Uganda's Early Gains Against HIV Eroding

By Craig Timberg
Washington Post Foreign Service
Thursday, March 29, 2007

KAMPALA, Uganda -- Students packed a grassy field at Makerere University in April 1989 for a farewell concert by singer Philly Lutaaya. This symbol of swaggering virility had grown gaunt, with splotchy skin and the fine, sparse hair of a baby. He sang hauntingly, "Today it's me, tomorrow it's somebody else."

Between songs, he warned the stunned crowd that having several sex partners was a sure way to die in the age of AIDS, echoing pleas also made by political and religious leaders of the time. When Lutaaya died that December, at age 38, the country already had begun its historic reversal of the epidemic, researchers say, because of the power of that single, terrifying message.

Despite this success story, unmatched elsewhere on this AIDS-ridden continent, no country has entirely replicated Uganda's approach. Most instead have followed a diffuse palette of other remedies pushed by Western donors -- condom promotion, abstinence training, HIV testing, drug treatment and stigma reduction -- while forgoing what research shows worked here: fear and a relentless focus on sexual fidelity.

Even in Uganda, these key ingredients have been lost as a new generation coming of age years after Lutaaya's death indulges in the same reckless behavior that first spread the disease so widely.

"We saw him. We saw him die. We abandoned the girlfriends," said Swizen Kyomuhendo, a social scientist at Makerere, who was an undergraduate when Lutaaya spoke there. "When you look at the university students now, they are not as terrified as we were then."

The percentage of sexually active men with multiple partners has more than doubled in recent years, undoing earlier declines, surveys show. Reports of sexually transmitted diseases among women, another indicator of dangerous behavior, have risen sharply as well.

A glimpse of changing attitudes can be seen every Friday night as cars stream onto Makerere's campus and pull into darkened parking lots outside women's dormitories. The glow of cellphones briefly illuminates the drivers, most 10 or 20 years older than the average student, as they call their girlfriends to come out for dates.

Cathy Katumba, 22, a student with a heart-shaped face and long braids looped into a knot at her neck, said many of these college women have on-campus boyfriends their age plus older, often-married ones with the means to provide dinners out and nice clothes. Many young women, Katumba said, arrive with few possessions but finish their studies with refrigerators, DVD players and closets full of the latest fashions.

As for AIDS, she said, most women at Makerere are more worried about getting pregnant. "They don't look at it as a deadly disease now," she said.

Yet even in an era of improved treatment, AIDS remains Uganda's leading killer of adults. The HIV rate has risen again at some urban hospitals. And a 2004 study put the adult infection rate at 7 percent -- several times lower than its estimated peak in the 1990s but higher than estimates just a few years earlier. Ugandans are contracting HIV five times faster than doctors are able to put new patients on the antiretroviral drugs that offer the only hope of long-term survival.

The country's once lean, focused programs, meanwhile, have grown complacent, Ugandans say. Even President Yoweri Museveni, praised for his leadership in early years, "has gotten a bit bored with the AIDS story," said his spokesman, John Nagenda.

"The whole thing is too big now, too heavy," said Sam Okware, a top Ugandan health official who designed early, frightening anti-AIDS campaigns. "It has adapted too much to international guidelines instead of sticking to our own methods, which were very controversial at first but which worked."

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