COVID-19 and impact on access to health service

COVID-19 | HIV

By Fred M Ssewamala and Betsy Abente

While COVID-19 is wreaking havoc across the globe, as of April 28, Uganda, a low resourced East African country that has in the past been heavily affected by civil wars, and continues to struggle with relatively high HIV prevalence rates, has yet to document their first COVID death.

The government of Uganda moved rapidly and was one of the first on the continent to place a quarantine on foreign visitors, implement a national curfew and close down schools and businesses in order to limit the spread of the lethal virus.

While these efforts have attracted mixed views with many commending the swift response to COVID-19, there are some more troubling, hidden aspects of this pandemic that, if not addressed, have the potential to upend this country of more than 40 million people and other countries in the region for years to come.

Uganda has one of the highest rates of HIV globally, with almost 6% of adults, and nearly 100,000 children living with HIV.

Our research center, the International Center for Child Health and Development (ICHAD), which is housed within the Brown School at Washington University in St. Louis, with field offices in Masaka district in Southern Uganda, works with at-risk youth, including boys and girls in and out of school and their families, as well as with poor vulnerable women to improve their health outcomes.

This is done through a variety of innovative combination interventions designed to reduce poverty and improve mental health.

As we have seen globally, those with the least have often struggled the most. This holds true for our study participants and the poor families in the regions where we work.

For example, poor vulnerable women in one of our studies, the "Kyaterekera Project," report that due to store closures, non-government organisations (NGOs) scaling back operations, and travel restrictions, they have diminished access to reproductive health services, including protection in form of PrEP, birth control and condoms.

To prevent the spread of HIV, Uganda provides PrEP (Pre Exposure Prophylaxis) mediations to HIV-negative individuals and key populations at high risk of obtaining the disease, such as women engaged in sex work.

Restrictions on both public and private transportation as well as increased food insecurities are causing people living with HIV to miss doses of their essential antiretroviral medications.

An April 28, 2020 story in New Vision, one of Uganda's main newspapers, reported that lack of food is causing people to miss their HIV treatments, since the medication must to taken with food to avoid weakness, dizziness and nausea.

Studies indicate that when people living with HIV are virally suppressed, it reduced HIV transmission. But we also know that over prolonged periods of time, missed doses have been associated with an increased viral load, a fall in CD4 cell count, and an increased risk of treatment resistance.

Without access to these basic prevention measures that have seen success in keeping HIV prevalence lower in key and at-risk populations, we are, as scientists - and others should also be - concerned and afraid that we will likely see higher rates of HIV infection post-COVID-19, setting back the years of efforts to control HIV infections.

While in the U.S. some people often talk of a "COVID baby boom", in a poor country like Uganda where women's maternal mortality and teenage pregnancy rates remain among the highest in the world, the situation is more complicated—and should be viewed as such.

A recent report out of the Washington Post indicated while again, there has been no COVID-specific deaths in Uganda, within the past few weeks, at least seven pregnant women who were unable to access public transport with the country on lock-down have died while attempting to walk to the nearest health clinic. (Washington Post, April 20, 2020).

Children are also going without treatment.

Gender-based Violence (GBV) is also on the rise due to restrictive travel and enforced curfews. Women (and men) are confined to their homes with abusive partners, and are unable to travel to clinics or community-level NGOs to get support and resources.

Uganda's Minister of Gender, Labor, and Social Development recently announced that there have been several deaths reported as a result of GBV, and between March 30 and April 28, 3, about 280 cases of GBV have been reported, which is nearly double the average rate.

These are real people. Not simply numbers. This is in addition to 283 cases of violence against children over that same period. This violent and abusive behavior has serious negative impacts on the health and overall wellbeing of victims, including unwanted pregnancies, increased sexually transmitted infections, and signs of post-traumatic stress disorder.

Unfortunately, I would not say that Uganda is the only country in the region experiencing these unfortunate incidences.

So yes, while Ugandans can be proud that the country has thus far limited the rapid spread of COVID-19 throughout the population, as the government slowly starts to lift some of the restrictions, the government, public-private partnerships, and people must collectively come together to address these underlying issues that can be even more devastating to the population.

There is a need to make sure we have the mental health, supply chain, and clinical supports, including public health experts, medical doctors, and social workers in place to limit further damage to our population.

Ultimately, we must do everything we can, to not undo the decades of progress a country like Uganda, and others in this very fragile region, have made in reducing HIV prevalence, combating GBV, and improving health outcomes for women and their families.

Fred Ssewamala, PhD William E. Gordon Distinguished Professor, Brown School Professor of Medicine, Washington University School of Medicine Director and Founder, International Center for Child Health and Development Co-Director, SMART Africa Center Washington University in St. Louis, Missouri, USA www.ichad.wustl.edu.

Betsy Abente  Associate Director, International Center for Child Health and Development Brown School, Washington University in ST. Louis, Missouri, USA