In 2013, an estimated 1.6 million people were living with HIV, and an estimated 63,000 Ugandans died of AIDS-related illnesses.1 As of 2013, the estimated HIV prevalence among adults aged 15 to 49 stood at 7.4%.1
Promising signs were shown between the years of 2005 and 2013 as the number of AIDS-related deaths in the country is reported to have decreased by an estimated 19%.1 Nevertheless, at the end of 2013, Uganda had 140,000 new cases of HIV infections, accounting for 7% of the world’s total increase – the third largest increase in any country.1
Robust treatment and prevention initiatives have been implemented in recent years, leading to improved conditions for people living with HIV. Due to the implementation of antiretroviral treatment throughout the country there has been a gradual increase in the number of people living with HIV receiving treatment. However, as of 2013 more than 60% of adults living with HIV were still not on treatment.1
Key affected populations in Uganda
A number of key affected populations exist in Uganda who are at high risk of HIV infection. A few of these populations are discussed below.
Men who have sex with men (MSM) and HIV in Uganda
For many MSM, Uganda’s HIV epidemic brings with it significant social burdens. A pervading social stigma and high levels of homophobic violence caused by enduring conservative attitudes, result in MSM feeling less inclined to access HIV services. Only 44% of MSM living with HIV have ever been tested for the virus and know their results.2
The Uganda Anti-Homosexuality Act, passed by parliament in December 2014 and officially signed into law in February 2014, is thought to have resulted in increased harassment and prosecution based on sexual orientation and gender identities. Uganda’s official adoption of new restrictive legislation has also triggered negative discussions from the general population via social media, in which violence and anti-homosexual discrimination were advocated.3 4
HIV outreach workers and services providers working with MSM in Uganda have also reported heightened challenges in reaching this population.
Sex workers and HIV in Uganda
One study, carried out between 2009 and 2013, indicates that HIV prevalence among sex workers is more than 34.2%.2 This figure is a harsh reminder of the HIV epidemic among sex workers – it is more than the highest national average among the general population in sub-Saharan Africa (Swaziland - 27.4%).
Signs indicate that the high HIV prevalence among sex workers could be due to a lack of condom use or education on safe sex. A report posited that HIV prevalence among sex workers who used a condom with their most recent client was 66%, and only 54% of sex workers received an HIV test in the past 12 months and knew their results.2
The reason for nearly one in two sex workers not receiving an HIV test and receiving their results is likely associated with the social attitudes towards those working in the industry. In addition to the criminalisation of sex work, entrenched social stigma has meant that 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 owing to homophobia. Indeed, many sex workers in Uganda consider social discrimination as a major barrier in their willingness or desire to test for HIV.5
Adolescent girls, young women and HIV in Uganda
The majority of new HIV infections occur among young women and adolescent girls. 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.
In 2013, the percentage of young women and men aged 15-24 who correctly identified ways of preventing the sexual transmission of HIV and who rejected major misconceptions about HIV transmission was an estimated 38.9%.6
The lack of sexual education is telling. At the close of 2013, the percentage of young women aged 15-24 who had had sexual intercourse before the age of 15 was 13.1%. For men in the same age bracket, it was estimated at 11.9%.6 The risks and choices adolescent girls make are shaped by their early experiences, and radical transformations are required to break these barriers.
People who inject drugs (PWID) and HIV in Uganda
In sub-Saharan Africa, people who inject drugs (PWID) are grossly stigmatised and open to harsh societal discrimination. In many cases this marginalisation can be felt on a governmental level, leaving this populace with very little in the way of adequate HIV and health services.
