relationships and it is [condoms] to very targeted communities such as the bars and the prostitutes and so on. So it is ABC, but it’s not all lumped together. It’s very segmented, [myself] having been there and looked at it very carefully.”65 In the years before PEPFAR, Ugandan AIDS programs were to a certain extent targeted toward certain populations and goals; many of these programs were developed and coordinated at local levels to address particular community concerns. But the sort of fracturing and policing of boundaries that Smith mentioned only became evident in the wake of PEPFAR’s implementation; for example, it was in 2004 that Museveni removed any mention of condoms from school sex-education curricula.66 As I discuss in the following section, in the wake of PEPFAR, U.S. efforts to categorize programs in order to evaluate them for funding established a new emphasis on the boundaries between distinct program areas, such as “condoms and related activities” and “abstinence/be faithful.”67 Smith’s statements foreshadowed, rather than reflected, what was to become a much more fractured approach to AIDS care in Uganda.
Representatives of the Bush administration brought up Ugandan “culture” as justification for the abstinence and faithfulness focus of PEPFAR, often in surprising ways. Dr. Anne Peterson, the director for global health at USAID in 2003 and, by her own account, a former “missionary doctor in Africa,” noted in testimony that “being faithful [to one partner] is a strong cultural norm that resonated strongly in Uganda and, from my own experience, I know it resonates also in many other African countries.”68 Many Ugandans would question this evaluation of Ugandan cultural norms or at least seek clarification of what “faithfulness” meant in the context of Peterson’s speech. Long-term concurrent sexual partnerships (maintaining more than one regular sexual partner at one time) have in fact figured prominently in epidemiological explanations for Uganda’s high HIV prevalence rates.69 Peterson’s comment also downplays the important distinction between Uganda’s locally developed programs—the most famous of which, “zero grazing,” targeted a reduction in the number of sexual partners—and PEPFAR’s faithfulness message. The terms used during the congressional debates highlighted the difficultly of transposing and translating program guidelines cross-culturally. And in several cases they revealed surprisingly superficial characterizations of Ugandan culture and sexuality, rarely emphasizing the historical and social complexity of AIDS prevention in the country.
Most depictions of Uganda’s program in the congressional record rightly focus on the issue of behavior change, but too often, as in the exchange between Capps and Smith, the debate came down to how important abstinence and faithfulness alone had been to Uganda’s success. Uganda’s far more nuanced and dynamic ABC program—integrating a variety of culturally relevant messages and dependent upon broader political and structural transformations—was lost in these discussions.70 In Republican testimony, behavior change came to be limited to two specific behaviors—being faithful and abstaining—that were familiar and appealing to conservatives in the United States but that on their own failed to encompass the broader set of strategies and social and political shifts that had enabled successes in HIV prevention in Uganda. Behavior change came to represent personal responsibility for one’s self, a discussion that was infused with references to Ugandan “tradition” and thinly veiled acknowledgment of Uganda’s conservative religious and political environment.
In the debates over PEPFAR, Uganda’s program was made the fodder for a particularly American political struggle—though one with global implications. Even so, this was not a battleground from which Ugandans were disengaged. American politicians sought out information about the Ugandan program in preparation to draft their own, and Ugandan First Lady Janet Museveni even traveled to Washington, DC in 2003 to help Republicans lobby for the dedicated abstinence funds in the PEPFAR legislation.71 By 2003, several high-level Ugandan government officials publically supported an emphasis on abstinence, especially for programs targeted to teenagers and schoolchildren. Janet Museveni, a convert to born-again Christianity, made the abstinence message a cornerstone of her agenda, spearheading youth abstinence programs through her office and, on World AIDS Day 2004, advocating a “virgin census” to encourage youth to remain chaste.
President Museveni and the First Lady were quoted in testimony during the U.S. congressional PEPFAR debates espousing a strongly proabstinence stance regarding sexual behavior in Uganda, with frequent references to the importance of self-control in the prevention of HIV infection.72 This was not in itself surprising or new; there had always been competing claims to moral authority in the debates over HIV/AIDS in Uganda. Male elders claimed “tradition” as a bulwark against shifting gender and generational relations that they viewed as the cause of the epidemic. Women also claimed authority from their positions as caregivers and mothers that bolstered their attempts at organizing to prevent the spread of the disease. Museveni, as the country’s most prominent political leader, would particularly be expected to chastise his population into behaving better. But PEPFAR’s funding stipulations asserted a moral discourse that was not rooted in Ugandan notions of proper gender and generational relations or ideas about political patronage and obligation. The rising influence of an American moral discourse rooted in a U.S. Christian conservativism reoriented Ugandan struggles from local relationships to global ones.
Accountable Subjects: A Policy in Action
With the implementation of PEPFAR in Uganda, new political and social capital was gained by cultivating connections with organizations and funding sources abroad. These connections often depended on a facility for engaging with American conservative agendas privileging accountability and personal responsibility. Perhaps most devastating for Uganda was the way in which behavior change was set in opposition to other approaches to HIV/AIDS prevention. In the wake of PEPFAR, Uganda’s broadly inclusive approach to program development was strongly challenged. Christians involved in prevention often told me that they wanted to change the meaning of Uganda’s ABC prevention plan from “abstain, be faithful, and use condoms” to “abstain, be faithful, and lead a Christian lifestyle,” seeking Christianity’s prominence in and dominance over disease prevention efforts.
The immediate effects of PEPFAR were felt most keenly among NGOs who sought to apply for program funds. Uganda’s prevention approach became more heavily fractured after PEPFAR’s implementation, with organizations forced to account for how their programs supported specific PEPFAR funding areas. Sometimes a program’s content had to be changed in order to satisfy these requirements. The prominent youth-focused group Straight Talk Uganda removed discussions about condom use from its educational radio shows after the American organization distributing PEPFAR funds to the group insisted that it do so.73 The founder of that organization, a British national who has lived in East Africa since the mid-1980s, told me how the environment surrounding prevention work became more politically tense in the years following PEPFAR’s implementation. The message of abstinence also became, in her words, “more rigid” and was increasingly informed by a Western view that understood sex to be driven by “only two things: desire and love.” Programs that addressed the broader cultural context that informed decisions about sexuality in Uganda (for instance, Uganda’s zero grazing program) were replaced by others better adapted to American grant requirements.
In order to seek PEPFAR funds, groups had to categorize themselves as addressing singular program areas, such as “abstinence/be faithful” or “condoms and related activities,” that did not necessarily reflect the ways Ugandans had previously imagined and categorized prevention strategies. These classifications left little room for the more nuanced partner reduction messages that the Ugandan ABC program had been known for. Public perception of PEPFAR in Uganda was also that it heavily favored prevention programs focused on abstinence. In its report on the impact of PEPFAR in 2005, Human Rights Watch quoted one Ugandan youth: “With funding coming in now, for any youth activities, if you talk about abstinence in your proposal, you will get the money. Everybody knows that.”74 PEPFAR’s own program report from 2005 also emphasized this focus, stating in the Uganda country section, “U.S. programming is increasingly emphasizing both A[bstinence] and B[e faithful].”75
The increase in donor funds for AIDS prevention also exacerbated the business-driven aspects of AIDS research and advocacy, in which a program’s dependence on donor aid worked to reshape