been a dangerous and profound shift in US donor policy from comprehensive prevention, education and provision of condoms and other prevention technologies, to a focus on abstinence only. So at the time that condom supplies are being diminished in Uganda and the inconsistency of supplies has become chronic, we also have a shift in which those condoms that are available are being made available only to those groups determined by the US government and the Ugandan government to be so-called "high-risk groups," such as sex workers and truck drivers, etc. So, while we have seen a marked decline in the number of condoms provided between FY 2004 and FY 2005, and no back-up plan on the part of the Ugandan government to replenish and reeducate the public about the safety and efficacy of condoms and certainly to undo the damage done to Engabu condoms, we are also seeing a shift in who may have condoms and who may have access to condoms and safer sex information in the country. These are the two broad themes of this call today, and as such I want to turn the call over to Beatrice Were, who is going to speak for a couple of minutes about the situation in Uganda. Beatrice:

Beatrice Were: Thank you, Jodi. Hi, everyone. Hi, Stephen hi, Zackie. I would like first to thank activists in Uganda and in the US. And a particular thanks to Stephen Lewis, for having honored us by joining us and for standing by us during this difficult time. I’d also like to thank Zackie and I'm very optimistic that together when we stand, this will gain the attention that it needs.

Speaking from Uganda, what I intend to do is not to dwell so much on the statistics, because Jodi, you have brought that out quite eloquently. But to give you a feel of what is happening on the ground and from a perspective of an activist and a woman living with HIV, the current situation in terms of the condom crisis, at the same time the issues surrounding the condoms, now have translated into what I call, unleashing stigma. We have a new wave of stigma in the sense that AIDS is now being treated as a moral issue. . There is now stigma attached to the use of condoms. And those of us who are promoting condoms are looked at as immoral people, those that are morally dead. We are looked at as people who are promoting what is not morally correct and this is quite sad for a country that has gone so much ahead and for the strides that we have made. And for those of us who are infected with HIV, it is a painful thing in the sense that we are now being looked at as people who deserve what we have looked for and caught, HIV.

And the other problem that we are now faced with is that there doesn’t seem to be political commitment to addressing the situation at hand and the big reason, I think, in my opinion and analysis, is that this whole situation is being driven by moralist groups, and by our political leaders. Looking at it in terms of the way AIDS has been addressed in Uganda, we have had political leadership strongly support condoms. Now, we're having political leaders taking a new turn in terms of looking at AIDS now as a moral issue and promoting judgment and that in itself is causing a lot of confusion in the community and chaos in what I will call the re-stigmatizing of AIDS and I think only this is quite a saddening situation. And I, Jodi, I’d like to stop there because most of my contribution will come from the questions.

Jodi Jacobson: Thank you, Beatrice. We certainly can have a rich discussion during the question-and-answer period. I think we will now turn to Stephen, actually, because it appears that Zackie is a bit late in returning from a previous meeting, so Stephen, if you wouldn't mind going ahead and then we'll wait on Zackie.

Stephen Lewis: Sure, by all means. Jodi, first of all, and for everyone on the call, I have been elevated to a status I do not deserve. And I may say that it's a pleasure to join in a call with Beatrice and Zackie, because we are all good friends who have collaborated in this struggle for some time.

Let me make four brief points. Number one, there is no question in my mind that the condom crisis in Uganda is being driven and exacerbated by PEPFAR and by the extreme policies that the administration in the United States is now pursuing in the emphasis on abstinence, far and away beyond that of condoms. And that distortion of the preventive apparatus of ABC, with which we're all familiar, is resulting in great damage and undoubtedly will cause significant numbers of infections, which should never have occurred.

Number two, it is of course a policy, this over-emphasis on abstinence, this preoccupied, obsessive emphasis on abstinence, it is of course both absurd and irrational. How, for the women, who are in married situations, does abstinence apply, if they have no opportunity to emphasize the need for condoms for a partner or a husband about whom they may have suspicions? How do they save themselves from infection? Abstinence doesn't work in marriage, obviously. Nor does it work where you have determined, sexually active adolescence and young people, who will always be sexually active. To impose dogmatically a policy, which is fundamentally flawed, is doing great damage to Africa. And frankly, I think the administration and PEPFAR have to come to their senses, just as they have come to their senses about the need for generic drugs over the brand-name pharmaceuticals. It's taken them a very long time to come to their senses, but they appear to have reached it, so they have to reverse their policies on abstinence because of the damage it's doing.

Number three, Uganda, for all of us has been a model of prevention and the reduction in prevalence rates from 15 or 20%, down to 5%, is of course a notable achievement and President Museveni lay right at the heart of that achievement, and it's extremely frustrating and sad now to see that the government, undoubtedly, understandably influenced by the extraordinary numbers of dollars which PEPFAR is investing in the country, that the government of Uganda should feel it must mirror the distorted priorities which PEPFAR is espousing.

And finally, for the United Nations, from time-to-time I have views, which are not always consistent with my colleagues, but for the United Nations, condoms are absolutely a vital preventive response. There is no equivocation about this. And if Uganda is in trouble as it is over supply, then there is always a possibility of turning to the World Health Organization for emergency supplies, certainly to the United Nations population fund, if the capacity of various individual suppliers like PSI are compromised. Remember, Uganda needs 120 to 150 million condoms a year. And in 2005, they may well be down to 20 or 25% of that, and frankly that is courting disaster.

Jodi Jacobson: Thank you, Stephen. I wonder if Zackie is available.

Operator: He has not arrived yet.

Jodi Jacobson: OK. I just wanted to point out to folks on the call that there is a set of basic facts and a timeline available on the Gender Health website, www.genderhealth.org, all one word, genderhealth, that includes some of the facts that have already been given to you in that call this morning and the background information can be easily accessed. Many of you have already received that background information in e-mail correspondence we've sent you, but for those of you that have not, it is available at www.genderhealth.org. If Zackie is not available, I wonder if we should just go ahead and open the question-and-answer period, so that we can get that rolling and when he becomes available, he can step in.

