Health GAP (Global Access Project)
www.healthgap.org
September 19, 2005
"The war against AIDS and condoms," The Economist, September 8, 2005.
Editorial :"The Missing Condoms," New York Times, Sunday, September 4, 2005.
"Prevention Is Still Better Than Cure," TIME, September 19, 2005.
The shine is coming off what was once hailed as triumph of government policy
AIDS has killed about 1m Ugandans, while some 1.1m may still be infected with HIVÑbig figures in a population of 27m. But by African standards, alas, they are something of a success story. Much of the credit has gone to Yoweri Museveni, president since 1986. But now the campaign against AIDS is faltering amid accusations of moralistic grandstanding and financial mismanagement.
In the 1990s, western donor governments lauded Uganda for setting the standard in the continent's fight against AIDS. Mr Museveni talked openly about the disease, when many of his peers remained silent. He also pioneered the now famous "AbstainÑBe faithfulÑuse a Condom" (ABC) campaign that showed Ugandans how best to protect themselves. Partly as a result, infection rates fell from 18% in the 1980s to 6% in 2003.
But the AIDS problem is worsening again. A Ugandan health-ministry survey suggests that the infection rate is going back up to 7% for men and 9% for women. And just as Mr Museveni basked in the praise during the good times, now heÑand particularly his wife JanetÑare taking the blame as things go sour. For they have been accused of promoting the A at the expense of the C, partly under American pressure. As a result, the disease is spreading once againÑa charge repeated last week by the UN's special envoy to Africa on AIDS. The government denies any change in policy, but critics point to several interlocking trends.
Since Mr Museveni made a speech strongly attacking condoms last year, say campaigners, primary-school children are no longer taught about condoms, which are no longer prominent in public advertisements. This chimes with the campaigning of the president's wife, a vocal evangelical Christian and condom-basher, who funds pro-abstinence and pro-fidelity posters and radio spots, and has called for a census of virgins in the country. Bolstering that approach is the (American) President's Emergency Plan for AIDS Relief (PEPFAR), which explicitly promotes abstinence and has pumped in more than $230m to the country since 2003. Uganda, say campaigners, is dancing to America's tune, so condoms are no longer a key part of public policy. That disgusts many Ugandans, who contend that all three prevention optionsÑA, B and CÑmust have equal priority . "We're not fighting HIV any more," complains Beatrice Were, an HIV-positive campaigner. "We're fighting each other."
This has led many to question why the government is storing 30m condoms that it used to distribute free. There was a safety scare about a batch of holed ones late last year, but critics fear the government has used worries about a few of them to scare people into not using any. On top of this, the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, which held a big conference this week in London (see article), has suspended $155m in grants to the government, citing a loss of $280,000 in irregular "exchange transactions". It marked another embarrassment for a country whose mantle of success is slipping.
The New York Times
Editorial
The Missing Condoms
Published: Sunday, September 4, 2005
Uganda became Africa's leader in fighting AIDS by waging an all-fronts war. In 1991, 15 percent of Uganda's adults were infected with the virus. Ten years later the figure was 5 percent. Ugandan officials achieved this drop by bringing the disease out into the open and encouraging people to protect themselves. President Yoweri Museveni called the fight "a patriotic duty." The government and a network of citizens' groups promoted abstinence, faithfulness and consistent condom use.
Now this balanced approach is tilting, and Ugandans will die as a result. The country still prescribes condoms for high-risk groups. But in the last few years, pushed by Washington, it has begun to emphasize abstinence only, for the general population. Washington is moving away from condom advocacy in all its overseas AIDS programs, but Uganda is the only place that this policy has been so fully embraced by the government. Last year at an international AIDS conference, Mr. Museveni gave a blistering speech attacking condoms. Meanwhile, his wife, Janet, has been condemning condom use as immoral and has called for a national census of virgins.
Billboards that promoted condom use have come down. More than half of Washington's funds for preventing sexual transmission of AIDS now go to groups promoting abstinence only. Among Washington's grantees are groups that argue incorrectly that the AIDS virus can pass right through a condom. While free condoms used to be widely available at clinics in Uganda, in the last year they have virtually disappeared, and condoms in stores have tripled in price.
The most important development of the past year is the disappearance of free condoms. A year ago, Ugandans began to complain that the Engabu brand made in Germany and China and distributed free by Uganda's health system smelled bad. Uganda sent a batch to Sweden for testing and they were found to have holes. Further widespread testing found that the condoms were actually fine, but by that time the government had so attacked the brand that people will not use them. Some 30 million Engabu condoms are sitting in warehouses.
