A mother and child in Arua hospital, which treats HIV-positive patients in Uganda.
(Photo from Doctors Without Borders)
How easy is it to fake a clean bill of health if you have HIV in Uganda? All you need is money and the right connections. This article from The Independent, a news magazine in Kampala, Uganda, explains.
"As the Handy Man tells it, he began falsifying HIV test results after his own brother fell ill to the disease in 2009. Up to that point he had used his networking skills to procure performance enhancing drugs that were beyond the reach of any of Uganda’s hospitals for his athletic acquaintances, and used distant family connections to import fine suits, perfumes and designer shoes. Then in 2008, he began to peddle falsified course work results and fabricated internship recommendation letters. However, when his brother contracted the disease from a local South African woman he had been dating, the Handy Man’s operations degenerated to a whole new level…"
Fake HIV test documents
A dark, dangerous deception (Part I) The Independent, Uganda>>
A dark, dangerous deception (Part 2) The Independent, Uganda>>
I’m posting the entire article below because the original had many formatting and font problems. (I also added the approximate conversion rates into U.S. dollars for any Ugandan shillings, listed as "Shs," and Americanized some of the spelling.)
A dark, dangerous deception
by Matthew Stein & Yvonne Rafaella
Falsifying HIV results is easier than you think
Just ask the Handy Man.
As the son of a successful and wealthy politician with businesses and properties spanning Kampala, Jinja, Mbarara and Masaka, the Handy Man was allotted many privileges growing up foreign to other children. In his village, where he lived with his grandmother until seven years of age, his large home had reliable electricity, a big TV and clean water. When he entered primary school in Kampala, he moved into his parent’s city home but quickly discovered that their business and social commitments took precedence over family interactions. Most of the time the Handy Man was on his own, a shy and quiet child.
One of the Handy Man’s biggest irritants growing up was the bean laden food he was routinely served for lunch at school. Matooke with beans, posho with beans, meat with beans – it never ended. To avoid them, he’d eat nearly a half a loaf of bread for breakfast. One day, during his first term holiday in S.1, the Handy Man frequented a clinic and reported to the doctor that he was in fact allergic to beans.
"Only beans?" the doctor inquired skeptically.
"No, also other legumes," he responded.
"Well then," replied the doctor. "Let’s take a test."
The Handy Man shook his head. "No," he said firmly. "I already know what happens when I eat it. I don’t need a test."
Fortunately for the Handy Man, the doctor relented and for the standard Shs 20,000 fee provided him with a medically stamped note that exempted him from beans for the rest of his stay at school. (NOTE: 20,000 is U.S. $8.50 – all subsequent amounts are also in U.S. dollars.) Although only a teenager at the time, the experience had proven the value of deceit.
Now in his mid-20s and in his final year at Makerere University, the Handy Man has become an expert on deception and on the surface at least, is thriving on account of it. In his luxurious hall room in one of the university’s most famous halls, he is regularly surrounded by characters – both male and female – seduced by his charm and money. His confidence manifests itself in the swag in his steps and the egotistical manner with which he speaks; he describes himself as "the ace card" within his group of friends – the rock they can all lean on. At almost 6 ft. he is a strapping figure who works out regularly; the visible tease in his eyes when he smiles denotes the lover boy image he has rightfully cultivated.
But despite all the goods he possesses and parties he throws, the Handy Man has a dark secret. On some occasions it has kept him up at night and on others it has impacted his intimate relations. He swears, come June, he will abandon it for good, but the damage it has likely already caused can never be erased.
As the Handy Man tells it, he began falsifying HIV test results after his own brother fell ill to the disease in 2009. Up to that point he had used his networking skills to procure performance enhancing drugs that were beyond the reach of any of Uganda’s hospitals for his athletic acquaintances, and used distant family connections to import fine suits, perfumes and designer shoes. Then in 2008, he began to peddle falsified course work results and fabricated internship recommendation letters. However, when his brother contracted the disease from a local South African woman he had been dating, the Handy Man’s operations degenerated to a whole new level of immorality.
According to the Handy Man, his brother, who will be referred to here as James to protect his identity, had never suspected his girlfriend to be sick. She never told him and it was only after she fell severely ill and eventually succumbed to the illness that James realized he needed to be tested. When the result came back positive, says the Handy Man, "All hell just broke loose." Their father, he says, had to fly down to South Africa to personally console his son. It then took three months of counseling before James was able to regain his personality.
Finally back on his feet and searching for work, James was offered a lucrative position in a company but considered walking away from it when he learnt that he would have to provide proof of his HIV status. James, says the Handy Man, frequented twelve different clinics trying to bribe his way to a negative result, but in the end he just came home with twelve positive slips. "He was completely devastated," says the younger brother. Out of support, the Handy Man tapped into his own network of contacts and had a lab technician friend arrange a falsified result. After much negotiating the price emerged at Shs 500,000 ($211.) James would subsequently be given a HIV negative document and his younger brother, together with his lab technician friend, discovered there was much money to be made in this new corrupt practice.
