This article was downloaded by: [Jan Kuhanen]On: 11 May 2015, At: 23:10Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Click for updates

Journal of Eastern African StudiesPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/rjea20

‘No sex until marriage!’: moralism,politics and the realities of HIVprevention in Uganda, 1986–1996Jan Kuhanena

a Department of Geographical and Historical Studies, University ofEastern Finland, P.O. Box 111, 80101 Joensuu, FinlandPublished online: 05 May 2015.

To cite this article: Jan Kuhanen (2015): ‘No sex until marriage!’: moralism, politics and therealities of HIV prevention in Uganda, 1986–1996, Journal of Eastern African Studies, DOI:10.1080/17531055.2015.1036500

To link to this article: http://dx.doi.org/10.1080/17531055.2015.1036500

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &

Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

‘No sex until marriage!’: moralism, politics and the realities of HIVprevention in Uganda, 1986–1996

Jan Kuhanen*

Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111,80101 Joensuu, Finland

(Received 6 August 2014; accepted 23 March 2015)

This article investigates the historical origins of Uganda’s HIV and AIDS preventionand the challenges it faced. By utilising a variety of sources, the article draws a pictureof the early prevention campaign that ended in crisis in 1990, the consequentrefurbishment of anti-AIDS efforts in the early 1990s and the ideological and practicalproblems they faced. The article argues that before the mid-1990s the HIV preventionmeasures were reluctantly accepted by the majority of Ugandans and that not only theUgandan public, but also the political leaders, donors and professionals involved inAIDS control in the early 1990s recognised this. The article puts the making of theUgandan ‘success story’ in its historical context, suggesting that it may have involvedmotives of great urgency and significance for the future of anti-AIDS work in sub-Saharan Africa.

Keywords: history; Uganda; HIV/AIDS; HIV prevention; moralism; sexual behaviour

Though much has been written about HIV and AIDS in Africa, the epidemic and itshistorical context have only recently received more thought.1 In the historiography ofHIV and AIDS in Uganda the Government’s HIV response and its alleged successfulnesshave attracted most of the attention.2 The historicisation of the government’s role hascreated a ‘grand narrative’ of Uganda’s struggle against HIV and established it as the‘official’ or ‘true’ history of HIV and AIDS. Yet representing the history of HIV andAIDS as a success story narrows its scope significantly, streamlining it into a wellplanned, well executed and logically proceeding sequence of events free of antagonismsand contradictions. As such it is a one-sided history that begins with the government’sinvolvement in 1986 and seems to end with the decline of the national HIV prevalenceclose to 6% in the early 2000s, when Uganda’s experience first received global attention.3

It is a history that celebrates Ugandan openness towards HIV and AIDS and glorifies itspolitical leaders, who made necessity a virtue by guising pragmatic motives as open-mindedness and progressiveness when in reality there were no other alternatives availableto them.4 It is a history that omits the conservative ideology of top-level political andreligious leaders who have reaped political credit from ‘defeating’ HIV. Even today theseleaders cherish their hostility towards modern methods of HIV prevention, including sexeducation for children and adolescents, in the face of slowly climbing national HIVprevalence and subsequent speculations about a resurgence of HIV in Uganda.5 They opt

*Email: jan.kuhanen@uef.fi

Journal of Eastern African Studies, 2015http://dx.doi.org/10.1080/17531055.2015.1036500

© 2015 Taylor & Francis

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

for traditional values and moral upbringing, the cure that they and their conservativesympathisers claim stopped HIV in the 1990s. Finally, it is a history that blurs the broaderhistorical context of HIV and AIDS by omitting local realities, voices and experiences,treating Uganda and Ugandans as a homogenous country and people who yield to theirleaders’ will despite pressing economic, social and personal concerns.6

The grand narrative of HIV and AIDS in Uganda represents the defeat of HIV in the1990s as a moral victory, achieved through the restoration of proper sexual morals andconduct among adolescents and sexually active adults.7 While this simplifies what reallyhappened in Uganda, this view is held by a surprising number of academics andprofessionals working in important HIV- and AIDS-related fields, whose creative yetoccasionally anachronistic use of evidence to back their views have largely escapedcritical attention.8 The Ugandan HIV prevention success has been canonised while itscritics have been labelled as poorly informed sceptics.9 Yet, the history and contextbehind the forging of the Ugandan HIV success story has so far been inadequatelyanalysed.

Objectives and methodology

This article describes HIV prevention efforts in Uganda between 1986 and 1996 in thecontext of a maturing, generalised HIV and AIDS epidemic. It describes how HIVprevention in Uganda was precariously balanced on slippery ground between epidemi-ology, politics, religion and culture, and how political and professional views and popularresponses to AIDS were frequently in conflict, a fact often omitted in previous research.The article highlights the major obstacles facing HIV prevention, arguing that before themid-1990s HIV prevention measures were reluctantly accepted by the majority ofUgandans, and that not only the Ugandan public, but also the political leaders, donors andprofessionals involved in AIDS control in the early 1990s recognised this. Against thishistorical background, Uganda’s alleged HIV prevention success appeared as unexpectedand sudden, if not anachronistic, but, as the article shows, understandable when placed inthe broader context of global HIV prevention in the mid-1990s.

The article utilises archived documentary materials and published documentsproduced by the WHO’s Global Programme on AIDS (WHO/GPA) from the mid-1980s onwards. While the published material is of a general nature, unpublisheddocuments contain valuable information regarding the early days of cooperation betweenthe Ugandan Government and the WHO/GPA. Other important documentary sourcesinclude the published reports of Uganda’s AIDS Control Programme (ACP) and otherMinistry of Health publications relating to HIV and AIDS. The quality and content of theACP material vary, particularly in the early period, and concern mostly urban populationsin Kampala and a few other towns. Nevertheless, these reports include importantinformation about the epidemic, its surveillance and control. Uganda’s HIV and AIDSepidemic has also been monitored and researched by two externally funded, longitudinalcommunity-based research projects working in close collaboration with local researchinstitutions and professionals since the late 1980s. The Rakai and Masaka projects,respectively founded by Columbia University and the Medical Research Council, werevirtually the only sources of information for HIV and AIDS in rural Uganda for most ofthe1990s. Though geographically and culturally confined to southern Uganda, thepopulation-based epidemiological and social surveys produced by these research projectsare crucial to understanding Uganda’s HIV epidemic.10

2 J. Kuhanen

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

This article also examines newspaper reports to grasp the general mood in Ugandaand the public’s views on AIDS, sex and HIV prevention during the late 1980s and early1990s. Importantly, these newspapers also reference the results of official reports andstudies which are virtually impossible to find today. Thus, while taking notice ofoccasional mishaps in reporting, newspapers constitute an important source aboutUganda’s AIDS response activities and the status of the epidemic from the mid-1980sto the present. Several newspapers were systematically analysed for AIDS-related newsand reports between 1984 and 2003.

Documentary evidence has been supplemented with interview data. Talking toordinary Ugandans as well as Ugandan and international professionals who lived throughthe AIDS era opens up a world which is often completely obscured in survey-type reportson AIDS – the local reality and personal experiences. Oral reminiscences are of immensevalue for those hoping to assess the reception of HIV prevention messages, as well as tounderstand different phases and turns in the HIV prevention campaign. The interviewmaterial used in this article was compiled from 2007 to 2008 and 2012 from the Rakaiand Kampala districts in the context of a project studying local histories of HIV and AIDSin Uganda. The material consists of 80 semi-structured, open-ended individual and groupinterviews. The informants include rural dwellers, townspeople from different walks oflife, academics, professionals, local administrators and civil servants, religious leadersand clan leaders. The common denominator for all informants is their personal experienceof the AIDS epidemic in Uganda since the 1980s. A thematically structured questionnairewas used, despite its liability to produce fragmented histories.11 Local collective memoryis a rich source for HIV- and AIDS-related information and, more often than not,consistent with many issues which bear great local (and national) significance, but whichare either omitted or differentially represented in the ‘official’ history of HIV and AIDS.However, interview data alone, such as used here, cannot override results produced bybroader population-based studies on local epidemiology or people’s behaviour, but it cancontribute by pointing out similarities to and differences from the general picture, thusilluminating the local context and complexity of situations in which people foundthemselves with their personal needs, desires and the demands of HIV prevention. Giventhe level of coherence between local histories, and their often marked differences with theofficial history, the value of these oral reminiscences in understanding the HIV and AIDSepidemic in Uganda is significant. Most of the interviews were conducted in Luganda bya native speaker. Ethical clearance for the research was granted by the Uganda NationalCouncil of Science and Technology and informed consent was obtained from eachinformant. For the sake of confidentiality, the identity of all informants has been withheld.

