Between 1989 and 1995, when HIV rates fell steeply, Ugandans became less likely to have multiple sexual partners and more likely to use condoms, according to A, B and C in Uganda: The Roles of Abstinence, Monogamy and Condom Use in HIV Decline, a new report from The Alan Guttmacher Institute (AGI). During this same period, according to the report, Ugandan adolescents increasingly delayed first sex; however, there was no change in sexual activity among those who had already had sex. The report concludes that, particularly in the late 1980s and early 1990s, positive changes in all three areas targeted by interventions in Uganda together contributed to the country's success in turning the tide of the HIV/AIDS epidemic and maintaining lower levels of infection. Young people delayed sexual initiation (or Abstinence), fewer people had multiple sexual partners (Be faithful, or monogamy) and Condom use increased among people who were sexually active. During the latter half of the 1990s, as HIV prevalence rates fell more slowly, condom use continued to rise while, in general, changes in abstinence and monogamy were mixed.

Policymakers around the world look to Uganda's policies and programs as a model because HIV prevalence in the country fell to an estimated 5% by 2001, after peaking at about 15% in 1991. Some commentators have seized upon increases in abstinence and monogamy to dismiss the impact or even the effectiveness of condoms. Even when policymakers have acknowledged the changes in all three behaviors, many have leapt to the conclusion that delayed sexual debut and increased monogamy came about solely as a result of programs with these messages as their exclusive focus. It is not yet known which interventions encouraged change in these three areas of sexual behavior, although some, including the U.S. Agency for International Development, are now investigating this question. Reaching a common understanding of the changes in Uganda is the first step in determining what could and should be replicated in other countries.

In A, B and C in Uganda, AGI analyzes data from two sources: (1) nationally representative Demographic and Health Surveys conducted in 1988, 1995 and 2000; and (2) national Global Programme for AIDS surveys carried out in 1989 and 1995. The analysis reveals the following:

• The proportion of women 15-17 who ever had sex fell from 50% in 1988 to 46% in 1995 and to 34% in 2000. Between 1989 and 1995, there were large declines in sexual experience among adolescent men; smaller declines occurred from 1995 to 2000. However, among women and men who had already had sex, sexual activity changed little overall, and some subgroups became more likely to be sexually active, counteracting some of the impact of sexual delay among young people.

• Men and women of all ages were much less likely to report more than one sexual partner in a 12-month period in 1995 than in 1989. Among unmarried women who were sexually active, 15% said in 1995 they had had more than one partner, compared with 31% in 1989; for unmarried men, the proportions were 26% in 1995 and 59% in 1989. The proportion of unmarried women with more than one sexual partner continued to decline between 1995 and 2000, but in some age-groups, unmarried men were more likely to report having had multiple partners in 2000 than in 1995.

• Condom use rose substantially during the 1990s among both men and women, especially those who were unmarried. Among unmarried women who had had sex in the past four weeks, the proportion who used condoms at last intercourse rose from 1% in 1989 to 14% in 1995. Among men in this category, condom use at last intercourse rose from 2% to 22%.

"One key to effectively halting the spread of HIV is a common understanding of what happened in Uganda," said Susheela Singh, Ph.D., AGI director of research and an author of the report. "The findings suggest that encouraging abstinence and monogamy while also providing information about and support for condom use can be a successful strategy. While HIV rates have certainly decreased in Uganda, many adults continue to have multiple sexual partners, and condom use is still relatively low; trends in these various sexual behavior changes should be monitored. Uganda's experience will be important to follow because it has implications for policies and programs to control HIV/AIDS in the rest of Sub-Saharan Africa and worldwide."