Study Paper No. 2
THE SOCIO-ECONOMIC IMPACT OF HIV AND AIDS ON RURAL FAMILIES IN UGANDA: AN EMPHASIS ON YOUTH 

2. MAIN FINDINGS 

 The findings of this report concern only the villages, and to a certain extent, the districts visited. Given the diversity of the country and the complexity of HIV infection patterns discussed above, they cannot be applied to Uganda as a whole. 

2.1 General Findings on HIV and AIDS 

1. In Kabarole, HIV infection rates for the town of Fort Portal are estimated at 25%-30% and are steady; in semi-urban areas, HIV infection rates are between 12% and 14% and rising, and in rural areas they are estimated at 6%-9% and are also rising⁷.  

2. In Gulu, HIV infection rates, according to Lacor Hospital data from ante-natal screening, show that 13%-15% of women from 16 to 40 years of age are HIV positive. Blood donor samples show similar rates of infection. Lacor Hospital has no data on rural areas.  

3. In Tororo, for every reported person infected with HIV in the district, there are 50 others infected, according to the general manager of TASO, Mr. Geoffrey Diloth. With a multiplication factor of 50, he believes that Tororo should rank among the "high" HIV-infected districts in the country. 

4. The incubation period of the disease appears to be maturing in Kabarole and Tororo districts, as most of the widows interviewed had lost their husbands during the past three to 12 months). 

5. The HIV epidemic is affecting the most productive age group in the villages. While it is impossible to obtain exact figures of AIDS cases, a basic but significant indicator is the incidence of AIDS in every family. Some families have more than one member suffering from AIDS. "Every home is affected by AIDS in Kwapa village," said Helen Onyango, a TASO AIDS councillor in Tororo. "Either a relative is suffering, a family member is dying, or someone suspects he has AIDS." "We are burying almost everyday; not a day goes by without burials," said one man in Kabarole. "Every village, every household, every family in Tororo has people affected by AIDS," argued Mr. Diloth of TASO.  

6. However, HIV and AIDS follow different patterns in each locality and it is difficult, if not erroneous, to generalize about a district on the basis of two villages. Geographic and ethnic factors, agro-ecological conditions, religion, gender, age and marital status play a role in the pattern and impact of the HIV epidemic and in people's perceptions of the disease. Even within one district, as was the case in Tororo, two villages can have radically different agro-ecological conditions and customs that determine sexual behaviour and attitude towards HIV and AIDS. It is therefore practically impossible to design nation-wide interventions for the epidemic.  

7. The impact of HIV and AIDS at the district level has been highly disruptive, as a significant number of highly qualified civil servants and technocrats are dying and are not being replaced. In Kabarole, the former DA and two, possibly three, of his staff have died in the past year from the disease. In Kantarara village, one extension worker who was very active with the YFP recently died of AIDS, signalling the downfall of the youth group.  

The DAO in Tororo further noted that it is becoming increasingly difficult to implement agricultural programmes as a result of HIV and AIDS: extension staff are attending burials continuously and whenever the Department calls a meeting, only five out of 10 or 12 people are able to attend. Every time there is a burial, the work week is reduced from six to three days (Tuesday, Wednesday and Thursday) as people have to take Saturday, Sunday and Monday off (Friday is the official day of rest) to travel to the village and attend the burials. Thus, the HIV epidemic is exacerbating the problems of an already overburdened and under-resourced agricultural extension service.  

2.2 Profiles of Families Affected by HIV and AIDS 

The section below consists of four in-depth profiles of families affected by HIV and AIDS. The reason they have been reproduced in full in the main body of the text is that they provide a comprehensive picture of the socio-economic impact of HIV and AIDS on the lives of rural families, focusing on young men and women. Analyzing the socio-economic impact of the HIV epidemic in segments, as is done in section 2.3, can often conceal the cumulative impact of the disease. This section is intended to assist in a better understanding of the impact of HIV and AIDS and of the dynamics of coping mechanisms adopted by rural families.

Profile 1 

Mary, who lost her husband to AIDS, is 42. She has 8 children, 25, 23, 20, 18, 16, 14 and 10 years of age, and an infant of 18 months. They live in Kwapa Village, Tororo District. Mary's husband, a policeman in Mbale district, died of AIDS in July 1992. He was a TASO client. She and her youngest child are HIV-positive and have tuberculosis. Her 23-year-old boy is retarded. 

Mary is also a TASO client and, as she is not receiving any help from her late husband's family, TASO is her only source of support. Her family is suffering from severe food shortages. "There is almost no food in the house," she said. She tries to provide two meals a day but finds it difficult, and five to six times a month, she only prepares one meal a day -- millet porridge. 

Mary only grows millet and cassava, but last year the millet crop failed and this year the cassava is still too young to be harvested. When her husband was still alive, they grew beans, maize, rice, cassava and millet, occasionally using hired labour. These days, because of labour shortages and lack of cash with which to employ labour, she has had reduce the number of crops under cultivation. It is only on rare occasions that she employs casual labourers. Most of the time, she has to do all the farm work herself but is too weak to do so properly.  

With only two crops, she finds it difficult to provide a balanced diet for the household. The family eats mostly millet bread, sometimes with greens or beans and rarely with meat. When her husband was alive, she remarked that the diet was varied: flour, beans, powder milk, fish, rice and cooking oil were bought on a regular basis. Hygiene was better because they could afford soap. In addition, she used to dry and sell some cassava and then use that money to buy essential goods. These days, she has reduced the acreage of the cassava shamba (garden) and there is no extra produce to sell. As a result, only rarely does she have money for salt, sugar, soap and beans. 

The children who are over 10 years are helping her in the shamba and she is making a conscious effort to teach them how to grow food: "I am trying to teach them as much as I can before I get too weak; this is their only hope... I have to teach them how to grow food if they are to survive," she said. 

The older children (10 years and up) work to supplement the household income. Three of them work in neighbouring fields as casual labourers, another buys soybeans whenever there is a little extra cash, fries it and sells it at the market, and yet another makes rope out of sisal fibre. 

The impact of the husband's death on the family has been devastating. Mary emphasizes the loss of financial security and sharp decline in living standard as the most significant change. The economic hardship has put a lot of pressure on the children. They are maturing faster than she thinks is right for them, she remarked, and even though she realizes the danger involved, she added: "I have no choice; I have to make sure that even the youngest ones become independent before I die." 

Her 20-year-old son recently ran away from home: "He was fed up with going hungry. There was no soap, no salt, no sugar, and sometimes not enough food in the house. He did not have proper clothing. One day, he disappeared and then we heard that he went to his cousin's sister far away from here. He left last April and has never been back since." He is now unemployed and does not assist his family. Mary fears that he may have run away because of the stigma attached to the family as a result of AIDS -- a stigma which he found too hard to bear. She never sees him and does not even know how he is surviving in his new home. Her greatest fear is that he will end up loitering and drinking in the nearby town.  

Mary fears that some of her other children may follow his example and run away to relatives to escape from the AIDS stigma and the poverty. Her inability to take care of her children properly is devastating to her, as is the process of watching her whole family disintegrate. She worries that one day her sons and daughters will lose contact and will not be to help one another in times of need. 

All her children have been stigmatized and ostracized from the extended family and the community. "Yesterday," Mary said, "my son came back from school in tears; his friends would not let him play with them because his father had died of SLIM." This has happened many times, she added, but "it saddens and depresses me more than anything else. To see my children go through this [humiliation] because of their father and myself is unbearable. And there is nothing I can do about it. I went to see the teacher to ask him to talk to the pupils, but I have done this many times before and nothing happened."  

