New Approaches needed in HIV/AIDS fight as new challenges emerge
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.
Dr. Kihumuro Apuuli, head of Uganda Aids Commision
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.
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.
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.
Limitations of ABC
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 method
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.
The Uganda Think Tank on AIDS (UTTA) in a report says that after many years of harmonious implementation of the ABC, and recognition of the fact that positive behavior changes informed by ABC messages collectively contributed to the declining HIV infection rates, HIV/AIDS activists are perturbed with the stagnant prevalence over the years and question whether the approach can bring any more positive results or needs to be revised.
The report says that some proponents of C label Abstinence and fidelity (Being faithful) as impractical or even impossible, while advocates of A&B have advanced issues of immorality and inefficiencies of the condom as a barrier method.
“Promoters of AB de-campaigning C as being an option for the immoral. They claim that the condom is not very effective as a barrier method, alleging the existence of holes big enough to allow the passage of HIV. The promoters of C on the other hand, allege that high level political leaders are de-campaigning the condom due to donor influence, particularly in order to access US Government PEPFAR funding with A&B conditionality,” says the report.
Consequently, the debate has resulted in competing and conflicting messages that confuse both the stakeholders and the target audience, leaving many puzzled about the government’s stand on ABC.
New Approach proposed
There are those who believe that the ABC should be replaced with a new method called SAVE- an acronym for Safer practices, Available medications, Voluntary counseling and testing and Empowerment through education.
According to the London-based nonprofit group, Christian Aid which has adopted the SAVE approach, the ABC approach “is not well suited to the complexities of human life” and “fuels stigma and precludes safer sexual practices” by placing people in one of the three categories.
Christian Aid said in a release recently said that Being Faithful to one sexual partner does not automatically protect a person against HIV transmission as one partner may be faithful while another partner is not faithful; meaning the one who is faithful in a relationship is not protected.
They said contrary to the AB or C debate, Condom users are not necessarily people who do not wish to abstain or be faithful, but some people are forced to have sexual relations and use condoms. For long, the example of disadvantaged girls and women who are forced to have sex to get money from rich men has been cited.
Under the SAVE method, “safer practices” include ensuring HIV-negative blood for transfusions, using methods to prevent HIV transmission during sexual intercourse, ensuring the availability of clean needles and adopting medical safety procedures.
This is also reflected in the UTTA report, which re-examines the strength and weaknesses of ABC as a single approach and those of its individual components.
The report notes that despite achievements, the ABC model has not been understood and consistently promoted as one model. “ABC has been looked at in ascending or descending order rather than synergistically,” the report notes.
This is the point well elaborated by proponents of SAVE approach. They point at inadequate targeting of ABC interventions to different population groups for instance the deaf and the blind who have difficulties in accessing information while others fail to act on the messages due to environments they are in, for example married women who cannot insist on condom use if they discover their husbands are having extra-marital affairs.
The AIDS think tank says that the single ABC components largely focus on individual responsibility vis-à-vis social responsibility. Many in the anti HIV/AIDS movement say that by focusing on individuals, the ABC strategy ignores environments, which greatly contribute to personal/individual actions.
Abstinence is defined as the choice or decision to refrain, avoid, decline, shun, deny oneself, renounce, or keep from something in this case sex.
Abstinence is promoted widely in Uganda schools
Whereas abstinence is commended for bringing the prevalence down in age group 15-20 years, which also corresponded with delayed sexual debut from 14 to 18 years, it has been found wanting among girls in an environment where boys are encouraged to be sexually aggressive and girls socialized to be submissive. Abstinence is also criticised because it is not an option for women who are in difficult situations and have no choice for instance in instances of rape and child sexual abuse.
It is defined as having strong belief, confidence in, or conviction, which translates into loyalty, dependability, devotion, fidelity and trustworthiness in case of one’s spouse. Being faithful is rated highly in causing the decline of prevalence in Uganda from 30% in the early 1990s to 6% by the year 2001, also leading to the decline of habits of multiple sexual partners.
The decline in casual sex is said to have registered a 60% decline over the last 20 years. “Despite the positive attributes, the strategy looks at the existing relationship without considering the environment in which the relationship started especially among young people,” the UTTA report says.
Being faithful has been criticized for assuming normative definitions of relationships usually in terms of religion or cultural norms, without for example considering that one party may decide to engage in another sexual relationship and thus put the faithful partner at risk of HIV infection.
Condom use in the fight against HIV/AIDS
Most adverts in Uganda have been saying “if you can’t abstain or remain faithful, then use a condom”. Condoms are being de-campaigned as a reward for the promiscuous largely because they have been promoted as a method for those who cannot abstain or stick to one partner, while some people including President Yoweri Museveni allege that some local sex styles are “too elaborate and do not favor condom use”.
Anti condom campaigners also point to the fact that mostly available condoms on market are for males and therefore controlled by males leaving women in no position to enforce protection. Others point to a lot of misconceptions on condoms, quality and supply factors.
Factors like disparities in free condom distribution across the country, the unforeseen shortage of condoms due to quality problems with some types of condoms.
Uganda's President Yoweri Museveni and Wife Janet
In fact, President Museveni insists that Uganda’s success in reducing HIV/AIDS prevalence levels is much a result of abstinence and be faithful campaign than it is of condom use.
Many organizations led by Human Rights Watch (HRW) and local NGOs argue that Uganda’s past success cannot be wholly attributed to behavioral change factors of abstinence and faithfulness. They have been warning that a shift to abstinence and faithfulness only programs promoted by the US Presidential Emergency Plan for Aids Relief under President George Bush might scale countries like Uganda keen on this to further infections.
