Sustaining free HIV treatment in Nigeria
Nigeria may not be able to meet the National Strategic Framework (NSF) 2017-2021 Targets and the United Nations 90-90-90 ambitious treatment plan to end Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) by 2030.
90-90-90 is a plan announced in January 2017 by the Joint United Nations Programme (UNAIDS) to ensure that: by 2020, 90 per cent of all people living with HIV will know their HIV status; 90 per cent of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART); and 90 per cent of all people receiving ART will have viral suppression.
This was immediately domesticated by the Federal Ministry of Health (FMoH), through the National Agency for the Control of AIDS (NACA), into the NSF 2017-2021 Targets: 90 per cent of diagnosed People Living with HIV (PLHIV) are on ART by 2021; 90 per cent of diagnosed PLHIV on treatment are retained in care by 2021; 90 per cent of eligible PLHIV receive co-trimoxazole prophylaxis by 2021; and all PLHIV diagnosed with tuberculosis (TB) have access to services by 2021.
The Guardian’s investigation has revealed why Nigeria may not be able to meet the NSF and UNAIDS targets; sustain the free national treatment programme; and put more PLHIV on treatment.
Of the estimated 3,228,842 PLHIV (2,981,946 adults and 246,896 children) in Nigeria in first semester of 2017, only 31 per cent that is 1,050,594 (991,584 adults and 59,010 children) are on treatment.
According to recent figures from NACA, ART coverage mid 2017 was 31 per cent for all PLHIV, 32 per cent for adults and 25 per cent for children respectively.
This means that in Nigeria only one out of three people in need of the life-saving ART drugs is accessing treatment compared to South Africa where two out of three persons in need are accessing treatment.
Also, the recent estimates from NACA and FMoH show that only nine states reached ART coverage of 50 per cent or more in first semester, 2017: Enugu, Benue, Delta, Adamawa, Anambra, Federal Capital Territory (FCT), Plateau, Kogi, and Ekiti states respectively.
According to NACA, the state with the lowest ART coverage was Sokoto state while the state with the highest ART coverage was Enugu state. It noted that total ART unmet need is highest (greater than 75,000 persons) in nine states (Oyo, Akwa-Ibom, Lagos, Sokoto, Edo, Taraba, Kaduna, Imo and Rivers).
Further analysis showed that though the number of persons currently on ART has increased, the country progress for the second 90 of the 90-90-90 target is just 31 per cent: there is still huge unmet need for ART in about one third of the states, inadequate Early Infant Diagnosis (EID) coverage and viral load testing services, and weak referral linkages.
According to UNAIDS, Nigeria has the highest number of new HIV infections among children with over 40,000 children born with HIV yearly; and more than 200,000 new infections. Mother-to-Child Transmission (MTCT) has been identified as a major route of pediatrics HIV infection. It refers to when an HIV exposed infant of an HIV-infected mother acquires HIV infection from the mother,
The main goal of Prevention of Mother To Child Transmission (PMTCT) is to prevent transmission of the virus from HIV positive mother to the exposed infant
Data from the states showed that the highest unmet need for PMTCT is in 12 states: Abia, Akwa Ibom, Bauchi, Benue, Cross River, Delta, Ebonyi, FCT, Gombe, Lagos, Oyo and Rivers.
National Strategic Framework (NSF) 2017-2021 aims to eliminate MTCT in Nigeria by 2021; and complimentary Fast Track Emergency HIV/AIDS 2016 plan that seeks to test 3,000,000 pregnant women and put all 75,000 estimated HIV plus on ART for life by the end of 2018 has also been developed.
Another major challenge towards meeting the 90-90-90 target is Nigeria requires at least N50 billion yearly to sustain the treatment of 1,050,594 PLHIV and N150 billion to treat all the 3,228,842 PLHIV; while the national budgetary allocation for health in 2017 was just about N303 billion.
Director General of NACA, Dr. Sani Aliyu, at an event ahead of the World AIDS Day (WAD) December 1, 2017, in Abuja, said: “If we must take our response to the next level, we must address the challenges related to our health system infrastructure, unmet need for commodities, data quality and human resource for health and funding. These challenges constitute key barriers to universal access to HIV/AIDS services in Nigeria. It costs about N50,000 to provide ART to a person living with HIV for a year. With the size of our treatment programme (at over one million PLHIV on ART), we will require at least 50 billion Naira annually to keep them on treatment, while we require triple that amount annually to achieve and maintain ART coverage saturation in Nigeria.”