Operator: If you would like to ask a question during this period, simply press star, and the number one, on your touch-tone phone. Once again, if you would like to ask a question, simply press star and the number one on your touch-tone phone.

Our first question comes from Joe Decapua. Your line is open.

Joe Decapua: Thank you. OK, Joe Decapua, thank you. Hello, everybody. I had a question about the condoms being in the warehouse. What was the latest determination regarding those condoms, because there was the whole issue of initial tests showing holes and odor? What does the government say about this? Where does it stand now, regarding the safety of these condoms?

Jodi Jacobson: Beatrice, would you like to answer that?

Beatrice Were: Yes, I will. The condoms are now lying in the warehouses. The condoms are still in the warehouses. They have not been distributed to the public, and the reason being that they are not sure that the public will have confidence in them. And what we are finding, therefore, is that while the public is desperate for these condoms, they are lying in the warehouses and they are considering, according to Elioda Tumwesigye, MP, chairperson, Ugandan Parliamentary Steering Committee on HIV/AIDS, they are considering changing the name. And what he told us in June, when I organized the meeting for activists, he said that they've not had the manpower to do the job of changing the name and re-labeling the condoms. And we did offer, as people who are directly affected by the problem, we did offer that we could give that labor for free. It just meant agreeing on a new name and each one of us had to like, stamp a new name, whatever the new name is. So as this situation stands, the condoms are still lying in the warehouses and it's now close to 30 million that are lying in the warehouses.

Joe Decapua: And they're all considered safe?

Beatrice Were: Yes, they have passed the post-shipment test. Those are the ones that were sent to the United States and they passed the post-shipment tests. Now, their fear is that they’re still the Engabu brand and that people have lost confidence in them. But I think the problem is that while all these fears are being raised by different government officials, there is no statement, officially from the government, from the Ministry of Health or Ugandan's Commission to allay the fears of the public.

Jodi Jacobson: I think, Beatrice, if I could add to that, one thing that we have found in talking with public health officials and others on the ground who have done condom promotion and distribution, is that the real concern, as Beatrice has noted, is the lack of public confidence now in the Engabu brand and the fact that these are in fact stamped as Engabu condoms, and so it's like any other consumer product which involves health and safety. Once you lose confidence in that, do you really want to turn to that product? And so part of the challenge here is where has the government stepped in, both to, generally speaking, reassert confidence in condoms per se, as a preventive technology; and specifically, to act quickly to have another brand of condom or another name developed for a brand of condom that can be provided free and to which access can be made universal in Uganda, and that we don't see happening. So I think that that is a critical issue.

The other thing I would point out about the Uganda situation is that, simultaneous with sending the Engabu condoms for testing and the problems that arose, was the levying of import taxes on condoms coming into the country for social marketing programs, which increased the price of condoms. And then also the requirement that any condoms coming into the country be post-delivery tested, even though the capacity does not exists in Uganda for such tests and they must be sent abroad. In other words, even those condoms that were coming from the US, which has stringent quality-control standards, had to be delayed at the port and be retested when they came into Uganda, which I find questionable at best.

Stephen, did you want to say anything more to that, or do we take another question?

Stephen Lewis: Just a very, very quick footnote. If I were suffering from arthritis, I probably wouldn't want to buy Vioxx and I think the analogy holds that people in Uganda are obviously very, very shy of the Engabu brand, but none of that should stand in the way of finding alternatives. There are tremendous supplies, which could be called upon if the government was so inclined, and if there were not so many inhibiting factors from price to quality assurance tests that are required post delivery. This is really a basic issue now of whether you're going to use condoms as a preventive protection against the virus, and that's what's at stake here.

Operator: Our next question comes from Tina Rosenberg. Your line is open.

Tina Rosenberg: Hi, thank you for holding this call. I have two questions for Beatrice. First of all, I'd like to ask Beatrice to describe what the situation is of someone in Uganda who wants to try and buy condoms and compare that to what it was a couple of years ago. I'm not clear as to whether they're completely unavailable or what the obstacles are. The second question is regarding what is specifically the government has added to towards these condoms? It's a little unclear as to whether you're describing a situation where the government is struggling to figure out how to restore confidence in condoms and what to do about the Engabu brand, or they are really doing all they can to keep these condoms locked up in warehouses.

Jodi Jacobson: Beatrice?

Beatrice Were: I'll begin with the last one, because this relates to what to the previous question that we just dealt with. The last question is mainly looking at what the situation is on the ground and what the government is saying about this situation. The fact that the government is still keeping about 30 million condoms that have passed the post shipment, that have passed the post shipment test in the warehouses while people are craving condoms is a sign that there is no commitment to probing this issue that is quite urgent. And the fact that this has taken 10 months, in a sense, illustrates the fact that the government is dragging its feet on this issue. And the other thing is also, the fact that the government has not come up with a statement, a policy statement to reassure people, the public's confidence in condoms, and have not even looked at alternatives if the Engabu condom has become so unpopular. In itself, it's a sign that this is not being treated with the urgency that it deserves.

The other thing is also being, the interesting sort of drama that is on the ground, while all of this is happening, the coincidence that condom availability is down at a time when the government abstinence-only programs are being pushed in Uganda. Obviously from there, the speed at which abstinence-only programs are promoted more and more as well as abstinence-only messages going on radio, all sorts of groups and the support in terms of funding of these programs and receiving from PEPFAR’s abstinence-only programs being promoted. I mean all of this is really showing the direction that Uganda is taking.

So personally and from what we are seeing on ground is the fact that science is being challenged. We know that the condom has been proven scientifically to work even in basic primary results tests; this is something that we should not be belaboring. So I feel very strongly that the government is not doing enough given the fact that this is a government that is looked at as a role model and we have taught the world quite a lot. For Uganda to challenge scientific support of condoms is quite a bad situation.

