AIDS IN UGANDA
Young people and HIV/AIDS in Uganda
Young people in Uganda have never known a world without HIV/AIDS. Since 1982, when the country’s first cases of HIV were detected on the shores of Lake Victoria in Rakai district, AIDS has killed an estimated 940,000 Ugandans, including 78,000 in 2003 alone. Most of these have been men and women of childbearing age, leaving close to one million Ugandan children without parental care, in addition to those whose parents are sick or dying. The impact of AIDS on children and young people is seen in their own risk of HIV infection: as AIDS impoverishes families, young people—especially young girls—are likely to be withdrawn from school and forced into exploitative situations to survive. Ignorance and denial fuel HIV even further, leaving young people without the critical information that could help them prevent infection. As of 2002, according to government estimates, HIV prevalence among young people in Uganda stood at an estimated 4.9 percent, with rates of 6.5 percent in major towns and 4.1 percent in rural areas.2
Although Uganda is widely recognized as the only country in sub-Saharan Africa to experience a significant drop in HIV prevalence, the extent of this decline has been exaggerated.3 The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that national HIV prevalence in Uganda fell from 12 percent in the early 1990s to just over 4 percent in 2003, though some of this decline is due to HIV-related deaths.4 Declines in urban areas have been more dramatic, from approximately 30 percent in three sites in 1992 to an average of 9.1 percent at the same three clinics in 2002.5 Local organizations working with communities affected by AIDS have challenged recent government figures as too low and estimated HIV prevalence to be between 10-17 percent nationally.6 In addition, reported declines in national HIV prevalence may mask some regional and demographic variations. In three sentinel sites—Mbarara, Mbale, and Kilembe—HIV prevalence between 2001 and 2002 either stagnated or rose. HIV rates tend to be consistently higher in Uganda’s urban areas than in rural ones—8 percent compared to 5 percent among the general population, and 6.5 percent compared to 4 percent among young people.
Uganda’s success against AIDS has not been felt equally by those at highest risk of infection. In Gulu, in northern Uganda where there has been a protracted and brutal civil war since 1986, HIV prevalence in 2002 was estimated at 12 percent in the general population and 8 percent among young people; the general figure is higher than in 2001, although rates are lower than in the early 1990s.7 HIV prevalence among military recruits increased from 3 percent to 13 percent in five sites from 1997 to 1999.8 The highest HIV prevalence in Uganda is found among sex workers, 47 percent of whom were HIV-positive in a 2002 survey compared to 28 percent in 2000.9 According to data collected by the AIDS Information Centre (AIC), a leading nongovernmental organization in the field of voluntary HIV counseling and testing (VCT), a significant percentage of women in sex work are girls aged fifteen to twenty-four.
The combination of economic, social, biological, and behavioral factors that render young Ugandans vulnerable to HIV, especially girls, is not perfectly understood. Sex accounts for the vast majority of HIV infections in Uganda, as in the rest of sub-Saharan Africa. Ugandans are estimated to have their first sexual experience as teenagers, the median being 16.7 years for girls and 18.8 years for boys as of 2001.10 By age seventeen, more than 50 percent of Ugandan girls have had sex, usually with someone older.11 Among girls aged fifteen to twenty-four, 31 percent report that their first sexual partner was three to four years older, and 11 percent report that their first sexual partner was ten or more years older.12 According to the Uganda AIDS Commission, “Ugandan youth begin sexual activity at fairly young ages and with little sexuality information.”13
The phenomenon of girls having sex with older men, often out of economic need, is thought to account for a significant number of new HIV infections in Uganda. Age disparities both increase the likelihood of sexual coercion and limit girls’ ability to demand fidelity and condom use. Early sex may also lead to early marriage: as of 2001, 32 percent of girls aged fifteen to nineteen in Uganda had been married, compared to only 6 percent of boys.14 Among married girls, a fifth were in polygynous unions.15 The combination of early marriage and polygyny further increases girls’ and young women’s HIV risk, as men often engage in concurrent sexual relationships without using condoms. The payment of bride price in connection with many marriages fosters the perception that a husband “owns” his wife and can demand sex from her without her consent. Domestic violence, which according to the United Nations affects 40 percent of Ugandan women, further inhibits girls’ ability to control the terms of their sex lives (including negotiating condom use) and exposes them to HIV.16 In 2001, only 4 percent of married men in Uganda reported having used a condom the last time they had sex, compared to 59 percent of unmarried men.17 While most women knew that condoms would protect them against HIV, only 27 percent of girls aged fifteen to nineteen and 36 percent of women aged twenty to twenty-four said they could convince their partners to use them.18
In 2002, six girls in Uganda were reported infected with HIV for every boy.19 Of the estimated 530,000 Ugandans living with HIV in 2003, over half were women and girls.20 In Kampala, Uganda’s capital city, the AIDS Information Centre reported in 2002 that 10.3 percent of girls and women aged fifteen to twenty-four seeking an HIV test for the first time tested positive, compared to 2.8 percent of boys and men in that age group.21 The AIC data also found that girls were entering into prostitution at a young age: of 218 sex workers surveyed, 65 percent were girls and young women aged fifteen to twenty-four.
The human right to HIV/AIDS information
HIV/AIDS is a disease that is fueled by stigma, denial, and ignorance. While Uganda boasts high levels of awareness of HIV—close to 100 percent of survey respondents in 2000 stated they had heard of the disease22—dangerous myths about HIV/AIDS persist. In the same survey, close to one quarter of Ugandans who said they had heard of AIDS agreed with the statement that HIV could be contracted from a mosquito bite.23 Both men and women harbored discriminatory attitudes towards people living with AIDS, such as the view held by roughly half of Ugandans that a female teacher living with HIV should not be permitted to go on teaching.24 This is a disturbing finding in Uganda, where the stigma associated with AIDS is thought to be less powerful than in Africa generally.