Coming to grips with the epidemic

In January 1986, the National Resistance Movement (NRM) led by Yoweri Musevenibecame the first government in Africa to face a generalised HIV and AIDS epidemic.From the beginning, the NRM government’s response to the epidemic followed theinstructions put forth by the World Health Organization’s Special Programme on AIDS(WHO/SPA, later WHO/GPA), which included the formation of national AIDScommittees to direct and coordinate anti-AIDS activities. These committees would bringtogether the relevant administrative sectors, mainly health care, social services andeducation, needed for prevention, treatment, care and research.12 Within the templateprovided by the WHO, each country was left to establish its own culturally andeconomically sound methods of HIV prevention and education.

Journal of Eastern African Studies 3

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

After years of war and unrest, the task faced by the new Ugandan Government wastremendous. Given the inadequacies of resources, manpower and basic infrastructure, itwould take time before the structures sketched out by the WHO could be put into place toenable an effective response to the epidemic at the national level. Therefore, the UgandaACP, launched in 1986 under the Ministry of Health, first had to limit surveillance,research and preventive activities to a geographically confined area around the capital,where existing communications and transport networks and health-care facilities allowedthe programme to function.13 Rural areas were largely left to their own devices, relyingon local health workers who were poorly equipped to deal with the epidemic.

There was also the problem of reaching the sexually active population. MostUgandans were rural, spoke many different languages, belonged to various ethnic andreligious groups and lived in poverty without electricity, safe water, public health care,reliable transportation and access to mass media. Even in urban areas, a fair share of thepopulation was illiterate or had a poor command of English. Communication was madeeven more difficult by the prevailing cultural attitudes on sexuality and gender, whichrendered public discussion about sex and related issues inappropriate, not only betweeneducators and the public, but even between members of the same family.14 Churches,schools and local administrators were called on to spread the information to the public,but these avenues for education were not without problems. The Catholic Church wasopposed to condoms, claiming that they encouraged promiscuity and consequentlyfacilitated the spread of HIV. Though the Anglican Church of Uganda later agreed tocondone the use of condoms within marriage, the messages delivered by the Christianchurches, partly contradicting those given by the ACP, were bound to cause confusionand uncertainty among the public.15

In schools there was no sex education before the 1990s, mainly because it wasadamantly opposed by religious and parent groups. Before new curricula could beintroduced, teachers had to be educated about HIV.16 Moreover, many children in Ugandawere not in school at all, or dropped out at some point before completing the primarylevel, so this avenue for public education was not very efficient early on.17 Localadministrators at the district, county and village levels who dealt with people on a dailybasis were probably the most promising channel to reach the masses. The district-levelHIV and AIDS education campaign did not begin until 1988 when a trial project waslaunched in the Kabale district in south-west Uganda.

The conservative views of the Catholic Church towards sexuality and condoms mayhave persuaded President Museveni to adopt a similar stance. While the Catholic Churchdogmatically saw that sex belonged to marriage, Museveni spoke about the need to returnto traditional family values as a social prophylaxis against HIV, and about creating a fearof AIDS in Ugandans so that people would be too scared to be promiscuous. Hechallenged parents to keep their children away from ‘anything that causes AIDS’ andapplauded religious leaders for instilling morality in their followers.18 For Museveni andthe Catholic bishops, HIV and AIDS represented a breakdown of sociocultural norms ofUgandan society and an encroachment of Western culture and lifestyles, most visibleamong the elite and youth.19 Sexual promiscuity appeared as an evil result of non-African, liberal and immoral un-Christian lifestyles, which provoked the youth andexposed them to HIV, threatening nation building and national recovery.20 From thepresident’s point of view, conservative religious leaders were not just moral watchdogs,but potential political allies whose support was necessary, even for a progressive-mindedleader like him. Fighting AIDS was not just a medical or epidemiological issue, but acultural, moral and political as well.21 The views of the president and conservative

4 J. Kuhanen

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

religious leaders demonstrate how the struggle against HIV in Uganda, as in much ofAfrica, has been and continues to be ‘an ideological struggle’ between traditional andmodern, conservative and liberal, moral and immoral and African and non-African.22

Museveni’s stance may be taken as political opportunism, but it should also be seen asan expression of genuine concern about the ongoing social change that eroded old socialhierarchies and gender roles. This process gathered momentum during the economic andmoral collapse under the Amin and Obote regimes in the 1970s and 1980s. Theconsequent poverty and rootlessness drove many Ugandans, particularly women, todesperate acts for survival.23 Museveni saw that people in rural areas lived in a peculiarworld characterised by old beliefs and practices on the one hand and the demands ofmodernity on the other.24 His government represented a force intended to make Ugandabetter for Ugandans, a task which could not be achieved without a profound change, andyet the change itself was the thing that exposed poor, uneducated and vulnerable peopleto the hard realities of the market economy, consumer capitalism and HIV. It was there,on the delicate contact surface between traditional and modern, poor and wealthy, whereHIV claimed its victims in Uganda.

The first phase of prevention, 1987–1989Given the difficult starting position for anti-AIDS work in Uganda, the first few years didnot witness any dramatic success in terms of HIV prevention. Most of the resourcesbetween 1986 and 1988 were invested in building the capacity for surveillance andresearch needed for monitoring the epidemic.25 Before there was enough correctinformation, no effective decisions on how to direct prevention efforts could be made.From the very beginning of the anti-AIDS campaign, it was assumed that promiscuousheterosexual behaviour of adult men was behind the rapid spread of HIV.26 For thisreason, the Ministry of Health coined a slogan, ‘zero grazing’, which was supposed toconvey a message discouraging extramarital sexual relationships. Another slogan used atthat time, ‘love carefully’, was equally vague and was interpreted in religious circles as anencouragement to use condoms. These two messages, indirectly encouraging monogam-ous relationships and safer sex, formed the backbone of the ACP’s message toUgandans.27

Due to differences of opinion on how Ugandans should be educated to protectthemselves, there was tension between the president and the ACP, and the ACP and theWHO. The president’s dislike of condoms forced the ACP to accept ‘quiet promotion’ asa part of their HIV prevention, a move that marked a shift from the WHO/GPA strategy.Museveni openly criticised ACP slogans for being difficult to understand, demanding thatAIDS education be taken away from posters and the media, and instead be placed ‘underthe trees’ and in ‘taxis’, i.e. places where common people gather and talk. For ACPprofessionals, the president’s public denouncements of its strategy may not have beenencouraging, and his talk about ‘no sex before marriage’ appeared unrealistic.28

Subsequently, the watering down of the ACP’s initial strategy by Museveni made theWHO/GPA pressure the ACP to increase condom promotion, which was not always well-taken. Moreover, the ACP and the WHO/GPA were frequently in conflict about financialissues and cooperation in the field. The ACP felt that the money for salaries and effectiveoperations was insufficient and coming in too slowly, while the WHO/GPA demandedthat the funds released be used on purposes agreed upon in the general preventionstrategy.29

Journal of Eastern African Studies 5

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

In December 1988 an international team of experts reviewed the activities of the ACPand recommended its expansion and decentralisation to district levels. In 1989 Musevenilaunched a national mass mobilisation against AIDS, which included AIDS education inschools, and education of public sector workers, officials at all levels of government,church workers and local administrators. Many of these improvements, however, took along time to be implemented effectively.30

‘Sitting on a bomb’ –the public response, 1986–1990As early as 1986, before the onset of the ACP campaign, the Ugandan press reportedpublic concerns over the inactivity of the government to disseminate correct informationabout the new deadly disease. After the onset of the campaign, criticism focused on theuse of slogans which did not provide any information but only created fear anduncertainty by discouraging open discussion and raising stigma and discriminationagainst victims.31 This disillusionment and frustration, particularly in areas outsideKampala, were frequently expressed in the press:

It seems since outside countries donated money to fight AIDS, that committee [ACP] has todo a campaign to show that they have done a big job, so they have focused only on urbanareas. People who have been trained to teach about AIDS in villages, they instead use themotorcycles they were given as taxis to generate their own money. Because of lack ofadequate sensitization, you find there some people who still think that AIDS is witchcraft orthat it chooses whom to catch.32

When no positive news about AIDS emerged, voices in the independent media grew evenmore critical towards how the ACP ran its campaign. It was claimed that the statisticsabout teenage pregnancies proved that HIV prevention was not working, because younggirls were still getting pregnant like before. The Ministry of Health was accused ofdeliberately denouncing condoms as an effective solution, and simply repeating theslogans ‘love carefully’ and ‘zero grazing’ without bothering to think about how manypeople actually received these messages. It was claimed that even where the slogans wereseen and understood correctly, their effectiveness was equivalent to a ‘scarecrow’. TheACP’s efforts on a national scale were described as insufficient and ineffective.33

