HARVARD SCHOOL OF PUBLIC HEALTH
Understanding Uganda’s
Behavior Change Success
Curbing a Generalized HIV Epidemic
Zeenah Haddad
5/13/2011
Presented to Professor Ichiro Kawachi
Table of Contents:
I.
II.
III.
Background …………………………………………………………………………………………………………………………….....1
Success Overview ……………………………………………………………………………………………………………………….2
Understanding the Behavior Change ………………………………………………………………………………………….3
a. Messages ……………………………………………………………………………………………………………………...3
i. Abstinence …………………………………………………………………………………………....…………4
ii. Be faithful / Partner Reduction / Zero Grazing . ……………………………....……….........5
iii. Condoms …………………………………………………………………………………………………………..7
b. Communication Channels ………………………………………………………………………………………….....8
i. Interpersonal Communication ………………………………………………………………………….9
ii. Mass Media ………………………………………………………………………………..………....………10
1. Above the Line …………………………………………………………………………………..10
a. Radio & TV …………………………………………………………………………….10
b. Newspaper …………………………………………………………………………….11
2. Below the Line ……………………………………………………………………………………11
c. Role of Government …………………………………………………………………………………………....……..11
d. Community mobilization …………………………………………………………………………………………....13
IV.
V.
VI.
Cost ………………………………………………………………………………………………………………………………………….15
Measures Limitations …………………………………………………………………………………………………………….…15
Lessons learned ……………………………………………………………………………………………………………………….16
a. Implications …………………………………………………………………………………………………………………16
b. Fear Based messages …………………………………………………………………………………………………..19
VII.
Conclusion ……………………………………………………………………………………………………………………………....20
I.
Background
Uganda is one of the world’s earliest and greatest success stories in curbing a generalized HIV epidemic
(Dyer, Wendo, & Uganda AIDS Commission, 2004; Epstein, 2007; Douglas Kirby, 2008; STD/AIDS Control
Programme, 2001; USAID, 2002) and establishing a national response program (Murphy et al., 2006;
Parkhurst, 2002). A country comprised of diverse tribes, with different spoken languages (Kaijuka, Kaija,
Cross, & Loaiza, 1989) and extreme levels of household poverty following the civil war period (E. C.
Green, Halperin, Nantulya, & Hogle, 2006) was able to subdue a deadly epidemic when most other
countries with far more resources failed.
Uganda's HIV epidemic is long-standing, with the first known AIDS case reported in 1982 (Douglas Kirby,
2008; Ministry of Health [Uganda] & ORC Macro, 2006; Opio et al., 2008; Serwadda et al., 1985).
mounting to 6,000 cases by 1988 (E. C. Green et al., 2006; Uganda AIDS Control Programme, 1989). By
1986–1987 15% of antenatal clinic (ANC) attendees in major urban centers were HIV positive (Slutkin et
al., 2006; Uganda AIDS Control Programme, 1989). Through 1987, prevalence increased very rapidly (D.
Kirby, 2008; Douglas Kirby, 2008) as the severe and generalized epidemic affected Uganda as a whole,
and kept increasing, though at a slower rate, in 1988 until it peaked in 1992 (D. Kirby, 2008). By then,
HIV prevalence in major urban areas was as high as 30% among women receiving (ANC) (Dyer, et al.,
2004; Douglas Kirby, 2008; Opio, et al., 2008). At which point, fear was instilled in everyone (Eckholm,
1990). And by 2000 The Ugandan health ministry announced that more than 800,000 Ugandans have
died of AIDS since the disease was first diagnosed and that nearly 1.5 million Ugandans -- over 7% of the
country's population -- carried HIV (Anon, 2000).
The prevalence rate decreased rapidly in 1993 for several years, and finally continued to decline through
2002. Indeed, by 2001 prevalence had declined by more than half in both urban and rural areas (D.
Kirby, 2008). U.S. Census and UNAIDS estimates are of a 67% drop in Ugandan national prevalence
between 1991 and 2001 (D. Low-Beer & R.L. Stoneburner, 2004; Sherry, Slutkin, Dellums, & Holcroft,
2000; Singh, Darroch, & Bankole, 2004; Slutkin et al., 2006). And according to the Uganda AIDS
Commission, estimates of national prevalence in Uganda fell from 18% in 1992 to 6% in 2002 (Douglas
Kirby, 2008; Uganda AIDS Commission, 2008). No other country has had such high rates of HIV infection
followed by such large declines (Douglas Kirby, 2008). Thus it is important to comprehend all the
elements that likely affected the course of this epidemic in Uganda, taking into consideration an array of
factors that likely affect the course of the epidemic in Uganda, including those epidemiological, sociocultural, political, as well as others (E. C. Green et al., 2006; USAID, 2002). Those factors in combination
could paint a rather consistent and compelling picture of what happened in Uganda in the HIV
prevalence reduction, to help guide future approaches. As the prevalence of HIV remains, to this date,
very high in many countries, particularly those in the sub-Saharan Africa suffering from generalized
epidemics, despite decade of effort (D. Kirby, 2008; UNAIDS, 2007).
This paper is not intended to definitively explain the success Uganda piloted in curbing this epidemic
during the 1980s and 1990s, but rather provide a mere attempt at analyzing the existing literature,
surveys and media coverage to better understand the drive behind Uganda’s success.
II.
Success Overview
It is hypothesized that the most important step taken by Uganda was recognizing the HIV epidemic
early. Uganda's President, Yoweri Museveni, was one of the first African leaders to deal candidly with
AIDS in 1986; one of his most successful moves was a multi-sectoral collaboration across the country
(Rule, 1986; UNAIDS, 2001). The government have played an integral role in the war on HIV, not working
solely but strongly supporting the mobilization of hundreds of community level organizations such as
NGOs, religious groups, and community activists (Murphy et al., 2006; Parkhurst, 2002; E. C. Green et al.,
2006). The successful collaboration efforts were evident when the government widely acknowledged
the roles other groups have played, as it referred to those organizations as “partners” in the country’s
effort to fight HIV, and involved them in the development of policy-level documents (Parkhurst, 2002).
