Is Uganda truly ready for HIV 'test and treat'?

In November 2015, The World Health Organization released new guidelines recommending that all diagnosed as HIV positive be enrolled on antiretroviral therapy (ART) regardless of disease stage. The universal ‘test and treat’ (UTT) policy soon followed. There is persuasive research which forecasts that, globally, if as many people as possible are tested, and immediately enrolled on treatment (if diagnosed as HIV positive), their ability to transmit the virus will be limited rendering the end of the HIV epidemic as a feasible target by as early as 2030. Indeed, many countries have rolled out ‘test and treat’. In Africa, Botswana is among the countries which have registered tremendous success in this regard. In Uganda, many health facilities began implementing ‘test and treat’ this year following its inclusion by PEPFAR, a predominant donor in Uganda, in its annual program targets. Without a doubt, ‘the test and treat’ policy is a potent strategy in the national HIV response in Uganda and globally. However, field research we have been conducting across Uganda with colleagues from Makerere University, School of Public Health and a partner U.S. university , over the last 6 months, suggests that a myriad of bottlenecks stand in the way of Uganda’s implementation of ‘test and treat’. Perhaps the most prominent of these is the widespread and prolonged stock-out of antiretroviral drugs (ARVs), especially second-line regimens in the regions of Busoga, Bugisu and Acholi which we visited twice this year in two rounds of data collection (mid this year and about a month ago). Patients who used to get a 3-month supply of ARVs have had that reduced to as few as 2 weeks. An un-interrupted supply of ARVs is a cornerstone of the ‘test and treat’ strategy. As the print media has consistently reported in the last couple of months, Uganda is in the throes of a nation-wide stock-outs of ARVs with the clear and present danger of a systemic drug resistance. It was welcome news a few days ago, when the Deborah Malac, the US ambassador announced over 18 million dollars US government grant to address ARV stock-outs. We can’t wait for operationalization of Uganda’s AIDS Trust Fund (ATF) to reduce our heavy dependence on international assistance in our national HIV response. Clearly, ‘test and treat’ demands new kinds of performance of the Ugandan health system and requires unprecedented resources. In one of the health facilities we visited, active patients on ART almost doubled from 2,000 to 3,800 in a space of less than 6 months. Health workers partly attributed ARV stock outs to increased demand due to ‘test and treat’ but we now know that factors were also at play at national level. Health workforce shortages, a perennial constraint, featured prominently. Despite a dramatic increase in patient volumes, the number of health workers remained the same or declined. In some health facilities, health workers shunned ART clinics due to punishing workloads. Because of implementation of ‘test and treat’ and escalating patient burdens, the waiting time for patients was reported to have become longer. As a country, we need to evaluate our readiness for implementing ‘test and treat’ or double our investments at the level of government and donors to realize its successful implementation. Surely, pilots must have been conducted before full-scale roll out as I have seen reported elsewhere. This piece is by no means aimed at discrediting ‘test and treat’ but is intended as a reflection on our national readiness for implementing of a clearly worthwhile and potent strategy. As things stand today, the more clinically needy patients may have been denied life-saving treatment as ‘test and treat’ may have spread ‘us’ thin. We found little evidence in the field of implementation of ‘differentiated care models’ which have been touted as another strategy for managing the escalating demand for HIV treatment where visits to clinics are reduced for ‘stable’ patients and more are permitted for patients not achieving viral suppression. This strategy too could potentially aid in Uganda’s implementation of ‘test and treat’.