Mary considered education to be critical for the future of her children, but remarked that the AIDS stigma seriously jeopardized their chances of finishing school. Their future, she added, was largely dependent on the education they received and their perseverance as farmers. 

Mary herself has been ostracized from the community and from the immediate family. She said that even though her late husband's family is in a position to help her and has the resources to do so, they refuse: "They are not willing to help me," she added, "because they do not want to help me. They even want to take the house [we live in]."  

Her husband left her 12 cows, but she has already sold 7 to support the family, pay school fees for the children and medical bills. "After I sell the last five cows, I will have nothing," she added, indicating that the cows are her last vestige of security. She said that from now on she will be forced to rely on the children to raise cash.  

Mary has never tried to talk to her children about HIV and AIDS. In fact, she said she had never told her children that she and her late husband were suffering from the disease. Her children know that she has AIDS but have found out from other people, during their father's funeral. When asked why she had not spoken to here children about AIDS, she replied that she found it too sensitive and painful now that she was also infected with HIV. She had tried to tell her children several times in the past, she said, but could not bring herself to do it. She said she would prefer an outsider to tell her children about her condition.  

The story of Mary's eldest daughter, Rose, 25, married, and mother of a 4-year-old child, clearly delineates the impact of AIDS on rural families, and especially young women. Rose has finished primary school and attended four years of secondary school. 

Rose had left her husband behind nearly six months ago to come and take care of her mother. She is very torn by this decision because on the one hand she wants to look after her mother, but on the other hand, she fears she might not have a marriage or a family to go back to. Her husband's village is far away and she is to unable visit him, even periodically. Rose worries that her husband might have already found another wife, or that he will refuse to take her back when she returns. She described being under enormous pressure, having to nurse her mother at the expense of neglecting her own husband and child. But her mother has no one else to help her, she added. Rose fears that if she does not stay, her mother will die and then, she wondered, "What will happen to her children?" Her siblings are all young and she will have to assume responsibility for at least five of them. Not only does she not have the means to support them, but she also fears her husband may not agree to take them in. 

Rose grows cultivates millet and cassava on her father's land for about four hours each day. Next, she tends to the housework and to her siblings. When the children return from school, they fetch water and fuelwood. She has difficulty managing the family all on her own while also taking care of her sick mother and indicated she had suddenly become a single parent of a large family. Controlling and disciplining the children, especially the boys, was her main worry. Her mother was trying hard to keep the family together, she said, but was getting too weak. Rose felt that no matter how hard she tried herself, the children refused to listen, particularly the adolescents.

Rose has learned about HIV and AIDS from her friends. Young men and women do not bother much about AIDS, she said. This she attributed to "negligence" on their part, largely a result of the fact that youths do not believe AIDS can "happen" to them. She has a lot of young women friends between the ages of 16 and 25 who have lost a partner to AIDS and fear they may be infected. "Some young women fear testing," she said, "try to deny the problem and forget all about it. When they suspect they may have AIDS, they become careless and go on a [sexual] rampage -- their argument being `What about the days when AIDS was not there? People were still dying.'" Even those young women who want to protect themselves from AIDS find it difficult to do so because boys do not respect girls who ask for condoms. They associate condoms with promiscuity and immorality. In general terms, she said, men and women her age are not faithful to their partners.

Rose remarked that these days many young girls are having sex to buy clothing, shoes, cosmetics and have extra pocket money. She attributed early sexual behaviour and multiple sexual partners partly to weekend beer parties and discos. Her description of these social events was as follows: About 30 to 40 boys and girls get together, with the consent of their parents. Some parents also join the parties. Children as young as 10 years thus begin drinking and engaging in sexual activity. The parties can last from two to seven days with continuous drinking and dancing. Rose pointed out that these days, youths dance "western style," which means that there is constant body contact, while traditional dancing does not involve direct physical contact. When people hold each other close, she added, they are easily led to sexual activity. "Almost none of the youths have condoms with them at the discos and even fewer use them" she added. About 10 years ago, discos were also popular in boarding schools but they were abolished under the pressure of the HIV epidemic. Those who are in school are more sexually active than those who are not in school, she thought. 

Rose mentioned that one of the reasons why young people drink heavily is because girls learn how to brew the local beer from a very early age so that by the time they are 12, they can distil alcohol on their own. Alcohol, then, has become part of youth culture and is to a large extent socially acceptable. For young men, she said, drinking and casual sexual partners goes along with the lifestyle involved in smuggling in border towns where sex is easily available.  

Rose feels uncertain about her future, about her own family and her siblings. She used to have a business of her own but lost all the capital. Now, she does not know how to start another business so that she can make a living and is not sure if she has a home to go back to. 

She said what she needed most was counselling to help her cope with AIDS and practical advice on how to help her mother, siblings and herself.  

Profile 2 

Joseph, 33, has AIDS. His 30-year-old wife, who also has AIDS, has been sick for nearly two years and has gone back to her family to die, leaving behind 4 girls, 4, 6, 7 and 10 years old. Joseph has been sick for two years. His two sisters and four brothers also died of AIDS. He and his family live in Kantarara village, Kabarole District. 

The household is now headed by his mother, but the family lives with Joseph's brother whose wife left him some years ago. Joseph's own house recently collapsed but he could not repair it because he is too weak. Joseph has some land which has not been cultivated for the past two years, ever since he got sick. His brother can hardly manage farming his own land singlehandedly; he is unable to tend to Joseph's land and their mother is too old and frail to help on the farm. Most of her time is taken up caring for the children and for Joseph. 

None of the children are in school. The family exhausted its savings long ago, when Everlesto and his wife first got ill and sought costly treatment. Not only does the family not have money for school fees, said Joseph's mother, but the children were not getting enough to eat and there was no money for Joseph to buy medication even though he was now in a lot of pain. When he first contracted typhoid and malaria, Joseph began treatment, but now he did not have enough money to complete it. He has never been visited by a health worker.  

In fact, Joseph said that nobody was helping him and his family in the village. He said that the RCs were more involved in collecting taxes and enforcing the law rather than assisting families in need. Initially, Joseph said, the elders in the village held a few meetings to discuss HIV and AIDS, but they could not agree on how to proceed and dropped the issue.  

Joseph's mother does not know whom to turn to. Her main concern is her grandchildren: "What will happen to them when I die, with no one to look after them?" she said. 

Profile 3  

Edith, a widow in her late 30s, has seven children, 25, 23, 22, 19, 18 and 12 years of age. They live in Tororo District. Edith was married when she was 13. Her husband died in April 1988 from AIDS. She also has AIDS, is bedridden and incoherent at times. She is a TASO client. 

Edith was severely undernourished, exhausted, and unable to lift herself upright on the bed. The bed had no sheets and was soiled. Edith was emaciated and had not washed in several days. She shares the hut with her daughter, who is 19, has had five years of primary school, and is not yet married, but has a child of two years. When Edith's husband died, she sent her daughter to Kenya to work as a housemaid for two years, earning 6,000 USh per month. Her daughter entrusted her salary to her landlady for safekeeping but at the end of two years when she was about to return home, the landlady kept the money. Her daughter returned home without any savings. At present, her daughter is the only one taking care of her. "Without my daughter, I could not have managed. I would not be alive today," Edith said. 