Furthermore, despite its poor financial resources, the government established the earliest and most
elaborate system of HIV monitoring in Africa at the time, allowing for continuous monitoring of the
epidemic (Asiimwe-Okiror et al., 1997; Moodie et al., 1991; Slutkin, Chin, Tarantola, & Mann, 1988,
1990; Slutkin et al., 2006; Stoneburner & Carballo, 1997; UNAIDS, 1998b).
Uganda’s success is widely attributed to successful behavior change on the population level (Anon,
1987; D. Kirby, 2008; UNAIDS, 2007) which occurred within two to three years of Uganda's planned and
extensively implemented AIDS education effort, thereby decreasing overall incidence rates among the
overall population (Douglas Kirby, 2008; Slutkin et al., 2006). Trends in sexual behavior appear to
further support the trends in HIV prevalence in this HIV epidemic (Kirungi et al., 2002).
However, Uganda’s falling HIV prevalence was confounded by speculation that it relates to
measurement bias (Stoneburner & Low-Beer, 2004; USAID, 2002), a “natural die-off syndrome,”
(Douglas Kirby, 2008; Stoneburner & Low-Beer, 2004; USAID, 2002), urban bias, migration, civil war, or
natural HIV dynamics rather than to reductions in HIV incidence linked to interventions (Korenromp et
al., 2002; UNAIDS, 1998a, 1999). There is evidence to counter these arguments, including relatively
stable HIV mortality rates since the early 1990s (Nunn et al., 1997; Stoneburner & Carballo, 1997;
Stoneburner, Lessner, Fordyce, Bevier, & Chiasson, 1993), similar decline in HIV prevalence rates in male
military, and other wide range of supporting data on the epidemiological and behavioral changes
(Amana, 1990; Asiimwe-Okiror et al., 1997; Atkinson, 1989; Kamali et al., 2003; Konde-Lule, 1995;
Moodie et al., 1991; Stoneburner & Low-Beer, 2004; USAID, 2002). In fact, Researchers estimated that
80% to 90% of the cases of HIV infection were caused by sexual transmission, and consequently
reductions in these sexual behaviors were the primary causes of the decline in prevalence (Douglas
Kirby, 2008). The rate of change in sexual partners, particularly concurrent partners, is a considered a
critical determinant in the spread of HIV (Garnett, 1998; Shelton et al., 2004). In general, the size of
sexual networks directly affects the rate of HIV transmission, and it has been found that reduction in the
number of sexual partners has the potential to destroying those sexual networks, and thus affecting HIV
transmission rate (D. Kirby, 2008; Douglas Kirby, 2008). Consequently, in Uganda, the key factor in the
reduction of this rate has been linked to the reduction in concurrent partnership among men and
women (Murphy et al., 2006; Cohen, 2004; Shelton et al., 2004) although more significantly among men
(Murphy et al., 2006; D. Low-Beer & R.L. Stoneburner, 2004; Stoneburner & Carballo, 1997).
However, we also cannot neglect all the other diverse interventions taken place in Uganda at the time,
for the decline in the incidence and prevalence of HIV in this country surely carries a more complex
relationship with a multitude of factors.
III.
Understanding the Behavior Change
a. Messages
Three primary prevention behaviors were promoted and recognized as being most important. Labeled
“ABC” (“A” for abstinence, “B” for “being faithful” to a single partner or having fewer sexual partners,
and “C” for condom use) (Douglas Kirby, 2008; Low-Beer & Stoneburner, 2001; D. Low-Beer & R.L.
Stoneburner, 2004; Shelton et al., 2004), with the behavior change campaign as the center of the
Ugandan program (Amana, 1990; Moodie et al., 1991; Slutkin et al., 2006; Uganda AIDS Control
Programme, 1989).
“Being faithful” was the dominant message in 1986–1991, and it was illustrated as “stick to one
partner,” and the ubiquitous “love faithfully” and “Zero Grazing” (E. C. Green et al., 2006; Slutkin et al.,
2006), alluding to the traditional way cattle were fenced in, or tied to a stick to limit grazing outside their
own pasture (Slutkin et al., 2006); warnings that were easily understood even by those who were
illiterate to mean “stick to one partner” (E. C. Green et al., 2006). This was a message of “fidelity”
although that word was rarely used at the time, as it not only pertained to those married, but to those
dating as well (Rule, 1986; Slutkin et al., 2006).
In terms of temporal order, the evidence suggests that “A” and “B” behavior change took place first,
followed by increases in “C” (D. Kirby, 2008; Douglas Kirby, 2008). This is because condoms were not
promoted, widely available or widely used in the late 1980s, but became so in the early to mid‐1990s
(D. Kirby, 2008; Douglas Kirby, 2008).
In a time when enjoyable sex and safe sex were thought to be mutually exclusive, it is quite admirable
how Ugandan government managed to get its people to forego their social norms, mating traditions and
usual sources of pleasure. Interestingly, there were several anecdotal reports of villages changing sexual
acceptability norms (Slutkin et al., 2006); changes that were reached by way of group decision making and enforced toward total unacceptability supported by Presidential directive at the time (AsiimweOkiror et al., 1997; Atkinson, 1989; Singh et al., 2004; Slutkin et al., 2006; Stoneburner & Carballo, 1997;
Uganda AIDS Control Programme, 1989).
i. Abstinence
Between 1988/9 and 2000, median age at first intercourse rose by 1.2 years for girls and 1.7 years for
boys (Murphy et al., 2006; Biraro et al., 2009; Stoneburner & Carballo, 1997). The proportion of male
and female youth aged 15–19 years old who reported that they have never had sex increased from 31%
and 26% in 1989, to 56% and 46% in 1995 respectively (Murphy et al., 2006; Asiimwe-Okiror et al., 1997;
Biraro et al., 2009; Shelton et al., 2004). And while there was no general pattern of increased abstinence
reported among those who had ever had sex (Singh et al., 2004; Slutkin et al., 2006), the overall sexual
activity decreased for most ages (Slutkin et al., 2006). Ugandan women between the ages of 15-24,
tended to report premarital sex much less than they did in the previous survey, with a decline from 53%
to 16%, while men of same age reported a decline from 60% to 23% (Murphy et al., 2006; USAID, 2002).
