    [Senate Hearing 108-106]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 108-106

                    FIGHTING AIDS IN UGANDA: WHAT WENT RIGHT?

    =======================================================================

                                    HEARING

                                   BEFORE THE

                        SUBCOMMITTEE ON AFRICAN AFFAIRS

                                     OF THE

                         COMMITTEE ON FOREIGN RELATIONS
                              UNITED STATES SENATE

                          ONE HUNDRED EIGHTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  MAY 19, 2003

                                   __________

           Printed for the use of the Committee on Foreign Relations

     Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                     senate

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                         COMMITTEE ON FOREIGN RELATIONS

                      RICHARD G. LUGAR, Indiana, Chairman

    CHUCK HAGEL, Nebraska                JOSEPH R. BIDEN, Jr., Delaware
    LINCOLN CHAFEE, Rhode Island         PAUL S. SARBANES, Maryland
    GEORGE ALLEN, Virginia               CHRISTOPHER J. DODD, Connecticut
    SAM BROWNBACK, Kansas                JOHN F. KERRY, Massachusetts
    MICHAEL B. ENZI, Wyoming             RUSSELL D. FEINGOLD, Wisconsin
    GEORGE V. VOINOVICH, Ohio            BARBARA BOXER, California
    LAMAR ALEXANDER, Tennessee           BILL NELSON, Florida
    NORM COLEMAN, Minnesota              JOHN D. ROCKEFELLER IV, West
    JOHN E. SUNUNU, New Hampshire            Virginia
                                         JON S. CORZINE, New Jersey

                     Kenneth A. Myers, Jr., Staff Director
                  Antony J. Blinken, Democratic Staff Director

                                     ------

                        SUBCOMMITTEE ON AFRICAN AFFAIRS

                      LAMAR ALEXANDER, Tennessee, Chairman

    SAM BROWNBACK, Kansas                RUSSELL D. FEINGOLD, Wisconsin
    NORM COLEMAN, Minnesota              CHRISTOPHER J. DODD, Connecticut
    JOHN E. SUNUNU, New Hampshire        BILL NELSON, Florida

                                      (ii)

                                C O N T E N T S

                                  ----------
                                                                       Page

    Alexander, Hon. Lamar, U.S. Senator from Tennessee, opening
      statement......................................................     3
        Letter from Mrs. Janet K. Museveni, First Lady of Uganda, to
          Chairman Richard G. Lugar, pertaining to the ``Uganda ABC
          model''....................................................    25
    Biden, Hon. Joseph R., Jr., U.S. Senator from Delaware, prepared
      statement......................................................     5
    Busch, Jeffrey, chairman and CEO, SafeBlood for Africa, statement
      submitted for the record entitled ``Blood Safety: An Important
      Tool in AIDS Prevention,''.....................................     5
    Feingold, Hon. Russell D., U.S. Senator from Wisconsin, prepared
      statement......................................................     6
    Green, Edward C., Ph.D., senior research scientist, Harvard
      Center for Population and Development Studies, Cambridge, MA...    32
        Prepared statement...........................................    35
    Mukasa Monico, Sophia, senior AIDS officer, Global Health
      Council, Washington, DC........................................    40
        Prepared statement...........................................    43
        Uganda AIDS Commission Status Report.........................    46
    Peterson, Dr. Anne, Assistant Administrator for Global Health,
      U.S. Agency for International Development, Washington, DC......     7
        Prepared statement...........................................    10
        ``What Happened in Uganda?'' a synthesis of presentations
          made in February 2002 at USAID by four individuals with
          long-term experience in HIV prevention in Africa...........    15

                                     (iii)

                   FIGHTING AIDS IN UGANDA: WHAT WENT RIGHT?

                                  ----------

                              MONDAY, MAY 19, 2003

                                   U.S. Senate,
                       Subcommittee on African Affairs,
                                Committee on Foreign Relations,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 2:31 p.m. in
    room SD-419, Dirksen Senate Office Building, Hon. Lamar
    Alexander (chairman of the subcommittee), presiding.
        Present: Senators Alexander and Feingold.
        Senator Alexander. The hearing will come to order. I would
    like to welcome everyone here. Senator Feingold is here and we
    will begin.
        Here is how we will proceed. I will make a very brief
    opening statement and I will invite Senator Feingold to do the
    same, and then we will begin with Dr. Peterson from USAID; and
    then we will go to our second panel, Dr. Green and Ms. Mukasa
    Monico, and we will have some questions for the two of you at
    that time.
        After we have completed the hearing, we will immediately
    move to the nomination hearing of Steven Browning, nominated to
    be Ambassador to Malawi, and we will hear from him. At that
    time, since he is here, we will ask him to reflect on what he
    has heard.
        In the midst of the AIDS pandemic, a beacon of hope shines
    out from Uganda. The rate of infection has declined from about
    15 percent in 1991 to about 5 percent in 2001. Uganda did this
    largely through a nationwide campaign focused on the ABC model:
    Abstain, Be faithful, use a Condom.
        Today we will look at how that model works in practice and
    what that implies for U.S. policy in combating AIDS. It is
    especially relevant because Senator Feingold and I and almost
    all Senators were up until about 2:30 in the morning on
    Thursday night expressing the agenda of both political parties
    as well as the President to do what this country can to help
    with this worldwide epidemic.
        The crisis posed by the AIDS pandemic is growing worse
    every day and the statistics are becoming all too familiar.
    Over 40 million people are now infected by HIV-AIDS. Thirty
    million of those are in sub-Saharan Africa, nearly 5 percent of
    the overall population of sub-Saharan Africa. The scope of the
    problem in some countries is overwhelming. Eleven million
    African children have lost their parents to AIDS. In Zambia 30
    percent of all children are AIDS orphans. In Botswana nearly 40
    percent of the adult population is HIV-positive. When I visited
    Botswana a year-and-a-half ago, at one hospital the nurse there
    told me that 97 percent, virtually all, of the women, the
    pregnant women she sees there are infected with HIV-AIDS.
        The disease also affects other sectors of African society.
    Seven million agricultural workers have succumbed to AIDS. The
    agricultural work force has been depleted by more than 20
    percent in several African countries, resulting in production
    declines that are a contributing factor to hunger and even
    famine. Young adults are the hardest hit by the virus, leaving
    not only millions of orphans but also ever-increasing numbers
    of households headed by grandparents.
        But in the midst of this human tragedy there is hope.
    Something different has been happening in Uganda. Despite the
    lack of a cure or vaccine, HIV infection rates are declining.
    As I mentioned, in 1991, 21 percent of pregnant women in Uganda
    were HIV-positive. Ten years later that number declined to 6
    percent. By comparison, 34 percent of pregnant women in
    Botswana were HIV-positive in the year 2000.
        What is Uganda doing differently? Led by President
    Museveni, Ugandan society has mobilized to combat HIV-AIDS with
    vigor and over a long period of time. Uganda has taken a
    comprehensive approach to combating the challenge. Religious
    and military leaders, many of whom are HIV-positive themselves,
    have led the way in creating an open dialog that has to a large
    extent de-stigmatized the disease. With the help of groups like
    the AIDS Support Organization of Uganda, the country has sought
    to provide treatment and care to those infected.
        But the heart of the story in Uganda is behavior change
    promoted by the ABC model. The campaign has had great success.
    In one area of the country, for example, 60 percent of youth
    age 13 to 16 reported being sexually active in 1994. By 2001
    the number had fallen to 5 percent. Similarly, the number of
    Ugandan men with two or more sexual partners per year dropped
    from over 70 percent in 1989 to less than 20 percent in 1995.
        So how does the Ugandan model work in practice? How can
    that model be replicated or adjusted to work in other countries
    and cultures, or can it be? What does that imply for United
    States policy and foreign assistance in combating this pandemic
    around the world? That is what we are here to find out and we
    have a distinguished panel to help us do that.
        I also hope we will explore with the witnesses this
    afternoon the idea of having what I would call an AIDS Corps,
    where American health professionals can volunteer to go to
    Africa or other hard-hit countries and help train professionals
    in country how to provide care and treatment for those who are
    infected and affected by HIV-AIDS.
        I introduced a bill for that purpose last week. There are
    provisions for that purpose in the legislation that passed on
    Thursday night. Many Senators of both parties, the President
    himself, have all talked about this idea and I thought this
    might be a good time to gain some additional advice about how
    we could help an AIDS Corps work if one were to be formed.
        But before I introduce our first panelist, I would like to
    comment that the AIDS subject is not new to this committee or
    to this subcommittee. The former chairman of this subcommittee,
    Senator Frist, now the majority leader, spoke about AIDS early
    on and vigorously and I believe helped to persuade this
    administration to take a more active role. He was joined in
    that by his partner on this committee Senator Feingold from
    Wisconsin, who has also been an early and active advocate for
    AIDS, has been to Africa many times. I welcome Senator Feingold
    for his opening statement.
        [The prepared statement of Senator Alexander follows:]

                  Opening Statement of Senator Lamar Alexander

        In the midst of the AIDS pandemic, a beacon of hope shines out from
    Uganda. The rate of infection has declined from about 15 percent in
    1991 to about 5 percent in 2001. Uganda did this largely through a
    nationwide campaign focused on the ABC model: Abstain, Be faithful, use
    a Condom. Today, we will look at how that model works in practice and
    what that implies for U.S. policy in combating AIDS.
        The worldwide crisis posed by the AIDS pandemic is growing worse
    everyday. Over 40 million people are now infected by HIV/AIDS. Thirty
    million of those are in sub-Saharan Africa--nearly 5 percent of the
    overall population. The scope of the problem is overwhelming. Eleven
    million African children have lost their parents to AIDS. In Zambia, 30
    percent of all children are AIDS orphans. In Botswana, nearly 40
    percent of the adult population is HIV-positive.
        The disease also affects other sectors of African society. Seven
    million agricultural workers have succumbed to AIDS. The agricultural
    workforce has been depleted by more than 20 percent in several African
    countries, resulting in production declines that are a contributing
    factor to hunger and even famine. Young adults are the hardest hit by
    the virus, leaving not only millions of orphans, but also ever-
    increasing numbers of households headed by grandparents.
        But in the midst of this human tragedy, there is a glimmer of hope.
    Something different is happening in Uganda. Despite the lack of a cure
    or vaccine, HIV infection rates are declining. For example, in 1991 21
    percent of pregnant women in Uganda were HIV-positive; ten years later
    that number had declined to 6 percent. (By comparison, 43 percent of
    pregnant women in Botswana were HIV-positive in 2000.)
        What is Uganda doing differently? Led by President Museveni,
    Ugandan society has mobilized to combat HIV/AIDS with vigor. Uganda has
    taken a comprehensive approach to combating the challenge.
        Religious and military leaders, some of whom are HIV-positive
    themselves, have led the way in creating an open dialogue that has to a
    large extent de-stigmatized the disease. With the help of groups like
    The AIDS Support Organization of Uganda, the country has sought to
    provide treatment and care to those infected.
        But the heart of the Ugandan story is behavior change, promoted by
    the ABC model--Abstain, Be faithful, use a Condom. The campaign has had
    great success. In one area of the country, for example, 60 percent of
    youth aged 13-16 reported being sexually active in 1994; by 2001 the
    number had fallen to 5 percent. Similarly, the number of Ugandan men
    with two or more sexual partners per year dropped from over 70 percent
    in 1989 to less than 20 percent in 1995.
        So how does the Uganda model work in practice? How can that model
    be replicated or adjusted to work in other countries and cultures? What
    does that imply for U.S. policy and foreign assistance in combating
    this pandemic around the world?
        That's what we're here to find out, and we have a distinguished
    panel to help us do that this afternoon. I also hope to explore with
    the witnesses the idea of having an AIDS Corps--where American health
    professionals could volunteer to go to African or other hard-hit
    countries and help train professionals in-country how to provide care
    and treatment for those infected and affected by HIV/AIDS. I introduced
    a bill for that purpose last week.

        Senator Feingold. Thank you very much, Mr. Chairman, and I
    would like to thank you for convening this hearing, for your
    willingness to work in such a cooperative way in putting it
    together. I genuinely appreciate your approach and frankly, Mr.
    Chairman, think that this is the perfect medicine for a recent
    minor outbreak of what I might call politicization when it
    comes to this issue.
        It is a little bit of a shame, really, that this hearing is
    coming after, rather than before, the floor action on the AIDS
    authorization bill, which, as you mentioned, occurred late
    Thursday night when people were pretty tired, although there
    was one good thing about it. Everybody had to be there to
    listen, and that does not happen a lot in the Senate.
        Let me compliment you on introducing and authoring,
    particularly so early in your tenure here in the Senate, Senate
    bill 1067, which is the AIDS Corps bill. It is interesting that
    in Botswana, a country that you and I have both visited and
    looked at the AIDS issue, that they had graduated, if you will,
    from the Peace Corps, did not have it any more, but because of
    the very severe problem with HIV-AIDS, the President, President
    Mogae of Botswana, asked if the Peace Corps would come back,
    and the Peace Corps there is exclusively working on the HIV-
    AIDS problem. So there is in a way a precedent, at least in one
    sense, for this very good idea that you have put forward, and I
    compliment you on it.
        Lately we have heard many different perspectives on the ABC
    approach in Uganda, which of course refers to awareness raising
    and educational campaigns urging people to abstain, to be
    faithful to one partner, and to use condoms. I think common
    sense tells us that all of these elements are important parts
    of combating this horrifying pandemic.
        Ugandan efforts have also been characterized by other
    things, by strong and visible political leadership, by
    grassroots involvement on a massive scale, and by concerted
    efforts to destigmatize the disease. The story is not a simple
    one.
        The bottom line is that Uganda's multifaceted approach to
    combating AIDS was successful. Ugandan AIDS prevalence rates
    have declined markedly over the 1990s. Mr. Chairman, I had a
    chance to sort of see this in the middle when I visited the
    country in late 1999, met with President Museveni and others to
    see what they were trying to do. And today, several years
    later, as you have indicated, the country continues vigorously
    addressing the crisis.
        This is a tremendously important example and Uganda
    deserves the acclaim that has come to the country in the wake
    of this achievement. But I must raise for a moment one other
    issue briefly because I think that it would be a mistake for
    this subcommittee to be convening today and discussing Uganda
    in any context without at least mentioning the ongoing crisis
    in Ituri province in the Democratic Republic of the Congo, a
    crisis that has involved Uganda and a crisis that will require
    international commitment to solve, including real commitment
    from Uganda and Rwanda to use their influence with Ituri's
    ethnic militia forces.
        Obviously, this serious situation is not the focus of
    today's hearing, but I did want to use this opportunity to go
    on record about my deep concern and my hope that the United
    States will play a constructive role in defusing this crisis
    rather than being an obstacle to urgently needed action.
        Turning back to the subject at hand, I think it is
    important that we recognize both the value in learning from the
    Ugandan experience and the fact that one country's model is not
    necessarily precisely the right model for every other AIDS-
    affected society. So this subcommittee is diving into this
    discussion with an understanding that Uganda is not Senegal,
    which is not South Africa.
        That said, Uganda's success has played an important role in
    convincing people here in Washington and around the world that
    it is possible to fight AIDS and win. That is a tremendous
    contribution and it deserves to be celebrated and studied
    closely.
        Mr. Chairman, I would ask that the statement of Senator
    Biden, the ranking member of the full committee, be added to
    the record.
        [The prepared statement of Senator Biden follows:]

               Prepared Statement of Senator Joseph R. Biden, Jr.

        Mr. Chairman, I would like to submit a statement for the hearing
    record from Jeffrey Busch, Chief Executive Officer of SafeBlood for
    Africa. SafeBlood for Africa is a not for profit organization whose
    objective is to improve the national blood supply of African countries
    where few or no mechanisms exist to test blood for infectious diseases
    such as HIV before tranfusion.
        Lately we have been hearing a lot about the importance of
    prevention in halting the transmission of HIV/AIDS. There has been a
    singular focus on what's know as the ABC model--Abstinence, Be faithful
    and use Condoms as the key to prevention. This model is very important,
    however as Mr. Busch's statement indicates, it is only one part of an
    overall prevention model which includes voluntary testing and
    counseling, prevention of mother-to-child transmission, and safety of
    the national blood supply.
        I think it is important to understand the need to focus on a
    comprehensive strategy of prevention which includes more than just the
    ABC's.

        [Attachment.]

               Blood Safety: An Important Tool in AIDS Prevention

     Statement Submitted by Jeffrey Busch, Chairman and CEO, SafeBlood for
                                     Africa

                              PREVENTION IN UGANDA

        Uganda is one of a few African countries to achieve a reduction in
    the prevalence of HIV in its population. While much has been made about
    the ABC approach in Uganda--Abstinence, Be faithful, use Condoms as a
    prevention strategy, I would like to point out that the ``ABC's'' are
    only a part of Uganda's overall prevention strategy. Other elements of
    the prevention strategy include prevention of mother-to-child
    transmissions, voluntary testing and counseling, and ensuring a safe
    national blood supply. According to a European Union report, the
    creation of a successful Uganda Blood Transfusion Service (UBTS) has
    been a major contributor to that success. (From 2nd Edition European
    Community Official Publication, Safe Blood in Developing Countries,
    www.tve.org/ho/doc.cfm?aid=413.)
        The UBTS has saved countless lives through:

       Intensive HIV/AIDS education drives for blood donors. This
            has resulted in many Ugandans taking an HIV test. The knowledge
            of one's HIV status has encouraged those who are negative to
            stay negative, and those who are positive to avoid passing on
            the infection.

       Provision of infection free blood for those in need of blood
            transfusions through recruitment of volunteer, non-remunerated,
            repeat blood donors.

       Systematic training of staff. Central coordination and
            organization of all transfusion services including standard
            operating procedures and quality control.

        The Ugandan experience stands in stark contrast to the rest of the
    African continent where unsafe blood is estimated to cause up to 10% of
    all new HIV infections. This is due to the fact that on much of the
    continent, blood transfusions occur with little or no pre-transfusion
    testing. Dr. Harvey Klein, Chief of Transfusion Medicine at the
    National Institute of Health, states, ``In the last century,
    transfusions have saved more lives than any therapy except
    antibiotics.'' It is unfortunate that in sub-Saharan Africa
    transfusions meant to save lives carry a significant risk of having a
    negative effect on the health of African patients.

