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HIV & AIDS in Uganda
Currently, 7.2 percent of Uganda’s population is living with HIV.1 This amounts to an estimated 1.4 million people, which includes 190,000 children.2 An estimated 62,000 people died from AIDS in 2011 and 1.1 million children have been orphaned by Uganda's devastating epidemic.3
HIV prevalence has been rising since its lowest rate of 6.4 percent in 2006.4 New infections are diagnosed in 150,000 people a year, of whom 20,600 are children.5 Despite this, the 2012 life expectancy of 55 years is nine years higher than the expectancy in 2000, likely to be a result of greater access to treatment for people living with HIV.6
The government's shift towards abstinence-only prevention programmes, alongside a general complacency or ‘AIDS-fatigue’ has reduced the practise of safe sex.7 It has also been suggested that greater access to antiretroviral drug treatment (ART) reduces people's fear and urgency to get tested for HIV, increasing the likelihood of engaging in risky behaviour.8 The number of new infections per year exceeds the number of annual AIDS deaths,9 explaining the rising HIV prevalence.
Almost a quarter of people living with HIV in Uganda are part of the education system - either students or staff.10 Only 39 percent of young people aged 15 to 24 know all the necessary facts about how HIV can be prevented, suggesting a lack of clear sex education.11 Women in particular are in need of sex education and access to HIV services; HIV prevalence is 5.4 percent, compared to 2.4 percent amongst men.12 The fact that Ugandan women tend to marry and become sexually active at a younger age than their male counterparts, and often have older and more sexually experienced partners, places them at an increased risk of HIV. AVERT.org has more about women and HIV.
Stigma and discrimination by families, local communities and the government continues to marginalise people living with HIV. This undermines national prevention and treatment efforts by creating fear of testing.13
HIV prevention in Uganda
The ABC Approach...Abstinence, Be Faithful, Use Condoms
The number of Ugandans who report using condoms at last sex is extremely low at 13.7 percent in 2011.14 More men are reporting having more than one sexual partner today than in 1990.15 These statements, along with the fact that 43 percent of new HIV infections are among heterosexual married couples, prompted a campaign in early 2013 to encourage condom use amongst men having extramarital sex.16 17 Whilst some saw it as promoting cheating, it is important for those men to use a condom to prevent infecting their partner. However, if condom promotion is to work, supplies need to be sustainable, unlike the condom shortage of 2011.18
This campaign is a change from abstinence-based approaches to prevention. Such approaches became dominant in previous years due to PEPFAR's significant investment of money for abstinence-only programmes. Delaying sex until marriage is hoped to reduce HIV infection rates among young people, and billboards widely advertise this. However, ignoring the importance of condom use and being faithful is contributing to rising HIV infections showing how important all three areas of the ABC approach are.
Prevention of mother-to-child transmission (PMTCT)
Expectant mothers are encouraged to know their HIV status. An estimated 94 percent of pregnant women who attended antenatal clinics received counselling and testing for HIV in 2011.19 This high level of coverage suggests knowledge about PMTCT is high in Uganda.
Administering antiretrovirals (ARVs) to HIV-positive women is very effective at preventing HIV from passing from a mother to her child. An estimated 86 percent of HIV-positive mothers received ARVs in 2011, significantly reducing the risk of their children being born with HIV.20 Uganda follow the most recent guidelines by WHO for PMTCT - Option B+. This involves placing pregnant women on a triple ARV drug regimen, for both the duration of their pregnancy and continuing for life regardless of their CD4 count, protecting the health of the mother and the child.21
Nevertheless, 20 percent of new HIV infections in Uganda are occurring through mother‐to‐child transmission, although this figure may be even higher as many births in Uganda take place outside healthcare facilities.22 This highlights the need to provide all HIV-positive women with antenatal services to prevent mother-to-child transmission altogether.
By placing PMTCT high on the political agenda, it is hoped that by 2015 Uganda will have achieved its target of eliminating mother‐to‐child transmission, through administering testing and treatment to all in need.
