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New Vision
Uganda: Are We Ready to Provide More Free ARVs?
<p>John Agaba</p>
August 3, 2013

The World Health Organisation has raised the level of CD4 cell count at which people living with HIV are eligible for treatment. This certainly comes as good news. However, challenges await. At the moment, Uganda contributes only 10% of the funds needed to fight against the pandemic. Even with the previous level of 350 CD4 cell count, only half of those eligible for treatment were getting it. Experts now believe that with political will, the new target can be achieved, writes, JOHN AGABA

There is good news for people living with HIV. Last month, the World Health Organisation (WHO) released new treatment guidelines, raising the level below which people living with HIV are eligible for free treatment. WHO called upon health authorities worldwide to start early treatment in adults whose CD4 cell count falls to 500 cells per cubic millimetre or less.

The new guidelines, released in Kuala Lumpur, Malaysia, at the end of June, are based on research that indicates that starting ARVs early, keeps patients healthy for many years and signifcanly reduces risk of infectious diseases. It also greatly lowers their viral load and cuts their risk of infecting others.

The previous threshold of 350 cells per cubic millimetre would find the patient already weak as a result of the virus damaging the immune system.

The guidelines also encourage immediate treatment for persons with HIV, who also have other opportunistic infections like TB, Hepatitis B, and severe chronic liver disease, no matter their CD4 count.

The guidelines require all expectant or breastfeeding mothers and their children under five and partners in discordant relationships to be started on treatment immediately, regardless of their CD4 count and that all HIV patients be regularly monitored to assess their 'viral load'.

But is Uganda ready?

But there is also the bad news. Uganda cannot afford to give all people living with HIV free treatment. Even at a threshold of 350 or less, many people eligible for treatment were not getting it free.

According to the latest Uganda Aids Indicator Survey report, only half of the people eligible for treatment are getting it free. This means only about 366,500 of the total 733,000 people eligible are actually accessing free treatment. The other 366,500 are either paying for it on their own or waiting to die.

However, these figures fluctuate. Musa Bungudu, the country representative of UNAIDS (a UN body overseeing HIV response), says about 485,000 Ugandans are on treatment.

Dr. Joshua Musinguzi, the AIDS control programme manager at the health ministry, says the people on treatment are about 489,000 out of the 733,000, who are eligible. Of these, there are 620,000 adults and 113,000 children.

He adds that 53% are women and 46% men. Statistics indicate that 51% are in urban areas, while the rest are in rural areas. At an HIV prevalence rate of 7.3%, about 2,409,000 people are estimated to get infected every year in Uganda. This means that about 6,600 people get infected every day.

About 2.4m of the country's 34 million people are living with HIV. And an estimated 64,000 people died of HIV-related illnesses last year.

Uganda contributes only about 10% towards the $344.4m spent on AIDS responses in the country. Over 79% of the funds come from donors and the rest from private individuals. So, what would happen if, one day, the donors pulled out?

During the Malaysia convention last year, Uganda was carved out as one of the worst performing countries in HIV response.

So, why is Uganda sleeping?

Musinguzi insists that the country is not sleeping.

He says contrary to reports that Uganda is losing the war against HIV when at one time it was the globe's success story, the situation is not as bad as portrayed.

"We are availing ARVs to all children below two years, all HIV-positive expectant mothers or breastfeeding women. Persons with opportunistic infections like TB are also getting free treatment. We have also significantly reduced the number of HIV-related deaths. Early treatment also means prevention. But we cannot just jump to implementing the guidelines," Musinguzi explains.

He says they have to establish the number of people who would be eligible for free treatment at CD4 count 500, plan the personnel, procurement of drugs and then the service delivery.

"Do we have the kits? Are all health centres able to cope with the guidelines? Are all patients sensitised about the new guidelines? Will they accept them? Then we have to lobby for the money. We cannot implement all this without resources," says Musinguzi.

On average, one HIV patient requires about sh600,000 for medication in a year. The first line treatment goes for about sh50,000 a month, excluding the opportunity cost.

Musinguzi says the health ministry and the Uganda AIDS Commission and other stakeholders, are in consultative meetings to find the best way to implement the guidelines.

"We hope to be through with the meetings by the end of September or mid-October. Then, hopefully by 2014, we should have started implementing most of these guidelines."

About Government's dismal contribution to the HIV basket, Musinguzi says the Government was considering increasing its contribution towards HIV funding. An AIDS Trust Fund was proposed by the AIDS Commission and the Bill is in Parliament, he said. MPs will determine whether the Government can levy a tax on airtime, cigarettes and beer to internally generate funds to go to HIV interventions.

"We are trying to see if our health centre IVs countrywide can carry out CD4 tests so that it becomes easier to determine who should be put on treatment," says Musinguzi.

HIV management in schools:

By Vicky Wandawa and Halima Nampiima

About 150,000 children below 15 years are HIV positive in Uganda today. Of these, 64% are in school, according to Dr. Sabrina Bakeera-Kitaka, a paediatric and adolescent health specialist at Mulago Hospital. Kitaka says most of them acquired HIV from their mothers.

She says most of the children face stigma and discrimination in school and many of them fail to adhere to their treatment, as a result of non-disclosure to schoolmates and the staff.

"Non-adherence is the commonest cause of treatment failure, resulting in their poor health," Kitaka says.

Dr. Philipa Musoke, a senior paediatrician with Makerere University Johns Hopkins University Research Collaboration, concurs.

