Is Uganda losing grip on the changing face of HIV?
Jan 08, 2009
WITH evidence of increasing new HIV infections, Uganda may be failing to stem the epidemic. The epidemic has evolved significantly but the prevention messages and target groups of the 1990s haven’t changed at the same pace.
WITH evidence of increasing new HIV infections, Uganda may be failing to stem the epidemic. The epidemic has evolved significantly but the prevention messages and target groups of the 1990s haven’t changed at the same pace. Ms Milly Nattimba, Dr. Fred Sengooba, Dr Fred Wabwire-Mangen, Prof. David Serwadda explain why Uganda needs change in her HIV prevention strategies
There is a time when Uganda was the face of success of the HIV epidemic globally. The Government, led by the President, mounted a popular campaign that saw almost everybody get actively involved in sounding the drums that ‘slim kills’.
Those were the days when our ears were assailed by messages of ‘loving faithfully’ and ‘zero-grazing’.
The focus was on prevention of infection among young people and people engaged in casual sexual relationships.
Uganda’s efforts paid off and the prevalence dropped considerably, from 18% between 1989 and 1992, declining sharply to 6.5% at the end of 2002.
The overall HIV adult prevalence has, however, since stagnated between 6.0% to 6.5% considering figures from both antenatal clinics and sero behavioural surveillance.
Among the major contribution to the decline were the grassroots efforts and a multi-sectoral approach that was employed in creating awareness.
The approach brought on board people and leaders from divergent sectors, ranging from political to religious leaders.
Indigenous innovations on care for the sick led to global models of care. Organisations like TASO and AIDS Information Centre emerged as global best practices on how to fight AIDS.
At the national level, the leadership was united and spoke with a common voice. Absitence Be Faithful and Condom Use (ABC) was like a national anthem for AIDS control and as a result, there was sexual behaviour change as shown by declines in casual sex and multiple sexual relationships.
A lot has, nevertheless, changed in the last few years. While about 10 years ago, only a few rich people were able to afford medication, more poor people can access free medication now.
The epidemic has also become mature and generalised; it has evolved into a heterogeneous epidemic with different transmission dynamics.
Evidence available indicates that there is a rise in the prevalence. Although this rise in prevalence might reflect reduced death from AIDS because of ARVs, it is also likely that the prevalence is rising because of the new infections.
The number of new people getting infected has continued to grow upwards, meaning that current prevention strategies are not able to keep in sync with the transmission dynamics.
In addition, although data from the Medical Research Council (MRC), Masaka and the Rakai Health Sciences Programme (RHSP) population-based longitudinal studies show evidence of declining prevalence in the study populations in Masaka and Rakai, this lasts only up till 2003.
Recent data from MRC and antenatal surveillance indicate that HIV prevalence is increasing.
The possibility that what has been achieved in the last 25 years may be lost is causing anxiety among those keenly following the trends of the HIV epidemic in Uganda.
Uganda is one of the five African countries that have just concluded a Modes of HIV Transmission (MoT) study, funded by UNAIDS, in a bid to understand the new face of the epidemic and the possible sub-epidemics that may be causing the rise in infections.
In Uganda, the study was undertaken by the Uganda AIDS Commission (UAC). Some of the findings are discussed below.
The changing modes of HIV transmission
Findings of the Modes of Transmission study that was conducted last year indicate that there have been shifts in the risk factors and drivers of the epidemic.
The bulk of new infections are now arising from couples in long-term marriage-like relationships and discordant couples-where one partner is HIV-positive and the other is HIV-negative. In many cases the two do not know each other’s HIV status. In the 1990s, the bulk of cases were in casual sexual partnerships.
The AIDS National Strategic Plan 2007/8 to 2011/12 estimated that in 2005 alone, there were 132,500 new HIV cases.
The modes of transmission study projected for the year 2008 that 43% of all new HIV infections were among mutual monogamous sexual relationships, while 46% were among persons involved in multiple sexual partnerships.
Commercial sex contributed 22%, while heterosexual casual sex contributed 14%.
Twenty years ago, when the epidemic had just been identified, the prevalence in urban centres was as high as 30% with a national average of 18%; it was concentrated around highways and urban areas where there were sexual networks.
The major modes of infection then included casual sex, infection in medical settings and others.
However, the modes of transmission study found out that most data generated over the years have not been utilised in designing new prevention interventions that respond to the changes in the epidemic.