Within the same age group, women who never been married who reported having sex in the previous
12 months significantly decreased from 36% in 1988/9 to 22% in 1995 (Bessinger, Akwara, & Halperin,
2003; D. Kirby, 2008). Comparable data for men is not available. However, according to the GPA surveys
performed between 1989 and 1995, less men 15-54 years old reported having had sex in the previous
year, regardless of marital status, with a decline from 85% to 77% (Bessinger et al., 2003; D. Kirby, 2008;
Shelton et al., 2004).
ii. Be faithful / Partner Reduction / Zero Grazing
The decrease in sexual partners and reduction in sexual networks appears to be the most important
determinant of the reduction in HIV transmission rate in Uganda (USAID, 2002; D. Low-Beer & R.L.
Stoneburner, 2004; Low-Beer, Stoneburner, Whiteside, & Barnett, 2000; Stoneburner & Carballo, 1997)
rather than the expected increased condom use (Stoneburner & Low-Beer, 2004). Indeed, partner
reduction was pivotal to success in Uganda (Bessinger et al., 2003; D. Low-Beer & R.L. Stoneburner,
2004; Mills et al., 1997; Shelton et al., 2004). In general, Ugandans have had considerably less casual sex
across all age partners (USAID, 2002; Asiimwe-Okiror et al., 1997; Atkinson, 1989; E. C. Green et al.,
2006; Sherry, et al., 2000; Singh et al., 2004; Stoneburner & Carballo, 1997; Uganda AIDS Control
Programme, 1989), as well as a decrease in the frequency of multiple partners (Asiimwe-Okiror, 1996;
Mertens et al., 1994; Musinguzi & al., 1996; Stoneburner & Carballo, 1997; Stoneburner & Low-Beer,
2004), as a high percentage of both men and women (78%) who are 15-19 years old and are unmarried
reported zero sexual partners in the past year of the survey (Murphy et al., 2006; Dyer, et al., 2004).
A closer look at the change in numbers reveals that in comparable population surveys 1989 and 1995,
the numbers reporting casual partners declined by 65% in Uganda among men and women (D. LowBeer & R.L. Stoneburner, 2004; Stoneburner & Low-Beer, 2004). The Global Program on AIDS surveys
also found that the proportion of men with one or more casual partners in the previous year fell from
35% in 1989 to 15% in 1995, and the proportion of women from 16% to 6% (USAID, 2002; Bessinger et
al., 2003; Kamali, et al., 2003; D. Kirby, 2008; Douglas Kirby, 2008; D. Low-Beer & R.L. Stoneburner,
2004; Shelton et al., 2004). Between 1989 and 1995 the percentage of women, regardless or marital
status, who had sex with a partner in the last 12 months who they were not married to / not living with,
decreased from 23% to 9% (D. Kirby, 2008; Douglas Kirby, 2008). Among men the percentage decreased
from 41% to 21% (D. Kirby, 2008; Douglas Kirby, 2008). Interestingly, in comparison with men in other
African countries (Kenya, Zambia and Malawi), Ugandan males in 1995 were more likely to be married
and keep sex within the marriage (USAID, 2002; E. C. Green et al., 2006).
Furthermore, the percentage of women having extramarital sex was always as low as 6% or less
(Murphy et al., 2006; Bessinger et al., 2003; D. Kirby, 2008) and remained stable during this period. For
men, however, there were declines in extramarital sex from 23% in 1989 to 16% in 1995 (D. Kirby, 2008)
and they were less likely to have multiple partners, particularly if never married (USAID, 2002; E. C.
Green et al., 2006).
In addition, engaging in sexual partnership with two or more partners became less likely for both single
men and women during the previous year, as the percentage was reduced (from 22% to 17% for single
women and from 54% to 33% for single men (D. Kirby, 2008; Douglas Kirby, 2008). Other studies yielded
similar results (Konde-Lule, 1995; Moodie et al., 1991; UNAIDS, 1998b). Strikingly, the proportion of
men reporting three or more casual partners in the previous year fell from 15 to 3% between the 1989
and 1995 GPA surveys (Murphy et al., 2006; Bessinger et al., 2003; Shelton et al., 2004; UNAIDS, 2002).
The latter figure was identical in both that GPA survey and the 1995 Uganda DHS (Murphy et al., 2006;
Bessinger et al., 2003).
This behavior change was observed and reported in local media. The New Vision, the main English
newspaper in the country, discussed at length how HIV had changed behaviors in 1987, describing how
‘‘naive complacency’’ was replaced by real concern caused by seeing relatives and friends dying of AIDS.
As a result, ‘‘the horror of Slim is forcing people to change social habits’’. The article described both the
challenges men faced to staying home more often and attempting to ‘‘zero graze’’, and the rewards to
wives. It also described how ‘‘the threat of Slim is forcing a large cross-section of people to change their
ways’’ (Anon, 1987). By the following year, there were a few additional newspaper articles describing
changes in sexual behavior at the population level, stating that people were changing their sexual
behaviors and that zero grazing had become fashionable as a result of AIDS (Anon, 1989; D. Kirby, 2008).
