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HIV/AIDS Across The Globe

Giselle Riker
Wayne State University

Author Note

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This paper was prepared for SW 3710, section 003, taught by professor Angelique Day.
Abstract
This essay will serve as a review of the HIV/AIDS epidemics in the U.S. and Uganda, all the
way from the first diagnoses up until now. The reading starts with a brief summary about what
HIV does to the human body. Each countrys definition of the issue will then be explained, as
well as statistics and demographics of the people affected in each country. Following that
section, policies dealing with the disease in both countries will be discussed, including the Ryan
White CARE Program in the U.S. and its effects and service for vulnerable populations, and the
National HIV/AIDS Strategic Plan in Uganda and how utilization of the ABC approach has been
perceived to be a major factor in successfully lowering HIV prevalence rates. Stigma and
discrimination in each country and how it affects the receipt of services is discussed. Finally
implications for social work practice and interventions based on the NASW Code of Ethics are
addressed for both countries.

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Introduction
It seems unreal that one of the deadliest diseases ever faced by humans was only
discovered around thirty years ago. Human Immunodeficiency Virus (HIV) and Acquired
Immunodeficiency Syndrome (AIDS) make up the two stages of an extremely controversial
infection that has had mortal consequences throughout the world. Although a great amount of
research has been done and still is being done today, unfortunately there is no cure. The
HIV/AIDS epidemic affected many different populations throughout the world over the past few
decades, all of which have reacted in various ways. North America and Africa are probably the
most discussed and researched continents affected by HIV/AIDS, but both approach the disease
differently and have had varied reactions. A closer look at the countries of Uganda and the
United States of America will reveal how the disease has manifested itself uniquely in each
region and how the causes and effects of the disease compare and contrast.
Definition of the Issue
To get an accurate understanding of the impact of the disease, one must first learn the
basics of the disease. HIV usually begins with a bout of illness characterized by flu-like
symptoms, during which the virus is beginning to reproduce and spread throughout the body
while simultaneously destroying vital immune system cells called CD4 cells (Centers for Disease
Control and Prevention [CDC], 2013a). Following the end of that initial illness, also known as
acute retroviral syndrome, HIV then enters a clinical latency period where the virus is still
reproducing but at a slower rate, and with proper treatment that reproduction can be controlled so
much that an individual can live with HIV for several decades (CDC 2013a). However, when the
CD4 cell levels drop below 200 cells per cubic millimeter of blood, the HIV diagnosis is now

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considered AIDS (CDC 2013a). At this point, the immune system is now heavily and
permanently damaged and at high risk for developing an opportunistic infection, which could be
a number of viruses that thrive only when the immune system is weak enough, and include
things like invasive cervical cancer, herpes simplex, multiple forms of lymphoma, pneumonia,
and several more viruses that can wreak havoc on the body (AIDS.gov, 2010). Without
treatment, life expectancy with an AIDS diagnosis is only about three years, and falls down to
one year if an opportunistic illness is also involved (CDC 2013a).
Demographics
Looking at some basic statistics will reveal the depth of the impact of HIV/AIDS. A
disease that was virtually non-existent in the U.S. before 1981 has been diagnosed in
approximately 1.1 million people by the end of 2009 (CDC 2013b). The CDC estimates that
about 50,000 people are becoming infected with HIV every year, and to date AIDS has caused
635,000 deaths in the U.S. (2013b). Although the HIV/AIDS epidemic has affected a wide
variety of people in the U.S., some groups are definitely more vulnerable than others. From a
race/ethnicity standpoint, the CDC (2013b) displays that African Americans are the population
most affected by the disease, accounting for 44% of new infections in 2010, with whites
following behind with 31%. But from a risk behavior standpoint, the CDC (2013b) notes that
HIV/AIDS is largely transmitted through sexual contact, and it is most often seen within men
who have sex with men (MSM) accounting for 63% of new infections in 2010.
Uganda has always been more heavily impacted by HIV/AIDS than the U.S. has ever
been. The most recent statistics for Uganda from UNAIDS (2012a) state that 1.5 million people,
or 7.2% of adults in Uganda, are living with HIV, and about 150,000 new infections occur ever
year. In 2012, approximately 63,000 AIDS related deaths occurred in Uganda, whereas in the

