Subjective Influencers Toward End Of HIV: A Note To Uganda Key And Priority Populations (KP/PP)

All Key and Priority Populations ( KP/PP) can contribute to efforts to eradicate HIV in Uganda. The LGBTIQ+ has made significant progress in fighting HIV and AIDS since mid 90's. However, the magnitude of the epidemic is such that more needs to be put in place to, among others, bring down new infections, morbidity and mortality.

HIV/AIDS Burden:

According to the Uganda AIDS Commission (UAC) report of 2019 titled: "HIV and AIDS Response in Uganda, 2019," there are 1,000 new infections and 500 death due to AIDS every week. Uganda's HIV/AIDS burden is estimated at 1,400,000 people living with HIV.

Forward Transmission:

Working with the LGBTIQ+ in Uganda, provides opportunities for anecdotal insights in knowledge, attitude, practices and behaviour supporting resilience against HIV/AIDS or subverting it.

Affordance And Normativity:

There are feelings, experiences and motivations that together form what is known as affordance. This is a state of achievement or possibility at which one feels they can make decisions depending on knowledge, skills, lived experiences, emotional awareness and utilitarian recognition. This enables us to pursue life and happiness. "We sit or stand on a chair because those affordances are fairly obvious," said Scott a researcher in life skills planning. Affordance, drives self determination as well as derives pathways for orientation, sexuality and norms. It is against this background that various growth and development intersecting parameters arise. These further inform one's emotional self, self-cognizance, self determination, self -direction and self-preservation. People then align themselves  or fit in communities they find comfort, liberty and opportunities to pursue a happy life.

Characterizing Preferences:

Engaging in consensual sexual acts is the idealized norm in Uganda. This means, sexual intercourse is expected to take place within marital heterosexual consensual sexual (MHCS) contexts. Heterosexual hegemony is legalized, while that which is otherwise is criminalized. Yet, not all sexual acts are marital, heterosexual or consensual. Meanwhile, the argue for sexual intercourse begins as early as 10. So, among the 10-19 year olds and those above 19 years, it is necessary to note that they may be both sexually active and of reproductive ages. Not all sexually active events occur in heterosexual contexts. Some occur in same-sex/gender oriented persons. Preferences can be as varied: penile-vaginal, penile-anal, penile-oral, vaginal-vaginal, vaginal-oral, and sexual object-to bodily orifice. This means, most sexual intercourse events are not protected against sexually transmitted infections, unplanned pregnancies, infected bodily fluids exchange and other consequences of sexual intercourse. The route of infection depends on sexual intercourse preferences and this in turn provides insight into prevalence profiles characteristic of given demography groups. Marital heterosexual sexual intercourse however, is not the only form of sexual intercourse practiced by Ugandans.

Sexual Behaviour:

The number of People Living With HIV as of December 2018, by demography are as follows: Children from 0-14 years are 100,000; Young People from 15-24 years are 160,000; Men aged 15 and above are 530,000; and Women are 770,000. These figures are taken from the Uganda Population HIV and AIDS Impact Assessment (UPHIA) report.

Multiple Sexual Partners:

Young People (15-24) who make up 58.6% of the entire Ugandan population reported having early sexual debuts, non-marital, or sex with non-cohabiting partners 12 months before the 2018 study was conducted. Adults (15+) who represented 36.7% of entire population reported having sex with someone who was not their marital or cohabiting partner.

Domestic Violence:

Domestic violence promotes vulnerability/susceptibility to HIV Transmission. The UAC (2019) report highlights violence and the hands of a partner supposed to be intimate partners. Physical or sexual violence are reported by respondents and so are what are known as emotional trauma-related violence. Among the consequences of violence are: missed medication doses; depression; bruises; pain from blows; disability; death; and vulnerability to other risks to HIV transmission.

 Preventive Protection:

The condom is a mainstay of HIV Prevention. However, only 33.4% of adults aged 15 and above who reported having sex with non-marital/non-cohabiting partner in last 12 months used condoms at last intercourse with that person. 

Treatment Cascade:

Having opportunities to fulfill needs for effective testing and treatment cascade is an important pillar in epidemic control and eventual eradication of HIV. However, according to the UAC ( 2019) report, one in three (1/3) people living with HIV were not able to achieve viral load suppression. 28 % were women and 45% were men.  The testing and treatment cascade involves: increasing knowledge of sero-status; those with positive diagnosis linked to and processed to receive ART; and optimal ARV adherence leading to suppression of viral load. Other attendant issues included: stable housing, nutrition, livelihood and entrepreneurship opportunities. 

AIDS related Deaths:

According to reports, the number of deaths due to AIDS and number of deaths averted due to ART have been influenced over the years from 2010-2018. In 2010, there were 56,000 deaths in 2010 but by 2018, there were 23, 000 deaths. This is 59% reduction  and if disaggregated it shows: Women had 71% reduction in deaths; men had 31%; Young People had 37%; and children 66%.