Now moving on from there, if I went out to procure a condom today in Uganda, one is the scarcity. You'll find that in -- in fact if I went out to look for a free condom even before I tried procuring, if you went to the government facilities where last year we had these condoms distributed for free, they are not there. If you went to the district hospitals, condoms are not available. Now you will find that because they are lying in the national medical stores and they are not being distributed in the hospitals, people then cannot have them as an alternative, as a potential alternative. Then that leaves you the alternative of going to the market, the open market. Now you'll find that when you go to procure in the open market, Lifeguard, that condom which costs -- in fact, it was really was costing 300 shillings, which is less than a dollar, which is in cents in US money, you'll find that now it is about -- a packet of three of Lifeguard is 1,000 Ugandan shillings, which is about almost $0.50. That is quite a lot of money for somebody in the rural areas.

The other thing is also the stigma that is attached to the condoms. Because of the abstinence-only messages, what you're finding is that there is a lot of stigma that is being unleashed when you go to the open market to buy a condom. You look at this person that is buying the condom, which has been first stigmatized, because the only picture that people have is the negative side of this. So that is what I can say about this situation. I don't know if that adequately answers that question.

Jodi Jacobson: Tina, I would just say that just as one point there to add to what Beatrice has said, and she may have said in the beginning and I was taken off for a moment to talk about Zackie coming on the call, is that the free condoms provided by the government made up 80% of condoms available to people in the country. Without those free condoms, you have a real crisis. So that is a fact that needs to be underscored. It also needs to be underscored that the Lifeguard condoms, and the Protector condoms that Beatrice was referring to, were the ones that were the social marketing condoms provided by the United States and by other donors through Population Services International (which by the way, just lost its contract in Uganda from the US government) and through Marie Stopes International through other donors. Those are social marketed condoms. They are not free, they do cost money. They were targeted at specific audiences. They are now further diminished in their targeting because of reduced supplies and also because the US government is not allowing them to be made as available as they were before.

Let me turn to Stephen for any follow up. And then also, ask that we hold for introducing Zackie Achmat to the conference call.

Stephen Lewis: You should get to Zackie. I just wanted to note, listening to Beatrice, it's very interesting in the way she dealt with this, that I was in Uganda, I guess it was at the turn of the year, if memory serves me, in the North, both Gulu and Kitgum and then up in Arua in the Northwest and traveling with the Minister of Health. And we were right in the middle of the political squall where the President, President Museveni, was openly attacking condoms and the Minister of Health quite publicly was supporting the use of condoms. And it was pretty obvious that within the government itself the position had not yet been reconciled.

Jodi Jacobson: Thank you, Stephen. Zackie, I believe you are now on the call, if you could confirm that?

Zackie Achmat: Yes, I am.

Jodi Jacobson: OK, great. Welcome.

Zackie Achmat: I'm really sorry I was running really late.

Jodi Jacobson: No problem. Can you just, if you have some opening statement you wanted to give we would really appreciate hearing that now and then we'll continue with question and answer.

Zackie Achmat: Yes. I just wanted to say I have the same disease, HIV, to Beatrice. But on behalf of the Treatment Action Campaign, we want to extend all the solidarity we can to the people in Uganda and to activists all over the world, and the entire international community to shame the United States and the Ugandan government for preventing people having access to condoms. For all of us, the crisis of prevention is indeed becoming a far greater crisis than the crisis of access to treatment. In our country alone, last year, there were over 500,000 new infections for the whole year of last year. Globally, we're seeing a dramatic increase in infections. And to both undermine the use of condoms and then to manufacture a shortage of condoms is really a tragedy and grossly irresponsible. Uganda does not need 20 million condoms from the Department of Foreign International Development alone; it needs at least 400 million condoms from the Department of Foreign International Development. There are 6.5 million men aged 15 to 64 in that country, and 20 million condoms do not go very far.

Jodi Jacobson: Thank you, Zackie.

Zackie Achmat: And from our point of view, what we would like to see is some serious global activist consultation and global activist mobilizing, to shame the Ugandan government and also to shame the international community.

Jodi Jacobson: Thank you very much Zackie. We will go on to question and answer. I might just point out that, to Zackie's point, when we look at US funding for HIV/AIDS in Uganda, 66 percent of US prevention funds goes to the prevention of sexual transmission, and of that amount 56 percent is going to Abstinence and Be faithful programs. In Nigeria, the share of prevention of sexual transmission under PEPFAR is 70%. The remaining share of funding is targeted only at sex workers. So there is no sort of abstinence-only and then comprehensive programs. You have abstinence-only and then only highly targeted and re-stigmatizing programs. And Center for Health and Gender Equity actually has a series of fact sheets coming out looking at the shares of abstinence-only funding under PEPFAR in these countries. And we'll turn back to questions now.

Operator: And our next question comes from Larry Altman. Your line is open.

Larry Altman: Yes. Two things I'd like to clarify earlier: what the cost of social marketing was before and now for the condoms, I didn't understand Beatrice's answer on that. And the main question I have is have you complained to PEPFAR and what has PEPFAR's response been to you?

Jodi Jacobson: Beatrice?

Beatrice Were: Back to me. In terms of US dollars, the cost for the social marketing condoms before this crisis was 300 shillings, which is less than a dollar, which is really in cents, for three pieces. A little package is three pieces. And what it is today is almost three times that price. It's about 1,000 Ugandan shillings, which is about $0.50.

Larry Altman: That’s what doesn't make sense. If it's less than a dollar for 3 for 300, now it's $0.50. This doesn't...

Jodi Jacobson: I think what we're losing is the translation. I don't know the immediate translation. I think what Beatrice is saying is that the price has effectively tripled. Is that correct, Beatrice?

Beatrice Were: It has almost become threefold, if you want to say. For a packet of three condoms, the social marketing condoms, you'll find that the price is now three times what it was before.

Jodi Jacobson: In shillings, right.

Beatrice Were: Yes.

Jodi Jacobson: Does that answer your question, Larry?

