KEY POINTS:

• In a country where 1.4 million people are living with HIV, women and young women in particular are disproportionately affected.
• There are many political and cultural barriers which have hindered effective HIV prevention programming in Uganda. As a result, new HIV infections are expected to rise in coming years.
• While there have been increased efforts to scale up treatment initiatives in Uganda there are still many people living with HIV who do not have access to the medicines they need.
• Punitive laws and stigmatizing attitudes towards men who have sex with men, sex workers, and people who inject drugs has meant that these groups most vulnerable to infection are far less likely to engage with HIV services.

28,000 Ugandans died of AIDS-related illnesses.
The epidemic is firmly established in the general population. As of 2016, the estimated HIV prevalence among adults (aged 15 to 49) stood at 6.5%.2 Women are disproportionately affected, with 7.6% of adult women living with HIV compared to 4.7% of men.
Other groups particularly affected by HIV in Uganda are sex workers, young girls and adolescent women, men who have sex with men, people who inject drugs and people from Uganda’s transient fishing communities.

There has been a gradual increase in the number of people living with HIV accessing treatment. In 2013, Uganda reached a tipping point whereby the number of new infections per year was less than the number of people beginning to receive antiretroviral treatment.
However, as of 2016 around 33% of adults living with HIV and 53% of children living with HIV were still not on treatment. Persistent disparities remain around who is accessing treatment and many people living with HIV experience stigma and discrimination.

Groups most affected by HIV in Uganda

Adolescent girls, young women and HIV in Uganda

HIV prevalence is almost four times higher among young women aged 15 to 24 than young men of the same age.8
The issues faced by this demographic include gender-based violence (including sexual abuse) and a lack of access to education, health services, social protection and information about how they cope with these inequities and injustices. Indeed, young Ugandan women who have experienced intimate partner violence are 50% more likely to have acquired HIV than women who had not experienced violence.
The lack of sexual education is telling. In 2014, only 38.5% of young women and men aged 15-24 could correctly identify ways of preventing the sexual transmission of HIV and rejected major misconceptions about HIV transmission.

Sex workers and HIV in Uganda

HIV prevalence among sex workers was estimated at 37% in 2015/16.
It is estimated that sex workers and their clients accounted for 18% of new HIV infections in Uganda in 2015/16.
A 2015 evidence review found between 33% and 55% of sex workers in Uganda reported inconsistent condom use in the past month, driven by the fact that clients will often pay more for sex without a condom.

– Female sex worker, Malaba
Violence is common, with more than 80% of sex workers experiencing recent client-perpetrated violence and 18% experiencing intimate partner violence. More than 30% had a history of extreme war-related trauma.
The criminalisation of sex work and entrenched social stigma means sex workers often avoid accessing health services and conceal their occupation from healthcare providers. In particular, stigma towards male sex workers who have sex with men is exacerbated by homophobia. Indeed, many sex workers in Uganda consider social discrimination as a major barrier in their willingness or desire to test for HIV.

HIV testing and counseling (HTC) in Uganda

Increasing knowledge of HIV status through HIV testing and counseling (HTC) is a key route to tackle Uganda’s HIV epidemic. HTC services have been expanded and the number of people testing for HIV is increasing as a result, from 5.1 million in 2012 to 10.3 million in 2015.25
Testing is conducted in health facilities, in community settings and in people’s homes. In recent years there has been more emphasis to promote HTC services for couples, workplaces testing, outreach to most at risk groups, and mobile or mass testing, especially during testing campaigns.26 In 2017, the Ministry of Health piloted oral HIV self-testing kits among fishermen, female sex workers and the male partners of women attending antenatal care.27
The proportion of women (ages 15-49) who have tested for HIV and received their results in the past 12 months increased from 47.7% in 2012 to 57.1% in 2014 and from 37.4% to 45.6% among men.28
As a result of this discrepancy, only 55% of men and boys living with HIV know their status, compared to 82% of women and girls. Some men report they would rather avoid knowing their HIV status because they associate being HIV-positive with ‘emasculating’ stigma.29

CASE STUDY: Sustainable East Africa Research on Community Health

The Sustainable East Africa Research on Community Health (SEARCH) combined HIV testing with screening and treatment for diabetes, hypertension and malaria in rural communities in Kenya and Uganda.
Multi-disease health fairs were planned and conducted by elected village leaders, with services provided by local clinical staff, in close proximity to where people live. For people who test positive for HIV, SEARCH adopts a client-centered model of HIV treatment, offering things such as flexible hours, a telephone hotline, appointment reminders (by phone or SMS) and client counseling.
Overall gains have been remarkable: after just two years, SEARCH had achieved all 90–90–90 targets in the communities it was serving. Especially noteworthy were the results achieved among men and young people, groups that have been historically difficult to reach with HIV testing and treatment services.

