Uganda halved the high prevalence of HIV/AIDS between 1990 and 1998. Though it still faces daunting challenges, it is worthwhile to study how it has scripted such a success story in AIDS control, says Sreejit E M
Uganda is a landlocked country situated in the eastern part of Africa. It is located in the Sub Saharan African region, which bears the heaviest burden of the HIV epidemic in the world. This region accounted for 28.5 million children and adults (about 64%) of those living with HIV/AIDS worldwide and about 97% of AIDS related deaths in 2005.
Uganda was among the first countries in sub-Saharan Africa, and the world, to witness the explosion of the HIV epidemic and experience the devastation caused by it. The first HIV/AIDS case was identified in the country in 1982. The first national survey in 1988 found the average HIV prevalence in the population to be 9%. According to UNAIDS, by the end of 1992, the national prevalence was estimated at 18.3% with some centres registering above 30%.
By the end of 2005, it was estimated that there were about 1 million people living with HIV/AIDS in the country, which puts the national prevalence of infection at 6.7% among adults (ages 15-49). About 520,000 women in the age group 15-49 were living with HIV/AIDS and UNAIDS estimated that more than 1 million children lost one or both parents to AIDS. Overall, infections in urban areas was at 10.7% compared to 6.4% in rural areas while infection amongst urban women was almost twice as high (13%) compared to women in rural areas (7%).
In Uganda, HIV is mainly (84 %) transmitted through heterosexual intercourse. Mother-to-child transmission accounts for about 15 % of cases. Unsafe blood/blood products account for up to 5% of all HIV cases. The portion of HIV transmission attributable to men having sex with men (MSM) and injecting drug users (IDUs) is not known. Sexual behaviours across cultures, different age groups, and gender played an important role in the spread of HIV in Uganda. These factors were further influenced by cultural, social and economic circumstances.
The disease has caused immense human suffering in Uganda over the past two decades. It also undermined development initiatives and the country’s economy. It has reduced life expectancy and has affected both rural and urban dwellers, adults and children.
Tackling the epidemic
Although Uganda was one of the first countries in the region to react swiftly to the spread of the epidemic, in the initial years there was little understanding of the disease and its far-reaching complications. The response from society was mostly limited to locally led community efforts for the care of those infected and affected. Consequently, the epidemic progressed very fast in all parts of the country, especially in urban and semi-urban centres.
If Uganda’s efforts against HIV/AIDS have been hailed as an example of successful intervention in HIV/AIDS, it is largely due to actions taken by the government once it woke up to the enormity of the problem. The success story can be charted from the time the government established the National Committee for the Prevention of AIDS in 1985. A year later, the newly-elected President, Yoweri Museveni, recognised HIV/AIDS as a national calamity and established the Uganda National AIDS Control Project (NACP).
In its formative years, NACP focused on blood safety, prevention of HIV infection in health care settings, and education and communication. The government also created AIDS control projects in 12 line ministries. In 1992, the government adopted the multi-sectoral approach to the control of AIDS. To coordinate this approach, the Uganda AIDS Commission (UAC) was established in 1992 by a statute of Parliament with the mandate of coordinating the activities of the various stakeholders. UAC, located in the office of the President, was also mandated to mobilise resources.
Uganda’s National Strategic Framework for HIV/AIDS Activities, first developed in 1997 and revised in 2000, put HIV/AIDS on the broader national development agenda. In 1997, Uganda enacted a policy of decentralisation which vested powers in local authorities to implement the strategic framework and develop HIV/AIDS interventions to suit their local needs.
These interventions started to yield results and in the capital city of Kampala, the rate of HIV infection among pregnant women attending antenatal clinics fell from 31% in 1993 to 14% by 1998. Meanwhile, outside Kampala, infection rates among pregnant women under 20 dropped from 21% in 1990 to 8% in 1998. Elsewhere, among men attending clinics for sexually transmitted infections (STI), HIV infection rates fell from 46% in 1992 to 30% in 1998.
Why was Uganda's response so effective?
Despite concerns about the quality of the data collected, there is an overwhelming consensus in the global HIV/AIDS community that the HIV prevalence rate in Uganda has shown a significant fall from the late 1990s. Some of the key factors that have contributed to this decline are:
Behaviour change and commitment to awareness and prevention
The approach used in Uganda is what is called the ABC approach: firstly, encouraging sexual Abstinence until marriage; secondly, advising those who are sexually active to Be faithful to a single partner or to reduce their number of partners; and finally, especially if you have more than one sexual partner, always use a Condom.
