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V. Findings on Abstinence Education in Uganda

We were told not to show [pupils] how to use condoms and not to talk about them at our school.  In the past, we used to show them to our upper primary classes.  Now we can’t do that.
—A primary school teacher in Kasese

In our assemblies and in the classroom, we explain what abstinence is and why it is important . . . . But around here, people don’t buy this idea of abstinence because in Uganda, many girls are using sex to buy their daily bread.
—A headteacher in Mbale

Uganda stands out among African countries for its high-profile embrace of U.S.-funded abstinence-until-marriage programs.  The country’s early success in bringing down rates of HIV prevalence, combined with its growing fundamentalist Christian population, has attracted the interest of U.S. policymakers eager to demonstrate the success of abstinence-only programs.  Support for abstinence-only approaches has extended to powerful figures in Uganda, most notably First Lady Janet Museveni, and can increasingly be found at the level of schools and service providers.  In what is widely viewed as a departure from his previous positions, President Museveni has publicly supported abstinence-only approaches and, before large international audiences, denigrated condoms as a means of HIV prevention.  All of this has occurred in the context of a growing condom shortage in Uganda, prompting some government officials to urge sexual abstinence to stave off a spike in HIV transmission.  These trends and their impact on Uganda’s HIV/AIDS programs are documented below.

Uganda’s official “AB” policy

In November 2004, Uganda claimed to be the first country in the world to draft an official national policy on abstinence and fidelity.  Titled the “Uganda National Abstinence and Being Faithful Policy and Strategy on Prevention of Transmission on HIV,” the draft policy is described by its authors as a companion to the country’s existing strategy on the promotion of condoms and a component of Uganda’s larger “ABC” strategy.⁵⁹  A review of the draft policy document, however, shows that the policy’s objective is to scale up abstinence-only programs styled after those in use in the United States.  Indeed, the definition of “abstinence education” in the draft follows almost verbatim the eight-part definition of “abstinence education” in the U.S. Personal Responsibility and Work Opportunity Reconciliation Act of 1996 cited above.  The Ugandan definition, which is in seven parts, reads:

Abstinence education means an educational or motivational approach which:

• Has as its exclusive purpose, teaching, supporting and empowering the social, psychological, and health gains to be realized by abstaining from premarital sexual activity;

• Teaches abstinence from sexual activity outside marriage (or “faithfulness”) as the expected standard;

• Teaches that abstinence from sexual activity is the only certain way to avoid sexually transmitted diseases, and other associated health problems;

• Teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity;

• Teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects;

• Teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society;

• Teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances⁶⁰

The U.S. legislation from which this is drawn is not cited anywhere in the policy document.  Later in the document, the AB policy is described as follows:

Sexual abstinence until marriage and faithfulness in marriage will be widely promoted as the most effective means of preventing STI [sexually transmitted infections]/HIV transmission.  Special emphasis will be placed on promoting delaying sexual debut among the young and faithfulness in marriage, eliminating sexual promiscuity.⁶¹

The document further calls for the establishment of an “A&B [Abstinence and Being Faithful] Coordination Unit” (ABCU) within the Ugandan Ministry of Health, as well as a “National A&B Policy Steering Committee” (NABPSC) and an “A&B Coordination Committee” (ABCC).  None of these proposed entities is given a mandate beyond promoting abstinence and faithfulness.

With respect to the promotion of condoms, the AB policy is contradictory.  At several points, the policy speaks in terms of bringing AB interventions on an “equal footing” with existing condom interventions; it states that local AIDS programs should “ensure that A, B and C are mutually complementary and not competitive strategies.”⁶²  Elsewhere, however, the policy suggests that information about condoms can undermine the message of abstinence.  Under the sections entitled “core values” and “quality assurance,” the document reads:

Messages about HIV and AIDS need not be ambiguous and mixed up.  A and B work in one sense are [sic] a personal challenge that calls for self-denial of immediate pleasure in favor of some good or positive health—or even survival.  The mixing of this message with an offer of perceived immediate gratification by means of condom use can be confusing to youth and indeed adults.  The condom message can compromise the power of the A and B message.  Nevertheless, the policy is to promote A and B without reducing the value of the C message, just as condoms must be promoted in ways that do not undercut or undermine messages of abstinence and faithfulness.

. . .

. . . since A&B messages work in part on the principle of motivating people to deny current pleasure in favor of a future good, it is possible to have the quality and strength of an A&B program diminished by simultaneously presenting a risk reduction behavior (e.g., condom use) as an equal and easier alternative; this is not true.  Implementers can do risk reduction education and promotion but not risk reduction adoption and sustainability.  Abstinence promoters should avoid diminishing program quality by sending out contradictory messages.⁶³

The AB policy’s narrow focus on abstinence and fidelity to the exclusion of all other determinants of HIV risk is reinforced in its section on monitoring and evaluation.  Despite recognizing the link between HIV infection and practices such as domestic violence, rape, and wife inheritance, the policy contains no indicators on reduction of these practices.  Nor does it even seek to measure whether program participants actually adopt abstinence or fidelity as HIV prevention strategies; rather, it measures only national trends in sexual behavior, which says little about the experience of program participants.  In addition, the policy measures numerous process issues such as meetings and reports of AB agencies and task forces and the preponderance of abstinence and fidelity messages being provided in the country.  By these indicators, the policy could be considered a success even if it fails entirely to effect changes in the sexual behavior or HIV risk of Ugandans.

