Hiv/Aids In Uganda Case Study

The very high rate of HIV infection experienced in Uganda during the 1980s and early 1990s created an urgent need for people to know their HIV status. The only option available to them was offered by the National Blood Transfusion Service, which carries out routine HIV tests on all the blood that is donated for transfusion purposes. Because the need for testing and counseling was great, a group of local non-governmental organizations such as The AIDS Support Organisation (TASO), Uganda Red Cross, Nsambya Home Care, the National Blood Bank, the Uganda Virus Research Institute[2] together with the Ministry of Health established the AIDS Information Centre in 1990 to provide HIV testing and counseling services with the knowledge and consent of the client involved.

In Uganda, HIV/AIDS has been approached as more than a health issue and in 1992 a Multi-sectoral AIDS Control Approach was adopted. In addition, the Uganda AIDS Commission, also founded in 1992, has helped develop a national HIV/AIDS policy. A variety of approaches to AIDS education have been employed, ranging from the promotion of condom use to 'abstinence only' programmes.

To further Uganda's efforts in establishing a comprehensive HIV/AIDS program, in 2000 the MOH implemented birth practices and safe infant feeding counseling. According to the WHO, around 41,000 women received Preventing Mother To child Transmission (PMTCT) services in 2001.[3] Uganda was the first country to open a Voluntary Counselling and Testing (VCT) clinic in Africa called AIDS Information Centre and pioneered the concept of voluntary HIV testing centers in Sub-Saharan Africa.

The Ugandan government, through President Yoweri Museveni, has promoted this as a success story in the fight against HIV and AIDS, arguing it has been the most effective national response to the pandemic insub-Saharan Africa. Though equally there has in recent years been growing criticism that these claims are exaggerated, and that the HIV infection rate in Uganda is on the rise.[4]

There are striking similarities with the history of HIV/AIDS response in Senegal, where an equally high-level political response was encouraged by the fact that the HIV-2 strain of the disease was discovered by the Senegalese scientist Dr. Mboup.

History[edit]

An overarching policy known as "ABC", which consisted of abstinence, monogamy, and condoms, was set up with the aim of helping to curb the spread of AIDS in Uganda, where HIV infections reached epidemic proportions in the 1980s.[5] The prevalence of HIV began to decline in the late 1980s and continued throughout the 1990s. Between 1991 and 2007, HIV prevalence rates declined dramatically. Various claims have been made on the extent of these declines, but mathematical models estimated falls from about 15 percent in 1991 to about 6 percent in 2007.[6]

Shortly after he came into office in 1986, President Museveni spearheaded a mass education campaign promoting a three-pronged AIDS prevention message: abstinence from sexual activity until marriage; monogamy within marriage; and condoms as a last resort. The message became commonly known as ABC: Abstinence, be faithful, use a condom if A and B fail. This message also addressed the high rates of concurrency in Uganda, which refers to the widespread cultural practice of maintaining two or more sexual partners at a time. Mass media campaigns also targeting this practice including the "Zero-Grazing" and "Love Carefully" public health messages in the 1990s[7]

The government used a multi-sector approach to spread its AIDS prevention message: it developed strong relationships with government, community and religious leaders who worked with the grassroots to teach ABC. Schools incorporated the ABC message into curricula, while faith-based communities trained leaders and community workers in ABC. The government also launched an aggressive media campaign using print, billboards, radio, and television to promote abstinence, monogamy, and condom use.[citation needed]

Condoms were not the main element of the AIDS prevention message in the early years.[8] President Museveni said, "We are being told that only a thin piece of rubber stands between us and the death of our Continent ... they (condoms) cannot become the main means of stemming the tide of AIDS."[9] He emphasized that condoms should be used, "if you cannot manage A and B ... as a fallback position, as a means of last resort."[10]

Some reports suggest that the decline in AIDS prevalence in Uganda was due to monogamy and abstinence, rather than condom use. According to Edward C. Green, a medical anthropologist at the Harvard School of Public Health, the promotion of fidelity to one's partner and abstinence were the most important factors in Uganda's success because they disrupted the widespread practice of having multiple concurrent sexual partners.[11] A 2004 study published in the journal Science also concluded that abstinence among young people and monogamy, rather than condom use, contributed to the decline of AIDS in Uganda.[12]

