Understanding HIV prevalence rate and why it remains high

In the late 1990s, Uganda was a global showcase in terms of how the country approached the response to the HIV epidemic. According to available statistics, the prevalence then was 18 per cent in 1989 and 30 per cent among some specific groups – namely sexual workers and the fisher folks. During this period, an average of 250,000 people got infected every year. Now, the rate is down to 7.3 per cent, what many might look at as an admirable feat.

Before we delve into the numbers further, we would need to talk about what prevalence really means.
Prevalence is essentially a proportion of people that are HIV positive at any one point.

That population includes those who were infected and are on treatment, and those who are newly infected.
Back to the numbers. Although the rate is 7.3 per cent now, it is an increase from 6.3 per cent in 2003. Which is not necessarily a doomsday announcement. At least not yet.
“What makes the prevalence go high now is that those living with the disease are not dying – they are living longer because of ARVs,” says Dr Francis Kiweewa, a researcher at the Makerere Walter Reed Project.

A mix of good and bad news
But Uganda’s HIV prevalence is a result of a mixture of factors both positive like the advance of Anti-Retroviral Therapy (ART), as well as negative such as the increase in new infections witnessed between 2004 and 2011.

By 2000, according to Dr Alex Ario, the coordinator for ART and Treatment in the HIV/Aids control Programme at the Ministry of Health, almost everyone in Uganda had lost someone – a mother, a father, a child, a brother or a sister or a relative to Aids. The HIV prevalence was highest in 1989, but started to fall as people died due to Aids-related diseases.

This instilled fear amongst the population and influenced how people viewed HIV/Aids – it was considered a disease that did not have treatment. Using the unwritten open policy, fear and hope at the same time – and much later, the ABC strategy, the HIV prevalence in Uganda was brought down after leaders in different spheres joined hands with experts to address the problem as a national disaster.

“The hidden factor that made us a success, which people don’t like talking about, is that literally every family got affected. Somehow, towards the late 1990s, and early 2002, everybody had lost someone and because of that, there was the fear factor,” says Dr Ario.

The other element which is rarely credited, according to Dr Ario is that there was a lot of stigma and so people feared to get HIV. Before the advent of antiretroviral drugs – the signs of the disease were evident.

Unlike today, he says, people feared those living with the condition while some abandoned sex for fear of “looking like those who had it”.

According to Prof Vinand Nantulya, the chairman Uganda Aids Commission, in the late 1990s and early 2000, people started dying and the prevalence went down. At the same time, different stakeholders, came on board – all with one intention, to fight the epidemic. “In public health, when people die, you have killed the source of the infection.

This coupled with the interventions that were being implemented at the time, the HIV prevalence dropped and by 2003, it was at 6.3 per cent,” explains Prof Nantulya. Then came ART in 2004. Initially, the antiretroviral drugs first came in 1993 - although it was for research, targeted populations, or those who had the money.

“The real ART started in 2004 when we rolled out the public health approach and when we started putting people on treatment in big numbers. When we did this, people started seeing more people with HIV living longer.” In his view and those of other experts, including Prof Ponsiano Kaleebu of the Uganda Virus Institute, ARVs have done amazing work.

“ARVS have done a wonderful job. But they have also contributed to the lax we are experiencing today in equal measure. This is a fact that people, even those involved in the HIV response don’t want to accept. Laxity in people’s sexual behaviour is as a result of ART. People no longer take it serious,” Dr Ario states.

It is no wonder, therefore, that a few years after the introduction of ART in Uganda, both prevalence and new infections, started rising, again.

According to the 2011 HIV/Aids Indicator Survey, the prevalence of HIV had increased to 7.2 down from 6.3 per cent while new infections nearly doubled from 70,000 to 160,000.

But for Prof Nantulya, this was not unexpected. There was generalised complacency in the population on the grounds that when you get HIV, you get drugs and live a normal life – in other words, HIV is not scary anymore.

“We saw it coming and we knew that complacency would set in. We had seen it happen among the homosexuals in New York, and UK, who because of availability of ARVs completely abandoned all the preventive measures and we projected that any country that had just introduced ART would suffer the same fate,” he explains, adding that though ART contributed to the rise in infections, there were three other major factors that drove both prevalence and incidence.

These were reduced mortality, a breakdown in communication strategy and a commercialisation of the responses.

