The Less They Know, the Better
Abstinence-Only HIV/AIDS Programs in Uganda
With funding coming in now, for any youth activities, if you talk about abstinence in your proposal, you will get the money.Everybody knows that.
-A teenager working with youth in Kampala
We don't think abstinence is really working in our communities.We work with children in primary five through seven who are engaging in sexual activities.We always come with the message to delay sexual debut.But for most children here, this is not enough.
-Youth leader in Kabarole
Widely hailed as a leader in the prevention of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), Uganda is redirecting its HIV prevention strategy for young people away from scientifically proven and effective strategies toward ideologically driven programs that focus primarily on promoting sexual abstinence until marriage.Although endorsed by some powerful religious and political leaders in Uganda, this policy and programmatic shift is nonetheless orchestrated and funded by the United States government.Pioneered in the United States in 1981, "abstinence until marriage" programs (also known as "abstinence only" programs) teach that abstaining from sex until marriage is the only effective method of HIV prevention and that marriage between a man and a woman is the expected standard of human sexual behavior.Numerous U.S.-funded studies have shown these programs to be ineffective at changing young people's sexual behaviors and to cause potential harm by discouraging the use of contraception.The effect of Uganda's new direction in HIV prevention is thus to replace existing, sound public health strategies with unproven and potentially life-threatening messages, impeding the realization of the human right to information, to the highest attainable standard of health, and to life.
Despite a reported dramatic drop in HIV prevalence in Uganda in the 1990s, from an estimated 15 percent nationally in 1992 to 6 percent in 2002, Ugandans of all ages continue to face a high risk of HIV infection.Ugandans tend to start having sex at an early age and with little sex education.Demographic and health surveys show that over half of Ugandan girls have had sex by age seventeen, usually with someone older.Among girls who marry before the age of eighteen, most marry men who have been sexually active for several years, often without having used condoms.These and other factors make it vitally important to educate young people about HIV and to caution girls at an early age about the risks of HIV infection in marriage.Abstinence-until-marriage programs fail on both of these counts.Not only do they fail to offer young people information about condoms and safer sex on the grounds that this would undermine the goal of abstinence, they additionally promote marriage to young people while withholding information on its inherent risks.
Uganda's increasing embrace of abstinence-only approaches is manifest on many levels, from the office of the president to the halls and classrooms of the nation's primary and secondary schools.In November 2004, the Uganda AIDS Commission (UAC) released a draft "Abstinence and Being Faithful (AB)" policy to guide the implementation of abstinence-until-marriage programs throughout the country.Intended as a companion to the country's existing strategy on the promotion of condoms, the policy in fact undermines condoms as an HIV prevention measure and suggests that promoting condoms alongside abstinence messages would be "confusing" to youth.The document contains virtually the same definition of "abstinence education" as in legislation governing abstinence-only programs in the United States, suggesting that Uganda's programs will replicate programs that have been proven ineffective in numerous U.S. states.As an HIV prevention strategy for married people, the document proposes compulsory HIV testing for all couples intending to marry-a strategy that not only infringes on the right to informed consent but, as discussed further below, fails to address the ongoing risk of HIV faced by married women.
In 2001, the Government of Uganda launched an ambitious program to expand HIV prevention education to all of the country's primary and secondary schools.Funded by the United States and known as the Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY), the program provides abstinence-until-marriage messages through a series of assembly messages, classroom activities and youth rallies.PIASCY materials were developed through a series of stakeholder meetings in Uganda that included public health experts, experienced HIV/AIDS educators, community and faith-based organizations, and others.Numerous participants observed that religious groups exercised an effective veto over the inclusion of objective health information, including images depicting ejaculation, body changes during puberty, the effectiveness of condoms, and even proper cleaning of the foreskin.At the insistence of these groups, pre-tested PIASCY materials were withdrawn from circulation and re-released with several explicit images purged and a chapter on "ethics, morals and cultural values" added.These developments occurred at the same time the U.S. Agency for International Development (USAID) had placed a technical adviser at the ministry of education to oversee PIASCY.Draft secondary school materials, under revision as of this writing, contain numerous falsehoods about condoms (including the claim that they contain microscopic pores that are permeable by HIV pathogens) and caution that premarital sex is "against religion and norms of all cultures in Uganda" and "is considered a form of deviance or misconduct."
Finalized PIASCY materials for primary schools included some information about condoms, which is consistent with a recently drafted strategy of the Uganda Ministry of Health calling for the promotion of condom use to "all sexually active people."However, teachers interviewed by Human Rights Watch said that USAID-funded PIASCY trainers had encouraged them to omit information about condoms in favor of an abstinence-only message.The political climate favoring abstinence-only approaches in Uganda, including numerous anti-condom statements by President Yoweri Museveni in 2004, also influenced school teachers to teach abstinence as an exclusive method of HIV prevention.Because of a 1997 Ugandan policy guaranteeing free primary education to everyone in the country, many children who had dropped out of school, returned and so an unusually high proportion of Ugandan primary school students are in their teens.This makes it especially important for the president and foreign donors not to contradict or undermine the health ministry's policy of promoting condoms to everyone who needs them.
Outside of schools, Human Rights Watch found that abstinence-only approaches were being promoted in Uganda through government-sponsored youth rallies and additionally, in programs run by community and faith-based organizations.At at least one rally, participants were told that "using a condom with a person with these [sexually transmitted] diseases is like using a parachute which opens only 75 percent of the time."Blending health messages with politics, participants were also encouraged to promote President Museveni, in power since 1986, in his bid for a third term.As of November 2004, the U.S. embassy in Uganda had budgeted approximately U.S.$8 million for "abstinence and behavior change" programs for young people, of which approximately U.S.$3 million was for PIASCY.One national organization already receiving U.S. support to carry out abstinence programs was the National Youth Forum run by First Lady Janet Museveni, perhaps the best-known proponent of abstinence-only programs in Uganda.Mrs. Museveni has described abstinence-only approaches as a blend of African and Christian values and has used her position of influence to intimidate organizations that promote condoms to young people.On World AIDS Day 2004, she called for a national "virgin census" to support her abstinence-only efforts, raising fears that children would be forced to submit to intrusive medical tests or otherwise disclose confidential information about their virginity status.
With the growth of abstinence-only approaches in Uganda, there are growing indications that condoms will gradually disappear from the country's HIV/AIDS strategy.In October 2004, the Ministry of Health issued a nationwide recall of all free government condoms, allegedly in response to failed quality control tests.The ministry then took the extraordinary step of requiring post-shipment quality control testing on all condoms imported into Uganda, including those that have already been tested.By December 2004, experts were forecasting a national condom shortage.Rather than take steps to address the shortage, however, Uganda's minister of state for primary health care stated, "As a ministry, we have realized that abstinence and being faithful to one's partner are the only sure ways to curb AIDS.From next year, the ministry is going to be less involved in condom importation but more involved in awareness campaigns; abstinence and behavior change."
This statement was only the latest in a series of anti-condom statements from senior government officials in Uganda.Throughout 2004, including at the International AIDS Conference in Bangkok, Thailand, President Museveni lashed out against condoms as inappropriate for Ugandans and suggested that condom distribution encouraged promiscuity among young people.First Lady Janet Museveni has criticized groups that distribute condoms to young people for "pushing them to go into sex" and stated that "it is not the law that our children must have sex."Non-governmental organizations that have traditionally promoted condoms in Uganda told Human Rights Watch they feared provoking the ire of political leaders if they continued their work, while those that deny the effectiveness of condoms have enjoyed unprecedented levels of government support."We don't want to be seen to be doing what government or political leaders are opposed to," the coordinator of a youth HIV prevention program told Human Rights Watch."We fear we would be blacklisted."
In numerous interviews, Human Rights Watch found that an exclusive focus on sexual abstinence as an HIV prevention strategy failed to account for the lived experiences of countless Ugandans."I got HIV in marriage.I was faithful in my relationship," said one Ugandan woman, expressing a common predicament.Indeed, the suggestion that marriage provides a safeguard against HIV may amount to a death sentence for women and girls.Ugandan women face a high risk of HIV in marriage as a result of polygyny and infidelity among their husbands, combined with human rights abuses such as domestic violence, marital rape, and wife inheritance (whereby a widow is forced to marry the brother of her late husband).While surveys suggest that Ugandan women are more likely to refuse sex with a husband who has an STD than women in other African countries, it is still widely believed in Uganda that women have no right to deny their husbands sex.Research by Human Rights Watch and others has shown that many Ugandan women who abstain until marriage and remain faithful to their husbands nevertheless face a very high risk of HIV because of their husbands' infidelity or prior HIV infection.Although abuses against married women may put them at equal risk of HIV as their unmarried counterparts, abstinence educators nevertheless champion the institution of marriage while at the same time withholding information about its risks.
Abstinence-only programs also fail to recognize that, as in all countries, AIDS in Uganda is a disease of poverty.Many Ugandans live on less than U.S.$1 per day, a situation that has been exacerbated by decades of political violence and civil war.New HIV cases occur among girls trading sex for school fees, women enduring violent marriages because they lack economic independence, and orphans being pushed onto the street and sexually exploited."I wish those who preach abstinence would come down to the slums and see how people are living," said one AIDS educator."These girls live five to a room.There is no supper for them.The man outside says he will get her money and a place to sleep.Now, what is she going to do, abstain?"Others noted that abstinence-only messages had no relevance for people who did not marry, not least lesbian, gay, bisexual, and transgender (LGBT) Ugandans whose very existence is denied by their government.LGBT communities are "erased from all HIV programs," said one activist."The Uganda AIDS Commission does not want to hear about them."
As the largest single donor to HIV/AIDS programs in Uganda, the United States is using its unparalleled influence to export abstinence-only programs that have proven to be an abject failure in its own country.No less than twelve U.S. government-funded evaluations at the state level have shown that U.S.-based abstinence-only programs have little influence on participants' sexual behavior and may cause harm by discouraging the use of contraception.Additional studies have suggested that "virginity pledges," a staple of abstinence-only programs in which young people promise to abstain until marriage, often fail and may result in lower contraceptive use (and higher STD rates) among sexually active unmarried youth.Officials in both the U.S. and Ugandan governments have ignored these studies.Instead, they have misleadingly used national survey data to suggest that abstinence and fidelity are more popular among Ugandans than condom use.Not only do such data provide a poor substitute for evaluation of abstinence programs, but research in Uganda clearly indicates that a comprehensive approach to HIV prevention-one emphasizing positive behavior change, high-level political leadership, condom use, widespread HIV testing, and a myriad other factors-is what allowed the country to reduce HIV prevalence in the 1990s.Nothing in the demographic or historical record suggests that "abstinence education" as conceived by the United States is what contributed to Uganda's HIV prevention success.
Government officials in both Uganda and the United States routinely characterize Uganda's HIV prevention strategy as "ABC," where A stands for abstinence, B for being faithful, and C for condom use.This acronym is designed in part to give the impression that Uganda has always encouraged abstinence as part of its anti-AIDS efforts, and that abstinence contributed significantly to marked declines in HIV prevalence in Uganda in the 1990s.Again, this impression is misleading.Delayed sexual debut was and continues to be one of many messages provided by Ugandan AIDS educators; however, Uganda did not implement abstinence education on a large scale until the United States began promoting these programs internationally around 2001.Moreover, there is scant evidence that abstinence (as opposed to other behavior changes) contributed significantly to reported declines in HIV prevalence in Uganda in the 1990s.Many veteran AIDS educators in Uganda told Human Rights Watch they had never heard of "ABC" until the United States branded Uganda's success with this alphabetical sound-bite.While ABC proponents have been able to uncover elements of Uganda's AIDS strategy that support the ABC model, the definition of ABC in the 2003 U.S. global AIDS strategy-Abstinence for youth, Be faithful for married couples, and Condoms only for "high risk" populations-is a uniquely American invention.
At this writing, an estimated 6 percent of the adult population in Uganda is infected with HIV, significantly less than the estimated 15 percent national prevalence a decade ago.Uganda has been rightly praised for this achievement.However, the country still faces a generalized HIV/AIDS epidemic and cannot afford to attack proven HIV prevention strategies and adopt discredited ones.Uganda is home to nearly 1 million children orphaned by HIV/AIDS, many of them at high risk of HIV infection themselves.Efforts to expand access to antiretroviral treatment for people living with HIV/AIDS still have a long way to go, making it especially important to sustain effective and widespread HIV prevention measures.As an acknowledged leader in HIV prevention, Uganda should be building on its success, not adopting the United States' failures.
To the Government of Uganda
- Replace programs that promote abstinence-until-marriage to the exclusion of other effective HIV prevention strategies.Use instead comprehensive programs that provide complete, factual, and unbiased information about HIV prevention, including information about the correct and consistent use of condoms.Encourage bilateral donors to redirect funding away from abstinence-until-marriage programs towards comprehensive programs.Until such time as abstinence-until-marriage programs can be replaced, ensure that nothing in these programs undermines effective strategies for HIV prevention.
- Integrate the draft "Abstinence and Being Faithful (AB)" policy into existing HIV prevention strategies to avoid any conflict between them.Remove any information from the policy that suggests that teaching young people about safer sex contradicts, confuses, or undermines the message of abstinence.Recognize in all HIV prevention programs and policy documents that marriage does not provide a guarantee of safety against HIV.
- Rescind the recommendation of compulsory HIV testing for couples intending to marry found in the AB policy.Consistent with public health and human rights standards, encourage instead universal access to voluntary HIV testing and counseling.
- In school-based programs, ensure that school teachers are adequately informed about the prevalence of sexual activity among young Ugandans and qualified to provide objective, unbiased HIV prevention information and counseling to sexually active pupils and students.Ensure that such messages (including about condoms) are not contradicted by political leaders.Take steps to supplement HIV prevention messages given in school assemblies with in-class lessons and activities promoting assertiveness, self esteem, and other life skills outlined in the school curricula.Involve pupils and students in the implementation of school-based HIV prevention programs and the evaluation of materials.
- For secondary school HIV prevention materials, ensure scientific accuracy and age-appropriate HIV prevention information, in addition to messages of abstinence.Remove references to non-marital sex as a form of deviance.Ensure that materials also assist young people who cannot legally or who do not marry, including lesbian, gay, bisexual, and transgender youth.Finalize curricular materials and take measures to avoid granting effective veto power to any particular religious or political point of view.
- Ensure that HIV prevention programs conducted out-of-school provide complete, science-based information.Enforce a requirement of scientific accuracy for the delivery of all HIV prevention information, whether by secular or faith-based organizations.Enact a clear policy opposing human rights violations against grantees or sub-grantees of HIV prevention funds, including "virgin censuses," discrimination against lesbian, gay, bisexual, and transgender youth, and discrimination against those who hold opposing religious views.
- Ensure that the special needs of vulnerable populations, including orphans and children affected by AIDS, internally displaced persons, street children, and lesbian, gay, bisexual, and transgender persons, are explicitly recognized in national and local HIV prevention policies and programs.Recognize the inherent limitations of abstinence-until-marriage messages for these populations and withdraw support from these programs accordingly.
- To reduce women's vulnerability to HIV/AIDS, enact and enforce laws that protect women and girls from violence and discrimination.These include laws that criminalize marital rape and that guarantee women's equal property rights.Ratify the protocol on women's rights under the African Charter on Human and People's Rights.
- Recognize the link between the spread of HIV/AIDS and discrimination based on sexual orientation, including the criminalization of same-sex relations.Repeal sections 140, 141, and 143 of the Penal Code which criminalize same-sex relations between consenting adults and are sometimes used as a justification for failing to provide life-saving HIV prevention information and services to lesbian, gay, bisexual, and transgender youth.
- Take urgent steps to ensure an adequate supply of free and low-cost condoms in Uganda to assist HIV prevention efforts.In light of the recent recall of government-funded condoms due to apparent quality control problems, urgently seek relief from international donors to fill the condom supply gap.Make publicly available all information about the condom recall, the steps the government is taking to address it, and how the public can obtain free condoms in the interim.Consistent with the National Condom Policy and Strategy (2004), ensure that all sexually active or potentially sexually active individuals, not just select populations, are targeted by condom promotion campaigns.
To the Government of the United States
To the U.S. Congress
- Repeal sections 402(b)(3) and 403(a) of the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act.These provisions require the expenditure of 33 percent of HIV prevention funds on abstinence-until-marriage programs that exclude consideration of other approaches to HIV prevention.In light of existing government-funded evaluations showing abstinence-only programs to be ineffective and potentially life-threatening, enact legislation prohibiting the expenditure of federal funds on these programs pending further research and evaluation.
- Redirect U.S. funding for abstinence-until-marriage programs to proven interventions that guarantee young people complete information about HIV prevention, including the use of condoms.Encourage the U.S. Office of the Global AIDS Coordinator to revise sections of the U.S. global AIDS policy that make false claims about the effectiveness of abstinence-only programs and promote abstinence-until-marriage as an HIV prevention strategy for young people.Ensure that age-appropriate information about condoms and condom promotion strategies are provided to all youth and not limited to "high-risk" populations.
- Request and publicly disclose information from the global AIDS office about all international funding for abstinence-until-marriage programs.Include regional and national-level funding as well as grantees and sub-grantees.Enforce policies prohibiting the use of U.S. federal funds for religious proselytizing, political purposes, or the provision of medically inaccurate information.Ensure that all HIV prevention programs for youth are evaluated according to their short and long-term impact on young people's sexual knowledge, attitudes, intentions, and behaviors, as well as trends in HIV transmission, and make these evaluations public.
- Request and publicly disclose information from the global AIDS office about all international funding for HIV prevention programs for young people other than abstinence-until-marriage programs.These include programs that combine abstinence messages with factual information about condom use and safer sex, seek to enhance women's sexual autonomy and empower them to refuse sex and insist on fidelity or condom use, and/or address human rights violations that increase women's vulnerability to HIV/AIDS, including in marriage.
To the Presidential Emergency Plan for AIDS Relief (PEPFAR) country team in Uganda
- Urge the removal of any scientifically inaccurate information from HIV prevention materials in Ugandan secondary schools.Withhold any funding for materials that provide false or misleading information, and support the publication of texts that contain complete and science-based HIV prevention messages.End support for HIV prevention materials, programs, or organizations that present heterosexual marriage as the sole legitimate context for sex or that directly or indirectly present marriage as providing safety from HIV infection.
- Evaluate the provision of HIV prevention messages in schools, with particular attention to whether teachers are censoring sensitive information contained in approved texts.Encourage political leaders not to contradict information in school materials.Ensure that U.S.-funded training programs do not discourage teachers from discussing condoms or otherwise promote an abstinence-only agenda.In U.S.-funded training sessions, remind teachers to answer all students' questions about safer sex and condom use, as stipulated in approved texts.
- Evaluate the impact of U.S.-funded HIV prevention programs for Ugandan youth.Include an evaluation of whether these programs affect young people's knowledge, attitudes, intentions, and behaviors related to sexual activity.Review existing programs to ensure that no HIV prevention money is being used for reasons other than intended, and investigate any misuse of HIV prevention funds, such as for partisan political activities, religious proselytizing, or virginity testing.Withhold support from projects that so misuse HIV prevention funds.
- Take immediate steps to counter all misinformation about condoms, including by government and private actors.Withhold funds from organizations that make false or misleading statements about condoms or actively discourage them as an HIV prevention strategy.Together with other donor governments, immediately import a sufficient number of condoms to ensure an adequate supply for free condoms until such time as safe and tested condoms are available through the national distribution program.
To the Office of the Global AIDS coordinator (OGAC) of the U.S. government
- Provide a full accounting of existing funding for youth HIV prevention programs.This should include programs administered regionally through Track 1.0 and in national programs through Track 2.0 of PEPFAR.Withhold funding from any grantee or sub-grantee that uses U.S. HIV prevention funds to provide false or misleading scientific information, engage in religious proselytizing, engage in partisan political activity, or discriminate against individuals based on their sexual orientation.
- Cooperate with requests by individuals or government agencies to make publicly available all information on abstinence-until-marriage programs.Provide information about national and regional funding for these programs, grantees and sub-grantees, and details about their activities.Establish a public mechanism for monitoring the effectiveness of HIV prevention programs, and include a wide range of civil society groups in this process.
To all other donors to Ugandan AIDS programs, including the Global Fund and U.N. agencies
- Review existing HIV prevention programs in Uganda.Ensure that funding is not provided to individuals or groups that deny young people factual information about HIV prevention, discriminate against marginalized communities such as sexual minorities, or use HIV prevention funds to engage in religious proselytizing.
- Develop a public position on U.S.-funded abstinence-until-marriage programs.Evaluate the impact of these programs on the availability of effective interventions such as comprehensive sex education, life skills programs that emphasize girls' empowerment and negotiation skills, and programs that address HIV risk among especially vulnerable communities.Evaluate the feasibility of compensating for this loss through increased funding and technical support to proven interventions.
- To reduce women's vulnerability to HIV/AIDS, support legal reforms that protect women and girls from violence and discrimination.Reforms should include protections against marital rape and unequal access to property.Support programs that promote women and girls' sexual autonomy and economic empowerment, including job training and credit programs.
