Being an abridged version of the lecture delivered at the Induction Ceremony of the Nigerian Academy of Sciences by Prof. John Idoko, FMCP, FAS. Idoko is also the Director General, National Agency for the Control of AIDS (NACA).

INTRODUCTION: IS THIS THE RIGHT TIME TO TALK ABOUT THE END OF AIDS?

THREE decades into the HIV/AIDS epidemic, there has been remarkable progress in tackling the disease. We have sensitive and specific tests to detect infection; there are effective antiretroviral drugs that prevent the relentless destruction of the body’s immune system by HIV; there are techniques that can effectively measure treatment success by quantifying the level of immunosuppression or amount of viral load in the blood; available resistance genotyping enables us to determine the emergence of strains that will not respond to prescribed drugs; and guidelines exist that will allow clinicians switch to more effective antiretroviral drug combinations.

We also more than ever have a relatively sound understanding of how to prevent HIV transmission and acquisition; effective suppression of viral load has been shown to minimize the risk of HIV transmission and there is a strong belief that treatment can have a very significant impact on curbing the epidemic. We also know that effective treatment of women in pregnancy, labour and during the breast feeding period significantly reduces the risk of perinatal transmission of HIV. More recent data from randomized clinical trials have shown that male circumcision can reduce female to male transmission of HIV by about 60% and that antiretroviral drug prophylaxis used in the form of oral drugs or vaginal gels can substantially reduce HIV transmission if used consistently.

Despite these significant advancements, many individuals in high prevalence states do not know their HIV status and according to UNAIDS report, only 40% of those eligible for treatment are currently receiving antiretroviral therapy. In sub-Saharan Africa, where the majority of children live, only 26% are receiving these lifesaving drugs. We are still witnessing new infections among children from poor prevention of mother to child transmission (PMTCT) programs. In sub-Saharan Africa, tuberculosis infections continue to grow because of the HIV epidemic and remain the most important cause of morbidity and mortality amongst HIV patients.

EPIDEMIOLOGY OF HIV AND AIDS

In 1981, a new syndrome, the acquired immune deficiency syndrome (AIDS), was first recognized among gay men in the United States. These men presented with Kaposis Sarcoma which was thought to be a form of cancer found among individuals with severe immunosuppression. By 1983, the etiological (causative) agent was identified but it was not until May 1986 that the International Committee on the Taxonomy of Viruses announced the human immunodeficiency virus (HIV) as the cause of AIDS.

HIV infection has been identified as one of the numerous diseases that can be transmitted through unprotected sex. However, HIV can also be transmitted through the sharing of needles and syringes, and from mother to child during pregnancy, during delivery or during breast feeding or through transfusion of HIV-infected blood or blood products. By the mid-1980’s, it became clear that the virus had spread, largely unnoticed, throughout most parts of the world. AIDS is terminal condition of the chronic HIV infection when the disease has severely destroyed the immune system and as a consequence, the individual is overwhelmed with opportunistic infections and cancers. HIV and AIDS remain a major cause of morbidity and mortality globally especially in sub-Saharan Africa, which bears 70% of the burden of disease.

The disease has claimed more than 60 million lives, many innocent children have been infected, homes destroyed, dreams aborted and shattered.

Globally, the number of new infections has continued to fall. There were 2.3 new infections in 2012. This represents a 33% drop and the lowest annual number of new infections since 1995, when about 3.5 million new infections was observed. The number of new infections declined by more than 50% in 26 countries between 2001 and 2012 and between 25% and 49% in another 17 countries including Nigeria.

The drop in new infections was even greater among children. From 2001 to 2012, the number of new infections among children dropped by 52%. Similarly, there was a corresponding 29% decline in AIDS related deaths among adults and children within the same period. There were almost 10 million people (adults and children) accessing antiretroviral drugs by 2012.

