‘Nigeria can defeat HIV with Ebola, polio experience’
Dr. Patrick Dakum is the Chief Executive Officer of the Institute of Human Virology, Nigeria, an organization that implements scale-up of the US President Emergency Fund for AIDS Relief (PEPFAR) programme and conducts research and training to promote quality evidence-based health systems strengthening. He coordinates the interdisciplinary responsibilities of the Institute for effective program output in addition to providing overall management of the Nigerian team in implementing the Institute’s several projects. In this interview with EMEKA ANUFORO in Abuja, he speaks on how Nigeria can celebrate zero mother-to-child transmission of HIV by 2030, among other issues. Excerpts:
RECENTLY, your organization was part of the facilitators of the National Implementation Science Alliance research meeting. What would you say were the core deliverables of the engagement?
The Nigerian Implementation Science Alliance is meant to bring together specifically groups or organizations that are involved in the implementation of health programs, specifically implementation of communicable diseases and then, subsequently off course, non-communicable diseases. In the context of research, what we have found out is that there are procedures or discoveries. We call them bench site findings in science; they are available, they have been tested.
However, they are not in use all over, or they have not produced the desired results in the general population and we found out that unless you apply some scientific methodology in finding out why this is not so and trying out in smaller situations, how you can scale it up, you will not be able to achieve the benefit of it.
That is why we have what is called Implementation Science Research. Now, in the context of HIV, this means then that, what are the proven technologies for prevention and for treatment? If these proven technologies are there, why it that we still is have high incidence and why is it that we still have the burden of disease that we still have? We decided to bring the Implementation Partners together, establish an alliance and share best practices.
The first conference that we had was aimed at, first of all, letting people know that an alliance like this exists and to also share best practices between Implementing Partners and this has to be research that is carried out in the context of helping implementation get better. In the last conference, we decided to focus on Prevention of Mother-to-Child Transmission and you will ask why? The reason is very clear. HIV/AIDS does not have a cure. HIV/AIDS has a treatment. HIV/AIDS has proven prevention technologies in the general population and specifically for an innocent child that just happens to be in the womb of a HIV infected mother. Globally, if you go to developed communities, there is hardly a single child that is born with HIV positivity from a mother who is HIV positive.
So, if it is working, why in Nigeria, do we still have a high transmission?
Different groups have gone into different implementation science research to see how we can improve uptake, retention and follow-up of the cascade, referred to as PMTCT cascade, from the general population of women to the population of pregnant women, to the population of those who are positive and pregnant, to the population of those who deliver, then to the population of the babies that are born.
Following this cycle, we checked for the bottlenecks that we could plug in to improve coverage. To that extent, I believe that the conference was successful. Different methodologies were shared and partners have gone to their different organizations to try and incorporate these into their implementation. For example, in IHVN, we have a research, that we call the MoMent Study that is trying to look at the benefit of having mentor mothers peer up with HIV positive pregnant women that have been newly diagnosed in order to see whether this bonding will improve uptake, will encourage the women to take their drugs, ensure that the babies take their drugs and follow up right to when the babies are negative. We have found out that from this research, it is scientifically proven, even though, anecdotally, people have known that it is useful, research has proven that it is useful, therefore, people will be able to scale that up.
One of the practices we have also seen is using the culture of the individual communities in order to introduce counseling and testing and to see whether that will improve uptake. We had an example from the South East of what is called the baby shower trial and that is looking at the culture in the South East of Nigeria, you find out that especially the community there, every child is normally christened, every pregnancy is celebrated. What the researchers did was to find out if they take the testing into these churches, will it improve the uptake and then retention and subsequent taking of the drugs and it showed
Some of the decisions from the conference are things that the government would need to use to change policy direction. What was the partnership like and to what extent did you get the commitment of government in implementing some of the decisions of the conference?
Some of the things that we have put before government are the issue of funding off course. Related to funding, we have gotten the commitment that the Federal Ministry of Health and National Agency for the Control of AIDS (NACA) is doing everything that it could in order to improve funding related to HIV. But secondly, we have also seen how government has commenced putting some money especially what is referred to as the President’s Comprehensive Response Plan that NACA is coordinating. That provides more funds. At the conference, they also agreed that they are going to see how they can put a percentage of whatever funding they get to research. If you don’t research and get out the best practices, the good discoveries will just be lying down in the bench.
They’ll never go to the bed. We want to say bench to bed, the bridge is research and we believe that’s very important. The other thing that we have placed before government is looking at the possibility of modifying the policy on treatment of pregnant women with HIV to what we refer to as Option B+. Currently, the Federal Ministry of Health Guidelines says that women who are pregnant should be treated and provided with prophylaxis and after their pregnancy, they stop taking the drugs until when they are eligible for treatment according to the general eligibility for the general population.
