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Introduction

Uganda since 1986 is one of the countries with a high HIV prevalence, but in recent years, there has been a decline not only in the general populations, but also patients with sexually transmitted infections¹. This is credited on the health measures undertaken against the HIV epidemic by the government, non governmental organizations and the international community through monitoring and surveillance².HIV/STI surveillance is critical in providing information to enable monitoring in an attempt to combat HIV and other sexually transmitted infections. This includes epidemiological surveillance, education on behavior change and screening of blood for transfusion³.

Surveillance and Monitoring of STI and HIV

Behavior Change

In monitoring, the health sector in Uganda has produced informed recommendations for effective health service delivery mechanisms in prevention, control, treatment and funding in response to the HIV/AIDS epidemic. The recommendation has focused on prevention and control of further spread through behavior change.

As recommended by the World Health Organization (WHO) in conjunction with the Joint United Nations Programme on AIDS (UNAIDS) on second generation HIV surveillance, and through biological surveillance of sexual behavior, Uganda is succeeding in tracking the magnitude of the HIV/AIDS epidemic⁴. During the 1990s, second generation surveillance included collection of behavioral data through field studies carried out in given regions of Gulu, Katakwi, and Rakai in Uganda. This has been effective in providing important retrospective information about the HIV epidemic progress⁵.This was intended to strengthen preventive efforts during program monitoring and evaluation throughout the country⁶. As observed, the is an ecological correlation between the trends in HIV prevalence and the increase in safer and protective sexual norms or behavior.

The prevalence among pregnant and young people since the early 1990s has been on the decline. This decline is consistent in all the sentinel regions of the country, according to Uganda Ministry of Health (MOH), with the exception of Tororo. Although, it is difficult to find very reliable information on prevalence trend like rates of new infection; Tororo, which is near the Ugandan border to Kenya, experienced a decline which started to show in 2000. There is a significant decline on the seroincidence; Masaka is a good example with a fall of 7.6 to 3.2 for every thousand annually⁷.

Government Initiatives

In 1986, to address an emerging epidemic, Ugandas President Museveni launched a National AIDS Control Program (ACP). Its mandate was community mobilization and creating awareness on the HIV epidemic. In reducing stigmatization, interventions targeted the health workers, the general population and key target groups like long distance drivers, fishermen, female sex workers and their clients. Prevention has been identified in Uganda as a cost effective measure in addressing the HIV epidemic. In during this, the Ugandan government has sort overtime to empower its people through formulation of programs and policies advocating for sexual behavior change⁸.

To involve the population, women and youth, in health policies, a regulation was passed by the parliament in 1989. The law demanded that one third of members of legislature to be women and four represent the youth caucuses. Since the late 1980s, teachers in Uganda have to undergo training to integrate sexual behavior change advocacy in the education curricula.

HIV infection is primarily transmitted sexually; therefore, promoting safer sexual behavior has continued to be emphasized⁹. As shown by many qualitative studies carried out in Uganda this decline has been attributed to behavioral changes. Although HIV/AIDS funding is largely dependent on donor funding through President Yoweri Museveni, the Ugandan government has had a very effective national response to the HIV epidemic. It is argued to be one of the best high political level responses to the epidemic in the sub- Saharan Africa region. Mass education against cultural practices that tend to encourage sexual relationships with more than one partner and public health messages is proving effective. This campaign has emphasized the ABC approach rule that encourages abstinence till marriage; being faithful and if both A and B dont work, condom use. This approach ensured the safety of the blood supply and started HIV surveillance¹⁰.A field study in a region in Uganda called Rakai showed that abstinence and fidelity was not very effective resulting to Museveni acknowledging condom use¹¹.

Interventions have included organizational, financial and regulatory measures to increase the availability and provision of reproductive health among both the infected and affected. This means it has to be an inclusive process being able to reach out to individuals, faith based organizations, the public sector, non governmental and government in mobilizing the entire community¹². All these have contributed to the decline of people living with HIV in Uganda, especially in recent years.

It is easier to establish safer sexual behavior early in life. Involving the young people before they become sexually active is therefore of great importance.

Despite the availability of proven interventions and substantial government, non-governmental and donor investments, there have been criticized by human rights groups on the approach by the Ugandan government¹³. Therefore, prospective approaches are used in research settings to determine; the efficacy of interventions suited to directly measure transmission rates¹⁴. These interventions monitor feasibility on mortality and causes of death in HIV cases and HIV-free survival in a well-defined group of patients or the prevention of mother-to-child HIV transmission. (PMTCT)¹⁵.There is also monitoring of HIV/AIDS prevalence among other vulnerable groups like commercial sex workers as well as assessing AIDS trends and their treatment impact. Another approach involves assessing trends of AIDS to monitor disease outcome and impact of treatment including emergence of resistance to antiretroviral treatment for HIV infection as a review for further use as an objective¹⁶.

