HIV and Aids in Uganda

One of the commonest questions new arrivals in Uganda ask about is “What about Aids?”

A true story is about a famous tropical disease specialist who was retiring and was asked, “How would you summarise all your experience into advice for someone going to live in the tropics?” He said, “Don’t drink and drive, and wear a seatbelt.” I would update it into “Don’t drink and drive, wear a seat belt and keep your knickers on.”

If I look through our book of death certificates of expatriates over the last 10 years, the top causes of death over and over again are road traffic accidents, murder and Aids. Some years there are no other causes. Malaria? -I’ve had only one in my 20 years here.

One survey I read a few years back looked at about 500 Dutch expats living in Africa and compared them to matched controls in The Netherlands. They found the death rate was almost the same: They were, if I can remember, about 5 times more likely to die in a road accident, twice as likely to be murdered, and about half as likely to die from disease, (but only if Aids was excluded.) As I have said before, Uganda is a very healthy place to live.

Of course things have changed totally in the last 2 years. Now, anyone who can afford triple therapy can remain completely well and no one would even guess they are sick: I have seen no expatriate deaths from Aids in the last 2 years.

Peoples’ attitude seems to vary from total paranoia to utter carelessness. Some freak at the thought that the house girl may cut her finger while washing the dishes and kill the entire family. Others have sex without an HIV test and without a condom and wonder why others think they are insane. I hope this chapter will throw a bit of light on a serious subject without adding to the confusion and, without upsetting people who may draw different conclusions from the same data!

History
Aids may have been around for a long time. The HIV status of the “Manchester sailor” who died in the 50’s is still, I understand, unresolved. However serum samples stored from the Ebola epidemic in Zaire in 1976 showed 1 to 2% were HIV positive, but there was no explosion. African traditional life styles were very strict, and if Aids got into a family it rarely spread beyond the family. Then big movements of people began along the main highways. Lorry drivers, traders, the urban drift, all disrupted traditional behaviour. The catalyst had arrived. Uganda was one of the first countries in the world to take HIV seriously, and mounted an amazing education programme in the 80’s. The Aids epidemic peaked in the early 90’s, deaths outnumbered new infections, and the prevalence dropped from as high as 20% to about 10% of the adult population.

In the early 90’s there were an estimated 400,000 deaths a year and it is possible that a total of 4 million have died of Aids in the last 20 years. It was said that everyone in the country had a family member who had died of Aids. These personal tragedies reinforced the education programme. People’s life styles changed drastically.

Present Situation
The epidemic is very patchy. It is not as if every village and town has 1 in 10 people infected. Obviously, 90% of the sexually active age group nation wide are HIV negative. Most of these men and women are negative because they belong to a low risk behaviour group. Many educated urban young people have chosen celibacy or monogamy as the only sensible way to avoid Aids and other STD’s. Most Ugandans live happily in their traditional rural communities; they too are most unlikely to get HIV. But think about it: if the rural areas are only 2 or 3% positive, and they make up the majority of the population, then there must be another community somewhere with 50 % or more positive to make up the average to 10%! So the non-celibate, non-monogamous group who have chosen a high-risk lifestyle have a very high rate of Aids and other STD’s. This means global figures are not very helpful. What matters, is what is your risk, or your partners risk?

Current Risk
Young Ugandan men and women have grown up knowing more about Aids than most other countries in the world. Most are very sensible. They know the risk; they have seen the consequences. Ask most 20 something educated Ugandan girls if they would have sex with a new boyfriend without an HIV test and they would think you crazy for asking such a question.

In Europe, awareness of Aids is much less, and most people have never met anyone who even knows an Aids case. In Denmark, I heard, only 2 people died of Aids last year. Most of my medical colleagues never see any. Not surprisingly, many Europeans are not very concerned, and if you asked your intended to have an HIV test he would be very offended.

In UK the prevalence is I believe about 1 in 10,000. The risk groups are entirely different. Most cases are drug users, bi- and homosexual men, prostitutes, or from overseas, and they are concentrated in just a few cities. The chance of the person who chats you up in a party being HIV positive is vanishingly small, probably around 1 in 80,000.