HISTORY OF HIV IN NIGERIA

In Nigeria, the first two cases of HIV/AIDS were identified in 1985 and reported in 1986. Since the first case was reported, the HIV & AIDS epidemic in the country has continued to attract the attention of Government and other stakeholders. Several efforts have been made at different levels to curtail this epidemic which is considered as a generalized epidemic. The Nigerian National AIDS Advisory Committee was established in 1987 and was shortly followed by the establishment of the National Expert Advisory Committee on AIDS (NEACA). The first national HIV prevalence survey was conducted in 1991 and it gave a prevalence rate of 1.8%.

This figure rose from 3.8% in 1993 to 4.5% in 1998 and then 4.1% in 2010. Presently, due to her large population, Nigeria ranks second in the world in the burden of HIV with about 3.6million people infected. Nigeria also accounts for about 14% of the estimated burden of HIV in Sub-Saharan Africa and 10% of the global burden. More women (58%) than men are living with HIV in Nigeria as a result of inequity in the social, political and economic status of women in Africa in general and in Nigeria in particular.

HIV PREVALENCE BY GEOPOLITICAL ZONES AND STATES

A comparison of HIV prevalence by geopolitical zone in Nigeria between 2008 and 2010 showed that prevalence in the North West and South-South zones reduced while it increased in the North Central, South East and South West zones. The HIV prevalence in the North-East zone has remained stable. Twelve (12) states and the Federal Capital Territory (FCT) have higher HIV prevalence than the national average and have been shown to be responsible for about 70% of the HIV burden in Nigeria.

These states which are referred to as the ‘12 plus one states’ are: Benue, Akwa-Ibom, Bayelsa, Anambra, FCT, Plateau, Nasarawa, Abia, Cross-River, Rivers, Kano, Lagos and Kaduna.

The lowest prevalence of 0% was reported in four locations in the country: Kwamiin in Gombe State, Rano in Kano State, Owhelogbo in Delta State and Ganawuri in Plateau State. The highest HIV prevalence of 21.3% was reported for Wannune in Benue State.

The spread of HIV has increased significantly in Nigeria since the official report of the first case in 1986. The results of periodic national surveys among ante-natal clinic attendees showed a progressive increase in the adult HIV sero-prevalence rate from 1.8% in 1991 through 4.5% in 1996 to peak at 5.8% in 2001 before declining to 5% (2003) and 4.4% (2005) and 4.6% in 2008. According to the 2010 National HIV sero-prevalence, Nigeria had an HIV prevalence of 4.1%. All the 36 states and the Federal Capital Territory (FCT) have HIV prevalence above 1% with 17 states having HIV prevalence greater than 5%. This translates to about 2.95 people (1.2 million men and 1.73 million women) living with the virus in the country.

The number of new infections is put at 323,000 adults and 57,000 children. Infection rates among young people aged 15-19 put at 3.3%; 20-24 at 4.6% and 25-29 at 5.6% are considered very high and a key national strategy in the current national strategic framework is to direct focused national HIV prevention efforts at addressing this trend.

HIV and AIDS have extended beyond the commonly classified high-risk groups and are now in the general population. HIV infection in Nigeria cuts across both sexes and all age groups. The number of HIV- positive children was high with mother-to-child-transmission as the principal route of infection. The number of the children orphaned by AIDS has increased substantially over the last decade to an estimated 2.2 million.

By all indications, HIV and AIDS epidemic has grown largely through heterosexual unprotected sexual relationships, mother-to-child transmission and contaminated blood and blood products. Among the high-risk groups, however, the findings from the 2010 Integrated Biological and Behavioural Surveillance Survey (IBBSS) showed that the most affected group is the Female Sex Workers (FSW) with HIV prevalence of 27.4% for Brothel-based and 21.1% for non-brothel based; followed by the Men having Sex with Men (MSM) and Injecting Drug Users (IDU) groups with prevalence of 17.2% and 4.2%, respectively; while the least affected group is the Transport Workers with HIV prevalence of 2.4%.

