18th May, 2006
The morning after

If there is one area that Uganda has shined, it is HIV/Aids. But as RICHARD M. KAVUMA writes on Millennium Development Goal Six, not only is there a danger of complacency, but the gains being made against HIV/Aids are threatened by Malaria.

Like the morning after a burial, a strange sombreness engulfed Kasensero fishing village in Rakai district on October 28.

The previous night had been stormy. Deep in the night, a boat had capsized and several fishermen had perished. Among them was the husband of one Grace.

Grace had lived with her husband for only three months. Women gathered outside their shanty wooden and corrugated iron houses to talk about Grace’s tragedy, as her mother struggled to keep her from rolling in the sand and into the lake water.

“Poor woman!” said Maama Naluyima, “their love was still very young. She was even beginning to put on weight.”

Yet from here, Lake Victoria looked calm, except for a swarm of lake flies a few kilometres off shore that deceptively made it appear stormy. It was here at Kasensero that the first case of HIV/AIDS in Uganda was confirmed around 1982.

According to 74-year-old Joseph Mbogo-Munaana, who has worked here since he was a boy, locals initially thought that AIDS was a result of witchcraft. It was believed that some Ugandan traders had robbed or cheated their Tanzanian counterparts and had been bewitched.

The authorities at the time said AIDS had been brought by Tanzanian forces who had deposed dictator Idi Amin in 1979.

“After falling sick, many traders came back here and threw merchandise and money they had made from goods back into the lake thinking it would make them recover,” says Mbogo, who now builds wooden houses for rent. “Others took the goods right back to Tanzania.”

A quarter of a century later, AIDS has killed more than a million Ugandans and threatens to wipe out entire families, even villages.
Mbogo himself cannot count how many relatives he has lost to AIDS. But they include four adult daughters in the early 1990s.

“In fact the third one was self-employed across the border in Tanzania,” recalls Mbogo, expressionlessly, like a battle-hardened fighter, “Then she became very sick; I fetched her from there and she died here.”

HELP US LIVE: A girl living with HIV/Aids pleads for anti-retroviral drugs as a social worker (left) and other HIV-positive children listen in Kampala

After the death of his daughters, Mbogo says, he started advising young people to have more responsible sex lives. He says although all people know that the disease is transmitted sexually, their sexual behaviour has not changed much.

“Because of lust, and because people are being told condoms can protect you from HIV, people’s behaviour has not changed much,” he says. “People are told that if one condom can’t work, use two; or that if you get infected, there are drugs that can keep you looking healthy.”

Uganda today is like a fishing village the morning after a stormy, deadly night on the lake – counting its dead, hoping that the missing will be found alive and thanking the gods for those who made it.

The storm is HIV/AIDS. The MDG target here is to have halted by 2015 and begun to reverse the spread of HIV/AIDS. This is one area where Uganda has scored inspiring success.

National Prevalence rates have dropped from around 15 percent in 1991 to 7 percent in 2005. This means that in relative terms, Uganda has already achieved the MDG target.

The entrance to Kasensero fishing village, where the first case of HIV in Uganda was confirmed

According to Uganda AIDS Commission Consultant Dr. Innocent Nuwagira, this is attributable to the political commitment right from President Yoweri Museveni, openness about the pandemic from the early 1990s, and a conducive policy environment that started with the creation of Uganda AIDS Commission in 1992.

“When everybody thought talking about HIV/AIDS was a taboo, the President, Parliament and everybody else opted to go open,” says Nuwagira.
Uganda has preached a three-way approach: Abstention from premarital sex, Being faithful and Condom use (ABC).

Nuwagira says the response to AIDS has had three pillars: prevention of new infections, care and treatment for those affected and mitigation of the HIV/AIDS impact e.g. orphans, widows, the workplace etc.

An HIV/AIDS Partnership that includes government departments, aid agencies, non-governmental organisations, religious bodies and people living with AIDS meets once a month to review progress and devise new ways of dealing with the epidemic.

In its July 2005 report on MDGs, the Ministry of Finance, Planning and Economic Development notes that the prevalence rate among pregnant women aged 15-24 may be understated. But the rates have no doubt dropped, partly due to the death of many infected people but also due to reduction in new infections.

ABC: So what worked?

Mid last year, an NGO organised an HIV/AIDS awareness and sensitisation seminar at Kasensero. As is the practice, the seminar organisers offered the participants money for lunch and a transport refund. But there were also provisions for condoms.

Mary Namubiru, a doctor who was conducting the seminar, was in for a surprise. She arranged two tables: one with condoms, and the other for people to sign for their money.

“I naturally thought that everyone would scramble for the money, so I stood there waiting,” Namubiru recalls. “Instead, everyone rushed for the condoms.”

Namubiru had to send for more supplies. This little incident seems to confirm a widely held view, that condoms are part of the solution.
“I don’t think people have changed their sexual behaviour; what has happened is that condoms have become crucial,” says Deo Semanda, 29, a carpenter at Kasensero since 2000.

