|Safe Blood in Developing Countries - The Lessons from Uganda (EC, 1995, 151 p.)|
|Section Two - Background: Uganda's history, health, and the HIV/AIDS epidemic|
|Chapter Three - AIDS in Uganda: A glimmer of hope?|
'Uganda is experiencing an epidemic that rivals the worst ever experienced by any nation... any discussion of the health sector in Uganda in the 1990s is dominated by STDs and AIDS in particular. Although other health issues remain critical, they are dwarfed by the magnitude and immediacy of an estimated 1.5 million Ugandans being infected with HIV
That is the World Bank's summary of the AIDS situation in its 1994 project proposal for a loan of US$ 73 million to Uganda to help control sexually transmitted diseases (STDs), including HIV/AIDS. Given that only a little over half the Ugandan population is over 15 years of age, the statistics mean that one in every six or seven adults is infected by HIV.
For some groups of people, the level of infection is worse. In Kampala, some 30 per cent of all pregnant women going to ante-natal clinics are infected, and in many parts of the country AIDS is the most common cause of adult admission to, and deaths in, hospital. During 1995 new evidence emerged that at long last the epidemic may be reaching some sort of plateau, or even declining. While still tentative, this evidence offers 'a glimmer of hope', and is discussed below.
Cases of AIDS first began to appear in the 1980s, and soon after HIV tests became available in 1985, the first case of AIDS was confirmed in the Rakai district, part of that area bordering on Lake Victoria which many regard as the epicentre of the AIDS pandemic in Africa. Estimates suggest that the cumulative number of AIDS cases since then is over 300,000, and projections suggest that in the 1993 - 1998 period, due to past infection rates, perhaps 565,000 adults and 250,000 children could have died of AIDS (though actual numbers will never be known, due to under-reporting and under-diagnosis).
The most common symptoms of HIV in Uganda are weight loss, chronic diarrhoea, prolonged fever and cough, and (more and more) tuberculosis. Once AIDS sets in, Ugandans survive for a far shorter time than in developed countries. Partly as a result of HIV/AIDS, tuberculosis has re-emerged (in Uganda as elsewhere in Africa) as a serious and growing public health problem.
What clearly distinguished Uganda from other African countries, where the existence of the HIV/AIDS epidemic was for some time denied or hushed up for fear of damage to the tourist trade, or out of pride and distaste, was that Uganda and its President swiftly and publicly acknowledged the presence and extent of HIV/AIDS, and invited outside help both in rebuilding the health system of the country, and in particular in mobilising efforts against HIV/AIDS. In 1987, the Uganda AIDS Control Programme (ACP) was set up within the Ministry of Health. Later, in 1991, an independent Uganda AIDS Commission was set up, with financial aid from the World Bank group, which had early on become involved in the rehabilitation of Uganda's health services. As an emergency response to the country's health problems, the IDA (International Development Association, part of the World Bank group) in 1988 launched the First Health Project, an ambitious programme to help restore health services in Uganda. The First Health Project encountered severe problems, principally over accountability for money spent, but it was a start. By 1990, external aid including aid from the EC accounted for almost half of Uganda's total health expenditure, against 20 per cent for the general run of sub-Saharan countries, and stood at about US$ 2.8 per head of the population, thus emphasising both the low level of national health expenditure and the dependence on foreign help.
HIV infection rates (%): among antenatal attenders at selected sites
The Nakasero computer records system
The First Health Project had several components, one of which was AIDS control. Within that, there was an element for blood transfusion, and along with the 1988 IDA loan there was a grant of about US$ 600,000 from SIDA (the Swedish aid agency) for help with the rehabilitation of the blood transfusion service. Part of the money was spent on training, and about half of it was spent on buying Elisa readers, refrigerators and other equipment, including vehicles. These were distributed to 12 district blood transfusion units outside Kampala. Later, these district facilities were put under the same administration as the Kampala blood bank, so contributing to today's national integrated blood transfusion service.
Two studies issued in 1995 offer what one of them calls 'a glimmer of hope' that the rate of HIV may at last be stabilising or even decreasing in Uganda, although Ministry of Health officials are cautious about placing too much weight on this evidence, too soon.
Packing blood bags in a coolbox for distribution
In the first study, a group of scientists headed by epidemiologist Daan Mulder and funded by the UK's Medical Research Council have been studying rates of HIV infection among adults in a group of 15 rural villages, all near to each other, in the Masaka district of south-west Uganda. Most of these adults are peasants who grow bananas as a subsistence crop and coffee for sale. Most are Roman Catholics, but one in four are Muslims. The study has been going on since 1990. The key finding in 1995 was that:
'During the 5-year period, the overall HIV-1 seroprevalence showed little change, from 8.2 per cent in 1990 to 7.6 per cent in 1994. In contrast, in males aged 20 to 24 years the prevalence decreased by 80 per cent, (from 11.8 per cent to 2.4 per cent); among females aged 13 to 19 and 20 to 24 years the decrease was 62 per cent and 34 per cent respectively. In males aged 13 to 19 years the incidence of HIV-1 infection also declined.'
