Global Health 101 - AK

GLOBAL FUND PROPOSAL

UGANDA: HIV INCIDENCE, WOMEN AND CHILDREN
MARLENA NORWOOD

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INTRODUCTION

Over the last decade, the country of Uganda has made significant progress in reducing their HIV prevalence. The Ugandan government, with significant help from NGOs, implemented policies that were extremely effective in halting the spread and reducing the prevalence of HIV including mandatory HIV testing beginning in 2007. Other programs included behavioral change programs such as encouraging abstinence and monogamous relationships as well as advocating for condom use (Green). After succeeding in the area of HIV, Uganda was seen as an example, a pillar of excellence in HIV prevention and treatment. As HIV prevalence now increases, questions arise concerning what can be done now that hasnt already been exhausted. Recently, the prevalence has risen from 6.4% to 7.3%. One hypothesis for this increase is that Ugandans, especially in wealthier areas with more readily available resources, may have changed their attitude towards HIV and ARTs. Anti-Retroviral Therapy is much more accessible than it was before the programs that drastically reduced HIV prevalence were put into effect. The same goes with condoms. HIV/AIDS may no longer be seen as a problem that should and must be prevented, but more of an inconvenience that can be treated easily (Green). The government seems to parallel the relaxed sentiment towards HIV. Yoweri Museveni, the president of Uganda, put forth great government effort towards HIV contributing to its steady decline. Now it seems as though the government has diverted its attention to other pressing issues like the major oil controversy (Green). The question now is how to fix the current situation and return Uganda to an even lower HIV prevalence. Uganda is comprised of four regions: Western, Northern, Eastern, and Central. The Northern Region has a somewhat high HIV prevalence, however the northern corners of the country in the East and West have a low HIV prevalence. When looking at a map of Uganda, the areas with the highest HIV prevalence are the majority of the West and the Central District, stretching up to the northern border with South Sudan (USAID). One of the reasons for this pattern seen in somewhat of a backwards L shape is because of the common truck routes through Uganda. There are three main truck routes and all travel to or from Kampala, the capital and city center. The least traveled route stretches from Kampala to Kigali, Rwanda. Next is the stretch from Kampala to Juba, South Sudan, which is much more heavily traveled. Lastly and most importantly is the route from Kampala to Mombasa, Kenya (Morris). Analysis of truck routes in Uganda is vital to understanding the areas of high HIV prevalence. On the highway from Mombasa, Kenya to Kampala, Uganda, truck drivers make up 30% of sex traffickers clientele. The sexual encounters/trafficking occur at the truck rest stops, which are very frequent, especially along the Kenyan portion of the highway (Kaiser, Morris). Right before crossing the Ugandan border, there is a very large rest stop where an average of 210 truckers stay for the night and also where much of the sex trafficking and prostitution occurs (Morris). After crossing the Ugandan border, the trucker will drive into the Eastern Region. There isnt much need for stops along this stretch into Kampala for it only takes three hours time. Once in the Central Region, the HIV prevalence skyrockets from around 5% to 10% (USAID). Here is where much of the exchange occurs between the truck drivers and their road wives, spreading the HIV they may have acquired

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in Kenya, where overall adult prevalence is 6.3% (Index Mundi). Truck drivers from here either travel to Juba or Kigali, both routes surrounded by a high HIV prevalence, perpetuated by the sex trafficking industry (Pickering).

GOAL AND EXPECTED IMPACT

Goal Reduce Women and Pediatric HIV Incidence
Impact Indicator % HIV incidence women (15-49) # new pediatric HIV infections Baseline (Year 0) 1.05% (UNICEF) 20,600 (UNICEF) Target (Year 5) .7% 15,000

