HIV/AIDS in Uganda

Uganda has been hailed as a rare success story in the fight against HIV and AIDS, widely being viewed as the most effective national response to the pandemic in sub-Saharan Africa. President Yoweri Museveni established the AIDS Control Program (ACP) within the Ministry of Health (MOH) to create policy guidelines for Uganda’s fight against HIV/AIDS. Uganda quickly realized that HIV/AIDS was more than a ‘health’ issue and in 1992 created a “Multi-sectoral AIDS Control Approach.” In addition, the Uganda AIDS Commission, also founded in 1992, has been instrumental in developing a national HIV/AIDS policy. A variety of approaches to AIDS education have been employed, ranging from the promotion of condom use to 'abstinence only' programmes. To further Uganda's efforts in establishing a comprehensive HIV/AIDS program, in 2000 the MOH implemented birth practices and safe infant feeding counseling. According to the WHO, around 41,000 women received Preventing Mother To child Transmission (PMTCT) services in 2001. Uganda was the first country to open a Voluntary Counselling and Testing (VCT) clinic in Africa and pioneered the concept of voluntary HIV testing centers in Sub-Saharan Africa.

There are striking similarities with the history of HIV/AIDS response in Senegal, where an equally high-level political response was encouraged by the fact that the HIV-2 strain of the disease was discovered by a Senegalese scientist Dr Mboup.

Criticism
The scope of Uganda's success has come under scrutiny from new research. Research published in The Lancet medical journal in 2002 questions the dramatic decline reported. It is claimed statistics have been distorted through the inaccurate extrapolation of data from small urban clinics to the entire population, nearly 90 per cent of whom live in rural areas. Also, recent trials of the HIV drug nevirapine have come under intense scrutiny and criticism.

US-sponsored abstinence promotions have received recent criticism from observers for denying young people information about any method of HIV prevention other than sexual abstinence until marriage. Human Rights Watch says that such programmes "leave Uganda’s children at risk of HIV". Alternatively, the Roman Catholic organization Human Life International says that "condoms are adding to the problem, not solving it" and that "The government of Uganda believes its people have the human capacity to change their risky behaviors." People in Uganda are also being taught the ABCD's. A=Abstinence, B=Be Faithful, C=Condom use, or D=Death.

There have been calls for a more nuanced view of Uganda's response to HIV/AIDS. There is no doubt that there has been sustained, long term political commitment at the highest levels of government on this issue. Determining why this happened in stark contrast to the majority of Sub-Saharan Africa is the key question.

One argument is the drop in HIV/AIDS prevalence rates had more to do with the end of the civil war in 1985 than with any prevention efforts which happened subsequently. Nonetheless, there was an appearance that these efforts had been working. This helped create a virtuous cycle, whereby in was in the interest of politicians to talk about HIV/AIDS as this helped the prestige of the country and encouraged HIV/AIDS related aid money.

Structure of health provision
The provision of all health services in Uganda is shared between three groups: the government staffed and funded medical facilities; private for profit or self-employed medics including midwives and traditional birth attendants; and, NGO or philanthropic medical services. The international health funding and research community, such as the Global Fund for Aids, TB and Malaria, or bilateral donors are very active in Uganda. Part of the success in managing HIV/AIDS in Uganda has been due to the cooperation between the government and the non-government service providers and these international bodies. Public Private Partnerships in Health are often mentioned in Europe and North America to fund construction or research. In Uganda, it is more practical being the recognition by the (public) government and (public) donor that a (private) philanthropic health facility can receive free test kits for HIV screening, free mosquito nets and water purification to reduce opportunistic infections and free testing and treatment for basic infections of great danger to PLHA.

Alternative proposals
Several studies, conducted in Uganda and its neighbors, indicate that adult male circumcision may be a cost-effective means of reducing HIV infection. A review on the acceptability of adult male circumcision indicated Across studies, the median proportion of uncircumcised men willing to become circumcised was 65% (range 29-87%). Sixty nine percent (47-79%) of women favored circumcision for their partners, and 71% (50-90%) of men and 81% (70-90%) of women were willing to circumcise their sons.

An economic analysis by Bertran Auvert, MD, from the INSERM U687, Saint-Maurive, France, and colleagues estimated the cost of a roll-out over an initial 5-year period would be $1036 million ($748 – $1319 million) and $965 million ($763 – $1301 million) for private and public health sectors, respectively. The cumulative net cost over the first 10 years was estimated at $1271 million and $173 million for the private and public sectors, respectively. After adjustment for averted HIV medical costs, the researchers determined that the program would result in a net savings of about $2 per adult per year over the first 20 years of the program.