Uganda; The Infrastructure HIV Epidemic

Case 3: Uganda; The Infrastructure Epidemic

Politics: The Economic, legal, cultural and social context 

Uganda still relies on development partner funds to support most of its service sector. However, the new Country Economic Memorandum (CEM), jointly prepared by the World Bank Group and Government of Uganda shows that proceeds from oil could accelerate growth and reduce poverty. With commercial production in full swing, the Bank postulated that the country, could earn up to $3b ( about Shs7 trillion) in revenues from exports of up to 60,000 barrels of oil per day. These revenues have the potential to propel the economy between 7-10 percent forecast up from the current stagnation of 4 percent. The Memorandum offers a series of recommendations including policy and institutional strengthening, to regulate the sector, and ensure greater transparency as well as accountability. Stimulating manufacturing and industry, as well as private sector businesses, along with investing in health and education, would create a more skilled labour force capable of driving growth for the long term. The start of commercial oil production in Uganda, according to the World Bank, offers long-term prospects to diversify the economy and catapult it to upper middle income status by 2040 This has emboldened many in the government to  go ahead for instance to re-enact punitive laws. This creates an atmosphere of hostility toward say, key populations and suspicion of NGOs and CBOs which further leads to disincetivization of initiatives promoting HIV-related service delivery. But, Uganda has been cautioned not to place much confidence in oil as a source of public revenue.

People: Knowing how many are involved in order to engage

7.3% of adults age 15-49 in Uganda are HIV-positive. HIV prevalence is higher among women (8.3%) than among men (6.1%). Among women, HIV prevalence is higher in urban areas (10.7%) than in rural areas (7.7%). In contrast, HIV prevalence is the same (6.1%) for men living in urban and rural areas.Uganda’s open policy toward HIV in 1986 and mobilization drives to warn communities about it made it a household epidemic. This prepared communities to dismiss much of the negative information about HIV. The need to limit sexual intercourse to one uninfected partner was commonly known. There were no ARVs then like today. Private individuals paid exorbitant amounts of money for 5 liter jerrycans of herbal medicines. Those who did not have the money relied upon contributions of extended families. This strained family resources so fast and left families so destitute because many families had more than one person living with HIV. The word used then for people living with HIV was “victim.” This had a denigrating connotation! Family heads or breadwinners sold off real estates to pay for herbal medicines. The herbal medicines were more like oral rehydration salts, bitter plant combinations of mineral supplements and methylated syrups. These became the available costly  medicines against HIV. The herbalists reaped large sums of money but when the Ministry of Health initiated a drug efficacy test, many of these herbalists disappeared. Few HIV-related deaths were recorded then. Around early 2000s, ARVs became available to a select few who could afford them. By mid 2000s with Global Funding and PEFAR an integrated HIV Prevention and care infrastructure was made possible. Clinics were opened and this made ARVs accessible to people. Communities were mobilized and trained in primary prevention and care skills. Community Based HIV/AIDS Initiatives were formed and provided with money to establish care continuum services at village levels. This built a bottom up structure which connected with health facilities and other social services at sub-county and county levels. This made it possible for nine in ten respondents of either sex to know personally of someone with HIV or who had died of AIDS. It made it easier to establish reporting and referral systems. The structure became a docking platform into which an AIDS Control Project was built. This was coordinated multisectorally and it helped integrate HIV prevention and care in all spheres of service delivery. HIV prevalence and incidence were brought down. HIV service delivery emphasized Abstinence and monogamy. This was followed by a culture of criminalization, punitive laws and stigmatising attitudes and it turned out to be Uganda’s undoing of a success story. So, sexual minorities, sexually active unmarried people, children and sex workers were left vulnerable and not likely to engage with HIV services. As of 2016 around 33% of adults living with HIV and 53% of children living with HIV were still not on treatment. Persistent disparities remain around who was accessing treatment and many people living with HIV experienced stigma and discrimination. It is apparent, the need to expand the meaning of prevention, reach out to demographics most at risk and address other political and cultural barriers hindering effective HIV prevention programming in Uganda is paramount.

Prevention: Making prevention a best-practice

Voluntary Testing made Uganda a success story in the early 90s but the neglect of other predictors of HIV prevalence led to peaks seen around 2007. By 2016, an estimated 1.4 million adults and children were living with HIV in Uganda; the Spectrum model estimated that there were approximately 52,000 new HIV infections and 28,000 HIV-related deaths during that year (UNAIDS 2017). The Uganda government has been at the forefront of developing and implementing innovative public health strategies that address the HIV/AIDS epidemic. Beyond designing and being among the first countries in sub-Saharan Africa to implement Option B+, Uganda is also among the initial countries to include Test-and-Start and the 90-90-90 objectives for epidemic control within its National Strategic Plan. Uganda initiated Test-and-Start in November 2016 and has consistently adopted aggressive strategies in its HIV programming that have moved the country closer to controlling the epidemic.

Planet: The idea of universalizing and synchronizing best practices

In 2015, Uganda developed the 2015/2016-2019/2020 National HIV and AIDS Strategic Plan (NSP), which provides a new framework for the implementation of HIV programs that align with the UNAIDS 90-90-90 targets. The NSP focuses on case identification and promotion of access to antiretroviral therapy (ART), adherence, and retention (Uganda AIDS Commission 2015). National efforts and investments from donors and other partners have also focused on HIV prevention, knowledge, and behavioural interventions. The Uganda country program has been monitoring the impact of these programs through routine HIV program monitoring, Demographic and Health Surveys, Biological Behavioural Surveillance Surveys, and a Population-based HIV Impact Assessment survey. It is hoped these reports will be used to inform policy and programming.

Punitive laws, violence, stigma, discrimination and a concentration of duplicate primary prevention services in urban centers have an interference role in the end to HIV objective for Uganda. They mask effective roll back efforts, make it harder to generate disaggregated reports which in turn affects HIV prevention and care service delivery. Such best practices to capture those who drop out of the care continuum or categorical processes addressing optimal ARV adherence are missed. In Uganda, concentrating HIV-related service delivery within political elite circles and urbanized settings makes HIV an infrastructure epidemic. This means refugees, women and key populations may be served by whim and not strategy in a country known for resolve against HIV. Service delivery organizations in Uganda are pivotal in rolling back HIV if they have solid mechanisms to negotiate renewal of contracts to engage in new prevention and care initiatives such as: demand creation, community mobilisation, planning, programme management, monitoring and evaluation, safer male circumcision, condom use, lobby for funds for critical mass demand for male circumcision money, rally around a sustained ARV supply chain, supply chain management and upholding of rights-based approaches. For more see: see HIV and AIDS in Uganda. 

A Basket Ball. Source: Google