Uganda's 30-year long struggle with HIV/AIDS

It was before people had the luxury of saying “Eddagala gyeriri e Mulago and Dr Stephen Watiti had just learnt he was HIV positive. Back then there was little to be done on matters of care and management. Watiti’s recollection of those bleak days are just what put Uganda on the world Aids map - men, women and children wasting away, wiping out of whole villages leaving child headed households.

“People died, we didn’t know what to do, not even to use Septrin to guard against some of the menacing opportunistic infections,” says the man who was a trained medical doctor by then.

Fast forward to a few years short of a decade and the story is quite different. There is a selection of drugs specially designed to combat the virus and prolong and improve the quality of life of those infected, and ground breaking discoveries in science that have changed the face of HIV, over the years. Things have changed from no drugs to drugs with terrible side effects to the days when ARVS involved swallowing over 10 tablets a day for the rest of your life.

A cure or vaccine may still be eluding the world as of now, but there is no shortage of other innovations and advancements and Uganda, since its first cases were documented 30 years ago in Rakai has seen several changes. If one were to draw a timeline it would look something like this.

1982-1986: The dark ages
First Aids cases are documented in Rakai Uganda. Very little is known of “slim” as it was known, except that infected persons have a life expectancy of few months to a couple of years, and there’s virtually nothing on cure.

1987: Beginnings
A behaviour change campaign based on ABC (Abstain, Be faithful and Condoms) as a way to combat the virus is launched in Uganda by the President.

The first drug designed to fight the virus, AZT also comes out that same year. But the dosage is high, and it comes with terrible side effects. Dr Cissy Kityo, deputy director in charge of research and clinical services at Joint Clinical Research Centre (JCRC) says it worked for a while, but was unavailable in Africa.

Early 1990's
The drugs that can help manage HIV become more available, but only to a select few who can afford to travel abroad to access treatment benefit as most Ugandans only hear talk and can’t even imagine accessing the highly priced drug. At that time the interventions are stuck at HIV prevention, and maybe faith and herbal concoctions that keep coming up, claiming to cure.

Uganda participates in a small study to see effectiveness of AZT. “We had 40 participants and the trials came up with results to show it could be given in small doses,” says Dr Kityo. Those that participate in the study continue receiving the drugs for free forming a small oasis of hope for treatment. The prevalence at this time is slated at 15 per cent. JCRC starts an organisation to import the drugs for those who can afford, a few hundreds at the time, according to Dr Kityo.

“It was becoming obvious one needed to take a combination of drugs to help fight the debilitating effects of the virus on the human body, but of those hundreds, only a few could afford the combination. Some could only afford one drug,” she narrates.

1996: Exciting news
It is announced that ARVS have the capacity to reduce viral load. And that the drugs need to be taken in a combination of at least three. However these announcements which come from the Vancouver International Aids Conference that year hardly cause a ripple in Uganda where access to these drugs is still a pipe dream.

“Many people were still progressing to Aids,” says Dr Kityo who adds that by then there was a paying clinic for Anti-retrovirals in Uganda.

Herbal remedies which claim to cure aids peak.

“They came with all this promises. Kemron and another one called Mariandina and desperate, people took them but sadly, some still died,” recalls Dr Watiti.

JCRC evaluates some of the herbal concoctions, six in all. “Some were effective for symptoms people with HIV develop like herpes and skin rash which is probably what stirred the whole cure talk, but our tests didn’t show them to have any real effect on the HIV virus,” says Dr Kityo.

2000: Glimmer of hope
Generic ARVs from India become available and because they tend to combine more than one drug, they are cheaper, not to mention the fact that they reduce on the number of tablets to swallow per day. Dr Watiti remembers his drugs cost about $500 when he first started in the year 2000 but drastically reduced to Shs100,000 onto Shs60,000 and finally to Shs5,000. Uganda participates in small pilot projects in the prevention of mother to child transmission

2003: Turning point
This comes with the Presidential Emergency Plan for Aids Relief (PEPFAR) and later Global Aids funds that avail the much needed drugs for free in Uganda. “ARV coverage shot up from 2 per cent to 30 per cent,” observes Dr Kityo who adds the criterion was a CD4 count of 200 and below.

Management Pediatric Aids is still lagging behind due to lack of appropriate formulations.

2006: A step at a time
Circumcision is proven to considerably reduce risk of contracting HIV in HIV negative heterosexual males, by 60 per cent according to World Health Organisation. Findings are from studies carried out in Kenya and Uganda and this adds to the growing list of interventions on HIV and Aids.

2007- 2012: Towards zero
Mother to child prevention takes off with studies showing ARVs being effective in prevention. Coverage of ARVS is about 400,000 people. Those on ARVs are living longer, like Dr Watiti who has been on ARVs for 12 years now. “There are fewer deaths from full blown Aids today but it is not zero,” he says. New findings from trials indicate that HIV positive persons who are started on ARVs early enough, immediately after testing, according to HPTN trials results, presented in Rome, May this year, reduce the risk of them transmitting the virus. National Institute for Allergies and Infectious Diseases (NIAD) which co-sponsored the HPTN trials says the risk is reduced at 96 per cent meaning the actual risk is negligible. Right now the hype abroad is to test and treat, says Dr Kityo.

What does it all mean?
It has been a 30-year-long journey, one that has seen better treatment options for HIV and Aids. But it is not time to get the celebrations drums yet. According to Dr David Serwadda, the executive director Taso, we may be slowly progressing on the treatment front (emphasis on the word slowly as coverage is now 40 per cent, a long way from the 80 per cent goal of universal coverage) but falling behind on another.

“In terms of prevention which is critical in reducing incidence which in turn will reduce need of treatment, we are not doing well,” says Sserwadda. He notes that for every person started on treatment, there are at least three new cases. All this despite the many proven HIV interventions at our disposal: Testing, condom use, behaviour change, early treatment, male circumcision, prevention of mother to child and ARVS, four more options available to many Ugandans as late as the mid 90s.

Uganda has participated in several trials that have seen the face of HIV change, but that isn’t the main point according to Serwadda. We are very good with science, participating in all those trials but we are slow to implement the facts,” he notes.

Among the facts that are going to change the fight against HIV further and put the future, at least the perceivable one for now on both treatment and prevention in the hands of ARVS is the HPTN trials which elicited a lot of excitement across the globe.

“They were very important,” he says, important enough for Rwanda and Zambia to start implementing them. Uganda is on the list of those who intend to implement the test and treat.

Right now the country cannot afford it, says Dr Kityo, citing the issue of first providing ARVS to all who need them before venturing on to the test and treat.

Among the places where intervention is needed is the prevention of mother to child transmission.

“As we mark the 30th year at least there’s great news from this front. We are almost running out of new paediatric cases,” says Dr Kityo.

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