UGANDA: A Study in Transitions and the Emergence of HIV/AIDS

1. UGANDA:A Study in Transitions and the Emergence of HIV/AIDS Mark Schmidt NRE 545 November 24, 1998

2. Outline • Why study Uganda? • The HIV/AIDS Epidemic • Worldwide • Uganda • Transitions and the Emergence of HIV/AIDS • Historical/Political • Urbanization/Industrialization • Theories of HIV Emergence • Transitions and the Impact of HIV/AIDS • Population • Family Structure • Conclusion

3. Why Study Uganda? • Origin of the HIV is thought to be the Lake Victoria region of Africa. • undetected for 20-30 years • brought from low endemnicity areas into central areas • Population/environment dynamics may have caused emergence of HIV/AIDS • Historical/Political • Urbanization/Industrialization

4. Epidemiology of HIV/AIDS • Recognition of a new disease • United States - 1981 • Retrospective Studies • Europe - 1976 • Africa - late 1950’s • 30.6 Million Infected at end of 1997 • 11 people infected per minute • Sub-Saharan Africa • 10% of World’s Population • 2/3 of HIV/AIDS Cases

5. Epidemiology of HIV/AIDS

6. HIV/AIDS in Uganda • Prevalence • 930,000 infected individuals • 9.51% prevalence rate in adults (15-49) • 1,900,000 cases since beginning of epidemic • 80% of cases in 15-45 age group • AIDS Mortality Burden • Leading cause of adult mortality • 1/2 of all mortality • 1/3 of mortality from infectious diseases • Transmission • 90% by heterosexual sex • Vertical transmissionalso important • Gender Differences • 1:1 Overall Male to Female Ratio • Females 15-19 - 6 times more likely to be infected • Leaving large orphan population • Increased vertical transmission

7. HIV/AIDS in Uganda

8. Transitions and the Emergence of HIV/AIDS

9. Historical/Political Transition • Pre-Colonial Period • No national boundary • Diverse tribes and kingdom monarchies • Buganda most powerful • Acholi and Lango • Ugandan Protectorate • 1898 Treaty with Buganda • Force, threat of force, and peaceful alliances for other tribes & kingdoms • Imperial (national) boundary established

10. Historical/Political Transition

11. Historical/Political Transition • North/South Dichotomy • South in Transition • Buganda located in fertile area • People receptive to British colonialism • Agriculture was expanded; cash crop system instated • Kampala established as commercial center • Indians recruited to lead economic class • Main trade routes developed • Educational transition • North stagnant • Arid land • People unreceptive to British colonialism • Agriculture was prevented • Lack of developed infrastructure • No educational transition • Recruitment of Northern tribes into military

12. Historical/Political Transition • Ugandan Independence • 1962-Milton Obote becomes leader • Continued British Policies • 1966-Kingdoms abolished • Obote became unpopular in the South • 1971-Obote overthrown by Amin - Eight Year Reign of Terror Begins • Amin expels Indians in 1972 • Destroys economy and foreign confidence • Removes commercial and industrial class • Sends industrial, agricultural, and urbanization transitions backwards • 1979-Amin overthrown in coup/war with Tanzania

13. Urbanization Transition • Migration was the direct result of British Colonialism • Domestic Migration • Male • Female • International Migration

14. Urbanization Transition: Domestic • Male migration • Agricultural Push • Land originally owned by families • Families grew and resources diminished • Young men left to reduce food burden on family • Labor Pull • British policies caused labor demand in South, especially in agriculture, and labor supply in North • Social Pull • Young men encouraged to make money in cities and return with wealth to villages • Result: Initial one-sided bulge of men into cities • Female migration • Economic Pull • Women not encouraged to migrate • Due to economic necessity • Most forced into commercial sex work

15. Urbanization Transition: International • “Asian” recruitment • British brought in Indians to run commerce • Indians comprised elite sector • Result: • Urbanization brought people to cities • Increased density, anonymity, and increased female sex work led to change in sexual behaviors

16. Theories of HIV Emergence • The historical/political and urbanization/industrialization transitions provide a context in which hypotheses of HIV/AIDS emergence occurred. • Three Hypotheses • Migrant Worker Hypothesis • “Truck-Town” Hypothesis • Military Involvement Hypothesis

17. Migrant Worker Hypothesis • Emergence as a result of population movement in search of labor • Urbanization created a population that amplified HIV infection • female sex workers • young male professionals • due to British policies & urbanization of 1950-60’s • Return migration brought HIV to villages • due to economic collapse during Amin dictatorship • Study of Migration and HIV Infection (Nunn, 1995) • 5.5% Prevalence among those who had not moved • 8.2% - moved within a village • 12.4% - moved to neighboring village • 16.3% - those joining cohort

18. Truck-Town Hypothesis • Accounts for spread of HIV outwards from Kampala • Occurred mainly during the Amin reign in 1970’s • Use of roads increased - encouraged by Amin • Smuggling increased dramatically • HIV Spread outwards along principle corridors of trade/smuggling traffic • Towns developed along routes • Female commercial sex work soon followed into towns • Truckers and commercial sex workers became driving core population of HIV infection • 35.2% of truck drivers infected with HIV

19. Military Involvement Hypothesis • Accounts for high seroprevalence in northern tribes (Lango & Acholi) • Specifically due to 1979 overthrow of Amin • Obote loyalists from these tribes recruited into Ugandan National Liberation Army (UNLA) • Fought in South • used commercial sex workers • Returned to North with infection • Shows positive statistical significance which cannot be accounted for by either migrant worker or truck-town hypotheses

20. Transitions and the Impact of HIV/AIDS

21. Population Transition • Uganda • 20,791,000 current population • 3.2% growth rate 1980-1995 • Sub-Saharan Africa • 3% increase per year • 1 billion people by 2025

22. Population Transition

23. Population Transition • HIV/AIDS and Mortality • Direct Effect of HIV on Mortality • 1.5 million additional deaths attributable to HIV by 2025 • Reduction in population growth • In Rakai: • high prevalence parishes have negative pop. growth in 1990-1995 • effects muted at district and national level • 0-4 age rage smaller than older cohorts • Indirect Effects • smaller youngest age range will cause lower birth rates as this cohort ages to reproductive age • HIV/AIDS will shift to younger age ranges • HIV/AIDS and Life Expectancy • Current life expectancy is 41 • 5 year drop

24. Population Transition

25. Family Structure Transition • Traditional Family - Clan • Emphasis on continuity of clan network • Made up of common ancestor and common totem under single residence • Principle unit of economic productivity • need for many offspring • Socialized young members • influenced behavior • social welfare • Support system in times of sickness and death • orphans taken in by extended family, especially grandparents • Modern Family • Nuclear/conjugal families • Minimal influence on behavior • Minimal support

26. Family Structure Transition • Traditional/Modern Family Conflict • Residence • Conjugal families cannot absorb multiple deaths • Nearby extended family unwilling/unable to help • Traditional family structure called upon • Socialization • Families feel AIDS is due to a behavior; won’t help/acknowledge members in need • stigma attached to disease • Social welfare is disrupted • Most productive members are removed • Grandparents must take care of orphans and provide for themselves

27. Family Structure Transition • Support • 1.2 Millions AIDS orphans • 38% taken by grandparents • 7% by aunts • 5% by uncles • 5% by sisters/brothers • 2% by children under 16 • Family Unit still is main source of support and care for most Ugandans

28. Conclusion • The Epidemiologic Transition of HIV/AIDS has had an incredible effect on Uganda. However, understanding cannot be fully realized without also analyzing the concurrent transitions that have led to the emergence of HIV as well as those that are impacted by it.