With HIV infections on the rise, so many questions are being asked: Is Uganda still a success story on HIV? What went wrong? Can Uganda get back on track?
By Carol Natukunda
Imagine the image of a man, weighing no more than 20kgs. He has sores, hair is falling off and he is vomiting relentlessly.
In the 1990s, it was scary to look at anyone suffering from HIV/AIDS. We feared that sex equaled AIDS or ‘slim’ as it was called. And ‘slim’ was equal to ‘death.’
The first AIDS cases were diagnosed in 1982 in Rakai district, at Kansensero landing site. It started as a rumor but soon spread like a wild fire with prevalence rates as high as 18% in 1992. People were succumbing to the epidemic and dying at a frightening rate.
Those who were infected had to face brunt of stigma and segregation. Singer Philip Lutaaya was the first person to come out publically and declare his status. He went about schools singing about how he was ‘alone and frightened.”
His honest testimoney was as moving as it was scary. Because of this fear, Ugandans got together in solidarity to fight the epidemic.
The ABC strategy
The government came up with three strategies; Abstain from risky sex encounters(A), be mutually faithful to your partner(B)and use a Condom(C) where you were tempted to stray – all of which came to be known as the ABC approach.
According to President Yoweri Museveni, the strategy was acclaimed worked wide. “We advised children to avoid getting involved in sex when they still young. This was to allow them to concentrate on their studies until marriage.
President Yoweri Museveni called on his countrymen to test for HIV when he took a test publicly as an example.
For those who were married, we urged them to be mutually faithful to each other. This was dubbed zero grazing. The third strategy recognized human weaknesses; if tempted, use a condom to protect yourself from the virus,” says the President Yoweri Museveni in his forward remarks published in a report titled, “To protect yourself, your child and your spouse,” by the Uganda AIDS Commission (UAC).
“These three strategies helped us to achieve the success we initially enjoyed,” Museveni says.
By 2000, the HIV prevalence rate had dropped tremendously and Uganda was being applauded the world over as a success story. In 2005, the prevalence rate was at 6.4%.
The rising epidemic
But worry started creeping up again when, for the next three years, and the prevalence rate stagnated at 6.4%. And before we knew it, the infections were rising again. The findings from the 2011 National HIV Indicator Survey were disturbing.
The prevalence rates i.e. proportion of Ugandans, aged 15-49, who are infected with HIV had risen and stood at 7.3% (and even higher in women at 8.3%), up from 6.4% in the 2004-05 survey. the primary concern was that the number of new infections had risen from 124,000 in 2009 to 128,000 in 2010 and to 145,000 in 2011.
By all indicators, there would be a higher number of new infections in the subsequent years. In fact, the UAC projected the HIV burden would increase by more than 700,000 infections over the next five years including an estimated 25,000 unfortunate babies born with the infection each year, through no fault of their own.
Where did we go wrong?
A number of reasons were cited, but among them was complacency. In an interview with New Vision, the chairman of the Uganda AIDS Commission Prof Vinand Nantulya said HIV was no longer a death sentence with improved health care.
“Ugandans are very naughty,” Nantulya said, “They no longer fear HIV at all. They think they can live with it.”
Part of the problem was the advent of the anti-retroviral therapy, according to Nantulya. Uganda launched the ARV programme on June 11 2004 to provide free antiretroviral drugs to HIV/AIDS patients across the country. Prior to that, the treatment was complex and only a preserve for the rich.
A newly installed CD4 Machine at Kibito Health Centre IV
One had to take several pills, each of them several times a day and on very strict timetables. In 1996, scientists in America established a better combination of ARVs which could suppress HIV to the extent that it could no longer be detected in blood.
This led to dramatic improvements in the lives of patients. However ARV had to be taken definitely as stopping them would lead to resurgence of the virus. These medicines remained expensive.
For instance in 1998, JRC, was treating a few patients with ARVs at a cost of 1,000 dollars per month. The government and development partners later negotiated with the drug companies based in Europe and America to reduce the cost to 600 dollars per month, but this was still too costly for Ugandans.
The turning point was when Uganda started importing them from Asian companies that were manufacturing the drugs. Consequently in 2004, the health minority announced that Uganda would supply ARVs free of charge to all those who needed them.
The government spent $1·3 million to buy antiretroviral for the 2,700 most needy patients, using a loan from the World Bank. With the same loan, the government spent a further $1·7 million on antiretroviral later that year.
In the subsequent months, most of the funds were got from the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria. Because of these modern medicines combined with positive living counseling, the typical AIDS symptoms which made one to look like a walking corpse disappeared from the scene.
And today, as they say, the rest is history. About 500,000 Ugandans are estimated to be receiving free treatment today. In 2007, a new factory in Kampala was commissioned to produce ARVs.