And anecdotal evidence from field researchers suggests that while having an sexually transmitted
infection, which was once considered a badge of manhood among younger men, has become a badge of
shame or stupidity in the era of AIDS. That said, the message of being faithful may also have been
significant for younger unmarried women who were sexually active and had multiple partners (Murphy
et al., 2006; Edward C. Green, 2003).
iii. Condoms
Even though prospective studies have shown that condoms reduce risk by about 80-90% when always
used, in real life they are often used incorrectly or inconsistently (Ahmed et al., 2001; Hearst & Chen,
2003; Shelton et al., 2004). They should therefore not be advertised in a manner that leads to
overconfidence or risky behavior (Shelton et al., 2004). Ironically, President Yoweri Museveni of Uganda
declared early in the epidemic that he and the Ugandan people refuse to believe that "only a thin piece
of rubber stands between [them] and the death of [their] continent.”(USAID, 2002;). The government
simply did not recommend using condoms as a way to fight AIDS (Low-Beer et al., 2000; E. C. Green et
al., 2006), a message that was later softened to state that people could use condoms if they could get
them (E. C. Green et al., 2006). And although condoms had been available in Uganda for family planning
purposes during the 1980s, Ugandans were uneducated about them as well as having legitimate and
illegitimate fears about them (Douglas Kirby, 2008; Perlez, 1991).
In 1989, Uganda began receiving millions of condoms from countries abroad, and by 1991, the media
started dispelling existing myths about condoms while encourage people to use them. Condom
advertisements appeared in The New Vision, but they created controversy and were then banned for
several years (USAID, 2002; Douglas Kirby, 2008; E. C. Green et al., 2006). Some changes in behaviors
toward more condom use incurred (Asiimwe-Okiror et al., 1997; Atkinson, 1989; Sherry et al., 2000;
Singh et al., 2004; Stoneburner & Carballo, 1997; Stoneburner & Low-Beer, 2004; Uganda AIDS Control
Programme, 1989), as levels of reported condom use at the last sexual act have increased over time and
were quite high, particularly among those not currently married (Biraro et al., 2009; Slutkin et al., 2006).
Percentage of women who reported ever-using condoms increased from 1% in 1989, to 6% in 1995
(USAID, 2002; D. Kirby, 2008; Douglas Kirby, 2008; Shelton et al., 2004; E. C. Green et al., 2006) and 16%
in 2000. Male ever-use of condoms was 16% in 1995 and 40% in 2000 (USAID, 2002; D. Kirby, 2008;
Shelton et al., 2004; E. C. Green et al., 2006). In 2000, among people reporting a casual partner in the
past 12 months, 59% of men and 38% of women reported using a condom with their last casual partner
(USAID, 2002; Anon, 1989; UNAIDS & WHO, 2004; E. C. Green et al., 2006). Condoms used between
married couples increased only slightly, while the use between unmarried couples increased
dramatically. However, there is a large proportion of unmarried youth who are also sexually active, who
do not use condoms at all, particularly among women, and even those who report they do use condoms,
there is little data on whether they use it correctly and consistently (Murphy et al., 2006). Condom use
in casual partnerships, although increased compared to 1989, was not substantially different in 1995
than it was in the other countries (Stoneburner & Low-Beer, 2004).
As a result, ambiguous impressions about the impact of condoms on the epidemic may be reached,
since most adults were married and those who are married rarely used condoms if at all (Douglas Kirby,
2008). The fact that there is an increase in condom use with casual partners should not be taken in
isolation from the information we have about the significant reductions in casual partners in the first
place. They are both interrelated, though the hypothesis is that partner reductions affected condom use
to a greater extent than the other way around (USAID, 2002).
Nearly the entire decline in HIV incidence (and much of the decline in prevalence) had already occurred
by the time condom use increased and, modeling suggests in order for condom use to achieve
significant reduction levels in a generalized epidemic, very high levels of consistent condom use is
necessary. This in turn, renders condom use as an unlikely major player in the HIV reduction in Uganda,
given that such levels of condom ever-use, let alone consistency, was undertaken at that time. However,
in more recent years, condom increased use could arguably have been contributing to the continuing
decline in prevalence (USAID, 2002; Shelton et al., 2004; E. C. Green et al., 2006).
b. Communication Channels
Communication campaigns are often reduced to the provision of messages, media and public health
campaigns (Global HIV Prevention Working Group, 2002; D. Low-Beer & R.L. Stoneburner, 2004; D. LowBeer & R. L. Stoneburner, 2004; Stover et al., 2002). However, the way Ugandans communicated about
AIDS and people with AIDS outside intervention settings directly reflected and influenced the behavioral
response (Kaleeba & Action Aid, 2000; D. Low-Beer & R.L. Stoneburner, 2004), as AIDS issues have taken
root among social networks of friends, families and in communities i.e. horizontal channels (D. Low-Beer
& R. L. Stoneburner, 2004). And while Vertical programs were still important, the way Uganda mobilized
horizontal channels and connected to contextual experiences is the most interesting and relevant point
(D. Low-Beer & R. L. Stoneburner, 2004).
i. Interpersonal Communication
Although all forms of media were clearly important vehicles for raising awareness and fostering changes
in behavioral norms, Uganda primarily relied on community-based and face-to-face communication
(USAID, 2002; Allen & Heald, 2004; Stoneburner & Low-Beer, 2004; Wilson, 2004). Strong NGO and
community-based support led to flexible, creative and culturally appropriate- very important
characteristics- interventions, that in turn helped facilitate individual behavior change, changes in
community norms, as well as sensitizing and subsequent involvement of public at large in AIDS
awareness and education (Edward C. Green, 2003; Kirby, 2003; Wilson, 2004; E. C. Green et al., 2006).
