Background of HIV/AIDS in Uganda

AIDS cases were first recognized in Uganda in 1983, with about 900 cases reported by 1986, rising to 6,000 cases by 1988. Uganda responded by taking an open stance to the epidemic and was among the first African countries to establish a national AIDS Control Program (ACP) and the National Committee for the Prevention of AIDS (NCPA).  Working with financial and technical support from WHO, ACP launched and effectively coordinated the first multi-sectoral mobilization campaign through which HIV prevention messages were widely disseminated in the country at a critical time when there was a dearth of knowledge and information about the epidemic. By early 1990s Uganda was among the African countries worst hit by the HIV/AIDS epidemic. However, with strong political leadership, a vibrant civil society, and an open and multi-sectoral approach, Uganda sustained an impressive response to the epidemic. Through the technical oversight and direction of Ministry of Health (MOH), the first national blood transfusion service, the first voluntary, confidential counseling and testing service, the first HIV/AIDS care and support organization and the first national STD control program were initiated in Uganda. These interventions jointly helped to slow down the epidemic. The decline in the weighted overall antenatal prevalence was 6.1% in 2001 from 18% in 1992. More significant declines were noted in urban sites where the weighted average prevalence rate dropped from 10.9% in 1999 to 8.7% in 2000, compared to declines of 4.3% to 4.2% in rural sites over the same period[1].

The technical leadership by the Ministry of Health in the national HIV/AIDS response has been consistent. This manifests through development of key policies and guidelines, monitoring and reporting on the status of the epidemic, development and dissemination of messages as well as research that generates new knowledge on HIV/AIDS transmission, survival and disease progression. Policies for comprehensive HIV prevention, care and treatment have been developed and updated in response to the emerging global and national challenges.  In 2007, STD/AIDS Control Program developed a four year Strategic Plan (2007-2010) with the primary goal of preventing further transmission of STIs and HIV infection and providing support for the mitigation of the impact of HIV and AIDS on individuals, families and the community. The plan sought to scale up proven prevention and care initiatives and ultimately contribute to the realization of the three health sector objectives and the broad national goals. Key among others being preventing new infections, mitigation of the impact of the epidemic, and strengthening the national capacity to coordinate and manage the multi-sectoral response to the HIV/AIDS epidemic.[2]

1.1      Current Status of HIV/AIDS epidemic and response in Uganda

Over the past decade, Uganda has sustained an impressive response to the HIV/AIDS epidemic grounded in a multi-sectoral approach coordinated by the Uganda AIDS Commission (UAC). However, HIV/AIDS continues to be a major socio-economic challenge and is among the leading causes of morbidity and mortality. The epidemic has matured and is generalized across the entire population. The Uganda Sero-Behavioural Survey (UHSBS) 2004/2005 estimated that 6.4% of sexually active Ugandans aged 15-49 years were infected with HIV. This prevalence rate, however, masks major heterogeneity across regions, sex, age and marital status. Low prevalence rates were recorded in North East and North Western regions with rates of 3.5% and 2.3%, respectively. On the other hand, the Central and North Central regions had the highest HIV prevalence with rates of 8.5% and 8.2%, respectively. Similarly, higher infection rates were noted in urban areas, where prevalence was estimated to be ten times higher than in rural areas.  HIV prevalence was also higher among women (7.5%) compared to men (5%). In aggregate terms, HIV prevalence in Uganda has remain high at about 6.5%. The estimated HIV prevalence from the ANC surveillance in 2009 was 7% with the adult HIV prevalence in 2008/2009 estimated at 6.2% and HIV prevalence among women attending ANC estimated at 6-7% which are way off the targets of recently ended HSSPII of 5%, 3% and 4.4% respectively.[3] In terms of absolute numbers, the number of newly infected people has more than doubled since 2005 but the impact is morphed by the rapidly increasing population.