Widespread awareness of HIV/AIDS in Uganda, moreover, does not translate into knowledge of how to prevent infection—particularly among women and girls. In 2001, some 13 percent of Ugandan women did not know any method of avoiding AIDS, compared to 5 percent of men.25 Women were less likely than men to know that condoms prevent HIV, less likely to know that limiting one’s number of sexual partners prevents HIV, and less likely to know that a healthy-looking person can be infected with HIV. Women and girls who were familiar with modes of HIV transmission were less likely than men to put them to use: in 2001, 69 percent of girls aged fifteen to nineteen said they knew condoms would protect them from HIV, whereas only 32 percent said they could obtain them. The corresponding figures for boys were 83 percent and 64 percent. Over 20 percent of young people surveyed in Kampala in 2002 believed that those who used condoms were “promiscuous.”26
Such gender disparities in knowledge of HIV prevention may be explained partly by girls’ unequal access to formal education. In 2001, over one-quarter of Ugandan women without schooling knew no way of protecting themselves from HIV, compared to only 2 percent of women who had attended secondary school or higher.27 Yetwhile school has become more accessible to Ugandans of both sexes in recent years, it continues to be less accessible to girls. As of 2001, four years into Uganda’s free education policy, 9 percent of Ugandan girls had never been to school compared to 2 percent of boys.28 Men were also more likely to stay in school, with 66 percent of young men aged fifteen to nineteen in school in 2001, compared to 44 percent of young women.29
Access to information about HIV/AIDS without discrimination is not simply a public health imperative—it is a human right. International treaties ratified by Uganda recognize that all people have the right to “seek, receive and impart information of all kinds,” including information about their health.30 The United Nations Convention on the Rights of the Child requires states to “ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health.”31 The Committee on the Rights of the Child, the U.N. body responsible for monitoring the implementation of the Convention on the Rights of the Child, states in its general comment on HIV/AIDS that children have the right to access adequate information related to HIV/AIDS prevention. The Committee has emphasized that:
Effective HIV/AIDS prevention requires States to refrain from censoring, withholding or intentionally misrepresenting health-related information, including sexual education and information, and that, consistent with their obligations to ensure the right to life, survival and development of the child (art. 6) States parties must ensure that children have the ability to acquire the knowledge and skills to protect themselves and others as they begin to express their sexuality.32
Access to health information is also essential to realizing the human right to the highest attainable standard of health and, ultimately, the right to life.33 Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) specifically obliges governments to take all necessary steps for the “prevention, treatment and control of epidemic . . . diseases,” such as HIV/AIDS.34 The Committee on Economic, Social and Cultural Rights, the U.N. body responsible for monitoring the implementation of the ICESCR, has interpreted article 12 as requiring “the establishment of prevention and education programmes for behaviour-related health concerns such as sexually transmitted diseases, in particular HIV/AIDS.”35 In language similar to that of the Committee on the Rights of the Child, the ICESCR committee notes:
States should refrain from limiting access to contraceptives and other means of maintaining sexual and reproductive health, from censoring, withholding or intentionally misrepresenting health-related information, including sexual education and information, as well as from preventing people’s participation in health-related matters. . . . States should also ensure that third parties do not limit people’s access to health-related information and services.36
The United Nations International Guidelines on HIV/AIDS and Human Rights, while not binding, similarly call on states to take positive steps to “ensure the access of children and adolescents to adequate health information and education, including information related to HIV/AIDS prevention and care, inside and outside school, which is tailored appropriately to age level and capacity and enables them to deal positively with their sexuality.”37
Uganda and the U.S. Global AIDS Initiative
Ugandan AIDS policy is strongly influenced by the United States, which significantly increased its international assistance to HIV/AIDS programs in 2003. Under President George W. Bush’s Presidential Emergency Plan for AIDS Relief (PEPFAR), U.S. funding for HIV/AIDS programs in Uganda doubled in 2004.38 As of August 2004, the United States had budgeted approximately U.S.$159 million for HIV/AIDS programs in Uganda for fiscal year (FY) 2005.39 The legislation authorizing PEPFAR requires that 55 percent of HIV/AIDS funds be used for the treatment of people living with AIDS, 15 percent for care and support of people living with AIDS, and 20 percent for HIV prevention. Uganda’s U.S.-funded HIV prevention budget for FY2005 is therefore estimated at U.S.$31.8 million.
For young people at risk of HIV/AIDS, the cornerstone of the United States’ HIV prevention strategy is the promotion of sexual abstinence until marriage. “Abstinence until marriage” programs are defined as programs whose sole purpose is to highlight the benefits to be gained by abstaining from sexual activity until marriage, and marriage is in turn held up as the expected standard of human sexual activity. Abstinence-only approaches may be contrasted with comprehensive sex education, which supports the choice not to have sex but also includes information about condoms and other safer sex options for young persons who are or who become sexually active. They may further be contrasted with educational programs that caution young girls about sources of HIV risk in marriage, such as infidelity, marital rape, domestic violence, polygyny, and widow inheritance. Abstinence-only approaches withhold information about the health benefits of condoms and contraception (beyond their failure rates) in the belief that such information contradicts the message of abstinence.
Despite numerous and unrefuted government-funded studies discrediting abstinence-only approaches as an exclusive HIV prevention strategy, the U.S. Congress requires that at least 33 percent of all HIV prevention money under PEPFAR be spent on abstinence-until-marriage programs, with the remainder spent on HIV testing and targeted outreach (including condom promotion) for “high-risk” populations (defined as “prostitutes, sexually active discordant couples (where only one partner is HIV positive), substance abusers, and others”),40 safe blood and improved medical practices, and prevention of mother-to-child transmission of HIV.41 The U.S. government singles out “faith-based organizations” as particularly qualified to implement abstinence-until-marriage programs. The U.S. Five-Year Global HIV/AIDS Strategy, the document that guides the implementation of PEPFAR programs, elaborates on abstinence education as follows:
Delaying first sexual intercourse by even a year can have significant impact on the health and well-being of adolescents and on the progress of the epidemic in communities. . . . The strategies for youth . . . encourage abstinence until marriage for those who have not yet initiated sexual activity and “secondary abstinence” for unmarried youth who have already engaged in intercourse. FBOs [faith-based organizations] are in a strong position to help young people see the benefits of abstinence until marriage and support them in choosing to postpone sexual activity. Programs will help youth develop the knowledge, confidence, and communication skills necessary to make informed choices and avoid risky behavior.42
While U.S. law does not explicitly define abstinence-until-marriage programs for the purposes of PEPFAR, years of experience with similar programs in all fifty U.S. states provides an indication of their main objectives. The U.S. government has funded abstinence education domestically since 1981; in FY2004, appropriations for these programs reached a historical high of U.S.$138.25 million.43 All federally-funded abstinence-only programs must meet an eight-part definition found in the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (commonly known as the Welfare Reform Act), which defines “abstinence education” as follows:
“Abstinence education” means an educational or motivational program which:
A. has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;
B. teaches abstinence from sexual activity outside marriage as the expected standard for all school age children;
C. teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;
D. teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity;
E. teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;
F. teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society;
G. teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and
H. teaches the importance of attaining self-sufficiency before engaging in sexual activity.44
As discussed below, a slightly modified version of this eight-part definition appears in a draft policy issued by the Uganda AIDS Commission in November 2004 to guide U.S.-funded abstinence-until-marriage programs in Uganda.45 Many of the architects of the U.S. global AIDS strategy are the same individuals who have a long history of supporting and implementing abstinence-only programs in the United States.
While numerous studies have demonstrated the ineffectiveness of U.S. abstinence-only programs, few have analyzed the content and delivery of abstinence curricula to see what participants are actually being taught.46 Analysis of these curricula is relevant to the Ugandan context, as domestic experience with (and support for) abstinence-only programs is largely what led the U.S. government to export these programs abroad. In 2002, Human Rights Watch published Ignorance Only: HIV/AIDS, Human Rights and Federally Funded Abstinence-Only Programs in the United States, a case study of abstinence education in the state of Texas.47 The report disclosed numerous ways in which U.S.-funded abstinence-only programs distort or otherwise restrict information about condoms, impede participants’ access to comprehensive HIV/AIDS information and AIDS experts, and encourage young people to “pledge virginity” despite the demonstrated risks of such pledges as an HIV prevention strategy.48 In 2004, at the request of Congressman Henry Waxman, the Special Investigations Division of U.S. House of Representatives’ Committee on Government Reform found scientific errors and distortions in eleven abstinence-only curricula being used by sixty-nine federal grantees in twenty-five U.S. states.49 The errors and distortions concerned, among other things, the effectiveness of condoms against HIV and other STDs, the health risks of sexual activity, and the causes of HIV transmission.