Larry Altman: Yeah, but to, what does it cost to purchase them now per condom?

Jodi Jacobson: What she's saying, if I am correct, is that the cost previous to the crisis and previous to the imposition of import taxes, was 300 shillings per package for social marketing of a condom like Lifeguard, but now they're approximately 1,000 shillings per package. Is that correct, Beatrice?

Beatrice Were: Yes.

Jodi Jacobson: So what we're looking at, because of the import taxes and the other conditions on the ground that the social marketing condoms, not the free condoms, the Engabu brand, but the condoms that came in under social marketing programs have effectively tripled in price.

Larry Altman: OK, and what is 1,000 Ugandan shillings equal to today?

Jodi Jacobson: I don't know the answer to that off the top of my head. Stephen, or Zackie, or Beatrice, does anybody know that? We can get you that information.

Beatrice Were: Equivalent of 1,000 Ugandan shillings? Let me work it out here.

Jodi Jacobson: I think in effect, what we're talking about is the purchase price by consumers and not necessarily what the relevant issue is in -- but what Beatrice is saying, my colleague has just come in and said that there's basically about $0.50 for the package of three, but the relevant issue is what that means in relation to the purchase price and purchasing power of Ugandans, not how much it means in the United States.

Larry Altman: I understand that, but it's still confusing what the comparison of three for less than a dollar.

Operator: Excuse me everyone; Health GAP has dialed in to give us an answer to that question. 300 shillings was approximately $0.16. 1,000 shillings is approximately $0.54. So the price has actually gone up from $0.16 to $0.54. You may go ahead please.

Larry Altman: OK. And then the question is what have you asked PEPFAR and what has PEPFAR's response to you been on the issue?

Jodi Jacobson: Is that question for Beatrice?

Larry Altman: For whomever would be -- or Stephen.

Stephen Lewis: I haven't spoken to PEPFAR. That's a good question, Larry. I haven't spoken to PEPFAR on the issue because they've been so determined about the abstinence position. But I don't know what's happened on the ground in Uganda. Beatrice, have people approached PEPFAR directly?

Beatrice Were: I do not know if my colleagues have, but what it is, is that this situation where there is pressure from the abstinence-only promoters. And because it's the government's position, people are afraid to challenge it. One thing that needs to be made clear is that this position is taking advantage of the Ugandan poor, people who are vulnerable, you know, there's that pressure that makes you forget that you have rights. So one of the things that this is difficult about challenging PEPFAR policies is because it's coming from government. People look at it like, how can we challenge the government and we have no voice, we have no (inaudible) situation there, we have (inaudible) directly. The other thing that is important to recognize is that the US government has got a lot of influence in Uganda, mainly because of the money. And you will find that if you have to put up any -- it's the first thing sort of like pressure on this issue you end up being alone, you are isolated. So we have found a Ugandan for instance where we have a few people like almost now three people who are out there, and other people are like, "oh, the money will be withdrawn and then what shall we do?" They are not looking at other alternatives. And then there's all this concern about national security and how can I be seen to be confronting the government. We are talking about a situation where you risk your life for protesting the government.

Jodi Jacobson: Yeah, and I would add to that if I may, Beatrice, and Larry, just to give you a sense. The Center for Health and Gender Equity does monitor US international policy on the ground in other countries on global AIDS and reproductive health issues. And we have in fact, with Health GAP and others, approached the Office of the Global AIDS Coordinator numerous times, to both give us information around what is happening with abstinence-only programs, and what the guidelines specifically are, and to whom the restrictions are being applied around who may get condoms and who may not. We've also worked with members of Congress on the House International Relations Committee at various points in time to question the Global AIDS Coordinator, Randall Tobias, on these issues. OGAC is steadfastly kowtowing to the fundamentalist right on this issue, because they are in fact funding abstinence-only programs or behavior-change programs applied to abstinence-only and be-faithful programs for the general public and focusing on their definition of high risk, which are sex workers and truck drivers only for condom distribution.

The problem with that is that in a population like Uganda, where 66% of males and females ages 15 to 24 are already sexually active, you cannot say that people who are ages 15 to 24 are not at high risk. This is the same kind of ratio we see in other countries where the actual rates of infection are highest among people ages 15 to 24 and/or highest, as in South Africa, among married women ages 20 and 30. So, we have a real problem here, a real disjuncture between what PEPFAR's funding and the accountability of that information and not being made public who's getting what money, as opposed to who's really at risk on the ground in these countries, which is older adolescents and young adults and married women.

Operator: And our next question comes from Joanna Buchan. Your line is open.

Joanna Buchan: Thanks very much. I've got a question for Stephen and a question for Beatrice. Stephen, a question to you is about the timing of the Global Fund's decision to suspend their grants to Uganda. Given what's going on with the way PEPFAR is using its money and the pressure it's putting on, the decision of the Global Fund to suspend money to AIDS, TB and Malaria couldn’t have come at a worse time surely.

Stephen Lewis: Well, obviously, the decision of the Global Fund complicates matters in Uganda rather badly because it deals with the Project Management Unit, the PM Unit in the Ministry of Health, which was responsible for the overall distribution of the funds, and it's that unit whose activities have been drawn into question and caused the Global Fund to respond as they did. It's presumably also very difficult for the Global Fund, which faces the Replenishment Conference in a few days time. So obviously they felt they had to act. I think I should note, because it was interesting, that when they took the decision to suspend the five grants and insist on a very serious inquiry into the management practices, the Global Fund rightly said they would make special provision for the continuance of treatment, obviously you can't interrupt treatment, and they said, for the distribution of condoms. So the Global Fund understood the importance of the condom issue even as they did what they felt was necessary around the grants.

Joanna Buchan: Thank you, Stephen. My question to Beatrice is about what you were saying earlier about the literature was posted about the abstinence-only programs that are going up around Uganda, and how easy it is to get information as about this abstinence-only work. Who is driving this? Is it the churches? Is it other government departments other than Health? Is it possible to say, Beatrice, are the churches is behind this?

