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Uganda is currently in a partial countrywide lockdown. The “second wave” of coronavirus infections has been particularly ruthless. There is no outbreak in Uganda to my knowledge that has not been affected by the COVID-19 pandemic. Social media posts are inundated with reports of deaths. Hundreds of lives cut short at their peak. It is no longer a story of old people. The frequency of death announcements in national newspapers is truly unprecedented.
Earlier this year, the world saw funeral pyres burning across India. At the time, the ravages of the virus seemed a bit distant. But with daily flights from New Delhi, Uganda was to have its own cases of the dreaded Delta variant, which was quickly confirmed by the Uganda Virus Research Institute. Observers also blamed the recent presidential and parliamentary elections in Uganda for the increase in infections, which had initially been admirably controlled.
Read more: What Uganda’s wrong – and right – in its fight to contain COVID-19
Uganda announced its first full lockdown on March 20, 2020. Both public and private transport have been banned. Individual travel was restricted. People needed a special pass to get around. The second 42-day lockdown was announced in mid-June 2021. This has now been relaxed. It looks like lockdowns will continue to be a fact of life in Uganda, which has vaccinated less than 1% of its population.
Just like in March of last year, people living with HIV are stuck at home and unable to make it to their favorite health facilities to get their medication refilled. Due to the widespread stigma associated with HIV, patients frequently seek HIV care at facilities several kilometers from their place of residence. There are currently 1.2 million Ugandans enrolled on antiretroviral therapy (ART) – they are particularly affected by the lockdown.
Studies suggest that people must strictly adhere to antiretroviral therapy to suppress the virus. Interruptions in access to anti-HIV drugs can lead to treatment failure or drug resistance.
My colleagues and I conducted a study shortly after Uganda’s first lockdown last year in eight districts in eastern and western Uganda. We have found that HIV care providers use alternative means to reach patients trapped in their homes by delivering HIV drugs to their doorsteps. The innovations identified include the decentralization of ART distribution to community platforms and six-monthly refills. These will be applicable beyond COVID-19.
Five ARV distribution strategies
Our study shows that districts and providers have devised five key strategies to overcome lock-in restrictions in antiretroviral distribution.
Home deliveries
Health facilities, supported by district health workers and organizations that implement the US President’s Emergency Plan for AIDS Relief (PEPFAR) programs, have engaged fleets of vehicles to deliver refills of door to door medication. These “mobile squads” were often made up of “expert patients” or HIV-positive patients who serve as informal staff in the facilities they frequent. They had the difficult task of locating farms in the heart of rural Uganda communities.
Extension of ART renewal periods
Before the lockdown, Uganda’s health ministry recommended that stable patients could be given three months of medication at a time. During last year’s lockdown, distribution was extended from three to six months for facilities with sufficient inventory. The health ministry has also asked facilities to extend refills to “visitors” and not just their registered patients.
Community distribution of ART
From 2017, Uganda allowed proximity sites where people living with HIV could collect their medicines. These are community drug distribution points. Collection points are designated places such as the community hall or even the nearest private pharmacy where patients come to pick up their anti-HIV drugs. The AIDS Support Organization, a group of HIV care providers in Uganda, said it routes most of its refills through community distribution points.
Geospatial technologies
Locating patient homes in predominantly rural Uganda can be daunting. Coverage of modern physical addresses is limited and many establishments are informal. These obstacles prevented the “mobile brigades” from distributing the ART reloads to distant outposts. Tertiary hospitals said they rely on geospatial technologies to locate geographic locations that could be linked to their traveling “mobile brigades”. Facilities have used available information about their patients, such as phone numbers or physical addresses, to locate geographic points where patients reside. Due to fears of unintentional disclosure of their HIV status, some patients in Uganda are providing false phone numbers to health care providers. This complicated distribution of ART recharge. The use of geospatial technologies has overcome this obstacle.
COVID-19 funding
District health workers said they took advantage of funding they received from the Ugandan government as part of the COVID-19 response to distribute ART refills during their outreach activities. It was reported that the vehicle fleet and fuel used during COVID-19 responses in the heart of rural communities also gave them the option of distributing refills of ART to patients living along these routes.
Beyond COVID-19
One of the bright spots of the lockdown has been the unprecedented demand for community-based ART delivery.
Before the pandemic, community-based ART models had experienced relatively low uptake, mainly due to HIV-related stigma. These innovations in community ART delivery will continue to be important even beyond the COVID-19 pandemic, which could last longer in sub-Saharan Africa than in other parts of the world, due to delays in the deployment of ART. vaccines.
Henry Zakumumpa is supported by the Consortium for Advanced Research Training in Africa (CARTA) under the auspices of a Post-Doctoral Research Fellowship with funds provided by the Carnegie Corporation of New York.
By Henry Zakumumpa, Health Systems Researcher, Makerere University
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