Status of HIV in Uganda

By Esther Nakkazi

This year, Uganda marks World Aids Day under the same theme as last year, ‘Re-engaging Leadership for effective HIV prevention’ but with the slogan: ‘Accelerating HIV prevention for Zero new infections.’

Indeed, with 130,000 new infections in 2011 according to the National AIDS Indicator Survey (UAIS) released mid this year, from 128,000 in 2010 and 124,00 in 2009, the status of Uganda’s HIV is alarming and at a critical crossroads.

Dr. Christine Ondoa, the minister of Health says the focus on zero new infections once re-energised by leadership at all levels and using the new available prevention tools in combination, would eventually lead to zero new HIV infections in Uganda.

The science is clear. These new HIV infections can be entirely eliminated using combination prevention tools like giving treatment to all the 1.3 million Ugandans currently infected and living with HIV, offering voluntary Medical Male Circumcision (VMMC), prevention of Mother-to-Child transmission of HIV (PMTCT) and use of condoms.

But all these prevention tools have to be implemented at the same time and scaled up to higher proportions, about 80 percent, that can create a dent on the epidemic. 

“We need a comprehensive response- with behaviour interventions backed by biomedical and social-cultural interventions at a scale that generates impact. We have been spreading ourselves at low levels on the ground,” said Dr. Joshua Musinguzi the HIV/AIDS control programme manager at the Ministry of Health.

The 2011, HIV/AIDS indicator survey, exposes Uganda’s current status of the epidemic showing a rise in prevalence after enjoying global yardstick status in the late 1990’s when the HIV/Aids prevalence was brought down to 5 from 18 percent in the 1980’s.   

The UAIS report shows that the prevalence still remains significantly high, currently at 7.3 percent for Ugandans aged 15-49 years from 6.4 percent in the 2004/05 survey. 

Like elsewhere in the world where women bear the burden of the disease, women in Uganda are disproportionately infected with the prevalence higher among women at 8.3 percent than among men at 6.1 percent from rates of 7.5 and 5.0 percent in 2004/05.

Currently, two-thirds, 66 percent of women report ever being tested for HIV and received their results, a marked increase from 13 percent in 2004-05.  HIV testing among men has increase four-fold, from 11 percent in 2004-05 to 45 percent in 2011.  

Overall, 72 percent of pregnant women reported prior testing and receiving their results during antenatal care. 

According to the most recent data, HIV prevalence is highest among the Most at Risk Populations including commercial sex workers, fishing communities and mobile populations.

Government statistics have put HIV prevalence in fishing communities at 28 percent, although there are fears that it could even be higher and 10 percent of all new infections are from sex workers.

Dr. Fred Wabwire-Mangeni, a public health specialist and medical researcher says it is these drivers of the epidemic that need to be focused on to bring a change in the tide of the HIV/Aids in Uganda now.

Moreover, in Uganda now, more urban dwellers are HIV-positive than those living in rural areas 8.7 percent versus 7.0 percent but even here the disproportional rates for women is significant.

Women living in urban areas have a prevalence rate of 10.7 percent and those in rural areas is 7.7 percent, there is not much difference among the men who live in either places as the prevalence is 6.1 percent.

HIV/Aids infection is highest among those who are widowed, high among divorced and separated men and women and least for those who have never been married.

Elsewhere in the world, the area where perhaps most progress is being made is in reducing new HIV infections in children. Half of the global reductions in new HIV infections in the last two years have been among newborn children.

Studies show that there are more than 50 percent reduction in the rate of new HIV infections has been achieved across 25 low- and middle-income countries––more than half in Africa, the region most affected by HIV.

But in Uganda 25,000 children get infected annually and 0.6 percent of the children under age five are HIV-positive.  There is no variation in HIV prevalence among children by gender or urban-rural residence.

“These results demonstrate indisputably that HIV/AIDS remains a significant health problem for Uganda and should serve as a call to action for us all,” said Ondoa.

“The Ministry of Health along with our dedicated international partners takes this as an opportunity to recommit ourselves to continued scale‐up of proven HIV interventions, to the goal of universal access to ARV treatment, and to our shared vision of a future free of HIV.” 