However, a field-study conducted in Rakai, a region in southern Uganda, showed that abstinence and fidelity rates had been declining during 1995–2002, but without the expected rise in HIV/AIDS rates, suggesting a greater role for condoms than acknowledged by Museveni. The other central finding of the Rakai study was that, due to Uganda's focus on prevention of the spread of HIV-AIDS, rather than treatment for those who had already contracted the disease, a large part of the decline in prevalence of HIV-AIDS is due to the premature death of those who have contracted it. This led to the popular play on the ABC campaign, 'A-B-C-D', with the D standing for Death. Because only prevalence is measured, incidence can actually increase while prevalence decreases if those who contract HIV are not treated for the disease, thereby dying younger. Later studies have seriously questioned the veracity of Uganda's miraculous HIV-AIDS claims[citation needed].

In the 1990s there had been limited access to treatment in the form of anti-retrovirals for those who are HIV positive. Through the combined effort of US PEPFAR, the government of Uganda, and international agencies (Clinton HIV/AIDS Initiative, the Global Fund, UNITAID) this has improved.[13] The country's HIV-AIDS campaign focuses solely on prevention rather than cure, and that prevention is of questionable success.[14]

Criticism[edit]

The scope of Uganda's success has come under scrutiny from new research. Research published in The Lancet medical journal in 2002 questions the dramatic decline reported. It is claimed statistics have been distorted through the inaccurate extrapolation of data from small urban clinics to the entire population, nearly 90% of whom live in rural areas.[15] Also, recent trials of the HIV drug nevirapine have come under intense scrutiny and criticism.[16]

US-sponsored abstinence promotions have received recent criticism from observers for denying young people information about any method of HIV prevention other than sexual abstinence until marriage. Human Rights Watch says that such programmes "leave Uganda’s children at risk of HIV".[17] Alternatively, the Roman Catholic organization Human Life International says that "condoms are adding to the problem, not solving it" and that "The government of Uganda believes its people have the human capacity to change their risky behaviors."[18]

It is feared that HIV prevalence in Uganda may be rising again; at best it has reached a plateau where the number of new HIV infections matches the number of AIDS-related deaths.[citation needed] There are many theories as to why this may be happening, including the government’s shift from abstinence-based prevention programmes, and a general complacency or 'AIDS fatigue'. It has been suggested that antiretroviral drugs have changed the perception of AIDS from a death sentence to a treatable, manageable disease; this may have reduced the fear surrounding HIV, and in turn have led to an increase in risky behaviour. Although prevention interventions, like safe male circumcision, have been shown to effectively reduce HIV transmission, studies in Uganda have shown delayed uptake of these interventions and attributed this to contestations over evidence by high-level leaders.[19]

Although abstinence has always been part of the country’s prevention strategy it has come under scrutiny since 2003 following significant investment of money for abstinence-only programmes from PEPFAR, the American government’s initiative to combat the global HIV/AIDS epidemic. It is felt that PEPFAR has shifted the focus of prevention in Uganda from the comprehensive ABC approach of earlier years. PEPFAR is channelling large sums of money through pro-abstinence and even anti-condom organisations that are faith-based, and believe sexual abstinence should be the central pillar of the fight against HIV. Abstinence-only is also being encouraged by evangelical churches within Uganda, and by the First Lady, Janet Museveni.

This money is making a difference – some Ugandan teachers report being instructed by US contractors not to discuss condoms in schools because the new policy is 'abstinence only'. Dozens of billboards around the country have sprung up promoting only abstinence to prevent HIV infection and sometimes discouraging condom use. Some leaders of small community-based organisations also report they are aware that they are more likely to receive money from PEPFAR (which is the largest HIV-related donor to the country) if they mention abstinence in their funding proposal.[20]

There have been calls for a more nuanced view of Uganda's response to HIV/AIDS. There is no doubt that there has been sustained, long term political commitment at the highest levels of government on this issue. In other countries such as Zimbabwe or South Africa, inept leadership has led to a serious crisis; some such as former President Thabo Mbeki deny the link between HIV and AIDS.

