tag:theconversation.com,2011:/global/topics/ugandan-health-23160/articlesUgandan health – The Conversation2020-05-07T15:13:22Ztag:theconversation.com,2011:article/1369602020-05-07T15:13:22Z2020-05-07T15:13:22ZUganda’s musicians are fighting COVID-19 - why government should work with them<figure><img src="https://images.theconversation.com/files/331764/original/file-20200430-42918-ebvmtl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bobi Wine.</span> <span class="attribution"><span class="source"> Isaac Kasamani/AFP/Getty Images</span></span></figcaption></figure><p>Ugandan pop musicians have released a raft of songs and music videos to educate and alert the public about <a href="https://theconversation.com/africa/search?utf8=%E2%9C%93&q=COVID-19">COVID-19</a>. </p>
<p>Notable among them have been Bobi Wine and Nubian Li’s <a href="https://www.youtube.com/watch?v=PUHrck2g7Ic"><em>Corona Virus Alert</em></a> and Bebe Cool’s <a href="https://www.youtube.com/watch?v=DOmAncrXRvM&list=RDDOmAncrXRvM&start_radio=1"><em>Corona Distance</em></a>. But there’s also the likes of Pastor Frank Kyeyune’s <a href="https://www.youtube.com/watch?v=L49yI3_vtDg"><em>Katonda Yekka ku Corona</em></a> (God Only On Corona), Dickens Ahabwe’s <a href="https://www.youtube.com/watch?v=tdc5GxMixhM"><em>Coronavirus in Uganda</em></a> and <a href="https://www.youtube.com/watch?v=a44VHZt6f-Q"><em>Corona</em></a> by Ykee Benda, King Saha, Joanita Kawalya, B2C, Fefe Busu Dre Cali and Myci Ou. </p>
<p>These are simple songs that assume a responsibility to help educate citizens. They are dense in information about COVID-19, about preventing its spread and getting help if one is infected. </p>
<p>But how effective are they in public health communication? As a music ethnographer in the region, I set out to examine this.</p>
<h2>Can songs help fight disease?</h2>
<p>As studies have <a href="https://bit.ly/2YnmqBj">shown</a> in relation to interventions to combat the HIV/AIDS pandemic, <a href="https://bit.ly/2SkUaeu">music</a> can create awareness about a disease while also providing <a href="https://www.who.int/hiv/topics/psychosocial/support/en/">psychosocial support</a> to victims.</p>
<p>Songs can be a valuable tool of communication in health pandemics. HIV/AIDS studies show that music not only <a href="https://bit.ly/2YnmqBj">creates awareness</a> about the ways the virus is transmitted, it also sensitises people on how to <a href="https://www.tandfonline.com/doi/abs/10.1080/17449850701820632">prevent</a> it. </p>
<p>Moreover, music is a mechanism for <a href="https://bit.ly/2SkUaeu">counselling</a>. Due to their power to employ <a href="https://literarydevices.net/10-great-metaphors-from-popular-music/">metaphor</a>, songs become objects through which impossibilities of <a href="https://theconversation.com/how-music-helps-us-understand-displaced-communities-in-uganda-129390">daily discourses</a> can be turned into hope, participating in the healing process of the patient. </p>
<h2>The state response to the virus</h2>
<p>Since Uganda <a href="https://www.health.go.ug/covid/">confirmed</a> its first COVID-19 case, the government has announced 34 <a href="https://www.independent.co.ug/full-list-of-34-ugandan-measures-to-contain-covid-19/">measures</a> to curb the virus. These have registered early success against infections and have included a mass shutdown and an extended <a href="https://www.reuters.com/article/health-coronavirus-uganda/uganda-extends-coronavirus-lockdown-for-three-more-weeks-idUSL5N2C24SS">lockdown</a>. Parliament passed a supplementary budget of approximately US $82 million to fight COVID-19. </p>
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<a href="https://images.theconversation.com/files/333094/original/file-20200506-49546-162yh59.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/333094/original/file-20200506-49546-162yh59.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/333094/original/file-20200506-49546-162yh59.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333094/original/file-20200506-49546-162yh59.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333094/original/file-20200506-49546-162yh59.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333094/original/file-20200506-49546-162yh59.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333094/original/file-20200506-49546-162yh59.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333094/original/file-20200506-49546-162yh59.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A community chairperson shares news about COVID-19 from the tallest building of his area in Kampala.</span>
<span class="attribution"><span class="source">Badru Katumba/AFP/Getty Images</span></span>
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</figure>
<p>Besides the health ministry’s COVID-19 messaging on state media, including television and radio, political leaders have also recorded messages in local languages to sensitise communities. Local leaders also broadcast COVID-19 information to their neighbourhoods, sometimes with loudhailers. </p>
<p>Although popular musicians are powerful tools of mobilisation, the Ugandan government has neither included them on any COVID-19 task forces nor formally contracted them to mobilise the public. </p>
<p>Inclusion of musicians in official campaigns against COVID-19 could have boosted the state’s fight in meaningful ways, particularly in combating stigmatisation of the victims.</p>
<h2>The pop culture response</h2>
<p>I regard <a href="http://currentwriting.ukzn.ac.za/articles/vol-18-2/challenges-of-archiving-ugandan-popular-music.aspx">popular music</a> as <a href="https://bit.ly/3d8fwnD">mass-mediated</a> and of its time and culture. </p>
<p><a href="https://www.youtube.com/user/omubandarealityshow">Bobi Wine</a> and <a href="https://www.youtube.com/user/bebecool1">Bebe Cool</a> are popular musicians. Their two songs employ innovative methods of communication to convey messages that are also amplified by their considerable social media followings.</p>
<p>Bobi Wine – who is also a <a href="https://theconversation.com/uganda-who-is-bobi-wine-and-why-is-he-creating-such-a-fuss-102138">politician</a> and vocal opponent of government – created a hit that soon passed a million clicks on YouTube and has garnered international <a href="https://www.ugandanz.com/cnn-names-bobi-wine-among-africas-heroes-against-covid-19/">kudos</a>. </p>
<p>In <em>Corona Virus Alert</em> he and Nubian Li emphasise, among others, the responsibility of all Ugandans to wash and sanitise their hands, observe social distancing, to isolate by going into quarantine if symptoms appear. The artists also list the signs and symptoms of COVID-19. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/PUHrck2g7Ic?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Bobi Wine and Nubian Li have been picking up awards for this video.</span></figcaption>
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<p>For their part, Bebe Cool and his associates display the ministry of health’s COVID-19 hotline number throughout their video. They implore people to avoid touching eyes, mouths and noses with unwashed hands and to not shake hands. People need to use tissues or bended elbow to cough and sneeze into. The song ends with an emphasis on the need to heed the lockdown. </p>
<p>Like most coronavirus songs on Ugandan TV and radio, messages are embedded in videos with visuals and text. Bobi Wine and Nubian Li exploit the text more than the visual element – mostly a studio setting – to underscore their message. </p>
<p>In the song a dialogue emerges, Bobi Wine sometimes singing in Luganda (the language of the Baganda of Central Uganda) while Nubian Li responds in English. The rap in the middle emphasises the messaging on symptoms and responses, echoing the central theme of warning people about coronavirus. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/DOmAncrXRvM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Bebe Cool and his fellow musicians demonstrate safety measures between graphics reinforcing messages.</span></figcaption>
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<p>Bebe Cool strikes a balance between visuals and the text. The artists in the video perform COVID-19 prevention tips, like washing hands, and the video then entrenches this by displaying animated illustrations showing six steps of thorough hand washing. The scenes are set in the home and church to normalise staying home while emphasising the fact that COVID-19 has killed many people.</p>
<p>The song features boy rapper Patrick Ssenyonjo. His inclusion shows that COVID-19 does not discriminate – it affects all people including the young. The rap style is widely consumed throughout the world and easily accessible, especially to the youth.</p>
<h2>Why co-opt pop music?</h2>
<p>Music generally plays a dual role – it entertains as it also communicates messages. In Uganda some community groups continue to <a href="https://www.newvision.co.ug/new_vision/news/1517207/minister-kania-warns-stigmatisation-covid-19">stigmatise</a> and reject <a href="https://www.independent.co.ug/medics-warn-public-against-stigmatizing-covid-19-returnees-from-treatment-centres/">victims</a> and suspected victims of COVID-19, sometimes with threats of violence. </p>