Another major challenge is that donor funds are dwindling. In fact the United States President’s Emergency Fund for AIDS Relief (PEPFAR) and the United States Agency for International Development (USAID) that use fund up to 70 per cent of Nigeria’s spending on HIV/AIDS activities have pull out substantially. There are also fears that with President Donald Trump’s proposed 28 percent budget cut for U.S. diplomacy and foreign aid next year, the support would become negligible.
According to latest figures from UNAIDS, there are about 34 million people living with HIV and Nigeria alone accounts for about 10 per cent of this global population. As at July 2017, of the 3.4 million HIV positive Nigerians, 1,000,050 are on ARV out of which about 763,050 are on PEPFAR, 179,000 on Global Fund and 58,000 on Federal Government of Nigeria support.
A breakdown shows that of the total people on ART in Nigeria PEPFAR treats 76 per cent; Global Fund 17 per cent while the Federal Government of Nigeria treats 5.8 per cent.
However, there still exists a gap of about 2.4 million people to be put on treatment which would still open wider with the Test and Start treatment policy in practice now.
The Guardian investigation also revealed that there is no recent national population based survey with up to date data on the current burden of the HIV/AIDS epidemic in 36 states and FCT.
There is also allegation that the Ministry of Finance is endangering the lives of PLHIV by refusing to process import duty waiver for drugs and health commodities donated by the Global Fund for the treatment of Nigerians with HIV, tuberculosis and malaria.
Executive Secretary, Civil Society for HIV/AIDS in Nigeria (CiSHAN), Walter Ugwuocha, told journalists that there are associated consequences of delayed approval of Import Duty Exemption Certificates (IDEC) waivers to all the donated drugs, health and non-health commodities and equipment donated by the Global Fund as part of its investment in the health of Nigerians.
Ugwuocha said the immediate consequences include: risk of expiry because the commodities are nearing their shelf life even while still at the sea ports waiting for clearance; and stock-out of drugs and health commodities at the health facilities which will lead to poor-adherence to treatment by the patients – the consequence of this is breeding of resistance strain of the AIDS virus which is more expensive and more difficult for the patient to manage.
So what happens to the over 1.05 million PLHIV already on free treatment and the remaining 1.9 million that require to be put on treatment for the country to achieve the 90-90-90 targets and eliminate HIV/AIDS by 2030?
Several studies have shown that if PLHIV stopped taking ART they will develop AIDS and will die within one year. Others researches indicate that delay or interruption in the therapy will lead to drug resistance, making the firstline drugs ineffective and the need for a secondline medication, which is usually very expensive and unaffordable.
Ibrahim Umoru has been living positively with HIV for over 15 years now. Umoru told The Guardian: “Nigeria in August 2010 signed a memorandum of understanding with the US government called the PEPFAR Partnership Framework promising to support the US government in her response to HIV in Nigeria with 50 per cent of the cost by 2015. As at 2014, Nigeria has only met about 15 per cent of this which led to the PEPFAR team to reduce their funding support to the national response and the worst hit of the programme is the laboratory monitoring back up for HIV response.
“As we speak, many PLHIV in Nigeria now pay for their laboratory monitoring in some facilities. This is causing many to miss appointment and proper follow up. On the long run we would have a deluge of people failing treatment and requiring second line treatment.
“Second line treatment is about 10 times or more expensive than the first line our poor system is messing up now. What is there to celebrate when the system in all sense is pushing many of my peers to their early graves?”
Umoru said the whole scenario is worrisome as the government is not truly taking her leadership responsibility rightly in this aspect thus the response is purely driven by donors. “As it is now with our AIDS epidemic reaching maturity we are yet to understand what the minimum package of care should be thus every implementing partner roles out what they feel best for them. This is not right,” he said.
Until now, several researches and the WHO have confirmed that HIV treatment reduces mortality and morbidity among PLHIV, improves their quality of life and reduces their potential to infect others.
The Nigeria national ART programme started in 2001 in 25 tertiary health facilities. The ART programme is focused on increasing access of PLHIV to ART, providing them access to isoniazid prophylaxis for tuberculosis prevention; and reducing their risk for other opportunistic infections using co-trimoxazole prophylaxis.
To make the treatment accessible to more PLHIV, free ART provision policy by Federal Government of Nigeria commenced in 2006. In 2015, Nigeria adopted the WHO’s policy of test and treat all.