Beatrice Were: What is happening is that the one of the major drivers behind this and what actually makes this a very difficult situation to deal with is that it is the government that is pushing this and particularly the First Family, the First Lady's office, being the perennial abstinence-only, so you'll find that the billboards at the universities there. These messages are targeting the youth, which are saying abstinence-only, why not, 100% safe and these billboards are at all university, in main university entrances. And you'll find that this is heavily funded by PEPFAR and the Global Fund money. And because the First Family is a moralist family in the sense that it is in the line of what shall I -- the puritanical sort of sect of religion, the Pentecostal religion here, that in itself has grown as a religious organization's first as one of the renowned person now called Pastor Martin Ssempa, people living with HIV directly. And one confrontation we had with him on a radio program he said, we are now -- we are taking it for granted, as people living with HIV, that we are living a long time, that we need to be reminded that fate is ugly, and that we are a potential danger to society and he blames the fact that we are being kept on medication and we are living a long time. So you will find that they’re a people like that who are taking advantage of the situation, and because they have now the blessing of the very political leadership that steers all of us in the positive direction, now because the political leadership is steering us in this direction of abstinence-only and stigmatizing those of us who are infected and who look at condoms as a means of living positively, they are taking advantage of this. So it's the moralist, the first house, the First Family, and the government that are promoting this.

Now, one thing I want to bring to your attention. When the Global Fund officials from Geneva announced that they are arriving today, this announcement came last Friday. On Saturday, abstinence only posters were being pulled down all around town and the billboards were being pulled down and one of them that is right in front of my office. When I asked why this was being pulled down, the man said, "oh, we are taking them, we are taking them for repainting." And up to now they are missing, so for us this is a very interesting thing. And all this was at the prompting of the office of the First Lady.

Operator: And our next question comes from Andrew England.

Andrew England: Hi. I'd just like to ask a couple of questions, one just to Stephen particularly and the other one generally. Your data doesn't seem to match up with the Ministry of Health. I spoke to the Minister of Health today and he said that the consumption of condoms was 5 million a month. They've already distributed, I think, 55 million Lifeguard condoms this year and another 55 million will come in September, so there is no shortage. So I'm just wondering, why is there this discrepancy? Is that a different way of working out what the consumption is and what is actually needed and what is actually available? And also, are we saying there has been a fundamental change in the government's policy? I mean just to clarify on the earlier question, are we accusing the government of deliberately hindering the ABC campaigns to just an AB campaign? Or is it more complex than that?

Jodi Jacobson: Stephen, did you want to be the first to respond?

Stephen Lewis: Others can deal with the numbers question. All these issues are desperately complex. I don't deny that for a moment, but on the other hand, I'm not going to retreat from what I think is the obvious proposition. All you had to do was be in Bangkok in 2004 and listen to Museveni's startling speech. Then realizing that the ground was shifting and that the, that condoms were falling more and more into disrepute in the equation of ABC, and it's rather interesting what's happened over the intervening year and more. The government is softening its stand somewhat according to the latter speeches I've heard of the President. I think the activists and the campaign generally has made the government feel that perhaps they went overboard in the abstinence-only emphasis and, or abstinence and fidelity, but primarily abstinence at the expense of condom use and it may be that we're gradually seeing a change. But given what has been said on this conference call by Beatrice in particular, who's physically there and on the ground, it seems to me that the government is still being very, very resistant. And everybody knows that the First Lady is very strong in her public criticisms of condoms and that obviously has an effect on the population. So when you say to me, is it a deliberate government policy? I would say yes, it has been a deliberate government policy to shift the emphasis to abstinence at the expense of condom use. That's what happens in a society when your senior political leadership takes a public position. Is it going to be that way forever? It would appear that as the pressure builds, the government's position may soften.

Jodi Jacobson: Thank you, Stephen. In terms of the breakdown of the numbers of condoms available, I want to reiterate a couple of things. First, there are a data sheet, basic facts and a press release outlining the numbers of condoms available in Uganda as against the need on www.genderhealth.org. We have done research including information, both from the Ugandan government, from Marie Stopes International and from Population Services International. The total number of condoms that were distributed in FY 2004 is about 88 million. And according to all sources, in FY 2005, the total number of condoms distributed in Uganda is 30 million condoms since last October. Now, the government had gotten 20 million of an emergency shipment of Lifeguard condoms and asked both PSI and MSI (Marie Stokes International), to help distribute those. Those are counted in that 30 million condoms figure. As Beatrice has mentioned earlier, there are some 32 million condoms remaining in storage, those are Engabu condoms. These are the hard facts on the ground.

What the Ministry of Health is saying, I'd like to see their evidence of that, because what we have been told, and we have been on the ground as well in Uganda, is that 30 million condoms have been distributed through these various sources, and that there are condom shortages and people unable, as Beatrice has mentioned, to get access to condoms. So if the government is claiming no crisis whatsoever, I'd wonder why has the price of Lifeguard tripled, and why are there no condoms available to people in government health clinics? There seems to be a problem of evidence here in terms of the hard facts on the ground versus what the government is saying.

I'd also like to point out and reiterate what Beatrice said earlier, and Stephen has just eloquently reinforced this, yes there is an issue of ideology here. And that PEPFAR funding, by funding religious and fundamentalist groups in Uganda and in other countries, including in Nigeria, including in Kenya, including in Tanzania, has helped to stigmatize condoms as a prevention technology. I think these two things cannot be separated. Programs that were put in place for HIV prevention before PEPFAR are eroding due to lack of support and now ideological attacks. PEPFAR and religious groups reinforcing each other. What is different about Uganda is that for now, the fundamentalist viewpoint enjoys the support of the government.

