HIV takes root in remote, unprepared Karamoja

Ten years ago, HIV/AIDS was unknown in the isolated semi-nomadic Karamajong communities of northeastern Uganda's volatile Karamoja region. Successive nationwide sero-surveillance reports put the rate of infection in Karamoja at less than one percent; today local health authorities estimate it has climbed to three percent. Dr Moses Ongong, district director of health services in Nakapiripirit, one of Karamoja's three districts, said the trend should be ringing alarm bells. "We are seeing a rapid increase [in the spread of the virus] in the region and we urgently need to scale up intervention, especially prevention," he pointed out. The Karamajong cattle herders traditionally interacted little with communities outside their region. Sexual promiscuity was unheard of: girls remained virgins until marriage; warriors, though polygamous, stayed within the bounds of marriage; HIV/AIDS was kept at bay. Drought and hunger are recurring features of life on the semi-arid grassland of Karamoja. Competition for water and pasture to feed the herds, regarded as a source of wealth and status, have produced a culture of raiding and warfare in which men are noted for their bravery and social standing. Cattle rustling, carried out for generations in times of emergency or ceremony, has become increasingly aggressive, as modern handguns replaced traditional weapons. Raping women and children during raids has become commonplace, bringing the warriors into sexual contact with communities where HIV/AIDS rates are higher. More parents are marrying off their daughters at puberty, fearing sex outside of marriage will lower the bride price, while the deployment of soldiers to establish order and maintain peace has raised the level of sexual interaction with local women and the risk of spreading HIV. The task of fighting the disease, already difficult, is compounded in a society ruled by guns. Development has halted in Karamoja, where health and education levels are the worst in the country. The late arrival of HIV/AIDS in the region means prevention efforts are more than a decade behind the rest of the country, and illiteracy is a barrier to promoting Uganda's pioneering Abstain, Be faithful, and use a Condom campaign, or 'ABC'. Just 35 percent of Karamajong children are enrolled in primary school, and only two in ten will make it to secondary school. "Posters and pamphlets are out - instead we have to rely on word of mouth," said Ongong. Few development agencies are present in Karamoja, and most HIV/AIDS education in Nakapiripirit is carried out by the International Rescue Committee (IRC) and the Church of Uganda, which refuses to promote contraception. "We are hearing about HIV/AIDS, but how do we know who is infected?" asked Samuel, 25, who lives in Karita, a two-hour drive south of Amudat, the main town in Nakapiripirit, where the IRC explained the dangers of unprotected sex to a group of elders and youths. He is not convinced that condom use can prevent HIV infection. "We want it direct, we never wear condoms - we don't even know how to put them on." A local elder, Cassius Paulo, recalled, "The last time they came to demonstrate how to wear a condom, the boys put them on straight away in case they forgot." Even if condoms were more widely accepted, procuring them in Nakapiripirit is a problem. "Condoms have little role to play in much of the region once you move away from the trading centres and health units," said Dr Patrick Sagaki, medical superintendent at Amudat Hospital. "The best approach in the bush is abstinence, but it is hard to predict if this is realistic for these tribes." Stigma and discrimination are deep-rooted. "There remains a lot of fear of HIV/AIDS in Karamoja," said an IRC employee. "If a Karamajong reveals his sero-status, he will be isolated by the community and left to die alone in the manyatta [homestead]." There are only three voluntary counselling and testing (VCT) centres in Nakapiripirit. The Church of Uganda and IRC run mobile clinics, but insecurity and poor infrastructure limit access to outlying areas. Amudat Hospital has run a VCT centre for three years and now tests up to 200 people a month, including pregnant women. "Nationwide, the service delivery of ARVs is improving, with 70 percent of those who need ARVs receiving them. The story in Karamoja is very different," said Richard Okech, Unicef HIV/AIDS project officer for eastern Uganda. Just 20 patients receive the life-prolonging medication from Tokora health centre, the only outlet for the drugs in the district. Nakapiripirit also lacks the equipment to run laboratory tests determining how advanced the infection is in patients. Patients are being placed on ARVs on the basis of clinical presentation -literally how the patient looks – rather than blood-screening tests. "The epidemic has been here for a shorter period than elsewhere in Uganda," Ongong said. "We have not yet learnt how to deal with it."