A broad range of HIV/AIDS education and awareness campaigns in Uganda since 1986 resulted in many Ugandans asking the question "Am I infected?" and a growing demand for HIV testing. Before the opening of AIC, there were few HIV testing services in Uganda and almost none with associated counselling programmes. Before long, an enormous burden was placed on the national Blood Bank where many Ugandans interested in knowing their HIV status went to donate blood. The Blood Bank was not able to offer supportive counselling, and donating blood for the purpose of learning one’s sero-status was an expensive misuse of blood banking services.
In response to the growing demand for testing, several organizations got together to discuss the need for anonymous and voluntary counselling and testing services in Uganda. These organizations included: the Ministry of Health’s AIDS Control Programme, Nakasero Blood Bank, Uganda Virus Research Institute (UVRI), TASO, USAID, InterAid, World Learning, Inc., Uganda Red Cross, Makerere University Faculty of Social Science, and the World Health Organization (WHO). The result of these collaborative discussions was the opening of AIC, on 14th February 1990, under the direction of the late Lydia Barugahare - a Ugandan nurse trained in the United Kingdom.
Offering Ugandans an HIV counselling and testing service distinct from the Nakasero Blood Bank (the national blood bank) had a tremendous positive impact. From 1989 to 1995 the amount of blood given by volunteer donors at Nakasero increased by over 400%, while the rate of HIV found in donations fell from 14% to 2%.
In the beginning, AIC provided services in Kampala, the national capital, through a main office in a downtown office building and several satellite sites in the Kampala area. Clients received VCT over the course of two visits, receiving test results after two weeks. In its first 11 months of operation, AIC provided VCT to more than 9000 clients. This well surpassed the target of 5000 clients expected in the first year and confirmed the strong interest in VCT, which has continued up to the present. In eight years, AIC has grown from a single office with four staff into a multi-faceted centre with four branches employing over 80 people. Since 1990 AIC has served over 380000 clients.
In 1997 AIC merged its Kampala operations and opened its current headquarters in Kisenyi, an impoverished neighbourhood near the nation’s largest public transportation hub and Kampala’s largest outdoor market.
Cumulative Demand for VCT at AIC
By 1993 district branches were opened in Jinja, the major industrial city of Uganda, Mbarara, the largest city in the western region, and Mbale, near the Kenya border. Demand rose sharply from 1990 to 1993, and fell slightly in 1994. Large client numbers early on were partly a result of the numerous satellites that AIC operated. Owing to high operational costs, satellite services were curtailed and as a result the total numbers coming to AIC declined, stabilizing at about 40000 annually. Demand has increased in 1998.
Demand for VCT by year
In an effort to serve Ugandans living in peri-urban and rural areas, AIC began operating satellite sites in 1992. These sites were in various locations, including health centres, community centres and churches. AIC counsellors and phlebotomists traveled to these sites either once a week, bi-weekly or monthly. Blood samples were transported back to Kampala for testing with counsellors returning to the site, with test results, two to four weeks later. By 1995, 20 satellite sites were operating. Although this worked well in some areas, there were numerous problems with the approach.
Some sites had low numbers of clients with high costs of transporting staff, resulting in high expenses per person served. Overall, the problem with satellite sites was one of logistics. Blood samples were transported from a satellite site to an AIC Branch, to AIC Headquarters, then to the Blood Bank. HIV test results were then taken from the Blood Bank to Headquarters for data entry, to the AIC Branch, then back to the satellite site. Given the complexity of the routing, it was not unusual for a client to return to a satellite site only to find that their test results were not ready. Since few if any rural clients have telephones, it was not possible to notify these clients in advance. Hence, some clients took unnecessary long walks or expensive trips and were too discouraged to return a third time.
This experience demonstrated that affordable VCT for rural clients necessitated a decentralized approach with counselling and testing performed locally, with same-day results.
Increasing availability of VCT by decentralization
AIC worked with health officials in 16 districts to address the sustainability of VCT and the need for integrated services. The result was an AIC expansion strategy that included integration of VCT into existing health facilities, at the district level, and technical assistance and training for district personnel. In hand with this AIC introduced a pilot protocol for rapid testing with same-clay results, as well as procurement and distribution of test kits, support supervision, monitoring and evaluation.
The expansion strategy required that AIC reorganize itself in order to provide adequate capacity for managing both the main branch and indirect sites. Collaboration was sought with district medical and political authorities and Memoranda of Understanding were signed. The stages of expansion included: needs assessment, site selection, personnel training, setting-up of VCT facilities (in district hospitals and health centres), assessment of performance and phase-out. By 1998, 35 VCT sites were operating at hospitals and health centres, and over 5000 clients had received VCT.