As result only eight million free condoms have been available to Ugandans in the past year, while 80 million were needed. The government has no plan to address the shortage. Instead, it has put a new fee on condoms sold in stores, raising a shortage-inflated price further. And it instituted a requirement that condoms undergo new testing after they are received in Uganda. Extra testing is fine, but Uganda has halted all condom distribution for months while it sets up the testing regime. An emergency supply received in April is still sitting in warehouses.
Promoting abstinence and faithfulness has been crucial to fighting AIDS in Uganda. But so have free condoms. One of the highest-risk groups is young married women infected by straying husbands. For them, abstinence is not an option, and they are already faithful. They need to be able to protect themselves. Abstinence-only teaching does not work in the United States, and there is no reason to think it will work in Uganda.
The policy shift in Uganda threatens to undermine the country's success in bringing AIDS into the open. Ugandans felt relatively free to talk about the risks of catching the AIDS virus and to be open about living with AIDS. If condom users are branded as immoral, it will drive the epidemic back underground. No one knows better than the Ugandans that lives are saved when AIDS is treated as a public health challenge, not a moral crusade.
TIME
©TIME. Printed on Monday, September 19, 2005
Prevention Is Still Better Than Cure
Is U.S. pressure encouraging the Ugandan government to favor abstinence over condoms in the fight against aids?
BY SIMON ROBINSON / KAMPALA
Ugandans learned their ABCs before other Africans. That's ABC as in Abstinence, Being faithful and using a Condom. The east African nation was at the center of the aids pandemic when it began in the 1980s Ñ and was the first African country to fight the disease seriously. The ABC approach has helped cut the hiv rate in adults from more than 15% in 1990 to just under 7% today.
Has the Ugandan government now forgotten its alphabet? A group of Ugandan and Western organizations and a senior U.N. aids expert claim that Uganda has over the last year allowed a condom shortage while promoting a message of abstinence based on religious dogma. "It's been a deliberate government policy to shift the emphasis from ABC to AB," Stephen Lewis, the U.N. Secretary-General's special envoy for hiv/aids in Africa, said last month. Ugandan aids campaigner Beatrice Were agrees: "There is a new wave of stigma É attached to the use of condoms. Those of us who promote condoms are looked at as immoral people."
The Ugandan government says that's nonsense. The Ministry of Health asserts the condom shortage resulted from the discovery last year of a bad batch of Engabu condoms from China; it's the brand the government gives away and accounts for around two-thirds of the 120 million used in the country each year. The recall last October means that since then, just under 30 million condoms, one-quarter the usual number, have been distributed for free. But the government says that some 150 million replacements are on their way, and also promises a new public education campaign stressing A, B and C.
Some activists remain unconvinced. Were and her colleagues point out that abstinence billboards now dot Uganda's capital Kampala where condom posters used to be. Uganda's First Lady Janet Museveni, a high-profile member of one of the country's fast-growing evangelical churches, has been spreading a message of abstinence and even advocates a "virginity census," though she's short on details about how to conduct it. President Yoweri Museveni last year attacked the widespread use of condoms in a speech to the U.N. aids Conference in Bangkok. With such powerful people on one side, Were thinks the official policy of a balanced approach is getting drowned out: "Evangelical churches are enjoying the crisis we are going through and taking advantage of it to promote abstinence-only programs," she says.
Some also link the shift in Kampala to the Bush Administration's President's Emergency Plan for aids Relief (pepfar), which, critics say, has shifted the emphasis toward abstinence only. "There is no question in my mind that the condom crisis is being driven and exacerbated by pepfar and by the extreme policies of the U.S.," said aids envoy Lewis. "You couldn't come up with a more bizarre conspiracy theory," counters Dr. Mark Dybul, deputy coordinator and chief medical officer at the State Department's Office of the U.S. Global aids Coordinator, which oversees pepfar. Dybul says it's the program's critics who are politicizing the issue because they are pushing a "condoms-only" agenda. To advocate a condoms-only approach, he says, "is really colonialistic and paternalistic." The U.S. is the biggest single donor for aids prevention in Uganda, and Ambassador Jimmy Kolker points out that U.S. funding for aids prevention has more than tripled in the past two years, from $45 million annually to $140 million. While pepfar stipulates that money for condoms should target only high-risk groups such as prostitutes and soldiers rather than the general population, "the truth is we're doing more of everything," says Kolker.
With reporting by Elaine Shannon/Washington
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