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U.S. only about 20,000 AIDS related deaths occurred (UNAIDS, 2012b). HIV/AIDS is most
often heterosexually transmitted (Uganda AIDS Commission [UAC], 2011, p. 5). Women are
more often diagnosed with HIV/AIDS, having a prevalence rate of 5.4% as compared to 2.4%
amongst Ugandan men (AVERT, n.d.). It is relatively universal in how it affects people and not
very much data or research exists for specific sub-populations/ethnic groups affected in Uganda,
but there are several high risks groups including MSM, female sex workers and their clients, and
those experiencing intimate partner violence (AVERT, n.d.). Even though they are high risk
populations, that doesnt mean they have a higher number of infected individuals. For example,
homosexuality is a crime in Uganda so there is virtually no data concerning MSM and their
HIV/AIDS prevalence rate is unknown.
History of the Issue - U.S.
According to A Timeline of AIDS on AIDS.gov, the HIV/AIDS epidemic was first
identified in the U.S. through a study published by the CDC in 1981 concerning a rare lung
infection, as well as other characteristics of of a compromised immune system, found in five
young and formerly healthy gay men of Los Angeles, CA, two of which died before the study
was even published. Following the release of the study to the public, several similar cases from
across the country were reported to the CDC, culminating in 270 reported cases of severe
immune deficiency among gay men (n.p.) and was officially given the name AIDS in 1982 by
the CDC (AIDS.gov, n.d.) In that initial time period following the official discovery of
HIV/AIDS in the U.S., gay men made up the majority of diagnosed individuals. In fact, the U.S
Health Services and Resource Administration, states by the end of 1983 71 of the 3,064
reported AIDS cases were among gay and bisexual men (n.d. p. 3). At this point in time,
homosexuality was nowhere near as widely accepted as it is today, and the virus was seemingly

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only affecting gay men, HIV/AIDS originally had a very negative connotation and stigma
attached to it that resulted in a lot of ignorance and discrimination. The media took a liking to
referring to HIV/AIDS as the gay plague or gay cancer (HRSA, n.d. p.3), and it was
basically written off as a homosexual problem, not something concerning the general public, and
so in those first few years very little was done by the U.S. government to address the problem.
As Randy Shiltz wrote few confronted AIDS for what it was, a profoundly threatening medical
crisis (as cited in Segal, 2013, p. 327).
Thankfully, public opinion has improved since then. A study done by the Kaiser Family
Foundation in 2011 found that although many Americans still feel uncomfortable interacting
with HIV/AIDS positive people, stigmatizing attitudes have declined (p.2), concern has
increased (p.1), and more than half of Americans support increased funding for HIV/AIDS (p.2).
But one may ask what brought about this change in opinion? The turning point occurred in 1987
when Ryan White stepped into the public eye and shared his experience with AIDS. HRSA (n.d)
explains that Ryan was one of the first hemophiliac children to be diagnosed with AIDS through
a tainted blood transfusion that occurred in 1984. Ryans story changed the way American
society viewed AIDS because his story became a paramount example that AIDS was not limited
to the gay population and could happen to a person through no actions of their own, and finally
encouraged Congress to pass the first major HIV/AIDS policy.
History of the Issue - Uganda
The first case of AIDS in Uganda was officially identified in 1982 in a fishing village in
the Rakai district along Lake Victoria (Tumushabe, 2006). Zakumumpa (2013) describes how to
local Ugandans nicknamed it silimu or slim because anyone diagnosed with the virus would
experience such severe weight loss it seemed like he or she was virtually wasting away. People

