HIV/AIDS in Northern Uganda: ‘A New War’

Uganda has a reputation of having controlled its HIV/AIDS problem. Matthew Wilhelm-Solomon writes that the extent of the virus in Northern Uganda is perhaps more severe than figures indicate, “as the expansion of combination antiretroviral therapy – the treatment which can suppress the replication of the human immunodeficiency virus - to the camps has been severely limited due to dangerous access routes and impoverished resources.”

In Northern Uganda World Aids Day on December 1st comes at a time of uncertainty; in the fragile peace that has come to the region, HIV and AIDS is emerging as a problem of significant magnitude for communities who have suffered two decades of war and displacement.

At present talks between the Lords Resistance Army – the religiously inspired rebel group, who have woven together themes of Acholi and Christian mysticism as a legitimation to inflict a supposedly purgatory violence on the population – and the Ugandan government haltingly continue in Juba, Southern Sudan. Communities in Northern Uganda are coming to terms with years of neglect and violence, in which an estimated 1.6 million people have been displaced, most of whom live in congested camps, or ‘protected villages’ with little access to agriculture, income or health services. Yet, the spectre of AIDS haunts the calm that has come to the region.

Says Odoi Charles, counseling coordinator of The AIDS Support Organsation (TASO) in Gulu Town: “We are using World Aids Day to sensitize people and to commemorate the gallant fallen ones. It’s a day to remember those who have died because of AIDS”

AIDS is the second highest reported reason for death after malaria in the region according to the World Health Organisation. In spite of Uganda’s reputation of having controlled its HIV/AIDS problem, a 2004/2005 Uganda National Sero-Behavioural Survey indicates the prevalence rate for the North Central Region is 8%, significantly above the national rate of 6.4%. Antenatal data at St Mary’s Lacor Hospital – a Catholic hospital near Gulu Town – indicate a prevalence rate of 11.9%, though local organizations believe the rates may be far higher in some camps. No reliable data exists for many of the camps in the region.

The extent of the impact of HIV in the region may be more severe than figures indicate, as the expansion of combination antiretroviral therapy – the treatment which can suppress the replication of the human immunodeficiency virus - to the camps has been severely limited due to dangerous access routes and impoverished resources. However, the past two years have shown a significant scaling up of treatment access in the region through a combination of government and non-governmental programmes, the latter predominantly funded by the Presidents Emergency Plan for AIDS Relief (PEPFAR), a United States government fund. Certain Catholic programs under this funding can’t actively promote or distribute condoms, which places a bar on strong coordination between treatment organisations in the region with differing views on the use of contraceptives. The government programs are being funded in part by the World Health Organisation after the withdrawal of funds to Uganda by the Global Fund to fight AIDS, Tuberculosis and Malaria in late 2005 as a response to financial mismanagement. This caused temporary supply-line stockouts in Gulu National Hospital.

The treatment in the region has already had its successes in areas where it has been available. Ilama Charles is a counselor with Comboni Samaritan a local Catholic HIV/AIDS care organization providing support to clients of St Mary’s Lacor, which was one of the frontier treatment providers in the region starting a treatment program in 2004 and which now provides over 1500 treatment slots in the Gulu district. Ilama has witnessed the changes it has brought in the area: “You saw people who were brought on wheelchair, starting riding bicycles, lifting Jerry cans of water on their head. If you are to go to the medical ward you would find the hospital filled with patients, even some are sleeping on the floors. Medical staff were really stressed. With the advent of ARVs there were many changes. Before patients were coming with three, four opportunistic infections, but others would have ten, eleven. Now these have disappeared, they now go once a month for the ARV for their drugs”. The program which has many clients from surrounding camps has shown high rates of drug adherence, a key concern for antiretroviral treatment programs, as low adherence rates effect both the efficacy of treatment and risk the spread of drug resistant viral strains.

The inception of treatment in the region has also led to a dramatic rise in numbers seeking testing HIV and news has spread quickly about the drugs. Numerous clients have returned to strength and been able to cultivate what land is available around outskirts of the camps; the return to digging is symbolic of both health and peace.