As a result, populations where available evidence indicates that they are at a higher than average risk of HIV infection, are not served with the kind of services they need.
The key risk factors now are multiple concurrent sexual partnerships, discordance and non-disclosure among couples, lack of condom use, transactional sex, cross-generational sex, intact foreskin among men and relaxed sexual behaviours due to antiretroviral treatment (ART).
It should be noted that northern Uganda is among the regions with the highest prevalence due to the breakdown in social order, health care system and reported cases of rape and survival sex. The army is also reported to have higher than average HIV infections.
Uganda is reported to have one of the fastest growing populations in the world.
According to the Population Secretariat, Uganda’s population is projected to hit 36.8 million in 2015 up from 12.6 million in 1980.
The implication is that there is growth in population of young people whose reproductive health needs including HIV will have to be addressed.
The age group 10-24 years constitutes 33% of the entire population. There are more people who have to be reached with HIV prevention messages and services besides sexual and reproductive health if Uganda is to contain and manage the epidemic.
Linking evidence to interventions
According to the Modes of Transmission study, the greatest need for HIV prevention is among persons with multiple concurrent sexual partners, whether in casual or long-term marital or co-habiting relationships, yet current programmes and delivery channels are targeting the general population.
They are not effective for married couples. Also, the bulk of new infections are now in the 35 – 39 year age category for men and 30 – 34 years for women, yet focus of interventions has not expanded from younger people of the 15-24 age group.
Over the last 10 years, there has been extensive evaluation of new prevention strategies. These included vaccine trials, vaginal microbicides, use of antiretroviral drugs to prevent infection, suppression of herpes simplex virus (HSV-2) and medical male circumcision.
Of these, only male circumcision has so far provided overwhelming evidence for efficacy as a preventive intervention for HIV transmission. WHO/UNAIDS in March, 2007, recommended circumcision as a method of HIV prevention.
It was, however, emphasised that this is to be used as part of a package of prevention services that include HIV testing and counselling and Health education.
Many countries in sub-Saharan Africa including Rwanda, Zambia and Botswana have moved quickly to develop policies or implement guidelines for the roll out of male circumcision.
Unfortunately Uganda, where one of the three efficacy trials were conducted, has not made significant progress in this direction.
This is despite the fact that high support for medical male circumcision exists in the communities. A study conducted by the Ministry of Health and Family Health International indicated over 50% acceptability among uncircumcised men and over 70% women approving it for their sons.
The National HIV/AIDS Strategic Plan 2007/8 to 2011/12 considers medical male circumcision as one of the key prevention interventions that should be added to the already existing array of interventions.
HIV messaging
The issues expounded above clearly show that there is lack of synchronisation between the epidemic dynamics and the prevention messages.
While the available data indicates the epidemic has shifted from single young people to married monogamous couples, the messages still target cross-generational sex and casual relationships.
Moreover, there is evidence showing a shift towards more risk-taking behaviour among men; more men are involved in casual sex and sex with multiple partners. There is also a decline in condom use.
Messages on abstinence and condom use do not have any practical promise for married couples either. Sexual abstinence and cross-generational sex programmes are well supported largely by donor initiatives, and the gap remains in addressing issues in monogamous stable marriages and discordant couple relationships, where condoms may not be very practical, and are most times not used.
Abstinence messages are not appropriate for married people, while messages on cross-generational sex are not comprehensive.
Interpersonal communication has also been neglected in favour of mass media which focuses on general audiences without appealing to the individual’s conscience.
According to the Modes of Transmission study, the focus of mass media messages is “poorly aligned to sexual behaviours such as multiple partnerships and HIV discordance that have been demonstrated to be responsible for most new infections in the country.
Funding priorities
There is an increase in the amount of funds coming in for HIV/AIDS programmes, in the last five years, but the bulk of this goes into care and treatment, leaving prevention programmes with less funding.
Although in the first phase of the epidemic there was less funding than now, Uganda was more in control of setting priorities and deciding where the resources were most needed.
According to the UNGASS Country Progress Report (January 2006 to December 2007), of the sh363,199,998,761 that is publicised as spent on the national response in the financial year 2005/2006 only sh67,883,659,823 (19%) was for HIV prevention interventions.
Care and treatment consumed sh152,789,491,261 (42%). Spending on treatment and care has improved the productivity of those on ART.