None of her sons are working. When her husband died, they all dropped out of school because she could no longer afford to pay school fees. Now they cannot find jobs. One of her sons is married and is living nearby. He only has a small cassava shamba which is not enough to feed his own family, let alone his mother and sister.  

When her husband was alive, the family grew potatoes and sorghum on their 3-acre plot. Some of the sorghum was sold to buy soap, salt, meat, fish and paraffin. These days, Edith only grows cassava and millet. The husband's family has not claimed the land yet, but she fears this may happen at any time. When she feels strong, she works as a casual labourer to earn some cash. The daily wage of casual labourers is about 1,000 USh (about US$.80). She would like to grow beans to diversify and improve the family diet but cannot do so at present as her yields have declined drastically. The old cassava shamba is nearly finished and the new one is too young to harvest. In addition, she said she tried to harvest millet this year but was unable to because the general body pain was too severe and she did not have the strength to work in the shamba. At present, the family does not grow enough food for subsistence.

Her diet consists of cassava, millet and a few greens. Edith's daughter tries to prepare two meals a day, but often they only have one. Eating the same food -- boiled cassava without sauce (there is no money to buy oil with which to prepare the sauce) -- has made Edith lose her appetite, she said. "I cannot eat the same food every day anymore. I need some variety," she said. Edith had not eaten fruit for at least a month.  

Edith has received no moral or material support from her late husband's family or from the village. No one ever comes to see her. Attitudes toward her and her family were very negative, she said. She does not want to ask for help from her husband's male relatives because she fears that their wives will suspect that she is sexually involved with them.  

When she is not bedridden, Edith works from 5:00 am to 9:00 pm. This long workday exhausts her but she cannot afford to rest because she and her daughter would not have enough to live on. She described this as a vicious circle she could not escape from: on the one hand, she cannot grow enough food to feed herself and her family because she is too weak and hungry, while on the other hand she needs to eat properly in order to be strong enough to work in the shamba. 

Edith's daughter, Florence, is 19 years old, has five years of primary education, and is the mother of a two-year-old child. She shares the hut with her mother and manages the household. One of her brothers is a farmer and a few times a year he gives them some cassava. Her other two brothers are being trained as prison wardens.  

She cannot earn money during this period because the weeding was finished and there is no other work in the shambas. To raise cash, she has decided to brew adjono (local beer) as a last resort. She said she can earn 4,000 USh (a little over US$3) a day selling adjono, while she only earns 1,000 USh (US$.80) from farm work. It takes her 10 days to prepare adjono.  

Florence has had no time to herself since her mother fell ill and hinted that her life was not her own since illness hit the family. She is depressed and feels helpless. Her mother has never talked to her about HIV or AIDS. Florence does not even know her mother has AIDS. She must suspect it, but does not want to admit it. 

Profile 4 

Patricia, 19, lives in Kwapa village, Tororo District, with her father's family. A 42-year-old hotel manager in Malaba (a small town near the Kenya border), he lost his wife to AIDS three weeks before we interviewed his daughter. Her mother's grave, which was right outside the hut, was still fresh. Her father, who is infected with HIV and sick, has two wives and a third partner in Malaba town who is also infected. His second wife, who shares the same house, has three young children living with her (two twin girls and one boy), but she does not think they are infected.  

Patricia and her one-year-old son also have AIDS. They have aggressive herpes zoster on their bodies and her child has severe diarrhoea and dry coughing. During the interview, her baby was too weak to breastfeed and flies were swarming its eyes, mouth and open sores. She was not covering the open sores of the child, not for lack of caring but because of the futility of the gesture, she said.  

Patricia's entire immediate family is infected with HIV, including her 10-year-old brother and her 7 and 14 year old sisters. When Patricia was asked how she thought her younger siblings got infected, she replied she was not certain whether this was through caring for her late mother or through sexual activity.  

A farmer with primary school education, Patricia grows maize, cassava and groundnuts. Her family often does not have enough to eat because the cassava shamba is almost finished and they do not have another one ready for harvesting. She wants to grow more cassava but her father insists on growing millet. The family diet consists of millet bread and vegetables.  

Patricia described her mother as the pillar of the family and said that her death had a devastating impact on the family. Now she has to rely on her stepmother with whom she, her late mother and her siblings never got along. Her brothers and sisters are neglected because their father still has his second wife and family. Patricia's stepmother has assumed responsibility for her siblings and, at the moment, they are all in school. But her mother's death is too recent and she does not know if her siblings will remain in school next year.

 Patricia shares the cooking and other household work with her stepmother. She brews adjono in order to raise cash, but brewing is seasonal and for the rest of the time she does not engage in any income-generating activity. With the money she earns from adjono she buys soap, meat, matches, paraffin and clothes. 

As she receives no help from anyone, Patricia has coped with her mother's death and her family's illness with great difficulty. She is severely depressed, apathetic and remote. It appears that she is so bewildered by what is happening to her family that she is unable to react. According to TASO, which regularly visits her father, Patricia has deadened herself to pain, anxiety and stress. She said she knows that her baby, her brother and sister, her father and herself were going to die and there was nothing left for her to do and nothing to hope for.   

The most important thing in her life was school. She said she liked learning in a group and sharing interests with other people. She felt that education would give her a brighter future and a purpose in life. "I had dreams and I could try to make them happen" she added. But when she got pregnant, her father stopped paying school fees and she dropped out.  

Patricia would like to see a youth group in her village encourage girls to develop skills and create income-generating opportunities that will keep them away from "bad company," as she put it. She said she had been misled as an adolescent because she did not have the confidence to stand up to boys and refuse sex. She would like to see young women have more opportunities than herself, she said and identified idleness, drinking and the absence of creative opportunities as the biggest problems for youths. 

2.3 Analysis of the Socio-Economic Impact of HIV and AIDS on Rural Families

HIV and AIDS affect men and women very differently. The socio-economic impact of the HIV epidemic on rural families has different repercussions depending on whether it is the man/father or woman/mother who dies. It should be emphasized, however, that the analysis below may only be applicable to areas undergoing a peak in deaths as a result of AIDS, particularly among men. This appears to be the case in Kabarole, Tororo and Gulu. 

A significant first finding is that in all three districts there are far more women who have lost their husbands to AIDS than men who have lost their wives. This trend was confirmed by AIDS councillors. In Tororo, Helen Onyango of TASO reported that only 5 of her 62 clients are widowers. The rest are young widows from 15 to 35 years. The reason for this is partly that men often have more than one wife. Many Christians and Muslims alike in Uganda are polygamous. In Tororo, 42% of all marriages are polygamous. Men who only have one wife tend to remarry soon after the death of their HIV-infected wife thereby transferring responsibility and care of the children to the new spouse. Some men begin looking for a second wife before their wife dies. When a woman/mother dies, the children are being cared for by the new wife. However, there are cases where the new wife does not tolerate the children who are then sent to the maternal aunt.

2.3.1 The Implications of HIV and AIDS for Widows and their Families 

Before analyzing the socio-economic impact of the HIV epidemic on young widows, it is important to assess what happens to widows in general (including war widows and widows whose husbands die from causes other than AIDS) in order to isolate the impact resulting from HIV and AIDS alone.  

