Uganda

New data show that the test and treat approach is having a significant impact on the number of people accessing HIV treatment. After Uganda adopted such an approach in 2017, according to government data the number of men newly initiated on treatment rose from 60 000 in 2016 to 80 000 in 2017, while the number of women newly initiated on treatment increased from 107 000 to 138 000 in the same time period.

Just as importantly, the treatment gap between people newly diagnosed as HIV-positive and people newly initiated on HIV treatment has shrunk for both men and women in Uganda. The gap for men narrowed by 45%, from 33 000 in 2016 to 18 000 in 2017, while for women it narrowed by 60% in the same time period, from 48 000 to 19 000. Although more women are testing HIV-positive than men, the HIV treatment gap is closing for both women and men.

Similar trends were observed in Zambia after the start of its test and treat policy in 2017. Zambia has seen the number of people newly initiating HIV treatment increase from 23 000 in the first quarter of 2016 to 45 000 in the final quarter of 2017, according to government data—an increase of 65%.

Through a test and treat approach, if a person tests HIV-positive, he or she is immediately enrolled on HIV treatment. Before the advent of test and treat, people living with HIV had to wait for their CD4 count to drop to a particular level before starting treatment.

Both these effects of test and treat were seen after the recent launches of so-called situation rooms in both Uganda and Zambia. The situation rooms are interactive software platforms that centralize data for HIV and other diseases to improve tracking of the diseases and programming in order to reach more people with services.

“Right now, I just want to go to a country where there is peace,” says a young student who fled the conflict in his home country, the Democratic Republic of the Congo. His new home is Kyangwali Refugee Settlement Area in the Hoima District of Uganda—the place that will give him a chance to fulfil his dream of a peaceful life.

The Kyangwali Refugee Settlement Area lies on the banks of Lake Albert on the border between southern Democratic Republic of the Congo and northern Uganda. Most of the refugees in Kyangwali are fleeing interethnic conflict in eastern Democratic Republic of the Congo and making the perilous journey into Uganda on fishing boats across Lake Albert. Since January 2018, approximately 59 000 people have made the crossing. On a normal day 500 refugees arrive; on a busy day it can be as many as 2000.

Families arrive with whatever personal belongings they can carry—from mattresses and cookware to valuables, such as solar panels, piled high among the passengers in the boats. The boat ride can take as little as six hours if people travel in a motorized vessel or as much as 12 hours if they travel by canoe. “Boats sometimes run out of fuel in the middle of the lake and Ugandan marine police have to bail them out,” says Bornwell Kantande, Representative of the Office of the United Nations High Commissioner for Refugees in Uganda. “Other boats have capsized from overloading—at the peak of the influx of refugees as many as 200 people would pile onto a single canoe.”

Upon arrival at the Kyangwali reception centre, refugees are registered by aid workers and given a wristband for identification purposes. They receive high-energy biscuits and water and those who need it are given emergency health care. Refugees stay at the reception centre for a day or two before being transported to the settlement area, where they are allocated a small plot of land and material and equipment to build temporary shelter while they establish themselves.  

In a recent visit to the reception centre, Michel Sidibé, UNAIDS Executive Director, witnessed first-hand the health services that are offered to newly arrived refugees at its small makeshift clinic. Here refugees obtain access to emergency health care and are informed about the minimum initial service package for reproductive health, which they receive throughout the different phases of new arrival: border crossing; the short stay at the reception centre; before transportation to the settlement area; and during settlement. Services include HIV testing and tuberculosis screening, prevention of mother-to-child transmission of HIV services, provision of HIV and tuberculosis treatment to people already on it and other sexual and reproductive health services.

During his visit, Mr Sidibé listened to the stories of many refugees, who told him not only of the impact that dislocation has had on their health and their lives, but also of their aspirations and dreams to make a better life for themselves and their families. “I heard stories of sadness, but also of hope and resilience,” says Mr Sidibé.

Uganda is home to the largest refugee population in Africa, with a population of almost 1.4 million refugees in 13 refugee settlements across the country. The majority of refugees are from South Sudan and the Democratic Republic of the Congo, the latter of which has close to five million displaced people—almost as many as in the Syrian Arab Republic.

“It is beyond admirable to selflessly offer refuge to hundreds of thousands of women, children and men who are in need of international protection,” remarked Mr Sidibé. “Uganda’s refugee policy is among the most progressive in the world and is a model for other countries to emulate.”

On International Women’s Day, which is celebrated on 8 March every year, Yosweri Museveni, President of Uganda, affirmed his commitment to empower women in the work place and in the domestic sphere. At an International Women’s Day celebration in Mityana District, in the Central Region of Uganda, President Museveni outlined the action taken by government to promote women in the civil service, including the army, police and in Parliament. Government is also currently developing legislation to promote the rights of women in the home.