These accusations were not baseless. By 1989 it had emerged that while AIDSawareness, particularly in urban areas, had increased considerably, there were still largeknowledge gaps in rural areas, even within such key groups as parish priests, and that theattitudes of rural dwellers towards AIDS-affected people were often harsh, with denialbeing the most frequent reaction to any enquiry about AIDS. Moreover, a WHO/GPA-funded study and surveys conducted by the Rakai project indicated that though there hadbeen some change in reported sexual behaviour, it was not to the extent required to slowdown the HIV epidemic.34 An epidemiologist conducting sero-behavioural surveys forthe Ministry of Health and the Rakai project in the late 1980s recalled:

When we did our first surveys in 1986–87, people were reporting a high number of sexualpartners. Subsequently, people were reporting much less … they realised it was no longersocially acceptable to report high numbers … So people’s reporting of sexual behavioursuddenly changed.35

It was those men who used to have multiple sexual partners who now claimed to haveshifted into ‘loving carefully’, either through more careful partner selection or through the

6 J. Kuhanen

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

use of condoms.36 Loving carefully, however, harboured some unwanted tendencies. Ithad become evident in Rakai in the mid-1980s that once people learned that HIV wastransmitted sexually, those men frequenting commercial sex workers started to look for‘safer’ sexual partners, turning their attention to teenage girls. In the late 1980s sexualharassment and abuse of adolescent girls seemed to have reached a new level.37

Commercial sex workers in Rakai lost regular customers to teenage girls. Stories depictedmale officials, secondary schoolteachers and university lecturers as sexual predators,taking advantage of their position to sexually abuse female pupils and students.38 By1990 the national extent of the problem and the subsequent public outcry forced theparliament of Uganda to take legislative measures to ‘curb immorality in society’ byintroducing tougher penalties for ‘defilers’ and other sexual abusers of children, teenagersand women.39

But if the people were not responding to HIV-prevention messages as desired, whatwas their reason? Though AIDS awareness was reportedly high at the end of the 1980s, atleast in the urban areas, information and knowledge alone do not automatically bringabout behaviour change.40 People frequently explained that sexual desire was too difficultto resist, and that sex was a biological necessity and essential part of culture, life andsocial reproduction.41 Even among the top echelons of society, attitudes changed slowly.Well-educated government employees, presumably well aware of HIV, continued to ordertheir subordinates in the districts to book a ‘full board’ for them whenever they camearound, meaning to procure the sexual services of local women. A doctor remembers howsome Ministry of Health officials working in rural areas explained that they were notgoing to skip their off-duty ‘routines’ because of HIV and AIDS. Even Dr Okware, thehead of the ACP, admitted that his colleagues were busy chasing women in their freetime, though they understood the risks involved.42

Besides biological and cultural reasons, perhaps the biggest obstacles for HIV andAIDS education to bring about large-scale behavioural change were political andeconomic circumstances. Until the mid-1980s Ugandans were subjected to extremeviolence and corruption by the state, which not only eroded public trust in the authorities,but also destroyed the economy, leaving everyone to struggle for survival. Once thecountry was pacified by the NRM government, the slow economic recovery could begin.By 1995 economic development and political stability had made Uganda one of themodel countries in sub-Saharan Africa. For the first time in years, Ugandans couldimprove the quality of their lives; for many, rapid enrichment became a paramountobjective.43 Getting money would enable a material standard of living never seen before.New consumer goods, previously scarce but now increasingly available, became statussymbols, particularly among adolescents and young adults. Men continued to have sexualpartners as an expression of their wealth and social status. Sex preserved its position as acommodity that was never out of demand. Many prostitutes, though aware of the risksinvolved, preferred to continue selling sex and enjoy an independent life, rather thanreturn to rural drudgery and subordination.44 It was now easier than ever for those betteroff to use their economic leverage for the fulfilment of personal desires.

In this economic and sociocultural context, even perfect knowledge about HIV didnot necessarily translate into a reduction of partners or safe-sex practices. On the contrary,increased wealth and prosperity may have actually encouraged ‘risky’ behaviours amongcertain groups.45 ACP director Okware, given his knowledge about the behaviour of hiscolleagues, was probably not surprised at the lack of behavioural response among thepublic. According to him, Ugandans were ‘sitting on a bomb waiting to explode’.46

Journal of Eastern African Studies 7

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

The bomb explodes, 1990–1992The increasing HIV prevalence and AIDS mortality witnessed in 1990 represented acrisis for HIV prevention in Uganda. In May 1990, Dr Okware made a bleak predictionthat AIDS would get worse before it got any better, claiming that the peak in deathswould occur in 1995–1996. The new Health Minister, Zack Kaheru, estimated that therewere at least one million HIV-infected Ugandans. In the press the ACP and thegovernment were attacked over their inactivity, incapability and lack of credibility, andeven the integrity of the president’s ‘crusade’ was questioned.47 MPs grilled the HealthMinister in Parliament about why the ACP’s information and education campaign werenot working and accused health officials of using donor money for personal profit. Also,the WHO/GPA saw that the implementation capacity and accountability of the ACP hadseriously weakened and demanded stricter rules on spending and strengthening ofleadership. In July 1990, Okware was promoted and transferred to another office.48

In August 1990, when the news about soaring AIDS cases reached the Ugandanpress, a National AIDS Task Force Committee demanded the WHO/GPA arrange anurgent meeting with Uganda’s major donors and supporters. At the meeting in August–September 1990, attended by representatives from the World Bank, the WHO, UNDP andother organisations and NGOs, the decentralisation of Uganda’s AIDS programme to thedistrict level was strongly recommended, and more effective measures to curb the sexualtransmission of HIV were proposed. Major donors such as USAID had for some timepressured the WHO/GPA to put more pressure on Ugandan authorities regarding condompromotion, education and HIV testing and counselling. The WHO/GPA now recom-mended a number of options to be used for more effective prevention, includingpropagation of sexual abstinence as part of the Information, Education and Communica-tion (IEC) package. Finally, since HIV and AIDS had also emerged as a social problem,the adoption of a multi-sectoral approach was recommended in order to encompass allsectors of society effectively. The significant financial costs were to be covered mostly byUSAID and the World Bank.49

The WHO/GPA and the major donors saw that, in light of rising HIV prevalence, thefuture for Uganda looked dreary unless there were substantial increases in resources tostrengthen the response.50 The multi-sectoral approach was a costly but necessarymeasure needed to take Uganda’s prevention efforts to an entirely new level with moremoney and technical assistance available. However, it included a difficult component, thecondom. While arguments were exchanged over the new approach, obituaries and deathannouncements filled the pages of Ugandan newspapers, indicating that the AIDSepidemic was in full swing. In November 1990, allegedly because of a presentationshown to Museveni and ACP officials by some Futures Group demographers sponsoredby USAID, the president, horrified by the potential demographic impact of AIDS, agreedto give condoms a larger role in Uganda’s HIV fight.51

In December 1990 the new director of the ACP, Dr Warren Namaara, said nearly amillion Ugandans would develop AIDS soon, and that the rate of new infections wascontinuing at a worrying pace, particularly among young people.52 Museveni himselfattended the World AIDS Day celebrations for the first time to give the anti-AIDScampaign new vigour. In his declaration of war on AIDS, Museveni did not talk aboutcondoms but demanded a return to past cultural norms, insisting that parents, by theirown example, should guide their children towards correct behaviour.53 Despite reluctantlysubmitting himself to the will of the donors, Museveni did not abandon his fundamental

8 J. Kuhanen

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

belief that AIDS was caused by Western cultural encroachment, and that condoms did notprovided a solution to the problem.54

Putting everything on the line

With the establishment of a multi-sectoral strategy, managed by the new Uganda AIDSCommission (UAC) under the direct supervision of the President’s Office, Uganda’sAIDS response became a fully politicised activity that surpassed purely epidemiologicaland medical concerns. A lot was at stake: HIV prevalence in the general population wasincreasing, rising from 6% in 1987/1988 to nearly 10% in 1993.55 Tens of thousands ofUgandans had died from and been orphaned by AIDS, hundreds of thousands wereinfected and sick, and hundreds, if not thousands, were being infected every day. AIDSthreatened to destroy the limping public health sector, already in trouble because of yearsof unrest and the IMF Structural Adjustment Policy. As AIDS was also killing off theprime workforce, economic repercussions were projected to be considerable.

