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How COVID-19 has derailed efforts to end AIDS, by Idoko

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Idoko

Dr. Chinedu Idoko is Executive Secretary/ Chief Executive Officer (CEO) of Enugu State Agency for the Control of AIDS (ENSACA) and former Chairman, Enugu State Hospital Management Board. The Executive Governor of Enugu State, Dr. Ifeanyi Ugwuanyi, appointed Idoko in March 2020. Prior to his appointment, Idoko have been a Senior Lecturer in the Community Medicine Department of the College of Medicine of the University of Nigeria as well as a consultant physician in the University of Nigeria Teaching Hospital (UNTH), Enugu. Idoko in this interview with The Guardian among other things explained how the novel coronavirus (COVID-19) pandemic has affected efforts to end the Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) by 2030. CHUKWUMA MUANYA writes.

Why is the country recording sharp rise in COVID-19 cases?
It is quite a thing of concern that despite government efforts to control the COVID-19 more cases are still being experienced in the country. This rise in cases can however be attributed to increased and improved COVID-19 testing due to establishment of more testing centres in the country. This is because the more people tested would only likely proportionally reveal more cases. You know there can be asymptomatic carriers of this virus; that is people with the disease but not manifesting any obvious symptoms but still capable of transmitting it to others. It is only testing more people that could reveal this.

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The improved testing occasioned by increased testing facilities and centres in the country is therefore accounting for this rise in cases observed. An important question therefore is more testing for good or bad? My take is that it is for good. This is because the more cases tested/ confirmed, the more the follow up on these cases in terms of isolation and necessary treatment and of course contact tracing of people that have been exposed to them with institution of the necessary measures.

How can the situation be addressed?
The important thing for us to do is to reduce the disease “prevalence” which is actually a product of the Incident cases and its duration. Once we deal with the incidence by breaking the chain of infectivity while isolating and treating the confirmed infected cases thereby shortening the duration, we would have been doing a lot in reducing the COVID-19 prevalence as well as combating its associated morbidity and mortality. When the right things are continually done therefore, these cases will only get to a peak and then start falling. Hopefully too, a vaccine would be discovered along the line that would ultimately break the chain of infection.

On our individual and community levels, we should therefore continue to adhere to all preventive measures as stipulated by the NCDC as well as comply with all Federal and State Government directed restrictions to curtailing the spread of this virus.

The watchword remain avoiding going out except when absolutely necessary, maintaining good personal hygiene of hand wash with soap and water (when not possible use of alcohol based hand sanitizers), social/ physical distancing, use of face mask when in the public, cleaning of surfaces with 1 in 6 concentration of bleach and water. With these measures as well as appropriate and complementary action of government and all relevant authorities, there will definitely be light at the end of the tunnel.

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What is the impact of COVID-19 on efforts to control HIV in Nigeria with Enugu State as a test case?
COVID-19, a novel virus has of course had a multifaceted impact on efforts to Control of HIV/ AIDS.

The access to Anti Retroviral Drugs of people Living With HIV/ AIDS (PLWHAs) has been hugely affected as people are not able to freely move occasioned by the lockdown and general movement restrictions both interstate and otherwise. As a result, these groups of people are not able to visit facilities to pick up their medications. This is a prominent issue we were faced with in Enugu State. ENSACA in combating this situation in association with our implementing partners enabled logistics for these drugs and consumables to be delivered centrally at different communities and Local Governments where the beneficiaries are domiciled. This way they could easily pick it up. For those affected by the interstate border restrictions we had the implementing partners liaise with sister organisations or branches in neighbouring States to ensure drugs reached the target population. We have coordinated these activities at this critical period via virtual platform the ENSACA has created with various Civil Society Organisations (CSOs), Non Governmental Organisations (NGOs), implementing partners, representatives of Line Ministries and Local Action Committees on AIDS (LACA) leads as members/ participants. ENSACA has also created “Official Government Pass” for the movement of specific people involved in HIV/ AIDS service delivery within the State.

Another impact of the COVID-19 on Control of HIV/ AIDS is shortage of funds. It is of course common knowledge that Government like any other enterprise globally is affected by the slow down in economic activities; of special interest is the scary fall in crude oil prices Internationally. This scarcity of funds in the short term is of course affecting other aspects of Health care delivery especially as huge funds are presently directed to ensuring a most important vital and strategic combat of the novel COVID-19 that of course happens to be an emergency. In this situation, Enugu State is not an exemption but the State Government in its dynamism mindful of this reality has taken various steps to mitigating the effect.

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The mental health issues of depression especially in PLWHAs occasioned by the COVID-19 pandemic and its effects cannot be over emphasized. We have and are continually creating support groups to mitigating the effect of these as well as planned voice media reach-outs to inform and reassure.