Despite the fact that numerous evaluations of abstinence-only programs have been conducted in the United States, none of these evaluations is mentioned in Uganda’s draft AB policy.  It is possible that the authors of the draft were not aware of these studies or did not consider them relevant to the Ugandan context; however, the Ugandan government should address this concern.  It is of the utmost relevance that every independent evaluation to study abstinence-only programs has found them to be ineffective at influencing participants’ sexual intentions and behavior, and possibly harmful.  (These studies are reviewed later in this report.)

A further concern is that the draft AB policy does not adequately address the high risk of HIV faced by married people, especially women.  At several points, the policy suggests that strengthening the institutions of marriage and the family is an effective approach to preventing “social problems” such as HIV/AIDS.  The section entitled “guiding conceptual principles/model” states:

The family institution is the cradle of civilization, because it [is] the natural training ground for civil behavior, morals, sexuality, integrity, interpersonal relationships essential for life, work ethics, life skills etc.  In other words when the family institution is functioning as it was meant to function, many social problems which ultimately feature on a national level can be eliminated, and hence the need to pay special attention to Marriage and the family institution.⁶⁴

From a public health point of view, it is true that mutual fidelity to an HIV-negative partner can help to prevent sexual transmission of HIV.  However, as the draft AB policy recognizes in its section on “implementation modalities,” women face a high risk of HIV from such things as domestic violence, unequal gender relations, and wife inheritance.⁶⁵  These issues should be more clearly integrated into the document’s discussion of marriage and the family.

In the section on “strategy for implementation,” the draft AB policy proposes mandatory HIV testing for married couples as a solution to HIV transmission in marriage.  The document states:

Communication for being faithful should be integrated in all pre-marital counseling and an HIV test should be required for all those intending to get married.⁶⁶

Forced HIV testing is in itself an infringement of the right to bodily autonomy and to informed consent for medical procedures, as recognized by national and international legal standards.⁶⁷  Making an HIV test a precondition of marriage also infringes upon the right to marry and, especially for women, leads to the risk of violence, discrimination, and stigma on disclosure of HIV status.  While couples intending to marry should have full access to voluntary HIV counseling and testing, this does not substitute for legal protections against marital rape, domestic violence, wife inheritance, and other human rights abuses that increase married women’s HIV risk.  Nor does it address widespread social approval of men’s infidelity, which persists in Uganda despite longstanding efforts to highlight the risk of HIV brought about by extra-marital sex.

Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY)

Following the 2001 U.N. General Assembly Special Session (UNGASS) on HIV/AIDS, President Museveni returned to Uganda with the goal of promoting increased education about HIV prevention to children and young adults.  Together with the Uganda AIDS Commission (UAC), Museveni launched the Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY) in 2002.  To date, PIASCY has included the creation and distribution of manuals on HIV prevention for primary school teachers, the drafting of secondary school materials, and HIV-themed youth rallies held in various districts. 

Although it preceded the launch of the U.S. global AIDS initiative (PEPFAR), PIASCY is at the cornerstone of the U.S. government’s abstinence-until-marriage initiative in Uganda.  PIASCY is funded by the U.S. government through USAID and the Centers for Disease Control, both of which have provided technical support to the initiative.⁶⁸  Since 2004, PIASCY has been supported mainly by PEPFAR funds.  According to an official at USAID in Uganda, PIASCY is an “abstinence curriculum” that seeks primarily to empower young people to delay sex until marriage.

PIASCY in primary schools

In 2004, two PIASCY teacher’s handbooks, one for pupils in grades Primary (P)3 and P4 and one for pupils in grades P5 to P7, were distributed to every primary school in Uganda.  Prior to the launch of PIASCY, in 1997, the implementation of a policy of seven years of free schooling under a universal primary education (UPE) scheme had caused net enrollment in primary schools to increase to nearly 100 percent with a majority of primary school entrants reaching grade five.⁶⁹  Targeted HIV/AIDS prevention messages delivered in schools can therefore theoretically reach nearly every primary school child in the country, at least in the early grades.  Children in Uganda’s primary schools are typically aged seven to thirteen, but in many schools, particularly in rural areas, children in upper primary school may be in their middle or late teens.  This is because many pupils who had previously dropped out of school re-enrolled at an older age once it became free.

PIASCY is the most recent prevention program in Uganda to target children at the primary level.  In 1986, the United Nations Children’s Fund (UNICEF) and the government of Uganda began working to provide prevention information to pupils, starting with the School Health Education Program (SHEP).  SHEP introduced ten units of science and health education into the primary school curriculum with an emphasis on HIV/AIDS information.  In the 1990s, national examinations included questions related to the disease.  By the middle of the decade, educators reported that pupils had sufficient knowledge of the disease but little corresponding behavior change; thus, in 1996 Uganda established “life skills education” (LSE) programs to supplement existing prevention information.  Life skills education focused on empowering girls and boys to be self-confident decision makers with the ability to delay sexual debut, negotiate safe sex, and become responsible citizens.  These programs emphasized student participation and incorporated an HIV prevention message of delaying sex, “zero-grazing” (reducing the number of sexual partners), and correct and consistent use of condoms.⁷⁰