A lot was also at stake from the political point of view. For the WHO/GPA theexpanding global pandemic brought a financial crisis. Since the late 1980s Africa hadtaken the lion’s share, about 40%, of the financial resources available for the WHO/GPA.With the pandemic growing globally, there was pressure to provide equal services andassistance on all continents. Likewise, the adoption of a multi-sectoral strategy in HIVprevention pushed expenditures up at a time when the financial contributions of some ofthe major WHO/GPA donors – like the USA, Canada, Sweden and Britain – stagnated oreven declined. At global fora critical voices accused the WHO/GPA of an inability tobring about any positive change in terms of HIV and AIDS.56

In the context of Uganda, the WHO/GPA cannot be blamed for inactivity but forinefficiency. Since 1986, when Uganda opted for an open policy about AIDS, the WHO/GPA and other international organisations had been treating Uganda as a special case, akind of a showcase for the WHO/GPA’s work in Africa, where they had free rein to tryeverything to stop the epidemic. Yet the implementation of policies and application oftechnical measures lagged behind, partly due to strict demands of financial accountabilityby the WHO/GPA, and partly because the WHO had to work through UgandanGovernment structures, which created a lot of bureaucracy, financial bottlenecks, delaysand frustration among the WHO/GPA’s Ugandan and international partners. Since themoralistic mass campaign to educate Ugandans about HIV and AIDS had failed to turnthe growing HIV and AIDS awareness into behavioural change as hoped by the ACP, thepresident and the churches, USAID and other major donors pressured the WHO/GPA todemand greater promotion of condoms as part of the IEC strategy and to bypass, ifnecessary, government structures by increasing support to non-governmental organisa-tions.57 They wanted to change the policy of ‘quiet promotion’ to active social marketingof condoms, a strategy that had worked well in curbing the spread of HIV in Zaire in thelate 1980s, for example. In doing so, they ran contrary to the ideas of top political andreligious leaders in Uganda, as well as the ACP and the UAC leadership, who still sawcondom promotion only as a third leg of HIV prevention, surpassed by the propagation ofsexual abstinence and faithfulness to one’s partner.

Another problem was the lack of quality condoms. The amounts imported were toosmall, and the quality of the product was not always good.58 Moreover, ignorance aboutcondoms was great among health workers, and still greater among the general public,who had many misconceptions and prejudices based on culture, religion and generalgossip. Given the negative attitude among political and religious leaders, the problems of

Journal of Eastern African Studies 9

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

supply, and the ignorance and prejudices among the health-care establishment and thepublic, the task of ‘condomising’ Uganda appeared unpromising. Should the IEC strategyfail to make Ugandans ‘zip up’, condoms would be the last resort for HIV prevention inUganda. Should the condom succeed, it would erode the moral authority of theconservative political and religious leaders speaking against it. Should it fail, it woulddemonstrate the ineffectiveness of the IEC, and the futility of ACP’s and WHO/GPA’sattempts to control the spread of HIV.

Prospects for the IEC to succeed

In 1989 a pilot study funded by the WHO on the behavioural aspects of HIV in Ugandaconcluded:

With a culture that does not condemn premarital sex and multiple sexual partners … withoutthe provision of condoms, the spread of HIV and AIDS is likely to proceed unabated. As it isusually easier to modify people’s attitudes toward a contraceptive/protective device than tochange culturally accepted patterns of sexual behaviour, more attention might fruitfully bedirected by the ACP to dispelling the ignorance and biased attitude that surround this devicein Uganda.59

As the report indicates, in the early 1990s people’s attitudes towards condoms were stillvisibly negative, at least in public. But after 1992–1993 this was to change when thedonors, spearheaded by USAID and local and international ideologically liberal NGOs,emerged in great numbers with the goal of providing treatment, care and testing andcounselling services. Many of them also distributed condoms. Along the lines of the ‘newopenness’ of the multi-sectoral strategy, posters and huge billboards emerged aroundKampala and other major towns promoting abstinence, faithfulness and condom use.Condom adverts emerged on the roadsides. Upon lifting the last restrictions on massmedia by the mid-1990s, small, independent FM radio stations aired jingles aboutcondoms, and talk shows on which issues related to sex, HIV and condom use werediscussed gained popularity. The press, even state owned, embarked on supportingcondom use, something the independent press had been doing for some time.60

According to the Ministry of Health, condom use within the sexually active populationincreased from 7% in 1989 to 42% in 1997, an increase of 600%. The number ofcondoms imported increased from a few million in the early 1990s to 30 million by theend of 1995.61

If condom promotion was troublesome in the early 1990s, the two other lines of HIVprevention were not doing much better either. Stories about rampant unprotected sexamong teenagers appeared in newspapers.62 Surveys on sexual behaviour reported onlyslight changes, namely a reduction in the number of sexual partners. Researchersfrequently pondered whether the reported changes were real, or whether they representeda bias towards socially acceptable reporting.63 In 1991 an evaluation report of the ACP’sIEC strategy discovered that implementation was seriously lacking because of misman-agement, tight schedules, inter- and intra-organisational complexities and rivalry, thelaxity of local authorities, and a lack of follow-up and feedback mechanisms.64

Consequently, the report confirmed serious shortcomings in bringing about sexualbehaviour change. It stated:

Strong resistance to monogamy and abstinence, together with the demand for condoms,suggests that, despite all the information received through religious leaders, politicians and

10 J. Kuhanen

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

health education messages, and despite high levels of fear and high exposure to death fromAIDS among relatives and close friends, some people still want to have sex, including somewho want sex outside recognized or de facto marriages. While there has been increasingpressure on individuals to reduce the number of their sexual partners, there are still manystrong traditional and contemporary forces influencing people not to abstain or to remainmonogamous.65

Given the diversity of Uganda, numerous cultural and socio-economic barriers forbehaviour change were easily found, some of them deeply rooted.66 A survey conductedin the rural Masaka district found that only 10% of respondents understood sexualabstinence to mean a total lack of intimate, physical contact, while the majority sawabstinence as ‘one-off encounters’ or even ‘coitus interruptus’.67 It was thus clear thatbringing about substantial sexual behaviour change would not happen overnight butwould take time and require some formidable socio-economic and cultural barriers to beovercome.

‘No sex until marriage’For the Catholic Church and majority of other Christian churches in Uganda the struggleagainst HIV in the 1990s incorporated the struggle against the condom, with the Churchof Uganda making the only marked exception to the rule.68 Criticism against the CatholicChurch, however, was growing among political leaders, professionals and the generalpublic. Some MPs openly accused the Church of playing with people’s lives. Even theACP admitted that since people were still engaging in sex outside marriage, it wasnecessary, according to Dr Namaara, that they practise ‘safer sex with condoms’.69 Manyprofessionals held the view that though condoms may not be the ideal solution forstopping HIV, it was essential that people use them to reduce the sexual transmission ofthe virus, and that the Catholic Church only caused harm by sending conflicting messagesto the public.70

There were doubts about the feasibility of abstinence in HIV prevention, particularlyamong adolescents. The editorial of the leading national newspaper read:

There is also a myth that the best way to protect young people from AIDS is by encouragingthem to abstain from sex before marriage … How many of us are capable of that self-discipline and moral courage? The truth is that most young people start having sex in theirteens, sometimes as young as twelve, and unless we recognize this, AIDS will continue tospread … we should accept and promote the use of condoms … [and] there should be fullsex education in schools. Young people should be taught about sex, reproduction andcondoms so that they are able to take care of themselves properly. We reject the falseargument that this will encourage promiscuity.71

The difficulty facing the APC in the field was that the public, particularly adolescents,were the least interested in sexual abstinence as a method of HIV prevention. Dr Namaarareported on a visit to a village in Iganga, where middle-aged men demanded tips forconvincing their wives to accept the use of condoms, and insisted that condoms be madeavailable at their local health centre. In another village, Namaara and the ACP teamaddressed a crowd of youths: ‘Many wanted to be taught methods of safe sex and only ahandful accepted abstinence as a method to prevent infection’.72 When quizzed aboutHIV, the youths replied that they should either ‘zero-graze’ or use condoms. ACPeducators responded: ‘The message [we] bring to you … is no sex until marriage. Youeither play sex and die, or abstain and live longer’, prompting responses like: ‘But sir,

Journal of Eastern African Studies 11

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

you know we cannot abstain, just tell us how to have safe sex’, a comment that rousedcheers from the crowd. The District Health Educator then intervened: ‘So you peopleseem determined to die young, for we are telling you, abstain or you will die’. When theyouths, the majority of whom were students, expressed their almost universal acceptanceof condoms as a preventive measure against HIV, the ACP megaphone sounded: ‘No sexuntil marriage’! The youths in the hall roared with laughter. After the event was over, thedemand for condoms at the ACP van was, according to Namaara, ‘overwhelming’.73

By 1993 Uganda had the highest HIV incidence in the world.74 HIV and AIDSsurveillance reported only an expanding epidemic and rising morbidity and mortalityfrom AIDS. With 1.5 million people, or 9% of the population, infected, with over400,000 dead from AIDS, and with little trace of sexual behaviour change, it appeared asif there was going to be no change in the course of HIV and AIDS in Uganda.75

Deus ex machina?