"When students see rashes on their colleagues, the rumours start. For adolescents, it is worse because they are at an age where they want to be like their peers, therefore, taking medicine reminds them that they are different."

Kitaka advises that for survival, HIV-positive students should be availed with treatment while at school, in addition to psycho-social support to cope with the disease. Programmes where learners are taught about chronic diseases should be stressed, with emphasis on empathy and compassion for those affected.

How schools handle HIV cases:

Schools have different ways of handling HIV-positive students. Seraphine Amulen, the head teacher of St. Mary's, Namagunga, says students and staff are often sensitised about HIV.

"We often have peer counselling sessions during assemblies. We encourage disclosure to the administration for easy monitoring," she says.

At St. Peter's SS, Naalya, Henry Mugisha, a counsellor, says they have about 15 students infected with HIV/AIDS.

"Students are not forced to disclose their status, but in case s/he realises the need for a teachers' help, for example with counselling, the teachers are available," says Mugisha.

"When the child's status is known, teachers get to know how best to handle the children and help them to fit in society," explains Mugisha.

However, care is taken to ensure that students do not disclose their status to fellow students, so as to reduce chances of stigma.

At St. Lawrence schools and colleges, in order to fight stigma, students are only required to disclose their status to the school nurse. The nurse is then cautioned that no word about such students' status gets out. HIV guidance and counselling sessions in the school are mandatory for each student.

Moses Serwanga, the proprietor of Golden Bell Infant and Junior School, says the school has about nine children who are HIV-positive. He says most of the pupils are not aware of their status.

"The parents are encouraged to disclose their children's status. On enrollment, the parent fills a health form; hence the status can be indicated. Such children are given special attention by our staff. We also provide ARVS," says Serwanga.

Are boarding schools advisable?

Kitaka says it is better for a parent to remain with their children at home to monitor and support them.

"Each family and every child is unique, and the demands to place a child in a boarding school vary," she says. Nonetheless, she adds that should a parent opt for boarding school, it's vital to disclose to the school nurse and the head teacher in order for them to support the child.

Ministry of education reacts:

Dr. Y. K. Nsubuga, the director of basic and secondary education, says HIV-positive students are protected under the HIV workplace policy.

"Although it is for workers, even students are included. No child should be excluded from school because of their sero status," he says.

Nsubuga adds that head teachers have the power to punish teachers who stigmatise students.

He also encourages students to report the cases and if ignored, to approach the district education officer or the chief administrative officer.

Treatment is prevention:

Margaret Happy, a person living with HIV and the advocacy manager for the national forum of People Living with HIV and HIV/AIDS networks in Uganda, wonders why many people should still be dying when ARVs can turn the situation around.

It is inexcusable, she says, that at a threshold of a CD4 count of 350, Uganda still has a big chunck of people eligible for treatment who cannot access free treatment.

"New evidence shows that treating people not only keeps them healthy, but also enables them to live longer, productive lives. Their viral load is also lowered, meaning that their efficacy reduces," she explained. "Already, we look at treatment as prevention. Bringing the threshold to 500 will yield better results, better responses to medication and easy adherence to the drugs. People start treatment when the virus has not yet weakened their immune system."

Happy explains that when more people are treated, the burden on the health care is reduced.

Dr. Lydia Buzaalirwa, the quality management director at the AIDS Healthcare Foundation, says the Government should not delay because the service provides are ready.

"These guidelines are new, but not the approach. We started at CD4 count of 200 and then went to 350. And along the way there are people we have been adding on to the treatment, like pregnant and breastfeeding women and children below two years. So, it won't pose a challenge."

Adherence is easier when you start treatment early and the people have the energy to go and get their drugs and even the response in terms of recovery is much easier.

What is the way forward?

Joshua Musinguzi, the AIDS control programme manager at the health ministry, says the Ministry of Health remains committed to reducing new infections and eliminating HIV-related deaths.

"We shall continue emphasising the ABC approach, circumcision, elimination of mother-to-child transmissions and have as many people as possible on ARVs," he says.

However, Bungudu cautions that without a strong political will to implement the new guidelines, funds would not be available.

"Money is not the issue. Money should never be seen as the obstacle in HIV treatment. The Government can do it if it wants," he says.

Dr. Elioda Tumwesigye, the Minister of State for Health, takes the stakes even higher. "The way to go is to remove the CD4 count barrier so that everybody with HIV gets free ARVs. This may increase the budget for drugs in the short run, but in the long run, it will reduce burden on treatment, reduce deaths, reduce infections and will be cost-effective."

Tumwesigye, the outgoing chairperson of the parliamentary committee on HIV/AIDS, adds: "We should not be talking about whether the Government can afford it. Saving life is the highest ethical responsibility. I hope the Government will cut a few costs elsewhere and save more money for ARVs."

Margaret Happy, a woman living positively, says the Government needs to revise its drug procurement and delivery, adding that National Medical Stores needs to establish regional stores so that the drugs are delivered on time. "Cases of people not finding drugs affects adherence. It puts them at the risk of drug resistance. Some often don't return because of long distances. The supply chain should be rationalised," she says.

Dr. Lydia Buzaalirwa, the quality management director at the AIDS Healthcare Foundation, says a lot of community mobilisation and education is needed so that people get to know the importance of HIV testing, adherence to ARVs and the ABC (Abstinence, Being faithful or the use of condoms) strategy.

"For the times we have taken services to the people, mostly women come to be tested. The men use the women's results as a litmus test for their status," she says.