GoU Plans Forced HIV Test for All Patients

I read in today’s Monitor that the Government of Uganda is planning to require all those who attend a health centre or hospital to have an HIV test. Whilst I understand why some will support such a policy, there will be others who will resist it, especially from a human rights perspective.

It is very important that we all have regular HIV tests and that we know our own status and that of our partner(s). Usually this is done on a voluntary basis in which we rely on an individual coming forward for counselling and testing, VCT. Sometimes counselling and testing is initiated by a health service provider, PITC, e.g. when women attend ante-natal or a man comes forward for safe male circumcision.

A policy which mandates testing will need to be carefully planned and we will need sufficient time to allow for wide and full discussions regarding the issues that will follow.

  • Is it right for the GoU to ask health workers to enforce such a policy, especially if the patient is refusing?
  • Are there enough, adequately trained, and skilled, counsellors to ensure that patients receive all relevant information to enable informed consent?
  • Will we be able to enrol all those that test positive onto the necessary care and treatment programmes, ART?

HIV prevalence is on the increase in Uganda and more people are becoming infected than the number of those that are started on treatment, so yes we need to improve Prevention. Testing accompanied with enrolment onto treatment programmes is an essential prevention measure, I’m just not convinced making it compulsory will work here and the backlash may in itself prove detrimental to other prevention campaigns.

20,000 HIV Infections Averted

SMC Small LogoThe SMC Programme in Uganda started in the second half of 2010. In the twelve months October 2010 to September 2011, a total of 40,000 SMCs were performed. From October 2011 to September 30th, 2012, PEPFAR reports a total of 348,000; which is a significant year-on-year increase. So, to date, the SMC programme in Uganda has reached a total of 388,000.

In 2011, DMPPT modelling for Uganda showed that in order to reach the target 80% prevalence of adult males circumcised by 2015, it needed to perform 4.25m circumcisions and an additional 2.1m in the years 2016 to 2025 to maintain that degree of prevalence. The total discounted cost of doing so was estimated at just over $350m. The number of SMCs required to avert one future infection varies from country to country; this modelling indicated that Uganda needs 19. This suggests that such a programme would avert 350,000 new infections, 25% of the total expected over that 14 year period, at a cost of $1,408 for each HIA, which in turn would generate future savings of $5,992.

In summary, 6.35m SMCs over the years 2011 – 2025, at a discounted cost of $350m, could generate total future savings of $1.52 billion.

The country still has a long way to go in the national scale-up of the programme. It has set a challenging target of 1m SMCs for the 12 months to the end of September 2013, a 250% increase in the current rate of output.

The good news is that these 388,000 SMCs may potentially avert some 20,000 new HIV infections, saving the country more than $100m in the cost of future treatments.

SMC is not an invisible condom, it is only partially protective against infection (60%) and men must continue to be serious about protecting themselves and their partner(s).

Gaming the System

There seems to be no end to people’s ingenuity when it comes to gaming a system. Donors funding the national safe male circumcision programme ask partners to provide lists of names and contact details for those that they have circumcised, before payment is made. I know some donors then check these randomly by calling and asking how the individual is healing, what they thought of the service provided, were they asked to pay etc.. Earlier today I heard that some are paying up to UGX 20,000 ($8) for a name, telephone number and agreement by that person that they will say they have been circumcised.

Factors Influencing SMC Scale-Up

Each day some 45 health centres are reporting the number of medical male circumcisions performed at that centre in the previous day. It’s clear even from a very quick skim of these numbers that there is still a long way to go in scaling up the SMC Programme.

These numbers alone of course will not tell us if a particular centre is able to increase its daily output, there is no reported measure of centre utilisation.

The opportunity to increase output and utilisation will depend upon three key factors. The first is the availability of trained staff and whether these can be dedicated to performing SMCs or if they will do these together with their normal duties. Second will be the space available within the centre for each of the different parts related to SMC; these include initial counselling, testing for HIV, screening for STIs, performing the circumcision, recovery and discharge. Efficiency of the centre will then depend upon ensuring an adequate flow of clients, which will depend upon successful community engagement and mobilisation. Some of the usual barriers may of course apply to SMC, as to other health services and health seeking behaviour. Whilst the service is being offered free of charge, the men attending will still need to take some time off work and travel to that centre. Loss of income and cost of transport may become real barriers to attendance.

Those tasked with considering how to scale-up will need to carefully consider each of the above as part of programme planning.

Uganda’s ABC Strategy Revisited

During this last week or so I’ve been reading about the history of HIV/AIDS in Uganda. The international charity Avert has an excellent webpage which discusses this and how strategies such as the ABC campaign helped to significantly reduce the rate of HIV infection.

This ABC campaign started in 1987 and encouraged people to Abstain from sex and to delay the age at which a young person first has sex or Be Faithful to a lifelong partner and if you are unable to do these, then use a Condom.

The good news is that some 25 years later the most recent AIDS survey shows that more than 9 out of 10 women and 8 of every 10 men can still tell you that remaining faithful and using condoms are the best ways to avoid becoming infected with HIV.


UNAIDS Executive Director Michel Sidibé said at the recent AIDS 2012 conference in Washington:

Let us not forget that the condom remains the cheapest and highly effective method we have to stop the spread of HIV… It is time for all of us to condomize!

However this same survey also shows that during the last 12 months for those that had more than one partner, only 1 in 8 used a condom the last time they had sexual intercourse. Condoms can be very effective but only if used correctly and consistently.