A cocktail of problems
Other factors are the weaknesses of the health system which have made access to preventive commodities like condoms difficult, even access to testing services are still problematic and low. The technocrats are, however, optimistic that the future of the HIV response is bright as shown already by the reduction in the new infections since the Uganda Aids Commission, ministry of health and other stakeholders started implementing the new HIV National Prevention Strategy in 2012, and the HIV and Aids policy 2014.

These focus on the most at risk groups like commercial sexual workers, fisher folks, men who have sex with men, the serodiscordant couples and elimination of child transmission of HIV.

The latest figures from the Ministry of Health indicate that the number of infections that occurred in 2013 reduced from 145,000 to 130,000.
Dr Ario asserts that the reduction of infections by 15,000 within just a year of implementing the new strategy means that “we are doing well following the new national prevention strategy that calls for addressing the most at risk groups and combination prevention, the philosophy being that no single intervention can actually bring down the infections.”

But combined, they all complement each other and have a bigger impact.

ART is so far rated the best, combined with Prevention of Mother to Child Transmission, condom use, safe male circumcision and effective messaging. The leaders in the fight against HIV are positive that the current picture will change in a few years. However, the heavy dependence on donor money threatens to be a dark cloud in the silver lining.

“With all this, there is hope in the next five years – we know what to do. We have the policies, the strategic plans - the only thing we need is government to increase funding for HIV. It’s currently heavily donor-funded and it is not sustainable,” says Prof Nantulya. Whether all this will happen, time will tell.

Three major factors that drove prevalence up

Reduced mortality

According to Prof Vinand Nantulya, reduced mortality meant that there were fewer people dying of HIV and Aids related illnesses compared to the pre-ART period. People on ART were living longer and therefore contributing to increased prevalence.

With renewed efforts, it’s expected that the prevalence will go even higher as more people are put on treatment, and then become stationary if the number of new infections does not exceed the number of people going on treatment annually – until such a point when those living with the disease die due to other illnesses or old age.

Breakdown in communication strategy

According to a communication strategy designed by the Uganda Aids Commission titled “to protect yourself, your child and your spouse; the choice is yours”, the HIV response in Uganda suffered a breakdown when the stakeholders stopped communicating messages directly to the people.

“The approach that we used in the early years of the epidemic was replaced by uncommitted, mundane and routine impersonal talks and huge billboards which deliver no real message that can guide the populations into making desired actions,” reads the report.

Commercialisation of response to HIV
Nantulya says the response became commercialised as so many NGOs and other players were coming in. Consequently, anybody was issuing out HIV messages that ended up confusing the public.

“The general population was left under the mercy of all sorts of messages ranging from claims of miraculous cures by self-acclaimed medicine men and women,” he says.

Lessons we can pick from India

It is estimated that when one sex worker has sex, the lowest number of people they sleep with per night is usually four – majority of these being married men who will in turn infect their wives at home, and if they happen to have other mistresses who also have boyfriends, all of them will get infected.

In other words, one sex worker will infect an average of 19 people annually, which is said to be a very big number if not targeted and stopped at that point.

Several studies have been done, most of which show, according to Dr Francis Kiweewa, a researcher at the Makerere Walter Reed Project, that targeting the most at risk populations prevents the infections from going to the rest of the community and if it does, it’s minimal.

India used this approach, and to date, it has one of the lowest HIV prevalence rates having moved from 4 per cent to 0.6 per cent.

Approaches that might work
“Our approach is not what the other people used, to bring down the number of infections like India,” Dr Alex Ario, the Coordinator of ART and Treatment in the HIV/Aids control Programme at the Ministry of Health said.

The doctor says India focused on where the highest source of infection was. “They approached it from the Most at Risk Populations and treated them,” he says.

This approach stopped the infection from going to the rest of the population but Uganda’s approach did not take that into consideration.

“But we have now woken up. We have known that the group of people – the real source of the epidemic and our 2014 HIV/Aids policy focuses on these groups because we have the facts that if we treat these, we will have reduced the HIV viral load in the community at the same time addressing the transmission rates.”

EXPLAINING INCIDENCE
Incidence is the number of new cases in a fixed time period, usually one year. Below is what Uganda’s incidence has been for the last 23 years.

1990s: The number of new infections was at 230,000

2000: The number of new infections dropped to 70,000

2011: The number of new infections Then rose to 160,000

2012: The number of new infections dropped to 145,000

2013: The number of new infections dropped further to 130,000