Unlike any other country, communication about AIDS through personal networks dominated in Uganda
among men and women (Murphy et al., 2006). 82% of women and 70% of men were found to have
heard of AIDS from this source compared to 40-65% in other countries (D. Low-Beer & R.L. Stoneburner,
2004). Personal networks were also dominant in urban (74%) as well as rural areas (84%) (Low-Beer &
Stoneburner, 2002; D. Low-Beer & R.L. Stoneburner, 2004; Ministry of Health [Uganda], 1996;
Stoneburner & Low-Beer, 2004). It is interesting to note that compared to Uganda, communication
through social networks was lower in Zambia and Tanzania (60-65%), and much lower in Zimbabwe and
Southern Africa (<45%) (USAID, 2002; Low-Beer & Stoneburner, 2002; Low-Beer et al., 2000).
In addition, there was a unique shift between 1989 and 1995 from impersonal (media) to personal
channels for communicating about AIDS in Uganda (D. Low-Beer & R.L. Stoneburner, 2004; D. Low-Beer
& R. L. Stoneburner, 2004). And a second distinction was the personal knowledge of someone with AIDS
or who had died of AIDS (Douglas Kirby, 2008; D. Low-Beer & R.L. Stoneburner, 2004; Low-Beer,
Stoneburner, & Mukulu, 1997; Low-Beer et al., 2000; Stoneburner & Low-Beer, 2004). By 1995, 91.5% of
men and 86.4% of women knew someone with AIDS (D. Low-Beer & R.L. Stoneburner, 2004; Ministry of
Health [Uganda], 1996; Stoneburner & Low-Beer, 2004). In Zambia, Kenya, and Malawi, the proportion
was lower—68 to 71%—and in Zimbabwe and South Africa, it was below 50% even by 2002 (D. LowBeer & R. L. Stoneburner, 2004; Shisana, 2002; Stoneburner & Low-Beer, 2004; E. C. Green et al., 2006).
When the relative importance of communication channels is assessed, mass channels dominated in
Kenya, as they did in Malawi, Tanzania, Zambia and Zimbabwe (and even in Uganda in 1989) (D. LowBeer & R.L. Stoneburner, 2004).
ii. Mass Media
The DHS data of 1995 attempted to gauge the reception of AIDS messages through different media
channels, one measure was to learn the proportion of those who heard about AIDS through the radio
which was estimated at 41.1% for women and 62.6% for men, while those who received the message
through TV were only 2.8% of women and 6% of men, and newspaper 3.9% of women and 14.2 % of
men. Noting that those with no mass media exposure whatsoever were 59.5% of women, and 32.3% of
men, the government ran the campaign daily for three consecutive years (Slutkin et al., 2006).
1. Above the Line
The media focused coverage on the radio, while newspapers and on television were relatively less
common. There were also many posters, billboards signs, and plays and music performances about
AIDS. Competitions were held in which the public competed for prizes by writing poems, songs, or plays
about AIDS. The delivery of these messages and plays in multiple indigenous languages helped spread
information (Douglas Kirby, 2008). Uganda's earliest AIDS posters used imagery of human skulls, coffins,
and grim reapers harvesting humans [Figure 1], then later, posters emphasized a cow in a pasture
surrounded by a fence, and many “Thank God I said no” posters, as well as messages of care and
compassion (Slutkin et al., 2006), such as “love carefully” [Figure 2].
Theater was also used to convey messages and almost all theater groups developed plays incorporating
HIV/AIDS messages (Slutkin et al., 2006).
a. Radio & TV
Every day on the government radio station, Ugandans heard the same pounding call to action from
“gwanga mujje” drummers, that beat somberly by a stern, raspy voice of an old man talking about AIDS
in the manner of announcing funerals multiple times per day on the radio, signifying the country was in
crisis. The drumming is followed by cautions to exercise “zero-grazing” (Edward C Green & Witte, 2006;
Douglas Kirby, 2008; Zummermann, 1991); Even though 15 years had passed, participants in one study
still quickly recalled it, reflecting the impact it had on them (Douglas Kirby, 2008). Other short “jingles”
were designed by NACP for radio to convey information on AIDS (Slutkin et al., 2006).
Ugandan TV (UTV) ran regular spots discussion programs and documentaries. President Musevini, Dr.
Okware – then National AIDS Program Director - and other Ministry officials were regular spokespersons
in the media, and the program appeared to speak with one voice so there was little opportunity for
confusion (Slutkin et al., 2006).
b. Newspaper
The Ugandan daily paper MUNNO ran daily articles on AIDS. The weekly Topic and daily New Vision ran a
combined 17 articles on AIDS in 1990. The New Vision ran the “AIDS Corner” on the last page of every
issue that posed a question and provided an answer (Slutkin et al., 2006).
2. Below the Line:
Other printed materials on AIDS such as pamphlets and booklets were developed, translated into local
languages, and distributed to District Councilors, Resistance Councilors and to members of NGOs at
training workshops. The general public was to get their materials through the Resistance Councilors
system and other key people such as “mass mobilizes” and community development workers. The 1995
DHS survey indicated that 2.1% of women and 7.1% of men saw information about AIDs through
pamphlets (Slutkin et al., 2006).
c. Role of Government
While national governments and individuals throughout Africa denied the problem of AIDS, Uganda
recognized, emphasized, and attacked the problem, rather than minimizing or ignoring it, and their
efforts primarily meant focusing on prevention. At all levels, people acknowledged that AIDS was an
important problem in their country, and addressed that problem both comprehensively and intensely
(Douglas Kirby, 2008). Many scholars and Ugandans feel that the pervasive behavior changes was mainly
driven by Uganda’s President (Murphy et al., 2006).
