The United States government recognizes that a healthy population is the foundation for a country’s social and economic development.
Almost 20 years ago on January 28, 2003, while announcing the President’s Emergency Plan for AIDS Relief (PEPFAR), then U.S. President George W. Bush said, “We must remember our calling, as a blessed country, to make the world better.”
Four months later, Congress authorized the first $15 billion with overwhelming bipartisan support that has increased to this day. And a Ugandan man was the first person in the world to receive PEPFAR-support HIV medication the following year.
I had the pleasure to meet him last year. He’s now a parent, a preacher, and a teacher and raising awareness in his community.
It is from this foundation that the U.S government invests over $500 million in Uganda’s health sector every year — the bulk of which goes to supporting HIV programs through PEPFAR.
Through the collective work of U.S. government agencies, including the Departments of State and Defense, the U.S. Agency for International Development, the U.S. Centers for Disease Control and Prevention, and others, we support Uganda’s HIV response programs with a focus on HIV prevention through the elimination of mother-to-child transmission, voluntary medical male circumcision, the DREAMS program for adolescent girls and young women, provision of pre-exposure prophylaxis, and implementation of care and treatment services, including managing TB co-infections and screening for cervical cancer.
In fact, my very first trip outside of Kampala back in 2020 was to Masaka to announce the expansion of the DREAMS program there. I still think back to the conversations I had with some of the young women, and the positive changes they saw in their lives because of the program.
This fiscal year (2023), the PEPFAR Country Operation Plan budget for Uganda is $400,200,000 or about 1.5 trillion Uganda shillings. This commitment reflects support for equitable HIV prevention and treatment and care services across the nation, implemented through strategic investments deemed critical for the country’s progress toward controlling the epidemic through collaboration by the PEPFAR team, the Government of Uganda, civil society, and other development partners.
Last year, PEPFAR introduced a clear requirement that there must be evidence of progress toward advancement of equity, reduction of stigma and discrimination, and promotion of human rights to improve HIV prevention and treatment outcomes for adolescent girls and young women, for key populations such as men who have sex with men, transgender people, sex workers, people who inject drugs, and people in prisons and other closed settings, and for other vulnerable groups.
HIV-related stigma, discrimination, and violence reduce access to essential health services and undermine efforts toward effective responses to HIV. In contrast, inclusiveness, equal treatment and respect for all, along with evidence-based policies and practices that reflect those principles, all facilitate access to essential health services and bolster effective responses to HIV.
The UNAIDS 10-10-10 targets require focus on removal of societal barriers, including legal barriers (specifically stigma, discrimination, punitive policy environments, and violence) that limit access to or utilization of HIV services.
Notably, President Biden issued the Memorandum on Advancing the Human Rights of Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Persons (LGBTQI+) around the world, which includes directives to U.S. government agencies to ensure that United States diplomacy and foreign assistance promote and protect the human rights of LGBTQI+ persons.
This includes expanding ongoing efforts by agencies involved in foreign assistance to promote respect for the human rights of LGBTQI+ persons and advance nondiscrimination.
Fostering a hostile legal environment and creating more legal barriers would worsen the HIV epidemic in Uganda.
In contrast, implementing solutions to the gaps identified in the recently launched Legal Environment Assessments, which were led by the Government of Uganda and supported by PEPFAR, would keep Uganda on the track to achieving President Museveni’s directive to end HIV/AIDS as a public health threat in Uganda by 2025.
Last year, the theme of the national commemoration event for the Candlelight Memorial was “Freeing workplaces of stigma and discrimination,” and earlier this year, the theme was focused on stigma and discrimination yet again.
I would like to re-emphasize the need to keep this as part of our conversations—but it must be more than a conversation. After almost four decades of death in the shadow of stigma and discrimination, HIV-related deaths have decreased.
This is because we have extended antiretroviral therapy (ART) to so many Ugandans. Still, stigma and discrimination remain, playing significant roles in new HIV infections and preventable deaths.
It is time for all of us to match our words with actions. But to do so, we must turn the conversation to what we are not talking about and what we are not doing, to acknowledge the things that need to change, and to make a deliberate choice to take action.
Our conversation needs to become about conscious decisions, who gets to make them, and who doesn’t get to make them due to gender disparity, stigma and discrimination driven by a lack of knowledge and understanding. Preventing HIV, knowing your status, and choosing lifesaving HIV treatment should be a deliberate choice for everyone, but for many, it is not.
PEPFAR seeks to address the gender equity gap by optimizing curriculum-based interventions to address specific needs of adolescent girls and young women (AGYW).
The use of evidence-based interventions such as Stepping-Stones, No Means No, Coaching Boys into Men, and Grassroot Soccer supports reducing gender-based violence by educating young people on the core components of healthy relationships and HIV prevention. Sinovuyo teaches parents and adolescents how to communicate in a healthy way and have important discussions around health and sexual relationships.