- Work with the government of Uganda to address the current condom supply shortage.Together with other donors, immediately provide a sufficient number of condoms to cover the current shortage until such time as safe and tested condoms are available through the national distribution program.
This report is based on information gathered in Uganda in November 2004 as well as extensive prior and subsequent research.Two Human Rights Watch researchers interviewed children and young adults in and around Kampala, Mbale, Mbarara, Kabarole, and Kasese.At schools, we spoke with dozens of pupils, teachers, headteachers, and members of AIDS clubs.For out-of-school children and young adults, we worked through nongovernmental organizations providing health and education services to children and assistance to street children, child laborers, and sex workers.Most interviews were conducted in English; translation was provided for young people whose first language was Luganda or Rutooro.
In Kampala, Human Rights Watch interviewed representatives of the president and first lady's offices, as well as representatives from the ministries of health and education.We spoke with officials of various United Nations agencies, the U.S. government, the Uganda AIDS Commission, and the Uganda Human Rights Commission.We collected information from health service providers, religious leaders, academics, nongovernmental organizations, and Ugandan AIDS activists.Secondary sources from peer-reviewed published literature, NGO reports, and other materials supplemented what we gathered in Uganda.All materials cited in this report are either publicly available or on file at Human Rights Watch.
For HIV prevention programs supported by the U.S. Agency for International Development (USAID), "youth" is defined as those aged fifteen to twenty-four.In Uganda, youth has been defined as anyone aged fifteen to thirty, or any young person who is not yet married.The term "youth" has no legal definition in international human rights law, though "child" refers to anyone under the age of eighteen.In this report, we use the terms "youth" or "young people" to describe those targeted in prevention programs in Uganda, and "child" when referring to those under eighteen.
Young people and HIV/AIDS in Uganda
Young people in Uganda have never known a world without HIV/AIDS.Since 1982, when the country's first cases of HIV were detected on the shores of Lake Victoria in Rakai district, AIDS has killed an estimated 940,000 Ugandans, including 78,000 in 2003 alone.Most of these have been men and women of childbearing age, leaving close to one million Ugandan children without parental care, in addition to those whose parents are sick or dying.The impact of AIDS on children and young people is seen in their own risk of HIV infection: as AIDS impoverishes families, young people-especially young girls-are likely to be withdrawn from school and forced into exploitative situations to survive.Ignorance and denial fuel HIV even further, leaving young people without the critical information that could help them prevent infection.As of 2002, according to government estimates, HIV prevalence among young people in Uganda stood at an estimated 4.9 percent, with rates of 6.5 percent in major towns and 4.1 percent in rural areas.
Although Uganda is widely recognized as the only country in sub-Saharan Africa to experience a significant drop in HIV prevalence, the extent of this decline has been exaggerated.The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that national HIV prevalence in Uganda fell from 12 percent in the early 1990s to just over 4 percent in 2003, though some of this decline is due to HIV-related deaths.Declines in urban areas have been more dramatic, from approximately 30 percent in three sites in 1992 to an average of 9.1 percent at the same three clinics in 2002.Local organizations working with communities affected by AIDS have challenged recent government figures as too low and estimated HIV prevalence to be between 10-17 percent nationally.In addition, reported declines in national HIV prevalence may mask some regional and demographic variations.In three sentinel sites-Mbarara, Mbale, and Kilembe-HIV prevalence between 2001 and 2002 either stagnated or rose.HIV rates tend to be consistently higher in Uganda's urban areas than in rural ones-8 percent compared to 5 percent among the general population, and 6.5 percent compared to 4 percent among young people.
Uganda's success against AIDS has not been felt equally by those at highest risk of infection.In Gulu, in northern Uganda where there has been a protracted and brutal civil war since 1986, HIV prevalence in 2002 was estimated at 12 percent in the general population and 8 percent among young people; the general figure is higher than in 2001, although rates are lower than in the early 1990s.HIV prevalence among military recruits increased from 3 percent to 13 percent in five sites from 1997 to 1999.The highest HIV prevalence in Uganda is found among sex workers, 47 percent of whom were HIV-positive in a 2002 survey compared to 28 percent in 2000.According to data collected by the AIDS Information Centre (AIC), a leading nongovernmental organization in the field of voluntary HIV counseling and testing (VCT), a significant percentage of women in sex work are girls aged fifteen to twenty-four.
The combination of economic, social, biological, and behavioral factors that render young Ugandans vulnerable to HIV, especially girls, is not perfectly understood.Sex accounts for the vast majority of HIV infections in Uganda, as in the rest of sub-Saharan Africa.Ugandans are estimated to have their first sexual experience as teenagers, the median being 16.7 years for girls and 18.8 years for boys as of 2001.By age seventeen, more than 50 percent of Ugandan girls have had sex, usually with someone older.Among girls aged fifteen to twenty-four, 31 percent report that their first sexual partner was three to four years older, and 11 percent report that their first sexual partner was ten or more years older.According to the Uganda AIDS Commission, "Ugandan youth begin sexual activity at fairly young ages and with little sexuality information."
The phenomenon of girls having sex with older men, often out of economic need, is thought to account for a significant number of new HIV infections in Uganda.Age disparities both increase the likelihood of sexual coercion and limit girls' ability to demand fidelity and condom use.Early sex may also lead to early marriage: as of 2001, 32 percent of girls aged fifteen to nineteen in Uganda had been married, compared to only 6 percent of boys.Among married girls, a fifth were in polygynous unions.The combination of early marriage and polygyny further increases girls' and young women's HIV risk, as men often engage in concurrent sexual relationships without using condoms.The payment of bride price in connection with many marriages fosters the perception that a husband "owns" his wife and can demand sex from her without her consent.Domestic violence, which according to the United Nations affects 40 percent of Ugandan women, further inhibits girls' ability to control the terms of their sex lives (including negotiating condom use) and exposes them to HIV.In 2001, only 4 percent of married men in Uganda reported having used a condom the last time they had sex, compared to 59 percent of unmarried men.While most women knew that condoms would protect them against HIV, only 27 percent of girls aged fifteen to nineteen and 36 percent of women aged twenty to twenty-four said they could convince their partners to use them.
In 2002, six girls in Uganda were reported infected with HIV for every boy.Of the estimated 530,000 Ugandans living with HIV in 2003, over half were women and girls.In Kampala, Uganda's capital city, the AIDS Information Centre reported in 2002 that 10.3 percent of girls and women aged fifteen to twenty-four seeking an HIV test for the first time tested positive, compared to 2.8 percent of boys and men in that age group.The AIC data also found that girls were entering into prostitution at a young age: of 218 sex workers surveyed, 65 percent were girls and young women aged fifteen to twenty-four.
The human right to HIV/AIDS information
HIV/AIDS is a disease that is fueled by stigma, denial, and ignorance.While Uganda boasts high levels of awareness of HIV-close to 100 percent of survey respondents in 2000 stated they had heard of the disease-dangerous myths about HIV/AIDS persist.In the same survey, close to one quarter of Ugandans who said they had heard of AIDS agreed with the statement that HIV could be contracted from a mosquito bite.Both men and women harbored discriminatory attitudes towards people living with AIDS, such as the view held by roughly half of Ugandans that a female teacher living with HIV should not be permitted to go on teaching.This is a disturbing finding in Uganda, where the stigma associated with AIDS is thought to be less powerful than in Africa generally.
Widespread awareness of HIV/AIDS in Uganda, moreover, does not translate into knowledge of how to prevent infection-particularly among women and girls.In 2001, some 13 percent of Ugandan women did not know any method of avoiding AIDS, compared to 5 percent of men.Women were less likely than men to know that condoms prevent HIV, less likely to know that limiting one's number of sexual partners prevents HIV, and less likely to know that a healthy-looking person can be infected with HIV.Women and girls who were familiar with modes of HIV transmission were less likely than men to put them to use: in 2001, 69 percent of girls aged fifteen to nineteen said they knew condoms would protect them from HIV, whereas only 32 percent said they could obtain them.The corresponding figures for boys were 83 percent and 64 percent.Over 20 percent of young people surveyed in Kampala in 2002 believed that those who used condoms were "promiscuous."
Such gender disparities in knowledge of HIV prevention may be explained partly by girls' unequal access to formal education.In 2001, over one-quarter of Ugandan women without schooling knew no way of protecting themselves from HIV, compared to only 2 percent of women who had attended secondary school or higher.Yetwhile school has become more accessible to Ugandans of both sexes in recent years, it continues to be less accessible to girls.As of 2001, four years into Uganda's free education policy, 9 percent of Ugandan girls had never been to school compared to 2 percent of boys.Men were also more likely to stay in school, with 66 percent of young men aged fifteen to nineteen in school in 2001, compared to 44 percent of young women.
Access to information about HIV/AIDS without discrimination is not simply a public health imperative-it is a human right.International treaties ratified by Uganda recognize that all people have the right to "seek, receive and impart information of all kinds," including information about their health.The United Nations Convention on the Rights of the Child requires states to "ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health."The Committee on the Rights of the Child, the U.N. body responsible for monitoring the implementation of the Convention on the Rights of the Child, states in its general comment on HIV/AIDS that children have the right to access adequate information related to HIV/AIDS prevention.The Committee has emphasized that:
Effective HIV/AIDS prevention requires States to refrain from censoring, withholding or intentionally misrepresenting health-related information, including sexual education and information, and that, consistent with their obligations to ensure the right to life, survival and development of the child (art. 6) States parties must ensure that children have the ability to acquire the knowledge and skills to protect themselves and others as they begin to express their sexuality.
Access to health information is also essential to realizing the human right to the highest attainable standard of health and, ultimately, the right to life.Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) specifically obliges governments to take all necessary steps for the "prevention, treatment and control of epidemic . . . diseases," such as HIV/AIDS.The Committee on Economic, Social and Cultural Rights, the U.N. body responsible for monitoring the implementation of the ICESCR, has interpreted article 12 as requiring "the establishment of prevention and education programmes for behaviour-related health concerns such as sexually transmitted diseases, in particular HIV/AIDS."In language similar to that of the Committee on the Rights of the Child, the ICESCR committee notes:
States should refrain from limiting access to contraceptives and other means of maintaining sexual and reproductive health, from censoring, withholding or intentionally misrepresenting health-related information, including sexual education and information, as well as from preventing people's participation in health-related matters. . . . States should also ensure that third parties do not limit people's access to health-related information and services.
The United Nations International Guidelines on HIV/AIDS and Human Rights, while not binding, similarly call on states to take positive steps to "ensure the access of children and adolescents to adequate health information and education, including information related to HIV/AIDS prevention and care, inside and outside school, which is tailored appropriately to age level and capacity and enables them to deal positively with their sexuality."
Uganda and the U.S. Global AIDS Initiative
Ugandan AIDS policy is strongly influenced by the United States, which significantly increased its international assistance to HIV/AIDS programs in 2003.Under President George W. Bush's Presidential Emergency Plan for AIDS Relief (PEPFAR), U.S. funding for HIV/AIDS programs in Uganda doubled in 2004.As of August 2004, the United States had budgeted approximately U.S.$159 million for HIV/AIDS programs in Uganda for fiscal year (FY) 2005.The legislation authorizing PEPFAR requires that 55 percent of HIV/AIDS funds be used for the treatment of people living with AIDS, 15 percent for care and support of people living with AIDS, and 20 percent for HIV prevention.Uganda's U.S.-funded HIV prevention budget for FY2005 is therefore estimated at U.S.$31.8 million.
For young people at risk of HIV/AIDS, the cornerstone of the United States' HIV prevention strategy is the promotion of sexual abstinence until marriage."Abstinence until marriage" programs are defined as programs whose sole purpose is to highlight the benefits to be gained by abstaining from sexual activity until marriage, and marriage is in turn held up as the expected standard of human sexual activity.Abstinence-only approaches may be contrasted with comprehensive sex education, which supports the choice not to have sex but also includes information about condoms and other safer sex options for young persons who are or who become sexually active.They may further be contrasted with educational programs that caution young girls about sources of HIV risk in marriage, such as infidelity, marital rape, domestic violence, polygyny, and widow inheritance.Abstinence-only approaches withhold information about the health benefits of condoms and contraception (beyond their failure rates) in the belief that such information contradicts the message of abstinence.
Despite numerous and unrefuted government-funded studies discrediting abstinence-only approaches as an exclusive HIV prevention strategy, the U.S. Congress requires that at least 33 percent of all HIV prevention money under PEPFAR be spent on abstinence-until-marriage programs, with the remainder spent on HIV testing and targeted outreach (including condom promotion) for "high-risk" populations (defined as "prostitutes, sexually active discordant couples (where only one partner is HIV positive), substance abusers, and others"), safe blood and improved medical practices, and prevention of mother-to-child transmission of HIV.The U.S. government singles out "faith-based organizations" as particularly qualified to implement abstinence-until-marriage programs.The U.S. Five-Year Global HIV/AIDS Strategy, the document that guides the implementation of PEPFAR programs, elaborates on abstinence education as follows:
Delaying first sexual intercourse by even a year can have significant impact on the health and well-being of adolescents and on the progress of the epidemic in communities. . . . The strategies for youth . . . encourage abstinence until marriage for those who have not yet initiated sexual activity and "secondary abstinence" for unmarried youth who have already engaged in intercourse.FBOs [faith-based organizations] are in a strong position to help young people see the benefits of abstinence until marriage and support them in choosing to postpone sexual activity.Programs will help youth develop the knowledge, confidence, and communication skills necessary to make informed choices and avoid risky behavior.
While U.S. law does not explicitly define abstinence-until-marriage programs for the purposes of PEPFAR, years of experience with similar programs in all fifty U.S. states provides an indication of their main objectives.The U.S. government has funded abstinence education domestically since 1981; in FY2004, appropriations for these programs reached a historical high of U.S.$138.25 million.All federally-funded abstinence-only programs must meet an eight-part definition found in the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (commonly known as the Welfare Reform Act), which defines "abstinence education" as follows:
"Abstinence education" means an educational or motivational program which:
A.has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;
B.teaches abstinence from sexual activity outside marriage as the expected standard for all school age children;
C.teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;
D.teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity;
E.teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;
F.teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child'sparents, and society;
G.teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and
H.teaches the importance of attaining self-sufficiency before engaging in sexual activity.
As discussed below, a slightly modified version of this eight-part definition appears in a draft policy issued by the Uganda AIDS Commission in November 2004 to guide U.S.-funded abstinence-until-marriage programs in Uganda.Many of the architects of the U.S. global AIDS strategy are the same individuals who have a long history of supporting and implementing abstinence-only programs in the United States.
While numerous studies have demonstrated the ineffectiveness of U.S. abstinence-only programs, few have analyzed the content and delivery of abstinence curricula to see what participants are actually being taught.Analysis of these curricula is relevant to the Ugandan context, as domestic experience with (and support for) abstinence-only programs is largely what led the U.S. government to export these programs abroad.In 2002, Human Rights Watch published Ignorance Only: HIV/AIDS, Human Rights and Federally Funded Abstinence-Only Programs in the United States, a case study of abstinence education in the state of Texas.The report disclosed numerous ways in which U.S.-funded abstinence-only programs distort or otherwise restrict information about condoms, impede participants' access to comprehensive HIV/AIDS information and AIDS experts, and encourage young people to "pledge virginity" despite the demonstrated risks of such pledges as an HIV prevention strategy.In 2004, at the request of Congressman Henry Waxman, the Special Investigations Division of U.S. House of Representatives' Committee on Government Reform found scientific errors and distortions in eleven abstinence-only curricula being used by sixty-nine federal grantees in twenty-five U.S. states.The errors and distortions concerned, among other things, the effectiveness of condoms against HIV and other STDs, the health risks of sexual activity, and the causes of HIV transmission.
Studies such as these provide an important sign of what is to come in countries like Uganda, where the United States has committed significant funds to abstinence-until-marriage programs.None of these studies is cited in any policy document or publication related to abstinence-until-marriage programs in Uganda or under PEPFAR, nor is any study demonstrating the effectiveness of abstinence-only programs.
The acronym "ABC"-A for abstinence, B for being faithful, and C for condom use-is often used to describe the U.S. (and Ugandan) approach to preventing sexually transmitted HIV internationally.On the surface, ABC appears to promote condoms alongside abstinence and fidelity as an effective HIV prevention strategy.A closer examination of the U.S. AIDS strategy, however, reveals that ABC is disaggregated as Abstinence for unmarried youth, Being faithful for married couples, and Condom use for "those who are infected or who are unable to avoid high-risk behaviors (such as discordant couples (where only one partner is HIV positive))."As noted above, the strategy defines "high-risk" populations as "prostitutes, sexually active discordant couples, substance abusers, and others."Thus, for unmarried young people who are not working in prostitution, the intervention message is abstinence only.Even where condoms are promoted to "high-risk" groups, the strategy stipulates that condoms should not detract from the overall message that "the best means of preventing HIV/AIDS is to avoid risk all together"-that is, to abstain from sex until marriage.
The U.S. Global AIDS Strategy has evolved in a climate of increasing censorship and distortion of information about condoms and safer sex.In 2002, the U.S. Centers for Disease Control and Prevention (CDC) removed a fact sheet on the effectiveness of condoms from its website and replaced it with a new fact sheet which, while factually accurate, eliminated instructions on how to use a condom properly and evidence indicating that condom education does not encourage sex in young people.Information on condom effectiveness was similarly altered on the website of the U.S. Agency for International Development (USAID).Guidelines proposed by the CDC in 2004 require that AIDS organizations receiving federal funds include information about the "lack of effectiveness of condoms" in any HIV prevention educational materials that mention condoms.In 2002, the CDC erased from its website an entire section entitled "Programs that Work," which had highlighted the effectiveness of comprehensive sex education programs.
Since taking office in 2001, President Bush has appointed as high-level HIV/AIDS advisers physicians who deny the effectiveness of condoms (either against AIDS or other STDs), such as Senator Tom Coburn and Joe S. McIlhaney, Jr., president of the pro-abstinence-only Medical Institute for Sexual Health (MISH) based in Texas.Coburn, who has stated that "the American people [should] know the truth of condom ineffectiveness, " served as co-chair of the Presidential Advisory Council on HIV and AIDS (PACHA) until he was elected to the U.S. Senate in 2004.He was replaced by Anita Smith, a vocal advocate of abstinence-only programs.Coburn is also widely known for his efforts to require cigarette-type warnings on condom packages stating that they offer "little or no protection" against human papilloma virus (HPV), some strains of which cause cervical cancer.Condom use is in fact associated with lower rates of cervical cancer and HPV-associated disease, though the precise effect of condoms in preventing HPV is unknown.McIlhaney's Medical Institute for Sexual Health, which promotes abstinence-only sex education messages, produced a comprehensive monograph on condoms stating that condoms do not make sex "safe enough" to warrant their promotion for STD prevention despite overwhelming evidence to the contrary.McIlhaney has also stated in testimony before the U.S. Congress that there is "precious little evidence" in support of comprehensive sex education programs.
V. Findings on Abstinence Education in Uganda
We were told not to show [pupils] how to use condoms and not to talk about them at our school.In the past, we used to show them to our upper primary classes.Now we can't do that.
-A primary school teacher in Kasese
In our assemblies and in the classroom, we explain what abstinence is and why it is important . . . . But around here, people don't buy this idea of abstinence because in Uganda, many girls are using sex to buy their daily bread.
-A headteacher in Mbale
Uganda stands out among African countries for its high-profile embrace of U.S.-funded abstinence-until-marriage programs.The country's early success in bringing down rates of HIV prevalence, combined with its growing fundamentalist Christian population, has attracted the interest of U.S. policymakers eager to demonstrate the success of abstinence-only programs.Support for abstinence-only approaches has extended to powerful figures in Uganda, most notably First Lady Janet Museveni, and can increasingly be found at the level of schools and service providers.In what is widely viewed as a departure from his previous positions, President Museveni has publicly supported abstinence-only approaches and, before large international audiences, denigrated condoms as a means of HIV prevention.All of this has occurred in the context of a growing condom shortage in Uganda, prompting some government officials to urge sexual abstinence to stave off a spike in HIV transmission.These trends and their impact on Uganda's HIV/AIDS programs are documented below.
Uganda's official "AB" policy
In November 2004, Uganda claimed to be the first country in the world to draft an official national policy on abstinence and fidelity.Titled the "Uganda National Abstinence and Being Faithful Policy and Strategy on Prevention of Transmission on HIV," the draft policy is described by its authors as a companion to the country's existing strategy on the promotion of condoms and a component of Uganda's larger "ABC" strategy.A review of the draft policy document, however, shows that the policy's objective is to scale up abstinence-only programs styled after those in use in the United States.Indeed, the definition of "abstinence education" in the draft follows almost verbatim the eight-part definition of "abstinence education" in the U.S. Personal Responsibility and Work Opportunity Reconciliation Act of 1996 cited above.The Ugandan definition, which is in seven parts, reads:
Abstinence education means an educational or motivational approach which:
Has as its exclusive purpose, teaching, supporting and empowering the social, psychological, and health gains to be realized by abstaining from premarital sexual activity;
Teaches abstinence from sexual activity outside marriage (or "faithfulness") as the expected standard;
Teaches that abstinence from sexual activity is the only certain way to avoid sexually transmitted diseases, and other associated health problems;
Teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity;
Teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects;
Teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society;
Teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances
The U.S. legislation from which this is drawn is not cited anywhere in the policy document.Later in the document, the AB policy is described as follows:
Sexual abstinence until marriage and faithfulness in marriage will be widely promoted as the most effective means of preventing STI [sexually transmitted infections]/HIV transmission.Special emphasis will be placed on promoting delaying sexual debut among the young and faithfulness in marriage, eliminating sexual promiscuity.