Next toilet innovation; no piped water or sewer

By Esther Nakkazi

Last year, the Bill and Melinda Gates Foundation put up a $3 million grant to reinvent the toilet, as a stand-alone unit, hygienic, safe, with no piped-in water or a sewer connection—all for less than 5 cents a day.

Eight universities, each with a grant of $400,000 got into the competition, one of these based in Africa, the University of Kwazulu-Natal, South Africa and in August this year, exhibited their innovations in the USA.

Toilets from the reinvent the toilet challenge do not discharge pollutants, are waterless and with no septic system, generate energy and recover salt, water, and nutrients from the waste.

They can also be easily be adopted by local entrepreneurs for a sanitation business as the operational cost per user is only 5 cents ($0.05) a day.

Three of the toilet innovations up for the challenge transform feaces into biological charcoal or biochar, using a technology that decomposes the human waste at high temperatures without oxygen. The produced biochar would be combusted and the heat generated used to recover water and salts from the feaces and urine.

The self-contained toilet system, using this technology, developed by Stanford University and the Climate Foundation in US, will be shipped before the close of the year to a Nairobi slum to process two tons of human waste daily, said a statement from the Bill and Melinda Gates Foundation.

Part of the strategy of reinventing the toilet also involves gathering what people want and measuring if it really works. So participating teams have to a duty to work in close collaboration with local communities in sub-Saharan Africa and south Asia where the burden of unsafe sanitation is greatest. 

The toilets should also spur behavior change, improving hygiene and stopping open defecation done by more than a billion people in the developing world.

Four other toilet innovations will use technology that will disinfect urine using ultra-violet light and boiling the urine under pressure to recover highly purified water.

The University of Kwazulu-Natal, South Africa, toilet system is designed to recover water and carbon dioxide from urine in community bathrooms and extrude feces into thin strands for faster drying and stabilisation.

A solar-powered toilet by the California Institute of Technology in the US, will generate hydrogen and electricity. This toilet will have a solar panel that will produce enough power for the electrochemical reactor that will break down water and human waste into hydrogen gas. It will be interesting for the winning toilet to be adopted in the developing world.

The Gates Foundation announced the reinventing the toilet challenge, for Universities, in April 2011, at the third African Conference on Sanitation and Hygiene, AfricaSan, in Kigali, Rwanda calling for new ideas and innovations for a toilet.

The current flush toilet was invented over 200 years ago, and it has been able to reach only one-third of the world, leaving more than a billion people to open defecation and diseases caused by unsafe sanitation leading to half of all hospitalizations in the developing world.    

The World Health Organization (WHO) says improved sanitation can produce up to $9 for every $1 invested by increasing productivity, reducing health care costs, and preventing illness, disability, and early death.

Reducing by half the number of people who don’t have access to basic sanitation is a key target of the United Nations’ 2015 Millennium Development Goals (MDGs).

According to WHO access to safe sanitation would reduce child diarrhea by 30 percent and significantly increases school attendance especially for girls, who often miss work or school when they are menstruating and risk sexual assault when they are forced to defecate in the open or use public restrooms. 

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East Africa Tea Growers reject electronic auction

By Esther Nakkazi

East Africa tea traders and growers have rejected the replacement of the current manual open outcry system, with the computerized electronic auction.

After sensitization of all users of the Mombasa tea auction, about switching to computer screens, or the ‘mouse’, stakeholders voted to retain the usual haggling over prices using the open outcry system, using the ‘hammer’.

Electronic auctioning was meant to improve efficiency-reduce auction time, transaction costs, improve transparency, and directly involve more players with no limitations on space by the auction halls.

It would also guarantee remunerative prices to tea growers and provide real-time information to all stakeholders through the tea growing and selling chain.

Tea auctioning at Mombasa, which sells all the teas grown in the East African region, and provides 20 percent of the teas on the world tea market, was to go electronic by 2013 and be implemented using the Indian tea e-auction model, the only country in the world using it. 

But stakeholders, overwhelmingly, voted against it, in a meeting held last month by the East African Tea Trade Association (EATTA) saying the auction, which basically, is a ‘public sales’, would lose its transparency, competition and risks technology failure without a guaranteed power supply at Mombasa.

