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Our HIV Epidemic

Our HIV/AIDS Epidemic: What each one of us must do?

A message to you as an individual from the Chairman, Uganda AIDS Commission Professor Vinand M Nantulya, MD, PhD, FRCPath

The epidemic is rising again!
The findings from the 2011 National HIV Indicator Survey announced recently are deeply disturbing to the public; to local and national leaders; and to our AIDS Development Partners alike. The trend revealed by the survey is not good at all; and we must be frank about it. The prevalence rates i.e. proportion of Ugandans, age 15-49, who are infected has risen and now stands at 7.3% (and even higher in women at 8.3%), and up from 6.4% in the 2004-05 survey. To crown it all the estimated number of new infections has been rising steadily: from 124,000 in 2009; 128,000 in 2010; to now 130,000 in 2011. More are expected next year; and the year after! This rising number of new infections outstrips the annual enrollment into anti-retroviral treatment by two-fold. If this status quo continues, the HIV burden in our country is projected to increase by 700,000 new infections over the next 5 years, including an estimated 25,000 babies born with the infection each year!

How long shall we just look on?
We cannot allow this to continue. As in 1989 we must rise up to the challenge. There is urgency and need for serious, unequivocal commitment on the part of every single citizen to be part of our renewed plan to face this epidemic. The plan is spelt out by the Uganda AIDS Commission in the National HIV Prevention Strategy 2011-2015. This strategy aims at mobilizing all people and institutions to work towards eliminating new HIV infections, putting an end to stigma and discrimination, and halting deaths from AIDS-related conditions by the year 2015. The work plans for all sectors, including those of our development partners, are to be aligned to this Strategy. The strategy is ambitious; but ambitious we must be if we are to arrest and reverse the trend of this epidemic and its disastrous repercussions.

The challenge to you as an individual is that you should play your part. You have the power to protect yourself, your children and others; the power to relate with respect and understanding to fellow citizens afflicted by HIV instead of discriminating against them; the power to seek treatment, care and support if you get infected; and the power to advise others to follow the right path.

Let us raise a generation that is free of HIV
The first call in our National HIV Prevention Strategy is to you men and women who wish to raise a family. You must make a clear choice to bring forth a baby that is HIV-free. This is central to raising a generation of Ugandans that are free from HIV. Every pregnant mother should seek antenatal care as early as after missing two menstrual periods and take an HIV test. A mother that tests positive can then be placed on treatment following guidelines issued by the Ministry of Health. The treatment aims to achieve two objectives: care for the mother’s health, and protection for the baby. It is also in the interest of the baby’s future that the father of the baby to be born also rises to the challenge and gets tested. After all recent evidence suggests that most of the infections passed on to the babies originate from their fathers, with the mothers as mere intermediaries who get infected by their partners.

Here the Ministry of Health faces a huge task in leading the effort to eliminate mother-to-child transmission of HIV. The required resources and services must be made available at all the health centres. Moreover, all facilities offering antenatal care must be worthy of their name. As long as these facilities remain dilapidated and offering substandard services, we shall not be able to achieve the goal of eliminating the transmission of infection to our babies. Government, parliament, the local councils and the public must rise to this challenge and make clear, conscious, and demonstrable commitment to radically improve the infrastructure, staffing, delivery and governance of our healthcare services.

Keeping our young generation free of HIV
The second call in the Strategy is to you the youth in and out of school. Your future is in your hands. You have a clear responsibility, as an individual, to protect yourself and your future. This begins with you keeping yourself HIV negative, rejecting risky behaviors and ensuring that you protect others from infection, while you also support those in need of treatment, care and social support. Those who apply pressure on you will not be by your side when you get infected. The National Prevention Strategy calls upon the health providers to offer you services that are youth-friendly so that you can access interventions like HIV counseling and testing, information on safe sexual behaviours, safe male circumcision, condom supplies, treatment, care and support for those infected and affected. But the message on circumcision must be very clear: it is not 100% protective; and certainly not a license to be reckless. You will still get infected if you ignore the other complementary interventions like self-restraint against engaging into sex relationships with partners whose sero-status you know not.

Parents, you should play your role in guiding and protecting our young generation against pressures to engage in behaviours and practices that expose them to HIV infection. The near-exclusive pre-occupation with your child’s school examination results, now deeply entrenched in our society, is not good enough for your child. You need to equally put emphasis on physical, social, emotional and spiritual development, inculcating in your child social norms and values. Spend quality time with your child. This is what will give your child the strength of character to withstand the many pressures and challenges that your child will face in his or her life, including pressure to engage in risky sex behaviour. Guide and enable your child to stay in school and complete his or her education but your child critically needs to delay his or her sexual debut and to delay marriage until after maturity as by law established. Biologically, your immature daughter is more susceptible to HIV infection and faces more complications in delivery should
she get pregnant. Encouraging and supporting your child to delay the sexual debut will allow the child time to mature and to develop the character, skills and strength to protect herself.