HIV SERO – PREVALENCE: NARHS 2012

The national HIV prevalence rate obtained in this population-based survey was 3.4%, lower than 3.6% reported in 2010. HIV prevalence was higher among the wealthier (3.7%) than the poorer (2.9%), among females (4.0%) than males (3.2%) and slightly higher in the urban area (3.6%) compared with the rural area (3.5%). It was highest in the South South zone (5.5%) and lowest in the South East (1.8%). The HIV prevalence was generally higher among respondents with primary and secondary education (4.0%) and lowest among respondents that had Qur’anic education only (2.4%). Also, HIV prevalence was highest among the 35-39 years age group (4.4%) and lowest among the 15-19 years age group (2.9%) with widowed having the highest prevalence (6.2%).

Prevalence of HIV of 3.7% reported among respondents who had sexual intercourse in the last 12 months was higher than the overall prevalence of 3.4%. HIV prevalence was found to be associated with transactional sex – with respondents who had exchanged sex for a gift/favour having higher prevalence. The prevalence of HIV declined in most states compared to the ANC survey of 2010 except in Rivers, Kaduna and Taraba states where the prevalence of HIV rose to much higher levels.

The decline in HIV and AIDS has created a renewed impetus against all facets of this devastating global health problem. A unique opportunity exists at this time for the global community to harness the prevailing momentum to envision the end of AIDS. The results of unprecedented international political commitment, resource mobilization, and civil society engagement have all combined to effectively implement programmes and services using evidence-based technologies and approaches, such as the scale-up of antiretroviral drugs for treatment as well as for prevention of mother-to-child transmission.

Complacency could rapidly reverse this trend and should therefore be greatly discouraged. New HIV infections continue to occur in key populations characterized by their marginalization and vulnerability in society. Greater effort than ever is needed at this point in the 33 year history of the AIDS epidemic for the world to witness the beginning of the end of AIDS. However, mathematical models demonstrate that combinations of available interventions have the potential to reduce the reproductive rate1 of infection to below 1, which is the level required to sustain the HIV epidemic.

IMPORTANT EARLY HIV INTERVENTIONS

Early important interventions before the arrival of antiretroviral drugs include behavioural interventions with the scale up of condoms, for example the 100% condom policy in Thailand and the “Not Grazing beyond Zero” in Uganda. Others include the provision of clean needles for people who inject drugs (PWID) in Asia. The arrival of antiretroviral drugs with the development of the first molecule (Zidovudine) in 1994 changed the landscape in the management of HIV and AIDS. This was quickly followed in 1996 by the use of a combination cocktail of these agents called Highly Active Antiretroviral Therapy (HAART) to manage the disease as HIV quickly developed resistance to monotherapy with Zidovudine. Other significant early interventions were the introduction of antiretroviral drug combinations to interrupt mother-to-child transmission and the introduction of HIV testing.

The introduction of antiretroviral drugs in Nigeria in the late 90s was the turning point in the HIV and AIDS epidemic in the country. Like other parts of the world, HIV and AIDS were suddenly transformed from a “death sentence” to any chronic disease like hypertension or diabetes. The diagnosis and treatment of other STIs including syphilis were strengthened and expanded in clinics managing HIV as evidence supported their role as co-factors in the transmission of HIV.

Early studies and interventions observed the high risk sexual practice among high risk groups which included sex workers, Men who have Sex with Men (MSM), injecting drug users, uniformed service men and transport workers and government facilitated programs for these marginalized and criminalized populations. In addition, it became also obvious that to tackle the issues of HIV and AIDS, HIV services must be integrated with sexual and reproductive health and rights as poor reproductive health services and abuse of these rights are fertile ingredients for the spread of HIV and AIDS in communities.

“WHY THE END OF AIDS”? WHY NOW?

Progress in preventing sexual transmission of HIV Achieving an end to the AIDS epidemic is not a dream. In more and more countries, the groundwork for an end to the AIDS epidemic is being laid, as HIV treatment and other high-impact strategies are being rapidly brought to scale, resulting in sharp declines in AIDS-related deaths and new HIV infections. These success stories exemplify the critical ingredients for success – ingredients that now need to be applied worldwide.

