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

3. CONCLUSIONS & RECOMMENDATIONS

The Spread of HIV and AIDS in Rural Uganda

 Available HIV seroprevalence data for rural areas may not always be reliable and indicative of the spread of the disease in a given area. Districts believed to be only marginally affected by HIV and AIDS may appear so only because there are no sentinel sites or other monitoring mechanisms in place. The spread of AIDS follows a different pattern in each village and district. Geographic and ethnic factors, agro-ecological conditions, religion, gender, age and marital status play a role in the pattern and impact of HIV and AIDS and in people's perceptions of the disease. Even within one district, two villages can have markedly different agro-ecological conditions and customs that determine sexual behaviour and attitudes towards HIV and AIDS. This has critical implications for the design of HIV and AIDS interventions, as district specific approaches are essential.

HIV and AIDS Impact on Rural Families and Youth

 The burden of the socio-economic impact of HIV and AIDS is disproportionately affecting rural women. More households were found to be headed by AIDS widows than by AIDS widowers in the districts where field work was conducted. Widows with dependent children tend to become entrenched in poverty as they typically lose access to land, labour, inputs, credit and support services. HIV and AIDS stigmatization compounds their situation further, eventually severing assistance from the extended family and the community, which is often their only safety net. 

Women's limited economic opportunities, their lack of rights to land and property, as well as traditional norms and customs, can have serious, and often devastating, repercussions on the nuclear and extended families in the context of the HIV and AIDS epidemic. These need to be addressed when designing HIV and AIDS interventions in the context of women's overall socio-economic status. For example:  

• Alcohol brewing/distilling is a major economic activity for many young rural women in Uganda. It is also a major economic activity which creates a high risk environment for the spread of HIV, as women's homes often become makeshift bars. While the link between heavy drinking and the spread of HIV is apparent and needs to be addressed, what is even more critical is the need to create alternative income-generating opportunities for rural women.
• Bride wealth, which has become unaffordable for many young men these days, and the breakdown of the institution of marriage are contributing to a growing number of informal unions between men and women, which deprive women of legal and socio-economic rights and status that marriage bestows upon them.  

Changes in legislation, legal literacy and social mobilization to promote women's legal rights also need to be part of effective HIV and AIDS interventions.  

• Ritual cleansing and wife inheritance can greatly facilitate the spread of the HIV virus to the extended family. Even though these are sensitive and difficult issues to address, they are often issues which may determine the economic and social status of an AIDS widow and her family. 
• Young men and women are vulnerable to HIV infection because they begin to be sexually active at an increasingly young age; they tend to have multiple sexual partners and have restricted access to information on safer sexual practices. In addition, the interplay of a wide range of factors, such as war and instability, the loss of appeal in agriculture as a gainful profession, economic hardship and the absence of income-generating opportunities, the increase in drop-out school rates and alcohol/drug abuse, have contributed to the creation of a high risk environment for rural young men and women. The resulting increase in poverty and illiteracy, the lack of employment opportunities, and the erosion of social values and family life education act as catalysts to high risk sexual behaviour.

Knowledge, Attitude and Practice 

The assumption that 80%-90% of Ugandan men and women are aware of HIV and AIDS and know how to protect themselves does not apply to the rural areas visited, particularly not to young rural women. Myths, misconceptions, superstitions, stereotypes and stigmatization are widely prevalent in Tororo and Gulu districts. The less people know about the disease, the more negative they tend to be about HIV and AIDS-afflicted and affected families and the stronger the stigmatization attached to persons and families afflicted or affected by the disease. What is particularly significant is that individuals tend to blame their partners for transmitting the HIV virus, not themselves for engaging in high risk sexual behaviour. Typically, men tend to blame women for carrying the HIV virus and for infecting men.

 In general terms, school children are better informed about HIV and AIDS than out-of-school youths; school boys are better informed than school girls; out-of-school young men are better informed than out-of-school young women; and older women are better informed than younger women. Interventions for HIV and AIDS prevention need therefore to differentiate between school and out-of-school rural youths. 

Out-of-school youths, including those who drop out, make up the majority of rural young people. As HIV and AIDS initiatives are already targeting school children with some success, it is most important to reach out-of-school rural youths, particularly girls. In rural areas, girls tend to drop out of school at the P3 or P4 level and do not benefit from HIV and AIDS education which begins at the P5 and P6 level. Young women therefore are highly susceptible to contracting HIV, not only because they have until recently been neglected by HIV and AIDS education interventions, but also because of biological, health-related and socio-economic reasons. 