Concurrence of Metrics/Integration of Interventions:

In order to effectively work toward eradication of AIDS, one shoe fits all approach has to be replaced with transmission-interruption-tailored interventions(TITIs). This allows containment of otherwise high prevalence pockets. Instituting such measures like rolling out opportunities for full treatment cascade; elimination of Mother-to-Child transmission; elimination of perinatal transmission; reducing numbers of sexual partners; numbers of KP reporting having attained the undetectable/untransmittable goal; number reporting completion of immunizations against HPV and Hep B; number of KP living with HIV identified to be consistently ARV Adherent; and other goals.

Key And Priority Populations (KP/PP):

A report of the Presidential Fast Track Initiative on Ending AIDS in Uganda (PFTI), highlights an inclusive narrative. It acknowledges the role of many in ending HIV. The initiative recentres HIV/AIDS back to the priority planning list for all stake holders in Uganda( page 10). The initiative highlights: hegemonic toxic masculinity; accelerates implementation of Test and Treat and Attainment of targets; consolidation of progress on elimination of Mother-to Child Transmission of HIV; Ensure financial sustainability for HIV/AIDS response; ensure institutional effectiveness for a well-coordinated/multi-sectoral response. 

Character Of Local Interventions Aligned to PFTI:

MARPS in Uganda started to provide HIV care and prevention targeting marginalized, hard to reach, most at risk and now Key/Priority Populations with specific objectives cascading into eradication of HIV. MARPS in Uganda, has always joined the call for efforts to transcend political, religious, cultural and any other classifications in order "to commit to winning together against HIV," (see report of the Presidential Fast Track Initiative on Ending AIDS in Uganda (PFTI)Page 11). In order for "underlying behavioural, biomedical and structural drivers for new HIV infections and support delivery of a harmonised response (pg. 14)," to be fully addressed, there was need to align approaches as well as characterize interventions targeting KP/PP.

Linkage Processes:

The Presidential Fast Track Initiative (PFTI) highlights need for involving and taking one's responsibility to work with: leaders who catalyze and stimulate change; Stakeholders who catalyze synergies thereby optimizing resources; entities addressing efforts to end HIV; reaching more people who had never tested but at higher risk of infection; engage in efforts to test and start same day ART for all newly identified HIV Positive persons irrespective of disease progression ( clinical, immunological and virological); adoption of high yield  HIV testing approaches  like assisted Partner Notification (APN) and HIV Self testing ( HIV ST); provide dates/venues to test outside health stationary facilities as part of the differentiated Services Delivery (DSD) model; link to care/attach beneficiaries to clinics providing efficacious ARVs to improve ART treatment initiation targets; position organizations to benefit  from social economic empowerment projects; align organization operations with the priorities in the National Strategic Plan (NSP) and the multi-sectoral AIDS response. 

Alignment:

We serve about 800+ beneficiaries Living With HIV who access ARVs. Meeting them was possible through word of mouth, Social media, referrals. One-on-one counselling, identification through tests/confirmatory tests/presumptive diagnosis, linkage and follow-up through home visits are some of the ways we track our cases. Over time, the numbers have increased due to high references from networks and high confidentiality standards that attracted many more beneficiaries.

Challenges:

i. Disparity in allocation of funds to HIV Prevention within LGBTIQ+ has led to stratified interventions. Strategic Litigation and Human Rights Advocacy Organizations have received funding for quite a number of years that enabled them to: institute legal cases; bail out those in conflict with the law; provide salaries for staff; facilitate establishment of office/resource spaces; and conducting planned recurrent activities. They would also mobilize for testing but did not address subsequent stages of prevention or care.

ii.  Strategic HIV Prevention And Public Health Advocacy Organizations on the other hand were not provided funding for a long time. These have been saddled with mobilization, clinical, immunological and virological management of HIV using privately collected funds. It is no wonder that very few LGBTIQ+ living with HIV are provided for. This anomaly needs addressing now. 

iii. Persistent stock out of the full range of prevention commodities/supplies.

iv. Lack of logistics to motivate tracer peers who track beneficiaries along the HIV Care and Prevention Continuum.

v. High loss to follow up of exposed Transgender Living with HIV.

vii. Inadequate funds to support comprehensive HIV services i.e., governance, coordination and service delivery.

viii. This demography accesses the online platforms, but social interactions can divert attention to education sessions.

Solutions And Current Initiatives:

Wider access, anchoring to care, holistic health, deliverables and optimal viral suppression goal (WATCH -DOG)

Element 1. Ensure awareness of status, mobilize communities to test, treat, adherence and viral suppression (STETAV).

Element 2. Sexual Partner reduction in high HIV prevalence countries, housing stabilization, adverse drug effects management, livelihood and entrepreneurship opportunities, nutrition support and safer sex negotiation to elicit consent or disclose HIV status (SHALNS).

Element 3. Engage policy, programming, and providers at national government and NGO levels to gain action, eventual traction guaranteeing epidemic control (Engage).

Element 4. Empower identified beneficiaries to mobilize, catalyze and engender full participation of people for optimal and wider eradication (Empower).

Element 5. Widely disseminate information stimulating participation by many in HIV prevention and AIDS eradication (WIDE).

MARPS in Uganda, continues to use various methods to ensure LGBTIQ+ Living With HIV are catered for and vulnerabilities or susceptibilities leading to non-optimal ARV adherence are addressed. With your support, this is possible.