Uganda has plenty of money invested in HIV treatment. Uganda received almost $900 million from the Presidents Emergency Plan For AIDS Relief. This money has been used in many areas of treatment in order to reduce the HIV prevalence. One of the main areas the funds are invested is in PMTCT (prevention of mother to child transmission) programs (PEPFAR). This proposal will not directly be measuring the HIV prevalence of the population because the prevalence takes into account people already living with HIV. If the prevalence significantly dropped, that could be a success indicator of the programs presented in this proposal or an indicator of failure of HIV treatment because a large amount of people died, reducing the prevalence. Women play a huge role in the prevalence of HIV through commercial sex workers and mother to child transmission. The more accurate way to measure HIV prevalence is to break it down into a measure of incidence of the two most at risk categories women and children. The main plan of action is focused on empowering women and providing women with the resources they need. These funds already dedicated to PMTCT must be supplemented by preventative measures that attempt to control and reduce some of the structural violence in Uganda oppression of women. The number of new pediatric HIV infections will measure the effectiveness of the PMTCT programs. In 2009, there were 20,600 new pediatric infections. The goal is to reduce the number of new infections in infants and children to 15,000 in five years. The percent HIV incidence in women ages 15-49 will measure the effectiveness of the programs to empower women. The goal is to reduce HIV incidence in women ages 15-49 from 1.05% to .7% (UNICEF).

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OBJECTIVES AND EXPECTED OUTCOMES

Objective 1 Reduce Number of Sex Workers
Impact Indicator # of female sex workers on Mombasa-Kenya Highway Baseline (Year 0) 8,000 (Morris) Target (Year 5) 6,000

Prostitution is not a job that women take by choice, but rather they are forced into it because of their personal economic situation and ultimately by the broader structures of society. Prostitution benefits the workers with money and the clients with satisfaction in the short term. The long-term effects of sex trafficking and prostitution stretch far and wide, one of the main effects being increased HIV infection rates. Nearly 40% of sex workers in Uganda are HIV positive, a shocking number compared to the much lower overall HIV prevalence in adults of 7.3% (Acaye). Even more incriminating is that the prostitution industry is responsible for 10% of the HIV incidence (PlusNews). Although condom use is a conservative 90% among sex workers and their one-time clients, it is only 69% with their regular clients (Morris). They may be regular clients, but the truckers can easily have more than one prostitute that they see. Decreasing the number of prostitutes in Uganda would decrease HIV incidence in women and overall HIV prevalence for the whole population. As was discussed earlier, there are three main highways in Uganda that are breeding grounds for prostitution: Kigali to Kampala, Juba to Kampala, and Mombasa to Kampala. The highway with the highest HIV prevalence is Mombasa to Kampala, stretching over 700 miles and providing work for about 8,000 sex workers (Morris). The number of sex workers on this highway is a good indicator for overall reduction in number of sex workers since it has such a high volume of traffic. The goal is to reduce the number of sex workers by at least 25% to 6,000 in five years by implementing the detailed course of action.

Objective 2 Reduce Mother to Child Transmission

Impact Indicator Mother to child transmission rate Baseline (Year 0) 31% (UNICEF) Target (Year 5) 10%

One of the other main perpetuators of HIV is mother to child transmission. When a mother is infected with HIV, and is not on full anti-retroviral treatment (ART), the child will most likely contract HIV. As previously discussed, Uganda has received large sums of money dedicated to PMTCT. There are ample funds and programs that need to be utilized to their full potentials. The overall indicator for reducing mother to child transmission is the percent of babies born to HIV positive mothers that contract HIV. Currently, about 31% of the children in Uganda born to HIV infected mothers contract HIV (UNICEF). The goal is to reduce that proportion to 10% in five years.

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ACTIVITIES AND COURSE OF ACTION

Activities for Objective 1 Reduce Number of Sex Workers
Main Activity Provide scholarships for women Incentivize teaching as a profession by increasing salaries Output Indicators % of women completed secondary schooling % of people 14-64 working in education per total workforce Baseline (Year 0) 21.9% (BOS) 3.5% (BOS) Target (Year 5) 25% 7%

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Main Implementing Agency Ministry of Education Ministry of Education

