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The less they know, the better: abstinence-only HIV/AIDS programs in Uganda

Human Rights Watch

March 2005

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With funding coming in now, for any youth activities, if you talk about abstinence in your proposal, you will get the money. Everybody knows that.
— A teenager working with youth in Kampala

We don’t think abstinence is really working in our communities. We work with children in primary five through seven who are engaging in sexual activities. We always come with the message to delay sexual debut. But for most children here, this is not enough.
— Youth leader in Kabarole

Widely hailed as a leader in the prevention of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), Uganda is redirecting its HIV prevention strategy for young people away from scientifically proven and effective strategies toward ideologically driven programs that focus primarily on promoting sexual abstinence until marriage. Although endorsed by some powerful religious and political leaders in Uganda, this policy and programmatic shift is nonetheless orchestrated and funded by the United States government. Pioneered in the United States in 1981, “abstinence until marriage” programs (also known as “abstinence only” programs) teach that abstaining from sex until marriage is the only effective method of HIV prevention and that marriage between a man and a woman is the expected standard of human sexual behavior. Numerous U.S.-funded studies have shown these programs to be ineffective at changing young people’s sexual behaviors and to cause potential harm by discouraging the use of contraception. The effect of Uganda’s new direction in HIV prevention is thus to replace existing, sound public health strategies with unproven and potentially life-threatening messages, impeding the realization of the human right to information, to the highest attainable standard of health, and to life.

Despite a reported dramatic drop in HIV prevalence in Uganda in the 1990s, from an estimated 15 percent nationally in 1992 to 6 percent in 2002, Ugandans of all ages continue to face a high risk of HIV infection. Ugandans tend to start having sex at an early age and with little sex education. Demographic and health surveys show that over half of Ugandan girls have had sex by age seventeen, usually with someone older. Among girls who marry before the age of eighteen, most marry men who have been sexually active for several years, often without having used condoms. These and other factors make it vitally important to educate young people about HIV and to caution girls at an early age about the risks of HIV infection in marriage. Abstinence-until-marriage programs fail on both of these counts. Not only do they fail to offer young people information about condoms and safer sex on the grounds that this would undermine the goal of abstinence, they additionally promote marriage to young people while withholding information on its inherent risks.

Uganda’s increasing embrace of abstinence-only approaches is manifest on many levels, from the office of the president to the halls and classrooms of the nation’s primary and secondary schools. In November 2004, the Uganda AIDS Commission (UAC) released a draft “Abstinence and Being Faithful (AB)” policy to guide the implementation of abstinence-until-marriage programs throughout the country. Intended as a companion to the country’s existing strategy on the promotion of condoms, the policy in fact undermines condoms as an HIV prevention measure and suggests that promoting condoms alongside abstinence messages would be “confusing” to youth. The document contains virtually the same definition of “abstinence education” as in legislation governing abstinence-only programs in the United States, suggesting that Uganda’s programs will replicate programs that have been proven ineffective in numerous U.S. states. As an HIV prevention strategy for married people, the document proposes compulsory HIV testing for all couples intending to marry—a strategy that not only infringes on the right to informed consent but, as discussed further below, fails to address the ongoing risk of HIV faced by married women.

In 2001, the Government of Uganda launched an ambitious program to expand HIV prevention education to all of the country’s primary and secondary schools. Funded by the United States and known as the Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY), the program provides abstinence-until-marriage messages through a series of assembly messages, classroom activities and youth rallies. PIASCY materials were developed through a series of stakeholder meetings in Uganda that included public health experts, experienced HIV/AIDS educators, community and faith-based organizations, and others. Numerous participants observed that religious groups exercised an effective veto over the inclusion of objective health information, including images depicting ejaculation, body changes during puberty, the effectiveness of condoms, and even proper cleaning of the foreskin. At the insistence of these groups, pre-tested PIASCY materials were withdrawn from circulation and re-released with several explicit images purged and a chapter on “ethics, morals and cultural values” added. These developments occurred at the same time the U.S. Agency for International Development (USAID) had placed a technical adviser at the ministry of education to oversee PIASCY. Draft secondary school materials, under revision as of this writing, contain numerous falsehoods about condoms (including the claim that they contain microscopic pores that are permeable by HIV pathogens) and caution that premarital sex is “against religion and norms of all cultures in Uganda” and “is considered a form of deviance or misconduct.”