HIV prevention programmes in Uganda

There were 52,000 new HIV infections in Uganda in 2016, mainly among adolescents and young people, women and girls, and key populations.
The country’s 2015/2016-2019/2020 prevention strategy identifies three objectives:

• to increase adoption of safer sexual behaviors and reduction in risk behaviors
• to scale up coverage and use of biomedical HIV prevention interventions (such as voluntary medical male circumcision and PrEP), delivered as part of integrated health care services
• to mitigate underlying socio-cultural, gender and other factors that drive the HIV epidemic.

Condom availability and use

Data reported by UNAIDS in 2017 suggest 60% of men and 45.5% of women used a condom the last time they had higher-risk sex (defined as being with a non-marital, non-cohabiting partner).
The number of male condoms distributed by the government rose from 87 million in 2012 to around 240 million by the end of 2015. However, this is far below the number of condoms required, given the population size. Strengthening the supply chain for both male and female condoms, and a coordinated approach to consistent condom promotion is an integral element in preventing the transmission of HIV in Uganda.

HIV education and approach to sex education in Uganda

In 2015/16, more than 2 million people were reached with prevention information through religious congregations and cultural institutions programmes. Millions more were reached with HIV prevention messages through mass media channels including billboards, radio, television, and print media.
Modules for life learning, with particular focus on sexuality education, were developed as part of the curriculum review process for lower secondary school classes. In addition, outreach to over 800 primary and secondary schools was conducted to provide HIV prevention information, with a focus on the risks of multiple partnerships, cross-generational, transactional and early sex. In total, just under 360,000 children were reached with 1 hour HIV and health education sessions in 2015/16.

Prevention of mother-to-child transmission (PMTCT)

In 2016, more than 97% of HIV-positive pregnant women received antiretroviral drugs to reduce the risk of mother-to-child transmission (MTCT), equating to 115,000 women.
In 2016, around 3,637 health facilities were providing antiretroviral treatment for pregnant women, new mothers and breastfeeding women living with HIV.
The positive stride Uganda has made towards PMTCT is evident by the 86% reduction in new infections among children between 2010 and 2016. However, the proportion of HIV-exposed infants tested for HIV remains low at 38% due to low retention of mother-and-baby pairs in PMTCT programmes.

Voluntary medical male circumcision (VMMC)

Voluntary medical male circumcision (VMMC) is a proven bio-medical HIV-prevention intervention, reducing female-to-male sexual transmission of HIV by 60%. In 2011, the most recent data available, HIV prevalence stood at 4.5% among circumcised men and 6.7% among uncircumcised men.
Although the percentage of eligible men receiving VMMC has risen to 40% in 2014 from 26.4% in 2011, problems with coverage and funding are hampering access.
As a result, annual circumcisions declined in 2015 and 2016.While traditional and religious circumcisions continue, they are far too limited in their coverage and safety to contribute to the success of this intervention.
In 2016, just 411,459 male circumcisions were performed, falling far short of the country’s projected annual coverage target of 1 million.

Access to PrEP (pre-exposure prophylaxis)

There are currently only an estimated 400-500 user of PrEP in Uganda. However, through a combination of clinical trials, demonstration projects, and implementation initiatives, this number could increase to 12,000-14,000.

Antiretroviral treatment (ART) availability in Uganda

In 2016, around 1,730 health facilities in operation in Uganda were offering antiretroviral treatment (ART). In the same year, nearly 898,200 people living with HIV were enrolled on treatment.
In 2015, Uganda introduced World Health Organization treatment guidelines, which state that all people testing positive for HIV should be enrolled on ART regardless of their CD4 count (which indicates the level of damage to the body’s immune system). However, in 2016 only 67% of adults and 47% of children eligible for access were enrolled on ART.
Just under 60% of adults living with HIV on treatment are virally suppressed. Increasing this percentage is a key target for the HIV response, as people who remain virally suppressed are unable to pass HIV on to others. Ugandan men on treatment are less likely to be virally suppressed than their female counterparts, with viral suppression rates standing at 53.6% and 62.9%, respectively. Children (aged 0-14 years) fare the worst in this respect, with just 39.3% virally suppressed.

Staying on treatment is difficult for certain groups. In particular, young people aged 15–19 in Uganda are more likely to drop out of HIV care, both before and after starting antiretroviral treatment, than are those aged 10–14 years or those older than 20 years. Studies suggest that stigma, discrimination and disclosure issues, as well as travel and waiting times at clinics, are among the reasons.