Tuesday, 25 June 2013


Services to strengthen action around Health seeking behaviour targeting sexual minorities
Purpose: To strengthen MARPS IN UGANDA CLINIC.

A brief over view of the MARPS IN UGANDA “BMAT” Programme

The beyond Malaria, HIV-AIDS and TB (BMAT) is a formal recognition of need for provision of comprehensive health services targeting sexual minorities. MOST AT RISK POPULATIONS' SOCIETY IN UGANDA (MARPS IN UGANDA) (www.marpsinuganda.org) has consistently provided healthcare services to MSM/WSW/LGBTIQQ. With time numbers and demand have increased. In 2012 we need support to open a formal clinic within our resource center. The numbers that need our services are overwhelming our meagre resources which we pull out of our salaries. We are to use the same approach of sand-wiching the clinic within the resource center. This has helped avoid stigmatisation such a clinic can cause.  Our BMAT Programme is the vehicle through we implement planned interventions by supporting beneficiaries in accessing care, management and treatment services. The support is in form of providing a schedule where health workers are present from Monday to Sunday to treat patients. With time a full range of health care services will be formally provided. Presently, minor ailments on top of SRH services are catered for.

The clinic activities are timely and reasons for this include serving:
  • Significant population groups with a HIV prevalence (USBHS reports, 2010).
  • High level of transactional sexual activity.
  • Significant numbers disclose a history of violence, abuse, discrimination and stigma.
  • Significant number not aware unprotected sex is a transmission route for HIV/STIs.
  • Significant numbers have families or intend to have.
  • Significant number in sex-work.
  • Significant lack of aggressive health seeking behaviour and few know their HIV status.

BMAT has FIVE major objectives that include:
  • Increasing access to, coverage of, and utilization of quality comprehensive prevention, care and treatment services.
  • Strengthening service delivery systems with emphasis on community outreach.
  • Improving quality and efficiency.
  • Strengthening networks and referral systems to improve access to, coverage of, and utilization of health services
  •  Intensifying demand generation activities for  Protection, leadership, empowerment, attitude-enhancement, education for skills development, Malaria, HIV&AIDS and TB prevention, care and treatment services.

Background and Problem
Since 2004, we are the only organisation consistently targeting MSM/WSW/GGBTIQQ health. MARPS IN UGANDA has affirmatively provided health care services beyond “malaria, AIDS and TB" targeting LGBTIQQ/msm/wsw, sex-workers and substance users. To avoid discriminatory and stigmatising tendencies such clinics draw towards themselves we also engage in mainstream health care provision for men and women through our “talk HIV while at play”-THWAT- initiatives. We are emphasizing working with "men and women" and this has played to our advantage! We are positioning ourselves towards the LVCT model. We ask you to extend funds that will go towards paying for two cost areas: rent and utilities for 12 months. Renewed initiatives increase prevention efforts and specific population based information on these specific sub-populations to guide development of effective interventions contributes to their risk reduction practices and low HIV prevalence. BMAT is MARPS IN UGANDA approach to fill in a gap to empower adoption of prevention skills.  MARPS IN UGANDA works through a combination of referral and direct health provision to reflect all the 4 clusters of the Uganda National Minimum Health Care Package (USPSAS, 2007): Cluster 1 comprises cross cutting areas of health promotion, disease prevention, community health initiative, environmental health, school health gender and health; cluster 2 represents integrated maternal and child health that emphasizes safe motherhood, newborn care and child survival; cluster 3 groups together prevention and control of communicable diseases with emphasis on HIV/AIDS, TB, malaria and diseases targeted for eradication and; cluster 4 addresses non-communicable diseases with emphasis on healthy lifestyles, control of poverty-producing conditions such as poor mental health, deafness, old age and disability.

Intervention areas:
BMAT has always sought to provide:

1.     A model Health Prevention emphasizing actions to address levels of their vulnerability.
2.     Unique needs.
3.      Information on key drivers and predictors pointing towards risky activity and factors associated with their vulnerability.
4.     Information on behaviour and what influences their behaviours, what they know, believe, and think about involvement in work, contribution to community activities, Malaria/TB/ HIV, their causes, impact and prevention.
5.     Information on accessing the needed prevention services and what the unique prevention needs are.

