Uganda's HIV Prevention Success: The Role of Sexual Behavior Change and the National Response

This report, originally published in the journal AIDS and Behaviour, discusses various reasons for the decline in HIV prevalence in Uganda and links Uganda's success with initiatives that discouraged multiple partnerships. The paper argues that behaviour change programmes, particularly those involving extensive promotion of "zero grazing" (faithfulness and partner reduction), contributed to the early declines in casual/multiple sexual partnerships and HIV incidence and, along with other factors including condom use, to the subsequent sharp decline in HIV prevalence. Largely developed by the Ugandan government and local non-governmental organisations, these include faith-based, women’s, people living with AIDS (PLWA), and other community-based groups.

The report outlines key elements in the country's response that contributed to this decline. The first is high-level political support and a multi-sectoral response. The second identified element is decentralised planning and implementation for behaviour change communication. According to the report, the Ugandan AIDS Control Programme launched an aggressive public media campaign that included print materials, radio, billboards, and community mobilisation for a grassroots movement against HIV. According to the authors, spreading the word involved not just information and education, but, in addition, a fundamental behaviour change-based approach to communicating and motivating. This strategy, according to the authors, relied heavily on community-centred and face-to-face communication based on culturally appropriate interventions. The report notes that these kinds of sustained interpersonal communication interventions reached not only the general population, but also key groups including female sex workers and their clients, soldiers, fishermen, long-distance drivers, traders, bar girls, police, and students, and did so without generally creating a highly stigmatising climate.

Another element in Uganda's response was the direct, front-line involvement of religious leaders and faith-based organisations, which, according to the report, wield enormous influence in Africa. In addition, addressing issues such as those specific to women and youth and those involving stigma and discrimination ensured that key vulnerable populations were involved in the campaign, and that issues around HIV were being discussed openly and without shame. According to the report, Uganda also opened Africa's first confidential voluntary counselling and testing centres that used rapid HIV tests to deliver quick results. A final element involved condom promotion, although the study reports that condom use was not a major factor in the decline of HIV prevalence.

The report shows that the incidence of multiple partnerships declined among Ugandans after the "zero grazing" campaign and that the decline may also be related to the aforementioned open, personal communication networks for acquiring AIDS knowledge, which have been argued to more effectively personalise risk and thereby result in greater levels of behaviour change.

The study concludes by stating that the data from Uganda would suggest that pervasive, fundamental changes in sexual behaviour can take place, perhaps contrary to previous expectations about the feasibility of such change. Available evidence from Uganda and more recent findings from other countries suggest that a comprehensive behaviour change-based strategy, ideally involving high-level political commitment and a diverse spectrum of community-based participation, may be the most effective prevention approach.