What is the significance of this? The study suggests that: 'This is the first report of a decline in HIV-1 seroprevalence among young adults in a general population in sub-Saharan Africa. The prevalence of HIV infection in this population was high and the intensity of intervention modest. It is too early to conclude that the epidemic in this population is in decline, but the results of this study give a glimmer of hope and should encourage the vigorous pursuit of AIDS control.'
In the second study, the HIV/AIDS Surveillance Report issued by the Ministry of Health in March 1995, it says that sentinel surveys carried out in up to 20 sites in Uganda 'appear to suggest a stabilisation in the prevalence rates of HIV infection, though the rates are still high.'
The data were first reported in 1994, but were re-examined at six sites to make sure that the results were valid. These results, with the significant downward curve setting in from 1993 onwards.
It is a fair assumption that the Uganda Blood Transfusion Service has played its part in this apparent stabilisation (or better than stabilisation) of the HIV rate in Uganda, as its director, Dr Peter Kataaha, and as is also indicated by recent estimates about the numbers of new HIV infections in Uganda prevented by various means.
Just as the Uganda Blood Transfusion Service has been a pioneering project in the area of safe blood for developing countries, so too the Uganda AIDS Information Centre (AIC) has been a pioneering experiment in the use of mass voluntary HIV testing and counselling as a contribution to AIDS control, and as a way of encouraging behaviour change in face of the HIV epidemic.
Funded by USAID (United States Agency for International Development), the AIC was the first such project in sub-Saharan Africa. There are now other similar projects in Africa (e.g. Zambia, Cote d'Ivoire), and a multi-country study is under way to determine whether or not such information and testing centres should become an officially recommended part of AIDS control strategy.
Since it began in 1990, the AIC has provided HIV tests with pre- and post-test counselling for about 200,000 people, initially in Kampala only, but more recently through 20 or more regional and local centres as well. The tests are entirely anonymous, based on each person being given a number rather than being asked their name, and about half those coming to the AIC are men, and half women.
The aim has been to replace the negative feelings of hopelessness and fatalism that used to be brought on by the terrifying HIV/AIDS figures in Uganda, by a positive awareness that through knowledge and informed behaviour much can be done to protect those as yet uninfected, not least the partners of infected people. Pre-marital testing, often at the behest of family, priests or clergymen, was another area of unmet demand. The significance of the AIC and its activities for the Uganda Blood Transfusion Service is two-fold:
1. some people were coming to the blood bank offering to donate blood, and so receiving a free blood test, but with no intention of actually becoming a blood donor. Their sole purpose was to get an HIV test, and to get it for free. This was wasting a lot of time and resources at the Nakasero testing laboratory, which anyway did not have the means to do AIDS counselling. So now such people have another place to go to.
2. the HIV testing of the blood samples taken at the AIC is done for the AIC by the Nakasero laboratory on a contract basis, and the UBTS gets paid for each test done, at the rate of over US$ 5 per test. This has been a valuable source of extra funding for the UBTS, and has enabled the UBTS to achieve a degree of self-financing and to pay extra salary money to key employees.
Besides the money, the USAID/AIC business has provided an important 'seal of approval' to the Nakasero laboratory. The AIC could hardly send its blood samples to a laboratory in which it did not have total confidence, especially given the highly sensitive nature of the tests done, determining whether or not a person has HIV/AIDS. The high rate of auto accidents in Uganda also meant that expatriates and visitors to the country were very concerned about the safety of the blood supply. So recognising its 'strong ethical burden to ensure the accuracy of the test results, 'USAID used consultants to carry out its own independent evaluation of the Nakasero laboratory and now calls it 'a remarkable institution... one of the best laboratories in Africa.'
People wanting an HIV test for job or visa applications have to go elsewhere. The AIC does not provide bits of paper stating that the person is HIV-negative. What it does do, is to refer HIV-positive people to TASO, the very active Ugandan AIDS support organisation, and/or to the Post-Test Clubs which the AIC has set up to enable clients, particularly but not only those who are HIV-positive, to get long-term support and advice. USAID recognises that without an adequate support system for those found to be HIV-positive (which not all countries have) mass HIV testing could have a devastating and negative effect, and would also raise serious moral and ethical issues. Taking into account all aspects, including this pre-and post-test counselling, it costs USAID about US$ 18-20 for every person tested at the AIC.