<p>These people are confronted by two enemies: the virus and social rejection. While it’s too soon to have studied the impact of Uganda’s coronavirus songs, HIV/AIDS has shown that the use of pop music provides psychosocial support to victims of ill-health. It can be used to supplement the effort of medical doctors. It not only soothes the minds of sick people and restores their hope, but can also be messaged to implore the community to accept the victims. </p>
<p>It can also help shape popular opinion. Most of the songs have addressed the indiscriminate nature of COVID-19, emphasising that it affects everyone. </p>
<p>Uganda’s national COVID-19 taskforce would do well to employ a multi-faceted approach to its public health communication. One where music – in schools, on radio, on the internet – is embraced as a measure towards preventing disease and loss as well as resettling the victims in their community lives.</p><img src="https://counter.theconversation.com/content/136960/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dominic D.B. Makwa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Uganda’s COVID-19 task force would do well to embrace pop music in its public health communications.Dominic D.B. Makwa, Lecturer, Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1185512019-06-12T14:10:31Z2019-06-12T14:10:31ZHow an ancient fireside gathering could tackle HIV stigma in Uganda<figure><img src="https://images.theconversation.com/files/278928/original/file-20190611-32351-1lkkh6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Dutourdumonde Photography/Shutterstock</span></span></figcaption></figure><p>For 25 years, northern Uganda was devastated by <a href="https://www.globalsecurity.org/military/world/war/uganda.htm">civil war</a>. During this time the area’s residents, many of whom belong to the <a href="https://www.britannica.com/topic/Acholi">Acholi people</a>, were forced from their homes. They ended up living in internally displaced camps, relying on the World Food Programme and battling a severe shortage of clean water. Hunger, malnutrition and a lack of adequate sanitation facilities took a dreadful toll.</p>
<p>Death rates rose <a href="https://www.doctorswithoutborders.org/what-we-do/news-stories/news/immense-suffering-northern-uganda-urgent-action-needed">significantly</a> next to the national average rate. Survival was the only priority. As such, many of the Acholi’s traditional practices were eroded.</p>
<p>One of these practices was the gathering around the <a href="https://www.theeastafrican.co.ke/magazine/434746-255916-c6ie1c/index.html">wang-oo</a>, a central, communal fireplace where elements of the culture – stories, songs, riddles and parables – were told and passed on from one generation to another. </p>
<p>The wang-oo usually happened in the evenings. It served as entertainment, moral education and conflict resolution. It was also a sort of informal school for the Acholi. There, information on taboos, rituals and expected behaviour was passed on. Elders used the time to indirectly correct community members’ misbehaviour’s by relating proverbs and folk tales.</p>
<p>Without a formal space to bind the community in the midst of serious social problems in the camps, the status of Elders was severely undermined and the continuity of traditional values from one generation to the next ceased to exist. When people began to return to their communities a decade ago during relative peace, many of the traditional practices, such as the wang-oo, were not re-established.</p>
<p>Now, researchers, Acholi elders, and teachers are working to together to revitalise the wang-oo. Our plan is to bring the practice into schools in a new way: by using it as a space where young people can discuss HIV and the stigma surrounding the condition.</p>
<p>Addressing HIV stigma through using the Acholi’s own local cultural system is an empowering process that will position the role of the elders back into the community. It will also provide a valuable space for vulnerable young people to talk openly about HIV and stigma and to learn folktales that support respect and responsibility.</p>
<h2>Tackling stigma</h2>
<p>Adolescents in sub-Saharan Africa account for <a href="https://www.who.int/hiv-aids/latest-news-and-events/why-the-hiv-epidemic-is-not-over">71% of new infections</a> every year.</p>
<p>While antiretroviral therapy is preserving health and prolonging life, stigma continues to cripple individuals and communities. <a href="https://www.sciencedirect.com/science/article/pii/S0190740914001443">My previous research</a>, also conducted in Uganda, has shown that adolescents with HIV face discrimination and bullying in school and in the broader community. This can lead to social isolation, school drop-out, depression and suicide.</p>
<p>To address these issues, we are drawing from the teachings that traditionally take place around the wang-oo. These demonstrate empowering concepts related to self and community, respect for self, peers and authority, and responsibility for caring for others. And it’s these concepts that will provide the inputs for our four-year research project intervention to decrease HIV stigma among school children, teachers and the broader community. </p>
<p>During my previous work in Uganda, living and working in the country for several years, I learned about the <a href="http://www.justiceandreconciliation.org/uncategorized/2013/the-first-step-towards-reconciliation/">many traditional practices</a> that were helping to reintegrate children who had been abducted during the quarter century of civil war back into their communities. I wondered how other Acholi traditional practices could support children in addressing issues such as HIV stigma. </p>
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<a href="https://images.theconversation.com/files/278857/original/file-20190611-32327-7tp0jz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/278857/original/file-20190611-32327-7tp0jz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/278857/original/file-20190611-32327-7tp0jz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/278857/original/file-20190611-32327-7tp0jz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/278857/original/file-20190611-32327-7tp0jz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/278857/original/file-20190611-32327-7tp0jz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/278857/original/file-20190611-32327-7tp0jz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/278857/original/file-20190611-32327-7tp0jz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The wang-oo is a fireside space for learning and talking.</span>
<span class="attribution"><span class="source">Author supplied</span></span>
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<p>Some members of our research team have just returned from Uganda where we learnt that Elders are very much interested in reestablishing their role. However, more work needs to be done with older youth to create interest. Integrating the project into schools and using creative methods will make learning more formalised, fun, and engaging for youth. </p>
<p>The idea is that this approach will be grounded in local cultural knowledge. Project activities include using visual art (painting, sketching), dance, singing, and theatre to change social and cultural norms, and directly address various types of stigma. Family, community members, and health care workers will be invited to weekly performance events. </p>
<p>These events, similar to the wang-oo, will bring together diverse groups of people to discuss HIV stigma and to participate in re-creating new behaviours and attitudes that demonstrate their moral teachings passed on by elders. The hope is that while not the wang-oo in its traditional form, a more modern form will emerge, making the traditional practice more appealing. </p>
<h2>Restoring cultural values</h2>
<p>The restoration of cultural practices and values will need long term effort and multiple strategies happening at the same time for sustained change. One such strategy happening in northern Uganda is <a href="https://www.facebook.com/pg/RadioKingUganda/about/?ref=page_internal">a radio programme</a> that airs every Saturday evening with local traditional stories, parables and riddles told by Elders. Individuals are encouraged to call into the show and guess the moral teaching. </p>
<p>There are other efforts underway to document traditional knowledge by video recording Elders as a way to capture the oral history of the Acholi people. </p>
<p>Bringing people together through theatre, radio, or video in a similar way as the wang-oo has the potential to promote healing and build resiliency in a society that has lost so much. Addressing HIV stigma through local cultural knowledge will support families and communities to help children become healthy productive citizens.</p><img src="https://counter.theconversation.com/content/118551/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bonnie Fournier receives funding from the The Canadian Institutes of Health Research (CIHR) for this research project</span></em></p>Addressing HIV stigma through utilising the Acholi’s own local cultural system is an empowering process that will position the role of the elders back into the community.Bonnie Fournier, Associate Professor, Thompson Rivers UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/946662018-05-08T13:55:27Z2018-05-08T13:55:27ZPrivate lab tests in Uganda are costly. But price doesn’t equal quality<figure><img src="https://images.theconversation.com/files/217945/original/file-20180507-46356-fy1v70.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Very few laboratories in Uganda are accredited. </span> <span class="attribution"><span class="source">Arne Hoel / World Bank</span></span></figcaption></figure><p>Laboratory tests are the <a href="https://scholar.google.com/scholar_lookup?author=Ngo%2C+et+al&title=Frequency+that+laboratory+tests+influence+medical+decisions&publication_year=2016&journal=J+Appl+Lab+Med&volume=1%3B4&pages=410-4">backbone of clinical care</a>. They are used to screen patients, to diagnose diseases and to manage conditions ranging from anaemia and diabetes to HIV and malaria. </p>
