Living positively in war-ravaged northern camps

HIV/AIDS was unheard of in northern Uganda in the mid-1980s; now it is the second most prolific killer in the region, where almost two decades of conflict between the Ugandan army and the cult-like Lord's Resistance Army (LRA) has driven thousands of people into camps for displaced persons, and the prevalence rate has climbed above nine percent. Although malaria causes more deaths, according to the 2004-05 Uganda Sero Survey the national HIV prevalence rate is much lower - only 6.4 percent. Residents in the Acholiland districts of Gulu, Kitgum and Pader have been terrorised by the LRA, notorious for the murder, rape and torture of thousands of innocent civilians and the abduction of an estimated 25,000 children for use as soldiers, sex slaves and domestic workers. Close to 90 percent of the people who have sought safety in the squalid, overcrowded camps for the internally displaced in this least developed part of the country have severely limited access to quality healthcare. The HIV/AIDS pandemic, fuelled by soaring levels of alcoholism, domestic violence and commercial sex work, has wreaked havoc among the population. Early each morning, Rose Omona should join the trail of women carrying their hoes to small plots of land outside Unyama camp. Instead, while semi-clad children with streaming noses play around pools of stagnant water, she sits on a bamboo mat and opens three plastic containers that hold her morning cocktail of drugs. A widowed mother of seven children, Omona tested HIV-positive four years ago and is one of a rapidly growing number of people who now depend on antiretroviral (ARV) medication. "Without these drugs I would be dead and my children would be orphans, left to fend for themselves," she said. Rose refuses to feel bitter towards the husband who inadvertently infected her before dying nine years ago. She considers herself fortunate, as life-prolonging antiretroviral treatment was not available in Gulu until a year before a blood test confirmed her HIV status. Life in northern Uganda's camps is dominated by insecurity and hunger. Women fetch water and firewood in fear of being raped, not only by rebel fighters but also by local defence forces, supposedly in place to protect camp residents. Unable to cultivate land more than two kilometres from the camp boundaries, the region's 1.5 million camp-dwellers depend on the United Nations World Food Programme (WFP) to keep hunger at bay. Access to good quality health, education and water is limited; there is minimal sanitation and waterborne diseases such as cholera are a chronic problem; entire families live in tiny, one-roomed mud huts where there is no privacy. However, growing stability across the region has allowed district health authorities and international organisations in Gulu to focus attention on drawing up prevention, care and treatment strategies to counter the spreading virus. IMPROVED ARV ACCESS The AIDS Support Organisation (TASO), a local NGO, offers care and support to more than 5,200 HIV patients, 500 of whom receive free ARVs. "This is still a small number, determined by the funding we receive from donors to procure the drugs," said Kimera Boogere, centre manager at TASO Gulu. "Our guess is that between 2,000 and 2,500 of our clients require ARVs. We are looking to transfer from branded drugs to generic drugs - these are more cost effective, do the same job, and will enable us to supply medication to more patients." HIV infection makes life more arduous. "It's difficult living with HIV in camps. Each day I struggle to make ends meet, selling second-hand clothes," said Patrick Oloya, 29. He was sick for two years before a blood test in 2004 confirmed he was infected. Counselling by TASO has helped him overcome his fear of death, but the illness saps his energy, preventing him from farming. "Things were better when I could dig, but doctors told me that I was not to get involved in heavy labour and now I no longer have the strength to dig what small patch of land we have." Oloya worries about his children: the two older ones have been tested for HIV and are negative, but the youngest one is breast-feeding, prompting fears that he may contract the virus from his mother. "What I know is that I must follow the doctors' advice if I am to see my children through their childhoods." ARVs require a nutritional intake that most people in the camps cannot afford. Christine Orama, an HIV-positive, widowed mother of three believes the risk of serious side affects and prohibitive food costs deter some people from seeking treatment. "The doctors advise us to take the ARVs with a well balanced diet of meat, vegetables and fruit," she said. "We don't have the land to dig, so we wait for the WFP to deliver monthly food packages, but they only give us maize, beans and corn flour." The provision of antiretroviral therapy (ART) in Gulu district is largely concentrated in the municipal area. According to TASO's statistics for 2005, three out of four patients live within 10km of Gulu town and four of the five ARV sites are based in and around the municipality. Only one in 20 patients lives further than 75km from Gulu town, and the other treatment centre, at Anaka Hospital, is situated near the district's southern border. RURAL POPULATIONS LEFT BEHIND "We [government and NGOs] are a long way from covering the entire district, and the majority of people suffering are in camps, not the town," said Boogere, who attributed the inadequate coverage to the ongoing insecurity in outlying parts of the district. "Demand for voluntary counselling and testing [VCT] is increasing, but the health units in the camps don't have the means to provide this service. As a consequence, the further you travel from Gulu, the fewer people know their serostatus," he added. Unyama camp is just eight km from town, but people on ARVs say the transport cost of 3,000 Ugandan shillings (US$1.60) places a huge financial burden on families who have no means of earning a regular income. However, access to ARV centres is set to improve, with additional sites in the villages of Attiak, Lalogi and Awach - accredited by the government - waiting for the first consignment of drugs to be prescribed by newly trained staff, according to Gabriel Lokach, HIV focal officer in the office of the Gulu district director of health services. "This is a tremendous step forward. The bulk of our people in need of ARV treatment are outside Gulu municipality and in the camps," he said. The new ARV sites will dramatically improve access in the district and reduce transport costs. "However, whilst ARVs have changed people's lives," Lokach cautioned, "They are initiatives influenced by government and donors, and we don't know when policy might change." Two decades of instability had been a major factor in limiting the outreach of VCT and ARV sites across northern Uganda. "The situation seems stable enough now to be making long-term plans in the district, but with guerrilla wars you just never know when the violence can return," he said. Dr Paul Onek, the ministry of health's most senior official in Gulu, says successfully fighting HIV/AIDS in northern Uganda goes beyond providing drugs. "You can give them all the ARVs in this world, but we will not get on top of HIV/AIDS in the north until people are able to regain their dignity."