Most at-risk populations (MARPs)
Men who have sex with men (MSM)
Homosexuality is a crime in Uganda. The Anti-Homosexuality Bill (or "Bahati Bill") was proposed in 2009 by David Bahati, to further criminalise same-sex relations, introducing the death sentence as punishment. Huge international condemnation led to the Bill being shelved until 2012, when the maximum punishment was 'reduced' to life imprisonment; the shelved Bill was then passed in December 2013.23 Ugandan President, Yoweri Museveni, signed the legislation on 24 February 2014, which enforces life imprisonment for 'aggravated homosexuality' and includes lesbians for the first time.24 Homophobia has heightened in the country since 2009, violating the human rights of MSM.25 Homophobia in Uganda has severely impacted knowledge about HIV amongst MSM and has hampered MSM access to HIV services. See our Gay Men in Africa page for more information.
- Data regarding MSM in Uganda is almost non-existent.
- HIV prevalence among MSM in Uganda is unknown.
- HIV services targeting MSM in Uganda equal almost none.
Due to the criminality of same-sex relations, MSM are often fearful of being tested in case they have to disclose their sexual orientation. This leads to HIV being transmitted more easily and rapidly amongst this at-risk population. They also face homophobic stigma and discrimination from all levels of society; with a marked increase since the media frenzy following the "Bahati Bill".26 27 Eliminating anti-gay legislation is key to improving access to HIV services for this at-risk population and central to reducing HIV transmission in Uganda.
Female sex workers (FSW)
Uganda's government has no clear outline of HIV service provision for FSWs. A 2009 study found that three quarters of their FSW participants claimed no access to family planning services or contraception.28 Sex work is illegal, and therefore FSW are reluctant to attend clinics where they may have to reveal the nature of their work. As a result, targeting them with HIV services is difficult.
- HIV prevalence among female sex workers is 35 percent in 2011.29
- HIV prevalence is four times higher among female sex workers aged 25 and over, than under 25.30 This suggests recent sex education for youths is having positive effects.
- Almost 95 percent of FSW had access to condoms, but only 80 percent used them in 2009.31
Female sex workers are offered more money for unprotected sex, than protected sex, perhaps explaining why only 80 percent use condoms.32 This fuels transmission of HIV from client to worker, and from worker to client as many still work after knowing they are HIV positive.33 The lack of FSWs seeking HIV services makes it hard to monitor the prevalence and rates of transmission which can make it difficult to design and implement effective prevention initiatives.
Intimate partner violence (IPV) is increasingly being recognised as a contributing factor to the Ugandan HIV epidemic. A study conducted between 2000 and 2009 found an increased risk of HIV-infection among women suffering from prolonged, frequent and severe IPV, compared to those that had never experienced IPV, or had experienced it less. The increased risk of HIV infection associated with IPV is a result of women experiencing forced sex, difficulty negotiating condom use, early sexual initiation, and stress which weakens the immune system. It is important that women who are victims of IPV access HIV testing in order to find out their HIV status.34
Circumcising men can reduce their risk of becoming infected with HIV by up to 60 percent.35 In Uganda where condom use is low and sexual infidelity reported by 1 in 5 men, voluntary medical male circumcision (VMMC) is an effective prevention strategy.36 Uganda set the target of offering VMMC to 80 percent of uncircumcised men by 2015. However, as of 2011 only 5 percent of this target has been reached.37 The number of circumcised men therefore equals 23.6 percent.38
A lack of trained health workers is one reason for the slow progress, alongside President Museveni's lack of political backing for the initiative. 39 More support and funding is needed for this method of HIV prevention to be widespread in Uganda.
HIV testing in Uganda
Ugandans who test for HIV early are more likely to remain healthy and less likely to suffer from opportunistic infections.42 The quicker the ARVs are started, the quicker the HIV infection is stabilised.
