Uganda's Early Gains Against HIV Eroding

In 1991, his government banned condom advertising. And at the International AIDS Conference that year in Florence, he told delegates, "We are being told that only a thin piece of rubber stands between our people and the death of the continent, but condoms cannot be the main means of stemming the tide of AIDS."

So rare were condoms in those years that Westerners working in Uganda had trouble getting them for their own programs. A clinic that the University of California at San Francisco had set up to treat sexually transmitted diseases resorted to ordering boxes of them in rainbow colors -- lemon yellow, cherry red, lime green -- that their Ugandan clients found odd, said Nick Hellmann, a doctor who ran the clinic from 1989 to 1991. Few knew how to use them.

"It clearly at the time was not a commonly utilized product," Hellmann said from Seattle, where he is a senior AIDS program official at the Bill & Melinda Gates Foundation.

Museveni gradually relented. The number of condoms delivered and promoted by international groups rose from just 1.5 million in 1992 to nearly 10 million in 1996, most paid for by the U.S. Agency for International Development. Uganda eventually adopted a national plan to distribute condoms whose packages featured pictures of healthy, amorous young couples.

But their role in curbing the epidemic is unclear.

Kampala's decline in new infections began in 1990 and ended by 1994, according to an analysis by U.S. researchers Rand L. Stoneburner and Daniel Low-Beer, meaning the change happened before massive condom imports began. The key factor in this reversal, they concluded based on models of the epidemic and surveys from the time, was the decision by Ugandans to have fewer casual sex partners.

One national survey in 1995 found that more than half of Ugandans said they were sticking to one sexual partner to protect themselves from AIDS. Only 11 percent of men and 2 percent of women said they were using condoms for that reason.

The major push on abstinence began even later, several years after Uganda had its dramatic decline in new infections. And though surveys have shown a gradual decrease in the age when youths here begin having sex, the connection to infection rates remains unproved. A 2005 journal article by national health officials here reported that among adult Ugandans, those who started having sex at 16 are no more likely to have HIV than those who started at 19.

Despite the uncertain science behind both condom promotion and abstinence training, AIDS activists worldwide hotly debated them after President Bush created his $15 billion anti-AIDS program in 2003. The program endorsed a prevention strategy called "ABC," for "Abstain, Be Faithful and Condomize," with $1 billion set aside for abstinence programs alone.

In the international debate that followed, conservatives rallied for abstinence, liberals for condoms. Each side bashed the other's strategy. And attention to the one element that clearly worked -- fidelity -- dwindled, even in Uganda.

Fueling confusion were the dynamics of AIDS itself. A decade often separates the date of HIV infection and death. So Ugandan health officials did not know they had made great strides against the epidemic until recently, when researchers identified those early years of zero grazing as decisive.

By then, the initiative had been overtaken by big-budget, bureaucratic programs that resembled those in most African countries. Persuading Ugandans to stay faithful to their partners was no longer the focus.