If this is the case, then President Yoweri Museveni finds himself in a difficult situation. Along with his wife Janet, they have over the last two years sought to downplay the role of condoms in containing the scourge.

Critics allege that this unofficial policy of downplaying condoms and emphasizing abstinence is meant to get more American money under the Presidential Emergency Plan for AIDS Relief (PEPFAR). PEPFAR’s approach is essentially to promote fidelity and abstinence as opposed to condoms.

During a recent sensitisation seminar at Kikube Village in Luwero, Caritas, a Church-based NGO, faced a tough question from a 14 year-old boy. If condoms are bad, he asked, why are they made and given to people.

While government officials maintain that there is no deliberate effort to discourage condoms, activists blame persistent condom shortages on government policy.

This debate about condoms and abstinence is critical; without a cure for HIV/AIDS, prevention remains the key and public awareness and education are indispensable.

The government report on MDGs quotes a 2002/03 survey suggesting that if Universal Primary Education (UPE) was fully implemented, 700 new cases of HIV in young people would be prevented every year. This is reportedly because educated women tend to delay sex activity and to take measures to protect themselves.

Another area that is potentially explosive is the fate of orphans many of them having lost parents to HIV/AIDS: a 2002/03 Uganda National Household Survey shows that orphans are less likely to sleep under a mosquito net, less likely to be in school, and generally more disadvantaged than children with parents. Government estimates that Uganda has two million orphan children, half of them due to AIDS, and the figure is expected to rise over the next decade.

“In our sub county of Kyebe, we have so many orphans whose parents were taken by AIDS. They have very little assistance from family members or no assistance at all. These children need help,” says Mzee Mbogo at Kasensero. But when asked to list the challenges facing the anti-aids struggle in order of importance, Mbogo started with drugs.

“We need more treatment. Let us have more hospitals with more AIDS drugs. Sometimes here we have drugs but there are no testing machines. Sensitisation campaigns should also be strengthened.”

The impact of HIV/AIDS cuts across almost all sectors. It kills skilled and unskilled labour, causes absenteeism from schools and other workplaces, causes reduced food security, and generally destroys the social fabric.

Anti-retroviral drugs (ARVs), which delay the onset of AIDS, are seen as critical to mitigating the impact of the scourge.

Official government figures show that 62,000 Ugandans are on ARVs out of over 150,000 who require them.

Uganda recently suffered a setback when the Global Fund for HIV, Malaria and Tuberclosis suspended funding over misuse of the money. While the ban was eventually lifted, the suspension dented the country’s leadership image.

Northern Uganda

A big dent in Uganda’s fight against HIV/AIDS has been northern Uganda, where infection rates remain alarmingly high.

With some 1.5 million people living in displacement camps because of the Lords’ Resistance Army rebellion, prevalence rates here are feared to be twice the national average. In late 2004, a report by World Vision International showed the prevalence rate in the north at nearly11.9 percent compared to 6.2 percent for the country. Gulu, one of the worst hit districts, reported 69% of deaths as being caused by Aids.

The World Vision blamed the north’s higher rates on poverty, abduction and rape of girls and women by rebels, and lack of healthcare, among other factors.

Explaining the Aids problem in Gulu two years ago, Acholi paramount chief Rwot Onen Acana told this writer that in an environment of abject poverty, many women and girls were left with no choice but to prostitute themselves to the few men with money.

A 2005 National Sero-prevalence and Behavioural Survey put HIV/Aids prevalence in the conflict-affected areas at 9.1% compared to the to the national average (7%).

The AIDS Control Program executive director Dr. Elizabeth Madra said last August government would introduce a special AIDS strategic plan against the spread of HIV/AIDS in the war ravaged north.

War continues

According to Dr. Nuwagira, the ideal situation is an HIV/AIDS-free Uganda. Although prevalence rates have fallen to 7 percent, he says, those are hundreds of thousands of Ugandans bound to die.

“For me the most immediate major challenge that this country faces is to fight complacency,” he says. “We fear it could be a big problem. Complacency would mean that people have left what they are supposed to be doing and, in a way, relaxed.”

Due to Anti-retroviral drugs, people who have been bedridden get back on the road and look healthy. There is fear they could default on the drugs, plunge into ill health and increase drug-resistance.

The commission is also hearing unconfirmed reports that people who begin to look healthy again are remarrying, with hope to raise families and have children through prevention of mother-to-child transmission.

“That is why we are very concerned; most of our effort now is geared at seeing how best we can prevent complacency,” says Nuwagira.

Dr. Chris Baryomunsi, United Nations Population Fund (UNFPA) Programme Manager in Kampala, is concerned that the prevalence rate has stagnated for virtually the last four years.

Although Uganda has got a lot of money to support its fight against HIV/AIDS, it must use the money properly and increase access to programmes like anti-retroviral therapy and testing and counselling.

Baryomunsi: “The issue of scaling up services is very important but also the issue of prevention especially for younger people is a key concern because when you now listen to what people say, you tend to think that provision of ARVs is all we need to do with HIV. But prevention is important.”