The document further calls for the establishment of an "A&B [Abstinence and Being Faithful] Coordination Unit" (ABCU) within the Ugandan Ministry of Health, as well as a "National A&B Policy Steering Committee" (NABPSC) and an "A&B Coordination Committee" (ABCC).None of these proposed entities is given a mandate beyond promoting abstinence and faithfulness.
With respect to the promotion of condoms, the AB policy is contradictory.At several points, the policy speaks in terms of bringing AB interventions on an "equal footing" with existing condom interventions; it states that local AIDS programs should "ensure that A, B and C are mutually complementary and not competitive strategies."Elsewhere, however, the policy suggests that information about condoms can undermine the message of abstinence.Under the sections entitled "core values" and "quality assurance," the document reads:
Messages about HIV and AIDS need not be ambiguous and mixed up.A and B work in one sense are [sic] a personal challenge that calls for self-denial of immediate pleasure in favor of some good or positive health-or even survival.The mixing of this message with an offer of perceived immediate gratification by means of condom use can be confusing to youth and indeed adults.The condom message can compromise the power of the A and B message.Nevertheless, the policy is to promote A and B without reducing the value of the C message, just as condoms must be promoted in ways that do not undercut or undermine messages of abstinence and faithfulness.
. . .
. . . since A&B messages work in part on the principle of motivating people to deny current pleasure in favor of a future good, it is possible to have the quality and strength of an A&B program diminished by simultaneously presenting a risk reduction behavior (e.g., condom use) as an equal and easier alternative; this is not true.Implementers can do risk reduction education and promotion but not risk reduction adoption and sustainability.Abstinence promoters should avoid diminishing program quality by sending out contradictory messages.
The AB policy's narrow focus on abstinence and fidelity to the exclusion of all other determinants of HIV risk is reinforced in its section on monitoring and evaluation.Despite recognizing the link between HIV infection and practices such as domestic violence, rape, and wife inheritance, the policy contains no indicators on reduction of these practices.Nor does it even seek to measure whether program participants actually adopt abstinence or fidelity as HIV prevention strategies; rather, it measures only national trends in sexual behavior, which says little about the experience of program participants.In addition, the policy measures numerous process issues such as meetings and reports of AB agencies and task forces and the preponderance of abstinence and fidelity messages being provided in the country.By these indicators, the policy could be considered a success even if it fails entirely to effect changes in the sexual behavior or HIV risk of Ugandans.
Despite the fact that numerous evaluations of abstinence-only programs have been conducted in the United States, none of these evaluations is mentioned in Uganda's draft AB policy.It is possible that the authors of the draft were not aware of these studies or did not consider them relevant to the Ugandan context; however, the Ugandan government should address this concern.It is of the utmost relevance that every independent evaluation to study abstinence-only programs has found them to be ineffective at influencing participants' sexual intentions and behavior, and possibly harmful.(These studies are reviewed later in this report.)
A further concern is that the draft AB policy does not adequately address the high risk of HIV faced by married people, especially women.At several points, the policy suggests that strengthening the institutions of marriage and the family is an effective approach to preventing "social problems" such as HIV/AIDS.The section entitled "guiding conceptual principles/model" states:
The family institution is the cradle of civilization, because it [is] the natural training ground for civil behavior, morals, sexuality, integrity, interpersonal relationships essential for life, work ethics, life skills etc.In other words when the family institution is functioning as it was meant to function, many social problems which ultimately feature on a national level can be eliminated, and hence the need to pay special attention to Marriage and the family institution.
From a public health point of view, it is true that mutual fidelity to an HIV-negative partner can help to prevent sexual transmission of HIV.However, as the draft AB policy recognizes in its section on "implementation modalities," women face a high risk of HIV from such things as domestic violence, unequal gender relations, and wife inheritance.These issues should be more clearly integrated into the document's discussion of marriage and the family.
In the section on "strategy for implementation," the draft AB policy proposes mandatory HIV testing for married couples as a solution to HIV transmission in marriage.The document states:
Communication for being faithful should be integrated in all pre-marital counseling and an HIV test should be required for all those intending to get married.
Forced HIV testing is in itself an infringement of the right to bodily autonomy and to informed consent for medical procedures, as recognized by national and international legal standards.Making an HIV test a precondition of marriage also infringes upon the right to marry and, especially for women, leads to the risk of violence, discrimination, and stigma on disclosure of HIV status.While couples intending to marry should have full access to voluntary HIV counseling and testing, this does not substitute for legal protections against marital rape, domestic violence, wife inheritance, and other human rights abuses that increase married women's HIV risk.Nor does it address widespread social approval of men's infidelity, which persists in Uganda despite longstanding efforts to highlight the risk of HIV brought about by extra-marital sex.
Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY)
Following the 2001 U.N. General Assembly Special Session (UNGASS) on HIV/AIDS, President Museveni returned to Uganda with the goal of promoting increased education about HIV prevention to children and young adults.Together with the Uganda AIDS Commission (UAC), Museveni launched the Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY) in 2002.To date, PIASCY has included the creation and distribution of manuals on HIV prevention for primary school teachers, the drafting of secondary school materials, and HIV-themed youth rallies held in various districts.
Although it preceded the launch of the U.S. global AIDS initiative (PEPFAR), PIASCY is at the cornerstone of the U.S. government's abstinence-until-marriage initiative in Uganda.PIASCY is funded by the U.S. government through USAID and the Centers for Disease Control, both of which have provided technical support to the initiative.Since 2004, PIASCY has been supported mainly by PEPFAR funds.According to an official at USAID in Uganda, PIASCY is an "abstinence curriculum" that seeks primarily to empower young people to delay sex until marriage.
PIASCY in primary schools
In 2004, two PIASCY teacher's handbooks, one for pupils in grades Primary (P)3 and P4 and one for pupils in grades P5 to P7, were distributed to every primary school in Uganda.Prior to the launch of PIASCY, in 1997, the implementation of a policy of seven years of free schooling under a universal primary education (UPE) scheme had caused net enrollment in primary schools to increase to nearly 100 percent with a majority of primary school entrants reaching grade five.Targeted HIV/AIDS prevention messages delivered in schools can therefore theoretically reach nearly every primary school child in the country, at least in the early grades.Children in Uganda's primary schools are typically aged seven to thirteen, but in many schools, particularly in rural areas, children in upper primary school may be in their middle or late teens.This is because many pupils who had previously dropped out of school re-enrolled at an older age once it became free.
PIASCY is the most recent prevention program in Uganda to target children at the primary level.In 1986, the United Nations Children's Fund (UNICEF) and the government of Uganda began working to provide prevention information to pupils, starting with the School Health Education Program (SHEP).SHEP introduced ten units of science and health education into the primary school curriculum with an emphasis on HIV/AIDS information.In the 1990s, national examinations included questions related to the disease.By the middle of the decade, educators reported that pupils had sufficient knowledge of the disease but little corresponding behavior change; thus, in 1996 Uganda established "life skills education" (LSE) programs to supplement existing prevention information.Life skills education focused on empowering girls and boys to be self-confident decision makers with the ability to delay sexual debut, negotiate safe sex, and become responsible citizens.These programs emphasized student participation and incorporated an HIV prevention message of delaying sex, "zero-grazing" (reducing the number of sexual partners), and correct and consistent use of condoms.
In every primary school visited by Human Rights Watch in November 2004, school staff members were following the PIASCY program.Officials at the Ministry of Education said that manuals had been distributed nationwide and trainings had been provided to at least three teachers per primary school.Every two weeks, entire schools were meant to hold assemblies with trained teachers instructing the student body with one of twenty-six "messages" found in the manuals.The assemblies opened with the message, "Choose to abstain" and proceed to address numerous aspects of HIV prevention (including messages entitled "Condom use" and "HIV testing"), sexual and reproductive health, and "life skills" such as self-esteem, assertiveness, and resisting peer pressure.Other abstinence-oriented messages include "Virginity is healthy," "Choose to delay sex," "Pre-marital sex is risky," and "Acceptable moral practices."In addition to the assembly messages, teachers were encouraged to incorporate each biweekly message periodically in their class lessons, regardless of the subject.According to the officials, PIASCY simply reinforced existing prevention and health messages in the science curriculum (which varied from district to district) and supplemented this information with a national, standardized program.
Educators, health officials, and aid workers in Uganda spoke favorably about PIASCY, particularly its ability to reach nearly every school-age child.Some raised concerns, however, with the content and appropriateness of the materials, the effectiveness of messages delivered at assemblies, and the lack of emphasis on student involvement.When presented with these concerns, Ministry of Education officials countered that if PIASCY were implemented correctly and further trainings and monitoring conducted, many of these issues would be resolved.
Although PIASCY was launched in 2002, the manuals for the primary level were only distributed nationally in 2004.According to several of those involved in the writing and editing process, initial drafts were prepared in late 2002 and edited in 2003, and a final book, pilot-tested and approved by teachers in two districts, was launched by the president on March 21, 2003.Around the same time, however, several groups began actively protesting the content, focus, and messages in the books, vocally denouncing them and delaying their national distribution.Concerns about the content of the manuals were largely voiced by religious groups who had not been included in the initial consultative process.An individual from one of these faith-based organizations argued that sexually explicit diagrams contained in the manuals, such as an illustration of a penis with a condom on it, would encourage children to start having sex.According to Ministry of Education officials, in addition to the diagrams, religious groups insisted on a separate section on "ethics and morals" and increased information on abstinence until marriage as an HIV/AIDS prevention strategy for youth.
In late 2003, the government held additional stakeholders meetings sponsored by the U.S. government in order to respond to these objections.One observer said of the faith-based groups' participation in the meetings, "Everywhere the manual said, 'There will be some children who have sex,' they crossed it out and said, 'They should be told to stop.'"In the end, the expanded group of stakeholders made some changes, and two books, one for upper primary and one for middle primary, were launched in February 2004.The new manuals omitted information from the initial text, including diagrams on how to correctly clean the penis and foreskin, how the body changes at puberty for boys, and how semen is ejaculated during sexual intercourse.A chapter on "ethics, morals and cultural values" was added as well as two assembly messages on the risks of pre-marital sex and on "acceptable moral practices."The assembly message on condom use was altered, and a diagram illustrating a condom offering protection from HIV was removed.
The withdrawal of important and potentially life-saving material from primary school texts raises serious concerns about children's right to complete and accurate HIV/AIDS information.In the case of PIASCY, the offending manuals were designed as teachers' handbooks only and were not intended for distribution to children.Moreover, many of the controversial pictures and diagrams, including information on correct condom use, had been presented in HIV prevention materials at the primary level in Uganda since the late 1980s.Asked why it was necessary to remove explicit images from teachers' handbooks, officials at the Ministry of Education said that some stakeholders were concerned that children might see the images if they borrowed the books from their teachers or saw them lying around.
The inclusion of religious actors in the development of primary school HIV/AIDS materials should not amount to a veto over science-based health information.Individuals with considerable experience in reproductive health and sex education in Uganda said they were stunned by the empowerment and involvement of religious activists in the development of PIASCY."Religious groups have never had a veto before," said one experienced sex educator.This individual noted that faith-based organizations had historically played an important role in fighting HIV/AIDS in Uganda, particularly in caring for people living with AIDS and providing spiritual guidance, but had never shown much interest in prevention materials for children."Religious groups have never vetted materials going into schools," the observer said."Where is it going to stop?"Another participant reported that some of these groups had recently become financially empowered due to funding from U.S.-based sources and had developed links to the highest political offices, so their comments could not be ignored.
The content and launch of the PIASCY materials for primary schools has been significantly influenced by U.S. policy and funding in support of abstinence-only programs.According to one USAID employee, PIASCY is the brainchild of Uganda but has been funded by the U.S. from "close to the beginning."An official at Uganda's Ministry of Education told Human Rights Watch that direct U.S. involvement in the PIASCY primary school materials began just as the initial teacher's volume had been completed.At the same time that religious organizations were voicing their concerns about the content of the PIASCY materials, an employee of the USAID-funded AIDS/HIV Integrated Model District Program (AIM) contacted the Ministry of Education and cautioned that it would be necessary to re-work the books so that they would be acceptable to everyone.The AIM employee relayed that AIM had considerable experience with schools in many parts of the world and that parents rejected books that were too graphic or explicit.Following this intervention, AIM sponsored and paid for the stakeholders' meetings that included religious groups not involved in the initial consultative process.AIM later facilitated the publication of the two primary teachers PIASCY volumes.In 2003, USAID also placed a technical advisor at the Ministry of Education to coordinate the PIASCY materials and oversee the content of the materials.
In 2004 the Uganda Program for Human and Holistic Development (UPHOLD), another USAID-funded entity, held trainings for teachers on the PIASCY materials.Approximately 40,000 teachers in over 14,000 schools were trained nationwide, and UPHOLD continues to be involved in the monitoring and evaluation of PIASCY.The UPHOLD employee responsible for the trainings told Human Rights Watch that during the trainings, teachers expressed interest in learning about correct condom use but were instructed to teach only abstinence to children."What we are telling them is, yes, we know the condoms are there, but at this age [primary school], we are preaching abstinence."This message contradicts information supplied in PIASCY's own Primary 5-7 manual, which states, "Pupils will definitely ask you about condoms, and there is no reason to avoid talking about them.Used consistently and correctly, condoms protect against HIV/STIs and pregnancy."
In response to questions about the U.S. influence on the PIASCY program, members of the U.S. government's PEPFAR team in Uganda stated that while PIASCY had been funded by the U.S., it was in no way an "externally driven" process.They said that internal groups were responsible for the changes in the content of the teacher's manuals, and that the process was owned by the Ugandan government."Even if we supply the majority of funds to PIASCY, it does not mean we control it," one said.It is evident from teachers and those involved in the drafting process, however, that the U.S. government through its implementing partners had considerable influence both on the removal of information from the materials and the training of teachers who would ultimately be presenting them to school children.
In all schools visited by Human Rights Watch in November 2004, PIASCY materials were being used at assemblies and in classes, but there was considerable variation in the information provided to pupils.Educators expressed divergent views on teaching pupils about condom use. Some said they evaluated the needs of the students and what they had done in the past against what they had been told in the PIASCY trainings or what they believed was politically strategic.At a primary school in Kasese district, teachers said that the message about condoms they had been told to give in PIASCY trainings conflicted with that found in the science curriculum.They said that they were not providing information on condom use because according to their PIASCY trainers, parents in the community might complain.At another school in the same district, teachers said that PIASCY's message on condoms is that "it is better to abstain."A group of three teachers said, "At the PIASCY training, we were told not to show [pupils] how to use condoms and not to talk about them at our school.In the past, we used to show them to our upper primary classes.Now we can't do that."
The headteacher at another primary school in Kasese district said that information on correct condom use was essential for older children at her school, as recognized in both PIASCY and science curriculum materials.She estimated that perhaps 20 percent of girls at her school were sexually active, so it was necessary to include information about condom use and partner reduction in addition to delaying or stopping sex as an HIV prevention strategy.
In one school in Mbale district in eastern Uganda, educators omitted any message about condoms in the PIASCY program because, as one headmaster put it, "President Museveni said there is no use teaching young people about condom use, because then children will go and experiment with them."The headmaster nevertheless felt that condoms had to be discussed with his older students, because:
Some primary children are already playing sex.Some girls from the villages rent houses here in town to attend school and are engaging in sexual relations with older men.Boys are doing the same, going to video shops, watching movies . . . . They are on their own and can get into trouble.For example, we recently had a girl from a nearby village in P4 who was having sex with a car washer in town.She is twelve years old.
In part because some of the children are sexually active, this teacher talks about condoms outside the context of the PIASCY program.
The headteacher at another school in Mbale district said that condom demonstrations were done at her school, but only by outside groups who were not part of PIASCY.She said, "The point of PIASCY is that these kids are too young for sex.In our assemblies and in the classroom, we explain what abstinence is and why it is important . . . . But around here, people don't buy this idea of abstinence because in Uganda, many girls are using sex to buy their daily bread."
Representatives of nongovernmental organizations specializing in education and HIV prevention raised concerns that PIASCY promoted marriage as an HIV prevention strategy.To their credit, the PIASCY teachers' manuals contain clear messages that marriage does not provide automatic protection against HIV.Other sections of the books, however, promote marriage as an ideal.They list sexual expression in marriage as a way to "avoid the sin of sexual immorality" and "protect society from sexual disease."This creates the risk that teachers will feel more comfortable presenting marriage as a prevention strategy than providing more detailed and frank explanations of the risk of HIV faced by married people, particularly married women.One teacher at a primary school in Mbale said that in PIASCY, "We talk about marriage, what it is, when one should marry and how to be good in marriage."This same teacher, when asked about using condoms either within or outside of marriage, said, "We discourage condom use.They can burst, and some can acquire STDs [sexually transmitted diseases] or become pregnant while using them.Condoms encourage pupils to keep practicing sexual behaviors."
Young people in Uganda have a right to accurate information that is based on scientific fact.Marriage does not "protect society from sexual disease" as stated in PIASCY, nor should it be presented as a reliable HIV protection strategy.Pupils have a right to know that inside and outside of marriage they face the risk of HIV and STIs, and that in Uganda, as in many countries, many men and women have contracted HIV and other sexually transmitted diseases from their spouses.The view expressed by many people involved in PIASCY that information about condoms encourages early sexual behavior is also inaccurate and should not be used as the basis for denying young people information that could save their lives.
Not only the content of PIASCY messages, but also the form in which they are delivered, suggested they were geared more toward preaching "good behavior" than toward preventing HIV and unwanted pregnancy.As noted above, PIASCY messages are delivered to students primarily at assemblies held at the beginning or end of the school day.Students gather outside the classroom, and teachers read aloud one of the messages contained in the teachers' handbooks.Schools hold assemblies at least once every two weeks, with some schools gathering students for PIASCY messages several times a week.Teachers with considerable primary school experience raised the concern that messages delivered at school-wide assemblies were unlikely to achieve lasting behavior change among youth.In the 1990s, education specialists had remarked that HIV prevention information provided to children in Uganda did not bring about expected behavior change, so the emphasis was adjusted to highlight child participation in group settings.With PIASCY, this adjustment was reversed.Some teachers raised fears that dictating message at assemblies revived pedagogical approaches already proven ineffective in the early 1990s.
PIASCY requires that messages delivered at assemblies be reinforced in the classroom through the inclusion of examples into daily lessons.In addition, the handbooks provide many suggestions to teachers for activities both inside and outside the classroom.Teachers said that the emphasis on holding assemblies, while publicly visible and easy to monitor, left little time for additional activities that would reinforce behavior change, such as student in-class involvement or group role-play.A teacher at a rural primary school said that PIASCY had come with no materials to assist with demonstrations or activities.When teaching girls how to manage menstruation, for example, she had to bring in her own cloth (for use as a menstrual pad) for the demonstration.Another teacher remarked that PIASCY activities were a good idea in theory, but that her school lacked materials for additional projects.
To these concerns, Ministry of Education officials countered that the program was just beginning and that it would evolve over time.They explained that PIASCY should not be seen as a "top down," dictated approach, but rather that through teachers' interpretation of the messages in the classroom, parent and community members' involvement and children's activities, the program would foster dialogue and communication and empower boys and girls to protect themselves.
PIASCY in secondary schools
At this writing, the Ugandan government is expanding PIASCY to secondary schools with the publication of handbooks for both students and teachers.Two books have been drafted and are in the editing process.Unlike at the primary level, the dissemination of PIASCY messages in secondary schools is to be done in the classroom and not at an assembly.Various suggestions have been put forward that PIASCY be incorporated into existing classes such as Christian Religious Education or Biology, and/or included sporadically throughout lesson plans in a number of subjects.
Partners involved in the editing of PIASCY secondary school materials told Human Rights Watch that factual information about masturbation, abortion, and homosexuality was at risk of being omitted because of vocal opposition against their inclusion by powerful groups.Much as was the case in the primary materials, information on condoms, family planning, and abstinence-until-marriage is also contested.Participants interviewed for this report said that some individuals or faith-based organizations who advocate abstinence-until-marriage and anti-condom positions are financed through U.S. churches and anticipated future funding through PEPFAR.They suggested that these links to outside sources explained their recent empowerment.In addition, they accused these groups of promoting abstinence not because it is a sound prevention strategy, but because this is the approach favored by both the U.S. government and U.S. fundamentalist churches that are fueling the growth of a Ugandan fundamentalist revival and more importantly, because funding is now being made available to Ugandan groups who promote abstinence.