The ART programme also promotes screening and treatment of all persons living with HIV for tuberculosis, and screening and treatment of all newly infected or relapsed tuberculosis cases for HIV infection.
In 2015, global leaders signed up to the Sustainable Development Goals, with the aim to achieve universal health coverage (UHC) by 2030. The UHC framework now lies at the centre of all health programmes.
To complement the global WAD December 1, 2017 campaign which promotes the theme “Right to health”, the WHO highlights the need for all 36.7 million people living with HIV and those who are vulnerable and affected by the epidemic, to reach the goal of universal health coverage.
Under the slogan “Everybody counts”, WHO advocates for access to safe, effective, quality and affordable medicines, including medicines, diagnostics and other health commodities as well as health care services for all people in need, while also ensuring that they are protected against financial risks.
According to the WHO, key messages to achieve UHC include: leave no one behind; HIV, tuberculosis and hepatitis services are integrated; high-quality services are available for those with HIV; PLHIV have access to affordable care; and the HIV response is robust and leads to stronger health systems.
Ahead of WAD, UNAIDS launched a new report titled Right to Health showing that access to treatment has risen significantly, globally, from just 685,000 people living with HIV accessing to antiretroviral therapy in 2000 to 20.9 million in June 2017. South Africa had the largest number of people on treatment, at 4.2 million, followed by India, Mozambique, Kenya, Zimbabwe, Nigeria and Uganda, which all had more than one million people on treatment.
National Coordinator of the Network for the People Living with HIV, Victor Omoshehin, told journalists: “Nigeria’s government should own up to the HIV and AIDS response. Putting money into the national response is an investment in humanity. Our continuous access to medication and our right to healthcare is a fundamental right. Government should make it happen.”
UNAIDS Country Director for Nigeria, Dr. Erasmus Morah, acknowledged President Muhammadu Buhari’s new commitment to maintain 60,000 people living with HIV on treatment and place an additional 50,000 more on treatment each year, using domestic resources. Morah, however, said stakeholders must work as quickly as possible to ensure that Nigeria funds and owns the HIV response.
Until now, several studies have indicated that country ownership and sustainability is crucial for an effective and efficient AIDS response and that the essential elements of country ownership include among other things political engagement and commitment.
The Guardian investigation revealed that concerted efforts geared towards ownership and sustainability of the National HIV/AIDS response is steadily gaining momentum and President Buhari has promised that Nigerians shall begin to see the results before the end of 2018.
The Guardian investigation revealed that some of the major steps taken recently include:
*Endorsement of HIV Sustainability roadmaps developed by States. It is believed that the roadmaps will assist the States to take ownership and chart the course towards domestic resourcing of the HIV response.
*NACA has made a strong case for the resourcing of the sustainability roadmaps in a presentation to the National Economic council in June this year, with a call to action to the Governors to earmark 0.5 to one per cent of the monthly federation allocation to states for financing the implementation of the HIV/AIDS programme.
The NACA DG said: “Every Nigerian has a right to good health. We have a responsibility to ensure that this basic right is available to all Nigerians. The Government is committed to enhancing ownership and sustainability of the HIV/AIDS response.”
Aliyu said one per cent of federal allocation to states in 2016 was N23.1 billion. “The proposal is that the funds be used to cover 50 per cent treatment scale up at a cost of N20.7 billion. We have since commenced high-level advocacy to States to secure commitments on increased budgetary allocation and releases. Eight states have responded and we are following up with the remaining states.
“We are currently exploring the integration of HIV services into the national, State and community health insurance schemes.
“… The rate of Mother to Child transmission of HIV in Nigeria is still unacceptably high. We certainly need to do more at the federal and state levels to take ownership of our HIV/AIDS response and close these gaps.”
The NACA DG said the overarching goal is to create a sustainable financing mechanism of the National HIV response driven by the private sector in Nigeria. He said the main objective is to raise private sector contribution to the National HIV response from 2.1 per cent to 10 per cent by the end of 2018/2019 and therefore contribute to ensuring HIV commodity security in Nigeria.
Aliyu said part of the solution is to foster Public Private Partnerships (PPP) for local production of ARV drugs, rapid test kits and condoms.
President Buhari said the burden of HIV on women, young people and babies born with HIV in Nigeria and in sub-Saharan Africa remains a clog in the wheel of our socio-economic development. “This ugly situation is unacceptable to the Federal Government and to all well-meaning political leaders. This situation has been compounded by the insecurity challenges faced in some parts of the country,” he said.
