Study Paper # 2
THE SOCIO-ECONOMIC IMPACT OF HIV AND AIDS ON RURAL FAMILIES IN UGANDA: AN EMPHASIS ON YOUTH 

1. INTRODUCTION

1.1 Overview of Youth and HIV in Uganda

Uganda is one of the least urbanized countries in Africa, with over 90% of the population living in rural areas. About half the population of the country is under 15 years of age (8.5 million), according to the 1991 Population and Housing Census, while those under 25 years make up about 67% of the population. Youth, as defined by the government of Uganda, includes boys/girls and young men/women from 10 to 25 years of age.

Agriculture accounts for over 60% of GDP, claims about 98% of export earnings and over 40% of government revenue, according to 1987 figures. Farming is labour-intensive, with 60%-80% of the labour for food and cash crops for household consumption and local markets provided by women.

The Acquired Immunodeficiency Syndrome (AIDS) is the most serious health problem in Uganda today and the leading cause of death for adults: About 1.5 million people (10% of the total population and 20% of sexually active men and women) are estimated to be infected with the HIV virus¹. Since 1982 when the Human Immunodeficiency Virus (HIV) was first recognized in the country, 41,193 cases have been reported. However, according to the Uganda AIDS Commission, this represents only a fraction of the actual number of people infected with HIV due to under-reporting and under-diagnosis.  

According to some estimates, up to one million men and women could become infected with HIV in the next five years as seropositivity rates have been rising by about 25%-30% per year since 1988. The projected population of Uganda could plunge from 30 to 20 million by the year 2010 as a result of the HIV epidemic, it has been argued by some epidemiologists. While estimates of the magnitude of the HIV epidemic vary, the common denominator of all projections is that the demographic structure of the country is undergoing considerable transformation.

Nearly 80% of those infected with HIV are between the ages of 15 and 45 -- the heads of households and parents of families which have on average more than seven children. Children having lost one or both parents to AIDS are estimated to be in the vicinity of 115,000 and rising, and some experts fear that this figure could increase five-fold in the next five years. War, an increase in children born out of wedlock and the collapse of health services account for the overall rising number of parentless children, estimated at between 400,000 and 1,100,000. About 69% of all parentless children in Uganda are between 10 and 19 years of age. According to one estimate reported by UNICEF, half the children in Uganda under 15 years will have lost one or both parents by the year 2000². 

TABLE 1: Estimated Current and Projected Magnitude of HIV and AIDS

Source: Uganda National Operational Plan for HIV/AIDS/STD Prevention, Care and Support, 1994-1998.

1 Projections are calculated under the assumption that the current level of intervention for prevention is maintained.
2 Cumulative number of children below 15 years who have lost their mother due to AIDS. Some of these will also have lost their father. Some (not included in the figure) will have lost their father only.

The economic repercussions of the HIV epidemic at the macro level are already being felt in the public and private sectors. Overhead costs are increasing as a result of rising medical expenditures, absenteeism from work and training of replacements, according to the National Operational Plan for HIV/AIDS/STD Prevention, Care and Support, 1994-1998. The Plan predicts a shift in national investments from long-term to short-term, indicating that investment and productivity in agriculture and industry are endangered. Labour shortage as a result of HIV and AIDS mortality and morbidity may well result in a crisis in the traditionally labour-intensive agricultural system in areas that have been severely hit by the HIV epidemic. National capacity-building efforts may be imperiled and decline in income is expected to affect the balance of payments. 

Geographic location, age and gender are key variables in the incidence of HIV and AIDS. Prevalence of HIV varies considerably from district to district. Infection rates are at their highest in urban centres (in the town of Mbarara and the city of Kampala, 24-36% of ante-natal mothers are HIV positive) and in the southern districts of Rakai and Masaka, where more than 12% of the entire population is believed to be infected with HIV.  

According to the Uganda AIDS Commission, the vast majority of new infections occur as a result of sexual transmission (84%), followed by perinatal transmission (14%), which are also a result of earlier sexual infection, while other routes of transmission account for only 2% of new infections. 

HIV infection increases rapidly between the ages of 11 and 19, especially among girls of 15 to 19 years, who are five times as likely to become infected as boys. Girls in the 20-24 age group are twice as likely to be infected as boys³. Peak infection occurs between 15 and 24 years, which implies that 15-year-old girls with AIDS are infected before or during puberty. There are 10% more women among the newly infected with HIV than men, largely as a result of women's vulnerability and inequality before the law.  

Clearly, the need to target rural youths, who are among the most vulnerable groups to HIV and AIDS, is urgent. Prevention of sexual transmission is the main strategy. This is recognized in the 1994-1998 National Operational Plan for HIV/AIDS/STD Prevention, Care and Support of the Uganda AIDS Commission:  

"The main emphasis of the Plan will be prevention of HIV-infection through behaviour change, promotion of STD-care and condom use for targeted groups of people with focused educational messages. The promotion of behaviour change will focus not only on the individual behaviour, but will equally focus on the collective behaviours, and the norms and the values of the community." "In order to achieve this," indicates the Plan, "it is necessary to give first priority to children and youth and to start addressing norms and values right from school entry, gradually making it more specific as the child grows." The second priority of the Plan is to address the status and needs of women, including rural women, and the third is to address cultural and traditional customs and specific sites with concentration of situations of risk. 