Draft copies of PIASCY secondary school materials obtained by Human Rights Watch contain incorrect and misleading statements that, if finalized, would infringe children's right to accurate information about HIV prevention.For example, the draft texts for both students and teachers state that "condoms are not 100% perfect protective gear against STDs and HIV infection.This is because condoms have small pores that could still allow the virus through."In fact, laboratory tests show that neither HIV nor any STD pathogen can penetrate a correctly used latex condom of standard acceptable quality, and that using a latex condom to prevent HIV has been estimated to be 10,000 times safer than not using a condom.These same drafts state, "Some statistics indicate that condoms have a less than 65% protection rate implying that reliance on them could mislead many youth into risky 'unsafe' sex."Beyond failing to cite where these statistics can be found, the drafts do not mention that epidemiological studies have shown that consistent condom users are in fact 80-90 percent less likely to become infected with HIV from sexual intercourse than non-users.The books then instruct teachers that the best approach to sex and HIV/AIDS education is to show students the inefficiency of condoms, to demonstrate the "loopholes" of the condom, and to debate the benefits of abstinence.
The handbooks later encourage children, when they reach adulthood, to use condoms in marriage to prevent unwanted pregnancies and HIV/AIDS.They even guide teachers to correctly demonstrate condom use in the classroom.These messages, however, do not explain why condoms are encouraged for married adults as useful in HIV control but unsafe for unmarried adults or adolescents.Nor do they explain why "small pores that could still allow the virus through" do not affect married couples.
Another troubling aspect of the drafts is their emphasis on marriage as an institution that provides a measure of protection against HIV.In Chapter Three, students are advised "to abstain from sex altogether until they are mature enough to get married.Sex before marriage is not only breaking school rules, but against religion and norms of all cultures in Uganda, and having pre-marital sex is considered a form of deviance or misconduct by the persons involved."In Chapter Eight, under advice on the best approaches to sex and HIV/AIDS education, teachers are recommended to tell students to wait until marriage and to use marriage teachings to encourage youth to wait.The texts contain no information on the number of Ugandans, especially women, who remain faithful until and during marriage only to contract HIV from their spouses. There is no explanation as to why many Ugandans in their twenties test positive for HIV, by which time many are already married.
Secondary school students and teachers interviewed for this report agreed that more HIV/AIDS information provided at school through a PIASCY program would be beneficial, but only if that information were relevant to their life experience.One history teacher told Human Rights Watch that students at his school were interested in learning how to use condoms correctly because some said they don't know how.A seventeen-year-old student said:
Some young people are sexually active when they reach secondary school.Many of my friends at school are having sex.The condom information provided at [after-school HIV] clubs is useful because you might feel you want or are ready to play sex.And when you are ready, you now know why and how to use a condom.
An HIV/AIDS training officer who holds meetings at secondary school clubs illustrated why providing information on correct condom use to youth was necessary.At one school she visited, a government-funded religious school, the headmaster refused to allow information on condoms to be presented in the belief that it would promote sex.After watching the trainer's presentation and the many questions from students about condoms, sexual relations, and HIV prevention, however, the headmaster agreed that providing correct information on condom use was necessary for the safety of the students.For this trainer, delaying sexual debut was an important prevention message that young people needed to hear, but it should not trump other equally important information.
According to teachers and students in secondary schools visited by Human Rights Watch, some HIV/AIDS and sexual reproduction information was already provided in both biology class and a class entitled Christian Religious Education (CRE).A religious education teacher said that he emphasized abstinence and the Bible when discussing sex and HIV.He taught children to fear God and to avoid sex in order to remain safe.Students who had enrolled in CRE said that the focus rested on marriage as "God's gift" and on the "sin" of premarital and same-sex relations.HIV was presented as a curse on immoral people who engage in sex.As noted above, one proposal for integration of PIASCY at the secondary level is in CRE class.
Abstinence programs out of school (including after-school programs)
A third part of the PIASCY initiative is to target children and young adults who are not receiving HIV/AIDS information in the classroom.In coordination with the Uganda AIDS Commission, the office of the president conducts youth rallies in districts around the country with the aim of training youth leaders in HIV/AIDS awareness.An official in the office of the president told Human Rights Watch that as of November 2004, seven rallies had been held throughout the country and eight more were planned.Rallies are held at schools that can accommodate large numbers of participants during school holidays.Youth leaders, out-of-school youth and students aged fifteen to thirty are invited to attend.Roughly one thousand participants are invited, but as many as 2000 youth have attended.Speakers at the rallies have included officials from relevant ministries, politicians, military officers, health care officials, religious leaders, and the president of Uganda.
In interviews with Human Rights Watch, long-time AIDS activists supported the targeting of out-of-school children and youth leaders in rural districts as a way of further educating young people on HIV prevention.But they questioned the applicability of the information provided at the rallies, with its emphasis on abstinence and its denigration of condoms-particularly as participants were largely men and women in their twenties who were already sexually active.They equally raised concerns about the apparent blending of politics and HIV prevention in a way that may alienate those who do not support the president.
A United Nations official familiar with the rallies said that the HIV prevention messages were little more than window dressing for delivering political messages to rural areas in support for Museveni's bid for a third-term in office.An AIDS activist in Kampala said:
PIASCY rallies appear to be promoting an ideology as much as providing HIV/AIDS information.The attendees and participants are clearly those interested in promoting a third term, not really youth leaders from the full spectrum of society.I feel that the goal of PIASCY is very good.The problem is that it tends to be associated with the personality of the president.When this happens, it fails to be educational materials, but increasingly, [is] perceived as a political tool.
This sentiment was echoed by numerous others.An official in the office of the president told Human Rights Watch that the rallies sought to provide information to young leaders about HIV/AIDS and development.But, she said, various officials from the government were available "to take questions about our government from the young people."She added:
We talk about the political transition, what is the process.Young people have grown up in the movement system.They need to understand what is happening now, they need to understand about the third term.So, they are very enthusiastic to learn about the NRM-O [National Resistance Movement Organization] and the plans for the future.
At one rally held in Arua in October 2004, during a session linking HIV/AIDS and good governance, the speaker stressed the achievements of the Movement system in fighting HIV/AIDS and warned that should there be a change in government, there may be an escalation of Uganda's AIDS epidemic.Youth were informed that the president's pursuit of a third term stemmed from popular demand.According to a summation of discussions held among young people at the rally, youth in attendance recommended, "The youth of West Nile Region join other citizens of Uganda in calling foran open term limit for the Office of the President."
At the same rally, various speakers informed participants that "condoms are becoming extremely unsafe, that is why emphasis is shifting to Abstaining and Be Faithful," and "using a condom with a person with these [sexually transmitted] diseases is like using a parachute which opens only 75% of the time."Participants were also told that "sex should only be in marriage," and that "there is an 80% chance of death during labour if one conceives below the age of 18."
As with other PIASCY programs, providing misleading information on the efficacy of condoms, promoting marriage as a foolproof HIV prevention strategy, and proving false information on maternal mortality denies young Ugandans their human right to accurate health information.Equally troubling is the apparent political motive of these rallies and their promotion of the movement system and the president's strategy for a third term in office.Ugandans have a right to choose their president and govern their country as they deem appropriate, but partisan political campaigning is not an appropriate use of public HIV/AIDS funding from Uganda's or any other country's treasury, quite apart from its lack of public health value.In at least some districts and in the case reported above on Arua, PIASCY rallies are financially supported by the U.S. government through its implementing partners in Uganda.
The use of U.S. government funds, even inadvertently, to promote the political aspirations of a party or personality do not fall under the stated goals of PEPFAR to "promote integrated [HIV] prevention, treatment and care programs."PEPFAR funding for HIV prevention programs should neither be associated with politics nor used to further any purpose beyond the provision of effective information and services to the largest number of recipients possible.
Faith-based organizations promoting abstinence
Aside from programs provided under PIASCY, a number of nongovernmental and faith-based organizations in Uganda are increasingly receiving support from the U.S. and Ugandan governments to promote abstinence to youth.Many of these faith-based organizations are represented by individuals or churches linked to fundamentalism, a rapidly growing brand of Christianity in Uganda particularly attractive among young people.Approximately 60 percent of Ugandans are Christian; while the Catholic church the largest denomination, it has been estimated that 25 percent of Ugandans identify with fundamentalist churches.The U.S. global AIDS strategy notes that "faith-based and community-based groups . . . have established excellent prevention programs in the [area] of abstinence promotion" and that "FBOs [faith-based organizations] are in a strong position to help young people see the benefits of abstinence until marriage and support them in choosing to postpone sexual activity."In December 2002, U.S. President George W. Bush issued an executive order establishing a Center for Faith-Based and Community Initiatives at the U.S. Agency for International Development, the purpose of which was to remove any obstacles to community and faith-based organizations' participation in USAID programs and promote their involvement "to the greatest extent possible."A USAID-funded HIV/AIDS organization in Uganda told Human Rights Watch that in their application to USAID for PEPFAR funds, they were required to state how much money that they would sub-grant to local faith-based organizations.
Uganda Youth Forum
Perhaps the best known abstinence advocate in Uganda is Janet Museveni, the wife of President Museveni.Mrs. Museveni has been an outspoken advocate for virginity for many years and has described abstinence as the perfect blending of Christian teachings and traditional African values.In 1991 Mrs. Museveni founded the National Youth Forum, an organization whose principal activity is to organize retreats in which boys and girls sign commitment cards to remain "sexually pure" until their marriage day.According to the Youth Forum, more than 70,000 youth have signed these cards since 1992.
Coupled with Mrs. Museveni's pro-abstinence stance is her anti-condom advocacy.On numerous occasions, the first lady has publicly lashed out against organizations that support condom use for young people, arguing that these organizations promote sex among children.She has claimed that condoms are not safe in preventing HIV and STIs and that she supports an exclusive message of abstinence and faithfulness for Ugandans.As an HIV prevention strategy, she has called for a national census to determine the percentage of children and young adults who are virgins, the percentage who have practiced "secondary abstinence" (abstinence among those who have already been sexually active), and the percentage that are sexually active.
Uganda already collects national data on sexual behavior through its periodic U.S.-funded demographic and health surveys.Mrs. Museveni's extraordinary call for a national "virgin census" raises legitimate fears that young people will be pressured into disclosing confidential information about their sexual lives or, worse, that they will be forced to submit to intrusive medical examinations of their virginity status.From a human rights point of view, virginity testing constitutes an infringement of the right to privacy, a form of gender discrimination when practiced predominantly among girls, and a violation of the right to bodily integrity.
Among the many criticisms of abstinence programs is that young people who "fail" to abstain will not be equipped with the information and tools they need to prevent HIV, other STIs and unwanted pregnancy.A young woman who had attended a National Youth Forum event in the mid-1990s told Human Rights Watch that some of her peers who signed commitment cards were already sexually active.As she put it:
There is real difference between the aims of the organizers [of the Youth Forum] and the aims of the youth who attend.We would go to meet boys there. Our parents were strict. This [the Youth Forum] was a legitimate excuse to get out of the house and socialize with members of the opposite sex . . . . While there are some who remain virgins until they are married, I did not and neither did my friends."
Further, U.S. surveys suggest that young people who commit to virginity until marriage may be at higher risk of HIV than others because they are less likely to use condoms when they begin having sex or to get tested for STDs.
According to a representative of the first lady's office, the Youth Forum is funded by foreign donors, and that "because of the Bush Administration's support for abstinence, it has helped us a lot."An article published in World magazine in November 2004 alleged that Mrs. Museveni had received U.S.$3 million from the U.S. government to promote her abstinence and faithfulness programs.Several U.S.-based nongovernmental organizations operating in Kampala also reported that the Youth Forum had been funded with PEPFAR HIV prevention money.Human Rights Watch was able to determine that at least one USAID-funded organization in Uganda was sub-contracting the Youth Forum and that, with U.S. government support, the Youth Forum was developing abstinence materials to be distributed nationally.In November 2004 the U.S. Office of the Global AIDS Coordinator approved a PEPFAR-funded abstinence-until-marriage grant to the Children's AIDS Fund (CAF), a Virginia-based organization with close ties and an intention to sub-grant to the Youth Forum, despite the fact that a technical review panel had found CAF "non-suitable" for such a grant.Providing U.S. HIV/AIDS funds to the National Youth Forum-an organization that engages in religious proselytizing and conducts HIV prevention rallies with an explicitly Christian message-constitutes a possible violation of U.S. law.The organization's promotion of virgin censuses, in particular, raises serious health and human rights concerns.
Another leading advocate of abstinence-only programs in Uganda and an author of the Uganda AIDS Commission's draft "AB" policy is the founder and pastor of MakerereCommunityChurch, Martin Ssempa.Known for his charismatic brand of fundamentalist Christianity, Pastor Ssempa has, on various occasions, spoken out against homosexuality, condoms, Islam, and women's human rights.The community church's student drop-in center on the campus of MakerereUniversity, known as the White House, provides counseling, meetings, musical entertainment, and a "deliverance room" where students ostensibly possessed by Satan can "exorcise their demons."
Speaking at an abstinence rally in December 2004, Pastor Ssempa reportedly stated, "We are promoting abstinence because Uganda is under attack from an agenda driven by homosexuals and Western experts."Ssempa has compared his fight against the Islamic faith in Uganda to the United States' invasion of Iraq.In late 2004, he called for re-baptizing the vice-President of Uganda whom he alleged to have made a covenant with a witchdoctor.
Human Rights Watch researchers made repeated requests to meet with Pastor Ssempa to discuss his HIV prevention programs for youth, but he said he was not available to meet with us.We did, however, visit the "White House" and speak with several staff members.According to the staff members, HIV prevention programs promoted by Ssempa promoted abstinence-until-marriage and a return to God's values; they opposed condom use, sex outside marriage, homosexuality, and abortion.The mission of the church, they said, was to train youth at elite universities today to replace leaders in secular governments with Christian fundamentalists.Staff members said that Ssempa received considerable financial support from U.S.-based churches and American evangelicals.In the week preceding the U.S. election in November 2004, members of Ssempa's church reportedly were required to fast and pray for the victory of George W. Bush.Staff members told Human Rights Watch that this was because Bush had a similar philosophy to their church and, more importantly, because they had been told by a prominent U.S.-based advocate for abstinence programs in Uganda that Bush's re-election would guarantee them PEPFAR money for their prevention work with youth.In part because Pastor Ssempa would not meet with us, Human Rights Watch was unable to substantiate claims of alleged PEPFAR funding to the MakerereCommunityChurch.
Family Life Network
The Family Life Network is a private non-profit organization that since 2002 has provided "values-based" sex education to some 130,000 students in 400 Ugandan schools.One of the main activities of the Network is to encourage students to sign "True Love Waits" cards, in which they pledge abstinence until marriage.Since the network began working in secondary schools in 2002, 72,000 students have signed these cards.
In an interview with Human Rights Watch, the executive director of the Family Life Network, Stephen Langa, stated that the four goals of the Network were to "bring back faith in the marriage institution," to "show the dangers of sexual involvement," to "warn children on the dangers of globalization, such as pornography," and to "ask children to make a commitment to abstinence."These interventions, Langa said, were rooted in the notion that AIDS is a "moral disease" and that "as long as we use technological means to treat moral issues, we will lose many lives."The Network's goal was "not just to prevent HIV," Langa said, but "to have responsible citizens.People who know hard work, people who plan.People who are going to make good marriages and good families."
Human Rights Watch asked Langa if he was aware of studies showing that students who pledged abstinence-until-marriage often broke their pledges and, in so doing, were often less likely to use condoms to prevent STDs."I'm not familiar with these studies," he said."I can't say there's no failure, there must be some."He added that personal testimonies he had heard from students suggested that they took their pledges seriously and felt badly if they broke them.Asked his position on the effectiveness of condoms against HIV, he replied inaccurately, "The failure rate of condoms used against HIV is 20 percent."He then presented a diagram comparing various cell sizes, including HIV, and argued that HIV was small enough to permeate microscopic pores in latex.His main point was that abstinence is the only 100 percent effective method against HIV."When you get involved in sex with someone who is not your wife or your husband, you are stepping into a danger zone," he said."You are driving on the wrong side of the road.It's just a question of when, not if, you're going to have an accident."
Asked how his organization advised gay and lesbian youth who could not legally marry, Langa responded that the Network did not condemn those who were victims of "vices" such as homosexuality, but that the organization would help them change if they were willing."If they can't get married, let them abstain," he concluded.
The Family Life Network is funded by both local and foreign donors, as well as individuals.According to Langa, the Network received 76 million Ugandan shillings (U.S.$38,000) from the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria to provide educational and behavior change activities.The Global Fund is a multilateral public-private partnership that takes contributions from wealthy nations and channels them through government-led "country coordinating mechanisms" in recipient countries such as Uganda.The Network has reportedly received no money from the United States through PEPFAR but, according to Langa, are "exploring possibilities to receive funding from the U.S."Langa is also an author of the Uganda AIDS Commission's draft "AB" policy.
VI. Especially Vulnerable Persons
In order to investigate the impact of abstinence-only programs on young people's right to information, Human Rights Watch interviewed a wide range of young Ugandans about their sexual attitudes, intentions, and behaviors, as well as their knowledge about HIV/AIDS prevention.Interviewees included boys and girls, both in and out of school; children orphaned by AIDS; young people affected by war and civil conflict; and young men having sex with men.These interviews revealed that for many segments of the Ugandan population, including some of those at highest risk of HIV, promoting abstinence to the exclusion of other messages violated their right to information and to protect themselves from a deadly disease.
Sexually active young people
Despite numerous claims by proponents of abstinence-only programs that young Ugandans are increasingly "choosing to abstain," sexual activity among young Ugandans has in fact increased since the mid-1990s.In 2000, 27 percent of single Ugandan girls aged fifteen to twenty-four reported having sex in the past year, compared to 22 percent in 1995.While the percentage decreased slightly among boys (from 33 percent to 31 percent), an increasing percentage of sexually active young men are reporting non-regular partnerships (from 55 percent in 1995 to 59 percent in 2000).Close to one-third of young sexually active Ugandan men reported having two or more sexual partners in 2000.
As noted above, Ugandan girls who are married or in other committed relationships are not safe from HIV.Girls typically marry men who are much older than they are, and who have been sexually active for a long period of time.In some cases, their husbands are already married and are moving on to their second or third wife.Even in non-polygynous marriages, extra-marital sex is much more common among men than among women; some 12 percent of married Ugandan men reported extra-marital sex in 2000, compared to 3 percent of women.Absent significant changes in the sexual behavior of men, therefore, HIV prevention messages that encourage young women (and men) exclusively to "abstain until marriage" provide a false sense of security.
The experience of Mary A., twenty-four, illustrates many of these points.Mary A. told Human Rights Watch that she met her first husband when she was sixteen, and that she entered a polygynous marriage without perceiving that she was at risk of HIV.
When I was sixteen, I met my first boyfriend.He was married.He promised me I could be his second wife, and I accepted.After my studies, I went and stayed with him.We had a baby boy, and he [the baby] died when he was one.At the time, I didn't even imagine having a son who could die of AIDS.Then, the following January, AIDS killed my husband.
Mary A. said that as a student, she was taught to abstain until marriage:
We used to go for seminars on HIV/AIDS in vocational school.They tried to tell us what HIV is, how someone can get it, and how someone can avoid it.The message was, abstain from sex, and if not, have protected sex and be faithful.But with my first husband, I asked if he had any tests.I said, are you sure you're HIV-negative?I trusted him.I'm sure I got it from him.
Insisting that her husband take an HIV test may have helped Mary A. avoid infection.But testing is not a complete solution, particularly for women who marry men who are unfaithful or have multiple wives.HIV prevention programs need to be forthright with young women about the risk of HIV in marriage, and also target sexually active young men-both married and unmarried-with information and condoms so that they will be less likely to transmit HIV to their wives.
Some argue that encouraging men to abstain until marriage would help people like Mary A. avoid HIV infection.But both quantitative and qualitative data suggest this strategy by itself would not be enough.As noted above, close to one third of single Ugandan men reported being sexually active in 2000, roughly the same percentage as in 1995.Of these, close to one-third reported having two or more partners.Like girls, boys can be driven by situations of extreme poverty into having sex with older partners who promise money and gifts in return.Fortunately, condom use among sexually active young men rose significantly in the late 1990s, with 62 percent in 2000 reporting they used a condom the last time they had sex with a non-regular partner compared to 40 percent in 1995.In this context, it is difficult to comprehend the current Ugandan strategy of not promoting condom use to young single males.
James K., seventeen, told Human Rights Watch he began living on the street when he was fifteen, shortly after his parents died of AIDS.Soon after, he met a "sugar mommy" who gave him a place to stay in exchange for sex and other favors.
I had a sugar mommy, she was thirty-two.She found me in the street.I know how to drive, so I used to drive for her.After a while, she began taking me to her place and making me her lover.She spent three and a half months with me.I didn't like staying with her and having sex with her, but I had nowhere else to go.She was acting as my guardian.
James K. said he always used condoms with his "sugar mommy" because, as he put it, "I'd gone to a seminar before, and they said whenever you have a woman you should use condoms."He said he has been tested for HIV seven times and is HIV-negative.
Peer educators interviewed by Human Rights Watch underscored the inadequacy, as well as the potential harms, of targeting young people with strict abstinence messages and denying them information about safer sex options.Moses T., nineteen, put it this way:
Abstinence is a good thing, but at times this message is too late for most of the groups we work with.Even for the "good" kids in school, many have strict parents and are not allowed to have boyfriends and girlfriends.So any chance they get, they sneak away and have sex with whomever.This is driving the problem.Abstinence until marriage can be possible, but only for a few.
