BLENDING BEHAVIOR AND BIOTECH TO FIGHT HIV/AIDS
Learning your ABC's means something entirely different in Uganda. It has nothing to do with knowing how to read and write and everything to do with stopping the rate of HIV infection. In this case, "A" stands for "abstain from sex," "B" for "be faithful to one partner," and "C" for "use a condom." Many in Uganda, including school children, learn these ABC's, which have been the cornerstone of a 20-year public campaign to tackle the spread of HIV in that country, and it appears to be working.
Many organizations - US Agency for International Development (USAID), the World Health Organization, and Uganda's Ministry of Health - tout Uganda as a major success story in fighting AIDS. According to WHO, rates of infection in Uganda among pregnant women have decreased by 50% and among adult males by 30% since the early 1990s when the rates for other nations were skyrocketing.
Uganda's low rates are not due to mortality figures, these organizations claim, but to a suite of behavioral changes that have been implemented and accepted in a systematic way in Uganda. Most important for stopping HIV infections, Ugandans are now having sex with fewer different partners and using condoms more often. And they owe much of this success to a public discourse on HIV.
"Uganda was one of the first countries that acknowledged the AIDS epidemic," explains Pontiano Kaleebu, assistant director of the Uganda Virus Research Institute and head of the basic sciences program of the Medical Research Council Unit in Entebbe. Moreover, Kaleebu has been working closely with the International AIDS Vaccine Initiative (IAVI) to test promising HIV/AIDS vaccines.
In 1986 Uganda's President Yoweri Museveni publicly acknowledged HIV/AIDS as an epidemic, and he spearheaded a campaign that he hoped would save his people from the disease. When other African nations were denying the very existence of HIV, or suggesting it had nothing to do with sex, Musevenie told his citizens it was their patriotic duty to join him in battling the disease. The governmental Ministry of Health quickly implemented a comprehensive HIV education and prevention plan, including the ABC approach, that involved local communities, religious groups, and traditional leaders. And they reached out to nongovernmental agencies for collaboration. There are now over 700 agencies dealing with HIV/AIDS within Uganda.
The country-wide media campaign was aggressive, comprehensive, and personal. Workers were trained and sent out to rural areas to talk with everyone. They also sought out high-risk populations, such as long-distance drivers and bar girls, and spoke with them one-on-one.
Early on, the Ugandan government also realized that one of their most vulnerable populations was women. "Women here are often controlled by men," Kaleebu explains. "They do not have the same opportunity as men to be educated and do not have the power to negotiate the terms of sexual relations. An effective AIDS vaccine would empower women to protect themselves from HIV infection with or without their partner's knowledge."
Recognizing that women were caught in traditional cultural values that left them at high risk for HIV, the government set out to empower and educate women in hopes that they can say no to unprotected sex. Again, there was a public campaign aimed at women and men to raise the status of women. In general, HIV/AIDS has a public face in Uganda. Since 1990, there has been anonymous and confidential HIV testing. Religious groups initiated respectful hospital medical care. And condoms are usually available and use has increased.
The ABC program, though, has been criticized because it focuses more on abstinence than safe sex, which has the whiff of religious zeal. In fact, US President George W. Bush has pledged $200 million to Uganda for HIV/AIDS programs, but one-third of that money must be earmarked for abstinence-only education for Uganda to receive the aid. That makes HIV/AIDS educational programs such as ABC a political football, and that can be dangerous. "Behavior is not constant," says Kaleebu. "It keeps changing. We see reduction and then it increases, and so the message is that we have to continue to inform the public, and work to provide new interventions." Rates of infection might be down in Uganda at the moment, but they are always on the brink of going up.
Uganda isn't singularly relying on trying to change behavior to reduce the infection rate. According to Kaleebu, Uganda is also in a unique scientific position. Early on, he says, "There was political support from the top, societal interest, and also public interests" that allowed Ugandan researchers to take the first opportunity to welcome any HIV research into the country. In fact, Uganda was the first country in Africa to conduct an AIDS vaccine trial in 1999. Since then, Uganda has participated in six different HIV vaccine trials, three of which remain ongoing.
"We initially thought making a vaccine would be easy, the way we had done it with other vaccines for polio, measles, for yellow fever," Kaleebu explains. "We have since realized that HIV is a little bit different, and so we have to tackle it differently. We have learned that we have to work with vaccines that would elicit different immune responses, including neutralizing antibodies, T-cells, and probably along mucosal surfaces. And we are learning more about the virus from people who have been repeatedly exposed to HIV, but do not become HIV positive." Kaleebu believes that there might not be one vaccine in the future, and that a first-generation vaccine might not be completely effective, but he looks forward to having vaccines that reduce infection rates. Research from IAVI reveals that even a modestly effective vaccine could reduce the number of new infections over a decade by one-third.
Kaleebu believes that there might not be one vaccine in the future, or one that is completely effective, but he looks forward to having vaccines that reduce infection rates. Moreover, Kaleebu will be part of that success because Uganda is not just campaigning to change the culture of sex, it has also wants to be a global player in the research on the virus and possible prevention.
