Journal of Social Development in Africa (1992) 7,2,53-61 
Aids in Uganda: Initial Social work 
Responses 
E MAXINE ANKRAH+ 
ABSTRACT 
AIDS, which was first diagnosed in Uganda in 1983, has since reached epidemic 
proportions, with approximately 1,5 million persons estimated to be infected by 
1991. Although the government of Uganda with several collaborating organisations 
has commencedacomprehensiveprogrammeofpreventiveeducation and services, 
patterns of sexual behaviour, unless changed, threaten to facilitate the further 
spread of HIV. Social work professionals have adopted a broad range of activities 
in varying organisations in beginning efforts involved in combating the spread of 
HIV/AIDS. Furtherinvolvementmay be related to the extentthat the social aspects 
of the disease are given heightened attention by the policy-makers in Uganda. 
Introduction 
No professional group in the human services in Uganda can ignore the question, 
"What response does AIDS require of us?" For, the disease has become a 
household name in this small landlocked East African country. This discussion 
will focus on the epidemiological dimension of the AIDS scourge. Some attention 
will be given to those behaviour patterns that appear to put Ugandans at risk of 
infection, for these differ from factors identified in industrialised countries. Of 
principle concern, however, is to suggest what social workers are attempting to do 
about the AIDS scourge. Some obstacles and opportunities are suggested as viable 
strategies to maximise the professional contribution. 
•Lecturer, Department of Social Work and Social Administration, Makerere University, Uganda.
54 E Maxine Ankrah 
The Epidemic 
From one to one and half million 
At some point in time Uganda must have had just one single case of AIDS. But 
spreads. Grasping this fact, and understanding the social as well as the biological 
factors that cause the process, is vital if nations are to stop this deadly disease before 
it spreads too far. Uganda did not. 
From 1981, when the first Ugandans started suffering from a disease never 
before seen, to 1982 when the local medical specialists were called to Rakai District 
to examine the phenomenon, to 1983 when the first cases of AIDS were diagnosed, 
the Human Immunodefiency Virus (HIV) had spread into all parts of the country. 
By December 1988,at the first review of the AIDS Control Programme (ACP), 
6 772 confirmed cases were reported. Uganda's Ministry of Health estimated that 
as of October 1989 between 800 000 and one million persons, out of a total 
population of 16,5 million, were carrying the virus. In 1991 the figure was 1,5 
million. AIDS has now been reported in all 38 districts of the country. 
Ninety percent of all Ugandans live in rural areas. AIDS was entrenched first 
in the villages among the populations least served by health or social services 
before it spread to the urban centres. It only later became what some choose to call 
an "urban disease". The disease started appearing among smugglers and wealthy 
traders and fishermen in Rakai District The local people believed that the patients 
were bewitched because of their prosperity of unfair practices against Tanzanian 
traders who lived in Bukoba on the opposite side of Lake Victoria. Soon, people 
began to notice that the wives were also falling sick, and by 1985 it was clear that 
this disease was heterosexually transmitted. This is made clear by the impact of 
AIDS on health care facilities. Thirty percent of the beds in the major hospitals in 
Kampala, the capital, are filled with male and female AIDS patients. Thirty percent 
of women attending antenatal clinics are also infected with the disease. 
Moreover, 20% of all Kampala residents are believed carriers of the virus. The 
travel of people between the urban centres and villages is high, and thus the 
expectation is the increasing numbers of persons in rural areas will contract the 
disease. From the current 6% seroprevalence for the nation as a whole, the 
percentage is likely to rise. 
Of the totals reported by the ACP Surveillance Unit, 89% were adults, mostly 
aged between 15 and 40 years, with 51% and 49% male to female cases, 
respectively. Children aged 11 years and below make up 10% of the cases. Of this 
latter total, almost all are paediatric cases through perinatal transmission whereby 
the disease is passed from mother to child. Less than one percent of the cases is
Aids in Uganda 55 
found among children whose ages range between six and 15 years. The "burden 
of orphans" has already begun to be felt in the hardest hit district, Rakai. 24 000 
orphans who have lost one or both parents because of the disease have been 
enumerated. This, however, is held to be a conservative figure. 
The figures above underscore the point that AIDS is rampant in Uganda. 
Particular to the fact of the age distribution, AIDS kills the young and most socioeconomically 
productive sectors—the 15 - 40 year-olds in whom much has been 
invested in terms of education. Their loss is expected to adversely affect 
agricultural production and other facets of the development of the nation. In 
striking the rich and the poor, too, AIDS has hit all levels of society. 
