Challenges of resettlement for HIV-positive displaced

Walter Okello clutched his wheezing, gaunt three-year-old son as they sat on a wooden bench outside northern Uganda's Lira Regional Hospital waiting for the results of an HIV test. "If Emy tests positive then it means my wife must be positive too, and that will make three of us," said HIV-positive Okello, resigned to the likely outcome of the blood test. "At the moment we live in Amuka [camp for the internally displaced], close to Lira hospital, but I hope soon we will return to the village, but getting [medical] help will then be difficult." In 2002, the bloody conflict between the rebel Lord's Resistance Army and government forces forced 70 percent of Lira's population into cramped, unsanitary camps. Now, across Lira district, improved security is offering hundreds of thousands of people the opportunity to end a day-to-day existence dependant on humanitarian handouts and return home to their villages. "People are returning home," said Felix Omunu, the district disaster preparedness coordinator. "In Dokolo, thousands have returned home, while in central Lira, many are heading to smaller camps closer to their villages to assess the security situation." There is general agreement resettlement will have a positive impact in the region. Without work, men in the camps resort to drinking; idleness, alcohol abuse and poverty have changed the sexual behaviour of the traditionally conservative Acholi and Lango populations, and rates of sexual abuse and prostitution have soared. People in the camps are unable to access quality healthcare services water or food. Disease is rife and opportunistic infections are hard for HIV patients to keep at bay. "A return to the villages will help curb the spread of AIDS. An idle mind always reflects onto one thing - sex. If they return to the village they will have a focus," said Jajja Okring, from the AIDS Information Centre. "We hope resettlement will change sexual behaviour. Uncharacteristic sexual promiscuity was forced onto people by camp life," agreed the district director of health services, Dr Peter Kusulo. "Returning to a more settled environment should lead to a more positive sexual behaviour." However, the movement of people from 42 camps to their villages across the district is expected to make the care, support and treatment of HIV patients more difficult. The one advantage of many people confined to a limited space, Kusulo noted, was the ease of access to large numbers to promote HIV awareness and to provide follow-up care. "We don't have the human resources, the transport and the fuel budget to provide follow-up care outside the hospital," said Dr Jane Aceng, medical superintendent at Lira Regional Hospital. She said once started on antiretroviral drugs, patients were introduced to community-based organisations that assisted in follow-up care, including counselling, ensuring patients stick to treatment programmes and income generation activities. "Even just tracing them once they leave the camps will be difficult," Aceng added. Patients, too, will face the prospect of travelling longer distances to receive ARVs until the local health authority expands the number of centres providing treatment. Nevertheless, Aceng said, the return of people to their home villages and, more importantly, to an environment in which they can be self-supporting, is imperative. In the long run, she believes, there will be more positives than challenges. "With an income from digging [farming] they will be able to afford transport to get the treatment they need," she said hopefully. Local authorities now face the considerable challenge of re-installing public services to areas of the district abandoned for the last four years and upgrading those that remained open. "Fortunately we don't need to develop new structures. We have health centres that we shut down during the insecurity so we need to functionalise them, and where there are no health centres we are going to use outreach programmes," said Kusulo. Access to health care in Lira district is inadequate, prompting fears outside the Ministry of Health the district authorities are ill prepared for the numbers expected to return over coming months. "That is why we are talking expansion," said Kusulo, adding that the target was to provide voluntary counselling and testing (VCT) at all sub-county health clinics to ensure that services were close to the communities. Karla Bil, project coordinator at Médecins Sans Frontières (MSF), agrees with Kusulo's assessment. "They [local health authorities] need to focus more on the main sites such as trading centres. The district is working hard, but at the moment the health service is not ready for the return," she said. "There is a huge need for staffing and for supplies." The district's target is to place VCT centres in all 14 sub-county level health centres within the next two years. Ultimately, says Kusulo, the goal should be to have ART in each VCT site. For Walter Okello and his family, the only option should he decide to return to the village, will be a 30 km ride on the back of a bicycle to the hospital.