Specific objectives/Deliverables/Outputs:
Specifically, BMAT has helped to;
a)     Characterize, categorize and facilitate development of focused and contextual interventions.
b)    Provide understanding into the Knowledge, Attitude and Practices (KAP) on Health and their perceived vulnerability to facilitate development of an effective behaviour change and communication strategy. In this case, strategies that enable policy/programme to look into issues of protection, legal, empowerment, attitude, education for skills, risk reduction messages, address appropriate needs and a documenting culture.
c)     Obtain and provide health.
d)    Contribute to the Health for all.
e)     Design appropriate capacity building strategies that increase knowledge, skills and ability of community structures, local government structures, households and groups themselves to access and sustain local response to Health prevention.
f)     Make recommendations pertaining to these groups.  

Geographical scope /coverage
With more support we intend to work through this clinic and reach out to all through identified spaces covering many parts of Uganda. 

Populations, Approach and locations
BMAT interventions target:
·         At-risk adults who engage in unprotected sexual behaviour.
·         At-risk adults who are in cross-generational sexual relations.
·         At-risk adults who engage in transactional sex
·         At-risk adults who normally work away from their designated home areas or education settings.
·         At-risk youths (having more than one sexual partner or those engaged in cross-generational sex or those engaged in both behaviours).
·         All who attend our resource center
·         Beneficiaries of our outreach services
·         PLHIV

We target sexual minorities as well as many others in need.

Roles of Sponsoring partner (SP)
      i.        Provide support in form of financial resources and other logistics needed to execute the exercise. This will go a long way to ensure rent is paid, salaries are paid and resources are in place.
     ii.        Empower MARPS IN UGANDA, share experience and technical expertise.
    iii.        Reviewing reports and providing feedback.

Financial support to go towards (USD 1=UGX. TBD):
Rent of premises
12 months
Utilities, consumables and sundries
12 months
Retainer fees
2 medical doctors x 12 mths
4, 800,000
Support staffs allowances
2 x 12 mths
Administrative costs


Supervision and Management 
The CEO is the Community mobilisation and health Promotion Focal person. The HIV/TB/Malaria Focal Person will provide the overall implementation functions. They form part of the management committee in addition to a person/s from SP.  All queries/ clarifications:

Plot 22 Kampala Road Zone, Lubaga Division, Kampala City Council Authority Box 27530 Kampala, Uganda

Background of HIV/AIDS in Uganda

AIDS cases were first recognized in Uganda in 1983, with about 900 cases reported by 1986, rising to 6,000 cases by 1988. Uganda responded by taking an open stance to the epidemic and was among the first African countries to establish a national AIDS Control Program (ACP) and the National Committee for the Prevention of AIDS (NCPA).  Working with financial and technical support from WHO, ACP launched and effectively coordinated the first multi-sectoral mobilization campaign through which HIV prevention messages were widely disseminated in the country at a critical time when there was a dearth of knowledge and information about the epidemic. By early 1990s Uganda was among the African countries worst hit by the HIV/AIDS epidemic. However, with strong political leadership, a vibrant civil society, and an open and multi-sectoral approach, Uganda sustained an impressive response to the epidemic. Through the technical oversight and direction of Ministry of Health (MOH), the first national blood transfusion service, the first voluntary, confidential counseling and testing service, the first HIV/AIDS care and support organization and the first national STD control program were initiated in Uganda. These interventions jointly helped to slow down the epidemic. The decline in the weighted overall antenatal prevalence was 6.1% in 2001 from 18% in 1992. More significant declines were noted in urban sites where the weighted average prevalence rate dropped from 10.9% in 1999 to 8.7% in 2000, compared to declines of 4.3% to 4.2% in rural sites over the same period[1].

