Introduction 1997 1995 1998 2003 2000 2006 2003 2003 2002 2004 1997 1997 2002 1998 2002 1997 2003 This article focuses on the years when the HIV/AIDS program in Uganda was first formed through the time when serologically measured changes in HIV prevalence occurred. Our analysis is based on the country documents, national program plans and reports of that period, and our experiences as part of that program. An attempt is also made to provide comparisons with other national AIDS programs in Africa that occurred in the same years and to describe the major differences between Uganda's program and other programs in the region at the time. First we describe our sources of information followed by our description of the Uganda AIDS prevention activities and their implementation. Information sources This paper focuses principally on program strategies, processes and activities of the Uganda National AIDS Control Program (NACP) for the years 1987–1994. Although noted here, we do not provide an in depth analysis of the trends in sexual behavior or HIV changes themselves which have been analyzed elsewhere and repeatedly. This article draws on sources from Ugandan Ministry of Health records and reports, World Health Organization (WHO) records and reports on the country program and programs of neighboring countries, Uganda country assignment reports, the Uganda National Program Review, and plans and country assessments by WHO and USAID written at the time. We also rely on data from specialized studies performed at the time and reports of those of us who were engaged directly in the program reviews, planning and implementation of the Uganda AIDS program during those years, some of whom were also involved in implementation or assistance to implementation of neighboring African countries at the same time. Brief history of the Uganda National AIDS Control Program (NACP) 1986–1995 1989 1992 2000 1996 2000 1987–1995 single set up to lead the way Emergency assistance – first plan in Africa 1989 1987–1995 1988 1989 The first Uganda program review 1989 1989 1989 weeks Regarding condoms, the NACP was advised by the co-sponsored review only to “review the use of condoms as part of the strategy particularly where transmission rates are high.” The Ministry of Health, the lead ministry for the Uganda program at the time and for the next several years, was not eager to embrace condoms, for a number of reasons that included availability (dependence), acceptability, and disposal, and the fact that putting trust in one measure was not strategic. These reasons were constantly cited by the program and President Musevini. The review repeatedly noted the need for an urgent push toward the rapid expansion of the information, education, communication and training. The Uganda medium term plan (MTP) 1989–94 1989 1990 1991 1993 1 Table 1 Uganda national AIDS control program budget 1989 Activity Total (× 1 mill. USD) Management 1.6 Health education 7.2 Surveillance and care 4.3 Lab support 5.0 Total 18.1 Source: 1 1988 1990 2 Table 2 Uganda AIDS health education budget 1989 and 1990 (× 1,000 USD) Category 1989 1990 Salaries 164 203 Consultants 241 164 Duty travel 12 14 Supplies-field projects 238 209 Equipment-field projects 388 120 Local costs 1,724 1,539 Program support costs 360 292 TOTALS 3,128 2,541 Source: In 1989, the first year in which financial information is available, $3.1 million of the $7.2 million available for health education activities were made available from the WHO Trust Fund. The additional $4.1 million were made available from bilateral sources, e.g. UNICEF, USAID, U.S. Red Cross, MSF and U.S. and other University projects. Of the $3.1 million, $1.7 million was made available for local costs. Similarly $1.5 million of the $2.5 million spent from the WHO Trust fund IEC budget was used for local costs. The 1991 Evaluation of the Uganda IEC activities stated that the DAMP and the ACP Mass Media activities were “two of the most visible of the NACP's projects and together utilize more than half of the IEC budget.” The 1989–1992 health education campaign 1990 1991 1989 Table 3 The 1982–92 AIDS information, education and communication (IEC) campaign sectors trained (partial listing) Resistance committees Agricultural workers Police Social mobilization Traditional healers Prisons Schools Universities Youth Media Midwives Army Performance artists Women's groups Religious organizations Family planning workers Refugees  Source: Fig. 1 Source: et al.  Training of trainers 3 1991 1989 District mobilization 1 The District course content as noted in a WHO funded special IEC review stressed 11 topics including scientific overview, basic prevention messages, common questions and misconceptions, communicating with high risk groups, cultural practices, special concerns of women, effective communication skills, care, and counseling. District level activities used to convey this content included public gatherings, plays, songs, contests, and the distribution and discussion of posters, leaflets, fliers, comic books, documentaries and videos. The basic content of these district, village and community sessions were of a type of allowing the correct information to be discussed, to give it time, to allow everyone to be involved and to disseminate accurate information for the population in order for their to be an adequate opportunity to mull over, discuss between each other, understand, and facilitate a critical mass of persons who knew the facts. Norm change was intended to follow facilitated group decision-making. IEC materials on AIDS such as posters, pamphlets, and booklets were developed and translated into local languages, and distributed to