The improvement of HIV/AIDS in Uganda under PEPFAR support
Introduction
Acquired Immune Deficiency Syndrome (AIDS) is the disease of human immunity that occurs due to the infection of the Human Immunodeficiency Virus (HIV). Patients with this immunocompromised condition will face with the higher risk of opportunistic infections and some tumors.(1) The pandemic of HIV/AIDS has been the global public health concern since the first patient was discovered and diagnosed in the 1980s.(2) Up until now, the data from the United Nations Joint Program on HIV/AIDS (UNAIDS) in 2017 revealed that over 25 million people had died as a consequences of contracting HIV and estimated that nowadays over 36.7 million people worldwide are living with the HIV infection, astoundingly 25.5 millions of those patients are living in Sub-Saharan African region.(3) Also, 17.3 million children become orphaned and cannot attend school because they lost either of their parents to HIV/AIDS and lack of their parent’s support.(4) Furthermore, this disease has made economic development stagnate and put countries into the cycle of poverty, for this reason, the United Nations identified AIDS as a security issue since 2001.(5)
Endeavour from plenty of countries and organizations try to mitigate and solve the HIV/AIDS issues by creating international aid flow such as the World Bank’s Multi-Country HIV/AIDS Program (MAP) in 2001, The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) in 2002 and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003.(6) While MAP and the Global Fund are multilateral initiatives, PEPFAR is both bilateral and multilateral approach which accounted for over 60 percent of the global funding to HIV/AIDS by governments, and this made the U.S. become the leader of the donor’s countries against HIV/AIDS.(5, 6)
Therefore, this essay aimed to demonstrate how PEPFAR impact on HIV/AIDS issue especially in Uganda which represents as one of the progressive countries in the fight against HIV/AIDS.
1.Getting to know PEPFAR
The attempt of the United States to help and alleviate HIV/AIDS related issues around the world saw concrete results during the presidency of President George W. Bush.(7) In January 2003, President Bush called for bipartisan support in Congress to approve funding of $15 billion over the next five years in fighting against HIV/AIDS. The result of his request was “The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003” which was duly passed by the Congress in May of the same year and authorized “the U.S. President’s Emergency Plan for AIDS Relief” or PEPFAR.(8)
Almost 80 percent of PEPFAR’s funding which initially authorized in 2003 was aimed at treatment and care. The allocation of the fund was designated as follow; 55 percent of the amounts for treatment of HIV/AIDS’ people, 20 percent of the amounts for prevention activities but at least 33 of which the prevention part must be spent on abstinence-until-marriage programs, 15 percent of the amounts for palliative care, and 10 percent of the amounts for supporting orphans and vulnerable children.(9) Most of the PEPFAR resources are dedicated to the programs in 15 focused countries due to the high level of prevalence and lack of resources; Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.(7, 9)
Over the five years of PEPFAR since its fund first available in January 2004, the goal was achieved.(10) In October 2008, more than 2 million HIV/AIDS patients were distributed with antiretroviral drugs (ARV) and more than 10.1 million were received HIV/AIDS related care.(10, 11) President Bush signed re-authorization of PEPFAR in 2008 which the allocation of $48 billion until 2013 and President Obama signed the PEPFAR Stewardship and Oversight Act of 2013 at the end of 2013, extending authorization for an additional 5-year period.(6, 12, 13)
The annual report progress of PEPFAR in 2017 unveil the impressive result that ever since the program launched, over 11.5 million people obtained ARV treatment, 6.2 orphans and vulnerable children receive supportive care, nearly 2 million babies born with HIV free, and over 200 thousand of health care workers have been trained.(14) Hence, the next part of this essay will demonstrate on how PEPFAR has succeeded in helping patients and those influenced by HIV/AIDS using examples from Uganda, one of the focus countries that shows the progressive result of the combat against HIV/AIDS.
2.HIV/AIDS situation in Uganda
Uganda is a country in the sub-Saharan African region which is the region that has the highest prevalence of HIV infection.(6, 15) However, Uganda’s development against the fight of HIV/AIDS has become a model for other African countries.(6) Early in the 1990’s, while it was estimated that the average prevalence of HIV infection among adults in Eastern and Southern African countries was 4.1%, but Uganda’s estimated rate was as high as 14.8%.(16, 17) In conversely, based on UNAIDS estimates in 2017, the prevalence of HIV/AIDS among adult Ugandan has dropped to just 6.5%, which is lower than the average prevalence of adult in Eastern and Southern African countries. The trend of estimates HIV prevalence among adult over time in Uganda and Eastern and Southern African countries have shown in Figure 1 and 2 respectively.(16, 17)
Many scholars have analyzed the decline in the prevalence of HIV infection in adults over the past thirty years in Uganda.(18-20) The form of reduction can be divided into two phases: 1990 – 2004 and 2004 to present. The breakdown of 2004 was when Uganda began receiving funding from the international aid like PEPFAR.
