Experts divided over HIV strategy

By Rukiya Makuma

Uganda’s retrogression after the success stories of the 1990s is main concern

HIV/AIDS experts and activists at a high profile public debate in Kampala on August 23 focused on one question: Is Uganda moving in the right direction as far as HIV prevention is concerned?

The `yes’ team included Dr. Stella Alamo-Talisuna, the executive director of Reach Out Mbuya HIV/AIDS Initiative and Fred Wabwire-Mangeni, the Director of the Regional Center for Quality of Health Care at the Makerere University College of Health Sciences.

Dr. Alex Coutinho, the executive director of the Infectious Diseases Institute, and Milly Katana, an activist with Wisdom Center and HIV/Aids, stood on the opposing to argue that the country was not heading to the right direction.

Stella Talisuna told the fully packed Primrose Hall audience that the interventions that have been adopted over time, like behavioral change and advocacy campaigns, and male circumcision, are in the right direction to combat new cases although more effort is needed in their implementation. Wabwire agreed that the policies are good but implementation is the problem.

But, armed with the most recent statistics, the `no’ team argued that despite the various strategies that have been developed to help reduce HIV transmission rates in the world, Uganda, which was once hailed as a model for its performance in combating the scourge, is being threatened by a high level of new infections.

For example, they said, the 2011 Uganda Aids indicator survey conducted from February to September 2011 and released in June 2012, showed that 1.2 million new cases had been registered bringing the number of people infected with HIV to 2.4 million.

In the same report, the prevalence rate, which is the number of infected people as a proportion of the total population, had increased by one percentage point from 6.4 percent in 2005 to 7.3 percent.

These findings make Uganda the only country among 22 sub-Saharan African countries surveyed where new cases of HIV are increasing.

HIV prevalence remained higher among women at 8.3% and at 6.1% for men; it was highest among widowed women at 32.4 percent and men at 31.4 percent and lowest among women at 3.9% and men 2% who have never married. The prevalence rate for urban women was higher at 11%, those in rural areas at 8% while the prevalence was the same for the rural and urban men.

At the release of the HIV survey results, Christine Ondoa, the Minister for Health, attributed the increased incidence to multiple sexual partnerships and failure to use condoms as one of the major reasons why the figures were going up.

In August 2012, the Uganda Aids Commission revised the National Strategic Plan to match the new increased response needs. The specific goals that are targeted include reducing the HIV incidence by 30 percent, improving the quality of life of people living with HIV and Aids (PLHIV) by mitigating the health effects of HIV/Aids, improving the levels of access for PLHIV and other vulnerable populations and strengthening systems to build an effective and efficient system that ensures quality, equitable and timely service delivery by 2015.

But at the debate, Coutinho was not positive about the national strategy saying it did not target the new sources of infection.

He singled out safe medical circumcision, which is being trumpeted as an important cog in the new strategy. Basing on the figures, Coutinho said medical circumcision should not be portrayed as the ultimate preventive measure against new infections.

“We need combination of other interventions to achieve zero tolerance if we are to emerge victorious,” he said.

Recent figures show that the transmission rate among circumcised men is 4.5% yet some reports said circumcised men have a 60 percent chance of not being infected. If circumcision was really effective as it is claimed, Coutino said, one would expect that the infection rates for circumcised men would be at 2.7%.

That the health budget was cut from Shs 814 billion to Shs 761 billion in the financial year 2012/13 was also viewed as an indication that the HIV fight was not heading in the right direction, according to those challenging the government strategy.

They warned that this would further derail the ambitious targets set to ensure that mother to child HIV transmission is eliminated and to make good on the pledge to double the number of HIV patients able to access treatment. They say this coupled with government’s noncommittal attitude to policies drafted to ensure that the new infections are prevented, would significantly impact on the future of the HIV in Uganda.

As a way forward, some of the debaters said using Truvada, pre- exposure prophylaxis (PrEP) should be adopted to supplement existing measures to combat HIV/Aids transmission. They argued that Truvada comes in as an additional strategy to prevention programs meeting the needs of hard-hit communities throughout the country. It is essential that the strategy be affordable and implemented in innovative, well-designed programs.

Given that Truvada is the first completely new biomedical HIV prevention tool to receive FDA approval in 19 years that is user-controlled, it has the potential to be a powerful tool for many individuals and couples struggling to remain HIV-free in Uganda. But with the drug being new, developing countries might not see this benefit quickly as the World Health Organization must first work on the PrEP strategies, which makes a must for the government of Uganda and development partners to increase funding.

Leonard Okello, the country director of International HIV/Aids, saw treatment as vital to the fight. He argued that among other issues that have contributed to the high prevalence rate is the failure by government to put all positive people on ARVS, yet it has been proved that if one consistently takes ARVS, the rate at which one is likely to transmit the virus to others is only 4%.

Yet, out of the 600,000 HIV positive people who need treatment, only half of them are on treatment because the country lacks the resources to cater for the rest. The government does not have the capacity to put all people who need ARVS on treatment, according to Kihumuro Apuuli, the director general of the Uganda Aids Commission.

But other experts such as Joshua Wamboga, the team leader at Advocacy and Networking at TASO, noted that there were a number of other interventions that could be adopted. These include enrolling the Option B+, which involves putting pregnant women on ARV treatment regardless of their CD4 count, to prevent them from spreading the virus to their new born babies. However, the challenge, according to Wamboga, remains the lack of commitment and the hesitation in adopting new measures.  For instance, though the 2007 scientific research, which was conducted in Rakai District, concluded that male circumcision reduced HIV incidence in men between by 55 to 65 %, the policy was not adopted until 2010 and even then, there was no national budget for it with the result that the project is now being funded by donors.

Katana highlighted the need for more regular monitoring so as to identify those that are working and those that are not and to see which strategies need strengthening and re-alignment. She said Uganda should not wait for six or more years to monitor the direction the HIV trend is taking. She said this makes it hard to align and monitor the progress the country is achieving.

On a positive note, the 5th Uganda Demographic and Health Survey report of 2011, which was released by the Uganda Bureau of Statistics (UBOS); indicates that there has been an improvement in HIV/Aids knowledge and awareness and that the majority of Ugandans know that the risk of getting HIV/Aids can be reduced by using condoms and limiting the number of sex partners to only one. This was one of the achievements that energised the feeling that the country could be moving in the right direction.

But other participants such as Sylvia Nakasi, the HIV Prevention Advocate at Uganda Network of AIDS Services Organizations, told The Independent that the notion that behavioral change is the best tool to fight HIV/Aids needed to change and the government should “get the priorities right.”

There wasn’t supposed to be winners and losers at the debate. Instead the noble objective was to engage all the major stakeholders in the HIV response in a dialogue focusing on what can be done to revitalize HIV prevention efforts in Uganda.

Despite strong arguments by Talisuna and Wabwire-Mangen, Coutinho and Katana evidently swung the majority of the audience to their side. However, Deborah Conner, of CDC-Uganda, noted that what is needed is to find a “middle ground” and work together within our available resources to implement innovative new strategies and reinvigorate Uganda’s once exemplary role at the forefront of the global HIV/Aids response.