Preaching Prevention. Lydia Boyd
funding, but its effects were keenly felt in the realm of Ugandan HIV/AIDS prevention. The director of Janet Museveni’s Uganda Youth Forum, a youth-focused AIDS prevention NGO, articulated this dilemma when he told me in 2011 that, at the end of a grant’s cycle, “You are left with unfinished business. But when the next resource comes you have either become irrelevant or they are focusing on another development area.” PEPFAR represented a dramatic ramping up of both treatment and prevention programming, but it was marked by many of the problems that plague international aid in general. The terms of its funding were defined and driven by political agendas far removed from Ugandan communities. These agendas reshaped which messages were privileged and which became “irrelevant.” Another long-term AIDS researcher in Uganda told me, “To me, the response to HIV/AIDS in Uganda was more effective before than it is now. Right now I see the overcommercialization—the overtechnicalization, and then the commercialization. People respond to money, not to the problem. The period before [now] there was no money. People were responding to the problem.”
As international aid funding patterns have shifted, international NGOs devoted to HIV/AIDS prevention and treatment have become increasingly important social and economic institutions in Uganda. The effect of PEPFAR on Ugandan NGOs was perhaps most apparent in the rapid mobilization of Christian organizations, both local and international, that became involved in HIV/AIDS work. Large U.S.-based Christian NGOs played especially important roles in the implementation of PEPFAR; the largest grants under the 2003–8 program went to treatment projects (80 percent of PEPFAR’s funds are dedicated to treatment), but international Christian NGOs, including World Vision and Samaritan’s Purse, received significant grants for prevention.76 Other smaller evangelical Christian NGOs, including some started by Ugandans, have also received funds. In 2007 Shepherd Smith, the missionary who testified before Congress, received a grant for abstinence and faithfulness programs on behalf of his NGO, the Children’s AIDS Fund. His organization in turn relied on two Ugandan subpartners, Janet Museveni’s Uganda Youth Forum and the Campus Alliance to Wipe Out AIDS, the latter founded by a Ugandan born-again pastor.77 Both of these programs were dedicated to promoting an abstinence-only approach to youth education.78
These and other born-again organizations played a role in establishing the strong emphasis that Uganda’s PEPFAR grantees have placed on abstinence and faithfulness as prevention strategies. In 2007, 39 percent of all of PEPFAR’s primary grant recipients in Uganda listed abstinence and faithfulness as one of their program areas.79 In 2008, PEPFAR’s own statistics note that of 6.3 million Ugandans reached through prevention programs, more than 72 percent received an abstinence and/or faithfulness message.80
The emphasis on abstinence and faithfulness is not in itself radical in a country that for nearly fifteen years emphasized behavior modifications to reduce HIV prevalence. What changed dramatically under PEPFAR was how this message was being conveyed to the Ugandan population. Uganda’s early program was thought to be so effective in part because it heavily relied on peer-to-peer education and locally produced content to educate about HIV prevention. The message about behavior risk was also integrated with other prevention messages, including partner reduction and condom use education, rather than viewed as a separate program area.
In Kampala in the years following PEPFAR’s introduction the immediate sense was that AIDS prevention had become contentious and politicized in ways it had never been before. The experience of Straight Talk Uganda, whose program leader felt the group was on tenuous ground because its programs were not perceived as sufficiently proabstinence, gives only a partial picture. Prevention was a political issue, one shaped by international aid and Uganda’s relationships with U.S. conservative lawmakers. In the years following PEPFAR’s introduction, religiously infused prevention activism became a platform on which students and other young people could advocate for new attitudes about sex that were viewed as more aspirational, more empowering, and (from certain perspectives) more “moral.” Troublingly, these messages were often placed in opposition to other prevention strategies that had previously been common in Uganda (the “zero grazing” program, or Straight Talk Uganda’s long-form radio shows that emphasized peer-to-peer sexual education) as well as those approaches that most often contrasted with behavior change in global debates about prevention during this period (biomedical interventions such as serostatus testing and condom distribution).
A Fractured Landscape: The Abstinence-Only Approach versus Condoms
At the 2006 World AIDS Day rally in downtown Kampala’s Centenary Park the heightened tension between prevention strategies and advocacy groups was evident. Various HIV/AIDS treatment and prevention groups had gathered to celebrate their work in a leafy plaza off Jinja Road, a main downtown thoroughfare. Speakers took turns talking about the ongoing challenge of HIV/AIDS in Uganda. A group of students from UHC, one of the local churches active in promoting abstinence, were carrying banners and signs reading abstinence pride and abstinence is the only way of preventing aids that they had painted that morning at the church. During a presentation by another group, which mentioned its condom distribution program, members of the church group booed and shouted “Abstinence oye!” Throughout the rally any mention of the word condoms was met with a similar reception.
The apparent faultiness of other prevention methods was a fact often brought home by Christian abstinence activists in the years I lived in Uganda. A PEPFAR-funded student newspaper managed by a church-affiliated group on the university campus once ran a story explaining the “nine meticulous steps” involved in putting on a condom correctly. One young woman asked me, “If you can’t be consistent with coursework, how can you expect to use condoms consistently?” Another pastor’s presentation on youth sexuality in 2006 included a slide with a magnified sperm next to much smaller sexually transmitted viruses, the (misleading) lesson being that these diseases are so small they can permeate the latex in condoms. And a commonly repeated myth circulating among born-again Christian youth during a visit to Kampala in 2010 was that condoms cause cancer. This backlash against condom use was generated by the belief espoused by many Ugandan born-again activists, that abstinence (and, later, marital faithfulness) was the only way to prevent HIV/AIDS. In the years following PEPFAR’s introduction the mobilization of religious actors and the increased funding for abstinence-only programs contributed to a growing environment of antagonism among HIV/AIDS groups in the country. Editorials in newspapers and speeches by politicians often offered support for one side of the abstinence argument or the other. The Church of Uganda, which had in earlier years demonstrated a relatively inclusive approach to prevention strategies (at times even counseling condom use), by this time had embraced a far more antagonistic stance regarding condoms. Church leaders adopted rhetoric condemning adultery and other “sexual sins” and promoted condom use only within marriage. Public rallies in central Kampala encouraged youth to consider abstinence the only way to prevent AIDS (see figure 1.1).
One of the most prominent church leaders to emerge during this period was Pastor Thomas Walusimbi, the founder of UHC, a congregation I will describe in greater detail in subsequent chapters. Pastor Walusimbi positions himself in Ugandan AIDS circles as a moral reformer, encouraging “appropriate” behavior as a way of preventing HIV/AIDS. He expertly emphasizes how abstinence and faithfulness are Ugandan cultural values that have been undermined by foreign AIDS agendas that he views as biased against a faith-based approach to HIV/AIDS prevention. During a speech on AIDS leadership given on the university campus in 2007 he characterized his work as a struggle against a foreign AIDS prevention establishment that is populated by experts who are “liberal, faithless, and have no families.” His message appealed to conservative American Christians, who also saw themselves fighting a moral battle against a nonbelieving, liberal establishment, as well as to an African audience for whom calls for a reassertion of “traditional” African gender and family norms in response to the social disorder of HIV/AIDS had become common. For young Ugandans, however, Walusimbi’s narrative of resistance to the corrupt influence of seemingly amoral foreigners provided a message about their own self-empowerment and global influence that was deeply appealing. When I interviewed him, Pastor Walusimbi elaborated on this argument, noting, “Africans have been so relegated to the backseat of development and modernism for so long. And there is a sense in which we always receive, we