Here in Uganda, the high-risk group is totally different. It is the mobile, educated, non-monogamous non-celibate heterosexual, i.e. exactly the most likely person to chat you up in a party! Obviously anyone willing to have sex with a visitor is choosing high-risk behaviour: by definition he or she is not monogamous or celibate. His risk of being HIV positive is likely to be very high.

Catch 22: If he is safe, he isn’t interested. If he’s interested, he isn’t safe.

So What Is Your Risk?
First of all, don’t worry about all the other ways of getting HIV. It hardly ever happens.

No medical practitioner in Ugandan is going to use anything other than a disposable needle. You are absolutely not going to get it from a dentist, nor from surgery. A very few ladies I know may have got infected during delivery, but not these days. Everyone is just too aware of the risk. You are not going to get it from your house-girl, schoolteacher or anyone else who may cut themselves in your presence. There is no need to sack your garden boy if he is HIV positive. A few people have contracted HIV after getting totally soaked in blood in car accidents or battles, but on the whole intact skin is an excellent barrier. If anyone asks if you can get HIV from a toilet seat, the answer is only Bishops and Doctors.

Almost everyone with HIV gets it from sex.

Women Are At Greater Risk Than Men
The risk of transmission per sexual act is higher from man to woman then from woman to man. This is obvious. The man leaves his infected fluid inside, perhaps for hours. It is well rubbed into the delicate skin and mucous membranes of the vagina and cervix, and it can get up into the uterus where there is very soft tissue with a good blood supply, where viruses can easily penetrate. The man is in contact with infected fluid for only a few minutes. He has a much smaller area of mucous membrane and more intact skin, which is a good barrier. In fact for that reason circumcised men have a very much lower risk of getting HIV.

Secondly, the man is in control of the condom. If it comes off it is “his fault”. The HIV positive man, or a man who doesn’t know and doesn’t care, is not likely to be too bothered if he feels the condom coming off. The woman may be very concerned about the condom coming off, but there is not much she can do about it.

If a condom leaks it is far more likely to leak semen out then to leak vaginal secretions in.
For all these reasons, in each sexual act the woman is at far greater risk of getting HIV then the man. I know many men with positive wives who have had unprotected sex for years without getting infected, yet I know girls positive after one time only.

In Uganda more women are infected than men, yet, I find men in general are far more paranoid about getting infected, and women apparently more careless. We see many men coming in for advice after a condom accident, often terrified and requesting prophylactic triple therapy for a month in case they have been infected. We almost never see the ladies coming in the next day for the same advice.

Ugandan women are already well aware of the risks, and sensible at choosing suitable partners. After all they know their men, they can read the body language. Most of them long ago changed their behaviour to suit the climate. For these reasons the following anecdotes are written mainly as a warning to single expatriate women.

Do Condoms Protect?
Yes, but not 100%.
It is quite scary how many people think wearing a condom gives them total protection, and call it “safe sex”. The correct term is “safer sex”. A condom reduces the risk of transmission by 10 times. “10 times safer with a condom” sounds pretty good, but what it really means is that 10 times with a condom equals once without. Put another way, if you compare the risk in a community with a 1 in 10,000 HIV prevalence with a society with a 10% prevalence, it is more dangerous to have sex with 1 man here with a condom then with 100 men in UK without!

I know a lot of people with children conceived while the parents were using condoms. I know 4 expatriate doctors in Kampala with “condom babies”! A sperm is thousands of times bigger than a virus: if it can get through, so can any infection.

Condoms reduce the risk, they do no eliminate it

What About HIV Testing?
Antibody tests are very quick and very accurate. The tests these days use one drop of blood from a pinprick and you get a result in 2 minutes. However someone can be very highly infectious in the first 3 months of infection, yet have a negative antibody test, the “window period”. A Viral load will usually be highly positive 10 to 14 days after contact, but results may take a week.

The Current Problem
I find most people working in health related work, especially women’s health or HIV research, very aware indeed of the risks of casual sex. They have seen patients with Aids, know the horror, and know that none of them voted for it. 2 million Ugandan women are dead because they made a mistake, trusting someone who could not be trusted. So they realise it could just as easily happen to them. However very similar people working in other fields behave as if Aids and other STD’s were of no importance at all. So I hope the problem is lack of knowledge rather than inevitable human behaviour! Unfortunately head knowledge is rarely translated into practice.

The following stories are used with permission.