In FY '04, the United States gave some $90 million to Uganda for PEPFAR. The next year, FY '05, $137 million was given to Uganda under PEPFAR. And in FY '06, they're expecting over $170 million. There is no question that there is a tie here between the amount of money going under PEPFAR to Uganda and what is happening in that country, particularly vis-à-vis the groups that are getting funded. So I think there is a real issue here and I would really encourage all of you to look further into these issues.

I wanted to note also that there are spokespeople listed on our website, including the folks on this call, but also others from Nigeria and other countries, who are willing and able to speak to these issues in their own countries. Unless we have another question, I wanted to ask if Stephen, Zackie and Beatrice wanted to give a closing statement.

Operator: We currently do have five other questions in queue.

Jodi Jacobson: OK. Well then, let's proceed with those questions and then allow for closing statements.

Operator: And the next question is coming from Andrew Quinn. Your line is open.

Andrew Quinn: Yes, this is a question for Stephen. Stephen, I was wondering if you could give us your views on how this PEPFAR situation is taking place in other African countries other than Uganda. Are you seeing the same pattern at work in other countries? Can you name any other countries where this is may be happening, and what evidence you might have to back up the idea that PEPFAR is doing this in more places than just Uganda?

Stephen Lewis: Right. What I see from PEPFAR, Andrew, is that when PEPFAR began, it was pretty isolationist, pretty truculent in pursuing its own agenda, frequently offended governments, indeed offended Ambassadors and USAID in missions. I saw it in Uganda. I saw it in Ethiopia. I saw it in Tanzania. I saw it in Kenya. There was a lot of tension between PEPFAR and the government itself. And over time, and I think this is important, and I'm perfectly willing to acknowledge it, over time they began to work out cooperative arrangements where PEPFAR would work in some sectors and governments would work in another sector. Where government would handle the first-line intervention drugs and PEPFAR would handle the second-line intervention and pediatric drugs, as that's the case for example, in Tanzania. So on various fronts, PEPFAR has gradually worked its way through, including its recent agreement I gather, with the World Health Organization to see whether generic drugs can't be rapidly approved through FDA and then used by PEPFAR rather than a dependence on brand name. So PEPFAR has made a lot of accommodation in the course of its evolution and I'd be the first to acknowledge that.

There is in most of the countries I've traveled through–and I don't want to pretend chapter and verse knowledge here–but there is an atmosphere around the abstinence question, which is palpable. There doesn't seem to be the same condom lack in some of the other countries. Or let me put it another way, the government doesn’t seem to be so focused on the abstinence agenda in some of the other countries, in Eastern, Southern Africa that I've been in. There are condoms coming from the United Nations and from groups like Marie Stopes and PSI and from Ministries of Health. There isn't the same retreat in the face of the abstinence campaign, but there is certainly a recognition that the government of the United States, through PEPFAR, sees abstinence as the primary preventive tool, not condoms. That is everywhere recognized.

Operator: And our next question comes from Massimo Alberizzi. Your line is open.

Massimo Alberizzi: Hello. Hi, my name is Massimo Alberizzi. I'm the African Correspondent of Corriere della Sera which is the Italian Daily Newspaper. I'm sorry, I didn't hear very well Beatrice, when she talked about the churches. I would like to know the role of the Catholic Church in this shortage of condoms in Uganda.

Beatrice Were: Yes, what I'd mentioned was that the moralist groups, the churches, they – and the fundamentalists in terms of the -- what I'll call the Pastoral -- the Evangelical churches as a group that are actually “enjoying,” if I may put it in quotes, they're enjoying, the crisis that we are going through. What is happening is because they have the blessings of the First Lady and the First Family, and now the clout of government as a whole, they are taking advantage of this situation to promote abstinence-only programs. Remember, all of this is backed by heavy funding from PEPFAR. So one of the things that they are enjoying is that their programs are heavily funded and they are cushioned by the First Lady and the President now says it outright. So what they are finding is that they are looked at as the people that are being good. They are now dealing with morals. AIDS is being treated as an issue of morals rather than a public health issue at that level.

So you will find the Catholic churches, we have had several instances where the Cardinal has come out to speak and applauded the President's and government's position on abstinence only. We have seen other by definition fundamentalists, one of the charismatic religious sects, actually the one that is in the lead. We have had people like that coming out with this statement, which we have actually sent out on to other activists and colleagues to give a feel of what's happening on the ground. We once had, I think it was in May, May last year, when there was a quiet meeting by religious leaders when they were looking at the abstinence-only policy, which actually now, the Ugandan's commission is in the process of (inaudible). And this was a quiet meeting; it was officially opened by the First Lady. It was low-key and it was mainly religious leaders, mainly from the key churches around. And what we had there was just the three people I invited. Some of us came to learn about this when it was closing, so surely we have a strong role that the church is playing and they too, are taking advantage of the current political climate.

Jodi Jacobson: Thank you, Beatrice.

Operator: And our next question comes from Bruce Edwards. Your line is open.

Bruce Edwards: Hi, I'm Bruce Edwards from the CBC. I was also going to ask you about the religious groups and how they're exacerbating the condom shortage in the country and you've essentially just answered my question. But I would ask are they all doing the same thing or are there potentially some groups that are resisting this abstinence-only policy? And I guess I should ask also, are there any groups that are known to be funded by American money, in fact?

Beatrice Were: Yes. What we have is, in terms of the first question, it is hard now at this point to say if it's all, but you would say that the major religious groups. The fundamentalists, the Pentecostal churches and the Catholic Church are ranking number one in funding. And you will find that these are the ones, especially the Catholic Church, are the major recipients of the PEPFAR funds through programs like CRS, the Catholic Relief Services. And I feel this wouldn't be a problem as long as they saw the rationale in allowing the other alternatives and looking at complex dimensions, and specific situations, such as women in conflict, the youth and other vulnerable groups like that. Now the problem is they are looking at issues like everything is like we have the same one standard. They are not looking at other situations. In terms of who is receiving money, I have already mentioned some of the Catholic Church groups who are receiving PEPFAR money through CRS, the Catholic Relief Services. We also have Pastor Ssempa, who is with…

Jodi Jacobson: Makerere Community Church.