One aspect of the response to HIV in Uganda bridges the Millennium Development Goals and prevention—that is vertical transmission or Prevention of Mother To Child Transmission (PMTCT). Through the Global Fund's Born HIV Free campaign BornHIVFree the need and impact of PMTCT is made clear. Funding is encouraged by UNITAID and MassiveGood

Structure of health provision[edit]

The provision of all health services in Uganda is shared between three groups: the government staffed and funded medical facilities; private for profit or self-employed medics including midwives and traditional birth attendants; and, NGO or philanthropic medical services. The international health funding and research community, such as the Global Fund for AIDS, TB and Malaria, or bilateral donors are very active in Uganda. Part of the success in managing HIV/AIDS in Uganda has been due to the cooperation between the government and the non-government service providers and these international bodies. Public Private Partnerships in Health are often mentioned in Europe and North America to fund construction or research. In Uganda, it is more practical being the recognition by the (public) government and (public) donor that a (private) philanthropic health facility can receive free test kits for HIV screening, free mosquito nets and water purification to reduce opportunistic infections and free testing and treatment for basic infections of great danger to PLHA.[21]

Alternative proposals[edit]

Several studies, conducted in Uganda and its neighbors, indicate that adult male circumcision may be a cost-effective means of reducing HIV infection. A 2007 review of studies about the acceptability of adult male circumcision[22] indicated the median proportion of uncircumcised men willing to become circumcised was 65 percent (range 29–87 percent). Sixty nine percent (range 47–79 percent) of women favored circumcision for their partners, and 71 percent (range 50–90 percent) of men and 81 percent (range 70–90 percent) of women were willing to circumcise their sons. The national AIDS Indicator survey in 2011 also indicated that over 48 percent of adult men were willing to be circumcised, generating a critical mass of demand for male circumcision.[23]

An economic analysis by Bertran Auvert, a physiciann from the INSERM U687, Saint-Maurive, France, and colleagues estimated the cost of a roll-out over an initial 5-year period would be $1036 million ($748 – $1319 million) and $965 million ($763 – $1301 million) for private and public health sectors, respectively. The cumulative net cost over the first 10 years was estimated at $1271 million and $173 million for the private and public sectors, respectively.[24]

See also[edit]

Notes and references[edit]