Studies such as these provide an important sign of what is to come in countries like Uganda, where the United States has committed significant funds to abstinence-until-marriage programs. None of these studies is cited in any policy document or publication related to abstinence-until-marriage programs in Uganda or under PEPFAR, nor is any study demonstrating the effectiveness of abstinence-only programs.
The acronym “ABC”—A for abstinence, B for being faithful, and C for condom use—is often used to describe the U.S. (and Ugandan) approach to preventing sexually transmitted HIV internationally. On the surface, ABC appears to promote condoms alongside abstinence and fidelity as an effective HIV prevention strategy. A closer examination of the U.S. AIDS strategy, however, reveals that ABC is disaggregated as Abstinence for unmarried youth, Being faithful for married couples, and Condom use for “those who are infected or who are unable to avoid high-risk behaviors (such as discordant couples (where only one partner is HIV positive)).”50 As noted above, the strategy defines “high-risk” populations as “prostitutes, sexually active discordant couples, substance abusers, and others.” Thus, for unmarried young people who are not working in prostitution, the intervention message is abstinence only. Even where condoms are promoted to “high-risk” groups, the strategy stipulates that condoms should not detract from the overall message that “the best means of preventing HIV/AIDS is to avoid risk all together”—that is, to abstain from sex until marriage.
The U.S. Global AIDS Strategy has evolved in a climate of increasing censorship and distortion of information about condoms and safer sex.51 In 2002, the U.S. Centers for Disease Control and Prevention (CDC) removed a fact sheet on the effectiveness of condoms from its website and replaced it with a new fact sheet which, while factually accurate, eliminated instructions on how to use a condom properly and evidence indicating that condom education does not encourage sex in young people.52 Information on condom effectiveness was similarly altered on the website of the U.S. Agency for International Development (USAID).53 Guidelines proposed by the CDC in 2004 require that AIDS organizations receiving federal funds include information about the “lack of effectiveness of condoms” in any HIV prevention educational materials that mention condoms.54 In 2002, the CDC erased from its website an entire section entitled “Programs that Work,” which had highlighted the effectiveness of comprehensive sex education programs.55
Since taking office in 2001, President Bush has appointed as high-level HIV/AIDS advisers physicians who deny the effectiveness of condoms (either against AIDS or other STDs), such as Senator Tom Coburn and Joe S. McIlhaney, Jr., president of the pro-abstinence-only Medical Institute for Sexual Health (MISH) based in Texas.56 Coburn, who has stated that “the American people [should] know the truth of condom ineffectiveness, ” served as co-chair of the Presidential Advisory Council on HIV and AIDS (PACHA) until he was elected to the U.S. Senate in 2004. He was replaced by Anita Smith, a vocal advocate of abstinence-only programs. Coburn is also widely known for his efforts to require cigarette-type warnings on condom packages stating that they offer “little or no protection” against human papilloma virus (HPV), some strains of which cause cervical cancer.57 Condom use is in fact associated with lower rates of cervical cancer and HPV-associated disease, though the precise effect of condoms in preventing HPV is unknown.58 McIlhaney’s Medical Institute for Sexual Health, which promotes abstinence-only sex education messages, produced a comprehensive monograph on condoms stating that condoms do not make sex “safe enough” to warrant their promotion for STD prevention despite overwhelming evidence to the contrary. McIlhaney has also stated in testimony before the U.S. Congress that there is “precious little evidence” in support of comprehensive sex education programs.
[2] STD/AIDS Control Programme, Ministry of Health, HIV/AIDS Surveillance Report: June 2003, p. 10.
[3] Uganda AIDS Commission (UAC), MEASURE Evaluation and Uganda Ministry of Health (MOH), AIDS in Africa During the Nineties: UGANDA: A review and analysis of surveys and research studies (2003), p. 1; Justin O. Parkhurst, The Ugandan success story? Evidence and claims of HIV-1 prevention", The Lancet, vol. 360 (2002), pp. 78-80.
[4] Estimates of national HIV prevalence in Uganda vary. In 2002, the STD/AIDS Control Programme of the Uganda Ministry of Health estimated that 6.2 percent of the national population was infected with HIV. It should also be noted that trends in HIV prevalence are not as good a measure of HIV prevention as trends in HIV incidence, which measure new HIV infections in a given year. STD/AIDS Control Programme, 2003 HIV/AIDS Surveillance Report, p. 6.
[5]Ibid.
[6] Rory Carroll, “Uganda’s AIDS success story challenged,” The Guardian, September 23, 2004.
[7] STD/AIDS Control Programme, 2003 HIV/AIDS Surveillance Report, pp. 6, 10.
[8] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO), Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Uganda (2004 Update), p.2.
[9] STD/AIDS Control Programme, 2003 HIV/AIDS Surveillance Report, p. 29.
[10] Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. Uganda Bureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.
[11] ORC Macro, Reproductive Health of Young Adults in Uganda: A Report Based on the 2000-2001 Uganda Demographic and Health Survey (Calverton, MD: ORC Macro, 2002), pp. 12-13.
[12] Ibid., p. 13.
[13] Uganda AIDS Commission, “National Young People HIV/AIDS Communication Program for Young People: Concept Paper” (2001).
[14] This includes those who were widowed, divorced or separated. ORC Macro, Reproductive Health of Young Adults in Uganda, p. 19.
[15] Ibid., p. 21.
[16] Human Rights Watch, Just Die Quietly: Domestic Violence and Women’s Vulnerability to HIV in Uganda, Vol. 15, No. 15(A) (August 2003).
[17] ORC Macro, Reproductive Health of Young Adults in Uganda, p. 15.
[18] Ibid., p. 41.
[19] Makerere University Institute of Public Health and Academic Alliance for AIDS Care and Prevention in Africa, Knowledge, Attitude, Beliefs & Practices on HIV/AIDS Care, Prevention and Control: A Quantitative Baseline Survey, Kampala District, Uganda (2003), p. 1.
[20] Joint UNAIDS/WHO, Epidemiological Fact Sheets: Uganda, p. 2.
[21] While HIV prevalence declined among boys between 2001 and 2002 (from 3.7 percent to 2.8 percent), it rose slightly among girls (from 10.1 percent to 10.3 percent).
[22] UAC/MEASURE/MOH, AIDS in Africa During the Nineties, p. 17.
[23] Ibid, p. 21.
[24] UBOS/ORC Macro, Uganda Demographic and Health Survey 2000-2001, p. 174.
[25] Ibid., p. 168.
[26] Makerere University and Academic Alliance, Quantitative Baseline Survey,table 3.3.
[27] UBOS/ORC Macro, Uganda Demographic and Health Survey 2000-2001, p. 169.
[28] ORC Macro, Reproductive Health of Young Adults in Uganda, p. 5.
[29] Ibid., p. 8.
[30] International Covenant on Civil and Political Rights, G.A. res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 52, U.N. Doc. A/6316 (1966), article 19; Convention on the Rights of the Child, G.A. res. 44/25, annex, 44 U.N. GAOR Supp. (No. 49) at 167, U.N. Doc. A/44/49 (1989), article 13.