In order to decrease the number of prostitutes, the broader structures of society must be analyzed. Job opportunities for women in Uganda are limited, especially if the woman is uneducated. Women must be educated if they are to break from the cycle of prostitution. The first step in this course of action will be to provide scholarships for women at any level of schooling. The scholarships will be provided to women that are from families in need that cannot afford to send their girls to school. In addition, the scholarships will be provided to strong and motivated female students that show exemplary work in their education thus far. The goal is that the scholarship programs deliver results and get more women through school and eventually to expand the program to a higher proportion of women. The effectiveness of the scholarships will be measured by the percentage of women completing secondary school. Currently, only 21.9% of women are completing secondary school, and most of them drop out because they cannot afford to continue their education. The goal is to boost that proportion to 25% in five years (UBS). The goal is relatively small because there is a limited amount of money that can be awarded. Once the program is proven effective, it will grow and be able to educate an even larger proportion of women that would not otherwise have the opportunity. Once women get out of school, there must be opportunities in the public sector for jobs. The most popular field for women in Uganda is education and teaching. Unfortunately, many teachers, especially along the Kampala to Juba highway are turning to prostitution because it is far more profitable. Women as prostitutes can make in one month what a teacher makes in a year (Mugwampeke). Even if a woman comes out of secondary school or higher, the most attractive profession is still prostitution because it pays so well. In order to combat this rising trend, teachers must be paid higher salaries. The Ministry of Education must raise the standard salary for teachers. It must become more lucrative to be a teacher than to sell ones body. The percent of jobs in the education sector will measure the effectiveness of increasing teacher salaries. The overall percentage does not distinguish gender. However, an overall increase in the percentage of jobs in education will indicate success. Currently, the percentage of jobs in education in Uganda is 3.5%. This percentage is far behind the sales industry and even further behind agriculture (UBS). A reasonable increase in five years is to 7%, doubling the proportion of jobs in the field of education. By educating women and increasing their professional opportunities, HIV incidence in women will reduce over time. There will eventually be less women working in prostitution or being forced

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into sex trafficking. Drastic reduction of prostitution, especially along the lines of the truck routes, will be a useful weapon in the fight against HIV, since it accounts for so many of the new cases.

Activities for Objective 2 Reduce Mother to Child Transmission

Main Activity Advertise PMTCT programs in clinics Supply ART for mothers at a lower cost Output Indicators % of women utilizing PMTCT % of HIV-positive women receiving full ART Baseline (Year 0) 51.6% (WHO) 17% (WHO) Target (Year 5) 90% 50% Main Implementing Agency Ministry of Health Ministry of Health

The first course of action to reduce mother to child transmission is to advertise PMTCT programs in clinics. There are many programs available that have been funded by PEPFAR, but only 51.6% of pregnant, HIV infected women are utilizing any aspect of them. The advertisement campaign must take place in the rural areas and especially the urban areas of Uganda, since that is where most of the sex workers are located. Forms of advertisement will include word of mouth, distribution of brochures/pamphlets, and visits to smaller cities and towns by clinic representatives. The current services of the PMTCT programs are counseling and testing, distribution of ARTs, and other drug treatments. The goal is to have 90% use of the extensive PMTCT services already available in five years. The second course of action, is to supply anti-retroviral treatment to HIV infected pregnant mothers at a lower cost than they would normally be. Lowering the cost of ARTs for this specific population will require some juggling of funds from PEPFAR. There is a lot of money out there, it just needs to be slightly redistributed without taking significant amounts away from the other PMTCT programs. ARTs are surprisingly effective in childbirth, with hardly any children contracting HIV. Successful distribution of drugs will be indicated by the percent of HIV-positive women receiving full ARTs. Currently, only 17% of women receive the full three pill ART regimen. Since there are such ample funds allocated to PMTCT interventions, a reasonable five-year goal would be to have 85% of HIV-positive women receiving full ART (WHO). Providing ARTs to HIV positive pregnant woman would make a huge impact on the HIV incidence, because 42% of all new cases of HIV in Uganda come from infants infected during childbirth (URN). Although not perfect, the efforts proposed in this Global Fund Proposal, coupled with the work that will happen in the next few years in Uganda combating HIV, will make a significant impact in the lives of those living with HIV and the overall HIV prevalence.

