Uganda is keen to implement new policies to put more people on life-prolonging antiretroviral (ARV) treatment sooner, as recent scientific breakthroughs indicate would be much more beneficial, but officials say the country's poor financial outlook means there is little chance of this.
"We have drafted policies for treatment as prevention, but we simply don't have the money to implement them," said Zainab Akol, HIV programme manager in the Ministry of Health.
Studies have shown that putting people on ARVs earlier significantly reduces their risk of transmitting the virus to sexual partners. The HPTN 052 study found that earlier initiation of HIV treatment led to a 96 percent reduction in HIV transmission to the HIV-uninfected partner.
Akol added that the country had expressed its willingness to adopt the recommendation by the UN World Health Organization (WHO) to raise the threshold for initiating treatment from a CD4 count - a measure of immune strength - of 200 to 350, but was not in a financial position to do so.
"We have all these as options, but we still haven't put all those with a CD4 of 200 and below on treatment, so our focus is to put all people on treatment but on a case by case basis, with those with the lowest CD4 count as our first priority," she explained.
Around 300,000 Ugandans are on ARVs, about half of the number who qualify for them.
Akol also noted that new programmes, such as male circumcision, were being implemented at a slower-than-ideal pace, largely because of inadequate funding.
Uganda's HIV programmes are more than 80 percent donor-funded, with the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria the largest contributors. In the past decade, the country has received close to one billion dollars from donors to fight AIDS.
Uganda's HIV programmes could be in for even tougher times. It recently missed out on US$270 million it applied for in the Global Fund's eighth round of funding, and Round 11 has been cancelled.
The government now contributes $60 million annually to purchasing ARVs from a local factory, but HIV activists say the amount is miniscule compared to the government's other priorities, such as very high defence spending - in 2011 President Yoweri Museveni spent an estimated $750 million on fighter jets for the army.
"We need to improve on the way we are using resources," said Bharam Namanya, executive director of the Uganda Network of AIDS Service Organizations (UNASO). "Are they in the most critical areas?"
He said an ongoing national AIDS spending assessment would determine whether too much money is being diverted to administrative costs, or if as much money as possible is being spent on actual services.
"The biggest gap is human resources for health," said Namanya. "We've had funding, but it's obviously not enough."
According to the WHO, Uganda has one doctor and 13 nurses for every 10,000 people, significantly lower than the organization’s critical threshold of 23 doctors, nurses and midwives per 10,000 people.
The gap in funding is often dismaying. The main health centre in Kalangala, the biggest town on the hard-to-reach Bugala Island in Lake Victoria, is doing its best to provide antiretroviral therapy says the head of the facility, Samuel Mugisha. Although the centre has drugs, it does not have the health workers.
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Instead, it has to rely on NGO and civil society partners to do outreach in the community, test people and refer them to the health centre for ARV therapy. He said the situation is improving, but "what makes it improve is the availability of implementing partners".
If those partners disappeared, it would devastate the centre's attempts to get and keep people on treatment, because the island's impoverished population is often unable to travel to the health centre on the mainland.
Dr David Kihumuro Apuuli, director general of Uganda's AIDS Commission (UAC), said the country was strategically using available funds to tackle the key drivers of the epidemic, but some programming - especially for prevention, and specifically from mother to child - has been underfunded.
Kihumuro acknowledged that the outlook for HIV funding was uncertain, but was optimistic that the country's international partners would continue to support the HIV response.
However, international organizations are advising Uganda to look inwards for money to fund its HIV response.
Local media quoted UNAIDS country coordinator Musa Bungudu as telling Uganda's parliament on 25 November: "These resources might not continue to come. Whatever money Uganda is expecting for 2011, forget it."
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions
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