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were so perplexed by this alien disease shrouded in mystery (n.p.), they immediately turned to
superstition and blamed it on a curse or witchcraft (Zakumumpa, 2013). Parkhurst (2010)
describes a fear among Ugandans that will never be replicated again: slim was a disease that
seemingly came out of nowhere with no scientific information or help readily available to
citizens to explain why this disease was taking their loved ones away so rapidly. Parkhurst goes
on to explain that a widespread campaign instilling the fear of death into citizens is most likely a
big part of why HIV prevalence rates decreased so significantly over the years: from a peak of
30% of population infected in some areas (Zakumumpa, 2013) to a record low of 6.4% in 2006
(AVERT, n.d.a). Now that HIV/AIDS has become rather normalised amongst Ugandans,
Parkhurst explains, that former sense of urgency that Ugandans shared is gone and HIV/AIDS is
no longer seen as being as serious of a problem as it once was, especially because there is so
much treatment available now. However, this type of thinking has very negative implications and
could even lead to a sharp increase in HIV prevalence rates if people are no longer taking proper
precautions.
Services/Policies - U.S
In the U.S., the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act
has been the most important piece of legislation for addressing the HIV/AIDS epidemic over the
past two decades. It was voted into legislation in 1990 with an overall goal to improve the
quality and availability of care for low-income, uninsured, and underinsured individuals and
families affected by HIV disease (HRSA, 2013). It has since been amended, added onto and and
reauthorized four times, and is currently in effect known as the Ryan White HIV/AIDS
Treatment Extension Act. The policy is broken down into several subprograms, or Parts, to meet
the needs of various populations and The Ryan White Program Overview Fact Sheet presented

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by HRSA (2013) lists the Parts currently active: Part A provides emergency assistance to urban
areas most severely affected by HIV/AIDS, Part B provides grants to all 50 states and U.S.
territories to improve HIV/AIDS health care and support services specifically concerned
pharmaceutical treatment, Part C focuses on early intervention services by funding health care in
outpatient settings for HIV positive individuals, Part D provides funding directly to organizations
for primary medical care for women, infants, children, and youth living with HIV/AIDS and
works to reduce mother-to-child transmission of HIV, Part F provides funds for several different
areas including the Special Projects of National Significance Program, the AIDS Education and
Training Program, the Dental Programs, and the Minority AIDS Initiative.
Over the years, the HIV/AIDS bureau (HAB) of HRSA has found that each
reauthorization has seen policy adjustments that reflect changes in the HIV/AIDS epidemic, such
as up and coming therapies and treatment or changes in funding and economics of the American
health care system (as cited in Hayes et al. 2005). Now, HRSA (2013) estimates that program
services reach 529,000 people each year. In 2010, HRSA reported that 72% of Ryan White
clients identified with a racial/ethnic minority. So how does this measure up with the
demographics from earlier, specifically with the most affected subpopulations: African
Americans and MSM? African Americans made up 47% of all Ryan White clients in 2010, and
were found to be utilizing all Program Parts (HRSA, 2012a) and MSM made up 39% of all Ryan
White clients in 2010, and were also found to be utilizing in all program parts (HRSA, 2012b).
Although these may seem like decent enough portions of clientele, considering how prevalent the
disease is among these groups the percentage of people receiving help should be higher.
Services/Policies - Uganda

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Unlike the U.S., the Ugandan government did not wait very long before they decided to
confront the problem head-on. In 1986, newly elected president Yoweri Museveni publicly
acknowledged the disease and and began the battle by forming the Uganda National AIDS
Control Project (NACP) which focused on blood safety, prevention of HIV infection in health
care settings, and education and communication (Garbus & Marseille, 2003, p. 11). The Uganda
AIDS Commission was formed in 1992, and it ultimately created the National Strategic
Framework for HIV/AIDS Activities (1997), which basically spelled out the goals and
guidelines and for controlling and decreasing HIV/AIDS in Uganda and served as a reference for
policy development (Garbus & Marseille, 2013). The document has since been revised and today
it is now known as the National HIV/AIDS Strategic Plan with the current goals of
reducing the overall incidence of HIV/AIDS by 30%, improving the quality of care for people
living with the disease, improving access to services, and strengthening the systems in place that
deal with HIV/AIDS (UAC, 2011). Interventions that have been implemented thus far include
widespread condom distribution and sex education (Garbus & Marseille, 2003) the creation of
confidential voluntary counseling and testing (VCT) sites, free antiretroviral treatment and care,
prevention of mother-to-child transmission (PMTCT) activities including testing, treatment, and
research and the promotion of voluntary male circumcision to lower the risk of infection.
(AVERT, n.d.a).
The prevalence rate of HIV/AIDS in Uganda steadily decreased from about 1992 to 2006,
making it to be considered one of the most successful countries in Africa to combat the disease
(Parkhurst, 2010, p.242). Many people credit this achievement to the incorporation of the ABC
approach: Abstain, Be Faithful, or Use Condoms (AVERT, n.d.b). Uganda began to utilize the
comprehensive approach through a media campaign designed to educate and change behavior i.e.

