HIV services have improved, but health systems a far cry

A new report by the Uganda Network of AIDS Services Organisations (UNASO) shows that HIV services in the country have generally improved, but a lot still needs to be done. Released early this year, the AIDS Accountability Score Card, which was done from September to December 2013, is the first national evaluation. JOHN AGABA reports on the detail.

As Ugandans discuss the recently passed HIV Bill, there is a strong argument that the country needs HIV services much more than it needs the law. And for the approximately 1.5 million Ugandans living with HIV and the 140,000 more expected to join them by the end of this year, the daily hustle of accessing services is a big issue.

UNASO looked at the quality and quantity of the main services needed by people living with HIV at the national and district levels. These included programmes like prevention of mother-to-child transmission (PMTCT), HIV counselling and testing (HCT) and safe male circumcision (SMC).

The study also evaluated anti-retroviral therapy (ART) for both adults and children, as well as tuberculosis (TB) treatment. The assessment looked at support services like adolescent treatment, social support, health infrastructure and equipment in selected health facilities offering HIV services.

 The study was done among beneficiaries of HIV services, such as people living with HIV, most at-risk populations, persons with disabilities and young people. Other people involved were health service providers, health management committee members, hospital directors, local council officials, technical staff, as well as village health teams.

The findings

Generally, there are significant improvements in the prevention of HIV transmission from mothers to babies, availability of HIV drugs (ARVs) and safe male circumcision. However, social support and health systems, which support delivery of HIV/AIDs services, have not been performing well.

Bharam Namanya, the UNASO executive director, said the findings were encouraging, albeit with challenges.

“We are doing well,” he said.

“There is high uptake of PMTCT services and the number of people on ARVs has almost doubled. But many people who are at risk of contracting the virus have not changed their behaviour. There is transactional sex, abuse of alcohol, gender-based violence, people have multiple sex partners and there is a decline in condom use. All these cripple efforts in the fight against HIV.”

The fight against HIV should be everyone’s responsibility, he advised.

“We need to go back to individualising the response, where you and I appreciate that we are at risk of contracting the virus and that the choice not to contract it is in our hands. HIV/AIDs is still a challenge,” Namanya said.

Prevention of HIV transmission to babies (PMTCT)

Babies get infected with HIV from their mothers during pregnancy, at birth and after birth, due to close interaction. There are drugs given to pregnant mothers to stop this transmission. In October 2013, the Government started a strategy of treating all pregnant and breastfeeding women living with HIV to reduce the risk of mother-to-child transmissions. It is known as the Option B+.

The research found that 64.3% of all respondents rated the strategy as good, 17.8% said it was very good and 17.8% said it was average.

None of the respondents rated it poor or very poor. Respondents praised its spread to many health centres, where they get HIV services. They also liked the public sensitisation on PMTCT through radio programmes.

The programme was doing well at Mbale Referral Hospital, Akokor health centre III in Apac and Kigalando health centre IV as well as Mulongo in Mayuge. Wakiso health centre IV was the worst in PMTCT services.

Respondents criticised the failure to track every HIV-positive mother, who has left the treatment. When such mothers stop taking ARVs, it can lead to drug resistance. Another problem was of mothers who fail to deliver at health facilities and the reluctance of their husbands to participate. The relationship between the health facilities and communities was deemed too weak to facilitate referrals and follow-up of mothers.

Condom supply

More than 57.1% of respondents rated condom supply as average because very often, they are out of supply. There is lack of knowledge about the female condom, community misconceptions and poor attitude of men towards condom use.

Inadequate community leadership support to condom promotion was blamed for the low condom utilisation. Mbarara Referral Hospital was the worst in condom supply, while Akokor health centre III was the best.

Safe male circumcision

In 2007, the World Health Organisation (WHO) recommended medical male circumcision (MMC) as one of the interventions in the fight against HIV after trials in Uganda, Kenya and South Africa showed it reduces the risk of female-to-male sexual transmission of the virus by about 60%.

In Uganda, the circumcision programme was launched in September 2010, targeting 80% of uncircumcised men – about 4.2 million men – by 2015. According to the report, 39.3% respondents said the programme’s performance was good and 35.7 % gave it average.

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According to the report, more people can now access HIV testing and counselling

They liked the different use of health centres, camps and outreaches, as well as the use of public education, mainly through the media. Kigalando Health Centre IV in Mayuge was deemed the best performing, while Kamwenge was generally poor, especially at Kamwengye Health Centre III and Rukunyu. Nadunget Hospital in Moroto and Mungula in Adjumani were poor, too.

Those who complained talked of limited trained medical staff to undertake circumcision, lack of kits sometimes, inadequate information on the benefits of circumcision and lack of support to people who have just been circumcised.

Religious leaders were singled out as some of the saboteurs of the programme. Other challenges named were stigma and misinformation and failure to handle post-circumcision effects.

Blood transfusion

This rated very poorly, with 50% calling it average, while 43.8% called it poor and very poor. Key issues include poor storage facilities and poor mobilisation of blood donors. The service was nonexistent in many centres and the only places it was described as good were Kakuuto in Rakai and Adjumani Hospital in Adjumani district.

Public education on HIV

A total of 39.3% of the respondents rated public education on HIV/AIDS as average, 35.7% as good and 14.2% as poor. Those who liked it praised the many dissemination channels, such as the mass media, religious facilities, village health teams and community support groups like people living with HIV/AIDS networks.

However, the respondents complained that many times, the education materials are not in local languages, have uncoordinated messages with too many implementers and do not cut across the communities.