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EXISTING WORK

The current National Priority Action Plan in Uganda focused on HIV/AIDS has just been put into place after reviewing the results of the previous plan over the last few years. One of the main goals of the plan is to have all of the organizations that are working to better health and reduce HIV work together and build off of each other (AIDS Commission). Many NGOs are currently at work in Uganda combating HIV from various angles. There are so many in fact, that Uganda has created the Uganda National NGO Forum in order that the NGOs work cooperatively with each other and dont have competing interests, lead the presence of international aid effectively, and work for the ultimate benefit of the people of Uganda, reflecting the National Priority Action Plan just put in place (NGO Forum). The existing work done by these NGOs will be complemented by the work in this proposal. Each NGO differs in its goals and tactics, but there are a few overarching themes: education, prevention, and treatment. The first program proposed here for womens empowerment would seamlessly supplement these programs because it will begin to shift some of the structures of society contributing to the HIV epidemic. The program proposed here is extremely preventative in nature because it halts the growth of prostitution, a sector where HIV thrives. The Presidents Emergency Plan for AIDS Relief (PEPFAR), which funds programs similar to those described above, devotes much of its resources to the technical side of AIDS relief including ARV Therapy and diagnostic testing, as well as patient support such as counseling. The second part of the program proposed here will work in conjunction with the PEPFAR programs already set up, specifically the ones focused on PMTCT to reduce mother to child transmission (PEPFAR).

ISSUES
BENEFICIARIES:

The groups of people that will benefit by these two programs the most are women and children. Women dont want to be prostitutes, but it is a much more attractive job than being an educator. However, if women had a choice to be a commercial sex worker sleeping with an average of two men per day, or a teacher for the same salary and benefits, the majority would most definitely choose being a teacher. The objective to reduce the number of sex workers is set up to give these women a choice. Some could still end up choosing prostitution, but if given the necessary resources, a good number will not. In turn, men will have lower HIV incidence as well because the number of sex workers will decrease. Children also will benefit because of reduced mother to child transmission with more frequent use of PMTCT programs.

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COMMUNITY PARTICIPATION: Both of the programs will foster community participation, but most specifically the PMTCT programs. The existing PMTCT programs need to be advertised to populations in Uganda. The most effective way to advertise the PMTCT programs to women and families in need is to have local workers in hospital clinics travel to the surrounding urban neighborhoods and also to the rural communities. In this way, the citizens of Uganda will be a part of improving the health system in their area. GENDER EQUALITY ISSUES: One of the main issues with gender equality in Uganda, and throughout the rest of the world is in the educational and professional sector. The number of women that attend school in Uganda is less than the number of men. Only 9.8% of men have no education in Uganda in contrast to 24.1% of women (UBS). By providing scholarships for women, the inequality in schools will begin to dissipate. Historically, women everywhere are paid less than men for doing the same job. By increasing the salaries for teachers, which is a traditionally female job, women will make more money and begin to break down the barrier of inequality. SOCIAL EQUALITY ISSUES: In Uganda, homosexuality is a very heated topic (The Economist). The government does not approve of homosexuality and have tried to make it illegal on multiple occasions, which is still a serious possibility. One of the potential clauses in the Anti-Homosexuality Bill will make homosexual sexual relationships illegal if one of the partners is infected with HIV (Burnett). By reducing the overall HIV prevalence over time by reducing the number of new infections, there will be fewer infections in homosexual partners, mostly through reduced mother to child transmission. Not being infected with HIV could save lives not only because of not having HIV, but additionally it could mean homosexual people in Uganda not being imprisoned. HUMAN RESOURCE DEVELOPMENT Human resource development ties into the overall community participation discussed earlier. The human resource department of hospitals and clinics will be used to spread the knowledge of PMTCT programs in Uganda. By sending Ugandan workers out into the community, they will be able to better articulate to the executives of the hospitals and clinics the needs of the population. The success of the utilization of these programs could potentially prompt the utilization and betterment of the human resource departments in other sectors of Ugandan society.

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POTENTIAL OPPOSITION

The most opposition to these programs will come from the human trafficking industry. Prostitution is a major industry in Uganda. Women are employed by a pimp that tells them they will provide them work (Masaba). By decreasing the amount of prostitutes in Uganda through the programs to empower women with educational and professional opportunities, the prostitution industry will hurt. Decreasing the amount of women susceptible to prostitution could easily cause some people running the prostitution industry to go out of business and have to find another industry. However, increasing professional and educational opportunities for women will increase the overall equality of society, which will increase the health outcomes of the population, and eventually improve the Ugandan economy. When the economy improves, there are more jobs, and potentially job opportunities for people formerly involved in the human trafficking industry.

