Hits, misses in anti-Aids fight 

At the backend of her 2020/2021 to 2024/25 National HIV Strategic Plan (NSP), Uganda finds itself dealing with a mixed bag. One of only eight countries across the globe that managed to achieve UNAIDS’s 90-90-90 targets by 2020, a steady stream of new infections has had authorities in  Uganda running scared.

“There were more than 51,000 new infections recorded in the year 2022/2023 in the country, which is a distant from the target of under 20,000 by 2024/2025,” Dr Andrew Kazibwe, the head of medical services at The Aids Support Organisation (Taso), disclosed, adding, “Majority of these are in adolescent girls and young women.”

The NSP, which provides the overall strategic direction for the national response to the HIV/Aids epidemic, makes clear Uganda’s aspiration to end what can easily morph into a public health and socio-economic threat in the country by 2030. Aligned to the country’s third National Development Plan (NDP III), the NSP was green-lit ticked the UNAIDS’s boxes in the 90-90-90 targets.

These included: ensuring that 90 percent of all people living with HIV will know their HIV status by 2020; 90 percent of all people with diagnosed HIV infection receive sustained antiretroviral therapy by 2020; and 90 percent of all people receiving antiretroviral therapy have viral suppression by 2020.

The NSP moved the bar slightly higher by setting out to reduce paediatric HIV infections by 95 percent by 2025. It also is intent on reducing youth and adult HIV infections by 65 percent. Statistics show that there were an estimated 1,433,337 people living with HIV (PLHIV) as of December 2022. Of these, 1,403,603 (98 percent) were on antiretroviral therapy (ART) as of June 2023. However, the ART coverage among children (0-14 years) was captured at 72 percent, which is significantly below the NSP target of 95 percent.

Mother-to-child infections
This points to the fact that there are glaring cracks in the elimination of Mother-to-child transmission of HIV (eMTCT) drive. While there are fewer infants or children acquiring HIV from their mothers, there’s still work to be done.

“We still have between 4,000 and 6,000 children who acquired HIV from their mothers, which is high, though those that acquired HIV by two months of age is less than two percent now,” Dr Kazibwe conceded, adding; “This implies that in the last few years, children are majorly acquiring HIV from their mothers during breastfeeding. That is unlike in the past where most new infections were during childbirth. This is because more women are acquiring HIV or abandoning anti-retroviral therapy during breastfeeding, hence a high maternal viral load contributing to high HIV transmission risk to their infants.”

The Uganda Aids Commission (UAC) is alive to the fact that 200,000 of the 1.4 million Ugandans living with HIV are not on ART. This increases the chances of infections at birth and during breastfeeding.
“All pregnant mothers should deliver in the hands of a qualified health worker and the HIV-positive mother should receive nevirapine syrup and septrin (co-trimoxazole) syrup for their baby,” Dr Eddie Mukooyo Sefuluya, the UAC chairperson, said, adding: “The infant should also be tested at particular intervals to make sure the baby has not acquired HIV.”

As of June, Uganda had scored 90-94-94 in her quest of a 95-95-95 target aimed at ending Aids as a public health threat by 2030. Per the UAC, 700 health facilities are accredited to provide ART. This has improved ART coverage amongst adults to 97.8 percent. Dr Mukooyo said the NSP’s goal is “to reduce Aids-related morbidity and mortality by at least 50 percent by 2025.”  The numbers among the children are, however, a cause for concern. Not all is lost, though, according to Dr Kazibwe.

“For out-of-school adolescents, we are looking at ways to ensure there is family stability hence stable drug adherence. For struggling young adults, we are linking them to socio-economic empowerment programmes to empower them holistically,” he said.

There is also the Determined, Resilient, Empowered, Aids-free, Mentored and Safe (Dreams) initiative to empower adolescent girls and young women against HIV. The programme looks at providing basic sexual reproductive health services to adolescent girls and young women, to teach them how to protect themselves from STIs, unwanted pregnancies and HIV.
“It also gives them social skills, decision-making, assertiveness so they can ably negotiate for safer sex and make better health choices. Those out of school are taught vocational skills for a source of income which reduces their vulnerability to unsafe sex, and hence HIV exposure,” Dr Kazibwe said.

The rewards of a continued scale-up of differentiated service delivery (DSD) models are also palpable. DSD aims to deliver ART in a way that addresses the unique circumstances and preferences of individuals on ART thus improving service access, and uptake.

As of June 2023, per the UAC 2023 report, 99 percent of ART facilities offered at least two DSD models for HIV care, with 14 percent of recipients of care enrolled in community models (Community Drug Distribution Point (CDDP) and Community Client Led ART Distribution (CCLAD). Elsewhere, 85 percent are enrolled in facility-based models, with the majority on fast track drug refill (50 percent).

Some of the drivers of the HIV/Aids success story that Uganda sustained in the 1990s was down to the information, awareness and behaviour change campaigns propped up. The ABC strategy anchored on abstinence, being faithful and using condoms hauled down the HIV prevalence rate from double to single digits. Dr Kazibwe said the ‘Time-Up” campaign is also making headway in the here and now. He attributed the low use of condoms to a stock-out of the same.
Through Orphans and Vulnerable Children (OVC) support and other economic empowerment programmes, progress has been made in addressing social vulnerability to HIV among HIV-positive individuals and their households. 
 
Regrettably, domestic violence cases have increased in Uganda yet violence fuels HIV acquisition risk. The fully functional Gender and HIV Reporting Dashboard (GRD) has improved timely access to data for strengthening prevention and response to sexual and gender-based discrimination and violence.
Dr Kazibwe said the government and donors such as Global Fund and the US President’s Emergency Plan for Aids Relief (Pepfar) have heavily invested in system strengthening.

Human resource has also improved, with more than 80 percent of districts, ministries, departments and agencies, and self-coordinating entities having functional coordination structures. Their HIV/Aids strategic plans also file reports regularly. These are responsible for multi-sectoral coordination at the district level.

“The government has also worked to mainstream HIV/Aids programmes into other ministries. Therefore, every ministry has a provision in their budget for HIV-related activities,” Dr Kazibwe said, adding that several policy guidance documents such as the consolidated guidelines for HIV Prevention, Care and Treatment (2022) have been developed and disseminated across sectors.

Taking stock
The government has also followed best practices of monitoring and evaluation (M&E) to the letter. This is to ensure quality and timely collection of HIV/Aids information to track progress towards attaining the national and global targets. It provides a framework for generating strategic information to guide evidence-based decisions.
Health Management Information Systems (HMIS) tools were revised for general and key populations. Dr Mukooyo said the revised tools were harmonised addressing all stakeholder needs. These include age disaggregation while additional indicators capturing emerging needs have been included.

KP data collection tools were harmonised and integrated into the national reporting systems. Dr Mukooyo said this will reduce the need for parallel reporting with improved efficiency, with “the tools … customised into DHIS2 in the coming year.” DHIS2 is a free and open-source software platform for the collection, reporting, analysis and dissemination of aggregate and individual-level data.

Elsewhere, the national M&E framework for adolescents and young people was developed and validated by key stakeholders. “The process was supported by Unicef and the framework will improve multi-sectoral tracking of progress on AGYW activities,” Dr Mukooyo said, adding that the many TVs and radios stations should be harnessed to pass on tailored and standardised spot messages on HIV prevention messages primarily during the peak hours.