Economic Management and Social Policy Human Development 127 ˘;,OSAL 89 January 1999 0 / O,p Findings reports on ongoing operational, economic, and sector work carried out by the World Bank and its member govemments in the Africa Region. It is publi.;hed periodically __________________________ by the Knowledge and Leaming Center on behalf of the Region. The views expressed in Findings ViWOR L D BA N K are those of the author/s and should not be attributed to the World Bank Group. Uganda: 22126 IVrONAg The Sexually Transmitted Infections Project Uganda is one of the flrst coun- fected, 1.9 million people have de- tries in Africa to show a sus- veloped AIDS and 1.8 million have C ,) tained decline in HIV/AIDS preva- died. Information from HIV sen- lence. Evidence suggests that a tinel surveillance indicates preva- change in the HIV incidence is lence levels ranging from 5% in occurring. The prevalence has dropped in certain communities - ~~and age groups, most notably, Box 2. Positive Trronds in - - among women in the 15-29 years Uganda age group. Population-based sur- * Delayed sexual debut veys of sexual behavior also a Fewer sexual relations with show substantial differences in non-regular partners sexual behavior particularly of * Increased condom use young people. o~~~ Reduced prevalence fn preg- "- r young people. nant women in 15-29 years age group HIV/AIDS in Uganda * Increased demand for STD ser- -gm w _vices An estimated 2.73 million Ugan- _ $ dans have been infected with the ur _ HIV virus since the flrst reported AIDS case in 1984. Of those in- most rural sites to 30% in some urban sites. Heterosexual trans- mission accounts for 75-80% of Box 1. HIVIAIDS in Uganda new infections. Mother-to-child transmission constitutes almost Population 20.7 million all other cases except for the 3% Estimated number of new infections caused by use of infected with HIV infected blood and blood products since the beginning (including sharing of non-sterile- of the epidemic 2.73 million piercing instruments). Kampala U Estimated number of (Uganda's capital), the Southwest- deaths due to AIDS 1.8 million em and the Northern regions are most affected by the epidemie. - ~~~~Estimated number of TeUadngvrmn a people living with The Ugandan govemment has HIV/AIDS, end of provided strong political leader- 1997 930,000 ship in the fight against he V (Source: UNAtDS. June, 1998) HIV/AIDS epidemic. It has devel- oped one of the most compre- hensive HIV/AIDS programs in Health, the project also supports community and home-based care. Africa. The government's first re- interventions of other ministries The aim is to reduce bed-occupan- sponse to the epidemic was to and NGOs. cy by AIDS patients who currently set up the National Committee account for more than 50% of in- for the Prevention of AIDS in XeŽ. ext+ures of the project patients in hospitals and health 1985. This was followed by the centers. This poses the risk of establishment of the AIDS Con- i. Prevention of Sexual Trans- crowding out patients requiring trol Program (ACP) in the Min- mission of HIV Change in sexual treatment for other illnesses. The istry of Health the following year. behavior is the most important project also supports NGO activi- The program was charged with ties in counseling, nutrition and the following responsibilities: income generation. epidemiological surveillance; en- g | iii. Institutional Development. suring safe blood supply; provid- The project supports capacity ing HIV/AIDS information, educa- building in planning and manage- tion; care and counseling; and Tis t ment of HIV/AIDS programs. At control of sexually transmitted ' f m the central level, it supports diseases. In 1988, following a re- C , X > strengthening the technical skills view of the ACP, it was recog- g fs > of staff and the management and nized that the flght against the t coordination functions of the spread of HIV/AIDS would require we tt AIDS Control Program of the Min- a multi-sectoral approach. The ' Oil istry of Health. At the district Uganda AIDS Commission was S art level, the project focus is on de- established to coordinate the im- tIeveloping a participatory planning plementation ofestig thisysusbctoaderhey and management process involv- strategy. A multi-sectoral Nation- are t ing district and local level man- al Operational Plan (NOP) for pre- o S f agers, NGOs and community- vention of HIV infection and mit-I based organizations. Support is igation of health and socioeco- also provided to monitoring and nomic impact of HIV/AIDS was evaluation to improve the informa- adopted in 1993. The plan em- tion base. A system of sentinel phasizes strengthening commu- approach to preventing the spread surveillance covering 20 sites is nities and families to cope with of HIV. The STIP supports promo- assisted by the project through the epidemic. tion of safe sexual behavior supply of testing kits and training Uganda's achievements in the through information, education of staff. Regular knowledge, atti- struggle against the epidemic to and communication (IEC); pro- tudes, practices and behavior sur- date are the result of a joint effort vides condoms and promotes veys are also conducted under the of the government, donors and their use; and promotes STD care project. The project also con- Non-Governmental organizations seeking behavior and provision of tributes funding to a number of re- (NGOs). effective STD care. search activities: the Rakai pro- ii. Mitigation of Personal Im- ject research on STD-mass treat- The Sexually Transmitted Infec- pact of AIDS. The project supports ment; a Tuberculosis-Ethambutol tions Project the development of treatment study in Mulago; and a study of guidelines, training of health sexual behavior among young The World Bank-assisted Sexually workers in the management of people. Transmitted Infections Project people with AIDS, and provides iv. Gender Issues. The STIP has (STIP), started in 1994, is current- drugs for the management of tu- mainstreamed gender in its activi- ly the largest HIW/AIDS project in berculosis and other opportunis- ties. This is important as the the National Operational Plan for tic infections associated with HIV/AIDS epidemic disproportion- HIV/AIDS control. Though a signif- AIDS. This covers public and NGO ately affects women, especially icant proportion of the project health