  1. ^ ab"Epidemiological Fact Sheet on HIV and AIDS: Core data on epidemiology and response – Uganda"(PDF). Geneva: UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance. 2009-02-12. p. 4. Retrieved 15 February 2010. 
  2. ^Peter Kitonsa Ssebbanja (2007). "4". In Glen Williams. Peter Kitonsa Ssebbanja. p. 25. ISBN 9781905746064. 
  3. ^Baryarama, F.; Bunnell, R. E.; Ransom, R. L.; Ekwaru, J. P.; Kalule, J.; Tumuhairwe, E. B.; Mermin, J. H. (2004). "Using HIV voluntary counseling and testing data for monitoring the Uganda HIV epidemic, 1992–2000". Journal of acquired immune deficiency syndromes (1999). 37 (1): 1180–6. doi:10.1097/01.qai.0000127063.76701.bb. PMID 15319679. 
  4. ^"The Gap Report"(PDF). Archived from the original(PDF) on 20 June 2016. 
  5. ^"HIV and AIDS in Uganda," Avert.org.
  6. ^Epidemiological Fact Sheet on Uganda. UNAIDS (2008).
  7. ^Pisani, Elizabeth (2008). The Wisdom of Whores. New York, NY: Norton & Company. ISBN 1847084052. 
  8. ^"HIV Prevention Strategies". Averting HIV and AIDS. Retrieved 27 January 2014. 
  9. ^Address by Janet K. Museveni, First Lady of Uganda at the Medical Institute for Sexual Health's "Common Ground: A Shared Vision for Health" Conference, Washington, D.C., 17–19 June 2004.
  10. ^President Museveni of Uganda, Interview with Jackie Judd, Kaiser Family Foundation, 14 June 2004.
  11. ^Green, Edward C. (29 March 2009). "Condoms, HIV-AIDS and Africa - The Pope Was Right". The Washington Post. Retrieved 18 April 2015. 
  12. ^Stoneburner, R. L.; Low-Beer, D. (2004). "Population-Level HIV Declines and Behavioral Risk Avoidance in Uganda"(PDF). Science. 304 (5671): 714–8. doi:10.1126/science.1093166. PMID 15118157. 
  13. ^UGANDA: Optimism as PEPFAR increases funding*. PlusNews (2010-08-25)
  14. ^Russell, Sabin (24 February 2005). "Uganda's HIV rate drops, but not from abstinence / Study concludes basis of Bush policy apparently irrelevant". The San Francisco Chronicle. 
  15. ^Parkhurst, JO (2002). "The Ugandan success story? Evidence and claims of HIV-1 prevention". Lancet. 360 (9326): 78–80. doi:10.1016/S0140-6736(02)09340-6. PMID 12114061. 
  16. ^Farber, Celia (2006-03-01). Out of ControlArchived 2007-11-14 at the Wayback Machine.. Harper's Magazine
  17. ^"Uganda: 'Abstinence-Only' Programs Hijack AIDS Success Story", Human Rights Watch (2005-03-30).
  18. ^"An open letter to Melinda Gates"Archived 2007-09-28 at the Wayback Machine., Human Life International (2006-08-29).
  19. ^Ssengooba, Freddie; et al. (2011). "Research translation to inform national health policies: learning from multiple perspectives in Uganda". BMC International Health and Human Rights. 11: S13. doi:10.1186/1472-698X-11-S1-S13. PMC 3059472. PMID 21411000. Retrieved 26 May 2012. 
  20. ^HIV and AIDS in Uganda. Avert.org (2012-09-21). Retrieved on 2012-11-26.
  21. ^Poverty News Blog: Hope Clinic Gives Hope to the Hopeless. Povertynewsblog.blogspot.com (2008-05-21). Retrieved on 2012-11-26.
  22. ^Westercamp, N.; Bailey, R. C. (2007). "Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: A review". AIDS and Behavior. 11 (3): 341–55. doi:10.1007/s10461-006-9169-4. PMC 1847541. PMID 17053855. 
  23. ^"Uganda Aids Indicator Survey 2011"(PDF). 2011. 
  24. ^Economic Analysis Supports Adult Male Circumcision for HIV Prevention in Sub-Saharan Africa, E. Hitt, Medscape Medical News, July 25, 2007
UNAIDS/WHO Epidemiological Fact Sheets on HIV and AIDS, 2008 Update[1]
UNAIDS/WHO Epidemiological Fact Sheets on HIV and AIDS, 2008 Update[1]
KEY POINTS:
  • In a country where 1.4 million people are living with HIV, women and young women in particular are disproportionately affected.
  • There are many political and cultural barriers which have hindered effective HIV prevention programming in Uganda. As a result, new HIV infections are expected to rise in coming years.
  • While there have been increased efforts to scale up treatment initiatives in Uganda there are still many people living with HIV who do not have access to the medicines they need.
  • Punitive laws and stigmatising attitudes towards men who have sex with men, sex workers, and people who inject drugs has meant that these groups most vulnerable to infection are far less likely to engage with HIV services.

Explore this page for more information on populations most affected, testing and counselling programmes, prevention programmes, antiretroviral treatment, civil society's role, HIV and tuberculosis, barriers to prevention and the future of HIV and AIDS in Uganda.  