Since the outbreak of the HIV in the 1990s in Uganda, the government has tried to solve those problems. Between 1990 and 2004, before Uganda was supported by PEPFAR and prior to the discovery of ARV, the decline in prevalence was seemed to determine by the high level of political support and multiple sectors responses.(19) The government of Uganda (GOU) has developed various policies and strategies that aimed to tackle the epidemic of HIV infection, for example, the National Strategic Framework for HIV & AIDS Activities in Uganda and the National Strategic Framework for Expansion of HIV & AIDS care and support in Uganda.(21) The concept of “Abstinence and Being Faithful” policy lead to the change in age of sexual debut, partner reduction, and condom use.(22)
3.How PEPFAR impact Uganda
Uganda has been targeting as one of the focus countries in the war against global HIV/AIDS of the United States government since the start of PEPFAR program in 2003.(7) Over the past fifteen years of the project, this country has received more than $ 3.6 billion of funding from PEPFAR.(23) These huge amounts of money have been distributed to both government and non-government organizations in Uganda for achieving PEPFAR’s strategy and policy framework.(24) The country operational plan (COP) has been developed annually in the association between PEPFAR and Uganda AIDS Commission (UAC) as well as various partners. This plan is the annual work scheme for PEPFAR’s activities of the country which provides the information about investments and anticipated result of the program.(25) Implementation of PEPFAR-funded projects in Uganda can be divided into various subtypes, but the two main categories are 1.Care and treatment, 2.Prevention.(10)
3.1 PEPFAR supported HIV care and treatment programs in Uganda
- ARV support and Orphans and Vulnerable Children CareBehind the success of scaling up HIV treatment, PEPFAR has seen as one of the key driving factors. Since the objective of treating HIV infection seems to be the primary goal of PEPFAR support which can be seen in the program’s budget framework.(9) More than a half of funding must be spent on HIV/AIDS treatment of individuals. This reflecting in the National AIDS Spending Assessment Report of Uganda that shows over 50 percent of expenditure was spent on treatment and care.(24)
In Uganda, PEPFAR has been partnered with several sectors to supply and distribute antiretroviral drugs.(26) The track 1.0 Program has been launched in order to support HIV treatment and other HIV related services such as technical, laboratories and infrastructure support.(27) This program in relationship with Ministry of Health, Government Official Health Office in the regional and provincial district, faith-based organization, NGO and other funders created the supply chain to storage and allocate drug treatment in Uganda (Figure 3).(28)
PEPFAR not only promoted the supply chain for the distribution of ARV but also improved the efficiency of drug selection. PEPFAR gradually encourages increased use of generic drugs, fixed-dose combination and constrains the use of local ARV production from manufacturers in Uganda.(27, 28) In 2005, only 16 percent of ARV procured by PEPFAR were generic drug, but it was increased to 97 percent in 2010. These supply chain management and enhanced of drug selection contributed to the reduction of PEPFAR’s per patient treatment cost (including drug and service delivery) from more than 1100 $ to 335 $ per year.(29)
Attempts in providing ARV to HIV-infected people under the support of PEPFAR have resulted in a longer life of countless Uganda’s patients. The graph in Figure 4 is a summary from PEPFAR’s official website, and the orange line represents the trend in the number of people living with HIV in Uganda who currently received ARV supported by the program from 2004 to 2016.(30) We can notice that since PEPFAR has encouraged generic drug use and product from local manufacturers which is cover over 90 percent of distributed drug in 2010, it is consistent with the dramatically increased in the number of patients receiving antiretroviral therapy from 2011 onwards. Nowadays more than 850,000 HIV patients in Uganda obtained ARV from PEPFAR.(30) However, this number could be better since the data from UNAIDS 2017 indicated that the coverage of people receiving ARV is only 67 percent among Uganda’s HIV population.(31) In addition, the expansion in access to treatment is associated with the substantial downfall of the number of AIDS-related death which shows in Figure 5.(27, 32)
In the field of care enhancement, PEPFAR concerns that HIV does not only a medical experience but it is also social and emotional combat which extremely affects lives and future. Therefore, Orphans and Vulnerable Children (OVC) program has been established to support children 0-17 years old who lost their parents from HIV/AIDS.(33) PEPFAR in associated with Ministry of Gender, Labor and Social Development of Uganda provide multi-aspect of care to children who affected by HIV/AIDS issues.(34, 35) Encourage them to be educated by providing education support to ensure retention, transition, and school completion. Provide caregiver and foster positive parenting by using the community facility linkage framework. A consequence of those effort reflecting in over 400,000 orphans and vulnerable children have been given the opportunity to improve their quality of life.(35)
3.2 PEPFAR supported HIV prevention programs in Uganda - Voluntary Male Medical Circumcision (VMMC) ProgramMale medical circumcision refers to the complete aseptic removal of men’s penile foreskin. This procedure is known as one of the oldest surgical operations in the world and has been accomplished for a religious and cultural reason for a long time.(36) Besides, it has been shown to reduce individual and partner’s risk of sexually transmitted infections (STIs) such as herpes simplex virus type 2, human papillomavirus (HPV), Mycoplasma genitalium and HIV.(36-38)
Various studies indicate that Male circumcision has a causal relationship of the decline in HIV incidence.(39-42) Three randomized control trial which performed among 10,000 HIV negative men in South Africa, Kenya and Uganda show more than 50 percent of the reduction in HIV incidence in male circumcised compared with uncircumcised male. Moreover, the five years extended follow up study in Uganda revealed a sustained reduction of 73 percent in HIV incidence.(42) Furthermore, a study sponsored by PEPFAR reports a mathematical model that if 8 out of 10 men in PEPFAR focused countries become circumcised it may be prevented 3.5 million people from new HIV infections within 15 years and averted approximately $ 16.5 billion in care and treatment cost of HIV.(5) Hence, VMMC program is a significant contributory factor to the achievement of PEPFAR’s prevention strategy.