The technical leadership by the Ministry of Health in the national HIV/AIDS response has been consistent. This manifests through development of key policies and guidelines, monitoring and reporting on the status of the epidemic, development and dissemination of messages as well as research that generates new knowledge on HIV/AIDS transmission, survival and disease progression. Policies for comprehensive HIV prevention, care and treatment have been developed and updated in response to the emerging global and national challenges.  In 2007, STD/AIDS Control Program developed a four year Strategic Plan (2007-2010) with the primary goal of preventing further transmission of STIs and HIV infection and providing support for the mitigation of the impact of HIV and AIDS on individuals, families and the community. The plan sought to scale up proven prevention and care initiatives and ultimately contribute to the realization of the three health sector objectives and the broad national goals. Key among others being preventing new infections, mitigation of the impact of the epidemic, and strengthening the national capacity to coordinate and manage the multi-sectoral response to the HIV/AIDS epidemic.[2]

1.1      Current Status of HIV/AIDS epidemic and response in Uganda

Over the past decade, Uganda has sustained an impressive response to the HIV/AIDS epidemic grounded in a multi-sectoral approach coordinated by the Uganda AIDS Commission (UAC). However, HIV/AIDS continues to be a major socio-economic challenge and is among the leading causes of morbidity and mortality. The epidemic has matured and is generalized across the entire population. The Uganda Sero-Behavioural Survey (UHSBS) 2004/2005 estimated that 6.4% of sexually active Ugandans aged 15-49 years were infected with HIV. This prevalence rate, however, masks major heterogeneity across regions, sex, age and marital status. Low prevalence rates were recorded in North East and North Western regions with rates of 3.5% and 2.3%, respectively. On the other hand, the Central and North Central regions had the highest HIV prevalence with rates of 8.5% and 8.2%, respectively. Similarly, higher infection rates were noted in urban areas, where prevalence was estimated to be ten times higher than in rural areas.  HIV prevalence was also higher among women (7.5%) compared to men (5%). In aggregate terms, HIV prevalence in Uganda has remain high at about 6.5%. The estimated HIV prevalence from the ANC surveillance in 2009 was 7% with the adult HIV prevalence in 2008/2009 estimated at 6.2% and HIV prevalence among women attending ANC estimated at 6-7% which are way off the targets of recently ended HSSPII of 5%, 3% and 4.4% respectively.[3] In terms of absolute numbers, the number of newly infected people has more than doubled since 2005 but the impact is morphed by the rapidly increasing population.

HIV prevalence in Uganda increases with age but peaks at different ages for men and women. For women, it peaks at 30-34 years and at 35-44 years for men, implying that men are more affected at older ages than women. A higher prevalence rate among women in young ages has considerable implications for HIV prevention given that these are the prime reproductive ages and hence the higher propensity for vertical HIV transmission. For instance, HIV prevalence among mothers seeking antenatal care was estimated to range between 5-15%.[4] Overall there are indications that HIV incidence is rising. About 135,000 individuals were newly infected in 2005[5] while another 124,000 were infected in 2009[6]. There is also significant variation in HIV infection risk among different population cohorts. Fishing communities, security personnel, truckers and cross border communities, commercial sex workers, and the internally displaced people have been identified to be at an elevated degree of risk and hence requiring special attention in HIV prevention programming[7].

The UHSBS 2004/2005 estimated that there were 915,400 individuals living with HIV/AIDS in Uganda, of whom approximately 120,000 were children under the age of 15. Although incidence is the most reliable measure of HIV epidemiology, there is paucity of data on HIV incidence patterns in Uganda. There is also lack of mechanisms to assist in routine examination and generation of evidence on the drivers of the epidemic in diverse settings, which ultimately affects the relevance of interventions to specific contexts. Using mathematical modeling techniques, Uganda AIDS Commission and UNAIDS provide annual estimates of new infections. In 2007, there were an estimated 132,000 new infections in Uganda,[8]while 124,000 were infected in 2009.[9] The rise in new infections has a direct bearing on overall HIV prevalence and consequently the ability of the national programs to achieve targets in this area. For instance, the goal of reducing HIV prevalence by 50% and by 45% as respectively stipulated in the HSSPII and NSP 2007/8-2011/12 has been elusive. With support from development partners, MOH is currently undertaking an AIDS Indicator Survey (AIS), as follow on to the UHSBS. Results from the survey, expected late next year, are expected to provide new insights into the realistic status of the HIV/AIDS epidemic in Uganda.

