Good news for HIV response in Uganda but...

Mary Nakirya’s daughter is now two years old but there was a time when she was not sure she would give birth to a healthy child.
In 2012, going for her first antenatal visit, at Kisugu Health Centre (HC) IV, at six months, Nakirya tested positive for HIV.

“My husband is a fisherman and sometimes he spends a month away from home, on the islands. When I showed him the results, he was shocked but he accepted to go for a test.”
The test confirmed that Nakirya’s husband was also infected.
“The nurses told me that it was possible to give birth to a healthy child if I took the drugs (anti-retroviral drugs) consistently.”
Three months later, Nakirya gave birth to a healthy child.

To date, the mother is still on ARV treatment and in good health, carrying out a vibrant trade, smoking fish for sale at Ggaba Landing Site.
Nakirya’s story illustrates one of the several ways Uganda has made tremendous gains when it comes to the response to HIV/Aids.
According to statistics from the Ministry of Health (MoH) and Uganda Aids Commission (UAC), the trend of new HIV infections (incidence) has been declining over the last three years from 170,000 in 2011 to 127,900 in 2014 representing a 30 per cent decline.

Progress made
Musa Bungudu, Country Representative, Joint United Nations Programme on HIV/Aids (UNAIDS), attributes this positive response to the support of the government and the private sector.
“By the end of 2014, less than 5,000 babies had been born with HIV. This is a reduction from 28,000 in 2011 – an 82 per cent decline. I believe it is in response to the Prevention of mother-to-child transmission (PMTCT) programme championed by the First Lady.”
The PMTCT initiative is targeting pregnant women from the lowest levels of the community, with the assistance of village health workers, encouraging them know their HIV/Aids status.

The MoH estimates that the number of paediatric new infections reduced from 28,000 in 2011 to 15,000 by end of 2013.
By the end of 2013, PMTCT services had been rolled out in all government and private non-profit health facilities up to Health Centres (HC) IIIs and 20 per cent of HC IIs. The number of active PMTCT sites offering lifelong anti-retroviral treatment (ART) increased from 965 in March 2012 to 2,130 in September 2013.

The proportion of those enrolled on anti-retroviral drugs (ARVs) for PMTCT in 2013 (72 per cent) was just two per cent short of the mid-term target for NSP (75 per cent by the end of 2013).
Dr Nelson Musoba, Director of Planning and Strategic Information, UAC says several reasons account for the achievements registered.
“For instance the principle of ‘Test and Treat’ or ‘Treatment as HIV Prevention’ and the involvement of leading politicians like the First Lady who have championed the promotion of PMTCT have helped.”

HIV/AIDS Trust Fund
In July 2014, President Museveni signed the HIV Control and Prevention Bill into law. The law, among other things, provides for the creation of an HIV/Aids Trust Fund.
“The main aim of the Fund is to reverse the current trend of donor reliance to address the funding gaps in the HIV/Aids fight,” Dr Musoba says.

“Currently, donor support makes up 68 per cent of the funding, while the government provides only 12 per cent. The remaining 20 per cent comes in through support from the private sector. So we need the Trust Fund to mobilise resources.”
Although the number of people dying of Aids has gone down, more people are living with the disease. Today, there are 713,744 Ugandans on ARTs as compared to 350, 000 in 2011.

This does not mean that the rate of infections has gone down. Instead, more people are openly coming out to seek treatment.
“Following Uganda’s success story, the country relaxed its vigilance and the infection rates shot up,” says Bungudu. “According to statistics (2014 UNAIDS Global Progress report) Uganda is now the third country with the highest level of new infections after Nigeria and South Africa.”
In 2012/2013, Uganda reached the tipping point of the epidemic when it enrolled over 193,000 people living with HIV (PLHIV) on ART surpassing 137,000 new HIV infections in the same period.

The purpose for which the Fund is being established is to secure a predictable and sustainable means of procuring goods and services for HIV and Aids counselling, testing and treatment.
Although the Bill was gazetted in February 2015, Musoba says together with the MoH, UAC is now working out a management structure on how the Fund will be managed.
“In the first quarter of the financial year 2015/16, it will be operational. At least, we will have collected enough money to begin implementation.”

Target groups
“In the last two years, there are districts in which the number of HIV positive pregnant women has increased,” Bungudu says, adding that, “Our focus is now on these districts.”

In statistics collected in hospitals and health centres, 20 per cent of the new HIV infections occur through mother-to-child transmission. These statistics do not cover births facilitated by traditional birth attendants.
In statistics released in 2011 showing HIV prevalence by region, the rates were higher in the central region, with the core central, central 2 and Kampala registering 10.6 per cent, nine per cent and 7.1 per cent respectively. South-western, mid-western and mid northern registered eight per cent 8.2 per cent, and 8.3 per cent respectively.

“Although there are no priority areas in the Trust Fund, pregnant women who test positive for HIV automatically qualify for treatment,” says Musoba.
“They are an important target because we want HIV free children. The policy is to encourage women to test before getting pregnant so that, using the results, they can make an informed decision.”

Focus on adolescent girls
Bungudu insists that there is a need for the focus to be shifted to include adolescent girls.
“The infection rate in this group has tripled compared to the boys in the same age group of 15 to 22 years. Every child, right from nursery school to university, should be given the opportunity to test for HIV.”

“The youth make up the largest HIV negative group in the population,” says Musoba. “If we neglect them, by the time they are in the 20-30 age group, they will be infected.”
Currently, data released by the Ministry of Health, is not disaggregated by these categories, but an open view towards sex education to adolescents is needed if infected girls, whether pregnant or not, are to begin early treatment.

“The issue here is that there is early sex, whether it is from peer pressure, early marriages or defilement,” Bungudu adds.
“The reality is that most of the time this sex is unprotected. By educating young girls we are telling them that they do not have to have sex but if it is inevitable, they need protection. Why should we deny these children information when in a matter of a few years they will be adults?”

Most at-risk populations
Men who have sex with other men are at a high risk of getting HIV. This is because homosexuality is a crime in Uganda, and an anti-gay attitude makes it difficult for gay men to access HIV services.
Yet in the Trust Fund, anyone who tests positive for HIV automatically qualifies for free treatment.
There is no clear government position on HIV service provision to female sex workers, mainly because their line of work is illegal.
Female sex workers are offered more money for unprotected sex, than protected sex, which fuels transmission rates. This makes them the most at-risk group among the population.

“With the Trust Fund, we can raise the HIV response, where by 90 per cent of the target groups can go for testing,” says Bungudu.
“If this happens, we can assume that new cases of patients who need ARVs will increase by 600,000. Remember it is this large group, which is not on treatment, which is spreading the disease.”
This calls for a committed action to raise the funds for the Fund, and for the policy makers to propose amendments to the Bill to gazette specific priority groups.

Society’s role
“Religious leaders can strengthen fa“Religious leaders can strengthen family values by advocating an end to early marriages,” says Bungudu. “They should emulate the President who cautions people about HIV/Aids wherever he goes.”
The family as a unit also has the moral and legal responsibility over its members’ health status.

Towards anHIV-free generation
Government and its partners are working towards the UNAIDS target of 90-90-90 to ensure that 90 per cent of PLHIV know their status; 90 per cent of people diagnosed with HIV are put on treatment; and ensuring that in 90 per cent of all people on treatment the virus is suppressed.

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