District Councilors, Resistance Councilors and to members of NGOs at training workshops. Three day seminars were held for health workers, followed by two day seminars for Resistance Councilors and district department heads, and sub-county chiefs. The general public was to get their materials through the Resistance Councilors system and other key people such as “mass mobilizers” and community development workers. Resistance committees were political administrative units that graduated into each other from the Resistance Councilors that was made up of 9 households. Resistance committees were later to be called local councils or local area councils, but they maintained the same function. These training activities were followed by a one week health education campaign conducted by Resistance Councilors in collaboration with assistant health educators, other health educators, community development workers and NGOs. The DAMP activities and the training of trainers through multiple formal and informal natural and other infrastructures would serve to cross fertilize, in other words allow multiple messengers to come at individuals and groups through multiple channels, but with the same message. Although DAMP was the “big concept,” UNICEF funded health education activities included a community Health Education Network (HEN) with community based health educators imbedded in the community, meant to sustain DAMP, and SHAPE (School Health Education Project). Both of these activities cross fertilized with and were thought to have augmented the DAMP. Parents and the community were to get information from HEN and their children got information from the schools – so there would be multiple channels alongside the district level work, and specific synergy at the household level. Country wide messaging The dominant message of the Ugandan program, as is well known, and which was well known at the time both throughout Uganda and throughout Africa (as the Uganda message) was “Zero Grazing,” alluding to the traditional way cattle were fenced in, or tied to a stick to limit grazing outside their own pasture. This clearly meant “stick to one partner” which was what was frequently said following the message or by way of explanation. This was a message of “fidelity” although that word was rarely used at the time, as it not only pertained to during marriage, but to during dating as well. One study in1990 supported by WHO/GPA reported higher village recall of the saying or having seen the posters “Love Faithfully” (30%), and “Love Carefully” (25%) than “Zero Grazing.” Over 70% of those aware of “Love faithfully” interpreted this to mean “stick to one partner”; over 50% of those who heard or saw “Love carefully” understood it to meant “choose your partner carefully” (which became a large confusion in Uganda), and over half of those who saw or heard “zero grazing” thought it to mean “stick to one partner.” All options including delaying sex, not engaging in sex, sticking to one partner, and to a lesser extent, using condoms were also described in the materials and discussions in trainings and in the district level courses and discussions. The posters at the time emphasized a cow in a pasture surrounded by a fence, and many “Thank God I said no” posters, as well as messages of care and compassion. The word abstinence per se was rarely if ever heard in Ministry conversations, although delaying onset of sex was part of usual information. Although all means of transmission noted here were provided as information, we believe the actual “ABC phrase” came out of the USAID in the mid or late 90 s, and was not seen in any of the country plans or program documents, or known at the time of the first 6–7 years of the Uganda program. Materials development and dissemination There was an enormous emphasis in Uganda on material development, production and reproduction, and active dissemination out of the capital to the districts. Local graphic artists held subsidized workshops with local residents to design materials and information packets for use in the trainings and DAMP activities. A full time printing press was paid for by WHO and put into the Ministry of Health along with other equipment and staffing support to intentionally “enhance the capacity of the Ugandan Ministry of Health - Health Education Unit.” A full time “U.N. Volunteer” (UNV), funded by WHO/GPA, was additionally supported for the Uganda program to run the printing press. The instructions to the UNV were to continue to print, produce, and disseminate materials no matter what else was occurring regarding the national program. Posters, leaflets, fliers, and comic books were produced by this and other means. Materials for persons with poor literacy skills were also developed and actively disseminated. Mass media Representatives from Ugandan radio and television were included in the program and planning process, and both radio (thought to reach over 87% of the population) and television were widely used. Short “jingles” were designed by NACP for radio to convey information on AIDS. The Ugandan daily paper MUNNO ran daily articles on AIDS. The weekly Topic and daily New Vision ran a combined 17 articles on AIDS in 1990. The New Vision ran the “AIDS Corner” on the last page of every issue that posed a question and provided an answer. This campaign ran daily for three consecutive years. The Q and A's were later compiled into booklets used in other countries. Ugandan TV (UTV) ran regular spots discussion programs and documentaries. Theater was used to convey messages and almost all theater groups developed plays incorporating HIV/AIDS messages. President Musevini, Dr. Okware – then National AIDS