Every year, 130,000 new infections are reported, and donors are growing weary and restless, as they consider the prospect of an ever-rising cost of keeping thousands of infected people alive. The national HIV strategic plan, for instance, targeted a 40 per cent reduction in new infections by 2012. This would be 100,000 infections annually.
According to Ministry of Health estimates, the country is still registering close to 130,000 new infections every year—a surplus of over 30,000 new cases above the target, causing leading experts to warn that unless critical interventions are put in place, the epidemic could be moving in a reverse direction.
So, what has gone wrong with Uganda’s anti-HIV campaign?
Speaking at a public forum on HIV/Aids, as part of Makerere University’s 90th anniversary celebrations, Dr Alex Coutinho, who heads the Infectious Diseases Institute, said multiple factors were behind the rise in Uganda’s HIV prevalence.
While there was a time when the government made HIV a major national concern, it is no longer the case among the political leadership.
Dr Coutinho says the leaders have not been speaking enough about HIV/Aids. Their support for the campaign is not as visible and vocal as it used to be in the early years of the epidemic. “Often times, leaders don’t do by example. When was the last time you saw leaders coming forward to be publicly tested for HIV/Aids? When have we seen leaders—the men coming out publicly to be circumcised,” he asks.
Although President Museveni has played a key role in leading the fight against HIV/Aids, Dr Coutinho says Uganda has several other leaders the people listen to, but who are not contributing much to the campaign against the scourge. He also accuses the government of having failed to direct programmes to the rural areas, which are a key driver of the epidemic.
“In fact, most of the movement (of HIV/ Aids) in the wrong direction is coming from rural areas. There are some programmes that we are not putting particularly to rural populations that are accounting for this rise from five to seven per cent,” he asserts.
There is also the question of double-standards. Married women can’t abstain and are expected to be faithful, so they can’t use condoms. But many men are not faithful or even expected to be. What’s more, the economic and social disempowerment of women forces them to remain in high-risk relationships, making it hard to achieve much progress.
On the other hand, Uganda also appears to be a victim of its own success, officials say. News of the early success and the comfort created by the availability of antiretroviral drugs that help postpone the onset of Aids have led to complacency and a return to risky sexual behaviour. As a result, fewer people are using condoms regularly and more people, including married people in long-term relationships are taking on multiple sexual partners.
The Modes of Transmission study shows that at least 43 per cent of the infections still occur among people who have multiple sexual partners. Although the early success was largely attributed to the ABC model -- Abstain, Be Faithful or use Condoms, which was adopted by several countries across the world, experts now warn that interventions must be expanded beyond this approach because it might be outdated.
While preventive messages have not expanded beyond the 15-to-24 age group, evidence shows that the bulk of new infections are occurring among couples in long-term, marriage-like relationships—in the 30-39 age group. Dr Hannah Kibuuka, a principal investigator at the Makerere University Walter Reed Project, says HIV messaging hasn’t changed with the changing face of the epidemic.
“The HIV messaging has not been innovative to accommodate the changes we have seen over time. In the era of antiretroviral therapy, I think we needed to change our messaging to suit the environment. But we have continued singing ABC.” She adds: “As a result, the public has become stuck on acronyms like ABC rather than looking hard at the actual risk factors.”
The Prevention of Mother to Child Transmission (PMTCT) intervention, for instance, remains low, with only 40 per cent of all pregnant women being able to access the complete services, according to the annual Health Sector Performance report.
This has led to over 25,000 babies being born with HIV every year.
According to the Modes of Transmission Survey, sex workers are also contributing significantly to the increasing HIV figures.
At least 10 per cent of new infections every year are from commercial sex workers, yet there are no specific programmes to address HIV/Aids among this group.
There is also little openness on discussing discordance in the population, yet studies have shown that it is at the centre of the sexual transmission of HIV.
According to Dr Coutinho, less attention is also being paid to alternatives to treatment and ABC, including interventions like male circumcision.
Health experts say a rapid roll-out of medical male circumcision is crucial in reducing the spread of HIV/Aids in countries with generalised epidemics such as Uganda.
In fact, a landmark randomised trial in 2005 and 2007 conducted in Uganda, Kenya and South Africa showed that male circumcision reduced the risk of contracting HIV/Aids by up to 60 per cent. But, as Dr Coutinho notes, Uganda is not making good use of this science. “We are aiming at circumcising 4 million, but have only done 150,000. We need to look at the issue of population coverage,” he says.
Uganda officially launched its medical male circumcision policy in 2010 and hopes to operate on at least 4 million people in the five-year programme.Dr Fred Wabwire, a senior professor at the Makerere University’s College of Health Sciences, says HIV being less visible and the onset of ARVs, could also be contributing to the rising prevalence. “Because of ART coverage, the number of people who have HIV are living longer and they may be contributing to the prevalence that we are seeing now,” he says.
This view is shared by Dr Kibuuka. “Before the 2000s there were no ARVs. People knew that the moment they got HIV it meant death. But now, people know that even if they get HIV it is just like any chronic disease such as hypertension, diabetes and the can survive on drugs. They have somehow become complacent to the messages we had in the 90s.”
Ms Milly Katana, an HIV/Aids activist, says more vulnerable groups, which are the main drivers of the Aids epidemic, have been largely ignored in the campaign against it. “We know that men who have sex with men are very vulnerable to HIV/Aids and also the fishing communities, yet we don’t seem to be paying attention to this group of people,” she says.
The new direction the country is taking, she warns, will not enable a reduction in HIV/Aids. “We are an embarrassment to the rest of Africa because we took the lead in turning the tide against Aids but now we are a shame,” she says.
According to Ms Katana, the rising prevalence will pose an enormous challenge for Uganda in the future.
Health experts say that to turn the tide, the country has to become more serious about preventing the spread of the disease. They argue that Uganda already has all the necessary policies and guidelines, and the challenge is implementation and a poor health system that cannot drive all these strategies.
In Part Three of our series, we look at what Uganda can do to reverse the growing rate of HIV/Aids.