“There is likely to be a loss of negotiation advantage offered by face to face and the system will reduce transparency. As Uganda, we confirm that due to the majority expression we do not want the e-auction for now,” said William Ssekitoleko, the Chairman of Uganda Tea Association.

While some members from the Kenya Tea Development Agency (KTDA) agreed to since they have already automated from farm to warehousing, James Finlay and Sotik tea felt EATTA should automate live capturing or recording of data and information, but not replace the ‘Hammer’ with the mouse.

For over 50 years now, buyers and brokers have haggled over tea prices, at the Mombasa tea auction, watching each other’s body language and facial expressions while endlessly sipping cups of tea and adding a dollar to become the highest bidder for the 8 hours that the auction runs with no health breaks.

Using the e-auction would be a health hazard if buyers were to sit uninterrupted through the 8 hours looking at computer screens and the auction would lose its gusto, those in favor of keeping the traditional ‘hammer’ or open outcry system said, in an EATTA report published last month.

Besides, Uganda, Rwanda, and Tanzania tea stakeholders also complained of a not so well developed IT system in their countries so they would not have access to computers and the internet all the time.  

Unconvinced that the e-auction would reduce costs, tea buyers say they would have to engage technology-savvy personnel, adding extra costs, and most of the brokers would lose their jobs since it would be possible for potential customers to buy directly from producers. 

To become a tea broker takes many years of developing skills of tasting, valuation, market reviews, and giving independent quality perceptions to buyers and producers, which makes them respectable and professional at their job.

Electronic auctioning would lessen the relevance of brokers in the tea auction process and their expertise would be lost, says the EATTA report with suggestions from tea buyers, packers, producers, and brokers from Uganda, Kenya, Tanzania, and Rwanda.

As it was supposed to be modeled alongside the Indian tea e-auction, a team from EATTA left for India on a fact-finding mission but found that despite it operating for eight years now, the Indians still preferred the manual open outcry system.

The report presented by the team to EATTA says the Indian government imposed the e-auction on them in order to collect more taxes from tea but they were unhappy with it because it was not interactive and it was too commercialized without meeting in the auction room.

But there are also differences in the Mombasa and Indian tea auctions. While Mombasa is unique, trading in dollars, dealing in different teas originating from all East African countries and exporting almost all its leaf, India trades in the local currency, the Rupee and the domestic market consumes most of the tea from the auction.

Some Indian tea producers felt there was reduced competition after the e-auction, which was now losing 3-4 percent of their annual production, although the loss was not entirely placed on it.

For instance, one type of tea, the Orthodox tea, had a price decline of 40 rupees (US $1) per kilogram in one year since going through the e-auction. But Indian producers of premium teas were happy that they gained good prices says the report.

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Uganda Men Prefer China Style Male Circumcision

By Esther Nakkazi

Andrew Sekitto, 35 years, was hesitant to be part of the research on voluntary medical male circumcision (VMMC) that was held in Rakai, Uganda, nine years ago. It was a landmark research in 2007 that proved that adult male circumcision reduced the risk of acquiring HIV infection by 60 percent. Sekitto just feared the ‘cut’.

Now, after conversations with friends, who were part of the China invented Shang ring research, still in Rakai, he has had medical male circumcision. He says his wife, Sarah Nambi, and him too, appreciate this procedure because his penis looks neat with no sutures, there was very little bleeding and pain, plus it all healed fast, only a week.

Like the growing trade between Africa and China, the ‘Chinese cut’, is preferred to the conventional method of VMMC by many Ugandan men. It is, thus, envisaged that the Shang ring might accelerate male circumcision programs in Africa.

Steven Mugamba, a researcher with the Rakai Health Sciences, which, has been part of both studies said, while they required 250 men to enroll for the just ended study on acceptability and safety of the Shang ring, the number of those who enrolled, more than doubled, to 520.

“We have done research for both methods in Rakai. Men say they prefer this method, there is high acceptability,” said Mugamba. The survey site for the Shang ring in Uganda is the third, after similar studies were done in South Africa and Zimbabwe.

A counter study was not done in tandem, but safety and acceptability of the ring by adult men was compared to the already collected data in 2007 that proved the benefit of female to male HIV transmission was reduced by 60 percent.