services. The project also young girls. Project activities are budget (US$ 73.4 million ) is im- supports NGO and community- required to take into considera- plemented by the Ministry of based organization activities for tion differences between men and women in health care seeking be- duction in HIV/AIDS in this group The government's policy on de- havior. will contribute signiflcantly to centralization of management of v. Global Partnerships. The economic productivity and social services to the district level has project exemplifies the need for ef- welfare in the country as this contributed to this by bringing the fective collaboration between dif- group constitutes a large propor- management of the programs ferent partners in the flght against tion of the economically produc- closer to the people. In many parts the spread of HIV/AIDS. The pro- tive population group. However, of the country, NGOs and commu- ject was designed to cover gaps the positive trends observed do nities submit their programs for taking into account existing com- not mean that the epidemic has funding through district plans for mitments by other donors and the been overcome in Uganda. The HIV/AIDS activities government. Coordination is car- current prevalence levels of ii. There is need to mobilize all ried out through the national and HIV/AIDS still present an enor- the resources available in the district level planning process. mous challenge. country to support HIVIAIDS pro- grams. In Uganda, a strong part- Impact Lessons I nership has developed involving the Government, NGOs, the Unit- Currently, there is a high level of i. Political commitment and ed Nations family coordinated by general awareness of HIV/AIDS local ownership are essential. UNAIDS and other donors sup- with urban areas registering The personal and active involve- porting HIV/AIDS programs. The greater depth of knowledge of the ment of the President and senior role of NGOs in particular, has disease. There are also changes in government officials has played been recognized, especially at the sexual behavior. Surveys show a an important role in raising gener- community level. A number of drop in non-regular partnership al awareness of the seriousness of competent local NGOs such as and casual sex across all age _ The AIDS Support Organization groups. Condom use has also in- (TASO) have developed strong creased. The most notable change BoS 4. Namungalwe Women HIVIAIDS programs. has occurred in the sexual behav- TaIs Force iii. There is need to use a wide ior of the 15-29 years age group This is a women's group com- range of multi-sectoral interven- normally considered to be at prising 31 members, 4 of whom tions to deal with the epidemic. greatest risk. Between 1989 and are men. The group undertakes However, in Uganda and many 1995, survey results show a delay sensitization activities through other developing countries, re- in sexual debut. The proportion of drama and song and is involved in sxua debt. he ropotio of in the cae and support of 43 sources are limited and cost-effec- males in the age group 15-19 families affected by AIDS. The tive interventions with an impact years reporting that they "never group cultivates vegetables on an on the largest share of the popula- had sex" has risen from 31% to 8 acre farm, donated by the tion have to be selected. The Gov- 56%, while that of females has in- chairperson of the group. Mem- ernment AIDS control strategy in- creased from 26% to 46%. Sentinel bers have formed five sub-groups cludes a wide range of interven- surveillance data collected be- that visit affected families once a week, delivering produce from tions- tween 1992 and 1996 show de- the farm to the families. iv. Capacity building is essen- clines ranging between 32% - 54% tial. Capacity building in technical in HIV prevalence in young preg- and management skills is an inte- nant women aged 15-29 years in gral part of both the public and some urban areas. This group is the epidemic and in providing offi- NGO AIDS control programs in fairly representative of the general cial support for the AIDS Control Uganda. population. It is important to note Program. Also, the government v. Information is important for that it is the younger population has recognized that communities monitoring the epidemic and which has registered the highest and families play a central role in adapting programs to meet the positive change in sexual behav- preventing and managing care of most critical needs. Uganda is ior. This has important implica- people with AIDS. Thus, many strengthening and expanding its tions for the long-term reduction programs have been designed to sentinel surveillance system. In in HIV/AIDS as this also is the better equip families and commu- addition, regular knowledge, atti- most sexually active group. A re- nities to deal with the epidemic. tudes, behavior and practices sur- veys are conducted. Research this end, the Uganda government 202-473-8299; e-mail address: being undertaken under the pro- is currently revising the National mmulusa@worldbank.org ject includes: STD mass treatment Plan of Action to determine future study, TB-Ethambutol study, the resource requirements. For more information on the Re- study of sexual behavior among gion's AIDS strategy, please con- young people and assessment of tact Dr. Debrework Zewdie, Lead the economic impact of the HIV in- Population and Reproductive fection on those affected . For more information on the Health Specialist, and HIV/AIDS vi. Sustainability. In order to project, please contact: Ms. Mary Coordinator, Rm. J10-085, World build upon the achievements al- Mulusa, Task Team Leader, Rm. Bank, 1818 H Street, Washington ready realized, there is need to en- J10-080, World Bank, 1818 H D.C. 20433. Telephone: 202-473- sure adequate and sustained Street, Washington D.C. 20433. 9414; fax: 202-473-8239; e-mail funding for HIV/AIDS programs. To Telephone: 202-473-1937; fax: address: dzewdie@worldbank.org 0 Findings Findings would also be of interest to: Name _ Institution Address Letters, comments, and requests for publications that are not available at the World Bank Bookstore, should be addressed to: Editor, Findings 1nowled and Learning Center Africa Region, World Bank 1818 HI Sti, N.W, Room J5-171: Washingto,b DC., 20433; E-Mail: pmohan @worldbank.org E i. 6Wa& : .db