An HIV/AIDS campaign in crisis?

Uganda's success in lowering its HIV/AIDS level, lauded as a rare African achievement, could be unravelling. The latest UNAIDS statistics show rising prevalence, and questions are being asked about the government's commitment to fighting the epidemic.

The 2006 UNAIDS epidemic update revealed that Uganda's prevalence rose marginally to 6.7 percent in 2005.

Neighbouring countries remained silent about HIV/AIDS in the 1990s when President Yoweri Museveni's administration took an open and aggressive stance against the epidemic, which paid off when infection rates tumbled from a peak of more than 20 percent to a low of 6.4 percent in 2000.

The health ministry has recently appeared to be in a state of crisis: there was a nationwide shortage of condoms after the government imported defective condoms in 2004, and life-prolonging antiretroviral drugs worth an estimated $500,000 expired in government stores in September 2006, a blunder activists said was "inexcusable" when Ugandans were dying from AIDS-related complications.

Positive developments, such as the country exceeding its targets for antiretroviral (ARV) rollout, have been overshadowed by high-profile corruption scandals involving the diversion of millions of dollars in AIDS grants from the Global Fund to fight AIDS, Tuberculosis and Malaria.

The Global Fund temporarily suspended grants worth US$367 million to Uganda in August 2005, citing "serious mismanagement" of funds; the grants were reinstated three months later. Museveni appointed a judicial commission of inquiry in 2006, which recommended that three former health ministers undergo further questioning with a view to prosecution for perjury, causing financial loss and uttering false statements.

Despite the fact that the ministers were dropped from the cabinet, no charges have yet been brought, causing donor countries to urge the government to take "expeditious" action against those accused of mismanagement.

To make matters worse, the Global Fund excluded Uganda from the list of countries receiving funds in its current round of grants for HIV/AIDS and malaria, and the country will only receive funds for combating TB in this grant year.

As Uganda joined the rest of the world in celebrating World AIDS Day on 1 December, questions remain as to the direction of the country's HIV/AIDS response, and activists are calling for the government to be held accountable for the misuse of Global Fund aid.

"This money went into politics instead of helping people; the governing leaders must explain exactly what happened," said Rubaramira Ruranga, an HIV-positive former army major and the founder of an NGO for people living with HIV/AIDS.

Uganda's new health minister, Dr Stephen Malinga, told PlusNews his ministry was developing a new system for channelling funds, and would have the "strictest possible attitude" to the use of donor money in future.

He suggested that the spike in prevalence could be attributed to "complacency". ARVs were now becoming more widely available, allowing HIV-positive people to live longer, which was somewhat blunting the message that AIDS was a life-threatening condition. "Some people mistakenly believe that ARVs are a cure when they are not," he added.

Ruranga agreed. "There is so much complacency," he said. "People don't feel as vulnerable as they used to feel in the past, and when they forget the risks, we know what happens."

There are still wide disparities between rural and urban HIV service provision. "There are so many claims being made about drugs and services being provided but when you actually go and look, particularly in rural areas, it's not actually working," said Ruranga. "People are coming from across the country to Kampala in search of their drugs. They spend money they don't have to get here, and many others are forced to give up."

Malinga acknowledged the gap, and said his ministry would be paying greater attention to people living in rural areas. "That's where the frontline is now," he said.

Some analysts have also blamed the loss of momentum in the struggle against AIDS on the apparent change in strategy from the well-established ABC - Abstinence, Be Faithful and use a Condom - to emphasising abstinence over condom use, an approach favoured by First Lady Janet Museveni.

ABC was widely credited with helping bring down Uganda's prevalence, but a shift to the religious right - brought about, some say, by the desire to access funding from US President's Bush's Emergency Plan For AIDS Relief (PEPFAR) - has seen the 'C' become increasingly condemned as promoting promiscuity and permissiveness.

Beatrice Were, co-founder of the National Community of Women Living with AIDS support group, and now HIV/AIDS coordinator for ActionAid International, believes infection rates are creeping up because "the political will has dwindled ... Museveni has stopped listening to voters with HIV and increased the stigma by giving a platform to evangelical radicals."

Ruranga echoed the view. "When you get the wife of the president and other senior people actually discouraging condoms, people listen," he said. "They think, 'who else knows better than them'?"

Pastor Martin Ssempa, who regularly organises pro-abstinence rallies at Makerere University, in the capital, Kampala, said the emphasis had moved too far in the direction of condoms. "We don't have to say C every time we say A and B," he insisted.

The government has always denied changing its strategy from ABC, but new data from the UNAIDS epidemic update suggests that people haven't stopped having casual sex, but are now less likely to use protection. Around three-quarters of men aged 15-24 had casual sex in the last year and, worryingly, only half the men and women between 15 and 49 years old reported using a condom the last time they had sex with a casual partner.

"The only policy change [needed] now is to be even more aggressive," said minister Malinga. "Do condoms play a part of that? Yes, there needs to be a role for both condoms and abstinence concurrently."

Dr Bernard Etukoit, ARV coordinator at The AIDS Support Organisation, one of Uganda's oldest AIDS NGOs, said a period of reflection from those working in the field was required.

"There has to be a review, and that is taking place now. We need to go back to where we began and see where we impacted well in the past," he said. "We have to go back to the roots."

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//This article is part of an IRIN/PlusNews series on HIV/AIDS and communities of humanitarian concern. Visit: PlusNews. //