A social worker at a youth drop-in center in the Kawempe Division of Kampala told Human Rights Watch, "Each group we work with needs its own message. . . . Some ages and some groups will not listen to abstinence, and we need to accept that as reality and work with them."A nurse in the same center added, "The condom message is working.We see the number [of condoms] being used and demanded has grown, plus we've seen a reduction in the number of STIs here at the center."
Providers of youth-friendly services added that judgmental attitudes toward premarital sex dissuaded young people, especially girls, from seeking health services and information.Abstinence-only messages, linking pre-marital sex with immorality, are only likely to make things worse."The girls are involved in sex when they are young, so when they go to health centers they get judged a lot," said the social worker cited above."So they don't go, and it's easier for men to deceive them because they lack information."
Orphans and children affected by AIDS
Uganda is home to nearly one million children orphaned by HIV/AIDS in addition to children whose parents are sick and dying from the disease.While some are taken in by relatives who care for them, others suffer abuse at the hands of their caretakers or are forced to establish child-headed households.Still others end up on the street, where they may engage in hazardous labor, including sex work, to survive.Without parental support or family income, orphans may be withdrawn from school and forced into severe economic hardship.Many of these abuses increase vulnerability to HIV infection.Children orphaned by AIDS may be more vulnerable to abuse and eventual HIV infection because of AIDS-related stigma and discrimination.
A recent global report on children orphaned by AIDS produced jointly by UNAIDS, UNICEF, and USAID concludes, "Because sexual activity (as well as substance abuse and other risky behavior) often begins during adolescence, it is critical to provide comprehensive sexual health education and services to reduce the risks-often heightened for orphans-of unwanted pregnancies, coerced sex, exploitation in commercial sex, and transmission of sexually transmitted infections. Programs must provide information on health behaviors and the life skills that adolescents need to protect themselves."
Groups working with orphans and children affected by AIDS in Uganda told Human Rights Watch that abstinence-until-marriage messages were both irrelevant and potentially dangerous.One youth activist working in the Kawempe neighborhood of Kampala said:
I wish those who preach abstinence would come down to the slums and see how people are living.Abstinence is a message for the elite; it has no place in the slums.These girls [orphans] live five to a room.There is no supper for them.The man outside says he will get her money and a place to sleep.Now, what is she going to do, abstain?These orphans need assistance, services, and access to protection, not judgmental messages.Better to be delivering services than abstinence messages.Around here, they are a waste of time and money.
A member of an outreach team organized by the AIDSInformationCenter (AIC) in Mbale explained that messages promoting abstinence and delayed sexual debut were commonplace in Uganda, but they had little resonance with the communities in which the team worked.Few orphans had the choice of abstaining from sex, he said, as poverty and hunger routinely drove them to engage in paid sex.
A seventeen-year-old orphan living in the Namatala neighborhood outside Mbale echoed this view, saying:
For those girls who don't have parents, many are involved in sex work.These are girls fourteen and up.These girls don't go to school, they lack fees.Some have good intentions.They raise money to go to school by selling sex.But after a while, because they are hanging out at night in bars, they lose interest in school and drop out.
Human Rights Watch met Simon K., a seventeen-year-old boy who had lost both his parents to AIDS, at a youth club in Kabarole district.Simon K. was in P7 (primary school grade seven) when his parents died, but he left school to care for two brothers and three sisters."I would look around for an extra banana in a plantation and try to sell it to pay for their schooling," he said.A sister and brother subsequently died, and when we met him he was caring for his two surviving sisters, aged fifteen and eighteen.With no income and little to eat, he said one of his sisters was trading sex for money and food.
She slept with an older man and was given money for it.It was last year.She was looking for a job and found work as a house girl.After she left, her boss followed her and offered her money to have sex with him. . . . He would pay her about 10,000 shillings (U.S. $5.80), I don't know exactly how much.She bought knickers and a bra with it, and with the rest she just bought something to eat.
Simon K. said he talked to his elder sister about the importance of abstinence, but to no avail."I feel she should at least try to wait for some time in the future to have sex, but not now," he said."I told her that, and she says she can't do anything about it, it's the only way she can make money.If I were able to care for her needs, I would. But there is nothing else I can do."
Refugees, internally displaced persons, and children affected by conflict
Ongoing conflict in the north of Uganda between government forces and the Lord's Resistance Army (LRA) has forced an estimated 1.6 million civilians to live in internally displaced persons (IDP) camps.Commenting in November 2003 on the plight of these civilians, Jan Egeland, the U.N. Under Secretary General for Humanitarian Affairs, called the situation in the north of Uganda the biggest forgotten humanitarian emergency in the world today.Children, together with adults, live in closely confined, overcrowded camps with limited access to food, water, schooling, and economic opportunity.The displacement, poverty, and lack of employment options drive women and girls to engage in paid sex with camp residents, local defense personnel, and Ugandan government soldiers.While this context makes it difficult to provide any information to those at risk of HIV, abstinence-only approaches make it particularly difficult for those affected to protect themselves from it.
According to one IDP camp leader, while there are cases of rape and sexual assault in the camps, much more common is "survival sex" or sex involving girls or young women in exchange for food or money.Soldiers, who spend considerable time away from their families at isolated posts in the camps and in positions of affluence compared to the destitute people they protect, pay women and girls for sex.One NGO worker said that soldiers sometimes "will pay boys a little money, so that they will lure the women and girls to the army installations.They will later get a little money or food for their services."
LRA attacks on villages and homesteads outside major towns in the north have led parents to send their children to urban centers at night to avoid abduction.Parents stay at home to guard their property while children, who are particularly targeted by the LRA for forcible recruitment into military service, are sent off near sundown and return home at sunrise.These "night commuters," as the children are commonly known, spend evenings largely unsupervised and face a high risk of sexual exploitation and assault in addition to engaging in sex with other children.Human Rights Watch has documented cases of rape of night commuters traveling to and from towns as well as in places where they sleep.More common is the phenomenon of girls engaging in survival sex with civilians and soldiers and, according to one municipal official, boys and girls engaging in drinking, drugs, and sexual activities with one another.
Sexual coercion and exploitation in the context of this conflict is likely responsible for higher HIV prevalence rates in northern Uganda than in the rest of the country.An antenatal testing program for mothers at LacorHospital in Gulu found that of those who volunteered to be tested, 11.9 percent tested positive for HIV in 2002 compared to a national prevalence rate of just over 6 percent.In Kitgum and Pader, testing programs at three hospitals found that HIV prevalence ranged from 4.8 to 10.4 percent among pregnant women between May and December 2002.
The increased risk of sexual violence, sexual exploitation, and heightened sexual activity among boys and girls require a realistic HIV prevention strategy.Preliminary results from a survey done on HIV awareness and service provisions for internally displaced persons found a large amount of early sexual activity among adolescent children; lower HIV awareness than in the rest of the country; and limited access to health services.The survey also showed that that vast majority of respondents felt that "abstinence until marriage" was an inappropriate strategy and had no relevance to their lives.
Children also face a heightened risk of HIV infection in the post-conflict districts of Bundibugyo, Kasese, and Kabarole in western Uganda where the government battled the Allied Democratic Forces until 2001.Estimated HIV prevalence rates in some of these areas are as high as 20 percent, three times higher than the national average.Youth leaders in Kasese told Human Rights Watch that conflict in that region had displaced tens of thousands of civilians, increased the number of orphans and street children, and contributed to lower ages of sexual debut and marriage among children.As in the north, poverty in these rural districts was exacerbated by the fighting and led more girls to engage in survival sex and prostitution.The leader of a youth network in Kabarole and Bundibugyo told Human Rights Watch:
We don't think abstinence is really working in our communities.These kids are having sex.We work with children in primary five through seven who are engaging in sexual activities.We always come with the message to delay sexual debut but for most children here, this is not enough.
The end of the conflict in 2001 combined with a policy of universal primary education, has resulted in an increasing number of children in western Uganda returning to finish primary school.Some of these boys and girls are in their mid to late teens and are already sexually active; some are married and have children of their own.According to youth outreach activists working in the schools, these older children were in particular need of appropriate information on how to protect themselves from HIV, not messages that promote abstinence-until-marriage.
Discrimination based on sexual orientation
By definition, abstinence-until-marriage programs discriminate on the basis of sexual orientation.For young people who are lesbian, gay, bisexual, or transgender (LGBT) and cannot legally marry in Uganda (as in most jurisdictions worldwide), these messages imply, wrongly, that there is no safe way for them to have sex.They deny these people information that could save their lives.They also convey a message about the intrinsic wrongfulness of homosexual conduct that reinforces existing social stigma and prejudice to potentially devastating effect.
Such stigma and prejudice in Uganda exist not only in the abstract, but are embodied in laws that criminalize same-sex sexual relations.Political and religious leaders as well as the media in Uganda help to create a climate in which the legal threat of imprisonment contributes to an environment of hatred and exclusion.In 1998, for example, President Museveni told a press conference, "When I was a in America, some time ago, I saw a rally of 300,000 homosexuals.If you have a rally of 20 homosexuals here, I would disperse it."His minister of gender, labour, and social development, Janet Mukwaya, later warned, "The West is bringing up homosexuality and lesbianism under a different name, called sexual orientation ... These people want their ideas to be focused in every programme, in case you come across something like sexual orientation, you have to think twice before you defend it."
In a manner significant to the debates about "abstinence until marriage," these warnings repeatedly focus around fears that gay or lesbian people might actually marry.In September 1999, after (inaccurate) published reports of a wedding ceremony between two men in Uganda, President Museveni told a conference on reproductive health:"I have told the CID [Criminal Investigations Department] to look for homosexuals, lock them up and charge them."Several people were jailed in the wake of this mandate.Five men and women who had formed a tiny lesbian and gay group were tortured by police. Others fled the country in fear.
This environment of intimidation has a particular effect on young people.In December, 2003, an eighteen-year-old secondary school student in Nysamba was, according to press accounts, "caned several times in front of a whole school after the administration told her parents that she has been found with love letters from her fellow girls."Suspended from classes, she was later found dead in her bed shortly thereafter; while officials ruled the death a suicide, activists in Uganda suspected she may have died as a result of the beatings.The press also reported that "A school in Lubaga Division punished four girls after finding out about their love affair.They were made to dig up three ant-hills plus received 30 strokes at the assembly.Another one in Makindye expelled six lesbians and two gays."Fear of gay and lesbian students is actively fostered by the government.In February 2005, for instance, a Ministry of Education official warned direly in a speech about the "spread of homosexuality and lesbianism in secondary boarding schools."
Despite the interlinked ignorance and fear surrounding, and silencing, homosexuality in Uganda, Human Rights Watch interviewed numerous young people in secondary schools and universities, as well as young people out of school, who identified as gay or lesbian and were sexually active.Young gay and lesbian Ugandans reported discrimination and ostracization by members of their communities, fear of seeking health services, and arrest and intimidation by law enforcement officials for suspicion of engaging in criminalized homosexual acts.The following statements, directed to Human Rights Watch researchers during the course of these interviews, all underscore the need to provide accurate prevention information on how HIV is transmitted:
The HIV/AIDS information we get says that girls under twenty are more susceptible to HIV than boys, so some guys think they can't get HIV from another boy, is this true?
At school, they talk about sex in the vagina but not anal sex, is it true you can't get HIV from anal sex?
I never knew that anal sex was a riskier form of HIV transmission than vaginal sex.
I didn't know you could get an STD from anal sex, this has never been explained to us.
Former and current street children interviewed by Human Rights Watch also said that street children often had sex with other children of the same sex, or with adults who paid boys for anal intercourse.One former street boy in Kampala said he used to engage in anal sex with older boys when he lived on the street, as well as with boys his age.He said that he had no information that penetrative anal sex put him at risk of HIV because in Uganda, "this is just not talked about."Another former street boy in Mbale said:
These homosexual acts occur all the time.You might have a man who wants to have sex, so he will pay a street boy a small amount of money to penetrate him.This could be anyone, a boda-boda [bicycle taxi] driver, a street cleaner, even an educated man.Some people think that by having homosexual relations, they are not going to get HIV. . . . Street children need information on the dangers of sharing razors, of not picking up from dump sites, and on using condoms correctly.They need this information to survive, not abstinence messages.
Individuals involved in providing HIV/AIDS information to young people said that the political climate and criminality associated with homosexuality made it impossible to convey accurate HIV/AIDS information to gays and lesbians.This did not stop some courageous secondary school students from occasionally requesting information from them about homosexuality and HIV/AIDS, however.One activist working in an academic institution told Human Rights Watch:
Men who have sex with men are erased from all HIV programs.The Uganda AIDS Commission does not want to hear about them.It is a fact that here in Uganda there is a percentage of men who are in heterosexual relationships but are having sex with men on the side.This puts women involved with them at heightened risk of contracting HIV.But nobody wants to talk about that in Uganda.
Indeed, in November 2004, the Minister of Information said publicly that he had written both the Joint United Nations Programme on HIV/AIDS, UNAIDS, and the Uganda AIDS Commission to protest any "support for lesbian, gay, bisexual and transgender groups," warning: "The government position is very clear, homosexuality is illegal."In response, the Uganda AIDS Commission told the press that they "had no mandate to create a policy supportive of gays when their activities were not recognized under national laws."
HIV/AIDS materials in Uganda's schools, including the PIASCY materials described above, provide inadequate information on how people who engage in anal and oral sex can protect themselves from HIV, regardless of their sexual orientation.In the PIASCY upper primary teacher's book, the only reference to anal sex or homosexuality is located in the chapter entitled "Morally Unacceptable Sexual Behavior for Young Adolescents."The chapter provides a list of "immoral behavior," including sexual activity between people of the same sex.The draft secondary materials for PIASCY state that HIV transmission can occur through anal sex because the lining of the anus is delicate and likely to be bruised during sex.There is no information provided, however, that condoms and lubricant when used correctly and consistently can prevent the transmission of HIV from anal sex.
VII. Restrictions on Condoms
As long as they're calling it ABC and not bashing condoms, that would be no problem.What would be a problem is to deny support for condoms.
-Elioda Tumwesigye, MP, chairperson, Ugandan Parliamentary Steering Committee on HIV/AIDS, November 2004
There is no common ground between contraception educators and authentic abstinence educators.That is because, like oil and water, abstinence and condoms never mix.
-Leslee Unruh, president, Abstinence Clearinghouse, January 2005
A year ago, ABC was still cool in Uganda.Now, C is out of the equation.
-Anonymous, representative of a U.S.-funded HIV/AIDS organization, Kampala, November 2004
Among the many pitfalls of abstinence-only programs is their outright denigration of condoms, the only device proven to prevent sexual transmission of HIV.Latex condoms are not a complete solution to HIV/AIDS, but they provide an essentially impermeable barrier to HIV pathogens and if used consistently reduce the risk of HIV transmission by 80-90 percent.Condom use also reduces the risk of other STDs that increase HIV vulnerability.Vigorous efforts to promote condoms in Uganda have resulted in dramatic increases in knowledge, attitudes, and behaviors towards condom use, achievements that are widely credited with helping to reduce HIV incidence and sustain relatively low rates of infection.While much work remains to be done in closing the gap between people's knowledge of condoms and their ability to obtain them, it is encouraging that in the period from 1995 to 2000, increases in rates of premarital sex in Uganda were accompanied by greater condom use among sexually active young people.
Far from building on its previous success in condom promotion, however, the Ugandan government has taken numerous steps to impede access to condoms for those at risk of HIV.In a series of highly publicized statements throughout 2004, President Museveni lashed out against condoms as "inappropriate for Ugandans" and suggested that condom distribution encouraged promiscuity among young people.These comments caused considerable controversy at the July 2004 International AIDS Conference in Bangkok, Thailand, where Museveni told delegates he saw condoms as "an improvisation, not a solution" to HIV/AIDS and that he favored "optimal relationships based on love and trust instead of intentional mistrust which is what the condom is all about."Following the conference, Museveni told a local newspaper that "this condomisation . . . is a recipe for disaster."
While Museveni's strongest criticism has been directed at those who distribute condoms in schools (against whom he has vowed open "war"), he has repeatedly claimed that condoms are appropriate only for women in prostitution.First Lady Janet Museveni, a vocal proponent of abstinence-only approaches, has criticized condoms even more vociferously than her husband.In August 2004, the first lady criticized people who distribute condoms to young people for "pushing them to go into sex" and stated that "it is not the law that our children must have sex."Shortly after, she criticized condom distributors for sending "vague messages" about HIV prevention and for concealing condoms' ineffectiveness against human papilloma virus (HPV).
Official statements against condom use contradict the Uganda Ministry of Health's National Condom Policy and Strategy (June 2004), which states that "correct and consistent condom use shall be widely and openly promoted to all sexually active individuals as an effective means of preventing HIV/STI transmission and as a family planning method."In February 2005, Uganda's Secretary of Health, Godfrey Masaba, asked politicians to stop criticizing condom use, stating, "Let's not bring politics in health issues by discouraging condom use.If the youth can't abstain, why not use condoms?"
On at least one occasion, the Ugandan government has supported an organization that spreads false information about the effectiveness of condoms against HIV.The Family Life Network, a faith-based organization that claims to have received a grant from the Ugandan government supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria, teaches young people that latex condoms contain microscopic pores that can be permeated by HIV pathogens.In an interview with Human Rights Watch, Stephen Langa, the director of FLN, presented a diagram comparing the small size of an HIV pathogen with the larger particles of sperm, syphilis and gonorrhea and stated, "I know that the holes are there [in condoms].I think I've seen several reports saying the holes are there.Some of the holes, from what I hear, are big enough for the virus to go through. . . . It's a possibility."In addition to receiving Ugandan government support through the Global Fund, Langa is one of five authors of the country's draft policy on abstinence and faithfulness.
In numerous interviews, non-governmental organizations that have traditionally promoted condoms in Uganda told Human Rights Watch they feared government restrictions if they continued their work."We fear we don't want to be seen to be doing what government or political leaders are opposed to," the coordinator of a youth HIV prevention program told Human Rights Watch.He added, "We fear we would be blacklisted.At the end of the day, . . . the Ministry of Education can say certain organizations cannot work in schools because they do ABC.So we will lose the grip of our constituency."This coordinator said that his organization had stopped promoting condoms directly to young people by May 2004."The vigor with which condom use was talked about is now coming down," he said."Youth say, 'I hear about abstinence, but I cannot abstain.We want condoms.'"
Another organization that had promoted condoms in Uganda since the early 1990s told Human Rights Watch that the recent shift toward abstinence was reversing their success in gaining acceptance of condoms among young people."We're almost back to square one," one of the organization's staff members said, adding:
[B]ecause of our culture, it was very difficult for us to get people to use condoms.Now, trying to promote abstinence in this social environment . . . is very difficult.If you tell people to abstain, they'll say, "You were the people telling us to use condoms, and now you're telling us to abstain.Does this mean condoms weren't effective and you were lying to us?"
Numerous groups attributed the current pressure to promote abstinence-only approaches to the influence of U.S. funding."If you're talking more about abstinence, you will get more money," said a member of a youth group in Kampala that had received sub-grants from a USAID-funded organization."The [U.S.] funding pushes you to adopt certain strategies."A service provider from a Ugandan organization that does not rely on U.S. funds said that the trend toward abstinence messages had not yet affected them, but still could."We are quiet now with our message and waiting to see what will happen," she said.
Numerous HIV/AIDS groups in Uganda told Human Rights Watch that the activities of Population Services International (PSI), a large U.S.-funded social marketing organization that sells subsidized condoms under the brand-name Protector, had been curtailed in recent months under pressure from the U.S. and Ugandan governments.A religious leader observed that PSI's billboards, advertisements, TV commercials, and other materials promoting condoms had disappeared in recent months."What a coincidence," he said."At a time when public officials are making statements against condoms, . . . all of a sudden, Protector is withdrawing their billboards."It is widely discussed among AIDS service providers in Kampala that First Lady Janet Museveni had accused PSI of distributing condoms at a promotional event designed to encourage abstinence among youth, and that the accusation had resulted in restrictions on PSI's HIV prevention work.
In addition to embracing abstinence messages and denigrating condoms as an HIV prevention strategy, the Ugandan government in October 2004 issued a nationwide recall on all government-funded condoms.Allegedly in response to failed quality control tests, this recall applied to all Engabu (Shield) brand condoms, the main source of free condoms in Uganda.Engabu condoms had been in use in Uganda since 1991; according to the National Drug Authority (NDA), the tests were prompted by recent consumer complaints about the condoms' smell.Shortly after the recall, the NDA issued a new policy requiring pre-shipment and post-shipment testing of all condoms being imported into Uganda.Millions of condoms were impounded in warehouses in Kampala while they awaited NDA clearance, a process that was expected to take approximately six months.
