Aliyu: Ending AIDS by 2030 without working with key affected population an impossibility

Dr. Gambo Gumel Aliyu is the Director-General of the National Agency for the Control of AIDS (NACA). Aliyu, an epidemiologist and public health specialist, studied at the Ahmadu Bello University, Zaria, Kaduna State. Until his appointment, he was the Chief of Party for the Nigeria Indicator and Impact Survey (NAIIS). He also worked as the Country Director for University of Maryland programmes in Nigeria and is an associate professor at the Institute of Human Virology, University of Maryland School of Medicine, United States. In this interview with journalists, ahead of World AIDS Day, Aliyu said the growing resistance of the Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) to first-line drugs is a matter of national security, and that it will be impossible to end AIDS in Nigeria by 2030, as projected by the United Nations, if NACA does not work with such key affected populations as prostitutes and homosexuals, among others. CHUKWUMA MUANYA reports.

There are growing concerns over the rise in drug-resistant strains of HIV. What is the situation in Nigeria and what is NACA doing to address it?
THESE are issues we check from time to time. Presently, we haven’t got the most recent data on it. Until then, we cannot make any statement. But suffice to say what produces or generates resistance basically issues with adherence, and this is one area we are focusing our attention on, in addition to getting people to come for treatment. Taking treatment is one thing, adhering to treatment is another, and we need both to successfully suppress the virus, to prevent the virus from leaving an infected person to affect another that does not have it. There is also a need to deny the virus the chance to break the body defence mechanism that exposes the person to AIDS and all associated illnesses. In most cases, that is actually a pointer which notifies healthcare providers that something is wrong here, leading to getting the individual tested and identifying HIV in the person.

Even after HIV is controlled, the resistance issue is going to linger because it borders on people having the discipline to continue taking medication and subjecting themselves to periodic testing to see how the medication is helping to make the virus disappear.

What is the burden of drug resistance in Nigeria?
It is not very significant to an extent that it has become a public health issue. But our responsibility is to prevent that occurrence, to ensure that it does not become alarming and that we do not give room for it to grow. One area that is very important to us that our service implementers, or service providers, is to ensure that there is no disruption in the supply of these medications. You may have a situation the patients are willing to take medication, but if you create an atmosphere where the medication becomes unavailable, then you are either consciously or unconsciously introducing an environment where such resistance can thrive.

And it would be unfortunate, if you have a significant proportion of your patients, especially in a place like here, where we have over a million individuals on treatment and carrying the virus, you introduce an atmosphere where resistance can grow. Then, your control mechanism is going to be challenging because you will see that resistance will develop.

Second is the case of someone that does not have the resistance but has the virus and the medicine is withdrawn. Exposing the virus to the medicine, which is later withdrawn temporally or permanently will provide an atmosphere for resistance to grow. The unfortunate thing is that if this guy develops drug resistance, and then happens to transmit it to someone else, that person is getting a new infection with a virus that does not totally respond to available drugs.

That is the danger, and if we are getting a significant proportion of them coming up, the implication is that you have a chunk of them that you need a more expensive drug to treat.

About three years ago, President Muhammadu Buhari promised to be adding 60,000 persons living with HIV/AIDS yearly to the number accessing free treatment nationwide. How far with the implementation? How many people are on treatment now?
Let me correct it, it is 50,000 and not 60,000 yearly. Last year, we had 50,000 patients on treatment by the Nigerian government. This year, we are having 100, 000 on treatment by the government. Next year, we hope to make it 150,000, despite scarce resources. That is on course. For this year, we have fulfilled the pledge.

Overall, there are 1, 240,000 Nigerians currently accessing free treatment.

There have been cuts in donor funding for HIV/AIDS. The United States and some other donors have threatened to cut and have cut their funding. How is this impacting your activities?
The cut in donor funding we have experienced so far has not been significant on the side of the US government. Maybe the cut will come this year or next year. For this year’s funding, which we received last year, there was only a drop by N20m. We had N390m the previous year and it dropped to N370m. That drop was taken care of by money made available by other donor agencies, such as Global Fund, and the fact that we are bringing ourselves together to align and make a single treatment programme or uniform treatment programme for the country.

What that means is that we look at what everyone is doing and what every one of us is good at doing. The three government stakeholders- the government of Nigeria, the Global Fund, and the United States President’s Emergency Preparedness Fund for AIDS Relief (PEPFAR) and we identified strengths and weaknesses and we apportion responsibility. That removed duplication, because we ensure that all our efforts complement each other and not duplicate.

And that saved us some money and prevented any gap from showing in terms of the effect of the N20m cut we had this year. We do not know about next year, whether that cut is going to be significant and severe. But we are hoping that even if it is going to come, it will be something we can handle.