The challenge however is to balance both by, initiating and managing all who need treatment for life and intensifying HIV prevention to avoid new HIV infections.
It is estimated that while in the early stages of the epidemic prevention was receiving about 90% of all the funding; this has dwindled to less than 25%. According to a 2002 USAID Report, the period 1989-1998 saw a total of $180m spent on HIV/AIDS work.;
According to the UNAIDS World AIDS Outlook 2009, it is worrying to note that “for every two people put on treatment, five others are newly infectedâ€.
As quoted in the UNAIDS World AIDS Outlook 2009 report, by the outgoing UNAIDS Director “What concerns me is that while we’ve made measurable progress on access to treatment, we don’t have the same impact when it comes to HIV preventionâ€.
HIV Prevention is made worse given that the little that is made available is put in areas with limited benefit to prevention. Individuals in long term sexual relationships, uniformed services, fishing villages, commercial sex workers and their clients are marginally supported with prevention activities.
Funds are sometimes committed to unyielding debates about which way to go in the ABC strategy which creates public confusion.
Unlike the 1990s where the central authority was coordinating the public awareness massages; we now have a multitude of international and national HIV prevention groups whose messages are not coordinated.
“The Uganda Modes of Transmission Synthesis Report notes a shift in the pattern of distribution and transmission of HIV from single, casual relationships to couples in long-term heterosexual relationships.
Nevertheless, it has been observed that comparatively, ‘be faithful’ has not been emphasised in programming and funding within prevention interventions.
So where is the B in our ABC strategy, who did the scanty interventions benefit? Right messaging, right targeting is the way to go.
More still, most at risk populations like commercial sex workers are not targeted by any special interventions.
Even condom use which is one of the most widespread interventions has not been able to cover these populations to desirable levels.
It is, however, encouraging to note that the country is beginning to focus on couples and mutual faithfulness and therefore, appropriate resources should be allocated.
In fact, condoms received one fifth of the prevention resources. It is estimated that every year Uganda needs well above 120 million condoms.
However, the country is experiencing interrupted supplies of condoms, yet they are a key prevention intervention among discordant couples and for prevention of transmission during higher risk sex.
Way forward
So, the question remains: “Is Uganda losing her grip on the changing face of the HIV epidemic?†With evidence of increasing new infections, it is clear that Uganda may be failing in stemming the HIV epidemic.
This realisation has prompted action on different fronts; implementers are working overtime to rectify the situation. The Modes of Transmission Study that was carried out late last year is one of the strategies that provided evidence on the situation.
This evidence should be used to design new strategies or re-focus those that are already in place, where necessary, and implement those that have proved efficacious, like medical male circumcision.
The debate on medical male circumcision in Uganda should be completed as soon as possible so as to hasten the development of an appropriate policy to roll out this intervention as part of the “prevention packageâ€.
In the meantime, HIV implementing partners should embark on an intensive public education and communication campaign on the benefits and limitations of this intervention.
In order to re-invigorate and intensify prevention interventions, there is an urgent need for an HIV prevention policy guideline that will provide appropriate policy guidance, harmonisation and standardisation of the delivery of the comprehensive HIV prevention package by all implementing partners.
Religious leaders need to urgently come back on board and encourage pre-marital testing for those intending to get married in church.
Religious leaders should also get actively involved in the promotion of interventions like medical male circumcision and help their flock appreciate its benefits and limitations.
The mismatch between resource allocation and the trends in the epidemic points at the need to re-focus priorities. The groups of people previously considered ‘low-risk’ will need to be specifically targeted now.
There is need to focus on couple counselling and to promote condom use in marriage — especially for discordant couples, continued counselling for people on ART and special programmes for commercial sex workers and other most at risk populations.
For the year 2005/2006, the Government contributed only 6% of all the funding for HIV programmes. With the economic crisis going on in the countries that provide major funding for HIV programmes, the Government of Uganda needs to allocate more of its own funds to HIV/AIDS programmes for both treatment and prevention.
There is also need for innovation and creativity in the leadership to be able to use limited resources to reach the increasing number of people in need of HIV services.
More resources should be allocated to prevention programs to curb the rise in new infections and therefore save on the money spent on treatment.
This will reverse the current situation where everybody seems to be standing at point Z waiting to treat the infected, while at point A where the new infections are coming from, there is no overseer. Donors need to be re-aligned to this thinking, as well.