<p>Considerable effort has gone into improving laboratory services in many African countries. But, as many <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0064661">previous studies</a> have shown, the quality of laboratory tests in much of sub-Saharan Africa is poor. </p>
<p>This is because most of these <a href="http://www.afro.who.int/sites/default/files/2017-06/afro-guidance-lab-systems-final_dec2014.pdf">laboratories don’t have</a> the necessary infrastructure nor enough competent staff who are adequately trained or the adequate management systems in place.</p>
<p>In many African countries laboratory testing is provided both as a free service in the public health sector and for a fee <a href="https://www.mm3admin.co.za/documents/docmanager/f447b607-3c8f-4eb7-8da4-11bca747079f/00060290.pdf">by private companies</a>. In some countries the majority of lab tests are done in the private sector; for instance, <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0064661">more than 90%</a> of the laboratories in Uganda’s capital city Kampala are privately owned.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/26226183">Research shows</a> that these services, for which patients pay out of their own pockets, tend to be costlier than those offered in the public sector. But there’s been no evaluation of whether the more expensive tests provide better, more accurate results. </p>
<p>We tried to answer this question in <a href="https://doi.org/10.1093/ajcp/aqy017">our study</a> which looked at the costs and accuracy of tests at laboratories in Kampala. We randomly selected close to 80 laboratories and ordered 13 of the most commonly ordered laboratory tests – among them tests for malaria, pregnancy, HIV, syphilis, glucose; complete blood counts, and liver and kidney function tests.</p>
<p>We found that people are paying up to 36 times more for private laboratory tests than they do in the public sector. And, most importantly, test prices do not predict their quality. Higher costs don’t mean more accurate or clinically useful results. </p>
<p>The findings suggest that Uganda should put an external system in place to ensure that the public gets what they pay for.</p>
<h2>Global standards</h2>
<p>There are two broad sets of measures where the quality of laboratories can be checked against. </p>
<p>Firstly, countries are obliged to set up guidelines for both public sector and private laboratories. </p>
<p>But many countries around the world failed to follow these prescriptions, leading to the World Health Organisation also creating <a href="http://www.afro.who.int/sites/default/files/2017-06/afro-guidance-lab-systems-final_dec2014.pdf">guidelines</a> to help them set up their laboratory systems.</p>
<p>Although this has improved the quality of a few laboratories, the challenge is that the vast majority of laboratories are still not meeting the lowest bar of the guidelines. </p>
<p>The second set of measures are international accreditation standards that monitor laboratory quality. There are two. One is <a href="http://www.cms.gov/clia/">US-based</a> and the other are standards created by the International Organisation for Standardisation <a href="http://www.iso.org/iso/home/standards.htm">based in Europe</a>. Laboratories that meet these standards are considered accredited and recognised as meeting international performance standards. But laboratories are not obliged to go through this accreditation. </p>
<p>There are thousands of laboratories across Africa. Ideally, each of these should be accredited. But a 2014 study shows that in <a href="https://doi.org/10.1309/AJCPQ5KTKAGSSCFN">37 of 49 sub-Saharan African countries</a> there was not a single accredited clinical laboratory. Only 380 laboratories accredited to international standards in the region – and 91% of these were in South Africa, Namibia and Botswana.</p>
<p>Uganda has both accredited and non-accredited laboratories. We included both in our study to try and gauge whether the relevant “stamp of approval” affected the tests’ accuracy.</p>
<p>To establish how accurate and expensive the tests were we sent real, but unknown samples, to all the laboratories in our study. And we then also recorded how much they charged us for performing the tests. To establish accuracy, we used results on the same samples from specialised laboratories both in Uganda and Australia to determine the correct results. </p>
<p>We made three important observations. </p>
<h2>Our findings</h2>
<p>Firstly, accuracy varied widely. About 98% of the samples from accredited laboratories were correct while only 66% of the samples from the unaccredited laboratories were correct. </p>
<p>Secondly, accuracy depended on the type of test that was being done. For example, about 90% of test results for HIV, malaria, and syphilis were correct. But only 38% of the tests for urine pregnancy screenings, blood counts, and liver and kidney function tests were accurate.</p>
<p>And test prices ranged widely for an individual test performed in different laboratories. Some labs in the private sector were charging 36 times more than others. Yet we found no relationship between price and quality. </p>
<p>Our findings show that both accreditation and the test being done matters. Tests done by an accredited laboratory is likely to produce correct results 98% of the time. The figure plummets in unaccredited labs.</p>
<p>The quality is likely to be acceptable at all the laboratories for common tests such as HIV and malaria. But for people who had kidney or liver disease, the quality of test is generally not good. These problems stem from a lack of clear and enforced laboratory quality requirements. They have real impact on what diagnoses and treatments patients receive, and must be fixed. </p>
<h2>The way forward</h2>
<p>The way to address this problem is to make the market more transparent by making quality measurable and obvious to the public. </p>
<p>Based on our study, there are two practical approaches that could work. The first is ensuring that laboratories in Africa have international accreditation. The second involves doing quality checks such as those used in this study. </p>
<p>Some countries –like South Africa and Namibia – have bodies that monitor the quality of the laboratories but this is not a uniform practise across the continent. The responsibility to enforce such a practice could emerge from bodies like the World Health Organisation or the <a href="http://www.aslm.org/">African Society for Laboratory Medicine</a> which aims to strengthen laboratories.</p>
<p>Achieving international accreditation should be the goal for every laboratory. </p>
<p>But accreditation is an expensive and challenging task in the short term, especially for small private laboratories. In the meanwhile countries that still have challenges with the quality of their laboratories could use the testing of unknown samples as an achievable, affordable, and effective way to monitor their laboratories and reestablish the public’s trust.</p><img src="https://counter.theconversation.com/content/94666/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy Amukele does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Considerable effort has gone into improving laboratory services in many African countries. But the quality of tests is questionable.Timothy Amukele, Assistant Professor Johns Hopkins University, and Director of the Hopkins Bayview Medical Center Clinical Laboratories, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/916312018-03-07T16:53:00Z2018-03-07T16:53:00Z40% of Uganda’s health centres don’t stock drugs to treat chronic diseases<figure><img src="https://images.theconversation.com/files/208664/original/file-20180302-65541-18v8w72.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>When the World Health Organisation created an <a href="http://www.who.int/medicines/publications/essentialmedicines/EML_2017_ExecutiveSummary.pdf?ua=1">essential medicines list</a> in the early 2000s, the aim was to provide a list of medicines that should be made available and accessible to country’s entire population. </p>
<p>The idea was that each country would adapt the list based on their local disease prevalence, cost-effectiveness and other national priorities. And each country would determine the lowest-level health facilities expected to stock each essential medicine. To qualify as accessible, drugs were to be available and affordable. </p>
<p>But <a href="https://www.scielosp.org/article/bwho/2011.v89n6/412-421/en/">studies</a> have shown that essential medicines used to treat non-communicable diseases are still <a href="https://www.scielosp.org/scielo.php?pid=S0042-96862007000400013&script=sci_arttext&tlng=pt">poorly accessible</a> to populations in low and middle income countries. The problem is that these are precisely where cases of non-communicable diseases such as cardiovascular disease, diabetes, chronic lung disease and mental health disorders are rising dramatically.</p>
