Gains and gaps in Ugandan HIV treatment

Over the past three years Uganda has succeeded in more than doubling the number of eligible children receiving antiretroviral therapy (ART). Paediatric HIV infections, meanwhile, have plummeted. But almost six out of every 10 children who need ART are still not receiving the treatment.

The new figures on children's access to ART came in the mid-term review of the National HIV/AIDS Strategic Plan (2011-2015) presented by the Uganda AIDS Commission (UAC) in September.

According to the UAC, 41,520 children were receiving ART in 2013, as opposed to just 17, 278 in 2010. During the same three-year period, the number of adolescents receiving treatment rose from 11,660 to 26,022.

"The proportion of eligible HIV-positive children who were enrolled on ART increased from 25 percent in 2011 to 41 percent [41,520 of an estimated 107,000] in 2013," said the report.

"We have accelerated accreditation of ART sites, mobilized the necessary financial and human resources to enrol more children and adolescents on care and treatment to give them a chance to survive," Asuman Lukwago, permanent secretary at the Health Ministry, told IRIN. Luwago said some 7,000 health workers had been recruited and 834 sites accredited.

Sarah Opendi, Uganda's state minister for primary health, conceded there was still a long way to go, with 59 percent of eligible children and 71 of eligible adolescents not receiving the ART they should be getting.

"Our biggest constraint to scale up paediatric and adolescent ART in Uganda has been financial resources and human capacity [health workers]. We didn't have enough trained health workers to provide paediatric and adolescent ART," she told IRIN.

"As a government we didn't have a deliberate policy to address paediatric and adolescent ART. Our focus in the past has been on adult ART, until 2013 when the new guidelines for paediatric ART were released," she added.

These guidelines call for ART to be provided to all HIV-positive children and adolescents.

"We have got funding from UNICEF, USAID [US Agency for International Development], Clinton Health Access Initiatives and the Global Fund [to fight AIDS, Tuberculosis and Malaria]. With this funding and support now, we shall be able to absorb and enrol all HIV-positive children and adolescents on HIV care and treatment," she said.

David Opwonya, a former government employee who now heads a private medical facility in northern Uganda, took a more critical stance, blaming the low level of ART provision on "the government's poor planning and lack of seriousness."

"There is limited capacity in many facilities, especially the peripheral units for paediatric HIV care and treatment," he told IRIN. He warned that the enrolment of children and adolescents and the maintenance of care were being handicapped by drug stocks running out, an inadequate supply of HIV testing kits and failures on follow-up treatment.

More ART sites, more health workers

The UAC's figures also show the number of paediatric new infections dropping from an estimated 28,000 in 2011 to 9,000 in 2013. The Ministry of Health attributed this to the implementation of a protocol called "Option B+", under which pregnant women are offered ART for life, regardless of the number of CD4 cells in their blood - an indication of the state of their immune system. Usually, ART is only recommended when a person's CD4 count falls below 350 per cubic millimetre of blood.

HIV experts in Uganda have welcomed the new statistics, but with some reservations.

"The increase of children on treatment is a step in the right direction given the evidence that children who start treatment earlier in life achieve better treatment outcomes", said Paul Mayende, communications coordinator for the not-for-profit Baylor College of Medicine Children's Foundation.

"Five years ago, children could have their first HIV test at nine months", Mayende noted. "At the moment, we are doing this as early as six weeks. This implies that children are identified very early in life and initiated into care and treatment. Without starting children in care and treatment, they cannot live beyond their fifth birth date."

Milly Katana, veteran HIV activist and Uganda country director for the International HIV/AIDS Alliance, said much more progress needs to be made.

"This has been a long way and a long fight," Katana told IRIN. "I am looking forward to a day when there will be no one - infant, adolescent, or adult - who has HIV and is clinically eligible for treatment but cannot access it."

For Katana, stigma is still a major stumbling block. "HIV should be demystified so that people feel comfortable to talk about it and get care," Katana stressed. "The legal environment that we currently live in just will not allow this," she said in reference to the recent Anti-Homosexuality Act, which the government is fighting to get reinstated after the constitutional court threw it out earlier this year, and elements of the HIV/AIDS Prevention and Management Act 2014, which controversially criminalizes wilful transmission of HIV.

Dennis Odwe, executive director of the Action Group for Health, Human Rights and HIV/AIDS (AGHA), emphasized the need for equity in the provision of ART services.

Odwe told IRIN that old people were being given priority ahead of children at present. "The implication of this is that some children are already dying and more will continue to die due to a lack of ART," Odwe warned, adding that more investment was clearly required by the government.