During the event the President, in the presence of UNAIDS Executive Director, Michel Sidibé, launched the Presidential Fast-Track Situation Room, a data visualisation platform which draws from multiple sources to provide real-time data for monitoring the implementation of the Presidential Fast-Track Initiative to End AIDS in Uganda by 2030. The initiative is a multi-sectoral effort to consolidate progress on key areas of HIV prevention revitalize HIV prevention, testing and treatment.

In a special ceremony, the President awarded Mr Sidibé the Most Excellent Order of the Pearl of Africa, the highest civilian award of the Ugandan Honours System, in recognition of Mr Sidibé’s contribution to the global AIDS response and his continued support to the Government of Uganda and its partners.

When Robinah Babirye was at boarding school, her secret was difficult to hide. Sleeping in an all-girls dormitory, everyone knew everyone else’s business, especially around bedtime. “It was hard to bring out my medicine,” she said. “It would raise questions.”

Ms Babirye and her twin sister were hiding their HIV-positive status. Before starting at boarding school, the daughters and their mother would take their medicine daily at 10 p.m., and that was all there was to it.

Once she enrolled at university in Kampala, Uganda, in 2013, hiding became more difficult. Her room-mate was suspicious and spread rumours. Having been born with HIV, she couldn’t help feeling that life was unfair.

“At the time, I hadn’t accepted that I was living with HIV and that I had to live with it for the rest of my life,” said Ms Babirye. She described years and years of avoiding ever speaking to anyone about her regular visits to the clinic or about taking treatment. Then her mother died from cancer and she didn’t know how to cope.

Glancing above her eyeglasses, she added, “When I saw my mother fighting, it gave me strength, but when she died that became a terror.”

Ms Babirye more or less gave up. She stopped taking her medicine and drifted.

Asia Mbajja, founder and director of the People in Need Agency (PINA), a nongovernment organization for young people living with HIV in need, described appeals from distraught teenagers. She had helped many of them as children while working as a treatment coordinator at the Joint Clinical Research Centre children’s clinic.

“I kept promising them that life would change and get better, but as they grew up, their needs changed,” she said. “I needed to do something that would make a difference.”

In 2012, Ms Mbajja quit her job to start PINA. Among her first clients was Ms Babirye, whom she has known since the age of 10. She hammered over and over the importance of taking the daily dose of antiretroviral therapy.

“The problem is that all of Asia Mbajja’s upbeat encouragement would come tumbling down once she was no longer around,” Ms Babirye said. The young woman felt defined by HIV.

“When you're told that you have to take medicine for the rest of your life, coupled with the rumours and stigma, I feared I would forever be stuck,” she said. “Despite living with HIV, I am still a woman with feelings.”

Through her involvement with PINA, in 2014 Ms Babirye travelled to the International AIDS Conference in Melbourne, Australia. The young woman felt elated to discover a world where her status seemed a non-issue, but upon her return she couldn’t help feel like there was a line she could not cross.

Ms Babirye felt tired. She wavered between ending her life and changing her life for good.

Donning an I am HIV Positive t-shirt she posted a photograph of herself on Facebook. “My heart started to beat so fast, I couldn't bear to see the comments,” she said. She paused and let out a gasp and said, “I was expecting a lot of negativity, but the comments were largely positive.”

Her twin sister, Eva Nakato, couldn't believe what she had done. After some thought, she decided she couldn’t let her sister fight alone, so she also disclosed her status.

“When people said we need more people like her it motivated us,” said Ms Nakato.

One of the first people to congratulate the twins was Ms Mbajja. Ever since, the duo have been at the forefront of PINA, testifying, mentoring and singing. Ms Nakato explained that at the children’s clinic they used to sing as a group, and at PINA they brought it to a whole new level.

“We started using music to convey HIV awareness messages," she said. Songs like Never Give Up, Yamba (Help) and ARV. Their latest projects now include launching a television series around HIV and relationships and documenting gender-based violence.

“When we met survivors of sexual abuse, that pushed me to make a movie,” Ms Nakato said, adding that videos and music can get messages across.

Ms Babirye finished her university degree last year and dreams of independence. 

In the long term, she said her vision is a generation that is AIDS-free and stigma-free. “To accomplish an AIDS-free world, each individual has a responsibility to do something and break down cultural and societal barriers,” she said.

Young people living with HIV have, with support from UNAIDS and youth leaders, begun an innovative and unprecedented partnership to strengthen South–South collaboration between networks of young people living with HIV in Latin America and the Caribbean and in Africa.

Young people living with HIV in both regions have for a long time organized in national and regional networks to advocate for increased access to HIV services. Now, through a new joint initiative called the 10 Questions Project, they will assess the organizational, advocacy and outreach capacities of networks of young people living with HIV globally, using social media tools, online surveys and in-depth interviews.

Through the initiative, lessons will be learned from each region’s ongoing efforts and from how young people living with HIV in each region participate in the AIDS response. The 10 Questions Project will outline and commit to common advocacy strategies and identify solutions to the challenges faced by young people living with HIV. The assessment will aim to better inform partners and key stakeholders, including donors, on investment choices for strengthening networks and organizations of young people living with HIV.