In every primary school visited by Human Rights Watch in November 2004, school staff members were following the PIASCY program.  Officials at the Ministry of Education said that manuals had been distributed nationwide and trainings had been provided to at least three teachers per primary school.  Every two weeks, entire schools were meant to hold assemblies with trained teachers instructing the student body with one of twenty-six “messages” found in the manuals.  The assemblies opened with the message, “Choose to abstain” and proceed to address numerous aspects of HIV prevention (including messages entitled “Condom use” and “HIV testing”), sexual and reproductive health, and “life skills” such as self-esteem, assertiveness, and resisting peer pressure.  Other abstinence-oriented messages include “Virginity is healthy,” “Choose to delay sex,” “Pre-marital sex is risky,” and “Acceptable moral practices.”⁷¹  In addition to the assembly messages, teachers were encouraged to incorporate each biweekly message periodically in their class lessons, regardless of the subject.  According to the officials, PIASCY simply reinforced existing prevention and health messages in the science curriculum (which varied from district to district) and supplemented this information with a national, standardized program.⁷²

Educators, health officials, and aid workers in Uganda spoke favorably about PIASCY, particularly its ability to reach nearly every school-age child.  Some raised concerns, however, with the content and appropriateness of the materials, the effectiveness of messages delivered at assemblies, and the lack of emphasis on student involvement.  When presented with these concerns, Ministry of Education officials countered that if PIASCY were implemented correctly and further trainings and monitoring conducted, many of these issues would be resolved.⁷³

Although PIASCY was launched in 2002, the manuals for the primary level were only distributed nationally in 2004.  According to several of those involved in the writing and editing process, initial drafts were prepared in late 2002 and edited in 2003, and a final book, pilot-tested and approved by teachers in two districts, was launched by the president on March 21, 2003.  Around the same time, however, several groups began actively protesting the content, focus, and messages in the books, vocally denouncing them and delaying their national distribution.  Concerns about the content of the manuals were largely voiced by religious groups who had not been included in the initial consultative process.⁷⁴  An individuals from one of these faith-based organizations argued that sexually explicit diagrams contained in the manuals, such as an illustration of a penis with a condom on it, would encourage children to start having sex.⁷⁵  According to Ministry of Education officials, in addition to the diagrams, religious groups insisted on a separate section on “ethics and morals” and increased information on abstinence until marriage as an HIV/AIDS prevention strategy for youth.⁷⁶

In late 2003, the government held additional stakeholders meetings sponsored by the U.S. government in order to respond to these objections.  One observer said of the faith-based groups’ participation in the meetings, “Everywhere the manual said, ‘There will be some children who have sex,’ they crossed it out and said, ‘They should be told to stop.’”⁷⁷  In the end, the expanded group of stakeholders made some changes, and two books, one for upper primary and one for middle primary, were launched in February 2004.⁷⁸  The new manuals omitted information from the initial text, including diagrams on how to correctly clean the penis and foreskin, how the body changes at puberty for boys, and how semen is ejaculated during sexual intercourse.  A chapter on “ethics, morals and cultural values” was added as well as two assembly messages on the risks of pre-marital sex and on “acceptable moral practices.”  The assembly message on condom use was altered, and a diagram illustrating a condom offering protection from HIV was removed.⁷⁹

The withdrawal of important and potentially life-saving material from primary school texts raises serious concerns about children’s right to complete and accurate HIV/AIDS information.  In the case of PIASCY, the offending manuals were designed as teachers’ handbooks only and were not intended for distribution to children.  Moreover, many of the controversial pictures and diagrams, including information on correct condom use, had been presented in HIV prevention materials at the primary level in Uganda since the late 1980s.  Asked why it was necessary to remove explicit images from teachers’ handbooks, officials at the Ministry of Education said that some stakeholders were concerned that children might see the images if they borrowed the books from their teachers or saw them lying around.⁸⁰

The inclusion of religious actors in the development of primary school HIV/AIDS materials should not amount to a veto over science-based health information.   Individuals with considerable experience in reproductive health and sex education in Uganda said they were stunned by the empowerment and involvement of religious activists in the development of PIASCY.  “Religious groups have never had a veto before,” said one experienced sex educator.⁸¹  This individual noted that faith-based organizations had historically played an important role in fighting HIV/AIDS in Uganda, particularly in caring for people living with AIDS and providing spiritual guidance, but had never shown much interest in prevention materials for children.  “Religious groups have never vetted materials going into schools,” the observer said.  “Where is it going to stop?”⁸²  Another participant reported that some of these groups had recently become financially empowered due to funding from U.S.-based sources and had developed links to the highest political offices, so their comments could not be ignored.⁸³

The content and launch of the PIASCY materials for primary schools has been significantly influenced by U.S. policy and funding in support of abstinence-only programs.  According to one USAID employee, PIASCY is the brainchild of Uganda but has been funded by the U.S. from “close to the beginning.”⁸⁴  An official at Uganda’s Ministry of Education told Human Rights Watch that direct U.S. involvement in the PIASCY primary school materials began just as the initial teacher’s volume had been completed.  At the same time that religious organizations were voicing their concerns about the content of the PIASCY materials, an employee of the USAID-funded AIDS/HIV Integrated Model District Program (AIM) contacted the Ministry of Education and cautioned that it would be necessary to re-work the books so that they would be acceptable to everyone.⁸⁵  The AIM employee relayed that AIM had considerable experience with schools in many parts of the world and that parents rejected books that were too graphic or explicit.  Following this intervention, AIM sponsored and paid for the stakeholders’ meetings that included religious groups not involved in the initial consultative process.  AIM later facilitated the publication of the two primary teachers PIASCY volumes.  In 2003, USAID also placed a technical advisor at the Ministry of Education to coordinate the PIASCY materials and oversee the content of the materials.⁸⁶  