In an expanding number of countries, from diverse regions of the world, important gains have been recorded following the implementation of sound, evidence and human rights-based approaches. In Ethiopia, major investments in HIV testing programmes and community-centred treatment delivery were put in place and this led to sharp increases in HIV treatment coverage, reaching 56% by 2011. The estimated HIV incidence rate fell by 90% from 2001 to 2011, in part due to HIV treatment. Sharp gains against HIV, as measured by estimates of HIV incidence, have been reported in numerous other countries in which HIV treatment has reached over 60 percent, including Botswana (70% reduction in HIV incidence from 2001 to 2011), Malawi (more than 70% incidence decline), Namibia (more than 50% reduction in incidence), and Rwanda with more than two-thirds decline in deaths and more than 50% reduction in incidence.

Speed in treatment expansion matter, as rapid scale-up of quality-assured HIV treatment services is associated with greater gains against the epidemic. Countries where HIV treatment has been rapidly scaled up in combination with other core prevention strategies have reported declines in the estimated HIV incidence rate of at least 50% between 2001 and 2011. In contrast, among countries with relatively slow scale-up, declines in HIV incidence from 2001 to 2011 were far more limited.

Expediting the comprehensive scale-up of HIV treatment will have a transformative effect on humankind, making our world healthier, more just and more prosperous. Accelerating the scale up of antiretroviral therapy will drive progress across the broader AIDS response. It will reduce HIV-related illness and death, prevent people from acquiring HIV infection, address the needs of women and girls, reduce stigma and social exclusion and promote service integration.

REACHING THE PROGRAMMATIC TIPPING POINT: A CRITICAL STEP TOWARDS REALIZING THE PROMISE OF HIV TREATMENT

In achieving universal access to HIV treatment, an important milestone is passed when the annual increase in the number of adults receiving HIV treatment exceeds the number of adults becoming newly infected with HIV. This transition is referred to as programmatic tipping point. This point represents when the response to the epidemic begins to outpace the epidemic itself.

As of December 2011, several countries had passed this tipping point. However, globally, the world has yet to reach the point where the scaling up of HIV treatment is outpacing the epidemic. In 2011, 2.5 million people were newly infected, while the number of people taking antiretroviral therapy increased by 1.6 million.

PROGRESS WITH MEDICAL MALE CIRCUMCISION

An estimated 3.2 million men in sub-Saharan Africa have received VMMC since WHO and UNAIDS issued their recommendation for scale-up in 2007 After slow progress in the target countries in the years immediately after WHO formally recommended VMMC for HIV prevention in 2007, it is currently projected that at least 4 million men will have been circumcised in the 14 priority countries by December 2013. That represents 20% of the 80% coverage target and a four-fold increase in circumcised men since 2009. This has been observed not to be a major issue in Nigeria and West Africa as most cultures encourage circumcision at birth of during childhood and has been postulated as one of the reasons for the much lower HIV prevalence than in Southern and Eastern Africa where most men are not circumcised.

TESTS FOR EARLIER DETECTION AND CONTROL

Although much has been accomplished in promoting knowledge of HIV status, much more must be done to fully leverage HIV testing as a gateway to HIV treatment. Even though it is becoming increasingly clear that annual testing is critical to timely initiation of treatment and rapid scale-up in countries or populations with elevated HIV prevalence, HIV testing services reach only a small fraction of the population annually in many countries.

Many people living with HIV first learn they are infected late in the course of infection, undermining the effectiveness of HIV treatment and facilitating the continued spread of HIV. In nine sub-Saharan African countries, the median CD4 cell count when HIV treatment was initiated in 2010 was below the critical life-threatening threshold of 200 cells/mm3 – substantially lower than recommended standards for the optimal start of treatment.

In many countries, investment in HIV testing services remains concentrated in stand-alone testing sites that require individuals to recognize their risk and voluntarily seek to learn their serostatus. Several countries, however, have shown the way towards more proactive and more effective approaches, using multiple low-threshold strategies to extend the reach and impact of testing services. In Kenya, for example, the number of tests administered rose seven-fold from 2008 to 2010 after the country implemented provider-initiated testing and counselling in health care settings and began supporting energetic community testing campaigns.