In 1986, President Museveni, a rather charismatic leader, and a hero of Uganda's civil war, personally
addressed AIDS explicitly (Murphy et al., 2006; Douglas Kirby, 2008); he declared that Uganda was still at
war with AIDS as the enemy (USAID, 2002; Murphy et al., 2006). He undertook public education on HIV,
and targeted men through an ongoing series of radio AIDS messages, asking them to be faithful, be
sexually responsible, and encouraged men and women to foster “mutual respect”, which was widely
interpreted as “mutual fidelity” (Murphy et al., 2006; Zummermann, 1991). He strongly encouraged
government and civil society to tackle AIDS (Parkhurst, 2002; Douglas Kirby, 2008). He appointed
competent people to prevent the spread of AIDS and he delegated authority to them. In addition, he,
himself, spoke forcefully about AIDS to the public. In speeches to communities, schools and other
groups, he used stories and gave clear behavioral messages that people could understand and
remember (Douglas Kirby, 2008). In interpersonal interactions with Ugandans, the president continually
emphasized his message of communication openness and faithfulness among couples, and asserted that
fighting AIDS was in fact, a patriotic duty. His charismatic directness in addressing the threat placed HIV
prevention on top of the national agenda, incurring a multi-sectoral response, and continuous national
media coverage that was direct and open. A wide variety of entities enlisted in this “war”. In 1992, the
multi-sectoral Uganda AIDS Commission (UAC) was created to coordinate and monitor the national AIDS
strategy. The UAC prepared a National Operational Plan to guide implementing agencies, sponsored
Task Forces, and encouraged the establishment of AIDS Control Programs in other ministries including
Defense, Education, Gender and Social Affairs. As of 2001, there were also reportedly at least 700
agencies—governmental and nongovernmental—working on HIV/AIDS issues across all districts in
Uganda (USAID, 2002; Douglas Kirby, 2008; E. C. Green et al., 2006). Most importantly, the government
decentralized planning and implementation for behavior change communication to better reach the
general populations (USAID, 2002; E. C. Green et al., 2006): In 1986, Uganda established a National AIDS
Control Program (ACP) (Douglas Kirby, 2008), followed by the AIDS Control Program (ACP) began
operations. In 1991 and 1992, the Uganda AIDS Commission was created (Douglas Kirby, 2008).
Other instrumental initiatives the government implemented included promoting gender equity and
empowering women (Murphy et al., 2006; Diarrah & Riley, 2002; Human Rights Watch, 2003a, 2003b;
Museveni, 2001) led by the president, whose actions were likely to have contributed to changing gender
dynamics, (USAID, 2002; Murphy et al., 2006; Douglas Kirby, 2008; E. C. Green et al., 2006) as well as
improving the quality of life of people living with HIV/AIDS (PLWHAs) by promoting their rights. This has
led to a remarkably accepting and non-discriminatory response to AIDS (USAID, 2002; E. C. Green et al.,
2006) as the president ensured that the stigma and discrimination against PLWHAs is aggressively fought
(PLWHAs) (USAID, 2002).
In addition, the government established Africa’s first confidential voluntary counseling and testing (VCT)
services in 1990 (Eckholm, 1990; USAID, 2002). Uganda was in fact rather unique in Africa in the
emphasis it placed on VCT, especially in a time that VCT was not yet established as a criteria for
prevention (USAID, 2002; Douglas Kirby, 2008; E. C. Green et al., 2006).
d. Community mobilization
Insite of turmoil brought on by the aftermath of civil war in the country, behavior change interventions
were introduced and undertaken, in part because of the strong support by nonprofit and communitybased organizations that led these interventions (USAID, 2002). Evidence from Uganda indicates not
only that individual behavior changed but also that group norms of behavior were altered (USAID, 2002;
D. Low-Beer & R.L. Stoneburner, 2004; Shelton et al., 2004; VanLandingham & Trujillo, 2002) as a
combination of explicit and repeated presidential pronouncements and the committed engagement of
faith-based organizations, the governmental apparatus, the military, the health system, and community
based and mass communications succeeded in rendering the avoidance of risky sex the norm in that
community, in light of the increasing death AIDS toll reality (USAID, 2002; Shelton et al., 2004). The
horizontal behavioral and communication process was widely mobilized by faith based organizations,
prominent cultural figures, political, military and community figures, non-governmental organizations
(NGOs) schools, and care organizations like TASO (The AIDS Support Organization) (D. Low-Beer & R.L.
Stoneburner, 2004).
By 1993 more than 600 NGOs were registered to address AIDS in Uganda and The New Vision estimated
that roughly 400 additional unregistered NGOs also addressed AIDS (Anon, 1993; Douglas Kirby, 2008;
Stoneburner & Carballo, 1997).
As for schools, and as early as 1987, health education programs started emphasizing the risk of AIDS and
methods of avoiding it. In addition to didactic materials, subsequent school AIDS prevention programs
included dramas, songs, and other activities designed to actively involve students. In addition, students
were encouraged to take information home to their parents (Douglas Kirby, 2008).
Religious leaders and faith-based organizations are credited to have worked the frontlines of the
epidemic as mainstream faith-based organizations wielded enormous influence in Africa (USAID, 2002;
Kagimu et al., 1998; Kaleeba & Action Aid, 2000; Kirby, 2003; Douglas Kirby, 2008; Sabatier, 1988; Slutkin
et al., 2006; E. C. Green et al., 2006). In Uganda, most people belonged to one of three religious
organizations: the Roman Catholic Church, the Anglican Church (Church of Province of Uganda) and the
Islamic Umma (or “community of Islam”). There were very few independent churches or sects in
Uganda. When the three faith communities developed programs to encourage behavior change, they
were able to act in an integrated fashion and to reach the large majority of Ugandans. At the local level,
efforts varied, but in some communities, pastors or Imams spoke about AIDS and faithfulness, both
during their regular services and sometimes during or after funerals for people who had died of AIDS
(USAID, 2002; Douglas Kirby, 2008).