In 2004 the Uganda Program for Human and Holistic Development (UPHOLD), another USAID-funded entity, held trainings for teachers on the PIASCY materials.  Approximately 40,000 teachers in over 14,000 schools were trained nationwide, and UPHOLD continues to be involved in the monitoring and evaluation of PIASCY.  The UPHOLD employee responsible for the trainings told Human Rights Watch that during the trainings, teachers expressed interest in learning about correct condom use but were instructed to teach only abstinence to children.  “What we are telling them is, yes, we know the condoms are there, but at this age [primary school], we are preaching abstinence.”⁸⁷  This message contradicts information supplied in PIASCY’s own Primary 5-7 manual, which states, “Pupils will definitely ask you about condoms, and there is no reason to avoid talking about them.  Used consistently and correctly, condoms protect against HIV/STIs and pregnancy.”⁸⁸

In response to questions about the U.S. influence on the PIASCY program, members of the U.S. government’s PEPFAR team in Uganda stated that while PIASCY had been funded by the U.S., it was in no way an “externally driven” process.  They said that internal groups were responsible for the changes in the content of the teacher’s manuals, and that the process was owned by the Ugandan government.  “Even if we supply the majority of funds to PIASCY, it does not mean we control it,” one said.⁸⁹  It is evident from teachers and those involved in the drafting process, however, that the U.S. government through its implementing partners had considerable influence both on the removal of information from the materials and the training of teachers who would ultimately be presenting them to school children.

In all schools visited by Human Rights Watch in November 2004, PIASCY materials were being used at assemblies and in classes, but there was considerable variation in the information provided to pupils.  Educators expressed divergent views on teaching pupils about condom use. Some said they evaluated the needs of the students and what they had done in the past against what they had been told in the PIASCY trainings or what they believed was politically strategic.  At a primary school in Kasese district, teachers said that the message about condoms they had been told to give in PIASCY trainings conflicted with that found in the science curriculum.  They said that they were not providing information on condom use because according to their PIASCY trainers, parents in the community might complain.⁹⁰  At another school in the same district, teachers said that PIASCY’s message on condoms is that “it is better to abstain.”  A group of three teachers said, “At the PIASCY training, we were told not to show [pupils] how to use condoms and not to talk about them at our school.  In the past, we used to show them to our upper primary classes.  Now we can’t do that.”⁹¹ 

The headteacher at another primary school in Kasese district said that information on correct condom use was essential for older children at her school, as recognized in both PIASCY and science curriculum materials.  She estimated that perhaps 20 percent of girls at her school were sexually active, so it was necessary to include information about condom use and partner reduction in addition to delaying or stopping sex as an HIV prevention strategy.⁹²

In one school in Mbale district in eastern Uganda, educators omitted any message about condoms in the PIASCY program because, as one headmaster put it, “President Museveni said there is no use teaching young people about condom use, because then children will go and experiment with them.”⁹³  The headmaster nevertheless felt that condoms had to be discussed with his older students, because:

Some primary children are already playing sex.  Some girls from the villages rent houses here in town to attend school and are engaging in sexual relations with older men.  Boys are doing the same, going to video shops, watching movies . . . . They are on their own and can get into trouble.  For example, we recently had a girl from a nearby village in P4 who was having sex with a car washer in town.  She is twelve years old.⁹⁴ 

In part because some of the children are sexually active, this teacher talks about condoms outside the context of the PIASCY program.

The headteacher at another school in Mbale district said that condom demonstrations were done at her school, but only by outside groups who were not part of PIASCY.  She said, “The point of PIASCY is that these kids are too young for sex.  In our assemblies and in the classroom, we explain what abstinence is and why it is important . . . . But around here, people don’t buy this idea of abstinence because in Uganda, many girls are using sex to buy their daily bread.”⁹⁵

Representatives of nongovernmental organizations specializing in education and HIV prevention raised concerns that PIASCY promoted marriage as an HIV prevention strategy.  To their credit, the PIASCY teachers’ manuals contain clear messages that marriage does not provide automatic protection against HIV.  Other sections of the books, however, promote marriage as an ideal.  They list sexual expression in marriage as a way to “avoid the sin of sexual immorality” and “protect society from sexual disease.”⁹⁶  This creates the risk that teachers will feel more comfortable presenting marriage as a prevention strategy than providing more detailed and frank explanations of the risk of HIV faced by married people, particularly married women.  One teacher at a primary school in Mbale said that in PIASCY, “We talk about marriage, what it is, when one should marry and how to be good in marriage.”  This same teacher, when asked about using condoms either within or outside of marriage, said, “We discourage condom use.  They can burst, and some can acquire STDs [sexually transmitted diseases] or become pregnant while using them.  Condoms encourage pupils to keep practicing sexual behaviors.”⁹⁷ 

Young people in Uganda have a right to accurate information that is based on scientific fact.  Marriage does not “protect society from sexual disease” as stated in PIASCY, nor should it be presented as a reliable HIV protection strategy.  Pupils have a right to know that inside and outside of marriage they face the risk of HIV and STIs, and that in Uganda, as in many countries, many men and women have contracted HIV and other sexually transmitted diseases from their spouses.  The view expressed by many people involved in PIASCY that information about condoms encourages early sexual behavior is also inaccurate and should not be used as the basis for denying young people information that could save their lives.

