In October 2017, Gaude Kyomugasho*, a 40-year-old married woman had sex with a man she had been flirting with since August.
“We met at a workshop in Kampala and then lost touch,” says the mother of five, continuing, “After three months, he called and we began flirting over the course of numerous phone messages. Initially, I had no intention of sleeping with him because he is much younger than I am and besides, both of us are born-again Christians. But, as we continued to exchange messages, I began to entertain the idea.”
After three months, the lovebirds agreed to meet at the young man’s home. “There was a lingering thought at the back of my mind to buy a packet of condoms but I brushed it off because I thought we would just have lunch and talk, since this was to be our first meeting.”
The visit went well, but her lover kept luring her to his bedroom. When she finally gave in, he did not have condoms on hand. They had unprotected sex.
“I did not know his HIV status but he assured me that he was negative and to prove it, we would link up the next day and go for a test.”
The next day, though, her lover did not call. By the second day, she was panicking. “He was not picking my calls or answering my messages. I became anxious. I began to think about the possibility of contracting HIV. Suddenly, I remembered that his red lips had bothered me. The colour of those lips possessed my every thought. It was a struggle to appear normal when I was with my husband. Suddenly, I remembered that people who have been raped are given PEP.”
What is PEP?
Post-exposure prophylaxis (PEP) is an emergency drug given to people who may have been exposed to the HIV virus. The Ministry of Health approved the use of PEP, sold under the brand name Truvada, in 2016. The drug is taken over a period of one month.
Dr Stephen Watiti of Community Health Alliance Uganda and a peer counsellor living with HIV says PEP is also used in instances where a condom has burst or when lovers forget to use condoms. “These drugs, if swallowed within 72 hours – the earlier the better – abort the HIV infection. They work by blocking the enzymes that the HIV virus uses to establish itself in the body.”
Kyomugasho went to the KCCA Health Centre at City Hall and asked for PEP. The receptionist informed her that they had run out of the drug. “I began crying. The receptionist told me she did not know where else I could go. I called a friend who is an HIV counsellor and told her my ordeal. She told me to go immediately to (Joint Clinical Research Centre) JCRC because time was running out.”
At JCRC, the counsellor advised Kyomugasho to persuade her lover to come for an HIV test because PEP has terrible side effects. “She said if he was negative, I did not have to take the drugs. I took an HIV test – which returned negative – and then went home. I was not given emergency contraceptives. I sent him an SMS. He replied that he was too busy to come for a test, but his schedule might open up in five days. Of course by then it would be too late.”
Who is eligible for PEP emergency drug?
Dr Watiti says all the client should tell a counsellor is whether the sexual encounter was protected or not. “The health worker should be able to believe whatever you tell them. It is wrong to ask you to bring your sexual partner. If you can convince him or her, that is good but if you cannot, the health worker should test you for HIV and then give you medication immediately.”
On the morning of the third day after her sexual encounter, the counsellor gave Kyomugasho a small tin of pills. “She told me about the side effects and advised me to remain hydrated. She said I would get so tired once I began taking the drugs and advised me to take the drugs at night. She talked about nightmares, saying that I would dream about dead people.”
She walked around with the drugs in her handbag the whole day, waiting for nightfall. Meanwhile, the clock was ticking away. “When it got to 3pm, I realised the counsellor had not paid much attention; probably that is why she had urged me to take the drugs at 10pm, long after the 72 hours had elapsed. I left work early and at 4pm, at the 67th hour, I took the first tablet.”
Is PEP increasing risky behaviour?
Although PEP has been on the market for two years, fewer people in Kyomugasho’s age bracket request for it. According to Martin Byamugisha, a counsellor with Naguru Teenage Centre, PEP is becoming popular among the young population. “In a week, we get about five young people requesting for PEP and of these, four are girls. They all claim to have been raped. I am happy, not because of the consumption, but because there is awareness about the drug. Young people now know that if they have an unprotected sexual encounter, they have to be at the facility before 72 hours.”
