UGANDA: Inadequate healthcare and rising HIV prevalence in Karamoja
A Karimojong woman demonstrates the use of a female condom
MOROTO, 30 April 2012 (IRIN) - The nomadic Karimojong ethnic group, once regarded as a low-risk HIV population because regional instability in northeastern Uganda and strong adherence to their culture kept them relatively isolated, have not been a priority on the country's HIV agenda, but recent statistics show prevalence among this community is now 5.8 percent, up from 3.5 percent five years ago.
Over the past decade large numbers of Karimojong have settled in urban centres, where business is flourishing and many NGOs have set up shop; there has also been heavy military deployment in the area as part of a disarmament exercise. These and other changes in a strongly traditionalist society have combined to push prevalence closer to the national average of 6.7 percent.
"The drivers of the pandemic that exist elsewhere are now occurring here. There is also a lot of alcoholism and [domestic] abuse here, which is one of the drivers of HIV/AIDS infection," Dr Michael Omeke, health officer for the Karamoja region's Moroto District, told IRIN/PlusNews.
Limited health services
Just five hospitals serve seven districts and a population of 1.2 million scattered over some 28,000 square kilometres. "In general, HIV treatment and care services are still low in the region," said David Wakoko, Karamoja area manager for the Mulago-Mbarara Teaching Hospitals' Joint AIDS Programme (MJAP).
Most health centres in the region do not have clinical officers trained to provide life-prolonging antiretroviral (ARV) drugs or offer HIV care and treatment. Kaabong District for example, has five health facilities, but only the district hospital has a medical officer authorised to treat HIV-positive patients, and the hospital does not have a CD4 machine to test blood samples and measure immune strength.
Few health workers are keen to live in the remote and underdeveloped region. "Human resources are a big challenge. You need someone who is qualified to help these people, but we are not attracting… personnel," said Dr John Anguzu, District Health Officer in Nakapiripirit. "Even the local people we try to train here to help, they leave."
The region has also not been spared the drug shortages that have occurred in other parts of the country. "We do experience ARVs stock-outs... We are trying to work with the Ministry of Health and National Medical Stores to see that these stock-outs are reduced," said Omeke.
A lack of food in the arid region and the long distances to health centres are major problems for people living with HIV. "These are weak people and can't move long distances to go for treatment and drugs. The health centres are too far," said Gabriel Lokubal, who lives in Moroto. "ARVs are very strong drugs, which require a lot of eating. However, most of us don't have food, so some people have stopped going for drugs."
Knowledge about HIV is also very low. A recently released preliminary report on the AIDS Indicator Survey shows that just 30 percent of women and 45 percent of men in the northeast are well-informed about HIV/AIDS.
A complex region
Spreading the word about HIV is not easy in Karamoja, where open discussions about sex are extremely unusual and the population is largely uneducated. According to MJAP statistics only 35 percent of Karimojong men have accessed HIV/AIDS services, compared to 65 percent of women.
|Because of the nature of the society and tradition, the men remain in the kraals [communal cattle pens] and are on the move... They have little interest in seeking HIV services
"Because of the nature of the society and tradition, the men remain in the kraals [communal cattle pens] and are on the move in search of pasture and water for their cattle. They have little interest in seeking HIV services," said MJAP's Wakoko. "Most of those who access HIV/AIDS services are women, especially the pregnant ones, who visit health facilities for ante-natal services."
"The HIV patients also tie HIV services to food. If you don’t have food, people don’t come," Anguzu said in Nakapiripirit.
Stigma is highly problematic for health services trying to reach people living with HIV. "When you test a person and… [the result] is HIV-positive, he or she will never come back again for further… [treatment]," said a nurse at the ARV clinic at Moroto Regional Referral Hospital. "We are trying to sensitize the community to accept their status and learn to live positively."
In an effort to bring the services closer to the people, Uganda's Ministry of Health and MJAP are running a home-based HIV counselling and testing programme, but low staffing and occasional insecurity in the region are affecting the door-to-door campaign.
"The security situation remains fluid, as it changes any time despite general improvement in the sub-region, thereby affecting the implementation of programme in most of the catchment areas," said MJAP's Wakoko.
Health workers in the region say the nature of the causes and effects of HIV mean it cannot be tackled in isolation, and a holistic approach should be used.
"The interventions need to be shared among sectors - health is concept which is determined by social, economic and cultural aspects," said Samuel Enginyu, a health educator with the Ministry of Health. "We are working on an integrated and collaborative approach with the Minister of Gender and Culture and other stakeholders."