<p>Uganda is a case in point. In <a href="http://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0192332&type=printable">our study</a> we looked at the availability of 10 non-communicable disease medicines on Uganda’s essential medicines list. We found that out of close to 200 facilities, just under 40% had none of these medicines. And not a single facility stocked all the medicines on the list. </p>
<p>Yet Uganda, like most countries in the developing world, has seen an <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-014-0077-5">increasing burden</a> of non-communicable diseases in the past 10 years. Just under a quarter of Ugandan adults suffer from <a href="http://www.who.int/ncds/surveillance/steps/Uganda_2014_STEPS_Report.pdf">high blood pressure</a> and about 15% of Ugandans are overweight.</p>
<p>Our study shows that the health centres where medicines are free of charge, and should therefore be the most accessible, are the least likely to stock medicines for these chronic conditions. This means that people need to travel to referral centres just to obtain medicines for these increasingly common conditions.</p>
<h2>Shortages abound</h2>
<p>To understand how medication was dispensed in Uganda we used <a href="http://www.who.int/healthinfo/systems/sara_reports/en/">data from a survey</a> that the World Health Organisation encourages low and middle income countries to fill in annually. The survey looks at a variety of services that health facilities offer. These range from malaria testing to HIV counselling to availability of essential medicines to basic amenities such as running water and electricity. </p>
<p>The survey helps countries assess both their private and public health facilities. </p>
<p>In 2013, <a href="http://www.who.int/healthinfo/systems/SARA_H_UGA_Results_2014.pdf?ua=1">the last available data for Uganda</a> at the time we conducted our study, the data included information gathered during spot checks done by surveyors. The checks involved looking at what was being kept on pharmacy shelves in health facilities and recording what was and wasn’t available. (While this method is widely used it is also not the most accurate, as pharmacy stockages are dynamic and fluctuate over time.) </p>
<p>The survey evaluated 20 essential medicines – 10 of which are used to treat non-communicable diseases. Not all of these medicines are expected to be stocked at every type of health facility all the time. For example, at the time of this study, the Uganda essential medicines list recommended that:</p>
<ul>
<li><p>Metformin, a common diabetes medicine, was expected to be stocked at a level four health centre.</p></li>
<li><p>Nifedipine, a drug used to treat high blood pressure, was expected at a level three health centre</p></li>
</ul>
<p>What we found was that:</p>
<ul>
<li><p>Metformin was available in 79.4% of facilities expected to stock it, but </p></li>
<li><p>Nifedipine was only available at just under half of the expected facilities. </p></li>
<li><p>Beclomethasone, an inhaler for chronic lung diseases like asthma, was only available in 2.9% of expected facilities. </p></li>
</ul>
<p>The lower level health facilities where the population is expected to receive primary health care, should be expected to stock essential medicines for a condition such as hypertension. But they don’t. </p>
<p>There were several other disparities we picked up, including: </p>
<ul>
<li><p>Private-for-profit facilities had nearly twice as many available non-communicable diseases medicines as public facilities; </p></li>
<li><p>general hospitals had nearly twice as many available non-communicable diseases medicines as the lowest level facilities; and </p></li>
</ul>
<p>Lower-level facilities – those that are closest to the population – are also the least likely to have these medicines available. </p>
<p>What this means is that people need to travel to referral centres just to obtain medicines for these increasingly common conditions. But even at the referral centres, availability remains sub-par. </p>
<h2>Fixing the system</h2>
<p>What our study shows is that health systems need to be strengthened with a focus on improving access to high quality, reliable services for increasingly common chronic conditions. </p>
<p>This will require investment in improving supply chains and better understanding the evolving demand for these medicines.</p><img src="https://counter.theconversation.com/content/91631/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In Uganda, essential medicines are not being stocked at facilities that need them most. This includes drugs to treat chronic diseases.Jeremy Schwartz, Assistant Professor of Medicine, Yale UniversityMari Armstrong-Hough, Associate research scientist in Epidemiology, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/692702016-12-04T18:20:04Z2016-12-04T18:20:04ZMale circumcision in Uganda will only improve if local beliefs are considered<figure><img src="https://images.theconversation.com/files/147947/original/image-20161129-10945-10lk4rv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Reuters/Simphiwe Sibeko</span></span></figcaption></figure><p>For the past 10 years voluntary medical male circumcision has been recommended as a way of reducing female-to-male transmission of HIV. Estimates show that it could <a href="http://dx.doi.org/10.1080/17441692.2014.989532">reduce infections by 60%</a>. Several sub-Saharan African countries with high rates of HIV prevalence but low rates of male circumcision have rolled out the procedure as part of their HIV prevention initiatives.</p>
<p>Since 2007 more than 9 million circumcisions have been performed in <a href="http://www.who.int/hiv/topics/malecircumcision/fact_sheet/en/">eastern and southern Africa</a>. But to cover more than 80% of men on the continent by 2025, about 20 million more men need to be circumcised. If this happens about <a href="http://dx.doi.org/10.1371/journal.pmed.1001132">3.4 million new HIV infections</a> could be averted, reducing the number of people who would need HIV treatment and care.</p>
<p>While circumcision has been encouraged there are <a href="http://dx.doi.org/10.1016/j.socscimed.2015.04.020">many places</a> where it has <a href="http://dx.doi.org/10.1080/13557858.2013.772326">faced challenges</a>. This is linked to misconceptions about the purpose of circumcision as well as religious and cultural concerns which prevent men from getting circumcised. </p>
<p>Uganda is a case in point. By the end of 2015 the country’s health ministry aimed to circumcise 80% – <a href="http://health.go.ug/docs/UAIS_2011_KEY_FINDINGS.pdf">or 4.2 million</a> – men aged between 15 and 49. But between 2008 to 2013 the country only managed to <a href="http://www.aidsuganda.org/resource-center/downloads/%20doc_download/3-consolidated-q-3-supervision-report-may-2014">circumcise 50% of this population</a>. Most of these were young boys.</p>
<p><a href="http://dx.doi.org/10.2989/16085906.2016.1179652">Our research</a> found that religious and cultural beliefs compete with the messages about the purpose of circumcision. We found that this got in the way of men deciding whether or not to be circumcised medically and also affected the way they behaved afterwards. </p>
<p>When medical circumcision is introduced in settings where there are high rates of HIV, it must take into account local beliefs about circumcision. And local religious and social group leaders and women must be involved in the roll-out.</p>
<h2>Conflicts of belief</h2>
<p><a href="http://dx.doi.org/10.1016/j.socscimed.2015.04.020">Several studies</a> have compared uptake of circumcision in societies where there is a tradition of circumcision and those where there are not. </p>
<p>When circumcision is not part of religious or cultural practices, introducing voluntary male circumcision can be problematic because it is associated with ethnic and religious identities. This is the case in <a href="http://dx.doi.org/10.1080/17441692.2015.1006241">Zimbabwe</a>, <a href="http://dx.doi.org/10.1080/09540120220097919">Kenya</a>, and parts of <a href="http://dx.doi.org/10.1080/13691058.2013.807519">South Africa</a> where there are both social and cultural barriers to circumcision. </p>
<p>In Uganda, only <a href="http://www.who.int/bulletin/volumes/88/12/09-072975/en/">20% of men practice traditional male circumcision</a> for cultural and religious reasons. This is considerably lower than Kenya (80%) or Tanzania (70%) but similar to many other southern African countries.</p>
<p>We conducted a study of the beliefs and perceptions about circumcision in fishing villages on the shores of Lake Victoria, Uganda. The villages were part of an HIV combination prevention pilot study. </p>
<p>The overall aim of the trial was to investigate factors limiting access to HIV prevention interventions and to determine the feasibility of conducting an HIV combination prevention effectiveness trial to reduce HIV incidence among fishing communities in Uganda. </p>
<p>HIV combination prevention packages would include male circumcision along with access to antiretrovirals, prevention of mother to child transmission, condom promotion, counselling and testing, and health education. </p>
