Uganda's successful reduction of HIV prevalence rates during the 1990s resulted from progress on all three fronts of its behavior-change prevention strategy—delaying sexual initiation among young people, reducing the number of sexual partners and promoting condom use among people who are sexually active—according to a new analysis by The Alan Guttmacher Institute (AGI). In "Flexible but Comprehensive: Developing Country HIV Prevention Efforts Show Promise," AGI's Director of Government Affairs, Susan Cohen, draws on the new analysis to illustrate that an integrated approach, which is being adopted by countries worldwide, shows the most promise for slowing the spread of HIV.

These findings reinforce the current strategy of the U.S. Agency for International Development, which promotes a multipronged program in its HIV prevention efforts. However, U.S.-based advocates of abstinence-until-marriage programs, including those within the Department of Health and Human Services (DHHS), are seeking to attribute Uganda's success mainly to increased abstinence. Cohen says these claims alarm reproductive health and HIV prevention advocates, particularly because DHHS, which supports domestic programs that deny U.S. teenagers medically accurate information about the benefits of sexual risk reduction strategies, has recently gained new authority to operate HIV prevention programs overseas.

According to estimates from UNAIDS/WHO based on surveillance data for pregnant women, Uganda's HIV prevalence declined in major urban areas from about 30% in 1990 to 14% in the late 1990s, and in non-urban areas from 13% in 1992 to about 8% in the late 1990s. As Uganda is a largely rural country, national trends are similar to the situation in non-urban areas. To better understand the cause of these declines, AGI analyzed data from nationally representative Demographic and Health Surveys in 1988 (of reproductive-age women) and 1995 and 2000 (of women and men) in Uganda to identify changes in sexual activity, multiple sexual partnerships and condom use. These nationally representative data are more relevant for understanding national trends in HIV prevalence than studies that have addressed behavior changes within particular geographic or demographic subgroups. The analysis [pdf file] reveals that:

• Condom use among unmarried women rose from negligible levels in 1988 to 24% in 2000. Condom use also rose sharply among unmarried men, from 39% in 1995 (the first year of available data) to 57% in 2000. Together, these increases make condoms a significant contributor to lowering risk of HIV infection.

• Reductions in the number of sexual partners also contributed to reducing exposure to HIV risk. The proportion of unmarried sexually active women who said they had more than one sexual partner within the past year declined from 10% to 4% between 1995 and 2000. (Among unmarried men, the proportion remained steady at about 25%.)

• In 2000, fewer adolescents (especially young women) reported ever having had sex than in the prior survey years, indicating that delayed sexual activity was a moderately important contributing factor in reducing HIV infection risks. Among those who were sexually experienced, however, there was no increase in abstinence.

Cohen emphasizes that the Ugandan government's program has been comprehensive, encouraging abstinence but also providing information about and support for condom use among those who are sexually active. The evidence from Uganda, like evidence in the United States, simply does not support a single-focus, abstinence-only approach to HIV prevention

Cohen's analysis appears in the October issue of The Guttmacher Report on Public Policy. Other analyses in this issue include:

• "Emergency Contraception: The Need to Increase Public Awareness," by Heather Boonstra;

• "New Medicaid Initiative, State Budget Woes Collide," by Rachel Benson Gold;

• "Reproductive Health-Related Developments in the States in 2002," by Adam Sonfield and Vitoria Lin; and

• "Bush Bars UNFPA Funding, Bucking Recommendation of Its Own Investigators," by Susan Cohen.