[31] Convention on the Rights of the Child (1989), article 24(2)(e).
[32] Committee on the Rights of the Child, General Comment No. 3 (2003) HIV/AIDS and the rights of the child, 32nd Sess. (2003), para. 16.
[33] Committee on Economic and Social Rights, General Comment 14: The Right to the Highest Attainable Standard of Health, 22nd Sess. (2000), para. 12(b), note 8.
[34] International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, entered into force January 3, 1976, GA Res. 2200 (XXI), 21 UN GAOR, 21st Sess., Supp. No. 16, at 49, UN Doc. A/6316 (1966), art. 12.
[35] Committee on Economic, Social and Cultural Rights (CESCR), The right to the highest attainable standard of health, para. 16.
[36] Ibid., paras. 34-35.
[37] Office of the United Nations High Commissioner for Human Rights (OHCHR) and UNAIDS, HIV/AIDS and Human Rights: International Guidelines, U.N. Doc. HR/PUB/98/1 (1998), para. 38(g).
[38] Human Rights Watch interview with Ambassador James Kolker, United States Embassy in Uganda, November 22, 2004.
[39] Fact sheet on the President’s Emergency Plan for AIDS Relief, http://www.avert.org/pepfar.htm (retrieved January 30, 2005).
[40] Office of the United States Global AIDS Coordinator (OGAC), The President’s Emergency Plan for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy (Washington, D.C.: United States Department of State, 2004), p. 27.
[41] H.R. 1298, United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, ss. 402(b)(3), 403(a). The Act does not specify a level of assistance for HIV prevention, but it caps such assistance at 20 percent of HIV/AIDS funds, or a maximum of U.S.$3 billion.
[42] OGAC, PEPFAR Five-Year Strategy, pp. 24, 29.
[43] Sexuality Information and Education Council of the United States (SIECUS), “Overall Federal Spending for Abstinence-Only-Until-Marriage Programs,” State Profiles: A Portrait of Sexuality Education and Abstinence-Only-Until Marriage Programs in the States (FY2003 edition). President Bush requested an increase to U.S.$268 million dollars for abstinence-until-marriage programs for FY2005.
[44] 42 U.S.C. § 710(b)(2).
[45] Swizen Kyomuhendo, Martin Ssempa, Lillian Lamalatu, Stephen Langa, Joseph Kiwanuka, and Edward C. Green, “Uganda National Abstinence and Being Faithful Policy and Strategy on Prevention of Transmission of HIV: Draft Policy and Strategy” (Uganda AIDS Commission, November 2004), p. iv.
[46] United States House of Representatives Committee on Government Reform – Minority Staff Special Investigations Division, The Content of Federally Funded Abstinence-Only Education Programs, report prepared for Rep. Henry A. Waxman (December 2004).
[47] Human Rights Watch, Ignorance Only: HIV/AIDS, Human Rights and Federally Funded Abstinence-Only Programs in the United States: Texas: A Case Study, Vol. 14, No. 5(G) (September 2002).
[48] See Peter Bearman and Hannah Brückner, "Promising the Future: Virginity Pledges as they Affect Transition to First Intercourse," American Journal of Sociology, vol. 106, no. 4 (2001), pp. 859-912; Bearman and Brückner, “After the Promise: the STD Consequences of Adolescent Virginity Pledges,” 2004, http://www.yale.edu/socdept/CIQLE/cira.ppt (retrieved November 10, 2004).
[49] Committee on Government Reform, Abstinence-Only Education Programs; see also, Martha E. Kempner, “Toward a Sexually Healthy America: Abstinence-only-until-marriage Programs that Try to Keep our Youth ‘Scared Chaste’” (New York: Sexuality Information and Education Council of the United States, 2001).
[50] OGAC, PEPFAR Five-Year Strategy, p. 29.
[51] See, e.g., Nicholas D. Kristof, “The Secret War on Condoms,” The New York Times, January 10, 2003; Marie Cocco, “White House Wages Stealth War on Condoms,” Newsday, November 14, 2002; Caryl Rivers, “In Age of AIDS, Condom Wars Take Deadly Toll,” Women’s eNews, December 10, 2003, http://womensenews.org/article.cfm/dyn/aid/1633/context/archive (retrieved February 16, 2004); Art Buchwald, “The Trojan War,” The Washington Post, December 11, 2003.
[52] Compare U.S. Centers for Disease Control and Prevention ( CDC), “Condoms and Their Use in Preventing HIV Infection and Other STDs” (September 1999), available at http://www.house.gov/reform/min/pdfs/pdf_inves/pdf_admin_hhs_info_condoms_fact_sheet_orig.pdf with CDC, “Male Latex Condoms and Sexually Transmitted Diseases” (2002), available at http://www.house.gov/reform/min/pdfs/pdf_inves/pdf_admin_hhs_info_condoms_fact_sheet_revis.pdf.
[53] Compare U.S. Agency for International Development ( USAID), “The Effectiveness of Condoms in Preventing Sexually Transmitted Diseases,” http://www.usaid.gov/pop_health/aids/TechAreas/condoms/condom_effect.html (retrieved January 28, 2003) with USAID, “USAID: HIV/AIDS and Condoms,” http://www.usaid.gov/pop_health/aids/TechAreas/condoms/condomfactsheet.html (retrieved July 10, 2005).
[54] CDC, “Proposed Revision of Interim HIV Content Guidelines for AIDS,” 69 Fed. Reg. 115, 33824, June 16, 2004.
[55] Compare CDC, “Programs that Work” (archived version at http://web.archive.org/web/20010606142729/www.cdc.gov/nccdphp/dash/rtc/index.htm) with CDC, “Programs that Work” (http://www.cdc.gov/nccdphp/dash/rtc/).
[56] See Rep. Henry A. Waxman, “The Effectiveness of Abstinence-Only Education,” in Politics and Science: Investigating the State of Science Under the Bush Administration, http://democrats.reform.house.gov/features/politics_and_science/example_abstinence.htm (retrieved February 7, 2005);H. Boonstra, “Public Health Advocates Say Campaign to Disparage Condoms Threatens STD Prevention Efforts,” The Guttmacher Report on Public Policy, March 2003, p. 2.
[57] Proponents of abstinence education have long sought to disparage condoms by speculating about the link between condom usage and cervical cancer. The legislation authorizing PEPFAR compels the president to report on the “impact that condom usage has upon the spread of HPV in Sub-Saharan Africa,” a mandate that many view as an effort to undermine confidence in the use of condoms against HIV. H.R. 1298, s. 101(b)(3)(W).
[58] CDC, “Male Latex Condoms and Sexually Transmitted Diseases” (2002); see also, C.J.A. Hogewoning et al., “Condom use promotes regression of cervical intraepithelial neoplasia and clearance of human papilloma virus: a randomised clinical trial,” International Journal of Cancer, vol. 107 (2003), pp. 811-816; M.C.G. Bleeker et al., “Condom use promotes regression of human papilloma virus-associated penile lesions in male sexual partners of women with cervical intraepithelial neoplasia,” International Journal of Cancer, vol. 107 (2003), pp. 804-810.