In general terms, widows in Uganda face the following scenarios:  

• they risk having their husband's land confiscated, as women do not have the right to inherit land. Sometimes they also lose rights to land use; 
• they may lose their property to the husband's family, unless the husband has left a will. Property acquired during marriage belongs to the husband, according to customary law. Women do not inherit property when their husbands die. Legally, a wife (or wives) can claim 15% of the husband's estate but most women are not aware of their legal rights; 
• they may be inherited by the late husband's brother or near male relative and if they refuse, can be forced to return to the parental home. When they are not inherited and remain in the conjugal home, they are often without protection;  
• the only security for widows is their sons (13-15 years or older) who can claim land and property; in some cases, younger sons who are physically strong enough to stand up to the extended family and claim their father's property and land may be able to offer their mothers and families some security;  
• they often have sole responsibility for the children;  
• they suffer a significant loss of cash income, as a result of which their standard of living can decline drastically;  
• they often lose access to support services as it is usually the men who have access to inputs, credit and extension services; and  
• they are overworked, have little time to themselves and are thus hard to reach and mobilize. 

The HIV epidemic does not only contribute to the rise of female-headed households on a large scale. What is significant about women whose husbands have died of AIDS is that they are younger and thus tend to have dependent children who need to be looked after and who cannot contribute to farm work and/or off-farm income-generation activities.  

a. Women and their Families May Become Entrenched in Poverty 

The interplay of a wide range of socio-economic problems resulting from the HIV epidemic often pushes women whose husbands have died of AIDS and their families below the poverty threshold, directly threatening the survival and well-being of their families. Even more importantly perhaps, female-headed households affected by AIDS become entrenched in poverty, as, in addition to the loss of labour and cash income, women have fewer legal rights than men, are often less literate than men, and have limited access to support services, credit and inputs. The result is a marked increase in poverty among AIDS widows. This feminization of poverty, a key characteristic of the socio-economic impact of the HIV epidemic, has far-reaching consequences for rural societies, and particularly youths, with girls/young women being most affected. Given the scale of the HIV epidemic in Uganda, the marked increase in poverty among young women and their dependent children is likely to have a profound impact on the nation as a whole, particularly on food security (as it is the women who are responsible for food production). For this reason, it is critical that interventions in the area of HIV and AIDS address this trend to mitigate its impact and arrest the crippling effect on Uganda's predominantly agricultural economy.  

b. Women and their Families May be Stigmatized and/or Ostracized 

The AIDS stigma, in particular, can sever the access widows would otherwise have to assistance from the extended family and the community. Much depends on how the husband's family reacts to the death of a son. Often, the widow is blamed for transmitting the disease to the son and is accused of promiscuity and immorality. Stigmatization may result in loss of respect within the extended family and the community, abuse and repression. Several young widows in Kabarole, Tororo and Gulu noted that their husbands' families could have helped them if they wanted to, implying that the problem was not lack of resources but contempt and stigmatization. Some women are harassed and forced to leave their village and migrate to the towns where they can escape from the stigma, earn their living as petty traders and re-marry in anonymity. The situation is worse for women who only have girl children, as the latter do not inherit land and property. 

c. Women may Develop a Crippling Anxiety Over their Sero-Status and the Sero-Status of their Children 

If a man is known to have died of AIDS or if a woman suspects that her husband may have died of AIDS, the possibility of herself and/or her children being infected with HIV becomes "crippling," in the words of one young widow. The greatest anxiety of a woman over her sero-status concerns her children rather than herself. A woman having lost her husband due to war may worry over the future of her children but she knows she can rely on herself to support her family. A woman having lost her husband to AIDS and who suspects she may be infected cannot rely on herself. This makes her helpless and, in the absence of assistance from the extended family and community, there are often no alternatives open to her.

Almost all widows interviewed in the three districts wanted to know their sero-status. Few women know where to turn to in order to get information and counselling on HIV testing. Most are not aware that there are testing facilities available in a nearby town. Ellen, a 52-year-old grandmother from Bwabya, Kabarole, mentioned that neither she nor her daughter were aware that one could be tested for HIV. The fact that AIDS widows feel the need to know their sero-status suggests that their state of helplessness can be overcome and need not be permanent. Providing women with information on HIV-testing and counselling is critical but may not be enough, however, as transport costs to the clinic can be prohibitively expensive, particularly considering that HIV testing requires at least two or three hospital visits.  

One young widow in Kwapa, Tororo mentioned that even if she tested HIV positive, she could at least start making provisions for her children and plan their future. The viewpoint that it is better to know one's sero-status even if this is positive was echoed by young widows in all villages. In fact, most of the HIV-infected widows who already knew their sero-status are far from helpless. One woman in Bwabya, Kabarole, has left an informal will with the RC1 and given copies to the elders of the village. Others are trying to find out how they can secure the future of their girl children. One widow in Gulu who was already sick with AIDS decided to open a bank account for her eldest daughter of 16 years who was to care for the rest of her siblings. Both women recommended that widows be informed of alternatives so that they could plan the future of their children accordingly. 

Most widows interviewed, with the exception of those who were TASO clients or clients of the Gulu Hospital AIDS unit, were not aware of the existence of wills. TASO and Gulu Hospital clients had difficulty accepting the rationale behind the will at first, but later recognized it as an absolute necessity for the survival and well-being of their families. Similarly, most women do not know how to open bank accounts and how to go about getting information with regard to their legal rights. 

d. Widows Who are Inherited may Infect the Extended Family with HIV 

Originally a social security system and safety net for widows who do not inherit land or property and have few legal rights, wife inheritance has become an acute problem as a result of the HIV epidemic.

According to tradition, in many parts of Uganda, when a man dies, his widow is inherited by his brothers or near male relatives. Wife inheritance is closely linked to the bride wealth paid by the man upon marrying a woman. The bride price effectively signals that a woman becomes the property of her husband and his clan.  

Wife inheritance greatly facilitates the spread of HIV and has the potential of infecting several families very rapidly: When widows are inherited by their late husband's brother, they risk infecting them as well as their co-wives. If any of the wives has children, they may also be infected with HIV. In some cases, widows whose husbands have died of causes unrelated to HIV may become infected with HIV if the brother-in-law is already infected.

 In all three districts visited, widows are trying to challenge this institution to protect their families. However, there is considerable resistance to change, particularly among male family members. In some instances, this is a result of ignorance. For instance, a man who sees his late brother's widow looking healthy may ignore the possibility that she may be HIV-positive.  

What is more alarming, however, is the fact that even though some men are aware of the dangers of wife inheritance, they insist on inheriting a widow at any cost. It appears that this may be linked to the bride wealth: as wives and their children are the property of the clan, if they are not inherited the clan looses claim to this wealth.  

The fact that men insist on inheriting widows even when they have good reason to suspect that they may be HIV-positive is puzzling. Most HIV and AIDS initiatives do not deal with the issue of wife inheritance as it is a private and sensitive matter. TASO and ACORD are trying to challenge the institution, but find it a formidable obstacle to their work. TASO's greatest challenge, according to TASO Councillor Helen Onyango, is to convince elders and male relatives to discontinue wife inheritance. Only three out of ten times does TASO succeed in overruling customary practice.  

In many parts of Uganda, wife inheritance continues. This implies that a) HIV/AIDS initiatives do not address the issue of wife inheritance; b) the imparted knowledge does not address the wife inheritance issue effectively; or c) the impact of this knowledge is neutralized as a result of women's inferior legal and socio-economic status, and the absence of negotiation/assertiveness skills.  