Rebecca Schleifer, a researcher with HRW says that censorship of information about condoms in government-funded programs, myths about condoms spread by religious leaders, and restrictions on condoms hamper the fight against the AIDS pandemic.
Uganda’s Presidential Advisor on HIV/AIDS, Kintu Musoke however says the Uganda government is still pursuing the ABC policy, only bringing abstinence and be faithful on the limelight which he says had been cast in the shadows in favour of promoting condom use. “What we are emphasising is that behavioural change is what we need most to fight HIV/AIDS,” Musoke said in an interview.
“The behavioral change remains low relative to the high levels of awareness,” adds Dr. Alex Opio of Uganda’s Aids Control Program.
Although government insists on behavioral change as the key factor in HIV prevention, the UAC report shows that only 50-55% of young men and women aged 15-19 use condoms during sex with non-regular partners.
Map of Uganda
This means that over 40% of the youth aged 15-19 have unprotected sex with non-regular partners, and are at high risk of contracting HIV, the virus that causes AIDS.
Worse still, the survey findings reveal that much as all the districts in the country now have some level of Prevention of Mother To Child Transmission (PMTCT) services, almost half (22) of the districts have disappointing coverage ranging from 25-50%.
So, what is the way forward?
All said, many HIV/AIDS activists still believe ABC as appropriate and effective approach for prevention of transmission of HIV, even when they disagree on which of the components is most effective.
Even the newly advanced SAVE approach, has many ingredients of ABC much as the proponents would wish us to believe it is an independent approach. They have only extended it to areas of care and support, which are necessary in the HIV/AIDS fight.
This may explain why the UTTA report recommends the re-launch of ABC model as ABC plus (ABC+) as a motherboard of future HIV/AIDS interventions to comprehensively accommodate the existing and emerging challenges in the response to the HIV/AIDS pandemic.
UTTA says that ABC should be promoted as one entity, putting emphasis on ABC in the policy strategies and practice as well as addressing the challenges associated with each of the three components. It says that A, B and C should be harmonized through specific policy framework as each of the components re-enforces the effectiveness of the other.
Where as Abstinence is very pertinent to the youth today, especially the girl child, Faithfulness is the best option for married couples in those long-term relationships. C should be targeted for high risk groups, should be promoted among those already infected especially in care settings and is key in discordant relationships,” the report notes.
But all these can work only if there is enhanced and sustained political commitment and leadership on ABC. “Leaders at all levels should be involved in the dialogue, harmonize their positions and provide visible leadership for ABC model. Identify and address human, institutional, societal, cultural and environmental factors and vulnerabilities that predispose certain categories of people to HIV infection,” the report recommends.
This together with bridging the knowledge gaps to raise risk perception, and reducing on confusing and conflicting messages on how to better fight HIV/AIDS will provide a more winning approach against the pandemic, the report says.
Beyond Prevention to HIV/AIDS Treatment
Yet beyond the prevention issues, it is also apparent that much of the country’s success against HIV/AIDS will depend on how those currently infected are handled. The Executive director of Aids Information Center, Dr. Raymond Byaruhanga, said Uganda faces a challenge of the increasing demand for HIV/ AIDS services due to the increasing number of infections.
The country in 2004 adopted a policy of providing free anti retroviral drugs (ARVS), the life prolonging medicines for HIV positive people. But UTTA says only 135,000 out of more than 300,000 people infected with HIV who urgently need the medicines are able to access them.
This has been blamed on limited government funding to the HIV/AIDS sector. According to the Ministry of Health, more than 80 percent of the country’s HIV funding is from foreign sources; the two leading donors being the Global Fund to fight AIDS, Tuberculosis and Malaria and the US President’s Emergency Plan for AIDS Relief.
Uganda’s Minister of Health, Dr. Stephen Malinga says while the government remains committed to its comprehensive plan to fight HIV/AIDS and solve all arising challenges, the country does not have enough money to invest in anti HIV programs. “We have limited resources and there are just so many priorities as a country,” he says.
Dr. Malinga says the Government, with the support of various development partners (DPs), CSOs and other stakeholders is implementing various programs including re-energizing HIV&AIDS control activities across the country, scaling up Anti Retroviral Therapy, HIV Counseling and Testing and PMTC.
The Uganda HIV Prevention Roadmap specifically highlights the following:
- Prevention of the sexual transmission of HIV,
- Prevention of mother-to-child transmission of HIV,
- Promotion of greater access to HIV counseling and testing (HCT) while promoting principles of confidentiality and consent,
- Integration of HIV prevention, care and support services with other health care and social services,
- Integration of prevention into care and support programs for PHAs;
- Prevention and treatment of STIs,
- Focusing prevention on vulnerable and higher risk groups including young people,
- Advocating for protection of rights of women, girls, children, PHAs, IDPs and other minority groups within existing policy and legal frameworks,
- Preparation for access to and use of promising new technologies for HIV prevention
- Consideration of appropriate and safe response to new evidence such as circumcision, HSV2 suppression therapy, microbicides and vaccines,
- Ensuring blood safety and reduce HIV transmission in the health care and other settings.
Assessing the Macro economic impact of HIV/AIDS in Uganda- a research done by Uganda
Ministry of Finance Planning and Economic Development and United Nations Development Programm
HIV/AIDS in Uganda- a comprehensive analysis of the HIV/AIDS situation in Uganda by avert.org
UNAIDS 2010 report on the global AIDS pandemic
By John Isingoma and Gerald Businge