HIV prevalence in Uganda increases with age but peaks at different ages for men and women. For women, it peaks at 30-34 years and at 35-44 years for men, implying that men are more affected at older ages than women. A higher prevalence rate among women in young ages has considerable implications for HIV prevention given that these are the prime reproductive ages and hence the higher propensity for vertical HIV transmission. For instance, HIV prevalence among mothers seeking antenatal care was estimated to range between 5-15%.[4] Overall there are indications that HIV incidence is rising. About 135,000 individuals were newly infected in 2005[5] while another 124,000 were infected in 2009[6]. There is also significant variation in HIV infection risk among different population cohorts. Fishing communities, security personnel, truckers and cross border communities, commercial sex workers, and the internally displaced people have been identified to be at an elevated degree of risk and hence requiring special attention in HIV prevention programming[7].

The UHSBS 2004/2005 estimated that there were 915,400 individuals living with HIV/AIDS in Uganda, of whom approximately 120,000 were children under the age of 15. Although incidence is the most reliable measure of HIV epidemiology, there is paucity of data on HIV incidence patterns in Uganda. There is also lack of mechanisms to assist in routine examination and generation of evidence on the drivers of the epidemic in diverse settings, which ultimately affects the relevance of interventions to specific contexts. Using mathematical modeling techniques, Uganda AIDS Commission and UNAIDS provide annual estimates of new infections. In 2007, there were an estimated 132,000 new infections in Uganda,[8]while 124,000 were infected in 2009.[9] The rise in new infections has a direct bearing on overall HIV prevalence and consequently the ability of the national programs to achieve targets in this area. For instance, the goal of reducing HIV prevalence by 50% and by 45% as respectively stipulated in the HSSPII and NSP 2007/8-2011/12 has been elusive. With support from development partners, MOH is currently undertaking an AIDS Indicator Survey (AIS), as follow on to the UHSBS. Results from the survey, expected late next year, are expected to provide new insights into the realistic status of the HIV/AIDS epidemic in Uganda.

The HIV/AIDS epidemic in Uganda has matured and the factors driving the new infections have changed. The Modes of Transmission Analysis in 2009 highlights HIV discordance especially among sexually stable couples, concurrent multiple sexual partners, lack of male circumcision, low condom use, transactional sex, cross-generational sex and complacency due to improved access to ART as some of the major drivers of the epidemic. There is also growing need to align the HIV/AIDS response to empirical evidence and to focus interventions in areas that will generate population level impact. There have been shifts in epidemiological patterns, with new infections now occurring more in married and co-habiting couples than in youth, as was the case a few years ago. Available data and analyses highlight that sexual transmission accounts for 76% of all new infections, followed by mother to child transmission (22%). Contaminated blood, needles and sharp instruments as well as men having sex with men account for approximately 2% of new infections. Sero-discordancy is a rapidly evolving phenomenon and accounts for the rising HIV incidence and prevalence among couples. Of the adults in married and co-habiting relationships, over 40% of those who are HIV positive have an HIV negative spouse[10].

Over the past five years, STD/ACP has been working in collaboration with development partners and other stakeholders to scale up HIV/AIDS services in the public and private sector. Through these efforts, HIV care and treatment and PMTCT services are currently provided in 66% and 83% of the public and private health facilities respectively. Access to ART has also improved and as at end of June 2010, 237,000 individuals were actively enrolled on ART, hence covering approximately 44% of the national estimated need for ART based on the modified eligibility criterion of <350 CD-4 T-cells per microliter of blood. Of these, 89 percent were adults aged 15 years+, and, eight percent were children 0-14 years.[11]

Capacity for chronic HIV/AIDS care and management of opportunistic infections has also greatly improved, leading to more PLHA living longer and with few incidences of illness. Chronic care services are currently estimated to reach 54% of those in need. Significant success was made in integrating HIV services with other services especially TB, reproductive health and maternal and child health. The HIV Early Infant Diagnosis (EID) was integrated into Child Days Plus increasing the number of HIV exposed children that accessed HIV testing from about 17,000 to 43,000. Ministry of Health through the STD/ACP has also provided impressive technical leadership through development of supportive policies, guidelines, rapid accreditation of sites as well as mentorship to the service delivery sites.

