Sunday Times, South Africa - August 8, 1999
Laurice Taitz

It's the first day of their visit to Uganda to look at the ways in which the country that is in the vanguard of Africa's fight against AIDS is coping. There is a gruelling schedule ahead.

Once the latecomers are seated, the minister's frown evaporates and the meeting gets underway in earnest.

"We have come here to listen and to learn," she says briskly. "We need to work in an integrated manner. Once we fragment ourselves we will have no global understanding of what Uganda is doing. I want an initial report ready before we leave Kampala on Thursday."

For Tshabalala-Msimang the visit to Uganda is a triumph. It affirms that there are African strategies to deal with the pandemic, that we need not look perpetually to the West for solutions.

It also acknowledges that in South Africa, where 1 600 new infections occur each day, the sense of urgency that led to this visit - first mooted 18 months ago - is long overdue.

By contrast, Uganda's response to the virus was swift. The first 17 cases of "slim disease" were reported in 1983 in the south-west of the country. A year later researchers confirmed it was AIDS.

According to Dr Sam Okware, director of the national AIDS Control Programme, the virus quickly spread along major roads from towns to rural areas. By 1987, 800 000 people were infected. Today, 1,4 million out of a population of 20 million are HIV-positive and 500 000 have already died of AIDS.

People say there is not a home in Uganda that has not been touched by AIDS.

There are many stories: of the woman who lost three siblings and is now raising their 13 orphaned children; of the eightyear-old who nursed her mother until her death; of the husband and wife who did not disclose to each other that they were HIV-positive until they met accidentally at the same AIDS clinic.

Uganda's success in dealing with the AIDS pandemic is as much about attitude as it is about action. Ugandans display abundant common sense, compassion and determination. Their tolerance levels are perhaps best described by the way in which drivers in Kampala weave their way through rush hour traffic. In this city of one million people and two traffic lights, no one hoots or curses.

Their pragmatic approach to AIDS, as to life, is exemplified in the person of President Yoweri Museveni who came to power in 1986, restoring political stability after a tumultuous and brutal history delivered by the dictator Idi Amin.

With his rise to power Uganda became the first African country to acknowledge the seriousness of the AIDS epidemic and vowed to put all its efforts into fighting it.

Museveni boldly declared the government's policy of openness and it was his early acknowledgement of the AIDS crisis that gave foreign donor agencies the incentive to unlock Uganda's potential as a research base in East Africa.

The result is that this poor, landlocked country has now developed the most advanced scientific strategies to fight AIDS on the continent. Testament to this is their research into a vaccine and their findings on Nevirapine, a cheap drug that prevents mother-to-child transmission.

Curiously, it is Uganda's poverty compared to South Africa's relative prosperity that has worked to its advantage in the AIDS field.

In South Africa, national pride and determination not to fall into the Third World paradigm, has prevented our government from seeking help.

In Uganda, there is no such extravagant posturing. As Ugandan Health Minister Dr Chrispus Kiyonga points out: "Africa has 10 percent of the world's population and 70 percent of its AIDS infections."

In Africa, HIV/AIDS is much more than a health issue. While highly active anti-retroviral therapy has become the standard of care in industrialised countries, the vast majority of Africans can't afford the treatment and nor can their governments. In Uganda, triple therapy, which costs around US1 000 (R6 200) a month, is not really a viable option - the average civil servant only earns about US50 (R310).

But at which many activists have launched drug inaccessibility has left Ugandans undaunted. And so came the call to action. Okware says: "We looked at building a continuum of care from the household to the hospitals where we treat all HIV-related infections."

Uganda has invested heavily in training health workers, in counselling networks, in treating sexually transmitted diseases, and in expanding HIV testing. Couples who plan to marry are encouraged to have an AIDS test and are counselled on their options.

Millie Katana was tested before her wedding. "When I heard the news [I was HIV-positive] I thought my life had come to an end. I cried for days, hiding. You feel as if you are dying. But you are not dying of AIDS, it's a psychological death."

Katana cancelled her wedding and it was only after she saw a prominent Ugandan discussing his HIV status on TV, that she confided in her friends and family.

The man on TV was Major Rubaramira Ruranga, who is still in the army 10 years after he was diagnosed as HIV-positive. It is thanks to people like him that the stigma of living with AIDS is no longer so prevalent.

