Addis Ababa — Uganda is globally famous for having achieved a massive reduction in HIV prevalence. According to the World Health Organisation, in the capital city, Kampala, the level of HIV infection among pregnant women attending antenatal clinics fell from 31% in 1993 to 14% by 1998. Outside Kampala, infection rates among pregnant women under 20 dropped from 21% in 1990 to 8% in 1998. Elsewhere, among men attending STI clinics, HIV infection rates fell from 46% in 1992 to 30% in 1998. The government now estimates prevalence at 6% overall. A wide range of explanations have been offered for the decline but there seems to be universal agreement that strong leadership from President Museveni downwards, played a very significant role. Francis Omaswa is Uganda's Director General of Health Services. When Akwe Amosu met him in Addis Ababa, she asked him to explain the strategy that had so much success.
Does the reduced HIV infection rate reflect sheer hard work, or did Uganda have a 'big idea' that made all the difference?
Well, first of all, it is true that the prevalence, as well as new infections of HIV, have declined in Uganda by a factor of about three. And, what did we do? It is very simple. We have to change the behavior of the people through knowledge. So what happened was that the head of state declared that there was this disease from which there's no cure. You catch it, you die. Then, the people were also told how you catch the disease and how you avoid the disease. And that information filtered all the way down to households, and there was, as a result, more responsible sex. And that, literally, is what is responsible for the decline of HIV prevalence in Uganda. Of course, there are other things to say, but that is it, in a nutshell. How did all that happen? Appropriate messages, researched properly, using both scientific and social research; then interventions in the health sector, interventions at the community level, interventions at civil society level, and interventions at various government sectoral levels, so that the entire country was transformed into one movement against HIV/Aids.
So if the Minister of Health had made that statement, or perhaps even you had made that statement, would it have had the same impact? Or, put another way, how important was it that it was the President who put out that message?
Well, I don't think it would have achieved the same results if it was just the Minister of Health or a technical head of health services like myself. The result would not have been the same. People, I think all over the world, they listen to their top leaders, and that is very important. So, once the head of state took that route, then other leaders down the line followed suit, cultural leaders, and professional leaders, and clan leaders, and religious leaders, everybody joined in talking about this disease, including family heads.
Did you or your colleagues have to do anything special to get President Museveni to take on that role?
Not really. This is something that he had observed himself, first as a guerilla, he had heard of this disease. And then he just must have felt that he needs to move. And it is also possible that it affected some people close to him, like his soldiers and his friends and so on.
But the thing is, it's so noticeable that other African heads of state have failed to do the same thing, with the honourable exception of President Mogae of Botswana. What is it that persuaded or allowed him to break the taboos and the stigma to talk about sex openly. Or was that not so unusual in Uganda?
Well, maybe not. But also, personalities are different. That is his inclination, to be frank about things and to be realistic, and maybe that's not a trait other heads of state have.
What about his statement recently in which he warned that his government could ban traditional male circumcision if it proved to be spreading HIV? Wasn't that heard with a great deal of shock?
Well, what he said, I read it in the newspapers, what he said is that if the traditional circumcision practices were not safe, then he would order them stopped. I think he just was passing a message to the ethnic groups who practice traditional circumcision, saying, "Wake up, chaps. You've got to do this job properly, otherwise stop it."
And do you think ordinary Ugandans feel uncomfortable with all this private stuff being spoken about openly? I mean, leaving President Museveni aside, this constant discussion of sex and very personal, private things, circumcision - do people feel a bit uneasy about it? Or does this vary a lot, from country to country?
Well, to some extent people feel uneasy, but really, circumcision is freely talked about. It's done in the open. There's nothing which is taboo about talking circumcision, at least in Uganda. It is not taboo to talk about circumcision, because it is done maybe every two years. Everybody prepares for it and people are running in the street, preparing the boys for the circumcision, everybody. So really, no problem. Then the other sex things. The words used are not always explicit, but the message gets there. You know, like with when we started, we talked about "zero grazing" for sticking to one or consistent partners, but the message got through. And now we talk about, is it the famous ABC, marrying early, but abstaining from sex until you do so and then, once you get married, you stick to one partner. Then, I think, the issue of condoms...
Yes, I was just going to ask you about that...
Really, condoms have got a role to play in the control of HIV/Aids. There are certainly people who do not practice abstinence, who do not practice faithfulness, and the message then is if you are foolish enough not to do those two, please don't die. Go and use a condom. And there are commercial sex workers and long-distance drivers and maybe people who are even in faithful, monogamous relations, who may be infected and they don't want to infect themselves and all those others, who feel that they must have sex which is not safe. Condoms are available for them. But the main thrust is not to promote condoms as the key intervention or the central intervention.
Despite that, have you had opposition from the Catholic church? I know you have a very strong cardinal there in Kampala, is there a lot of hostility to the condom recommendation?
At the beginning, we had to have a vigorous debate. It's not only the Catholic cardinal who was speaking against condoms. The chairman then of the Aids Commission was an Anglican bishop. He too was not talking in favor of condoms. The Muslims also do not support the use of condoms. But we reached a pact with them, saying, "You concentrate on what you are strong at, and leave us to promote condoms, but don't fight us in our work."
Now, you've made a strong and powerful statement to the new African Union commission here in Addis Ababa about Africa's capacity to fight back. What are the key points you would be making to your opposite numbers in other African countries about how to tackle the crisis? Take a country like Nigeria, which so far still has HIV prevalence below 10%?
Well, really, this is a serious problem, this HIV/Aids. I think that's the first thing: to recognize that we are standing in the face of a precipice, and once you do recognize that this is a disease which will disrupt society, then that will give you the strength and the motivation to work hard on it. So that's the first message. Aids is disruptive and it is a disease which will affect the economic growth, poverty levels, human resources, so let's get on and do something about it. I think that's the beginning point: recognizing that Aids is a serious problem. I think that is where the difference is between the countries which have moved and the countries which have not moved.
Do other African countries come to you? Do people in ministries of health around the continent come to you to find out what you have done?
Yes, very many, very many. We get a lot of study tours from African countries, Asian countries, even American countries have some to see what we are doing. We also participate actively in international fora. Our work is widely published, so I would think that the information is out there about what has been done in Uganda.
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So what's actually important for you now, given that you're in this position of having so much reduced the infection rate? What are your priorities right now?
Well, of course, at six percent, it's still too high! Too high, far too high! So we have to work. We have to redouble our efforts. And that's what we are doing. We are putting in new messages to the people. We are addressing groups which we had not worked on as sufficiently before. We are focusing on the youth in schools through special programs and we are also addressing the question of support to the orphans. We are addressing and sharpening the question of terminal care through the coordination, better coordination of civil society and the NGOS, so the job is not done. It's still a long way.
Can you actually get prevalence down much lower, given the war in Uganda, in the north? Where there's conflict it's very difficult to do the sort of management you're describing.
I think now we are focusing on reducing new infections, but prevalence as such may stagnate a bit because people are living longer, especially with drugs. So we are focusing on reducing new infections among the 15-25 age group. And infections are declining among that group. They are the ones in which the decline is most marked. So, I can't predict how the trend will move, really can't do that now, but I think, as the saying goes, "You carry on doing the right things, and the results will also be right."
What about a vaccine? Are you hoping for that soon?
Not so soon, from what the specialists in this area say. The earliest vaccine may be eight years away. But we have got vaccine research programs going on in the country and we are also participating with the international community in this area of work. It holds great hope for a final solution to this disease, but I think we have to be patient with that. It may be some time to come.