Remarkably, traditional healers were also involved in the initiatives, although mostly focusing on
providing herbs to alleviate the symptoms of AIDS, they also conveyed a prevention message. Nearly all
the organizations involved in AIDS prevention focused on clear and consistent messages (Douglas Kirby,
2008).
One of the major players in the public figures arena was Uganda’s top singer at that time, Philly
Bongoley Lutaaya, who played an instrumental role in the prevention efforts (Anon, 1990). The famous
star launched an anti-AIDS crusade in his country even as he courageously battled the disease himself
(Lim, 1992). He popularized the song Born in Africa upon his return to his homeland following years as a
political refugee in Sweden (Lim, 1992). This song nearly became a national anthem, and his concerts
were all sold out (Anon, 1990). Lutaaya became the first prominent Ugandan to publicly announce that
he had contracted AIDS (Anon, 1990; Lim, 1992), while the killer disease was still taboo. He wrote songs
that became incredibly popular, including Alone and Frightened which expressed his feelings as a victim,
and return to Uganda with all important messages: be proud to be African, be faithful, stick to one
sexual partner, do not condemn those dying from AIDS, and that not only the immoral suffer from it
(Lim, 1992). The crew of Born in Africa traced his 1989 trip through Kampala and villages reduced to
near-ghost towns by AIDS. He spoke freely about his condition to school children, religious leaders, truck
drivers, women’s organizations, and with other AIDS victims (Lim, 1992). The 90-minute documentary
closed with the announcement of his death in December, 1989. He was eulogized by Ugandan leaders as
a hero. And although the documentary did not deal with the details of AIDS prevention, Philly Lutaaya’s
well-told story released some shocking facts about the disease’s toll in Uganda, at least, and did more
for AIDS victims than public awareness advertisement or magazine articles (Anon, 2007; Lim, 1992).
IV.
Cost
Total donor support for all AIDS-related contributions during the period 1989-1998 was about $180
million or approximately $1.80 per adult per year over that 10-year period. Donor contributions amount
to an estimated 70% of total expenditures on AIDS prevention and care in Uganda. (According to an
analysis by Elizabeth Marum, USAID/CDC HIV program director in Kampala throughout the 1990s)
(USAID, 2002).
V.
Measures Limitations
There were two main survey studies carried out in Uganda at the time; the Demographic and Health
Surveys (DHS) and the World Health Organization’s Global Program on AIDS (GPA) survey (Ankrah, 1993;
D. Kirby, 2008) referenced in this paper. Unfortunately, these DHS surveys provided little data about
sexual partners in 1989 (Douglas Kirby, 2008), and no males were then surveyed (E. C. Green et al.,
2006).
As for newspaper accounts, and given that large surveys of sexual behavior were not conducted in
Uganda until 1988/9, these accounts may provide the earliest documentation of behavior change
though not necessarily representative. They also shed some light into the internal coverage in Uganda at
the time. Uganda’s primary newspaper in English, The New Vision was referenced in this paper.
However, while newspaper articles can accurately date events, they cannot provide strong evidence for
the magnitude of changes in sexual behavior nationwide. Only representative surveys can provide such
evidence (D. Kirby, 2008).
VI.
Lessons learned
a. Implications
Uganda’s experience has several significant implications for AIDS policy in other countries with
generalized epidemics (Douglas Kirby, 2008). The country addressed the ABC factors through multiple
interventions and did this through the means exemplified (and often pioneered) by Uganda and in turn
successfully implemented a “social vaccine” in Africa (USAID, 2002; E. C. Green et al., 2006). However,
questions remain as to whether these behavior changes are attainable in other developing countries.
One thing that is important to understand is that there is no “silver bullet” — no single element of the
Ugandan experience — that produced the behavior change and that, on its own, would change behavior
elsewhere. Rather, the Ugandan experience suggests that the more elements and components of the
Ugandan initiative that countries implement, the more likely they are to succeed in changing sexual risk
behaviors. With that in mind, we can theorize as to what components can and should be considered in
HIV/AIDs prevention efforts in a generalized epidemic (Douglas Kirby, 2008).
Certainly the government’s early, vigorous and comprehensive action (Douglas Kirby, 2008) is one of the
major components of the success that needs to be considered (USAID, 2002; Singh et al., 2004). And the
government’s equally important role in gender equity and women empowerment (E. C. Green et al.,
2006) should be tackled to the extent feasible. Countries should try to improve the status and rights of
women and increase women’s ability to avoid unwanted sex given many women's relatively limited
control over their sexual relationships (Douglas Kirby, 2008). Countries should also consider
decentralizing planning and having multi-sectoral responses, while involving all motivated and able
parties (E. C. Green et al., 2006). Indeed, Ugandan government did not impose messages on
participating organizations, and allowed them to promote whichever approach they deemed
appropriate, as long as the overall message was reasonably balanced, and no organization undercut the
messages of others; a strategy that would allow organizations to optimally operate for the shared
interest (Douglas Kirby, 2008).
Countries should also incorporate respected and beloved national public figures in the prevention effort
as the role the pop star musician in Uganda played was considerable (D. Low-Beer & R. L. Stoneburner,
2004).
Countries should also get the “right message” across. As we learned from the Ugandan experience,
condoms may not be the most effect approach to curb the epidemic, while partner reduction and zero
grazing, were (Douglas Kirby, 2008). In fact, according to Stoneburner, during the past decade in
Uganda, the effect of HIV prevention interventions in general, and partner reduction in particular, seems
to have had an impact equivalent to that of an 80% efficacy vaccine (USAID, 2002; E. C. Green et al.,
2006). Some countries may benefit from a more comprehensive approach to behavior change
incorporating all aspects of behavior change available (Singh et al., 2004).