Given the critical role that wife inheritance plays in the infection and/or transmission of HIV, there is an urgent need to address this problem, sensitize men and women and help families find alternative coping strategies.  

The case of Agnes (see Figure 4), points to the fact that with some help, women can successfully resist wife inheritance. Agnes' husband probably did not die of AIDS and thus she did not have to face the AIDS stigma. However, the fact that she was able to stand up to the family, resist being inherited and remain in her home is significant in itself. In addition, elders pointed out that given the devastating impact of wife inheritance, proper sensitization addressing the dangers involved could play a catalytic role in eradicating the practice.

2.3.2 Focus on the Socio-Economic Implications of HIV and AIDS for Orphans

The impact of the HIV epidemic on orphans depends on a variety of factors, including the socio-economic status of their families, their age and the age of their siblings. The following trends were observed: 

a. Orphans May be Uprooted from the Towns and Sent Back to the Village 

Youths whose parents die of AIDS in the towns are usually taken back to the village. Very often, the youths have to adjust at once to being orphans as well as to adapting to village life. In some cases, they may have never lived in the village and feel estranged from their new surroundings. The return to agricultural work is often looked down upon by city youths. In addition, the security and stability of family life is abruptly disrupted and there is no social safety net or mechanism to help youths through this transition. Family life education often ceases, thereby increasing risk behaviour among youths.

 b. Orphans may Run Away from Home to Escape the Stigma and Poverty 

In some cases, orphans may run away from home or from the extended family home to escape the AIDS stigma and the poverty that AIDS-afflicted and affected families are subjected to. A case in point is Mary's 20-year-old son, Paul, (see AIDS Profile 1), who left home to escape from the AIDS stigma and from poverty. He is now unemployed and his mother fears he may become a delinquent. 

As a result of AIDS, Tororo district is for the first time seeing the emergence of street children, most of whom are orphans, according to TASO. Several TASO clients, aged between 8 and 14 years, left their villages to work in the town as boda-boda (hired cyclists transporting people and goods). 

c. Orphans may be Taken out of School and Sent to Work

Under the pressure of the AIDS stigma which often severely hampers the ability of young widows to earn a living, orphans may be sent in the capital or abroad to make up for the loss of income and to help support younger siblings. A case in point is Edith (AIDS Profile 3), who after her husband's death sent her 14-year-old daughter to work as a housemaid in Kenya. 

d. Orphans may be Sent to Live with Relatives or Neighbours 

During the last funeral rites, a new head of family is appointed and the future of the orphans is decided upon. If both parents have died, the orphans are dispersed to various relatives. The disintegration of the family often means that adolescents and young men and women do not receive adequate attention and guidance from relatives, particularly family life education. Grandparents in particular often find themselves unable to control and discipline adolescents.  

Losing a parent to AIDS means that orphans have to assume new roles and responsibilities within the nuclear as well as extended family. One AIDS widow in Bwabya, Kabarole, who has six orphans expressed grave concern about the impact of HIV and AIDS on her family: "The children are lonely and sad without any family around the house while I work in the fields. I do not know how to comfort them. I tell them they have to be self-reliant from now on, that they cannot even rely on me as I also fear I am infected. I know I am asking them to grow up before their time, but I see no other alternative if they are to survive." 

Traditional roles, duties and responsibilities of family members become blurred, as AIDS places additional demands and pressures on orphans, particularly economic uncertainty, stigmatization and emotional insecurity. Girls appear to be carrying the brunt of the burden within the home and are given more responsibilities and duties than boys. They are taken out of school to work at home and on the farm and to sell produce in the market.

Some young women may be forced to break up their families to assist their HIV-infected parents. Rose (AIDS Profile 1) left her husband behind in January 1993 in order to take care of her mother who is suffering from AIDS. She is very torn by this decision because on the one hand she wants to take care of her mother, but on the other hand, she fears she may not have a marriage or family to go back to, as her husband may decide to take another wife. Even if he does not take another wife, however, Rose fears he may be engaging in high risk behaviour now that she is away but feels she does not have the right to confront him with it as she has "abandoned" him.  

2.3.3. The Impact of HIV and AIDS on the Household Economy and the Family Value System 

The impact of the HIV epidemic on the nuclear family ranges from break-down to disintegration, depending on whether one or both parents have died. The section below will analyse the socio-economic impact of HIV and AIDS on young widows, focusing on how the nuclear family breaks down and how the extended family network is strained to breaking point as traditional coping mechanisms collapse.  

The Household Economy Becomes Impoverished 

Having already depleted meagre resources and savings toward costly treatment for husbands suffering from AIDS and/or for funerals, widows suddenly find themselves deprived of labour, cash income and access to credit, inputs and support services. In widow-headed households with many young children and elderly and/or infirm family members, the impact can be devastating. The following coping mechanisms may emerge:

  i. The Working Day may be Lengthened  

Almost all widows interviewed mentioned that their working day had increased by two to four hours to make up for labour shortages and loss of income. One of the consequences of this coping mechanism, however, is that children were left unattended, their meals were poorly and hastily prepared and the widows' own health and diet deteriorated as a result of exhaustion and less food intake.  

Older children (10 years and above) are also working longer hours to assist single parents and their contribution to agricultural activities increased significantly. Those who have lost both parents and are living with relatives are more likely to work longer hours than children who have only lost one parent and remain in the nuclear home. Children assume greater responsibility in gathering fuelwood and fetching water, to allow their mothers more time in the shambas.  

Loss of agricultural knowledge was not observed in any of the three districts. This may be either because HIV has not hit the areas visited as hard as districts where loss of agricultural knowledge has been reported, such as Rakai and Masaka, but also because the disease is only now reaching its peak and the full impact is only beginning to be felt. In addition, agricultural knowledge is transmitted through women (mothers and grandmothers) and in the villages visited, there are more men than women dying of AIDS.

 ii. Land Area Under Cultivation may be Reduced 

Reducing land area under cultivation to accommodate labour shortages was the most commonly observed coping strategy among widows in the villages visited. Agricultural productivity tends to decline and families may become more vulnerable to crop failure. In Tororo and Gulu districts, vulnerable farming systems trigger periodic food shortages which are acutely felt by AIDS-affected families.  

iii. Cash Crops may be Substituted by Less Labour-Intensive Food Crops 

As a result of labour shortages and lack of resources for pesticides and other inputs, cash crops may be substituted with less labour-intensive (and often less nutritious) crops. Widows in Kabarole gave up growing tomatoes, a major cash crop, which they previously grew jointly with their husbands due to lack of money for fungicides. Rice and millet, which are labour-intensive, are also often abandoned in favour of maize and cassava which require less labour.  

iv. Planting and Weeding may be Delayed Leading to Poor Harvests or the Loss of an Agricultural Season 

When a family member dies, relatives stop working in the shambas and do not engage in agricultural activities anywhere from a week to several months, depending on the age of the deceased. At times, the entire village may stop agricultural activities for a week. If three people die consecutively, then farmers may neglect their shambas for three or more months. As a result, the time of planting is often delayed and some families may lose an agricultural season. The impact on food security can be severe and households may experience food shortages. Failure to comply with this custom can lead to beating or to ostracism from the family. There is evidence, however, that this trend is changing as people are forced to disregard cultural norms and resume agricultural activities after two or three days of mourning, particularly in Gulu.  

 v. Shambas may be Neglected and/or Abandoned

HIV-infected men and women may be unable to engage in agricultural activities as they grow weaker and eventually abandon the shamba. Joseph of Kantarara, Kabarole abandoned his land because he was too weak to farm (AIDS profile 2). If AIDS widows are themselves infected with HIV or already ill, they are often weak and therefore unable to work in the shamba. In Kwapa and Bumanda villages, several widows had ceased farming because they felt it was pointless to grow food when they did not know if they would survive the season. This was echoed widely across villages: "Why plan for tomorrow when you know you will go [die] today?" said one man in Kabarole. In other instances, if a mother has a sick child, she may have to neglect the shamba in order to care for it. Therefore, the impact on agriculture may also be indirect.