The Rakai study, now endorses, further and proves that VMMC if done safely, is affordable and has minimal side effects or pain, it is easily acceptable. But also more men, in Uganda, accepting VMMC using the Shang ring could improve progress towards the target of having 4.2 million males circumcised in the country by 2015.

Only 25 percent of the required target of men to be circumcised in Uganda has been met, which questions the country’s ability to use scientifically proven medical interventions to reverse the rising prevalence and infection rates.

“This country’s national safe male circumcision plan lacks a budget, annual targets or concrete plans for scale-up. In fact, there is persistent contradictions among officials about whether even circumcision has a role in the response to HIV in Uganda,” said Alice Kayongo, an HIV advocate from Alliance Uganda.    

UNAIDS and the World Health Organization (WHO) issued recommendations for VMMC, for countries with high prevalence rates, hoping that at least 80 percent of males aged 15-49 years in 14 priority countries including Uganda, Kenya and Tanzania would be circumcised.

According to mathematical modeling based on a timeline, if 80 percent coverage where achieved by 2015, more than 20 percent of new HIV infections would be averted by 2025, with an estimated $16.6 billion saved in future medical costs in these countries. 

However, even if Uganda’s HIV prevalence has risen from 6.4 to 7.3 percent, its progress towards bringing this prevention intervention to scale is still so slow. But the Shang ring could be helpful and this is why.  

One bright sunny morning, when Sekitto decided to go for the Shang ring VMMC after being convinced by a friend, he was amazed. The procedure that took about 5-10 minutes with no general anesthesia but only for the part to be operated part was not painful at all.

Basically, his penis was marked to gauge its size that would fit the forceps (plastic rings) which were placed on it, the sides of the skin were cut, to give way for applying the outer ring. He then walked home to his wife, with the ring on the penis, only to return after a week to have it removed. There were no sutures, little bleeding and no pain.     

Experts believe that once the PrePex, another non-surgical procedure, which is the next research that the Rakai Health Services will embark on is introduced even more men will opt for VMMC and the targets are met.

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First Steps for Geothermal Power in Uganda

By Esther Nakkazi

Katwe Geothermal Power Project Limited (KGPL), an indigenous investment, is in the process of establishing the first geothermal electric power station in Uganda. 

KGPL is teaming up with an American investor, AAE systems Inc, a global engineering and development company in the turn-key geothermal project, investing a venture capital of $2 billion.

The project is also eligible for accessing the African Rift Geothermal Development Facility (ARGEO) mitigation funds against risk.

Geothermal energy is heat in form of steam derived from the earth’s geological structures used directly or indirectly for generating electrical energy. The steam goes to a turbine, which drives a generator that produces electricity.

The project will get a Power Purchase Agreement from government to operationalize its licence in Katwe Kikorongo-Bunyampaka geothermal field, said Ralph K. B. Nyakabwa-Atwoki, the project consultant.

Uganda under this project will be able to generate up to 300MW, a half, of its total geothermal power potential capacity of 600MW. Its implementation however, will be in three phases; surface surveys and drilling of at least three geothermal wells will be completed in 2 years to produce 10MW.

After finding the steam, an electric generator or steam turbine will be installed using the ‘Well Head Technology’ to produce up to 200 MW initially in about 4 years time.

Mr. Nyakabwa-Atwoki, also businessman said they are positive about the project because of its location; the subsurface temperatures for Katwe are about 140-200 degrees Celsius predicted by Geothermometry models.

While underground, drilling to a shallow depth of 200-300 meters suggests temperatures of 30-36 degrees Celsius per kilometer, which are slightly above the global average of 30 degrees and also suggest deep reservoirs in Katwe area.

Mr. Amos George Basaza, the chairperson of Petroleum Technical Committee said the 200MW geothermal would improve electricity coverage in Uganda, which is still one of the lowest in Africa, at 12 percent for the whole country, and 6 percent in rural areas. 

Uganda also has a modern renewable energy policy that aims to increase geothermal use from as low as 4 percent to 61 percent of total energy consumption by 2017.

Mr. Vicent Kato, the geothermal coordinator at the Ministry of Energy and Mineral Development said the government has a development plan for geothermal power and since 1993 they have been drilling wells. 

However, the programme is faced with barriers like lack of a geothermal policy and an Act, which is a big problem, specifically affecting the levels of investment in the sector and attracting investors.

