Field trip to Iganga. Part 1: the tug of war

It may have been at the end of the workshop, but we got to Iganga in the end. And not only Irene and I, but the country director (CD) of a high profile development agency who had also come along for the ride. He had cancelled his attendance at a presentation, justifying his actions by explaining that while his job requires his to make mission statement after mission statement he has nothing to state because he never gets let out of the office to see anything. His mission that day was clearly stated then: to get out into the field and try and see first hand what the HIV situation was out there. Irene and I were visiting to observe what NACWOLA does, to see some psycho social support groups, a community sensitisation activity and to shadow a community support agent doing his rounds in a village.  

We arrived 3 hours or so after leaving Kampala, driven there by a female driver from Irene's agency, in traditional attire which for Uganda was pretty unusual on both accounts. The driver explained that she liked her job as a driver because it was low pressure, mentally unchallenging and physically easy. Having spent most time in Ghana where driving to the end of the road is made out to be a big job, this easy honesty was also extremely refreshing. After going around in a few too many circles following Esther’s confusing directions, we managed to find her and she hopped in the with a shy smile. We first went to the NACWOLA office: two rooms, two computers, two volunteers and a store room stacked with condoms.

While Obama changed the US HIV/AIDS prevention policy of Abstinence and Be faithful to finally include C for condoms, the USAID Star EC project was still only, by policy, offering condoms to HIV positive people as part of positive prevention. While funded by STAR EC, NACWOLA however are able to distribute condoms regardless of HIV status,  by other means. I asked how often they got deliveries and if there were enough condoms to go around. Esther explained that because the area was predominantly Muslim men tended to have more than one wife. She said, with a giggle, that it wasn’t uncommon for a man to require 3 condoms a day in order to practise safe sex with his three wives.

After picking up copies of the data collection forms and being introduced quickly to the monitoring and evaluation procedure for the project we piled back into the car, ready to visit the community sensitisation activity. However, much to my initial dismay, the CD hijacked the agenda somewhat, initiating instead that we visit the district hospital. So we missed the community sensitisation and went straight there. The hospital was crumbly and ramshackle but quiet, as Fridays apparently tend to be. I saw no men, but rather lots of women; women clustered outside on the grass, eating and talking, old women heaped up on wooden waiting benches and corridors of young mothers and babies lining the walls.

I lingered behind to take photographs while the others wove through the corridors to reach an office or other, which was locked. The person Esther had advised to the CD would not be there, was indeed, not there. We wandered on through, past a lady whose crossed legs blossomed into what looked like huge fungi where one expected feet. A vintage ambulance rusted, neglected into the earth while a shiny new one pulled up alongside it. Passing into a new block which was undergoing a shambolic reorganisation we were ushered into an office space where a nurse sat down to answer our unexpected questions.

The CD asked the nurse whether or not she thought HIV infection rates had increased or decreased. The nurse was unsure how to answer and I was unsure as to whether or not this was the CDs method of trying to find out the actual answer or just to gauge peoples perceptions. The CD thanked the nurse for her time when he was satisfied and rose to leave. I added that, actually, I also had a couple of questions and proceeded to learn from the nurse that HIV Alliance had first put community health workers in the facility, that the same people have been coming over the years but that their names have changed...from village health teams to community support agents etc. She perceived them to be doing a good job without treading on hospital staff toes.

The nurse explained too that the structure of HIV testing had changed and was now being offered across all the wards. This was news to the CD who became genuinely excited and exclaimed "this is brilliant, this should be rolled out all over the country." Irene later confirmed that this was already national policy.I asked if this had impacted on the ability of the already overstretcheed staff to offer pre and post testing counselling to everyone but she seemed not to think so.  

We then paid a visit to the ante natal unit to look at PMTCT care (prevention of mother to child transmission). A couple of CSAs from mother2mother, our main competitor in the business model, were there. I took the opportunity to stop for a chat and to find out that mother2monther approach NACWOLA for staff recommendations and that NACWOLA had recommended and pretty much handed the lady over to mother2mother to take on. Rather than feeling that the mother2mother contract was a short term offer (1 year) with limited opportunities for skills learning, as NACWOLA staff believed, she thought that her contract would be renewed because of good performance and she noted receiving higher skills training and that she was now even taking blood for testing. 

We sat down with another nurse, this time with a brilliantly twee uniform and a couple of dolls in her office (one black and one white). A scrawled note to “always ask for information on family planning” was, like the other posters, fixed clumsily with brown tape to the wall.The CD proceeded to ask questions about drug and testing kit availability and HIV infection rates. This time he was able to do spot checks in the nurses records to see how many mothers out of ten had tested positive. I asked about the counselling offered to discordant couples and men, and she said that while it was “a tug of war" to get men into the hospital for HIV services at all, they had received 3 couples that week.The CD continued with spot checks for a further ten minutes or so. He was optimistic that these promisingly low infection rates could be indicative of a regional trend, despite them reflecting a group of women that were already accessing treatment and services, in a fairly low risk community compared to the fishing villages, plantation workers and truck stop over sites further out. The CD was charming, and offered his card to the nurse, saying "if you ever come to Kampala we will take you for lunch...call if you need anything." The nurse looked at the card, confused, and checked: "I can call you if we have a problem here?" Irene stepped in to clarify that he would be more likely to put her in contact with the relvant service rather than offer direct assistance. We thanked the nurse for her time and left, but not before I got a picture of their wonderful hats.