Despite these achievements, many challenges still remain. Besides the rising HIV incidence, there are declining behaviors’ associated with discrimination and stigma among the young positives living in institutions of learning, low coverage of services and institutional constraints for the health sector HIV/AIDS response. The STD/AIDS Control Programme is mandated to provide leadership in the Health Sector HIV/AIDS response in the country. Over the years STD/ACP has provided the leadership in policy and implementation, coordination of the response; resource mobilization; planning and reporting on HIV/AIDS as well as representation at national and international levels. However, the challenges of management and institutional capacity are daunting. There are persistent delays in passing policies and guidelines and even when they are passed, implementation is extremely slow. The involvement and coordination of stakeholders in planning has been equally minimal. For instance, the HSHASP 2007-2010 is known to a few stakeholders. The plan was never reviewed annually nor was the operational plans of both the MOH and implementing partners aligned to the strategic plan. Most of the plans of partners were more likely to be based on the NSP rather than the HSHASP.

The inadequate human resources for continues to affect the capacity and quality of HIV/AIDS service delivery. Although the government has been striving to improve working conditions of health workers, terms of service are far below the desired level resulting in continued exodus of highly experienced personnel from the ministry to the private sector. Paradoxically, the problem has worsened with the increase in HIV/AIDS resources from the global initiatives such as the Global Fund and PEPFAR, worse hit being rural facilities, notably at levels below HCIV. Consequently, STD/ACP continues to function sub-optimally especially in terms of supervision and quality assurance. For instance, the most common mode supervision is the integrated MOH and district supervision which is also irregular. As noted in the Health Sector HIV/AIDS Review (2010) the supervision on HIV care often takes parallel channels with the CSOs, the police, army and MOH (jointly with district officials) carrying they own our supervision. While these supervision channels can be opportunities of quality assurance but when uncoordinated, they can weaken the district supervision system.

Standardization and institutionalization of quality across the spectrum of HIV/AIDS prevention and care services is another key challenge. A number of studies and reports[12],[13] reveal that MOH standards and guidelines for delivery of most quality HIV/AIDS services are available but are not matched by the infrastructure, equipment and funding to make them operational. Rural sites are more disadvantaged as they are unable to attract adequate human resources and/or funds

Funding for the health sector HIV/AIDS activities continues to fall below expectations. Despite the increase in the national resource envelop for HIV/AIDS, it is acknowledged that over 80% of the resources are donations from external sources whose resources are mainly programmed through the private sector. The STD/ACP continues to rely predominantly on funding provided by government whose allocation to health as a proportion of the total GoU budget has not significantly increased implying capacity and sustainability challenges of the health sector HIV/AIDS response.[14]

The Health Sector HIV/AIDS Strategic Plan 2010/11-2014/15 provides a programmatic strategic framework for the health sector HIV/AIDS response in the sector wide approach as presented in Health Sector Strategic and Investment Plan, 2010/11-2014/15 and the National Health Policy II, 2010.

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[1] Asiimwe D., Kibombo R. and Neema S. (2003):  Focus Group Discussions on Social Cultural Factors Impacting on HIV/AIDS in Uganda.  UNDP/MISR,  Kampala, Uganda.

[2] Ministry of Health, Health Sector HIV and AIDS Strategic Plan 2007-2010

[3] Ministry of Health, Health Sector Strategic and Investment Plan, 2010/11-2014/15, Kampala

[4] Ministry of Health (2010), Annual Health Sector Performance Report: Financial Year 2009/2010

[5] Republic of Uganda (2009), Uganda HIV Prevention Response  and Modes of Transmission Analysis

[6] Ministry of Health (2010), Annual Health Sector Performance Report: Financial Year 2009/2010.

[7] Republic of Uganda of Uganda (2009), Uganda HIV Prevention Response and Modes of Transmission Analysis

[8] Republic of Uganda of Uganda (2009), Uganda HIV Prevention Response and Modes of Transmission Analysis

[9] Ministry of Health (2010), Annual Health Sector Performance Report: Financial Year 2009/2010

[10] The Republic of Uganda  (2009), Uganda HIV Prevention Response and Modes of Transmission Analysis

[11] Ministry of Health- STD/AIDS Control Program (2010), Status of Anti-Retroviral Therapy Service Delivery in Uganda, Quarterly Report for April-June 2010

[12] Ministry of Health, Health Sector HIV/AIDS Review 2007-2010, Health Service Delivery  Building Block

[13] Health Sector Strategic and Investment Plan

[14] Ministry of Health, Annual Health Sector Performance Report, Financial Year 2009/2010, Kampala