<p>We looked at the influence that different understandings and beliefs about male circumcision may have on voluntary male circumcision in the fishing communities, which are ethnically mixed and have high HIV prevalence. </p>
<p>In Uganda just over <a href="http://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/uganda">7% of the population</a> is living with HIV. </p>
<h2>How the men felt</h2>
<p>We found that even when men opted for voluntary medical male circumcision, they followed practices afterwards that were informed by traditional beliefs. This at times involved engaging in unsafe sexual behaviour. While men understood the health benefits of medical circumcision, these messages were sometimes mixed with beliefs drawn from traditional circumcision practices. </p>
<p>For example, several respondents believed that vaginal fluids helped them heal after being circumcised. Some also believed that vaginal fluids could heal wounds from cuts and snake bites as a form of first aid. In these villages it was reported that women also used vaginal fluids to treat themselves and their children’s injuries. </p>
<p>They also believed that having sex with a non-regular partner could chase away spirits and that circumcision offered them protection from sexually transmitted infections. These encouraged unsafe sexual practices.</p>
<h2>Changing the mindset</h2>
<p>Both personal and community-wide misconceptions need to be improved if the uptake of male circumcision is going to be improved, and if post-procedure behaviour is going to be changed. This can only be done if local knowledge systems in the community are engaged. </p>
<p>Engagements must include local religious and community leaders and must involve both men and women. And this must happen during the roll out of the circumcision procedures but also afterwards.</p>
<p>Key local actors such as traditional and religious leaders from different ethnic groups could help provide support for an approach that takes into account local beliefs about circumcision.</p><img src="https://counter.theconversation.com/content/69270/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janet Seeley receives funding from British Medical Research Council </span></em></p><p class="fine-print"><em><span>Martin Mbonye and Monica Kuteesa do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Medical circumcision in settings where there are high rates of HIV will only be successful if these interventions take into account local beliefs about circumcision.Martin Mbonye, Social scientist, MRC/UVRI Uganda Research Unit on AIDSJanet Seeley, Professor of Anthropology and Health, London School of Hygiene & Tropical MedicineMonica Kuteesa, Senior scientist, MRC/UVRI Uganda Research Unit on AIDSLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/584422016-04-29T04:26:55Z2016-04-29T04:26:55ZKenyans and Ugandans need to change their ways to arrest lifestyle diseases<figure><img src="https://images.theconversation.com/files/120251/original/image-20160426-1327-i6eocx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Reuters/Siegfried Modola </span></span></figcaption></figure><p>More than 90% Kenyans consume less than five servings of fruits and vegetables on most days. Nearly a quarter always add salt to their food before eating or during their meals. And 28% always add sugar to beverages. </p>
<p>More than half of the adult Kenyan population have never had their blood pressure tested. Yet one in four people has high blood pressure. Diabetes testing has even worse adherence, with only one in ten adults ever being tested.</p>
<p>The majority have never had their cholesterol levels tested, while 27% are either overweight or obese.</p>
<p>These are the results from the newly released <a href="http://aphrc.org/wp-content/uploads/2016/04/Steps-Report-NCD-2015.pdf">2015 Kenya STEPwise Survey</a>, a nationwide study that looked at how non-communicable diseases are affecting the country. </p>
<p>What the results show is that non-communicable diseases such as diabetes, cancer, heart disease and chronic respiratory illness have all skyrocketed in the country over the past ten years in the same way that they have in sub-Saharan Africa. </p>
<p>Globally, more than 16 million people die from non-communicable diseases. Of these, 80% are in low- and middle-income countries. And according to the World Health Organisation’s projections for the next ten years, <a href="http://www.afro.who.int/en/clusters-a-programmes/dpc/non-communicable-diseases-managementndm/npc-features/1236-non-communicable-diseases-an-overview-of-africas-new-silent-killers.html">28 million people</a> in sub-Saharan Africa will die from a chronic disease. </p>
<p>Responsibility to address the situation does not only lie with governments. The choices individuals make also have a huge role to play. </p>
<h2>Kenyans and Ugandans are too unhealthy</h2>
<p>Non-communicable diseases are linked to a number of risk factors, including:</p>
<ul>
<li><p>unhealthy diets;</p></li>
<li><p>smoking;</p></li>
<li><p>alcohol intake; and</p></li>
<li><p>a lack of exercise.</p></li>
</ul>
<p>These all significantly increase the individual’s risk of dying from a non-communicable disease.</p>
<p>Though the picture isn’t pretty in Kenya, the country is not alone. In Uganda, the <a href="http://www.who.int/chp/steps/Uganda_2014_STEPS_Report.pdf">2014 Uganda STEPwise Survey</a> shows figures that are as bad. </p>
<p>Here, 88% of the population consume less than five servings of fruits and vegetables on most days. And while 70% have never had their blood pressure measured, just under a quarter suffer from high blood pressure. More than 90% have never had their diabetes or cholesterol tested. And about 19% are overweight or obese.</p>
<p>The two surveys paint a shocking picture of how East Africans are exposing themselves to the mounting risks of non-communicable diseases. </p>
<p>These surveys must be a wake-up call to governments to find better solutions to the growing crisis of non-communicable illness. But they also suggest that individuals should and can be doing more.</p>
<h2>How to change behaviour</h2>
<p>So where do individuals start? </p>
<p>These days healthy food has been replaced with tasty and, most often, easy food. Grabbing food on the run means that only <a href="http://aphrc.org/wp-content/uploads/2016/04/Steps-Report-NCD-2015.pdf">6% of Kenyan adults</a> get their recommended five-a-day servings of fruits and vegetables. In <a href="http://www.who.int/chp/steps/Uganda_2014_STEPS_Report.pdf">Uganda</a> the figure is 13% for women and 12% for men. </p>
<p>Maintaining a healthy diet can help to reduce the risk of some cancers as well as the chances of being obese – which itself is a marker for all sorts of non-communicable diseases, including heart disease and diabetes.</p>
<p>A healthy diet also restricts salt intake, which for Kenyans is even more of a challenge than adding fruit and vegetables. One in four Kenyans and Ugandans add salt to their food before they even taste it. Every shake of that salt shaker carries with it a risk of high blood pressure and lasting damage to the heart, kidneys and brain.</p>
<p>High consumption of alcohol can also have an effect on weight and the organs most vulnerable to disease: the heart, the liver, the stomach and the pancreas. One in four Kenyan men <a href="http://aphrc.org/wp-content/uploads/2016/04/Steps-Report-NCD-2015.pdf">drink alcohol daily</a> and one in eight are <a href="http://aphrc.org/wp-content/uploads/2016/04/Steps-Report-NCD-2015.pdf">heavy drinkers</a>. </p>
<p>This means that half of men who are daily drinkers are daily heavy drinkers. Beyond the long-term damage of over-consumption, heavy drinking can also mean you – and others who share the road with you – are at higher risk of traffic accidents leading to serious injury or death.</p>
<p>Another risk factor is tobacco – smoking or being around smokers. The Tobacco Control Act in Kenya has been around since 2013. Yet one in four Kenyans is still exposed to tobacco in the workplace or in the home. </p>
<p>More than 13% of Kenyans currently smoke. And in Uganda 40% are exposed to second-hand smoke. Passive smoking – when a person is exposed to someone who smokes, even if he or she doesn’t smoke – is equally dangerous, as it heightens the risk of cancer, chronic respiratory conditions or <a href="http://www.who.int/tobacco/research/secondhand_smoke/en/">heart disease</a>.</p>
<h2>Taking action</h2>
<p>What all this means is that individuals have the responsibility to remove the risks from their lifestyles. </p>
<p>Governments, too, have a responsibility to develop systems to help people mitigate the risks.</p>
<p>Without concerted action at the systems level, the burden on overstretched health services will be even greater, and the costs of inaction will stymie economic growth and development.</p>
<p>Damage to a person’s health and body happens over the long term. It may manifest as a treatable condition, such as being overweight, or having high blood pressure or diabetes, but it can quickly deteriorate into a degree of suffering that can only be managed, not cured.</p><img src="https://counter.theconversation.com/content/58442/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Kyobutungi receives funding from International Development Research Centre (IDRC).
