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

SUMMARY

1. While youths are among the most vulnerable groups to HIV infection, they are also the most promising agents of behaviour change. Young men and women are vulnerable to HIV infection because they begin sexual activity at an increasingly younger age, tend to have multiple partners and have restricted access to information on safer sexual practices. In addition, the interplay of a wide range of factors -- war and instability, the loss of the appeal of agriculture as a 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. An increase in poverty and illiteracy, lack of opportunities, and the erosion of social values and family life education act as catalysts to high risk sexual behaviour.

2. Young women are more susceptible to contracting HIV than young men for biological, health-related and socio-economic reasons, but also because they have until recently been neglected by HIV/AIDS education interventions.

3. The HIV epidemic 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 in people's perceptions of the disease. Even within one district, two villages can have radically different agro-ecological conditions and customs that determine sexual behaviour and attitude towards HIV and AIDS. This has critical implications for the design of HIV interventions -- namely that district-specific approaches are essential.

4. Available 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.

5. The HIV epidemic is disproportionately affecting young rural women. There are far more women who have lost their husbands to AIDS than men having lost their wives in the three districts visited. Young widows with dependent children tend to become entrenched in poverty as a result of socio-economic pressures related to HIV and AIDS. The AIDS stigma, for instance, which largely results from the prevailing stereotype that it is the women who are responsible for transmitting HIV, is undermining traditional coping mechanisms accessible to young widowed women and changing the socio-economic fabric of the extended family.

6. 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-affected families and the stronger the stigmatization. What is particularly significant is that individuals tend to blame their partners for transmitting HIV, not themselves for engaging in high risk sexual behaviour.

7. 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 men are better informed than out-of-school women; and older women are better informed than younger women.

8. There is a need to differentiate between school and out-of-school youths. As HIV 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 education which begins at the P5 and P6 level. Out-of-school youths, including those who drop out, make up the majority of rural young people.

9. If behaviour change is to be effective, it should involve the youth itself in the generation of appropriate messages and should address socio-economic and cultural realities that influence sexual behaviour. Creating a forum for discussion and for interactive learning, where respect for HIV/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.

10. Behaviour change strategies that do not address socio-cultural norms, including early sexual behaviour, STDs, alcohol and drug abuse, bar and disco culture, ritual cleansing and wife inheritance, etc. but only hinge on sexual behaviour per se are not likely to be effective, particularly among youths. 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.

11. Traditional norms and customs concerning wife inheritance, oral or written wills, widows' rights to land and property, etc. often tend to overrule the implications of HIV and AIDS. This needs to be taken into account when designing interventions.

12. Behaviour change is also conditional on communication, negotiation and assertiveness skills, motivation and perseverance for men as well as for women.

13. 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.

14. Women's socio-economic status and the breakdown of the institution of marriage in some areas, need to be addressed, in particular: alcohol brewing/distilling as a major economic activity for young rural women and the need to create alternative income-generating opportunities; bride wealth, which has become unaffordable for many young men; and the growing number of informal unions between men and women which translates into a loss of legal rights for women living with their partners outside of marriage.

15. 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.

16. A strong youth programme aimed at increasing opportunities and creating choices for young people in rural areas through income-generating activities, leadership and management training, recreation, health education, and communication/negotiation skills is in itself a strategy to respond to the HIV epidemic. This is in line with the Uganda AIDS Commission approach which specifies that "prevention activities should be integrated into mainstream health programmes and other programmes dealing with community, women and youth development."

17. As a group, youth includes children (ages 10-14), adolescents -- some of whom are parents, particularly girls -- (15-18 years) and young adults, most of whom are parents (19-25 years). These groups may have to be targeted separately, given the fact that their lifestyles, sexual behaviours and learning abilities differ. Childhood/adolescence, marriage and parenthood are often very close together for girls/young women. This needs to be taken into account when designing interventions.

18. The HIV epidemic is 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 the village and attend the burials. HIV interventions targeting rural youth through the agricultural extension service may be ineffective, without appropriate measures to strengthen extension.