In recent years the Ugandan government has displayed hesitancy in providing substantial financing for health services specifically for people who inject drugs. However, since The Global State of Harm report in 2014 estimated that HIV prevalence among PWID is 16.7% in Uganda, the government has pledged to prioritise innovative approaches to help this population.7 An earlier analysis from the World Bank suggests that access to antiretroviral treatment among people who inject drugs lag far behind other people living with HIV, especially so in low-income countries such as Uganda.1
HIV testing and counselling (HTC) in Uganda
Knowledge of one’s HIV status through HIV testing and counselling (HTC) is a key driver in tackling Uganda’s HIV epidemic. Of the 8.2 million individuals who received HTC across Uganda between 1 October 2012 and 30 September 2013, 8.5% were children younger than 15 years old and 91.5% were adults, two-thirds (65.4%) of who were women.8
As a result of scaled-up HTC efforts, the proportion of adults aged 15-49 who have ever been tested for HIV and received their results increased from 12.7% in 2004/2005 to 65.8% in 2011 among women; and from 10.8% to 44.9% among men.8
HIV prevention programmes in Uganda
Prevention of mother-to-child transmission (PMTCT)
Since it was launched in 2011, the UNAIDS Global Plan has had a marked effect on bringing HIV services to children and women in Uganda. By the end of 2013, 93% of pregnant women were tested for HIV and knew their result.1
The overall PMTCT service coverage by March 2013 was 2,138 health facilities – 48% of all health facilities in the country.1 By the end of 2013, all 112 districts in the country had at least one health facility providing the full scope of PMTCT services.8
The 2011-2013 HIV National Priority Action Plan helped increase the percentage of HIV-positive pregnant women who received antiretroviral drugs to reduce risk of mother-to-child transmission (MTCT) to 71.7%, equating to a total of 88,792 individuals.9 The positive influence of the plan is illustrated by the fact that since 2009, Uganda has seen an estimated 50% reduction in new infections among children.8 However, of the 22 countries prioritised by The Global Plan, in 2013 Uganda had the fourth highest number of new infections among children.8
High-level advocacy for elimination of MTCT was supported at both the national and district level. Not only did it draw participation of the political, cultural and religious leaders, but the First Lady of the Republic of Uganda also championed it. However, in spite of this support, between 2012 and 2013 Uganda experienced a stalling of the number of pregnant women receiving antiretroviral prophylaxis or treatment.8
Voluntary medical male circumcision (VMMC)
While voluntary medical male circumcision (VMMC) is recognised as an aid to preventing the transmission of HIV, there seems to be a lack of uptake in Uganda. The 2011 AIDS Indicator Survey (AIS) report found that only 26.4% of men in Uganda were circumcised, only slightly up from the 24.8% in 2005.10 The positive effect of circumcision was reiterated however with HIV prevalence at 4.5% among circumcised men and 6.7% among uncircumcised men.11
In September 2010, a nationwide Safe Male Circumcision (SMC) policy and communication strategy was launched, focusing on promoting voluntary safe male circumcision for all men 15 years and older as an essential health service. Recent indications suggest that after a slow start the policy has garnered positive results. Between October 2012 and September 2013 the number of men circumcised in Uganda was 801,678.8
In an effort to maintain this momentum, in 2013 the service delivery for SMC intensified. As a result, the number of health facilities providing SMC increased from 420 (in 105 districts) in 2012 to 1,117 (in all 112 districts) in 2013. This increase in facilities brought the cumulative total number of males receiving SMC to 1,411,798.8
Although condom use continues to be a commonly practiced strategy to reduce the risk of HIV infection, its use declined substantially in Uganda between 2005 and 2011.8
Statistics from the 2014 UNAIDS Fast Track report put condom use among people with multiple sexual partners at less than 30%. In the same report, condom use among sex workers was estimated to be between 30 to 50% and among men who have sex with men at less than 30%.12
Between 1 October 2012 and 30 September 2013, 187 million male and 5.8 million female condoms were procured into Uganda. While these numbers are promising, they’re by no means an indication of the overall situation in Uganda as the country has reported frequent periodic shortages and stock-outs of free condoms.8
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.
Antiretroviral treatment (ART) in Uganda
A survey in 2013 reported 1,478 health facilities in operation in Uganda offering antiretroviral treatment (ART) and that by 30 September 2013, nearly 800,000 people living with HIV were enrolled on treatment.8 According to the 2010 World Health Organisation (WHO) guidelines for ART, the proportion of all ART-eligible people living with HIV that were on treatment by the end of September 2013 in Uganda was 69.4%.8 However, the introduction of the 2013 WHO treatment guidelines mean that ART access now only stands at 40% for adults and 22% for children.1
Barriers to HIV prevention programmes
Social stigma and discrimination
Prejudices and social discrimination are some of the leading causes for certain groups of Uganda’s population, such as sex workers and men who have sex with men, to avoid seeking health care or HIV testing. However, even the general population of people living with HIV are subjected to excessive amounts of negative judgement.