Highlights
HIV infection rates rising again
Extra-marital sex increasing Married people aged 30-40 are getting infected most, but prevention programmes still target mostly younger, unmarried people
Most people do not know their HIV status Most funding going to treatment while prevention is under-funded
There is a time when Uganda was the face of success of the HIV epidemic globally. The Government, led by the President, mounted a popular campaign that saw almost everybody get actively involved in sounding the drums that ‘slim kills’.
Those were the days when our ears were assailed by messages of ‘loving faithfully’ and ‘zero-grazing’.
The focus was on prevention of infection among young people and people engaged in casual sexual relationships.
Uganda’s efforts paid off and the prevalence dropped considerably, from 18% between 1989 and 1992, declining sharply to 6.5% at the end of 2002.
The overall HIV adult prevalence has, however, since stagnated between 6.0% to 6.5% considering figures from both antenatal clinics and sero behavioural surveillance.
Among the major contribution to the decline were the grassroots efforts and a multi-sectoral approach that was employed in creating awareness.
The approach brought on board people and leaders from divergent sectors, ranging from political to religious leaders.
Indigenous innovations on care for the sick led to global models of care. Organisations like TASO and AIDS Information Centre emerged as global best practices on how to fight AIDS.
At the national level, the leadership was united and spoke with a common voice. Absitence Be Faithful and Condom Use (ABC) was like a national anthem for AIDS control and as a result, there was sexual behaviour change as shown by declines in casual sex and multiple sexual relationships.
A lot has, nevertheless, changed in the last few years. While about 10 years ago, only a few rich people were able to afford medication, more poor people can access free medication now.
The epidemic has also become mature and generalised; it has evolved into a heterogeneous epidemic with different transmission dynamics.
Evidence available indicates that there is a rise in the prevalence. Although this rise in prevalence might reflect reduced death from AIDS because of ARVs, it is also likely that the prevalence is rising because of the new infections.
The number of new people getting infected has continued to grow upwards, meaning that current prevention strategies are not able to keep in sync with the transmission dynamics.
In addition, although data from the Medical Research Council (MRC), Masaka and the Rakai Health Sciences Programme (RHSP) population-based longitudinal studies show evidence of declining prevalence in the study populations in Masaka and Rakai, this lasts only up till 2003.
Recent data from MRC and antenatal surveillance indicate that HIV prevalence is increasing.
The possibility that what has been achieved in the last 25 years may be lost is causing anxiety among those keenly following the trends of the HIV epidemic in Uganda.
Uganda is one of the five African countries that have just concluded a Modes of HIV Transmission (MoT) study, funded by UNAIDS, in a bid to understand the new face of the epidemic and the possible sub-epidemics that may be causing the rise in infections.
In Uganda, the study was undertaken by the Uganda AIDS Commission (UAC). Some of the findings are discussed below.
The changing modes of HIV transmission
Findings of the Modes of Transmission study that was conducted last year indicate that there have been shifts in the risk factors and drivers of the epidemic.
The bulk of new infections are now arising from couples in long-term marriage-like relationships and discordant couples-where one partner is HIV-positive and the other is HIV-negative. In many cases the two do not know each other’s HIV status. In the 1990s, the bulk of cases were in casual sexual partnerships.
The AIDS National Strategic Plan 2007/8 to 2011/12 estimated that in 2005 alone, there were 132,500 new HIV cases.
The modes of transmission study projected for the year 2008 that 43% of all new HIV infections were among mutual monogamous sexual relationships, while 46% were among persons involved in multiple sexual partnerships.
Commercial sex contributed 22%, while heterosexual casual sex contributed 14%.
Twenty years ago, when the epidemic had just been identified, the prevalence in urban centres was as high as 30% with a national average of 18%; it was concentrated around highways and urban areas where there were sexual networks.
The major modes of infection then included casual sex, infection in medical settings and others.
However, the modes of transmission study found out that most data generated over the years have not been utilised in designing new prevention interventions that respond to the changes in the epidemic.
As a result, populations where available evidence indicates that they are at a higher than average risk of HIV infection, are not served with the kind of services they need.
The key risk factors now are multiple concurrent sexual partnerships, discordance and non-disclosure among couples, lack of condom use, transactional sex, cross-generational sex, intact foreskin among men and relaxed sexual behaviours due to antiretroviral treatment (ART).