“With ARVS, people saw that HIV/AIDS no longer kills. Someone who is on ARVs might even look healthier than someone who is not sick. Some people, say, oh, well we shall all die, so why the bother?” Nantulya says.
As such the number of practicing unsafe sex, out of recklessness, complacency, or even deliberate unprotected sex, continues to grow.
“Zero grazing,” which was the single most important driver for the decline in HIV infections, is no more.
There is evidence that there has been reversal in sex behavior, as more people, especially men have more sexual multiple partners. In fact, the latest AIDS indicator survey shows that among adult males, sex with multiple partners is back to where it was at the beginning of the epidemic.
A drama perfomance on HIV/Aids courtesy of TASO in Gulu
Consequently, up to 43% of new infections in adults (age 15-49) in 2008 were among people claiming to live in monogamous relationships, while 46% were among persons reporting multiple sexual partners. Commercial sex workers, their clients and partners of the clients contribute 10% of the new infections.
While multiple sex partnerships have remained low among women, Nantulya says this does not protect them because evidently, they are getting infected by their trusted male partners who pick up the infection from unprotected sex elsewhere.
According to Nantulya, this complacent phenomenon is nothing new. He says as early as 2002, one of the researchers at the International AIDS Conference in Barcelona showed how the same trend was occurring in New York, Australia and other development partners.
“People thought because of ARVs and condoms, they could be reckless,” he says, adding that condoms are not 100% safe, and that receiving treatment is not a bed of roses.
At the same time, Uganda seemed to have lost solidarity in preaching the ABC gospel.
“Parents are too busy for their children and do not have time to guide them. Leaders across all platforms including religious leaders went quiet and were not preaching the gospel. At the same time, we had several contracting messages all over the streets and airwaves, including miraculous messages by self-acclaimed medicine men,” said Nantulya.
Market vendors have also engaged themselves in the fight against HIV/Aids
Some critics also blamed the Government agencies and local charity organizations for concentrating on holding workshops instead of doing “real work that could deter new infections.
“HIV has been commercialized. We have many workshops and conferences, which are mostly held in Kampala,” said Musa Bungudu, the coordinator of the UN programme on HIV/AIDS.
Is Uganda still a success story?
There has been a lot of criticism that Uganda is failing the war. But proponents say the situation is not as bad as it was when HIV was recorded in Rakai.
Some argue that Uganda’s initial AIDS-prevention success was based on the extreme fear that the disease generated among the ignorant population. Today, more people are knowledgeable about HIV prevention.
For instance, according to the AIDS indicator survey, over 70% were aware of ways to prevent the virus. About 75% of adults said that remaining faithful to one uninfected partner and always using a condom were ways of reducing the risk of becoming infected with the AIDS virus, HIV.
The survey also identified the numbers of those with misconceptions about how HIV is transmitted. Less than 50% of adults think that HIV can be transmitted by mosquito bites – a previously common misconception.
The fight against HIV/Aids is both local and global. Here, people take to the streets in a campaign in Ethiopia.
Getting back on track
In a bid to reduce the new infections by 30% in 2015, UAC is implementing an ambitious five year plan to curb the epidemic. Among the interventions include ensuring that there is mandatory HIV testing for pregnant mothers.
“We should ensure that all pregnant mothers find out their HIV status as soon as they are pregnant. We now have methods that can stop mother to child transmission,” says Dr. Kihumuro Apuuli, the director general of UAC, adding that men must come and test alongside their spouses.
The Commission is also working to ensure that every Ugandan is counseled and tested. And if you are negative, there are methods available to you to remain negative. And if you are positive we enroll you for treatment right away,” says Kihumuro.
UAC is also working with politicians, district and religious leaders to be involved in promoting in behavioral changes.
“The danger of carelessly having sex with someone whose status you don’t know is recipe for disaster. “Also ask yourself, would you be happy giving birth to a child who is HIV positive?” asks Nantulya.
Celebrating World Aids Day.
“If you are HIV positive, don’t think treatment is easy to take. That treatment (ARVS) is daily, and it is for life,” stresses Nantulya.
“There is the ever present threat of drug resistance, which might require change of drug combinations. So if you choose to take these risks, let it be clear to you that these drugs are not curative,” says Nantulya.
Besides, Uganda cannot afford to have enough drugs to treat all Ugandans living with HIV. Already, only half of the 500,000 Ugandans who need to be on treatment are currently enrolled in the treatment programmers.
“So do you really want to join the queue?” asks Nantulya.
While one might argue that Uganda is producing its own ARVs, the demand is overwhelming. According to a statement released ahead of the Jubilee celebrations independence last year, the pharmaceutical plant produces only six million tablets a day.
However, given the widening market, they are to put up a second plant which will increase the capacity to 18- 24 million tablets every day.
In the meantime, UAC is regulating all the messages put out to the public to avoid contradiction.