The People Living with HIV Stigma Index 2013 reported experiences of both external and internal stigma. The index states that the most common forms of external stigma and discrimination directed at people living with HIV are gossip at 60%, followed by verbal harassment, insults and or threats at 37%, and sexual rejection at 21.5%.13
Outlining the common forms of internal stigma experienced by both men and women living with HIV, the index cites low self-esteem at 67%; self-blame at 50%; shame at 50%; guilt at 50%; and blaming others at 50%.13
On the whole, experiences of all forms of internal stigma were higher among females compared to their male counterparts. The prevalence of adult women aged 15-49 who reported being subjected to some form of discriminatory attitude stood at 80.3% in 2011.6
In recent years the prevalence of gender-based violence has seen a promising decline since the Domestic Violence Act and the Prohibition of Female Genital Mutilation Act were both enacted in 2010. Nevertheless, a sizable percentage of Uganda’s female population has been sexually or physically abused by a male partner in their lifetime. One report states that the overall prevalence of domestic gender-based violence remains high, with 50.5% of ever-married women reporting physical or sexual violence from a spouse in the preceding 12 months.14
In 2013, a government-led initiative supported more than 200 local government leaders across Uganda to be trained on gender and HIV, focusing specifically on addressing gender barriers of key population groups in urban municipalities. As a result, all of Uganda’s 24 municipalities integrated gender and HIV activities in their annual work plans; and four of them (Ntungamo, Kitgum, Lubaga and Masindi) established dedicated HIV services targeting MARPs.8
In Uganda, the capacity to reform laws and policies that constrain HIV and AIDS responses was enhanced through training of government officials and law enforcement officers on HIV, stigma and discrimination. This process contributed to the major revisions to the Anti-Homosexuality Bill, as reflected in the Act that was passed in 2013. Although the passage of the Anti-Homosexuality Act is thought to have resulted in increased anti-gay sentiment, the training scheme also led to Ugandan authorities implementing effective policies prohibiting the spread of gender-based violence.8
Uganda’s experience has shown that donor funding is not a guarantee, is unpredictable and is becoming less available. Additionally, funding often comes with conditions that may not be in accordance with Uganda’s national goals.
PEPFAR (US Presidential Emergency Fund for AIDS Relief) is the major contributor to the international funding of HIV and AIDS around the world, particularly to African countries including Uganda. However, there are indications that PEPFAR is facing a number of global issues such as competing health and development demands across Africa; an ever-increasing burden of HIV/AIDS treatment; and continuous resource constraints due to global financial crisis and increasing domestic deficit.8
With this being the case, more efforts have to be made by Uganda to increase their domestic resource mobilisation. The concentration of donor funding for HIV among a very small number of donors in Uganda suggests potential vulnerability should the magnitude of their funding commitments change in the future.
The future of HIV and AIDS in Uganda
For successful mitigation of Uganda’s severe HIV epidemic, a series of comprehensive health, political and social strategies will need to be implemented. The country has a set of specific goals to work towards including the delivery of lifesaving antiretroviral treatment to 15 million people living with HIV and to eliminate new HIV infections among children by the close of 2015.
For people who inject drugs, both political and cultural conditions need to be redressed, starting with transforming punitive laws that criminalise the use of drugs. Continued movement away from criminalisation towards a humane and supportive approach to drug users will transform national strategies into the best public health outcomes. Improving access to antiretroviral treatment among people who inject drugs who are also living with HIV, and ending the criminalisation of drug use, will have a knock on effect in terms of how society views PWID in Uganda.8
Uganda has pledged to intensify circumcision scale-up in the formal health sector and among district health systems. There is evidence that programmes have had much greater success in reaching males younger than 25 years. However, men in their twenties and thirties are at highest risk of HIV in sub-Saharan Africa, so these ages groups need to prioritised when scaling up VMMC.1
- 1. a. b. c. d. e. f. g. h. i. j. k. UNAIDS (2014) ‘The Gap Report’
- 2. a. b. c. d. Uganda Ministry of Health (2010) ‘The CRANE Survey Report: High Risk Group Surveys Conducted in 2008/9, Kampala, Uganda'
- 3. BBC News (2013, 18 Dec) 'Ugandan MPs pass life in jail anti-homosexual law'
- 4. Amnesty International UK (2012, 7 February) 'Uganda: Anti-homosexuality bill a "grave assault on human rights"'
- 5. African Sex Workers Alliance (2011) ‘“I expect to be abused and I have fear”: Sex workers’ experiences of human rights violations and barriers to accessing healthcare in four African countries’
- 6. a. b. c. Uganda Ministry of Health (2012) ‘AIDS Indicator Survey 2011’
- 7. IHRA (2014) ‘The Global State of Harm Reduction 2014’
- 8. a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. Ministry of Health (2014) ‘HIV and AIDS Uganda Country Progress Report; 2013’
- 9. UNAIDS (2014) ‘Progress Report on the Global Plan’
- 10. Uganda Ministry of Health (2005) ‘AIDS Indicator Survey 2005’
- 11. Uganda Ministry of Health (2012) ‘AIDS Indicator Survey 2011'
- 12. UNAIDS (2014) ‘Fast-Track: ending the AIDS epidemic by 2030’
- 13. a. b. The National Forum of People Living with HIV Networks in Uganda (NAFOPHANU) (2013) ‘The People Living with HIV Stigma Index, Uganda’
- 14. Uganda Bureau of Statistics (2012) ‘Uganda Demographic and Health Survey 2011’