Finalized PIASCY materials for primary schools included some information about condoms, which is consistent with a recently drafted strategy of the Uganda Ministry of Health calling for the promotion of condom use to “all sexually active people.” However, teachers interviewed by Human Rights Watch said that USAID-funded PIASCY trainers had encouraged them to omit information about condoms in favor of an abstinence-only message. The political climate favoring abstinence-only approaches in Uganda, including numerous anti-condom statements by President Yoweri Museveni in 2004, also influenced school teachers to teach abstinence as an exclusive method of HIV prevention. Because of a 1997 Ugandan policy guaranteeing free primary education to everyone in the country, many children who had dropped out of school, returned and so an unusually high proportion of Ugandan primary school students are in their teens. This makes it especially important for the president and foreign donors not to contradict or undermine the health ministry’s policy of promoting condoms to everyone who needs them.

Outside of schools, Human Rights Watch found that abstinence-only approaches were being promoted in Uganda through government-sponsored youth rallies and additionally, in programs run by community and faith-based organizations. At at least one rally, participants were told that “using a condom with a person with these [sexually transmitted] diseases is like using a parachute which opens only 75 percent of the time.” Blending health messages with politics, participants were also encouraged to promote President Museveni, in power since 1986, in his bid for a third term. As of November 2004, the U.S. embassy in Uganda had budgeted approximately U.S.$8 million for “abstinence and behavior change” programs for young people, of which approximately U.S.$3 million was for PIASCY. One national organization already receiving U.S. support to carry out abstinence programs was the National Youth Forum run by First Lady Janet Museveni, perhaps the best-known proponent of abstinence-only programs in Uganda. Mrs. Museveni has described abstinence-only approaches as a blend of African and Christian values and has used her position of influence to intimidate organizations that promote condoms to young people. On World AIDS Day 2004, she called for a national “virgin census” to support her abstinence-only efforts, raising fears that children would be forced to submit to intrusive medical tests or otherwise disclose confidential information about their virginity status.

With the growth of abstinence-only approaches in Uganda, there are growing indications that condoms will gradually disappear from the country’s HIV/AIDS strategy. In October 2004, the Ministry of Health issued a nationwide recall of all free government condoms, allegedly in response to failed quality control tests. The ministry then took the extraordinary step of requiring post-shipment quality control testing on all condoms imported into Uganda, including those that have already been tested. By December 2004, experts were forecasting a national condom shortage. Rather than take steps to address the shortage, however, Uganda’s minister of state for primary health care stated, “As a ministry, we have realized that abstinence and being faithful to one’s partner are the only sure ways to curb AIDS. From next year, the ministry is going to be less involved in condom importation but more involved in awareness campaigns; abstinence and behavior change.”

This statement was only the latest in a series of anti-condom statements from senior government officials in Uganda. Throughout 2004, including at the International AIDS Conference in Bangkok, Thailand, President Museveni lashed out against condoms as inappropriate for Ugandans and suggested that condom distribution encouraged promiscuity among young people. First Lady Janet Museveni has criticized groups that distribute condoms to young people for “pushing them to go into sex” and stated that “it is not the law that our children must have sex.” Non-governmental organizations that have traditionally promoted condoms in Uganda told Human Rights Watch they feared provoking the ire of political leaders if they continued their work, while those that deny the effectiveness of condoms have enjoyed unprecedented levels of government support. “We don’t want to be seen to be doing what government or political leaders are opposed to,” the coordinator of a youth HIV prevention program told Human Rights Watch. “We fear we would be blacklisted.”

In numerous interviews, Human Rights Watch found that an exclusive focus on sexual abstinence as an HIV prevention strategy failed to account for the lived experiences of countless Ugandans. “I got HIV in marriage. I was faithful in my relationship,” said one Ugandan woman, expressing a common predicament. Indeed, the suggestion that marriage provides a safeguard against HIV may amount to a death sentence for women and girls. Ugandan women face a high risk of HIV in marriage as a result of polygyny and infidelity among their husbands, combined with human rights abuses such as domestic violence, marital rape, and wife inheritance (whereby a widow is forced to marry the brother of her late husband). While surveys suggest that Ugandan women are more likely to refuse sex with a husband who has an STD than women in other African countries, it is still widely believed in Uganda that women have no right to deny their husbands sex. Research by Human Rights Watch and others has shown that many Ugandan women who abstain until marriage and remain faithful to their husbands nevertheless face a very high risk of HIV because of their husbands’ infidelity or prior HIV infection. Although abuses against married women may put them at equal risk of HIV as their unmarried counterparts, abstinence educators nevertheless champion the institution of marriage while at the same time withholding information about its risks.

