The history of Uganda’s HIV response

The first stage of Uganda’s HIV epidemic saw the rapid spread of HIV through urban sexual networks from its origin in the Lake Victoria region. Doctors in this area had become aware of a surge in cases of a severe wasting disease, known locally as ‘slim disease’, as well as a large number of fatal opportunistic infections.3

In 1982, the first AIDS case in Uganda was diagnosed,4 and the link between ‘slim disease’ and AIDS was clinically recognized. It was not until 1986 when the Ugandan civil war ended and President Museveni was firmly in power that the country had a major HIV prevention programme. By this time the country was in the midst of a major epidemic, with a prevalence of up to 29 percent in urban areas.5

Uganda’s first AIDS control programme was set up in 1987 to educate the public to avoid becoming infected with HIV. The programme promoted the ABC approach (abstain, be faithful, use condoms), ensured the safety of the blood supply and started HIV surveillance.6 Strong political leadership and commitment to tackling the rampaging HIV epidemic was a key feature of the early response in Uganda.

Prevention work at grass-roots level also began during this era, with a multitude of small organizations educating their peers about HIV. One of the first community-based organizations formed was The AIDS Support Organization (TASO,),which was run by 16 volunteers who had been personally affected by HIV and AIDS. TASO later became the largest indigenous AIDS service organization providing HIV/AIDS services in Uganda and Africa, and providing emotional and medical support to many thousands of people who are HIV positive.7

The second phase of the Ugandan HIV epidemic ran from 1992 to 2000. During this period the HIV prevalence fell dramatically, from a peak in 1991 of around 15 percent among all adults, and over 30 percent among pregnant women in the cities,8 to around 5 percent in 2001.9

It is thought the government’s ABC prevention campaign was partly responsible for the decline in prevalence. However, as treatment was not widely available in Uganda during this time the high numbers of AIDS-related deaths also contributed to the reduction in the number of people living with HIV.

The Ugandan government’s prevention initiatives continued throughout the Nineties with high levels of funding from both the government and international donors such as the World Bank. In 1998, the government ran a trial to test the feasibility of rolling out antiretroviral treatment to people in developing countries.

The third phase of HIV/AIDS in Uganda has seen the stabilisation of prevalence from 2000-2005, and reports of a slight increase in prevalence since 2006.10

Free antiretroviral drugs have been available in Uganda since 2004. It is thought that the introduction of HIV drugs may have led to complacency about HIV as AIDS is no longer an immediate death sentence. Many experts have also speculated that Uganda’s shift in prevention policy away from ABC towards US-backed abstinence-only programmes may also be responsible for an increase in risky behavior, as comprehensive sex education and condom promotion are no longer mainstream.

The number of people living with HIV in Uganda fell dramatically during the 1990s. The interesting questions are what caused this decline, whether other countries can adopt similar methods, and whether the lower rates of transmission are sustainable.

The drop in HIV prevalence in Uganda in the 1990s cannot be attributed to a single factor. It is likely to have been a result of both a fall in the number of new infections (incidence), and a rise in the number of AIDS-related deaths.

Deaths

It has been suggested that the high number of AIDS-related deaths in the 1990s may have been largely responsible for the decline in the number of people living withHIV in Uganda during this period.11 The reason so many people died in this decade is that there was no available treatment to delay the onset of AIDS, and high numbers of people infected with HIV in the 1980s were reaching the end of their survival period. In 2000 the Ugandan health ministry estimated that 800,000 people had died of an AIDS-related illness since the beginning of the epidemic.12

However, the high death rate alone may not account for the significant reduction in the number of people living with HIV in Uganda. Many other countries in sub-Saharan Africa experienced similar patterns of HIV incidence and death but did not experience a similar decline in prevalence.

New infections

It is likely that the number of new HIV infections in Uganda peaked in the late 1980s, and then fell sharply until the mid 1990s. This is generally thought to have been the result of behavior changes such as increased abstinence and monogamy, a rise in the average age of first sex, a reduction in the average number of sexual partners and more frequent use of condoms.13 Uganda’s entire population was mobilised in the fight against HIV and everyone was made aware of the consequences that risky behavior could have for their country.

President Museveni encouraged input from numerous government ministries, NGOs and faith-based organizations. He relaxed controls on the media and a diversity of prevention messages spread through Uganda’s churches, schools and villages.

This frank and honest discussion of the causes of HIV infection seems to have been a very important factor behind the changes in people’s behavior. Music and educational tours by popular musician Philly Lutaaya (who was the first prominent Ugandan to openly declare he was HIV positive) also spread understanding, compassion and respect for people living with HIV.

Uganda aim to achieve the drug supply problems by producing its own generic drugs.

In 2007, the Luzira factory opened on the capital Kampala, in partnership with the Indian pharmaceutical Cipla. It started producing in 2009. Now two million tablets are produced there every day but this is still not enough for demand.