                               OTHER EXPERIENCES

        At the XIV International Conference on AIDS held in Barcelona in
    2002, the Global HIV Prevention Working Group, composed of nearly 40 of
    the world's leading HIV prevention experts, stated that that an
    effective global HIV prevention strategy should consist of several
    different approaches. One of the experts, Dr. Helene Gayle of the Bill
    and Melinda Gates Foundation, emphasized this point by stating that
    ``Just as combination therapy attacks HIV from different angles,
    prevention requires a combination of approaches. There is no single
    magic bullet. `Combination prevention,' however, has proven very
    effective.''
        Supporting a multidimensional approach to HIV prevention, the
    United Nations Special Session on HIV/AIDS in June 2001 indicated that
    ``Prevention programmes must concentrate on [all] the main routes along
    which HIV spreads [that is] by addressing blood safety, mother-to-child
    transmission, injecting drug use and sexual transmission.''

                        SAFE BLOOD FOR AFRICA FOUNDATION

        Our organization is a 501(c)(3) not-for-profit corporation whose
    purpose is to help prevent the spread of HIV/AIDS by blood transfusion
    in sub-Saharan Africa. We will achieve this goal by working with the 34
    countries in sub-Saharan Africa where blood contaminated with
    infectious diseases--including HIV, Hepatitis B and Hepatitis C--is
    most prevalent to develop national blood screening and safety systems.
    When our programs are fully implemented, we estimate that we will save
    between 10 and 20 million lives over the next 10 years.

        Senator Alexander. It will be done.
        Senator Feingold. Thank you very much, Mr. Chairman.
        [The prepared statement of Senator Feingold follows:]

               Prepared Statement of Senator Russell D. Feingold

        Mr. Chairman, I want to thank you for convening this hearing and
    for your willingness to work in such a cooperative way in putting this
    together. I genuinely appreciate your approach and frankly think that
    it is the perfect medicine for a recent minor outbreak of
    politicization when it comes to this issue. It is a shame that this
    hearing is coming after, rather than before, floor action on the AIDS
    authorization bill.
        Lately we have heard many different perspectives on the ABC
    approach in Uganda, which of course refers to awareness-raising and
    educational campaigns urging people to abstain, to be faithful to one
    partner, and to use condoms. And I think common sense tells us that of
    these elements are important parts of combating this horrifying
    pandemic. But Ugandan efforts have also been characterized by strong
    and visible political leadership, by grassroots involvement on a
    massive scale, and by concerted efforts to destigmatize the disease.
    The story is not a simple one.
        The bottom line is that Uganda's multi-faceted approach to
    combating AIDS was successful. Ugandan AIDS prevalence rates have
    declined markedly over 1990s, and the country continues vigorously
    addressing the crisis today. This is a tremendously important example
    and Uganda deserves the acclaim that has come to the country in the
    wake of this achievement.
        But I must raise one different issue, just briefly, Mr. Chairman,
    because I think that it would be a mistake for this subcommittee to be
    convening today and discussing Uganda in any context without mentioning
    the ongoing crisis in Ituri province in the Democratic Republic of the
    Congo--a crisis that has involved Uganda, and a crisis that will
    require international commitment to solve, including real commitment
    from Uganda and Rwanda to use their influence with Ituri's ethnic
    militia forces. Obviously this serious situation is not the focus of
    today's hearing, but I do want to use this opportunity to go on the
    record about my deep concern and my hope that the United State will
    play a constructive role in defusing this crisis rather than being an
    obstacle to urgently-needed action.
        Turning back to the subject at hand, I think it is important that
    we recognize both the value in learning from the Ugandan experience,
    and the fact that one country's model is not necessarily precisely the
    right model for every other AIDS-affected society. So this subcommittee
    is diving into this discussion with an understanding that Uganda is not
    Senegal, which is not South Africa. That said, Uganda's success has
    played an important role in convincing people here in Washington and
    around the world that it is possible to fight AIDS and win. That is a
    tremendous contribution, and it deserves to be both celebrated and
    studied closely.

        Senator Alexander. Thank you, Senator Feingold.
        We are delighted to have Dr. Anne Peterson testifying on
    behalf of the administration. She is currently Assistant
    Administrator of the Bureau for Global Health at USAID.
    Something like our majority leader, she is a medical doctor.
    She has done volunteer work in Africa, I guess may still do;
    formerly worked on the front lines in African countries as a
    volunteer doctor and in many nonprofit organizations.
        Dr. Peterson, we are delighted to have you. We look forward
    to your comments. I would suggest to you and the other
    witnesses perhaps you could keep your comments to within 10
    minutes or less and then that will leave more time for
    questions and discussion.

      STATEMENT OF ANNE PETERSON, M.D., ASSISTANT ADMINISTRATOR,
        BUREAU FOR GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL
                      DEVELOPMENT, WASHINGTON, DC

        Dr. Peterson. Thank you, Mr. Chairman. It is an honor to be
    here today and thank you for holding this hearing on the grave
    public health crisis of HIV-AIDS. I would like to submit my
    written testimony for the record and then summarize it. I will
    try to be brief.
        You have already spoken about the devastation that HIV-AIDS
    has wrought on the developing world. Every hour 350 people
    around the world die of AIDS and, as President Bush said last
    month at the White House, ``time is not on our side.'' I am
    really thrilled with the urgency that is now really moving this
    epidemic and its response, our response to this epidemic.
        President Bush called for a massive U.S. Government
    response to the crisis, the $15 billion over 5 years, and
    Thursday you voted to support that call to action. It has
    ambitious goals, to prevent 7 million infections, treat 2
    million people with life-extending drugs, and provide care for
    millions.
        Mr. Chairman, I am a public health physician and my career
    has been focused on both domestic public health and health
    development in Africa. My very first time in Africa was in the
    Bunia area of Congo that is now in such difficult
    circumstances, but most of my time was in Kenya and Zimbabwe,
    very close to the border of Uganda. I believe that the work
    that I have done in Africa and my American public health work
    has given me a good grasp of what is going on in Africa and the
    programmatic realities that we need to be dealing with now.
        As you have recognized, Uganda is not only important
    because it is a success, but because there are many elements of
    that success that can be replicated. The Ugandan epidemic
    peaked in 1991 and has fallen to about 5 percent in 2001. I
    would like to quote again President Bush, who cited the example
    of Uganda in his call to action: ``This is a terrible disease,
    but it is not a hopeless disease. We know that AIDS can be
    prevented. In Uganda President Museveni began a comprehensive
    program in 1986 with a prevention strategy emphasizing
    abstinence and marital fidelity, as well as condoms to prevent
    HIV transmission. The results are encouraging. Congress should
    make the Ugandan approach the model for our prevention efforts
    under the emergency plan.''
        The dramatic decline is unique to Uganda. What can we learn
    from it? I would like to enter for the record, Mr. Chairman, a
    study that was published last fall by USAID on Uganda's
    successful battle against HIV-AIDS. That report and my written
    testimony \1\ contain a great deal of other information.
    ---------------------------------------------------------------------------
        \1\ Dr. Peterson's written testimony and the report referred to can
    be found beginning on page 10.
    ---------------------------------------------------------------------------
        The Ugandan story is a story about prevention. As you said,
    before terrorism or vaccine was available, when President
    Museveni came to power in 1986, his country was already being
    decimated by AIDS. Under his leadership, every sector of
    society responded to the crisis by sending a unified and
    forceful message. Their message was as simple as ABC:
    ``abstain, be faithful, and if necessary use a condom.'' This
    message was disseminated widely through all sectors of society
    during the 1980s.
        The first is abstinence. By 1990 the percentage of youth
    age 15 to 19 in Uganda ever having had sex decreased
    noticeably. In 1989, 32 percent of males and 28 percent of
    females age 15 to 19 reported being virgins, while by 1995
    these numbers had increased to 55 percent of males and 45
    percent of females. As you can see in your handout, the decline
    is even more dramatic for 13- to 16-year-olds in an after-
    school educational program.
        We can also measure abstinence in the trend toward delayed
    age of sexual debut among youth. In the 1990s, sexual debut
    among girls in Uganda increased from 16.5 to 17.3 years. This
    does not look like much, but it has profound impact on the
    prevalence of HIV-AIDS and it also demonstrates huge cultural
    changes that young girls were able to abstain. For boys it rose
    from 17.6 to 18.3 years in the second half of the decade. For
    youth the A of the ABC message, abstinence, is probably the
    most important single message.
        The second message is B. The ABC message of Uganda is not
    just abstinence. Many people, including Uganda's first lady,
    acknowledged that the B, be faithful, which includes partner
    reduction, may be overall the most important factor. Also known
    as ``zero grazing,'' being faithful is a strong cultural norm
    that resonated strongly in Uganda and, from my own experience,
    I know it resonates also in many other African countries.
        In general, Ugandans of all ages now have considerably
    fewer non-regular sex partners. Surveys conducted in 1989 to
    1995 show that men with one or more casual partners declined
    from almost 40 percent to 15 percent, and for women the decline
    was from 16 percent to 6 percent. The number of men reporting
    three or more non-regular partners in a year fell from 50
    percent to 3 percent.
        The 1995 survey also revealed an amazing statistic: 89
    percent of men reported that they had changed some behavior
    relative to HIV-AIDS, with most of them adopting faithfulness
    as the behavior change. In the second data slide, you can see
    that for all ages Ugandans now reports significantly fewer non-
    regular partnerships than compared to other African countries.
        The third message is C. While condom promotion was not a
    dominant element in Uganda's early response to AIDS, in more
    recent years, there has been increased condom use. The
    beneficial role of condoms is clear when one spouse is HIV-
    positive and the other is not, but it is also an important
    prevention tool for people who have sex with non-regular
    partners.
        Again, in the condom use slide, the third one, Uganda is a
    model. They are responding to the A and B message by having
    fewer partners, but when they do stray outside of marriage they
    are also leading the way on condom use.
        We know that these ABCs have played key roles in the
    decline of HIV prevalence in Uganda, but there is more to learn
    about the relative contributions of each and the other factors
    that contribute to the decline of AIDS and the success of the
    ABC message. These include: the political commitment to
    fighting AIDS from President Museveni and his wife; the
    important role of faith-based organizations and churches in
    changing behavior; communicating a consistent message with
    credible messengers, such as Ugandan pop star Philly Lutaaya;
    fighting stigma that clouds the attitude toward HIV and AIDS
    and, as you are seeing in Botswana, this has been an incredible
    limiting factor. There were also important policy and law
    changes and the bringing in of voluntary counseling and
    testing.
        I am pleased, Mr. Chairman, that USAID was able to play an
    important role in Uganda's success. Seventy percent of Uganda's
    prevention and care activities are funded by donor nations.
    USAID funded nearly half of that donor support. Last year we
    provided $20 million to Uganda for HIV-AIDS programs, and this
    year our budget will be over $27 million in Uganda.
        The program includes a spectrum of activities from
    prevention to care, support, and treatment. I would like to
    mention just a couple examples. The AIDS Support Organization,
    or TASO, is world-renowned and has provided care and support to
    more than 60,000 individuals and their families, as well as
    supporting 200,000 children affected by AIDS. USAID has been a
    long-time supporter of TASO and today provides TASO with
    approximately $2 million a year. The former head of that
    organization, Sophia Mukasa Monico, will testify before you in
    a few minutes and is one of the many heros of Uganda's war on
    AIDS. Since 1995, we have also been supporting the First Lady
    Museveni's orphan and microcredit work and have been working
    with faith-based organizations since 1991.
        USAID will continue strong support of the Uganda success
    and support of both the implementation and research into ABC
    programs. But the real question, days after the passage of the
    emergency AIDS bill--and again I thank you--is not only what
    happened in Uganda, but can we replicate Uganda's success? The
    short answer is emphatically yes. Uganda is unique, and it is
    hard to imagine the amazing leadership role of the President
    and his wife will be repeated, but many elements of Uganda's
    success can be recreated elsewhere.
        In Uganda we have learned that a comprehensive behavior
    strategy, ideally involving high-level political commitment and
    a diverse spectrum of community and faith-based participation,
    building on cultural norms, can change the course of the
    epidemic.
        The Uganda model is also a flexible model. It takes into
    account the epidemiological, the demographic, and the cultural
    norms, and can be balanced between the A, B, and C components
    as well as all of the other supporting elements.
        Every country will be different, but we can learn from the
    successful elements of the action in Uganda. In some countries
    we are beginning to hear the voices of Presidents and other
    political leaders take on new roles. In other countries we see
    strong leadership from the faith community and civil society.
    In South Africa the engagement of the business community is
    remarkable and likely to be a significant factor in future
    successes.
        And we are seeing signs that other countries are beginning
    to turn epidemics around. Recent studies among youth in Zambia
    indicate that a similar success story there may be in the
    making. Clear and positive changes in all three of the ABC
    behaviors have been reported in surveys, and a significant
    decline in casual sex has occurred among both men and women
    between 1996 and 1999.
        Mr. Chairman, as you noted, I spent 6 years in Africa as a
    missionary doctor. I worked with communities, children in
    school, street children, AIDS patients, and families in the
    most desperate of circumstances. I helped develop and teach
    abstinence programs to African youth. I have seen the light in
    young people's eyes when they realize they can take control of
    their own lives. The data shows this as well. It is as simple
    as ABC.
        But we need that simple message, together with all the
    supporting elements involved that made the ABC success in
    Uganda, to save lives. We cannot ignore the moral issues
    involved in finding a solution to the HIV-AIDS crisis. To
    protect the next generation of African youth, we cannot step
    aside from difficult dilemmas of abstinence and faithfulness.
        Uganda's First Lady Museveni last Tuesday in a speech said:
    ``How are we going to teach children to be law-abiding citizens
    if we do not train them to exercise self-control and to learn
    to police themselves while they are still young and teachable?
    Not to guide our young in this way implies that we as adults
    and leaders have no faith in human nature and in our ability as
    beings to exercise self-control. If this is the case, then we
    are surely a doomed species.''
        My own experience tells me that Mrs. Museveni's words are
    directly on point. Our mission at USAID is to learn from the
    successes that we have before us and bring similar successes to
    other devastated countries around the world.
        Thank you for letting me testify before you today.
        [The prepared statement of Dr. Peterson follows:]

     Prepared Statement of Dr. Anne Peterson, Assistant Administrator for
            Global Health, U.S. Agency for International Development

        Good afternoon. Thank you for inviting me to testify on the
    important topic of Uganda's successful battle against HIV/AIDS. This
    issue could not be timelier or more urgent. The HIV/AIDS pandemic is
    currently claiming 350 lives per hour worldwide. President Bush
    announced an unprecedented five-year, $15 billion program to fight the
    disease. It is crucial that we take the right lessons from Uganda's
    experience and apply them effectively elsewhere.
        We are at a turning point in the battle against HIV. While HIV
    infection rates are still increasing and the disease is raging in many
    places, we now have success stories. We know what works and soon will
    have sufficient resources to implement those successful strategies much
    more broadly. It is important that we highlight the successful
    interventions in Uganda so we can better apply them to other countries.
    The new Emergency Plan for AIDS Relief that President Bush announced in
    January in the State of the Union Address is based on one of these
    successful models.
        I have been serving as the Assistant Administrator of USAID for
    Global Health for 18 months. I came to the agency with a long history
    of service in medicine and public health. I spent six years in Africa,
    working with AIDS patients and their families. My work in both Zimbabwe
    and in Kenya, near the Ugandan border, included similar interventions
    to ones we'll be examining today from Uganda.
        I have seen first-hand the devastation that AIDS has wreaked on
    individuals, families and communities. While we often hear of the
    hopelessness of HIV/AIDS, today there are many signs that give us hope
    of winning the war against this deadly disease.

                            WHAT HAPPENED IN UGANDA?