Beatrice Were: Yes, Pastor Martin Ssempa is receiving a lot of money. Then we have the First Ladies’ Initiative, it is called, the African's First Ladies Against AIDS, which is a number of other First Ladies, but in Uganda, the First Lady's Initiative is receiving money. That's why she's put up these billboards and all these messages and recently there was a big launch in which groups were awarded for promoting virginity. If you'll remember, some of you who have been following the developments, at the beginning of the year, when university students were enrolled for the first year students, the First Lady addressed them and warned them about condoms and how bad they are. And she said they have holes and they cause diseases. And she warned them and told them they must abstain because condoms are very dangerous for their lives.

So you will find that those groups that are receiving money. Recently there was a big launch of a new project, which the First Lady opened. Some of these groups were called and given big grants from PEPFAR because they were going to promote virginity, you know, abstaining and making sure that the young people are frightened.

Today we have in one of the newspapers, I think it's The Monitor, or New Vision, I don't recall which one, where one church, this Baptist church is promoting abstinence-only through a program called, True Love Waits. So we have all these -- most of these churches that'll say, of course, they agree to promote this. Now in terms of some of those that are not, I would say it's actually individuals. Some individuals, you'll see individuals in the church like Canon Gideon Byamugisha, have stood up and said, no to abstinence only, and very eloquently. But what you'll find is that a person like Canon Gideon Byamugisha standing up is one and he is infected with HIV so he’s got that personal experience. The other thing is also this person—Gideon--who is a social scientist, and the activist PLWHA look at things objectively. But you will find that this is one person out of so many.

Jodi Jacobson: Just to follow up on Beatrice's comments, for those of you interested in the list of recipients from the First Lady's Initiative and the recipients under the core agreement of US funding to faith based organizations, we have the full list of grant recipients plus the amounts of money they have received. And we can post that to our website at www.genderhealth.org or provide anyone interested with that information directly.

I would also just point to another thing to expound on what Beatrice has just said, apart from for example, Martin Ssempa's organization, Makerere Community Church, which was listed as an OGAC partner in the OGAC partner list in FY 2004, we also saw the awarding of funding to the Children’s AIDS Fund, which if you will recall, was an organization that was turned down by a technical review committee based on the merits of its proposal. In other words, a group of scientists and public health professionals gave it so low of a grade that it could not pass their committee review for being a worthwhile proposal, and yet the Bush Administration pushed through funding for that organization over other organizations that have public health capacity in Uganda. So I think we're seeing a corruption of funding. Evangelical religious groups are being supported heavily by PEPFAR even when they have little or no capacity or experience on public health. We're also seeing an attack by US Congressmen and Senators on groups like International Community of Women Living with HIV (ICW) and others who do public health work through letters to the President, undermining ICW’s reputation based on specious charges. So there are two things happening here. One is the funding of groups that don't have public health capacity and the other is attacking groups like Population Services International and others that are doing public health work. The woman who runs the Children’s AIDS Fund is on the President's Advisory Council for HIV/AIDS. So there is some link there to support for the Bush Administration.

Operator: And I believe Mr. Lewis had a comment to that question as well.

Stephen Lewis: I just wanted to say to Bruce that the Catholic Church does not need PEPFAR funding in order to encourage their position on condoms. They're quite happy to pursue the position with which we're all familiar without any particular tie to PEPFAR. What PEPFAR has done, which is so interesting, is to have made it possible for numbers of Pentecostal and more fundamentalist churches, to pursue the abstinence agenda in a way which they didn't pursue quite so vigorously before. And what you have in Uganda, I think, which you do not have in other countries from my observation, is this strange brew of political leadership and PEPFAR in pursuing the abstinence agenda at the expense of condoms. I haven't run into political leadership in other countries in Eastern, Southern Africa who are so intensely perfervid, who are so publicly determined to debunk condoms, both the President and the First Lady, as is the case in Uganda. Uganda is a particularly acute situation. The PEPFAR agenda on abstinence is present in many countries, but it doesn't command the same political loyalties, as is the case in Uganda.

Operator: And we still have three questions in queue. Our next question is coming from Adam Graham Silverman. Your line is open.

Adam Graham Silverman: Hi, thanks. Two questions for anyone who would care to field them. First of all, what's the ideal solution to the situation in Uganda right now? And second, given the stakes that some of you have outlined, the potential for many more infections and so forth, why do you think that these forces, particularly in the government there, are so focused on reducing the, well what comes down to reducing the availability of condoms? I mean it seems awfully cynical to say that they're putting a moral choice above an obvious result, the obvious risk of many more infections.

Jodi Jacobson: Beatrice and Stephen, or Zackie, any of you want to respond?

Operator: Zackie, your line is open.

Zackie Achmat: Yes. I would say on the last question, that actually Museveni and Mrs. Museveni really do have a religious belief. But I believe that Uganda is seriously economically dependent on the aid and particularly trade, but more particularly aid rather than trade, with the United States. And I think it's the economic pressure of the Bush Administration, just as much as the Clinton Administration put pressure on the South African government in relation to drug companies, I believe that the Bush Administration is putting the pressure on the Ugandan government and especially that way.

Jodi Jacobson: I would just add we cannot separate this from what is happening in the United States around the fundamentalist right in the United States and its attack on reproductive technologies at large. We have here a government that is at least indirectly supporting pharmacists not filling contraceptive prescriptions. We have attacks in the US Congress on a daily basis on condom efficacy, on contraception, on the choice of women, whether or not to carry a pregnancy to term. And these ideologies are being exported. It's plain. It's clear. Under PEPFAR, those same ideologies are being exported.