  • One 20 something expat girl came in from up country and asked for an HIV test because her house-girl had died of Aids. Or perhaps not. In fact she had got into a relationship that at the time she thought was a romance but now she had realised was a convenient way of escaping continual harassment in an otherwise lonely situation. She had put the condom on herself, every time, and as far as she knew it had never leaked, slipped or come off. Yes she admitted she maybe did have a discharge. In fact, she had a severe infection and was pregnant! Condoms had not prevented disaster. She was lucky: the infection was treatable, she was HIV negative. She realised that the relationship had been mental gymnastics, the “gold fish bowl” or “Ship board romance” situation. Her conclusion? “Women my age should not be sent into such situations alone” Lesson: Sex is a dangerous cure for boredom.
  • One lady came in after a condom accident and told me it was OK, as he had been tested and was negative. Being a bit of a cynic I asked was she there when he had the test? Of course not! I suggested it made sense. So she went with him for another test. He was positive. Her advice to all my readers: “Never go to his place, never start a relationship without first going together for a test, and if he ever suggests sex without a condom, find someone else.” Another suggestion was to say you have an allergy to semen and can never have sex without a condom or you will have painful sores for weeks!

A recent survey reported in the New Vision showed that 90% of men are unfaithful to their wives. So don’t insult your boyfriend’s manhood by suggesting you are the only girl!
Lesson: Men lie. Ask any magistrate. Men lie about sex. Ask any man.

Mental gymnastics can make you believe some very silly excuses.

One lady I asked, “Why didn’t you go along together for an HIV test?” She said that turning up at the local hospital together for the test would let everyone know they were having a relationship.
‘So kiss and tell only happens in Hollywood?’ Is rural Uganda the only place in the world where the outsider isn’t news, and the source of endless speculation and exaggeration? Discrete? – Be sensible. I suspect everybody already knew, and a lot more than she would like! One man told me how he won a bet among 4 “lads” by bringing back a “trophy”. So beware if something small and personal disappears, you might have been the subject of a bet.

Another traveller came in for a test, because of a 3 month sexual relationship last year including quite a few times without a condom. I asked why she hadn’t used a condom. She said it came off the first time, so she thought, oh well, if I’ve got it I’ve got it, so why worry? Now that she was off the ‘Titanic’, she realised how crazy she had been. But at the time, she just shut her mind to it, and carried on photographing the sunsets.

Fact. The more tickets you buy the more likely you are to win the lottery. One mistake should mean “stop being stupid” not “Oh well….”

Many girls take the pill. Why, if condoms are effective? Surely subconsciously it means you know they are not effective, and think pregnancy is the worst thing that can happen, so that needs extra care? You can get pregnant 4 days a month. You can get HIV any day of the month, and bacteria and viruses are thousands of times more likely to escape a condom than a sperm.

Something we here very often is “We trust each other…..”

– So did the 40 million dead worldwide.

Can you really know someone that well in less a year? Women have been given HIV after 10 years of marriage.

If someone from the same culture and language can be deceived how much more the visitor? You may be the weekday girlfriend. Even if he is HIV negative now, he may not be next week.

HIV Is Treatable
The earlier it is treated the better, and very early treatment may prevent it.

After rape, an accident, or if you wake up in the morning and realise you have been very silly, it may be worthwhile starting treatment immediately. A viral load can be positive in 10 days, a negative viral load in 14 days is very reassuring. Most doctors who get a significant injury, involving injected blood for example. They will take the medicine for a month, do a viral load, and if it is negative, stop. It seems to be helpful. Some embassies have “starter packs” for such emergencies. The Canadian consulate for example keeps a starter pack with us here at The Surgery. We also keep the triple therapy drugs for anyone who needs it in emergency.

If you are the slightest bit worried about HIV, have a test. It is quick, cheap and reliable. You know the result in 2 minutes. Treatment is readily available here. There is a lot of expertise, and most people now believe early treatment is beneficial. It may even keep people healthy indefinitely.

Summary
The general risk of STD’s and Aids is high. Your risk can vary from extremely high to non-existent according to your behaviour.

Many STD’s are difficult to detect and difficult to treat. The first step to adequate treatment is being aware of the possibility and aware of the long-term consequences of untreated disease. HIV is easily detectable by a simple blood test, and is now treatable.

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