This joint effort between regions aligns with #uproot, a recently launched youth-led political agenda to end AIDS by 2030, which highlights the need to innovate and reinvigorate partnerships within the youth movement working on HIV, including between youth networks from countries in the global South.

UNAIDS is working to ensure that the world keeps its commitment made in the United Nations Political Declaration on Ending AIDS that 90% of young people have the skills, knowledge and capacity to protect themselves from HIV and have access to sexual and reproductive health services by 2020.

In Uganda in the late 1980s and early 1990s, the President, Yoweri Museveni, showed the world, through pioneering high-level political leadership, that it was possible to reverse the AIDS epidemic, and for many years new HIV infections declined in Uganda. New HIV infections were reduced from 150 000 in 1990 to 66 000 in 1998—an incredible decline of 56%. However, by the early 2000s, the AIDS epidemic had begun to rebound, and by 2009 had climbed back up to 130 000 new HIV infections per year, a devastating blow to the country’s efforts to push the epidemic into permanent decline.

In the past few years, steps have been taken to once again reduce the epidemic, and in 2015 new HIV infections had dropped to 83 000. However, a disproportionate number of adolescent girls and young women between the ages of 15 and 24 are being affected and around 360 are becoming newly infected every week.

President Museveni is ready to reclaim his leadership role in the AIDS response, and on 6 June in Kampala, Uganda, at an event attended by the UNAIDS Executive Director, Michel Sidibé, launched the Presidential Fast-Track Initiative on Ending AIDS as a Public Health Threat in Uganda by 2030. Dubbed “Kisanja hakuna mchezo” (no playing games), the initiative contains a five-point plan for more focused and urgent action to accelerate achieving control of the HIV epidemic in Uganda.

The plan will aim to revitalize HIV prevention, especially among adolescent girls and young women, and consolidate progress on elimination of mother-to-child transmission of HIV. It will also accelerate implementation of HIV testing and treatment for men, particularly to ensure they reach the 90–90–90 targets, address financial sustainability for the AIDS response and ensure institutional effectiveness for a multisectoral response.

The First Lady of Zambia, Esther Lungu, attended the launch to reaffirm her commitment to the AIDS response and that of the Organisation of African First Ladies against HIV/AIDS.

During a meeting with the First Lady of Uganda, Janet Museveni, who is also the Minister for Education, Mr Sidibé congratulated her for her commitment to the elimination of mother-to-child transmission of HIV. As a result of her personal drive, Uganda has experienced a 90% decline (from 2009 to 2015) in the rate of mother-to-child transmission of HIV, the highest of the 21 priority countries of the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive.

The Director for the UNAIDS Regional Support Team for Eastern and Southern Africa, Sheila Tlou, has visited Uganda to advocate for accelerated action to address the trend of rising new HIV infections in the country. According to UNAIDS data, 360 new HIV infections occur per week in Uganda among adolescent girls and young women aged 15–24 years.

Uganda has been identified as one of the Fast-Track countries globally that can make a significant contribution to ending AIDS as a public health threat by 2030.

Ms Tlou congratulated the First Lady of Uganda, Janet Museveni, for the country’s efforts to prevent mother-to-child transmission of HIV. Uganda saw a drop in new HIV infections among children of 86% from 2009 to 2015.

The First Lady took note of the commitment by UNAIDS to support the delivery of a country-specific sexual health educational programme that reflects the will and values of the Ugandan people. Comprehensive sexuality education, championed by UNAIDS, is a critical aspect of empowering young women to prevent HIV infections.

While in Uganda, Ms Tlou also met with the King and Queen Mother of the Tooro Kingdom and the Speaker of Parliament, Rebecca Kadaga.

King Oyo Nyimba Kabamba Iguru Rukiidi IV of the Tooro Kingdom in Uganda expressed his commitment to ending the AIDS epidemic as a public health threat by 2030 as he accepted the role of Cultural Champion for HIV and AIDS among Young People in Eastern and Southern Africa on 8 September. At 24, King Oyo is the youngest reigning monarch in the world and has significant influence and respect among young people in the eastern and southern Africa region.

Speaking in Fort Portal, Uganda, in the presence of the UNAIDS Regional Director for Eastern and Southern Africa, Sheila Tlou, King Oyo highlighted the need to eliminate new HIV infections in the kingdom. He emphasized that this should not be the role of women alone and called on men to support their partners, especially with regard to the prevention of mother-to-child transmission of HIV.

Uganda has made much progress in its HIV response. Prevention of mother-to-child transmission of HIV coverage is over 95%, which has led to a reduction in the number of babies born with HIV from approximately 28 000 in 2011 to 3400 in 2015. New HIV infections have also dropped by more than half, from 162 294 in 2011 to 83 000 in 2015. While there have been many successes, new HIV infections remain high. Uganda registers an estimated 33 new HIV infections per day among young people between the ages of 15 and 24 years and comprehensive knowledge of HIV, as well as uptake of HIV prevention and treatment services among young people, remains low. Thus, King Oyo’s new role is critical to addressing HIV prevention among young people.