Why Uganda still needs US HIV/Aids money

The Ugandan media has been awash with reports of threats by PEPFAR to cut HIV funding over Uganda’s proposed anti-homosexuality legislation.
I was taken aback by the reactions of some Members of Parliament published in last Friday’s dailies which in essence boiled down to the notion that the US government can take back its HIV money and Uganda will foot its own HIV treatment bill.
Now, as a Ugandan, I totally get the religious and cultural foundations of this anti-gay stand which is quite admirable actually. But as a Ugandan who is embedded in the global village in which we live I have come to appreciate that the fight against homosexuality is a global wave we may be unable to withstand.

It is no secret that western donors use global health aid as a tool of power and influence in donor-dependent countries.
I have been conducting research on the effects of loss of donor aid on health programs for more than eight years particularly with regard to HIV programmes.
Unfortunately, Uganda is heavily dependent on PEPFAR for HIV treatment for the 1.4 million Ugandans accessing this care. In 2020, a national Aids spending assessment revealed that external donors account for up to 83 percent of national HIV spending. This includes spending on HIV prevention such as on male medical circumcision, condoms and pre-exposure prophylaxis.

In 2017, PEPFAR cut HIV aid in 10 districts in Eastern and Northern Uganda and in 741 facilities which were deemed to be ‘low volume’ under a strategy known as ‘geographic prioritization’. The latter policy sought to align U.S. HIV aid with disease burden at sub-national level.
We tracked the impact of loss of this PEPFAR support in districts in Eastern Uganda between 2017 and 2021. We found that districts which lost PEPFAR support had their HIV prevalence more than double. These districts also reported increased community HIV transmissions, decreased TB case notifications, declines in engagement in HIV care and more importantly, increased reports of deaths in communities of recipients of HIV care. Our key findings were highlighted in The Lancet Journal early this month. 

While Uganda may be able to pick the bill for buying antiretrovirals alone, HIV epidemic control is a much broader undertaking. It involves community outreach activities in rural communities for ensuring people take their medicines on time and report to clinics on scheduled days. It involves community-based HIV testing and linking all those diagnosed as HIV positive on treatment immediately under ‘test and treat’.

What is often underestimated are the extra personnel on PEPFAR payroll in Uganda who ensure seamless HIV service delivery and epidemic control planning. Experts such as those in supply chain, counsellors, laboratory technologists, specialist programme managers with advanced degrees are not provided for in district local government staffing norms. 
We urge caution in belittling US HIV support and reducing it to merely buying antiretrovirals. This aid includes HIV prevention and community outreaches. 
  Our research demonstrates that inability to sustain the levels of HIV programming funding that PEPFAR invests in Uganda is counted in human lives lost.  Playing politics with peoples’ lives is grossly immoral.

Dr Henry Zakumumpa was funded by WHO/ Alliance for Health Policy and Systems Research for this study.