AIDS-related deaths hav e been redu ced by more than 55% since the peak in 2004
In the build-up to World Aids Day on December 1, Vision Group is covering the subject of HIV on a daily basis. The theme for 2019 is, Communities make the difference, in recognition of the essential role that communities have played in the AIDS response at the international, national and local levels.
Today, Elvis Basudde and Hilary Bainemigisha appraise the Government, implementers, peer educators, networks of people living with or affected by HIV, counsellors, health workers, service providers, civil society and grassroots activists on whether Uganda is winning the war.
According to the World health organization (WHO), of the 37.9 million people living with HIV at the end of 2018, 79% received testing, 62% received treatment and 53% had achieved suppression of the HIV virus with no risk of infecting others. In 2018, around 1.7 million people were newly infected with HIV, compared to 2.9 million in 1997.
That is a 58% score. AIDS-related deaths have been reduced by more than 55% since its peak in 2004. In 2018, around 770,000 people died from AIDS-related illnesses worldwide, compared to 1.2 million in 2010 and 1.7 million in 2004. This is a positive surge in the global war against HIV.
In Uganda, 1,400,000 people were living with HIV by the close of 2018. But the number of new HIV infections (incidence) was 53,000 (1.4%). The percentage of people living with HIV (prevalence) among adults (15-49 years) was 5.7%. Ninety-three percent of pregnant women living with HIV accessed ARVs to prevent transmission of the virus to their babies and 17,000 new HIV infections were prevented among newborns. Early infant diagnosis — the percentage of infants exposed to HIV tested for HIV before eight weeks of age — stood at 45% in 2018.
While this is a drop from over 100,000 new annual infections and over 50,000 AIDS deaths three years ago, health experts say it is still worrying because the global target is to have zero new infections and zero AIDS-related deaths.
"One thousand new infections per week is better than the past years, but not yet safe," Dr. Abdallah Nkoyooyo, the programme manager at the Infectious Disease Institute-Makerere University, says.
The WHO data further reveals that among the 1,000 new infections, a third are young people between the ages of 15 and 25. In addition, 3.7% of females and 2.4% males in the age group live with HIV in Uganda, which also ranks ninth in Africa, followed by Tanzania, Rwanda and Burundi. Nkoyooyo says any complacency now can be very costly. And the risk of complacency is greater now because people living with HIV have happy and healthy lives as long as they adhere to the treatment.
"The frail, sickly, dying frame, marked with multiple scars, which was the representative image of whoever got infected with HIV, is no longer there to scare people into keeping guard. One look left you shuddering and many people dreaded having unprotected sex," he recalls.
The Uganda AIDS Commission (UAC) director-general, Dr. Nelson Musoba, expresses concern about studies that have shown that many adolescents and young women neither consider themselves to be at a high risk of acquiring HIV nor do they worry about it.
"In fact, the common saying is that a young girl would rather get infected with HIV than get pregnant. But this is largely due to misinformation and lack of access to correct information," Musoba says.
Tackling the risk factors
Musoba suggests that if leaders at all levels come on board again, the resurgence of HIV can be averted. He, however, assured the public that they have considered the risk factors for the new infections in the different groups of Uganda's population and set out to address them.
Risky groups in Uganda are young girls (HIV prevalence is almost four times higher among young women aged 15 to 24 than young men of the same age) and sex workers (HIV prevalence estimated at 37% and accounted for 18% of new HIV infections).
Others are men who have sex with fellow men (estimated at 13% in 2013), people who use injectable drugs and people from Uganda's transient fishing communities, with a prevalence of 22%.
UAC has come up with different interventions for each of these groups.
For young girls, the strategies include reviewing the criteria for socioeconomic 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.
Notwithstanding the challenges, there is optimism that with continued efforts, Uganda could do better to eliminate HIV and AIDS in the country.
The UNAIDS country director, Dr. Karusa Kiragu-Gikonyo, says Uganda is on the right track to make the epidemic history by 2030.
"Uganda is making good progress towards the elimination stage. We thank everybody who is trying to make this happen," Kiraga says.
In 2017, UNAIDS came up with an ambitious treatment target to end the HIV epidemic. Experts did computer modelling and revealed that if people who test HIV-positive get treatment and adhere to it, they would bring down their viral load to levels that make them less infectious. This will bring down new infections. According to the modelling, the elimination of HIV can be possible if, by 2020, countries can be able to test 90% of all people living with HIV, put 90% of all those diagnosed with HIV on sustained treatment and achieve viral suppression among 90% of all people receiving ARVs. Thus the 90-90-90 strategy.
By 2018, Uganda had achieved 84-87-88 success rate. Which means, 84% of all people with HIV have discovered their status. Eighty-seven percent of all those who tested HIV-positive have been started on ARVs and 88% of those have suppressed the virus.
According to Kiraga, Uganda's chances of achieving the 90-90-90 by next year are high. Musoba is also optimistic, considering the treatment achievement with the elimination of mother-to-child transmission of HIV. Ninety-five percent of mothers who test HIV positive are accessing prevention of mother-to-child treatment.
However, Musoba says we still have gaps.
"The AIDS Trust Fund (ATF) has not started. The law was passed by Parliament and assented to by the President in July 2017. The regulations were endorsed by cabinet and forwarded to Parliament for approval. However, Parliament raised some issues that require further clarification on the regulations and asked the health minister to modify them. Parliament is now waiting for the health ministry to revise the regulations before they can pass them, after which the Aids Trust Fund will become operational," he says.
The fund imposes on the government a commitment to make quarterly contributions and remit the money directly to the fund and not through the consolidated fund.
Testing and counselling
Increasing knowledge of HIV status through HIV testing and counselling is a key route to tackle Uganda's HIV epidemic. These services have been extended to all health facilities, workplaces and outreaches among the most at risk populations. Mobile or mass testing is also being out.
As a result, the number of people testing for HIV increased from 5.1 million in 2012 to 10.3 million in 2015. The proportion of women (15-49) who tested and received their results increased from 47.7% in 2012 to 57.1% in 2014.
Last month, the ministry launched a self-test kit that is not intrusive.
The kit tests the oral presence of HIV antibodies around the gum. It is expected to be rolled out for free to encourage people who previously feared the hospital setting to test.
HIV prevention interventions that can easily be accessed free of charge include ARVs, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), condoms, medical male circumcision and prevention of mother to- child transmission (PMTCT)
In 2017, more than 97% of HIV-positive pregnant women received ARVs to reduce the risk of mother-to-child transmission (MTCT). This has reduced new HIV infection among children by 86% between 2010 and 2016.
The next most successful intervention is provision of antiretroviral treatment (ARVs). By the end of 2016, the number of health facilities that were offering ARVs had increased from 1,730 to nearly 898,200. By the end of 2018, 73% of all people who tested HIV-positive were put on treatment.
Barriers to HIV response
Apart from the risk of complacence, challenges in HIV intervention include prejudices and social discrimination, gender barriers, legal issues, especially those which bar minority groups from HIV care access and criminalises HIV transmission and funding challenges.
Funding for HIV in Uganda is heavily donor-reliant, not guaranteed, unpredictable and dwindling. It also often comes with conditions that may not be in accordance with Uganda's national goals.
The Government is, therefore, urged to increase domestic resource mobilisation and regularise the AIDS Trust Fund. It is estimated that the government will contribute around $2m annually towards the AIDS Trust
Fund through money raised by taxing alcohol and bottled water.
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