Critics: Bush AIDS plan blurs message

Katy Pownall

KAMPALA, Uganda — Beatrice Were says she did just what her government recommended — shunned sex until her marriage and stayed faithful to her husband.

What she didn’t realize is that he was unfaithful. Soon after their first child was born, he caught the AIDS virus and unwittingly infected her.

The question of why Ugandans like her husband didn’t use a condom is at the heart of a dispute between some health activists and the U.S. government. The activists, as well as some Ugandan officials, accuse the United States of blunting the condom message in favor of abstinence, while the Americans say they are victims of misinformation and have actually increased nearly tenfold the number of condoms they supply to this African nation of 26 million.

Moreover, abstinence is an option promoted not just by faith-based U.S. groups but by many Ugandan charities, including one headed by the conservative Christian wife of President Yoweri Museveni.

The debate has unfolded in a country that was once among Africa’s worst AIDS victims, with a million deaths and an estimated 900,000 additional infections. Uganda is also the pioneer of a groundbreaking strategy credited with cutting HIV prevalence by more than half since 1992 to about 7 percent. The multipronged approach, known as A, B, C, calls for abstinence until marriage, being faithful to one’s partner, and correct condom use.

“By assumption, you are saying that when you are married, marriage is a safety net — which is not true,” said Were, who now campaigns to protect others with the international anti-poverty group ActionAid. She does not blame America for her plight, but said U.S. policies threaten the lives of young Ugandans.

Billboards urging condom use have disappeared from the capital, Kampala. In their place are posters, some funded by the U.S. government, urging youth to delay sex until marriage. The Ugandan office of Washington-based Population Services International, a leading supplier of free and subsidized condoms, says it was ordered to take down posters and pull radio ads in Uganda in 2004.

Its deputy director, Dr. Susan Mukasa, said the portion of the group’s U.S. funding that is spent on prevention was not renewed and its funding from PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief, dropped from $600,000 to $100,000.

“We got a call from the PEPFAR people and were told what we were doing was unacceptable,” said Mukasa. “We also got a lot of pressure from faith-based groups in Uganda who wanted the condom message removed from the general public.”

PEPFAR, a $15 billion package to combat AIDS in the world’s 15 worst-hit countries, won praise when Bush announced it in 2003. But Dr. Sam Okware, a senior Health Ministry official and architect of the ABC plan that has become the model across Africa, says PEPFAR had initially skewed the message away from condoms.

“PEPFAR really shifted the emphasis to A and B just because of the amounts of money being put into these programs,” said Okware.

He said the government has redressed the balance by using funds from other sources to promote condoms, including the World Bank. But an official with the government-appointed Uganda AIDS Commission disputed that, saying abstinence and fidelity programs still dominate. He spoke on condition of anonymity for fear of repercussions.

Dr. Mark Dybul, the U.S. deputy global AIDS coordinator in Washington said government policy is to support all three components of the ABC plan.

In a telephone interview, Dybul said he doubted anyone would have called PSI’s work “unacceptable.” But he said U.S. officials want to move away from simply mass marketing condoms and support more door-to-door and peer education plans.

“Mass marketing is important, but it doesn’t change a lot of behavior. It just provides information and provides awareness,” he said.

Last year, the U.S. government spent $9.7 million on promoting abstinence and fidelity in Uganda, compared with $6.5 million on condoms and related activities, while the number of U.S.-supplied condoms has surged from 7 million to 47 million in the last five years, Dybul said.

“Tough to argue we’re pushing away from condoms in Uganda with numbers like that,” Dybul said, adding: “There is so much misinformation about what our policies and approach are that I wouldn’t be surprised it’s having an impact on people in the field.”

President Museveni, who once championed condoms, now considers them more appropriate for people considered at high risk of infection, such as prostitutes and soldiers. Special clubs and rallies encourage teens to sign virginity pledges, and a legislator has promised university scholarships for top students who keep the promise.

First lady Janet Museveni’s National Youth Forum, which received $180,000 from the U.S. emergency plan last year to help 12- to 25-year-olds protect themselves from AIDS, says it’s willing to answer the public’s questions about condoms but does not teach how to use them.

“In our traditional society, girls used to marry when they were virgins. Why has this changed?” asked Margaret Kiwanuka, the forum’s national coordinator. “Abstinence is 100 percent effective. That is our message.”

The Anglican Church, which received $86,620 from the plan last year, helps educate sexually active adults about condoms but not under-18s.

“Why give an alternative and have them take a risk?” said Rev. Sam Lawrence Ruteikara, who heads the church’s AIDS program.

But some activists not affiliated with churches worry that the prevention message is becoming blurred, jeopardizing hard-won gains. HIV prevalence crept up to 7.1 percent in 2004-2005, after stagnating at around 6 percent the preceding three years, according to government figures.

“Young people are confused,” said Dr. Abeja Apunyo, country representative for the U.S.-based Pathfinders reproductive health group. “Of course I have no problem with the abstinence approach, but you have to be realistic and offer an alternative for different situations.”

About 20 percent of U.S. assistance globally is channeled through faith-based groups, many of which counsel only abstinence and fidelity. They are valued because of their strong community ties and reach into some of the remotest corners of Africa.

Emergency plan rules do not require such groups to discuss condoms — other U.S.-funded organizations do that. But nor may they denigrate condoms. Any condom promotion must include a component on abstinence and fidelity.

Museveni’s wife has angered some activists by suggesting that promoting condoms encourages promiscuity and can cause genital warts.

“Now, someone is free to do whatever they want to do without U.S. government money. We can’t control that,” Dybul said. “But no one who receives money from the U.S. government can provide such medical misinformation. It’s not only our policy but it’s in the law.”

(Associated Press writers Rodrique Ngowi in Kampala and Rita Beamish in San Francisco contributed to this report.)