The spread of AIDS and its control 
Epidemiologist Struchiner (1990) describes AIDS as "a disease of poverty." In 
conditions of poverty, he asserts, the AIDS virus flourishes. Another view is that 
the high rates of AIDS that currently plague African countries are intimately linked 
to their history of underdevelopment. 
As a consequence of distorted, export-oriented economies shaped by centuries 
of colonial rule, these nations confront problems of an increasingly marginalised 
peasant labour force, the social disorganisation of rural society, a growing migrant 
labour force and the emergence of squalid slums surrounding major cities with 
contingent high rates of unemploymentand prostitution. Lacking adequate resources 
to counter the diseases which fester under such conditions, these countries suffer 
enormously from malnutrition, malaria, measles, tuberculosis and sexually 
transmitted diseases. 
An examination of the AIDS menace in Africa should take very seriously the 
context in which the problem is being experienced. An analysis of the Ugandan 
situation through the 1980's from the contextual perspective will reveal that a 
combination of factors appears to have conditioned the present strength of the 
attack of the disease on the society. The nation was in a state of civil war for about 
20 years, from the 1970's. There is prevailing widespread urban as well as rural 
mass poverty. The elementary necessities of life, such as clean drinking water, 
sanitation, sufficient amounts of food, clothing and adequate shelter are not 
guaranteed to the majority of Ugandans. Most villages lack any social welfare 
services at all. Schools are closing for lack of funds by parents to pay school fees 
for their children or salaries to retain teachers. Over the years of political upheaval, 
the health system, until recently neglected, suffered near collapse. AIDS, thus, 
appeared at a time when Uganda was ill-prepared to fight it 
Yet, it has attempted to put a national operation into place through its AIDS
56 E Maxine Ankrah 
Control Programme which, in broad outline, addresses the problem through health 
education, training of medial personnel and leaders of public opinion, through 
national surveillance activities, blood screening and testing. Programmes of 
counselling and patient care have been promoted largely through non-governmental 
organisations. The government works through the central Ministry of Health with 
its efforts being supported by local non-governmental organisations (NGOs), and 
the World Health Organisation, UNICEF, US AID, UNDP, Save the Children and 
other international organisations. In collaboration with these the government has 
pursued the goals of prevention and involvement. 
Of the latter aim, Uganda's policy has been one of "openness". The media as 
well as international researchers have been permitted to monitor the spread of the 
disease within Uganda's borders. Its strategy has been inclusive: from 1988 a 
decision was taken to decentralise AIDS prevention activities. District medical 
personnel have the responsibility to work with local leaders through "Resistance 
Councils", with non-governmental organisations including missionary hospitals 
through education and services. 
Any progress that has been made to arrest the spread of HI V/AIDS through this 
extensive involvement of all relevant parties must be measured against the earlier 
described constraints within the Ugandan setting, of poverty and backwardness, 
due to a history of underdevelopment. The second aim, that of prevention, has been 
conditioned to a large extent by the traditions and cultural norms that underlie the 
behaviours whichclinic findings have confirmed are at the base of HIV transmission. 
Unlike the industrialised countries of North America and Europe and South 
America, Africa's AIDS epidemic has not been spread by homosexual practices or 
through intravenous drug abuse. Neither of these are known in the Ugandan 
cultures, except in the confined situations of some institutions such as prisons. 
Even the ineffectiveness of Uganda's health care system may have been a blessing 
in disguise, as the country's blood bank system was also adversely affected when 
AIDS began to strike. The result is that only one percent of the Ugandan carriers 
were infected through transfusions of contaminated blood, and fewer still were 
infected through needle injections. 
AIDS and the Social Worker: An Overview 
Within the short period accelerated effortsbythegovernmentandother organisations 
to check the advance of the virus in Uganda, ie 1986-1991, the social work 
profession has been proactive. Its engagement with the problems of AIDS has 
spanned a wide range of activities; there are challenges still; the opportunities for
Aids in Uganda 57 
greater participation exist. What the Ugandan social workers are doing may 
suggest ways of preventive work to professionals in countries which have yet, if 
ever, to experience the massive rates of infection that Uganda now witnesses. 
Areas of Involvement 
A purposive sampling was taken in April 1990 of all social workers known to be 
employed full time in AIDS related organisations in Kampala and in Entebbe — 
the headquarters of the Ministry of Health — and who were available at the time 
of the survey. Twelve of the 16 listed persons who are currently involved in AIDS 
activities in these two settings were interviewed. A few others are expected to be 
full-time practitioners elsewhere in the country: some other professionals have 
duties that bring them into contact with persons with AIDS from time to time. 
