people against the disease, to talk about it candidly, and to use multiple approaches toward education and building awareness. Uganda’s success was dependent on the individual actions of people who followed the ABC (abstain, be faithful, use condoms) message that became famous by the end of the 1990s, but such individual decisions depended in turn on a broader set of social and structural changes that involved communities in the response to the epidemic, worked to reduce the stigma of living with and speaking about AIDS, and encouraged women and youth to organize and address the different ways in which the epidemic affected certain groups.61
By the year 2000, the broader set of structural changes that had accompanied HIV prevention success were overshadowed by a narrowed focus on individual accountability and self-control as primary tactics of disease management. Behavior change reflected the rhetoric of the neoliberal reforms of this new era, privileging values like autonomy and self-sufficiency. Yet as I have briefly outlined here, a drive toward self-control had not always been the dominant message regarding HIV/AIDS in Uganda. As the nation’s success circulated to the global level in the late 1990s, the story of its precipitous drop in HIV prevalence was applied as support for a broader U.S. political agenda that sought to emphasize the correlation between compassionate aid and the redemptive possibilities of personal accountability. Thornton recounts how USAID officials who had sponsored his research in an effort to prove that behavior change was the root of Uganda’s success became dissatisfied when his work argued instead that abstinence had not been a key component of Uganda’s early program.62 By 2003, when PEPFAR was introduced, the narrative of Uganda’s success had become contested terrain as various stakeholders sought to redefine why and how behaviors changed. This was nowhere more apparent than in the discussions that surrounded the initial funding of PEPFAR.
Ugandan Behaviors and U.S. Congressional Debates over PEPFAR
During the U.S. congressional debates that preceded PEPFAR’s funding, Uganda’s prevention strategy and the reasons for its success were strongly contested along political lines, with Republican lawmakers and Bush administration officials emphasizing the importance of abstinence and marital faithfulness to Uganda’s ABC strategy and Democratic lawmakers resisting this characterization of Uganda’s success. Testimony before the Senate and House subcommittees charged with addressing the new initiative demonstrated how Ugandan prevention policies were refracted through U.S. political and cultural divisions, leading to the program stipulations outlined in the 2003 legislation that funded PEPFAR. In one of the first of these meetings Representative Lois Capps, a Democrat from California, and Shepherd Smith, an American missionary with ties to the Bush administration, each framed Uganda’s success quite differently.63 Capps emphasized the integrated approach of Uganda’s program and noted that abstinence alone had not been effective in Uganda, noting, “Reports from USAID and U.N. AIDS indicates [sic] that comprehensive and community-based approach to HIV/AIDS prevention works best. The fundamental goal of these public health interventions is to change behavior and it appears that Uganda’s use of integrated behavioral change programs has had remarkable success. There is also no evidence that abstinence works alone. There is no data that sufficiently reports abstinence only rhetoric as causally decreasing rates of HIV/AIDS in Africa.”64 Smith—who, with his wife Anita, had founded a Christian NGO in Uganda—directly responded to Capps’s comments, challenging her emphasis on an “integrated behavioral change” strategy: “I think that it’s important to remember that this isn’t ABC in the context that we think of comprehensive sex here in America. It’s very targeted. It’s abstinence to kids. It’s be faithful to those in marriage or in monogamous relationships and it is [condoms] to very targeted communities such as the bars and the prostitutes and so on. So it is ABC, but it’s not all lumped together. It’s very segmented, [myself] having been there and looked at it very carefully.”65 In the years before PEPFAR, Ugandan AIDS programs were to a certain extent targeted toward certain populations and goals; many of these programs were developed and coordinated at local levels to address particular community concerns. But the sort of fracturing and policing of boundaries that Smith mentioned only became evident in the wake of PEPFAR’s implementation; for example, it was in 2004 that Museveni removed any mention of condoms from school sex-education curricula.66 As I discuss in the following section, in the wake of PEPFAR, U.S. efforts to categorize programs in order to evaluate them for funding established a new emphasis on the boundaries between distinct program areas, such as “condoms and related activities” and “abstinence/be faithful.”67 Smith’s statements foreshadowed, rather than reflected, what was to become a much more fractured approach to AIDS care in Uganda.
Representatives of the Bush administration brought up Ugandan “culture” as justification for the abstinence and faithfulness focus of PEPFAR, often in surprising ways. Dr. Anne Peterson, the director for global health at USAID in 2003 and, by her own account, a former “missionary doctor in Africa,” noted in testimony that “being faithful [to one partner] is a strong cultural norm that resonated strongly in Uganda and, from my own experience, I know it resonates also in many other African countries.”68 Many Ugandans would question this evaluation of Ugandan cultural norms or at least seek clarification of what “faithfulness” meant in the context of Peterson’s speech. Long-term concurrent sexual partnerships (maintaining more than one regular sexual partner at one time) have in fact figured prominently in epidemiological explanations for Uganda’s high HIV prevalence rates.69 Peterson’s comment also downplays the important distinction between Uganda’s locally developed programs—the most famous of which, “zero grazing,” targeted a reduction in the number of sexual partners—and PEPFAR’s faithfulness message. The terms used during the congressional debates highlighted the difficultly of transposing and translating program guidelines cross-culturally. And in several cases they revealed surprisingly superficial characterizations of Ugandan culture and sexuality, rarely emphasizing the historical and social complexity of AIDS prevention in the country.
Most depictions of Uganda’s program in the congressional record rightly focus on the issue of behavior change, but too often, as in the exchange between Capps and Smith, the debate came down to how important abstinence and faithfulness alone had been to Uganda’s success. Uganda’s far more nuanced and dynamic ABC program—integrating a variety of culturally relevant messages and dependent upon broader political and structural transformations—was lost in these discussions.70 In Republican testimony, behavior change came to be limited to two specific behaviors—being faithful and abstaining—that were familiar and appealing to conservatives in the United States but that on their own failed to encompass the broader set of strategies and social and political shifts that had enabled successes in HIV prevention in Uganda. Behavior change came to represent personal responsibility for one’s self, a discussion that was infused with references to Ugandan “tradition” and thinly veiled acknowledgment of Uganda’s conservative religious and political environment.
In the debates over PEPFAR, Uganda’s program was made the fodder for a particularly American political struggle—though one with global implications. Even so, this was not a battleground from which Ugandans were disengaged. American politicians sought out information about the Ugandan program in preparation to draft their own, and Ugandan First Lady Janet Museveni even traveled to Washington, DC in 2003 to help Republicans lobby for the dedicated abstinence funds in the PEPFAR legislation.71 By 2003, several high-level Ugandan government officials publically supported an emphasis on abstinence, especially for programs targeted to teenagers and schoolchildren. Janet Museveni, a convert to born-again Christianity, made the abstinence message a cornerstone of her agenda, spearheading youth abstinence programs through her office and, on World AIDS Day 2004, advocating a “virgin census” to encourage youth to remain chaste.
President Museveni and the First Lady were quoted in testimony during the U.S. congressional PEPFAR debates espousing a strongly proabstinence stance regarding sexual behavior in Uganda, with frequent references to the importance of self-control in the prevention of HIV infection.72 This was not in itself surprising or new; there had always been competing claims to moral authority in the debates over HIV/AIDS in Uganda. Male elders claimed “tradition”