AIDS has been present in Uganda since the first case was discovered in 1982 along the shores of Lake Victoria. By the end of 1992, according to the Uganda AIDS Commission (AIC), the disease’s national prevalence rate was estimated at 18.3 percent. Fortunately, a period of steady decline ensued cutting the prevalence rate to six percent by 2002. Today, the national rate remains close to 6.4 percent but prevalence amongst some communities such as fishing villages, truck drivers and sex workers remains at a staggering 28 percent. However, AIC also reported recently that the HIV rate amongst university students stands at an impressive 1.15 percent.
Campuses such as Makerere have reinforced the gravity of the disease through awareness campaigns, on-campus counseling and testing at the onset of each semester. Condoms are also readily available and are at times distributed for free. "People are becoming more cautious," explains Irene Odette, a junior counselor who volunteers with a children’s NGO. "HIV does not only attack your health but your psyche because you’re always thinking of your looming death."
Jada Ali, a 22-year-old second year law student attributes the decline to the university’s annual intake of new students, while the largely infected populace drops out.
Although students on campus understand that HIV is not necessarily a death sentence, and unlike cancer or pregnancy can even stay hidden so long as one exercises, maintains a healthy diet and takes their medications, the implications of having HIV – the stigma, and the alternative lifestyle it produces – forces many students to exercise maximum caution when engaging in sexual behavior.
Brenda, a second year undergraduate student at Makerere, was 20 years old when she and her boyfriend of several months agreed to mutually take an HIV test. When the test results were ready, Brenda handed her sealed envelope to her boyfriend and he handed his to her. Inside, hers read negative; his read positive. "It was a complete shock," recalls Brenda. "Afterward our communication was no longer the same."
Three weeks after they broke up, Brenda discovered that her ex had begun dating another girl. She confronted him to ask whether he had told her about his status. When provoked, explains Brenda, her ex produced an official looking document that stated that he was HIV negative. "The result was typed out, but I knew it was a hoax," says Brenda. Her ex, however, acted as if he believed the new result to be true. "He was so young. He had his whole life ahead of him. He just couldn’t accept it," she says.
Days later Brenda’s ex mysteriously disappeared; his phone was shut off and he was nowhere to be found on campus. He had told Brenda that he was a Makerere student, but now, a year later, Brenda believes this was just one of the numerous lies she could have been told. She is also still bewildered by the suspicious second HIV document her ex acquired.
At the AIDS Information Centre’s (AIC) office in Old Kampala, Daniel Lukenge Mukasa, the organization’s public relations and advocacy manager, responds dejectedly to this dangerous and corrupt trade. "This behavior doesn’t surprise me," he says. "There are people out there that repackage expired drugs." Mukasa takes me down to the ground floor where the AIC registers its clients and provides them with initial counseling. Once the individual agrees to be tested, they are led to a lab where a nurse draws a sample of blood. The sample tube is then placed vertically in a small rack with a sticker that details the person’s client number. A copy of the same sticker is subsequently placed on an AIC document, the test paper and on the individual’s respective client card and test paper. The client’s test paper, once a result is determined, is then signed by the relevant lab technician and counselor. "Our lab technician doesn’t even know which client gets which result," says Mukasa. It is a meticulous system that abides by the Ministry of Health’s guidelines to the letter.
AIC’s process, however, is not the norm. As a registered, government-monitored testing facility with relatively substantial testing resources, AIC can ensure that its employees are governed through a corrupt-proof system. At unregistered clinics or even registered clinics where the drawing of blood, the test and the results are all performed by one person, the opportunity to falsify a result becomes readily available.
"We can’t check if they’re all doing the HIV tests properly," says Dr. Zainab Akol, program manager for STD/AIDS control program. "We don’t have the competences or human resources." Akol explains that the Ministry of Health’s Central Public Health Lab is supposed to collect and re-test five percent of negative blood samples and five percent of positive samples from clinics around the country to verify their accuracy. "That’s what the policy says," she explains, before adding that it is simply implausible to be done. "There are almost 2,000 testing sites in the country," she says. "HIV testing is happening under trees. Even teachers can now do it."
Akol goes on to list the number of government-linked regulatory bodies that exist in the country to protect the public from entrusting corrupt medical practitioners or clinics: the Catholic, Muslim and Protestant Medical Bureaus each monitor their respective private not-for-profit clinics; the Uganda Private Practitioners Association attempts to ensure that all private clinics are registered with the Ministry of Health; Allied Medical Professionals Council regulates paramedicals; and the Uganda Medical and Dental Practitioners is charged with dealing with any unethical conduct amongst doctors.
Zainab also claims that her department within the ministry monitors all public hospitals and registered clinics on four separate occasions during the year. They check whether the clinics’ respective nurses and doctors are aptly trained and certified; whether supplies are kept in sanitary conditions; and whether the clinics’ yellow HIV results logbook, provided by the Ministry of Health, has any abnormalities. "You have to take the region into consideration," says Akol. "But generally if there are more than three positives on a page or no positives at all, then you know something is going on."