So I think we can't look at it outside the context of what is the agenda of the global fundamentalist right in regard to women's rights, in regard to sexuality as being a normal aspect of human development, and in regard to the fact that there are diverse sexualities and diverse sexual experiences. So that while we may wish that everyone would refrain from having sex before they marry, the fact of the matter is, based on the overwhelming evidence from virtually every country, is that the majority of people have sex before they marry, they initiate sexual contact. So it's really, a war of ideology versus science in a broader sense. And I think we're seeing that being played out in Uganda, because of the special circumstances there.

Operator: And our next question comes from Simon Robinson. Your line is open.

Simon Robinson: In fact, most of my questions have been answered. So you can skip me if you would like.

Operator: All right. And our final question comes from Affefa Abdur-Rahman. Your line is open.

Afeefa Abdur-Rahman: Thank you. This is going back to the question about the churches, the Catholic churches and the religious groups in Uganda that are promoting this ideology. I was hoping to hear something about other religious groups, i.e., Islamic groups in Uganda and what their role is in this? And do they have a role? And, what are they doing, are they supporting this ideology or are some of them going the opposite direction? This is a general question to anyone on the panel.

Jodi Jacobson: Beatrice?

Beatrice Were: In regard to other religious groups, what you'll find is that the Islamic religious organizations, even before this whole saga, they have not been supportive of condoms. They have not supported the use of condoms, but because Uganda has always followed the ABC, which tended to, with time, change people's mindsets and we became accommodated in the sense that each partner did what they were best at, but allowed room for other players to come, you know, to make their contribution. Before, we had a situation where we coexisted with other religious organizations. We had a situation where, even when the Catholic Church did not support the use of condoms, they did not attack the condoms. They were not interested; they were not actually attacking it at all like it is now. We also had a situation where the Muslim groups did not attack the condoms even when they didn't openly promote it. And what to my surprise has happened at this point in time, the Muslim organizations have not come out like the Pentecostal fundamentalists on abstinence only, like you'd find in these other groups.

So what does that indicate to me? My interpretation of that is that this certainly means that because of the role of the First Lady, being Pentecostal fundamentalist in terms of her religion, that the other religious organizations that believe in her faith follow her in a kind of path. It is also very amazing that they are the ones actually that are receiving most of the money from PEPFAR. As for the Islamic groups, I have had not known them to contribute to this whole complication by attacking the condoms, downplaying its role, and promoting virginity and fidelity.

Operator: And we have no more questions in queue at this time. So Ms. Jacobson, I'll turn the call back over to you.

Jodi Jacobson: Thank you, Judy, so much. I wanted to ask Zackie, Stephen and Beatrice, if they had any closing comments that they could offer?

Operator: Stephen, your line is open.

Stephen Lewis: All right, fair enough. Just the obvious comment that it's perhaps the ultimate irony that the country and the political leadership most dramatically associated with the decline in prevalence rates is now in a position of attacking one of the strongest preventive protections we have. And that then speaks to the complex political relationships between Uganda and the United States and the complex politics internally in Uganda itself at this moment in time. And I must say that of course, the intervention of PEPFAR in all of this, while it has come to terms with other things for which it was originally criticized on the abstinence front, it simply has been both dogmatic and largely immovable. And I think the consequences will be grim for a great many people.

Operator: Zackie, your line is open.

Zackie Achmat: As I'm speaking to you, I'm looking at the poster from the office of the First Lady of Uganda, which is Thank God, I said no to AIDS driving home to me wife, and it’s a truck driver driving home and sex workers running after the truck. And it says “abstinence and faithfulness 100% guaranteed.” And for me it is deeply stigmatizing and painful. And for all of us, it undermines all of the work that has been done to de-stigmatize HIV and groups of people who are targeted by the government and being replaced by the government. And the money from PEPFAR will be going to stimulate religious fundamentalism in not only Uganda, but throughout Africa. And we know what the results of the United States' previous foray into funding religious fundamentalists are.

Operator: Beatrice, your line is open.

Beatrice Were: I would like to call for solidarity as a person speaking on behalf of the people who are sitting in the hot seat. And one thing that I want to mention very critically is, in terms of the US government support, which we do appreciate, I feel very strongly that what this needs to be conscious of is the fact that PEPFAR is actually undermining our health system, it is weakening our health system and they need to rethink, the designers of PEPFAR and the funders of PEPFAR need to rethink in terms of what they are doing. What they should be doing is strengthening our already weakened health systems. And I think they are harming prevention as the situation stands. It doesn't pay to give people the pills that they are taking, to have access to treatment or to be free from HIV and then they get exposed to HIV because the prevention is being underplayed. And I think this is quite critical to look at.

The other thing that I'd like to stress is the issues in Uganda are beyond just what we can cope with as activists. And we look upon solidarity of other activists, global solidarity, all nations that are at hand, because it is -- and every day they get more complicated because of the politics involved, because of the people that are involved, the political muscle and the authority and clout that they have. And for the few voices, those of us who are standing out here to challenge what is happening, we are so isolated and marginalized and threatened. We feel very vulnerable. You'll find that most people are feeling for us, but they are not able to stand up and speak. And really, the change will come from out there because inside the country, we are very few who are willing to stand up and be counted. But we are committed to sustain this battle to the end because it is about our lives.

Jodi Jacobson: Thank you, Beatrice. Again, this is Jodi Jacobson. I just want to first, thank all three of our main spokespeople for their phenomenal participation today and remind all of you that their contact information and background information, as well as the contact information for other spokespeople on these issues is available at www.genderhealth.org and at www.healthgap.org. We also have included on that list spokespersons from Nigeria and Kenya who are able to speak to the same issues about the trends in fundamentalism and abstinence-only undermining prevention in those countries. So I encourage you, for those of you who are interested in this issue in a broader sense, to look up those spokespeople and their contact information and contact them or contact us for additional people.

I also want to thank all of you for participating and my co-sponsors, Health GAP, Human Rights Watch and Advocates for Youth and encourage any of you to follow up with us on any of the issues or questions that you might have. Again, additional material is available on our website and if you have further questions, you can clearly contact any one of us. Thank you very much for your participation on the call today.