Young people in Uganda have never known a world without HIV/AIDS. Since 1982, when the country’s first cases of HIV were detected on the shores of Lake Victoria in Rakai district, AIDS has killed an estimated 940,000 Ugandans, including 78,000 in 2003 alone. Most of these have been men and women of childbearing age, leaving close to one million Ugandan children without parental care, in addition to those whose parents are sick or dying. The impact of AIDS on children and young people is seen in their own risk of HIV infection: as AIDS impoverishes families, young people—especially young girls—are likely to be withdrawn from school and forced into exploitative situations to survive. Ignorance and denial fuel HIV even further, leaving young people without the critical information that could help them prevent infection. As of 2002, according to government estimates, HIV prevalence among young people in Uganda stood at an estimated 4.9 percent, with rates of 6.5 percent in major towns and 4.1 percent in rural areas.2
Although Uganda is widely recognized as the only country in sub-Saharan Africa to experience a significant drop in HIV prevalence, the extent of this decline has been exaggerated.3 The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that national HIV prevalence in Uganda fell from 12 percent in the early 1990s to just over 4 percent in 2003, though some of this decline is due to HIV-related deaths.4 Declines in urban areas have been more dramatic, from approximately 30 percent in three sites in 1992 to an average of 9.1 percent at the same three clinics in 2002.5 Local organizations working with communities affected by AIDS have challenged recent government figures as too low and estimated HIV prevalence to be between 10-17 percent nationally.6 In addition, reported declines in national HIV prevalence may mask some regional and demographic variations. In three sentinel sites—Mbarara, Mbale, and Kilembe—HIV prevalence between 2001 and 2002 either stagnated or rose. HIV rates tend to be consistently higher in Uganda’s urban areas than in rural ones—8 percent compared to 5 percent among the general population, and 6.5 percent compared to 4 percent among young people.
Uganda’s success against AIDS has not been felt equally by those at highest risk of infection. In Gulu, in northern Uganda where there has been a protracted and brutal civil war since 1986, HIV prevalence in 2002 was estimated at 12 percent in the general population and 8 percent among young people; the general figure is higher than in 2001, although rates are lower than in the early 1990s.7 HIV prevalence among military recruits increased from 3 percent to 13 percent in five sites from 1997 to 1999.8 The highest HIV prevalence in Uganda is found among sex workers, 47 percent of whom were HIV-positive in a 2002 survey compared to 28 percent in 2000.9 According to data collected by the AIDS Information Centre (AIC), a leading nongovernmental organization in the field of voluntary HIV counseling and testing (VCT), a significant percentage of women in sex work are girls aged fifteen to twenty-four.
The combination of economic, social, biological, and behavioral factors that render young Ugandans vulnerable to HIV, especially girls, is not perfectly understood. Sex accounts for the vast majority of HIV infections in Uganda, as in the rest of sub-Saharan Africa. Ugandans are estimated to have their first sexual experience as teenagers, the median being 16.7 years for girls and 18.8 years for boys as of 2001.10 By age seventeen, more than 50 percent of Ugandan girls have had sex, usually with someone older.11 Among girls aged fifteen to twenty-four, 31 percent report that their first sexual partner was three to four years older, and 11 percent report that their first sexual partner was ten or more years older.12 According to the Uganda AIDS Commission, “Ugandan youth begin sexual activity at fairly young ages and with little sexuality information.”13
The phenomenon of girls having sex with older men, often out of economic need, is thought to account for a significant number of new HIV infections in Uganda. Age disparities both increase the likelihood of sexual coercion and limit girls’ ability to demand fidelity and condom use. Early sex may also lead to early marriage: as of 2001, 32 percent of girls aged fifteen to nineteen in Uganda had been married, compared to only 6 percent of boys.14 Among married girls, a fifth were in polygynous unions.15 The combination of early marriage and polygyny further increases girls’ and young women’s HIV risk, as men often engage in concurrent sexual relationships without using condoms. The payment of bride price in connection with many marriages fosters the perception that a husband “owns” his wife and can demand sex from her without her consent. Domestic violence, which according to the United Nations affects 40 percent of Ugandan women, further inhibits girls’ ability to control the terms of their sex lives (including negotiating condom use) and exposes them to HIV.16 In 2001, only 4 percent of married men in Uganda reported having used a condom the last time they had sex, compared to 59 percent of unmarried men.17 While most women knew that condoms would protect them against HIV, only 27 percent of girls aged fifteen to nineteen and 36 percent of women aged twenty to twenty-four said they could convince their partners to use them.18
In 2002, six girls in Uganda were reported infected with HIV for every boy.19 Of the estimated 530,000 Ugandans living with HIV in 2003, over half were women and girls.20 In Kampala, Uganda’s capital city, the AIDS Information Centre reported in 2002 that 10.3 percent of girls and women aged fifteen to twenty-four seeking an HIV test for the first time tested positive, compared to 2.8 percent of boys and men in that age group.21 The AIC data also found that girls were entering into prostitution at a young age: of 218 sex workers surveyed, 65 percent were girls and young women aged fifteen to twenty-four.
The human right to HIV/AIDS information
HIV/AIDS is a disease that is fueled by stigma, denial, and ignorance. While Uganda boasts high levels of awareness of HIV—close to 100 percent of survey respondents in 2000 stated they had heard of the disease22—dangerous myths about HIV/AIDS persist. In the same survey, close to one quarter of Ugandans who said they had heard of AIDS agreed with the statement that HIV could be contracted from a mosquito bite.23 Both men and women harbored discriminatory attitudes towards people living with AIDS, such as the view held by roughly half of Ugandans that a female teacher living with HIV should not be permitted to go on teaching.24 This is a disturbing finding in Uganda, where the stigma associated with AIDS is thought to be less powerful than in Africa generally.