By December 2004, HIV/AIDS experts in Uganda were forecasting a national condom shortage.Numerous HIV/AIDS organizations visited by Human Rights Watch said they had either run out of free condoms or stopped distributing them under government orders.While some parts of the Ugandan government took steps to address the condom crisis, others seized on it as platform to promote abstinence and fidelity as preferable to condom use.Dr. Alex Kamugisha, Uganda's minister of state for primary health care, said in response to the crisis:
We want to slowly move away from the condom.As a ministry, we have realized that abstinence and being faithful to one's partner are the only sure ways to curb AIDS.From next year, the ministry is going to be less involved in condom importation but more involved in awareness campaigns; abstinence and behavior change.
Other ministry officials suggested that, pending a solution to the Engabu crisis, Ugandans should simply abstain from sex.For his part, President Museveni responded to the Engabu crisis by blaming the country's stagnating HIV prevention efforts on faulty condoms, though he acknowledged that condoms can be effective if manufactured properly:
I am told Ngabo [Engabu] is not good, it breaks.That is another crisis.I don't know who approved that type.It breaks and kills people.Whoever allowed the importation of that condom into Uganda is a killer.Maybe that is why the prevalence rate has stagnated because people believed in the safety of such condoms and found they break.There must be a limit to condoms, but for sure if they are well manufactured they can control AIDS.
Some of these statements by government officials fueled suspicion that the Engabu crisis had been orchestrated to support the government's burgeoning abstinence campaign.In late January 2005, a German manufacturer of Engabu condoms, Stephen Buchmann Medical Care and Services, defended the quality of its product and threatened to take legal action against "those persons and organizations responsible for maligning our otherwise good record."Others questioned whether the NDA's new policy of requiring post-shipment testing of all imported condoms constituted a proportionate response to concerns about Engabu's quality.The coordinator of condom procurement at the Uganda Ministry of Health, Vastha Kibirige, told Human Rights Watch in November 2004 that the source of the alleged defective condoms was under investigation.Kibirige added that she was not at liberty to discuss the results of the quality control tests or the policy discussion leading up to the government's response.
As of November 2004, the nationwide Engabu recall had already had a noticeable negative impact on condom promotion efforts throughout Uganda."There is a big outcry now," said a representative of a youth association in FortPortal."People say they want condoms, but not Engabu.Only Protector is currently available, and people can't afford to buy them."A religious leader who had distributed condoms and HIV/AIDS information to young people told Human Rights Watch, "There are challenges now.If Engabu is withdrawn, . . . access to condoms will be difficult.Every time we go into the field we carry a box of condoms with us, and already the demand is more than we can provide."Even officials of the U.S. State Department and USAID expressed concern about Uganda's decision to require post-shipment testing of all imported condoms (a decision that delayed distribution of U.S.-funded condoms that had been tested prior to shipment), but as of November 2004 their efforts to advocate against this policy had not borne fruit.
Even the perception of opposition to condoms in Uganda, a regional leader in HIV prevention, has the potential to fuel anti-condom sentiment in other parts of Africa.In January 2005, the head of the Catholic Bishops' Conference of South Africa, Cardinal Wilfred Napier, cited Uganda as an example of why the South African government should not be promoting condoms.Napier reportedly stated, "If we look at the one example of success [against AIDS] we have which is Uganda then there is a clear message that it was a return to moral values that halted the disease.Where condoms have been promoted, we have not seen the effect we've seen in Uganda."Just days earlier, Pope John Paul II had reaffirmed the Roman Catholic Church's opposition to condoms for HIV prevention as part of its larger opposition to birth control.
VIII. Arguments For and Against Abstinence-Only Programs
Encouraging young people to delay sex and reduce the number of their sex partners forms a rational part of any comprehensive approach to HIV prevention.However, governments have an obligation not to censor or distort information about effective methods of HIV prevention, including condoms, and to pursue HIV prevention strategies that are scientifically valid.When moral considerations (such as discouraging sex for its own sake or promoting the institution of marriage) overwhelm sound HIV prevention, this impedes the realization of internationally recognized human rights, including the right to information, the right to the highest attainable standard of health, and ultimately the right to life.
The following sections address two aspects of whether abstinence-only-until-marriage programs constitutes a sound approach to HIV prevention that is consistent with internationally recognized human rights: first, whether abstinence messages in fact contributed to Uganda's decline in HIV prevalence in the 1990s; and second, whether abstinence-only programs for young people have proven effective in the United States, where they have existed since 1981.
Distortion of Uganda's HIV prevention efforts
Between 2002 and 2004, the U.S. government sponsored at least four studies which concluded that the drop in HIV prevalence in Uganda in the 1990s resulted from increased rates of abstinence and fidelity in Uganda during that period, as well as a concerted government effort to encourage these behavior changes.The aim of these studies was apparently to provide a scientific basis for current abstinence-until-marriage programs.The most recent of these studies claims that Ugandan youth adopted at least twelve "protective behaviors" between 1989 and 2000, nine of which may be grouped under the category of abstinence or fidelity.The remaining three behavior changes relate to increased condom use, though the study notes that few national data are available on condom use before 1995.The study does not attempt to ascertain the causes of various behavior changes (e.g., government-funded HIV prevention campaigns versus broader social factors), nor does it measure the relative impact of different behavior changes (e.g. abstinence versus condom use) on HIV spread.It concludes that "[i]t is likely that a combination of abstinence and partner reduction resulted in the decline in prevalence, but that the increase in condom use helped maintain the low prevalence levels throughout the rest of the nineties."
There are multiple problems with using survey data such as these as the basis for U.S.-funded abstinence programs.First, the U.S. government's own research suggests that condoms played an important role in Uganda's HIV decline, and not only for "high-risk" populations such as sex workers.According to the above study, the percentage of all sexually active Ugandan women and girls who had ever used a condom increased from 9 percent in 1989 to 26 percent in 1995, a period that saw a significant decline in HIV prevalence.Among men and boys, the percentage rose from 22 percent to 35 percent.While consistent condom use is difficult to measure, a helpful indication of the contribution of condom use to HIV prevention is the percentage of sexually active Ugandans who used a condom the last time they had sex with a non-regular partner.National data for this indicator are available only for the period 1995 to 2000, during which the percentage rose from 25 percent to 44 percent among women and 40 percent to 62 percent among men.As noted above, this increase in condom use coincided with a steep increase in non-regular sexual partnerships among young men, suggesting it staved off a significant number of new HIV infections.Median HIV prevalence among ante-natal clinic attendees dropped from 11.8 percent to 5 percent during this period, though incidence (new HIV infections) likely dropped earlier.National data on increased condom use are supported by studies in specific regions.
Second, of the primary behavior changes documented in Uganda in the 1990s, partner reduction (or a reduction in casual sex) appears to have played a much larger role in HIV decline than abstinence.One indication of this is that teenage pregnancy rates did not fall in Uganda during this period, and that teenage girls who became pregnant did not do so at older ages.This suggests that any drop in HIV prevalence among girls could not have been due to girls' postponing sex or becoming less sexually active, but instead to their having sex in more regular partnerships.Mathematical models have suggested that having multiple non-regular sex partners can dramatically increase HIV spread, more than having one regular partner after another (i.e., "serial monogamy").The fact that Uganda engaged in an intensive campaign in the 1990s to promote fidelity (known locally as "zero grazing") further suggests that fidelity, not abstinence, was the most successful component of its HIV prevention efforts.
Third, demographic data on the causes of HIV decline in Uganda do not substitute for evaluations of abstinence-only programs.Program evaluations require a comparison of the attitudes, intentions, and sexual behaviors of program participants over time, as well as in comparison to those who have not participated in abstinence-until-marriage programs.Evaluations of this nature have been occurring in the United States since the 1990s and are reviewed below.They indicate that abstinence-only programs have little to no impact on participants' sexual risk-taking behaviors, and that participants are less likely to use condoms once they become sexually active.If these are a guide, abstinence-only approaches would have been more likely to detract from Uganda's HIV decline than to contribute to it.
Finally, the HIV prevention campaigns implemented by the Ugandan government in the 1990s, which enjoyed some success, differ vastly from abstinence education as defined and implemented by the United States.Historical accounts, including those funded by the U.S. government, disclose numerous components of what has been described as the "Museveni" approach to HIV prevention.A hallmark of this approach was the president's personal commitment to fighting AIDS, combined with his engagement of numerous government ministries, active encouragement of NGOs and faith-based organizations, and relaxation of state controls on mass media.The openness of Uganda's approach allowed a diversity of prevention messages (including the "zero grazing" message noted above) to permeate the country's schools, churches, and airwaves.Central to the effort was breaking down the stigma associated with HIV/AIDS and encouraging frank discussion of sex and other causes of HIV transmission.As one veteran AIDS educator described it, "It's not true that Museveni talked about abstinence.What he did was give us complete freedom of the press.There were pictures of vaginas and penises everywhere."A government minister added, "It was not easy [at first] because culturally we don't talk about sexual matters openly.The church didn't want to talk about condoms.Eventually, we managed to break through.[Especially] once we explained the multiplicity of methods of acquiring AIDS, the stigma reduced."It would be a revision of history to suggest that U.S.-funded abstinence-only programs, which were pioneered in the U.S. in 1981 as a means of pregnancy prevention and before HIV/AIDS was an epidemic, are a natural outgrowth of Uganda's early anti-AIDS efforts.
Even the so-called ABC (Abstinence, Be Faithful, Condom use) approach to HIV prevention, which is routinely cited by U.S. officials and others as the "Ugandan approach," does not accurately capture Uganda's anti-AIDS effort before 2002.In November 2004, the AIDS educator cited above told Human Rights Watch, "About one and a half years ago we started hearing about ABC, and we'd never heard of it before.We were told this is what Uganda's model was." Another educator, who had directed USAID-funded HIV prevention programs in Uganda since the early 1990s, said:
In about 1999 or 2000 . . . someone made a reference to ABC, and I had to ask what ABC was.Although everyone says we were doing it in Uganda, I'd never heard of it.I don't even know where it came from.A faith-based organization recently said that Janet Museveni had founded ABC, and I thought, you must be joking.History has been substantially rewritten here.
It is true that some Ugandan HIV/AIDS materials dating to the 1990s refer to "delayed sexual debut" as part of a comprehensive HIV prevention strategy; however, this does not amount to a national ABC approach, much less to abstinence-only-until-marriage as currently defined by the United States.
Reverend Gideon Byamugisha, an Anglican priest from Uganda who is known as the first African cleric to reveal his HIV-positive status, said of Uganda's alleged ABC strategy, "It makes me angry to hear that Uganda's success is because of ABC. It goes far beyond that.It's the amount of effort, information, attitudes changing, skills for self-protection, programming, VCT [voluntary counseling and testing], blood transfusions, training counselors and doctors . . . a supportive environment.Uganda's success is not an 'either/or.'Everything is important."
Ultimately, Uganda's anti-AIDS efforts in the 1990s cannot be reduced to a particular government intervention such as abstinence-only or ABC.As one commentator recently put it, "The government is but one player in the fight against HIV-1.There are hundreds of nongovernmental organizations, religious groups, and community activists also working to prevent the spread of HIV/AIDS in Uganda."This multiplicity of voices stands to be jeopardized by the government's emerging focus on abstinence as an exclusive method of HIV prevention.More importantly, the implication behind abstinence-only programs that AIDS is a "moral" disease stemming from "promiscuous" behavior is the antithesis of Uganda's effort to de-stigmatize AIDS early in the pandemic.
Studies discrediting abstinence-only approaches in the U.S.
The exportation of abstinence-only programs from the United States to Uganda is occurring notwithstanding unrefuted evidence of the ineffectiveness and potential harms of these programs.Government-funded evaluations in at least twelve U.S. states, as well as a federally mandated independent evaluation authorized in 1997, indicate that abstinence-until-marriage programs show no long-term success in delaying sexual initiation or reducing sexual risk-taking behaviors among program participants, and that program participants are less likely to use contraceptives once they become sexually active.The Institute of Medicine, a body of experts that acts under a Congressional charter as an advisor to the U.S. federal government, noted in 2001 that there was no evidence supporting abstinence-only programs, and that investing "millions of dollars of federalfundsin abstinence-only programs with no evidence of effectiveness constitutes poor fiscal and health policy."Assessments such as these provide some indication of the likely success (or failure) of abstinence-only programs in Uganda, as U.S.-based abstinence-only programs are administered according to the same guidelines, and in some cases by the same organizations, as proposed Ugandan programs.No independent evaluations of abstinence-only programs exist from Uganda, largely because such programs did not exist there on a significant scale before 2004.
Evaluations of abstinence-only programs typically measure whether program participants change their sexual attitudes, intentions, and behaviors over the short and long term.According to a 2004 review of abstinence-only program evaluations conducted by Washington, D.C.-based Advocates for Youth, only one program showed any impact on participants' sexual behavior, and this impact disappeared by the end of the program.While some programs had short-term impact on participants' attitudes and intentions to abstain, and one (in Pennsylvania) had some long-term impact on intentions, these attitudes and intentions did not translate into behavior changes.In one county in Pennsylvania, 42 percent of female participants were sexually active by the second year of their abstinence-only program.In another, rates of sexual debut among females increased from 6 to 30 percent as program participants progressed from seventh to ninth grade.In Minnesota, where an abstinence program showed mixed results on changing attitudes towards abstinence in the long-term, the percentage of youths who were sexually active was higher in several counties with abstinence programs than the state average.
Of equal concern is that abstinence-only programs may discourage young people from using contraception once they become sexually active.As noted above, abstinence-only programs do not provide participants with information about contraception other than (sometimes exaggerated) failure rates.In one county in Pennsylvania, only half of those who said they started having sex in ninth grade used any form of contraception.The Missouri evaluation found that program participants developed a less favorable attitude toward birth control from the beginning to the end of the program.Virginity pledges, a staple of abstinence-only programs in which students pledge to remain sexually abstinent until marriage, have been shown in peer-reviewed national surveys of adolescent sexual behavior to reduce the likelihood of contraceptive use once pledgers become sexually active.
Proponents of abstinence-only programs often claim that teaching young people about condoms and safer sex will contradict or otherwise undermine the message of abstinence.However, studies that compare abstinence-only education with programs that include factual information about contraception show the latter to be more effective on all counts.A 2001 report analyzing studies of HIV prevention programs found that programs that include information about both abstinence and condoms can delay the onset of sex and increase condom use among sexually active teens.The same study found no evidence existed that abstinence-only programs had an effect on sexual behavior.A 1998 study comparing a program that educated students about safer sex (including condom use) with an abstinence-only program found that both programs affected sexual behavior in the short term, but that the safer sex program was more effective at reducing unprotected sexual intercourse and frequency of intercourse in the long term.
In 2001, the Institute of Medicine concluded that scientific studies have shown that comprehensive sex and HIV/AIDS education programs and condom availability programs can be effective in reducing high-risk sexual behaviors.A 1997 report by the Joint United Nations Programme on HIV/AIDS (UNAIDS) found evidence that sexual health education for children and young people that included the promotion of condom use and safer sexual practices, did not increase participant's sexual activity.
In 2004, a "gold-standard" review of HIV prevention research by the Cochrane Collaborative Review Group on HIV infection and AIDS concluded that "[p]rograms promoting abstinence were found to be ineffective at increasing abstinent behavior and were possibly harmful; more rigorous research is needed to determine the effectiveness of abstinence programs on HIV risk."A 2004 consensus statement in The Lancet signed by numerous experts in HIV prevention from around the world, stressed abstinence as a "first priority" for young people who are not sexually active but concluded:
For those young people who are sexually active, correct and consistent condom use should be supported.Young people and others should be informed that correct and consistent condom use lowers the risk of HIV (by about 80-90% for reported "always use") and of various sexually transmitted infections and pregnancy, and they should be cautioned about the consequences of inconsistent use.
Officials of the U.S. government did not endorse the Lancet statement, though they were asked to do so.
U.S. officials systematically ignore independent evaluations of abstinence-only programs, instead making broad and unscientific claims about the benefits of abstinence.The U.S. global AIDS strategy, for example, posits that "[d]elaying first sexual intercourse by even a year can have significant impact on the health and well-being of adolescents and on the progress of the epidemic in communities."Beyond failing to cite evidence for this claim, the strategy neglects to mention that some countries with higher average ages of sexual debut than Uganda-Zimbabwe and South Africa, for example-have much higher rates of HIV incidence.The important point is that delaying sex does not protect people from HIV unless they protect themselves once they become sexually active.Abstinence-only programs in fact increase HIV risk by withholding information about contraception and safer sex and by suggesting that married people are safe from HIV infection.
As further "proof" of abstinence-only programs, proponents frequently cite evidence of reduced teen pregnancy rates in the United States in the 1980s and 1990s, a period that saw increased federal funding for abstinence-only programs.This logical fallacy assumes that just because abstinence-only programs occurred at the same time as a reduction in teen pregnancy, they must have caused this reduction.Indeed, studies also show that contraceptive use increased during the same period, and (as noted above) that rates of premarital sex are higher in some regions with abstinence-only programs than in those without these programs.The fact that participants in abstinence-only programs are less likely to use contraception once they become sexually active suggests that teen pregnancy rates might have dropped even further were it not for these programs.
IX. Government Response
Human Rights Watch interviewed a number of government officials about the implementation of abstinence-only programs in Uganda and the wide range of objections to these programs.Officials representing the offices of the president and first lady, together with representatives of the Ministry of Health, the Ministry of Education, the Ugandan Parliament, and the Uganda AIDS commission, spoke favorably of the country's increasing emphasis on abstinence and being faithful as a way of preventing new HIV infections among youth.
Some government officials expressed the view that abstinence-only programs did not and should not detract from providing information about other prevention strategies, and that a comprehensive strategy represented Uganda's approach to HIV prevention.This position was well summarized by Dr. Elioda Tumwesigye, chairperson of Uganda's Parliamentary Committee on HIV/AIDS, who said:
I support a balanced approach.If everyone could abstain that would be fine, but not everyone can or will, so why not emphasize condoms instead of having young people go live [without condoms]?Let us make every tool available for every program to have full and correct information available.Unless someone brings information that talking about condoms increases sexual practice, than we shall promote condoms, too.
Human Rights Watch asked numerous government officials if they were aware of research studies done in the United States that had discredited abstinence-only approaches or shown them to be potentially harmful.No official was aware of the studies.When asked how they would respond to the studies, some stressed that Uganda was a different society than the United States with different morals and values.Research needed to be done on abstinence-only programs in Africa, they said.Most agreed that the United States had been a strong driving force behind Uganda's abstinence policy, and that certain U.S. policy makers had alerted decision-makers in Uganda to the supposed benefits of abstinence-only approaches.
Asked whether abstinence messages were appropriate for all young people, even young people whose poverty, displacement, sexual exploitation, and orphanhood increased their risk of HIV/AIDS, officials responded that messages were individually tailored for the intended audiences.One official said:
For prostitutes and others, we tell them to go ahead and use condoms.Abstinence messages are for the appropriate sectors in society, for those who can strengthen themselves with these messages.These messages are for those in school, those with both parents living who are going to be receiving higher education.
Human Rights Watch also asked officials to respond to the objection that abstinence-only programs promoted stigma against people living with AIDS by implying that HIV infection resulted from "sinful" or "immoral" behavior.A member of the Uganda AIDS Commission acknowledged that it was possible some people would feel stigmatized.She added, however, that morality needed to be addressed in HIV prevention because, as she put it, some people who "lack morals" might pass the infection on to others who are "innocent."
The concern that abstinence-only approaches undermined the promotion of condoms also failed to resonate with Ugandan officials.A representative of the First Lady's Office stated, "I have my rights too.I am personally angry when I feel people are pushing condoms on me.People who talk about abstinence believe in it.We are offended by those organizations that promote condoms."
As an activist and woman living with AIDS, it makes me feel judged.You are supposed to abstain and be faithful.Condoms are only for those who are promiscuous.I got HIV in marriage.I was faithful in my relationship.The battle to come out and be open was a struggle.Now, instead of moving forward, we are moving strides back.
-Ugandan woman living with AIDS
Uganda is unique among African nations for its early and high-level leadership against HIV/AIDS.The government's willingness to address HIV/AIDS openly and break taboos surrounding sexually transmitted diseases is widely acknowledged as the cornerstone of its early success against the epidemic.By involving a wide range of nongovernmental organizations in the AIDS struggle and allowing candid messages about sex to reach a wide audience, Uganda achieved high levels of awareness of HIV, increased voluntary HIV testing, and ultimately fewer new HIV infections.
Today, this progress may unravel as U.S.-funded organizations scale up programs that promote sexual abstinence and fidelity within heterosexual marriage to the exclusion of all other HIV prevention strategies.These programs deprive young people of information that could save their lives.They mock the plight of countless Ugandan women and girls who abstain until marriage and are faithful within it but nevertheless become infected with HIV.They provide scant information or assistance to those at highest risk of HIV infection, including street children who trade sex for survival, children affected by conflict, and lesbian, gay, bisexual, and transgender youth.They distort factual information about condoms and safer sex strategies, placing young people at a higher risk of HIV and other sexually transmitted diseases.
