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Without a vaccine the AIDS epidemic can still end, UNAIDS boss

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Over the years, the HIV/AIDS discussion has changed from tackling transmission to treatment and prevention. Worldwide, experts are now looking to a cure to end the epidemic.In Uganda, however, despite efforts to reduce new infections, what still baffles experts are the increasing infection rates in adolescents now at 66% of new infections recorded annually. The new Joint United Nations Programme on HIV/AIDS (UNAIDS) Uganda Country Director Sande Amakobe spoke to The Independent’s Flavia Nassaka about her analysis of the country’s progress in tackling the epidemic and what approaches she comes with.

UNAIDS has set a target of 90 9090 by 2030. What progress has been made so far?

The 90 90 90 strategy means 90% of people living with HIV must know that they are positive by 2030.The second 90 is about treatment and the idea is that 90% of those living with the virus are enrolled on treatment.The last 90 is about how well you are doing once you are on treatment. This means that 90% of those on treatment should be virally suppressed to the extent that the virus is undetectable if a test is done. This target has been endorsed by the government of Uganda and has been included in the National Strategic Plan. It’s now revising the guidelines to ensure that the target is made. Now that the World Health Organization has also issued new guidelines of test and treat, we expect that anyone who is identified as HIV positive is immediately started on treatment. So far in Uganda, of the 1.5 million people living with HIV, 900,000 have been enrolled on treatment. What I hope to see Uganda adopting these guidelines if we are to achieve the target.

Recommendations like ‘test and treat’ have been made and countries have adopted them. Uganda hasn’t. What are the issues facing adoption in this country?

I have only been here for a short while but as a person who understands the science of HIV, test and treat should be the next automatic stage in the management of the epidemic. If people are on treatment and are virally suppressed the chances of spreading the disease to others are reduced by 96%. If you are talking about control then test and treat makes sense. UNAIDS is calling on countries to adopt a fast track approach so that we don’t have to deal with the rebound of the epidemic. The arguments for not rolling out these guidelines here are financial. From my discussion with the Health Minister, she wants to ensure that we have the financial guarantees that people will be sustained on life-long medication. I really hope that the Ministry of Finance will see the wisdom in test and treat because if we don’t pay now we are allowing for more and more infection which means we will pay a bigger bill in future. There is a cost-benefit analysis that needs to be done here very quickly.

World AIDS day is just weeks away and UNAIDS is running the Hands-up for HIV prevention campaign. What exactly do you seek to achieve?

The Hands-up for HIV prevention campaign is about revitalizing the prevention message by looking at the tools available today. There is use of condoms, medical male circumcision and ARVs among others. We are saying we have this tool box of a number of actions you can take, let’s put up our hands and commit to using the tools at our disposal to prevent infection. What will work for you may not work for me but in that same tool box, I can pick what is relevant and effective.

It’s hard to talk about HIV prevention and control in Uganda without talking about the main source of its funding – the donors. What does the heavy dependence on foreigners to solve a local problem mean for the country?

In very simple terms we are saying for a Ugandan to take that medication everyday someone in Washington or Geneva has to sign a cheque. Whilst that global solidarity is important it’s not a guarantee into the future. A call is being made and has been adopted by the African Union which asks for a three part solution to the financial sustainability problem. It’s contained in a document called the African Union Road map for Global Solidarity and Mutual Accountability. The framework talks about government increasing domestic finance for HIV. Previous studies show that the Ugandan government contributes only 10% to AIDs finance. UNAIDS together with Makerere University and Uganda AIDs Commission are conducting a study to get the latest financial flows information. Currently Uganda is seen to be asking somebody else to take care of 90% of its problem and there is inevitable risk in this. For instance, Europe is currently dealing with a refugee crisis and has had to decrease some of its funding. If this money was going into buying drugs for someone, it means they may not be able to survive.

Will the AIDs Trust Fund currently being mooted save anything?

Government is going in the right direction. Now that it has passed through parliament, we quickly need to go into implementation. I understand a paper is to go to cabinet and then back to parliament because they have to look at the regulations for operationalising the Trust Fund. I heard the projections are of having $2m in the fund a year. This is good enough for the start but we need to look for other innovative sources of financing. For instance currently the private sector contributes only 1% to the HIV response. There could be an opportunity to look at that and increase it. With accountable management of the money available, something viable can be done.

30 years after the epidemic you really hope you could say I used to live with HIV but now I am cured

As the new Country Director, what are your major areas of focus in the four years you will be around?

When I look at the figures I get excited about the energy put into prevention, that HIV positive mothers are enrolled on treatment to almost universal coverage for we stand at 95%. New infections have also reduced. My objective will be to ensure that we consolidate progress on that. My other area will be in ensuring more people are enrolled on treatment in addition to supporting government adopt the test and treat approach. I am not worried by the financial arguments being made because it’s a smart investment to make. However, my biggest worry is with the adolescents. While efforts have been made to prevent mother to child transmission, these children who are born HIV free only have to be with us for a few years before they acquire the disease. Of the 83,000 new infections every year, 66% are adolescent girls. It’s frightening and something that needs to lead us to question how our HIV interventions are operationalised if very young people are the majority of those acquiring new infections. We can’t talk about an AIDs free generation when its young people getting sick. That will be my other area of concentration.

What specific programmes are you looking at for women and girls?

There’s a ‘DREAMS’ programme. It’s a short form for Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe and looks at the problem in a comprehensive manner to understand biological, structural and behavioral concerns. Structural involves things to do with poverty which heightens vulnerability to HIV. It’s not a silver bullet that’s why the UN talks about a comprehensive package; in other words, you are educating the girl about her body and how she should protect herself, economic empowerment and poverty alleviation programmes. We need to be alive to those than condemn them. We can’t tackle one and leave the other. That’s why we are here to complement the government and other institutions.

Over the years, a lot of research has gone into finding a cure and a vaccine. Why in your view has it taken the world so long yet some trials have given us hope?

This is a complicated disease to manage in the body. There is a lot of investment going into vaccine research as well as the cure but nothing has been validated so far by the World Health Organisation. 30 years after the epidemic you really hope you could say I used to live with HIV but now I am cured. While it would be nice to have a vaccine and a cure, it’s important to appreciate that we have all the tools we need today for people with HIV to live a full productive life. We also have all the tools to prevent infection including pre and post exposure prophylaxis.

Uganda has passed a law criminalising willful transmission of HIV something that caused us a lot of backlash. What’s your view on the law?

Laws criminalising HIV are not helpful. The approach for managing any epidemic is creating an enabling environment for people to come out and get the services but when you start to criminalise certain actions the worry for people in epidemic control is that you drive people underground than bring them to the fore. What happens when the transmission is from mother to child? Do you want this child to grow up later and sue the parents? In criminal law, there are provisions for anyone who endangers the life of another person willfully and recklessly. These pieces of legislation can take care of that.

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editor@independent.co.ug

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