The ABC approach lacked a clear definition and was always a subject of great debate in the HIV/AIDS community. Basically it was a catchy slogan that highlighted the risk reduction and risk avoidance methods of sexual transmission. Simple messages on HIV prevention very early on in the epidemic, helped, such as ‘zero grazing’, which instructed people to avoid casual sex.
Very early in the epidemic, the Ugandan government created the right environment for people to participate in the fight against HIV/AIDS. One of the first community-based organisations to be formed was The AIDS Support Organisation (TASO), which is often hailed as a model of good practice. Founded in 1987, it helped to address issues of stigma and discrimination of people with HIV.
The Ugandan government displayed remarkable openness and honesty about the epidemic, the risks, and the modes of transmission. The National AIDS Control Project encouraged inputs from numerous government ministries, NGOs and faith-based organisations. Early on, they sought the help of community leaders, civil society, households, traditional healers and religious leaders. The involvement of prominent personalities such as the archbishop of the Church of Uganda and the late musician Philly Lutaaya also helped bring HIV to the centre stage. The President relaxed controls on the media and facilitated the use of various types of prevention messages. All government ministries have HIV/AIDS work plans. The Ugandan government also promoted excellent principles of non-discrimination in the strategic framework.
In the late 1980s, the Uganda Blood Transfusion Service was strengthened to screen all blood received through the central and regional blood banks. Voluntary, non-remunerated blood collection has increased in all regional blood banks, from 60% in 1998 to 96% in 2001.
Sex education and condom distribution
In 2004, UNAIDS and WHO acknowledged that condom distribution and use in Uganda, among high risk groups was an important factor in the decline of HIV prevalence. Condom distribution and social marketing services were implemented nationwide. Sex education programmes in schools and in the media focused on the need to negotiate safe sex and encouraged teenagers to delay their sexual debut. Since 1990, condom promotion campaigns, including social marketing of condoms, has boosted condom use from 7% nationwide to over 50% in rural areas and over 85% in urban areas.
In the early years of the epidemic, young women with a secondary education were found to have higher HIV prevalence than those with no education. This was attributed to a lifestyle that was relatively free of restrictive traditional norms. Secondary schools were thus targeted for interventions.
Voluntary Counselling and Testing (VCT)
Uganda established Africa’s first confidential VCT service, launching the AIDS Information Centre (AIC) in Kampala in 1990. It used VCT as a prevention strategy at a time when even the WHO was not recommending it as a prevention strategy. AIC also provided for same-day results using rapid HIV tests, as well as creation of post-test clubs.
By 2002, AIC had about 70 sites across the country serving a total of 55,000 clients. VCT services were available in 34 of 56 districts. Eighty per cent of VCT and 90 % of post-test counselling and care is provided by non-governmental agencies. There are plans to scale up VCT services to include all 56 districts, as well as strengthen VCT capacity to provide information on antiretroviral treatment.
Involvement of marginalised populations
Messages about HIV and AIDS was effectively communicated to a diverse population by both government agencies and grass-roots level organisations representing people who were infected with HIV and those who were from marginalised communities like women. These efforts not only helped break down some of the stigma associated with AIDS but also encouraged frank and honest discussion of sexual topics.
Care, support, and recognition of the rights of PLWHA
Home-based care (HBC) for People Living with HIV/AIDS (PLWHA) has been of immense value in the battle against HIV/AIDS in Uganda, given the scarce health care facilities, difficulty in accessing available care facilities by the very ill, and the preference for terminal care and death in the home setting. The cost of HBC is borne by the private sector, often religious or charitable, with financing largely from external donors.
ART, vaccine development in Uganda
In the late 1990s, Uganda undertook a landmark clinical trial on mother-to-child transmission of HIV that found that the drug Nevirapine was associated with a 41% reduction in relative risk of HIV transmission.
Uganda has been proactive in securing reduced prices for antiretroviral therapy (ART), as well as funding from international agencies to finance treatment, including provision of ART. In 1996, the health ministry created the National Committee on Access to ARV Therapy. In 1998, Uganda established the Drug Access Initiative (DAI) to advocate for reduced prices for ARVs and the creation of infrastructure to administer them. DAI was followed by the Accelerated Access Initiative (AAI), a partnership between the United Nations and five pharmaceutical companies.
