First of all, the HIV/AIDS is still very much prevalent in the district with hetero-sexual relationship being the commonest mode of transmission followed by mother-to-her-unborn baby spread. This situation has not been helped by the fact that Tororo district borders Malaba, a town that has gained notoriety because of the many sex workers there, long-distance truck drivers, street children, cross border traders, factory workers and bar maids. The good news is that since 2000, there has been a decline in HIV/AIDS infection rates in Tororo district following the adoption of the multi-sectoral strategy to scale up the response to the epidemic. It still is alarming that young women in the age group of 15 – 19 years are about 5-6 times more infected than their male counterparts. So the district health department must work on more preventive measures.
HIV/AIDS is still prevalent in the district, and the commonest mode of transmission is through Hetero sexual relationship. It is now evident, that the second commonest route of transmission is from an HIV infected mother to her unborn baby. Transmission through blood products and infected unsterile materials is however not yet well documented, but there is growing evidence that this could be happening in the formal Health care set up.
Due to its geographical location, there are many high risks population who include commercial sex workers especially in Malaba border town, long distance truck drivers, and street children, cross border traders, factory workers and bar maids.
Since 2000, there has however been a decline in the infection rate in the district following the adoption of the multi-sectoral strategy to scale up the response to the epidemic. Infection rate was at 12.8% in 2002 dropping to 6.3% in 2003 (MOH/ACP/STI Surveillance report 2003). Young women in the age group of 15 – 19 years are about 5-6 times more infected than their male counterparts. There has been no clear documentation on the infection rate among children 0 – 5 years. The rates are higher in urban set up than in rural centres 8.3% of the 4.2% respectively (MOH/ACP/STI Surveillance report 2003).
Prevention and Behaviour Change
Prevention and behaviour change strategies and activities fall under Goal 1 – to reduce HIV prevalence by 25% by the year 2005/06. The MTR and LQAS surveys found that varying progress has been achieved in this thematic area in spite of considerable constraints. The study found out that 61% of the men aged 15 – 49 years knew at least two methods of preventing sexually transmission of HIV compared to 85% nationally. Among young people (15-24) 58% knew at least two methods.
Emerging issues and recommendations are recorded below.
Progress
With the multi-sectoral strategy approach to the Prevention and Control of HIV/AIDS significant progress has so far been made.
•The estimated prevalence reduction of HIV/AIDS from 12.8% in 2000 to 6.3% in 2004 (MOH-STC/ACP, 2003) indicates slower than expected progress towards reducing prevalence by 25% over the course of this district strategic framework time period.
•Male condom use has steadily increased, especially in urban areas, and a total of 2,193, 732 condoms were distributed during the review period.
•The LQAS findings indicated that 27.3% of the women aged 15-49 years have ever used condoms, while 62.7% of the men in the same age group had used condoms and 61.6% of the young people aged 15-24 years had ever used condoms. This gives the district an average coverage of 51% compared to the national one of 70%
•There are eight Voluntary Counselling and Testing (VCT) centres in the district that is at every health centre IV and all the three Hospitals plus two NGOs. There are more people accessing this service. The LQAS study found out that only 23%, and 16% women and men respectively aged between 15-49 years were taking VCT services, and just about 17% of the young people aged 15-24 were taking the service, compared to the national of 10%, 15% and 15% respectively. It was further found out that 53.6%, 65.2% and 66.3% of the women, men and young people respectively knew the benefits of VCT.
•Laboratory services have improved following the refurbishing and equipping six of the laboratories by AIM. The district Laboratory focal person has been identified and is working.
•While most of the planned strategies for reducing sexually transmitted infections (STIs) have been substantially achieved, progress against the objective of reducing STIs by 25% cannot be measured in the absence of baseline information to measure STI prevalence. However, it is important to note that there is increase in recruitment of the trained health professionals in the district health care system.
•The establishment of three sites for the prevention of Mother –to- Child Transmission (PMTCT) of HIV has further contributed to the significant reduction in the prevalence rate of the scourge, though accessibility remains poor.
•It is hoped that the Blood from Mbale regional Hospital is free from the risk blood borne HIV transmission by 50% and has been substantially achieved from 2 – 4 to 1 – 2.