Widespread awareness of HIV/AIDS in Uganda, moreover, does not translate into knowledge of how to prevent infection—particularly among women and girls. In 2001, some 13 percent of Ugandan women did not know any method of avoiding AIDS, compared to 5 percent of men.25 Women were less likely than men to know that condoms prevent HIV, less likely to know that limiting one’s number of sexual partners prevents HIV, and less likely to know that a healthy-looking person can be infected with HIV. Women and girls who were familiar with modes of HIV transmission were less likely than men to put them to use: in 2001, 69 percent of girls aged fifteen to nineteen said they knew condoms would protect them from HIV, whereas only 32 percent said they could obtain them. The corresponding figures for boys were 83 percent and 64 percent. Over 20 percent of young people surveyed in Kampala in 2002 believed that those who used condoms were “promiscuous.”26
Such gender disparities in knowledge of HIV prevention may be explained partly by girls’ unequal access to formal education. In 2001, over one-quarter of Ugandan women without schooling knew no way of protecting themselves from HIV, compared to only 2 percent of women who had attended secondary school or higher.27 Yetwhile school has become more accessible to Ugandans of both sexes in recent years, it continues to be less accessible to girls. As of 2001, four years into Uganda’s free education policy, 9 percent of Ugandan girls had never been to school compared to 2 percent of boys.28 Men were also more likely to stay in school, with 66 percent of young men aged fifteen to nineteen in school in 2001, compared to 44 percent of young women.29
Access to information about HIV/AIDS without discrimination is not simply a public health imperative—it is a human right. International treaties ratified by Uganda recognize that all people have the right to “seek, receive and impart information of all kinds,” including information about their health.30 The United Nations Convention on the Rights of the Child requires states to “ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health.”31 The Committee on the Rights of the Child, the U.N. body responsible for monitoring the implementation of the Convention on the Rights of the Child, states in its general comment on HIV/AIDS that children have the right to access adequate information related to HIV/AIDS prevention. The Committee has emphasized that:
Effective HIV/AIDS prevention requires States to refrain from censoring, withholding or intentionally misrepresenting health-related information, including sexual education and information, and that, consistent with their obligations to ensure the right to life, survival and development of the child (art. 6) States parties must ensure that children have the ability to acquire the knowledge and skills to protect themselves and others as they begin to express their sexuality.32
Access to health information is also essential to realizing the human right to the highest attainable standard of health and, ultimately, the right to life.33 Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) specifically obliges governments to take all necessary steps for the “prevention, treatment and control of epidemic . . . diseases,” such as HIV/AIDS.34 The Committee on Economic, Social and Cultural Rights, the U.N. body responsible for monitoring the implementation of the ICESCR, has interpreted article 12 as requiring “the establishment of prevention and education programmes for behaviour-related health concerns such as sexually transmitted diseases, in particular HIV/AIDS.”35 In language similar to that of the Committee on the Rights of the Child, the ICESCR committee notes:
States should refrain from limiting access to contraceptives and other means of maintaining sexual and reproductive health, from censoring, withholding or intentionally misrepresenting health-related information, including sexual education and information, as well as from preventing people’s participation in health-related matters. . . . States should also ensure that third parties do not limit people’s access to health-related information and services.36
The United Nations International Guidelines on HIV/AIDS and Human Rights, while not binding, similarly call on states to take positive steps to “ensure the access of children and adolescents to adequate health information and education, including information related to HIV/AIDS prevention and care, inside and outside school, which is tailored appropriately to age level and capacity and enables them to deal positively with their sexuality.”37
Uganda and the U.S. Global AIDS Initiative
Ugandan AIDS policy is strongly influenced by the United States, which significantly increased its international assistance to HIV/AIDS programs in 2003. Under President George W. Bush’s Presidential Emergency Plan for AIDS Relief (PEPFAR), U.S. funding for HIV/AIDS programs in Uganda doubled in 2004.38 As of August 2004, the United States had budgeted approximately U.S.$159 million for HIV/AIDS programs in Uganda for fiscal year (FY) 2005.39 The legislation authorizing PEPFAR requires that 55 percent of HIV/AIDS funds be used for the treatment of people living with AIDS, 15 percent for care and support of people living with AIDS, and 20 percent for HIV prevention. Uganda’s U.S.-funded HIV prevention budget for FY2005 is therefore estimated at U.S.$31.8 million.
For young people at risk of HIV/AIDS, the cornerstone of the United States’ HIV prevention strategy is the promotion of sexual abstinence until marriage. “Abstinence until marriage” programs are defined as programs whose sole purpose is to highlight the benefits to be gained by abstaining from sexual activity until marriage, and marriage is in turn held up as the expected standard of human sexual activity. Abstinence-only approaches may be contrasted with comprehensive sex education, which supports the choice not to have sex but also includes information about condoms and other safer sex options for young persons who are or who become sexually active. They may further be contrasted with educational programs that caution young girls about sources of HIV risk in marriage, such as infidelity, marital rape, domestic violence, polygyny, and widow inheritance. Abstinence-only approaches withhold information about the health benefits of condoms and contraception (beyond their failure rates) in the belief that such information contradicts the message of abstinence.
Despite numerous and unrefuted government-funded studies discrediting abstinence-only approaches as an exclusive HIV prevention strategy, the U.S. Congress requires that at least 33 percent of all HIV prevention money under PEPFAR be spent on abstinence-until-marriage programs, with the remainder spent on HIV testing and targeted outreach (including condom promotion) for “high-risk” populations (defined as “prostitutes, sexually active discordant couples (where only one partner is HIV positive), substance abusers, and others”),40 safe blood and improved medical practices, and prevention of mother-to-child transmission of HIV.41 The U.S. government singles out “faith-based organizations” as particularly qualified to implement abstinence-until-marriage programs. The U.S. Five-Year Global HIV/AIDS Strategy, the document that guides the implementation of PEPFAR programs, elaborates on abstinence education as follows:
Delaying first sexual intercourse by even a year can have significant impact on the health and well-being of adolescents and on the progress of the epidemic in communities. . . . The strategies for youth . . . encourage abstinence until marriage for those who have not yet initiated sexual activity and “secondary abstinence” for unmarried youth who have already engaged in intercourse. FBOs [faith-based organizations] are in a strong position to help young people see the benefits of abstinence until marriage and support them in choosing to postpone sexual activity. Programs will help youth develop the knowledge, confidence, and communication skills necessary to make informed choices and avoid risky behavior.42
While U.S. law does not explicitly define abstinence-until-marriage programs for the purposes of PEPFAR, years of experience with similar programs in all fifty U.S. states provides an indication of their main objectives. The U.S. government has funded abstinence education domestically since 1981; in FY2004, appropriations for these programs reached a historical high of U.S.$138.25 million.43 All federally-funded abstinence-only programs must meet an eight-part definition found in the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (commonly known as the Welfare Reform Act), which defines “abstinence education” as follows:
“Abstinence education” means an educational or motivational program which:
A. has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;
B. teaches abstinence from sexual activity outside marriage as the expected standard for all school age children;
C. teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;
D. teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity;
E. teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;
F. teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society;
G. teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and
H. teaches the importance of attaining self-sufficiency before engaging in sexual activity.44
As discussed below, a slightly modified version of this eight-part definition appears in a draft policy issued by the Uganda AIDS Commission in November 2004 to guide U.S.-funded abstinence-until-marriage programs in Uganda.45 Many of the architects of the U.S. global AIDS strategy are the same individuals who have a long history of supporting and implementing abstinence-only programs in the United States.
While numerous studies have demonstrated the ineffectiveness of U.S. abstinence-only programs, few have analyzed the content and delivery of abstinence curricula to see what participants are actually being taught.46 Analysis of these curricula is relevant to the Ugandan context, as domestic experience with (and support for) abstinence-only programs is largely what led the U.S. government to export these programs abroad. In 2002, Human Rights Watch published Ignorance Only: HIV/AIDS, Human Rights and Federally Funded Abstinence-Only Programs in the United States, a case study of abstinence education in the state of Texas.47 The report disclosed numerous ways in which U.S.-funded abstinence-only programs distort or otherwise restrict information about condoms, impede participants’ access to comprehensive HIV/AIDS information and AIDS experts, and encourage young people to “pledge virginity” despite the demonstrated risks of such pledges as an HIV prevention strategy.48 In 2004, at the request of Congressman Henry Waxman, the Special Investigations Division of U.S. House of Representatives’ Committee on Government Reform found scientific errors and distortions in eleven abstinence-only curricula being used by sixty-nine federal grantees in twenty-five U.S. states.49 The errors and distortions concerned, among other things, the effectiveness of condoms against HIV and other STDs, the health risks of sexual activity, and the causes of HIV transmission.