Of this latter category are the social workers who are employed by the Ministry 
of Rehabilitation which concerns itself with broad social welfare problems. This 
ministry addresses itself to the macro consequences of HIV/AIDS, such as the 
needs of widows and orphans, more than with the individual persons with AIDS. 
The role of social workers in the Ministry of Health, too, focuses indirectly on the 
problem through activities of health education, mobilisation, research and 
programme management. 
The largest influx of professionals has been into non-governmental indigenous 
and international humanitarian organisations. These include the AIDS Information 
Centre (AIC) and The AIDS Support Organisation (TASO), the two agencies that 
provide testing and counselling and counselling and relief, respectively. The 
church related hospitals at Nsambya and Rubaga, Kampala, employ practitioners 
onafull-timebasis. TheRedCross, World Vision, theExperiment in International 
Living, Save the Children Fund, UNICEF, USAID serve as agencies for much 
social work activities. The ACP of the Ministry of Health and the Medical 
Research Council (UK) provide opportunities for indirect social work practice. 
The Expanding Roles 
Supportive counselling is the most visible of the several functions being undertaken 
by an increasing number of graduates. This role, more than any other at present, 
calk for directprofessional intervention with AIDS sufferers and their families. Its 
expansion is facilitated by the decentralisation of ACP activities and the 
establishment of additional AIDS counselling services in the districts through 
TASO and AIC. In connection with counselling is the role that professionals are 
playing in building or strengthening social networks between persons with AIDS
58 E Maxine Ankrah 
and their families to the communities to secure the assistance that they require, be 
it health care, funds, transport or emotional support. Networking is also used 
extensively by the social workers for liaising with other professionals in advocacy, 
identifying resources and in making referrals. Building a community-based 
support system is an area assigned increasingly to the professionals. 
Social workers engaged by the Uganda Red Cross, the ACP, and the churches 
have, for example, assumed major responsibilities in health education activities. 
These have included designing and executing KAP studies, developing appropriate 
materials and conducting community education. Others at ACP, where community 
mobilisation is a dominant concern, also fulfill the functions of mass/health/AIDS 
educators. They target audiences such as Resistance Councils of local leaders, 
religious leaders, teachers, employers, the security forces of the military, the police 
and the prisons, school children, women's groups, agricultural and other extension 
staff at the district to village level, as well as in towns. This i s labelled as primary 
dissemination. In addition, social workers in the non-governmental agencies and 
in the government are heavily involved in the training of trainers through seminars 
and workshops which too, are, held at the district level. 
Researchinto the social, cultural and behavioural aspectsof AIDS has provided 
an important entry point for social work into the policy-making and programme 
development areas. This activity has been spearheaded by the Department of 
Social Work and Social Administration, significantly. In 1988-1990,16 graduates 
obtained field research experience; eight are now employed as full-time AIDS 
researchers. Through this same activity, the Department has gained a seat on the 
gazetted, or statutory, National Committee for the Prevention of AIDS, and on the 
executive committee of the AIDS Information Centre, the Network of ADDS 
Researchers in East Africa, and several other bodies. 
The pretest already referred to and national WHO/ACP/Makerere University 
Social and Behavioral Survey on AIDS have been completed, with data being 
currently analysed. These sources potentially provide vital baseline data for 
further social planning and intervention. 
The continuing challenges 
The yetlimited numbers of social workers who have addressed the AIDS challenge 
is in part a consequence of the way mat AIDS control and prevention was 
introduced into Uganda as probably, in other parts of Africa. The disease was 
viewed initially as a medical problem. The near-monopoly of AIDS by the medial 
profession continues to the present time.
Aids in Uganda 59 
Therefore, a major barrier to increased participation by social workers tends to 
be their exclusion rather than their reluctance to get involved. Hospitals and nongovernmental 
organisations persist in hiring non-qualified persons to undertake 
social work - related functions, particularly, counselling. There is an apparent lack 
of awareness on the part of local social service agency leadership, of the complexity 
ofhandlingAIDS-relatedstressproblems.Thedifficultiesof community mobilisation 
for combating an epidemic and building support systems are not fully appreciated. 
The dangers of hurriedly setting into place old solutions to new social problems, 
such as is happening in the mushrooming of orphanages, have not been fully 
appraisedJn addin'on,global institutional building to deal with AIDS at the national 
level has progressed only slowly. There are therefore few agencies that concern 
themselves with the problem, holistically, and consequently which provide 
opportunities to social workers for employment. 