Ruranga was diagnosed in 1989. "The doctors told me I had three years to live. So I prepared to die."

He says his attitude changed after he went to an AIDS conference in Amsterdam in 1992.

"There I saw people who were HIV-positive fighting for rights, for access to treatment. I asked them how long they had been positive. Imagine my surprise when some said six years, others said eight. I realised then I was going to live."

Today, besides commanding his battalion, Ruranga coordinates the National Guidance and Empowerment Network of People Living with HIV/AIDS in Uganda, of which Katana is an active member.

While Ruranga is not shy to take on the government and tackle controversial issues, he feels great pride in what Uganda has done and in Museveni's decision to tackle HIV head-on. "Our government has brought liberty and given me the freedom to challenge anyone in it," he said.

He does not believe that offering anti-retroviral drugs to pregnant women is any kind of solution. "What we are saying if we do this is that women are disposable containers that bear children. We should be putting money into family planning and into prevention, otherwise we will be raising a nation of orphans."

There are already 1,7 million orphans in Uganda. Many say that extended family networks have been strengthened by the burden.

At St Francis Hospital in Nsambaya, health workers have been trained to counsel children and the bereaved. Many hospitals run feeding schemes and projects to economically empower orphans and widows.

In the case of one 18-year-old who was left with three siblings and no money for food or school fees, a start in life consisted of a donated sewing machine and the skills to operate it. For others it is a small grant to start a business.

Even practicalities like the drafting of a will that will protect wives' or orphans' inheritance rights have been ironed out. The Ministry of Gender has embarked on a project to encourage HIV-positive women to document their life story, thoughts and feelings for the children they leave behind.

Dr Monica Etima, of St Francis, says AIDS awareness is not enough and nor are condoms.

"A condom alone cannot protect the mind. As our president says, here we practice our ABCs. A is for abstinence, B is for being faithful to your partner and C is for those that can't - condom use. We have to start somewhere . . . "

The Catholic St Francis Hospital, like other religious institutions, has been drawn into the campaign against HIV/AIDS. Museveni appointed directors of the Ugandan AIDS Commission, the national co-ordinating body, from the churches. While at first priests and imams were unhappy about promoting safe sex or family planning, they were slowly won round by the idea that there would be a much greater heavenly reward for stopping the sin of killing.

Recognising that government alone could not tackle a disease on this scale, the work started by Museveni has devolved down to the smallest unit of society: the household.

Each parish in Mukono, one of many districts where homebased care is in place, has been given a bicycle so that volunteers can move between the hospital and individual homes, caring for the dying.

Okware says: "At first we would beat the war drums in the villages telling people to abandon their bad ways and to fear AIDS. We tried to encourage fidelity and morality. But we soon learned that fear stops working. We realised we needed a programme to change behaviour so we started preaching the gospel according to AIDS, to mobilise people at every level.

"We encouraged communitybased initiatives and our campaign has produced a lot of mass networks. We encouraged condom use and in 10 years have seen it go up from seven percent to 42 percent."

Ugandans point out that their united political will has had a lot to do with their successes. A decline in HIV infections has been noted at antenatal clinics around the country. In the Nsambaya district, in 10 years the infection rate has dropped from 24,5 percent to 13,4 percent of pregnant women.

In the town of Jinja, the infection rate has fallen by more than half, while nationally the age of sexual debut has been delayed from age 14 to 16.

One of Uganda's most impressive achievements has been the marked decline in infections in teenagers aged 15 to 19.

Remarkable, say the South Africans. Not really, say the Ugandans. "We still have a long way to go," says Okware. "There's no blueprint, that's the most important lesson we've learned: if something isn't working, we change it."

By the third day of the South African working trip, the first report had been drafted according to Tshabalala-Msimang's instructions. The visit has cemented a crucial relationship between the two countries and encouraged continued cooperation. Most importantly, it presents policymakers with cost-effective strategies that work and are within reach.

Tshabalala-Msimang says: "I was so excited after the first day, I phoned Brigitte [Mabandla, the Deputy Minister for Arts, Culture, Science and Technology] who was in the room next door at 4am and said: 'We can do this. We can make it work.'"

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