</span></em></p>Non-communicable diseases are skyrocketing in Kenya and Uganda. Though the countries’ governments have a responsibility to tackle the problem, individuals need to take action too.Catherine Kyobutungi, Director of Research, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/553672016-03-01T04:28:29Z2016-03-01T04:28:29ZWhy a new vaginal ring could be a game-changer in HIV prevention<figure><img src="https://images.theconversation.com/files/113373/original/image-20160301-8057-vbe88q.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">supplied</span></span></figcaption></figure><p>The results of the two studies showing that a vaginal ring can help reduce the risk HIV infection among women is being hailed as an important HIV prevention <a href="http://www.nytimes.com/2016/02/23/health/vaginal-ring-hiv-aids-drug-dapivirine.html?_r=0">breakthrough</a>. </p>
<p>Launched four years ago, the two clinical trials, known as <a href="http://www.mtnstopshiv.org/news/studies/mtn020/factsheet">ASPIRE</a> and <a href="http://www.ipmglobal.org/the-ring-study">The Ring Study</a>, set out to determine how safe and effective the ring was in prevention of HIV infection in women. The ring, which is used for a month at a time, contains an antiretroviral drug called dapivirine that acts by blocking HIV from multiplying. </p>
<p>The studies enrolled close to 4500 women aged 18 to 45 in South Africa, Uganda, Malawi and Zimbabwe. Each study found that the ring helps reduce the risk of HIV infection in women. In ASPIRE, the ring reduced the risk of HIV infection by 27% overall. In The Ring Study, infections were reduced by 31% overall.</p>
<p>But there were differences in how effective the ring was based on how consistently the women used it. Both studies showed that the more consistently the ring is used, the more effective it is in protecting women. </p>
<p>For women aged 18 to 21 in both studies there was no significant protection because they did not use the ring consistently. ASPIRE found that HIV protection was greater in groups with evidence of better ring use. Incidence of HIV was cut by more than half – 56% – among women 21 and older, who, as a group, appeared also to use the ring most consistently. </p>
<p>The studies show that the ring has the potential to help make a difference in reducing the burden of HIV by at least one third in women overall. This has significant implications for reducing the burden of disease in women in Africa.</p>
<h2>Women can have another option</h2>
<p>It is the first time two phase-three clinical trials have confirmed statistically significant efficacy for a <a href="http://www.who.int/hiv/topics/microbicides/microbicides/en/">microbicide</a> to prevent HIV. The dapivirine ring was designed to offer potentially long-acting protection against HIV through slow, continuous delivery of dapivirine into the vaginal tissues over the course of four weeks. </p>
<p>Women account for nearly 60% of <a href="http://www.unaids.org/en/resources/campaigns/2014/2014gapreport/gapreport">adults with HIV</a>. Unprotected heterosexual sex drives this figure. Despite tremendous advances in preventing and treating HIV, women still face a disproportionate risk of infection because there are insufficient practical HIV prevention options available to them.</p>
<p>If the ring becomes available for commercial use it will add to the tools in the HIV prevention toolbox for women alongside female condoms and Truvada, an antiretroviral tablet taken by HIV negative people as daily pre-exposure prophylaxis.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=418&fit=crop&dpr=1 600w, https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=418&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=418&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=525&fit=crop&dpr=1 754w, https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=525&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=525&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Truvada is a pre-exposure antiretroviral tablet.</span>
<span class="attribution"><span class="source">EPA/Maurizio Gambarini</span></span>
</figcaption>
</figure>
<p>In 2015, South Africa and Kenya joined the US in <a href="https://theconversation.com/how-a-drug-can-help-prevent-5000-girls-being-infected-with-hiv-every-week-52539">approving Truvada</a>. Pre-exposure prophylaxis has been proven to be very effective for people at risk of HIV. </p>
<p><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1011205">Studies</a> have shown that Truvada provides users with up to 90% protection provided it is taken consistently. In earlier studies it was shown to be less successful in women who did not take the drug daily. </p>
<h2>Hurdles that need to be cleared</h2>
<p>There are still several more steps that need to be followed before the ring becomes available to women. </p>
<p>Dapivirine was originally developed as an oral antiretroviral compound. This was tested in phase- one and two <a href="http://www.ipmglobal.org/our-work/ipm-product-pipeline/dapivirine-tmc120">clinical trials</a> with more than 200 participants. </p>
<p>Although it was first conceived as an oral therapeutic, dapivirine became a promising topical microbicide candidate because it was effective both in vitro and in vivo, had a favourable safety profile, and the right physical and chemical properties.</p>
<p>To licence the product, the ring must be approved for public use by global and national regulatory authorities. Because at least two phase three efficacy trials are needed for regulators to approve a licence for the product, the two phase-three trials were conducted in parallel to speed up the process to potentially approve the ring. </p>
<p>Licensure is an important but complex and timeous process. The authorities will review the comprehensive dossier of scientific evidence when deciding to licence the ring. The ring’s developer, <a href="http://www.ipmglobal.org/about-ipm/how-we-work">International Partnership for Microbicides</a>, a global health non-profit enterprise, will follow this process.</p>
<h2>Next round of studies</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The dapirivine vaginal ring.</span>
<span class="attribution"><span class="source">Supplied</span></span>
</figcaption>
</figure>
<p>In the meanwhile, as the ring is under regulatory review, there are several more studies planned. Two of the studies are open-label extension (OLE) studies called DREAM and HOPE. </p>
<p>These OLE studies aim to provide all women who participated in the phase-three trials access to the dapivirine ring. This will help understand how the ring is used in a real world setting now that the level of effectiveness is known and also inform its future roll out. These studies are currently being reviewed by local regulators. </p>
<p>A third study, MTN-034, that is also under review, will offer women both the dapivirine ring and oral Truvada. Targeted at adolescent girls and young women between the ages of 16 and 21, this study will help understand what young women want and how they respond to the active products once they know their levels of effectiveness. </p>
<p>This study is important because across both efficacy trials, women aged 18 to 21 showed no significant protection because they did not use the ring consistently. Young women <a href="http://www.unaids.org/en/resources/documents/2014/Adolescentgirlsandyoungwomen">aged 15 to 24</a> are at the highest risk of HIV infection globally and so this is clearly an age group where research is needed. </p>
<p>But poor adherence may not be the only reason for the lack of protection among these women. Further research is needed to understand if there are biological or physiological factors that may affect how dapivirine is taken up in vaginal tissue, or whether the trial design itself is especially intimidating to young women. </p>
