Thursday, March 29, 2012

HIV in Uganda: Museveni, Myth and Misogyny

Moses Balyeku, writing in Uganda's New Vision, feels that it is 'Time to Revisit Museveni HIV/Aids Approach', in the light of a recent survey which shows that HIV prevalence has been rising in recent years. But what was Museveni's approach? We are told that it involved things like abstinence, being faithful and using condoms (ABC) by those who still believe that such a strategy works. There are even those who insist that it was just abstinence, which sounds more like wishful thinking that any genuine belief in such a strategy.

However, it has never been clear what Museveni 'did'; it has been shown that ABC didn't exist as a strategy in the late 1980s and early 1990s, when Museveni was supposed to have been working his magic. It has also been shown that, even if the word 'abstinence' ever played any role at that time, it is very unlikely that it had much effect on HIV transmission. In fact, even condom use was not very common in the 80s and 90s, nor was Museveni very enthusiastic about condom use. And that was before his wife took up the cudgel against condoms, presumably with some funding from the fundamentalists who later supported the inhumane anti-gay legislation still being discussed in the country.

While Gary Slutkin and colleagues, in an article entitled 'How Uganda Reversed Its HIV Epidemic', show that it is not really clear what Museveni 'did', they feel that, hidden in the various data and stories, there is something; something that no other country has been able to repeat. Except, perhaps, in the sense that many other countries also saw a rapid drop in prevalence following a rapid rise a few years before. Perhaps what happened in Uganda was that lots of people died and that's why HIV prevalence dropped; and the same would go for other countries which saw such a decline in prevalence.

There may have been other factors, but why should they all have related to sexual transmission of HIV? Slutkin and colleagues barely mention non-sexual HIV transmission, except to cite some sources which recount a campaign that included measures “to reduce transmission through blood transfusion by setting up laboratories to test all blood before transfusion and to reduce transfusion to a minimum” and “to advocate careful sterilization of instruments and contaminated hospital areas to assure patient and health worker safety”. But perhaps that was it; non-sexual transmission would have then dropped to a very low level. Sexual transmission may have dropped a bit, but is unlikely to have dropped enough to explain the massive drops that were seen in Uganda after prevalence peaked.

Things are very different now. while HIV incidence is a lot lower than it must have been before the initial peak in prevalence in the 80s, it is still high enough to drive prevalence up, rather than allowing it to flatline. More and more people are now receiving treatment for HIV, which means that more are living with the disease, which may explain some of the increase in prevalence. But what accounts for various drops in incidence, the annual rate of new infections, and for the current increase? Is it really changes in sexual behavior?

Balyeku feels we need to "revisit the strategies which were used in the mid-1980s and early 1990s that led to a sharp decline in the prevalence rates". But it is almost certain that many of the people who are infected now, and those who are becoming infected, were recipients of Museveni's 'messages'. Maybe some of Museveni's messages were not as powerful as Balyeku and others seem to imagine? Or perhaps they were all too powerful, but still don't explain drops in sexual transmission of HIV?

We are told that the president "would address [schoolchildren] with two bottles of soda to illustrate his teachings. One bottle would be full of soda with its bottle top cover intact while the other would be half empty with no bottle top. On demonstrating the two soda bottles to the children, the President would ask a child to pick any of the two bottles he or she would prefer to take. All the children pointed at the sealed bottle which was full of soda ignoring the opened one which they were not sure whether it wasn't contaminated. In that analogy, the President's message to the children was that abstinence was the best way for them as they concentrate on their studies."

It's hard now to imagine what the president's 'analogy' was, but it sounds very misogynistic to me. Balyeku goes on: "The second analogy the President used was in comparison to a snake that lives in a hole. He locally referred to the hole as mpompogoma. To him, AIDS is like a poisonous snake that lives in a hole. He advised that the moment you carelessly insert your hand or finger into that hole, you would be luring the poisonous snake to bite. He thus counselled the public to desist from trying these mpompogoma or least snakes bite them. With this analogy many people realised the option of protective sex especially the use of a condom." Does Museveni do it differently, or have I been getting it wrong all these years?

These reminiscences are difficult to square with Slutkin's findings. I wonder how many other 'messages' were made up later, reinterpreted later or entirely misunderstood by their audience. Slutkin writes about the constantly mentioned 'zero grazing' campaign. To people from a rural background, this might refer to feeding animals, especially cattle, food substitutes so they don't need to graze. Slutkin and others interpret it differently, saying it alludes "to the traditional way cattle were fenced in, or tied to a stick to limit grazing outside their own pasture." Does it carry a clear message of 'fidelity', as Slutkin claims? He also remembers posters depicting a cow in a pasture surrounded by a fence. Am I being too literal in also seeing this as misogynistic?

Perhaps I'm imagining things but my interpretation of the above, and other accounts, is that it is either fairly unclear how HIV spread, peaked, declined and subsequently increased in Uganda, and perhaps elsewhere, or that there is a strong disinclination to admit that HIV transmission is about a lot more than just sex. If the Ugandan epidemic was never entirely driven by sexual behavior, it was never entirely 'reversed' (Slutkin's term) by changes in sexual behavior, and the recent increase was also probably not caused by changes in sexual behavior either. The relative contributions of sexual and non-sexual modes of transmission in Uganda and other African countries need to be established before we can hope to reverse any epidemics successfully.

[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]



Petit Poulet said...

One of the problems with interpreting the changes in incidence and prevalence of HIV infection in Africa over the past decades is that the definition of what was considered AIDS has been a moving target. When clinical symptoms were the determinants of AIDS, the rates were wildly overestimated because of the overlap of symptoms with other illnesses. Also UNAIDS and other organizations also wildly overestimated the number of people with AIDS to keep their financial sources sending them more money.

Simon said...

Yes, there's quite a problem with data, especially early data. I'm assuming that incidence at some earlier stage was high and then reduced, but not to zero. Perhaps that's not true, but you need to start somewhere. I don't believe there have really been significant changes in sexual behavior, though things were never as bad as often made out. And even changes claimed seemed to have little influence on incidence. Therefore, something else, aside from sexual behavior, must have been behind changes in incidence rates. But you always have to take figures with a pinch of salt and a lot of theorizing may turn out to be without foundation!