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Unlike many developing nations struggling with a high burden of HIV, Uganda is failing to reduce its prevalence. Despite over 750 million dollars in aid money each year from the United States government, which focuses largely on infectious disease, the spread of HIV continues to plague vulnerable communities throughout the country. The virus truly does not discriminate—both rural and urban, poor and rich, young and old. An influx of affordable anti-retroviral therapy (ART) therapy, mostly provided by aid programs such as PEPFAR, has reduced the imminent death sentence previously associated with the virus. However, better medication has its own implications. Those living with the virus now are living longer and healthier lives. This allows for both hope and increased opportunity for transmission.

After various trips into the field, in which I visited ART clinics found across rural Uganda, I am able to draw on a few conclusions on why the spread continues to persist. My job allows me to promote the ABC’s of prevention: A is for Abstinence. B is for Be Faithful. C is for Condoms. However, in a country where the average fertility rate per women is over 6 children, the acronym seems to be an unrealistic solution in effectively curbing transmission. Instead, I offer the ABC’s of HIV transmission.

A is for apathy. This can be a debilitating force when it comes to changing human behavior. Some beneficiaries simply do not understand the importance of adhering to daily medication for them and their children. I work with HIV affected mothers, and have experienced a myriad of attitudes regarding providing medication to their kids, even though the drugs are free. Many mothers will stop providing preventive ART to their babies once a child receives a negative result, or fail to test themselves during pregnancy. Such instances can lead to pediatric transmission through birth or subsequent breastfeeding. In one instance, a mother brought her child to a clinic, nearly dead and severely malnourished. When asked why she didn’t provide the child with medication, she simply stated that if it was God’s will for the child to die, the child should die. Such indifference is very dangerous. HIV transmission should be a concern for positive mothers. New medications have made the condition manageable, but they also have reduced the fear in the general population regarding the virus.

B is for Being Discordant. Discordant couples are couples in which each partner has a different HIV status. This causes transmission between partners in a relationship, a major reason for Uganda’s high prevalence. For those who know their status, they may be scared to share their status with their partners. Women may fear a rise in domestic violence if they are positive and their male partners are not. At ART clinics, women often are scared to involve their male partners in Prevention of Mother to Child Transmission (PMTCT) services due to this. Furthermore, the status of each partner is commonly not known. Stigma continues to be a big barrier in getting tested. Communities are small and individuals do not want to be seen at an ART clinic. Those who have affairs outside their relationships are scared of what their test results might say and how that might affect their relationship.

C is for countless. I asked my driver how many kids he had. His response? A Ugandan man cannot count how many kids he has. A women can count. But a Ugandan man can count how many wives he has. The more wives and children, the better. Given, this is a particularly antiquated opinion, but the patriarchal, polygamous culture found in Uganda is fostering an environment for HIV transmission. It is common for both men and women to have “side dishes,” or individuals they date outside of their marriages. With multiple partners in short periods of time, in areas of high HIV prevalence, each night out without a condom is playing Russian roulette. Even radio and billboard public health campaigns highlight the importance of getting tested when “you don’t know where he’s been last night.” Infidelity, prostitution, and promiscuity all exacerbate the endemic.

In order to successfully combat HIV in Uganda, the ABC’s of transmission need to be addressed. This requires an open dialogue and systemic support. There needs to be sex education at early ages in order to instill a healthy fear of the virus and its spread. Couples should be encouraged to get tested together out of respect for their partner’s safety, and ART healthcare workers should incentivize women to bring their male partners. As for addressing deep cultural changes regarding the role of men, women, and monogamy, this will be difficult and take time. However, that doesn’t mean it is not a fight worth fighting. In order to effectively combat the spread of HIV in Uganda, the push must come from the community. The tools and the materials are already developed and fairly available, but they require adequate support to community health workers and education campaigns to change community attitudes. Each life lost to HIV is preventable and the time is now to create lasting results.