Studies such as these provide an important sign of what is to come in countries like Uganda, where the United States has committed significant funds to abstinence-until-marriage programs. None of these studies is cited in any policy document or publication related to abstinence-until-marriage programs in Uganda or under PEPFAR, nor is any study demonstrating the effectiveness of abstinence-only programs.
The acronym “ABC”—A for abstinence, B for being faithful, and C for condom use—is often used to describe the U.S. (and Ugandan) approach to preventing sexually transmitted HIV internationally. On the surface, ABC appears to promote condoms alongside abstinence and fidelity as an effective HIV prevention strategy. A closer examination of the U.S. AIDS strategy, however, reveals that ABC is disaggregated as Abstinence for unmarried youth, Being faithful for married couples, and Condom use for “those who are infected or who are unable to avoid high-risk behaviors (such as discordant couples (where only one partner is HIV positive)).”50 As noted above, the strategy defines “high-risk” populations as “prostitutes, sexually active discordant couples, substance abusers, and others.” Thus, for unmarried young people who are not working in prostitution, the intervention message is abstinence only. Even where condoms are promoted to “high-risk” groups, the strategy stipulates that condoms should not detract from the overall message that “the best means of preventing HIV/AIDS is to avoid risk all together”—that is, to abstain from sex until marriage.
The U.S. Global AIDS Strategy has evolved in a climate of increasing censorship and distortion of information about condoms and safer sex.51 In 2002, the U.S. Centers for Disease Control and Prevention (CDC) removed a fact sheet on the effectiveness of condoms from its website and replaced it with a new fact sheet which, while factually accurate, eliminated instructions on how to use a condom properly and evidence indicating that condom education does not encourage sex in young people.52 Information on condom effectiveness was similarly altered on the website of the U.S. Agency for International Development (USAID).53 Guidelines proposed by the CDC in 2004 require that AIDS organizations receiving federal funds include information about the “lack of effectiveness of condoms” in any HIV prevention educational materials that mention condoms.54 In 2002, the CDC erased from its website an entire section entitled “Programs that Work,” which had highlighted the effectiveness of comprehensive sex education programs.55
Since taking office in 2001, President Bush has appointed as high-level HIV/AIDS advisers physicians who deny the effectiveness of condoms (either against AIDS or other STDs), such as Senator Tom Coburn and Joe S. McIlhaney, Jr., president of the pro-abstinence-only Medical Institute for Sexual Health (MISH) based in Texas.56 Coburn, who has stated that “the American people [should] know the truth of condom ineffectiveness, ” served as co-chair of the Presidential Advisory Council on HIV and AIDS (PACHA) until he was elected to the U.S. Senate in 2004. He was replaced by Anita Smith, a vocal advocate of abstinence-only programs. Coburn is also widely known for his efforts to require cigarette-type warnings on condom packages stating that they offer “little or no protection” against human papilloma virus (HPV), some strains of which cause cervical cancer.57 Condom use is in fact associated with lower rates of cervical cancer and HPV-associated disease, though the precise effect of condoms in preventing HPV is unknown.58 McIlhaney’s Medical Institute for Sexual Health, which promotes abstinence-only sex education messages, produced a comprehensive monograph on condoms stating that condoms do not make sex “safe enough” to warrant their promotion for STD prevention despite overwhelming evidence to the contrary. McIlhaney has also stated in testimony before the U.S. Congress that there is “precious little evidence” in support of comprehensive sex education programs.
[2] STD/AIDS Control Programme, Ministry of Health, HIV/AIDS Surveillance Report: June 2003, p. 10.
[3] Uganda AIDS Commission (UAC), MEASURE Evaluation and Uganda Ministry of Health (MOH), AIDS in Africa During the Nineties: UGANDA: A review and analysis of surveys and research studies (2003), p. 1; Justin O. Parkhurst, The Ugandan success story? Evidence and claims of HIV-1 prevention", The Lancet, vol. 360 (2002), pp. 78-80.
[4] Estimates of national HIV prevalence in Uganda vary. In 2002, the STD/AIDS Control Programme of the Uganda Ministry of Health estimated that 6.2 percent of the national population was infected with HIV. It should also be noted that trends in HIV prevalence are not as good a measure of HIV prevention as trends in HIV incidence, which measure new HIV infections in a given year. STD/AIDS Control Programme, 2003 HIV/AIDS Surveillance Report, p. 6.
[5]Ibid.
[6] Rory Carroll, “Uganda’s AIDS success story challenged,” The Guardian, September 23, 2004.
[7] STD/AIDS Control Programme, 2003 HIV/AIDS Surveillance Report, pp. 6, 10.
[8] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO), Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Uganda (2004 Update), p.2.
[9] STD/AIDS Control Programme, 2003 HIV/AIDS Surveillance Report, p. 29.
[10] Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. Uganda Bureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.
[11] ORC Macro, Reproductive Health of Young Adults in Uganda: A Report Based on the 2000-2001 Uganda Demographic and Health Survey (Calverton, MD: ORC Macro, 2002), pp. 12-13.
[12] Ibid., p. 13.
[13] Uganda AIDS Commission, “National Young People HIV/AIDS Communication Program for Young People: Concept Paper” (2001).
[14] This includes those who were widowed, divorced or separated. ORC Macro, Reproductive Health of Young Adults in Uganda, p. 19.
[15] Ibid., p. 21.
[16] Human Rights Watch, Just Die Quietly: Domestic Violence and Women’s Vulnerability to HIV in Uganda, Vol. 15, No. 15(A) (August 2003).
[17] ORC Macro, Reproductive Health of Young Adults in Uganda, p. 15.
[18] Ibid., p. 41.
[19] Makerere University Institute of Public Health and Academic Alliance for AIDS Care and Prevention in Africa, Knowledge, Attitude, Beliefs & Practices on HIV/AIDS Care, Prevention and Control: A Quantitative Baseline Survey, Kampala District, Uganda (2003), p. 1.
[20] Joint UNAIDS/WHO, Epidemiological Fact Sheets: Uganda, p. 2.
[21] While HIV prevalence declined among boys between 2001 and 2002 (from 3.7 percent to 2.8 percent), it rose slightly among girls (from 10.1 percent to 10.3 percent).
[22] UAC/MEASURE/MOH, AIDS in Africa During the Nineties, p. 17.
[23] Ibid, p. 21.
[24] UBOS/ORC Macro, Uganda Demographic and Health Survey 2000-2001, p. 174.
[25] Ibid., p. 168.
[26] Makerere University and Academic Alliance, Quantitative Baseline Survey,table 3.3.
[27] UBOS/ORC Macro, Uganda Demographic and Health Survey 2000-2001, p. 169.
[28] ORC Macro, Reproductive Health of Young Adults in Uganda, p. 5.
[29] Ibid., p. 8.
[30] International Covenant on Civil and Political Rights, G.A. res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 52, U.N. Doc. A/6316 (1966), article 19; Convention on the Rights of the Child, G.A. res. 44/25, annex, 44 U.N. GAOR Supp. (No. 49) at 167, U.N. Doc. A/44/49 (1989), article 13.