        Despite all my African experience, it is humbling to be here
    talking about what happened in Uganda. This is a Ugandan story and
    should be told by Ugandans. The saving grace is that I know many of you
    heard from Mrs. Janet Museveni, the First Lady of Uganda last week. Her
    passion and depth of insight are vital elements of the political
    leadership from her and her husband, President Yoweri Museveni, which
    has made, and continues to make, such a difference in Uganda.
        Today, I would like to focus on four areas: first, the data on HIV/
    AIDS from Uganda; second, the data and cultural support for the ABC
    approach to AIDS prevention; third, USAID's past role in Uganda; and
    fourth, what the U.S. government can do to replicate Uganda's success
    elsewhere.
        With your permission, Mr. Chairman, I would like to enter, for the
    record, a study published by USAID last fall on Uganda's successful
    battle against HIV/AIDS.
        In Uganda, according to estimates by UNAIDS, HIV prevalence among
    adults peaked at around 15 percent in 1991, and fell to 5 percent as of
    2001. While some quibble on the numbers, we know this dramatic decline
    is unique to Uganda, which is why it is important that we examine what
    led to the turnaround.
        The Uganda success story is about prevention. When President
    Museveni came to power in January 1986, his country was already being
    decimated by AIDS. Under President Museveni's leadership, leaders at
    every level of society responded to this crisis by sending a unified
    and forceful message. They urged people to prevent the spread of HIV.
    Their message was as simple as ABC: Abstain, Be faithful, and, if
    necessary, use a Condom. This message was disseminated widely through
    all sectors of society during the late 1980s.
        ``A'': By the 1990s, the percentage of youth aged 15-19 in Uganda
    reporting ever having had sex decreased noticeably. In 1989, 32 percent
    of males and 28 percent of females age 15-19 reported being virgins,
    while by 1995 these numbers had increased to 55 percent of males and 45
    percent of females. In addition, there was a clear trend towards
    delayed age of sexual debut among youth. In the 1990s, sexual debut
    among girls in Uganda increased from 16.5 to 17.3 years. For boys, it
    rose from 17.6 to 18.3 years in the second half of the decade. For
    youth--I agree with Mrs. Museveni--the A of ABC, abstinence, is the
    most important single message. USAID will be funding additional studies
    to verify that our current body of evidence is in fact correct as to
    the contribution of abstinence to AIDS education.
        ``B'': But the ABC message of Uganda is not just A. Many people,
    including Uganda's First Lady, acknowledged that ``B'', Be faithful,
    may be overall the most important factor. Also known as ``Zero
    grazing''--being faithful is a strong cultural norm that resonated
    strongly in Uganda. The rise in couples that are mutually faithful is
    striking.
        In general, Ugandans of all ages now have considerably fewer non-
    regular sex partners. In surveys conducted in 1989 and 1995, men with
    one or more casual partners declined from 35 percent to 15 percent, and
    for women the decline was from 16 percent to 6 percent. Also
    significant, the number of men reporting three or more non-regular
    partners fell from 15 percent to 3 percent. A 1995 survey found that 89
    percent of men reported they had changed their behavior to avoid AIDS,
    with most of them adopting faithfulness to one partner, and other
    partner-related changes.
        ``C'': While condom promotion was not a dominant element in
    Uganda's early response to AIDS, in more recent years, increased condom
    use has contributed to the continuing decline in prevalence. The
    beneficial role of condoms is clear when one spouse is HIV positive and
    the other is not. But it is also a particularly important prevention
    tool for people who have sex with a ``non-regular'' partner. In Uganda,
    condom use by women with non-regular partners rose from 20 to 38
    percent, and for men rose from 36 to 59 percent, over the last five
    years of the 1990s.
        We know that these ``ABCs'' have played key roles in the decline of
    HIV prevalence in Uganda, but there is much more to be learned about
    the relative contributions of each. There are still many unanswered
    questions about how Uganda has moved so many people to make such
    significant changes in behavior. Some of the critical elements we know
    contributed to the adoption of the ABC message were:
        Political commitment: Uganda in 1986 was just emerging from 15
    years of civil unrest. When he had just assumed office, President
    Museveni received evidence of an emerging epidemic and immediately
    began a proactive prevention campaign that continues to this day. In
    meetings and speeches, he emphasized that fighting AIDS was a patriotic
    duty requiring openness, communication and strong leadership at all
    levels. This early support from the President enlisted a wide variety
    of national participants in the war against the new disease.
        Role of faith-based organizations: Religious leaders are uniquely
    positioned to influence the behavior of large numbers of people. Early
    and significant mobilization of Ugandan Christian and Muslim leaders
    and organizations resulted in their active participation in AIDS
    education and prevention activities. For example, the Catholic Church
    and mission hospitals provided leadership in designing AIDS home care
    projects and special programs for AIDS widows and orphans. The Church
    of Uganda and the Islamic Medical Association of Uganda used their
    extensive networks to train more than 1800 religious leaders and 5000
    peer educators.
        Communicating a consistent message: Along with elected and faith-
    leaders, other influential people who did not normally work on health
    issues, like First Lady Janet Museveni and pop music star Philly
    Lutaya, became involved in AIDS awareness and education. An aggressive
    media campaign, including print, radio and billboards, educated people
    to change their behavior. This was reinforced by old-fashioned,
    interpersonal communication, with Uganda training thousands of
    community-based AIDS counselors and educators, who in turn motivated
    people to change their behavior.
        Fighting stigma: The stigma attached with HIV and AIDS often serves
    as a barrier to effective prevention measures. Openness on the part of
    President Museveni led to openness from every level of society down to
    local community leaders, producing an accepting and non-discriminatory
    response to AIDS. In addition, The AIDS Support Organization, known as
    TASO, advocated effectively against discrimination and stigma. TASO is
    recognized around the world as a leader and innovator in the field of
    HIV/AIDS care and support. The former head of that organization, Sophia
    Mukasa Monico, will join us in a later panel.
        Policy and law change: ``Gender vulnerability'' refers to the
    problem of wives exposed to HIV through the indiscretions of their
    husbands or young girls put at risk through intergenerational sex. This
    is a deeply cultural and sensitive part of the problem in many African
    countries. When I asked Mrs. Museveni how Uganda overcame these
    problems, she talked about policy and law change. Women could prosecute
    for rape, wives would not lose their homes if they refused to have sex
    without protection with their HIV+ husband. And these weren't just
    verbal promises; free legal support, including from women lawyers, was
    made available so that this was a real hope. While not completely
    overcoming this problem and not reaching all parts of Uganda with legal
    support, these policy and legal changes make it possible for women to
    abstain when in other circumstances their exposure to AIDS would be out
    of their control.
        Confidential voluntary counseling and testing: In 1990, the first
    confidential voluntary counseling and testing center opened in Kampala.
    The AIDS Information Center was the first to provide same-day results
    using rapid HIV tests. The Center also started ``post-test clubs'' to
    provide long-term support for those who have been tested, whether they
    are HIV-positive or negative. The availability of these services, and
    the lack of stigma associated with getting tested, were important
    assets in Uganda's prevention efforts.

                             USAID'S ROLE IN UGANDA

        I am pleased to be able to report that USAID was a strong supporter
    of Uganda's approach and the largest financial supporter to its success
    story. Donor countries, particularly the United States, played
    important roles during those critical years by complementing Uganda's
    energy and initiative with financial and technical support.
        Donor support covered 70 percent of Uganda's prevention and care
    activities, amounting to $180 million from 1989 to 1998. USAID has
    provided more than $83 million in AIDS funding since 1988. I will now
    describe the activities of USAID in Uganda, though I note that other
    federal agencies have also participated in the fight against AIDS in
    Uganda.
        Last year, USAID provided $20 million to Uganda for HIV/AIDS
    programs, and this year's budget will be over $27 million. Our program
    includes prevention, care and support, voluntary counseling and
    testing, and programs for children affected by AIDS. Let me mention a
    few highlights of our past and present programs:
        USAID has a long history of supporting Uganda's two largest local
    non-governmental organizations dedicated to the fight against AIDS.
    TASO, as I mentioned earlier, is world-renowned, and has provided care
    and support services to more than 60,000 individuals and their
    families, as well as supporting 200,000 children affected by AIDS.
    Today, USAID provides TASO with approximately $2 million a year.
        The AIDS Information Center, which provides HIV counseling and
    testing, has served over half a million Ugandans. USAID was the first
    donor to support the AIDS Information Center, and currently funds more
    than 80 percent of its annual budget.
        USAID/Uganda's partnerships with faith-based organizations began
    early in 1991, with a project designed to mobilize civil-society
    organizations, including those that are faith-based. These
    institutions, especially the Church of Uganda and the Islamic Medical
    Association, were able to utilize their extensive networks to educate
    and influence people's behavior. Today, USAID funds World Vision to
    reinvigorate and strengthen the role of faith-based organizations in
    their response to HIV/AIDS. This initiative is strengthening the
    Interreligious Council of Uganda, as well as providing sub-grants.
        USAID, working with Catholic Relief Services, World Vision and
    others, currently has a five-year, $30-million project in Uganda to
    provide food aid to over 60,000 individuals. Good nutrition plays an
    important role in the quality--and we believe also length--of life of
    people living with AIDS. In addition, since it is not uncommon for
    economically disadvantaged women to trade food for sex, food aid can
    play an important role in decreasing this risky behavior that can drive
    the epidemic.
        The Uganda Women's Effort to Save Orphans, founded by First Lady
    Janet Museveni, has more than 7500 members, most of whom provide direct
    care for orphans. Since 1995, with support from USAID, this group's
    small-scale credit program has provided income generation activities
    for orphan households. Their programs have assisted over 25,000 orphans
    and 2,600 micro-entrepreneurs.
        USAID provided the leadership and technical expertise for a
    planning meeting for representatives from the major religious
    communities in Uganda: Anglican, Roman Catholic, Orthodox Christian,
    and Muslim. Out of this meeting, the Interreligious Council of Uganda
    HIV/AIDS Task Force was established.
        Currently, USAID and the Centers for Disease Control are funding a
    program to develop comprehensive, integrated HIV/AIDS prevention and
    care services in 16 of Uganda's 56 districts. These integrated programs
    will create a model for serving Uganda's rural poor.
        Preventing mother-to-child transmission of HIV is one of the
    aspects of this program. USAID/Uganda is also supporting a private
    sector initiative designed to increase utilization of services to
    prevent mother-to-child transmission through a program for midwives.
    These programs will be scaled-up significantly thanks to President
    Bush's International Mother and Child HIV Prevention initiative and the
    President's Emergency Plan for AIDS Relief.

               USAID'S BALANCED APPROACH TO AIDS PREVENTION TODAY

        Although USAID has always acknowledged a balanced ABC approach to
    the HIV/AIDS pandemic is needed, it is true that in the past, the
    agency's programs tended to skew towards those that are easier to
    measure such as the social marketing of condoms. Uganda is leading the
    way in helping to provide data on the contribution of the abstinence
    and be faithful messages to successful AIDS prevention. There is
    supporting evidence from abstinence and teen pregnancy prevention
    programs in the United States and evidence is accumulating from a
    variety of international programs that these messages are successful.
        Rarely do we have a controlled study environment in international
    programs that would allow interventions to definitely prove cause and
    effect. This is also true for the assessment of the ABC approach. But
    we do have a growing body of evidence of ecological, programmatic and
    time oriented associations that is very strong. Based on this body of
    evidence, USAID's policy since last fall has been modified to follow a
    more balanced approach to the ABC's of HIV prevention. The balance is
    set for an individual country based on culture, epidemiology, and the
    stage of the epidemic. The ABCs of HIV prevention reinforce one
    another, and the appropriate message must reach the appropriate
    audience. These messages and target audiences can be segmented without
    denigrating any one message.
        In Zambia, we have seen evidence of a program that successfully
    applies a balanced approach. It is also a program that we think can be
    replicated in other similar situations. The HEART program--or Helping
    Each Other Act Responsibly Together--was designed by youth for youth
    and uses the mass media to promote AIDS prevention through abstinence,
    being faithful to one partner, and, when necessary, correct and
    consistent condom use.
        According to a survey of Zambian youth, girls in particular said
    they want concrete messages with reasons to stay virgins or return to
    abstinence. The decision to abstain was frequently reported as a direct
    result of exposure to the HEART program. Respondents were also more
    likely to say they chose ``to abstain'' rather than to use condoms--a
    finding that counters the common argument that television and radio
    spots about safe sexual behavior encourage promiscuity. The study
    clearly shows we can promote abstinence as ``cool'' and reinstitute it
    as a social norm among Zambian youth, whether they are still virgins or
    for those wanting to return to abstinence.
        In Jamaica, a USAID-funded program promotes abstinence with the
    slogans such as ``go real slow, take the time to know.'' This message
    is promoted through popular rap songs, with lyrics like, ``Now I don't
    want to complicate this life of mine, so right now sex is out, and
    that's just fine.'' An evaluation of this campaign found that more than
    half the youth who recalled the ads said they had influenced the way
    they handle relationships.
        In Namibia, past surveys show that girls begin sex at a young age,
    and 12 percent of 15-19 year aids are HIV positive. USAID began a
    campaign last year that works with churches, including the Catholic
    Church and the Evangelical Lutheran Church, to encourage church leaders
    to use their pulpits to speak about the importance of educating
    children about HIV prevention, with an emphasis on delaying first
    sexual intercourse. Another component of the program will adapt the
    Christian Family Life Education to be implemented as part of Sunday
    School lessons. The program will also seek to form partnerships between
    churches and parenting organizations.
        Similarly the B component of ABC is vitally important (Be faithful
    or Behavior change--partner reduction) to a comprehensive approach. B
    is a bridge between A and C and preliminary data suggests it may be the
    most important element of all. USAID will continue to support a strong
    B emphasis and continue to study to validate the data evidence for its
    contribution.
        Condom promotion is also an important tool to stem the spread of
    the disease among high-risk populations. While messages of abstinence
    and faithfulness are key to young and married adults, it is important
    to provide information on condoms to those who have sex outside or
    before marriage. Prostitutes and their clients, long-distance truck
    drivers, and migrant populations, like miners and fishermen, are
    audiences that are appropriate for a condom promotion message. Social
    marketing is designed to tailor messages to a target audience. It is
    used successfully for hygiene initiatives, oral rehydration therapy,
    malaria control, and HIV prevention. Social marketing of condoms can
    provide appropriate and effective messages targeted to specific at-risk
    groups.
        USAID uses indicators developed with UNAIDS to measure the success
    of A, B and C. We are analyzing the data we collect to make sure our
    programs are as effective as possible.

                      CAN UGANDA'S SUCCESS BE REPLICATED?

        Uganda's experience was unique in many ways, particularly in the
    early and strong voice of the President and his wife. Many elements of
    Uganda's response, including the political and community action that
    supported the ABC approach and led to real changes in sexual behavior,
    worked together in order for HIV rates to fall so dramatically.
    However, many elements of Uganda's success can be and are being
    replicated elsewhere.
        Every country will be different, but we learn successful elements
    of action from Uganda. For instance, in some countries, we are seeing
    political leaders, including and in addition to the head of state, take
    on a leadership role. In other countries, we see strong leadership from
    the faith community or civil society. In South Africa, the engagement
    of the business community is remarkable and likely to be a significant
    factor in future successes.
        We are seeing strong signs that other countries are beginning to
    turn their epidemic around. Recent studies among youth in Zambia
    indicate that a similar success story there may be in the making. Clear
    and positive changes in all three of the ``ABC'' behaviors have been
    reported in surveys, and a significant decline in casual sex occurred
    among both men and women between 1996 and 1999.
        Senegal, Thailand and Cambodia have also had successes, and their
    stories also suggest that a balanced ABC approach should be promoted.
        In Uganda, we have learned that a comprehensive behavior change
    strategy--ideally involving high-level political commitment and a
    diverse spectrum of community and faithbased participation, building on
    cultural norms--can change the course of an epidemic.
        Mr. Chairman, let me again thank you for holding this important
    hearing today.

        [Attachment.]

               Project Lessons Learned Case Study--September 2002

                          WHAT HAPPENED IN UGANDA? \1\
    ---------------------------------------------------------------------------

        \1\ This document was developed with support from the Office of
    HIV/AIDS, Bureau for Global Health, U.S. Agency for International
    Development under contract number HRN-C-00-99-00005-00. The opinions
    expressed herein are those of the contributors and do not necessarily
    reflect those of USAID.
    ---------------------------------------------------------------------------
      DECLINING HIV PREVALENCE, BEHAVIOR CHANGE, AND THE NATIONAL RESPONSE

        This document is not intended to provide a definitive explanation
    for Uganda's AIDS prevention successes during the 1980s and 1990s.
    Rather, it is a synthesis of presentations made in February 2002 at the
    U.S. Agency for International Development (USAID) by four individuals
    \2\ with long-term experience in HIV prevention in Africa. USAID's
    Office of HIV/AIDS decided to commission a summary document
    synthesizing the ideas presented by these researchers. The following
    pages do not include all the various statistical and other details that
    were presented; however, it is hoped that the main points described
    here provide some insight into how Uganda has managed to control its
    HIV epidemic during the past 15 years.
    ---------------------------------------------------------------------------
        \2\ Editor: Janice A. Hogle, Ph.D. Contributors: Edward Green,
    Ph.D., Vinand Nantulya, M.D., Ph.D., Rand Stoneburner, M.D., M.P.H.,
    John Stover, Ph.D.

        HIV prevalence has declined significantly in Uganda: Now considered
    to be one of the world's earliest and best success stories in
    overcoming HIV, Uganda has experienced substantial declines in
    prevalence, and evidently incidence, during at least the past decade,
    especially among younger age cohorts. According to Ministry of Health
    (MOH) data, prevalence among pregnant women has declined consistently
    since the early 1990s at all of the country's sentinel sites (except
    Tororo, near the Kenyan border, where prevalence increased a little
    during the mid-to-late 1990s, but declined significantly again by
    2000). While it is more difficult to find reliable data on trends in
    incidence (or the rate of new infections), seroincidence also appears
    to have fallen significantly. In one site, Masaka, incidence fell from
    7.6 per thousand per year in 1990 to 3.2 per thousand per year by 1998.
    As with prevalence, the decline was more pronounced among younger
    women.
        Seroprevalence among 15-19-year-old pregnant women, which is
    believed to he reflective of HIV incidence, fell sharply from the early
    1990s, when this data was first collected, until 1995 or 1996, and
    since then has remained low. Based on this trend, as well as the fact
    that national seroprevalence peaked in 1991 and from some other
    indications (e.g., syphilis rates in Rakai plummeted in 1988), it is
    probable that incidence in Uganda would have peaked sometime in the
    late 1980s. Regarding prevalence, estimates by the U.S. Census Bureau/
    Joint United Nations Programme on HIV/AIDS UNAIDS) are that national
    HIV prevalence peaked at around 15 percent in 1991, and had fallen to 5
    percent as of 2001. This dramatic decline in prevalence is unique
    worldwide, and has been the subject of curiosity since the mid-1990s,
    and recently of even more intense scientific scrutiny.
        Observed consistently over time and across many different
    geographic and demographic populations, Uganda's falling HIV prevalence
    is likely not due merely to measurement bias or a ``natural die-off
    syndrome,'' but rather mainly to a number of behavioral changes that
    have been identified in several surveys and qualitative studies. Some
    have postulated that the decline in seroprevalence was primarily a
    result of so many people succumbing to the disease that the rate of new
    infections was simply outweighed by the numbers of AIDS deaths.
    However, a number of other African regions (e.g., Zambia, Zimbabwe,
    western Kenya) have experienced nearly as old--and at least as severe--
    epidemics as Uganda's, yet prevalence has yet to decline at the
    population level. Furthermore, the large decline in prevalence among
    younger age cohorts in Uganda argues against this as a primary
    explanation.

        The relationships between the large variety of interventions in
    Uganda and the decline in incidence and prevalence are complex and not
    yet completely understood. This is especially true regarding the
    earlier years (i.e., there is little HIV-related Demographic and Health
    Surveys (DHS) data prior to 1995). However, changes in age of sexual
    debut, casual and commercial sex trends, partner reduction, and condom
    use all appear to have played key roles in the continuing declines.
    Although we know that HIV knowledge, risk perception, and risk
    avoidance options can ultimately lead to reduced HIV incidence, there
    is a complex set of epidemiological, socio-cultural, political, and
    other elements that likely affected the course of the epidemic in
    Uganda. Many of these elements appear to be absent or less significant
    in other African countries that have not yet seen significant
    seroprevalence declines, such as Zimbabwe, South Africa, Botswana,
    Kenya, and Malawi. These key elements are summarized in roughly
    chronological order in the following pages.

        1. High-level political support with multi-sectoral response set
    the tone: In 1986, after 15 years of civil strife, Uganda's new head of
    state, President Yoweri Museveni, responded to evidence of a serious
    emerging epidemic with a proactive commitment to prevention that has
    continued to the present. In face-to-face interactions with Ugandans at
    all levels, he emphasized that fighting AIDS was a patriotic duty
    requiring openness, communication, and strong leadership from the
    village level to the State House. His charismatic directness in
    addressing the threat placed HIV/AIDS on the development agenda, and
    encouraged constant and candid national media coverage of all aspects
    of the epidemic. This early high-level support fostered a multi-
    sectoral response, prioritizing HIV/AIDS and enlisting a wide variety
    of national participants in the ``war'' against the decimating disease
    known as ``Slim.'' In 1992, the multi-sectoral Uganda AIDS Commission
    (UAC) was created to coordinate and monitor the national AIDS strategy.
    The UAC prepared a National Operational Plan to guide implementing
    agencies, sponsored Task Forces, and encouraged the establishment of
    AIDS Control Programmes in other ministries including Defense,
    Education, Gender and Social Affairs. As of 2001, there were also
    reportedly at least 700 agencies--governmental and nongovernmental--
    working on HIV/AIDS issues across all districts in Uganda.