The Plan identifies three age groups for youth: 6-10, 11-14 and 15-20 year olds and indicates that different approaches need to be developed for each age group. It also recognizes that as less than half the child/youth population is in school, out-of-school youths will be addressed with appropriate approaches.  

Gender issues are accorded top priority in the National Operational Plan for HIV/AIDS, given the fact that the pattern of sexual transmission of HIV infection is determined by the social, legal and economic relations between the sexes. Women are identified as a "highly vulnerable group" for the following reasons: a) less than half of the women can read and be reached by written messages; b) rural women do not often participate in discussion and decision fora; c) women do not often receive services from extension or outreach health workers; d) women are economically and socially dependent on men. The Plan also recognizes that customs and socially accepted practices including wife sharing, divorce practices, widow inheritance, polygamy, property inheritance practices and the lack of income-generating opportunities for single women increase their risks and restrict their decision-making status vis-a-vis high risk situations. Rural women are one of two target groups identified by the Plan in urgent need of intervention. 

A critical point recognized in the Plan is that while women are targeted as a particularly vulnerable and disadvantaged group, men have a key role to play in interventions designed to reach and benefit women. In particular, it is indicated that "A meaningful decrease in HIV risk in Ugandan society will require changes in male behaviours and attitudes concerning gender relationships and sexuality." In particular, norms, values, practices and relations between men and women create situations and sites (alcohol drinking, visits to bars, discos and social functions) with increased risk of sexual transmission of HIV infection.  

Lastly, it is clearly indicated that "prevention activities should be integrated into mainstream health programmes and other programmes dealing with community, women and youth development." HIV/AIDS initiatives are to be decentralized and the RC system will be the key instrument of implementation. According to the Plan, "NGO support will be encouraged to develop activities to reach specific sites and populations, such as: trading centres, make-shift markets, bar girls and prostitutes, etc. and in the areas of home/community based care and support to surviving family members in the form of e.g. income-generating projects." 

1.2 The Research Team 

The research team consisted of the international consultant on HIV and AIDS and field research, the national counterpart on HIV and AIDS and the Associate Professional Officer (APO) from the Rural Youth Programme, ESHE, FAO. In each district, the team worked closely with YFP Field Officers, Subject Matter Specialists on Women and Youth, Agricultural Extension Officers and HIV councillors⁴.  

1.3 Methodology 

1.3.1 Selection criteria:  

Kabarole, Tororo and Gulu Districts were selected on the basis of the following criteria:  

1. Geographic, agro-ecological, ethnic and linguistic diversity to ensure a representative picture of the country.  
2. Low, medium and high HIV infection rates and AIDS cases. According to surveillance reports of the Uganda AIDS Commission, Gulu ranks among the highly infected districts, Kabarole among the medium infected districts and Tororo among the districts with a low rate of infection.  

During the field work, however, this criterion turned out to be largely irrelevant and inaccurate. Tororo, for instance, is considered to be among the districts with a low rate of HIV infection. This is, however, primarily due to the lack of data and the absence of research activities in the region. The only available data for Tororo concern HIV infection rates from antenatal clinic attendees which stand at about 13.2% in 1992 -- a comparatively low figure⁵. Part of the reason for the paucity of data is that there is only one NGO, The AIDS Support Organization (TASO), providing assistance with regard to HIV/AIDS in Tororo. A handful of other projects have HIV components but there is no coordination between them and the Ministry of Health or TASO. TASO has baseline data which have not been compiled or analysed on a systematic basis. 

In terms of the number of reported AIDS cases by district and intensity of population, Gulu has the third largest number of AIDS cases in the country, but this may largely be due to Lacor Hospital, which attracts people from many other districts and collects data on a systematic basis. According to this indicator, Kabarole and Tororo are close together in the low to medium category.  

TABLE 2: Distribution of Reported AIDS Cases by District and Intensity per 10,000 of Population

Source: UNICEF, SYFA, New Phase of UNICEF Support for AIDS Control in Uganda, April 1992.

With regard to the number of parentless children in the three districts, Gulu ranks "high", Kabarole ranks "medium" and Tororo "low," as shown in the table below. However these figures can also be misleading: in Gulu, for instance, many of these children are war orphans and not children whose parents have died of AIDS. Similarly, in Kabarole, many of the children are born to unmarried mothers and are necessarily from families affected by HIV and AIDS. 

TABLE 3: Parentless Children Results Derived From the 1991 National Population and Housing Census

Source: Ministry of Labour and Social Affairs.