Occasions and sites where out-of-school rural youths can be mobilized include meeting places such as wells, markets, bars, and social or recreational events (weddings, funerals, football/netball matches). Out-of-school youths can be mobilized more effectively when labour demand is at its lowest, i.e. during the dry season, when they have more free time. School premises can be used for out-of-school activities during weekends and holidays.  

The Uganda National Operational Plan for STD/HIV and AIDS Prevention, Care and Support 1994-1998 has proposed that HIV and AIDS education should aim at behaviour change with a priority on children and youth and that "prevention activities should be integrated into mainstream health programmes and other programmes dealing with community, women and youth development. 

When designing interventions, age groups may have to be targeted separately, given the fact that their lifestyles, sexual behaviour and learning abilities differ. Youth includes children (ages 10-14), adolescents -- some of whom are parents themselves, particularly young women -- (ages 15-18), and young adults most of whom are parents (19-25 years). A critical point about youth is that childhood and adolescence, and marriage and parenthood, are often very close together, particularly for girls/young women. 

Effective behaviour change strategies need to involve the youth itself in the generation of appropriate messages and should address youth-specific socio-economic and cultural realities that influence sexual behaviour. Creating a forum for discussion and for interactive learning, where respect for HIV and AIDS as well as for young people's social and sexual needs co-exist, can help create an enabling environment for the generation of appropriate messages. 

The socio-cultural norms to be addressed include early uptake of sexual activity, STDs, alcohol and drug abuse, bar and disco culture, ritual cleansing and wife inheritance, etc. If behaviour change is measured in part in terms of changing patterns of alcohol/drug use, frequency of bar visits, etc., a more accurate picture of behaviour change would emerge. 

The fact that behaviour change is a continuous process and a change in lifestyle rather than an occasional exercise in self-control needs to be addressed in the design of interventions. Behaviour change is, in addition to knowing the facts about HIV and AIDS, also conditional on knowing how to communicate, negotiate and be assertive with a sexual partner, on being motivated to continue practicing safe sex and on persevering. The adoption of a change in sexual behaviour, however, has different implications for men and for women and for the way they relate, and these need to be taken into account systematically.  

Many young men and women, want to be tested for HIV (sometimes along with their children), but they do not have access to information and facilities. Pre-testing counselling and practical advice on how to persuade a partner to take the HIV test are key components. A major issue to be addressed, however, is transport cost, which is often prohibitively high, especially for women.

Planning HIV and AIDS Educational Interventions for Youth Programmes 

Youth programmes aiming at increasing opportunities for young men and women in rural areas through income-generating activities, leadership and management training, recreation, health education, and communication/negotiation skills are in themselves a strategy against HIV and AIDS and need to be targeted as such. Youth development activities can help prevent the spread of HIV and AIDS by informing young men and women about HIV and AIDS, empowering them to make choices and change their social and sexual behaviour and their lifestyles in general. 

When planning HIV and AIDS education components (prevention and impact alleviation) for youth programmes in rural areas, the following issues need to be addressed: 

• The integration of HIV and AIDS education within a Health Promotion package which will include primary health care (safe water, water-borne diseases, Oral Rehydration Salts, etc.), nutrition, first aid, family planning, and sexually transmitted diseases. This primary health care component, including HIV and AIDS, should be targeted to both women and men.  

• Sensitizing youth to HIV, AIDS and STD issues does not mean "teaching" and/or "preaching". A top-down approach may alienate youths and/or generate inappropriate messages. Rural women reported, for instance, that health workers usually talk in general terms and do not address concrete situations and problems, such as wife inheritance. Participatory training addressing group dynamics, gender relations, social norms, etc., may be more effective in generating appropriate messages. The objective should be not simply to disseminate information but to stimulate discussion and debate that will allow boys/young men and girls/young women to internalize the information and messages generated during the discussion. AIDS activities can and should be creative, entertaining, educational and relevant to young men's and women's lives. Some of these activities could be initiated by the youths themselves -- the more involved they are in the design and implementation process, the more effective the message is likely to be.

• The need to communicate on a continuous basis the basic facts about HIV and AIDS transmission and prevention. Many young people have memorized the facts about HIV and AIDS but have not internalized this knowledge and are not confident with what they know about the disease. The goal should be to delay the onset of sexual activity among the under 10 year olds and promote low risk practices amongst those who are already sexually active. 