Major contributing factors to the decline in HIV incidences in Uganda

According to the World Health Organization, the course affecting HIV incidence in most parts of the world includes education on HIV, risk avoidance and perception. Yet in other African countries like Botswana, Malawi and Zimbabwe these elements have not been very effective their seroprevalence declines. In Uganda, other contributing factors to reduced HIV incidence are elements of epidemiological, political, cultural and social¹⁷.

Political Commitment

The level of political commitment in Uganda has led to the extent to which increased knowledge from individual- and population-level leads to changes in sexual behavior¹⁸.

The context also includes the amount and type of program resources¹⁹. Ideally, the Ugandan government has a national programmme for evaluation which has three phases at the national level. Its content and coverage has been assessed to determine quality for the implementation process to achieve both short and long- term objectives.In reviewing short term goals and outcomes; it has facilitated strategies for long term impact on HIV infection being set up²⁰.

Uganda, Senegal and Jamaica are some of the countries with indicators of programme input and output, of changing behavior and of impact. In Uganda, the assessment of trends in HIV/AIDS and sexual behavior has majorly concentrated on community-based research studies, including selected districts like Rakai²¹,

Although the main focus of the national AIDS programmes, HIV prevention and STD control, care and support for infected people and reduction of the impact of the epidemic on their families and communities are key components in the intervention process. Support and care is a milestone in curbing the spread of the virus simply because it means a longer and healthier life.

Education

The introduction of education, to health workers on how to treat and refer patients for testing, counseling, and treatment service have also created more impact to HIV/AIDS surveillance program²². Enlightening both patients and community on opportunity to avoid sickness and early death has been successful in most parts of Uganda; in fostering health-seeking and behavior change. Other analytical frameworks have been set up by the AIDS national council to determine survival. For example, factors contributing to child survival include the social economic level of the household. The literacy levels of the mother play a role in hygiene, reproductive and child care²³.

There are several factors that contribute significantly to HIV and sexual transmitted infections. These include economic, gender and religious aspects.

During the 1990, HIV was highly stigmatized in Uganda as in many African countries. This was as a result of economical, social, gender disparity, religious and cultural factors. Observation shows that stigma reduction could contribute to an increase in condom use, early detection and treatment. This has an impact on HIV incidence. In Uganda, economic issues, gender issues and religious issues have a significant bearing on any sexually transmissible infections and HIV prevention.

Gender

Gender issues have a role in the pattern of the sexual transmission of HIV infection as determined by the social and economic relations between the sexes²⁴.HIV/AIDS affects men and women differently; regarding the different infection rates and cultural values and norms. These encompass early marriage, stereotypes, gender roles and power imposed on women in general and traditional notions of masculinity where men tend to engage in risky sexual behavior like having multiple sexual partners²⁵.The infection rates for young women between the ages 15 to 19 years are sometimes five times higher than for boys in the same age bracket²⁶. Therefore, in addressing the HIV/AIDS requires social mobilization is essential in establishing structures to address in gender inequalities²⁷.

The Ugandan government, in addressing the plight of women in the face of HIV/AIDS, has identified strategic responses. These include policies and programmes in response to HIV/AIDS that are broadly informed; involving not only the women but the community at large²⁸. These policies are effective because at community level, interventions have become the focal point of the national level response. Obliteration of wife inheritance to assist widows experiencing economic difficulties as a result of inadequate cash initially cared of by their husbands.

Women are identified as a vulnerable group simply because they are mostly socially or economically dependent on men. The strategic response that Ugandan leaders have given attention to is the communities by implementing and supporting community-based HIV/AIDS prevention and care activities. The Ugandan first lady, Janet Museveni, has been actively involved in leading other stakeholders in identifying root causes that make women more vulnerable to HIV/AIDS. In the process she has indentified that by empowering women at all levels it assert their sexual and reproductive rights²⁹.

Female commercial sex workers, because of economic pressure, find it difficult to negotiate the use of condoms with their multiple male partners. It is a similar situation in Uganda as many other African countries where the man is the final authority in the family³⁰. This makes it difficult for married women to confront their husband who are possibly having extra marital affairs to use condoms as a preventive measure. Efforts by government to improve the status of women in Uganda has been criticized has been too slow. The need to educate women in communicating to their male partners to negotiate safer sex practices should be long term measure. The men also need to be on the forefront in curbing HIV/AIDS prevalence³¹.Short term strategies include attending to immediate needs of the people. Education campaign has been established as a long term measure to address underlying cultural and social aspects undermining gender equality³².