Ugandans were keen to be tested and know their HIV status as of 2008, with a study finding that only 5 percent of people refused to take a routine HIV test, showing fear of testing is reducing.43 Uganda delivered HIV testing and counselling to an estimated 5,524,327 people aged 15 years and older in 2011.44
Interestingly, Uganda was the first country in sub-Saharan Africa to open a voluntary counselling and testing (VCT) clinic.45 Widespread provision of the now routine testing shows the progress made since that first VCT was opened.
It is now important for HTC services to target at-risk populations directly and encourage people to get tested confidentially. This is particularly since the "Bahati Bill" has heightened discrimination against LGBT people.
HIV treatment in Uganda
A study in Uganda showed that those who adhere to effective antiretroviral treatment and care experience a very similar life expectancy to the national average of 55.46 It has also been found that women have longer life expectancies than men, and those who initiated treatment soon after infection lived longer than those who delay testing and start treatment later.47 This shows the success and importance of accessing testing and treatment quickly, and adhering to it for life.
It was not until June 2004 that Uganda began to offer free ARV medication to people living with HIV. ARVs were initially funded by the World Bank, with future drugs to be paid for by The Global Fund and PEPFAR.48 Preliminary drug roll out was fairly slow; by 2006 only 24 percent of adults in need of antiretroviral treatment were receiving it.49
The Global Fund suspended funds to Uganda in August 2005, after financial irregularities and mis-allocation of funds towards non-HIV/AIDS activities were discovered.50 51 Grant disbursement was restarted in November 2005, and in 2008 the Global Fund signed Round Seven of funds pledging $254m for HIV/AIDS over the next five years.52
- An estimated 54 percent of those in need are receiving antiretroviral treatment.53
- 62 percent of adults living with HIV are receiving treatment.
- Only 32 percent of children eligible for treatment are able to access it.54
Low uptake of treatment among Ugandan children is of severe concern. It has been suggested that parents fear that their child will be stigmatised and are reluctant to disclose their child’s HIV-positive status.55 A lack of funds for travel to healthcare settings can also be another reason for low access to treatment among children.
Uganda’s government is working to ensure sustainable drug supplies. In financial year 2009/10, the Government of Uganda provided 10.5 percent of the overall funds for antiretroviral treatment - a notable increase on previous years.56 The remaining funding was sourced from international donors, notably the Global Fund and PEPFAR.57 Pressure is mounting for Uganda to become less reliant on donor funding and to increase the overall amount of national finance allocated for HIV and AIDS treatment - the 2013/14 health budget allocated $38.5 million, much less than civil society groups expected.58
In 2007, the Luziria factory opened in Kampala, in partnership with Cipla. It was hoped that the factory would reduce the cost of drugs as well as the likelihood of stock-outs.59 However, between 2010 and 2011, reports of corruption and the sale of imported drugs at inflated rates, indicated that barriers remain between Ugandans living with HIV and affordable treatment.60 In 2012, the government proposed levy increases on bank transactions, interest and taxes, and certain consumer goods. This was in order to raise a $1 billion trust fund to support local HIV programmes and to increase domestic funding.61 This move comes as one of Uganda's main donors, PEPFAR, release their 2009-2013 strategy; indicating a shift away from just funding treatment programmes, towards providing more technical support in order to encourage self-sufficiency.
It is important to note that as Uganda increases availability of antiretroviral drugs, access to them will be increasingly reliant on greater investment in the national healthcare system, to ensure clinics are equipped to handle even greater patient numbers.
Dr. Fiona Kalinda, Clinical Manager at the Joint Clinical Research Centre in Kampala said:
“The dilemma here is that we made a promise to patients. If they came here for HIV care, we said if you qualify for treatment, you'll get treatment. Now we have to tell them to go elsewhere.”62
Patient numbers will rise for two main reasons. The adoption of Option B+ means Uganda will be placing all HIV-positive pregnant women on antiretroviral treatment for life. Also, if Uganda reaches its target of placing 80 percent of eligible people with HIV on treatment by 2015, more people will be attending health clinics to receive HIV treatment and counselling over the next few years.63
Preventing a rise in drug resistance among people taking HIV treatment in Uganda is reliant on patients having access to it for life.64 Good adherence to treatment is also essential; this is reliant on the training of healthcare professionals and on patients receiving a high standard of HIV treatment counselling and support.