Not only the content of PIASCY messages, but also the form in which they are delivered, suggested they were geared more toward preaching “good behavior” than toward preventing HIV and unwanted pregnancy.  As noted above, PIASCY messages are delivered to students primarily at assemblies held at the beginning or end of the school day.  Students gather outside the classroom, and teachers read aloud one of the messages contained in the teachers’ handbooks.  Schools hold assemblies at least once every two weeks, with some schools gathering students for PIASCY messages several times a week.  Teachers with considerable primary school experience raised the concern that messages delivered at school-wide assemblies were unlikely to achieve lasting behavior change among youth.  In the 1990s, education specialists had remarked that HIV prevention information provided to children in Uganda did not bring about expected behavior change, so the emphasis was adjusted to highlight child participation in group settings.  With PIASCY, this adjustment was reversed.  Some teachers raised fears that dictating message at assemblies revived pedagogical approaches already proven ineffective in the early 1990s.

PIASCY requires that messages delivered at assemblies be reinforced in the classroom through the inclusion of examples into daily lessons.  In addition, the handbooks provide many suggestions to teachers for activities both inside and outside the classroom.  Teachers said that the emphasis on holding assemblies, while publicly visible and easy to monitor, left little time for additional activities that would reinforce behavior change, such as student in-class involvement or group role-play.  A teacher at a rural primary school said that PIASCY had come with no materials to assist with demonstrations or activities.  When teaching girls how to manage menstruation, for example, she had to bring in her own cloth (for use as a menstrual pad) for the demonstration.  Another teacher remarked that PIASCY activities were a good idea in theory, but that her school lacked materials for additional projects.⁹⁸ 

To these concerns, Ministry of Education officials countered that the program was just beginning and that it would evolve over time.  They explained that PIASCY should not be seen as a “top down,” dictated approach, but rather that through teachers’ interpretation of the messages in the classroom, parent and community members’ involvement and children’s activities, the program would foster dialogue and communication and empower boys and girls to protect themselves.⁹⁹ 

PIASCY in secondary schools

At this writing, the Ugandan government is expanding PIASCY to secondary schools with the publication of handbooks for both students and teachers.  Two books have been drafted and are in the editing process.  Unlike at the primary level, the dissemination of PIASCY messages in secondary schools is to be done in the classroom and not at an assembly.  Various suggestions have been put forward that PIASCY be incorporated into existing classes such as Christian Religious Education or Biology, and/or included sporadically throughout lesson plans in a number of subjects. 

Partners involved in the editing of PIASCY secondary school materials told Human Rights Watch that factual information about masturbation, abortion, and homosexuality was at risk of being omitted because of vocal opposition against their inclusion by powerful groups.  Much as was the case in the primary materials, information on condoms, family planning, and abstinence-until-marriage is also contested.  Participants interviewed for this report said that some individuals or faith-based organizations who advocate abstinence-until-marriage and anti-condom positions are financed through U.S. churches and anticipated future funding through PEPFAR.  They suggested that these links to outside sources explained their recent empowerment.  In addition, they accused these groups of promoting abstinence not because it is a sound prevention strategy, but because this is the approach favored by both the U.S. government and U.S. fundamentalist churches that are fueling the growth of a Ugandan fundamentalist revival and more importantly, because funding is now being made available to Ugandan groups who promote abstinence.¹⁰⁰

Draft copies of PIASCY secondary school materials obtained by Human Rights Watch contain incorrect and misleading statements that, if finalized, would infringe children’s right to accurate information about HIV prevention.  For example, the draft texts for both students and teachers state that “condoms are not 100% perfect protective gear against STDs and HIV infection.  This is because condoms have small pores that could still allow the virus through.”¹⁰¹  In fact, laboratory tests show that neither HIV nor any STD pathogen can penetrate a correctly used latex condom of standard acceptable quality, and that using a latex condom to prevent HIV has been estimated to be 10,000 times safer than not using a condom.¹⁰²  These same drafts state, “Some statistics indicate that condoms have a less than 65% protection rate implying that reliance on them could mislead many youth into risky ‘unsafe’ sex.”¹⁰³  Beyond failing to cite where these statistics can be found, the drafts do not mention that epidemiological studies have shown that consistent condom users are in fact 80-90 percent less likely to become infected with HIV from sexual intercourse than non-users.¹⁰⁴  The books then instruct teachers that the best approach to sex and HIV/AIDS education is to show students the inefficiency of condoms, to demonstrate the “loopholes” of the condom, and to debate the benefits of abstinence.¹⁰⁵

The handbooks later encourage children, when they reach adulthood, to use condoms in marriage to prevent unwanted pregnancies and HIV/AIDS.  They even guide teachers to correctly demonstrate condom use in the classroom.  These messages, however, do not explain why condoms are encouraged for married adults as useful in HIV control but unsafe for unmarried adults or adolescents.  Nor do they explain why “small pores that could still allow the virus through” do not affect married couples.¹⁰⁶    

Another troubling aspect of the drafts is their emphasis on marriage as an institution that provides a measure of protection against HIV.  In Chapter Three, students are advised “to abstain from sex altogether until they are mature enough to get married.  Sex before marriage is not only breaking school rules, but against religion and norms of all cultures in Uganda, and having pre-marital sex is considered a form of deviance or misconduct by the persons involved.”¹⁰⁷  In Chapter Eight, under advice on the best approaches to sex and HIV/AIDS education, teachers are recommended to tell students to wait until marriage and to use marriage teachings to encourage youth to wait.¹⁰⁸  The texts contain no information on the number of Ugandans, especially women, who remain faithful until and during marriage only to contract HIV from their spouses.  There is no explanation as to why many Ugandans in their twenties test positive for HIV, by which time many are already married.¹⁰⁹

