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How a country fought back

Through grassroots and government efforts, an impoverished African nation has kept its infection rates down

BY RACHEL SCHEIER AND NICOLE ITANO | Newsday Special Correspondents

June 12, 2006

KAMPALA, Uganda - Of Federesi Lutwama's 12 children, four have died of AIDS. Three are HIV-positive. There have been so many funerals for nieces, cousins and in-laws that it's hard to keep count.

"We are not unique," said one of her daughters, Noerine Kaleeba, who 20 years ago sat by her own husband's hospital bed and watched him die of a strange new disease that no one understood.

It is rare to find a family that hasn't been touched by AIDS in Uganda, which was among the countries earliest and hardest hit. But in the 1980s, Kaleeba and other Ugandans whose lives had been transformed by the disease did something that was unique in Africa, especially at the time. They began to talk about it.

"We started to see the value of people who were infected coming together, crying together," she said.

It was this relative openness in those early years of the epidemic in Uganda - by Ugandans as well as their government - that is believed to have saved perhaps a million lives in the decade that followed. In the 1990s, the prevalence of HIV fell from about 15 percent to about 6 percent, an achievement that was a first on the continent.

Uganda, a small, poor country known mostly for its brutal former dictator, Idi Amin, had become that rare thing: an African AIDS success story.

It was an entirely different story in South Africa, where the government continues to send mixed messages on whether to use drugs for treatment, and the health minister promotes bogus natural treatments for AIDS.

A tale of two attitudes

When she died in a South African hospital on May 19 at age 32, Nozipho Bhengu became another statistic. But her story, though tragic, is different: Unlike millions of others across Africa, she did not lack access to life-prolonging antiretroviral drugs.

The daughter of a prominent South African politician and one of the first high-profile South Africans to live publicly with the disease, Bhengu chose not to take these drugs. Instead, for several years, she embraced an unproven alternative therapy of olive oil, lemon and garlic supported by South Africa's controversial health minister, Manto Tshabalala-Msimang.

"The minister is to blame," said Sipho Mthathi, general secretary of the Treatment Action Campaign, a nongovernmental coalition of groups that has been a harsh critic of the South African government's highly ambiguous AIDS policy. "If she knows, and the government has proved that antiretroviral therapy works, why is she still supporting these unproven alternatives?"

Uganda, a source of hope in combating AIDS, and South Africa, a source of continuing despair, highlight in their very different approaches to dealing with the AIDS virus the most distressing statistics of all. AIDS, which originated in Africa, has wreaked the heaviest carnage on this continent and continues to spread at devastating rates.

Globally, nearly 40 million people are believed to be infected with HIV/AIDS, and 24.5 million of those are in Africa. South Africa, with an estimated 5.5 million infected out of a population of 44 million, has been edged out by India, with 5.7 million AIDS victims among its 1 billion populace.

But in many ways, South Africa is the epicenter of the AIDS pandemic. Eighteen percent of South African adults are HIV-positive. Among five of South Africa's neighbors, the adult infection rate is near or above 20 percent.

Today, AIDS is no longer an immediate death sentence. More than 1.3 million people in less developed countries now have access to treatment; in some places like Uganda, more than half of those who need them are receiving antiretroviral drugs. But except for a handful of countries on the continent, the virus continues to spread and the epidemic to expand.

Examining the successes

There has been much debate about what went right in Uganda. Why did HIV rates fall there while they did not in other countries where AIDS had been raging for nearly as long?

Public health experts concluded the reason was that Uganda relied on a range of prevention messages instead of just one, a strategy known as ABC (abstain, be faithful or use condoms). It has since been copied worldwide.

But the ABC strategy has become controversial in recent years, after President George W. Bush made it the cornerstone of American AIDS prevention policy. Financial necessity underlies Ugandan President Yoweri Museveni's decision to adopt the policy to make condoms a third of the response, but Bush's decision to emphasize abstinence and monogamy rather than condoms is widely thought to be ideological - at the behest of evangelical Christians in his core constituency.

"The truth is, we don't know what worked. It was a combination of factors," said David Serwadda, director of the Institute of Public Health at Makerere University in Kampala. A young Ugandan doctor in the early 1980s, Serwadda was one of the first to notice reports of a mysterious deadly ailment the locals in southwestern Uganda called "slim," which sounded eerily similar to the new disease that was killing gay men in New York and California.