The theme of this year's(2012) World AIDS Day, Getting to Zero (zero new HIV infections, zero discrimination and zero AIDS-related deaths), shows how far the world has gone in reversing the killing tide of the deadly virus.
But while they are strategising on how to reduce the HIV impact to zero, Uganda is not sharing the euphoria because the prevalence rates are rising instead. VICKY WANDAWA and HILARY BAINEMIGISHA explore ways in which we, too, can jump onto the celebrating wagon
Uganda the master of HIV management
In 1991, HIV prevalence among pregnant women peaked at 21%.
The general incidence was 15% and about 1.3 million people were living with HIV. Uganda impressed the whole world by wrestling down this incidence to about 4.4% by 2003.
The world flocked to our shores to study Uganda's holistic multi-sectoral approach to HIV/AIDS epidemic. They took back the lessons and implemented them. Not only did they manage to halt their infection rates, but also started reducing their HIV incidence.
In the meantime, something was going wrong for us. We lost the plot, HIV incidence stagnated at 6.5%, before rising and to 7.3%. People living with HIV are now over 1.2 million. Our former students, the neighbours, have raced past to become our teachers. Kenya's incidence is now at 6.3%, Tanzania at 5.6% while Rwanda is at 2.8%, from 27% and DR Congo, 1.4%, and all these are going down.
Today, scientists know a great deal about the virus; how it spreads, mutates, hides and how to kill it. Many countries have national programmes of free ARVs, medical circumcision, prevention of mother-to-child transmission of the virus (PMTCT), free condom distribution and functional health systems. HIV is taken as a condition and not a death sentence.
However, in Uganda, the AIDS Commission (AiC) still says we are losing 64,016 people to AIDS-related illnesses every year. Uganda is the only major recipient of PEPFAR (US global AIDS funding), with rising HIV infection rates.
According to UAC's statistics, about 128,980 people acquired HIV in 2010, up from 124,261 in 2009. Kenya, Rwanda, Tanzania, Sudan and DR Congo have declining HIV rates.
Yet these neighbours have similar problems of poverty, a high debt, disease, malnutrition and poor sanitation levels, population growth that exceeds resources and political instabilities.
What are we not doing right?
Mothers infecting babies:
Let us take this example of mothers transmitting HIV to their babies, which the world has generally rolled down to zero. Uganda pioneered the Nevirapine research, which brought to the world an important drug in PMTCT. But PMTCT is hardly visible.
Last year, 22,000 Ugandan babies were infected by their mothers. Over 50% exposed infants are not tested, 39% of those tested do not receive results, 35% of those who receive results are not enrolled into ART care and 42% of those enrolled are not followed up.
Rwanda was providing free ARVs to 60% of HIV-positive pregnant women by 2007 and, as a result, mother-to-child transmission rates decreased from 30.5% in 2001 to 8.9% in 2007. Today, it is 4.2% and it is still aiming at less than 2% by 2015.
Where did we go wrong?
According to Dr Carol Nakazzi, the HIV prevalence officer at UAC, the reverse gear started when Uganda lost funding in 2006, due to corruption. Global Fund cut off its aid after most of the money sent was stolen.
"Losing GAVI funding stagnated our efforts to fight HIV. Earlier, we were improving faster than other counties, but when the funding was withdrawn, the programmes stalled, while Tanzania and Rwanda continued receiving their money," Nakazzi explains.
In an earlier interview, the Director General of AIC, Dr Kihumuro Apuuli, explained that corruption cost us a lot. "You talk of Rwanda; do you know that Kigali receives about three times more money for HIV than Uganda? When donors suspended funding because of the Global Fund scandal, our programmes were affected.
"You know 67% of our interventions are donor-funded. The Government only contributes 11%. We cannot roll out circumcision, for instance, use treatment as protection, or offer ARVs to all who need them. We need more money."
Citizens propose 10-point programme to reverse trend:
Civil Societies Organisations (CSOs) in Uganda came together and drafted a 10-point plan to fight the scourge. It was presented to the joint review by HIV stakeholders, organised by UAC last month. According to Alice Kayongo, a fellow in the Community Health Alliance Uganda, the CSO plan was well received, but the Government says there is no money to implement the proposal.
"Look at the money being stolen," she said. "It can put all people who need treatment on ARVs. It is clear our Government is not prioritising HIV, health systems and workers."
People living and affected by HIV in Alwa sub-county, Kaberamaido district receiving sheep and goats donated by Child Fund International, an NGO, last year
Proposals from civil society organisations:
1. Give ARVs to many more and in time
Research has shown that when a person living with HIV starts ARVs early, his ability to transmit the virus to someone else reduces by 96%. His survival opportunities remain high, preventing costly infections that may arise because of low immunity from HIV, such as chronic herpes, simplex virus and Tuberculosis.