Abstinence-only programs also fail to recognize that, as in all countries, AIDS in Uganda is a disease of poverty. Many Ugandans live on less than U.S.$1 per day, a situation that has been exacerbated by decades of political violence and civil war. New HIV cases occur among girls trading sex for school fees, women enduring violent marriages because they lack economic independence, and orphans being pushed onto the street and sexually exploited. “I wish those who preach abstinence would come down to the slums and see how people are living,” said one AIDS educator. “These girls live five to a room. There is no supper for them. The man outside says he will get her money and a place to sleep. Now, what is she going to do, abstain?” Others noted that abstinenceonly messages had no relevance for people who did not marry, not least lesbian, gay, bisexual, and transgender (LGBT) Ugandans whose very existence is denied by their government. LGBT communities are “erased from all HIV programs,” said one activist. “The Uganda AIDS Commission does not want to hear about them.”

As the largest single donor to HIV/AIDS programs in Uganda, the United States is using its unparalleled influence to export abstinence-only programs that have proven to be an abject failure in its own country. No less than twelve U.S. government-funded evaluations at the state level have shown that U.S.-based abstinence-only programs have little influence on participants’ sexual behavior and may cause harm by discouraging the use of contraception. Additional studies have suggested that “virginity pledges,” a staple of abstinence-only programs in which young people promise to abstain until marriage, often fail and may result in lower contraceptive use (and higher STD rates) among sexually active unmarried youth. Officials in both the U.S. and Ugandan governments have ignored these studies. Instead, they have misleadingly used national survey data to suggest that abstinence and fidelity are more popular among Ugandans than condom use. Not only do such data provide a poor substitute for evaluation of abstinence programs, but research in Uganda clearly indicates that a comprehensive approach to HIV prevention—one emphasizing positive behavior change, high-level political leadership, condom use, widespread HIV testing, and a myriad other factors—is what allowed the country to reduce HIV prevalence in the 1990s. Nothing in the demographic or historical record suggests that “abstinence education” as conceived by the United States is what contributed to Uganda’s HIV prevention success.

Government officials in both Uganda and the United States routinely characterize Uganda’s HIV prevention strategy as “ABC,” where A stands for abstinence, B for being faithful, and C for condom use. This acronym is designed in part to give the impression that Uganda has always encouraged abstinence as part of its anti-AIDS efforts, and that abstinence contributed significantly to marked declines in HIV prevalence in Uganda in the 1990s. Again, this impression is misleading. Delayed sexual debut was and continues to be one of many messages provided by Ugandan AIDS educators; however, Uganda did not implement abstinence education on a large scale until the United States began promoting these programs internationally around 2001. Moreover, there is scant evidence that abstinence (as opposed to other behavior changes) contributed significantly to reported declines in HIV prevalence in Uganda in the 1990s. Many veteran AIDS educators in Uganda told Human Rights Watch they had never heard of “ABC” until the United States branded Uganda’s success with this alphabetical soundbite. While ABC proponents have been able to uncover elements of Uganda’s AIDS strategy that support the ABC model, the definition of ABC in the 2003 U.S. global AIDS strategy—Abstinence for youth, Be faithful for married couples, and Condoms only for “high risk” populations—is a uniquely American invention.

At this writing, an estimated 6 percent of the adult population in Uganda is infected with HIV, significantly less than the estimated 15 percent national prevalence a decade ago. Uganda has been rightly praised for this achievement. However, the country still faces a generalized HIV/AIDS epidemic and cannot afford to attack proven HIV prevention strategies and adopt discredited ones. Uganda is home to nearly 1 million children orphaned by HIV/AIDS, many of them at high risk of HIV infection themselves. Efforts to expand access to antiretroviral treatment for people living with HIV/AIDS still have a long way to go, making it especially important to sustain effective and widespread HIV prevention measures. As an acknowledged leader in HIV prevention, Uganda should be building on its success, not adopting the United States’ failures.

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