The ACP’s HIV surveillance report for 1993 was completed and released in June 1994,bringing good news which nobody expected. In 1993 there had been a decrease in HIVsero-prevalence in four urban antenatal surveillance sites around Uganda, indicating anew turn in the progress of the epidemic. About six months later, in early 1995, it wasconfirmed that in 1994 a total of six urban surveillance sites reported a decline in HIVprevalence, two of which were located in Kampala.76 The ACP ordered an evaluation ofall six sites to ensure that their procedures followed the WHO guidelines. Once the siteswere found to be in order, the officials concluded that the decline in prevalence theywitnessed was real.77

Health officials attributed the decline at sentinel sites to ‘slight changes in sexualbehaviour, increased condom use and safer sex practices’, brought about by ‘greaterawareness of AIDS’.78 They cautioned that the HIV prevalence observed in a sub-population of pregnant women did not necessarily reflect HIV trends in the generalpopulation. Others were more optimistic: Dr Elizabeth Marum, the USAID TechnicalAdvisor on AIDS in Uganda, said there was a lot of evidence of changing behaviour, likea reduction in the number of partners and increased condom use, but without citing anyresearch or survey report.79 In October and November 1995 Ministry of Healthresearchers conducted a series of population-based studies among 15–19-year olds andfound evidence of sexual behaviour change that could ‘partly explain’ the recently founddecline in HIV prevalence in Uganda.80

In 1994 the Masaka and Rakai research projects also reported declines in adult HIVincidence and prevalence. In Masaka the decline in incidence was only slight and theresearchers attributed it to ‘modest’ prevention measures. While both projects reported adecline in HIV prevalence as well, it was more pronounced in Rakai where, however, theHIV incidence remained stable. This led the Rakai researchers to conclude that shifts inHIV prevalence in mature epidemics did not necessarily reflect shifts in HIV incidence,but other factors, like a high AIDS-related mortality, as observed in Masaka as well as inRakai, could explain the change.81

The findings of the Masaka and Rakai research projects received no publicity in theUgandan press until the Ninth International Conference on AIDS and STDs in Africa(ICASA), held in Kampala in December 1995, with nearly 4000 guests from around theworld.82 The results of the two projects were presented and discussed at the pre-conference workshop, which brought together epidemiologists from all over the world.The workshop, and later the conference itself, took the results of the Masaka project and

12 J. Kuhanen

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

the results from the six urban antenatal sentinel sites as proof of declining HIV incidencein the 15–19 age group. The alleged decline in incidence, based on an abstractionproduced by a mathematical model developed by the WHO, was combined with therecent results of the Ministry of Health researchers on sexual behaviour, and presented asa proof of behaviour change among the youngest age groups.83 This seemed to prove thatthe ABC strategy of the Ugandan Government ‒ Abstain, Be faithful, or use a Condom, aslogan coined at the conference ‒ was working, and that it should be used as a templatefor AIDS control for the rest of the African countries.84 Curiously, the results presentedby the Rakai research team, which had some important reservations concerning therepresentativeness of the observed prevalence decline, were almost completely ignored bythe official conference communiqué and the media, while the success of the ABC madeheadlines.85

It thus seems that in December 1995 Uganda’s HIV prevention campaign turned froma near failure into a success almost overnight. The WHO praised Uganda’s ‘crusade’against HIV and the ‘ABC strategy’. Dr Okware kept citing the research results from theMasaka study.86 He talked about an 80% drop in the infection rate among adolescents,which, considering the results of the Masaka project, was not entirely true.87 In the post-conference reports, however, the ‘80% drop’ was cited as dramatic proof of the success ofUganda’s AIDS control. Other African countries reporting stabilisation or drops in HIVprevalence, like Zaire, Rwanda and Tanzania, received little attention, probably becausethey had less dramatic numbers to offer.88 At the ICASA, no one besides the researchersfrom the Rakai project seemed to bother themselves with the issue of increased AIDSmorbidity and mortality, and their effects on prevalence and incidence.89

At the 11th International AIDS Conference in Vancouver in 1996, Uganda’s HIVsituation was discussed by a special symposium of specialists, and the drop in prevalencewas attributed to successful prevention programmes.90 The Vancouver conference sealedUganda’s HIV prevention success, making Uganda an example for the rest of the Africancountries struggling with AIDS. Few at the time questioned the validity of Uganda’ssuccess, the data it was based on, or the functionality of the new model that was nowbeing prepared by UNAIDS, the new United Nation’s joint programme on AIDS. ForUNAIDS, officially launched in January 1996, Uganda’s example provided the splendidstart it needed to convince donor countries of the importance of funding the expensiveand so-far-seemingly ineffective HIV prevention projects in many African countries.91

Conclusion

This article has discussed some of the major obstacles for early HIV and AIDS preventionin Uganda. The article has shown how economic, cultural and ideological factorscomplicated HIV prevention in Uganda, and how popular and professional statementsfrequently expressed doubts regarding its success. In the case of Uganda, any claims ofHIV prevention success, or failure for that matter, must be put into the appropriatehistorical context that extends beyond nationalist, ideologically charged rhetoric on onehand, and the agenda and symbolic power of global public health actors on the other.Only in this way may the achievements and shortcomings of Uganda’s lengthy strugglewith HIV and AIDS be understood and correctly appreciated.

AcknowledgementThe author wishes to thank Herbert Tumusiimwe, Jonathan Ngobi and Thomas Kanooti.

Journal of Eastern African Studies 13

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

Disclosure statementNo potential conflict of interest was reported by the author.

FundingThis work was supported by the Academy of Finland [grant number 252356].

Notes1. Seeley, HIV and East Africa; Doyle, Before HIV; Kinsman, AIDS Policy; Thornton,

Unimagined Community; Iliffe, The African AIDS Epidemic; Kuhanen, “Deadly Gonorrhea.”2. See Kuhanen, “Historiography.”3. Hogle, What Happened in Uganda?4. Kinsman, AIDS Policy, 71–72.5. Ministry of Health, “Release of Key Results”; The Daily Monitor, 3 March 2012; The Daily

Monitor, 19 March 2012.6. Museveni, “Report.”7. Green et al., “HIV Prevention Success”; Kirby, “Changes in Sexual Behaviour.”8. USAID, “The ABC’s”; Timberg and Halperin, Tinderbox. For critical analysis, see

Parkhurst, “Ugandan Success Story,” 78–80; Parkhurst, “What Worked?,” 275–283; Thornton,Unimagined Community, chapter 2; Chin, AIDS Pandemic, 153–154.

9. Ghys et al., “Correspondence,” 1425; Dyer, The Story of AIDS, 26.10. See Kuhanen, “Balinsalamu,” 38 (endnote 17); Kinsman, AIDS Policy, chapter 6.11. See Henige, “Oral Tradition.”12. Recommendations for a plan for action for AIDS control in the African region of the WHO, 6

February 1986, WHO/SPM/WP/05 Add. 1; Workshop on AIDS in Central Africa, Bangui, 22–25 October 1985, WHO/CDS/AIDS/85.1; Special Programme on AIDS: Strategies andStructure. Projected Needs, WHO/SPA/GEN/87.1; AIDS Prevention and Control in the AfricanRegion, 20 August 1990, WHO/AFR/RC40/3 Add. 1.

13. Interview with medical doctor, 3 December 2007, Kampala.14. Olowo-Freers, Sociocultural Aspects, 13–18.15. The AIDS Epidemic, The Message of the Catholic, 3–5, 11; Batwala, “Speech,” 19.16. Kinsman et al., “Implementation”; Ankrah and Rwabukwali, Knowledge, Attitudes and

Practices, 25–25, 57–58.17. UNICEF/SYFA, New Phase, 15, 19.18. Munno, 14 January 1988.19. The AIDS Epidemic, The Message of the Catholic; Museveni, What Is Africa’s Problem?,

247–256.20. See Guidelines for Resistance Committees on the Control of AIDS. s.l.: UNICEF; NRM

Secretariat; Uganda Ministry of Health, s.d., 2–3, 40–48; Parkhurst, “The Response,”571–590.