Yet, for many treatment is still out of reach. Even where antiretroviral treatment may be available, many cannot afford to get to treatment sites or even to be tested. In Pabbo, the largest camp in the North with an estimated population of 60 000 people, there is still no access to antiretrovirals other than for the few who can afford the 90km monthly trip to Gulu Town. The route is one in which, until this year, ambushes were common. In Pabbo a vast dusty field outside the health centre has become a nursery and playground – boys kicking balls made from plastic bags, children following and peering through the windows of aid vehicles, desperate for entertainment. It is places like these where the destitution of war is most apparent. In seems that here there are two worlds and times: one in which children live and die, with their own daily rhythms, cycles and wanderings - often ended by malaria, fire, or diarrhea - and the world of adults which requires a fierce resilience and patience to survive. Child morbidity rates in the area are, according to the WHO, of ‘emergency proportions’.

Treatment for children provides a particular difficulty: they are often left unattended or with elderly caregivers, who cannot monitor their adherence properly. Health Alert is a local NGO trying to expand care and treatment follow up for children and pregnant mothers in the Gulu district. Says Achero Joyce Stella, a counselor at Health Alert: “In the camps, the issue of child neglect is a problem. For instance in Awach, the father had neglected the child. The child died, from opportunistic infections. Because of lack of money, distance from the treatment centre, the child died.” In some camps, the return to health of parents and the peace has been a mixed blessing: the parents go to garden during the days, leaving their children alone to wander unattended. For other young men and women a return to health is an opportunity to marry and have children, which raises concerns about mother to child transmission and the spread of drug resistance.

In spite of the fragile peace, the toll of violence and daily suffering on the population has been remains severe. Almost everybody has suffered direct violence on themselves or their families. Alcoholism is rife. Disillusionment with the prospect of peace is widespread; many believe that the army has no interest in ending the war and have benefited from it through stealing cattle and land. A thirty five year old women in the St Thomas camp near Gulu Town, was left looking after seven children after her husband, who was a soldier, was killed by the LRA. She says: “I hear people talking about peace talks, but I am never interested because I know it may happen the way it has been happening since they tried to talk peace; it never succeeds, no change ever occurs” She began taking antiretroviral in 2005. The treatment process has helped not only her physical but mental health. “When I started using the medicine, it brought about change in my life, in terms of health, because before I started using the medicine I was almost running mad. There is my last born whom I wanted to kill because I knew I was going to die so she could not remain to suffer on earth, but when I started using this drug all the bad thoughts went out of my mind…the problem has affected everyone, but for us women it is very painful, because you will be the house head, responsible for everything in the home.” With many men dead from the war and disease, the burden for household and community cohesion is increasingly being placed on widows, and it is predominantly widows who are enrolled in treatment programmes. This places an adverse burden on women in supporting their families with meager resources. Many men still fear the shame and perceived guilt of being tested for HIV and seeking treatment, though the situation is improving.

Yet, the peace is creating new possibilities for the expansion of treatment into areas that were previously inaccessible. TASO are presently adding a further 600 antiretroviral slots to their present 500 introduced in 2005. They are celebrating World Aids in Awach, one of the camps to which antiretroviral treatment has become available in recent months.

“The whole region has been very calm. We have very high hopes,” says Odoi Charles, counseling coordinator at The Aids Support Organisation (TASO), Gulu. Comboni Samaritan are presently expanding their services from a 40km radius from St Mary’s Lacor Hospital to 70km because of the peace in the area.

The material and logistical obstacles to scaling up treatment in the region remain, however, daunting. There are major shortages of medical staff and diagnostic equipment, particularly at government health facilities. At some of these health facilities there is poor treatment follow up which could lead to poor adherence. This raises the possibility of the spread of drug resistant strains of the virus – a threat which could undermine the treatment effort in years to come. The problem of transportation for many in the North is huge; many simply cannot afford to get to treatment and testing facilities or they arrive when it is too late to be helped.

At present, the camps are being ‘decongested’: residents of the larger camps are being allowed by the army to move to smaller camps closer to their land. Patients are becoming more increasingly scattered, making monitoring more difficult. If the peace talks fail, renewed conflict could undermine attempts at treatment expansion. Yet, there is hope among caregivers and patients that these obstacles are not impassable and community based strategies are being developed to overcome them. In uncertain times, the healing of those suffering from HIV/AIDS could be an analogue for social healing. World Aids Day provides a moment to recollect past losses and look forward towards the prospect of a difficult peace.

Odoi Charles of TASO claims “We are now going to begin another war: the HIV/AIDS war.”

* Matthew Wilhelm-Solomon is a South African Rhodes Scholar and MPhil Candidate in Development Studies at Oxford University. He is also a committee member of Student Stop Aids at Oxford University, and ahas worked as a freelance journalist in South Africa while studying Political Science at the University of Witwatersrand publishing mainly in the Mail & Guardian.

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