“We have succeeded where everybody else failed, we have an investor who is interested,” said Nyakabwa-Atwoki excitedly of AAE systems Inc.

As an eligible candidate for accessing the African Rift Geothermal Development Facility (ARGEO), it will have 80 percent guarantee of surface surveys, which are estimated to cost $250,000.

While the risks of finding no steam or steam laden with heavy metals or of corrosive nature rendering it unusable for power generation has a 40 percent guarantee against $700 million investment. The project is also in an earthquake prone area.  

This is in addition to further protection by Uganda’s membership of Multilateral investment Guarantee Agency (MIGA) of the World Bank.

KGPL officials said they would rely heavily on Kenya, for its expertise in training the manpower, engineering works, management and to generally transfer geothermal technology to Uganda.

Kenya already has an installed capacity of about 280MW in geothermal energy, but in 2011, the Menengai Well with a geothermal potential of 1600MW was discovered. It is expected to produce 800MW by 2018.

However, scientists wondered about its environmental impact since it is found in a tourist area, around Lake Edward and Mountain Rwenzori, said chairperson of Uganda National Academy of Sciences (UNAS) Prof. William Banage.

Scientists believe the Katwe-Kikorongo geothermal areas could be recharged from high ground in the Rwenzori Mountains and the hot spring water is a mixture of high-elevation component, local ground water from the Katwe cold springs and water from lakes in the area. The source of sulphate for the Katwe-Kikorongo hot spring water is magmatic and hydrothermal.

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One HIV Pill a Day: Is supply assured ?

By Esther Nakkazi

The once-a-day pill approved recently for HIV medication may reduce costs and improve compliance to life-prolonging medicines, HIV advocates in Uganda say.

Last month, the US Food and Drug Administration or FDA, approved a new combination pill, Stribild, to treat HIV infection effective for only adults who have never been treated for HIV infection.

One of the biggest problems with HIV treatment in Uganda and sub-Sahara at large is drug adherence, which is deepened by the pill burden on a daily basis.

But even though some anti-retroviral therapy users say they are not worried about the price, Uganda's  drug regulatory body, National Drug Authority (NDA) says unless they are confident about supply, the drug will never be introduced here. 

US based Big Pharma, Gilead Sciences is the only global manufacturer so far. The pill infused with four different drugs costs about $75 per day.

“The innovator might not be able to rapidly produce enough quantities. Yet for ARVs we cannot start patients on any drug without assured continuity or its lifetime availability,” said Gordon Katende Sematiko the Executive Secretary NDA.

For any new drugs to get onto the Ugandan market the Ministry of Health would first develop a policy to introduce them and alert development partners to accept to fund it. There should also be a local applicant to register it.

About 95 percent of all anti-HIV drugs distributed in Uganda are funded by development partners and these cater for only 60 percent of the people who need them. So universal access is still a big issue. 

But while the first reaction for development partners was price and they would probably not pay the bill, some Ugandans with deep pockets feel they could for the sake of adherence and convenience pay the price. 

Stribild is estimated to cost about $75 per day, more than 100 percent increase from the $10 for the cheapest regimen on the market today in East Africa. The AIDS Healthcare Foundation that supports many HIV people around the world, reacted by calling the price ‘shockingly irresponsible and unsustainable.’

“I take two pills at night, one pill in the morning and 1 Septrin everyday. But it is difficult not to miss a dose- so a single dose is very conducive. The chances of missing this will be minimal,” said Flavia Kyomukama the national coordinator Global Coalition of Women against AIDS in Uganda. 

On average, an HIV patient on medication takes at least four pills per day if they do not have any opportunistic infections. If one is infected with tuberculosis the pill number triples.

“Approving the once-a-day pill for HIV is very good news - the cost notwithstanding for now,” said Robert Nakibumba a Community Health Research Consultant.

We know that with advocacy the cost will collapse drastically. In fact, as we push for research into the cure, we want scientists to get a drug with a longer shelf-life like a week if possible, said Nakibumba.

According to a press release from FDA, the safety and effectiveness of Stribild was evaluated in 1,408 adult patients not previously treated for HIV in two double blind clinical trials.