Mr. President said the Federal Government is aware that procurement of health commodities from foreign sources is not sustainable for a country with a huge disease burden like Nigeria. “In order to overcome this challenge, the Federal Government is working with relevant stakeholders to provide an enabling environment to promote the local manufacture of health commodities that meet global standards,” he said.
Buhari said the Federal Government is aware of the huge financial requirements for health including HIV/AIDS and other infectious diseases. He explained: “In this regard, the 2018 budgetary provision for Health will witness a substantial increase. However, this will not be adequate due to a number of other significant priorities. I therefore use this opportunity to call on State Governments and the Private Sector to support the Federal Government’s aspiration to provide universal healthcare for all Nigerians.
“As we hope to increase local resources for health in the coming years, it is important to establish effective accountability frameworks for the efficient use of resources.”
Aliyu said NACA is working with the Federal Ministry of Health and our development partners to conduct a national population based survey that will provide up to date data on the current burden of the HIV/AIDS epidemic in 36 states and FCT. “Beyond HIV burden, this survey will also provide reliable data on HIV incidence, rate of viral suppression among PLHIV on ART, and prevalence of hepatitis B and C. I thank the United States Government, The Global Fund and the United Nations family for their support in this regard. The results of this survey will indeed improve our understanding of our epidemic and provide more accurate and reliable data for planning and decision making.”
On how to achieve sustainable funding of HIV Treatment and PMTCT services for Nigeria, Managing Director, Society for Family Health, Nigeria (SFH), Bright Ekweremadu, recommends increased government funding for the HIV response as is done in South Africa. “South Africa despite having the biggest and most high profile HIV epidemic in the world, with an estimated 7.1 million people living with HIV in 2016, has the largest ART programme globally and these efforts have been largely financed from its domestic resources. The country now invests more than $1.5 billion annually to run its HIV and AIDs programmes. So far, the country has 56 per cent adults on ART and 55 per cent of children on ARTs,” he said.
Ekweremadu said what is required here is a multi-tier and multi-stakeholders financing plan with State government, local government, NHIS and the Federal government articulating and implementing a comprehensive financing plan under the coordination of NACA.
He advocates exploration of better private sector integration for financing including private health Insurance and also possibility of creating a voluntary pooled procurement of ARVs and other consumable to reduce cost of treatment in private sector.
UN Secretary General, Mr. Antonio Guterres, in a message ahead of WAD, said: “On the first World AIDS Day since I became Secretary-General, I am hopeful that the world will meet the target of ending the AIDS epidemic by 2030, but mindful that much more needs to be done to ensure that target is reached. With nearly 21 million people living with HIV now accessing HIV treatment, the world is on its way to meeting the target of 30 million people on treatment by 2020. With declining AIDS- related deaths and falling numbers of new HIV infections comes hope that the world can deliver on its promise.”
UNAIDS Executive Director, Michel Sidibé, called for a renewed commitment to finish what has begun and renew efforts to make the AIDS epidemic a thing of the past.
Morah said to achieve “Right to Health” for People Living with HIV in Nigeria; the health sector needs all proposed additional funding with which to provide all people with the health services they need, including access to the full range of HIV services, without subjecting them to financial hardship.
Umoru said: “I strongly recommended that treatment of HIV should be free, comprehensive, qualitative and accessible all over the country. This way we would begin the regaining of already lost grounds and consolidating grounds still held. In working towards this, our government should take her rightful place in the national response by owning it and leading the whole process. Funding to health should be given priority while checking for abuse and misuse with strong reprimands where found. We all need to prove to the world that testing positive to HIV is not a death sentence and our inactions should not prove otherwise.”
According to the WHO, expanding access to treatment is at the heart of a new set of targets for 2020 which aim to end the AIDS epidemic by 2030.
The Sixty-ninth World Health Assembly endorsed a new Global Health Sector Strategy on HIV for 2016-2021. The strategy includes five strategic directions that guide priority actions by countries and by WHO over the next six years.
The strategic directions are:
*Information for focused action (know your epidemic and response).
*Interventions for impact (covering the range of services needed).
*Delivering for equity (covering the populations in need of services).
*Financing for sustainability (covering the costs of services).
*Innovation for acceleration (looking towards the future).
WHO is a cosponsor of UNAIDS. Within UNAIDS, WHO leads activities on HIV treatment and care, HIV and tuberculosis co-infection, and jointly coordinates with United Nation Children’s Fund (UNICEF) the work on the elimination of mother-to-child transmission of HIV.
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