21. Waal, AIDS and Power, 94–111; Lyons, “The Point of View.”22. Seidel, “Thank God I Said No to AIDS”; Lyons, “The Point of View,” 141–145; Feldman,

“Conclusion,” 283.23. Harmsworth, “The Ugandan Family,” 91–100; Hooper, Slim, 288; Weekly Topic, 7

March 1980.24. Munno, 20 July 1987; The New Vision, 25 April 1988.25. Okware, “Towards,” 726–729; Ministry of Health/AIDS Control Programme (MOH/ACP),

Progress on the AIDS Epidemic in Uganda 1987–89, 6.26. Carswell, “AIDS in Uganda,” 24–25.27. The New Vision, 9 September, 3 October, 28 October 1986.28. The New Vision, 12 July 1988; Interview with medical doctor, 23 May 2008, Kampala.29. Lema to Bata, 14 November 1988/WHO/GPA/A20-370-2 UGA/4; Ankrah to Carballo, 4

November 1988/WHO/GPA/A20-370-8 UGA; Memorandum by Widdus to Friel, 10 January1989/WHO/GPA/A20-370-2 UGA/4; Feeney to Mann, 21 December 1989/WHO/GPA/ A20-370-2 UGA/6.

14 J. Kuhanen

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

30. Owor, “Education”; The Star, 18–19 July 1989; The New Vision, 11 August 1989; Moodieet al., An Evaluation Study, 17.

31. The Star, 28 April 1986; The New Vision, 28 May, 24 June 1986; Weekly Topic, 9 September1987; The Star, 28 April 1989.

32. Munno, 1 December 1989.33. The Star, 19 July 1989; Weekly Topic, 6 December 1989; Weekly Topic, 27 July 1990.34. Ankrah et al., “The Family”; Ankrah et al., “AIDS and the Church”; Ankrah and Ouma, “Impact

of AIDS”; Konde-Lule et al., “Knowledge,” 513–518; Ankrah and Ouma, AIDS in Uganda.35. Interview with epidemiologist, 16 October 2007, Kampala. See also Grant et al., “Trends of

HIV”; Plummer et al., “A Bit More Truthful.”36. Hudson et al., “Risk Factors”; Forster and Furley, “1988 Public Awareness”; Assessment of the

Impact of Group Health Education Regarding the Control of HIV Infection and AIDS in aRural Area of Uganda. WHO/GPA/667/A20-442-2 UGA.

37. Barnett and Blaikie, AIDS in Africa, 45; Bukenya, Pastoral Care, 33–48; Kuhanen,“Balinsalamu,” 35–36.

38. The New Vision, 9 January, 7 August 1987; 31 March 1988; 3 May 1989; 25 October, 29November 1991.

39. The New Vision, 15 June, 22 June 1990.40. See MOH/ACP, AIDS Surveillance Report, Third Quarter, 1990, 1.41. Olowo-Freers, Sociocultural Aspects, 16; Interview with health educator, 8 November 2007,

Kalisizo; Group interview with men, 15 May 2008, Kangabwe; Group interview with men, 6May 2008, Kampala-Mulago.

42. Interview with medical doctor, 3 December 2007, Kampala; The New Vision, 15 June 1990;Munno, 24 August 1988.

43. The New Vision, 26 January 1987; 25 April 1988.44. Interview with epidemiologist, 16 October 2007, Kampala; The People, 20 November 1996;

The Monitor, 27 February 1997; The Sunday Vision, 28 September 1997.45. See Westway et al, “Feckless”; Nyanzi et al., “Male Promiscuity.”46. Munno, 24 August 1988; 11 December 1989; Okware, “Towards,” 726–729; Okware,

“Giving,” 18–20.47. The New Vision, 31 August 1990; Weekly Topic, 1 November 1989; 27 July, 14 December 1990.48. The New Vision, 15 June, 19 June, 25 July 1990; MOH/ACP, AIDS Surveillance Report, Third

Quarter, 1990, 15; Notes on the meeting between Dr Muzira, DMS Uganda and R. Widy-Wirsky, J. Wickett, and B. Daly, 15 May 1990, WHO/GPA/A20-370-2 UGA/5.

49. Feeney to Mann, 21 December 1989; MOH/ACP, AIDS Surveillance Report, Third Quarter,1990, 15; MOH/ACP, AIDS Surveillance Report, Fourth Quarter, 1990, 23; Aide Memoire byJoint Government of Uganda and Donor Mission on HIV/AIDS, 6 September 1990, WHO/GPA/A20-370-2 UGA/8; The New Vision, 7 September 1990; Prevention of Sexual Transmis-sion of Human Immunodeficiency Virus. WHO AIDS Series 6 (Geneva: WHO, 1990).

50. Current and Future Dimensions of the HIV/AIDS Pandemic. A Capsule Summary, September1990, WHO/GPA/SFI/90.2 Rev 1, 7–8.

51. Culotta, “Forecasting,” 852–854; Financial Times, 21 February 1991; The New York Times, 30January 1991; USAID, USAID Action Plan, 22.

52. Weekly Topic, 7 December 1990; The New Vision, 2 March 1990.53. The Star, 5 December 1990: Munno, 3 December 1990; Weekly Topic, 14 December 1990; The

New Vision, 20 April 1991.54. The New Vision, 10 January, 18 June, 21 November, 11 December 1991; The New Vision, 7

December 1992.55. W. Namaara and S. Okware to D. Tarantola, 7 March 1990, WHO/GPA/A20-370-2 UGA/5;

The HIV/AIDS Pandemic: 1994 Overview, 9–10, WHO/GPA/TCO/SEF/94.4; Armstrong,Uganda’s AIDS Crisis, 12–13; Uganda AIDS Commission, “Multi-sectoral.”

56. Proposed Programme Budget for 1994–1995, WHO/GPA/DIR/93.1, 10–15, 49; Report of the TenthMeeting of the Management Committee, WHO/GPA/GMC(10)/94.14, 35; Editorial, “FortressWHO,” 203–204; Patterson, The Politics of AIDS, 3; Parkhurst, “Ugandan Success Story?,” 80.

57. The Costs of HIV/AIDS Prevention Strategies in Developing Countries, WHO/GPA/DIR93.2,8; Feeney to Mann, 21 December 1989.

58. See Kirby, “Changes in Sexual Behavior,” ii38–ii39.

Journal of Eastern African Studies 15

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

59. “AIDS in Uganda: Social and Behavioral Dimensions of the Epidemic. Report of the Pretest,April 1989,” WHO/GPA/A20-370-8 UGA.

60. The Weekly Topic, 18 January, 14 June 1991; The Monitor, 21 February 1997; Kaleeba, OpenSecret, 12.

61. Uganda Health Bulletin, 1 (1992), 8–11; The New Vision, 1 December 1995; The Monitor, 29September, 2 October 1995; The Monitor, 1 December 1995; The New Vision, 2 Decem-ber 1997.

62. The New Vision, 24 February, 16 June 1992; The New Vision, 26 May 1993.63. Ankrah and Ouma, “Impact of AIDS”; Musagara et al., “Recent Changes”; Grant et al.,

“Trends of HIV”; The New Vision, 9 July 1994.64. Moodie et al., An Evaluation Study.65. Ibid., 52; Also Group interview with women, 13 May 2008, Kateera; Group interview with

women, 6 May 2008, Kampala-Mulago.66. Olowo-Freers, Sociocultural Aspects; Nabaitu et al., “Community Perceptions”; Bakibinga and

Kasozi, “Overcoming”; The Monitor, 11 December 1992; Weekly Topic, 14 May 1993.67. Ssali et al., “Exploring”; Kaharuza et al., “Risk Perception.”68. The New Vision, 1 February, 8 February 1994.69. The New Vision, 18 June 1993.70. The New Vision, 4 September, 10 October 1993; The Monitor, 3 December 1993; The New

Vision.71. The New Vision, 2 December 1993.72. The New Vision, 22 April 1992.73. Ibid.74. MOH/STD/AIDS Control Programme, Surveillance Report, June 1993, 1; The New Vision, 24

February 1992; The New Vision, 14 March 1993.75. The New Vision, 14 March, 23 May 1993; The New Vision, 29 July 1994.76. The New Vision, 20 February, 24 February 1995.77. Konde-Lule, “Declining,” 28.78. The New Vision, 9 July 1994.79. The New Vision, 24 February 1995.80. Opio et al., “Sexual Behavior.”81. Kengeya-Kayondo et al., “HIV-1 Incidence”; Mulder et al., “Decreasing”; Wawer et al.,

“Incidence”; Wawer et al., “Trends.”82. Boahene, “International Conference.”83. Workshop on the Status and Trends of the HIV/AIDS Epidemics in Africa: Final Report,

available online at: http://fhi.org/en/HIVAIDS/pub/Archive/confrpts/Wkshp_Status_Trends_HIV_AIDS_Africa.htm (accessed June 14, 2012); The Status and Trends of the Global HIV/AIDSPandemic: Final Report, available online at:http://www.fhi360.org/en/HIVAIDS/pub/Archive/confrpts/Status_Trends_HIV-AIDS_Pand_Fnl_Rprt.htm (accessed June 14, 2012); Timberg andHalperin, Tinderbox, 132–135; Chin, AIDS Pandemic, 153–154.