Patients were randomly assigned to receive Stribild or Atripla, an HIV drug that contains two HIV drug compounds- Truvada and Efavirenz, once daily in the first trial. In the second trial the new drug Stribild or the anti-HIV drug Truvada with compounds- Atazanavir and Ritonavir were given once daily.

Results showed between 88 percent and 90 percent of patients treated with Stribild had an undetectable amount of HIV in their blood, compared with 84 percent treated with Atripla and 87 percent treated with Truvada plus atazanavir and ritonavir.

The studies were designed to measure the percentage of patients who had an undetectable amount of HIV in their blood at 48 weeks. “The cost of producing new drugs is exorbitant. Uganda can afford to pay for that pill, it is merely a question of leadership and commitment,” said Kyomukama.

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State of River Nile Basin Report Launched in Uganda

By Esther Nakkazi

Policy makers based in the River Nile Basin, now have a monitoring tool to support their decisions and present expert analyses with factual data to communities for better stewardship of the common Nile waters and environmental resources.

A report on the state of the Nile basin- which, will be issued every three years- was launched by Betty Bigombe, the Minister of State for Water and prepared by the Nile Basin Initiative (NBI), an inter-governmental regional organization for the River Nile recently in Kampala.

The State of the River Nile Basin Report 2012 was prepared by NBI staff and funded by the German government through GIZ, is also expected to generate discussion, trigger common policy interventions and convergence.

“The report takes stock of past actions, present challenges and future opportunities for improving the stewardship of the Nile, and defines a list of indicators for monitoring the health of the basin,” said Stanislas Kamanzi, the minister of Natural resources, Rwanda.

Kamanzi also the chairperson of Nile Council of Water Ministers said the report, now a flagship knowledge product of the NBI countries, would promote cooperation amongst Nile riparian states for successful management of the basin.

In Europe, it has been established that creation of common basin monitoring tools for transboundary river basins can contribute to mutual trust and joint policy-making. 

As a common planning tool for the River Nile basin, this report is expected to contribute to the building of trust and confidence amongst Nile riparian countries, said Dr Nicholas Azza, a water policy specialist with the NBI who is one of the lead researchers.

And with time it will discern trends into the future facilitate the understanding of complex issues and will draw attention to emerging critical happenings, said Dr. Azza. 

One of the critical issues about the 4,100-mile River Nile is access to the waters by upstream countries Ethiopia, Uganda, Kenya, Tanzania, Congo, Burundi, and Rwanda which felt unfairly treated by the agreements signed by the British in 1920 that favoured downstream countries Egypt and Sudan.  

The upstream countries have been demanding for more access to the Nile waters and a series of meetings have been held to have a new agreement, the Cooperative Framework Agreement, which would regulate the water use by different countries. 

“It is comprehensive and important for planning for all those who will read it. We shall use it to create awareness in our communities using its accurate information,” said Fekahmed Negash, the Head of the Nile Basin Administration Directorate.

Negash said in the past they have been presented with uncoordinated and biased information depending on the source and their interests but this factual information will now ease that problem.

But it is not your traditional report with a lot of research, rather many facts were pulled together and policy briefs generated by NBI staff who carried it out. It has many photos and graphs for easy readability.

The Nile is the longest river in the world and has a drainage area exceeding 3 million square kilometers, shared by eleven countries.

“It is a credible source of information we can rely on and keep updating. It is a chance to have a better judgment for the good of our people who share the Nile basin,” said Dr. Sherif M. EL Sayed the head of Information Central Directorate, Ministry of Water resources and Irrigation in Egypt.

The 256-page report, and the first ever, however points to the quality of the Nile waters which has generally deteriorated because of increases in population, intensification of agricultural activities, industrial development and accelerating in soil erosion.

It is only in the sparsely populated areas along the Nile water in countries like Uganda, Tanzania, and Rwanda where the quality is still within the standards of the riparian countries and the World Health Organization (WHO).

The launch ceremony was witnessed by members of the Nile Technical Advisory Committee (Nile-TAC) representing the ten NBI Member States of Burundi, DR Congo, Egypt, Kenya, Rwanda, South Sudan, Sudan, Tanzania and Uganda as well as NBI Development Partners, representatives of the Nile Basin Discourse as well as staff of NBI.

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