Condomize deflated

So it seems that Public Health professionals cannot solely rely upon people behaving as they know they should and we cannot rely solely on the correct and consistent using of barrier methods such as condoms. We need to combine these together with biomedical methods of prevention such as earlier treatment of those already infected, treating more of those who are infected, treatment for the non-infected partner in a discordant couple, eliminating Mother to Child transmission and voluntary male medical circumcision.

I enjoyed reading an article about this same issue by Andrew Green in Voice of America last month.

Reaching Men with a Minimum Package

Removal of the foreskin is only one element of a comprehensive SMC Programme. PEPFAR and other donors have a ‘minimum package’ of services that programme implementers must provide.

This starts with community engagement and mobilisation during which we have a great opportunity to reach men with a broad public health message, whilst of course focussing on many aspects of reproductive health. Men are very often not present at other ‘outreaches’ that may be more focussed on water and sanitation, malaria or family planning and child health.

Men registering for circumcision are first offered voluntary HIV counselling and testing. Knowing your status is essential and for many of these men this may be the first time they have been tested. Those who test positive are enrolled onto treatment programmes.

The men have a chance to learn more about how to avoid HIV and other sexually transmitted infections. They are offered STI screening and provided with any necessary treatment and care.

Men are informed about the correct and consistent use of condoms and why this is such an important part of prevention both before and after circumcision.

All of these services are provided free of charge.

VMMC – An HIV Prevention Priority for PEPFAR

A paper authored by Reed, J., Njeuhmeli, E., Thomas, A., et al. has been published in the JAIDS journal. It outlines the background to the development of Voluntary Medical Male Circumcision (VMMC) as part of a comprehensive HIV prevention package and moves on to discuss some of the challenges being faced in programme scale-up. In it the authors note that President Obama has committed PEPFAR to provide funding and technical support to help 13 countries in Africa to achieve 4.7m procedures by 2014. This in itself is a step towards a previously set target of 20.8m VMMCs by 2015.

The WHO formally recommended VMMC as part of its HIV prevention strategy in 2007. Between October 2009 and March 2012, PEPFAR has supported the delivery of 901,900 VMMCs at a cost of more than $250m. This financial support has been alongside more than $140m from the Bill and Melinda Gates Foundation since 2001.

The 901,900 represents just 4.3% of the overall 2015 target. The paper shows relative performance across all 13 countries. Kenya, so far, has shown most progress in overall numbers performed (295,800) and also in progress towards meeting its national target (34%). Uganda follows 2nd, having so far performed 149,400 VMMCs, but this is just 3.5% of its 4.2m national target.

Clearly these National programmes need to be scaled-up if the 2014 and 2015 targets are to be achieved:

The Challenge

The authors discuss a number of issues that need to be managed if scale-up is to be achieved.

VMMC is a one-time, relatively low-cost, quick and effective intervention. Protection against HIV infection can be more than 60% and such protection is permanent; the procedure does not need to be repeated again and again, nor does it rely on user adherence. Modelling shows that if we can reach a significant prevalence rate of male circumcision (80%) then millions of new infections could be averted, saving billions of dollars in the cost of future care and treatment; but these benefits take some years to accrue and health care professionals may prefer to use scarce resources on other health interventions that are more immediate and in which the benefits are more easily, more quickly, seen.

There is an interesting note that perhaps some countries have already seen the ‘early adopters’ with the implication that reaching these early numbers has been relatively easy. In the next phase as countries seek to scale-up the programmes there will need to be a greater emphasis on community engagement and mobilisation to ensure that not just the targeted numbers are achieved, but that we also focus more on the most at risk groups.

Two other matters will be essential for successful scale-up:

  1. Acceptance at Policy level that VMMC can be task-shifted to lower credentialed, specifically trained staff
  2. Inclusion of non-surgical (device) methodology, with full WHO approval and agreed funding support from PEPFAR and other donors.

Studies are currently on-going in a number of the 13 countries to evaluate both of these innovations.


Reed, J.B. et al., 2012. Voluntary Medical Male Circumcision : An HIV Prevention Priority for PEPFAR. JAIDS, 60(August), pp.88–95. Available at: http://bit.ly/Pcq8QP
[Accessed August 22, 2012].

Make Voluntary Medical Male Circumcision a Priority

Earlier this week Christine Ondoa, Uganda Minister of Health, called on all leaders – political and traditional leaders, religious and community leaders, youth and women leaders, professional and business leaders – to support VMMC. (text link here)

Five years ago UNAIDS and WHO recommended VMMC scale-up in countries with low male circumcision coverage and high HIV prevalence. Emmanuel Njeuhmeli et al published a paper in November 2011 which showed the need to perform more than 20m circumcisions across 14 countries in eastern and southern Africa to reach a male circumcised prevalence rate of 80% by the end of 2015. They estimated that doing so would cost about $2b but could save more than $16b in treatment and care costs by preventing more than 3.36m new HIV infections.

However since then progress has been very slow. A report issued last month by AVAC shows, as of March 2012, just 1.5m VMMCs have been completed, less than 8% of the 20m target. Uganda has completed 204,000 of its 4.2m target which, whilst reflecting slow progress, may already be contributing to averting more than 10,000 new infections. (PDF Summary here)


There is a need for all implementers to scale-up their operations and, as one potential solution, there is growing interest in the use of innovative non-surgical devices.