Uganda’s HIV/AIDS control efforts have been undermined by a lack of consensus and clarity over which people constitute Key Populations (KPs) to be targeted in various prevention, care and treatment efforts, say experts.
There is no consensus on the definitions of, and who to include as, KPs, with activists noting that the lack of clarity on KPs at policy level has an adverse impact on HIV prevention, care and treatment.
“The fight against HIV-AIDS will continue to be jeopardized if marginalized groups are not well defined and included in the fight against HIV/AIDS, yet we all agree that [these] are the highest drivers of HIV,” said Moses Kimbugwe, the advocacy and programme director with Spectrum Uganda, a lesbian, gay, bisexual, transgender and intersex (LGBTI) advocacy organization.
According to studies, the most at-risk populations (MARPs) in Uganda, who account for HIV prevalence rates often more than double the national average, include fisher folk, transactional sex workers and their partners, men who have sex with men (MSM) and men in uniformed services. The Joint UN Programme on HIV/AIDS uses the term “key populations" to describe these groups.
In Uganda, the national HIV prevalence rate is 7.3 percent, a rise from 6.4 percent over the past five years. This is compared to the estimated prevalence rates of 15-40 percent in fishing communities, 37 percent among sex workers, 18 percent in the partners of sex workers, 13 percent in MSM, and 18.2 percent among men in the uniformed services.
A recently released Uganda AIDS Commission (UAC) mid-term review report of the 2011-2015 national HIV/AIDS strategic plan notes that "limited interventions addressing key populations... [are] exacerbated by inadequate knowledge about the context and extent of the problem of key population groups.”
“Moreover, the legal environment and programming design issues intervene to undermine interventions for KPs," it adds.
The “legal environment” refers to issues such as Ugandan government attempts at criminalizing homosexuality. In August, the country’s constitutional court threw out the Anti-Homosexuality Act (AHA), which would penalize those guilty of "homosexual acts" with jail terms of up to 14 years and life sentences in "aggravated" cases, such as those committed by an HIV-positive person, or those involving minors, the disabled and serial offenders. AHA also prohibited the "promotion" of homosexuality. Related to this is the HIV/AIDS Prevention and Management Act 2014, which criminalizes wilful transmission of HIV with fines and jail terms of up to 10 years.
According to Sylvia Nakasi, the policy and advocacy officer with Uganda's Network of AIDS Service Organizations (UNASO), “the lack of clarity and consensus on key populations and MARPs creates confusion especially to the programmers, donors and service providers. There is confusion on who to target their services to and in the end [they] leave out the right target.”
“They [key populations] should be mapped out to know how many there are, where they are and what their needs are, so [that] interventions are targeted to meet their needs and curb the HIV incidence among them and the general population.”
Asia Russel, international policy adviser for the US NGO Health Gap, added: “Key populations such as MSM need access to prevention and treatment services delivered in a friendly environment, without discrimination or fear of stigma. This means establishing specialized clinics, but it also means training health workers in existing, non-specialized clinics for the general population so that they meet a minimum standard for non-discrimination and quality provision of care in service delivery.”
While Uganda's Health Ministry has opened some specialized MARP clinics in Kampala and other HIV/AIDS hot spots in the country, needs remain with discrimination persisting.
"The specialized clinics came into existence because the Ministry of Health has failed to open up its centres to LGBTI persons receiving health services without discrimination," Kimbugwe of Spectrum Uganda, told IRIN. "Sometimes these specialized clinics continue to stigmatize our people and it's the reason we orient healthcare service providers in the health needs of LGBTI people so that they are free to receive services at any place of their choice."
Denial and stigma
According to UNASO’s Nakasi, “the denial of the existence of MSM increases stigma and discrimination against MSM in the communities, limiting access to HIV services especially prevention, and also deters donors and service providers from planning for them.”
“Given that MSM are part of the general community, majority end up bisexual in order to fit in and be acceptable socially hence spreading the risk of HIV transmission to the general population.”
The denial of the existence of some MARPs by some government officials is a challenge too. “People know that homosexuality is not Ugandan or an African issue. It’s few individuals here in Kampala who are practising and trying to promote it,” Sarah Achieng Opendi, Uganda’s acting minister for health, told IRIN.
The UAC report recommends expanded access and provision of comprehensive packages for HIV prevention, care and treatment. According to a 2014 Ministry of Health and UAC report, there are an estimated 10,533 MSM, 54,549 transactional sex workers, two million fisher folk, 650,000 uniformed forces and 31,588 truckers in Uganda. As of 2013, the number of KPs reached with HIV interventions in Uganda had doubled from 139,758 in 2010 to 287,302, according to the US President's Emergency Plan for AIDS Relief.