•Massive awareness creation has been carried out at all levels through IEC/BCC interventions. The use of Community Based organisations (CBOs), Non Government Organisations (NGOs) and other CSOs has greatly contributed to this strategy.
Challenges
•There is still inadequate capacity among the key implementing partners at both district and lower level to cultivate the necessary human and financial resources to ensure that prevention and behaviour change initiatives are fully implemented.
Implementation Strategy
•VCT and PMTCT will be strengthened and expanded to ensure that this important bridge between prevention and treatment is a readily accessible service throughout the district.
•Approaches to behaviour change communication (BCC) will emphasize all three elements of the ABC approach to prevention, e.g. abstinence, being faithful and condom use, while also improving access to condoms throughout the district.
•Strengthen blood quality control, supply and appropriate use of blood and blood products in all health service delivery system.
Care and Treatment
Care and treatment strategies and activities are covered under Goal II – to mitigate the health and socio-economic effects of HIV/AIDS at individual, household and community level. Significant strides have been made in this area though quantifying progress has proved difficult because the indicators were primarily process indicators which could not be measured by routine data collection approaches or by the M & E system.
Progress
•Palliative care has been introduced in the health care system. A total of 30 health providers were trained/oriented for five days and 40 community volunteers were also trained. One registered Comprehensive Nurse has completed a nine months training in palliative care. Eligible patients are accessing Morphine solution to reduce pain.
•Twelve health providers were trained in provision of comprehensive HIV/AIDS care services including ART.
•Mukujju HC IV and Tororo Hospital are providing ART services.
•Proportion of PLWAs accessing ARVs 7.3%
•ARVs are procured from the Ministry of health and JCRC.
•Availability of TB drugs has been improved in all HC III with increased access to them through the CB-DOTS strategy.
•Proportion of PLWAs of health facilities providing OI treatment is 100%
•Proportion of PLWAs accessing Seprtin (Cortimoxazole) prophylaxis is 29.5%.
Challenges
•Lack of collaboration between traditional and modern medicine, lack of evidence of impact, constraint further development in this area.
• Guidelines for palliative care are needed to enhance developments in this strategic area.
•Mitigation of psychosocial and economic impact of HIV/AIDS among PLWA and OVC still pose a big challenge. Few organisations have openly come up to economically support these vulnerable segments of the society.
•Packaging of IEC/BCC messages needs to be streamlined for well coordinated and harmonised information. The “ABC” strategy implementation is still weak.
Implementation Strategy
•The directorate of Health services and its development partners will play a major role in procurement of ARVs and other drugs for treatment of OIs.
•Training of health providers in the provision of comprehensive ART services.
•Support and expand provision of palliative care in the district.
•All new care and treatment initiatives noted above (ART, HBC, Paediatric care, private sector and PHA involvement) will be enhanced and given increased attention and support in the district strategic framework.
•A system and guidelines for linking or networking all these new care initiatives will be developed to ensure they meet their full potential in the district response.
Psychosocial Support, Protection and Human Rights
Psychosocial support, protection and human rights also fall under Goal II – to mitigate the health and socio-economic effects of HIV/AIDS at individual, household and community level.
Progress
•Significant progress has been achieved in building life skills of youth, both those in and out of schools, through the efforts of local government, Civil Society Organisations (CSOs), and Faith Based Organisations (FBOs)
•A movement of towards greater involvement of persons with AIDS has expanded, including the involvement of PHAs as full partners at all levels of decision making and implementation.
•Some few CSOs, have started providing Home based care services to PLWA, although the number of trained Home based care providers is still quite low.
•Psychosocial support to PLWAs and OVCs has been initiated in some parts of the district notably Tororo County.
•A number of community led HIV/AIDS Initiatives (CHAI) were formed since 2003 and so far 105 groups have accessed funds mainly to address orphan support in terms of education, scholastics materials, nutrition.
Challenges
•Guidelines and policies as well as legal, financial and social support for this thematic area are lacking.
•The limited number of agencies providing psychosocial support are underfunded and under staffed to meet the growing demand for these services.