And SASA!, an intervention developed here in Uganda and used across the world, is aimed at addressing the balance of power between men and women, and of special note, it shapes the equity agenda and reshapes social norms and behaviors related to gender-based violence within communities.
Developed with a combination of theory, practice and relentless optimism, SASA! encourages communities around the world to personally and collectively use our power to create safe, violence-free communities for women.
PEPFAR also provides life-saving person-centered HIV services through local Ugandan partners, such as Baylor and Rakai Health Sciences Program, to ensure people remain on continuous HIV treatment, which includes ensuring the most effective HIV treatment regimens are used and that we remove all barriers to care and maximize convenience and responsiveness to people’s needs and preferences.
Through implementing partners such as Mildmay Uganda, which provides comprehensive HIV prevention, care, and treatment services in the Mubende region, we have leveraged the PEPFAR platform to rapidly support the Ministry of Health Ebola response in the areas of infection prevention and control and surveillance including community-based contact tracing to interrupt Ebola transmission.
Additionally, PEPFAR will implement a two-pronged approach that addresses health-related stigma and discrimination at the facility level and enhances community-level enablers. In health care facilities, we continue to train health care workers on Gender & Sexual Diversity and have designated Key Population Focal Persons at all health facilities.
We have maintained collaboration between healthcare providers and Civil Society Organizations (CSOs), and utilize Community-Led Monitoring findings to refine our program. We will continue to empower civil society to advocate for legal reform and access to legal systems.
PEPFAR Uganda earmarked funds (more than $750,000) to be sub-granted to KP CSOs through our comprehensive regional partners. In addition, nationwide efforts to build the capacity of CSOs in legal and policy review, grants and human resources management, and other priority areas are ongoing.
PEPFAR will utilize the findings from the Legal Environment Assessments to help shape and inform legal advocacy and policy reforms related to stigma and discrimination.
We also recognize that the HIV pandemic does not affect children the same way it affects the adult population.
According to UNAIDS, in 2021, globally 81% of pregnant women living with HIV and 76% of adults with HIV overall were receiving HIV treatment, while only 52% of children (0-14 years) living with HIV were accessing treatment.
We need to acknowledge the impacts of stigma and gender-based violence that have interfered with many mothers receiving PMTCT services.
This was reinforced for me on a visit to Oyam district, where I met youth peer leaders who told the story of an 18-year-old pregnant woman who tested positive for HIV. Because of stigma, and fear of being shunned by her family and future husband, she was apprehensive about getting on treatment and disclosing her status, despite the consequences for herself, her unborn baby, and fiancé.
Fortunately, the peer leaders are deeply engaged and if their commitment is any indication of success, this woman will have disclosed and embraced treatment.
Through PEPFAR, the United States government is working with the Uganda Ministry of Health and Uganda AIDS Commission to implement impactful innovations to close program gaps in both the prevention of mother-to-child transmission (PMTCT) and pediatrics programs through the umbrella initiative, Accelerating Progress in PMTCT and Pediatrics.
In this fiscal year, the U.S. government has allocated over $30 million to meet clients where they are and with the care they need through dedicated health workers for children and mothers, implementation of evidence-based interventions, and management of a responsive, precise monitoring system.
Furthermore, the U.S. government is investing in local Ugandan partners to minimize the impact of HIV on Orphans and Vulnerable Children (OVC).
Although the rate of orphaning due to AIDS continues to decline with the expansion of HIV treatment, significant risks and vulnerabilities remain for infants, children, and adolescents because of HIV.
To address these issues and ensure equity, PEPFAR’s OVC program increasingly works through Ugandan non-governmental organizations to deliver child-centered and family-based services to ensure that children, adolescents, and their caregivers have the resources and skills needed to confront the challenges of the HIV/AIDS epidemic and fulfill their own health and well-being needs.
With a budget allocation of over $24 million this year, the OVC program is reaching over 490,000 Ugandan children, adolescents, and their families providing health, education, child protection, and economic empowerment services. The program also supports gender-based violence prevention for boys and girls through positive parenting and life skills interventions, as well as the school-based prevention curriculum, Journeys Plus.
These interventions, delivered by Ugandan NGOs who have decades of experience, reach children where they are and help create safer homes, schools, and communities where they can thrive.
Finally, in alignment with efforts by the U.S. government to support diversity, equity, inclusion, and accessibility, as well as to advance equity for underserved communities and prevent and combat discrimination or exploitation on the basis of race, religion, gender identity or sexual orientation, PEPFAR will work to ensure that these principles are upheld, promoted, and advanced in all PEPFAR programs and in how we do business.
We look forward to continuing our partnership with Uganda to work to end stigma and discrimination, advance gender equality, and to end HIV and AIDS in Uganda.