As their proponents admit, abstinence-only programs are not simply about preventing HIV/AIDS, but about promoting moral values.However, censoring or distorting factual information about HIV/AIDS is not a moral value.Moreover, casting HIV/AIDS as a "moral" disease that results from "promiscuity"-as abstinence-only programs invariably do-reinforces the deadly stigma associated with HIV/AIDS.Throughout the 1990s, Uganda stood for the idea that AIDS could affect anyone, not simply "promiscuous" people.This idea proved critical to respecting the human rights of people living with AIDS and protecting them from violence and discrimination.Now, abstinence-only programs give Ugandans a new reason to stigmatize people living with AIDS and to judge their actions as immoral or blameworthy.
To its credit, Uganda continues to recognize that its young people face a high risk of HIV infection and has faced up to that challenge by expanding school-based sex education programs.However, as a perceived global leader in HIV prevention, Uganda is accountable to evidence and best practices in HIV prevention.The country's high-profile U-turn toward unproven HIV prevention strategies for young people has, at this writing, already begun to resonate throughout other parts of Africa.Its complicity in the rewriting of history around its HIV prevention "success" could have implications on HIV prevention programs for years to come.Ultimately, it is not just Ugandans who will pay the price for the country's back-steps in HIV prevention.It is the entire effort against the global AIDS pandemic.
This report was researched and written by Jonathan Cohen, researcher in the HIV/AIDS and Human Rights Program, and Tony Tate, researcher in the Children's Rights Division of Human Rights Watch.The report was reviewed by Lois Whitman, executive director of the Children's Rights Division; Rebecca Schleifer, researcher with the HIV/AIDS Program; Janet Walsh, deputy director of the Women's Rights Division; Scott Long, director of the Lesbian, Gay, Bisexual and Transgender Rights Project; James Ross, senior legal advisor; and Iain Levine, program director of Human Rights Watch.We are grateful to Joanne Csete, executive director of the Canadian HIV/AIDS Legal Network, and Helen Epstein for their helpful comments.Jennifer Nagle, Veronica Matushaj, Andrea Holley, and Fitzroy Hepkins provided production assistance.
Human Rights Watch extends its gratitude to the young people in Uganda who shared their stories and experiences with us.We also thank the many teachers, school administrators, youth outreach workers, and service providers who spoke with us.Without them this report would not have been possible.
Human Rights Watch gratefully acknowledges the willingness of the offices of the president and first lady, the ministries of health and education, the Uganda AIDS Commission, and the Uganda Human Rights Commission to share their views with us for this report.Among the dozens of nongovernmental organizations, service providers and religious leaders who contributed to our field research, we extend particular thanks to the Naguru Teenage Centre, Uganda Youth Development Link, AIDS Information Center, The AIDS Support Organization (TASO), Africa Youth Alliance, the Uganda Youth Anti-Aids Society, Save the Children, National Youth Organization for Development, the Kabarole Research Centre, and the Lyamabwa Youth Center.
We recognize with appreciation the funding provided for our work by the Oak Foundation and the Independence Foundation.
 The U.N. Convention on the Rights of the Child states: "For purpose of this present Convention, a child is every human being below the age of eighteen years unless under the law applicable to the child, majority is attained earlier." Convention on the Rights of the Child, Article 1, adopted November 20, 1989 (entered into force September 2, 1990).
 STD/AIDS Control Programme, Ministry of Health, HIV/AIDS Surveillance Report: June 2003, p. 10.
 Uganda AIDS Commission (UAC), MEASURE Evaluation and Uganda Ministry of Health (MOH), AIDS in Africa During the Nineties: UGANDA: A review and analysis of surveys and research studies (2003), p. 1; Justin O. Parkhurst, "The Ugandan success story?Evidence and claims of HIV-1 prevention," The Lancet, vol. 360 (2002), pp. 78-80.
 Estimates of national HIV prevalence in Uganda vary.In 2002, the STD/AIDS Control Programme of the Uganda Ministry of Health estimated that 6.2 percent of the national population was infected with HIV.It should also be noted that trends in HIV prevalence are not as good a measure of HIV prevention as trends in HIV incidence, which measure new HIV infections in a given year.STD/AIDS Control Programme, 2003 HIV/AIDS Surveillance Report, p. 6.
 Rory Carroll, "Uganda's AIDS success story challenged," The Guardian, September 23, 2004.
 STD/AIDS Control Programme, 2003 HIV/AIDS Surveillance Report, pp. 6, 10.
 Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO), Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Uganda (2004 Update), p. 2.
 STD/AIDS Control Programme, 2003 HIV/AIDS Surveillance Report, p. 29.
 Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four.Uganda Bureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.
 ORC Macro, Reproductive Health of Young Adults in Uganda: A Report Based on the 2000-2001 Uganda Demographic and Health Survey (Calverton, MD: ORC Macro, 2002), pp. 12-13.
 Ibid., p. 13.
Uganda AIDS Commission, "National Young People HIV/AIDS Communication Program for Young People: Concept Paper" (2001).
 This includes those who were widowed, divorced or separated.ORC Macro, Reproductive Health of Young Adults in Uganda, p. 19.
 Ibid., p. 21.
 Human Rights Watch, Just Die Quietly: Domestic Violence and Women's Vulnerability to HIV in Uganda, Vol. 15, No. 15(A) (August 2003).
 ORC Macro, Reproductive Health of Young Adults in Uganda, p. 15.
 Ibid., p. 41.
 Makerere University Institute of Public Health and Academic Alliance for AIDS Care and Prevention in Africa, Knowledge, Attitude, Beliefs & Practices on HIV/AIDS Care, Prevention and Control: A Quantitative Baseline Survey, Kampala District, Uganda (2003), p. 1.
 UNAIDS/WHO, Epidemiological Fact Sheets: Uganda, p. 2.
 While HIV prevalence declined among boys between 2001 and 2002 (from 3.7 percent to 2.8 percent), it rose slightly among girls (from 10.1 percent to 10.3 percent).
 UAC/MEASURE/MOH, AIDS in Africa During the Nineties, p. 17.
 Ibid., p. 21.
 UBOS/ORC Macro, Uganda Demographic and Health Survey 2000-2001, p. 174.
 Ibid., p. 168.
MakerereUniversity and Academic Alliance, Quantitative Baseline Survey,table 3.3.
 UBOS/ORC Macro, Uganda Demographic and Health Survey 2000-2001, p. 169.
 ORC Macro, Reproductive Health of Young Adults in Uganda, p. 5.
 Ibid., p. 8.
 International Covenant on Civil and Political Rights, G.A. res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 52, U.N. Doc. A/6316 (1966), article 19; Convention on the Rights of the Child, G.A. res. 44/25, annex, 44 U.N. GAOR Supp. (No. 49) at 167, U.N. Doc. A/44/49 (1989), article 13.
 Convention on the Rights of the Child (1989), article 24(2)(e).
 Committee on the Rights of the Child, General Comment No. 3 (2003) HIV/AIDS and the rights of the child, 32nd Sess. (2003), para. 16.
 Committee on Economic and Social Rights, General Comment 14: The Right to the Highest Attainable Standard of Health, 22nd Sess. (2000), para. 12(b), note 8.
 International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, entered into force January 3, 1976, GA Res. 2200 (XXI), 21 UN GAOR, 21st Sess., Supp. No. 16, at 49, UN Doc. A/6316 (1966), art. 12.
 Committee on Economic, Social and Cultural Rights (CESCR), The right to the highest attainable standard of health, para. 16.
 Ibid., paras. 34-35.
 Office of the United Nations High Commissioner for Human Rights (OHCHR) and UNAIDS, HIV/AIDS and Human Rights: International Guidelines, U.N. Doc. HR/PUB/98/1 (1998), para. 38(g).
 Human Rights Watch interview with Ambassador James Kolker, United States Embassy in Uganda, November 22, 2004.
 Fact sheet on the President's Emergency Plan for AIDS Relief, http://www.avert.org/pepfar.htm (retrieved January 30, 2005).
 Office of the United States Global AIDS Coordinator (OGAC), The President's Emergency Plan for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy (Washington, D.C.: United States Department of State, 2004), p. 27.
 H.R. 1298, United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, ss. 402(b)(3), 403(a).The Act does not specify a level of assistance for HIV prevention, but it caps such assistance at 20 percent of HIV/AIDS funds, or a maximum of U.S.$3 billion.
 OGAC, PEPFAR Five-Year Strategy, pp. 24, 29.
 Sexuality Information and Education Council of the United States (SIECUS), "Overall Federal Spending for Abstinence-Only-Until-Marriage Programs," State Profiles: A Portrait of Sexuality Education and Abstinence-Only-Until Marriage Programs in the States (FY2003 edition).President Bush requested an increase to U.S.$268 million dollars for abstinence-until-marriage programs for FY2005.
 42 U.S.C. 710(b)(2).
 Swizen Kyomuhendo, Martin Ssempa, Lillian Lamalatu, Stephen Langa, Joseph Kiwanuka, and Edward C. Green, "Uganda National Abstinence and Being Faithful Policy and Strategy on Prevention of Transmission of HIV: Draft Policy and Strategy" (Uganda AIDS Commission, November 2004), p. iv.
 United States House of Representatives Committee on Government Reform Minority Staff Special Investigations Division, The Content of Federally Funded Abstinence-Only Education Programs, report prepared for Rep. Henry A. Waxman (December 2004).
 Human Rights Watch, Ignorance Only: HIV/AIDS, Human Rights and Federally Funded Abstinence-Only Programs in the United States: Texas: A Case Study, Vol. 14, No. 5(G) (September 2002).
 See Peter Bearman and Hannah Brckner, "Promising the Future: Virginity Pledges as they Affect Transition to First Intercourse," American Journal of Sociology, vol. 106, no. 4 (2001), pp. 859-912; Bearman and Brckner, "After the Promise: the STD Consequences of Adolescent Virginity Pledges," 2004, http://www.yale.edu/socdept/CIQLE/cira.ppt (retrieved November 10, 2004).
 Committee on Government Reform, Abstinence-Only Education Programs; see also, Martha E. Kempner, "Toward a Sexually Healthy America: Abstinence-only-until-marriage Programs that Try to Keep our Youth 'Scared Chaste'" (New York: Sexuality Information and Education Council of the United States, 2001).
 OGAC, PEPFAR Five-Year Strategy, p. 29.
 See, e.g., Nicholas D. Kristof, "The Secret War on Condoms," The New York Times, January 10, 2003; Marie Cocco, "White House Wages Stealth War on Condoms," Newsday, November 14, 2002; Caryl Rivers, "In Age of AIDS, Condom Wars Take Deadly Toll," Women's eNews, December 10, 2003, http://womensenews.org/article.cfm/dyn/aid/1633/context/archive (retrieved February 16, 2004); Art Buchwald, "The Trojan War," The Washington Post, December 11, 2003.
 Compare U.S. Centers for Disease Control and Prevention (CDC), "Condoms and Their Use in Preventing HIV Infection and Other STDs" (September 1999), available at http://www.house.gov/reform/min/pdfs/pdf_inves/pdf_admin_hhs_info_condoms_fact_sheet_orig.pdf with CDC, "Male Latex Condoms and Sexually Transmitted Diseases" (2002), available at http://www.house.gov/reform/min/pdfs/pdf_inves/pdf_admin_hhs_info_condoms_fact_sheet_revis.pdf.
 Compare U.S. Agency for International Development (USAID), "The Effectiveness of Condoms in Preventing Sexually Transmitted Diseases," http://www.usaid.gov/pop_health/aids/TechAreas/condoms/condom_effect.html (retrieved January 28, 2003) with USAID, "USAID: HIV/AIDS and Condoms," http://www.usaid.gov/pop_health/aids/TechAreas/condoms/condomfactsheet.html (retrieved July 10, 2005).
 CDC, "Proposed Revision of Interim HIV Content Guidelines for AIDS," 69 Fed. Reg. 115, 33824, June 16, 2004.
 Compare CDC, "Programs that Work" (archived version at http://web.archive.org/web/20010606142729/www.cdc.gov/nccdphp/dash/rtc/index.htm) with CDC, "Programs that Work" (http://www.cdc.gov/nccdphp/dash/rtc/).
 See Rep. Henry A. Waxman, "The Effectiveness of Abstinence-Only Education," in Politics and Science: Investigating the State of Science Under the Bush Administration, http://democrats.reform.house.gov/features/politics_and_science/example_abstinence.htm (retrieved February 7, 2005);H. Boonstra, "Public Health Advocates Say Campaign to Disparage Condoms Threatens STD Prevention Efforts," The Guttmacher Report on Public Policy, March 2003, p. 2.
 Proponents of abstinence education have long sought to disparage condoms by speculating about the link between condom usage and cervical cancer.The legislation authorizing PEPFAR compels the president to report on the "impact that condom usage has upon the spread of HPV in Sub-Saharan Africa," a mandate that many view as an effort to undermine confidence in the use of condoms against HIV.H.R. 1298, s. 101(b)(3)(W).
 CDC, "Male Latex Condoms and Sexually Transmitted Diseases" (2002); see also, C.J.A. Hogewoning et al., "Condom use promotes regression of cervical intraepithelial neoplasia and clearance of human papilloma virus: a randomised clinical trial," International Journal of Cancer, vol. 107 (2003), pp. 811-816; M.C.G. Bleeker et al., "Condom use promotes regression of human papilloma virus-associated penile lesions in male sexual partners of women with cervical intraepithelial neoplasia," International Journal of Cancer, vol. 107 (2003), pp. 804-810.
 S. Kyomuhendo et al., "Uganda National Abstinence and Being Faithful Policy," pp. 1, 8-9; see also, STD/AIDS Control Programme, Uganda Ministry of Health, "National Condom Policy and Strategy" (June 2004).
 Ibid., p. iv.
 Ibid., p. 14.
 Ibid., pp. 10-12.
 Ibid., pp. 13, 29.
 Ibid., p. 13.
 Ibid., pp. 23-28.
 Ibid., p. 15.
 See, e.g., Office of the High Commissioner for Human Rights (OHCHR) and UNAIDS, HIV/AIDS and Human Rights: International Guidelines, guideline 3, para. 28(b).
 Human Rights Watch interview with Sereen Thaddeus, USAID, Kampala, November 17, 2004.
 Human Rights Watch interview, Aggrey Kibenge and Catherine Baraza, Ministry of Education, Kampala, November 15, 2004;United Nations Children's Fund, The State of the World's Children 2005 (New York: United Nations Publications, 2005), http://www.unicef.org (retrieved January 11, 2005).
 Human Rights Watch interview, Ministry of Education, Kampala, November 22, 2004, Human Rights Watch interview, Kampala, November 10, 2004.
 Ministry of Education and Sports, PIASCY Helping Pupils to Stay Safe, A Handbook for Teachers, P5-P7, (Kampala: Ministry of Education and Sports, 2004), pp. 124-177.
 Human Rights Watch interview, Aggrey Kibenge and Catherine Baraza, Ministry of Education, Kampala, November 15, 2004.
 Compare, Ministry of Education and Sports, PIASCY Helping Pupils to Stay Safe, Handbook for Primary School Teachers, (Kampala: Ministry of Education and Sports, 2003), acknowledgments, with, Ministry of Education and Sports, PIASCY Helping Pupils to Stay Safe, A Handbook for Teachers, P5-P7, (Kampala: Ministry of Education and Sports, 2004), acknowledgments.Copies on file at Human Rights Watch.
 Human Rights Watch interview, Kampala, November 9, 2004.
 Human Rights Watch interview, Aggrey Kibenge and Catherine Baraza, Ministry of Education, Kampala, November 15, 2004.
 Human Rights Watch interview, Kampala, November 9, 2004.
 Human Rights Watch interviews, Kampala, November 9, 10, 15, & 22.
 Compare, Ministry of Education and Sports, PIASCY Helping Pupils to Stay Safe, Handbook for Primary School Teachers, (Kampala: Ministry of Education and Sports, 2003), pp. 53, 55, 99-100, with, Ministry of Education and Sports, PIASCY Helping Pupils to Stay Safe, A Handbook for Teachers, P5-P7, (Kampala: Ministry of Education and Sports, 2004), pp. 9-22, 172-175.
 Human Rights Watch interview, Aggrey Kibenge and Catherine Baraza, Ministry of Education, Kampala, November 15, 2004.
 Human Rights Watch interview, November 9, 2004.
 Human Rights Watch interview, Kampala, November 22, 2004.
 Human Rights Watch interview, Sereen Thaddeus, USAID office, Kampala, November 17, 2004.
 AIM is implemented by the U.S.-based John Snow Research and Training Institute, Inc.
 Human Rights Watch interview, Ministry of Education, Kampala, November 22, 2004.
 Human Rights Watch interview, UPHOLD, Kampala, November 17, 2004.
 Ministry of Education and Sports, PIASCY Helping Pupils to Stay Safe (2004), p. 30.
 Human Rights Watch interview, US Embassy, Kampala, November 22, 2004.
 Human Rights Watch interviews, primary schools, Kasese district, November 19, 2004.
 Human Rights Watch interview, primary school, Mbale district, November 12, 2004.
 Human Rights Watch interview, primary school teacher, Mbale district, November, 2004.
 Ministry of Education and Sports, PIASCY Helping Pupils to Stay Safe (2004), p 12; compare with pp. 27 & 173.
 Human Rights Watch interview, primary school, Mbale district, November 12, 2004.
 Human Rights Watch interviews, Mbale District, November 12 & 13, 2004.
 Human Rights Watch interview, Aggrey Kibenge and Catherine Baraza, Ministry of Education, Kampala, November 15, 2004.
 Human Rights Watch interviews, Kampala, November 9 & 16, 2004.
 Ministry of Education and Sports, PIASCY Handbook for Students of Secondary Schools, First Draft, (Kampala: Ministry of Education and Sports, August 2004), p. 22.
 STD/AIDS Control Program, Ugandan Ministry of Health, National Condom Policy and Strategy (June 2004), p.9; U.S. Centers for Disease Control and Prevention, "Fact Sheet for Public Health Personnel:Male Latex Condoms and Sexually Transmitted Diseases, January 23, 2003, http://www.cdc.gov (retrieved January 27, 2005); R. Gardner, R.D. Blackburn, and U.D. Upadhyay, Closing the Condom Gap: Population Reports, series H, no. 9 (Baltimore, USA: Johns Hopkins University School of Public Health, Population Information Program, 1999), p. 13 (citing studies); European Union Commission, "HIV/AIDS: European Research provides clear proof that HIV virus cannot pass through condoms,"; National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, "Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention," July 20, 2001, p. 7; R.F. Carey et al., "Effectiveness of Latex Condoms as a Barrier to Human Immunodeficiency Virus-sized Particles under the Conditions of Simulated Use," Sexually Transmitted Diseases (July/August 1992), vol. 19, no. 4, p. 230.
 Ministry of Education and Sports, PIASCYSecondary Schools, p. 61.
 CDC, "Fact Sheet", January 23, 2003; National Institutes of Allergy and Infectious Diseases, "Workshop Summary"; "Comment: The time has come for common ground on preventing sexual transmission of HIV," The Lancet, vol. 364 (November 27, 2004), p. 1913.
 Ministry of Education and Sports, PIASCYSecondary Schools, p. 62.
 Ibid., pp. 63 67.
 Ibid., p. 21.
 Ibid., p. 62.
 Human Rights Watch interview, Kampala, November 9, 2004.
 Human Rights Watch interview, History Teacher, Mbale, November 13, 2004.
 Human Rights Watch interview, Mbale, November 12, 2004.
 Human Rights Watch interview, Kampala, November 16, 2004.
 Human Rights Watch interview, Christian Religious Education teacher, Mbale, November 13, 2004.
 Human Rights Watch interviews, students, Mbale & Mbarara, November 12 & 18, 2004.
 Ministry of Education and Sports, PIASCYSecondary Schools, p. 29.As an elective, children should be free to choose CRE and follow their religious beliefs.Messages on HIV prevention for secondary school students, however, should not be associated with judgment, stigma, or religion but presented in a way that it applicable to all Ugandans.
 Human Rights Watch interview, Alice Kaboyo, Office of the President, Kampala, November 22, 2004.
 President Museveni came to power in Uganda through a military victory, has twice been elected president, and has led the country for nineteen years.At this writing, legislation is being debated in Uganda that would amend the constitution and allow the president to run for a third term in 2006.
 Human Rights Watch interview, UNAIDS official, Kampala, November 8, 2004.
 Human Rights Watch interview, Kampala, November 16, 2004.
 The Movement can be loosely defined as a political organization rather than a political party.All Ugandans belong to the Movement, including those who oppose it.It has many characteristics of a ruling political party in a single party state.In Uganda, there are strict regulations on political activities and opposition parties which do not apply to the Movement.For more information on the Movement system in Uganda, see Human Rights Watch, Hostile to Democracy The Movement System and Political Repression in Uganda (New York: Human Rights Watch, 1999).
 Human Rights Watch interview, Alice Kaboyo, Kampala, November 22, 2004.
 The HIV/AIDS Integrated Model District Program (AIM), Report of the Fourth Presidential Dialogue with Young Leaders on HIV/AIDS and Development, West Nile Region, Arua Public Primary School, October 1113, 2004, pp. 32-33.
 Ibid, pp. 45 & 53.
 Ibid., pp. 19 & 60.
 Ibid., pp. 17 & 21.
 Human Rights Watch interview, US embassy, Kampala, November 22, 2004.
