Displacement, migration, and limited employment opportunities can dramatically increase the risk of HIV infection in low-resource countries such as Uganda. However, collaborative partnerships and health outreach are proven methods of reaching those most and risk, providing them with prevention and treatment services. To combat HIV in the places of highest prevalence, health workers in southwest Uganda are joining forces with displaced tribal members, migrant workers and other most at risk populations.
"HIV is a killer," said Jacob, a member of the Batwa tribe who I met one day at the Bwindi Community Hospital in southwest Uganda.
The Batwa had lived, foraged, and hunted in the Bwindi Impenetrable Forest in southwest Uganda for thousands of years. But in 1992 they were evicted when the forest became a national preserve for the rich wildlife, such as the mountain gorilla. The Batwa became environmental refugees, settling uneasily into the surrounding communities. The upheaval has taken a toll.
Scovia, the supervisor for HIV/AIDS and tuberculosis at the Bwindi Community Hospital spoke candidly about the hardships faced by the Batwa. Alcoholism is rampant, and HIV rates have skyrocketed within the once-isolated forest community. On top of that, those living with HIV face stigma and rejection.
"Those who are HIV-positive do not want to disclose," Jacob confirms. "They will be discriminated against."
Stigma toward people living with HIV is just one of the elements that can result in a person being classified into a most at risk population -- meaning that he or she is in greater danger of facing a serious health situation. Poverty, political upheaval, and dramatic shifts in circumstances are other factors that might identify someone as being most at risk.
I have spent nearly a year documenting the experiences of those most at risk in the southwest region of Uganda -- from displaced Batwa people, to long-distance truck drivers, to sex workers. As the research and documentation officer for the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), I have listened to starkly different life stories and challenges from the people I have met. And I have learned how varied circumstances shape the health care people seek and the services they receive.
Bwindi Community Hospital, an EGPAF sub-grantee and partner, serves as a link to healthcare, outreach, and support for marginalized populations. This partnership is one of many that EGPAF has fostered with civil society organizations in the implementation of the Strengthening TB and HIV/AIDS response in the South Western Region of Uganda (STAR-SW) project, which is funded by the U.S. Agency for International Development (USAID). One goal of the STAR-SW project is to promote health equity for individuals who are most at risk for contracting HIV.
On the day of my visit to Bwindi Community Hospital, Scovia leads me to a group of transient workers under her care. She greets each man by name and engages in friendly conversation as she checks in about their health.
"People here are free with [their status]," says Israel, one of the men. "[Scovia] comes for HIV testing, counseling ... drugs from the hospital, CD4 counts .... We appreciate the services. One time we were short on condoms. We complained to her and she brought us more very quickly."
All of the nine of the men openly admitted to employing sex workers, but said that it is common practice to engage the same sexual partner in each location and that they routinely test together, which Scovia confirmed. The mobile nature of work for these men puts them at risk as they move away from rooted family structures. But because of the hospital's outreach and reputation for high quality care and treatment, these men return for services, and stigma has been drastically reduced.
In her work with members of the Batwa tribe, Scovia understands the stigma that many would face if they were to disclose that they are living with HIV, and she maintains strict confidentiality while ensuring that patients are adhering to treatment. The tribe often fears and shuns outsiders, but Scovia has built the relationships necessary to bring them vital healthcare services and education.
Twenty of the thirty-five female sex workers who routinely seek services from Bwindi Community Hospital are HIV-positive. All but three of the women are actively involved in support groups run by the hospital.
When asked what Bwindi Community Hospital has done for her, Beatrice, a sex worker, responded, "It gave us drugs for the prevention of mother-to-child transmission [of HIV]. I am happy my child is HIV-negative."
Sarah, another sex worker, agreed with Beatrice, claiming that the most vital service provided to her was focused health education.
Seeing these women as agents for their own health is a key component in advocating for an HIV-free generation. Noting that many of the challenges faced by sex workers in this region stem from poverty, Bwindi Community Hospital has designated a public relations staff member to work with the women on income generation.
Scovia and the other health workers at Bwindi Community Hospital demonstrate that global health is not only about providing services -- it is about creating an environment conducive to respect, trust, and human dignity. Through specific collaborative partnerships between EGPAF and civil society organizations, more than 41,000 most at risk individuals in the southwest region of Uganda have been reached since 2010, a testament to the power of partnerships and collective action.
*Please note that the names of the most at risk individuals in this article have been changed to ensure confidentiality.
This article has been supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) under the terms of funding provided to the Elizabeth Glaser Pediatric Aids Foundation in the implementation of the USAID Strengthening TB and HIV AIDS response in the South Western Region of Uganda (STAR-SW project). The contents are the responsibility of the Elizabeth Glaser Pediatric AIDS Foundation and do not necessarily reflect the views of USAID or the United States government.