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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.196  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,197 achievements that are widely credited with helping to reduce HIV incidence and sustain relatively low rates of infection.198  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.199

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.200  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.”201  Following the conference, Museveni told a local newspaper that “this condomisation . . . is a recipe for disaster.”202 

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.203  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.”204  Shortly after, she criticized condom distributors for sending “vague messages” about HIV prevention and for concealing condoms’ ineffectiveness against human papilloma virus (HPV).205 

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.”206  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?”207

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.”208  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.’”209

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?”210

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.”211  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.212

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.”213  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 only source of free condoms in Uganda.214  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.215   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,216 others seized on it as platform to promote abstinence and fidelity as preferable to condom use.217  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.218

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.219

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.”220  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 Fort Portal.  “People say they want condoms, but not Engabu.  Only Protector is currently available, and people can’t afford to buy them.”221  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.”222  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.223

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.”224  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.225

[196] 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.

[197] 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.

[198] Ibid.; see also, Bob Roehr, "Abstinence programs do not reduce HIV prevalence in Uganda," British Medical Journal, vol. 330 (March 5, 2005), p. 496.

[199] 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.

[200] 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.

[201] Darren Schuettler, “Abstinence, Condom Controversy Erupts at AIDS Meet,” Reuters NewMedia, July 12, 2004.

[202] UN Integrated Regional Information Network, “Uganda: President’s New Attack on Condoms in AIDS Battle,” October 12, 2004.

[203] See, e.g., Ssejoba, “Museveni Condemns Condom Distribution.”

[204] Joyce Namutebi, “Mrs. Museveni Decries Condom Distribution,” New Vision, August 30, 2004.

[205] 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.

[206] STD/AIDS Control Programme, Ministry of Health, National Condom Policy and Strategy (June 2004), p. 8.

[207] Joseph Malinga, “‘Don’t discourage condom use,’” The Monitor, February 2, 2005.

[208] Human Rights Watch interview, Kampala, November 22, 2004.

[209] Human Rights Watch interview, Kampala, November 16, 2004.

[210] Human Rights Watch interview, Kampala, November 8, 2004.

[211] Human Rights Watch interview, November 10, 2004.

[212] Human Rights Watch telephone interview, New York, October 19, 2004.

[213] Human Rights Watch interview, Kampala, November 16, 2004.

[214] Mwanguhya Charles Mpagi, “Engabu Put Off Market,” The Monitor, October 20, 2004.

[215] BBC News, “Uganda to run short of condoms,” December 13, 2004.

[216] Peter Nyanzi, “Government Imports 80 Million Condoms,” The Monitor, December 14, 2004.

[217] 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.

[218] Simon Kasyate, “How Fake Condoms Got Onto the Market,” The Monitor, January 2, 2005.

[219] Milton Olupot and Josephine Maseruka, “Museveni Opposes Condoms in Schools,” New Vision, November 30, 2004.

[220] Press Statement by Buchmann Medical Care and Service on Engabu Condoms, January 21, 2005.

[221] Human Rights Watch interview, Fort Portal, November 20, 2004.

[222] Human Rights Watch interview, Kampala, November 16, 2004.

[223] Human Rights Watch interview, Kampala, November 22, 2004.

[224] Peter Apps, “South African church attacks condom promotion,” Reuters, January 26, 2005.

[225] 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.

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