Kampala — HIV is on the rise in Uganda and officials are pointing the finger at people like Margaret Kintu, who tested positive two years ago.
Like most young Ugandans, the 26-year-old had been drilled in the ABCs of HIV prevention - abstain, be faithful or use a condom. The slogan spearheaded the behaviour-change campaign launched in the 1990s, contributing to a double-digit drop in the country's HIV rate.
Kintu says she encouraged her boyfriend to wear condoms, but that he "wanted to produce" so eventually they went without. She says she assumes that is how she became infected, though her boyfriend has never been tested, so she cannot be sure.
The rising number of new infections - now estimated at 130,000 per year - has pushed Uganda's HIV prevalence rate up from 6.4% in 2005 to 7.3% last year. A country that was once a star of the international AIDS community is moving backwards.
Relaxing on HIV?
After the new numbers were released in June, Dr Vinand Nantulya, chairman of the Uganda AIDS Commission, put out an exclamation-point laden statement saying, "The key driver of infections in adults is complacency!" Indeed, this idea of complacency forms the chief line taken by officials in explaining the rising numbers.
But activists and HIV patients say that spinning a complacency narrative around the rising rate oversimplifies the situation. While people still have a responsibility to reduce their own risk, there are biomedical interventions - unknown at the advent of the ABC campaign - that can dramatically reduce the risk of transmission. Scaling up these interventions could help safeguard people like Kintu who forgo traditional prevention strategies, but, some groups say, the country has not moved fast enough in deploying them.
Though incomplete, however, the complacency narrative is not entirely inaccurate. The AIDS Indicator Survey (AIS) that announced the rise in HIV prevalence also reported that more than three-quarters of Ugandans between 15 and 59 know how to protect themselves from contracting HIV - either by using a condom or sticking to one uninfected partner. But despite this knowledge, many are not. Among the number of men who reported having more than one sexual partner over a year, for example, less than 14 % said they used a condom when they last had sex.
"To some extent, people have relaxed," Frank Matsiko, a counsellor with Ugandan NGO Integrated Community Based Initiatives (ICOBI), tells Think Africa Press. The introduction of antiretroviral therapy (ART) went a long way towards slowing the drumbeat of deaths in the country, he says. But "some people - especially those who are not well sensitised - have relaxed and taken it for granted that one can have HIV and go on treatment and stay as long as he wants."
According to the AIS, the Ministry of Health identified "declines in protective sexual behaviour and increased risk-taking behaviour" as early as five years ago, as the first generation which grew up when ART treatment was available came of age.
According to Reverend Canon Henry Ntulume, archdeacon of the Nateete parish in Kampala, this knowledge did not lead the government to call religious or cultural leaders to encourage their followers to take greater vigilance, as happened during the 1990s. It is not just the general public that has "relaxed", he says.
The difference between now and the 1990s is that a successful HIV prevention strategy is more than just a behaviour-change campaign led by invigorated leaders. Research advances have offered a slew of new interventions - such as prevention of mother-to-child transmission (PMTCT), safe male circumcision (SMC) and access to universal treatment - that have the potential to slash a country's HIV transmission rate.
These programmes are the lynchpins of US president Barack Obama's goal of an "AIDS-free generation" which he announced on World AIDS Day 2011 - a vision that Uganda's Ministry of Health has signed on to. However, these services are still not broadly available in Uganda. While complacency and the leadership gap are important challenges to overcome, activists say it is equally important to focus on scaling up the biomedical interventions.
Uganda still has at least 20,000 HIV-positive babies born every year. This is "something we could cross out overnight," Richard Ochai, outgoing executive director of the AIDS Support Organisation (TASO), tells Think Africa Press. "If only we had the commitment to put the resources into PMTCT, we could stop it."
In addition, three randomised control trials in sub-Saharan Africa, including one in Uganda, found circumcision could reduce HIV transmission by as much as 60%. Critics say the results were skewed by biased researchers, but the findings were accepted by the World Health Organisation which recommended SMC as an intervention for HIV prevention in 2007. In Uganda, where three-quarters of men are uncircumcised, AIS found that 50% of those men actually wanted the procedure. Demand has outstripped resources though, and the programme has made little headway in reducing the uncircumcised population.
Then there is treatment. Uganda has not yet introduced universal access to ART; it is only available for patients whose immune systems have deteriorated beyond a certain point. However, nearly 250,000 of the patients who qualify for drugs under the country guidelines are not receiving them, according to UNAIDS. As the number of new annual HIV infections (130,000 in 2011) continues to outnumber the number of new patients being enrolled in ART (40,000 in fiscal year 2010-11), the gap will only grow wider.
Winning the battle
The complacency narrative is a convenient headline to redirect attention from the more systemic problems that have slowed down these programmes. ICOBI's Matsiko points to a short-staffed and underpaid cadre of government health workers. Only about half of Uganda's public-sector health positions are filled, which means that there are not enough people to do the necessary outreach, counselling and follow up, he says.
But even as key health officials publicly chide people for complacency, donors and the government are beginning to direct more energy toward finding the resources to make programmes like PMTCT and SMC work. TASO's Ochai highlighted the idea of an AIDS trust fund being floated by officials, which would tax things like cigarettes and alcohol sales and plough the money into HIV interventions. Advocates say that this is a tacit acknowledgement that despite the finger pointing, there is general recognition that Uganda's HIV problem is much broader than mere complacency.
"Government is getting the point that we need to do something," says Ochai. "We have to be relevant to the changing environment, the changing policies, the changing science. We have to modify how we fight, so we can win the battle."
Andrew Green is a freelance journalist based in Kampala, Uganda, primarily covering global health and governance. You can follow him on Twitter @_andrew_green.