It should be noted that northern Uganda is among the regions with the highest prevalence due to the breakdown in social order, health care system and reported cases of rape and survival sex. The army is also reported to have higher than average HIV infections.
Uganda is reported to have one of the fastest growing populations in the world.
According to the Population Secretariat, Uganda’s population is projected to hit 36.8 million in 2015 up from 12.6 million in 1980.
The implication is that there is growth in population of young people whose reproductive health needs including HIV will have to be addressed.
The age group 10-24 years constitutes 33% of the entire population. There are more people who have to be reached with HIV prevention messages and services besides sexual and reproductive health if Uganda is to contain and manage the epidemic.
Linking evidence to interventions
According to the Modes of Transmission study, the greatest need for HIV prevention is among persons with multiple concurrent sexual partners, whether in casual or long-term marital or co-habiting relationships, yet current programmes and delivery channels are targeting the general population.
They are not effective for married couples. Also, the bulk of new infections are now in the 35 – 39 year age category for men and 30 – 34 years for women, yet focus of interventions has not expanded from younger people of the 15-24 age group.
Over the last 10 years, there has been extensive evaluation of new prevention strategies. These included vaccine trials, vaginal microbicides, use of antiretroviral drugs to prevent infection, suppression of herpes simplex virus (HSV-2) and medical male circumcision.
Of these, only male circumcision has so far provided overwhelming evidence for efficacy as a preventive intervention for HIV transmission. WHO/UNAIDS in March, 2007, recommended circumcision as a method of HIV prevention.
It was, however, emphasised that this is to be used as part of a package of prevention services that include HIV testing and counselling and Health education.
Many countries in sub-Saharan Africa including Rwanda, Zambia and Botswana have moved quickly to develop policies or implement guidelines for the roll out of male circumcision.
Unfortunately Uganda, where one of the three efficacy trials were conducted, has not made significant progress in this direction.
This is despite the fact that high support for medical male circumcision exists in the communities. A study conducted by the Ministry of Health and Family Health International indicated over 50% acceptability among uncircumcised men and over 70% women approving it for their sons.
The National HIV/AIDS Strategic Plan 2007/8 to 2011/12 considers medical male circumcision as one of the key prevention interventions that should be added to the already existing array of interventions.
HIV messaging
The issues expounded above clearly show that there is lack of synchronisation between the epidemic dynamics and the prevention messages.
While the available data indicates the epidemic has shifted from single young people to married monogamous couples, the messages still target cross-generational sex and casual relationships.
Moreover, there is evidence showing a shift towards more risk-taking behaviour among men; more men are involved in casual sex and sex with multiple partners. There is also a decline in condom use.
Messages on abstinence and condom use do not have any practical promise for married couples either. Sexual abstinence and cross-generational sex programmes are well supported largely by donor initiatives, and the gap remains in addressing issues in monogamous stable marriages and discordant couple relationships, where condoms may not be very practical, and are most times not used.
Abstinence messages are not appropriate for married people, while messages on cross-generational sex are not comprehensive.
Interpersonal communication has also been neglected in favour of mass media which focuses on general audiences without appealing to the individual’s conscience.
According to the Modes of Transmission study, the focus of mass media messages is “poorly aligned to sexual behaviours such as multiple partnerships and HIV discordance that have been demonstrated to be responsible for most new infections in the country.
Funding priorities
There is an increase in the amount of funds coming in for HIV/AIDS programmes, in the last five years, but the bulk of this goes into care and treatment, leaving prevention programmes with less funding.
Although in the first phase of the epidemic there was less funding than now, Uganda was more in control of setting priorities and deciding where the resources were most needed.
According to the UNGASS Country Progress Report (January 2006 to December 2007), of the sh363,199,998,761 that is publicised as spent on the national response in the financial year 2005/2006 only sh67,883,659,823 (19%) was for HIV prevention interventions.
Care and treatment consumed sh152,789,491,261 (42%). Spending on treatment and care has improved the productivity of those on ART.
The challenge however is to balance both by, initiating and managing all who need treatment for life and intensifying HIV prevention to avoid new HIV infections.
