Public debate on HIV Prevention

To celebrate 90 years of Makerere University and 50 years of Ugandan independence, a public debate was held yesterday on "HIV Prevention in Uganda: are we moving in the right direction?"

Prof David Serwadda of Makerere University School of Public Health introduced the debate, proudly noting that all speakers were Makerere University graduates.  We'd rushed to get to the downtown venue since I was scheduled to give my final project presentation immediately beforehand, but happily the meeting was running on Ugandan time, i.e. about 30 minutes late so we caught his opening remarks.
Serwadda explained the rules of the debate - two proponents and two opponents would speak, with written questions taken from the audience.  There was some amusement about the coin toss to decide which side went first since Ugandan coins don't have heads or tails but a coat of arms on one side and an animal on the other.

Alex Coutinho, Head of the Infectious Diseases Institute where I've been working these last three months, won the toss and spoke first for the opposition.  Alex reviewed the most recent statistics, which no-one disputed are all moving in the wrong direction.  HIV prevalence in Uganda has increased from 6.4% in 2005 to 7.3% in 2011 and from 5.7% to 7.2% in rural areas, where fewer people receive antiretroviral therapy (ART), so the increase can't be due to more people living longer on ART.  In fact the number of new infections per year is 130,000, well above the national target of <100,000.  Uganda's neighbors are doing better with HIV prevalence in Kenya 5.2%, Tanzania 5.7% and Rwanda 3%.  Alex asked 'What on earth are we doing wrong?"

Alex had three recommendations for moving forward:

1) Engage leaders - not just President Museveni but the leaders of the opposition, religious leaders, district leaders - to be visible, vocal and sustained about the issue and to lead by example, coming forward to be tested or circumcized.

2) Scale up HIV prevention efforts to cover more of the general population; currently only 50% of eligible Ugandans receive ART (treatment of infected individuals as prevention), only 25% of pregnant women and their babies have access to prevention of mother to child transmission programs (PMTCT) and only 150,000 of the targeted 4 million men have been circumcised.

3) Strengthen the health system, which is not functioning well, per AIDS and other indicators like infant and maternal mortality.

Dr. Fred Wabwire-Mangen, Professor of Epidemiology spoke next for the Proposition.  Historically most efforts went into scale up of ART; 46% of US aid dollars went to treatment of infected individuals in 2005 and only 26% to HIV prevention.  The focus is now shifting to prevention. Fred described the new Ugandan National Prevention Strategy whose goal is to reduce the number of new infections by 30% from 2011 to 2015 and to eliminate MTCT through behavioral, biomedical and structural interventions that are tailored to high risk groups such as commercial sex workers (CSWs).  The challenge will be implementation - is Uganda's health system up to it?

Next up was firebrand AIDs activist Milly Katana speaking for the opposition. Milly was an instigator and founding director of the United Nations Global Fund for AIDS. "We are the embarrassment of Africa; We are ashamed to show our nametags at international meetings!" was her opener. Milly spoke passionately against current Ugandan AIDS policy which she claimed is based on ideology not science.  She exposed the ugly underbelly of the AIDS epidemic in Uganda - "things that some of us don't want to believe are happening in our communities."  Millie urged the audience to focus on addressing the drivers - poverty, gender based violence and substance abuse.  She asked who is helping or providing programs for the most vulnerable communities - fishing communities, commercial sex workers and men who have sex with men.  "We either ignore them or send law enforcement to round them up and bury them in prison."

The last speaker, for the Proposition was Dr. Stella Alamo-Talisuna, head of Reach Out in Mbuya, who recently hosted a visit by Hillary Clinton.  Stella argued that Uganda has led past successes against AIDS through openness and innovation, and urged the audience to keep the momentum in the fight and not cry defeat too soon.  Stella urged us to challenge stigma, encourage public debate and dispel fear and secrecy.  "We have been too silent, too long about too many things, and that includes HIV prevention." She listed some of Uganda's successes - leading innovation in pivotal studies of preventive therapy, circumcision and PMTCT, successes in coverage for HIV counseling and testing.  Ugandan First Lady Janet Museveni has recently agreed to champion the new goal to eliminate MTCT.

Stella's recommendations were to promote a combination of preventive approaches and to focus on translating scientific breakthroughs into real practice.

All four speakers agreed on the need to pursue combination prevention approaches since no approach alone is 100% effective - the shotgun approach since there is no magic bullet.  Moreover they agreed on the urgent need to fix the broken healthcare system, and to introduce some form of national health insurance system to reduce reliance on foreign aid, which currently pays for 85-90% of HIV health costs - the remainder is provided in kind via space and staff by the Ugandan Ministry of Health.

The audience submitted a large number of questions; most of these were focused around the question of what was being done to help the most at-risk groups.  10% of new infections are among commercial sex workers, but there is no legal framework governing either these workers or their male clients within which programs can be run.  HIV prevalence is 13% among men who have sex with men, but these people are being rounded up by the police.

The chair of Uganda's National AIDS Commission, Professor Vinand Nantulya took the podium to make some remarks.  He pointed ruefully to his receding hair as he told us of his sleepless nights since being appointed to the Commission.  "All is not well and it disturbs me."  Nantulya called for a return to the integrated 'ABC' (Abstain, Be faithful, use a Condom) approach that worked so well in Uganda in the past, claiming that separation of A, B and C was the reason for movement in the wrong direction.  He outlined his five point plan calling on all Ugandans to take responsibility to protect themselves - babies, youth, adults, leaders and finally a call to align local resources in the fight against AIDS.