Places disappointing people in public education included Kakuuto in Rakai and Adjumani Hospital in Adjumani. Those rated good were Kamwengye Health Centre III and Nanduget Hospital in Moroto. n hiV counselling and testing Performance is generally good and peaks in Wakiso Health Centre IV, Bufumbo in Mbale, Mugula in Adjumani and Akokor Health Centre III in Apac.

Fifty percent of the respondents rated counselling and testing of HIV as good and 28% as very good. They mentioned better persuasion tactics, community outreaches, integration of counselling and testing with ante-natal ART care, as well as safe male circumcision.

Even in places like Aduku Health Centre IV in Apac district, where there were complaints of intermittent supply of testing kits, limited human resource, lack of home-based support and limited male and youth involvement, the situation was not very bad. 

HIV CARE FOR CHILDREN, ACCESS TO CD4 MACHINES

Most people (57.1%) were happy with the performance of HIV care for children and 28.5% even called it very good. Availability of drugs, public education and counselling of mothers were given as some of the reasons for the score.

Kaberamaido and Mungula in Adjumani excelled in performance, while Kapchorwa Hospital and Aduku health centre IV registered a few complaints. Others rated were adolescent HIV care and treatment, the integrated TB programme, palliative care performance, family planning services, provision of nutrition, home-based care performance, psychological services and capacity- building of care-givers. 

Access to CD4 machines People living with HIV need to be periodically tested to ascertain their immunity progress and this requires CD4 count machines. These show the amount of fighting cells you have in your blood and reflects whether the ARVs are working.

The scorecard evaluated the availability of these machines to people living with HIV and 25% said it was very good. An equal percentage also said it was very poor. CD4 machines were easily available in Adjumani Hospital, Mungula in Adjumani and Kakuuto in Rakai.

But patients said they face problems in areas like Mwizi health centre IV, Kamwenge, Mulongo in Mayuge, nadunget Hospital in Moroto, Ochera health centre in Kaberamaido and Layibi in Gulu.  

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WHAT THEY SAY ABOUT THE REPORT

Dr. Stephen Watiti, Senior medical officer and HIV activist

Credit needs to be given where it is due. But a lot is desired to harmonise service delivery. While more people living with the virus are on treatment and many other interventions like SMC have been rolled out, the tendency to prioritise one intervention over the other will not get the country the desired results. We don’t have a single intervention that we can say stops HIV 100%.

Circumcision protects the man up to about 60%, ARVs decrease infectiousness by 92%, PMTCT is not 100%, same as condoms. So, it is a combination that we need. if you are circumcised, you still have to wear a condom if you do not know the other person’s status. We need to ensure that everyone who needs a condom gets one; everyone who tests positive starts on treatment.

The national target is to circumcise over four million sexually active men. We should circumcise them. We need a biometric registration in HIV services to reduce the cases of people starting on treatment and then dropping out. Sometimes, people do not drop out.

They change centres and providers register them as dropped out. Biometric registration will enable a person who comes from the village to Kampala to use his thumbprint to get ARVs.

Dr. Joshua Musinguzi, AIDS control programme manager

We are scaling up all biomedical interventions to reach everyone who qualifies to get the services. We want people who are HIV-negative to stay negative and those who are positive to start on treatment. We received a grant from the Global Fund to recruit over 600 medical workers to help avert the staffing challenges.

On the stock-out of testing kits, there is still a challenge. But we now have a good stock to last us about six months. All we need is to improve the supply chain management so that all the supplies are distributed effectively. Sometimes, our poor supply chain causes an artificial stock out. We have supplies at the national stores and stock-outs at facilities. Also, we shall have enough condoms. Between august 2014 and June 2015, we expect 250 million condoms from the global fund.

The national Drug authority has started testing over 20 million condoms a month, compared to 13 million previously. On the issue of bitter ARVs, one of the procurements accidentally got a box of drugs that were not coated.

The question was: should we throw away these drugs when there are people who need them, but can’t get them? No, we decided that the care-givers should ask the patients to be patient with us. After two months, we know the drugs will be out of circulation.

Dr. Walter Dreak Erabu, in-charge of Kaberamaido health centre IV

Many health centres do not have qualified and HIV competent personnel, so the available few have to take on extra work.

Lilian Mworeko, executive director, international community of people living with HIV in East Africa

The report findings do not reflect the actual picture on the ground. It looks like we, Ugandans, have reached a level where we are settling for less. Everything that comes in, we celebrate. For instance, PMTCT scored highly, but how many mothers attend antenatal care? How many deliver in health facilities? And how many are lost to follow-up?

It is not just about more numbers accessing the services as compared to the previous year. How many women need family planning services, but cannot access them? Prevention is treatment. Why do we still have some people who need ARVs, but cannot get them? We need to improve on the quantity and quality of services delivered.

Margaret Happy, advocacy manager for the national forum of people living with HIV

There is still need for improvement in the quality of HIV care. The drugs they brought us were very bitter. We complained because they were not coated and were causing adherence challenges. The drugs were recalled, but now they are back. Condom stock-outs are common. If you are putting pregnant mothers on treatment, ensure you monitor them. But how many mothers are later lost? Women need to be sensitised to understand why they are taking the medicine and why they need to continue.

IN NUMBERS

2,138 Number of health centres where PMTCT Option b+ has been rolled out

750,000 Males, 74.2% of the annual national target of 1,000,000, have been circumcised under the SMC project.

41% Treatment coverage among eligible children. This stood at 28% in June 2012

577,000 People on free ARV treatment increased from 329,060 (57% coverage) to 577,000 (76.5%), under the 2010 WHO treatment guidelines of CD4 cell count of 350 or less.

86% retention on treatment. This surpasses the target of 85%.

205,000   Blood units (79% of the national target) have been collected and screened for HIV, syphilis and Hepatitis A and B.