At the Pearl Medical Centre in Wandegeya, Jaliah Nakato, flips through her clinic’s yellow HIV book that sits prominently on her desk. As the center’s nurse, technician and counselor, it is only Nakato who has access to the book. She has the freedom to write whatever results she pleases and so long and as they don’t contradict Akol’s expected boundaries, they are unlikely to raise suspicion. Moreover, if Nakato was a less moral person, she could even write one result in the ministry’s book and another on the test card she provides to her clients.
"Very many people have approached me to change their results. So many I can’t count," says Nakato. "It’s mostly adult women that tell me they need a negative result to get married or to earn money." Nakato says she is often offered between Shs 100,000-200,000 ($42-$85) for a negative result or a blank official form with a serial number and stamp, but has always refused.
Around the corner at the isolated Monak Medical Centre, we try to assess the rigidity of other local clinics. Although the nurse on duty doesn’t outright dismiss our request for a falsified result, she is hesitant about issuing false papers in the presence of her boss. "It’s very hard to get it done," she says quietly from outside. "Go speak to someone at Jicca Clinic and Lab around the corner." But at Jicca, after numerous inquisitive questions, we are also offered a skeptical response: "And if I asked for millions of shillings what would you say?" replies the nurse mockingly.
Nevertheless, in Kampala at least, there are other ways to have results fixed. Walking along Nasser Road where idle employees watch the traffic pass from inside innumerable print, photocopy and stationary shops, we find a woman named Agnes. We explain to Agnes what we want – a photocopy of an HIV test slip, void of the result, but with a replica of the stamp and serial number. Agnes consults with her colleagues and returns with a price of Shs 120,000. ($51)
"You know what this is?" we ask her.
She looks at the slip but doesn’t respond.
"It’s an HIV test. We want you to change the result."
But Agnes is unmoved. "I don’t care what it is," she responds.
Before we leave, Agnes advertises that she can also copy academic transcripts. "All I need is your name, age and hall of residence."
A block down the road, we meet a man who tells us his name is Omugezi (the clever one). We present him with the same proposal and he quotes us a fee of Shs 20,000. ($8.50) Again we explain how we are attempting to manipulate an HIV test result. "That’s ok," he replies. "I’m only giving you the blank page. It’s you who changes the result."
Copy specialists are to be found everywhere on this road. Even sitting on the side of the street we are connected to a potential forger by a young man named Godfrey who himself is having a company ID fabricated in order to open up a bank account and apply for a loan. He calls his contact, a man named Isaac who has been in the business for eight years and has his own shop on the street. Moments later we explain to Isaac what we want. "You’re not the first," he replies confidently. "You should trust me." He quotes us a price of Shs 50,000 ($21): stamp cutting, he says, runs at Shs 30,000, ($13) labor Shs 10,000 ($4) and electricity to copy the serial number another Shs 10,000. ($4) "People who ask for less are new in the business and they’re going to do a fake thing for you."
The Handy Man’s prices are considerably higher than those found on Nasser Street; most of his customers pay between Shs 250,000 ($106) and 500,000 ($211) for an authentic HIV test form. In approximately one year the Handy Man says he has fixed seven women and 23 men, all of whom have been between the ages of 20 and 35.
Most of the men that come to him, he says, are students whose girlfriends want them to prove their HIV status before they begin having unprotected sex. The men then approach the Handy Man for an official negative result often out of fear of getting tested.
The Handy Man’s first female client, however, admitted to being positive when she approached him. She was 24 and badly needed a negative result to secure her potential marriage partner’s trust. The Handy Man went to work and to his knowledge she is still married to that partner. "Do you think she ever told him?" he asks.
Unlike his brother James who had had only three girlfriends before contracting HIV, the Handy Man is a self-admitted womanizer. However, since he began to falsify HIV results he has become considerably more cautious in his own sexual behavior. "I can go even six months without having sex," he says now. "I get tested every three months and I cannot have unprotected sex."
According to Professor Joe Oloka, a senior lecturer at Makerere University Faculty of Law, the Handy Man could be legally liable for numerous crimes including fraud, forgery and impersonation. "He is as good as a drug dealer," says Professor Oloka. "He is the primary offender in the crime but for murder (of his client’s spouse or partner) it would be stretched to have him liable."
However, forgery and fraud under respective Sections 342 and 345(a) of the Penal Code Act Cap 120 could land the Handy Man in jail for three years; impersonating a lab technician or a doctor and conspiring with a client to commit a felony is punishable by seven years in jail under Section 390.
But it’s not the potential legal consequences that keep the Handy Man awake at night – it’s the legacy he could be potentially remembered for if he were to be caught. "Later in life a man must settle and work in a respectable place and make clean money," he says. "I make money but I can’t live as happy as the rest of the students. I carry my guilt and that of my customers almost everywhere I go. What’s worse is meeting the spouses of some of the people for whom I falsify results. I could never bring myself to tell them what I have done for their men."
To atone, he goes to Church early every Sunday and on Thursdays visits Christ the King Church to confess. The Handy Man promises that he’ll abandon this work for good once he graduates from university. But whether he personally stays in or out, there will always be someone, he admits, taking advantage of the system’s vulnerabilities. "Every man has his price," he says before returning home to his luxurious campus hall room.