Questions frequently raised during the field work, and which need to be addressed in STD/HIV/AIDS education initiatives include:  

Where did AIDS come from? Is Africa responsible for the disease? What is a virus? What does the HIV virus look like? Why can an infected man/woman look healthy for a long time? Is it unhealthy to abstain from sex? Why not? Should a woman use the same cloth to clean herself and the man after sex? ("enkumbi" practice). What can single men/women do when they are not married but want to have sex? What are the alternatives to penetrative sex? How can one persuade a partner to use condoms? How can a wife deny her husband sex when he is drunk and she knows he has other partners who may be infected with HIV? How can one persuade the husband's wife that a widow should not be inherited? Where can an AIDS widow seek advice, support and assistance? What can one do to live longer with AIDS? How can one help people suffering from AIDS? Myths and misconceptions about HIV and AIDS need to be dispelled, as well as stereotypes (that it is the women who are responsible for the transmission of HIV and AIDS), superstitions (witchcraft), and prejudices. These need to be eradicated by addressing them systematically in HIV and AIDS prevention and mitigation programmes. 

The dynamics of social interaction between young men and women, traditional norms and customs, and particularly male and female attitudes toward consent to sexual intercourse. HIV and AIDS prevention programmes need to empower girls and young women to be in control of their relationships with men, to have confidence in their knowledge about HIV and AIDS, and to discuss HIV and AIDS with their partners. They also need to target men with issues concerning women, wife inheritance, forced sex, alcohol, discos, early sexual activity, condom use and STDs. Instructional materials for youth and community workers on the socio-economic context of HIV and AIDS for rural youths in English as well as in local languages can be developed in collaboration with local NGOs. It is critical that these materials be developed locally. 

Training in negotiation skills and assertiveness should constitute an integral part of HIV and AIDS education for men and women. Discussing with young women ways in which they can say no to sex, and if forced into having sex, ways of handling it are some of the points to be addressed. Instructional materials on communication, negotiation, decision-making and assertiveness skills addressing problems most frequently encountered by young men and women may also need to be developed. To impart these skills, role playing exercises with the sexes exchanging roles could be used. The issues of motivation, peer support and perseverance in every behaviour change communication also need to be built in the training. 

The importance of training male as well as female trainers to deliver HIV and AIDS messages. These can be youth leaders, RC youth officers, youth leader office bearers, health workers, and/or youths afflicted or affected by HIV and AIDS, or a combination of the above. Ways of ensuring that trainers, in this case male and female youth leaders, will disseminate the imparted information and messages to young men and women need to be built into the training curricula. During the field work, it was observed that trainers often do not disseminate the imparted information to the villagers, particularly to women. 

Social interaction habits like alcohol and drug abuse that facilitate casual sexual contacts also needs to be addressed. To combine health messages with an anti-alcohol campaign is far from simple and care should be taken not to pass judgment on alcohol abusers. A more effective approach would be to alert young men and women to the dangers of alcohol abuse, stimulate discussion, and leave the decision up to them. 

The promotion of condom use should be accompanied by extensive sensitization covering issues such as how to raise the subject with a sexual partner, when to use condoms, how to use them properly, how to dispose of them properly, and underscoring the importance of consistent use. 

Basic legal literacy for youths and widows. Informing widows and young women of their rights before the law, especially with regard to inheritance/property rights and sexual abuse, should be part of every HIV and AIDS prevention component. For instance, in 1990, the government of Uganda passed a bill rendering sexual abuse of children below 18 years punishable by up to 10 years imprisonment. Such progressive legislation should be disseminated as widely as possible in rural areas. Women are usually not aware of their legal rights, nor of ongoing revisions of statutes affecting them and their children.  

Sensitization of women's rights should not only be undertaken for the women but also for the men who need to be informed of women's rights before the law. It is also important to refer women to places where they can get legal assistance. Information on the benefits of opening bank accounts (why, how and where) may also be of assistance, particularly to women who have only girl children. 

Support for people with AIDS or people who are vulnerable to HIV and AIDS. Young widows/ widowers whose families have been affected by AIDS could be involved in HIV and AIDS education and related activities and possibly given some incentives. They can also be assisted with information on how to live positively with AIDS within the community, and instructed how to make wills. 

Training and working with young PWAs to reinforce HIV and AIDS messages. ACORD has sponsored training for PWAs in order to make its AIDS sensitization seminars more effective. Working with PWAs is proving to be more successful than costly and impractical video shows, most of which are in English, and it provides income to AIDS afflicted families. Uganda's youth programme could introduce the concept of organizing STD/HIV/AIDS education with assistance from youths who are afflicted or affected by HIV and AIDS. This will ensure that youths and their families affected by HIV and AIDS will not be marginalized, that PWAs will have a new purpose and positive role in life while also supplementing their income. Finally, it will also enhance interactive delivery of HIV and AIDS messages and make behaviour change more effective.  

