When a mysterious illness first hit the landlocked central African country of Uganda during the 1980s, no one knew what to make of it. It happened with alarming suddenness – formerly healthy people, most of them young adults, began losing weight and showing high susceptibility to common ailments.

Doctors called it ‘the slim disease.’ But after a couple years of investigation, medical researchers finally attributed the scourge to a sexually transmissible retrovirus. Today, we know it as HIV.

Once Ugandan officials knew what they were dealing with, they responded with alacrity. Since then, the country of about 35 million has been lauded for its outstanding success in dealing with the deadly virus – infection rates have been on the decline for years.

That is, until recently.

A new uptick in HIV prevalence threatens to turn Uganda’s success story on its head.

“There are troubling indications again that the country’s response is off track,” says Asia Russell, the Uganda-based director of international policy for Health GAP, an activist group focused on global HIV/AIDS prevention.

The causes of this backslide are complicated, but a solution is still in reach. Russell and other global health activists say it’s not too late to change course and get those infection rates back down.

Moving Forward

Sub-Saharan Africa bears the world’s heaviest HIV/AIDS burden, especially in southern countries like South Africa, Lesotho, Botswana and Swaziland, where infection rates are between 11 and 26 percent.

Uganda avoided that fate by rolling out a prevention program as early as 1987. At that time, a devastating civil war had just ended and current President Yoweri Museveni had been in office for less than a year. His administration worked with both national and local leaders to implement a system of HIV infection prevention, based on the acronym ABC: abstain from sexual activity, be faithful and use condoms.

Dr. Fred Muwanga, an advisor for the International HIV/AIDS Alliance Uganda, explains that a strong commitment was key to the program’s success.

“Uganda's earlier success was based on strong political leadership at both national and sub-national levels,” he said.

“HIV/AIDS was declared as an emergency and became a top priority for all political leadership. The leadership’s open approach not only helped reduce [the] stigma, but also mobilized communities and civil society into action.”

As a result, the prevalence of HIV infection in Uganda fell precipitously during the 1990s and into the new millennium. Data from the World Health Organization and UNAIDS show that the virus was present in up to 16 percent of Ugandans aged 15 to 49 in 1990. By 2005, those infection rates had fallen to just over 6 percent.

But things have taken a turn for the worse since then.

Two Steps Back

Today, only two countries in Africa are seeing an increase in AIDS prevalence. One of them is Chad, which is one of the poorest and most politically corrupt countries on Earth. The other is Uganda.

A 2012 press release from the Uganda AIDS Commission publicized the surprising news; it was sprinkled with exclamation points. “The findings from the 2011 National HIV Indicator Survey announced recently are deeply disturbing to the public,” it said.

“The proportion of Ugandans, age 15-49, who are infected has risen and now stands at 7.3 percent (and even higher in women at 8.3 percent), and up from 6.4 percent in the 2004-05 survey. To crown it all the estimated number of new infections has been rising steadily: from 124,000 in 2009; 128,000 in 2010; to now 130,000 in 2011. More are expected next year; and the year after!”

There are myriad explanations for why Uganda’s HIV infection rates are on the rise. There is, for instance, a question of context; perhaps the decline in HIV-positive people during the 1990s was a result of AIDS-related deaths. Now that anti-retroviral treatments are more common, there could be more cases of infection simply because HIV-positive individuals are enjoying longer, healthier lives.

Or perhaps those improved medical treatments have normalized the virus somewhat, making young people less afraid of HIV and less likely to exercise caution when having sex.

But a more common criticism has to do with a misguided methodology for HIV prevention – and some say the United States shoulders some of the blame.

Family Values

In 2003, the United States launched a program called the President’s Emergency Plan for AIDS Relief, or PEPFAR. It has been lauded as one of President George W. Bush’s greatest achievements.

Through PEPFAR, the United States has spent more than $25 billion in the global fight against AIDS, with a focus on 15 countries in Africa, including Uganda. After initial successes providing care to HIV-positive patients, supporting orphans and pregnant women, and helping locally-based groups spread awareness and erase stigma, Bush doubled PEPFAR funding in 2008.

Today, there is no question that PEPFAR has been an overwhelmingly positive force in sub-Saharan Africa. But there are also concerns that the program didn’t work as well as it could have.

