Increased male circumcision does not mean Uganda will meet its target

By Esther Nakkazi

The latest 2016 Uganda Population HIV Impact Assessment (UPHIA) survey includes much to celebrate. The proportion of men aged 15-49 years that are circumcised increased from 26% in 2011 to 43% in this survey.

"This is good progress which must be lauded," said Angelo Kaggwa Katumba program officer at AVAC. "Question is, is this pace fast enough for Uganda to achieve its Voluntary Medical Male Circumcision (VMMC) targets?"

It has been documented that between 2010 to 2016, the total number of VMMCs performed in Uganda increased from 9,052 to more than 3.4 million. However, an estimated 4.2 million men and boys between the age of 10-49 years remain uncircumcised.

In terms of funding, U.S President's Emergency Plan for AIDS Relief (PEPFAR) continues to be the principal donor for VMMC – supporting about 85% of all circumcisions during this period.

"If it has taken us 6 years to circumcise 3.4 million men then definitely its going to be tricky reaching the 4.2 million uncircumcised men by 2020 and given that Uganda's targets are used to meet the global targets this is going to impact on the global performance," said Kenneth Mwehonge -Program Officer- Advocacy & Networking Coalition for Health Promotion and Social Development (HEPS Uganda).

The report shows that the proportion of men circumcised ranges from 14% in Mid Northern region to 69% in Mid-Eastern region. The prevalence of male circumcision was highest among young people l5-29 years at over 45%.

It also shows that about 6% of of Uganda's adult population aged 15-49 years in Uganda are living with HIV. Among children under five and 5- 14 years, HIV prevalence is 0.5%. Based on the survey results, the total number of adults and children of all ages living with HIV in Uganda is estimated to be approximately 1.3million.

The 2016 UPHIA, is a nationwide survey that was conducted to provide estimates of HIV incidence, HIV prevalence, viral load suppression, syphilis, hepatitisB infection, and other important HIV/AIDS programme indicators. 

Data were collected in all districts of the country from a sample of households that are representative of the Ugandan population. The survey was conducted from August 2016 to March 2017 from 12,483 households and achieved very high participation rates of over 95% for both interviews and blood draws.

A total of 16,670 women and 12,354 men aged 15-64 years were interviewed and tested for HIV, syphilis and hepatitisB. In addition, 10,345 children aged 0-14years were tested, including 6,527 aged, 0-4years and 3,818 aged 5-14 years. 

The 2016 UPHIA was led by the Government of Uganda and conducted by the Ministry of Health in collaboration with ICAP at the Columbia University. Funding for the survey was provided by the U.S President's Emergency Plan for AIDS Relief . 

Technical assistance was by the U. S Center for Disease Control and Prevention (CDC) other collaborating partners included Uganda Virus Research Institute, Uganda Bureau of Statistics, WHO and UNAIDS. 

In the survey results released on 17th August, adult HIV prevalence was found higher among women at 7.5% compared to 4.3% among men. The HIV prevalence among young people 15-24 years was 2.1% (0.8% in men and, 3.3% among women). 

Among adults, HIV prevalence is lowest in those 15-19 years and highest among men aged 45 to 49 years at 14%. Among women, HIV prevalence is highest in the age groups of 35 to 39 years and 45 to 49 years at 12.9% and 12.8% respectively. 

"Let us first first salute everyone involved in the fight against HIV as there is something to celebrate in terms of the general HIV prevalence in Uganda, however when we dis-aggregate data, we realize that there is a significant increase of prevalence among certain categories of people like adolescents, young girls and women," said Mwehonge.

It was also higher among residents of urban areas at 7.1% compared to 5.5% in rural areas.  There was also differing magnitude depending on the geographical region from 2.8% in West Nile, 3.4% in North East region, 4.4% in East Central(or Busoga region); 4.8% in Mid-East region; 5.5% in Mid-West region. 