In 2016, an estimated 1.4 million people were living with HIV, and an estimated 28,000 Ugandans died of AIDS-related illnesses.1

The epidemic is firmly established in the general population. As of 2016, the estimated HIV prevalence among adults (aged 15 to 49) stood at 6.5%.2 Women are disproportionately affected, with 7.6% of adult women living with HIV compared to 4.7% of men.3

Other groups particularly affected by HIV in Uganda are sex workers, young girls and adolescent women, men who have sex with men, people who inject drugs and people from Uganda’s transient fishing communities.4

There has been a gradual increase in the number of people living with HIV accessing treatment. In 2013, Uganda reached a tipping point whereby the number of new infections per year was less than the number of people beginning to receive antiretroviral treatment.5

However, as of 2016 around 33% of adults living with HIV and 53% of children living with HIV were still not on treatment.6 Persistent disparities remain around who is accessing treatment and many people living with HIV experience stigma and discrimination.7

Groups most affected by HIV in Uganda

Adolescent girls, young women and HIV in Uganda

HIV prevalence is almost four times higher among young women aged 15 to 24 than young men of the same age.8

The issues faced by this demographic include gender-based violence (including sexual abuse) and a lack of access to education, health services, social protection and information about how they cope with these inequities and injustices. Indeed, young Ugandan women who have experienced intimate partner violence are 50% more likely to have acquired HIV than women who had not experienced violence.9

The lack of sexual education is telling. In 2014, only 38.5% of young women and men aged 15-24 could correctly identify ways of preventing the sexual transmission of HIV and rejected major misconceptions about HIV transmission.10

Sex workers and HIV in Uganda

HIV prevalence among sex workers was estimated at 37% in 2015/16.11

It is estimated that sex workers and their clients accounted for 18% of new HIV infections in Uganda in 2015/16.12

A 2015 evidence review found between 33% and 55% of sex workers in Uganda reported inconsistent condom use in the past month, driven by the fact that clients will often pay more for sex without a condom.13

…you could be in a bad situation yet you are sick and on medication. At the same time you may not have anything to eat… you look for a man who can help you. Then that man will give you conditions… if you are going to have sex with him with a condom he will give you Uganda Shillings (UGX) 2,000/ =, then he says that if it is without a condom he will give you 20,000/=. Because you can't help yourself, there is no way you can leave UGX 20,000/= and go for UGX 2,000/=

- Female sex worker, Malaba14

Violence is common, with more than 80% of sex workers experiencing recent client-perpetrated violence and 18% experiencing intimate partner violence. More than 30% had a history of extreme war-related trauma.15

The criminalisation of sex work and entrenched social stigma means sex workers often avoid accessing health services and conceal their occupation from healthcare providers. In particular, stigma towards male sex workers who have sex with men is exacerbated by homophobia. Indeed, many sex workers in Uganda consider social discrimination as a major barrier in their willingness or desire to test for HIV.16

Men who have sex with men (MSM) and HIV in Uganda

HIV prevalence among men who have sex with men (sometimes referred to as MSM) in Uganda was an estimated 13% in 2013, the most recent data available.17

A 2017 study among men who have sex with men in Kampala reported high risk behaviours to be common, including 36% of respondents reporting regularl unprotected anal sex, 38% selling sex, 54% having multiple steady partners, 64% having multiple casual partners, and 32% injecting drugs.18

Pervasive HIV-related social stigma and high levels of homophobic violence caused by conservative social attitudes and stigmatising legislation result in men who have sex with men feeling less inclined to access HIV services. The 2017 study mentioned above found 40% had experienced homophobic abuse and 44.5% had experienced suicidal thoughts.19

The Uganda Anti-Homosexuality Act was passed by parliament in December 2013 and officially signed into law in February 2014. Although the law was annulled in August 2014 due to a technicality based on the number of MPs present during the vote, it is thought to have resulted in increased harassment and prosecution based on sexual orientation and gender identities. It has also triggered negative discussions from the general population on social media, in which violence and anti-homosexual discrimination are advocated.20

HIV outreach workers and services providers working in Uganda with men who have sex with men have also reported heightened challenges in reaching this population.

People who inject drugs (PWID) and HIV in Uganda

In sub-Saharan Africa, people who inject drugs (sometimes referred to as PWID) are highly stigmatised and open to severe discrimination. In many cases this marginalisation can be felt on a governmental level, leaving this group with very little in the way of adequate HIV and health services.