It is estimated that while in the early stages of the epidemic prevention was receiving about 90% of all the funding; this has dwindled to less than 25%. According to a 2002 USAID Report, the period 1989-1998 saw a total of $180m spent on HIV/AIDS work.;
According to the UNAIDS World AIDS Outlook 2009, it is worrying to note that “for every two people put on treatment, five others are newly infectedâ€.
As quoted in the UNAIDS World AIDS Outlook 2009 report, by the outgoing UNAIDS Director “What concerns me is that while we’ve made measurable progress on access to treatment, we don’t have the same impact when it comes to HIV preventionâ€.
HIV Prevention is made worse given that the little that is made available is put in areas with limited benefit to prevention. Individuals in long term sexual relationships, uniformed services, fishing villages, commercial sex workers and their clients are marginally supported with prevention activities.
Funds are sometimes committed to unyielding debates about which way to go in the ABC strategy which creates public confusion.
Unlike the 1990s where the central authority was coordinating the public awareness massages; we now have a multitude of international and national HIV prevention groups whose messages are not coordinated.
“The Uganda Modes of Transmission Synthesis Report notes a shift in the pattern of distribution and transmission of HIV from single, casual relationships to couples in long-term heterosexual relationships.
Nevertheless, it has been observed that comparatively, ‘be faithful’ has not been emphasised in programming and funding within prevention interventions.
So where is the B in our ABC strategy, who did the scanty interventions benefit? Right messaging, right targeting is the way to go.
More still, most at risk populations like commercial sex workers are not targeted by any special interventions.
Even condom use which is one of the most widespread interventions has not been able to cover these populations to desirable levels.
It is, however, encouraging to note that the country is beginning to focus on couples and mutual faithfulness and therefore, appropriate resources should be allocated.
In fact, condoms received one fifth of the prevention resources. It is estimated that every year Uganda needs well above 120 million condoms.
However, the country is experiencing interrupted supplies of condoms, yet they are a key prevention intervention among discordant couples and for prevention of transmission during higher risk sex.
Way forward
So, the question remains: “Is Uganda losing her grip on the changing face of the HIV epidemic?†With evidence of increasing new infections, it is clear that Uganda may be failing in stemming the HIV epidemic.
This realisation has prompted action on different fronts; implementers are working overtime to rectify the situation. The Modes of Transmission Study that was carried out late last year is one of the strategies that provided evidence on the situation.
This evidence should be used to design new strategies or re-focus those that are already in place, where necessary, and implement those that have proved efficacious, like medical male circumcision.
The debate on medical male circumcision in Uganda should be completed as soon as possible so as to hasten the development of an appropriate policy to roll out this intervention as part of the “prevention packageâ€.
In the meantime, HIV implementing partners should embark on an intensive public education and communication campaign on the benefits and limitations of this intervention.
In order to re-invigorate and intensify prevention interventions, there is an urgent need for an HIV prevention policy guideline that will provide appropriate policy guidance, harmonisation and standardisation of the delivery of the comprehensive HIV prevention package by all implementing partners.
Religious leaders need to urgently come back on board and encourage pre-marital testing for those intending to get married in church.
Religious leaders should also get actively involved in the promotion of interventions like medical male circumcision and help their flock appreciate its benefits and limitations.
The mismatch between resource allocation and the trends in the epidemic points at the need to re-focus priorities. The groups of people previously considered ‘low-risk’ will need to be specifically targeted now.
There is need to focus on couple counselling and to promote condom use in marriage — especially for discordant couples, continued counselling for people on ART and special programmes for commercial sex workers and other most at risk populations.
For the year 2005/2006, the Government contributed only 6% of all the funding for HIV programmes. With the economic crisis going on in the countries that provide major funding for HIV programmes, the Government of Uganda needs to allocate more of its own funds to HIV/AIDS programmes for both treatment and prevention.
There is also need for innovation and creativity in the leadership to be able to use limited resources to reach the increasing number of people in need of HIV services.
More resources should be allocated to prevention programs to curb the rise in new infections and therefore save on the money spent on treatment.
This will reverse the current situation where everybody seems to be standing at point Z waiting to treat the infected, while at point A where the new infections are coming from, there is no overseer. Donors need to be re-aligned to this thinking, as well.
Highlights
HIV infection rates rising again
Extra-marital sex increasing Married people aged 30-40 are getting infected most, but prevention programmes still target mostly younger, unmarried people
Most people do not know their HIV status Most funding going to treatment while prevention is under-funded