Sexual behaviors leading to the decline of HIV prevalence in Uganda – confirmation from multiple sources of evidence

Background: HIV continues to infect many people in generalized AIDS epidemics in Sub-Saharan Africa. Of all countries with generalized epidemics, Uganda achieved the greatest reduction in HIV prevalence in the early 1990s. This study sought to identify the changes in sexual behavior that led to this dramatic reduction.

Methods: We collected and examined eight different types of evidence: 1) models of HIV prevalence and incidence data in Kampala and other sentinel sites in Uganda, 2) reports of behavior change in the primary newspaper in Uganda, 3) large demographic and health surveys collected in 1988/9 and 1995 and large Global Program on AIDS surveys in 1989 and 1995, 4) smaller, less representative surveys of sexual behavior, 5) surveys with questions about personal behavior change, 6) interviews with key informants and focus groups, 7) reports of numbers of condoms shipped to Uganda, and 8) historical documents describing the implementation of HIV prevention programs in Uganda.

Results: All eight types of evidence produced coherent and compelling evidence that people in Uganda first reduced their number of sexual partners outside of long-term marital or cohabitating relationships and then increased their use of condoms with non-marital and non-cohabitating partners.

Conclusions: Consistent with basic theories about transmission of sexually transmitted infections, first reducing the number of sexual partners and then reducing the chances of HIV transmission with casual partners by using condoms can be achieved and can dramatically reduce the sexual transmission of HIV in generalized epidemics.