Uganda Faces Antiretroviral Treatment Shortage as HIV Prevalence Rises


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KAMPALA, UGANDA – Medius Kyomukama, 43, is a cab driver living with HIV in Kampala, the capital of Uganda. She learned of her HIV-positive status about 15 years ago when her husband died after a battle with AIDS.

“My husband died in 1997,” she says. “We had one child, a daughter, who was 4.”

Kyomukama says this prompted her to get tested.

”After he died, I tested for HIV and found I was positive,” she says.

Kyomukama was born and raised in Akashenda, a village in Mbarara district in southwestern Uganda. She says she was a village belle, and many young men admired her beauty.

“I was a beauty queen,” she says, reminiscing with her left hand cupping her chin. “Only the stiff-necked men would not take a second look at me. I did not know that I would end up like this – surviving on drugs.”

Kyomukama says she is grateful to the Ugandan government for providing free anti-retroviral treatment to HIV-positive citizens. Otherwise, she says she would be dead.

“It is good the government is providing free anti-retroviral therapy for us now,” she says. “That’s why I am still alive.”

She says that her husband would still be alive, too, if free anti-retroviral treatment had been available at that time.

“Those days, ARVs were very expensive, and we could not afford them,” she says. “Otherwise, my husband would be alive.”

She says the treatment has enabled her to live positively with HIV. She has been able to take care of her two daughters, Margaret and Mackline, and to secure a future so far for Mackline, who is in her last year of high school. She has also been able to construct a house of her own in the nation’s capital.

“I have taken my daughter through school,” she says, her face brightening. “She is in senior six. And I now built a house for myself, in which I live.”

Women in Uganda with HIV say they are able to live positively thanks to free anti-retroviral treatment. But an increasing number of women, who make up nearly 60 percent of the infections here, are saying that health centers lack the supplies to enable them to start the treatment they need. Cuts in international funding, which provides the bulk of support for the fight against HIV in Uganda, threaten the country with future shortages. International donors have asked the government to increase its contribution to the funding of HIV and AIDS prevention and treatment, but preliminary budget plans have not done so.

HIV prevalence in Uganda has increased from 6.4 percent to 6.7 percent, according to the preliminary results of an HIV and AIDS survey released by the Ministry of Health in February 2012. A final report will be published in June.

As of 2009, women made up 57 percent of Ugandans infected with HIV, according to the Uganda AIDS Commission, which Parliament established in 1992 under the office of the president.

Janet Kamujuni, 52, is a counselor at the Joint Clinical Research Centre in Rukungiri, another district in southwestern Uganda. She says she learned that she and her late boyfriend were HIV-positive 20 years ago.

“I learned that I was HIV-positive in 1992 when my boyfriend started falling sick,” she says. “We took an HIV test and found we were positive. He died a few months after.”

Kamujuni says her immune system was still strong, and she had not started getting sick. She began taking co-trimaxazole prophylaxis, a tablet given to people with new HIV infections to fight opportunistic infections caused by pathogens that take advantage of compromised immune systems.

“I started taking co-trimaxazole for about 15 years,” she says. “I was not eligible for ARVs because my CD4 cell count was high. I only started taking ARVs recently when my son refused to go to school. I was so worried about dying and leaving him when he does not have sufficient education. That was when my CD4 cell count went low.”

But not everyone living with HIV in Uganda has been able to access the free anti-retroviral treatment.

Only 42 percent of people living with HIV and AIDS in Uganda who need treatment have been enrolled in the anti-retroviral program because of infrastructure limitations, resource constraints, population growth and the addition of 20,000 new people who become eligible for the treatment every year, according to a 2007 report by the Uganda AIDS Commission.

Kankusi Sylvia, 42, a peasant mother of five who lives in Isingiro, another district in southwestern Uganda, says she has not been able to access the free anti-retroviral treatment. When she went for testing in January 2012 at the Kabuyanda Health Centre, her CD4 cell count was low.

“I went to the health center in Kabuyanda, and I was told that my CD4 count was low and I was ready to start on ARVs,” she says.

But she says that staff members told her that although she needed to start taking anti-retroviral treatment, they did not have enough medication to start new people on the treatment. It was available only for those who were already enrolled.

