26 February 2003

Uganda: Lessons From Uganda's Aids Success Story

Uganda has become Africa's HIV/Aids success story but critics say many claims have been predicated on selective pieces of information.

However, one critic and Aids researcher, Justin O Parkhurst, says although there are big holes in Uganda's HIV/Aids story, all available evidence shows that the country has successfully managed to prevent the spread of HIV-1 in many ways. He says there are meaningful lessons to be learnt from the way the Ugandan government and other institutions have tackled the deadly disease.

"However, the importance of the Ugandan experience will be compromised if conclusions are drawn out of context and statements are made on the basis of oversimplified assessment of epidemiological data," Parkhurst wrote in the medical journal, The Lancet, early this year. According to a study by a Harvard University intern Sarah Trafford, promotion of abstinence through billboards, radio programmes and school sex education curricula, has resulted in a slow and steady drop in HIV infection rates, as well as new attitudes about conquering Aids in Uganda. Uganda has also successfully introduced the anti-retroviral (ARV) therapy or treatment of people with HIV/Aids.

Ugandan doctor Dickson Opul, who spoke at a recent one-day regional symposium on Access to HIV/Aids Treatment, gave an insight into the success of the programme. Dr Opul is the chairman of the Uganda Business Coalition on HIV/Aids secretariat and has worked as a country representative for an international company introducing anti-retroviral drugs to the Ugandan market. He has also worked as an African regional advisor for the Aids Health Care Foundation where he developed model Aids treatment centres to provide anti-retroviral therapy to the most needy and poorest countries in Africa. After his presentation on how people's lives can be saved by ARVs, one could not help feel that many Zimbabweans have died and continue to die needlessly from Aids because they have no access to drugs that could otherwise prolong their existence.

Dr Opul says Uganda's population is about 24 million with 84 percent living in the rural settings and over 1,5 million infected with HIV. "One million Ugandans have perished due to Aids since the first case was reported in 1983. Uganda has close to 1,5 million orphans due primarily to Aids. Close to 90 000 new HIV infections occur each year but national HIV prevalence has dropped from 30 percent in 1986 to its current level of 6,1 percent (2001)," Opul says. How and why has this happened when in Zimbabwe HIV/Aids is increasing every day? According to Dr Opul, a multi-sectoral approach with a strong political leadership and commitment, contributed enormously to behavioural change and the subsequent drop in HIV prevalence. "The burden of disease is still very high and it seems the fall in prevalence may have levelled," he says.

In Uganda it is estimated that between 10 and 20 percent of people living with HIV (100 000 and 200 000), are in urgent need of anti-retroviral therapy. Between 4 000 and 10 000 have access to ARV drugs meaning that only 4 percent of the very needy are on therapy. "There is no government subsidy or financing for ARVs in Uganda. The national ARV policy is not yet in place although it is under development. The cost of (branded) drugs has significantly dropped from nearly US$ 1 000 (Z$55 000) a month in 1997/98 to the present US$60. "Generic drugs are gaining rapid entry with prices of about US$30 a month. Annual income per capita is US$300 as compared to $360-$720, the annual cost of ARVs. Nearly 45 percent of Ugandans live on less than US$1 a day or below the poverty datum line." Opul says it is unlikely that price reduction strategy alone can significantly increase the proportion of people living with HIV on ARVs in rural areas.

Dr Opul spoke on the Uganda Cares programme, an experience of integrating and delivering a comprehensive model of ARV in a rural African community setting in Masaka district. A partnership of the government and the private sector, the programme aims at the feasibility of delivering free highly-active anti-retroviral therapy to the sickest and socio-economically disadvantaged people living with HIV in rural areas. As one example of numerous studies carried out in Uganda's Masaka district, 47 people were put on ARVs and their initial average weight before treatment was 55,30kg. After 3-6 months of therapy the average weight rose to 59,78kg, realising a percentage weight gain of plus 8,10 percent. Two patients showed a decrease in body weight of minus 05 to minus 1kg. One patient showed no change in weight after three months but remained in good health. At least 93,6 percent of the patients recorded positive weight gain with an average gain of 6,4 kg after 3-6months of therapy.

Dr Opul says there are numerous challenges to implementing community-based ARV programmes which include long distances to laboratories where the CD 4 count (cell count is performed to determine the need for ARVs) is done, lack of transport, inadequate communication and the high cost of the drugs. Lessons learnt showed that people in rural settings can adhere well to ARV medications as shown by 91,5 percent of patients with 100 percent adherence after six months of treatment. Dr Opul says family and community support through non-governmental organisations are vital for the success of the programme. "Remarkable and significant improvement in the quality of life of patients within a short span of time has been shown by weight gain and immunological recovery. There was no reported stigma associated with taking ARV medications in the community."

Another Ugandan with first-hand experience of HIV/Aids, is Noerine Kaleeba who set up The Aids Support Organisation in Uganda. Kaleeba, who currently works for UNAids, feels very strongly about the stigmatisation of HIV/Aids patients. "As long as the stigma continues to hang in the air, we keep away. Naturally, as human beings, we want to protect ourselves from being associated with HIV/Aids. So we have to address the stigmatisation issue before anything else." One of the key actions that must be taken to address the stigma problem, is to care for people with HIV/Aids so that they become healthy again and go back to work, standing by themselves.

"Once people begin to see them as healthy individuals again, we get rid of the stigma attached in Africa because this upsets the person or the family," she says. The treatment of infected people will also help address the problem of orphans because once a person is treated with ARVs which Kaleeba stressed are not a cure for HIV/Aids, they will begin to fend for their families. "My children cannot be orphans when I am healthy and alive so we must make every effort to provide treatment and stop discussing he issue of more orphanages," Kaleeba says but acknowledges that the ARV medicines are not accessible by everybody. But she says that should not be an excuse as there has to be a start somewhere. "Equity is a debate that continues. Everything starts with something. Let's give anti-retrovirals to those who need them most," she says and gives an example of how eight members in her family - two adults and six children, were infected with HIV. "I could not afford to buy ARVs for all of them. We made a decision as a family of who had the most urgent need, so we settled for my brother. It was an ethical choice we made, so that by treating him, we delayed orphanhood for his children," she says. At least there is a glimmer of hope that HIV/Aids patients can survive longer if they can have access to treatment or complete abstinence on the part of the uninfected and the unaffected.

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