An important landmark in ART provision was achieved in October 2000 when the Joint Clinical Research Centre (JCRC) began importing low-cost generic ARVs from India. Seventy per cent of Ugandans on ART receive their antiretroviral medication and treatment services from JCRC. Currently, about 10,000 Ugandans are receiving ART.
Uganda was the site of the first AIDS vaccine trial in Africa in 1999. In February 2003, researchers at the Uganda Virus Research Institute, in partnership with the International AIDS Vaccine Initiative, began enrolling participants for a phase 1 trial.
The 2001 surveillance survey showed that the prevalence of HIV in samples taken from antenatal clinics during the annual surveillance has gone up to 6.5% from 6.1% in 2000. Though the ministry of health and some independent analysts call this rise insignificant, they have called for caution as they feel that it would be a daunting task to ensure further declines and sustain the lowered rates of infection. Some of the challenges are:
Resource management: Despite political will and good governance, the country, which is one of the poorest in the world, is struggling to sustain the programmes. Military spending and poor provision for health in the budget only makes things worse. Voluntary and civil society organisations are hampered by inadequate finance, skilled manpower and institutional resources.
Surveillance, knowledge, and prevention gaps: Unrest in the northern region and a migrant population hinders data collection and skews the data on HIV prevalence. Despite education campaigns pursued vigorously in the late 1980s and mid 1990s, lack of awareness and misconceptions about HIV/AIDS still hampers prevention efforts.
Rural populations: As in other developing countries, services like counselling centres, treatment for sexually transmitted infections (STI) and condom delivery is poor in rural areas.
Unmet need: Demand for sexual and reproductive health services, including those related to HIV/AIDS/STI are not being met in most parts of the country because of a fast growing population and tremendous strain on the health system.
Needs of the vulnerable population: Migrants from rural areas and war-torn areas, sex workers and women are still vulnerable to the epidemic and addressing their needs is crucial. It is believed that up to 2 million Ugandan children may have been orphaned by AIDS. There are a significant number of child-headed households who are particularly vulnerable, as are children living in conflict areas.
STI treatment and increased care and support burden: Despite being a leader in the provision of many HIV/AIDS related services, Uganda has to increase and improve the quality of these services.
Stigma, discrimination and human rights: A lot of work needs to be done to strengthen campaigns to eliminate stigma, avoid discrimination and safeguard human rights of PLWHA. HIV/AIDS-related discrimination, stigma, and denial declined significantly in the late 1990s, but it is still high, particularly in relation to family and community attitudes toward PLWHA. One of the most severe forms of HIV/AIDS-related discrimination is faced by Ugandan women in relation to inheritance, particularly in terms of remaining in the marital home after the husband dies.
Many believe that it was mortality and not behaviour change that was responsible for up to 80% reduction in the prevalence of HIV/AIDS. Also that condom use rather than abstinence was responsible for the lack of increase in HIV incidence. Some even argue that increased condom use helped offset very high-risk behaviours in some parts of the country.
In November 2004, Uganda drafted an official national policy on abstinence and fidelity - the first of its kind in the world. It is meant to be used as a companion tool to the country’s existing strategy on the promotion of condoms and a component of Uganda’s larger ABC strategy.
Money from the United States has increased in the last few years but critics argue that this cash flow comes with conditions imposed reportedly by the far right in the US. Conditions include giving one-third of all prevention money to "abstinence-only" projects, which, critics say, will derail Uganda’s previous "balanced" approach that has been deemed so effective. Today, in Uganda, condoms are promoted only in the high-risk groups such as truck drivers, soldiers and "discordant" couples (where one of the partners is HIV-positive) and not to the general population. This is also seen to be in line with the conservative religious beliefs of President Museveni and his wife. Some analysts argue that holding back information on condoms is not so much the result of US pressure but rather at the insistence of the private religious schools and churches.
- http://www.aidsmap.com; Henry J. Kaiser Family Foundation • Prevention /Epidemiology; Uganda's Decline in HIV/AIDS Prevalence Attributed to Increased Condom Use, Early Death from AIDS, Study
(Sreejit E M is a public health professional and consultant working with HIV/AIDS)
Infochange News & Features, February 2008