        2. Decentralized planning and implementation for behavior change
    communication (BCC) reached both general populations and key target
    groups: In 1986, Uganda established a National AIDS Control Program
    (ACP), which launched an aggressive public media campaign that included
    print materials, radio, billboards, and community mobilization for a
    grass-roots offensive against HIV. A national sentinel surveillance
    system, which has tracked the epidemic since 1987, began with four
    sites and by 2000 included 15; also of importance, there has been
    surveillance of AIDS cases since 1986. The ACP became the STD/AIDS
    Control Programme in 1994 and has since trained thousands of community-
    based AIDS counselors, health educators, peer educators, and other
    types of specialists. Led by their leaders' examples, the general
    population in both urban and rural areas eagerly joined the fight
    against AIDS, so that it became a ``patriotic duty'' to support the
    effort. Spreading the word involved not just ``information and
    education'' but rather a fundamental behavior change-based approach to
    communicating and motivating. Decentralization itself was actually a
    type of local empowerment that involved local allocation of resources--
    in itself a motivating force.
        Notably, Uganda's approach to BCC has relied more on ``non-
    electronic'' mass communication--which was community-based, face-to-
    face, and culturally appropriate. Strong nongovernmental organizations
    (NGO) and community-based support led to flexible, creative, and
    culturally appropriate interventions that worked to change behavior
    despite extreme levels of post-civil war house-hold poverty. As Edward
    Green observed, ``low-tech'' approaches also led to the sensitization
    and subsequent involvement in AIDS awareness and education of not only
    health personnel, traditional healers, and traditional birth attendants
    (TBAs), but influential people normally not involved in health issues
    such as political, community, and religious leaders, teachers and
    administrators, traders, leaders of women's and youth associations, and
    other representatives of key stakeholder groups. BCC interventions
    reached not only the general population, but also key target groups
    including female sex workers and their clients, soldiers, fishermen,
    long-distance drivers, traders, bar girls, police, and students,
    without creating a highly stigmatizing climate.

        3. Interventions addressed women and youth, stigma and
    discrimination: Linked to high-level political support and grassroots-
    level communication for behavior change was a strong emphasis on
    empowerment of women and girls; targeting youth in and also out of
    school; and aggressively fighting stigma and discrimination against
    people living with HIV/AIDS (PLWHAs). Since at least 1989, teachers
    have been trained to integrate HIV education and sexual behavior change
    messages into curricula. At the same time, the country's President and
    his political party have attempted to empower women and youth by giving
    them more political voice, including in Parliament where by law women
    make up a minimum one-third of the members. Four members elected by
    youth caucuses represent youth in Parliament. Youth-friendly approaches
    promoted partner reduction through talking about delaying sexual
    debut--remaining abstinent, remaining faithful to one uninfected person
    if ``you've already started,'' ``zero-grazing,'' and using condoms if
    ``you're going to move around.'' Of particular note is the indicator
    for the proportion of youth that has not yet begun to have sex. In an
    African Medical and Research Foundation (AMREF) study in Soroti
    District cited by Vinand Nantulya, among youth age 13-16 nearly 60
    percent of boys and girls reported having already ``played sex'' in
    1994, but in 2001 that proportion was down to less than 5 percent.
        Respecting and protecting the rights of those infected by HIV has
    been inspired since 1988 by a number of prominent Ugandan citizens, and
    by public events such as candlelight memorials and World AIDS Day
    observances. In the late 1980s, a celebrated European-based Ugandan
    musician, who went public about his HIV status at the beginning of the
    epidemic, returned home and devoted his last days to giving testimonies
    in schools, colleges, churches and elsewhere. Of critical importance,
    The AIDS Support Organization (TASO) was organized back in 1987, and
    has advocated against discrimination and stigma while pioneering a
    community-based approach for care of PLWHAs. The work of TASO and other
    care organizations has also made important contributions to prevention
    efforts, exemplifying the concept of a prevention-to-care continuum.
    Other national spokesmen included a Major in the Ugandan army who
    talked openly about his infection and how he used condoms to avoid
    infecting his wife, and a Protestant minister who disclosed that he
    learned of his infection when his first wife died, and talked publicly
    about using condoms to avoid infecting his new wife and their children.
    Openness on the part of the President, other government and community
    leaders, and prominent activists has led in general to a remarkably
    accepting and non-discriminatory response to AIDS.

        4. Religious leaders and faith-based organizations have been active
    on the front lines of the response to the epidemic: Mainstream faith-
    based organizations wield enormous influence in Africa. Early and
    significant mobilization of Ugandan religious leaders and organizations
    resulted in their active participation in AIDS education and prevention
    activities. Also, Mission hospitals were among the first to develop
    AIDS care and support programs in Uganda. In 1990, the Islamic Medical
    Association of Uganda (IMAU) piloted an AIDS education project in rural
    Muslim communities that evolved into a larger effort to train local
    religious leaders and lay community workers. Documenting increases in
    correct knowledge and decreases in risky behaviors, the IMAU project
    was selected as a ``Best Practices Case Study'' by UNAIDS. The
    Protestant Church of Uganda organized a workshop for bishops and other
    religious leaders in 1991, and implemented an extensive AIDS education
    project in many dioceses. The Catholic Church and mission hospitals
    provided leadership in designing AIDS mobile home care projects and
    special programs for AIDS widows and orphans. The three chairpersons of
    the Uganda AIDS Commission have included an Anglican and a Catholic
    Bishop. (The first leader was President Museveni.)

        5. Africa's first confidential voluntary counseling and testing
    (VCT) services: In 1990, the first AIDS Information Center (AIC) for
    anonymous VCT opened in Kampala. By 1993, AIC was active in four major
    urban areas as more and more people became interested in knowing their
    sero-status. AIC pioneered providing ``same day results'' using rapid
    HIV tests, as well as the concept of ``Post Test Clubs'' to provide
    long-term support for behavior change to anyone who has been tested,
    regardless of sero-status. Uganda was fairly unique in Africa in the
    emphasis it placed on VCT, at a time when the Global Program on AIDS
    and other international organizations were not yet recommending it as a
    prevention strategy.

        6. Condom social marketing has played a key but evidently not the
    major role: Condom promotion was not an especially dominant element in
    Uganda's earlier response to AIDS, certainly compared to several other
    countries in eastern and southern Africa. In Demographic Health
    Surveys, ever-use of condoms as reported by women increased from 1
    percent in 1989, to 6 percent in 1995 and 16 percent in 2000. Male
    ever-use of condoms was 16 percent in 1995 and 40 percent in 2000.
    Nearly all of the decline in HIV incidence (and much of the decline in
    prevalence) had already occurred by 1995 and, furthermore, modeling
    suggests that very high levels of consistent condom use would be
    necessary to achieve significant reductions of prevalence in a
    generalized-level epidemic. Therefore, it seems unlikely that such
    levels of condom ever-use in Uganda (let alone consistent use, which
    was presumably much lower) could have played a major role in HIV
    reduction at the national level, in the earlier years. However, in more
    recent years, increased condom use has arguably contributed to the
    continuing decline in prevalence.

        In the early 1990s, there was resistance on the part of the
    President and some religious leaders to promoting condom use, but by
    the mid-1990s the controversy had generally faded. Purchased mainly
    with external donor funds, millions of condoms have since then been
    distributed by the MOH through health centers and NGO projects. Condom
    sales and reported use have increased significantly during the past
    half-decade (although still not to the same extent as in other
    countries like Zimbabwe, South Africa, Botswana, and Kenya). High
    levels of condom use have been reported for commercial sex work (i.e.,
    reportedly at near-100 percent levels in Kampala), and according to
    Uganda's 2000 DHS, among people reporting a non-regular partner in the
    past 12 months, 59 percent of men and 38 percent of women reported
    using a condom with their last non-regular partner. Therefore, current
    condom use rates with non-regular partners are probably playing a role
    in the continued declining seroprevalence. Note that while condom use
    with non-regular partners has been increasing, Ugandans are also
    reporting significantly fewer non-regular partners. In contrast,
    according to John Stover, if condom use in Kenya had not been as
    plentiful, seroprevalence might have increased even more than it has.
    But without the other, Uganda-like behavior changes (i.e., delay of
    sexual debut and ``zero grazing''/partner reduction), prevalence did
    not decline.
        Sexually transmitted infections (STI) control and prevention
    programs have received increased emphasis: Since 1994, after declines
    in HIV prevalence began to be documented, two donor-funded projects
    addressed improving STI diagnosis and treatment of STIs. Adequate
    supplies of STI drugs in the country suffered from considerable delays
    in offshore procurement but by the end of the 1990s, drug supplies were
    adequate and distribution to rural health facilities was improving.
    Donor funding also financed a national reference laboratory at Mulago
    Hospital to study drug resistance. Two large randomized trials in
    Uganda (Rakai and Masaka) attempted to look at the impact of STI
    treatment on reducing HIV prevalence. Although both interventions
    reduced the rates of some STIs, there was no significant reduction in
    HIV incidence. According to an expert panel at the 2002 World AIDS
    Conference in Barcelona, the main reason for the lack of effect on HIV
    from STI treatment was the large decrease in risky sex/multiple partner
    trends that had occurred in Uganda by the time the STI trials began.
    (Most HIV transmission therefore now occurs within monogamous regular
    partnerships, where bacterial STIs tend to be rare.)

        8. The most important determinant of the reduction in HIV incidence
    in Uganda appears to be a decrease in multiple sexual partnerships and
    networks: In general, Ugandans now have considerably fewer non-regular
    sex partners across all ages. Population-level sexual behavior,
    including the proportion of people reporting more than one sexual
    partner, in Kenya (1998), Zambia (1996), and Malawi (1996), for
    example, appear comparable to those reported in Uganda in 1988-89. In
    comparison with men in these countries, Ugandan males in 1995 were less
    likely to have ever had sex (in the 15-19-year-old range), more likely
    to be married and keep sex within the marriage, and less likely to have
    multiple partners, particularly if never married.
        According to Rand Stoneburner, such behavioral changes in Uganda
    appear related to more open personal communication networks for
    acquiring AIDS knowledge, which may more effectively personalize risk
    and result in greater actual behavior change. Comparing DHS survey data
    with Kenya, Zambia, and Malawi, Ugandans are relatively more likely to
    receive AIDS information through friendship and other personal networks
    than through mass media or other sources, and are significantly more
    likely to know of a friend or relative with AIDS. Social communication
    elements, as suggested by these kinds of indicators, may be necessary
    to bridge the motivational gap between AIDS prevention activities and
    behavior change sufficient to affect HIV incidence. If these elements
    are present, the success of prevention activities may be greatly
    enhanced. Model simulations suggest that knowledge can diffuse rapidly,
    even early in an epidemic, in an environment of ``open'' personal
    networks. Uganda's President set the example for the nation with his
    matter-of-fact approach to dealing with the HIV threat, and inspired
    thousands of community, religious, and government leaders to talk
    candidly to people about delaying sexual activity, abstaining, being
    faithful, ``zero grazing,'' and using condoms (roughly in that order).

        What did all this cost? According to an analysis by Elizabeth
    Marum, USAID/Centers for Disease Control and Prevention (CDC) HIV
    program director in Kampala throughout the 1990s, total donor support
    for all AIDS-related contributions during the period 1989-1998 was
    approximately $180 million, or about $1.80 per adult per year over the
    10-year period. Donor contributions amount to an estimated 70 percent
    of total expenditures on AIDS prevention and care in Uganda. Although
    this proportion is clearly significant, Uganda itself (both public and
    private sectors) must be credited with developing much of the
    successful approach, specifically: involvement of religious
    organizations, bold IEC in schools, VCT, and community-based and
    culturally appropriate BCC strategies.

        A ``social vaccine'' in Africa? (Can this success be replicated?)
    It must be remembered that many of the elements of Uganda's response,
    such as high-level political support, decentralized planning, and
    multi-sectoral responses, do not affect HIV infection rates directly.
    Sexual behavior itself must change in order for seroincidence to
    change. According to Stoneburner, the effect of HIV prevention
    interventions in Uganda (particularly partner reduction) during the
    past decade appears to have had a similar impact as a potential medical
    vaccine of 80 percent efficacy. The historical and socio-cultural
    context, various interventions and other factors are complex and may be
    somewhat unique to Uganda, and it is not clear to what extent this
    success can exactly be replicated elsewhere, especially in more
    cosmopolitan, Westernized settings. However, recent seroprevalence and
    behavioral survey data among youth in Zambia indicate that a Uganda-
    like success story may be in the making there as well. According to a
    recent study by Population Services International, the main factor
    behind the large decline in prevalence among Zambian youth during the
    1990s was a significant reduction in multiple partner trends.
        In conclusion, although we may never fully know ``what really
    happened in Uganda,'' the experience there and in other countries that
    have achieved some success suggests that a comprehensive behavior
    change-based strategy, ideally involving high level political
    commitment and a diverse spectrum of community-based participation, may
    be the most effective prevention approach.

                                    SOURCES
        1. Edward C Green, Ph.D. ``What happened in Uganda?'' [Powerpoint
    presentation]; ``What are the lessons from Uganda for AIDS prevention?
    [10-page document]. Presentation to USAID, Washington DC, Feb. 5, 2002.
        2. Vinand M Nantulya, M.D., Ph.D. ``HIV/AIDS prevention: Policy and
    program context of Uganda's success story'' [Powerpoint presentation].
    Presentation to USAID, Washington DC, Feb. 5, 2002.
        3. John Stover, Ph.D. ``The effects of behavior change on trends in
    HIV incidence in Uganda and Kenya'' [Powerpoint Presentation].
    Presentation to USAID, Washington DC, Feb. 5, 2002.
        4. Rand Stoneburner, Daniel Low-Beer, Tony Barnett, Alan Whiteside.
    ``Enhancing HIV prevention in Africa: Investigating the role of social
    cohesion on knowledge diffusion and behavior change in Uganda.''
    Presentation at the World AIDS Conference, Durban, South Africa, July
    2000; also presented at the World Bank, October 2000, and at USAID,
    Washington DC, February 2002.
        5. Elizabeth Marum & E. Madraa. ``A decade of an effective national
    response to AIDS: A review of the Ugandan experience.'' Draft ms.,
    1999.
        6. SM Mbulaiteye, C Mahe, JAG Whitworth, et al. Declining HIV-1
    incidence and associated prevalence over 10 years in a rural population
    in south-west Uganda: A cohort study. Lancet 2002;360:41-44.
        7. S Agha. Declines in casual sex in Lusaka, Zambia: 1996-1999.
    AIDS 2002;16:291-93.
        Summary produced by Jan Hogle, Ph.D., Synergy Consultant.

        Senator Alexander. Thank you, Dr. Peterson, and thank you
    for your service. It is helpful to have someone with as much on
    the ground experience as you have had with this.
        I have a few questions and I know Senator Feingold will
    have some and then I may have a couple more on a little
    different subject. I would like to talk with you for a moment
    about--and you referred to both of these--will the ABC approach
    work in other African countries? And then, then the more
    practical question of just how you go about implementing the
    model.
        Let me begin with the ``will it work'' point. You referred
    to several factors, but Mrs. Museveni last week here referred
    often to self-control in the remarks I heard her make. You
    mentioned that. And she said that, what you also said, which is
    the abstinence part, the A part, which she starts with and
    gives more emphasis to, although she does encourage strongly
    the B and the C, she says that fits the Ugandan culture. She
    basically said, in not so impolite words, that until the
    foreigners came in and began messing up behavioral patterns in
    Uganda, things were better in this respect.
        No. 1, how true is that? In your own experience, how much
    does abstinence fit the Ugandan culture for children? And No.
    2, is Uganda unique in that respect among African countries and
    does that mean that this model does not fit other countries
    quite so neatly?
        Dr. Peterson. Thank you. I think there has been a change in
    African cultures, and I am sure Sophia can say many more things
    about that. But most of the cultures do very highly regard
    abstinence in their cultural traditions. There are a few
    examples that are slightly different than that in sort of
    exceptional cases or with the Masai coming-of-age rites. But
    for the most part, abstinence and faithfulness is a cultural
    norm and, just as our own society went through a revolution and
    a sort of loosening of morals, African culture did as well.
        So when the call came for abstinence and ``zero grazing,''
    it was very much based on coming back to your African roots.
    Zero grazing is where you put a stake in the ground and you tie
    your cow to it and he grazes just around that stake. That zero
    grazing in their agricultural society means to them the same
    thing: Put your stake in the ground for your marriage and you
    graze only within that household. So it resonated very much
    with the cultural norms and bringing them back to their
    cultural roots.
        As far as whether it is appropriate for other countries, I
    would say, in all of the other countries that I have been in,
    yes, that they have that same cultural norm. It will be pulling
    them back to that cultural norm.
        The other thing we need to remember is that most of the new
    infections, 50 to 69 percent of new infections, are with the
    young people, 15- to 24-year-olds, where abstinence is a very
    appropriate message to bring and the delay of onset of sexual
    activity. So if we are truly going to turn the epidemic around
    in a country, we do need to focus on what is best for the youth
    of that country. Uganda has really found a good balance and
    that is, as she said, abstinence was No. 1. Once you are
    married, be faithful, but they have also been very good at
    reducing the number of partners if they were outside of the A
    and B norms. But then using condoms also in the casual sex.
        So they have heard all three parts and Uganda has done an
    amazing job of implementing all three parts.
        Senator Alexander. In a letter that Mrs. Museveni wrote to
    Senator Lugar, the chairman of our committee, April 2, which I
    will put in the record and share with Senator Feingold,
    although he may have seen it, she says: ``My experience has led
    me to conclude that when dealing with young people especially,
    it is vitally important to emphasize abstinence as the first
    line of defense, so to speak.'' She also points out in her
    letter the importance of B and C in the ABC formula.
        [The letter referred to follows:]

                                 The Republic of Uganda
                                    State House, P.O. Box 25497
                                       Kampala, Uganda, 2nd April, 2003

    The Honorable Richard G. Lugar,
    Chair
    Senate Foreign Relations
    United States Senate
    Washington, DC 20510

