Glum HIV/AIDS outlook for Kampala's slum dwellers

Hundreds of thousands of people live in the expansive slums of Uganda's capital city, Kampala, most of whom migrated from their rural homes to escape poverty, only to encounter hardship, squalor and exposure to disease. "Male residents usually do not have any choice but to become day labourers, hawkers, domestic workers in the middle-class areas or the city centre, and sometimes get involved in other risky professions, like pick-pocketing, drug-selling or selling sex," said Nelson Seruma, of the Kamwokya Christian Caring Community (KCCC), a community-based organisation working to reduce the spread of HIV/AIDS in the slums. Kamwokya is one of the capital's most populous informal settlements, where thousands of small corrugated iron dwellings are built so close together that their inhabitants lack any privacy. Jackson Kakuba, 28, rents a one-roomed house that has no toilet facilities, and complains that the neighbour's children use the trench in front of his house instead. "What can I do? Here I am paying 20,000 shillings [US$11] per month, elsewhere I would pay much more." Frustration born of poverty pushed many slum residents into desperation, said Seruma. "Consequently, they become drug abusers, and buyers or sellers of sex at various pubs in the areas, and become more vulnerable to HIV infection." Anthony Lubowa, a Kampala City Council official, attributed the high rate of HIV in the city - estimated at between 8.5 and 12 percent - to a number of issues, such as people migrating to find work to improve their standard of living, or who have lost their spouses to AIDS and want access to treatment. "Most of them are illiterate, or partially literate, and do not have any expertise that will allow them any decent employment," another city official said as he walked around the filthy dwellings. Women are particularly vulnerable to the pandemic, as commercial sex is often their only option, while those who are married have little power to negotiate condom use with their spouses. "We have some females who depend on males for survival, and these cannot decide their [own] destiny," Seruma commented. The stigma still attached to HIV/AIDS in Uganda means many women, even when they know their HIV status, never disclose it to their husbands for fear of being abandoned. "Even when they come to us and we find out that they need help, like being put on antiretroviral treatment, they will refuse, saying their husbands will notice them taking drugs regularly and they will not get any support for themselves and their children," Seruma said. Jennifer Nakawuki, 32, a mother of three, said she sold charcoal to feed her children because her husband often did not give them money to buy food and "instead uses his money to buy booze". "We fear this place because many of the prostitutes you see in the city centre reside with us here. At night they terrorise the people in the city and during the day they encroach on our husbands here, and I know my husband has one - I don't know whether AIDS has spared us," she said, admitting that she was too afraid to take an HIV test. Poverty also drives women into the lucrative alcohol trade. They brew a potent liquor, locally known as 'malwa', which often leads drinkers to risky sexual conduct. The women make their home brew, as well as food for sale, beside filthy drainage channels strewn with polythene bags, which are used as a substitute for proper lavatories and known as 'flying toilets'. Although a recent French grant of $5 million has enabled the city authorities to start improving sanitation, the water is unsafe to wash with, let alone drink, and the slums are rife with diseases like malaria, tuberculosis and cholera. HIV-positive residents, already immersed in such grinding poverty that they are unable to afford a decent daily meal, are particularly vulnerable to these diseases. KCCC has 6,037 clients in the slums, 874 of whom are on ARVs, but Seruma said some who had started treatment had failed to keep it up due to insufficient food. "The ARVs tend to improve their appetite, but some don't have enough food to sustain that demand, so they decide to abandon treatment," he said. "TB patients are overburdened by taking ARVs while at the same time taking TB drugs." The mobile nature of slum residents also prevented them from adhering to the ARV regimen - they often travelled far to find work and new people moved in to replace them. "Patients in distant areas have been difficult to reach, making follow-up very difficult," he said, adding that this also meant HIV awareness messages needed to be constantly recycled, as new arrivals needed to be sensitised to the dangers of the epidemic. Seruma stressed that awareness was a vital tool in the city's overpopulated slums, where ignorance was widespread and misinformation easily passed for fact. He commented that HIV awareness campaigns had so far made little headway in changing people's behaviour. "AIDS is there during the day, but at night you find people in dark corners," said Kakuba, pointing to the condoms that littered the ground - a sight as reassuring as it was disturbing. "Many of them are illiterate - they cannot read messages about HIV/AIDS prevention and this gives us a challenge, because the main medium of communication is through literature," Seruma explained. "Negative preaching by both the religious leaders in the area and belief in witchcraft is rampant. Many have been preaching that prayers can cure HIV/AIDS, while some people spend time blaming witchcraft for their ailment, aggravating their situation," said Joseph Mwanje, a health worker in another part of the slum. KCCC, a Roman Catholic organisation, does not preach condom use but, according to Seruma, "we give a client all the information, including information about the condom, and leave him or her to make his or her own choice, knowing the risks involved."