Kiwoko Hospital has several different clinics for HIV+ patients, including one for adults, one for children and adolescents, and one for mother-baby pairs. There are also extensive counseling and testing efforts that happen in formal and informal ways and a special program for HIV+ women who make woven baskets sold by the hospital for income (as they have often been rejected by their partners and communities and have limited education to support them).
I spent 2 days at HIV clinic, one for adults and one for children/teens. The process at Kiwoko is a well-oiled machine. Patients are checked in for vitals, then proceed to a counselor who counts pills for compliance. If there are any compliance concerns, the patient goes to additional adherence counseling to talk about the family’s financial situation, medication side-effects, and anything else that may be affecting compliance. After this, patients go to the lab (as needed) for viral load and CD4 testing. Finally, the patients come to the clinical officer (similar to a physician assistant in the U.S.) for evaluation and refills. The pharmacy (where all HIV medications are free, covered by USAID and other multinational organizations) is the final stop of the day.
Since instituting free HIV care and more aggressive screening and treatment during pregnancy, the mother-to-child transmission rate has decreased significantly at Kiwoko (often limited to mothers who delivered at home). This is great news! However, there remain many children who are already infected with the virus. I saw two sisters, aged 9 and 11, come to clinic by themselves from another town 30 minutes away. One had a fungal infection of her scalp; the other reported anal pruritis and stated that her grandmother had seen pinworms in her stools. Although we prescribed them medications and refilled their HIV medications, watching these two young girls leave the clinic alone (despite repeatedly requesting that a caregiver accompany them to clinic) made me feel that we hadn’t done nearly enough to relieve the burden on their young shoulders. There are some things no child should have to face alone.
Being in the HIV clinic gave me an opportunity to ask sensitive questions about sexual practices and family planning in Uganda. The staff were generally happy to discuss with me. Encouraging condom use, even among the HIV+ patients, remains a major challenge at Kiwoko. In a culture where men remain the head of the household and women have minimal agency regarding their sexual health, condoms are not a popular form of contraception or STI prevention. The stigma has decreased for HIV testing, but is still more challenging in men who tend to come to the hospital less frequently than women (who also receive testing with each pregnancy). Despite improved education about HIV and the relatively easy access to free medications for management, there are still widespread ideas about treatment of HIV that are not scientifically based (including various natural remedies and the theory that the virus can be cured by having sex with a virgin). An emerging problem seems to be the early age of onset of sexual activity. In Kampala, girls as young as 13 and 14 are initiating sexual activity (apparently related to the negative influences of alcohol, drugs, prostitutes, and media), while in the more rural areas like Kiwoko girls may begin sexual activity at 15 or 16. All of these behaviors combine to produce a high HIV rate in Uganda – but, like in the U.S., health behaviors are often the most difficult to change.