The HIV/AIDS epidemic in Uganda has matured and the factors driving the new infections have changed. The Modes of Transmission Analysis in 2009 highlights HIV discordance especially among sexually stable couples, concurrent multiple sexual partners, lack of male circumcision, low condom use, transactional sex, cross-generational sex and complacency due to improved access to ART as some of the major drivers of the epidemic. There is also growing need to align the HIV/AIDS response to empirical evidence and to focus interventions in areas that will generate population level impact. There have been shifts in epidemiological patterns, with new infections now occurring more in married and co-habiting couples than in youth, as was the case a few years ago. Available data and analyses highlight that sexual transmission accounts for 76% of all new infections, followed by mother to child transmission (22%). Contaminated blood, needles and sharp instruments as well as men having sex with men account for approximately 2% of new infections. Sero-discordancy is a rapidly evolving phenomenon and accounts for the rising HIV incidence and prevalence among couples. Of the adults in married and co-habiting relationships, over 40% of those who are HIV positive have an HIV negative spouse[10].

Over the past five years, STD/ACP has been working in collaboration with development partners and other stakeholders to scale up HIV/AIDS services in the public and private sector. Through these efforts, HIV care and treatment and PMTCT services are currently provided in 66% and 83% of the public and private health facilities respectively. Access to ART has also improved and as at end of June 2010, 237,000 individuals were actively enrolled on ART, hence covering approximately 44% of the national estimated need for ART based on the modified eligibility criterion of <350 CD-4 T-cells per microliter of blood. Of these, 89 percent were adults aged 15 years+, and, eight percent were children 0-14 years.[11]

Capacity for chronic HIV/AIDS care and management of opportunistic infections has also greatly improved, leading to more PLHA living longer and with few incidences of illness. Chronic care services are currently estimated to reach 54% of those in need. Significant success was made in integrating HIV services with other services especially TB, reproductive health and maternal and child health. The HIV Early Infant Diagnosis (EID) was integrated into Child Days Plus increasing the number of HIV exposed children that accessed HIV testing from about 17,000 to 43,000. Ministry of Health through the STD/ACP has also provided impressive technical leadership through development of supportive policies, guidelines, rapid accreditation of sites as well as mentorship to the service delivery sites.

Despite these achievements, many challenges still remain. Besides the rising HIV incidence, there are declining behaviors’ associated with discrimination and stigma among the young positives living in institutions of learning, low coverage of services and institutional constraints for the health sector HIV/AIDS response. The STD/AIDS Control Programme is mandated to provide leadership in the Health Sector HIV/AIDS response in the country. Over the years STD/ACP has provided the leadership in policy and implementation, coordination of the response; resource mobilization; planning and reporting on HIV/AIDS as well as representation at national and international levels. However, the challenges of management and institutional capacity are daunting. There are persistent delays in passing policies and guidelines and even when they are passed, implementation is extremely slow. The involvement and coordination of stakeholders in planning has been equally minimal. For instance, the HSHASP 2007-2010 is known to a few stakeholders. The plan was never reviewed annually nor was the operational plans of both the MOH and implementing partners aligned to the strategic plan. Most of the plans of partners were more likely to be based on the NSP rather than the HSHASP.

The inadequate human resources for continues to affect the capacity and quality of HIV/AIDS service delivery. Although the government has been striving to improve working conditions of health workers, terms of service are far below the desired level resulting in continued exodus of highly experienced personnel from the ministry to the private sector. Paradoxically, the problem has worsened with the increase in HIV/AIDS resources from the global initiatives such as the Global Fund and PEPFAR, worse hit being rural facilities, notably at levels below HCIV. Consequently, STD/ACP continues to function sub-optimally especially in terms of supervision and quality assurance. For instance, the most common mode supervision is the integrated MOH and district supervision which is also irregular. As noted in the Health Sector HIV/AIDS Review (2010) the supervision on HIV care often takes parallel channels with the CSOs, the police, army and MOH (jointly with district officials) carrying they own our supervision. While these supervision channels can be opportunities of quality assurance but when uncoordinated, they can weaken the district supervision system.

Standardization and institutionalization of quality across the spectrum of HIV/AIDS prevention and care services is another key challenge. A number of studies and reports[12],[13] reveal that MOH standards and guidelines for delivery of most quality HIV/AIDS services are available but are not matched by the infrastructure, equipment and funding to make them operational. Rural sites are more disadvantaged as they are unable to attract adequate human resources and/or funds

Funding for the health sector HIV/AIDS activities continues to fall below expectations. Despite the increase in the national resource envelop for HIV/AIDS, it is acknowledged that over 80% of the resources are donations from external sources whose resources are mainly programmed through the private sector. The STD/ACP continues to rely predominantly on funding provided by government whose allocation to health as a proportion of the total GoU budget has not significantly increased implying capacity and sustainability challenges of the health sector HIV/AIDS response.[14]

The Health Sector HIV/AIDS Strategic Plan 2010/11-2014/15 provides a programmatic strategic framework for the health sector HIV/AIDS response in the sector wide approach as presented in Health Sector Strategic and Investment Plan, 2010/11-2014/15 and the National Health Policy II, 2010.