However, in Uganda, only about 50% of the people who need ARVs get them free. World Health Organisation wants every HIV positive person, regardless of the CD4 count, to get ARVs. under the Millennium Development Goals set countries a goal to avail ART to all who need it by 2015.
By 2009, 95% of all people in Rwanda, who needed ARVs were getting them for free. About 65% of the people in Kenya get free ARVs.
CSOs demand that the Government targets at enrolling 80% of people living with HIV and implements the PMTCT Option B+, where pregnant HIV-positive mothers are placed on highly active ARVs, regardless of their current immunity, to prevent passing HIV onto their babies.
Response from UAC:
Dr. Carol Nakazzi says while the health ministry is the official implementer of Government health programmes, UAC plays a a cordinating role with other stakeholders and development partners. Last year, UAC changed the qualification to free ARVs from 250 CD4 count (a measure of immunity - ability to fight infections) to 350.
However, she notes that the Government cannot afford to raise the number.
"UAC is encouraging community involvement and participation," she says. "Under UAC, a number of organisations are scaling up ART, for example the Civil Society Fund, community based organisations, non-governmental organisations, Integrated Community Based Initiatives, community based initiatives and a number of AIDS support organisations which are district based."
Nakazzi contends that treating 80% is unrealistic and reaching it is an uphill task. "I do not see us increasing," she says.
2. Focus where HIV impact is high
CSOs acknowledge that the Government policy of Abstinence from sex, Being faithful in marriage and Condom use 'if you are too weak to abstain or be faithful' helped us in the past.
"But the situation has changed and our prevalence stagnated before it started rising again," Kayongo said.
"It is clear that ABC alone will not help us. But we have other alternatives that other countries are using; the scientifically proved preventive technologies"
These are ART, PMTCT and safe male circumcision. Because of scarce resources, CSOs suggested priorities in prevention investment. ABC should be reinforced with tested prevention technologies like free treatment to all people living with HIV, safe male circumcision, house-to-house HIV testing, immediately followed by free treatment.
"We need to move away from behaviour change programmes that are not working towards evidence-based, comprehensive HIV prevention," advises Kayongo.
"Condom use has declined sharply over the last five years, while the HIV prevalence is rising! Disparaging condom use is completely counterproductive."
CSOs also want leaders to stop blaming individuals or groups at high risk of infection. The emergency is to access effective prevention and treatment services without debates on who has the moral high ground because it builds stigma over vulnerable groups like discordant couples, men who have sex with men, fishermen, sex workers, migrant populations and prisoners, they wrote.
CSOs also want the Uganda Revenue Authority to stop taxing essential health commodities like medicine, mama's kits and family planning items.
Response from UAC:
The Government recognises that discordant couples, fishing communities, migrant populations, prisoners and youth are vulnerable populations and has specific HIV programmes targeting them, Nakazzi says.
However, she insists, sex workers and homosexuals are excluded because their operations are not legalised. However, Nakazzi adds, the Government does not stop any NGO which can address the HIV problem among sex workers and homosexuals.
She says the Government and a number of NGOs like ICOBI and TASO are doing the house-to-house HIV testing in central, mid-western and mid north and, by August next year, the whole country should have been covered.
"For fishing communities, there are AIDS support organisations like the Alliance of Mayors' Initiative for Community Action on AIDS (AMICAAL) in Kalangala, Mayuge and Rakai districts Star EC (American government) is operating in Mayuge and Jinja. All these organisations give comprehensive HIV services. The services include counselling, testing, link to care and psychosocial support," she says.
In the prisons, there are health departments giving all services, except condoms. But these are given to inmates when they are released to protect their wives.
"As for halting taxation by URA, negotiations are ongoing," she says.
3. Endorse and expand safe male circumcision
Safe male circumcision reduces the risk of HIV infection by 60%, but the Government, apart from coming up with the policy, has not committed to investing in the excercise.
Elsewhere, Governments are taking it seriously. Rwanda offers free medical male circumcision at all district hospitals. Kenya offers it free in districts where male circumcision is not traditionally practiced. WHO estimates that if Uganda achieved the 80% circumcision target within five years, about 340,000 new HIV infections could be averted.
But political leaders are not showing support for safe male circumcision. According to a WHO report, Uganda's male circumcision lacks leadership, with no prominent national champion. Activists blame President Yoweri Museveni's continued lack of enthusiasm and always questioning the scientific evidence behind it.
By contrast, Kenya's Prime Minister, Raila Odinga,who comes from the non-circumcising Luo community, embraced it by leading several Government officials for public circumcision events.
Response from UAC:
Nakazzi defended the Government, saying there is a circumcision policy in place. Although there has been no money released for free circumcision, UAC coordinates for all activities in HIV management and whoever is carrying out circumcision is doing it on behalf of the Government.
"So far, 25% of adult males have been circumcised and we are aiming at 4.2 million men by 2016."