Another important point to consider when designing behavior change interventions is utilizing the
optimum communication channels unique to that country. Uganda thrived in the interpersonal
communication area (D. Low-Beer & R. L. Stoneburner, 2004), and while the historical and socio-cultural
context, various interventions and other factors are complex and may be somewhat unique to Uganda,
it is believed that interpersonal communications are the major drive to behavior change in most settings
(USAID, 2002).
In addition, one major issue that the Ugandan government focused on was emphasizing the importance
of behavior change not only to the individual and immediate family, but to the community and the
country as a whole. In other words the government invoked the sense of duty. Countries need to
explore all motivational levels (Douglas Kirby, 2008).
Encouraging and promoting testing is another important issue to replicate, and those who are tested
positive should be encouraged to acknowledge HIV/AIDS and talk about it, exactly as Uganda did
employing people living with AIDS (Douglas Kirby, 2008) and involving them in the prevention while
fighting the AIDS stigma at the same time (E. C. Green et al., 2006).
Perhaps the population-level behavioral response to HIV in Uganda will not be transferable with the
same effect or appropriate for all situations; however, similar tactics of community mobilization and
population risk avoidance have characterized other intervention successes in Thailand and among
homosexual men in the United States. Potential access to what are believed to be curative therapies
may shift perceptions of risk from avoidance to reduction, or coexistence, as the fear and visibility of
AIDS diminishes. The current practice of scaling up biomedical and risk-reduction HIV prevention
elements may not reduce sexual transmission at the population level. To ensure that these lessons are
replicated, we need a shift in strategic thinking on health policy and HIV/AIDS, with greater attention to
epidemiological intelligence and communications to mobilize risk avoidance (Stoneburner & Low-Beer,
2004). Similarly communication and behavior changes may not be easily transferable. They cannot be
packaged as a standard intervention, since real social and political capital is required in addition to
financial capital. Despite barriers, President Museveni of Uganda comments, “I would like to say that
fighting this sickness actually is not as difficult as people make it ... AIDS is avoidable it is not like
influenza … but you will not make the appropriate responses unless you know your community well…
you must know your community well” (D. Low-Beer & R. L. Stoneburner, 2004). Health officials say
Uganda's campaign against AIDS is the most advanced in Africa. World Health Organization officials say
the lessons learned in Uganda can be applied elsewhere on the continent because many other African
countries share the problems of inadequate hospitals, medical supplies and reporting, as well as
attitudes and customs that add to the epidemic (Rule, 1986). More research is needed, both to compare
patterns of change in other countries with the Ugandan situation and to ascertain more about what
social changes and interventions led to these behavioral changes; some studies are already underway
(Singh et al., 2004; USAID, 2003).
b. Fear Based messages
Prevention in Uganda went beyond the headspace of awareness, education and counseling to
“affective” behavior change “where fear, care, survival, even a little stigma, affective or emotional as
well as a cognitive response, and other motivators of risk avoidance coexist” (D. Low-Beer & R. L.
Stoneburner, 2004). Ugandans were conditioned to fear AIDS, and feel they are personally at risk of
contracting it. This heightened the belief that their lives depended on their actions (Edward C Green &
Witte, 2006; E. C. Green et al., 2006). This is especially true of the period 1986-1991. At the same time,
Ugandans were taught very clearly, from their president and from leaders and peers in their local
communities (Edward C Green & Witte, 2006; E. C. Green et al., 2006) exactly what to do to avoid AIDS.
The high level of fear, paired with strong efficacy perceptions and the knowledge that they could do
something to avert infection, created optimal conditions for behavioral change, in line with what current
fear appeal theory suggests (Stoneburner & Low-Beer, 2004; E. C. Green et al., 2006). And while most
western health behavior change experts feel strongly against fear-based messages, and believe that
they fail to motivate sustained behavioral change, the essence of the Ugandan success was the very
same fear-based messages that are constantly put down (Edward C Green & Witte, 2006).
Indeed, in Uganda, the prevention effort in its early phases differed from other AIDS prevention
programs as “alarm” was sent out by all sectors of the country to change sexual behavior fundamentally
(Allen & Heald, 2004; Edward C. Green, 2003; D. Low-Beer & R.L. Stoneburner, 2004; Shelton et al.,
2004). Ugandan officials involved the control program admitted that they “focused on instilling fear in
the population,” after which options for avoidance of risk were promoted, starting with “avoidance of
sexual contacts” (Ankrah, 1993, p. 1114); a tactic that managed to succeed because of the little
influence from American experts at the time (Edward C Green & Witte, 2006). And the outcome was
equivalent to a highly effective vaccine (Stoneburner & Low-Beer, 2004).
VII.
Conclusion
Uganda’s approach to curbing the HIV epidemic was unique and at that time even innovative. Ugandans
vision ended up to have most of the elements that we consider important in public health behavior
change today. Although this paper shows several different perspectives of researchers over the past two
decades, and although we might never really know what exactly happened there at that time, there is
no doubt that their success was a result of a comprehensive package, that ranged from political
involvement, to the involvement of a wide array of community-based organizations, which in turn is
what made a difference (USAID, 2002; Douglas Kirby, 2008; E. C. Green et al., 2006).
Furthermore, the result of this Ugandan approach suggests that contrary to previous expectations,
pervasive behavior change can occur (E. C. Green et al., 2006), and contrary to common belief, fearbased approaches can succeed in deterring harmful behaviors.
This Ugandan success that has become one of the strongest planned and implemented HIV program in
the history of the HIV epidemic, has thus contributed greatly the field of behavior change that benefited
the rest of the world.
Figures:
[1] Example of a typical fear arousal AIDS poster from Uganda from the 1980s.
[2] Poster from Uganda’s AIDS Control Progam in the late 1980s
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