The United States – and with it, the Ugandan administration – have put more emphasis on medical treatment than ever before. According to a 2010 report from the Center for American Progress, a full 55 percent of PEPFAR funding was slated for HIV/AIDS treatment. Another 15 percent went for palliative care, with 10 percent set aside for orphans and other vulnerable children.

That left only 20 percent for prevention.

On Oct. 1, 2005, the United States added an important stipulation that “66 percent of resources dedicated to prevention of HIV from sexual transmission must be used for activities that encourage abstinence and fidelity.”

Critics lambasted the new requirement, arguing that that it shifted the focus from prevention to containment. As a result, condom use among youths – the ‘C’ in Uganda’s successful ABC program – was no longer emphasized as strongly.

But some critics of the Bush administration missed the reality on the ground. The problem was exacerbated by conservative politics in Uganda, a deeply religious country where homosexuality is outlawed and pre-marital sex is often pursued in secret.

Getting Back on Track

It is no surprise that the recent resurgence of HIV cases in Uganda has dovetailed with a decline in safe-sex education.

According to a September report on the National AIDS Indicator Survey from IRIN, the United Nations news agency, “only 36.2 percent of women and 52.9 percent of men between 20 and 24 used a condom during their last sexual intercourse in the past 12 months.”

In addition, “a majority of young Ugandans lack comprehensive knowledge about HIV; just 39 percent of men and women aged 15 to 24 have all the facts on how HIV is spread and how it can be prevented.”

Condoms are still a part of Uganda’s efforts to combat the disease, but access to these contraceptives is limited, according to Muwanga.

“Free condoms are available at clinics, but not all the time due to poor supply chain systems within the health care system,” he said. “Primary health centers, where the majority of communities access health services, face frequent stock outs of commodities, including condoms.”

Recognizing the danger, Uganda rolled out a new National Strategic Plan in December of last year.

“The inadequate translation of universal awareness of HIV into behavior is the biggest challenge in the HIV/AIDS response,” wrote President Museveni in the report that detailed the proposed changes. “We shall therefore aim at stopping new infections, and if we can achieve this, then we shall meaningfully provide care and treatment of all those eligible as well as providing support and protection to the affected.”

PEPFAR II – as the post-2008 version of the initiative has been called – was right there with the president. It reversed the requirement that two-thirds of prevention funding must go to abstinence and fidelity education, and it also reflected new research on medical treatment is a tool to cut down on transmission.

“The U.S. is funding condom promotion and procurement, whereas this was initially – under PEPFAR I – for prevention for those living with HIV, under PEPFAR II this has since been expanded to include primary prevention as well,” says Muwanga.

The Next Chapter

On Thursday, U.S. Secretary of State Hillary Clinton unveiled an ambitious document called the “PEPFAR Blueprint: Creating an AIDS-Free Generation.”

The globally-oriented blueprint places a heavy emphasis on science-based prevention and treatment initiatives. New research has revealed promising new tools in the fight against HIV, including better medications, safe male circumcisions and Option B+, which is a long-term treatment plan for pregnant women that can reduce the rate of transmission to children and partners by up to 60 percent.

These are lessons that Uganda should take to heart.

“Uganda urgently needs to expand domestic investments in HIV prevention and treatment, while PEPFAR and the Global Fund continue to expand their investments,” explains Russell, adding that the administration’s current protocol won’t cut it.

“Uganda's prevention interventions continue to invest in unproven abstinence only until marriage messages, while communities at high risk of infection – fishing communities, sex workers, serodiscordant couples [in which only one partner is HIV-positive], men who have sex with men – lack access to life-saving prevention and treatment services. Key populations must be at the heart of the response.”

The challenge is great, but so is the potential.

With HIV prevalence rates still under 10 percent, Uganda has certainly come a long way from the 1980s, when ‘the slim disease’ was a mysterious epidemic and the government was in shambles following a devastating civil war. During that time, says Muwanga, “high rates of morbidity and mortality for a generalized epidemic meant that everybody and every family was affected by HIV.”

Progress since those dark times has been nothing short of impressive. And although the recent resurgence shows that HIV is a big problem for Uganda, it’s not too late for smart science and good governance to solve it.

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