Uganda's program promoting abstinence, being faithful in marriage and condom use is often credited with arresting the spread of HIV-AIDS in that country. But Ugandan officials and activists say the ABC program, as it's called, isn't a cure-all. There are still huge challenges in controlling and preventing AIDS, such as providing antiretroviral drugs to all in need -- and preventing the rise of drug resistance, when microbes evolve defenses that render medicines powerless.
Uganda has been a case study for slowing the AIDS epidemic, but AIDS control chief Dr. Elizabeth Madraa says there are signs the epidemic may no longer be declining. She says married women remain especially vulnerable to infection by unfaithful husbands.
"Culture-wise, it's very difficult to promote condom use in marriage,” Dr. Madraa said in an interview at the health ministry in Kampala, “and that's the challenge we really do have."
Ugandan AIDS activist Beatrice Were agrees. She was infected by her first husband, who has since died. Ms. Were notes that African women often lack control over sex in marriage. Marital rape, for example, is not recognized as a crime in Uganda. "From my own experience, I abstained, and when I was married, I was faithful to my spouse, but it didn't protect me from HIV.” Ms. Were said. “The school of thought that believes in abstinence and faithfulness in marriage ignores the fact that HIV has a lot to do with gender and power relations."
Makerere University medical professor Francis Mmiro says the second largest route of HIV infection in Uganda is from mothers to children: prenatally, during delivery, and through breastfeeding. Dr. Mmiro helped invent one of the most effective protocols for preventing mother-to-child transmission in pregnant and nursing women – known as PMTCT -- using a drug called nevirapine. "Our objective was to find something cheap, simple and effective,” he says, noting that while better drugs have since been developed, even now nevirapine remains the one that Uganda can afford.
He says the program has cut mother-to-child transmission in Uganda half, to fewer than 15 percent of babies born to HIV-infected mothers. Critics of nevirapine note it is toxic, but Dr. Mmiro says that isn't true when it's used as a one-time preventative. "Nevirapine as used for PMTCT doesn't provide any toxicity, because it's just a single dose, a single tablet."
For those needing ongoing drug treatment, Dr. Elizabeth Madraa says social support is also important. “We have a kind of organization, of people living with HIV and AIDS, who came voluntarily and trained the relatives to become what they call treatment supporter or buddies,” she says. “So, if you have been initiated on treatment, you can come with your relative, who sees you through the first weeks to comfort you during that reaction, because some drugs are very strong, at the beginning they feel so bad, but if there's somebody who's gone through it is there to tell you, 'that's how I felt, after some time I felt better,' at least you're given that hope."
Dr. Madraa says Uganda's goal is to provide free antiretroviral drugs for every person in need. Currently they're reaching 38 percent of the 156,000 Ugandans who need them. But she adds that prescribing practices must be tightly regulated as part of the effort to reduce the chances of anti-microbial resistance, virus strains that become resistant to the medication.