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Uganda's AIDS Decline Attributed to Deaths

By David Brown
Washington Post Staff Writer
Thursday, February 24, 2005; Page A02

BOSTON, Feb. 23 -- Abstinence and sexual fidelity have played virtually no
role in the much-heralded decline of AIDS rates in the most closely studied
region of Uganda, two researchers told a gathering of AIDS scientists here.

It is the deaths of previously infected people, not dramatic change in human
behavior, that is the main engine behind the ebbing of the overall rate, or
prevalence, of AIDS in southern Uganda over the last decade, they reported.

The findings, not yet published, contradict earlier evidence that attributed
Uganda's success in AIDS prevention largely to campaigns promoting
abstinence and faithfulness to sex partners. Much of the prevention work in
the Bush administration's $15 billion global AIDS plan is built around those
two themes, and Uganda is frequently cited as evidence that the strategy
works.

If the report here stands up to scrutiny -- and, more important, is borne
out by surveys elsewhere in Uganda -- it will deflate one of the few
supposed triumphs to come out of AIDS-battered Africa in the last decade.
The success of Uganda's ABC strategy -- the letters stand for "abstinence,"
"be faithful" and "(use) condoms" -- has been widely touted and is on the
verge of being exported to neighboring countries with the help of American
money.

"There is an urgent need to assess abstinence and monogamy in other parts of
Uganda," said Maria J. Wawer, a physician at Columbia University's Mailman
School of Public Health who presented the data at the 12th Conference on
Retroviruses, the annual mid-winter AIDS meeting in the United States.

Ironically, she and her colleagues found that the one prevention technique
whose use did increase between 1994 and 2003 was condoms -- the part of the
ABC triad that has been relatively de-emphasized in the Bush plan.

"Abstinence and monogamy are very good behaviors," she said in a press
briefing after her presentation. "On the other hand, the data support that
in this setting, the behavior that seems to have been the easiest to
increase over time is condom use."

President Bush and administration officials have repeatedly cited Uganda's
experience in promoting their approach. "We can learn from the experience of
other countries when it comes to a good program to prevent the spread of
AIDS, like the nation of Uganda," Bush said last June in Philadelphia,
adding that the ABC program is "a practical, balanced and moral message."

Wawer's findings come from a study of 10,000 people ages 15 to 49 who live
in 44 villages near Uganda's border with Tanzania. Each year researchers
have gone door to door collecting blood and urine samples and asking about
health and behavior. About 85 percent of residents cooperate with the study,
which over the years has grown to include AIDS treatment and prevention
services as well as research.

Today, the Rakai Health Sciences Program -- which is run by Columbia, Johns
Hopkins University and several Ugandan organizations -- has about 400
employees. They include physicians, counselors and AIDS prevention
educators.

Uganda is one of the 15 "target countries" in the Bush AIDS program,
formally known as the President's Emergency Plan for AIDS Relief.

In the Rakai district, the percentage of women infected with HIV fell from
20 percent in 1994 to 13 percent in 2003. For men, the rate of infection
declined from 15 percent to 9 percent, a decline of roughly one-third.

Over that same period, however, the fraction of men reporting two or more
sexual partners in the previous year rose from 28 percent to 35 percent. The
fraction of young men ages 15 to 19 who were not sexually active fell from
about 60 percent to just under 50 percent. For women that age, the
proportion not having sex remained at about 30 percent through the decade.

The median age of first intercourse for men fell from 17.1 to 16.2 years,
and for women from 15.9 to 15.5 years.

Condom use, however, changed markedly over the survey period. In 1994, only
about 10 percent of the men said they consistently used condoms with
non-marital partners, compared with 50 percent in 2003. For women of the
same age, the rate of condom use in non-marital sex increased from 2 percent
to 28 percent.

Earlier data indicating that young Ugandans were delaying first intercourse
came from surveys of primary school students and national health studies in
1989, 1995 and 2000 that were conducted in different regions each time.

Because the Rakai survey has continued for years in the same place, it also
provides an unusually precise measure of the rate of new infections, or
incidence.

For women ages 15 to 24, incidence has risen slightly over the last decade,
from just below 1.5 new infections per 100 women per year to just above that
number. For men, incidence increased from about 0.7 infections to 1 per 100
men per year.

That means Rakai's declining HIV prevalence is not due to a falloff in new
infections. Instead it appears to be explained by an increase in deaths.
Between the 2002 and 2003 surveys, 125 people became newly infected, and 200
people with long-standing infections died.

"Death alone accounted for a 0.6-percent-point reduction in HIV prevalence
that year," Wawer said.

Among her more troubling findings was that the percentage of men who had
become infected in the previous year and also reported having two or more
partners that year rose from about 48 percent to 68 percent. Newly infected
people have unusually large amounts of AIDS virus in their blood and by some
estimates are up to 10 times more likely to infect someone during
intercourse.

2005 The Washington Post Company