PEPFAR still proceed to be a major contributor to VMMC program in Uganda.(30, 35) During 2010 to 2016, PEPFAR accounted for 85 percent of all circumcisions in this country, and the total number of Ugandan who receive VMMC procedure has been dramatically increased from about 9000 to more than 3.4 million in this period.(35) What PEPFAR did to succeed in Uganda VMMC program included provision of medical devices, local anesthesia and suture, provide technical support in establishing a national program, encourage the coordination between government and civil society and also financial support.(5, 39) VMMC program also offers comprehensive prevention package to participants by provides health education, HIV testing and counseling, screening for other STIs, and refers HIV positive patient to decent care and treatment.(35)
In addition to the direct effect of male circumcision that can reduce the risk of HIV infection of men, the indirect result also contributes to the improvement of the HIV epidemic.(39) PEPFAR expects that VMMC program will reduce the risk of HIV infection in women, men who do not receive circumcision, and infants.(8, 39) Because of the direct effect of male circumcision reduces the risk of men HIV infection, which in turn decreases the prevalence and incidence of HIV infection among male in general population. Subsequently, the possibility of woman confronted HIV infection from male sex partners in population will also decrease. Eventually, the lower rate of HIV prevalence and incidence among reproductive age woman will contribute to lesser infants at risk of vertical transmission from mother to child.(8, 10, 39) - Preventing mother-to-child transmission (PMTCT) ProgramAlthough the VMMC program means to indirectly reduce the incidence of neonatal HIV infections. However, the direct result that has affected reducing the incidence of new pediatric HIV infections is PMTCT program.(43) In the past, mother-to-child (MTC) HIV transmission was one of the main factors contributing to the high incidence of HIV in children. The number of infants who born with HIV positive in Uganda was as high as 40,000 persons per year in the early 1990s.(44) However, with the support from international aids especially PEPFAR, Uganda has succeeded in reducing that number.
PEPFAR nowadays help Uganda government provides PMTCT services over 1300 site in the country.(45) Their effort focused on funding and technical support to enhance the program from testing HIV status to the treatment of mother and follow-up testing the status of babies.(14) Procure ARV for HIV positive mother who participated in the program on the basis of the guideline from WHO which indicate that without any treatment, the possibility of HIV to pass from mother to child is up to 45 percent, but ARV intervention can reduce the risk to below 5 percent.(46) The result of their attempt is the lower incidence of babies born with HIV positive from 8 percent in 2011 to 2.3 percent in 2017, and the trend is shown in Figure 6.(47) Moreover, UNAIDS estimated that since 2012 the proportion of children HIV infection averted from PMTCT is more than the number of infected children and the recent data in 2016 estimated that 27,000 children were saved from MTC infection which shows in Figure 7.(44)
According to all programs that have been previously stated, it can be indicated that PEPFAR has played a major role in overcoming HIV/AIDS in Uganda. Whether providing antiretroviral drugs, supporting voluntary male medical circumcisions, and preventing of mother to child transmission, these have all contributed to the advancement of Uganda in reducing the rate of new infections among people.(5, 48) Recent estimates from UNAIDS show that in 2016, the incidence of HIV infection in all ages fell to only 1.5 per 1,000 population from the originally estimated at 4 to 5 per 1000 population between 1997-2007 (Figure 8).(49) Cannot be denied that without PEPFAR support, countless people in Uganda may not be able to live until today, many children may not have the opportunity to be born with HIV-free, and a lot of orphan and vulnerable children may not be properly educated or caring. However, even though the results are exemplary, the worrying aspect of the fight against HIV/AIDS in Uganda is that the country relies heavily on foreign aid to support programs in tackle HIV/AIDS problems.(21) If one day, there is an obstacle in supporting those international aids, the problems that will happen may affect the lives of millions of Ugandans and the situation of HIV/AIDS in Uganda could be back to worst again.