How about domestic funding? Has Nigeria the requirement in this regard? What percentage of the proposed 2021 budget is allocated to HIV programmes?
The Federal Government has responded to the issue of domestic funding with vigour. Last year, we requested money to place 100,000 people on treatment, and this year, that money was made available, which enabled us to successfully place the 100, 000. There is another area we are looking at. We are not only limiting domestic funding to the government alone, but to both government and private sector.

In the private sector, we have made some progress, in that it is the private sector wing of the business community, where we plan to have HIV Trust Fund and raise money to support HIV programmes in the country. In that area, we have recorded a situation where presently we have the trust fund registered and identified individuals interviewed for the chief executive’s position. The hired Chief executive will be ratified before the end of the year and in the next quarter, beginning next year; we plan to launch the trust fund. So the work is ongoing.

However, we have not made significant progress in the area of getting contributions from the states, which means states contributing to the response and giving the FG money for the response, but making money available to state agencies to coordinate and control HIV response in the respective states. This is one area we will be focusing on next year, simply because states are very critical for controlling HIV and for ending AIDS. Over 80 per cent of people presently on treatment are state patients and over 95 per cent of the hospitals providing services for HIV belongs to states, while over 90 per cent of health workers that provide services in those facilities belongs to states. The Federal Government has less than 150,000 patients among those we are treating now in federal facilities.

It is important and it is time we work with the states, so that they take over leadership of this response, not necessarily that the states provide resources, but that they coordinate. This is because, in the long run, there is no way we can achieve sustainability without the states taking that leadership, being in the driver’s seat. So, this is the area we need to do more work on going forward and we need to pay more visits to state governments and make more presentations at the National Economic Council with the help of the Vice President.

Two years ago, the Vice President helped us, and we had a presentation and a few state governors responded. We need to remake the case because the HIV resistance issue is a national security issue, simply because if you get a significant proportion of your patients developing drug resistance, then the possibility of you controlling the epidemic and putting it where you want is going to be extremely difficult.

A new study showed there is a new injection that is more effective than the regular daily pill, especially for women in preventing HIV infection. Do we have any such opportunity in Nigeria? Is there any effort to have it here?
We have had formal communication that this injection exists and it is working well. Traditionally, when such things are available, we take them and check the data available globally, where such medication has been used and for how long and how many patients were involved, and how successful. This is because we need to do due diligence before introducing such development or innovation. The injectable ARV is a very good idea. It is given once or twice a month or once every month or once every two months. The good thing is that it makes life easier for people who have an issue taking pills every day.

However, these patients are required to come to the facility for injection 12 times a year. Every month, they come to a facility and get injected and they have to show up every month, whereas, with the pills, they may only have to come four times a year. This is because when they come, we give them pills that will last for three months. We call it multi-month dispensing. The patients can now pick and choose which they prefer. Do they want to pick the pills and keep on taking them every day? If they are fine with it, then they can go for that option. Or, if they prefer the injection, they can have it. We have not started doing the injection here in Nigeria, but it is something we will be looking at very soon.

What has been the impact of COVID-19 on efforts to end AIDS?
The lockdown period particularly impacted in such a way that it has denied us the opportunity to identify newly identified people monthly and yearly, we go after the remaining unidentified people. We identify them and bring them for treatment, which is the only way to control HIV and end AIDS. So, our numbers reduced in the month of April and May this year, simply because of the lockdown. Aside from this, it has also competed with HIV in certain things. For instance, when it first came, most of the laboratories that do COVID-19 tests are HIV laboratories, and even now, they still provide those services. So, we ran HIV tests during the day, and at night we ran COVID-19 tests. It was not easy for our staff nationwide.

Is the HIV self-test in use in Nigeria, especially for those in rural areas, who may not have access to standard facilities to undergo HIV tests to see if they are HIV positive and know their viral load?
What I should have done was to bring along such a test and probably make them available to you. Yesterday, I presented it to some people at our Abuja office. It is quite amazing, especially for people desiring privacy, which is good because they have the right to do that. They can decide to take this test in the comfort of their home, and the result can be out in 20 minutes.

At the beginning of this fight, it would have been risky to introduce this, because people then took stigma and discrimination very seriously. I have seen somebody that committed suicide just because his wife tested positive for HIV. That was over 15 years ago at Asokoro Hospital in Abuja. These days, we don’t see those kinds of things because people now understand that having HIV is not the end of the road. It is just the beginning of another journey to healthy living when you have the virus.

This is what we want people to know: have the courage, the confidence to test yourself. Don’t be afraid, just go and do it. When you do it and if the result shows you have the virus, have the courage to go to a facility and get tested there with the utmost confidentiality. You should confirm that the virus exists in you and have the courage to come forward to take medication. You can go to centres where the medications are offered, and they are given free of charge. You can call us at 6222 from wherever you are in the country, and we will direct you to where medications are given and where you feel comfortable to take the medication.

