HIV This Week

Kirby D. Changes in sexual behaviour leading to the decline in the prevalence of HIV in Uganda: confirmation from multiple sources of evidence. Sex Transm Infect. 2008;84 Suppl 2:ii35-41.

Kirby set out to identify the changes in sexual behaviour that led to the dramatic reduction in the prevalence of HIV in Uganda in the early 1990s. Seven different types of evidence were examined: (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of reported sexual behaviour collected in other years; (6) reports of numbers of condoms shipped to Uganda; and (7) historical documents describing the implementation of HIV prevention programmes in Uganda.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 seven 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. Consistent 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.

Editors’ note: HIV incidence in Uganda began declining from a peak in 1987-88 and then declined more rapidly after 1992-93. Although each of the seven types of evidence presented here has limitations, together they paint a convincing picture that people restricted their sexual activity outside long-term marital and cohabiting relationships and then increased condom use with casual sexual partners when condom availability improved with the arrival in the early 1990s of large shipments of condoms. The debates about ‘the one thing’ that led to Uganda’s historical fall in HIV prevalence are put to rest by this article highlighting the importance of combination prevention, including a good dose of political leadership, in stimulating and sustaining incidence declines.