Secondary school students and teachers interviewed for this report agreed that more HIV/AIDS information provided at school through a PIASCY program would be beneficial, but only if that information were relevant to their life experience.  One history teacher told Human Rights Watch that students at his school were interested in learning how to use condoms correctly because some said they don’t know how.¹¹⁰  A seventeen-year-old student said:

Some young people are sexually active when they reach secondary school.  Many of my friends at school are having sex.  The condom information provided at [after-school HIV] clubs is useful because you might feel you want or are ready to play sex.  And when you are ready, you now know why and how to use a condom.¹¹¹

An HIV/AIDS training officer who holds meetings at secondary school clubs illustrated why providing information on correct condom use to youth was necessary.  At one school she visited, a government-funded religious school, the headmaster refused to allow information on condoms to be presented in the belief that it would promote sex.  After watching the trainer’s presentation and the many questions from students about condoms, sexual relations, and HIV prevention, however, the headmaster agreed that providing correct information on condom use was necessary for the safety of the students.  For this trainer, delaying sexual debut was an important prevention message that young people needed to hear, but it should not trump other equally important information.¹¹²

According to teachers and students in secondary schools visited by Human Rights Watch, some HIV/AIDS and sexual reproduction information was already provided in both biology class and a class entitled Christian Religious Education (CRE).  A religious education teacher said that he emphasized abstinence and the Bible when discussing sex and HIV.  He taught children to fear God and to avoid sex in order to remain safe.¹¹³  Students who had enrolled in CRE said that the focus rested on marriage as “God’s gift” and on the “sin” of premarital and same-sex relations.  HIV was presented as a curse on immoral people who engage in sex.¹¹⁴  As noted above, one proposal for integration of PIASCY at the secondary level is in CRE class.¹¹⁵

Abstinence programs out of school (including after-school programs)

A third part of the PIASCY initiative is to target children and young adults who are not receiving HIV/AIDS information in the classroom.  In coordination with the Uganda AIDS Commission, the office of the president conducts youth rallies in districts around the country with the aim of training youth leaders in HIV/AIDS awareness.  An official in the office of the president told Human Rights Watch that as of November 2004, seven rallies had been held throughout the country and eight more were planned.  Rallies are held at schools that can accommodate large numbers of participants during school holidays.  Youth leaders, out-of-school youth and students aged fifteen to thirty are invited to attend.  Roughly one thousand participants are invited, but as many as 2000 youth have attended.  Speakers at the rallies have included officials from relevant ministries, politicians, military officers, health care officials, religious leaders, and the president of Uganda.¹¹⁶

In interviews with Human Rights Watch, long-time AIDS activists supported the targeting of out-of-school children and youth leaders in rural districts as a way of further educating young people on HIV prevention.  But they questioned the applicability of the information provided at the rallies, with its emphasis on abstinence and its denigration of condoms—particularly as participants were largely men and women in their twenties who were already sexually active.  They equally raised concerns about the apparent blending of politics and HIV prevention in a way that may alienate those who do not support the president.¹¹⁷

A United Nations official familiar with the rallies said that the HIV prevention messages were little more than window dressing for delivering political messages to rural areas in support for Museveni’s bid for a third-term in office.¹¹⁸  An AIDS activist in Kampala said:

PIASCY rallies appear to be promoting an ideology as much as providing HIV/AIDS information.  The attendees and participants are clearly those interested in promoting a third term, not really youth leaders from the full spectrum of society.  I feel that the goal of PIASCY is very good.  The problem is that it tends to be associated with the personality of the president.  When this happens, it fails to be educational materials, but increasingly, [is] perceived as a political tool.¹¹⁹

This sentiment was echoed by numerous others.  An official in the office of the president told Human Rights Watch that the rallies sought to provide information to young leaders about HIV/AIDS and development.  But, she said, various officials from the government were available “to take questions about our government from the young people.”  She added:

We talk about the political transition, what is the process.  Young people have grown up in the movement system.¹²⁰  They need to understand what is happening now, they need to understand about the third term.  So, they are very enthusiastic to learn about the NRM-O [National Resistance Movement Organization] and the plans for the future.¹²¹

At one rally held in Arua in October 2004, during a session linking HIV/AIDS and good governance, the speaker stressed the achievements of the Movement system in fighting HIV/AIDS and warned that should there be a change in government, there may be an escalation of Uganda’s AIDS epidemic.¹²²  Youth were informed that the president’s pursuit of a third term stemmed from popular demand.  According to a summation of discussions held among young people at the rally, youth in attendance recommended, “The youth of West Nile Region join other citizens of Uganda in calling for…an open term limit for the Office of the President.”¹²³

At the same rally, various speakers informed participants that “condoms are becoming extremely unsafe, that is why emphasis is shifting to Abstaining and Be Faithful,” and “using a condom with a person with these [sexually transmitted] diseases is like using a parachute which opens only 75% of the time.”¹²⁴  Participants were also told that “sex should only be in marriage,” and that “there is an 80% chance of death during labour if one conceives below the age of 18.”¹²⁵

As with other PIASCY programs, providing misleading information on the efficacy of condoms, promoting marriage as a foolproof HIV prevention strategy, and proving false information on maternal mortality denies young Ugandans their human right to accurate health information.  Equally troubling is the apparent political motive of these rallies and their promotion of the movement system and the president’s strategy for a third term in office.  Ugandans have a right to choose their president and govern their country as they deem appropriate, but partisan political campaigning is not an appropriate use of public HIV/AIDS funding from Uganda’s or any other country’s treasury, quite apart from its lack of public health value.  In at least some districts and in the case reported above on Arua, PIASCY rallies are financially supported by the U.S. government through its implementing partners in Uganda.¹²⁶

The use of U.S. government funds, even inadvertently, to promote the political aspirations of a party or personality do not fall under the stated goals of PEPFAR to “promote integrated [HIV] prevention, treatment and care programs.”¹²⁷  PEPFAR funding for HIV prevention programs should neither be associated with politics nor used to further any purpose beyond the provision of effective information and services to the largest number of recipients possible.

