KAMPALA, 1 March 2013 (PlusNews) - The condom has played a central role in Uganda’s official HIV prevention strategy for over two decades, but the country has yet to get it right, with condom use declining and the government unable to meet what demand does exist.
The country's ‘ABC’ strategy for HIV prevention - Abstinence, Being faithful and Condom use - had early success in lowering HIV prevalence, but the government later faced accusations of bowing to US pressure to emphasize abstinence over condom use, which experts say has hurt prevention efforts.
Now experts say that if the country is to roll back rising HIV prevalence, the condom must reclaim its place as one of the main thrusts of Uganda's HIV prevention strategy.
"The fact that there is a recorded increase in new HIV infections is a proxy indicator that the tool that is known to prevent HIV has been used in a relaxed manner. Condoms have been long established as one of the most effective technologies for the prevention of not only HIV but also STIs [sexually transmitted infections] and unwanted pregnancies," said Milly Katana, a long-time HIV activist and one of the inaugural board members of the Global Fund to fight HIV, Tuberculosis and Malaria.
"In order to have consistent condom use among sexually active populations that are at risk of HIV infection, the country needs to go back to basics - people who have scientific evidence of the efficacy of condoms [should] work with communities in providing accurate information that is not based on moral judgments and biases."
"This is a crisis"
Research shows that while high-risk sex is common, condom use is not. According to the 2011 AIDS Indicator Survey, "among respondents age[d] 15-49 who were sexually active in the preceding 12 months, 17 percent of women and 34 percent of men engaged in sex with a non-marital, non-cohabiting partner. Of them, 29 percent of women and 38 percent of men reported using condoms at the most recent high-risk sex."
This represents a sharp decline from the 47 percent of men and women in this age group who used condoms during high-risk sex in 2005.
"This is a crisis government must not ignore. The government must support all efforts to increase access to and use of condoms through aggressive condom promotion, fixing chronic procurement delays and reforming the outmoded post-shipment batch testing requirement," Alice Kayongo Mutebi, HIV/AIDS policy adviser for the Community Health Alliance Uganda, told IRIN.
The post-shipment testing requirement was introduced following a scandal in 2004 in which government-subsidized ‘Engabu’ (meaning “shield”) condoms failed a "free from holes" and "smell" test; the requirement has, in the past, lead to delays in condoms reaching the public, sometimes resulting in condom shortages.
According to Vastha Kibirige, the Ministry of Health’s condom programme coordinator, although Uganda requires some 240 million condoms annually, the public sector procures just half that, and some years, as few as 80 million.
"Condom use is erratic in Uganda, partly because they are not always available to users," Kibirige told IRIN. "Condoms are not on the essential drugs list and therefore, for the public sector, condoms are [supplied] as per available resources from UNFPA [the UN Population Fund] and USAID [the US Agency for International Development] or the Global Fund... This support is given when the resources are available rather than when the country needs condoms."
But critics say the government must reduce its reliance on donors and increase domestic spending on vital HIV services such as the purchase of condoms.
Kibirige said the government was currently working to launch a new brand of condoms - the first since the Engabu fiasco - within three months.
"We are still doing research, design and branding in order to produce attractive and more appealing condoms for the public," she added. "We need to step-up social mobilization... condom promotion and education for the key populations, as well as programmes targeting the vulnerable populations, including married people."
Denis Kibira, medicines adviser at the Coalition for Health Promotion and Social Development Uganda, cast doubt on the efficiency of the government's condoms delivery channels.
"Condoms are also mainly distributed through the public health facilities, and it is questionable that if one wants a condom, they will endure and queue up at a health facility," he told IRIN. "In contrast, you will not find condoms in places where they should be... such as public entertainment places like bars and restaurants. We need to make use of dispensing facilities for condoms in the restrooms of all public places."
But, Kibira adds, placing condoms in the right venues without a clear message on their use would be counterproductive. "The condom campaigns are hurt by the lack of support and mixed messages sent out by, especially, the political leadership," he said.
"Our HIV prevention strategy lists ABC, but political leadership - and, in particular, the president - comes up to frequently emphasize A and B, and has openly spoken against safe medical male circumcision," he added. "This confuses the public."
President Yoweri Museveni has criticized the emphasis placed on condom use in Uganda's HIV strategy, saying that rather than having three equal prongs, the ABC strategy should focus on abstinence first, faithfulness second and condoms third.
And in a country where the vast majority of people are strongly religious, religious institutions' objection to condom use plays a part in the public's perception and use of them.
"For the Catholic faith, condoms are absolutely out. The church will not advocate for the use of condoms," Vincent Karatunga, secretary for inter-religious dialogue and ecumenism at the Roman Catholic secretariat, told IRIN. "Sex is a gift from God and [should take place] strictly in marriage. It's abstinence for the unmarried and faithfulness for those who are married."
Many leaders of the increasingly popular Pentecostal churches are also vehemently anti-condom; popular preachers like Martin Ssempa - who has set fire to condoms during his sermons - are not only against condom use, but are also heavily critical of high-risk populations they consider immoral, including men who have sex with men (MSM) and sex workers.
The Crane Survey, a 2009 study of high-risk groups in Uganda, reported that the HIV prevalence among MSM respondents was 13.7 percent, more than twice the national prevalence of about 6.4 percent. A 2011 study published in the Journal of the American Sexually Transmitted Diseases Association found that 37 percent of 1,027 female sex workers surveyed in Kampala's red-light districts were HIV-positive, compared to that year’s average national prevalence of 7.3 percent.
Widespread discrimination against MSM and sex workers, including by health workers, keeps them from accessing vital HIV prevention services, including condoms and safe personal lubricant.
The national HIV strategy does not make any provisions for HIV prevention among sex workers and MSM; activists say including them would present legal challenges given that same-sex activity and sex work are both illegal.
"These communities have very patchy coverage of effective, high-impact prevention programmes. This is a massive missed opportunity," said an activist who preferred anonymity. "There is need to protect these key populations by scaling up condoms. The higher-than-average HIV prevalence among these populations means it is particularly crucial for the government to make sure condoms are not just available, but are being used."
According to UNAIDS, “popular opinion in countries with generalized epidemics is that HIV infection is found evenly across the adult population”; however, the evidence points to large numbers of new infections driven by high-risk groups such as sex workers and MSM.
Experts also say there is a need to divorce morality from public health policy if results are to be achieved. "These new figures showing rising HIV incidence and declining condom [use] require a robust, evidence-based response," Allen Kuteesa, the executive director of the Health Rights Action Group, told IRIN. "We cannot bury our heads in the sand with ineffective, moralistic approaches."
"However much we want them to work, such [moralistic] approaches only provide false protection," Kuteesa added. "Our communities need bold scale-up of all effective prevention tools, including women-controlled methods such as the female condom, alongside biomedical approaches such as male circumcision and HIV treatment as prevention."