 Once shambas are neglected, AIDS-afflicted families become almost entirely dependent on relatives or neighbours for food and basic necessities. In extreme cases, AIDS-afflicted families may experience severe food shortages and hunger. A case in point is Edith (AIDS Profile 3) of Kwapa village, Tororo. A widow suffering from AIDS, she was severely undernourished as a result of skipping meals regularly and confining her diet to one or two foods. Edith was caught in a vicious circle of being unable to grow food because she was not getting enough to eat and was therefore not strong enough to work in the shamba.

 However, it should be noted that while agricultural labour shortages were observed at the family level in all villages visited, these were not acute enough to have a significant effect on agricultural productivity at the village level. 

The extended family network is also often unable to withstand the strain of the impact of the HIV epidemic. Poor families, in particular, with infirm children and grandparents that take in one or several orphans find that they cannot support even their own children properly.

 In Elizabeth's case (see Figure 9), the impact of HIV and AIDS coincided with her husband's paralysis and her own illness. The burden of the fatherless children has virtually made it impossible for the family to cope. Elizabeth herself needs to go to the hospital to receive treatment but says that her sick child and husband are more in need of treatment than herself. Yet, the weaker she gets, the more difficult it will be for her to take care of the children and the infirm. Her case illustrates the fact that in many cases, the extended family may be in a weak position to cope with the HIV epidemic in the first place. In such cases, the HIV/AIDS burden may strain the extended family network to breaking point. 

The same applies to Patricia from Kwapa village, Tororo (see AIDS profile 4), who has witnessed her entire family become infected with HIV. Her stepmother is already burdened with caring for four orphans and a sick husband. Patricia's fear is that when she dies, there will be no one to look after her children. Sometimes, she said, this makes her think it may be better if the children do not survive her.

 Sometimes, the extended family may not consist of more than one individual. The case of Rebecca (figure 10), a young woman who heads a household of 11 girls/young women and does not have any support, is not unusual. Rebecca does not have access to any income-generating activity except for beer brewing. As she does not even have enough food for three meals a day, she cannot think about how she will be able to ensure that her children as well as her brothers' orphans, will stay in school. Rebecca said that if she had access to training for an income-generating activity that would help her supplement her income and could belong to a youth or farmer group, her situation could improve significantly.

b. The Health Status of the Nuclear/Extended Family may Deteriorate

i. The Nutritional Status of the Family may Decline

 Loss of access to labour in the shamba may result in declining agricultural productivity which in combination with loss of cash income often leads to a deterioration of the quality of household diet and a reduction in the number of meals. Malnutrition is on the rise in Gulu among HIV-affected families. Lacor Hospital's Assistant Medical Superintendent said that kwashiorkor, which was never a problem in the past, had since three years ago become the main reason for child admission in the hospital, especially during the "hungry season".

It should be noted, however, that in Tororo and Gulu the decline in the quantity and quality of food consumption may also be the result of the "hungry season" (May-July) which affects poorer families, rather than a result of the HIV epidemic, per se. It can be argued, however, that HIV-affected families are harder hit during the "hungry season."  

Hunger among HIV-affected households was not witnessed in Kabarole. These families may have reduced the number of meals per day and resorted to a less varied diet but they still had enough to eat. This may be due to the fact that land is more fertile in Kabarole and farming systems are more resistant than those in Tororo and Gulu. Farming systems in Tororo (with the exception of Iyolwa county) and Gulu are more fragile. In Tororo, the soil is less fertile and food crops like cassava, sorghum and millet are more labour-intensive and need more attention. The seasonality of crops is also an important factor. In Kabarole, for instance, matoke can be harvested all year round. This is not the case with sorghum and millet in Tororo. Tororo is also suffering from drought and its sandy soils may be affected more severely. The district has a high population density and the land is cultivated beyond carrying capacity. In addition, the diet in Tororo is poorer because fresh vegetables are not readily available throughout the year. Vegetables (greens, tomatoes, eggplant, okra and pumpkin) are only available during the rainy season. In addition, vegetables need extra preparation, oil and spices which poor people cannot afford. Lastly, people in Tororo are not aware of the nutritional value of vegetables.  

Declining agricultural productivity and loss of income often force widows to modify the family diet and, in particular, to:  

* Limit the Household Diet to One or Two Staple Foods 

As a result of reducing the number of crops under cultivation and/or switching to less labour-intensive crops, the diet becomes restricted to one or two starches (finger millet and cassava, matoke, or poshio [maize porridge], often of poor nutritional value, that are served with a vegetable sauce. Few widows had money for meat/fish, cooking oil and some were no longer able to afford salt.  

In Bwabya, Kabarole, one widow said that her family's diet changed drastically after her husband's death. When he was alive, she regularly bought oil for frying, milk, sugar, salt, maize flour for porridge, and soap. These days, she can only afford paraffine, salt, matches and soap. Food preparation has suffered as a result and the quality and nutritional value of the household diet have been affected.

 * Reduce the Number of Meals

Widows may be forced to reduce the number of meals they provide for their families. In Kabarole, the number of meals was in some cases reduced from three to two and in Tororo and Gulu from two to one. Young widows reported regularly skipping meals (especially lunch) thereby jeopardizing their health and their ability to take care of their families.

 * Sell Part of their Produce to Buy Essential Goods and Medicine

Widows may be forced to sell part of the food they grow in order to maintain basic levels of hygiene and tend to their children's medical needs. Selling food crops to buy soap, matches and drugs was common, particularly in Tororo.

ii. Resources for Essential Medical Care and Treatment May be Depleted 

Families affected by HIV and AIDS are required to spend most of the household budget treating family members with AIDS. As a result, there is often little money left to tend to children's health needs. The first expenditure to be cut when the household budget has been depleted is essential drugs, according to Helen Onyango of TASO Tororo. Widows are often reluctant to use the household budget to tend to their own medical needs and will postpone treatment in order to accommodate the needs of their children. The long-term consequences of this strategy are often disastrous for the family and by the time women go to the doctor, they are already quite ill and unable to care for their children. 

 c. Education may be Discontinued

 According to TASO Tororo, one in five children of HIV-affected households in the district remain in school. HIV- affected families are often forced to take their children out of school either because they have no money for school fees or else because they need the children's labour. Families who receive orphans are faced with the dilemma of having to select which children to put through school. Boys are usually chosen over girls. In some cases, when all children cannot be accommodated, relatives are forced to select their own children over the orphans.  

The AIDS stigma sometimes pressures children to drop out of school. In the case of Mary, (AIDS Profile 1), her son was virtually ostracized from school because his father had died of AIDS. Mary feared that skipping school could lead to dropping out of school altogether.

 d. The Value System of the Nuclear and Extended Family may be Eroded 

The socio-economic impact of HIV and AIDS is beginning to have an effect on the value system of the family as traditional norms and customs are breaking down under the pressures triggered by the HIV epidemic. The result is that the social fabric of the extended family is showing signs of erosion and the close bonds that hold family members together are disappearing. The ramifications of this erosion have yet to be felt fully.

