Closing tap on new infections key to ending HIV/AIDS by 2030

At 22, Mary Grace Kisaakye has been living positively with HIV for the last 12 years. Today, she is an advocate for HIV and mental health, a Young People and Adolescent Peer Supporter (YAPS) at Alive Medical Services, and a peer educator at Reach A Hand Uganda.

The twelve years have been a time of coping with the news of her diagnosis, becoming a beacon of hope and determination, and advocacy. Her journey began in 2012 when she was 10 years old, in Primary Three.

“My family was living with my mother’s brother, who provided our basic needs and paid our school fees. One day, when my mother was outside the home, my uncle defiled me. I did not tell my mother because he was our support system, and I thought she would not believe me,” she says.

A week after the vile deed, Kisaakye began bleeding. She fell sick. At the hospital, some tests were done and she was given medication. However, the heath workers did not conduct an HIV test. Despite the medication, her health did not improve.

“My mother’s friend advised her to test me for HIV. The test result was positive, although my mother did not tell me at the time. We had a confirmation test at Baylor College of Medicine Children’s Foundation - Uganda. I told the counselor my story and when I was checked, my body showed signs of defilement," she says.

However, the little girl was still scared of telling her mother about what her uncle had done, so the counsellor took it upon herself to enlighten her mother.

“We had been studying about HIV transmission, but in Primary Three, my brain was too young to register the fact that I was infected. I was transferred to Alive Medical Services, where I still get medication even today. That is where I got to know that I was not the only little girl carrying this burden,” Kisaakye says.

She is one of many adolescents girls and young women (AGYW) who now carry the high burden of HIV in the country.

Threat of new infections

While Uganda has made progress in the fight against the HIV epidemic, recent data from Uganda AIDS Commission (UAC) shows stagnation. This, according to Dr Maureen Kwikiriza from UAC’s Department of HIV Prevention, is against the background that the country has only six years left to end the AIDS epidemic as a public health threat by 2030.

“By the end of last year, our HIV prevalence stood at 5.1 percent, which is a 12.9 percent reduction from the 18 percent recorded in the early 1990s. We have had a 57 percent decline in AIDS-related mortality since 2010 and a 61 percent decline in new HIV infections since 2010,” Dr Kwikiriza says.

Against the Joint United Nations Programme (UNAIDS) 95:95:95 targets, in Uganda, by 2023, 92 percent of persons living with HIV (PLHIV) knew their status, 90 percent of known PLHIV were on treatment and 95 percent of those on treatment had achieved viral load suppression. The number of those who have not achieved viral suppression stands at 51,000.

“Our target is to reduce new infections by 80 percent although currently, we are at 60 percent. We are working towards being the number one in Africa when it comes to countries which have reduced their new infection rates to 100 percent,” Dr Kwikiriza explains.

Between October 2023 and June 2024, there were 49,111 new diagnosed HIV positive tests. Of these, 5,928 (12 percent) were confirmed as recent infections - 4,070 females and 1,858 males.

Dr Robert Mutumba, the acting commissioner, STD/AIDS Control Division in the Ministry of Health, says the biggest threat in the fight against HIV is the increasing number of new infections within certain groups.

“We are noting an increase among adolescent girls and young women. We seem to be stagnating over the past two to three years. If, generally, we are getting 38,000 new infections per year, that means every day, 104 people are infected with HIV. A third of the new infections occur in young people,” he explains.

This means every day, 35 young people are newly infected with HIV. If the tap on these new infections is not closed, a huge chunk of the country’s investments will be going into a bottomless pit.

“The high number of new infections is burdening the national budget in terms of buying testing kits and offering antiretroviral treatment (ARVs). As long as that tap is open, we will continue seeking support from development partners because sometimes, the budget may not be sufficient enough to respond to this need,” Dr Mutumba says.

HIV is now in its fourth decade and to compound the financial situation, those who are already living with the infection are now showing up with non-communicable diseases (NCDs) such as diabetes and high blood pressure. This means there has to be a constant budget for procuring medicine for NCDs and antiretroviral drugs (ARVs).

“Every year we spend about USD$115 million on NCD treatment and USD600 million per year on ART, which includes test kits and laboratory reagents. If, as a country, we are unable to cut this budget down, we will not easily achieve Vision 2040’s goal of becoming a middle-income country,” Dr Mutumba warns.

While the number of AIDS-related deaths has gone down over the years, currently, approximately 19,000 individuals die due to Aids-related illnesses per year. This translates into 52 people per day.

“I want you to understand the disease burden of Uganda. Currently, 52 people die per day from AIDS-related illnesses, we have 16 maternal health related deaths per day, 14-16 malaria deaths per day and I am reliably informed that 32 people die from tuberculosis per day,” Dr Mutumba says.

Why young people are most at risk 

The available data shows that HIV prevalence is very high in young women and older men. For Dr Rogers Ssennyonjo, the in-charge of the Katego Clinic of Reproductive Health Uganda (RHU), the question is, of the two, who is spreading the disease to the other?

