Arthur Baguma
10 August 2008
analysis
Kampala — WHEN HIV/AIDS was at its worst, the world turned to Uganda for the solution. Consequently Uganda became a role model in the HIV/AIDS fight.
However the latest report by the United Nations programme on HIV/AIDS (UNAIDS) presents a worrying situation about the country's trend of HIV/AIDS prevalence.
The 2007 AIDS epidemic update report states that starting in 1992, a significant decrease in HIV prevalence were observed in Uganda alongside evidence of substantial behavioural change that inhibited the spread of HIV.
"However, that trend appears to have stabilised in the early 2000s and there are now concerns that the HIV epidemic could grow again," the report states. The report provides the most recent estimates of the AIDS epidemic and explores new findings and trends in the epidemic's evolution.
Health ministry officials have blamed the concerns on complacency in the public. Paul Kagwa, the assistant commissioner in charge of health promotion, observes that at one point if you had AIDS it was a fast and direct passport to death, but today people treat AIDS like any other disease. "Today the emphasis is on care and support of AIDS patients.
Antiretroviral drugs (ARVs) are available; people no longer fear death from AIDS," Kagwa notes.
His view is echoed by the Uganda Aids Commission. James Kigozi, the public relations officer of the Uganda AIDS Commission, observes that what is happening is a general trend in the epidemic.
"It is about issues of complacency. The availability of drugs has caused a negative effect to some extent. People know that they will get treatment even if they get AIDS."
However some sections of the anti-AIDS campaign have blamed the west for imposing their own ways of fighting HIV/AIDS on Uganda. "We are losing the war against HIV/AIDS," Pastor Martin Ssempa says.
A renown anti-gay activist Ssempa accuses UNAIDS of "forcing us to turn away from our original ABC strategy in favour of the universal access.'
"Universal access puts emphasis on condoms, treatment and a cottage industry of rights, like gay rights, stigma rights. It minimises the role of prevention through behavioural change, abstinence and faithfulness," Ssempa said.
He laments that AIDS has become a big business with most AIDS activists out to make money. "We used to say AIDS kills but now when you say AIDS kills, they say you are creating stigma.
We have a big conflict between the western approach based on human rights against Uganda's approach which was based on prevention (the social vaccine). We have abandoned behavioural change. People are no longer afraid of HIV/AIDS," Ssempa says.
Uganda was the first country in sub-Saharan Africa to register a drop in adult national HIV prevalence.
The report points out that Uganda's decline in HIV prevalence seems to have ended in the early 2000s.
An estimated 6.7% of adults (15-49 years) were living with HIV in 2005 - about one million people.
Infection levels are highest among women 7.5% compared to men, 5.0%. The prevalence is also rampant among urban residents10.0% compared to 5.7% among rural residents. Prevalence among children younger than five years of age is 0.7%.
While the decline in HIV prevalence observed among pregnant women attending antenatal clinics in Kampala and some other urban areas appears to have persisted through 2005, other urban and most rural surveillance sites indicate an overall levelling of prevalence.
Similarly, a cohort study in a rural area in southern Uganda suggests that HIV prevalence and incidence rates have levelled since about 2000 in both men and women.
But with a population growing as rapidly as that of Uganda (which had a total fertility rate of 6.7), a stable HIV incidence rate means that an increasing number of people acquire HIV each year
The stable HIV trends are occurring alongside an apparent increase in behaviour that favours HIV transmission.
All stakeholders agree that it is high time Uganda reviewed and revived the prevention pressure message to the people.
"We are no longer emphasising key things; there is noticeable reduction in prevention pressure which we should address.
Today's messages are not scaring enough to bring to people the reality of AIDS and death," says Kagwa.
The report states that there is an urgent need to revive and adapt the type of prevention efforts that helped bring Uganda's HIV epidemic under control in the 1990s.