        Dear Honorable Lugar,

        Re: GLOBAL AIDS SENATE BILL

        We in Uganda are very pleased and grateful for the leadership that
    the United States of America has shown as far as the struggle against
    HIV/AIDS, Tuberculosis and Malaria is concerned. We believe that the
    commitment of the Bush Administration to this cause is genuine, as
    proven by the sizeable funding it has recently made available for the
    purpose of supporting developing nations hit by those killer diseases.
        I have been made to understand that the Global AIDS Bill is soon
    coming before the Senate, and that the important issue of preferred
    methods of prevention of HIV is likely to be a point of contention. I
    note that one of the approaches to prevention is now being referred to
    as the ``Uganda ABC model,'' namely ``Abstain, Be Faithful, Use
    Condoms,'' in that order of preference.
        I feel that I should shed some light on the issue of preventive
    measures against HIV/AIDS, since I have had first hand experience in
    activities of behaviour change in Uganda for over a decade. My
    experience has led me to conclude that, when dealing with young people
    especially, it is vitally important to emphasize Abstinence as the
    first line of defence, so to speak.
        I believe that we humans have an innate mechanism called
    conscience, which convicts us concerning what is wrong and what is
    right, or what is good for our survival and what is harmful. It is this
    mechanism that society builds on to form certain norms and value
    systems to ensure the survival and continuity of it's people. When
    dealing with a disease such as HIV/AIDS which has no known cure, it is
    important to tap into this in-built sense of right and wrong and
    encourage it, particularly in young people who have not yet become set
    in their habits or behaviour patterns. I cannot help but recall the
    verse in the Bible which says, ``Train a child in the way that he
    should go, and when he is old he will not turn away from it.''
    (Proverbs 22:6)
        And so, for the young, I believe it is our obligation to try to
    form their character by teaching them the benefits of abstaining from
    sex until they are ready to engage in it in the right context and with
    the right partner. Not to do this, to me, implies that we as adults and
    leaders have no faith in human nature and in our ability as human
    beings to control ourselves. How then are we going to prevent our young
    people from indulging in other practices such as excessive intake of
    alcohol, substance abuse, stealing, and killing other human beings? How
    are we going to teach them to be law-abiding citizens if we do not
    train them to exercise self-control while they are still young? Human
    beings must learn to police themselves internally; this is the first
    safeguard of civilization. This is the wisdom of the ages, and we
    ignore it at our own peril. Incidentally, I must mention that even
    before Christianity came to Uganda, promiscuity, specifically sex
    before marriage was severly punished; therefore in teaching abstinence
    to our children, we are also reinstating our cultural practices and
    traditions. A culture of promiscuity is, literally, a culture of death
    to the human race.
        The practice of being faithful in marriage relationships then
    follows quite naturally when you have been practicing abstinence, and
    there is no need to elaborate on this.
        We in Uganda have not advocated against the use of condoms as a
    method of prevention against HIV/AIDS. Condoms are freely available in
    all appropriate public places, freely and continuously advertised in
    our electronic and print media. Indeed they are even to be found in the
    remotest of our villages.
        However, my husband and I belong to the school of thought that
    maintains that our preferred method of prevention for certain
    catagories of our population, particularly the young, is Abstinence and
    Faithfulness in sexual matters. We have seen it work in Uganda, and I
    would strongly advocate that it be considered as the method that, in
    the long run, is likely to be the most beneficial.
        This is my humble opinion, based on 15 years of hands-on-experience
    in combating the killer disease, HIV/AIDS. I hope it can be transmitted
    to the august assembly of the Senate of the United States of America as
    they deliberate these issues, which are critically important to our
    populations.
            Sincerely,
                                        Janet K. Museveni (Mrs)

        Senator Alexander. As I understand USAID policy, the
    emphasis has shifted somewhat from a focus, more of a focus on
    condoms, to more of a primary focus on abstinence, still
    recognizing the importance of the B and C part of the formula.
    Can you describe that shift of policy, if indeed there has been
    a shift?
        Dr. Peterson. I think this is part of the balanced approach
    and being able to shift the balance based on what you know,
    what you have learned, and on the specific country. For a long
    time we did not have data on abstinence, and within the public
    health community it was extraordinarily controversial. Senator
    Feingold pointed out that many of these issues have become very
    political at times. What I hope is to find the middle ground
    that everyone can agree to.
        What has happened in the last few years is we are getting
    more and more data that supports abstinence as a public health
    intervention, not just as a philosophy or a moral mandate, but
    as a data-based public health intervention. The question
    initially, everyone said was: Yes, if you could get people to
    abstain, of course that would help reduce transmission of
    disease, but would youth ever do that? Would they ever wait?
        What we are seeing, and I have seen it on the domestic
    front in teen pregnancy prevention programs as well as in
    Uganda and now in a number of other countries, is that with
    full education and really understanding the issues, you can
    wait, and they will wait. They will choose to wait, and
    therefore it is truly a public health intervention that can be
    used in HIV-AIDS programs successfully.
        Senator Alexander. My last question in this round is: After
    we get beyond the model and the talk and the legislation,
    somebody has to spend the money and make things work. How do
    you take a model like this into some country other than Uganda
    and make it work? What exactly do you do? What steps do you
    take? How do you go about that?
        Dr. Peterson. First certainly is to know the situation in
    that country, both the distribution of AIDS, the age groups at
    risk, whether it is what we call a concentrated epidemic, which
    would be more like the Cambodia/Thailand, or, as in the
    Presidential initiative countries, a more generalized epidemic.
    Look at the age spectrums and the routes of exposure.
        Then you really need people and partners who are in the
    country who then can look at how much abstinence: Are we
    reaching a youth group or are we reaching married families with
    too many partners? Or is it really being primarily moved along
    by high-risk sexual activity of prostitutes and their clients?
        Once you have done that, then you go to the partners who
    know how to work with those groups, with the in-country
    experts. We have examples of programs in many different
    countries, both on abstinence--our Zambia program is social
    marketing of abstinence. We have worked in policy change,
    quality assurance, voluntary counseling and testing.
        The elements are all there. What you have to do is take all
    of those elements that have been supportive to the ABC message,
    find the political leaders, the faith-based leaders, and engage
    as many different sectors of society as possible to address the
    issues in their own cultural and epidemiological priorities.
        Senator Alexander. Thank you.
        Senator Feingold.
        Senator Feingold. Thank you, Mr. Chairman. I found your
    line of questioning there to be very helpful and very much
    along the lines I want to pursue.
        I would like to ask you a little bit more about this point
    that Senator Alexander was just asking you about, the
    differences from country to country. I noticed your answer
    essentially talked about looking at the same factors in each
    country and trying to adapt it to the country, but it is my
    sense, having visited 14 or 15 African countries and having
    tried to talk about AIDS or visiting an AIDS program in each of
    those countries, that each of those countries is not the same
    culturally. I am not suggesting you said that, but I think
    there are significant differences within the traditional
    cultures. There are also significant differences because of the
    different religious and colonial influences that occurred in
    the countries.
        In fact, I have been struck by, for example, the difference
    in the willingness to talk about the disease in different
    places. So I guess I would like to pursue a little more
    specifically: How do you account for the differences between
    countries? Are there religious differences? For example, there
    was a very successful program in Senegal to prevent AIDS from
    ever getting out of control. That is a largely Islamic country
    and Uganda of course is a country that has a significant
    Christian population and traditional religions.
        I am just wondering if you are able to take that into
    account and if it affects people's willingness to address A, B,
    and C.
        Dr. Peterson. Yes, I think there are significant
    differences. In Botswana it is utterly amazing that they have
    both some political leadership speaking about AIDS, they have a
    good health system for Africa, they have been making treatment
    available, and yet stigma has been an incredible stumbling
    block, and they are still not getting people to come in. In
    South Africa violence is an underlying factor that is
    dominating a lot of the response there.
        What we have to do is talk to the people who have been
    working and how they have tried to overcome some of the
    problems. In Haiti, which traditionally is one of those
    countries that does not do very well and has never had the
    political voice, I went to an area, Jeremie on the South
    Peninsula. There was a physician who had mobilized the
    political leaders, the religious leaders, and the civil
    leaders. It is the only place that I have been to recently--and
    I have not been to Uganda in the last few years--where there
    was no stigma.
        At least one of the unifying factors seems to be that
    political or social voice that allows the disease to be talked
    about that says: We will care for you. And Uganda was really
    remarkable about this. Mrs. Museveni talks a lot about
    responsibility and self-control, which sometimes is seen as
    negative, but immediately following that call to responsibility
    she says: But if you are HIV-positive, we will take care of you
    and we will take care of your children. And they have overcome
    stigma there.
        We have seen it in Haiti.
        So I think we need to be very specific in our analysis of
    the problems. There are unifying factors. We know that we need
    to get all sectors involved. We know we need to deal with
    stigma. We know we need to deal with youth. And we put
    relatively different amounts of effort into the problems that
    are the biggest barriers in that particular country.
        But all of the elements were there in Uganda, and they are
    there in other countries as well. We are going to learn new
    responses in some other countries. The business sector is new
    in South Africa. In some place or another, we are going to have
    to learn how do we overcome the violence that is a problem?
        South Africa is beginning to overcome some stigma by
    providing grants that are disability grants, and suddenly
    people are willing to come in to be tested who were not before.
    That is a novel way of overcoming stigma. So we need to keep
    learning lessons, but we can also use what we have learned in
    Uganda and apply the pieces that fit for each country.
        Senator Feingold. I appreciate that answer, because on a
    recent trip to Botswana and South Africa there was so much
    conversation about situations involving older men and younger
    women. Essentially younger women were being put in a position
    where--I do not know if it was completely involuntary.
    Certainly in some cases it was. But you know, that is not an
    abstinence issue.
        So I would suggest that as the policy tries to create the
    proper balance between A, B, and C--I think you are already
    aware of this--that the places in which the shift to focusing
    more on abstinence would be a certain number of places, but not
    necessarily every place, given the very points that you just
    made about, for example, violence in South Africa. I am not at
    all sure that abstinence is as relevant to that as it is to
    some of the issues that occur in other places.
        Obviously, this is what you do, but that is just a point I
    would like to make.
        What kind of information should be available at a voluntary
    counseling and testing center? For example, what if a man comes
    in and gets tested and tests positive? What would he learn? And
    if he returns bringing his spouse and she tests negative, what
    kind of counseling and information will the couple get?
        Dr. Peterson. Very good questions. Before he tests
    positive, he should have had pre-test counseling which should
    have covered the disease, the test itself, and the likelihood
    of testing positive, the windows where it might test negative,
    how it is transmitted, and what it might mean if he tests
    positive for himself.
        After the test comes back, we actually do a lot of
    counseling for those who are HIV-negative, not just for those
    who are HIV-positive, and it has been shown that post-test
    counseling for HIV-negative has also been very helpful in
    behavior change. Presumably they are coming in because they
    have put themselves at risk. So we are seeing changes in
    behavior post-counseling even if they are negative.
        If they are HIV-positive, then certainly they will learn
    about the disease, the progression of the disease, how they can
    keep themselves healthy as long as possible, and their
    responsibility to not pass the disease on.
        If you have what we call a discordant couple--HIV-positive,
    usually husband, and then an HIV-negative spouse--then
    certainly they have two options. They either abstain, which
    some couples actually do, or use condoms. We have studies in an
    African setting that show correct, consistent, every single
    time use can protect the uninfected partner, and they would be
    recommended to do that very diligently.
        I would like to go back to the gender issue, the young
    girls, and say that I agree completely. You have in your
    handout my favorite slide that I used for teaching in schools
    in Zimbabwe with the older man and the younger girl. I think
    this is an element we really need to again delve deep into the
    Uganda story. The fact that the young girls in Uganda did have
    a delay in onset of sexual activity, that they were able to
    stay virgins longer, means there has been a change in this
    situation. Either the girls have been given the power to say no
    or the men's activities have changed, probably both.
        But we need to know how that very deep cultural change has
    happened. So those are the kinds of issues we will continue to
    look at very strongly. I see it as the backdrop to the ABC. It
    is one of those elements that supports the AB--you cannot just
    say abstain. What we have to do, especially for youth that are
    so critical, is say how can you abstain, how are you going to
    have the ability, the authority, to protect yourself?
        That is true for wives as well. I used to have Kenyan wives
    come and say: My husband is coming home from Nairobi, I know he
    has that disease; what can I do to protect myself? And in 1986,
    1987 in Kenya, I did not have anything that I could do for her.
        Senator Feingold. Well, I appreciate that as well, because
    in a sense, at least in some contexts, the abstinence is really
    a good consequence of empowering women or young girls to
    protect themselves. It is not actually the solution. It is the
    result of allowing women to make their own choices and to have
    the legal power and other powers to avoid something they may
    not want or may not be ready for.
        So I think that needs to be a part of the analysis. I have
    found an awful lot of women talking about that element of it.
    That is really the driving force, giving women the power to
    protect themselves.
        One of the concerns that has been voiced about abstinence-
    only programming is the concern that unless that programming is
    supplemented with other information when abstinence fails,
    individuals have no information about how to protect
    themselves. Other concerns center on the possibility that some
    may seek to discourage promiscuity by arguing that condoms do
    not work, thereby discouraging people from bothering to use
    them when they do actually begin a sexual relationship.
        Will USAID work to ensure that to the extent possible
    communities have access to complete and accurate information
    about prevention strategies?
        Dr. Peterson. The short answer is yes, very strongly. I
    worked in an abstinence-only program in Zimbabwe in the
    schools, but we gave youth full information about their sexual
    development, about the disease, about how they could protect
    themselves. Many of the faith-based organizations have said,
    can we talk about condoms, and this is in an abstinence-only
    kind of setting, and give the data on how effective condoms
    are.
        So there are some that are uncomfortable talking about it
    at all and there are others--and what I have said would be our
    policy--if they are to talk about condoms then they must be
    absolutely scientifically accurate. With a group that we are
    working with actually on either side of the debate, what we
    would want to have is accuracy in what they teach the children.
    And we have good data that condoms are protective. Is it
    perfect? No. But we have good data that condoms are protective
    and therefore that they play a role. We are very comfortable
    having all of our partners do that.
        Senator Feingold. Well, I appreciate your very reasonable
    answers and your willingness to get into some depth on them.
        Thank you, Mr. Chairman.
        Senator Alexander. I have a couple of questions and then I
    will go back to Senator Feingold, and then we will go to our
    second panel.
        My first question is to go back to this AIDS Corps idea.
    What I am really trying to do here is understand the idea well
    enough to move it on down the path, recognizing, as Senator
    Feingold pointed out, that a lot of people have this idea. The
    President in his speech in the East Room a couple of weeks ago
    turned around to the Peace Corps Director at the end of the
    speech and said: ``Now, Mr. Peace Corps Director, I want you to
    go to work on this idea.''
        As I looked at the House bill that we passed last Thursday
    night, I saw three things about it that if I were in a magical
    world I would have changed with a sweep of the wand, and I
    wonder what you might think about this. One is I like the name
    ``AIDS Corps'' because I would like to focus. I think it gives
    a focus to the idea.
        Two is I would like to put training for treatment ahead of
    treatment. In other words, my sense of things is that there is
    a real demand for volunteers or employees from this country who
    can go to African countries, as an example, and train people to
    treat people.
        A third point is I would like to see the time limitation
    for that more flexible. I believe the legislation we enacted
    said 3 years. There are organizations in this country of health
    professionals and physicians who regularly go to other parts of
    the world for shorter periods of time and do a lot of good.
    They go all over the world. I am wondering whether if we could
    not make it easier for health professionals and doctors to go
    to Uganda, Botswana, wherever, for a month or 2 months or 3
    months and fit into a program where they could train people to
    treat people and then come home, whether that is a practical
    idea.
        Then the last change I would make would be to try to avoid
    the medical malpractice issues that might arise with any sort
    of treatment, to put these, these persons, these health
    professionals from the United States, say, who might go to an
    African country to train people, if they do incidental
    treatment and incur some sort of liability that they would be
    under the same set of circumstances that a Federal employee
    would be under the Tort Claims Liability Act.
        Now, anything you might say about this general idea would
    be useful to me and the committee, I think, as we look ahead to
    take an idea of many Senators and the President and push it
    forward.
        Dr. Peterson. Clearly, especially with the passage of the
    emergency AIDS bill and the Global Fund, we are getting to the
    point where we have got a fair amount of dollar resources. It
    is very soon that we are going to have what we call human
    capacity, the people as the limiting factor. We have an
    expanding epidemic, with more people at risk. We have a
    contracting number of health personnel because, frankly, they
    are as devastated by the disease as others.
        When I was in Zimbabwe, my husband trained the higher level
    Ministry of Health people, and a third of the 20 or so people
    he trained are now dead. So human capacity is going to be one
    of the biggest limiting factors. Before you can just go and do,
    you truly should be training. So I agree with you completely
    that training needs to be first.
        The Peace Corps is absolutely marvelous. They are more
    likely to be the ones to do this, and in fact are doing really
    wonderful, community-based training in many places, but that is
    going to be mostly on the prevention end. When you get to the
    clinical and treatment piece, then, as you said, there are many
    groups that are already experienced medical professionals. The
    only thing that I would have liked is experience, international
    experience, as one of the criteria, because that is what would
    lead us to being able to be more flexible about how long they
    went.
        If they already had experience in similar countries, then
    they would be much more able to get up to speed quickly and
    make sure that they were training appropriate for that country,
    and not just trying to transfer our technology.
        As we have been looking at this problem, both within the
    agency overall, but also together with HHS and other USG
    agencies on the mother-to-child transmission, we have been
    looking at this idea of a medical volunteer corps. At least
    initially, we were going to try and embed that volunteer
    medical corps within a twinning program where a U.S.
    institution is twinned with an African or Caribbean institution
    so they have an ongoing relationship and the volunteers are
    within those institutions and go back and forth.
        So we are very supportive. We have been working very hard
    on this. I think this is one part of how we begin to deal with
    the human capacity issue. But we also need to do lots more
    training, as well as deal with systems issues like brain drain
    that are causing this to be such a difficult problem in many of
    the countries hardest hit by AIDS.
        Senator Alexander. Senator Feingold, do you have more
    questions?
        Senator Feingold. No, thank you.
        Senator Alexander. Dr. Peterson, thank you very much.
        May I invite our next two witnesses to come forward while I
    introduce them.
        I would like to welcome to the hearing Dr. Edward Green and
    Ms. Sophia Mukasa Monico. Dr. Green is the senior research
    scientist at the Harvard Center for Population and Development
    Studies. He is a medical anthropologist with 30 years
    experience in developing countries, one of the leading
    authorities in academia on the Ugandan success story in the
    application of the ABC model.
        Ms. Mukasa Monico is a Uganda. She is currently the senior
    AIDS program officer with the Global Health Council here in
    Washington, DC. She is a leading human rights and AIDS activist
    from Uganda. She has formerly led the AIDS Support Organization
    of Uganda, a leading civil society organization.
        May I suggest Dr. Green first and Ms. Monico second, if you
    could keep your remarks to about 10 minutes or less, and then I
    and Senator Feingold will have questions for both of you. Thank
    you for coming.