Economic Issues

AIDS affects several economic sectors including the agriculture health, education, transport and mining sectors. Uganda needs a collective action in addressing the AIDS epidemic, as it has negative impact from individual household to the effects on national economy growth³³. At the household level, it begins with loss of income from the patient, medical expenditure and reduced labor in rural Uganda. At the national level economic growth tends to slow down³⁴. The effects of economy on the severity of AIDS epidemic is varied but in Uganda there are two aspects that are most affected; labour supply and cost in all the economic strongholds of any country. Labor supply is the impact HIV/AIDS has on the young adults who are the most affected especially in their prime productive years³⁵. This has a direct impact on a growing economy. The cost of AIDS includes reduced investment to cover the expenses to cover medical treatment, orphans, training and recruitment of health workers.

AIDS has had adverse effects on agriculture which in Uganda accounts for 80% of the total employment, including loss of labor supply and remittance income³⁶. A study carried out by FAO in Gwanda, a village in Rakai district shows that most of their land which previously was cultivated is now lying fallow because of the lack of labor³⁷.

Education campaign against stigmatization is vital. The Ugandan government has also put up labor policies to ensure people infected with virus are not stigmatized at their work places³⁸.

Poverty is a contributing factor to interventions on HIV/AIDS. It affects both social and economical exposure to risk behavior that could lead to HIV infection and spread³⁹.

In Uganda, for example, it leads to migrant labor, this is rural- urban migration. This affects the family unit adversely because the separation between a husband and wife tend to encourages increased incidences of multiple and casual sexual relationships⁴⁰.

Economical analysis show that male circumcision is cost effective as it reduces the rates of HIV infection saving up on expenses on its treatment⁴¹. Poor general hygiene could lead to increased risk of HIV transmission. Ecologic studies indicate that the countries, especially in Africa with prevalence of male circumcision have up to 20% reduced risk of HIV infection⁴². Although culture, religion, and risk behavior play a significant role in regard to some of the differences in HIV infection, male circumcision has its also important. Research shows that this is a cost effective way of curbing further spread of the virus not only in Uganda but other countries in the sub Sahara Africa region⁴³. The Ugandan government has to devise strategies that empower its population economically to reduce the spread and transmission of HIV/AIDS. These strategies can entail creating empowerment programs for women and young people, creating more job opportunities, expanding education opportunities for women and young people and support through financial aid. This will eradicate economic strain, thus directly minimizing the spread of HIV/AIDS.

Religious issues

Religious and cultural issues are influential factors especially in Uganda where 80% of the population identify themselves with established religious beliefs like Catholic, Muslim, Protestants and indigenous traditions⁴⁴. Religious beliefs and practices have significance to sexual behavior that lead to risk of HIV infection⁴⁵.Religious institutions influence perspective on HIV issues including the inclination to stigmatizing or care and support to HIV-positive individuals⁴⁶. This social dimension in the health mandate can no be overlooked. With regard to curtailing the spread of HIV, Museveni and his government have chosen to take a multifaceted approach to address cultural and religious beliefs. For example, he has extensively involved religious organizations to increase HIV/AIDS awareness⁴⁷. Most Protestant religion and various Christian sects do not recognize pre- marital sex. But in recent years, the reality that many young people are having sex before marriage has led to the other prevention measures⁴⁸.

Religious institutions in Uganda continue to play a significant role in campaign against drug use that has contributed greatly to the sporadic HIV infection⁴⁹.

It is important to understand that in the analysis of religious beliefs, high risk groups make their own decisions on behavior change⁵⁰. Education and counseling done by religious organizations has proven effective; approach does not advocate for sex related practices⁵¹. Instead there is advocacy on regular screenings for sexually transmitted infections, including HIV and antiretroviral therapy. These are significant contributions to HIV prevention, early detection, and appropriate treatment where necessary⁵². Most churches encourage counseling and testing for couples before marriage and even those already in marriage⁵³.

The involvement of religious leaders is fundamental in addressing HIV prevalence⁵⁴. The Muslim community, under the Islamic health Association of Uganda developed a project intended to prevent AIDS in 1992. Its role was to conduct a survey at the community level to encourage preventive actions in local Muslim communities⁵⁵. This home visits show an improved condom use among males in urban centers. Tangible evidence to the decline of HIV/AIDS incidences in Uganda has been recorded especially among the Muslim community, hence from 18 percent in the early 90s to 6 percent in recent years⁵⁶.