Faith-based organizations promoting abstinence

Aside from programs provided under PIASCY, a number of nongovernmental and faith-based organizations in Uganda are increasingly receiving support from the U.S. and Ugandan governments to promote abstinence to youth.  Many of these faith-based organizations are represented by individuals or churches linked to fundamentalism, a rapidly growing brand of Christianity in Uganda particularly attractive among young people.  Approximately 60 percent of Ugandans are Christian; while the Catholic church the largest denomination, it has been estimated that 25 percent of Ugandans identify with fundamentalist churches.¹²⁸  The U.S. global AIDS strategy notes that “faith-based and community-based groups . . . have established excellent prevention programs in the [area] of abstinence promotion” and that “FBOs [faith-based organizations] are in a strong position to help young people see the benefits of abstinence until marriage and support them in choosing to postpone sexual activity.”¹²⁹  In December 2002, U.S. President George W. Bush issued an executive order establishing a Center for Faith-Based and Community Initiatives at the U.S. Agency for International Development, the purpose of which was to remove any obstacles to community and faith-based organizations’ participation in USAID programs and promote their involvement “to the greatest extent possible.”¹³⁰  A USAID-funded HIV/AIDS organization in Uganda told Human Rights Watch that in their application to USAID for PEPFAR funds, they were required to state how much money that they would sub-grant to local faith-based organizations.¹³¹

Uganda Youth Forum

Perhaps the best known abstinence advocate in Uganda is Janet Museveni, the wife of President Museveni.  Mrs. Museveni has been an outspoken advocate for virginity for many years and has described abstinence as the perfect blending of Christian teachings and traditional African values.  In 1991 Mrs. Museveni founded the National Youth Forum, an organization whose principal activity is to organize retreats in which boys and girls sign commitment cards to remain “sexually pure” until their marriage day.  According to the Youth Forum, more than 70,000 youth have signed these cards since 1992.¹³²

Coupled with Mrs. Museveni’s pro-abstinence stance is her anti-condom advocacy.  On numerous occasions, the first lady has publicly lashed out against organizations that support condom use for young people, arguing that these organizations promote sex among children.  She has claimed that condoms are not safe in preventing HIV and STIs and that she supports an exclusive message of abstinence and faithfulness for Ugandans.  As an HIV prevention strategy, she has called for a national census to determine the percentage of children and young adults who are virgins, the percentage who have practiced “secondary abstinence” (abstinence among those who have already been sexually active), and the percentage that are sexually active.¹³³

Uganda already collects national data on sexual behavior through its periodic U.S.-funded demographic and health surveys.  Mrs. Museveni’s extraordinary call for a national “virgin census” raises legitimate fears that young people will be pressured into disclosing confidential information about their sexual lives or, worse, that they will be forced to submit to intrusive medical examinations of their virginity status.  From a human rights point of view, virginity testing constitutes an infringement of the right to privacy, a form of gender discrimination when practiced predominantly among girls, and a violation of the right to bodily integrity.¹³⁴ 

Among the many criticisms of abstinence programs is that young people who “fail” to abstain will not be equipped with the information and tools they need to prevent HIV, other STIs and unwanted pregnancy.  A young woman who had attended a National Youth Forum event in the mid-1990s told Human Rights Watch that some of her peers who signed commitment cards were already sexually active.  As she put it:

There is real difference between the aims of the organizers [of the Youth Forum] and the aims of the youth who attend.  We would go to meet boys there. Our parents were strict. This [the Youth Forum] was a legitimate excuse to get out of the house and socialize with members of the opposite sex . . . . While there are some who remain virgins until they are married, I did not and neither did my friends.”¹³⁵  

Further, U.S. surveys suggest that young people who commit to virginity until marriage may be at higher risk of HIV than others because they are less likely to use condoms when they begin having sex or to get tested for STDs.¹³⁶

According to a representative of the first lady’s office, the Youth Forum is funded by foreign donors, and that “because of the Bush Administration’s support for abstinence, it has helped us a lot.”¹³⁷  An article published in World magazine in November 2004 alleged that Mrs. Museveni had received U.S.$3 million from the U.S. government to promote her abstinence and faithfulness programs.¹³⁸  Several U.S.-based nongovernmental organizations operating in Kampala also reported that the Youth Forum had been funded with PEPFAR HIV prevention money.¹³⁹  Human Rights Watch was able to determine that at least one USAID-funded organization in Uganda was sub-contracting the Youth Forum and that, with U.S. government support, the Youth Forum was developing abstinence materials to be distributed nationally.¹⁴⁰  In November 2004 the U.S. Office of the Global AIDS Coordinator approved a PEPFAR-funded abstinence-until-marriage grant to the Children’s AIDS Fund (CAF), a Virginia-based organization with close ties and an intention to sub-grant to the Youth Forum, despite the fact that a technical review panel had found CAF “non-suitable” for such a grant.¹⁴¹  Providing U.S. HIV/AIDS funds to the National Youth Forum—an organization that engages in religious proselytizing and conducts HIV prevention rallies with an explicitly Christian message—constitutes a possible violation of U.S. law.¹⁴²  The organization’s promotion of virgin censuses, in particular, raises serious health and human rights concerns.