Parents, you must also do more to demand protection of our young girls from the menace of older men who exploit them sexually using all sorts of coercion and end up infecting them. Society must speak up against it. You are part of that society. You need also to demand protection of our young generation from the now rising trend of exposure to pornography and wrong information through irresponsible mass media and widespread video shows on unlicensed premises in shopping centres in urban and rural areas.

Protection for you the adults
The third call is to you the adults. The key driver of infections in adults is complacency! A high proportion of sexually active Ugandans have become complacent about risk-taking sex lifestyles such as engaging in sexual encounters with partners whose sero-status they know not! This is deadly. Indeed, close to 90% of new infections occur in adults engaging in such practices. At the drinking places and other places for socialization popularly known as kafundas cheap misleading talk is commonplace, such as “HIV/AIDS is not cancer. There is treatment for it” or as the popular Luo proverb goes "Dhiang Nyaka Thoo Gi Lum E Dhoge," literally translated word for word as "A Bull Must Die with Grass in Its Mouth." Such blind, heroic statements will lead you into an act you will live to regret the next day, and you will face the repercussion alone.

Yes, it is true that anti-retroviral therapy is life-saving and must not be denied any Ugandan who needs to be put on treatment. However, if you choose to take these risks, let it be clear to you that these drugs are not curative; they are to be taken daily for life; the drugs are not easy to take because they cause serious side effects and require strict adherence to the treatment regimen. Moreover, there is the ever- present and overhanging threat of emergence of drug resistance with its associated consequences of treatment failure requiring change of drug combinations. But the combinations are not inexhaustible. Our fellow Ugandans who are on this treatment are taking the drugs not out of choice, but rather that the drugs are life-saving. It is not wise, therefore, to be casual about it and to needlessly expose yourself to the risk of infection. The country does not and cannot afford to have enough drugs to treat all those Ugandans that are already living with the disease and need treatment. Indeed only half of those who need to be on treatment are currently enrolled in the treatment programme.

The starting point in protecting yourself is for you to take an HIV test so that you get to know your sero-status. If you test negative, of which the vast majority are, the Prevention Strategy provides guidelines for a package of interventions for you such as advice on safe sex behaviour, condom use, and access to free and safe male circumcision. But I must emphasize again that you must not treat circumcision as a license to take risk because protection is not absolute! There is also a package for you if you should test positive. This includes: access to treatment, care and
support, condom use to avoid acquiring super infection with drug resistant strains of the virus and advice on positive living so as to stop spread of the infection to other members of society.

Leadership for HIV
The fourth call is to you our leaders at all levels. For this renewed campaign to succeed, you individually must engage. You the political leaders at all levels must go all out to deliver to your people in your constituencies the messages I have summarized in this article. You our religious leaders played an important role at the beginning of this epidemic by sending clear, constructive, and non-contradictory messages to their flock, including requiring HIV testing for prospective couples as part of marriage counseling. Your flock needs you to resume these and many more supportive practices. Our cultural leaders, you, too, should re-engage and deliver messages to your subjects. Those cultural norms and practices that expose individuals to HIV risk such as widow inheritance, wife sharing, wife replacement, polygamy, early marriages, sex and gender based violence- all must be addressed. Legislation and regulations already in place against these practices need to be enforced. The public must in addition be protected from misleading and confusing messages prevalent in the mass media, especially, FM radio stations, bill boards, and so-called gutter press. It is critical for the public good that a quality assurance mechanism is put in place to protect the public from wrong messages on HIV and AIDS disseminated in the media. The Ministry of Health together with the Uganda AIDS Commission and the Ministry of Information should seek to establish a pact with media to ensure that messages to the public are accurate and positive, and this as part of corporate social responsibility.

Resourcing the campaign against the epidemic
The final call is to you as an individual in Government and Parliament to ensure that interventions by all the sectors are well resourced for effective implementation of this campaign. Our AIDS Development Partners have committed to be by our side, despite the challenges they face on their domestic scene brought about by the global fiscal and economic crisis. But on our part, we must show that we mean business by examining alternative options for mobilizing additional domestic resources for the struggle. Current allocations are far below what is needed to contain this epidemic! However, I must quickly add that for you the implementers (public sector, civil society and private sector) it is essential that you are both accountable for and innovative enough to do more with the limited resources availed to you. Responsibility starts with you as an individual to ensure that resources for our national response are used for the intended purpose. The kind of stories that appeared in the press concerning misuse of grants from The Global Fund does not do the country any good whatsoever. The Global Fund resources come from the very development partners who are standing by our side in this fight against HIV/AIDS.

As I conclude let me stress that the power is in your own hands as an individual to protect yourself, your child, your wife or husband, and your neighbour. Let each one of us stand up again and face this epidemic.