By Richard Serunkuuma

Who of us, in the last two decades, would have predicted an end to AIDS as a public health threat by 2030?

That is when very few had access or were eligible for antiretroviral therapy (ART). It is when the lucky ones would receive collections of ARVs from friends in Europe and the US. Who does not remember abaakolamu (those who had earned enough money) spending sh900,000 for a monthly ARV dose?

So, thanks to the local and international activists and advocates including Rev. Canon Gideon Byamugisha, Major Rubaramira Ruranga, whose effort helped in dropping those prices. They made noise and communicated to the world that Africa was ready for the life-saving medication.

Dr. Noerine Kaleeba the founder of TASO, Dr. Elly Katabira, Dr. Alex Courtinoh, Mr. Peter Ssebbanja, Dr. Xavious Francis Mubiru (RIP), Sr. M.F. Dagan and others are partly the reason we can now talk of ending AIDS as a health threat.

Thanks for their brevity in standing up during those difficult ‘80s and ‘90s. Who told you that we have forgotten the tremendous efforts by TASO, Nsambya Home care, Kitovu Homecare, PEPFAR, the GFATM, DFID and Irish Aid?

Shall we have ended AIDS as a public health threat by 2030? Depending on how one looks at things, the answer can be a ‘yes’ or a ‘no.’

In my view, the target is achievable if the following roadblocks are dismantled! 

Government and her partners’ reluctancy to embrace counseling as a critical pillar in HIV care, treatment and prevention will undoubtedly prevent us from having hitting this target. Although entering a physician’s examination room is important, seeing a counsellor is far more important for mental and psychological ambiance, which prevails upon the physical body. There is often a lot to know, much to discuss and plenty to understand from a counsellor.

The reassurance of living a longer healthier life, discussions on disclosure and Positive Living (a loose code of conduct that all those who have tested HIV positive are compelled to abiding) are exceedingly rewarding.

There is no other challenge that has caused treatment failures, lost-to-follow-ups and drug resistance than lack of counseling at the facilities. So, the status-quo will not allow us to get to our target unless counseling is restored and regarded as a basic component in HIV care.

Insufficient preparation for the newly tested and beginners on antiretroviral therapy (ART) is a huge roadblock in our vision 2030. Despite being praised for the elimination of earlier time-taking procedures (such as the CD4 count thresholds of 200, 350 and 500 and the four or more ART preparation visits), the Test & Treat strategy has caused setbacks in the management of HIV. We have seen and heard people throwing away their ARVs or completely abandoning treatment as soon as they are enrolled in care.

“My biggest role is to find and help return those lost-to-follow-up,” said Resty a Linkage Facilitator at the Tirinyi Health Centre III’s ART Clinic. Geoffrey, who does the same job at the Infectious Diseases Institute (IDI) Kampala is facilitated with a monthly airtime of sh50,000 to call those who have missed their appointments. Their role is to encourage and ask them to return and stay in care.

It should be understood that getting an HIV positive result is still as shocking as it was in the 1990s. Being given tins of ARVs and being told that it is treatment for life are all outrageous! Therefore, people need adequate preparation to accept, start and stay in care if we are to eliminate AIDS as a threat.

Men’s low uptake of HIV services will unquestionably hinder our progress to elimination of AIDS as a public health threat in Uganda. Despite widespread acknowledgement that male involvement is miserably low, knowledge that men are the biggest drivers of HIV infection, that their health seeking behaviour remains wanting and the understanding that they are crucial decision makers in their families, little has gone into working with and supporting initiatives such as POMU that would help to lift them up.

The blame game just keeps running around instead of attacking the problem right from its roots. Activities like providing men with HIV services from their workplaces and facilitating men to reach out to fellow men would greatly reassure us of their access to, utilization of and retention in services.   

A speedy rollout of the Community Pharmacy Drug Refills (CPDR) system is another area that will help us achieve the vision by 2030. These are pharmacies that the MoH has their accredited to issue ARVs to some clients. The last time I checked at the Makerere Mbarara Joint AIDS Program (MJAP), they had just one in Kawempe and another in Nakulabye.