<p>Not knowing whether they are using an active product or a placebo, or how safe and effective it is, may have influenced their use.</p><img src="https://counter.theconversation.com/content/55367/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thesla Palanee-Phillips receives funding from the National Institutes of Health, DFID and USAID</span></em></p>If the vaginal ring becomes available for commercial use it will become one of the tools in the HIV prevention toolbox for women alongside female condoms and daily pre-exposure prophylaxis.Thesla Palanee-Phillips, Director: Clinical Trials, Wits Reproductive Health and HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/547032016-02-22T04:27:20Z2016-02-22T04:27:20ZHow the death of two Ugandan mothers is helping entrench the right to health care<figure><img src="https://images.theconversation.com/files/112170/original/image-20160219-25876-1iuepln.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sixteen women die in Uganda every day during child birth in instances that could be avoided.</span> <span class="attribution"><span class="source">Reuters/Jonathan Ernst</span></span></figcaption></figure><p>When Sylvia Nalubowa went into labour in Uganda’s Mityana district in August 2009, she was taken to a local health centre where she expected to have a normal birth, supervised by a midwife. </p>
<p>After she had delivered her first baby the midwife realised there was a twin on the way. The midwife recommended that Nalubowa be taken to the district hospital where a doctor could handle the second delivery. </p>
<p>But when she arrived at the Mityana District Hospital in Central Uganda, the nurses asked for her maternity kit. This is commonly known as a “mama kit” and contains a plastic sheet, razor blades, cotton wool or gauze pad, soap, gloves, cord ties, and a child health card. All mothers delivering babies in Ugandan hospitals and clinics are expected to bring their own “mama kits” when they go into labour.</p>
<p>But Nalubowa had used her “mama kit” at the first health facility when delivering her first child. The nurses would hear none of her excuses and demanded money to purchase the kit before they could attend to her. </p>
<p>Nalubowa and her baby died. </p>
<p>Jennifer Anguko died under similar circumstances. She arrived at the Arua hospital in North Western Uganda at 8.30am on December 10, 2010 but was not attended to for 12 hours by which time her condition and cries for help were out of control. </p>
<p>One hour later she was taken to theatre but she and her baby died during the procedure. The cause of her death listed in the post mortem report was a ruptured uterus.</p>
<h2>The women’s cases are two of many</h2>
<p>Sixteen women die in Uganda every day during child birth in instances that could be <a href="http://www.irinnews.org/report/93420/uganda-too-many-deaths-childbirth">avoided</a>. In 2011, the World Health Organisation reported that Uganda registers up to <a href="http://www.who.int/pmnch/media/membernews/2011/ugandabackgroundpaper.pdf">440 deaths</a> for every 100 000 live births.</p>
<p>This is unlike Rwanda where maternal mortality decreased by <a href="http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_eng.pdf">77%</a> between 2000 and 2013 and currently stands at <a href="http://www.prb.org/Publications/Articles/2015/rwanda-maternal-health.aspx">320 deaths</a> for every 100 000 live births.</p>
<p>Most maternal deaths in Uganda are due to severe bleeding, infection, hypertensive disorders and obstructed labour. Others are due to causes such as malaria, diabetes, hepatitis and anaemia. All these are aggravated by pregnancy.</p>
<p>The Ugandan government is committed to providing all citizens with free health services. But it is common to go to a government health facility and find that medicines are not in stock and health workers are not paid. Patients also say that they are often met by health staff who are unenthusiastic about attending to patients expecting free services. </p>
<p>In 2013, the doctor to patient ratio in Uganda was estimated at one doctor for just <a href="http://www.finance.go.ug/dmdocuments/6-13%20Health%20Workers%20Shortage%20in%20Uganda%20May%202013.pdf">under 25 000</a> patients. The nurse to patient ratio sat at one nurse for 11 000 patients. </p>
<p>The country’s public health system has a <a href="http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=2835">tiered structure</a> with two national referral hospitals, 11 semi-autonomous regional referral hospitals, and a well established district health system with healthcare centres in 56 districts. </p>
<p>Health care services are <a href="http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-015-0683-9">financed</a> through general tax revenue and donor funding. Although user fees for health services in public facilities were abolished in 2001 patients are still expected to make direct out-of-pocket payments for some services and drugs.</p>
<h2>Fighting for a right</h2>
<p>In 2011 lawyers at the <a href="http://www.cehurd.org/about/">Centre for health, Human Rights and Development</a>, a non-profit, research and advocacy organisation, began gathering evidence to hold the Ugandan government to account for Nalubowa and Anguko’s deaths.</p>
<p>The case is now before the country’s Constitutional Court. </p>
<p>In what has turned into a landmark case, the centre has argued that failing to provide essential maternal health commodities in government health facilities is an infringement on women’s rights. The rights to life as well as health are guaranteed under the country’s constitution as well as international human rights instruments the government has signed up to. These include the:</p>
<ul>
<li><p>International <a href="http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx">Covenant</a> on Economic Social and Cultural Rights (ICESCR),</p></li>
<li><p><a href="http://www.un.org/womenwatch/daw/cedaw/">Convention</a> of Elimination of All forms of Discrimination Against Women (CEDAW), and</p></li>
<li><p>Maputo <a href="http://www.achpr.org/files/instruments/women-protocol/achpr_instr_proto_women_eng.pdf">protocol</a>.</p></li>
</ul>
<h2>The court erred</h2>
<p>At the first hearing before the Constitutional Court government lawyers objected to the case. They argued that the judiciary was <a href="http://www.cehurd.org/2011/10/activists-sue-ugandan-government-over-maternal-deaths/">not competent</a> to hear a case that required the executive arm of government to allocate resources to the health sector. </p>
<p>The court agreed and dismissed the case.</p>
<p>But the centre appealed to the Supreme Court, the highest court of appeal in Uganda. It argued that the justices of the Constitutional Court erred in denying them an opportunity to hear the case based on its merits. </p>
<p>In October 2015 the Supreme Court’s seven judges agreed. They made a <a href="http://www.cehurd.org/2015/11/judgement-supreme-court-orders-the-constitutional-court-to-hear-maternal-health-cases/">unanimous ruling</a> that the Constitutional Court judges had erred in dismissing the case. In their judgment they argued that the case had key questions that needed constitutional interpretation for the people of Uganda. </p>
<p>They contended that there is nothing the executive or legislature can decide on that may not be subjected to judicial review - especially if it is done in line with the constitution. And they have ordered the Constitutional Court to hear the case which is now before the Constitutional Court pending a hearing by a new panel of judges. </p>
<h2>Making health care a priority</h2>
<p>The case has contributed to jurisprudence to help people realise their social economic rights in Uganda. </p>
<p>But it has also catalysed improvements in health service provision. Since the case was initially heard government funding for the health sector has improved from US$ 215 million (UGX 737.60 billion) to US$ 328 million (<a href="http://www.statehouse.go.ug/media/speeches/2015/06/11/uganda-budget-20152016">UGX 1127.48 billion</a>) and more health workers have been <a href="http://www.newvision.co.ug/new_vision/news/1324564/government-recruit-health-workers">recruited</a>. Mothers, however, are still expected to bring their own “mama kits” when going into labour.</p>
<p>There has also been a reduction in maternal deaths. These have fallen from 440 deaths for every 100 000 live births in 2010 to 343 by <a href="http://data.worldbank.org/indicator/SH.STA.MMRT">2015</a>. </p>
