By Sam Agona
Why increase in new HIV infections and deaths whilst increased access to ARVs in Uganda?
The Daily Monitor, a publisher in Uganda posed the question above and I found it worth responding to in my way.
Undeniably, recent years have seen access to ARVs more leveraged. Since 1996 Uganda has pioneered the use of ART in sub-Saharan Africa. ARVs were initially imported and distributed to patients who could afford to buy them. In Uganda there are pharmaceutical plants (Quality Chemical Industries) which produce ARVs.
According to Dr. Peter Mugenyi, Joint initiatives between international organizations such as UNAIDS and private organizations such as the Joint Clinical Research Centre (JCRC) helped to reduce the cost of ARVs. Equally, open acceptance that there was an AIDS problem in Uganda helped in tackling the pandemic. A diversity of groups including NGOs, religious groups, community self-help groups and reknown persons who came out and talked openly regarding their HIV status Philly Lutaaya, Noerine Kaleeba, Rtd. Major Ruranga Rubaramira among other activists.
The National AIDS Control Programme (ACP) along with the unwritten policies, in 1986 when infection rate was 31% helped decrease infections to 6% in 2006, partly because Ugandan government and NGOs insisted on the ABC model which yielded results. However according to UBOS statistical abstract of 2012, HIV was among the top two causes of hospital based mortality standing at 2.61% for children under 5, and 13.67 for humans above 5. A statistic only bettered by malaria which sternly stood at 27.16% for infants below 5, and 16.9% for humans above 5. In general AIDS accounted for 9.4% of total deaths in 2010/11.
Since 2006, the percentage of new HIV infections increased from 6% to an average of 7.2% according to UNAIDS. Partly this was attributed to a situation called “AIDS fatigue”; a state of public desensitization about the impact of HIV/AIDS after receiving continual messages about the same dangers over a long time.
Today, youth are keen on not getting pregnant than contracting HIV. The open knowledge that there are drugs that can be taken to control HIV has made several young youth less afraid of contracting it. This view was reported in New Vision, November 29, 2009 and Observer, June 26th 2006.
There has been situational misuse of ARVs by patients such as sharing ones’ dose with other patients who were not able to get their drugs in right time. This is compounded by various situations that create barriers to proper usage or access to ART. This phenomenon is heavily discussed by NR Kunihira, F. Nuwaha etal in their study titled "Barriers to use of antiretroviral drugs in Rakai district of Ugandan", 2010.
Thriving of sex trade among young people increases both new infection and deaths. On 19th January 2014, the Observer reported that East African truck drivers prefer Ugandan sex workers this means more sexual activity on the Ugandan side. According to an International AIDS Society research in 2014, several people who go buy sex from sex workers are intoxicated with drugs or alcoholic substances thus impairing their sense of judgment therefore always exposed to taking the short cut of having unprotected sex.
Many people hear about HIV/ AIDS but there is still a knowledge gap on the pandemic. UBOS 2012, noted, that by 2011, the proportion of 15-24 year olds who had comprehensive knowledge of HIV by gender stood at 31.9% for female and 38.2 for male. This is quite low for a disease that has caused a lot of despair is families.
Related to the above, there are several misunderstandings surrounding PrEP. Pre-exposure prophylaxis, or PrEP, is a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill (tenofovir and emtricitabine) every day. According to a Thai Ministry of Health study in June, 2013, when someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing a permanent infection.
When taken consistently, PEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. However, experience has shown that PEP is much less effective if it is not taken consistently. This can be very important for people engaging in commercial sex business. However, they must commit to taking the drug every day and seeing their health care provider for follow-up every 3 months. This is a challenge due to the stigma, cost and discipline by people. According to a study by CATIE (Canada), they are not willing to expose themselves as people who had any sort of encounter with someone who is HIV positive and still people lack the discipline of taking medication daily when they are at risk. Such people have ended up contracting HIV thus increasing new infections.
Experience has shown that, people under ART take drugs without taking note of their regimes. This makes them resistant to some kinds of drugs. They are not keen on the dynamics; they never monitor their CD4 count. When CD4 count is low, the viral load is high thus a high propensity to transmit the virus in case of unprotected sexual intercourse with an HIV negative person. It is therefore important that to achieve zero new infections, patients under ART manage their viral load as much as possible so that at all times their load is undetectable.
Many people in Uganda do not know their HIV status; not until the mandatory HIV testing. This is against a backdrop, agreed with by John Frank Mugisha of TASO that so many young people who were infected peri-natally and have grown into adolescents or even adults without knowing their status. Such victims tend to have strong immunity, therefore not feeling any ailments. This compounded by a tendency Ugandans have that young people are safe thus going as far as risking to have unprotected sex with them therefore contracting HIV.
Failure to know ones’ status flourishes AIDS being an opportunistic disease. As the viral load piles, any small sickness that comes by has the ability to kill such a victim. A June 2014 report by UNAIDS notes that of the 35 million people living with HIV, 19 million are unaware of their status. Such people (of the 19 million) are very vulnerable to death caused by diseases like malaria, typhoid among others which would have otherwise been controlled if the victim knew their HIV status.
The misconception that circumcision makes one immortal has precipitated permissive behavior and thus exposure to HIV by male youth. According to studies by UNAIDS and WHO, male circumcision is a way of reducing venerability of heterosexual men to HIV infection. This is not necessarily elimination of chances of infection. These endorsements were based on findings of three recent studies which indicate that circumcised men are up to 60% less likely to contract HIV from vaginal intercourse than uncircumcised men.
Lastly, retrogressive religious influence; some churches announce that they can cure HIV through prayer. In August, 2011 the Observer published a story where then Health Minister Dr Christine Ondoa Dradid reported that she knew of 3 people who were cured of HIV through prayer. On July 14th, 2014 the same paper published a question "Does God cure AIDS?” giving an account of people who got healed of serious ailments through prayer. Yet in another perspective, in 2008, one Grace Kashemeire came out to declare that she had lied to the world that Pastor Imelda Namutebi had cured her of HIV/AIDS through prayer. Such blind beliefs have affected how victims take their ARVs hoping that prayer would help them out unfortunately it does not, this can lead to more infections and as well death caused by AIDS.
The writer is a Global Health Corps Fellow (2014-15) placed in Uganda