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delaying sex until after marriage, monogamy and fidelity, and the promotion of safe sex and
distribution (AVERT, n.d.b). Several studies assert that all facets of the ABC approach had a
significant impact on the behavior of Ugandans and directly lowered the risk of HIV infection
(Singh et. al., 2003), while others believe that increased condom use and distribution was the
only effective part of the ABC method (Parkhurst, 2010). The latter would actually make a lot of
sense because the HIV prevalence rate in Uganda has been rising since 2006, and many speculate
that this is due to the fact that the Ugandan government moved away from the comprehensive
ABC approach in 2003 and now focuses mainly on abstinence and no longer promotes condom
distribution and sex education as strongly as it used to (AVERT, n.d.a).
All types of people in Uganda are affected by these services and interventions.
Adolescents are especially targeted when it comes to the ABC approach since that is the prime
age for any sexual education, and according to Singh et. al. the ABC approach was actually
effective because a survey revealed that girls ages 15-19 were asked about their sexual history,
they were less likely to have been sexually active in 2000 than they would have been in 1988,
and the same goes for young men ages 18-19 due to the adaptation of abstinence (2013). Women,
probably the group most affected by HIV/AIDS in Uganda, have also experienced success with
PMTCT. 86% of HIV positive expecting mothers in 2011 took the necessary step and got ARVs
to reduce the risk of their baby being born HIV positive (AVERT, n.d.a). It is expected that if
PMTCT remains a priority, mother-to-child transmission will be completely eliminated by 2015.
Thanks to the initiatives that pushed for increased HIV counseling and testing (HCT), all
Ugandan hospitals have now made it available and over 5.5 million Ugandans were tested in
2011 (AVERT, n.d.a). Another effect of the improved policies for treatment has put Uganda at a

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level of 53% of people who need ART are receiving it, a percentage that is even higher than the
global average (Zakumumpa, 2013)

Effects of Social Stigma & Discrimination on Policy

HIV/AIDS stigma and discrimination may have declined over the years in the U.S. but
definitely still has an impact because so many people living with the disease are a part of a
marginalized, minority group. The Population Fact Sheet presented by HRSA (2012b) discusses
minority MSM and how they often face significant barriers to support and treatment, one of the
main barriers being HIV stigma within their community. The Research done by Earnshaw et al.
(2012) has revealed that the more HIV stigma is endorsed and spread, we will see a decreased
number of HIV testing, which implies that more infected people will not be getting diagnosed
and will go longer without their HIV being treated which could ultimately lead to an earlier
transition to AIDS and a sooner death. People also tend to rely on these stereotypes to evaluate
their own risk of experiencing negative outcomes such as HIV. Earnshaw et al. gives an example
of this type of thinking: if a man believes that homosexual men are most at risk for HIV, and he
does not identify as a gay man, then he may perceive that he is at a low risk for developing HIV,
and will not see a need to ever get tested, even if he does engage in drug use and unprotected
heterosexual sex with various partners (p. 575). Socioeconomic barriers also play a big role for
minority access to treatment and care. For example, HRSA (2012b) reported that things like
lack of health insurance and poverty...can create barriers to HIV testing and entry into HIV
primary care (p.1) within the MSM community and therefore could also be an explanation to
the lower a amount of MSM receiving Ryan White related services.