•Some relevant laws and policies for the protection of the legal, ethical, and social rights of the PHAs, but these have not been clarified, widely disseminated.
•Inadequate information on the actual number of PHAs In the district.
Implementation Strategy
•The district will lobby for funding to support the PHAs.
•The district through the department of probation will compile the register for PHAs, OVCs in the district.
•The district will ensure psychosocial and spiritual support all OVCs in ald out of school.
•The district will ensure the protection of legal, ethical and social rights of the vulnerable groups in relation to HIV/AIDS.
Coordination and Institutional arrangement
Goal 3 of the NSF relates to strengthening of district capacity to coordinate and manage the multi-sectoral response to HIV/AIDS.
Progress
•Tororo district has an established and functional District HIV/AIDS Committee (DAC) that coordinates the HIV/AIDS activities at all levels.
•Tororo district HIV/AIDS Task force (DAT) is in place though inactive.
•The DAC has appointed a focal point person/officer (DFP/O) to guide and coordinate HIV/AIDS activities at all levels.
•The leadership of Tororo at all levels is well sensitized on issues related to HIV/AIDS epidemic.
•The biannual stakeholders’ forum has become an effective mechanism for coordination, information sharing, and decision-making.
Challenges
•Mainstreaming HIV/AIDS activities in the departmental work plans is still a major problem.
• Information sharing is still lacking as even reports are not readily submitted to the DFP/O.
•The formation of coordination structures at lower levels is yet to be carried out.
Implementation Strategy
•The district leadership will ensure the formation and the functionality of all coordination structures at all levels.
•The DAC will sensitise all departments to mainstream HIV/AIDS activities.
Monitoring and Evaluation
Progress
•The district M&E framework for HIV/AIDS has been drafted and is awaiting finalisation.
•The inventory of the stakeholders in the district response for HIV/AIDS is already in place.
•A data collection tool is underway for development.
•Five district trainers on M&E are available.
Challenges
•The objectives and strategies and activities of the NSF are silent on the issue of M&E.
•Limited human resource knowledgeable on M&E.
• The multiplicity of unused or poorly maintained databases and tracking systems and their lack of harmonization present a significant barrier to achievement of M&E objectives.
•Districts are requested to complete different M&E forms for various agencies and yet no feedback is given hence creating a barrier to full participation in the M&E process at the lower level.
Implementation Strategy
•Monitoring is recognized as an important management tool and, as such routine monitoring will be encouraged.
•Planning and budgeting for monitoring will be included in regular work plans and will be separated from evaluation at operational level.
The Tororo HIV/AIDS Strategic Framework has been developed to provide strategic direction to the HIV/AIDS response at the district and community levels. The framework has the following goals:
Goal 1: To reduce HIV prevalence by 25%
Goal 2: To Mitigate the effects of HIV/AIDS
Goal 2a): To mitigate the health effects of HIV/AIDS and improve the quality of life of PLWHA
Goal 2b): To mitigate the psychosocial and economic effects of HIV/AIDS
Goal 2c): To mitigate the impact of HIV/AIDS on the development of Uganda
Goal 3: To strengthen the district capacity to coordinate and manage the multi-sectoral response to HIV/AIDS.
The Local Government Act requires district and lower level participation in the development and implementation of HIV/AIDS activities. This should be taken within NSF policy framework and the decentralized HIV/AIDS response. The decentralized HIV/AIDS response has the following objectives:
•To attain the goals of the National Strategic Framework by decentralization of the national HIV/AIDS response,
•To create a rallying point for HIV/AIDS activities at the district level,
•To provide a forum for dialogue for local government, the private sector, NGOs, CSOs and communities on HIV/AIDS,
•To ensure the mobilization of human, financial and material resources for HIV/AIDS at the district level.
•To present a comprehensive implementation strategy for the prevention, care and support priorities of the HIV/AIDS National Strategic Framework.
As required the District has developed a strategic HIV/AIDS plan to operationalize the NSF, harmonize and coordinate HIV/AIDS activities and facilitate grassroots participation and community involvement in the response to the epidemic, within the framework of the decentralization policy.