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WORKS CITED
Acaye, Elizabeth. "Ugandan Sex Workers Post Highest HIV Rates." UPI. United Press International, 13 Dec. 2012. Web. 09 Mar. 2013. (Acaye) Burnett, Maria. "Uganda Making Life Tough for NGOs, LGBTrights." Human Rights Watch. N.p., 30 Aug. 2010. Web. 07 Mar. 2013. (Burnett) "Countdown to Zero." UNICEF. UNICEF, July 2012. Web. 9 Mar. 2013. (UNICEF) "Educational Status." Uganda Bureau of Statistics. N.p., 2010. Web. 10 Mar. 2013. (UBS) "Gays in Uganda: Keep Them off the Stage." The Economist. The Economist Newspaper Limited, 23 Feb. 2013. Web. (The Economist) Green, Andrew. "Why Is Uganda's HIV Rate Back on the Rise?" Think Africa Press. N.p., 12 Oct. 2012. Web. 07 Mar. 2013. (Green) "History of NGO Forum." Uganda National NGO Forum. Uganda National NGO Forum, n.d. Web. 6 Mar. 2013. (NGO Forum) "HIV and AIDS." UNICEF Eastern and Southern Africa. UNICEF, n.d. Web. 09 Mar. 2013. (UNICEF) Kaiser Family Foundation, Henry J. "Research Examines Role of Truck Drivers in HIV/AIDS Along Routes in Africa." The Body. Remedy Health Media, 7 Aug. 2008. Web. 09 Mar. 2013. (Kaiser) "Kenya HIV/AIDS - Adult Prevalence Rate." Index Mundi. IndexMundi, 2009. Web. 09 Mar. 2013. (Index Mundi) Kuznik, Andreas. "Evaluating the Cost-effectiveness of Combination Antiretroviral Therapy for the Prevention of Mother-to-child Transmission of HIV in Uganda." WHO. World Health Organization, 10 Apr. 2010. Web. 10 Mar. 2013. (WHO) "Labour Force and Time Use." Uganda Bureau of Statistics. N.p., 2010. Web. 10 Mar. 2013. (UBS) Masaba, John, and John Semakula. "Uganda: Prostitution Soars Amid Weak Laws." All Africa. N.p., 27 Oct. 2012. Web. 10 Mar. 2013. (Masaba) Morris, Chester N., and Alan G. Ferguson. "Estimation of the Sexual Transmission of HIV in Kenya and Uganda on the Trans-Africa Highway: The Continuing Role for Prevention in High Risk Groups." Sexually Transmitted Infections. BMJ Journals, 19 July 2006. Web. 09 Mar. 2013. (Morris)

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Morris, Chester N., and Alan G. Ferguson. "Mapping Transactional Sex on the Northern Corridor Highway in Kenya." Science Direct. Elsevier Ltd, June 2007. Web. 09 Mar. 2013. (Morris) "Mother-to-child HIV Transmission Rates Remain High in Uganda." Uganda Radio Network. N.p., 30 Aug. 2008. Web. 09 Mar. 2013. (URN) Mugwampeke, Christine. "Teachers in Uganda Turn to Prostitution." Teachers In Uganda Turn To Prostitution. UGEE - Uganda Online, n.d. Web. 10 Mar. 2013. (Mugwampeke) "Partnership to Fight HIV/AIDS in Uganda." The United States President's Emergency Plan for AIDS Relief. Office of U.S. Global AIDS Coordinator, n.d. Web. 07 Mar. 2013. (PEPFAR) Pickering, H., M. Okongo, and K. Bwanika. "Sexual Mixing Patterns in Uganda: Small-time Urban/rural Traders." Europe PubMed Central. Europe PMC Funder's Group, n.d. Web. 09 Mar. 2013. (Pickering) Uganda AIDS Commission. "Global AIDS Response Progress Report." The Republic of Uganda, Apr. 2012. Web. 9 Mar. 2013. (AIDS Commission) "UGANDA: Sex Workers Missing out on HIV Care." PlusNews Global. IRIN, 14 Nov. 2012. Web. 09 Mar. 2013. (PlusNews) USAID. Uganda Ministry of Health. Uganda AIDS Indicator Survey. N.p., 2011. Web. 9 Mar. 2013. (USAID)

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