NGOs carrying it out include Walter Reed, Rakai health project, and PEPFAR.
Nakazzi further explains that women are told to encourage their husbands and sons and male relatives to go for safe male circumcision and be patient for the six weeks it takes their husbands to heal, before sex is resumed.
4. More government funding for HIV/AIDS projects
CSOs demand that in the next financial year, more money should be committed to the HIV fight. More health workers should be recruited and be paid more, so that they are retained. They recognise resource constraints and propose an 'AIDS levy' or a small tax to generate additional resources.
This is a tax on some element of the economy, for example large corporations, liquor, oil or on the payroll where the revenues raised would be ring-fenced to be used strictly for service delivery, such as ARVs.
Parliament has been briefed on this idea, but concrete action is urgently needed. It has been implemented in Zimbabwe.
Response from UAC:
Nakazzi says the Government welcomed the proposal and negotiations are ongoing. As for the HIV funding, she notes that currently, 68% of Uganda's HIV funding comes from donors, and 20% from individuals and their families. "But while only 11% comes from the Government and 1% from the private sector, funds are being sought from the World Bank to run a project for recruitment," she said.
So far, Nakkazi added, the health ministry was given an additional sh49.5b, sh6.5b of which will cater for recruitment of 6,172 health workers. "The plan is to recruit 800 health workers within four years, 200 each year," she says.
5. Streamlime the health systems
Uganda has a massive shortage of professional health workers, especially at local government levels. The additional 6,172 professional health workers promised by the Government are not enough. CBOs want the Government to ensure that health centre IIIs are in position to give ARVs.
Response from UAC:
Nakazzi explains that they are currently trying to empower health centre IIIs to provide ARVs and PMTCT, depending on the infrastructure of the health centre, number of patients it receives and presence of human resource trained to handle HIV patients.
"This is a nationwide project, though not all districts have accredited health centre IIIs, but we want to finish them by the end of next year."
6. Community based HIV prevention and treatment services
Rather than people crowding at health centres, where health workers and essential health commodities are in short supply, CSOs recommend use of village health teams (VHTs).
The Government should fund VHTs, civil society organisations and people living with HIV, who play a role in spreading the gospel about the HIV scourge.
Response from UAC:
Nakazzi says UAC is already using VHTs, people living with HIV and other stakeholders. She, however, explains that due to financial constraints, the VHTs may not be motivated financially, or well enlightened on what they should do.
"They are barely paid and facilitated to move around," she said. "NGOs are encouraged to motivate them, for example the Centre for Diseases Control, gives some allowance or items like soap. They are also overwhelmed because they are not only giving HIV services, but malaria, and Tuberculosis among others."
7. Help women and girls
HIV prevalence is higher in women at 8.3% compared to men at 6.1%. It is also particularly high among married women. 63% of young women start sex before age 18, yet only 27% of them use condoms.
Lack of economic independence, access to quality, free education, and lack of protection from sexual coercion and sexual violence is fueling th HIV epidemic among women and girls in Uganda. Many pregnant HIV-positive women report an alarming rate of abuse and stigma by health workers. As a result, they fear accessing PMTCT services.
Response from UAC:
Nakazzi notes that the Uganda National HIV and AIDS policy 2011, focuses on reducing gender based vulnerability, concerns in HIV prevention, AIDS care, treatment and impact mitigation. The Government will support appropriate cross sector strategies developed to address them.
8. HIV testing
CSOs want the Government to saturate communities with testing programmes and immediate linkage to care and treatment. Currently, only 15 districts have home-based HIV testing. These are Gulu, Masaka, Mityana, Soroti, Mbarara and Kumi. Others are Rukungiri, Masindi, Jinja, Wakiso, Tororo, Kalangala and Apac.
Massive testing will identify people for treatment. During the Uganda AIDS indicator survey 2011, 55% of the people found HIV-positive did not know they had it. 26% had never tested and 29% had last tested negative.
Response from UAC:
The Government is doing its best, through the health ministry and a number of NGOs carrying out home-based care and house-to-house testing. The Government also asked every organisation giving HIV/AIDS services to provide house-to-house testing, but some do not because of limited funds.
9. Avail information to people
CSOs complain that data on the AIDS response is unreliable, incomplete or simply unavailable. The Government should prioritise data collection and recording, they say.
Response from UAC:
UAC is developing a comprehensive addendum with all strategies against HIV. By the end of the next financial year, we shall have all the data," says Nakazzi.
10. End harmful discriminatory policies
CSOs challenged Uganda's policy positions and bills, such as the HIV/AIDS prevention and control Bill and the Anti-Homosexuality Bill, which would criminalise people with HIV, people at highest risk of infection and criminalise efforts to provide evidence-based prevention to these communities.
"These bills should not be passed and vulnerable populations should instead be prioritised in an effort to expand HIV service delivery," the document reads.
Response from UAC Discussions on these are still ongoing.