Normally, PEP is supposed to be administered within a process, especially for cases of rape and defilement, beginning with reporting the crime to police, getting a medical form, and then going to the health centre. Nowadays, though, even those who engage in risky sexual behaviour are visiting health centres for PEP.
“These girls, who claim to have been raped, come in smiling,” Byamugisha says, adding, “They are not interested in reporting to the police or using our free services offered to people who have suffered sexual gender-based violence. All they care about is not getting HIV. Sometimes, they come back after two months, after another unprotected sexual encounter. But, we accompany every tin of drugs with a heavy package of information.”
Byamugisha adds that most of the girls do not have bargaining power in their relationships because their sexual partners usually offer them money. “Since they cannot persuade their partners to come for a test, the girls agree to unprotected sex and then come for PEP. We tell them that even if a taxi has an emergency exit door, not many people ever use it. So, frequent use of PEP makes the body resistant to it with time. Eventually, it might not work.”
The side effects of PEP
Sticking to her routine of taking the drugs at 4pm every day, the first side effect Kyomugasho had to deal with was fatigue. “I always felt tired, even early in the morning. I also felt very thirsty. My throat would literally dry up even though I followed the counsellor’s advice and drank a lot of water.”
She kept the tablets in her money purse, which she never once let out of her sight. “I told my husband that I had a swelling in my womb and my gynaecologist had advised me not to have sex for a month. Luckily, he bought it. The counsellor had advised me to tell my husband that I was on PEP so that we could use condoms. But, how could I tell him that I had cheated?”
After one week, Kyomugasho began to gain weight around her upper abdomen. On the fourth day, the nightmares began. “I was talking to dead people who had rotting flesh falling off their faces. Sometimes, in the dreams, I found myself in graveyards. I dreaded going to bed, but I was lucky that after four nights, the nightmares stopped. The fatigue, weight gain, and thirst continued though.”
Health workers ask the client to bring their sexual partner because of the terrible side effects of PEP. “If the partner is HIV negative and you start taking the drugs, the side effects are even worse than if you have been infected with HIV but are taking the drugs to prevent the virus from multiplying.”
Availability of PEP
Every Health Centre III in the country is supposed to have PEP. The drug is free of charge. However, with the recent ARV stockouts, some health centres do not have it. For those who can afford the drug, pharmacies in Wandegeya sell Truvada at Shs50,000 (made in India) and Shs150,000 (made in the UK).
Besides PEP, the ministry also approved Pre-exposure prophylaxis (PrEP), which is taken daily before an unprotected sexual encounter to reduce the chances of contracting HIV. This may be used by discordant couples or people at high risk of getting HIV. PrEP can stop HIV from taking hold and spreading in the body if used as prescribed.
Effectiveness of PEP
“We have never registered anyone testing HIV positive after taking PEP as prescribed,” Byamugisha says, adding, “Before administering PEP, the client has to take an HIV test. If they are positive, we put them on ARVs immediately and try to persuade them to bring their sexual partner so that he or she can begin on PEP.”
PEP is not 100 per cent effective; and it is recommended that after completing the dose, one should return for an HIV test.
After completing her dose in November, Kyomugasho was too scared to take an HIV test. “I kept imagining the conversation I would have with my husband if I tested positive. Remember, I had taken the drug in the 67th hour. Finally on January 31 this year, I steeled myself and tested at a clinic out of town. The result was negative. I was stunned. Suddenly, a huge burden was lifted off my shoulders,” she recalls.
The man with whom Kyomugasho had unprotected sex has never called her again. Although she is elated to be HIV negative, she was advised to take a second HIV test after three months to confirm her negative result.
Hiv infection level high among girls
According to the HIV Situation Report for February 2017, Uganda has 230 new HIV infections per day, while every day, 76 people die of HIV related causes.
The Situation report jointly issued by Uganda AIDS Commission and UN Uganda office states that young people, especially girls aged between 15 and 24, are disproportionately affected by HIV infection. Among adolescent girls; every single hour, two young women are getting infected with HIV in Uganda. The prevalence of HIV among adolescent girls stands at 9.1 per cent, compared to the national prevalence rate of 7.3 per cent.