The survey found HIV prevalence was higher in urban areas at 6.6% in Kampala; 7.4% in Central 2 (Greater Mubende, Luwero and Mukono); 7.6% in central region (greater Masaka) to 7.7% in south Western region. This is similar to the findings of the 2011 Uganda AIDS Indicator Survey (UAIS) when Mid-Eastern showed the lowest and Central the highest estimated HIV prevalence, a press statement from the Ministry of Health said.

The 2011 UgandaAIDS Indicator Survey estimated national HIV prevalence among adults at 7.3% compared to 6.0% in the 2016 UPHIA. Among women and men, HIV prevalence declined from 8.3% and 6.1% in 2011 to 7.5% and 4.3% in 2016 respectively.

In urban areas, it declined from 8.7% to 7.1%, while in rural areas it fell from 7.0% to 5.5%. These declines in HIV prevalence may be due to a decreasing number of new infections in recent years due to the impact of the intensified HIV prevention and treatment services in the country.

 
The 2016 UPHIA also established the rates undetectable virus or suppressed HIV viral load(VLS). UPHIA showed that adults age 15-49 years had a VLS of 57.4%. This finding shows that with support from development partners such as PEPFAR, the Global Fund and other programs, the Government of Uganda's HfV programme is having an impact and making great progress toward the UNAIDS and national goal of having population level VLS of at least 73% by 2020.

Data from UPHIA identified existing gaps in HIV programmes and specific populations that need special focus. For instance, HIV prevalence the 15-19 year olds was 1.1% (1.8%in girls and 0.5% in boys) there was an increase to 3.3% among those aged 20-24 years (5.1% in young women and 1.3% in young men) which suggests that new infections remain an issue in these age groups said the Ministry of Health statement.

"This continuing infection risk necessitates innovative interventions to prevent new infections in young people beginning around age 20."

Furthermore, women 15-24 and men under 35 years of age who are living with HIV have rates of VLS <500h. 'These lower rates of VLS are driven by younger people being unaware of their HIV status and not accessing available services. Interventions are needed to ensure young people know their statusand if HIV positive are linked to care.

UPHIA also established the magnitude of syphilis and hepatitisB infection in the general population. The prevalence of active syphilis among adults aged 15- 49 years was l.9% (2% among women and 1.8% among men).This was similar to the findings in 2011, in which the prevalence of syphilis was l.8%. 

The prevalence of active hepatitisB infection among adults was 4.3% (5.6% among men and 3.l% among women). HepatitisB prevalence was highest in the Northern Region, Mid North(4.6%), followed by North East(4.4%), and WestNile (3.S%).

HepatitisB infectionwaslower in the rest of the country with a range of 0.8% in the South West region to 2.7% in East Central Region. The preliminary results of 2016 UPHIA demonstrate that Uganda has made significant progress in the national HIV as HIV prevalence has declined across socio-demographic subgroups and across the country.

"This decline may be a result of falling new HIV infections. Furthermore, almost 60%of people living with HIV (PLHIV) have undetectable HIV, which means that treatment programs are successfully reaching the majority of the population with HIV," said the MoH statement. But there needs to be more  prevention awareness creation and treatment is needed for those 15-29 years.

"Moving forward, the UPHIA results demonstrate the urgent need to prioritize and fast track the roll-out of high impact interventions if we are to meet the global set targets and achieve epidemic control," said Mwehonge.

"There is need for innovative approaches to reach the 4.2m men by 2020 especially the men between 45-49 years whose HIV prevelance was reported at 14%," Sylvia Nakasi, Policy and Advocacy Officer, Uganda Network of AIDS Service Organisations (UNASO).

"With the launch of the Presidential Fast Track Intiative to end HIV by 2030 in June 2017 by the President,  I hope there is an opportunity to increase investment in prevention and care interventions among vulnerable populations. With this pronouncement its an opportunity to advocacte and hold our leadership accountable," concluded Nakasi.

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