84. The New Vision, 29 May 1996.85. The New Vision, 15 December 1995; The New York Times, 7 April 1996.86. The New Vision, 11–14 December 1995.87. See Mulder et al., “Decreasing.”88. Boahene, “International Conference,” 613.89. See Aral, “Behavioral Aspects,” 327–328.90. The Status and Trends.91. Piot, No Time to Lose.

ReferencesAIDS Surveillance Report. Third Quarter, Entebbe: Ministry of Health/AIDS Control Programme,1990.

Ankrah, E. M., M. Lubega, and S. Nkumbi. “The Family and Care-giving in Uganda.” InInternational Conference on AIDS, June 4–9, 1989; 5:1015 (abstract no. W.G.P.32).

Ankrah, E. M., S. Nkumbi, and M. Kisembira. “AIDS and the Church Clergy.” In InternationalConference on AIDS, June 20–23, 1990; 6:281 (abstract no. F.D.79).

Ankrah, E. M., and Steven Ouma. AIDS in Uganda. Social and Behavioral Dimensions of theEpidemic. Kampala: Ministry of Health, Makerere University, WHO, 1989.

16 J. Kuhanen

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

Ankrah, E. M., and S. O. Ouma. “Impact of AIDS on Rural and Urban Behaviour in Uganda.” InInternational Conference on AIDS, June 4–9, 1989; 5:973 (abstract no. M.G.O.15).

Ankrah, E. Maxine, and Charles B. Rwabukwali. Knowledge, Attitudes and Practices (KAP) Studyfor School Health Education: Implications for AIDS Control. Kampala: UNICEF, 1987.

Aral, S. O. “Behavioral Aspects of Sexually Transmitted Diseases: Core Groups and BridgePopulations.” Sexually Transmitted Diseases 27, no. 6 (2000): 327–328. doi:10.1097/00007435-200007000-00005.

Armstrong, Jill. Uganda’s AIDS Crisis. Its Implications for Development. Washington, DC: WorldBank, 1995.

Bakibinga, P., and A. Kasozi. “Overcoming Difficulties in Changing Behaviour in Uganda.” InInternational Conference on AIDS, July 19–24, 1992; 8:201 (abstract no. PuD 9015).

Barnett, Tony, and Piers Blaikie. AIDS in Africa. Its Present and Future Impact. New York:Guilford Press, 1992.

Batwala, I. J. “Speech by the Deputy Minister of Health Dr. I. J. Batwala at the Launching of anAIDS Seminar in the Kampala City Council on 25th September 1986.” Health InformationQuarterly 2 (1986): 19–23.

Boahene, K. “The IXth International Conference on AIDS and STD in Africa.” AIDS Care 8(1996): 609–616.

Bukenya, A. L. Pastoral Care in Ugandan Schools. A Sociological Perspective. Kampala: Marinum,2007.

Carswell, W. “AIDS in Uganda – A Review.” Health Information Quarterly 2 (1986): 22–29.Chin, James. The AIDS Pandemic. The Collision of Epidemiology with Political Correctness.Reprinted. Oxford: Radcliffe, 2008.

Culotta, Elizabeth. “Forecasting the Global AIDS Epidemic.” Science 253, no. 5022 (1991): 852–854. doi:10.1126/science.1876845.

Doyle, Shane. Before HIV. Sexuality, Fertility and Mortality in East Africa, 1900–1980. New York:Oxford University Press, 2013.

Dyer, Elaine. And Banana Trees Provided the Shade. The Story of AIDS in Uganda. Kampala:Uganda AIDS Commission, 2004.

Editorial. “Fortress WHO: Breaching the Ramparts for Health’s Sake.” The Lancet 345, no. 8944(1995): 203–204. doi:10.1016/S0140-6736(95)90215-5.

Feldman, Douglas E. “Conclusion, It’s Not Just about AIDS – The Underlying Agenda to ControlHIV in Africa.” In AIDS, Culture and Africa, edited by Douglas A. Feldman, 276–283.Gainesville: University Press of Florida, 2008.

Forster, Sarah J., and Kemlin E. Furley. “1988 Public Awareness Survey on AIDS and Condoms inUganda.” AIDS 3, no. 3 (1989): 147–154. doi:10.1097/00002030-198903000-00005.

Ghys, Peter, Neff Walker, and Catherine Hankins. “Correspondence.” The Lancet 360 (2002): 1425.Grant, R. M., N. Hellmann, P. Nsubuga, C. Walker, I. Tager, R. Leblond, S. Baingi-Baingana, andE. Mbidde. “Trends of HIV Seroprevalence and Risk Behaviors in STD Patients in Uganda.” InInternational Conference on AIDS, July 19–24, 1992; 8:C248 (abstract no. PoC 4022).

Green, Edward C., Daniel T. Halperin, Vinand Nantulya, and Janice A. Hogle. “Uganda’s HIVPrevention Success: The Role of Sexual Behavior Change and the National Response.” AIDS andBehavior 10, no. 4 (2006): 335–346. doi:10.1007/s10461-006-9073-y.

Harmsworth, Josephine Wanja. “The Ugandan Family in Transition.” In Beyond Crisis. Develop-ment Issues in Uganda, edited by Paul D. Wiebe and Cole P. Dodge, 91–100. Hillsboro: MISR &African Studies Association, 1987.

Henige, David. “Oral Tradition as a Means of Reconstructing the Past.” In Writing African History,edited by John E. Philips, 169–190. Rochester, NY: University of Rochester Press, 2005.

Hogle, Janice, ed. What Happened in Uganda? Declining HIV Prevalence, Behavior Change, andthe National Response. Washington, DC: USAID, 2002.

Hooper, Edward. Slim: A Reporter’s Own Story of AIDS in East Africa. London: BodleyHead, 1990.

Hudson, Christopher P., Anselm J. M. Hennis, Peter Kataaha, Graham Lloyd, A. Timothy Moore,Gordon M. Sutehall, Rod Whetstone, Tim Wreghitt, and Abraham Karpas. “Risk Factors for theSpread of AIDS in Rural Africa: Evidence from a Comparative Seroepidemiological Survey ofAIDS, Hepatitis B and Syphilis in Southwestern Uganda.” AIDS 2, no. 4 (1988): 255–260.doi:10.1097/00002030-198808000-00003.

Iliffe, John. The African AIDS Epidemic. A History. London: James Currey, 2006.

Journal of Eastern African Studies 17

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

Kaharuza, F., R. Moodie, A. Katahoire, D. Balikowa, J. Busuulwa, T. Barton, and W. Naamara.“Risk Perception in Rural Ugandans as a Guide to Planners and Educators.” In InternationalConference on AIDS, July 19–24, 1992; 8:D447 (abstract no. PoD 5361).

Kaleeba, Noerine. Open Secret: People Facing up to HIV and AIDS in Uganda. London:ActionAid, 2000.

Kengeya-Kayondo, J., A. Nunn, S. Malamba, H. Wagner, and D. Mulder. “HIV-1 Incidence inAdults and Risk Factors for Seroconversion in a Rural Population in Uganda: 3 Years of Follow-up.” In International Conference on AIDS, August 7–12, 1994; 10:24 (abstract no. 068C).

Kinsman, John. AIDS Policy in Uganda. Evidence, Ideology and the Making of an African SuccessStory. New York: Palgrave Macmillan, 2010.

Kinsman, J., S. Harrison, J. Kengeya-Kayondo, E. Kanyesigye, S. Musoke, and J. Whitworth.“Implementation of a Comprehensive AIDS Education Programme for Schools in MasakaDistrict, Uganda.” AIDS Care 11, no. 5 (2010): 591–601. doi:10.1080/09540129947749.

Kirby, Douglas. “Changes in Sexual Behaviour Leading to the Decline in the Prevalence of HIV inUganda: Confirmation from Multiple Sources of Evidence.” Sexually Transmitted Infections 84,suppl. 2 (2008): ii35–ii41. doi:10.1136/sti.2008.029892.