Since the Global State of Harm report in 2014 estimated HIV prevalence among people who inject drugs at 16.7% in Uganda, the government has pledged to prioritise innovative approaches to help this population.21 In 2017, the Ugandan Ministry of Health authorised a number of needle and syringe programmes to be piloted.22

Fishing communities

HIV prevalence among Uganda’s fishing communities is estimated to be three times higher than the general population. A 2013 study of 46 fishing communities found HIV prevalence to be at 22% with no variation between men and women.23

The reason for such high prevalence among this community is thought to be the result of a complex range of factors including a high degree of mobility, a high rate of fisherman who pay for sex, injecting drugs use, and a lack of access to HIV prevention and testing services.24

HIV testing and counselling (HTC) in Uganda

Increasing knowledge of HIV status through HIV testing and counselling (HTC) is a key route to tackle Uganda’s HIV epidemic. HTC services have been expanded and the number of people testing for HIV is increasing as a result, from 5.1 million in 2012 to 10.3 million in 2015.25

Testing is conducted in health facilities, in community settings and in people’s homes. In recent years there has been more emphasis to promote HTC services for couples, workplaces testing, outreach to most at risk groups, and mobile or mass testing, especially during testing campaigns.26 In 2017, the Ministry of Health piloted oral HIV self-testing kits among fishermen, female sex workers and the male partners of women attending antenatal care.27

The proportion of women (ages 15-49) who have tested for HIV and received their results in the past 12 months increased from 47.7% in 2012 to 57.1% in 2014 and from 37.4% to 45.6% among men.28

As a result of this discrepancy, only 55% of men and boys living with HIV know their status, compared to 82% of women and girls. Some men report they would rather avoid knowing their HIV status because they associate being HIV-positive with ‘emasculating’ stigma.29

CASE STUDY: Sustainable East Africa Research on Community Health

The Sustainable East Africa Research on Community Health (SEARCH) combined HIV testing with screening and treatment for diabetes, hypertension and malaria in rural communities in Kenya and Uganda.

Multi-disease health fairs were planned and conducted by elected village leaders, with services provided by local clinical staff, in close proximity to where people live. For people who test positive for HIV, SEARCH adopts a client-centred model of HIV treatment, offering things such as flexible hours, a telephone hotline, appointment reminders (by phone or SMS) and client counselling.

Overall gains have been remarkable: after just two years, SEARCH had achieved all 90–90–90 targets in the communities it was serving. Especially noteworthy were the results achieved among men and young people, groups that have been historically difficult to reach with HIV testing and treatment services.30

HIV prevention programmes in Uganda

There were 52,000 new HIV infections in Uganda in 201631,mainly among adolescents and young people, women and girls, and key populations.32

The country’s 2015/2016-2019/2020 prevention strategy identifies three objectives:

  • to increase adoption of safer sexual behaviours and reduction in risk behaviours
  • to scale up coverage and use of biomedical HIV prevention interventions (such as voluntary medical male circumcision and PrEP), delivered as part of integrated health care services
  • to mitigate underlying socio-cultural, gender and other factors that drive the HIV epidemic.33

Condom availability and use

Data reported by UNAIDS in 2017 suggest 60% of men and 45.5% of women used a condom the last time they had higher-risk sex (defined as being with a non-marital, non-cohabiting partner).34

The number of male condoms distributed by the government rose from 87 million in 2012 to around 240 million by the end of 2015. However, this is far below the number of condoms required, given the population size.35 Strengthening the supply chain for both male and female condoms, and a coordinated approach to consistent condom promotion is an integral element in preventing the transmission of HIV in Uganda.

HIV education and approach to sex education in Uganda

In 2015/16, more than 2 million people were reached with prevention information through religious congregations and cultural institutions programmes. Millions more were reached with HIV prevention messages through mass media channels including billboards, radio, television, and print media.

Modules for life learning, with particular focus on sexuality education, were developed as part of the curriculum review process for lower secondary school classes. In addition, outreach to over 800 primary and secondary schools was conducted to provide HIV prevention information, with a focus on the risks of multiple partnerships, cross-generational, transactional and early sex. In total, just under 360,000 children were reached with 1 hour HIV and health education sessions in 2015/16.36

Prevention of mother-to-child transmission (PMTCT)

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