    STATEMENT OF EDWARD C. GREEN, PH.D., SENIOR RESEARCH SCIENTIST,
        HARVARD CENTER FOR POPULATION AND DEVELOPMENT STUDIES,
                             CAMBRIDGE, MA

        Dr. Green. Thank you, Senator Alexander, distinguished
    members of the Africa Subcommittee. I am an anthropologist
    working at the Harvard School of Public Health. For most of my
    professional career I have worked in less developed countries
    as a behavioral science researcher and as a designer and
    evaluator of public health programs. I have worked extensively
    in Africa and other resource-poor parts of the world. A good
    deal of my work has focused on reproductive health, some of
    this including the social marketing of contraceptives.
        I applaud the President's initiative to commit major U.S.
    funding to address HIV-AIDS in the parts of the world with the
    highest infection rates. I am also glad that notice has been
    taken of Uganda's success in AIDS prevention since there is
    much to be learned from the country that has had the greatest
    amount of AIDS prevalence decline. Infection rates have
    declined from 21 percent to 6 percent. We have also heard the
    figure 15 to 5 percent. It depends on whether you do a
    weighting for rural-urban residents.
        The Government of Uganda, led by President Museveni,
    developed a distinctive approach to AIDS prevention known as
    the ABC approach: abstain, be faithful, or use a condom. The
    abstinence message for the most part took the form of urging
    youth to delay having sex until they were older, preferably
    married. Many of us in the AIDS and public health communities
    did not believe that abstinence and faithfulness were realistic
    goals. It seems now that we were wrong.
        Uganda's ABC AIDS program began in 1986, the year Museveni
    became head of state. Since the rate of new infections began to
    decline in the late 1980s, incidence rates, it becomes
    important to know what programs were in place at that time and
    what behaviors changed in order to account for the decline of
    infection rates.
        None of the standard programs we associate with AIDS
    prevention--condoms, social marketing, voluntary counseling and
    testing, treatment of sexually transmitted diseases, and most
    recently prevention of mother to child transmission based on
    the drug nevirapine--were in place in the 1980s. I am certainly
    not saying that these standard biomedical interventions are not
    useful, only that we need to look at what interventions were
    actually in place when infection rates began to decline.
        It is also important to work backward from the
    epidemiological and behavioral data. We know that prevalence
    decline and changes in sexual behavior were most pronounced in
    youth age 15 to 19. These findings took many of us by surprise
    since we believed that teenagers are driven by raging hormones,
    therefore abstinence is an unrealistic or impossible objective.
    In fact, many of us also believed that women had no power to
    negotiate sex or to refuse unwanted sex or to insist upon
    condom use because African societies are male-dominated.
        In spite of these legitimate concerns, based on real
    cultural patterns, Uganda designed interventions aimed at
    fundamentally changing sexual behavior, something the standard
    interventions just listed do not attempt. The primary target
    audience was youth. Let me provide two examples of
    interventions that were among the first developed by Uganda.
    One is the youth program which was and is national in scope.
    The second example involves faith-based organizations.
        The program to introduce AIDS education in Ugandan primary
    schools began in 1987, starting with the School Health
    Education Program, or SHEP, of the Ministry of Education. The
    aim of this program was to teach youth with AIDS prevention
    information, reach youth with this information, before they
    became sexually active. It was also known that the dropout
    rates after primary school were high.
        AIDS was not the only component of SHEP, but it was an
    important one. The behavior change emphasis was on delay of age
    of first sex, but education about condoms was also part of the
    program.
        To implement the new program there was a training of
    trainers approach that went from the district level down to
    sub-districts, then to teachers, who were the ones who taught
    students. Students themselves were trained as peer educators
    and they were expected to teach their parents and friends about
    AIDS. This was all done in a relatively short time. The basic
    facts about AIDS and how to prevent it were taught.
        So-called life skills education also has been taught in
    Ugandan schools for a number of years beginning in about 1987.
    Life skills might be regarded as AIDS Education 102, which
    comes after the basic course in what AIDS is and how it is
    transmitted and prevented. Life skills refers to training youth
    in skills such as interpersonal relationships, self-awareness
    and self-esteem, problem-solving, effective communications,
    decisionmaking, negotiating sex or not having sex, resisting
    peer pressure, critically thinking, formation of friendships,
    and empathy. These are referred to as cognitive skills and they
    seem to help youth make healthy and indeed life-saving
    decisions.
        Did this and similar programs have impact? According to
    studies by the World Health Organization, the proportions of
    young males age 15 to 24 reporting premarital sex decreased
    from 60 percent in 1989 to 23 percent in 1995. For females the
    decline was from 53 percent to 16 percent.
        The take-home message for the U.S. Senate is that, while
    condoms were part of the education for youth, the emphasis was
    on persuading children to postpone sexual activity until they
    were older, until they were married.
        In addition to the national statistics already cited, we
    have some findings concerning the impact of a school-based AIDS
    education program in Soroti District, a program that benefited
    from additional inputs from an East African nongovernmental
    organization called AMREF. Baseline and followup studies of
    primary 7 students, which is age 13 through 16, but mostly
    around age 14, showed that as an apparent result of the school
    AIDS prevention program self-reported sexual activity among
    boys dropped from 61 percent for the class of 1994 to 5 percent
    for the class of 2001, while in girls the change was of similar
    magnitude, from 24 percent in 1994 to 2 percent in 2001. Some
    evidence other than self-reported findings corroborate these
    remarkable data, and I have some figures in the paper that has
    been handed out.
        Now to the faith-based example. Some other early efforts
    involve faith-based organizations or FBOs. In 1992 USAID
    allocated funds for three major religious groups in Uganda--
    Catholic, Anglican, and Muslim. Each developed an AIDS
    prevention project and each received roughly a third of a
    million dollars from USAID. The FBOs said at first that they
    wished to promote fidelity and abstinence rather than condoms.
    At the time many working in AIDS prevention thought that
    fidelity and abstinence promotion would lead to few, if any,
    measurable results. Nevertheless, USAID made the grants and
    only asked that the FBOs not criticize condom promotion by
    other groups. This was agreed to and adhered to.
        In the months to follow there were few, if any, problems
    over condoms. In fact, before long there was some condom
    promotion by two of the projects.
        All three projects were found to be successful. The
    experience of the Muslim project, IMAL, has been published as a
    U.N. AIDS so-called best practices paper. So I will say a
    little bit more about the Anglican church project because it is
    less well known. This program was implemented in 10 out of 40
    districts in Uganda at the time, meaning that the project had
    relatively large coverage. Clergy and laity were trained in
    AIDS prevention using the peer education approach. AIDS
    education messages were delivered from the pulpit in sermons as
    well as at funerals, weddings, and other occasions.
        A USAID-funded evaluation of sexual behavior change among
    those reached by this project was conducted in 1995. It found
    that those reporting two or more sexual partners declined from
    86 percent to 29 percent for men and from 75 percent to 7
    percent for women. Ever-use of condoms rose from 9 percent to
    12 percent in the same period.
        These findings underscore that in Uganda reduction in the
    number of sexual partners was probably the single most
    important behavior change that resulted in prevalence decline.
    Abstinence was probably the second most important change. Why
    do I say this? We measured both behavior and HIV prevalence
    through surveys of people age 15 through 49. Most people in
    these age groups are married, especially in Africa, where the
    age of marriage is relatively young, and therefore sexually
    active. This is why Uganda's main message directed at the
    majority population was ``zero grazing,'' meaning being
    faithful to one partner. Fidelity to one partner also seems to
    have been the main response to the epidemic, if not to Uganda's
    prevention program.
        When Ugandans were and are asked in surveys what is the
    main thing they have done to avoid AIDS, faithfulness to one
    partner is the first and overwhelming response in all age
    groups except 15 to 19, among whom the first answer is
    abstaining or delaying, closely followed by fidelity to one
    partner.
        Unfortunately, the American political debate over
    abstinence versus condoms has contributed to monogamy or
    partner reduction being somewhat overlooked. It is very good
    that the United States through USAID has adopted the new ABC
    policy for those countries with generalized epidemics, that is
    epidemics where most HIV is found in the general population
    rather than in distinct high-risk groups. This policy should
    guide the development of programs in Africa and the Caribbean
    funded under the President's initiative.
        Indeed, there are other countries in these regions that
    have implemented ABC approaches and they have achieved measures
    of success--Senegal, Zambia, Jamaica, and the Dominican
    Republic.
        My concern is that the ABC from Uganda be recognized for
    what it actually is, a comprehensive approach to AIDS
    prevention that recognizes that people are different and
    therefore a range of behavioral options for AIDS prevention
    needs to be presented, not just one or two. It should be
    remembered that ``zero grazing'' or remaining faithful to one
    partner was the main message for the majority of Uganda's
    population.
        The reason I must say ``was'' is that Uganda's AIDS
    prevention program has gradually changed, perhaps due to the
    funding priorities of foreign donor organizations. Since the
    mid-1990s there has been less emphasis on sexual behavior and
    more on medical solutions. In recent years there has been a
    small but disturbing trend toward riskier sexual behavior and
    for the first time in a decade there has been a slight up tick
    in national infection rates. The distinctive Ugandan ABC model
    of the earlier period, the one developed primarily by Ugandans
    for Ugandans, is the one that seems to have worked the best and
    the one that probably has the most to teach the rest of the
    world. Thank you, Senators.
        [The prepared statement of Dr. Green follows:]

         Prepared Statement of Edward C. Green, Ph.D., Senior Research
       Scientist, Harvard Center for Population and Development Studies,
                                 Cambridge, MA

        Thank you, Senator Alexander and distinguished members of the
    Africa subcommittee. I am an anthropologist working at the Harvard
    School of Public Health. For most of my professional career, I have
    worked in less developed countries as a behavioral science researcher
    and as a designer and evaluator of public health programs. I have
    worked extensively in Africa and other resource-poor parts of the
    world. A good deal of my work has focused on reproductive health, some
    of this including the social marketing of contraceptives.
        I applaud the President's Initiative to commit major U.S. funding
    to address HIV/AIDS in the parts of the world with the highest
    infection rates. I am also glad that notice has been taken of Uganda's
    success in AIDS prevention, since there is much to be learned from the
    country that has had the greatest amount of HIV prevalence decline.
        Infection rates have declined from 21% to 6% since 1991 [Fig. 1].
    The Government of Uganda, led by President Museveni, developed a
    distinctive approach to AIDS prevention known as the ABC approach:
    Abstain, Be faithful, or use Condoms if A and B are not practiced. The
    abstinence message for the most part took the form of urging youth to
    delay having sex until they were older, and preferably married. Many of
    us in the AIDS and public health communities didn't believe that
    abstinence and faithfulness were realistic goals. It now seems we were
    wrong.

                                    Fig. 1.

        Uganda's ABC AIDS program began in 1986, the year Museveni became
    head of state. Since the rate of new infections began to decline in the
    late 1980s, it becomes important to know what programs were in place at
    that time and what behaviors changed in order to account for the
    decline of infection rates. None of the standard programs we associate
    with AIDS prevention:

    Condom social marketing;

    Voluntary counseling and testing (VCT)

    Treatment of STDs

    And most recently, prevention of mother-to-child transmission (PMTCT,
    based on the drug nevirapine)

    were in place in the 1980s.

        I am certainly not saying that these standard, biomedical
    interventions are not useful, only that we need to look at what
    interventions were actually in place when infection rates began to
    decline. It is also important to work backwards from the
    epidemiological and behavioral data. We know that prevalence decline
    and changes in sexual behavior were most pronounced in youth age 15-19.
    These findings took many of us by surprise, since we believed that
    teenagers are driven by ``raging hormones,'' therefore abstinence is an
    unrealistic or impossible objective. In fact, many of us also believed
    that women had no power to negotiate sex, or to refuse unwanted sex, or
    to insist upon condom use, because African societies are male-
    dominated. In spite of these legitimate concerns based on real cultural
    patterns, Uganda designed interventions aimed at fundamentally changing
    sexual behavior, something the standard interventions just listed do
    not attempt. The primary target audience was youth.
        Let me provide two examples of interventions that were among the
    first developed by Uganda. One is a youth program which was and is
    national in scope. The second example involves faith-based
    organizations.

                                THE SHEP PROGRAM

        A program to introduce AIDS education in Ugandan primary schools
    began in 1987, starting with the School Health Education Program (SHEP)
    of the Ministry of Education. The aim of this program was to reach
    youth with AIDS prevention information before they become sexually
    active. It was also known that dropout rates after primary school were
    high. AIDS was not the only component of SHEP, but it was an important
    one. The behavior change emphasis was on delay of age of first sex, but
    education about condoms was also part of the program.
        To implement the new program, there was a ``training of trainers''
    approach that went from the district level, down to sub-districts, and
    then to teachers, who were the ones to taught students. Students
    themselves were trained as peer educators, and they were expected to
    teach their parents and friends about AIDS. This was all done in a
    relatively short time. The basic facts about AIDS and how to prevent it
    were taught.
        So-called Life Skills education has also been taught in Ugandan
    schools for a number of years, beginning in about 1987. Life Skills
    might be regarded as AIDS Education 102, which comes after the basic
    course in what AIDS is and how it is transmitted and prevented.
        Life Skills refers to training youth in such skills as
    interpersonal relationships, self awareness and self esteem, problem
    solving, effective communication, decision-making, negotiating sex or
    NOT having sex, resisting peer pressure, critical thinking, formation
    of friendships, and empathy. These are referred to as cognitive skills
    and they seem to help youth make healthy and indeed life-saving
    decisions.
        Did this and similar programs have impact? According to studies by
    the World Health Organization, the proportion of young males age 15-24
    reporting premarital sex decreased from 60% in 1989 to 23% in 1995. For
    females, the decline was from 53% to 16%.
        The take-home message for the U.S. Senate is that while condoms
    were part of AIDS education for youth, the emphasis was on persuading
    children to postpone sexual activity until they were older, until they
    were married. In addition to the national statistics already cited, we
    have some findings concerning the impact of a school-based AIDS
    education program in Soroti District, a program that benefited from
    additional inputs from an East African NGO called AMREF. Baseline and
    follow-up studies of Primary 7 pupils (age 13-16) showed that as an
    apparent result of the school AIDS prevention program, self-reported
    sexual activity among boys dropped from 61% for the class of 1994 to 5%
    for the class of 2001, while in girls the change was of similar
    magnitude, from 24% in 1994 to 2% in 2001 [Fig. 2]. Some evidence other
    than self-reported findings corroborate these remarkable data. [Fig. 3]
    (AMREF/Uganda. (2001; Nantulya 2002).

                          THE ANGLICAN CHURCH PROJECT

        Some other early efforts involved faith-based organizations (FBOs).
    In 1992, USAID allocated funds for three major religious groups in
    Uganda: Catholic, Anglican and Muslim. Each developed an AIDS
    prevention project and each received roughly $350,000 from USAID. The
    FBOs said at first that they wished to promote ``fidelity'' and
    ``abstinence'' rather than condoms. At the time, many working in AIDS
    prevention thought that fidelity and abstinence promotion would lead to
    few if any measurable results. Nevertheless, USAID made the grants and
    only asked the FBOs to not criticize condom promotion by other groups.
    This was agreed to and adhered to. In the months to follow there were
    few if any problems over condoms, in fact before long, there was some
    condom promotion by two of the projects.
        All three projects were found to be successful. The experience of
    the Muslim project has been published as a UNAIDS so-called Best
    Practices paper. I will say a bit more about the Anglican project since
    it is less well known. This program was implemented in 10 out of 40
    districts of Uganda, meaning the project had relatively large coverage.
    Clergy and laity were trained in AIDS prevention, using the peer
    education approach. AIDS education messages were delivered from the
    pulpit in sermons, as well as at funerals, weddings, and other
    occasions.
        A USAID-funded evaluation of sexual behavior change among those
    reached by this project was conducted in 1995. It found that those
    reporting two or more sexual partners declined from 86% to 29% for men,
    and from 75% to 7% for women (Lyons 1996:8-9). Ever-use of condoms rose
    from 9% to 12% in the same period [Fig. 4].

        These findings underscore that fact that in Uganda, reduction in
    the number of sexual partners (mutual monogamy, also reduction in
    partners among the minority of core transmitters reporting 3 or more
    partners) was probably the single most important behavioral change that
    resulted in prevalence decline. Abstinence was probably the second most
    important change (see Green 2003 and Hogle et al 2002 for more
    supporting data).
        Why do I say this? We measure both behavior and HIV prevalence
    through surveys of people age 15-49. Most people in these age groups
    are married (especially in Africa, where age of marriage is relatively
    young) and sexually active. This is why Uganda's main message, directed
    at the majority population, was ``zero grazing,'' meaning being
    faithful to one partner. Fidelity to one partner also seems to have
    been the main response to the epidemic, if not to Uganda's prevention
    program. When Ugandans were (and are) asked in surveys what is the main
    thing they have done to avoid AIDS, faithfulness to one partner is the
    first and overwhelming response in all age groups except 15-19, among
    whom the first answer is abstaining or delaying, closely followed by
    fidelity to one partner.
        Unfortunately, the American political debate over abstinence versus
    condoms has contributed to monogamy or partner reduction being
    overlooked. It is very good that the United States through USAID has
    adopted a new ABC policy for those countries with generalized
    epidemics, that is, epidemics where most HIV is found in the general
    population rather than in distinct, high-risk groups. This policy
    should guide the development of programs in Africa and the Caribbean
    funded under the President's Initiative. Indeed, there are other
    countries in these regions that have implemented ABC approaches, and
    they have also achieved measures of success: Senegal, Zambia, Jamaica,
    and the Dominican Republic.
        My concern is that the ABC model from Uganda be recognized for what
    it actually is: a comprehensive approach to AIDS prevention that
    recognizes that people are different and therefore a range of
    behavioral options for AIDS prevention needs to be presented, not just
    one or two. And it should be remembered that ``zero grazing,'' or
    remaining faithful to one partner, was the main message for the
    majority of Uganda's population.
        The reason I must say ``was'' is that Uganda's AIDS prevention
    program has gradually changed, perhaps due to the funding priorities of
    foreign donor organizations. Since the mid-1990's, there has been less
    emphasis on sexual behavior and more on medical solutions. In recent
    years, there has been a small but disturbing trend toward riskier
    sexual behavior, and for the first time in a decade there has been a
    slight uptick in national infection rates. The distinctive Uganda ABC
    model of the earlier period, the one developed primarily by Ugandans
    for Ugandans, is the one that seems to have worked best, and is the one
    that has most to teach the rest of the world.

