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Am J Public Health. 2007 July; 97(7): 1184–1186.
PMCID: PMC1913074

Framing HIV Prevention Discourse to Encompass the Complexities of War in Northern Uganda

Michael J. Westerhaus, MD, MA, Amy C. Finnegan, MALD, Yoti Zabulon, MD, MPH, DTMH, and Joia S. Mukherjee, MD, MPH

Abstract

In northern Uganda, physical and structural violence (political repression, economic inequality, and gender-based discrimination) increase vulnerability to HIV infection. In settings of war, traditional HIV prevention that solely promotes risk avoidance and risk reduction and assumes the existence of personal choice inadequately addresses the realities of HIV transmission.

The design of HIV prevention strategies in northern Uganda must recognize how HIV transmission occurs and the factors that put people at risk for infection. A human rights approach provides a viable model for achieving this aim.

UGANDA, A COUNTRY THAT has demonstrated dramatic success in reducing national HIV prevalence, remains at the center of the current debate between the proponents of risk avoidance and harm-reduction strategies for the prevention of HIV transmission.1,2 In this debate, enormous energy and expenditures are invested in efforts that pit abstinence and behavior change against condom promotion. However, both strategies rest on the assumption that individual behavior and personal choice are to blame for HIV transmission. Neither strategy acknowledges that poverty, political instability, and gender inequality are driving forces in the epidemic.36 The experience of those living in northern Uganda, where HIV prevalence stands at nearly double that of the rest of the country, challenges the supposition that individual choice determines HIV transmission risk.7

NORTHERN UGANDA AND VULNERABILITY TO HIV INFECTION

For 21 years, northern Uganda has experienced a particularly brutal conflict between an insurgent group called the Lord’s Resistance Army (LRA) and the army of the Ugandan government.8 The war has been characterized by child abductions, frequent rapes, attacks on civilian camps, deliberate maiming, and ruthless killings. Three unique exigencies of the war in northern Uganda make traditional HIV prevention programs ineffective: the mass abduction of children into the LRA, the phenomena of night commuting, and the existence of internally displaced people’s camps.

First, child abductions create increased vulnerability to HIV infection among the young. During the war, more than 66000 children have been abducted to fight as soldiers or serve as sex slaves.9 Males abducted into the LRA are coerced through physical violence to use rape as a weapon of war, and many of the girls are forced into sexual slavery as “wives” to LRA commanders, with some eventually contracting HIV.

Second, tens of thousands of “night commuters,” most of whom are children, flee the insecurity of their communities each evening and traverse northern Uganda unsupervised to seek safety in hospitals and city shelters.10 These children are often sexually victimized, and even when the sexual activity is consensual, it often occurs at an early age and without the benefit of information about safe sexual practices. This reality creates an environment ripe for HIV transmission.11 (Currently, because of a cessation of hostilities while the government and the LRA are negotiating peace, the number of night commuters has dramatically fallen. However, night commuting has been a factor that has contributed to HIV vulnerability.)

Third, the 1.8 million people currently living in internally displaced people’s camps are vulnerable to HIV infection because of both insecurity and severely limited economic opportunity. Women who tend crops and collect firewood on the perimeters of the camps are frequently attacked and raped by both Ugandan soldiers and members of the LRA.12 Additionally, women are frequently driven to transactional sex (i. e. providing sexual services for money) in order to provide for their children and attain the means to provide educational opportunities for their children.

EXPANDING THE FRAME OF HIV PREVENTION

The sole promotion of traditional forms of HIV prevention (abstinence, behavior change, and condom prevention) will not reduce the prevalence of HIV in northern Uganda. The unique and interconnected realities of child soldiers, night commuters, and the internally displaced people’s camps that entangle the population in a dangerous web of physical and structural violence (i.e., political repression, economic inequality, and gender-based discrimination, structures that disadvantage certain populations) must be accounted for to design successful HIV prevention programs.

Condom promotion does not adequately minimize HIV transmission for women and children who are raped by members of the LRA and government soldiers, because women in this situation lack power to negotiate condom use. Furthermore, condom promotion programs fail to protect women who have limited negotiation power and are driven into transactional sex to meet basic living necessities. Abstinence and behavior change strategies ignore how poverty and war strip individuals of personal choice essential to avoid HIV transmission. Although some may argue that individuals never lose personal agency—the ability to affect one’s surroundings and personal relationships in a manner consistent with personal desires—the situation in northern Uganda demonstrates that settings permeated by war and poverty obstruct the expression of such agency.

Given the context of conflict in northern Uganda, it is imperative that efforts to prevent HIV transmission expand beyond traditional risk avoidance and reduction strategies to include the need for personal, political, and economic security in such communities. Child soldiers, night commuting, and life in the internally displaced people’s camps create widespread vulnerability to HIV infection in northern Uganda. To reduce HIV transmission in this region, the social and political forces that underpin risk must be understood, a task that rests on attentiveness to the local and global contexts. A human rights approach to HIV prevention promotes recognition of the ways in which a lack of basic social and economic rights—including the right to food, shelter, health, education, and economic opportunity—augment HIV risk significantly in northern Uganda.

With a human rights approach in mind, it is clear that poverty eradication and income-generation activities are essential for effective HIV prevention among women in internally displaced people’s camps, where livelihoods are severely limited or nonexistent. If options for income generation existed, women could avoid transactional sex as a means for meeting basic human needs, thereby diminishing their risk of HIV infection. Furthermore, HIV prevention programs must also target men. In northern Uganda, displacement has compromised male gender roles, creating frustration that manifests itself in violence against women.13 HIV prevention programs must acknowledge these realities and attempt to counter this violence by working with men to reshape their gender roles in ways that are acceptable to both men and women.

TOWARD A HUMAN RIGHTS APPROACH

Further, Uganda and countries with significant influence in East Africa, such as the United States and Great Britain, must focus on interventions that provide real security for vulnerable populations, such as the deployment of peace-keepers and the establishment of well-protected centers of education, health care, and shelter, which will decrease not only HIV risk but also the overall morbidity and mortality in the region. Conflict resolution and peace advocacy efforts must also form a critical component of strategies to reduce HIV transmission in northern Uganda, because resolution of the war will diminish the social pressures that contribute to HIV transmission. Such interventions will require significant funding, a collective responsibility of the United Nations, wealthy countries, the Ugandan government, and both local and global nongovernmental organizations.

These lessons from northern Uganda’s experience have applicability on a global scale, particularly in conflict settings where risk of HIV infection clearly extends beyond individual choice.14,15 Without understandings of local contexts and the impact of global forces upon those contexts, HIV prevention efforts risk failure on a grand scale. A rigorous incorporation of social, political, and economic context into HIV prevention strategies promises a new dawn in curbing HIV transmission.

Figure 1
Internally Displaced Peoples Camp in Northern Uganda 2004. Photo courtesy of A. C Finnegan.

Acknowledgments

We would like to thank the staff of both Lacor Hospital and Human Rights Focus in Gulu, Uganda, who facilitated the research and provided critical insights. We are also grateful to the staff of Partners in Health who provided useful commentary on the ideas presented here.

Human Participant Protection
No approval was required.

Notes

Peer Reviewed

Contributors
M. J. Westerhaus originated the study, participated in the analysis, and led the writing. A. C. Finnegan assisted with the study, participated in the analyses, and contributed to the writing. Y. Zabulon supervised the research and assisted with the analyses. J. Mukherjee helped to conceptualize ideas, interpret findings, and review drafts of the article.

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