Once touted as the success story of not just the continent, but the world, Uganda seems to be slipping further off that decorated wagon and paving way for new golden girls such as Kenya.
Having brought HIV prevalence rates down from double digits in the 1980s and 1990s to just five per cent at the turn of the millennium, Uganda’s prevalence rates have since shot back up to 7.3 per cent from 6.4 per cent in 2005.
In contrast, Kenya’s universal access prevalence now stands at 5.6 per cent, down from 7.2 per cent in 2007, according to the 2012 Aids Indicator Survey.
Once the regional teacher when it came to the HIV response, Uganda may now consider taking a backseat and hand Kenya the whiteboard. Uganda and Chad are the only African countries whose HIV prevalence rates are rising.
Kenya, which two months ago rolled out universal access to HIV drugs, is leading the rest of the world (outside the USA) in embracing the latest research breakthrough in HIV/Aids prevention – pre-exposure prophylaxis (PrEP) – by incorporating it in their national HIV prevention roadmap. On this, Uganda still lurks at the fence.
PrEP, according to results from various trial sites in Africa and Asia, can reduce the risk of catching HIV by up to 96 per cent - the closest to a vaccine that the fight against the pandemic has come. The trials found that by an HIV-negative person taking antiretroviral drugs (ARVs) at a dose of a pill a day, those at high risk of contracting the virus can be saved.
A two-in-one drug, Truvada, was proven to be the most effective, with minimal side effects. PrEP is meant for HIV-negative most-at-risk populations, including discordant couples (where one spouse is HIV-positive and the other is negative), sex workers and men who have sex with men.
During a symposium on PrEP and microbicides for Kenyan and Ugandan journalists at the Sarova Stanley hotel in Nairobi on July 29, Dr Patrick Ndase, the regional physician for the Partners PrEP Study, said the Uganda government was not convinced it should roll out PrEP as part of the national HIV/Aids strategic plan.
“Kenya getting on board will soften the ground for us. Historically, Uganda never embraces new interventions quickly; we first look at the neighbours...If South Africa approves Truvada for PrEP, our countries will also approve,” said Ndase, also the regional physician for the Microbicides Trials Network.
The US Food and Drug Authority (FDA) approved the use of Truvada-based PrEP, which, if adopted by high-burden countries such as Uganda, could revolutionise management of the disease. But with most sub-Saharan African countries, including Uganda, already struggling to treat all their HIV-positive citizens, the obvious sentiment is: why take on the healthy ones too?
“We don’t have enough resources for our HIV-positive people... We are not throwing PrEP out, but we want to look into more evidence around pricing and implementation. If the National Antiretroviral Committee (NARC) is convinced, they will make the recommendation,” Dr Joshua Musinguzi, the programme manager of the Aids Control Programme (ACP), told The Observer in a telephone interview.
The market price for Truvada is about Shs 100,000 in a pharmacy for a monthly dose per person, but is as high as $1,000 in the USA. Currently, 1.4 million Ugandans are living with HIV, and Musinguzi says that while government is committed to rolling out treatment for all of them, ACP has adopted consolidated guidelines for HIV treatment set by the World Health Organisation (WHO) last year.
“The WHO guidelines emphasise providing access to treatment to as much of the population as you can as per resources available to you. But PrEP was not part of the WHO recommendations,” Musinguzi said.
“We launched new treatment guidelines last week and under those, we are treating all HIV-positive adults with a CD4 count of 500 and lower (it was previously at 350), all HIV-positive children under 15 years, all HIV-positive pregnant mothers, all patients with HIV, TB and Hepatitis B, discordant couples, and most at-risk population.”
Kenya, on the other hand, in June rolled out universal treatment for all her HIV-positive people regardless of CD4 count, and subsidised the Truvada price for easier implementation once demonstration trials currently ongoing in Thika and Kisumu are complete. PrEP proponents insist that if new infections (130,000 a year in Uganda) are prevented, the long-run cost for governments will be cut, while sceptics are worried about creating the wrong impression and sending out the wrong message with a preventive drug.
But according to Ndase, an HIV-positive patient can live an additional 54 years on ARVs. In contrast, PrEP is recommended only during the season of high risk, say if – in a discordant relationship – the HIV-positive partner is not taking ARVs. Once the HIV-positive partner starts taking the lifesaving drugs, PrEP for the HIV-negative partner would be discontinued.
“All HIV treatment is prevention. ARVs for the HIV-positive reduce the HIV in one’s genital secretion such as semen and vaginal fluid,” Ndase said.
Ugandans will soon also have options of using microbicides for HIV prevention, such as vaginal gels, vaginal rings and vaginal films that release drugs slowly to deal with the invading HIV. Ndase said breakthroughs on these are expected in 2015/16.
HIV prevention trials have previously brought advancements in safe male circumcision, post-exposure prophylaxis (PEP) for people such as health practitioners who get infected while on duty and rape victims, as well as prevention of mother-to-child transmission.