Education, Training and Research (ERT) Associates

This 8-page paper details an approach to identifying the changes in sexual behaviour that led to an observed dramatic reduction in the prevalence of HIV in Uganda in the early 1990s. Rather than present the evidence from one scientific method, this paper reviews 7 kinds of evidence and examines the consistency among them; they include:

1. models of HIV prevalence and incidence in Kampala and other sentinel sites in Uganda;
2. reports of behaviour change in the primary newspaper in Uganda;
3. surveys with questions about perceptions of personal behaviour change;
4. large demographic and health surveys (DHS) collected in 1988/9 and 1995 and large Global Program on AIDS (GPA) surveys in 1989 and 1995 with questions about reported sexual behaviour;
5. smaller less representative surveys of reported sexual behaviour collected in other years;
6. reports of numbers of condoms shipped to Uganda; and
7. historical documents describing the implementation of HIV prevention programmes in Uganda.

All 7 types of data produced consistent evidence that people in Uganda first reduced their number of sexual partners prior to or outside of long-term marital or cohabiting relationships, and then increased their use of condoms with non-marital and non-cohabiting partners. The author notes that, while each type of evidence has limitations, "the limitations of one method are sometimes offset by the strengths of another. For example, the newspaper accounts can accurately describe the timing of some events but cannot describe the representativeness of behaviour change. In contrast, the nationwide surveys were representative but cannot describe the exact timing of the beginning of behaviour change."

The author offers some specific reflections on the data gathered in an effort to provide a picture of behaviour change in this case. Here is an excerpt from the concluding portion of the report (footnote numbers have been removed from this excerpt):

"...[F]ew people used condoms before 1989 but...condom use increased, especially in urban areas and especially with casual sexual partners. These survey data are consistent with the very large increases in the shipments of condoms received in Uganda in the early 1990s, shipments that demonstrate the availability and presumably the need for condoms. In numerous qualitative analyses, many focus group and interview respondents indicated that first there was a change in norms regarding casual sex and a reduction in casual sex, followed by greater acceptance of condoms and condom use. Finally, the temporal order of these behaviour changes is also supported by programmatic efforts of the times. First the emphasis was on 'zero grazing' and 'being faithful' then, beginning in 1991, the emphasis on condom use increased markedly. This combination - breaking up the sexual networks by having fewer sexual partners and then decreasing the risk of STD [sexually transmitted disease] transmission through the use of condoms - is a powerful one. Modelling of the relationship between number of sexual partners and the size of sexual networks demonstrates that, in general, even small decreases in the mean number of sexual partners can sometimes markedly reduce the size of sexual networks. The reductions in numbers of sexual partners in Uganda demonstrated by multiple kinds of data certainly had the potential to break up these sexual networks and thereby reduce the transmission of HIV. The greater use of condoms in the remaining smaller sexual networks further reduced HIV transmission. Then, according to multiple sources, the incidence and prevalence of HIV declined dramatically. These findings are consistent with other analyses of declines in HIV prevalence in other generalised epidemics in sub-Saharan Africa (eg, in Kenya and Zimbabwe), which suggest that giving a strong emphasis to partner reduction while also encouraging condom use (and abstinence) is much more effective than primarily promoting condom use (or abstinence)."

In conclusion, "[c]onsistent with basic theories about transmission of sexually transmitted infections, first reducing the number of sexual partners and breaking up sexual networks and then reducing the chances of HIV transmission with remaining casual partners by using condoms can be achieved and can dramatically reduce the sexual transmission of HIV in generalised epidemics."

Editor's note: The author indicates (email communication, November 17 2008) that several reports (available free of charge on the ETR Associates website) provide more evidence for behaviour change and an explanation of other factors leading to the decline in HIV prevalence in Uganda, as follows:

• A 3-page summary of the campaign to reduce HIV transmission in Uganda and its success;
• a more in-depth summary of the major findings that have policy implications for other countries with generalised epidemics;
• a more in-depth analysis of the evidence for behaviour change;
• an analysis of Uganda's HIV prevention efforts and other factors that affected perceptions of HIV risk and helped to change sexual behaviour (It covers efforts by the President of Uganda, the national government, local councils, non-governmental organisations (NGOs), the media, health care providers, schools, faith communities, employers, the military, condom promoters, and distributors and HIV testing centers. It describes the content of messages about sexual behaviour and provides a logic model identifying the major programmatic efforts and their collective impact on important psychosocial mediating factors, such as perceptions of risk, social norms regarding multiple partners, and attitudes towards condoms.); and
• a detailed historical summary of events in Uganda that affected the epidemic, presenting the timing and sequence of events and their implications for the causal impact of different factors.

Sexually Transmitted Infections 2008; 84 (Suppl. 2): ii35-ii41; and email from Doug Kirby to The Communication Initiative on November 17 2008.