CPDRs will drastically reduce barriers like long costly distances, lengthy HIV clinic procedures, stigma and discrimination, overwaiting and the negative attitudes from dispirited healthcare workers. More importantly, men who have often shied services for lack of time will become wordless!

Issuance of unique identifiers to people like long distance truck drivers and fishermen enable is another area whose study should be completed and implemented. These will allow mobile populations like the fisher folk and long-distance truck drivers to access HIV services irrespective of where they are. Such a system should enable them to not only receive HIV services in Uganda but the region the rest of Africa. A Tanzanian truck driver from Dar-es-Salaam to Juba should be able get his ARV refills, viral load tests and other services in any country be it Kenya, Uganda, Somalia or South Sudan.  

Collaboration with nonconventional health workers such as traditional birth attendants will also bring us huge yields in wiping out AIDS as a public health threat by 2030. Attributes like the ability to speak the common man’s language, ability to serve and accept debts, provision of interpersonal care and avoidance of bureaucracies in their service provision make them so dear that their clients find themselves running there for healing, advice and care. The health care system can take advantage of this to reach these clients who flock there by working with these dear traditional careers. They can be turned into channels for HIV sensitization, advice, information and referrals to the healthcare system.

Strengthen and purposely reward low carder resource persons such as expert clients, case managers, Linkage Facilitators, Mentor Mothers, Village Health Team (VHT) members who do a lot of work their communities and facilities These corps provide psychosocial support to their peers, conduct health talks at the facilities, answer peers’ burning questions, deliver drugs to those that are too weak to make it to the facilities, complete the different clinic registers (whose data greatly informs planning, decision making and commodity requisitions among others) following up, finding and relinking lost clients to care amazingly at no cost except a few HIV implementing partners who provide them with a monthly stipend of UGX 200,000 or less. It is certainly clear that these would do a better and bigger job if well motivated!

Rejuvenating and relaunching of tested, proven, tolerable and cost-free strategies such as DOTS and ABC will also help us to accelerate the country’s arrival at the zero AIDS mark. DOTS is Directly Observed Treatment and ABC stands for Abstinence, Being faithful (to your partner or partners) and applying Condoms in case A and B fail. I have been reminded that a ‘D’ for Death had been added as a fourth option. While DOTS did a lot to improve adherence to TB treatment the ABC strategy was praised for great reductions in HIV infections in the ‘90s. Such brought down HIV prevalence in the ‘90s from 38% to only 16%, prompting many to fly in to study how Uganda had done it! So, amidst the disturbing treatment failures, there is great optimism that such strategies will accelerate our attainment of a zero AIDS nation by 2030.

A deliberate removal of all barriers that deter people from HIV testing services is another path we can take to attain the desired goals. Stakeholders including donors have got so rigid with phrases like ‘most at risk,’ ‘targeted testing’ and ‘hot spots.’ These have become a foundation for resource allocation and service delivery. The phrases mean that anyone not belonging to a population considered most susceptible or living in a high-risk place with a weighty concentration of HIV will not be targeted for services such as HIV testing or PrEP, Pre-Exposure Prophylaxis.

“In the past, everyone would access HIV testing no matter the risk and what population category they belonged to,” reiterated Steven a VHT member and one of the PLHIV leaders in Buliisa. “But nowadays, you have to meet a certain criterion (involving answering several questions) before you are tested,” he lamented.

Of course, there are other things that we need to do in the rush to elimination such as accelerating the fight against stigma and discrimination in our communities, repealing the punitive clauses in the HIV Act 2014 and encouraging families to engage in constructive conversations about HIV and AIDS.  

The writer is a CEO Positive Men’s Union. Secretary of the Community Advisory Board UVRI-IAVI HIV Vaccine Program and Facilitator at the Game Changers Program at the Infectious Diseases Institute (IDI)

TOMORROW: What the E.D. of HEPS-Uganda says