 To give but some examples:  

i) the stigma attached to those infected with HIV is, as discussed above, in some cases, breaking up families and distancing mothers from their children;  

ii) parents are forced to either send their children to work or to take them out of school. In both cases, youths are being deprived of family life education which is instrumental in establishing a code of conduct between men and women and husbands and wives. Family life education is critical in the social development of young men and women, ensuring the transmission of family values, mores and norms, establishing a social/sexual code of conduct and setting limits in sexual conduct. Many parents attribute early sexual activity and multiple/casual partners to the disappearance of family life education;  

iii) in some areas, families are being forced to adjust burial rites and ceremonies to cope with economic pressures resulting from HIV and AIDS. Firstly, the mourning time is being shortened to only three or four days. Secondly, less money is being spent. And thirdly, the drinking and socialization taking place during burials is changing to discourage substance abuse and casual sex; and  

iv) traditions such as ritual cleansing⁸ and wife inheritance are threatening the well-being of the extended family as a result of the HIV epidemic but no acceptable alternative mechanisms have been developed. 

2.4 Youth and HIV: Knowledge, Attitude and Practice (KAP) 

2.4.1 Knowledge⁹ 

In all three districts, it was observed that HIV education initiatives primarily concentrate along the highways but do not reach villages even a few miles off the main road. Knowledge of HIV and AIDS is directly linked to distance from towns and roads. In general terms, people were better informed about HIV and AIDS in Kabarole than in Tororo and were very poorly informed in Gulu. 

A recent ACP evaluation reported that "Awareness of AIDS [in Uganda] was found to be almost universal. Levels of basic knowledge about AIDS, particularly sexual transmission, were very high."¹⁰ As a result, HIV and AIDS initiatives are now focusing on the next step -- translating knowledge into behaviour change by empowering people to make informed decisions about sex.  

In all six villages visited, the professed 80-90% awareness of HIV and AIDS that was quoted by many district officials, was incorrect. In one focus group discussion in Lawiye Adul in Gulu, 4 out of 13 women had never heard about HIV and/or AIDS and 8 did not know the modes of transmission. In four villages in Tororo and Gulu, villagers initially denied that the HIV epidemic was a problem in their communities and attributed it to witchcraft. 

The TASO general manager in Tororo argued that "People may know what AIDS is [in Tororo], but they lack even the most basic facts about the disease." One reason why knowledge of HIV and AIDS has not been effectively imparted is that often it is taught in a top down one-way process rather than shared in an interactive manner. Teachers make assumptions about the level of knowledge of men and women that are often erroneous. When out-of-school youths do not understand something, they may be reluctant to ask questions for fear of being ridiculed. This is especially true of out-of-school girls.  

Our focus group discussions revealed that even when people knew the basic facts about the disease, they understood very little about the dynamics of HIV and AIDS. Knowledge of the modes of transmission and prevention exists largely on a theoretical level: people can quote how the disease is transmitted but they do not understand how this may actually happen to them. As a result, this knowledge is academic and abstract, rather than practical and tangible, and does not relate to the individual's own life experience. It is the kind of knowledge that comes from memorizing rather than grasping issues. And even when women did have the basic facts about HIV and AIDS, they were not confident with what they knew about the disease and did not feel empowered by this knowledge. One reason for this is that most HIV messages have been health-oriented and have not been integrated in the overall social context.  

This partly explains the prevailing stereotype that was observed in all three districts -- that it is the women who are responsible for spreading HIV. This stereotype has inflicted a heavy stigma on women and is a formidable obstacle to behaviour change as many men absolve themselves from responsibility by automatically blaming the women for the transmission of HIV.

Another factor which demonstrates that people have not understood the basic facts about the HIV epidemic is the abundance of misconceptions. In Gulu and Tororo, some people thought that those with blood type 0 are less likely to get HIV. A point of concern in all three districts was the transmission of HIV through mosquitoes. In Bumanda, Tororo, it was argued that someone who has malaria always tests HIV positive. In Kabarole, women and men believe that those who have syphilis or gonorrhoea do not get infected with HIV. Abstinence was perceived to be unhealthy, especially among young males. One male youth said that teachers at school had told them that if they abstained from sex, the tail of the sperm would fall off.  

The significance of sexually transmitted diseases (STDs) in the spread of HIV is still unknown to most rural Ugandans and the incidence of STDs appears to be very high. In Tororo, STDs are rampant but men and women know very little about them. In Kabarole, people were more aware of STDs and usually sought treatment. Some young people, however, said that the cost of seeking medical attention was prohibitive. In Gulu, many women did not know much about syphilis and gonorrhoea and did not know that STDs can be treated. Some women knew about HIV and AIDS but not about STDs. In Bumanda, Tororo District, some people suffering from STDs were using veterinary drugs given to them by retired Veterinary Officers. Both men and women were eager to have more information on STDs and how they can be prevented.  

On the whole, five general observations were made in all districts concerning knowledge of HIV and AIDS: 

a. Adult men are far better informed about HIV and AIDS than adult women.

Men are more mobile, have more access to information and have more leisure time to socialize and exchange ideas. HIV and AIDS are often discussed in the bars, for instance. In addition, some men have the opportunity to attend HIV sensitization seminars. Not a single woman in the villages we visited had attended one. Training of religious leaders and opinion-makers has also tended to be male-oriented and none of the men who had been trained and sensitized in HIV-related issues had shared the knowledge with their wives or fellow villagers. In addition, health and community workers who are engaged in HIV sensitization tend to be men. Many reported that women were "not interested in health issues," but when they were asked if they had actually approached women to discuss HIV and AIDS, they admitted that they rarely did so. In Nyankuku, Kabarole, women said that no health workers ever visited their village but pointed out that since most health workers were men, they could not discuss with them intimate problems such as sexually transmitted diseases (STDs) and HIV in the first place. 

b. School youths are far better informed than out-of-school youths.

Although school and out-of-school youths are not distinct groups, one can trace substantial differences. School youths have direct access to information, greater opportunities and more choices in life. They are easy to reach, organize and monitor and for this reason they have been targeted extensively by governmental and non-governmental organizations working on HIV and AIDS. HIV education is now part of the school syllabus at the P5 and P6 levels. Findings from the school questionnaires distributed in three districts reveal that schoolchildren are considerably better informed about HIV and AIDS than out-of-school youths. In one school in Gulu, young boys and girls were even knowledgeable about condoms, in sharp contrast to out-of-school youths. Teachers confirmed that school boys are beginning to use condoms.

Out-of-school youths consist mostly of young men and women who have had little or no schooling. They constitute over 50% of the youth between the ages of 15 and 19¹¹. Young women are by far the majority in this group. Out-of-school youths are hard to reach and difficult to target. They have little access to information, are often intimidated and lack self-confidence. They are rarely given the opportunity to learn about health issues and even in the rare instances where sensitization sessions are held, they are not specifically invited, made welcome and involved in discussion.  

c. School boys are better informed than school girls.

In all the schools visited, boys of 13-15 had a better understanding of the issues than girls of the same age. This may largely be a result of the fact that many young men have a P7 education while most girls drop out at the P3-P4 level before they begin HIV education at the P5 and P6 level. 

d. Adult women are better informed than young out-of-school girls.