                                   REFERENCES

    AMREF/Uganda. (2001, August). The effects of the Katakwi/Soroti school
            health and Aids prevention project. Kampala, Uganda: African
            Medical and Research Foundation (AMREF).

    Green, E.C., ``Rethinking AIDS Prevention.'' Westport, Ct.: Praeger
            Press, Greenwood Publishers, (2003, in press).

    Hogle, J. (editor), Green, E.C., V. Nantulya, R. Stoneburner, J.
            Stover, ``What Happened in Uganda? Declining HIV Prevalence,
            Behavior Change and the National Response.'' USAID/Washington
            and The Synergy Project, TvT Associates, Washington, D.C.
            September 2002. Available online: http://www.usaid.gov/pop--
            health/aids/Countries/africa/uganda--report.pdf

    Lyons, M. (1996, January 20). Summative evaluation: AIDS prevention and
            control project. Kampala: USAID/Uganda.

    Nantulya, V. (2002, February). HIV/AIDS prevention: Policy and program
            context of Uganda's success story. Presentation to USAID,
            Washington, D.C.

        Senator Alexander. Thank you, Dr. Green.
        Ms. Sophia Mukasa Monico, welcome.

    STATEMENT OF SOPHIA MUKASA MONICO, SENIOR AIDS PROGRAM OFFICER,
                 GLOBAL HEALTH COUNCIL, WASHINGTON, DC

        Ms. Mukasa Monico. Thank you, Mr. Chairman. My name is
    Mukasa Monico.
        Senator Alexander. Mukasa, I am sorry. Mukasa.
        Ms. Mukasa Monico. Mr. Chairman, subcommittee members,
    ladies and gentlemen: Thank you for giving me this opportunity
    to be here with you this afternoon. I think you all agree with
    me that this is a historic moment. On behalf of the thousands
    of health practitioners what are members of the Global Health
    Council and the communities they care for around the world, I
    want to thank you and your colleagues in the Senate for the
    speed with which you passed the President's emergency plan for
    AIDS relief.
        From 1995 to 2001, Mr. Chairman, I was the chief executive
    officer of The AIDS Support Organization, TASO. TASO is an
    indigenous nongovernment organization in Uganda which was
    founded in 1987 to contribute to the process of restoring hope
    and improving the quality of life for people and communities
    infected and affected by HIV and AIDS. TASO is now recognized
    around the world as a leader and innovator in the field of AIDS
    care, prevention, and support and, like what Anne said, the
    real heroes of TASO are the people living with HIV and AIDS and
    the founders who have passed away in the past years.
        Mr. Chairman, ladies and gentlemen, my task this afternoon
    is to share with you some key elements that constitute Uganda's
    relatively small but significant success story, and I refer you
    to my testimony for more detailed information and statistics
    around this success story.
        As we have all heard, as early as 1986 the then new Ugandan
    President Yoweri Museveni learned through his army that his
    nation was confronting an epidemic threatening to decimate his
    nation. The President has made it his personal and governmental
    priority to speak out about HIV and AIDS and is an advocate for
    reducing HIV-AIDS-related stigma and denial.
        Mr. Chairman, reduction in stigma and denial is an
    indispensable element in the positive response to HIV and AIDS.
    It enables individuals to proactively take steps to avoid
    infecting others or being infected, as well as promote access
    to services that add to the overall success of prevention
    efforts. Additionally, it improves people's attitudes, making
    them more accepting of the infected and willing to provide
    compassionate care and support.
        Ladies and gentlemen, reduction in stigma and denial is not
    enough to halt HIV transmission. Individuals must take action
    to change their own behavior and take precautions to avoid
    getting infected. Accordingly, President Museveni's personal
    commitment was quickly followed by a national policy and
    strategy, a strategy which is embedded in the conviction that
    HIV and AIDS affects every level of the population and poses a
    serious threat to the socioeconomic strata and development of
    our country.
        The national policy charges all Ugandans individually and
    collectively with the responsibility of being actively involved
    in AIDS control activities within their mandates and capacities
    in a coordinated way at the various administrative and
    political levels down to the grassroots level. Ownership of the
    response is critical to an effective response to HIV and AIDS,
    Mr. Chairman.
        Working with a nongovernmental faith-based, tradition, and
    community-based organizations, President Museveni has promoted
    prevention and care interventions that are relevant and
    culturally appropriate and sensitive. For some he promotes a
    message of delaying sexual relations, for others he urges them
    to be faithful to each other and promotes the use of condoms as
    an effective barrier. It is this three-part message that has
    made it possible for Ugandans to respond effectively to the
    devastating epidemic. I cannot stress strongly enough that all
    these program elements need to be in place for prevention to
    work.
        Mr. Chairman, this is the foundation of the massive social
    mobilization effort that has given birth to the result that
    constitutes the success of Uganda. The interventions that
    contributed to this success go beyond ABC. They include the
    implementation of a comprehensive package of services for
    prevention, care, support, and treatment which serve
    overlapping but not identical goals. Prevention, support, and
    care efforts are not additive, but rather each strategy
    increases the impact of the other through synergistic effects.
    Further, prevention and treatment involve different sectors and
    constituencies. It is therefore necessary to invest in all
    three simultaneously to achieve more than would be accomplished
    by investing in any one alone.
        As a Ugandan, Mr. Chairman, I am deeply concerned when I
    hear people taking a single element of our successful national
    program, like abstinence, out of context and ascribe all our
    achievements to that one element. All three elements must be
    implemented together in order for prevention to work.
        Ladies and gentlemen, Ugandans were very much cognizant of
    their society and as early as 1986 we acknowledged that
    providing comprehensive and candid information about HIV and
    AIDS was not enough. We had to reinforce those messages by
    formulating other policies and creating an environment that
    enables us to turn our knowledge into meaningful action. Hence
    other sectoral changes were also necessary in order to assure
    that prevention of HIV infection is attained in Uganda.
        For example, Mr. Chairman, we worked with the existing
    decentralized political system to ensure that the voices of the
    most vulnerable populations, especially the girls, women, and
    the youth, are heard and acted upon. Through the education for
    all policy, as we have heard, and other programs, Ugandans
    ensure that social alternatives to sex are created for the
    youth and the children by keeping them productively busy
    through formal and informal education.
        This policy change is important because schools provide a
    natural protective environment for the children, putting girls
    out of reach of older men and transactional sex. According to
    Ugandan data, girls are four to six times more vulnerable to
    HIV infection than boys of the same age group. Schools also
    provide an opportunity to inform, educate, and communicate
    about HIV and AIDS to the youth in an appropriately mixed and
    balanced way that is not interpreted as inciting the youth into
    early sex or promiscuity.
        From a legal protection point of view, Mr. Chairman,
    significant changes have been made to the laws relating to
    sexual abuse, especially for the youth. For example, the age
    for consensual sex was increased from 14 to 18 years. In
    addition, Uganda has made economic empowerment of women a
    priority in order to improve their status in society, turning
    the rhetoric ``no to risky sexual contacts'' to meaningful
    protective actions.
        It is worth reiterating, Mr. Chairman, that it was
    important for Uganda to have all of these and more programmatic
    elements in place for our balanced and comprehensive program to
    work.
        The next step in addressing the epidemic in Uganda and
    throughout the developing world is extending anti-retroviral
    treatment. In his State of the Union Address, President Bush
    outlined his vision and commitment for the United States to
    expand access to anti-retroviral drugs. These medicines will
    provide hope to millions of Africans who do not see a future
    for themselves or their community today.
        In a nutshell, Mr. Chairman, a motivating rather than a
    judgmental environment in Uganda made it possible for the
    community at large to forge ways and means that are both
    culturally sensitive and relevant to meaningful behavior
    change, protecting people from HIV infection, and encouraging
    compassionate care.
        Mr. Chairman, Uganda, just like most countries in the
    world, is implementing the universal approaches that are
    recommended by public health practitioners. As Ugandans, as
    Africans, we know what works. The real issue following the
    passage of the emergency plan for AIDS relief is to identify,
    expand, and replicate those elements that make the HIV-AIDS
    universal interventions work for Ugandans.
        Mr. Chairman, to answer your question about the AIDS Corps,
    but also to move the agenda forward, the Global Health Council
    will be sponsoring a summit meeting for those charged with
    delivering these programs during the International Conference
    on AIDS and STDs [sexually transmitted diseases] in Africa this
    September in Nairobi, Kenya. At this summit, Mr. Chairman,
    representatives from the public, private, and governmental
    sectors will come together to share lessons learned and
    strategies that work.
        The meeting will also discuss the practicalities needed to
    effectively and efficiently implement President Bush's
    challenge. We must be ready to put this legislation together--
    to work, and immediately.
        Thank you for the opportunity to share my views with you
    today and I am happy to answer any questions you might have.
        [The prepared statement of Ms. Mukasa Monico follows:]

    Prepared Statement of Sophia Mukasa Monico, Senior AIDS Officer, Global
                         Health Council, Washington, DC

        Mr. Chairman, subcommittee members, ladies and gentlemen, thank you
    for giving me the opportunity to be with you today. This is a historic
    moment. On behalf of the thousands of health practitioners who are
    members of the Global Health Council, and the communities they care for
    around the world, I want to thank you and your colleagues in the Senate
    for the speed with which you passed the President's Emergency Plan for
    AIDS Relief. As a native Ugandan, I believe that the onus is now on
    African and Caribbean people to make it work. I join my colleagues at
    the Global Health Council, which is the world's largest membership
    alliance dedicated to saving lives by improving health around the
    world, in looking forward to working with the Administration and
    Congress to put this plan into action.
        From 1995 to 2001, I was the Chief Executive Officer of The AIDS
    Support Organization (TASO). TASO, an indigenous Ugandan NGO, was
    founded in 1987 to contribute to the process of restoring hope and
    improving the quality of life for persons and communities infected and
    affected by HIV/AIDS. TASO is now recognized around the world as a
    leader and innovator in the field of AIDS care, prevention and support.

                                 AIDS IN UGANDA

        Uganda is a large country about the size of Oregon, with an
    estimated population of 22 million people. AIDS was identified in 1982
    in Uganda and early surveillance data showed that in 1988, the
    prevalence rate was 9 percent. This quickly escalated and, by 1992,
    urban areas were registering a prevalence rate of 30 percent, while the
    nationwide average rate was 18.5 percent. With the benefit of a
    concerted national effort, by the end of 1999 infection rates dropped
    50 percent to the current prevalence rate of 5.7 percent in urban
    areas.
        Children have been hit particularly hard by the epidemic, with two
    million children under age 18 having lost either one or both parents to
    the disease. This is detrimental to the development of an entire
    generation, which have lost their parents at the moment when parental
    care, guidance, and socialization are pivotal as a child develops his
    or her identity.
        The effects are varied. A study carried out in southwest Uganda
    reported that school absenteeism in AIDS-affected household is
    significantly higher among girls than boys. This is largely due to the
    fact that girls are often the main care givers at home when their
    parents are ill. Not attending school has also had a significant impact
    on the overall success of Uganda's prevention strategy. In Uganda, HIV/
    AIDS prevention messages have been incorporated into primary school
    curricula, with Ugandan boys and girls reporting behavior change as a
    direct result.
        The epidemic has also had a significant impact on the overall
    health status of children, wiping out the significant gains we had
    achieved in child survival over the past decade. Uganda's child
    mortality rates remain high, with 134 out of every 1,000 live births
    not surviving until their fifth birthday because of AIDS.

                           WHY WAS UGANDA SUCCESSFUL?

        Mr. Chairman, my task this afternoon is to share with you some of
    the reasons why Uganda has become a relatively small, but significant,
    success story. The epidemic is still raging in Uganda, and we have much
    to do before we can claim victory over our HIV/AIDS epidemic.
        As early as 1986, the new Ugandan president, Yoweri Museveni,
    learned from his Army that his nation was confronting an epidemic
    threatening to decimate his nation. Early on in his presidency,
    President Museveni both spoke out about HIV/AIDS and became an advocate
    for reducing HIV/AIDS-related stigma. Strong political leadership is
    key to Uganda's success, and stigma reduction has been critical on many
    levels. When stigma is reduced, individuals are more willing to seek
    counseling and voluntarily seek HIV testing. This enables individuals
    to proactively take steps in order to avoid contracting and
    transmitting the virus to others, and adds to the overall success of
    prevention efforts. Additionally, if the stigma of HIV/AIDS is reduced
    in communities, people become more accepting of the infected and
    willing to provide compassionate care for them. Reducing stigma has
    benefits for both the community and the individual.
        But, a reduction in stigma alone is not enough to halt HIV
    transmission individuals must take action to change their own behavior
    and take precautions. Accordingly, an environment that supports this
    individual choice must be created and sustained. President Museveni
    spoke out loudly and often about the need for individual Ugandans to
    protect themselves from the virus. Working with non-governmental,
    faith-based, traditional and community-based organizations, President
    Museveni promoted prevention interventions that were creative,
    culturally appropriate and compassionate, for people who were infected
    and affected by HIV/AIDS.
        For some, he promoted a message of delaying sexual relations; for
    others, he urged them to be faithful to one partner and to use a
    condom. It was this three-part message that was effective in Uganda. In
    my personal experience, I believe that this comprehensive approach is
    critical. Different populations require different messages, and it is
    essential that people of all ages are educated about how to protect
    themselves.
        I cannot stress strongly enough that all these program elements
    need to be in place for prevention to work. As a Ugandan, I am deeply
    concerned when I hear people taking a single element of our successful
    national program like abstinence out of context, and ascribe all of our
    achievements to that one element. All three elements must be
    implemented together, in order for prevention to work.
        Museveni's personal commitment was quickly echoed by a National
    Policy and Strategy, which was embedded with the conviction that HIV/
    AIDS affects all every level of the population, and posed a serious
    threat to the socio-economic development of our country. The National
    Policy charges all Ugandans, individually and/or collectively, with the
    responsibility of being actively involved in AIDS control activities
    within their mandates and capacities in a coordinated way, at the
    various administrative and political levels down to the grassroots
    level.
        This is the foundation of the massive social mobilization that has
    given birth to the results that constitute the success of Uganda. The
    interventions that contributed to this success include the
    implementation of a comprehensive package of services for prevention,
    care, support and treatment, which serve overlapping but not identical
    goals. Prevention and care efforts are not afterthoughts but, rather,
    each strategy increases the impact of the other through synergistic
    effects. Further, prevention and care involve different sectors and
    constituencies. It is therefore necessary to invest in all three
    simultaneously, to achieve more than would be accomplished by investing
    in any one alone.
        We know what works and these interventions are not unique to
    Uganda. They are the universally recommended approaches advocated by
    all public health institutions and practitioners. Therefore, the issue
    is not what to do. Rather, we must identify, expand and replicate what
    the Ugandans did and are doing, to make the universal interventions
    work for everyone.
        I will take this opportunity, to discuss further an issue that has
    been pulled out of context and risks to reverse the prevention gains we
    have achieved so far: bringing abstinence-only programs into the
    discussion.
        We all know how critically important it is for prevention programs
    to target youth before they become sexually active. Uganda has achieved
    this on a personal and a societal level. Cognizant of our society,
    early in the process we acknowledged it was insufficient to only
    provide comprehensive and candid information about HIV/AIDS. We had to
    reinforce those messages by formulating other policies and creating an
    environment that would enable youth to turn their knowledge into
    meaningful action, which encouraged them to choose to protect
    themselves. In order to achieve this objective, the environment and
    messages had to be motivational rather than judgmental.
        Political Change: We worked with the existing decentralized
    political system to ensure that the voices of the most vulnerable
    populations--especially girls, women and youth were heard, by:

       Setting a policy that \1/3\ of members of Parliament had to
            be women;

       Establishing a seat in Parliament for youth; and

       Ensuring that women and youth were represented at all levels
            of the political decision-making apparatus.

        Social Change: Ugandans ensured that youth and children were kept
    busy through both formal and informal education, which created social
    alternatives to sex. Under a policy change that calls for education for
    all, communities have promoted sending more girls to schools. However,
    it is not enough to promote only primary education. As education is
    still not free-of-charge in Uganda, communities are advocating for a
    policy that would make high school education free for all as well.
        This policy change is important because schools provide a natural
    protective environment for children, putting girls out of reach of
    older men and transactional sex. Schools provide an opportunity to
    provide information about HIV/AIDS that is appropriately mixed and
    balanced, so that it is not interpreted as inciting the youth into
    early sex or promiscuity. These classes, which have demystified sex,
    impart sensitive and relevant life skills to youth so that they can
    make responsible choices.
        Legal Change: Significant changes were made to laws in Uganda
    relating to the treatment of rape and statutory rape. Female lawyers in
    Uganda came together to seek these changes, and continue to work to
    stiffen the punishments for these offences. Other laws need to be
    established that will both serve as a disincentive to adults who might
    consider having sex with youth, and will enable enforcement against
    those who violate the law.
        Economic Change: Uganda has made improving the status of women
    through economic empowerment a priority. Credit facilities targeted
    towards women were established, enabling many women to establish small
    businesses and attain economic self-sufficiency.
        I cannot stress strongly enough how important it was for Uganda to
    have all of these programmatic elements in place, for our balanced and
    comprehensive program to work. Mr. Chairman, meaningful implementation
    of abstinence cannot be left open for interpretation by individuals
    with differing moral values. Uganda was very much aware of this, and
    complemented its ideology and sexual morals with an environment that
    encourages abstinence and change.
        The next step in addressing the epidemic in Uganda and throughout
    the developing world is extending anti-retroviral treatment. In his
    State of the Union Address, President Bush outlined his vision and
    commitment for the United States to expand access to anti-retroviral
    drugs. These medicines will provide hope to the millions of Africans
    who do not see a future for themselves or their communities today.
    Pilot projects in Africa offering these life-extending medications have
    begun to reap their just results, with people returning to their normal
    lives as working, self-sufficient members of society, rather than as
    people waiting for death. Treatment is not only a humanitarian
    imperative--treatment supports prevention efforts, because it provides
    the requisite hope that will encourage individuals to learn their HIV
    status and it will reduce associated stigma.