To address the difficulty of penetration, attention is being given to inclusion of 
AIDS education into the training syllabus for social workers at the undergraduate 
level at Makerere University. An already developmental and broad-based approach 
rather than a clinical orientation in social work education prepares the professional 
for a practice stance in the great variety of agencies and fields already described. 
More needs to be done, however, to indicate to others the multi-disciplinary 
approach that is necessitated by this multi-dimensional problem in the African 
context There is a need for formal courses in health as a social issue, however, 
rather than the informal approach that is now being taken. 
What about the fear that professionals have of contracting AIDS? The 
practitioners reported that while at the onset of the epidemic most of them were 
afraid of working directly with persons with AIDS, such fear gradually gave way 
to empathy, sympathy and a desire to help remove from the society the high level 
of blaming, discrimination and stigma that nevertheless still prevails among some 
people who think of themselves as being free of AIDS. 
Conclusion 
The Human Immunodeficiency Virus (HIV) is currently widespread in rural as 
well as urban parts of Uganda. With an estimated 14 million persons potentially 
carrying the virus, most of whom are unaware of being HIV infected, hundreds 
more will become infected in the years ahead. AIDS deaths, now in mounting 
proportions, leave in their wake social problems of the surviving children, spouse, 
families and whole communities. Uganda's health care system is being further 
strained. Sexual behavioral patterns that are deeply embedded in the traditions of
60 EMaxineAnkrah 
society will need to be better understood and effective means found to sensitively 
influence change. Given these several facets of the problem, what have social 
workers learned that may guide their probable intensified effort to prove relevant 
in the face of the AIDS epidemic? 
The broad-based activity of most practitioners suggests that the attention of the 
profession will not be focused solely on the primary sufferer, the person with 
AIDS. The needs of the family, the survivors, including whole communities that 
are being adversely affected by the disease will also need to be considered through 
direct and indirect intervention. Social workers may initially increase their strength, 
numerically, in taking up positions as counsellors. The societal context will 
continue to beckon them to a more critical engagement, with the totality of needs 
the AIDS epidemic generates. 
The advocacy, education, training, research, and administrative roles that have 
emerged as dominant activities of social workers in Uganda will likely be further 
promoted. To ensure maximal impact the professional will require further 
development The responsibilities plus the involvement of some social workers in 
policy-making have not been matched yet by an indepth and systematic review of 
the AIDS content in social work education to understand what is needed for the 
opportunities that will emerge in future practice in AIDS control and prevention. 
Much of AIDS education is done piecemeal. This suggests the need for specific 
courses in schools of social work within Africa to prepare professionals for 
employment in the health sciences. 
The social work profession in Uganda, however, has taken an aggressive 
posture commensurate to its interpretation of AIDS as a deadly threat to the nation. 
Although the threat is new, theprofessional achievements are already commendable. 
But there is the urgent need for greater clarity of goals and specific strategies set 
by professionals, if the initiatives highlighted above are to be sustained and 
surpassed as Uganda confronts the AIDS epidemic. 
The Assistance of Mr S M Wangalwa in the research for this paper is deeply 
appreciated. Ms Rose Kiggundu is thanked for her help in the preparation of the 
manuscript. 
The first version of this paper was presented at a workshop of "AIDS '90: The 
Social Work Response", the Second International Conference on Social Work and 
AIDS, June 16-19 1990, San Jose, California, USA.
Aids in Uganda 61 
References 
Republic of Uganda (1989) Review of Uganda Aids Control Programme In 
collaboration with the World Health Organisation, Ministry of Health, 
Entebe. 
Republic of Uganda (1989) Progress on the AIDS Epidemic in Uganda 
1987-1989, Ministry of Health, Entebe. 
Republic of Uganda (1990) AIDS Surveillance Report, Fourth Quarter (1989) 
AIDS Control Programme, Ministry of Health, Entebe. 
Hunter S (1989) "Demographic policy implications of the growing 'orphan 
burden' of AIDS in African countries" International Conference on the 
Implications of AIDS for Mothers and Children, Paris, November 
Abstract J.7). 
Nabarro D McConnel C (1989) The impact of AIDS on social and economic 
development .AIDS, 3 (Suppl. 1) S256-S272. 
Struchiner C (1990)" Intervention" at AIDS and Reproductive Health Network 
Meeting, Bangkok, Thailand, February 3. 
Women's World (1988) The International AIDS Crisis and the Consequences 
ofUnderdevelopment ,No. 18, June. 
Mueller O Lubega J Senoga J (1989) "Knowledge and attitudes to AIDS 
shown by Ugandan school children based on a nationwide poster 
competition" V. Int Conf. on AIDS, Montreal, June 1989 (Abstract 
W.E.P. 22).