Is there any relationship between COVID-19 and HIV/ AIDS?
It depends on the perspective from which you look at it. Both are of course viral diseases that has hit on a pandemic proportion but however with different routes of transmission. COVID-19 of course is a novel virus and evolving, much about it being learned in the process.

From what we know of COVID-19, the most vulnerable population usually are the elderly and people with underlying medical conditions who most likely would have been immune compromised. If that is the case it means PLWHAs should particularly be careful not to pick the virus because of the vulnerability factor. Also at this time it is most important that there is no break in the supply and delivery of ARVs to PLWHAs so as to ensure that ones already with suppressed viral loads remain same; this would make for an unlikely debilitating COVID-19 in an unfortunate situation of their being infected.

Possibility of ending AIDS by 2030
Before the National AIDS Indicator and Impact Survey (NAIIS) survey in Nigeria, the prevalence of HIV/ AIDS in Nigeria was at some stages above four per cent. Today it is 1.4 per cent. Who says if we continue doing the right things it won’t further depreciate and maybe, hopefully eradicated. An International Conference I had recently attended in the United States centred much on issues of possible HIV eradication so it is indeed an issue being discussed at the highest levels. Presently researches are ongoing and new gains made to control and treatment. In Nigeria, Government has pledged and stressed commitment to continued attention to all approaches to bringing down prevalence/ burden. Enugu State is in this line of thought. In fact at a recent visit to Enugu State by the United States (US) Government led by the US Consul General and Centers for Disease Control (CDC) country Representative in pursuance of the implementation of the SURGE programme, the Enugu State Governor Rt. Hon. Dr. Ifeanyi Ugwuanyi expressed unalloyed commitment to the State playing it’s expected role in the synergistic efforts. I am therefore part of the school of thought that if the right things are done in a practical, focused and sustainable manner; there is a great light at the end of the tunnel.
Challenges towards meeting ENSACA‘s mandate

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I actually just recently got graciously appointed to this office by the Executive Governor Rt. Hon. Dr. Ifeanyi Ugwuanyi. Part of the challenges I was immediately faced with are ones I have brought before the Executive Governor and got firm assurances of his support for which we are certain that as the COVID-19 situation gets more relaxed we would effectively hit the ground running.

Be reminded of course that part of ENSACA’s mandate is mobilization of funds from different sources to ensuring effective coordination of HIV/ AIDS Control in the State.

We are therefore not going to relent in seeking other legal and genuine areas of sponsorship and support locally and internationally to achieving our mandate.

What is your blue print as the newly appointed Executive Secretary of ENSACA to advancing health care in Nigeria with Enugu State as a reference point?
The terminology of my office is actually Executive Secretary not Director General (DG). However, for the ENSACA of today, our, and my blue print is essentially that of pursuing the age long mantra/ saying of “prevention is better than cure”.

With that realisation that HIV/ AIDS affects the healthy productive workforce of a country, which is mostly the youths. We would focus especially on efforts to prevention of infections amongst the generality of the populace especially the youths.

The time lost to morbidity and attendant mortality in one person that gets infected directly and indirectly affects families, relationships and of course the country’s Gross Domestic Product (GDP).

You could then imagine the huge gap between an individual which preventive measures, awareness creation/ sensitization and a cascade of preventive measures has helped prevent getting infected to one that is already infected and facing a life long treatment regimen. Our focus principally is therefore going to be Health promotion (through various media both formal and informal); Health Education and engagement of stakeholders, opinion leaders, key populations to preventive measures and information; as well as enhancing modalities to ensuring sustained HIV Counselling and Testing Services (HTS), continued supply of Anti Retroviral drugs (ARVs), and other consumables to PLWHAs.

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Still looking at advancing Health Care in Nigeria, there are three major delays to accessing health care. These are the delays of ignorance/ decision-making, that of problem of distance to point of access/ facility and finally that of availability of competent hand/ skilled personnel when patients indeed get to the facility. These three delays if appropriately attended to and solved would advance health care delivery in Nigeria. On my blue print coming on board, I would approach making a difference having these delays in mind on how to bypass, remove or ameliorate them.

Continuing public enlightenment, health education, sensitization, awareness creation or whatever you call it, utilizing different information channels and media outlets including the social media improves people’s/ population’s health knowledge, awareness, healthy practices and information on available healthcare thereby aiding their decision making and choice of Health care options.

On the second delay, effort to bringing closer Health care to people’s doorsteps is already on in many areas like in Enugu State where the State Government is strengthening the Primary and Secondary Health Care for maximal functionality with the empowerment of the State Primary Health Care Development Agency and upgrade and equipment of many General Hospitals for better services to people of Enugu State.