Konde-Lule, Joseph. “The Declining HIV Seroprevalence in Uganda: What Evidence?” HealthTransition Review 5, suppl. (1995): 28.

Konde-Lule, Joseph K., Seth F. Berkley, and Robert Downing. “Knowledge, Attitudes and PracticesConcerning AIDS in Ugandans.” AIDS 3, no. 8 (1989): 513–518. doi:10.1097/00002030-198908000-00005.

Kuhanen, Jan. “‘Balinsalamu Embawo?’ The Context of Sexual Behaviour Change and Adjustmentin Rakai, Uganda, c. 1975–90.” Journal of Eastern African Studies 4, no. 1 (2010): 20–43.doi:10.1080/17531050903550108.

Kuhanen, Jan. “‘ Deadly Gonorrhea’: History, Collective Memory and Early HIV Epidemiology inEast Central Africa.” The African Journal of AIDS Research, forthcoming.

Kuhanen, Jan. “The Historiography of HIV and AIDS in Uganda.” History in Africa 35 (2008):301–325. doi:10.1353/hia.0.0009.

Lyons, Maryinez. “The Point of View: Perspectives on AIDS in Uganda.” In AIDS in Africa and theCaribbean, edited by George C. Bond, John Kresnike, Isa Susser, and Joan Vincent, 131–146.Boulder, CO: Westview Press, 1997.

Ministry of Health. “Release of Key Results of the 2011 Uganda AIDS Indicator Survey, June2012.” Accessed September 7, 2012. http://www.tasouganda.org.

Moodie, Rob, Anne Katahoire, Frank Kaharuza, David Ouma Balikowa, Sesse Busuulwa, and TomBarton. An Evaluation Study of Uganda AIDS Control Programme’s Information Education andCommunication Activities. Draft Report. s.l.: Ministry of Health AIDS Control Programme &WHO/GPA, 1991.

Mulder, Daan, Andrew Nunn, Anatoli Kamali, and Jane Kengeya-Kayondo. “Decreasing HIV-1Seroprevalence in Young Adults in a Rural Ugandan Cohort.” BMJ 311, no. 7009 (1995): 833–836. doi:10.1136/bmj.311.7009.833.

Musagara, M., J. Konde-Lule, S. Musgrave, D. Serwadda, M. Wawer, and N. Sewankambo.“Recent Changes in Behaviour and Practices in Relation to the HIV Epidemic in Rakai, Uganda.”In International Conference on AIDS, June 20–23, 1990; 6:161 (abstract no. Th.C.109).

Museveni, Yoweri K. “Report on Political Commitment and Accountability.” Paper presented at theXIV International Conference of AIDS and STDs, Bangkok, July 12, 2004.

Museveni, Yoweri K. What Is Africa’s Problem? Minneapolis: University of Minnesota Press, 2000.Nabaitu, J., E. Kajura, J. Seeley, and D. Mulder. “Community Perceptions of Determinants ofSexual Behaviour in Rural Uganda.” In International Conference on AIDS, July 19–24, 1992; 8:D471 (abstract no. PoD 5508).

Nyanzi, Stella, Barbara Nyanzi-Wakholi, and Bessie Kalina. “Male Promiscuity. The Negotiation ofMasculinities by Motorbike Taxi-drivers in Masaka, Uganda.” Men and Masculinities 12 (2008):1–17. doi:10.1177/1097184X07309503.

Okware, Samuel. “Giving AIDS a New Face.” World Health October (1989): 18–20.Okware, S. I. “Towards a National AIDS-control Program in Uganda.” The Western Journal ofMedicine 147 (1987): 726–729.

Olowo-Freers, Bernadette, ed. Sociocultural Aspects of Sexual Behaviour Practices That Contributeto the Transmission of HIV/AIDS in Uganda. Kampala: UNICEF, Republic of Uganda, 1992.

18 J. Kuhanen

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015

Opio, A., J. Musinguzi, G. Asiimwe-Okiror, C. Byabamazima, P. Turyaguma, E. Madraa, P.Nsubuga, and D. Kawesa. “Sexual Behavior Change Due to HIV/AIDS: Results from PopulationBased Surveys Conducted in Five Districts of Uganda.” In International Conference on AIDS,July 7–12, 1996; 11:35 (abstract no. LB.D.6069).

Owor, M. F. “Education, Information, Communication.” In International Conference on AIDS, June4–9, 1989; 5:936 (abstract no. E.805).

Parkhurst, Justin O. “The Response to HIV/AIDS and the Construction of National Legitimacy:Lessons from Uganda.” Development and Change 36, no. 3 (2005): 571–590. doi:10.1111/j.0012-155X.2005.00424.x.

Parkhurst, Justin O. “The Ugandan Success Story? Evidence and Claims of HIV-1 Prevention.” TheLancet 360, no. 9326 (2002): 78–80. doi:10.1016/S0140-6736(02)09340-6.

Parkhurst, Justin O. “‘ What Worked?’: The Evidence Challenges in Determining the Causes ofHIV Prevalence Decline.” AIDS Education and Prevention 20, no. 3 (2008): 275–283.doi:10.1521/aeap.2008.20.3.275.

Patterson, Amy. The Politics of AIDS in Africa. Boulder, CO: Lynne Rienner, 2006.Piot, Peter. No Time to Lose. A Life in Pursuit of Deadly Viruses. New York: W. W. Norton, 2012.Plummer, M., D. Ross, D. Wight, J. Changalucha, G. Mshana, J. Wamoyi, J. Todd, A. Anemona, F.Mosha, A. Obasi, and R. Hayes. “‘ A Bit More Truthful’: The Validity of Adolescent SexualBehaviour Data Collected in Rural Northern Tanzania Using Five Methods.” SexuallyTransmitted Infections 80, suppl. 2 (2004): ii49–ii56. doi:10.1136/sti.2004.011924.

Seeley, Janet. HIV and East Africa. Thirty Years in the Shadow of an Epidemic. London:Routledge, 2013.

Seidel, Gill. “‘ Thank God I Said No to AIDS’: On the Changing Discourse of AIDS in Uganda.”Discourse & Society 1, no. 1 (1990): 61–84. doi:10.1177/0957926590001001004.

Ssali, A., T. Barton, G. Katongole, and J. Seeley. “Exploring Sexual Terminology in a Vernacular inRural Uganda: Lessons for Health Education.” In International Conference on AIDS, July 19–24,1992; 8:D472 (abstract no. PoD 5513).

The AIDS Epidemic. The Message of the Catholic Bishops of Uganda. Kampala: Marianum, 1989.Thornton, Robert. Unimagined Community: Sex, Networks and AIDS in Uganda and South Africa.Berkeley: University of California Press, 2008.

Timberg, Craig, and Daniel Halperin. Tinderbox. How the West Sparked the AIDS Epidemic andHow the World Can Finally Overcome It. New York: Penguin Press, 2012.

Uganda AIDS Commission. “Multi-sectoral Approach to AIDS Control in Uganda.” 1993.Accessed December 12, 2006. http://www.aidsuganda.org/pdf/maca_executive_summary.pdf.

UNICEF/SYFA. New Phase of UNICEF Support for AIDS Control in Uganda. SummaryDocument. Kampala: The Government of Uganda, UNICEF, 1992.

USAID. “The ‘ABC’s’ of HIV Prevention.” Report on ‘ABC’ Experts Technical Meeting,Washington, DC: USAID, September 17, 2002.

USAID. USAID Action Plan FY 1989/90: Uganda. Washington, DC: USAID, 1989.Waal, Alex de. AIDS and Power. Why There Is No Political Crisis – Yet. London: Zed Books, 2006.Wawer, Maria, Nelson Sewankambo, Seth Berkley, David Serwadda, Stanley Musgrave, RonaldGray, Maako Musagara, Rebecca Satlings, and Joseph Konde-Lule. “Incidence of HIV-1Infection in a Rural Region of Uganda.” BMJ 308, no. 6922 (1994): 171–173. doi:10.1136/bmj.308.6922.171.

Wawer, M., N. Sewankambo, and R. Gray. “Trends in Crude Prevalence May Not Reflect Incidencein Communities with Mature Epidemics.” In International Conference on AIDS, August 7–12,1994; 10:84 (abstract no. 289C).

Westway, Elizabeth, Janet Seeley, and Edward Allison. “Feckless and Reckless or Forbearing andResourceful? Looking behind the Stereotypes of HIV and AIDS in ‘Fishing Communities.’”African Affairs 106, no. 425 (2007): 663–679. doi:10.1093/afraf/adm055.

Journal of Eastern African Studies 19

Dow

nloa

ded

by [

Jan

Kuh

anen

] at

23:

10 1

1 M

ay 2

015