Several adolescent girls (married as well as single) in the six villages visited had never heard about "SLIM." In Nyankuku, Kabarole and in Bumanda, Tororo, out-of-school girls had heard about the disease but had confused information about transmission and prevention. Adult women appear to be better informed, mostly because they are more confident in raising sexual issues with their husbands while younger women feel too shy or intimidated by their spouses.  

e. Sex/HIV education within the family is almost non-existent.

In all three districts, parents do not discuss sex or HIV with their children. Some parents fear that talking to their children about sex and HIV may encourage them to become sexually active. Others find it too sensitive and embarrassing.

Most adolescents learn about sex and sexuality from their friends. For instance, the Medecins Sans Frontieres AIDS Control Programme in Moyo District found that only 16% of the people surveyed had subsequently discussed HIV with their children. HIV education campaigns have not been very successful in breaking down this taboo. Perhaps even more significant is the fact that in all three districts, young women who had lost their husbands to AIDS and were themselves infected, had not revealed to their children the cause of death of their father or their own sero-status. Edith (AIDS Profile 3) has not been able to tell her daughter about her condition and has not talked with her about HIV. Another widow in Bwabya, Kabarole, whose husband recently died of AIDS had not even considered telling her children about HIV and AIDS because they were not sexually active. When it was pointed out to her that children in the village were known to start at an even younger age than her children, she was surprised but said she could not bring herself to think that her children could ever be infected with HIV. With only one exception, infected widows had never discussed AIDS with their children. A frequently given explanation was: "I could not bring myself to tell my children." Often, it is during the burial that children find out the cause of death of their father from relatives or neighbours and their mother's sero-status.  

2.4.2 Attitudes

 "Youth still feels free from AIDS" remarked the DMO in Tororo, indicating that youths are carefree, fearless and feel they are invincible. This is largely true of rural youths whose attitudes can be extremely cynical. "The only medicine to AIDS is death itself," said one young man in Bwabya, Kabarole. A 25-year-old woman who recently died of AIDS in the same village, was reported to have had sex with "everyone she could mess with" in search of revenge.

 The fact that in Tororo and Gulu villagers initially denied that AIDS was a problem in their communities partly shows that proper sensitization has not taken place and also explains why many people attribute HIV and AIDS to witchcraft. For some, witchcraft is a far more acceptable explanation than AIDS, which is associated with immorality. In Gulu, many people thought that AIDS was a form of punishment for evil deeds. A born again Christian in Tororo wondered if AIDS was the incurable disease that, according to the Bible, would come at the end of the world. Denial of the problem and witchcraft were not prevalent in Kabarole where people talked openly about HIV and AIDS. 

Attitude is directly linked to knowledge or the absence of knowledge. The fact that many rural youths have largely an abstract knowledge of HIV and AIDS explains why they blame the HIV positive partner for transmitting HIV rather than themselves for engaging in high risk sexual behaviour. As a result, messages are not internalized, knowledge is ignored or dismissed, and does not translate into behaviour change. In Gulu, Mr. James Lomoro, District Inspector of Schools, argued that even actors are not abiding by the messages they communicate through plays addressing HIV and AIDS. HIV messages are viewed as a nuisance, he added, and when they recommend pre-marital abstinence, young people laugh it off.

The less people know about the disease the more negative they tend to be about HIV-affected families. Some men and women suggested isolating people with AIDS in camps, and since "these people are going to die anyway", they thought that resources should be reallocated toward HIV prevention for those who are free of HIV. Attitudes toward AIDS organizations can also be negative. In Bumanda, Tororo, some people blamed TASO for the spread of HIV, claiming that TASO helped sick people recover and resume sexual activity. As a result, clients do not want to be visited by the TASO vehicle, and councillors often have to park their car far from the client's home.  

Tradition is often stronger than knowledge and it can make people overlook the dangers of HIV, according to Helen Onyango of TASO Tororo. For instance, a father who has lost a son to AIDS may still encourage his daughter-in-law to be inherited. And as discussed above, wife inheritance has not been challenged yet except in isolated cases, despite the dangers it entails. 

Attitudes toward the "faithful partner" prevention strategy, are ambivalent and concern was raised over trusting one's partner: "I have a [girl]friend who lives in a village about five miles from here," said a young man. "I go there, perhaps every two weeks. How can I know what she does when I am not there?" Another one said: "The girls around here are very smart. They attract you in all ways and tell you they are healthy. What can we do?" And another: "How can we live without eating?" referring to the difficulty of being faithful to one partner or resorting to abstinence. 

Attitudes toward blood testing were overwhelmingly positive, particularly among young women who feared they may be infected with HIV. Testing for HIV before marriage was also raised as a must. Some youths were skeptical about the reliability of the AIDS test and did not understand the need to have more than one test to account for the "window period." Youths wanted practical advice on how to go about persuading a partner to get the AIDS test. The need for communication and negotiation skills emerged as a critical issue in HIV prevention among young people.  

2.4.3 Practice 

a. Early Sexual Activity 

Adolescents are most at risk because they tend to experiment more than married couples and have many sexual partners. For girls, adolescence may be very brief as childhood, marriage and parenthood are often very close together.  

It has been reported that sexual activity in Uganda begins between the ages of 10 and 15 and that the average age of first sexual intercourse for boys and girls in Uganda is about 15 years¹². Preliminary findings of a research proposal on the sexual behaviour of out-of-school adolescents (15-18 years of age) indicate that for both sexes, the reported age of first sexual activity is from 8 to 14 years and that penetrative sex begins at about 13 years. Some studies have found that more than 40% of girls have had sexual intercourse before the age of 14 years¹³. Factors contributing to early sexual activity include poverty, overcrowding and urbanization¹⁴.  

In Tororo District, a study of adolescent mothers conducted in 1990 revealed that 70% became sexually active between the ages 10 and 14 while 10% became active before the age of 10. These figures correspond closely with our findings. 

Youths in all three districts are engaging in sexual activity increasingly younger for the following reasons: 

1. Children share the same hut with their parents until they are 10-12 years old. Lack of privacy means that children are present when their parents have sex, become curious and want to try it themselves.  
2. Parents do not talk to their children about sex. Oftentimes, youths become sexually active before they are aware of the consequences and dangers involved not only in terms of HIV but also in terms of pregnancy and the contraction of STDs.  
3. Parents do not spend enough time with their children and many youths, feeling neglected, turn to sex to compensate for the lack of attention.  
4. When girls and boys visit each other, they bring cousins, relatives and friends along with them. They sometimes spend the night with the extended family or friend. These occasions provide opportunities for sex. 
5. Poverty often means that youths lack basic essentials and are willing to have sex in exchange for food, clothes, shoes, school fees, and other rewards or favours. In one school in Tororo district, most of the sexually active P6 girls had sex in return for food, clothing, money or a gift.
6. In homes where alcohol is consumed by one or both parents, sexual activity among their children begins earlier, sometimes as early as 6-8 years.
7. In Lawiye Adul, Gulu, boys of 13-14 years of age leave the parental home and are given their own separate homestead. This practice means that the family exercises little control over the sexual behaviour of their children thereafter. Parents argued that this custom encouraged early sexual activity.  
8. According to one school questionnaire, 27 out of 184 primary school children in Uganda who had had sexual intercourse reported that it was "forced."¹⁵ Forced intercourse may be violent and may result in lacerations and bleeding, thereby increasing the risk of HIV transmission.