“Early marriage is one of the cultural norms to look out for. We need to admit that in Uganda today, there are still communities where men look at their daughters as assets, waiting for that age where they will look a bit mature so that they can sell them off," he says.

Dr Ssennyonjo also adds that by 15, most adolescents have started having sex due to different reasons and this puts them at high risk of infections.

“Poverty now cuts across both parents and adolescents, and maybe that is why young girls are getting HIV from older men. However, we also have a high demand for luxury goods. A girl with a Tecno mobile phone will admire her friend who has an iPhone 14. This will entice her into having sex with a man who can afford to buy her the latest phone," he explains.

HIV is a behavioural diseases and a number of people have normalized having multiple sexual partners or engaging in risky sexual behaviour, especially after drinking alcohol.

“People are having sex for fun. We live in a digital era where it is okay to have a boyfriend and a bestie with ‘benefits.’ People are attending house parties where they have sex competitions. The HIV stakeholders are bragging about bringing numbers down but they do not know that such things are happening,” Dr Ssennyonjo laments.

He blames the status quo on the general lack of support and guidance to the young people today. Today, although the country needs 328 million condoms, about 141.8 have so far been distributed. Overall, AGYW age-specific service packages have been provided in 44 out of the 73 high burden districts.

“The main problem we have is that adolescent girls cannot negotiate for safe sex. Maybe, initially, they go out to have fun and then end up having sex. In the African setting, only a small percentage of people actually plan for sex. For most, it just happens and by that time they do not have access to protection,” Dr Kwikiriza explains.

Some of the behavioural factors fueling the HIV epidemic include having multiple sexual partners, discordance and non-disclosure, transactional sex, low condom use, low male circumcision, alcohol and drug abuse, and complacency due to ART. The structural factors include unequal power dynamics, poverty, stigma, and poor access to health care.

“Previously, our programming included delivering condoms only to the health centers. Now, we are engaged in Last Mile Distribution (LMD) to ensure that we put condoms even in hotel washrooms, so that people have protection whenever they need it,” Dr Mutumba says.

LMD of condoms to the community hotspots has increased the availability and demand of condoms in communities. Getting the message across In June 2017, the Presidential Fast Track Initiative on Ending AIDS 2030 (PFTI) was launched as a catalyst for fast tracking the country’s national efforts towards ending AIDS as a public health threat. PFTI’s goal is zero new HIV infections, zero AIDS-related deaths and zero discrimination against PLHIV.

“The first of our five-point plan is to engage men in HIV prevention and close the tap on new infections particularly among AGYW. A cursory glance at the data shows that we seem to be making strides but when you desegregate it, you will realise that men have been left behind right from the point of testing to know their status,” Dr Kwikiriza says.

If the tap on new infections is to be closed, the focus should also be on interesting adolescents in taking the initiative to voluntarily test themselves instead of waiting for them to walk into health facilities, since at that age, they rarely fall ill.

“We need to target the age group of women between 20 to 29 years. For men, the infection starts when they are slightly older, at around 30 years. So, it is the men in their 30s who are infecting the women in their 20s. We know in Uganda, HIV transmission is not by needle injury or blood transfusion, but through sexual intercourse,” Dr Kwikiriza advises.

The slow progress in behavioural change continues to drive transmissions upwards, showing that the HIV messaging is not reaching the intended target. According to the Uganda Demographic and Health Survey (UDHS) 2022, access to information remains a concern, with 30 percent of women and 18 percent of men reporting no regular access to newspapers, television, or radio.

“How do we reach the young women and the men with information about the new interventions? Sometimes, young girls aged 15 years go for family planning services and the nurses, instead of giving them commodities and more information, lecture them, asking why they are having sex. So, they go away and do not return,” Dr Kwikiriza. laments.

The way forward

The first vulnerability in the HIV fight is identifying the person with the infection. Currently, Uganda has identified 92 percent of the PLHIV in the country and the health ministry has committed to increasing the number identified to 95 percent next year.
 
“We piloted the Munonye Campaign - a six-month HIV testing campaign that aims to identify children and adolescents who are living with HIV but have not yet started treatment. So far, we have been able to identify over 6,000 individuals under 15 years,” Dr Mutumba says.

The second vulnerability is the fact that external funding is dwindling yet the response is 80 percent funded by donors. The stakeholders expound on the need to integrate malaria, tuberculosis, and HIV interventions.

“Top on our agenda is sustainability. We are in the process of preparing ourselves to be weaned off aid gradually. We are grateful to partners such as the U.S President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to fight AIDS, Tuberculosis and Malaria, but the question is, if they stop funding us, will we be able to continue with the HIV fight?” Dr Mutumba asks.

According to Dr Mutumba, there are no ARV stock outs in the country because increasingly, the government has been committing more money to the HIV response. He adds that even next year, there is no shortage in ARV commitments.

With a reduction in funding now a tangible possibility, all Ugandans, including the media, have a role to play in the HIV response. And if empowered, young people like Kisaakye who are already educating and sensitising their peers, can champion and lead the fight against HIV.