[1] Asiimwe D., Kibombo R. and Neema S. (2003):  Focus Group Discussions on Social Cultural Factors Impacting on HIV/AIDS in Uganda.  UNDP/MISR,  Kampala, Uganda.
[2] Ministry of Health, Health Sector HIV and AIDS Strategic Plan 2007-2010
[3] Ministry of Health, Health Sector Strategic and Investment Plan, 2010/11-2014/15, Kampala
[4] Ministry of Health (2010), Annual Health Sector Performance Report: Financial Year 2009/2010
[5] Republic of Uganda (2009), Uganda HIV Prevention Response  and Modes of Transmission Analysis
[6] Ministry of Health (2010), Annual Health Sector Performance Report: Financial Year 2009/2010.
[7] Republic of Uganda of Uganda (2009), Uganda HIV Prevention Response and Modes of Transmission Analysis
[8] Republic of Uganda of Uganda (2009), Uganda HIV Prevention Response and Modes of Transmission Analysis
[9] Ministry of Health (2010), Annual Health Sector Performance Report: Financial Year 2009/2010

[10] The Republic of Uganda  (2009), Uganda HIV Prevention Response and Modes of Transmission Analysis
[11] Ministry of Health- STD/AIDS Control Program (2010), Status of Anti-Retroviral Therapy Service Delivery in Uganda, Quarterly Report for April-June 2010

[12] Ministry of Health, Health Sector HIV/AIDS Review 2007-2010, Health Service Delivery  Building Block
[13] Health Sector Strategic and Investment Plan
[14] Ministry of Health, Annual Health Sector Performance Report, Financial Year 2009/2010, Kampala


Thomas M., Santa Barbara, Santa Barbara County, California, USA.

This summer in Washington DC, citizens from other parts of the world were well received by Washingtonians during the AIDS-2012 Conference. AIDS has inspired many activists, the affected and the infected to work together. It has inspired grass-root groups to work towards networking and together be the voice for against human rights abuses. It has brought together the Global North and Global South. It is now possible to chart AIDS, join dots and do something about the infected and dying. Today key affected populations are provided with platforms to increase participation in decision-making. However, resources have decreased. A frugal approach is making it hard to target formerly un-attended population groups. Funds and resources still pour into the coffers of the desirable populations. Religious and cultural fervour are still skewed towards these desirable population groups. Risk reduction tools for the key affected populations face low promotion due to structural war paths including outright denunciation of some population groups being despicable and therefore not deserving a glance at all. The ambitious vision: zero new infections, zero discrimination and zero AIDS-related deaths is still a relevant clarion call. It makes universal access achievable and therefore calls upon all to not stand in the way of service provision, calls upon them to make contribution towards eradication of HIV-AIDS.
Evidence-based protocol has revealed that HIV-1 has different forms and that all these persist in patients on HAART. Establishing centers of excellence and laboratories to investigate HIV, through to ensuring access to the scientific products by all beneficiaries, providing Intellectual property laws that are friendly, to providing opportunity to affected persons to present their psychosocial status and lastly allowing communities to meet and invigorate each other as the fight to eradicate HIV continues, requires all of us to bring down the discrimination barriers.
Over 30,000 persons flocked to the Venue of the convention. This moment’s theme: Turning the Tide of the HIV epidemic together will remain the enduring call for everyone to be involved in the fight against HIV. This calls for consistency, planning, endurance, accountability, re-designing, re-dedication, capacity building and passing on skills to others as well. You too can do something as we move towards AIDS 2014, Melbourne.