“I was advised to go to Mbarara district, which is very far from home, and I am not yet able to afford the transport,” she says. “They said that they don’t have ARVs for new people like me. They only gave me Septrin to stop other diseases from attacking me.”

But Mbarara University Teaching Hospital, where the staff advised her to go for the anti-retroviral treatment, is about 75 kilometers from her home. She has not yet been able to afford transportation to the hospital, which costs about 45,000 shillings ($18) round-trip.

She is hoping that one day, the medication will become available for her at a nearby public health facility. Meanwhile, she is taking co-trimaxazole prophylaxis, which she received at Kabuyanda Health Centre, to prevent opportunistic infections.

Uganda relies heavily on donor funding, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. President’s Emergency Plan For AIDS Relief. The latter supports 75 percent of all of Uganda’s patients receiving anti-retroviral treatment, with a target to reach an additional 36,000 to 50,000 patients each year for the next three years, according to a December 2011 report by Médecins Sans Frontières. But the Global Fund rejected Uganda’s application for the last two funding rounds and deemed Uganda ineligible for the full amount for the second phase of an earlier round, which the country is currently relying on, because it underspent during the first phase.

Florence Buluba, the executive director of the National Community of Women Living With HIV/AIDS in Uganda, says that the cancellation of the next Global Fund round means that there will be a shortage in treatment. This will lead to an increase in infections, particularly in mother-to-child transmission of HIV.

“There will be a shortage in treatment,” she says. “If many women are not on treatment, this will increase the infection among the newborns.”

Buluba also adds that treatment contributes about 90 percent of prevention efforts among people living with HIV and AIDS. She says death rates will increase if women are not on treatment, and this will consequently increase the government expenditure on health.

Flavia Kyomukama, an HIV and AIDS activist, says that the Global Fund’s cancellation of its next round will increase the disease burden – not only of HIV and AIDS, but also of other opportunistic infections and deaths.

“There are already stockouts of medicines for tuberculosis and ARVs in some areas,” she says. “Cancellation of the Global Fund round 11 means that more people on HIV treatment will miss taking drugs and thus become more infectious, leading to increase in HIV prevalence. The deaths related to HIV/AIDS will also increase.”

Uganda, like other low-income countries, can’t afford to provide anti-retroviral treatment to everyone who needs it, according to a 2011 press release from the Uganda AIDS Commission. There is also a need for a more sustained supply of medicine, with fewer side effects and at a cheaper cost from manufacturing companies.

People also need to get tested, according to the release. Sixty percent of Ugandans have not been tested and do not know their HIV statuses. People who have been tested and have started treatment sometimes stop if they are not having symptoms.

The country also needs a more robust and functional health system with the necessary infrastructure, equipment, medical supplies and skilled personnel, according to the release.

International donors have called on the Ugandan government to increase domestic spending on HIV, according to the Médecins Sans Frontières report. But the national budget approved in September 2011 did not include an increase for many areas of the health sector. Currently, the Ministry of Health covers just 10 percent of the national HIV budget.

The 2012-2013 budget strategy paper presented by Maria Kiwanuka, minister of finance, planning and economic development, in March 2012 did not include domestic HIV financing among the key challenges facing the health sector.

Sam Lyomoki, chairman of Parliament’s Committee on Social Services, which oversees the health budget, called for increased funding during a committee session this month on the 2012-2013 budget.

“On this matter, the committee this time is very serious,” he said. “And they are not going to accept a situation where we comment, and Finance doesn’t want to support the recommendation.”

He said that he hoped that more money would be allocated to the health sector, especially to HIV prevention and treatment.

“After committees conclude their reports, the budgets will be returned to the various ministries, including Health, for revisions,” he said. “I am hopeful more money will be forthcoming. If not, my committee will look at reallocating money from expenditures, like conferences and workshops, toward beefing up HIV programs and filling staffing gaps.”

Kyomukama advises that if the government is not able to provide anti-retroviral treatment for all, then those who can afford the medication should buy it for themselves. That way, the government and development partners can provide anti-retroviral treatment for the rest of the population who can’t afford it on their own.