Thus, after carefully considering statistical shortcomings, the difficulties involved in classifying districts according to one indicator, and the complexity of infection patterns within a given region, ranking districts according to "low," "medium," and "high" HIV rates or according to the number of reported AIDS cases ceases to be a valid and useful criterion. It may be more accurate to argue that each district has high, medium and low infection rates which vary considerably from one village to another, as the pattern of AIDS can differ radically from one community to another.  

1. The third criterion was to conduct field work in districts where little research has already been undertaken, where there are few local and international NGOS active on AIDS, and where the need for intervention is great⁶. Virtually no research has been conducted in Gulu, largely due to insecurity and distance from Kampala. Similarly, Tororo, as mentioned above, has been largely neglected by HIV researchers and NGOs. Kabarole has a comprehensive AIDS Control Programme supported by GTZ, but this has a limited radius at present, focusing mostly on urban centres and along the main road.  
2. The fourth criterion was to visit two villages per district, one with an active Young Farmer Society (YFS) and another with an inactive YFS, as YFS were used as entry points for the field work on HIV and AIDS. Where possible, one of the two villages was off the main road. In Gulu, however, due to security reasons, both villages had to be chosen close to the town. The team first made a comprehensive assessment of the YFS, evaluating on-going activities, analyzing constraints and identifying ways of reviving youth groups before dealing with the socio-economic impact of HIV and AIDS and Knowledge-Attitude-Practice of youths on HIV and AIDS.  

1.3.2 Procedure 

In Kabarole District, the research team briefly visited Kantarara Village, but focused on Nyankuku and Bwabya villages. In Tororo District, field work focused on Kabosa Zone 2 and Bumanda villages, while additional research on HIV and AIDS was also conducted in Kwapa Village which borders Kabosa 2. In Gulu, research focused on Lawiye Adul and Layibi villages. 

The first day was spent at the district headquarters, where meetings where held with key district officials, including District Administrators (DA), District Agricultural Officers (DAO), District Medical Officers (DMO), District Education Officers (DEO), Agricultural Assistants (AA), Field Assistants (FAs), NGOs involved in HIV and AIDS activities, Youth Organizers and Field Officers for Young Farmers. These meetings enabled the team to assess YFP activities in the districts and to get an overview of the impact of the HIV epidemic on agriculture, health and rural communities.

On average, the team spent three days in each village and applied Rapid Rural Appraisal and Participatory Rural Appraisal techniques. The first day began with informal talks with the Resistance Council Chairmen (RC1) and YFS leaders and was followed by transects. Focus group discussions with the YFS members focused on constraints, felt needs, reasons for the decline of YFP and lessons learned from the old YFP.  

On the second day, focus group discussions on Knowledge-Attitude-Practice (KAP) on HIV and sexual behaviour were held with young men and women separately. Assessing situations of risk, identifying obstacles to behaviour change and identifying strategies and appropriate messages for HIV education involving the youths themselves were among the key objectives of these discussions. Focus group discussions developed into participatory HIV sensitization fora with lively contributions, question/answer sessions with the researchers and condom demonstrations. In-depth semi-structured individual interviews with HIV afflicted and affected families and youths were also conducted, with assistance from TASO or other trained AIDS councillors. Interviews with key informants on the impact of HIV and AIDS on agriculture and farming systems were also undertaken. 

The third day included a visit to the local primary school where grade 7 (P7), and on one occasion female P6, pupils completed a questionnaire on HIV/AIDS and sexual behaviour. The number of respondents varied from school to school and from district to district. The KAP school questionnaire was followed by a focus group discussion on HIV/AIDS with the pupils and the teachers separately, a general talk on felt needs of school youths and on the role of the youth programme. The results of these questionnaires were not formally incorporated in the study, but provided valuable insight into knowledge-attitude-practice among school children with regard to HIV and AIDS. 

Endnotes

1. Uganda AIDS Commission Secretariat, Uganda National Operational Plan for HIV/AIDS/STD Prevention, Care and Support, 1994-1998, p. 1. 

2. UNICEF, Safeguard Youth From AIDS, New Phase of UNICEF Support for AIDS Control Programme in Uganda, April 1992. 

3. UNICEF, SYFA, New Phase of UNICEF Support for AIDS Control in Uganda, April 1992. 

4. In Kabarole, the research team included: Mr. S. Kamba, YFP Field Officer and Ms. Deborah Mouhoumouza, former teacher. In Tororo, the team worked with Mr. Haumbahatagata, YFP Field Officer, Mr. A. Ofono, Agricultural Extensionist, Ms. Helen Onyango, TASO Councillor and Ms. Deborah Musuane, Field Officer. In Gulu, the team comprised Mr. Otto Alli, YFP Field Officer, Ms. Florence Opoka, Gulu Government Hospital AIDS Councillor and Senior Nursing Officer, and Mr. William Odu, AIDS Councillor, Gulu Government Hospital.

5. Progress Report on AIDS Control Programme, Ministry of Health, 1.5.-30.9.92.

6. We are greatly indebted to Dr. Tom Barton of the Child Health and Development Center for his advice on the selection of the districts and on research methodology.