What, unfortunately, transpires during conferences for some activist-cum-leaders (who have personalised funders and continue to make sure it is their names that appear everywhere) is very de-motivating and the list is long: from stifling potential activists, lack of grooming tendencies, through to being the permanent figure/s at all conferences and engaging more in parties and dinners than actual conference sessions. As a leader at your own micro-level what are you doing to either continue doing something about eradicating HIV or giving room, and acknowledging those who are genuinely doing HIV work ? Is it about enjoying trips when it comes to HIV conferences in your case? Is it about not allowing your data collectors or staff below you, access to processes that would have enabled them benefit from support in form of scholarships by denying them recommendations? We know of so called leaders who claim to have interventions and groups but in reality they are just hood winking funders and they get all the support which they use for personal gains. This goes to them: Stop being the burden.


                                     CAMPAIGN FACT SHEET


Do something about IDUs, LGBTIQQ, MSM AND WSW….why? Because they are worse off and are treated as second citizens.

They have a unique and high prevalence of HIV compared with general population.

HIV care and support poses unique challenges because of the broader care context issues (Packages Of intervention for HIV Prevention amongst Most at Risk Populations-MARPs, UNDP, 2012).

There is a tendency by policy and programming to indicate one route of transmission and therefore being comfortable with building and supporting interventions around penile-vaginal transmission. Except for Mother to Child Transmission (MTCT) any mention of other routes is laughed upon, ridiculed and further constricted by law.

They are generally part of the larger population; they need health care services like any other human beings BUT access issues pose challenges. These in turn lead to low health preserving practices. This affects the larger population groups.

Support the activities of MARPS IN UGANDA by joining the ‘friends of MARPS IN Uganda club whose acronym is FOMIU. Areas below are where the support goes:
  • The support goes towards office rent, paying subsistence for volunteers and consumables.
  • The support goes towards enabling membership at national and international level networks.
  • The support goes towards running the clinic and providing capacity building.
  • The support goes towards providing logistics during regular community outreaches .



Young MSM HIV prevention, research, care and treatment in Uganda is done using various forms but three forms of approaches stand out solidly. The first kind is to use safe spaces by MSM-friendly organisations, such as MARPS IN UGANDA, to conduct HIV testing and counselling. The second approach is to train MSM-peers in mobilisation and peer education skills then follow them up regularly. The third is to provide dates, venues for HIV services and health care opportunities using a listserve, text messages or e-mails where MSM can report to anonymously access services. This report is for only beneficiaries from 5 districts where MARPS IN UGANDA has worked targeting young people only.

Objectives of MARPS IN UGANDA 2009-2012:

Improve uptake of safe male circumcision, risk reduction skills and use of lubricants during anal intercourse. This was possible after a safe space with a clinic was established, a strategic plan was drawn and a young MSM Desk established to be led by a young MSM-Peer educator who with the support of 42 other volunteers aged between 17 years to 24 years managed to visit education facilities, other groups, non school going individuals known to be part of the MSM networks, provide lubricant re-fills, share IEC materials and also networking with health facilities. It was envisioned to reach out to 300 young MSM by 2012. This target was overshot by 100 by February 2012. This number was possible through use of small groups, karaoke/talent-show exhibitions, linkage with 27 young person-friendly clinics also able to conduct safe male circumcision and systematic community visits by two medical doctors and 3 counsellors volunteering with MARPS IN UGANDA.
Challenges faced:

Uganda criminalises same sex behaviour and MSM fall under such behaviour. In this context it is a challenge to conduct health care services. The second most demoralising challenge is from some LGBTIQQ groups that have got funds to address health issues but do not have the capacity. This causes competition for funding and non access to funds for the organisations in position and with capacity. The third challenge is lack of support funds and reliance on volunteers. MARPS IN UGANDA has since inception never received any external support funding yet such support will go a long way to make it a better organisation. The fourth challenge is media outing which shadows organisations which are genuinely doing health programmes among LGBTIQQ, MSM, WSW and other MARPs.

Way forward for Young MSM prevention in Uganda:

It is possible to conduct health care services targeting young MSM if support from donors is provided to all players targeting MSM in Uganda. There are over 12 organisations doing good work but it seems only three or four organisations are supported fully including rent and staff remuneration. Uganda’s health care system does not discriminate any one; therefore with established linkages it is possible to utilize the referral mechanism in place. This requires logistical support in form of transport, telecommunication, paper work and administrative services. This is where support needs to go to. MARPS IN UGANDA is currently responsible for 170 people living with HIV, 150 of whom are on ARVs. 77 are young persons.