••• What this will do is: First, it will take care of the virus and ensure it is denied the opportunity of multiplying, which is very good. The ability to multiply is what gives the virus the strength to get out of you to affect another person and to hack down the body’s defence mechanism. Why should you allow it? You should not. So if you have it, fight the virus also. One sure way to fight the virus is you coming to take the medication and deny the virus the chance to grow in you and when you do that you live a healthy life. Nobody will see any sign of HIV in you and when you see people living with HIV now, they look like fresh tomatoes. When they see you anywhere if they tell you they are HIV positive you will not believe simply because the medicine has taken care of the virus and the virus no longer disturb the body’s defense mechanism and they are no longer giving it to other people. So this is what we want to do. To get the majority, 95 per cent of people that live with the virus, get to identify them and put them on medication, make sure about 70 per cent of them are taking care of the virus and limiting the virus within himself or herself. When we do that when you see new infection will be rare, you don’t see it anymore and death from HIV/AIDS, you don’t see it anymore because the virus is brought under control. It is there in the body but it is not harming the body to the extent that it brings the body down. I was telling one of my bosses that if everyone in Nigeria will take that courage to test themselves within the next one year or from now to the second quarter of next year, I can guarantee you that we can control HIV in a year or two here in this country. It is doable. We can do it.

What is the situation as regards the number of new infections?
We still have new infections and this is what measures your ability to control the virus. But the good thing is that the number of new infections and deaths due to HIV is declining. But it is not declining at the rate we had wanted to see and what that is telling us is that either these people that are taking these medications are not faithful to it or they are not taking it regularly and because of that some of them have dropped out of treatment. Those who have dropped out of treatment, the virus is growing very fast in them and they are giving other people. Some people have never known they have HIV because they never tested. So if you don’t test there is no way you will know whether you have the virus or you don’t have. Every citizen has the responsibility to help the government to control HIV simply because it ravages society, brings people down, and also bring them to hospital. Also, it ravages loved ones especially the newborn that are going to live their entire life with this virus. We should do everything within our ability to prevent the transmission of HIV to newborn babies. These are people you expect to live the next 70 years or more but they are coming into this world with a tragedy and this thing is preventable. Why do we allow it to happen and we cannot prevent it if we don’t know whether we have it or we don’t have it. Especially every pregnant woman should have the opportunity to have HIV testing and her husband and somebody who has responsibility for it should also help to make sure that pregnancy is tested for HIV and if there is HIV, necessary steps are taken to prevent the newborn from having it. It is doable and we are doing it and continue to do it but we cannot do it when individuals refuse to have the test, they refuse to come to the hospital to deliver and even when they deliver at home they refuse to have an HIV test done.

Do you have special outreaches to vulnerable groups like prostitutes, men having sex with men? Unfortunately, some of these groups cannot feature openly because of our laws. So how do you get around that?
We have access to the vulnerable group. Those are the ones we call key affected populations. As I am talking to you we have a survey that is nationwide that is restricted to two states in each geopolitical zone that will give us an idea. Just similar to the nationwide study we did two years ago to tell us what the status is with the general population and we know this epidemic is declining in the general population. However, in the key affected population, we believe the story may be different. This is the group that is at highest risk of getting HIV infection and this is the group that is at the highest risk of giving HIV to people. If we don’t find them, if we don’t work with them, if we don’t make services available to them, then it will be impossible for us to control HIV. We are aware of that. So because of that, we are now collecting data to know their size and the size of their typology and to know the services they prefer giving the services that are available and re-tweak our strategy to make sure that we meet them half way or where it possible for us to see them or provide these services to them.

How far with the challenges of accessing pediatric version of ARV?
We treat HIV in all categories now. We have pediatric, adults, and pregnant women. In all these, we are making good progress. One area that we keep on emphasizing and we keep on paying attention to is how will we get the women, how we get to test them, how we get to test their newborn babies to identify whether this newborn has HIV or that they don’t. And that is the area that is the next coming year, 2021, we are going to be paying extra attention to. We will see how we will reach out in a way that is different from the one we have now because if you have a strategy and the strategy doesn’t seem to be working well, it doesn’t look smart on your side to continue to thread that path. We need to look for alternatives; we need to look at ways that can yield this number that we are talking about, culturally, socially and in whatever way given the available access we have at the community level.

What is your message to Nigerians on World AIDS Day?
We started World AIDS Day on Tuesday, November 24, 2020, with a press briefing in Abuja. My message is to help us contribute to controlling HIV/AIDS in Nigeria by testing yourself to know your HIV status today. If your status is positive, call us or meet our health workers anywhere in the country to make sure they help control this virus in you and to make sure this virus does not leave you. We have been doing that and will continue to do that. If your status is negative you can still call us at 6222 to learn how you remain negative for the rest of your life and this is our responsibility to make this information available. Please do not disenfranchise yourself from the services that are free and that are there waiting for you, take advantage of it. Know your status, if you are negative learn how to remain negative for the rest of your life. If you are positive, it is not an end to this road, it is the beginning of a journey to healthy living with HIV.