ANALYSIS: Can Uganda achieve zero new HIV infections and AIDS deaths by 2015?

"Getting to zero:  Zero new HIV infections. Zero discrimination. Zero AIDS related deaths," is the theme for World AIDS Days between 2011 and 2015, in line with a new global vision being spearheaded by UNAIDS. Whether all countries, regardless of the size of their epidemic and level of development, will achieve this target is another issue all together. However, countries around the world are trying to work out ways of achieving the UNAIDS vision.

Uganda occupies a special place in the fight against HIV/AIDS for both good and wrong reasons.  According to a 2003 article in the African Journal of AIDS Research, Uganda’s HIV prevalence declined from 21.1 to 9.7 percent from 1991 to 1998 across 15 antenatal clinics. Similarly, the decline was from 18.5 to 4 percent (1991-2002) in 21 year old army recruits. While in another notable shift, HIV prevalence fell from 24 to 7 percent (1989 -1998) among blood donors. 

Ultimately, prevalence had reduced dramatically from a 1991 average peak of 15 percent to 5 percent in 2001 among the 15 - 49 age group. However, the 2011 Uganda AIDS Indicator Survey shows that prevalence has gone up again from 6.4 percent in 2006 to 7.3 percent. And ministry of Health estimates show that HIV incidence has also increased from 115,775 in 2007/08 to 124,261 during 2009/2010 and now at an estimated 130,000 new infections in 2011/12.

Leadership (under the stewardship of President Yoweri Museveni) played a great role in Uganda’s success story of the 1990s. Therefore when the Uganda AIDS Commission (UAC) modified this year’s theme to “Re-engaging Leadership for Effective HIV Prevention” with a supporting slogan of “Accelerating Action towards zero new infections,” the UAC knew well that all efforts coming up to fight HIV will and still need leadership.

According to Uganda AIDS Commission Board Chair Prof. Vinand Nantulya, the country’s hope rests with the national HIV prevention strategy 2011- 2015 if well implemented.

"This strategy aims at mobilizing all people and institutions to work towards eliminating new HIV infections, putting an end to stigma and discrimination, and halting deaths from AIDS-related conditions by the year 2015," says UAC Board Chairman Prof. Vinand Nantulya.

The strategy sets out ambitious objectives. These include: increasing adoption of safer sexual behaviour and reduction of risk taking behaviour, and attaining critical coverage of effective HIV prevention services. Others are creating a sustainable enabling environment that mitigates the underlying structural drivers of the epidemic; improving strategic information for HIV-prevention, and reengaging leadership and re-energizing coordination for HIV prevention.

To achieve these objectives, US$3.4 billion would be required during the implementation phase of 2011 through 2015. With most of these funds expected from donors –who are increasingly tightening the taps - amid governance and integrity queries on management of foreign aid, the country is in difficult times.

Matters have not been helped by President Yoweri Museveni’s latest shift in thinking from a multi pronged approach to HIV prevention in preference to a moralist approach that espouses abstinence and fidelity.

The President used the World AIDS Day platform where he was chief celebrant to castigate biomedical approaches to HIV prevention. He particularly picked out medical male circumcision and condom use arguing that these are causing a false sense of security and therefore contributing to the rising incidence and prevalence.

As if that is not bad enough, policy (official and unofficial) hurdles and programmatic issues in have hampered attempts to accelerate sound scientific interventions like voluntary medical male circumcision (VMMC), prevention of mother to child transmission (PMTCT) and antiretroviral therapy (ART) programmes.

The latest annual health sector performance report, covering the year 2010/2011, shows not so good indicators in the fight against HIV/AIDS. Access to HIV counseling and testing services remained the same (38% of 4,980 facilities), yet this is a critical entry point for prevention and treatment interventions. Coming to PMTCT, facilities offering the services only increased from increased from 23 percent in financial year 2009/10 to 32 percent in 2010/11. That shows that the country still has an uphill task to reduce the 25,000 to 30,000 vertical transmissions that occur annually. Uganda is targeting a less than 4 percent mother to child transmissions by 2015.

Results of the 2011 Uganda AIDS Indicator Survey show that whereas male circumcision has been shown to have a protective effect on HIV transmission, the proportion of Ugandan men age 15-49 that are circumcised has remained almost unchanged at 26 percent. Without a costed work plan for the rollout of circumcision, it is not clear whether the 2015 target of 85 percent coverage will be met. On the treatment front, just about a half of those who need treatment are receiving it. Bleakly, that new infections doubling cases of those put on treatment annually, is further complicating the situation.

HIV is the leading risk factor for the development of tuberculosis disease. At the same time, tuberculosis is the leading cause of death among people living with HIV. In a country like Uganda where the TB burden is so huge (the community has with TB germs in the air) and HIV/AIDS that is depressing the immunity of persons with HIV, then chances of picking TB are high. Dr Anna Nakanwagi Mukwaya, the Chief of Party in Uganda for the International Union against Tuberculosis and Lung Disease (The Union) said: "In countries where TB and HIV services are under the same roof things are much better. For example in Zimbabwe these services are given under the same roof. Patients are not referred. If you go to Benin, it is the same thing. In Uganda, because our services have been structured separately, it takes time. When it comes to health workers, very few in HIV know how to give TB care and in TB it is the same situation. Uganda needs to get resources and ensure that all health workers in HIV care know how to diagnose TB, treat it and follow up the patient. It should be the same thing on the TB side. Traditionally, the training has been separate. Joint planning by the national TB and AIDS control programmes is also still weak." No doubt Uganda should implement TB-HIV collaborative activities optimally.

With most bilateral donors halting aid just recently due to corruption, it remains to be seen how an already struggling health system will cope. However, all hope is not lost. The US President’s Emergency Plan for AIDS Relief (PEPFAR), the biggest funder to Uganda’s AIDS response, recently released its blueprint showing how Uganda could turn the tide against HIV.

This trend notwithstanding, according to the PEPFAR blueprint, “analysis indicates that more rapid national scale-up of combination prevention interventions, including ART, can reverse the course of Uganda’s epidemic. Under an accelerated combination prevention approach, Uganda could achieve 80 percent ART coverage for individuals with CD4 counts below 350 cells/mm3, while continuing the current pace of scale-up for condoms and HIV testing and counseling.”

The authors of the blueprint argue that if the 80 percent circumcision coverage is achieved success registered, this together with the recently started option B+ which offers ARVs to pregnant women as soon as they test positive, high numbers of new infections will be averted.

None-the-less, with the PEPFAR blueprint espousing the use of new scientific advances in addition to existing behavioral strategies, while influential leadership over emphasizing the latter and as stated earlier with sometimes the president publically downplaying new prevention technologies, Uganda appears to be at crossroads once again.

Kakaire A Kirunda - CNS

December 2012

(The author is a senior journalist based in Uganda. He has written on health extensively for noted media such as The Monitor, The Observer, CNS among others. He is also the CNS Health Fellow  and AIDS Vaccine Fellow for this year 2012) 

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