The way forward
Uganda needs to move away from abstinence-only prevention initiatives, back towards the comprehensive ABC approach of the nineties when prevalence was falling not rising. At a time when the legal protection of high-risk individuals is undecided, and confidence among LGBT people is low, the need for prevention programmes to target these groups is greater than ever. Uganda has shown that it can achieve change; PMTCT progress has been extremely successful and mother-to-child transmission is hoped to be eliminated by 2015.
As fear around HIV has continued to be broken, and HIV education increased, testing uptake has continued to rise.
Despite progress in certain areas, the Ministry of Health has predicted that the current rate of untreated HIV infections is seriously impeding economic growth and will continue to do so, particularly as HIV and AIDS is affecting people in their most economically productive years.65
Experts believe that complacency and the ‘normalisation’ of AIDS may be leading to an increase in the risky behaviour that early prevention campaigns sought to reverse.
“People now think that because we have had HIV for so many years, it is a normal condition among the population.” - Kihumuro Apuuli, director of Uganda Aids Commission (UAC)66
The history of AIDS in Uganda
This can be divided into three distinct phases:
- 'Slim disease' originates at Lake Victoria, and then spreads along urban sexual networks and major highways.67
- In 1982 the first Ugandan case of AIDS is diagnosed, and 'slim disease' is clinically recognised.68
- President Museveni comes to power in 1986, and through his commitment to tackling HIV, a prevention programme based around ‘being faithful’ is created.
- HIV prevalence is 29 percent at this time.69
- An AIDS control programme is set up in 1987 based around education and the ABC approach (abstain, be faithful, use condoms).70
- Small grass-roots organisations begin peer education initiatives. E.g. TASO (The AIDS Support Organization), which later became the largest indigenous AIDS service organisation providing emotional and medical support to thousands of people.71
- HIV prevalence is 15 percent among all adults in 1991.72
- Between 1989 and 1995 the number of Ugandan men reporting three or more non-marital sexual partners fell from 15 percent to 3 percent.73
- The ABC approach is implemented. The population is mobilised in the fight against HIV through frank and honest discussions.
- Condoms are heavily promoted and distributed and usage of them rises.
- Large amounts of government and international donor funding, e.g. the World Bank, allows prevention initiatives to thrive throughout the nineties.
- AIDS-related deaths soar because treatment is not yet widely available.
- In 1995, 91 percent of Ugandan men and 86 percent of women knew someone who was HIV positive.74
- In 2000 an estimated 800,000 Ugandans had died of AIDS-related illnesses since the epidemic began.75
- HIV prevalence among adults is 5 percent in 2001.76
- Uganda launched its first PMTCT policy guidelines in 2002.
- Abstinence until marriage controversially becomes the dominant strand of the ABC approach since 2003, following significant investment of money for abstinence-only programmes from PEPFAR.77
- Sex education and condom promotion are no longer as mainstream as they were in the nineties.
- Free antiretroviral drugs become available in 2004.78
- All condoms distributed free in health clinics are recalled in 2005 over reliability concerns.79
- Condom use during sex with non-regular partners is 51 percent in 2005.80
- 2006 onwards sees an incline in prevalence rates.81
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- 24. New York Times (2014, Feb 24th) 'Uganda’s President Signs Antigay Bill'
- 25. Amnesty International UK (2013) 'Uganda: Anti-homosexuality bill a "grave assault on human rights'
- 26. Al Jazeera (2013) 'Uganda's 'Kill the Gays' Bill spreads fear'
- 27. The Guardian (2012, Dec 30th) 'The disgrace of Church backing for Ugandan homophobia'
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- 51. The Lancet (2006) 'Uganda is learning from its Global Fund grant suspension', 366(9500)
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