 Fact Sheet on the President's Emergency Plan for AIDS Relief,http://www.state.gov/documents/organization/36194.pdf (retrieved January 30, 2005).
 Human Rights Watch interview, Kampala, November 10, 2004.
 OGAC, PEPFAR Five-Year Strategy, pp. 24, 29.
 Executive Order 13280: Responsibilities of the Department of Agriculture and the Agency for International Development With Respect to Faith-Based and Community Initiatives, Federal Register, vol. 67, no. 241, December 12, 2002.
 Human Rights Watch interview, Kampala, November 11, 2004.
Janet Museveni, "The AIDS Pandemic: Saving the Next Generation," World Congress of Families, New York, May 3, 2002, http://www.worldcongress.org (retrieved January 11, 2005).Anne Mugisa, "Janet to Host 70,000 Virgins," The New Vision, December 1, 2004, http://allafrica.com (retrieved December 2, 2004).
 Joyce Namutebim, "Mrs. Museveni Decries Condom Distribution," The New Vision, August 30, 2004, p. 3, Anne Mugisa, "Abstain, Condom Not Safe, Mrs. Museveni," The New Vision, September 27, 2004, p. 4, Grace Matsiko, "First Lady Calls for Census of Virgins," The Monitor, December 2, 2004, p. 7.
 See Human Rights Watch, A Matter of Power: State Control of Women's Virginity in Turkey (New York: Human Rights Watch, 1994); Human Rights Watch, Scared at School: Sexual Violence Against Girls in South African Schools (New York: Human Rights Watch, 2001); Human Rights Watch, Deadly Delay: South Africa's Efforts to Prevent HIV in Survivors of Sexual Violence, vol. 16, no. 3(A), March 2004.
 Human Rights Watch interview, Kampala, November 11, 2004.
 Bearman and Brckner, "Promising the Future,"; Bearman and Brckner, "After the Promise."
 Human Rights Watch interview, Beat Bisangwa, office of the first lady, Kampala, November 16, 2004.
 Priya Abraham, "Hooked on Failure Africa: In Africa's Fight Against AIDS, the United States Continues to Support Family-Planning Groups that Stifle the White House Abstinence and Fidelity Message," World Magazine, November 6, 2004, http://www.worldmag.com (retrieved December 8, 2004).
 Human Rights Watch interviews, Kampala, November 9, 10, & 11, 2004 and WashingtonDC, December 21, 2004.
 Human Rights Watch telephone conference with NGO in Kampala, February 8, 2005.Human Rights Watch was not able to determine the full amount of U.S. funding for the Youth Forum, whether channeled through in-country PEPFAR funds, Washington-controlled funding, or both.
 Letter from Rep. Henry A. Waxman (D-CA), ranking minority member, Committee on Government Reform, U.S. House of Representatives to The Honorable Randall L. Tobias, U.S. Global AIDS Coordinator, February 15, 2005, citing Andrew S. Natsios, Action Memorandum: Recommendation to Fun Children's AIDS Fund, October 21, 2004; see also, David Brown, "Group Awarded AIDS Grant Despite Negative Appraisal," The Washington Post, February 16, 2005.
 A December 2002 executive order governing federal funding of community and faith-based organizations states that, in accordance with the U.S. Constitution's separation of church and state, "organizations that engage in inherently religious activities, such as worship, religious instruction, and proselytization, must offer those services separately in time or location from any programs or services supported with direct Federal financial assistance."Executive Order 13279-Equal Protection of the Laws for Faith-Based and Community Organizations, Federal Register, vol. 67, no. 241, December 16, 2002.
 Human Rights Watch interview, the White House, Kampala, November 22, 2004.See also, Ssempa Ministries, Our Mission, http://www.emakerereoye.com/mission.html (retrieved January 9, 2005).
 Daniel Wallis, "Uganda Virgins to Rally to Promote Abstinence," Reuters, December 10, 2004.
 Andrew Rice, "Evangelicals v. Muslims in Africa Enemy's Enemy," The New Republic Online, August 04, 2004, http://www.siu.edu (retrieved December 7, 2004).
 Jane Nafula, "Born Again Christians Invite Bukenya," The Monitor, December 13, 2004, http://allafrica.com (retrieved December 16, 2004).
 Human Rights Watch interviews, Kampala, November 11 & 22, 2004.The name of the U.S.-based abstinence advocate is withheld.
 Human Rights Watch interview, Stephen Langa, Kampala, November 22, 2004.
 Others have highlighted the inappropriateness of abstinence education for vulnerable communities.See Sara Rakita, "From Coffins to ABCs: AIDS Prevention in Uganda", Pambazuka News, May 13, 2004, p. 4, http://www.pambazuka.org (retrieved January 3, 2005).
 This is occurring even though increasing proportions of young Ugandans are postponing sex to a later age.The data in this paragraph are taken from Uganda HIV/AIDS Partnership, Uganda Ministry of Health, Uganda AIDS Commission, and MEASURE Evaluation Project, AIDS in Africa During the Nineties: Uganda: Young people, sex, and AIDS in Uganda (Chapel Hill, NC: MEASURE Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill, 2004, pp. 60-62.
 UAC/MEASURE/MOH, AIDS in Africa During the Nineties, p. 29.
 Human Rights Watch interview with HIV positive woman, Kampala, November 17, 2004.
 Human Rights Watch interview, Kampala, November 15, 2004.
 Human Rights Watch interview, Kampala, November 15, 2004.
 Human Rights Watch interview, Kampala, November 15, 2004.
 Human Rights Watch interview, Kampala, November 15, 2004.
 UNAIDS, UNICEF, and USAID, Children on the Brink 2004, A Joint Report on New Orphan Estimates and a Framework for Action (New York: United Nations Publications, 2004), Fourth Edition, p. 30, http://www.unicef.org (retrieved January 29, 2005).The word orphan as used here described any child in Uganda who has lost one or both parents.
 Ibid., p. 18.
 Human Rights Watch interview, Kampala, November 11, 2004.
 Human Rights Watch interview, Mbale, November 13, 2004.
 Human Rights Watch interview, Mbale, November 12, 2004.
 Human Rights Watch interview, FortPortal, November 20, 2004.
 Human Rights Watch interview, Kabarole, November 20, 2004.
 Agence France-Press (AFP), "War in Northern Uganda World's Worst Forgotten Crisis: UN", November 11, 2003, http:// www.reliefweb.int (retrieved February 1, 2005).
 Human Rights Watch interview, Gulu, February 9, 2003.
 Human Rights Watch interview, Awer camp, Gulu, January 31, 2003.
 Human Rights Watch, "Abducted and Abused:Renewed Conflict in Northern Uganda," A Human Rights Watch Report, vol. 15, no. 12(A), July 2003, pp. 68-72.
 Human Rights Watch interview with local councilor, Gulu, February 6, 2003.
 UNAIDS/WHO, Epidemiological Fact Sheets: Uganda, p. 15.
 Information provided by the Associazione Volontari per il Servizio Internazionale (AVSI), March 6, 2003.
 Human Rights Watch interview, Save the Children Staff, Kampala, November 9, 2004.
 Joseph Mugisa, "Bundibugyo Has 20 Percent HIV/Aids Prevalence Rate," The Monitor, February 9, 2005, http://allafrica.com (retrieved February 11, 2005).
 Human Rights Watch interview, Kasese, November 19, 2004.
 Human Rights Watch interview, Kabarole, November 20, 2004.
 Human Rights Watch interviews, W. Uganda, November 18-20, 2004.
 It should be cautioned that many men who have sex with men, in Africa or elsewhere, might reject or might not even know the terms "homosexual" or "gay"; many women who have sex with women might not see themselves as comprehended under the label "lesbian."In general, Human Rights Watch describes people by the identities they ascribe to themselves; in using these terms here, we recognize that not everyone facing abuse based on sexual orientation or gender identity would recognize themselves in them.
 See, e.g., Daniel Elwana, "Church backs Museveni against homosexuality," Daily Nation, Nairobi, Kenya, November 14, 1999.
 "Museveni warns off homosexuals," The Monitor, Kampala, Uganda, July 22, 1998.
 Quoted in "Minister warns of homosexuals," Crusader, Kampala, Uganda, August 18, 1998.
"Museveni opens a war on gay men," The Monitor, September 28, 1999. See also "Wandegeya homos marry," Sunday Vision, Kampala, Uganda, September 12, 1999; "Police probe Kampala's homosexual weddings," New Vision, Kampala, Uganda, September 13, 1999; and "Museveni, police homo probe out: `Story was made up,'" The Monitor, October 5, 1999.
 See Amnesty International Appeal, "Uganda: Criminalizing Homosexuality: A License to Torture," June 27, 2001; and Amnesty International, Crimes of Hate, Conspiracy of Silence: Torture and Ill-Treatment Based on Sexual Identity, AC 40/016/2001, pp. 4-6.
 "Schoolgirl commits suicide," The Red Pepper, December 12, 2003; e-mail communications from Ugandan activist who wished to remain anonymous, December 19, 2003.
 "Schoolgirl commits suicide," The Red Pepper, December 12, 2003.
 Samuel Wossita, "Rising gay numbers in schools worry govt," The Monitor, February 9, 2005.Almost simultaneously, the Chancellor of Makerere University, Apolo Nsibambi, "castigated" homosexuality, saying it had "rocked" the institution: "I am saddened that homosexuality has reached the university. As the chancellor, I condemn such acts." Apollo Mubiru, "MakerereUniversity homos worry Nsibambi," New Vision, February 8, 2005.
 Human Rights Watch interviews, secondary school students, Uganda, November 18, 2004.
 Human Rights Watch interview, Kampala, November 15, 2004.
 Human Rights Watch interview, Mbale, November 12, 2004.
 Human Rights Watch interview, Kampala, November 9, 2004.
 Human Rights Watch interview, Kampala, November 10, 2004.
 Izama Angelo, "Govt warns UNAIDS over gays," The Monitor, November 29, 2004.
 Ministry of Education, Handbooks, p. 15.
 Ministry of Education, Draft Secondary Handbooks, p. 9.
 See studies cited in PIASCY in secondary schools, above.This does not mean there is a 10-20 percent chance of becoming infected with HIV from sex with a condom.It means that the chances of HIV infection through an act of unprotected sex decrease by 80-90 percent with consistent condom use.
 See, e.g., UHP/MOH/UAC/MEASURE, Young people, sex and AIDS in Uganda, pp. 9, 18, 35-41 (especially claim on p. 37), 45.
 Ibid.; see also, Bob Roehr, "Abstinence programs do not reduce HIV prevalence in Uganda," British Medical Journal, vol. 330 (March 5, 2005), p. 496.
 See, e.g., ORC Macro, Reproductive Health of Young Adults in Uganda: A Report Based on the 2000-2001 Uganda Demographic and Health Survey (Calverton, Maryland, USA: 2002), p. 42.
 Eddie Ssejoba, "Museveni Condemns Condom Distribution to Pupils," New Vision, May 17, 2004; Health and Development Networks Key Correspondent Team, "Condom U-turn puts many young Ugandans at risk," May 26, 2004.
 Darren Schuettler, "Abstinence, Condom Controversy Erupts at AIDS Meet," Reuters NewMedia, July 12, 2004.
 UN Integrated Regional Information Network, "Uganda: President's New Attack on Condoms in AIDS Battle," October 12, 2004.
 See, e.g., Ssejoba, "Museveni Condemns Condom Distribution."
 Joyce Namutebi, "Mrs. Museveni Decries Condom Distribution," New Vision, August 30, 2004.
 Mugisa, "Abstain, Condom Not Safe."As noted above, condom use is in fact associated with lower rates of cervical cancer and HPV-associated disease, though the precise effect of condoms in preventing HPV is unknown.
 STD/AIDS Control Programme, Ministry of Health, National Condom Policy and Strategy (June 2004), p. 8.
 Joseph Malinga, "'Don't discourage condom use,'" The Monitor, February 2, 2005.
 Human Rights Watch interview, Kampala, November 22, 2004.
 Human Rights Watch interview, Kampala, November 16, 2004.
 Human Rights Watch interview, Kampala, November 8, 2004.
 Human Rights Watch interview, November 10, 2004.
 Human Rights Watch telephone interview, New York, October 19, 2004.
 Human Rights Watch interview, Kampala, November 16, 2004.
 Mwanguhya Charles Mpagi, "Engabu Put Off Market," The Monitor, October 20, 2004.
 BBC News, "Uganda to run short of condoms," December 13, 2004.
 Peter Nyanzi, "Government Imports 80 Million Condoms," The Monitor, December 14, 2004.
 Mary Karugaba and Paul Kiwuuwa, "MPs Quiz Minister on Condom Shortage," New Vision, December 22, 2004; Robert Mwanje, "Priest Opposes Condom Importation," The Monitor, December 23, 2004.
 Simon Kasyate, "How Fake Condoms Got Onto the Market," The Monitor, January 2, 2005.
 Milton Olupot and Josephine Maseruka, "Museveni Opposes Condoms in Schools," New Vision, November 30, 2004.
 Press Statement by Buchmann Medical Care and Service on Engabu Condoms, January 21, 2005.
 Human Rights Watch interview, FortPortal, November 20, 2004.
 Human Rights Watch interview, Kampala, November 16, 2004.
 Human Rights Watch interview, Kampala, November 22, 2004.
 Peter Apps, "South African church attacks condom promotion," Reuters, January 26, 2005.
 See Human Rights Watch, "Unprotected: Sex, Condoms and the Human Right to Health in the Philippines," A Human Rights Watch Report, vol. 16, no. 6(c), May 2004, pp. 16-20.
 See Janice A. Hogle, ed., What Happened in Uganda?Declining HIV Prevalence, Behavior Change, and the National Response, USAID Project Lessons Learned Case Study, September 2002; Edward C. Green, Rethinking AIDS Prevention: Learning from Success in Developing Countries (Westport, CT and London: Praeger, 2003); Uganda HIV/AIDS Partnership, Uganda Ministry of Health, Uganda AIDS Commission, and MEASURE Evaluation Project, AIDS in Africa during the Nineties: Uganda. Young People, Sex, and AIDS in UgandaChapel Hill, NC: MEASURE Evaluation, CarolinaPopulationCenter, University of North Carolina at Chapel Hill, 2004); USAID Bureau for Global Health, Phase I Report of the ABC Study: Summary of HIV Prevalence and Sexual Behavior Findings, August 2003.
 The nine behaviors are premarital sex, age at first sex, sexual debut before age fifteen, age at first marriage, past year abstinence, past year secondary abstinence (i.e. abstinence among those already sexually active), non-marital partnerships, extramarital sex, and multiple partnerships.
 UHP/MOH/UAC/MEASURE, Young people, sex and AIDS in Uganda, p. 49.Conclusions such as this are unfortunately highly politicized.Studies not funded by the U.S. government have made more nuanced conclusions from the same data; see, e.g., Susheela Singh, Jacqueline E. Darroch, and Akinrinola Bankole, "A, B and C in Uganda: The Roles of Abstinence, Monogamy and Condom Use in HIV Decline" (December 2003), Alan Guttmacher Institute Occasional Report No. 9. While a comparative analysis of these studies is beyond the scope of this report, theimportant point is that the U.S. government's own assessment does not support the establishment of abstinence-only programs as described in the U.S. Global AIDS Strategy.
 As noted above, condoms are not part of abstinence education programs funded by the U.S. government, but rather are targeted at "high risk" populations.
 In Rakai District, for example, condom use increased from 2 percent to 66 percent of the sexually active population, a period that saw a decrease in HIV prevalence to 12 percent from 44 percent.Sadab Kitatta Kaaya, "Rakai Condom Use Reaches 66 Percent," The Monitor, January 27, 2005.See also, Roehr, "Abstinence programs do not reduce HIV prevalence in Uganda."
 Helen Epstein, "The Fidelity Fix," The New York Times Magazine, June 13, 2004, p. 56.The epidemiologists Rand Stoneburner and Daniel Low-Beer have also elaborated this argument in a series of articles.
 See, e.g., Emily Dyer, And Banana Trees Provided the Shade: The Story of AIDS in Uganda (Kampala: Uganda AIDS Commission, September 2003); Helen Epstein, "AIDS: The Lesson of Uganda," The New York Review of Books, July 5, 2001, pp. 18-23, Edward C.Green, Rethinking AIDS Prevention: Learning from Successes in Developing Countries, (Westport, CT and London: Praeger, 2003), pp. 141-226.
 Human Rights Watch interview with Miria Matembe, minister of ethics and integrity, Kampala, January 13, 2003.
 Human Rights Watch interview, November 10, 2004.
 In late 2004, the British medical the journal The Lancet published a consensus statement on HIV prevention which stated, "The ABC (Abstain, Be faithful/reduce partners, use Condoms) approach can play an important role in reducing the prevalence of HIV in a generalised epidemic, as occurred in Uganda."Daniel Halperin et. al., "The Time Has Come for Common Ground on Preventing Sexual Transmission of HIV," The Lancet, Volume 364, Number 9449, November 27, 2004.It is unfortunate that by using the term "ABC" in reference to Uganda, the statement contributed to the misperception that the U.S. AIDS Strategy, which uses the term ABC, follows the Ugandan approach.
 Dyer, Banana Trees, p. 18.
 HIV-1 is the predominant type of HIV in Uganda and most of the rest of the world.
 Parkhurst, "The Ugandan success story?"
 See Mathematica Policy Research Institute, Inc., The Evaluation of Abstinence Education Programs Funded Under Title V Section 510: Interim Report, p. 4, as well as state-level studies cited by Advocates for Youth, below.A second federal report was completed in 2004 and submitted to the U.S. Congress and U.S. Department of Health and Human Services for review, but has yet to be released.
 Committee on HIV Prevention Strategies in the United States, Institute of Medicine, No Time to Lose: Getting More from HIV Prevention (Washington, D.C.: National Academy Press, 2001), pp. xi-xii and pp. 118-20.
 See "Uganda's official AB policy," above.
 Eleven state-funded evaluations of abstinence-only programs are reviewed in Debra Hauser, Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact, (Washington, D.C.: Advocates for Youth, 2004).A twelfth evaluation was released by the state of Texas in late 2004.Patricia Goodson, B.E. (Buzz) Pruitt, Eric Buhi, Kelly L. Wilson, Catherine N. Rasberry, and Emily Gunnels, Abstinence Education Evaluation: Phase 5 Technical Report (Department of Health & Kinesiology, TexasA&MUniversity, September 2004).Information in this section is drawn principally from Advocates for Youth's review.
 Edward Smith et al., Evaluation of the Pennsylvania Abstinence Education and Related Services Initiative: 1998-2002, Pennsylvania Department of Health, January 2003, pp. 1 and 21.
 Department of Health, Minnesota Education Now and Babies Later Evaluation Report 1998-2002, 2003.
 Peter Bearman and Hannah Brckner, "Promising the Future: Virginity Pledges as they Affect Transition to First Intercourse," American Journal of Sociology, vol. 106, no. 4 (2001), pp. 859-912; Bearman and Brckner, "After the Promise: the STD Consequences of Adolescent Virginity Pledges," 2004, http://www.yale.edu/socdept/CIQLE/cira.ppt (retrieved November 10, 2004).
 Douglas Kirby, Emerging Answers:Research Findings on Programs to Reduce Teen Pregnancy (Washington, D.C.:National Campaign to Prevent Teen Pregnancy, 2001), pp. 5, 88-91; Jennifer Manlove, Angela Romano Papillio, and Erum Ikramullah, Not Yet: Programs to Delay First Sex Among Teens (Washington, D.C.: National Campaign to Prevent Teen Pregnancy, 2004).
John B. Jemmott et al., "Abstinence and Safer Sex HIV Risk Reduction Interventions for African American Adolescents," Journal of the American Medical Association, vol. 279, no. 19, May 20, 1998, pp. 1529-1536.
Institute of Medicine, No Time to Lose.
 UNAIDS, Impact of HIV and Sexual Health Education on the Sexual Behavior of Young People: A Review Update (Geneva: UNAIDS, 1997), p. 15.
 The Cochrane Collaborative Review Group on HIV Infection and AIDS, "Evidence Assessment: Strategies for HIV/AIDS Prevention, Treatment and Care" (July 2004), University of California, San Francisco Institute for Global Health, executive summary; see also, pp. 4-8.
 "Comment: The time has come for common ground on preventing sexual transmission of HIV," The Lancet, vol. 364 (November 27, 2004), p. 1913.
 OGAC, PEPFAR Five-Year Strategy, p. 24.
 See, e.g., "Abstinence Clearinghouse Points to Two Reports Supporting Abstinence Education," The Christian Post, December 10, 2004.
 Human Rights Watch interview, Dr. Elioda Tumwesigye, Mbarara, November 21, 2004.
 Human Rights Watch interviews, Beat Bisangwa, office of the first lady and Rose Kabugo, Uganda AIDS Commission, Kampala, November 16 & 22, 2004.
 Human Rights Watch interview, Beat Bisangwa, office of the first lady, Kampala, November 16, 2004.
 Human Rights Watch interview, Rose Kabugo, Uganda AIDS Commision, Kampala, November 22, 2004.
 Human Rights Watch interview, Beat Bisangwa, office of the first lady, Kampala, November 16, 2004.