WHY UGANDA MUST STOP MORALISING THE HIV RESPONSE

By Henry Mutebe

There is a growing contradiction at the heart of Uganda’s HIV response. On one hand, the country claims to be guided by science, epidemiology and public health evidence. On the other hand, policy discussions and programming are increasingly shaped by moral judgment about the people most affected by the epidemic.

This contradiction is not harmless. It is dangerous.

When moral arguments begin to dominate epidemiological decision-making, the outcome is predictable: the people most at risk are pushed further away from services, and the epidemic continues quietly in the shadows. If Uganda is serious about ending HIV as a public health threat, we must begin with a simple professional principle: doctors should not become reverends, and reverends should not become doctors. Each profession has its role. When we confuse them, everyone suffers.

Uganda has made remarkable progress against HIV over the past decades, but the epidemic has not disappeared. Instead, it follows patterns of vulnerability. While HIV prevalence in the general population remains about 4.9 percent, certain communities experience far higher rates of infection.

Data from the Uganda AIDS Commission shows that among female sex workers, HIV prevalence ranges between roughly 26 percent and more than 50 percent in some areas. Other populations — including fisherfolk, men who have sex with men, and people who inject drugs — also face significantly higher infection rates.

Population estimates reveal the scale of the challenge. Uganda has about 130,000 female sex workers and more than 730,000 fisherfolk, two groups carrying some of the country’s heaviest HIV burdens. When epidemics concentrate within particular networks, targeted interventions are not optional; they are essential.

Yet this is precisely where Uganda struggles.

In many policy discussions, conversations about key populations quickly shift from epidemiology to morality. Instead of asking where infections are occurring, how transmission networks function, and what interventions can interrupt them, the debate turns to whether such groups deserve government services.

Such questions may belong in religious sermons or philosophical debates, but they cannot sit at the centre of a public health response. Viruses do not respond to moral judgment. They respond to biology, exposure and transmission networks.

Understanding this reality requires confronting uncomfortable social truths.

Consider the life trajectory of many young women who eventually enter sex work in urban settlements. A girl grows up in a low-income neighbourhood such as Kimombasa or Mabito in Nateete, Bwaise, or other informal settlements. Her parents struggle to afford quality schooling. She drops out early, acquires no vocational skills and has no capital to start a business. Then she becomes pregnant. At that point, survival takes over.

For a mother with a child to feed, the most powerful instinct in human nature emerges: survival. No amount of judgement will stop her from seeking income to feed her baby.

Those with stable salaries and financial security often stand on the altar of moral authority and condemn such choices. But survival economies do not respond to condemnation. They respond to opportunity, access and structural change.

Across Uganda’s transport corridors — from border towns like Malaba, Busia, Elegu and Mutukula to trading hubs such as Bweyogerere, Namanve, Nansana, Nateete, Lukaya, Masaka, Mubende, Fort Portal, Hoima and Mbarara — the epidemiological pattern is visible. Transactional sex networks follow trucking routes, fishing economies and trade flows.

Fishing communities such as Kasenyi, Kigungu, Kiyindi, Lambu and Kalangala have long been recognised as HIV hotspots. Yet public debates about key populations often become narrowly focused on sexuality politics while ignoring the far larger populations of sex workers and fisherfolk driving the epidemiology.

Pretending these realities do not exist does not eliminate them. It simply pushes the epidemic underground.

Traditional health systems were never designed to effectively reach these communities. Consider a sex worker whose work begins at seven in the evening and ends at six in the morning. Asking her to wake early, travel to a health facility, sit in queues for hours and risk public exposure is unrealistic. During the day she is sleeping. At night she is working. The system and the individual operate on completely different clocks.

This is why public health programmes around the world adopted community-based approaches: mobile clinics, night clinics, peer outreach and drop-in centres that bring services to people rather than forcing people to come to the system.

Yet these community-based programmes now face new risks. With the withdrawal of some international funding — particularly from the United States — community structures that have long connected vulnerable populations to health services could weaken before the public health system expands enough to replace them.

Uganda’s progress against HIV has been significant. Of the roughly 1.3 million people living with HIV in the country, about 96 percent are virally suppressed — meaning treatment has reduced the virus in their bodies to levels so low that they are unlikely to transmit it through sexual contact.

This achievement is the backbone of HIV control.

When people living with HIV receive treatment and maintain viral suppression, the chain of transmission breaks. But sustaining this progress requires reaching everyone, including those society may prefer not to see.

When organisations working with vulnerable communities are harassed or restricted, the fragile bridges between health systems and hidden populations collapse. The consequences can be severe. For example, a sex worker arrested and detained without access to her antiretroviral medication may experience treatment interruption. When treatment stops, viral load rises, and the risk of transmission increases again.

What appears to be a moral victory can quietly become an epidemiological setback.

The financial implications are equally significant. Uganda already spends more than one million shillings annually to keep one person on HIV treatment. Every infection prevented reduces future healthcare costs. Every infection that could have been prevented but was not increases the long-term burden on the health system.

There is also an uncomfortable irony in many of these debates. In many middle-class households, parents loudly condemn programmes serving sex workers while ignoring another growing risk within their own homes: drug use among young people.

Drug use significantly increases HIV vulnerability by impairing judgement, increasing risky sexual behaviour and exposing young people to exploitation. Yet this reality often receives far less attention in public discourse.

At its core, this debate is about professional boundaries.

Religious leaders play an important role in guiding moral reflection, strengthening families and shaping community values. But epidemiology is not theology, and medicine is not a pulpit.

When doctors prescribe morality instead of medicine, they abandon the scientific foundations of their profession. Likewise, when religious leaders attempt to design epidemiological strategies, they step outside their expertise.

The solution is not competition between professions but complementarity. Faith leaders can promote responsibility and compassion. Economic programmes can expand opportunities so fewer people enter survival economies. Parents must guide their children honestly. Public health professionals must focus on stopping disease transmission.

Each role strengthens the other — but none should replace the other.

The case for reaching key populations is not ideological; it is practical. When sex workers access testing, condoms, treatment and prevention services, they protect their clients. Those clients protect their partners. Those partners protect their children.

Public health rests on a simple truth: no one is safe until everyone has access to care.

Uganda’s HIV response once became a global model because it confronted the epidemic honestly. President Yoweri Museveni was widely praised in the early years for openly acknowledging the crisis and mobilising the nation to confront it.

Today, Uganda faces another test.

Will we allow moral discomfort to distort health policy, or will we continue confronting HIV with science, evidence and compassion?

Viruses do not care about moral debates. They follow opportunity. If we abandon the people most vulnerable to infection because we disapprove of their circumstances, the epidemic will not disappear. It will simply return quietly through our communities — and eventually into our own homes.

Let doctors be doctors.
Let reverends be reverends.
And let Uganda confront HIV with science, compassion and honesty before decades of hard-won progress are undone.