Education programmes abound in Uganda to keep AIDS at bay — but are they working?WHO

Hard-earned gains in the fight against AIDS may be eroding in Uganda, according to data presented Thursday at the XVI International AIDS Conference in Toronto, Canada.

The data are disheartening because Uganda was the first country in southern Africa to report a drop in both the rate of new infections and the percentage of the overall population infected with the HIV virus. These successes came in the 1990s and were attributed to the country's ABC strategy, for 'Abstinence, Be faithful, use Condoms' (see 'Uganda's HIV epidemic wanes').

But during the past 5 years, these positive trends have changed, according to biostatistician Leigh Anne Shafer of the Medical Research Council's research programme on AIDS in Uganda.

"The decline in HIV prevalence and incidence that occurred throughout the 1990s has stopped, and there are some indications that it is rising," Shafer said. "This is new and important data from a public-health point of view, and there is a need to react right away."

On the up?

Shafer presented data from pregnant mothers tested at 24 clinics, and from people surveyed in 25 rural villages. In 2000, 5.6% of men and 6.9% of women in the villages were infected with HIV. But by last year, Shafer reports, these numbers had climbed to 6.7% for men and 8.9% for women.

These data could be skewed by population moves between villages, Shafer says, so it is not definitive on its own. But she noticed the same trend in the pregnant women reporting to clinics: the percentage of women infected with HIV declined at seven clinics, but increased at ten and remained unchanged at seven. Shafer estimates that overall, 6.4% of Ugandans are now infected with HIV, compared with 5.6% in 2000.

The upward trend in HIV infection isn't statistically significant from these results; but the fact that infections are levelling off is. Other scientists at the meeting reported similar results, bolstering Shafer's conclusion.

Everyday threat

It is not yet clear what is causing the erosion of Uganda's gains, Shafer says, although there are some clues that it is simply down to more unprotected sex.

The rate of new HIV infections per year in older men is rising for the first time, for example. And in every year since 2000, more and more older men have reported having sex with more than two casual partners in the previous month.

The percentage of 16-year-old boys who report being sexually active has also risen in recent years.

So it is possible that people are not as careful now as they were during the 1990s, either because they are weary of hearing the prevention message or because they are simply not as scared of getting HIV. "There is a concern of normalization — that people are becoming more used to HIV in their everyday lives," Shafer says.

Bad-mouthing the condom

The Uganda data are sure to be seized upon by activists who have decried the ABC prevention model.

The United States has showcased Uganda as a model for the success of the ABC strategy, which is a hallmark of its flagship AIDS aid programme. But critics of this programme have been concerned that its emphasis on abstinence undermines efforts to promote condom use.

Beatrice Were, an activist with ActionAid Uganda, says that the proportion of Ugandan AIDS-prevention funding going to activities promoting abstinence and fidelity has increased from 50% in 2004 to 60% last year. She also says that the money is going to "moralistic faith groups that bad-mouth the condom".

Shafer's team did not analyse rates of condom use, although she said in a press conference that "condom use has not changed much".

Alex Opio, who was in Shafer's study team and is assistant commissioner for health services in the Ministry of Health's National Disease Control Department, says the country is reacting to the data by stepping up prevention efforts. "It is not true that Uganda has slackened in promotion of condom use," he says.

Whatever the cause of the change, experts agree that the negative news shows that countries must fight against complacency in the battle against HIV. "Uganda has been such a well-publicized success story," says Charles Morrison, an epidemiologist with Family Health International, based in Research Triangle Park, North Carolina, who has also studied Uganda. "They really need to pay attention and make sure their guard doesn't fall."

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