Now, the international community and World Health Organisation (WHO) have come up with new guidelines that say that, look, a woman who is HIV positive, once you find out, place her on drugs for life because if you look at it this way, a woman gets pregnant, she takes the drugs and stops. That is stopping the drugs and you are increasing the chance for resistance because the HIV is not going away because the pregnancy went away. The HIV is still there so why not continue with treatment because this same woman is likely to get pregnant again, and then you’ll start again at the next pregnancy, and then stop. In the past, that is what was available, but now, this is what the international community is moving at.
The Federal Ministry of Health has promised that, they were looking at general cost implication of changing the policy and the logistics of retention in care because when you start a woman on treatment, you have to continue to figure out where she is. If she comes to the clinic, will you be able to go to her home if you don’t see her again. All these things are what they are considering but we have conducted pilot research on those ones and found out that given all the challenges, Option B+, that is placing the woman on treatment for life still provides better outcomes and therefore we are looking forward to the finalization of that.
For us in IHVN, and the US Government committee, we are trying to do a pilot of that to provide further evidence for that policy support in 32 Local Government Areas in Nigeria and in these 32 Local Governments, we’ll be providing treatment to women for life once identified as positive. That way, we are able to look at the data and provide the evidence that supports what the global community has already accepted.
With these initiatives and all that the Nigerian Government and Partners are doing, is there a chance that by 2030, we will still achieve zero infections?
Between now and 2030 is 15 years. If we succeed in this next two years to achieve what is called epidemic control in these 32 Local Governments, I believe that by 2030, we should be able to celebrate zero mother-to-child transmission of HIV in Nigeria. People say it may be tough and difficult but I say that Nigeria along with the international community stopped a number of diseases. We are able defeat small pox. We were able to defeat Ebola. We were able to defeat Polio, why not HIV?
It is possible to defeat HIV, defeat in the sense that you don’t have new infections going on again or the percentage is such that it is not an epidemic. You have controlled it and those who are positive are living normal lives like every other person. That way you can say that it is now totally under control. You don’t have as many new infections as people are being placed newly on treatment. You have overtaken the virus and stopped it and remember that treatment is also prevention because when you treat the individuals in the community, the quantity of virus in the various individuals, that is, viral load, is too low to transmit and in that community, nobody gets it because you don’t get HIV from people who are not transmitting.
In specific terms, would you just briefly tell us that the Institute is doing to prevent mother-to-child transmission of HIV?
Let me put it this way and also dovetail into what we earlier talked about, that is looking at the current strategy that IHVN and the US Government is looking at to achieve the epidemic control. It is in the context of this that the PMTCT sits in. The strategy of doing the right things in the right places at the right time and this is a strategy that has been adopted from the Office of the Global AIDS Coordinator, Dr. Deborah Birx, from the US, to all the countries that they are supporting.
Doing it in the right places means then that you go and provide concentrated treatment where the burden is high. There’s no need spreading HIV/AIDS services in a place where the virus is not there. We have looked at the data for instance of our national spread and seen that there are facilities that we have tested maybe ten thousand women and we have found only one positive and in another place, we have tested only one thousand and we have found 100 positive. Doing the right thing is to provide treatment in that place you have the high burden. This is the principle that underlies the 90-90-90 strategy.
To specifically ensure that the PMTCT is addressed, IHVN is adopting the specific findings. We have had in our researches in order to scale-up. Therefore, in all the facilities that we are going to, we are also going to be having mentor mothers. That is, experienced mothers who are HIV positive that have delivered providing the mentorship to newly diagnosed HIV positive pregnant women. Secondly, we are also going to the communities, because it’s not everybody that comes to the hospital. Therefore, we are using community gatekeepers.
We are using the Ward Development Committees, all the Primary Health Centers around. We are using whoever are the gate keepers, whether they are community leaders, women leaders etc. to ensure that women are encouraged to get tested and when there are tested, we have community resource persons there that link them up to care. The idea is, wherever a pregnant woman is, at home, community, in the market square, in the church, in the mosque or in the clinic, she gets tested. Unless you find out whether she is positive, you can’t provide her with any treatment so the challenge is in finding the women, not only there, in testing and making sure that they are put on treatment immediately.
These are what we will be scaling up not only in these LGAs that are the saturation LGAs but also in some of the other maintenance LGAs, as we call them that we are working.
What would you want to be remembered for?
Well, I think the legacy that I want to leave behind is the legacy of having created an organization that continuously partners with all stakeholders to provide high-level implementation and research for health. We will never be able to conquer diseases. There will always be there but if there is a center of excellence that partners with government and non-governmental organizations, it is an indispensable partner. You will find that encapsulated in the vision of IHVN and that is the legacy I want to leave behind.