Monday, July 2, 2012

Uganda's HIV Response: Hit Snooze Again

There have been several mentions of results from Uganda's 2011 Aids Indicator Survey over the past 6 or more months. However I can't find a copy of the report anywhere, not even the highlights or executive summary. But the news doesn't sound good. According to one of the newspaper mentions, the number of people infected with HIV has increased from 1.2m in 2005 to 2.4m today. That's a heck of an increase for a country that is supposed to have been the first in Africa to bring the epidemic under control.

As usual, someone has pointed out that high prevalence does not necessarily mean failed prevention policies because if more people are on treatment they will live longer, keeping the prevalence higher. However, the figure is increasing quickly, not staying the same. Tens of thousands of HIV positive people still die every year. The fact that about half of the 600,000 people eligible for treatment are receiving ARV drugs is great, but it's probably better not to draw too much attention to an epidemic that more than doubles (almost half a million probably died) in 7 years, despite the amount of money being spent on treatment.

The 'treatment as prevention' strategy, which goes under various names, involves the hypothesis that if every HIV positive person, or at least 80% of them, were to be put on ARVs straight away, they would be far less likely to transmit HIV to others. Transmission among people responding to treatment has been shown to be very low. But Uganda struggles to keep less than 15% of HIV positive people supplied with drugs, with frequent stock outs and many people being lost to follow up every year and resistance developing at an increasing rate.

There is still the constant argument and counter-argument about promiscuity and the rest, but this aspect of HIV transmission is now sounding rather idiotic. It's been going on since the 1980s. If people want to believe that a few sound bites about abstinence and faithfulness had any significant influence on the course of the epidemic, let them. But it's not having any influence any more, nor has it likely to have played any part for the last 20 years. It's time to move on.

Another article claims that HIV prevalence in Kabarole district among secondary schools is 30%. If that's true, and I have no way of corroborating it, such an outbreak would need to be investigated. It is claimed that a lot more females than males are infected, which is attributed to cross-generational sex. Males, on the other hand, are said to have been infected since birth.

The proportion of males infected must be very small indeed as prevalence among children under 5 is less than 1% and many of them will not survive into their teenage years, let alone adulthood. The percentage of children receiving treatment for HIV is also very low. Someone interviewed for the article said they want to avoid infections by using the ABC (abstain, be faithful, use a condom) strategy, presumably believing that it was used successfully in the past.

Perhaps believing it will be successful in the future, despite evidence being slight, students in a Uganda high school are putting their faith in male circumcision. The target of 1000 students was exceeded by 23, so now those extolling the virtues of circumcision have to ensure that neither the students nor their sexual partners believe that they can enjoy unprotected sex just because the male has had the operation. You'd think that wouldn't be too hard, but research has shown these beliefs to be common.

Sadly, although male circumcision may reduce HIV transmission from females to males, prevalence is currently a lot higher in females; and male circumcision may increase transmission from males to females. So it's hard to see any net benefit.

Instead of obsessing about sexual behavior, which is probably not that different in Uganda than in many other countries, those who express concern about HIV transmission rates could take a look at conditions in health facilities. If they expect people to use those facilities, safety and infection control procedures would need to be increased. But hospitals and clinics are understaffed, underfunded, there are shortages of drugs, equipment and supplies, standards of safety and hygiene are appalling. This is likely to have some influence on HIV transmission rates. But even if it doesn't, everyone will benefit from better health and healthcare and confidence in health service provision will increase.

But somehow, I can't see campaigns to improve health services, nutrition and food security, water and sanitation, infrastructure and education having quite the headline grabbing value as campaigns about sex, Africans, HIV positive babies, abstinence, condoms and whatever else the publicity people at UNAIDS dream up. I imagine the 'Woes of Tororo Hospital' and 'Kitgum Hospital - a Facility Falling Apart' receive a lot less attention than ones about circumcision, sex in schools, gay bashing and HIV figures doubling. It's hard to know what proportion of HIV is transmitted through non-sexual routes, such as unsafe healthcare. But it's unlikely to become clearer until healthcare associated HIV infections are properly investigated.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]



Anonymous said...

Male circumcision prevalence

Kikuyu - 98%
Luhya - 95.9%
Kalenjin - 93.8%
Luo - 21.5%

Male HIV prevalence

Uncircumcised Luo - 17.3%
Circumcised Luo - 16.4%
Circumcised Luhya - 2%
Circumcised Kikuyu - 1.6%
Circumcised Kalenjin - 1.5%

Female HIV prevalence

Luo - 22.8%
Luhya - 12%
Kikuyu - 5.9%
Kalenjin - 2.1%

Uncircumcised Kikuyu men - sample of 12 too small

Uncircumcised Luhya men - sample of 22 too small

Uncircumcised Kalenjin men - sample of 27 too small


Your thoughts?

Anonymous said...

Some scientists are insisting till now that 2/3rds of HIV in Africa is spread through unsafe medical practices.

Do women have a much higher HIV rate than men because they use hospitals much more (prenatal, maternity, postnatal)?

Do Luo men have a much higher HIV rate than other men because they use hospitals a lot due to malaria and other water-borne diseases?

The Kikuyu men lucky enough to live on the foothills of Mt Kenya never use hospitals because the water is uncontaminated (there are few or no people living upstream), there's no malaria, and they don't give birth. Is that why they have a low HIV rate?

HIV, hepatitis scare may affect 40,000 US clinic patients

What about Kenya which has overwhelmed hospitals?

Alice said...
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Simon said...

Hi Anonymous, thanks for your comments, I think the second comment makes some useful suggestions.

It's very hard to say what the relative contribution of sexual and non-sexual HIV transmission are. The figures and arguments presented here and elsewhere are a start, but there's no substitute for a proper investigation of possible outbreaks in healthcare facilities and an assessment of conditions with a view to improving them.

Also, DHS and similar data are not suitable for identifying possible outbreaks of non-sexually transmitted HIV. You'd need to identify times and places, whereas DHS data is a sample from a few places over a short period of time.

Dorispinto1001 said...
This comment has been removed by a blog administrator.
Anonymous said...

Could the huge differences in the HIV prevalence rates also be attributed to receptive anal sex?

Anal sex HIV risk misunderstood among heterosexuals

Assessing the role of anal intercourse in the
epidemiology of AIDS in Africa

Simon said...

Hi. Anal sex, heterosexual and male to male, is probably under-studied. Perhaps it explains some areas with high rates of transmission but it's unlikely to explain everything. But it would be good to have high quality research instead of the sort of idle speculation that UNAIDS seems to prefer.

arman said...
This comment has been removed by a blog administrator.