His Excellency the Executive Governor of Enugu state has also taken his time to ensure that the right people with the requisite skills/ expertise, experience and commitment are appointed to head vital health related Ministries Departments and Agencies (MDAs). Our drive therefore in ENSACA is not to take the Governor’s goodwill for granted but ensure that all efforts are maximally put in place to taking the agency to an enviable level. In line with this we want to commence institutionalization of PMTCT (Prevention of Mother to Child Transmission) of HIV/ AIDS in multiple additional facilities spanning the length and breadth of the State to Control the vertical transmission of HIV/ AIDS whilst offering HTS to pregnant mothers in these facilities.

Going forward also, we intend to improve on competence and availability of skills at health facilities by embarking on training of trainers in order to foster effective and efficient capacity building and training of staff at the frontline of HIV/ AIDS service delivery at the different facilities while ensuring robust monitoring and evaluation of service delivery at these facilities as well as QISS (Quarterly Integrated Supportive Supervision) at these facilities. QISS offers the added advantage of On the Job Capacity Building (OJCB).

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We would continue to actively work effectively and in synergy with partner CSOs, NGOs, international development partners, Local Agency for the Control of AIDS (LACAs) to getting the best of input/ support from them to ensure a multi-sectoral approach to Control.

Recommendations on how to advance health care in Nigeria especially containment of COVID-19
A lot of positive things have been done in Nigeria to containing the deadly COVID-19. The important thing is to stay focused and not let down our guards.

Going forward establishment of more testing centres should to be encouraged, possibly cascaded to at least one per state of the federation. Robust contact tracing of suspected and confirmed cases should be expanded and sustained. Sensitization and awareness creation on preventive measures should not be taken to the back seat. Life has to continue but preventive measures like already practised such as social distancing, regular hand washing with soap and water and when unavailable use of alcohol based hand sanitizers, use of face masks when in public places or outside one’s household should all continually be emphasized. These measures to a very relative extent and as much as possible should be encouraged and enforced with civility.

Interstate border restrictions enforcement should as well be sustained as long as the National/ State Governments directives to that respect lasts.

Ultimately, the experience of this pandemic should serve a wake up call to strengthening in all spheres the Nigerian health care delivery system for the better.

Claims and counter claims of herbal/ local cures for HIV/ AIDS
I do not underrate or undermine the efficacy or potency of herbal medications as long as it is subjected to the necessary medically institutionalized protocols to ascertaining its authenticity and safety.

Is there a cure for HIV?
Science is making tremendous progress in terms of Anti-retrovirals. Presently available drugs when taken daily by PLWHAs is capable of suppressing the viral load to undetectable levels such that these ones are unable to infect others. Efforts are being made in the directions of reducing frequency of ingestion of drugs to possibility of a one single injection that could carry the patients for as much as 3 months before the next dose. This is work in progress and at this pace one can’t definitely rule out the possibility of a cure in the not too distant future. That would indeed be very interesting.

How do you intend to address the issues of healthcare financing?
Health care financing has majorly been a problem in the Nigerian health care system as majority of populace make ‘out of pocket’ payments at hospitals. This has left a lot of people without health care access and this definitely is not sustainable on the long run.

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A recipe actually should be to improve on the Health Insurance system in order to have a wider spread of people accessing healthcare under this umbrella. Presently, mostly individuals on government employ, of Banks and other big institutions/ organisations are the ones captured in the formal Health Insurance Schemes. The insurance system does not trickle down to the generality of the masses as the market women, petty traders, farmers and daily wage earners are all left out. I think capturing this group of people in a form of insurance system would go a long to helping the Nigerian healthcare financing system.

A ready answer would be a form of Community Based Social Insurance System (CBSIS). Here, the local people and low-income earners in Communities could be enrolled. Though individual contributions may be meagre, combined yearly contributions of this people would be substantial and serve a pooled risk. Having in mind the unlikely situation of every one being sick at same time, it is evident that these pooled resources can effectively take care of medical expenses of the minor ailments and commonly endemic disease conditions in our environment like malaria etc. that these people may present within the time/ period. These are diversification that our Nigerian Health System when fully explore, would tremendously improve health care access and I believe in many are already being explored for immediate and long term health gains.

Coming back home to Enugu State, HIV/ AIDS Control and at ENSACA, we intend to diversify and look into more options of financing HIV/ AIDS Control to support/ complement present Government funding. Don’t get me wrong we are already minimally getting some form of support from one or two of implementing partners for instance United Nations Children Fund (UNICEF) which has been supporting ENSACA’s Prevention Technical Working Group’s (TWG’s) Meetings/ activities but we intend to further expand the scope of our outreach. Considering the fact that the World Bank funding is not yet forthcoming and SACA activities had been built around these expected funding, we definitely must sit up to create more options to funds mobilisation and application in our activities. It is definitely work in progress.

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