Let us not relax; fight against HIV/AIDS is still on

The Uganda AIDs Commission (UAC) recently held their tenth Joint Annual HIV/AIDS Review. The activity aimed at bringing together all partners involved in the fight against HIV/AIDS to review their activities and design a way forward.

According to the acting director general of the Uganda AIDS Commission, Dr. Nelson Musoba, overall, Uganda is winning the war against HIV/AIDS. The greatest victory has been demonstrated among women and children with elimination of mother-to-child transmission of HIV. With 95% of mothers accessing prevention of mother to child treatment, Uganda qualifies to be assessed by the World Health Organisation for a pre-elimination certificate.

Musoba also noted that there has been a reduction in HIV prevalence in all regions in the country apart from the mid-eastern. Lillian N. Magezi caught up with him to discuss the strategies being employed in the fight against HIV/AIDS.

Q: The fight against HIV/AIDS has been on for almost 30 years. In the beginning, we recorded many successes, but now, we do not seem to be achieving much in terms of reducing prevalence. Where are we going wrong?

A: It is true Uganda was a success story in the early phase of the epidemic. We reduced the HIV prevalence from 18% in the 1990s to 6.4% by 2005. The mainstay of our efforts was prevention. The President led this fight and at every public function he cautioned the population to protect themselves. All other public leaders did the same and the media also conveyed the same message.

However, between 2006 and 2011, the prevalence rose to 7.3% and new infections rose to 170,000 annually; close to the same levels of the 1990s. This period coincided with the time most Ugandans with AIDS started accessing anti-retroviral treatment (ART). Once started on treatment, the health of people with AIDS improved markedly. The opportunistic infections and other symptoms associated with AIDS, for example skin rash, herpes zoster, skin cancers, weight loss all disappear once started on treatment. This means that the person lives a more productive life, but also with less stigma and is freer and happier.

However, we also noticed that people became less vigilant towards protecting themselves. The community gatekeepers (teachers, parents, religious leaders, politicians and business leaders) stopped to do their work of talking about HIV and AIDS as still being a threat. After seeing the reversal of gains in 2006, we started on a new strategy.

Q: The current strategy is test-and-treat, which seems to have replaced the ABC strategy which focused on prevention through behavioral change and promoting safe sex.

A: The test-and-treat strategy has not replaced the ABC strategy. Both approaches are being used. The National HIV and AIDS strategic plan focuses on prevention as well as treatment. This is because no single intervention works for all the groups. We advocate for abstinence for those who are not married and being faithful for those who have partners.

People are advised not to have sex with anybody whose HIV status they do not know. But if they must do it, then they should use condoms consistently and correctly. We encourage everyone to test and know their HIV status. Those who are found to be HIV positive will be counseled and started on anti-retroviral treatment, which they should take according to instructions. With this, their viral load will reduce significantly, allowing them to live a healthier and productive life. They are also less likely to pass on the HIV infection to other people.

Q: HIV/AIDS care involves more than people getting tested and treated; what else are you focusing on?

A: In June 2017, the President launched the Presidential fast track Initiative to end AIDs as a public health by 2030. The initiative highlights five areas of focus:

1) engaging men in HIV prevention to close the gap on new HIV infections especially among adolescent girls and young women;

2) Accelerating implementation of test-and-treat to achieve 90:90:90 especially among men

3) Consolidating progress on elimination of mother-to-child transmission of HIV;

4) Ensuring financial sustainability for the HIV response

5) Ensuring institutional effectiveness for a well coordinated multi-sectoral response.

Q: What are the riskfactors for the new infections in the different groups of our population and what have you done to address them

1. Young girls

A: Young girls may not have correct information about HIV and AIDS and they tend to be a target as sexual partners by older men who themselves maybe infected. The young girls are vulnerable to new HIV infections partly because of biological factors and also for structural reasons. Because of the biological factors they have a larger surface over which the HIV virus can enter their body. They are also more likely to sustain tears during sex, therefore, more likely to become HIV infected. The young girls may also be forced to engage in transactional sex to meet their basic needs and yet may not be in position to negotiate for safer sex with their partners who often are older men.

The strategies to protect the young girls include: reviewing the criteria for socio-economic development programmes (for example operation wealth creation, youth livelihood funds, women poverty funds) to ensure a focus on addressing issues that predispose young men and women to new HIV infections, we are designing a social Behaviour change communication campaign targeting young girls, the Ministry of Gender, labour and Social development has developed programmes for Vocational and livelihood skills building for young people through formal and informal educational systems linked to productive occupations, the Ministry of Education and sports together with the Ministry of Gender, labour and Social development are leading the process and have reviewed, updated and will soon implement young people and adolescent relevant policies, including a national sexuality Education framework and the school health policy targeting young people in school and out of school.

An example of a successful program is the DREAMS program supported by PEPFAR that is being piloted in 10 districts of Uganda targeting young HIV-negative girls with a menu of interventions to shield them from acquiring HIV. Initial results show that this program is working well and the Government is collaborating with partners to see lessons learnt and decide which aspects can be selected and operated at scale. 

2. Young boys

The risk factors for young boys to acquiring new HIV infections are lack of information and poverty.  

3. Women

Similar to young girls, the Government is strengthening Reproductive, Maternal, Neonatal, Child, Adolescent Health services to ensure that all pregnant women and partners, deliver at health facilities, attend postnatal services.

4. Men

From the program modelling data of the Ministry of Health 2015, 45% of HIV infected men did not know their HIV status and 48% of those who knew their results had not been initiated on treatment, and 60% of the AIDS-related deaths were men.  The causes are partly due to the patriarchal and societal norms but also associated stigma.

The strategies for men: UAC working with other actors is designing and will roll out training materials for key actors to use to reach men. We are also working with Parliament to design a parliamentary toolkit that will be used by other leaders. Key among the leaders supporting this campaign include: cultural leaders, religious leaders, politicians, business leaders and opinion leaders.

Q: The increased access to ARVs, seems to have come with increased failure to adhere to treatment and thus drug resistance. What strategies have you put in place to address these problems?

A: The strategies in place to minimize drug resistance include approaches that target the clients and the health worker to increase adherence. The Ministry of health has finalized guidelines and will soon rollout a new approach called the Differentiated Service Delivery Model (DSDM).

This means that services are carefully calibrated, and tailored to suit the client needs. The approach focuses both at the health facility and the community and focuses on the client to make it more convenient for them while improving the health system efficiency. The DSDM approach will significantly improve adherence and reduce drug resistance.  

Q: How far have we gone in setting up the HIV/AIDS Trust Fund? Where will the money come from? How will it be used?

A: The AIDS Trust Fund (ATF) will soon be operational. The law was passed by Parliament and assented to by the President in July in 2017. The regulations were endorsed by cabinet and forwarded to Parliament for approval. The HIV committee of parliament has been scrutinizing them and reported that they lay them on the floor of parliament for approval when during the next session of parliament after recess. We are hopeful that soon after that the ATF should be operational

Q: There are so many organizations involved in the fight against HIV/AIDS; do you think we still need the fund? Why?

A: Uganda needs the AIDS Trust Fund. The majority of our funding for HIV and AIDS still comes from development partners. Most of these organizations involved in HIV and AIDS are not funding sources but rather implementing partners. The external funding sources for HIV and AIDS have been reducing and now remain limited. The AIDS Trust Fund will help minimize on the dependency on foreign assistance.