The report mentions that in most of the countries in East Africa, adult HIV prevalence is either stable or declining slightly. The latter trend is most evident in Kenya, which is experiencing a slow, but steady decline in HIV prevalence amid evidence of changing behaviour.
In Uganda's national population-based surveys conducted in 1995, 2000, 2004-2005 and 2006, sex with a non-regular partner was reported by 12%, 14%, 15% and 16% of adult women, respectively, and by 29%, 28%, 37% and 36% of adult men, respectively.
In the same surveys, condom use during sex with partners was reported by 20%, 39%, 47% and 35% of women in 1995, 2000, 2004-2005 and 2006, respectively, and by 35%, 59%, 53% and 57% of men, respectively, indicating a lack of progress in promoting safer sex in recent years.
The report notes that Kenya's AIDS epidemic is of the same scale as Uganda's. The estimated 5.1% of adults (15-49 years) living with HIV in 2006 represented nearly one million people - a large epidemic, despite evidence of a slow, but steady decline in HIV prevalence.
In Kenya, adult HIV prevalence is almost twice as high among women (8.7%) than men (4.6%). Nationally, HIV infection levels decreased from about 14% in the mid-1990s to 5% in 2006.
The downward trend was especially profound in the urban sites of Busia, Meru, Nakuru and Thika, where median prevalence declined from 28% in 1999 to 9% in 2003 among 15-49 year-old women attending antenatal clinics and from 29% in 1998 to 9% in 2002 among those women aged 15-24 years.
Behavioural change in Kenya may be linked to these declines in HIV prevalence. Adult national HIV prevalence in Burundi declined markedly, from nearly 6% in the late 1990s to about 3.3% [2.7%-3.8%] in 2005.
However, recent HIV surveillance among women seeking antenatal care suggests that the decline did not continue beyond 2005, when HIV infection levels started to increase again (sometimes substantially) at most surveillance sites.
The highest prevalence was found in the capital, Bujumbura, where, in 2005, 18% (up from 13% in 2004) of adult and 16% (up from 9% in 2004) of young pregnant women (15-24 years) tested HIV-positive.
Adult national HIV prevalence in Rwanda was estimated to be 3.1% [2.7%-3.8%] in 2005. The 2005 antenatal clinic survey showed that 4.1% of pregnant women were HIV-positive, with prevalence highest in Kigali (13%) but, on average, about 5% in other urban areas and slightly more than 2% in rural areas.
Substantial declines in HIV prevalence were observed in Rwamagana (from 13% to 4% between 1998 and 2005) and in Gikondo in the city of Kigali (14% to 8%).
HIV prevalence in other African countries
HIV infection levels have also declined in Tanzania, where about 6.5% [5.8%-7.2%] of adults (15-49 years) were living with HIV in 2005, down from slightly more than 8% a decade earlier.
There is substantial regional variation in HIV prevalence, both between Zanzibar and the mainland and on the mainland itself.
The most recent information shows that HIV prevalence among antenatal clinic attendees in Zanzibar ranged from 0.7% in the island of Unguja to 1.4% in the island of Pemba, while on the mainland; it was 8.7% among women using antenatal services in 2003-2004.
Among people aged 15-24 years surveyed in 2004-2005, 34% of young women and 83% of young men said they had engaged in risky sexual behaviour in the previous 12 months.
However, in the 2004-2005 survey, less than half (46%) of the young men reported using a condom the last time they had higher risk sex, as did only a third (32%) of the young women (down from 42% in the 2003-2004 survey).
A similar reduction in condom use during sex with a non-regular partner was evident among adult women (15-49 years) generally from 38% to 28% over the same period.
Among men, however, condom use levels with a non-regular partner remained steady in the two surveys.
Age mixing appears to be on the decrease.
Only 6% of women (15-19 years) reported in the 2004-2005 survey that they had had non-marital sex with someone at least 10 years older than them during the previous year, compared with 9% in the 2003-2004 survey.
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