After years, in fact decades of operations against HIV/AIDS, where have we reached and what have we learned in efforts to prevent infection and impacts of HIV/AIDS on our communities? Gerald Businge writes that about the successes and challenges in Uganda and the need for fresh thinking in face of a growing HIV positive population and stagnant infection rates.

Uganda is internationally acclaimed for its successful fight against HIV/AIDS that has provided lesson to different countries in their own responses to the pandemic. Uganda was among the first countries where HIV/AIDS was confirmed in 1982.

The disease then known as slim (because of making sufferers slender before they died) killed many people as its causes were not known, or how it was transmitted. Disaster of an epidemic proportion was apparent as health workers and the government embarked on spirited efforts to understand and prevent infection by the HIV- Human Immune Virus that was causing AIDS- acquired immune deficiency amongst HIV carriers.

According to Dr. Philip Kihumuro Apuuli, the Executive Director of the Uganda AIDS Commission (the body responsible for coordinating the country’s response to HIV/AIDS), Uganda managed to reduce the HIV prevalence (infection) rate reduced from about 30 % in the late 1980s to 6.2% in 2002-3.

Dr. Kihumuro Apuuli, head of Uganda Aids Commision

Strong government leadership and openness about HIV infection (emphasizing the fact it is mostly transmitted through sexual intercourse with an infected partner), broad-based partnerships and effective public education campaigns are said to have contributed to a decline in the number of people living HIV/ AIDS.

Making fight against HIV as simple as ABC

President Yoweri Museveni and many other government officials made it a policy to speak about HIV/AIDS and how it is transmitted and can be avoided at every public gathering addressed. Anti HIV/AIDS campaigns were started in 1988 using the much acclaimed ABC (Abstinence, Be Faithful, and Condom use) method.

The policy encouraged youths to abstain from sex until marriage, and those who are married to remain faithful to their partners. It also encouraged those who cannot abstain or be faithful to use condoms in order to prevent themselves from getting infected through sexual intercourse.

Traditional Healers have also been involved in the fight against HIV/AIDS

This approach in addition to campaigning against stigmatizing those infected and taking the disease as a national problem instead of an issue of those infected, is said to have resulted in behavioral change that saw HIV infection rates declining in Uganda.

But HIV/AIDS has still had a devastating impact on Uganda. HIV/AIDS has killed more than 1 million people (2007 estimates), while reducing life expectancy of many more.  The UAC says an estimated 61,000 people died from AIDS in 2008. About 2 million children have been orphaned by HIV/AIDS. It is estimated that Uganda has about 1.4 million people infected with HIV, in a total population of about 30 million people.

The impact of HIV/AIDS on Uganda’s economy can be seen in the depleted labour force, reduced agricultural output and food security resulting from inability of the sick to engage in economic activities, mostly farming.

Declining success against HIV/AIDS

According to the 2010 National HIV&AIDS Stakeholders & Services Mapping Report, sexual transmission continues to contribute 76% of new HIV infections while mother to child transmission contributes 22%. Currently, estimates indicate that over 100,000 new infections occur annually (during 2008, an estimated 110,694 new HIV infections occurred countrywide and approximately 61,306 people died from AIDS related illness in 2008).

Commercial sex workers, their clients and partners of clients contribute 10% of new infections. Men who have sex with men (homosexuals) and intravenous drug users contribute less than 1%.

According to this report, Ugandan adults living in urban areas are almost twice as likely to be infected with HIV compared to their rural counterparts, yet those in urban areas are presumably more informed about preventive measures against HIV.

The report also notes worsening of behavioural indicators especially an increase in multiple concurrent partnerships. There has also been a shift in the epidemic from people in single casual relationships to those in long-term stable relationships. “Incidence modeling reveals that 43% of new HIV infections are among monogamous relationships while 46% are among persons reporting multiple partnerships and their partners,” the report says.

The latest Uganda HIV/AIDS sero-behavioral survey shows that HIV infection levels for both males and females is highest among those in age category of 30-40 years. This age bracket is presumed to be having adequate knowledge on prevention of HIV infections.

The report also shows that women have higher predominance of HIV infection across all age categories and regions of the country, the reason many activists have been calling for an anti-HIV/ADS strategy and policy that focuses on the vulnerability of women.

Dr. Kihumuro says that all these facts point to the biggest concern in Uganda’s fight against HIV/AIDS, namely, the fact that the country’s HIV prevalence has stagnated between 6 and 7.2 percent since 2001.

“People now think that because we have had HIV for so many years, it is a normal condition among the population,” he says.

Uganda’s new National HIV&AIDS Strategic Plan (NSP) 2007/08-2011/12 and the second Health Sector Strategic Plan 2005-2010 (HSSP-11) spell out the country’s priority of comprehensive, evidence-based HIV prevention interventions to be implemented on a commensurate scale with careful analysis of the current drivers of the HIV epidemic.

Uganda has confirmed itself to Universal Access (UA) to HIV&AIDS prevention, care and treatment in line with World Health Organisation and UNAIDS recommendations. But debates are rolling on whether something new needs to be done in the country’s HIV/AIDS prevention strategy or the response to the pandemic as a whole.

There is growing disagreements of what is effective within the ABC method for prevention of HIV infection as well as growing dissatisfaction with ABC as a whole.

The debates with the ABC HIV prevention method

counselling vital for those tested for HIV

Since 2004, there has been a growing debate about the merits and demerits of the ABC components and also the sufficiency of the ABC approach, as a package in responding to sexual transmission of HIV. Following years of a near miraculous reversal of HIV prevalence, there is general fear that the country is becoming complacent and slowly slipping back into the danger zone. The failure to reduce HIV infections since 2002 has resulted in the questioning of the effectiveness of the current prevention interventions.

The ABC approach has been besieged with a heated debate about the effectiveness and feasibility of its individual components. Some people have emphasized abstinence and be faithful only programs, while other are quick to front condom use citing the risky nature of many people’s sexual behavior.

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