The challenge of addressing the spread of HIV/AIDS is significant. Risk needs to be addressed in the context of social, economical and religious considerations⁵⁷. The framework set in Uganda can be an initial model for other countries. The social mandate in addressing heath dimensions to incorporate diverse stakeholders ⁵⁸.Ugandas efforts in setting up policy and program measures to curb AIDS are commendable. Although the government continues to provide proper health mechanism, a balance in economical, gender, social, and religious issues is vital⁵⁹. Other measures include creating awareness campaign and mobilization of diverse stakeholders, particularly political and religious leaders; training health workers and establishing sustainable financing for AIDS treatment and drug provision⁶⁰, improvement of health infrastructures, counseling and treatment services, screening and safe delivery of blood. These strategies should be integrated to existing economical, social, cultural frameworks⁶¹. In Uganda there is an urgent need to implement the good policies and programs that have been developed over the years in addressing the HIV/AIDS epidemic⁶². The commitment by leaders to facilitate awareness campaigns, prohibit stigmatization and improve the health infrastructure in the country.

Conclusion

HIV/AIDS is a pandemic that affects not only the Sub Saharan region but many parts of the world⁶³. In addressing this epidemic, Uganda has a comprehensive response on HIV incidences. This has been made possible by the commitment especially by the government to address the HIV/AIDS prevalence. Policies and programs have been set up to monitor and evaluate economic, gender, social, cultural and religious factors affecting its prevalence⁶⁴.

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Footnotes

1. Kaleeba Natasha. Open Secret: People facing up to HIV and AIDS in Uganda. ACTIONAID: London,2002.
2. Gulrium Jaber. Analyzing Field Reality: Qualitative Research Methods, London, 1988.
3. WHO-AFRO: HIV/AIDS. Epidemiological Surveillance Update for the WHO; African Region 2002, Harare,2003.
4. Government of Uganda, Ministry of Health. STD/AIDS Control Programme, STD/HIV/AIDS Surveillance Report, Kampala, 2003.
5. Konde Lule et al. Impact of AIDS on Families in Rakai,Nairobi,Macmillan,1998.
6. In Gibney et al. Preventing HIV in Developing Countries: Biomedical and Behavioral Approaches, New York, Macmillan, 1998.
7. Ministry of Health of Uganda.STD/AIDS Control Program.HIV/AIDS Surveillance report, Kampala,1998.
8. Edward, Green. What happened in Uganda? What are the lessons from Uganda for AIDS prevention, Washington DC, 2002.
9. Marum Kagimu et al. Evaluation of the effectiveness of AIDS health education intervention in the Muslim community in Uganda, Kampala, 1998.
10. Uganda Bureau of Statistics (UBOS) and ORC Macro. Uganda Demographic and Health Survey 2000-2001, Calverton, Maryland, 2001.
11. James Wawer et al. Trends in HIV-1 Prevalence may not reflect Trends in Incidence in Mature Epidemics: Data from the Rakai Population-based Cohort, Uganda. AIDS, Nairobi, Longhorn Publishers, 1997.
12. Lancet, Preventing HIV/AIDS through poverty reduction: the only Sustainable Solution, 2005, Web.
13. USAID and Ministry of Health Uganda. Promoting Child Growth and Health in Uganda; a Handbook for Community Growth Promoters; USAID/UPHOLD/MOH, Kampala, 2005.
14. WHO/UNAIDS. Progress on Global Access to HIV Antiretroviral Therapy,2005. Web.
15. Allen Sam et al. The evolution of Voluntary Testing and Counseling as an HIV Prevention Strategy, London, Macmillan, 1999.
16. Aids Map. Routine or Opt-out Counseling and Testing: Findings from the 2006. PEPFAR Meeting, 2006.
17. WHO-AFRO. HIV/AIDS. Epidemiological Surveillance Update for the WHO; African Region 2002, Harare, 2003.
18. Daily Monitor, August 7, 2009. Uganda Service Provision Assessment Survey 2007. Kampala,1996.
19. Evaluation of the effectiveness of AIDS health.AIDS Education in Africa, 2011. Web.
20. Uganda AIDS Commission. Country Response: Support to National Response, 2002. Web.
21. Martin Mbulaiteye et al. Declining HIV-1 Incidence and Associated Prevalence over 10 years in a Rural Population in Southwest Uganda: a Cohort Study, London, Lancet Publishers, 2002.
22. WHO Report. Acceptability of Routine HIV Counseling and Testing, and HIV Seroprevalence in Ugandan hospitals, 2008.
23. Davis Altman. Power and Community: organizational and cultural response to AIDS, London, Taylor & Francis, 1994.
24. Megan Gottemoeller. Empowering Women to Prevent HIV: the Microbicide Advocacy in Agenda, Munich, 2000.

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