Makerere Community Church

Another leading advocate of abstinence-only programs in Uganda and an author of the Uganda AIDS Commission’s draft “AB” policy is the founder and pastor of Makerere Community Church, Martin Ssempa.  Known for his charismatic brand of fundamentalist Christianity, Pastor Ssempa has, on various occasions, spoken out against homosexuality, condoms, Islam, and women’s human rights.  The community church’s student drop-in center on the campus of Makerere University, known as the White House, provides counseling, meetings, musical entertainment, and a “deliverance room” where students ostensibly possessed by Satan can “exorcise their demons.”¹⁴³ 

Speaking at an abstinence rally in December 2004, Pastor Ssempa reportedly stated, “We are promoting abstinence because Uganda is under attack from an agenda driven by homosexuals and Western experts.”¹⁴⁴  Ssempa has compared his fight against the Islamic faith in Uganda to the United States’ invasion of Iraq.¹⁴⁵  In late 2004, he called for re-baptizing the vice-President of Uganda whom he alleged to have made a covenant with a witchdoctor.¹⁴⁶

Human Rights Watch researchers made repeated requests to meet with Pastor Ssempa to discuss his HIV prevention programs for youth, but he said he was not available to meet with us.  We did, however, visit the “White House” and speak with several staff members.  According to the staff members, HIV prevention programs promoted by Ssempa promoted abstinence-until-marriage and a return to God’s values; they opposed condom use, sex outside marriage, homosexuality, and abortion.  The mission of the church, they said, was to train youth at elite universities today to replace leaders in secular governments with Christian fundamentalists.  Staff members said that Ssempa received considerable financial support from U.S.-based churches and American evangelicals.  In the week preceding the U.S. election in November 2004, members of Ssempa’s church reportedly were required to fast and pray for the victory of George W. Bush.  Staff members told Human Rights Watch that this was because Bush had a similar philosophy to their church and, more importantly, because they had been told by a prominent U.S.-based advocate for abstinence programs in Uganda that Bush’s re-election would guarantee them PEPFAR money for their prevention work with youth.¹⁴⁷  In part because Pastor Ssempa would not meet with us, Human Rights Watch was unable to substantiate claims of alleged PEPFAR funding to the Makerere Community Church.

Family Life Network

The Family Life Network is a private non-profit organization that since 2002 has provided “values-based” sex education to some 130,000 students in 400 Ugandan schools.  One of the main activities of the Network is to encourage students to sign “True Love Waits” cards, in which they pledge abstinence until marriage.  Since the network began working in secondary schools in 2002, 72,000 students have signed these cards. 

In an interview with Human Rights Watch, the executive director of the Family Life Network, Stephen Langa, stated that the four goals of the Network were to “bring back faith in the marriage institution,” to “show the dangers of sexual involvement,” to “warn children on the dangers of globalization, such as pornography,” and to “ask children to make a commitment to abstinence.”  These interventions, Langa said, were rooted in the notion that AIDS is a “moral disease” and that “as long as we use technological means to treat moral issues, we will lose many lives.”¹⁴⁸  The Network’s goal was “not just to prevent HIV,” Langa said, but “to have responsible citizens.  People who know hard work, people who plan.  People who are going to make good marriages and good families.”

Human Rights Watch asked Langa if he was aware of studies showing that students who pledged abstinence-until-marriage often broke their pledges and, in so doing, were often less likely to use condoms to prevent STDs.  “I’m not familiar with these studies,” he said.  “I can’t say there’s no failure, there must be some.”  He added that personal testimonies he had heard from students suggested that they took their pledges seriously and felt badly if they broke them.  Asked his position on the effectiveness of condoms against HIV, he replied inaccurately, “The failure rate of condoms used against HIV is 20 percent.”  He then presented a diagram comparing various cell sizes, including HIV, and argued that HIV was small enough to permeate microscopic pores in latex.  His main point was that abstinence is the only 100 percent effective method against HIV.  “When you get involved in sex with someone who is not your wife or your husband, you are stepping into a danger zone,” he said.  “You are driving on the wrong side of the road.  It’s just a question of when, not if, you’re going to have an accident.”

Asked how his organization advised gay and lesbian youth who could not legally marry, Langa responded that the Network did not condemn those who were victims of “vices” such as homosexuality, but that the organization would help them change if they were willing.  “If they can’t get married, let them abstain,” he concluded.¹⁴⁹

The Family Life Network is funded by both local and foreign donors, as well as individuals.  According to Langa, the Network received 76 million Ugandan shillings (U.S.$38,000) from the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria to provide educational and behavior change activities.  The Global Fund is a multilateral public-private partnership that takes contributions from wealthy nations and channels them through government-led “country coordinating mechanisms” in recipient countries such as Uganda.  The Network has reportedly received no money from the United States through PEPFAR but, according to Langa, are “exploring possibilities to receive funding from the U.S.”¹⁵⁰  Langa is also an author of the Uganda AIDS Commission’s draft “AB” policy.