Program Director - and other Ministry officials were regular spokespersons in the media, and the program appeared to speak with one voice so there was little opportunity for confusion. Church leaders and imams were a major sources of information for about 12% of the population, but between 81% and 95% of three villages reported having received messages on AIDS from the church. Fidelity and monogamy were emphasized “in addition to abstinence.” Eighty-five percent of respondents in the 1991 NACP study felt that abstinence “was not a practical prevention strategy or behavioral option for any or all members in their community”; 44% similarly felt that monogamy was not practical or possible at that time. Changes in social norms At the time there were several anecdotal reports of villages changing norms of the acceptability of sexual contacts between teachers, police and the military in terms of their relations with young women. These decisions were arrived at by group decision making - and these changes in enforced norms toward total unacceptability were also supported by Presidential directive at the time. The results reported were that teachers or police who did engage in sexual relations with young women and girls were removed from their assignments, and likewise forced to leave the towns or villages. The full extent of these specific changes in norms and practices is unknown. Changes in sexual behavior 1997 1989 2003 1997 1998 2003 2000 1998 2003 2003 1991 Changes in HIV prevalence 1997 1991 1988 1990 1997 1998 2003 2000 4 Table 4 HIV prevalence (%) changes in Uganda for 15–24 years old 1990–1993 and 1995–1996 Antenatal sentinel    surveillance sites 1990–1993 1995-1996 P Nsambya 30.6 (25–36) 14.7 (13–17) <.001 Rubaga 24.0 (18–30) 17.5 (14–21) <.05 Mbarara 30.7 (25–36) 14.0 (11–17) <.001 Jinja 17.7 (14–22) 12.1 (9–15) <.05 Mbale 15.0 (12–18) 7.4 (5–10) <.001 Tororo 15.5 (11–20) 12.2 (9–15) NS Summary and conclusions 1991 1998 1991 1989 1993 1991 2003 2003 1998 2002 President Musevini's commitment and personal leadership and the involvement of the whole government was well known to all staff at WHO at the time and throughout the continent. This allowed open discussion throughout the country and even more so encouraged it. The President guided all ministers and other senior level government officials to mention and speak about AIDS at all public functions. As a matter of policy President Musevini's speeches were to end with a note on HIV/AIDS. As far as we know, no single speech, local or international, ended without talking about HIV/AIDS. A note was always left to himself to use his knowledge and imagination to convey the message. There is nothing intrinsically different about the Ugandan people, problem or program, although the Resistance Council structure did facilitate some aspects of the decentralization performed, and the post-revolutionary nature of the society at the time probably helped ensure an appropriate amount of zeal for the effort. However the implementation of the program itself was notably different as compared to all of the neighboring countries at the time. We believe that the principal difference between the Uganda's HIV/AIDS prevention and education campaign and that of neighboring countries relates mostly to the intensity, depth, breadth, and extensiveness of programming of its behavior change campaign, the level of involvement of all sectors, the pragmatism and extension of the district level work deep into communities, including the involvement of local churches and mosques, and the high level of financial support that allowed this to occur. Although there are several matters different about the HIV/AIDS situation now, most notably the increased availability of drug treatment, it is still believed that given the full support, proper planning, and strength of implementation, serious HIV/AIDS prevention and public education campaigns of this nature, still largely missing in Africa, could and should be implemented in almost any country with this degree of problem or risk of problem. behind first 2000 Authors Biography Dr. Slutkin was the WHO/SPA and then WHO/GPA epidemiologist assigned to support the Uganda program from 1987–94. He also co-developed (along with Drs. Chin and Tarantola) the serosurveillance methods used to monitor trends in HIV within and among all countries (global), and supported the 12 other countries of Central and East Africa during the same years. Dr. Sam Okware was the director of the National AIDS Programme of Uganda. Dr. Warren Naamara was the epidemiologist responsible for the serosurveillance system of Uganda, and director of the Uganda ACP from 1990–1993. Dr. Don Sutherland was the WHO Team Leader and epidemiologist assigned to Uganda following the work of Dr. Ros Widi-Wirski, now deceased whose trip reports were consulted. Donna Flanagan was the health educator assigned to Uganda from 1990–1994. Dr. Erik Blas provided the logistic, managerial and financial back-up support to the Uganda program, as well as dozens of other programs around the world from WHO/GPA. Dr. Paul Delay was the epidemiologist of the Malawi AIDS program and then the global USAID program director for AIDS, and subsequently Chief of Monitoring and Evalution for UNAIDS. Dr. Michel Carael worked in the social and behavioral research unit of WHO/GPA. Dr. Daniel Tarantola the Chief, National Programme Support was responsible for all national programs globally for WHO/GPA. During this time frame Dr. Tarantola supervised the development of over 120 national programs. The authors would also like to acknowledge Adjoa Amana, the driving force for the IEC training and messaging in the period 1987–90.