UGANDA: A Study in Transitions and the Emergence of HIV/AIDS

Mark SchmidtNRE 545November 24, 1998

Outline

Why study Uganda? The HIV/AIDS Epidemic

Worldwide Uganda

Transitions and the Emergence of HIV/AIDS Historical/Political Urbanization/Industrialization Theories of HIV Emergence

Transitions and the Impact of HIV/AIDS Population Family Structure

Conclusion

Why Study Uganda?

Origin of the HIV is thought to be the Lake Victoria region of Africa. undetected for 20-30 years brought from low endemnicity areas

into central areas

Population/environment dynamics may have caused emergence of HIV/AIDS

Historical/Political

Urbanization/Industrialization

Epidemiology of HIV/AIDS

Recognition of a new disease United States - 1981 Retrospective Studies

Europe - 1976 Africa - late 1950’s

30.6 Million Infected at end of 1997 11 people infected per minute Sub-Saharan Africa

10% of World’s Population 2/3 of HIV/AIDS Cases

Epidemiology of HIV/AIDS

HIV/AIDS in Uganda Prevalence

930,000 infected individuals 9.51% prevalence rate in adults (15-49) 1,900,000 cases since beginning of epidemic 80% of cases in 15-45 age group

AIDS Mortality Burden Leading cause of adult mortality 1/2 of all mortality 1/3 of mortality from infectious diseases

Transmission 90% by heterosexual sex Vertical transmission also important

Gender Differences 1:1 Overall Male to Female Ratio Females 15-19 - 6 times more likely to be

infected Leaving large orphan population Increased vertical transmission

HIV/AIDS in Uganda

0

20

40

60

80

15 16 17 18 19

Age

Percent of Women with First Child

Transitions and the Emergence of HIV/AIDS

Historical/Political Transition

Pre-Colonial Period No national boundary Diverse tribes and kingdom monarchies

Buganda most powerful Acholi and Lango

Ugandan Protectorate

1898 Treaty with Buganda

Force, threat of force, and peaceful

alliances for other tribes & kingdoms

Imperial (national) boundary established

Historical/Political Transition

North/South Dichotomy South in Transition

Buganda located in fertile area

People receptive to British colonialism• Agriculture was expanded; cash crop system instated

• Kampala established as commercial center

• Indians recruited to lead economic class

• Main trade routes developed

• Educational transition

North stagnant Arid land People unreceptive to British colonialism

• Agriculture was prevented• Lack of developed infrastructure• No educational transition• Recruitment of Northern tribes into military

Historical/Political Transition

Ugandan Independence 1962-Milton Obote becomes leader

Continued British Policies 1966-Kingdoms abolished

Obote became unpopular in the South

1971-Obote overthrown by Amin - Eight Year Reign of Terror Begins

Amin expels Indians in 1972• Destroys economy and foreign confidence

• Removes commercial and industrial class

• Sends industrial, agricultural, and urbanization transitions backwards

1979-Amin overthrown in coup/war with Tanzania

Historical/Political Transition

Migration was the direct result of British Colonialism Domestic Migration

Male Female

International Migration

Urbanization Transition

Urbanization Transition: Domestic Male migration

Agricultural Push Land originally owned by families Families grew and resources diminished Young men left to reduce food burden on

family Labor Pull

British policies caused labor demand in South, especially in agriculture, and labor supply in North

Social Pull Young men encouraged to make money in

cities and return with wealth to villages Result: Initial one-sided bulge of men into

cities Female migration

Economic Pull Women not encouraged to migrate Due to economic necessity Most forced into commercial sex work

Urbanization Transition: International

“Asian” recruitment British brought in Indians to run commerce Indians comprised elite sector

Result: Urbanization brought people to cities

Increased density, anonymity, and increased female sex work led to change in sexual behaviors

Theories of HIV Emergence

The historical/political and urbanization/industrialization transitions provide a context in which hypotheses of HIV/AIDS emergence occurred.

Three Hypotheses Migrant Worker Hypothesis

“Truck-Town” Hypothesis

Military Involvement Hypothesis

Migrant Worker Hypothesis Emergence as a result of population movement

in search of labor Urbanization created a population that amplified

HIV infection female sex workers young male professionals due to British policies & urbanization of 1950-60’s

Return migration brought HIV to villages due to economic collapse during Amin dictatorship

Study of Migration and HIV Infection (Nunn, 1995) 5.5% Prevalence among those who had not moved 8.2% - moved within a village 12.4% - moved to neighboring village 16.3% - those joining cohort

Truck-Town Hypothesis Accounts for spread of HIV outwards from

Kampala Occurred mainly during the Amin reign in

1970’s Use of roads increased - encouraged by Amin Smuggling increased dramatically

HIV Spread outwards along principle corridors of trade/smuggling traffic

Towns developed along routes Female commercial sex work soon followed

into towns Truckers and commercial sex workers

became driving core population of HIV infection 35.2% of truck drivers infected with HIV

Military Involvement Hypothesis Accounts for high seroprevalence in

northern tribes (Lango & Acholi) Specifically due to 1979 overthrow of Amin

Obote loyalists from these tribes recruited into Ugandan National Liberation Army (UNLA)

Fought in South used commercial sex workers

Returned to North with infection Shows positive statistical significance which

cannot be accounted for by either migrant worker or truck-town hypotheses

Transitions and the Impact of HIV/AIDS

Population Transition

Sub-Saharan Africa 3% increase per year 1 billion people by 2025

Uganda 20,791,000 current population 3.2% growth rate 1980-1995

Population Transition

Population Transition

HIV/AIDS and Mortality Direct Effect of HIV on Mortality

1.5 million additional deaths attributable to HIV by 2025

Reduction in population growth• In Rakai:

– high prevalence parishes have negative pop. growth in 1990-1995

– effects muted at district and national level• 0-4 age rage smaller than older cohorts

Indirect Effects smaller youngest age range will cause lower

birth rates as this cohort ages to reproductive age

HIV/AIDS will shift to younger age ranges

HIV/AIDS and Life Expectancy Current life expectancy is 41 5 year drop

Population Transition

Family Structure Transition

Traditional Family - Clan Emphasis on continuity of clan network Made up of common ancestor and common

totem under single residence Principle unit of economic productivity

need for many offspring Socialized young members

influenced behavior social welfare

Support system in times of sickness and death

orphans taken in by extended family, especially grandparents

Modern Family Nuclear/conjugal families Minimal influence on behavior Minimal support

Family Structure Transition

Traditional/Modern Family Conflict Residence

Conjugal families cannot absorb multiple deaths

Nearby extended family unwilling/unable to help

Traditional family structure called upon Socialization

Families feel AIDS is due to a behavior; won’t help/acknowledge members in need

• stigma attached to disease Social welfare is disrupted

• Most productive members are removed• Grandparents must take care of orphans

and provide for themselves

Family Structure Transition

Support 1.2 Millions AIDS orphans

• 38% taken by grandparents• 7% by aunts• 5% by uncles• 5% by sisters/brothers• 2% by children under 16

Family Unit still is main source of support and care for most Ugandans

Conclusion

The Epidemiologic Transition of HIV/AIDS has had an incredible effect on Uganda. However, understanding cannot be fully realized without also analyzing the concurrent transitions that have led to the emergence of HIV as well as those that are impacted by it.