[31] Convention on the Rights of the Child (1989), article 24(2)(e).
[32] Committee on the Rights of the Child, General Comment No. 3 (2003) HIV/AIDS and the rights of the child, 32nd Sess. (2003), para. 16.
[33] Committee on Economic and Social Rights, General Comment 14: The Right to the Highest Attainable Standard of Health, 22nd Sess. (2000), para. 12(b), note 8.
[34] International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, entered into force January 3, 1976, GA Res. 2200 (XXI), 21 UN GAOR, 21st Sess., Supp. No. 16, at 49, UN Doc. A/6316 (1966), art. 12.
[35] Committee on Economic, Social and Cultural Rights (CESCR), The right to the highest attainable standard of health, para. 16.
[36] Ibid., paras. 34-35.
[37] Office of the United Nations High Commissioner for Human Rights (OHCHR) and UNAIDS, HIV/AIDS and Human Rights: International Guidelines, U.N. Doc. HR/PUB/98/1 (1998), para. 38(g).
[38] Human Rights Watch interview with Ambassador James Kolker, United States Embassy in Uganda, November 22, 2004.
[39] Fact sheet on the President’s Emergency Plan for AIDS Relief, http://www.avert.org/pepfar.htm (retrieved January 30, 2005).
[40] Office of the United States Global AIDS Coordinator (OGAC), The President’s Emergency Plan for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy (Washington, D.C.: United States Department of State, 2004), p. 27.
[41] H.R. 1298, United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, ss. 402(b)(3), 403(a). The Act does not specify a level of assistance for HIV prevention, but it caps such assistance at 20 percent of HIV/AIDS funds, or a maximum of U.S.$3 billion.
[42] OGAC, PEPFAR Five-Year Strategy, pp. 24, 29.
[43] Sexuality Information and Education Council of the United States (SIECUS), “Overall Federal Spending for Abstinence-Only-Until-Marriage Programs,” State Profiles: A Portrait of Sexuality Education and Abstinence-Only-Until Marriage Programs in the States (FY2003 edition). President Bush requested an increase to U.S.$268 million dollars for abstinence-until-marriage programs for FY2005.
[44] 42 U.S.C. § 710(b)(2).
[45] Swizen Kyomuhendo, Martin Ssempa, Lillian Lamalatu, Stephen Langa, Joseph Kiwanuka, and Edward C. Green, “Uganda National Abstinence and Being Faithful Policy and Strategy on Prevention of Transmission of HIV: Draft Policy and Strategy” (Uganda AIDS Commission, November 2004), p. iv.
[46] United States House of Representatives Committee on Government Reform – Minority Staff Special Investigations Division, The Content of Federally Funded Abstinence-Only Education Programs, report prepared for Rep. Henry A. Waxman (December 2004).
[47] Human Rights Watch, Ignorance Only: HIV/AIDS, Human Rights and Federally Funded Abstinence-Only Programs in the United States: Texas: A Case Study, Vol. 14, No. 5(G) (September 2002).
[48] See Peter Bearman and Hannah Brückner, "Promising the Future: Virginity Pledges as they Affect Transition to First Intercourse," American Journal of Sociology, vol. 106, no. 4 (2001), pp. 859-912; Bearman and Brückner, “After the Promise: the STD Consequences of Adolescent Virginity Pledges,” 2004, http://www.yale.edu/socdept/CIQLE/cira.ppt (retrieved November 10, 2004).
[49] Committee on Government Reform, Abstinence-Only Education Programs; see also, Martha E. Kempner, “Toward a Sexually Healthy America: Abstinence-only-until-marriage Programs that Try to Keep our Youth ‘Scared Chaste’” (New York: Sexuality Information and Education Council of the United States, 2001).
[50] OGAC, PEPFAR Five-Year Strategy, p. 29.
[51] See, e.g., Nicholas D. Kristof, “The Secret War on Condoms,” The New York Times, January 10, 2003; Marie Cocco, “White House Wages Stealth War on Condoms,” Newsday, November 14, 2002; Caryl Rivers, “In Age of AIDS, Condom Wars Take Deadly Toll,” Women’s eNews, December 10, 2003, http://womensenews.org/article.cfm/dyn/aid/1633/context/archive (retrieved February 16, 2004); Art Buchwald, “The Trojan War,” The Washington Post, December 11, 2003.
[52] Compare U.S. Centers for Disease Control and Prevention ( CDC), “Condoms and Their Use in Preventing HIV Infection and Other STDs” (September 1999), available at http://www.house.gov/reform/min/pdfs/pdf_inves/pdf_admin_hhs_info_condoms_fact_sheet_orig.pdf with CDC, “Male Latex Condoms and Sexually Transmitted Diseases” (2002), available at http://www.house.gov/reform/min/pdfs/pdf_inves/pdf_admin_hhs_info_condoms_fact_sheet_revis.pdf.
[53] Compare U.S. Agency for International Development ( USAID), “The Effectiveness of Condoms in Preventing Sexually Transmitted Diseases,” http://www.usaid.gov/pop_health/aids/TechAreas/condoms/condom_effect.html (retrieved January 28, 2003) with USAID, “USAID: HIV/AIDS and Condoms,” http://www.usaid.gov/pop_health/aids/TechAreas/condoms/condomfactsheet.html (retrieved July 10, 2005).
[54] CDC, “Proposed Revision of Interim HIV Content Guidelines for AIDS,” 69 Fed. Reg. 115, 33824, June 16, 2004.
[55] Compare CDC, “Programs that Work” (archived version at http://web.archive.org/web/20010606142729/www.cdc.gov/nccdphp/dash/rtc/index.htm) with CDC, “Programs that Work” (http://www.cdc.gov/nccdphp/dash/rtc/).
[56] See Rep. Henry A. Waxman, “The Effectiveness of Abstinence-Only Education,” in Politics and Science: Investigating the State of Science Under the Bush Administration, http://democrats.reform.house.gov/features/politics_and_science/example_abstinence.htm (retrieved February 7, 2005);H. Boonstra, “Public Health Advocates Say Campaign to Disparage Condoms Threatens STD Prevention Efforts,” The Guttmacher Report on Public Policy, March 2003, p. 2.
[57] Proponents of abstinence education have long sought to disparage condoms by speculating about the link between condom usage and cervical cancer. The legislation authorizing PEPFAR compels the president to report on the “impact that condom usage has upon the spread of HPV in Sub-Saharan Africa,” a mandate that many view as an effort to undermine confidence in the use of condoms against HIV. H.R. 1298, s. 101(b)(3)(W).
[58] CDC, “Male Latex Condoms and Sexually Transmitted Diseases” (2002); see also, C.J.A. Hogewoning et al., “Condom use promotes regression of cervical intraepithelial neoplasia and clearance of human papilloma virus: a randomised clinical trial,” International Journal of Cancer, vol. 107 (2003), pp. 811-816; M.C.G. Bleeker et al., “Condom use promotes regression of human papilloma virus-associated penile lesions in male sexual partners of women with cervical intraepithelial neoplasia,” International Journal of Cancer, vol. 107 (2003), pp. 804-810.
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