Motorcycle taxi driver Richard Okiror has seen the devastating cost of AIDS firsthand. He has watched people wasting away and dying from a virus that infected nearly one-fifth of all adults in his country. His own parents died of AIDS in the 1990s when he was a teenager, leaving him an orphan.
Yet today, in an era of life-saving medicine, he notices that his friends are less worried by the virus. Some of them, he says, are even paying extra money to prostitutes for sex without a condom.
“People don’t take it as seriously as before,” he said. “It’s a disease that doesn’t kill you very fast.”
Others put it even more bluntly. “People look at HIV as a cough,” said Joseph Matovu, a Ugandan health analyst. “You get it and then you are cured.”
With the growing availability of antiretroviral drugs, people can live with the virus for decades. And because they see fewer people dying from AIDS, they are less likely to take precautions.
“We have stagnated, and there’s evidence of increasing infections,” said Asuman Lukwago, the permanent secretary in Uganda’s health department. “There’s a new generation of young people who are unaware of the dangers of not using condoms.”
In the early days of the AIDS crisis, Uganda was hailed as one of the greatest success stories. With a massive education effort, it reduced its national HIV rate to 6 per cent of adults, compared with 18 per cent at the peak of the pandemic in the early 1990s.
But now its HIV rate is creeping back up again. New infections are increasing, and the sense of urgency has vanished. Uganda is one of the few countries in the world where the decline in HIV infections has stopped and even reversed. It has become an early warning signal to the rest of the world: If the fight against AIDS fades into complacency and neglect, the disease can roar back again.
“It’s very worrying,” says Denis Kibira, a health researcher in Uganda. “In the next five or 10 years, we’re going to face a real crisis.”
Over the past decade, the national HIV rate has edged back up to 6.7 per cent. An estimated 129,000 Ugandans became infected with the virus last year – a rise of 11 per cent in the past four years – and experts predict the number of new infections will rise to 140,000 this year.
“Every year it rises by 10,000 or 15,000 and soon it will be 20,000 or 30,000,” says Raymond Byaruhanga, director of the AIDS Information Centre, a Uganda non-governmental group.
But while the complacency of ordinary people might be one reason for the rise, government policies are equally important factors. And two key governments – those of Uganda and the United States – have contributed to the rise in HIV infections here, analysts say.
Ugandan President Yoweri Museveni, who played a key role in fighting AIDS in the 1990s, has been noticeably less outspoken on the AIDS issue in recent years. He has even publicly questioned the value of male circumcision – one of the most important tools in reducing HIV transmission, according to all the latest scientific evidence.
His government has failed to make progress toward universal HIV testing, another key weapon against the virus. Only about 40 per cent of Ugandans have been tested for the virus, so most never receive the counselling sessions that help galvanize them into behavioural changes.
Perhaps the biggest factor, however, is the increasing emphasis on abstinence and faithfulness as the official response to the AIDS pandemic.
In the early days of the crisis, Uganda adopted an “ABC” policy: Abstinence, Be faithful, and wear a Condom. But today the policy seems to be “AB” without the “C.”
The Ugandan government, which heavily promoted condoms in the 1990s in a successful strategy to reduce the HIV rate, rarely talks about condoms any more. Many religious groups, hugely influential in this predominantly Christian country, oppose the promotion of condoms. So, too, is the president’s powerful wife, Janet Museveni, a born-again Christian who gives praise to God on nearly every page of her autobiography. And so the government has backed away from condom advertising.
Official aid agencies in the United States, one of the biggest donors in the campaign against AIDS, took a similar stance against condoms during the George Bush administration from 2001 to 2009. It was only recently that the United States dropped its restrictions on financial support for condom promotion.
As a result of religious lobbying and government reluctance, condoms are effectively banned from Ugandan billboards these days. And condoms cannot be advertised on Uganda’s television channels, except after 9 p.m.
“Everyone in the industry knows that it’s a ‘no-go’ area,” says Daudi Ocheing, head of communications at the Uganda Health Marketing Group, a non-profit company that distributes condoms as part of its health activities.
“Everyone’s hands are tied,” he says. “We should have billboards to promote condoms, but we don’t have them. If you don’t put condoms in the mix, you’re wasting a lot of time.”
The idea of promoting abstinence and faithfulness as the sole solution for all Ugandans will never work, Mr. Ocheing said. “It’s a lie. Are you going to tell an 18-year-old to be abstinent? It’s never going to happen, not in a thousand years.”
He also criticized the government’s refusal to allow condom advertising on television before 9 p.m. Teens as young as 14 years old are already sexually active, he noted.
Young people are not the only source of HIV transmission. More than 40 per cent of new transmissions are occurring within couples, where one partner has HIV and the other does not. Because of this, condom use should be promoted within couples too. But the Ugandan government is extremely reluctant to do so, since it would imply that one partner might be unfaithful – an implication the government doesn’t want to accept.
Stephen Lewis, the former United Nations ambassador on AIDS in Africa, says he is deeply concerned by the rise in HIV infections in Uganda. The “crazy obsession” with abstinence in U.S. aid to Uganda may have led to a rise in infections, he said.
“There has to be much more emphasis on prevention,” Mr. Lewis said. “They have to beat the drums again.”