NRM government can end AIDS by 2030

Feb 05, 2020

In a nation estimated to have at least 1.4 million HIV-infected people less than one percent of the world’s total the drive to hit 90-90-90 by 2030 seems achievable to many experts

OPINION

By Grace Aldon Walukamba

On a Monday morning in January 2020, a public of 74 HIV-infected people pitches camp at Jinja regional referral hospital, a wing of The AIDS Support Organisation (TASO), Jinja Hospital in Jinja district, Uganda.

In most places in the country, where clinics are ill resource equipped, this would signal a wait of up to five hours or go away without medication. But here something different is happening.

Medical staffers at drug dispensing locations, swiftly log in people and dispatch them for triage or, if they have tuberculosis, a special area away from others. Those who only need their antiretroviral (ARV) drugs walk directly to the pharmacists before the drugs are dispensed to them, who retrieve each patient's medical record and pull drugs from shelves and fill orders.

The average wait time is 10 minutes to 50 minutes to complete a doctor or nurse visit and 15 minutes at the pharmacy. What only misses out is a prototype automated machine to promise and further speed up visits by directly dispensing ARV pills; one day, under the National Resistance Movement Organisation government it is hoped, such pill machines in other public places could make some clinic visits unnecessary.

"This is an awesomely efficient place," says Edmund Tayebwa, Programme Manager TASO Jinja, a nongovernmental organization that runs this and several other clinics in collaboration with the Ministry of Health.

In developed countries, where patients complain about much shorter waits, this boast might seem absurd. But in Uganda, the TASO Jnja Clinic is celebrated as an example of what can be done to care for large numbers of HIV-infected people. This is at once a compliment to the clinic and a hint of the Uganda's HIV/AIDS challenge.

Uganda has pledged to ramp up efforts to end its massive HIV/AIDS epidemic, by 2030. Through a multi-faceted approach, it will offer every infected person ARVs, which both stave off disease and make people less infectious.

The immediate goal is to reach what is known as 90-90-90 by 2030: to have 90% of infected people aware of their status, 90% of known positives start ARVs, and 90% of that group drive the amount of virus in their bloodstream down to undetectable levels, with an achievable although ambitious goal of stopping all new infections before 2030. The theory applies in a way that when viral levels drop among infected people, transmission will, too, leading the epidemic to spiral downward.

This 90-90-90 target is the cornerstone of a grand campaign, articulated by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and widely embraced by world leaders, to end the AIDS epidemic "as a global public health threat" by 2030. 

In a nation estimated to have at least 1.4 million HIV-infected people less than one percent of the world's total the drive to hit 90-90-90 by 2030 seems achievable to many experts.

And the obstacles faced by Uganda provide a sobering reality check to the patronising, admirable aspiration of ending AIDS, a topic that promises to occupy center stage later this month as the Ugandan government celebrates 35 years in governance but also suppressing the deadly killer HIV and AIDS infections since 1986.

Uganda has already made vast gains against its HIV/AIDS epidemic since 1986. At the time, only the wealthiest Ugandans had access to ARVs, which cost about $1000 per person for an annual supply.

But by the end of 2016, the price had dropped to less than $100, and close to one million HIV-infected Ugandans were receiving ARVs more than in any other country in the world. Uganda, in fact, consumes the same amount of the life-saving drugs as Rwanda and the other East African countries combined. 

As a result, life expectancy jumped 9 years between 2004, when ARVs started to become widely available, and 2016. The country has pioneered innovative ways to deliver drugs and help people stay on them.

And Uganda's strong cadre of HIV/AIDS investigators, spearheaded by the Uganda AIDS Commission (UAC) has made the country a hub of cutting-edge basic research and clinical trials. "Given our resources, we've done amazing things," says Dr. Carol Nakkazi, an HIV/AIDS researcher UAC in Kampala, Uganda.

As part of an exercise to determine what it could afford, the Ugandan government allocated funds and expatriates on the many interventions now proven to work. The "ABC", Condom use, PMTCT, and Safe Male Circumcision are among some of the prominently emphasized.

The Uganda HIV and TB treatment interventions, directly supervised by the Ministry of Health and the Presidential Initiative to fast track ending AIDS by 2030.

But a new 2018 report concludes that meeting the UNAIDS target will require additional funding close to $5 billion over the next decade. "UNAIDS is pushing very hard on our health ministry, which doesn't want to go short of ending AIDS by 2030 and wants to make the case that we can reach 90-90-90," says Dr. Henry Mwebesa, Director Health Services Ministry of Health.

The cost of drugs is just one part of the equation, He says. Ending AIDS by 2030 will also require massive HIV testing and the costly delivery of ARVs to patients who must be monitored and then helped if they're not suppressing the virus. "I'm really, really anxious about the resources it's going to take optimistic it will work." 

There are real questions, too. The assumption that reaching the 90-90-90 target will end AIDS is based on mathematical models that factor in ARV "coverage" in combination with other proven prevention strategies like male circumcision, condom promotion, and behavior change efforts.

HIV / AIDS specialists note that the HIV epidemic in Uganda, which has "concentrated" among populations such as men who have sex with men, extensive sexual networks and sex workers, such strategies could dwarf Uganda's expectation to end AIDS by 2030, allowing HIV to continue spreading at high rates even after the country reaches 90-90-90. 

The bottom line is that it remains an open question whether the 90-90-90 treatment goal really can stop the spread of HIV in Uganda, with strengthening community systems to allow for behavior change among youths and men. To empower communities out of poverty, raise the sex induction age and aim to stop gender-based and sexual violence in Uganda. 

For now, 90-90-90 is the most powerful tool available to Uganda in its quest to end its epidemic, even if PrEP and other new strategies ultimately are needed. UAC's Head of Special Programs Lillian Twatebwa, takes a pragmatic view of meeting the UNAIDS deadline by 2030. "I think we should plan for it, because if we don't hit it by 2022, we'll do it by 2030," she predicts.

"What we're really after is bringing down new infections to low levels," along with getting as many HIV-infected people as possible on treatment and living longer lives. If not well executed, the virus itself, Tatwebwa says, "will be with us for the next 10 decades."

The writer is a journalist and Communications Manager Uganda National Renewable Energy and Energy Efficient Alliance (UNREEEA)

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