                                   CONCLUSION

        Uganda's current successes were realized through an effective
    social mobilization effort that fostered an environment that was
    motivational, rather than judgmental. Uganda's efforts against HIV/AIDS
    continue to be substantially, financially and technically supported
    both by the government, as well as multilateral organizations including
    UNAIDS, the United Nations Development Program, the World Bank, the
    European Union and the World Health Organization. In addition, efforts
    are funded through bilateral mechanisms supported by the U.S., Danish,
    British, Swedish, Italian, German, French and Japanese governments.
    Various international and local NGOs also fund and implement a variety
    of programs and activities.
        This positive environment makes it possible for the community at
    large to forge ways and means that are both culturally sensitive and
    relevant to meaningful behavior change, protecting people from HIV
    infection and encourages compassionate care. In addition, you will note
    that these interventions represent a multi-sector response. AIDS is not
    just a medical condition in Africa HIV prevention work is not carried
    out by people wearing white coats but it is the responsibility of
    individuals, families, schools, media and religious institutions,
    political leaders and traditional leaders to ensure that further spread
    of HIV infection is halted.

                                   NEXT STEPS

        The real question following passage of the Emergency Plan for AIDS
    Relief is how to replicate the success in Uganda in other countries. It
    is critical for the U.S. government to remember the importance of
    working with local partners, which will guarantee cultural sensitivity
    and effectiveness.
        Toward that end, the Global Health Council will be sponsoring a
    summit meeting of those charged with delivering these programs this
    September in Nairobi, Kenya, discussing the practicalities needed for
    effectively and efficiently implementing President Bush's challenge. At
    this summit, representatives from the public, private, and governmental
    sectors will come together to share lessons learned and strategies that
    work. We must be ready to put this legislation to work immediately.
        Thank you for the opportunity to present my views here today and I
    am happy to answer any questions you might have.

                      Uganda AIDS Commission Status Report

                               www.aidsuganda.org

                    HIGHLIGHTS OF KEY EVENTS AND ACTIVITIES

    1982--Uganda medical doctors identify first AIDS cases on the shores of
                Lake Victoria in Rakai district, Southern Uganda.
    1982-86--The epidemic largely handled by the health sector with
                spontaneous community initiatives to care for the infected
                and affected.
    1986--Uganda's Health Minister of the new government announces the
                existence of HIV/AIDS in the country during the World
                Health Assembly in Geneva. This marked the beginning of
                political openness about the epidemic, creating a conducive
                environment for mass campaigns spearheaded by President Y K
                Museveni.
    1986--The first AIDS Control Program was established in the Ministry of
                Health. Its priorities were safe blood, prevention of HIV
                infection in health care settings, information, education
                and communication about how to avoid HIV transmission
                (beginning of the ABC policy). This marked the first
                government-structured effort to address the epidemic.
    1987--An AIDS Control Program was established in the Ministry of
                Defense to respond the special needs of the armed forces.
    1987-91--Consultations began on a multi-sector approach to controlling
                AIDS. The government recognized that the epidemic's impact
                went beyond the health sector, and required planning and
                implementing relevant activities in other sectors.
    1987--Establishment of The AIDS Support Organization (TASO) to provide
                much needed psychosocial support for the infected and
                affected. Quickly complemented by other initiatives,
                especially from the missionary hospitals (Kitovu, Nsambya,
                Rubaga and Mengo).
    1990--Establishment of the AIDS Information Center (AIC) for voluntary
                Counseling and testing services (VCT).
    1992--The Government adopts the multi-sectoral Approach to the Control
                of AIDS (MACA) as a policy and strategy for responding to
                the epidemic. This approach was aimed at building broad
                coalitions between the government and other partners,
                including community-based organizations and business.
    1992--The Uganda AIDS Commission (UAC) is established by Act of
                Parliament to coordinate and harmonize the multi-sectoral
                efforts of the response.
    1993--UAC leads and coordinates the development of the first multi-
                sectoral National Operational Plan (NOP) for HIV/AIDS/STD
                Activities 1994-1998, reflecting the priority need for
                different sectors to take the lead in addressing the
                epidemic.
    1994-95--More AIDS Control Program Units are established in the
                Ministries of Gender, Education, Agriculture, Internal
                Affairs (Police and Prisons), Justice, Finance, Public
                Service and Local Government.
    1994-Government secures a $75m soft loan from the World Bank to fight
                the epidemic, executed by the Ministry of Health through
                the Sexually Transmitted Infections Project (STIP) 1995-
                2000.
    1995--Uganda successfully hosts and organizes the International
                Conference on AIDS and STDs in Africa (ICASA). Uganda
                announces the observed declining trends in HIV prevalence.
    1996--Uganda receives the first UNAIDS Country Program Adviser (CPA).
    1996--The country begins preparing for HIV vaccine trials after
                thorough consultations with all key stakeholders. Actual
                trial begins 1998.
    1997-99--Participation in the study for the prevention of mother-to-
                child transmission of HIV using anti-retroviral drugs.
    1997--With the support of UNAIDS, a comprehensive review of HIV/AIDS
                activities in Uganda is conducted by partners to assess
                coordination and implementation of HIV/AIDS activities.
    1997--Uganda shifts from its traditional observance of World AIDS Day
                (WAD) to an annual World AIDS Campaign (WAC), culminating
                in WAD every year. WAC has since become a major advocacy
                activity in the country.
    1997--Development of the 1998-2002 National Strategic Framework (NSF)
                for HIV/AIDS Activities with consensus from partners from
                various sectors at national and district levels.
    1998--Establishment of the Drug Access Initiative, advocating for
                reduced prices for Anti Retroviral (ARV) drugs and
                supporting the establishment of the proper infrastructure
                for administering these drugs.
    2000--Revision of the 1998-2002 NSF and development of the 2000/1-2005/
                6 NSF, which puts the HIV/AIDS problems into the broader
                context of national development goals.
    2000--Recognizing the impact of HIV/AIDS on development, the Government
                embarked on the process of mainstreaming HIV/AIDS issues in
                the country's Poverty Eradication Action Plan while
                targeting integration in the government sector budgeting
                exercise.
    2001--Accomplishment of the preparation of the Uganda AIDS Control
                Project prepared under the aegis of Multi-country AIDS
                Project (MAP) of the World Bank. A $50 million loan has
                been secured to support HIV/AIDS activities in all sectors
                at national, district and community levels.

        Senator Alexander. Thank you, Ms. Mukasa Monico. I
    appreciate your coming.
        I have a question and it is one I asked Dr. Peterson
    earlier. Mrs. Museveni suggested that the African culture is
    congenial to the idea of self-control, of young people delaying
    sex, of married people being faithful. One, do you believe that
    is true? And two, do you believe that is unique in Uganda? I
    would be interested. Let me start with you, Ms. Mukasa Monico.
        Ms. Mukasa Monico. I will start with the last one. I do not
    think it is unique to Uganda. I think every human being,
    especially every parent, if I can start from that as a parent,
    will agree with me that abstaining would be the best solution
    for every youth in the world to avoid getting infected. But
    again, we know that the youth--or that children become youth
    and they become adults who make their own decisions.
        So the best alternative to avoid getting infected would be,
    when you start getting--when you become sexually active, at
    least stick to one partner so that you do not get STDs or even
    HIV infection from outside your partnership or your union.
        But as we know as human beings, if that were just the
    answer to it, Mr. Chairman, we would not be having infections
    right now. So we have to get together all the other approaches
    that will actually ensure that if A does not work and B does
    not work, then there is another way, another practical way to
    avoid getting infected and dying of HIV.
        So if you find yourself in a situation where you actually
    cannot abstain, you are not sticking to your partner, or
    actually your first partner, who you do not know what his
    status is, but you have to get sexually involved, then you must
    do everything possible to protect yourself.
        Senator Alexander. It seems to me that all the witnesses
    and most people agree that part of the genius of the Ugandan
    proposal seems to be the combination of things, starting with
    exceptional leadership over a long period of time, that
    includes not just the government but many other, many other
    parts of the community, and that is comprehensive in that it is
    A, B, and C.
        Yet it seems to me the news about it is not just that it
    worked, but that A and B worked better than most health care
    professionals expected. Most of the talk was that condoms were
    the answer and the news I am hearing is that condoms are a part
    of the answer, but that abstinence and faithfulness are more of
    the answer than many people were willing to admit 5 and 3 years
    ago. Would you agree with that or not?
        Ms. Mukasa Monico. My simple answer to that is I do not
    think it is A, B, or C. I think it is A, B, and C together that
    have made it happen.
        Senator Alexander. No, I am not disagreeing with that. But
    I am saying I believe--and Dr. Green, let me just go to you. Do
    I not hear you saying that, that among health care
    professionals over the last several years that most were
    skeptical of abstinence or faithfulness as contributing much
    toward prevention of AIDS?
        Dr. Green. That is right, Senator.
        Senator Alexander. And what the data suggests is that they
    are important parts of the comprehensive approach?
        Dr. Green. Part of the genius of Uganda's response to AIDS,
    and it occurred early, is that it treated AIDS as a behavioral
    issue, not simply as a medical issue for which there were
    medical solutions, such as condoms, male or female condoms,
    such as drugs for treating standard sexually transmitted
    diseases, which if you treat them the idea is that you will
    have less opportunity for infection.
        But I think that you have put your finger on it, Mr.
    Chairman, that the real difference between ABC as practiced in
    Uganda and elsewhere is there was genuine balance. There was
    some real emphasis on A and B, not just the occasional nod in
    the direction of A and B and the funding goes into condoms and
    drugs and the program impact indicators are attached to condoms
    and drugs. It was truly a balanced program. I think we do not
    find so much balance elsewhere.
        Senator Alexander. Senator Feingold.
        Senator Feingold. Thank you, Mr. Chairman. This is an
    excellent panel and an extremely important discussion.
        I want to say particularly to Ms. Mukasa Monico how
    important her message is. I heard your message loud and clear,
    and that is that we dare not oversimplify what happened in
    Uganda. You know, Uganda was a country that arguably had one of
    the worst reputations of any country in the world in the 1970s
    and 1980s, and somehow miraculously, through incredible effort
    of the Ugandan people, this country has made great progress. In
    the whole world now, if you know anything about HIV-AIDS, if
    you want to talk about somewhere where people were able to help
    bring this under control, the first place that is discussed is
    Uganda, which is a tremendous credit to your country, to your
    leadership, and to all the people of your country.
        I guess I feel so strongly that we should not
    mischaracterize or accidentally portray in a way that is not
    accurate what was really done there, and I believe that
    somebody like you who has devoted your life to this has a very
    important message when you tell us to be sure that we
    understand the complexity of it, that abstinence itself
    certainly is not the only answer and is not sufficient. And I
    believe the chairman is saying that and I believe other
    witnesses are saying that as well, in fairness.
        But your phrase that this needs to be motivational but not
    judgmental is very, very important, because there are people
    who will take this data and these concepts and this
    straightforward talk about what is going on and use it in a way
    to suggest something that, frankly, is way too simplistic to be
    effective and in my view is extremely unfair to the people of
    Uganda who have achieved this success.
        So I appreciate your message and believe that we have to
    continue to tell the story as it has actually occurred in
    Uganda and I will strive to be as accurate as I can about it
    and to avoid the judgmental aspect that potentially could
    accompany it.
        My questions sort of relate to that aspect for both of you.
    First, Dr. Green, do the data show that people who have
    previously been sexually active respond meaningfully to the
    abstinence message or are the B and C messages typically more
    effective for this segment of the population?
        Dr. Green. The short answer is yes, typically for people
    who have experienced sexual debut, as they call it, that the B
    and C messages are more appropriate. We have data from, for
    example, the demographic and health survey funded by the United
    States that shows that a not insignificant proportion of
    Ugandans who are widowed or single, but are, say, over 21 and
    who have had sexual intercourse are abstaining because they are
    not currently married.
        But most of those who report zero partners in the last year
    are those who have not started to have sex yet, yet. But yes,
    the B and C messages are probably the most important messages
    for the sexually active, and it was so recognized by Uganda.
        Senator Feingold. With regard to certain specific groups of
    people within the country, let me ask first Ms. Mukasa Monico:
    What kind of steps have been taken in Uganda to work with high-
    risk groups like long-haul truck drivers?
        Ms. Mukasa Monico. A comprehensive program, especially a
    prevention program and information, education, and
    communication, but candid communication about HIV and AIDS. But
    let me just take you another step up from just truck drivers,
    because what we realized in Uganda is the fact that sex workers
    are very young girls and mainly girls who have parents or are
    orphans. And unfortunately the clients of the sex workers are
    none other than our husbands, our brothers, and our children.
    So to ignore them as a population which is at high risk and
    actually risk to transmit HIV into our families--we had to
    target them.
        The only way to make sense while working with them was to
    promote the use of condoms. Actually, there was a great
    increase in the use of condoms among sex workers, from 20
    percent in 1991 to 80 percent in 2001, which is a very big
    contribution to HIV prevention, especially from a high-risk
    group to a normal group.
        But going to the truck drivers, if you go to Uganda you
    find that along the highway from Kenya to Rwanda that is where
    you find all the TASO programs. You find a program in Jinja,
    Mulago, Tororo, and up to Rwanda practically. The one reason
    why we put those programs there was to target the truck drivers
    by, first of all, demystifying HIV and AIDS; and after
    demystifying it making sure that they actually have the right
    information and devices to protect themselves from HIV
    infection. So that was another targeted high group, high-risk
    group, in our interventions.
        Senator Feingold. Dr. Green, you want to comment on that?
        Dr. Green. There was an attempt not to stigmatize groups
    like commercial sex workers and bar girls and truck drivers and
    soldiers. So the information, education, and communication was
    mostly done sort of low-key, through peer educators. And there
    was a lot of condom promotion to groups that were known to be
    at special risk.
        Senator Feingold. What about the military? You point out
    the history of this and how President Museveni found out about
    the problem through the military. We have heard very similar
    concerns in South Africa. What strategies have been targeted to
    the military, Ms. Mukasa Monico?
        Dr. Green. I think that that is----
        Senator Feingold. Dr. Green?
        Dr. Green [continuing]. Another high-risk--Sophia was
    looking at me, so maybe she wanted me to answer it first.
        Senator Feingold. Go ahead.
        Dr. Green. I think that that was another high-risk group.
    There was a lot of peer education in the military. Infection
    rates fell in the military in the late eighties, early
    nineties, quite dramatically. But this was also true for
    military recruits. So you just had a lot of HIV prevalence
    decline among all groups, but including the military, and there
    were special programs.
        I think maybe the first program in Africa that was directed
    at the military was there. I was part of the design of such a
    program in Swaziland a year ago, funded by the USAIDs of
    Defense, and the question arose what are the--out of A, B, C,
    what do you promote to soldiers? The answer was B and C.
        When you mentioned truck drivers, about 10 years ago I was
    working in Tanzania in a project for commercial sex workers and
    I was driving to Mulago and our car broke down and we had to
    hitchhike, and we hitchhiked with a couple of truck drivers on
    the famous highway that you have all heard about, along which
    HIV infection spread. We asked the truck drivers what they were
    doing about AIDS and one driver said that he was faithful to
    his girlfriend that he is living with and the other one said he
    is getting married and no longer stopping and having sex along
    the way the way they used to.
        So this was 1993, and it gave me my first clue that
    something other than the model that we had in mind as
    international AIDS experts might be going on. Then soon after
    that, I went to Uganda for the first time and saw that indeed
    something different was being promoted and something different
    seemed to be happening.
        Ms. Mukasa Monico. Maybe just to answer you about the
    military. One important element that has been incorporated in
    the military is voluntary counseling and testing as an entry
    point to behavior change and also seeking prompt medical care,
    which you find everywhere--not everywhere, like 60 percent in
    Uganda. But this is a specific service for the military men.
        Senator Feingold. I appreciate both of your answers because
    obviously I focus on the truck drivers and the military because
    of the stories I have heard all over Africa about the way in
    which HIV-AIDS can be spread. I remember hearing on a trip
    where we went first to Tanzania, then Mozambique, the concerns
    about the highways and the travel and the way in which it may
    have spread through Tanzania to Mozambique.
        I appreciate the candor that realistically the most likely
    thing to work here is B and C, although you do express some
    hope that, it sounds like, that A has some role in this regard.
    But I think you are looking at the type of lifestyle and
    situation realistically. It is so important to remember what
    the role of B and C are in preventing the spread among very
    mobile people, which by definition the military and the truck
    drivers are.
        We have even heard this with regard to sometimes troops
    that we have helped assist us in various difficult situations
    in Africa being sent from one country to another to keep the
    peace. This is a potential negative side effect for a country
    that may not have a particular high HIV-AIDS rate, when
    individuals may come and be involved in those areas. Even
    though they may be trying to keep the peace, other things
    obviously happen. This is a very critical part of understanding
    how the problem has spread throughout the continent.
        Where do efforts to increase access to treatment stand in
    Uganda? Have efforts to increase access to treatment in Uganda
    encouraged people to participate in voluntary counseling and
    testing? Ms. Mukasa Monico?
        Ms. Mukasa Monico. The first targeted initiative to
    increase access to treatment in Uganda started around 1998 with
    the drug access initiative from UNAIDS. That is when we
    negotiated with big pharma to import drugs with reduced prices.
    It was not so reduced, because a person was paying around
    $1,500 per month just for triple therapy.
        But around 2001, through again an increased effort to
    decrease prices and through contacting CIPLA India we managed
    to negotiate for generics and now drugs are costing $300 per
    year in Uganda, which is a substantial decrease from $1,500 per
    month. So that is one step forward.
        So what we did was to import generics of anti-retrovirals,
    but by importing generics of anti-retrovirals we also managed
    to bring down the prices, some of the prices of the brand names
    for anti-retrovirals.
        I think, just like any other incentive, knowing that you
    have a support system to fall back on, people are encouraged to
    go and test and find out where they are with HIV and AIDS
    because they know at the end of the day I can improve my
    quality of life because I can get access to anti-retrovirals.
    So undoubtedly, with more access to anti-retrovirals more
    people find out about their HIV status, and by finding out
    their HIV status they either know that they have to change
    their behavior if they are not infected, and if they are
    infected at least they know that they can get support.
        But it also decreases the stigma around HIV and AIDS, and
    again improving access to services.
        Senator Feingold. Mr. Chairman, I thank both the witnesses.
    Thank you, Mr. Chairman.
        Senator Alexander. Thank you very much. I think the Ugandan
    experience has done something in the United States that we
    ourselves could not do. You have those who strongly believe in
    abstinence talking about condoms, and those who strongly
    believe in condoms acknowledging the importance of abstinence.
    That is a lot of progress in this country.
        So we are grateful to you for the work you have done in
    Uganda and in helping us understand the role of that model as
    we go about an effort, particularly on this subcommittee, to
    help make sure the United States marshals the resources that we
    are beginning to approve and that we spend them as wisely and
    effectively as possible and with as much respect for the
    countries and the people that we hope to serve.
        Thank you very much for being here.
        Dr. Green. Thank you.
        [Whereupon, at 4:02 p.m., the subcommittee adjourned, to
    reconvene subject to the call of the Chair.]