<p>Most importantly, civil society organisations are now, more than ever, alert to demanding women’s health care rights.</p>
<p><em>*Primah Kwagala, a human rights lawyer at the Centre for Health, Human Rights and Development (CEHURD) where she manages strategic litigation programmes, was integral in the writing of this article.</em></p><img src="https://counter.theconversation.com/content/54703/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Moses Mulumba receives funding from the Open Society Foundation and IDRC-Canada.</span></em></p>The cases of two women who died in childbirth in two different parts of Uganda are being used in a Constitutional Court battle forcing the government to fulfill its healthcare obligations.Moses Mulumba, Executive Director at the Centre for Health, Human rights and Development and lecturer , Uganda Christian UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/511432015-12-04T04:26:44Z2015-12-04T04:26:44ZWhat drove women to lie in an HIV clinical trial in southern Africa<figure><img src="https://images.theconversation.com/files/104299/original/image-20151203-6775-gcwapn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman prepares ribbons ahead of World Aids Day. </span> <span class="attribution"><span class="source">Reuters/Antony Njuguna</span></span></figcaption></figure><p>Two years ago women were found to have lied in a clinical trial in South Africa for a new HIV drug. The VOICE trial was <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1402269">unsuccessful</a> due to low adherence. When the trial was completed it was revealed many women involved had not been honest about their adherence to the drug regime they had signed up to take.</p>
<p>The fact that the trial did not achieve its aim of proving the drugs were effective led to a <a href="http://mg.co.za/article/2013-03-08-00-women-confound-hiv-researchers/">fierce debate</a> about the <a href="http://news.sciencemag.org/biology/2013/03/human-nature-sinks-hiv-prevention-trial">morality</a> of clinical trials and the role of women in them.</p>
<p>Many directed blame at the women. They were accused of deliberate deception to remain in the trial to access “stipends” of between US$10 and $15. They were also accused of being responsible for prolonging the spread of HIV.</p>
<p>Our <a href="http://www.tandfonline.com/doi/full/10.1080/01459740.2015.1116528#abstract">research</a> wanted to find out why the women who participated in the research lied. </p>
<p>It found many women in the trial came from the rural areas of South Africa and neighbouring states. They were young and unmarried, and many faced uncertain futures. They struggled to find work and many were caught in abusive relationships. And frequently they had no choice but to engage in exploitative relationships with men, employers, police and landlords. The trial represented hope for a better future.</p>
<p>Although the money was a motivation, it was not the main reason they participated in the trial. Instead, the trial allowed them to access good quality health screening and care and to be viewed as responsible virtuous women. It gave them a chance to forge a new moral identity, challenging the stereotypes of “loose” single women.</p>
<h2>The trial</h2>
<p>When the clinical trial was introduced to test the effectiveness of drugs on healthy women as a means of prevention, it was thought this would tackle the challenge of new HIV infections.</p>
<p>If they were successful, it would have resulted in a single product containing one or a combination of drugs – administered orally or vaginally – that could protect high risk women simply by it being taken daily.</p>
<p>The Vaginal and Oral Interventions to Control the Epidemic trial, more commonly referred to as VOICE, took place in Zimbabwe, South Africa and Uganda. The drugs were given to women considered most at risk of contracting HIV. These are women between the ages of 15 and 49, who have an incidence rate of more than 2% in South Africa alone.</p>
<p>More than 5000 women were part of the study to test novel ways for women to protect themselves from HIV infection using pre-exposure prophylaxis.</p>
<p>Some of the women took a pill containing two anti-HIV drugs while others took pills containing only one. A third set were given a vaginal gel with one of the drugs while a fourth set were given an inert gel or dummy pills.</p>
<p>Adherence calculations based on pill counts, interviews and audio computer aided self-interviews showed that adherence ranged from 86% to 90%. Just under half of the participants rated their own adherence as <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1402269">“very good”</a>.</p>
<p>But an analysis of the pharmacokinetic (PK) tests to detect the drug in blood samples taken from 647 women, found the drug in less than half of the samples. This directly contradicted participants’ claims and exposed them as “dishonest”.</p>
<h2>A rhetoric of blame</h2>
<p>The criticisms of the women in the trial echo similar allegations that young women deliberately fall <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=365428&fileId=S0021932005000957">pregnant</a> or even intentionally expose themselves to HIV to receive state welfare <a href="http://www.tandfonline.com/doi/abs/10.2989/16085900609490386">grants</a>.</p>
<p>These criticisms also potentially threaten public confidence in clinical trials because they place a question mark over the trust established between trial participants, and the scientific community and donors.</p>
<p>In Hillbrow, where we conducted our <a href="http://www.tandfonline.com/doi/full/10.1080/01459740.2015.1116528#abstract">research</a>, we found that many women came from rural areas in South Africa and neighbouring states. Only half were employed and even those who had jobs struggled to sustain work.</p>
<p>Many women were migrants. Because of this they experienced the disruption of social networks and frequently had no choice but to engage in exploitative relationships with men, employers, police and landlords.</p>
<p>They also valued the trial, which was reflected in the <a href="http://www.biomedcentral.com/1472-6874/14/88">high retention</a> rates. It helped them get regular health checkups, HIV testing and quality care at clinics.</p>
<p>While they welcomed the US$15 travel stipends, the trial represented more than immediate monetary gain. Participating in the trial was an investment in “a better life”, as 40-year-old Lily put it. The logic was that if the trials worked, their lives would also improve. Being part of a solution to the AIDS epidemic was also extremely meaningful.</p>
<p>The trial also disrupted the monotony of sitting at home unemployed.</p>
<h2>Performing perfect participation</h2>
<p>Although participants faced considerable difficulties in adhering to taking the study product once a day, many portrayed themselves as “perfect participants”, never missing a dose.</p>
<p>Why did the women feel it necessary to sustain this fiction of perfection? The trial was seen as an opportunity for the women to assert credibility. For them, admitting to being non-adherent threatened their ongoing participation in the trial. This would have affected the benefits as well as their social status.</p>
<p>Trial participants wanted to redefine themselves as virtuous women. They used the trial as a way to do so. Reputations were managed as women crafted an image of themselves as responsible agents looking to a better future. Crucially, this rested on a performance of being the “perfect trial participant”, whether or not this reflected their adherence.</p><img src="https://counter.theconversation.com/content/51143/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Stadler receives funding from USAID, NIH, UKAID, and the MRC </span></em></p>Women who were found to have lied in a clinical trial testing anti-HIV drugs were heavily criticised. But there are several factors that drove them to lie.Jonathan Stadler, Technical Head, Social Science Research, Wits Reproductive Health and HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.