Published July 21, 2012
KAMPALA, Uganda – Once every month, John Robert Engole checks into a clinic on the outskirts of the Ugandan capital to collect his medication before quickly returning to the village in northern Uganda where he is a teacher.
The regular trips have made Engole special at Reach Out, the AIDS clinic where in March 2004 the Ugandan became the first person in the world to benefit from the U.S. President's Emergency Plan for AIDS Relief, or PEPFAR.
Now he is one of nearly 260,000 Ugandans accessing treatment through PEPFAR, and those familiar with the man's story say he is a remarkable example of the program's necessity in poor African countries where governments have been slow to put more resources toward prevention and treatment of AIDS.
This is a crucial moment in the epidemic. There is no cure yet and no vaccine. But recent research suggests it finally may be possible to dramatically stem the spread of the AIDS virus, even in some of the hardest-hit and poorest countries, such as Uganda.
"Turning the tide," is the goal as described by the International AIDS Conference that begins Sunday in Washington. More than 20,000 scientists, activists and people living with HIV from around the globe will gather to begin figuring out how to do that — which combinations of protections work best in different countries — and how to pay for it.
One key will be increasing the number of people like Engole who are treated for their HIV infection, preferably before they're too weak or sick. Recent research shows keeping HIV patients healthy has the added benefit of making them less likely to infect other people. A new report from the United Nations shows that 8 million people in low- and middle-income countries got that treatment last year, with 6.2 million of them living in Africa. The global goal is to have 15 million treated by 2015.
Engole was about to die when he started treatment, his immune system destroyed. He says these days he only worries about "raising school fees for my children," not the morbid thoughts that once plagued his mind. Stella Talisuna, a physician who attends to Engole, said he was one of thousands of Ugandans "able to get back on their feet" because of PEPFAR, which President George W. Bush launched in 2003.
But thousands become infected with HIV each year in Uganda, keeping pressure on the government and its foreign benefactors to sustain AIDS relief. A new government report says the prevalence of HIV in this East African nation increased from 6.4 percent in 2004 to 7.3 percent in 2011, a shocking statistic for a country once praised for its global leadership in controlling AIDS. The same report says the number of Ugandans with HIV had doubled since 2004, from 1.2 million to 2.4 million.
Officially, the rate is going up mainly because more Ugandans are having multiple sex partners. But critics of Uganda's AIDS control policy say the country's past success in reducing the infection rate from double digits to single digits had been undermined later by a shift in attention from prevention to treatment. Some say this had the effect of making a generation of Ugandans less frightened by AIDS, which once had spread terror for its ability to shrink its victims.
At least half of the 600,000 Ugandans in need of AIDS treatment are able to access the drugs, mostly through PEPFAR. U.S. government officials have been pressing Uganda to devote more resources to AIDS and issues such as maternal health, saying dependency on foreign support is unsustainable in the long term.
Michael Strong, the PEPFAR coordinator in Uganda, said the program is set to transition from service delivery to technical assistance, and that Ugandan authorities would have to play the lead role going forward.
"We'll no longer be hands-on," Strong said.
About 130,000 Ugandans get HIV every year, and Joshua Musinguzi, who heads Uganda's AIDS control program, said this was the figure most discouraging of all. It means that far too many Ugandans are getting AIDS than the government can possibly manage to treat.
"There is need for continuous dissemination of information," Musinguzi said. "Individuals have the power to make the correct decision if they want to. The menu is there: ABC."
Uganda once earned a reputation for successfully putting in place a policy called ABC: abstain, be faithful, or use condoms. Students of a certain generation were shown videos of the devastating toll of AIDS on the human body, and then told to postpone the first act of intercourse. Some believe the fear factor, now gone, was decisive in Uganda's successful control of AIDS in the mid-1990s.
"They now see AIDS as much more like diabetes, one of these chronic diseases you can live with indefinitely," Timothy Kalyegira, a well-known Ugandan social critic, said, talking about the changing attitude toward AIDS among Ugandans.
The government recently added male circumcision to the plan against AIDS, in response to studies showing the procedure reduces the risk among African men of getting HIV in half. Officials want to circumcise 4 million men by 2015 in hopes that mass circumcision, as well as a persistent media campaign urging Ugandans to "get off the sexual network," will reduced substantially the rate of new infections. They remain optimistic that U.S. support for AIDS treatment will be stable for years to come.
In April three U.S. lawmakers touring Uganda with the humanitarian group CARE visited the clinic where Engole, the first PEPFAR beneficiary, gets his medication. He told the lawmakers his story and thanked them for PEPFAR, and some hugged him.
"To see this man who has a second chance now at living a healthy life, raising a family and children, to me was a very humbling experience," U.S. Rep. Barbara Lee, a California Democrat, said after meeting Engole. "It also was confirmation of the fact that United States foreign aid works."
Lee said Engole's example made her realize the U.S. "can't pull back" from AIDS relief in Africa.