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The causes of HIV/AIDS are still not universally understood by the citizens of Uganda,
and it is this lack of knowledge and understanding that can lead to increased risk of infection as
well as increased stigma and discriminatory practices. For example, a study done by Makoae et.
al. (2009) found that people on highly active antiretroviral therapy (HAART) were more
stigmatized than others and experienced verbal abuse, negative-self perceptions, and social
isolation all because others view them as being more sickly and infectious than they really are (as
cited in Nattabi et al, 2011). HIV positive people are also not allowed to serve in the Army, a rule
personally backed by President Museveni who is supposed to be preventing this type of
discrimination (Tumushabe, 2006, p.17). Gender inequality is also unfortunately still a noticeable
part of Ugandas culture. As discussed in the demographics section, there are a higher number of
women living with HIV/AIDS in Uganda than men, and this is most likely due to womens low
prestige in Ugandan society. They are typically considered to be of a lower social status, are less
educated, have higher rates of unemployment, and have weaker social skills, all of which makes
them more vulnerable to infection (Garbus & Marseille, 2013, p. 8). Even if a woman has
symptoms of HIV, she may not be able to go out and get tested without her husbands
permission, or she may not even have ever been exposed to HIV/AIDS education.
Global Differences and Similarities
Although the U.S. and Uganda have both faced the problem of HIV/AIDS, it has been a
bit more limited to specific populations in the U.S., namely gay men and minorities, whereas in
Uganda the effect has been universal and affected the majority population due to different
cultural practices such as polygamy (Garbus & Marseille, 2003). Both have been largely
transmitted through unprotected sex, but in Uganda it is almost always heterosexual sex rather
than homosexual sex. It was also more widespread of a problem in Uganda because of the lack of

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knowledge concerning safe sex practices that persisted while the U.S. had had that information
for years. Although Ugandan government responded more quickly than U.S. government, I think
that they still shared the same distant attitude towards victims. In fact, if the majority of the
people affected in Uganda by HIV/AIDS were gay, I can guarantee that the Ugandan government
would have shown no sympathy and would not have offered assistance because homosexuality is
extremely taboo and illegal in that country.
Relation to Social Work Values
Social workers fit right into the issue of HIV/AIDS if one takes a look at the NASW
Code of Ethics (2008), especially when it comes to the values of service and social justice.
Service should be relatively self-explanatory: social workers are expected to help people in
need and address social problems and people living with HIV/AIDS in both the U.S. and
Uganda usually need social support to cope with the physical and psychological toll the virus
takes. The fact is that social injustice has been a major factor in the HIV/AIDS epidemic in the
U.S., historically and in the current day and age. I was disgusted to find out about the lack of
action taken by the government and negative attitudes society kept during the first few years of
the epidemic because the majority of individuals affected were gay. If HIV/AIDS had primarily
affected heterosexual individuals from the beginning, I can guarantee that there would have been
a lot more done to address the problem throughout the years. Today, social injustice is still an
issue within HIV/AIDS because of the highly disproportionate number of HIV positive people
within minority groups and the negative stigma associated with those groups. Social workers
should be working to ensure that all Americans and (regardless of their race, social class,
sexuality, age or gender) have equal access to proper treatment and prevention awareness for

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HIV/AIDS, and the same goes for Ugandans and their access to treatment and comprehensive
knowledge of the disease.
Conclusion
AIDS does not mean the same thing to Americans as it does to Ugandans because both
countries have such a diverse history with the disease. Analyzing the HIV/AIDS policies of
Uganda and the U.S. and then comparing and contrasting them has helped me see the social issue
of AIDS in a totally new light. It has been so interesting to research about what has worked and
what hasnt worked in each country, and how different cultures can deal with the same issue but
respond to it in very different ways, and also learn from each others mistakes or successes.
HIV/AIDS may not be as serious of a problem as it was in the past, but there is still a lot of work
to be done in order to keep decreasing the incidence of infection in each country. My hope is that
policies can continue to positively grow and change in each country so HIV/AIDS can one day in
the not so distant future be an extinct disease.

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