AIDS Drama Competition for rural youth groups. Youths can be asked to write their own plays based on their own experience. By inviting rural youth groups to write their own plays, the youths will be essentially designing their own personal and village-specific AIDS campaign. Stereotypes on HIV and AIDS, myths about AIDS and the attitudes of youths on AIDS can be thus tackled, debated and clarified. Topics such as alcohol, early sexual activity, wife inheritance, STDs and living positively with AIDS can be explored in such plays. 

Linkages between rural youth programmes and related Ministries, international organizations and NGOs involved in HIV and AIDS interventions. Collaboration between the above-mentioned agencies may be uneven at the district level, given the fact that resources are unequally distributed between the districts. Rakai has more than 30 NGOs working on AIDS while Tororo and Gulu have only a handful. In Kabarole, GTZ and ACP have launched a comprehensive programme on HIV and AIDS (though mostly focusing on urban and peri-urban areas) and there are several other NGOs working there. GTZ-ACP have considerable resources and linkages could be established with the

youth programme to tap these resources. The issue of district coordination of AIDS activities also needs to be addressed. District coordination of AIDS activities is poor in Kabarole and Tororo Mdistricts (there were no District AIDS Committees at the time of field research) but encouraging in Gulu district.

HIV/AIDS and Agricultural Extension

 HIV and AIDS are having an adverse effect on the already overburdened and under-resourced agricultural extension service. Highly qualified civil servants and technocrats are increasingly dying of AIDS and are not being replaced. In some districts, it is becoming difficult to implement agricultural programmes as a result of HIV and AIDS: extension staff are frequently attending burials. Every time there is a burial, the work week is reduced from six to three days (Tuesday, Wednesday and Thursday) as civil servants have to take Saturday, Sunday and Monday off (Friday is the official day of rest) to travel to villages and attend burials. HIV and AIDS interventions targeting rural youths through the agricultural extension service may be ineffective without appropriate measures to strengthen extension services.

 Training for agricultural extension workers could: a) raise awareness of groups vulnerable to AIDS (youths, including widows/widowers and orphans) and address the needs of each of these groups; b) sensitize agricultural extension workers to the impact of HIV and AIDS on agriculture (vulnerable farming systems) and rural development; and c) strengthen existing household and community coping mechanisms.  

PROPOSAL - A three-day workshop for agricultural extension workers, consisting of:  

• Presentation of the different farming systems and rural settings in the districts, including:
  -agro-ecological conditions;
  - crops;
  - livestock;
  - labour use, labour division;
  - off-farm activities; and
  - community life with special emphasis on youth. 
• Methodology: participants make presentations on their respective districts, e.g., preparation of paper or poster. 
• General introduction to the HIV and AIDS pandemic and situation analysis of the districts. 
• Methodology: lecture with discussion. 
• How are HIV and AIDS linked to agriculture and rural development? 
• Methodology: Brainstorming with visualisation (participants write their ideas on cards which are then grouped and discussed). 
• Case studies:
  -Household level: Case studies of HIV- and AIDS-afflicted and affected households in different farming systems, with a focus on households with young household members;
  - Community level: Case study of an HIV- and AIDS-affected community. 
• Issues: What types of problems will appear in these households? How will the households respond to the pandemic and why? What kind of coping strategies will develop? What kind of changes occur in terms of agricultural and off-farm activities? How will rural youths respond?
• Methodology: Group work with presentation and discussion; presentation of own experiences with regard to HIV- and AIDS-affected and afflicted households in various districts. 
• Issues: How can the Agricultural Extension Service support the various coping mechanisms and livelihood strategies of different types of households, especially young widows? Which extension packages will have to be adjusted to address the impact of the disease? 
• Methodology: Brainstorming with visualisation and discussion. 

Subjects for discussion:
- recommendations for changing cropping patterns, unutilized plots, livestock (i.e., promotion of small ruminants, bee-keeping, etc.);
- labour-saving technologies;
- encouragement of self-help groups, especially youth groups;
- income-generating activities for youth groups;
- support for community groups (older members) to assist and train orphans in agricultural skills to compensate for the loss of knowledge through the death of parents;
- cooperation between the Agricultural Extension Service and active NGOs in the districts.  

• Elaboration of a strategy in the form of guidelines and a workplan for the different districts to mitigate the impact of the epidemic.  
• Methodology: Group work with presentations and plenary meeting.