Nigeria making shaky progress in ending HIV/AIDS transmission

Today is World AIDS Day, and the theme of this year’s celebration is “Communities Make the Difference.”

The World Health Organisation (WHO) is highlighting the difference communities are making to end the Human Immuno-deficiency Virus (HIV) epidemic, while drawing global attention to the need for their broader engagement in strengthening primary healthcare.

Although Nigeria has made some progress in reducing the number of AIDS-related deaths and prevalence in the general population, recent reports suggest that the pace of decline in new adult HIV infections in the country, and indeed some other parts of the world remains short of ambition.

Prevalence is a statistical concept referring to the number of cases of a disease that are present in a particular population at a given time, whereas incidence refers to the number of new cases that develop within a given period.

According to the 2018 National HIV/AIDS Indicator and Impact Survey (NAIIS) released in March this year, Nigeria has recorded about 40.6 per cent decline in the number of persons infected with HIV from 3.229 million people, with a prevalence of 3.0 per cent in 2014, to 1.9 million persons with a prevalence of 1.4 in 2019.

This decline moved Nigeria from the second position on countries with the highest HIV prevalence to fourth behind South Africa, India and Mozambique.

Based on the 2014 HIV Sentinel (ANC) Survey, the HIV prevalence for Nigeria was three per cent, which made Nigeria a country with the second-highest burden of HIV/AIDS in the world after South Africa.

The data from the NAIIS are based on a revised and enhanced methodology. The survey provides a clearer understanding of Nigeria’s HIV epidemic and shines a light on progress made, the remaining gaps and challenges.

It is believed that the improved understanding of the country’s HIV epidemic will allow for more efficient investments in the response to HIV and more effective planning for the provision of HIV prevention, care and treatment services, including a focus on key populations, such as female sex workers.

It will also permit the adoption of a population–location approach to delivering services to the people and areas where they are most needed.

The new data differentiates HIV prevalence by state, indicating an epidemic that is having a greater impact in certain areas of the country. The South-South zone of the country has the highest HIV prevalence at 3.1 per cent among adults aged 15–49 years.

HIV prevalence is also high in the North Central zone (2.0 per cent) and the South East zone (1.9 per cent). HIV prevalence is lower in the South West zone (1.1 per cent), the North East Zone (1.1 per cent) and the North West zone (0.6 per cent).

Nigeria has shown steady progress on increasing access to treatment for people living with HIV, with the adoption of a test and treat policy in 2016. This measure has further accelerated referrals to treatment facilities for people who test positive for the virus.

From 2010 to 2017, the country almost tripled the number of people living with HIV that have access to antiretroviral therapy, up from 360 000 people in 2010 to more than one million in 2018.

However, the new estimates released recently indicate that more than half of people living with HIV still do not have suppressed viral loads.

The new data are more accurate as they are based on an expanded surveillance system and a revised and enhanced methodology. In recent years, there has been a significant expansion in the country’s response to HIV. The number of sites providing treatment has more than tripled, the number of sites providing services to prevent mother-to-child transmission of HIV has increased eightfold, and the number of HIV counselling and testing sites has increased fourfold.

A total of 11.3 million adults were counselled and tested for HIV in 2016, four times as many as in 2012.

Meanwhile, the first case of AIDS in Nigeria was reported in 1986. Since then, the epidemic has grown steadily from 1.8 per cent in 1991 to 3.8 per cent in 1993; 4.5 per cent in 1995, and 5.4 per cent in 1999, and peaked at 5.8 per cent in 2001.

The prevalence began a gradual reduction from 5.8 per cent to five per cent in 2003, this decline continued to 4.4 per cent in 2005, 4.6 per cent in 2008 and 4.1 per cent in 2010. By 2014 the HIV prevalence rate was 3.0 per cent.

According to the NAIIS, Nigeria has fewer people living with HIV than previously estimated.

How Did Nigeria Achieve 40.6 Per Cent Decline In HIV Prevalence In Four Years?
The intensive free national treatment programme with antiretroviral (ARV) drugs has suppressed the virus in persons living with HIV (PLHIV) and made them unable to transmit the disease. Indeed, viral load suppression (VLS) is an important marker of transmission, as those with undetectable virus in their bloodstream will not transmit the virus.

According to the NAIIS, VLS, defined as having less than 1,000 HIV Ribo Nucleic Acid (RNA)/genetic material copies per ml of plasma, showed the positive effect of ARV treatment. Achieving VLS maximises the health benefits to PLHIV, minimises the risk of HIV transmission, and is necessary to halt the epidemic.

Key findings by the NAIIS include the fact that for every 1,000 persons aged 15-49 years, 14 will be are carrying the virus; HIV prevalence is highest among females age 35-39 years at 3.3 per cent, and highest prevalence among males age 50-54 years at 2.3 per cent.

It also revealed that the HIV prevalence of gender disparity between females and males was greatest among younger adults, with females age 20-24 years having four times the prevalence of males in the same group.

Furthermore, the new prevalence gives an estimate that 1.9 million people are living with HIV in Nigeria, even as the highest prevalence is in the South-South Zone and the lowest prevalence in the North West Zone.

The over $90m (N34.29t) worth survey was conducted by the Federal Government and sponsored by the United States (U.S.) President’s Emergency Plan for AIDS Relief (PEPFAR), with $70m, and the Global Funds for AIDS, TB and Malaria with $20m and other development partners.

The survey reached around 220, 000 people in about 100, 000 households, and the fieldwork was conducted between July and December 2018.

The Director-General of the National Agency for the Control of AIDS (NACA), Dr. Gambo Gumel Aliyu, in his comment said: “It is important that all people living with HIV get into treatment and achieve viral suppression. To halt the epidemic, we need to act now. As a government working with our partners, we have what it takes to support HIV-positive persons, to provide treatment, to protect their families and to help people live long and healthy lives.”

Commenting on why more women than men are infected with the virus, Aliyu said: “It has to do with the physiology of the woman. It also has to do with the lower bargaining power for sex and socio-economic status of most women. Women are also victims of violence and rape. Forced sex increases the risk of HIV transmission among women due to lacerations. Women dreading or experiencing violence, are less likely to negotiate for safe sex, go for HIV testing, share their HIV status and access treatment.”

Indeed, several studies have demonstrated why women are at a greater physiological risk of contracting HIV than men.

A study published in the AIDS Research Therapy, titled “Women and HIV in Sub-Saharan Africa” noted: “This is in part because women have a greater mucosal surface area exposed to pathogens and infectious fluid for longer periods during sexual intercourse and are likely to face increased tissue injury.

“Young women are at particularly high risk due to cervical ectopy, which facilitates greater exposure of target cells to trauma and pathogens in the vagina. It has been well documented that Sexually Transmitted Infections (STIs) increase the risk of HIV acquisition. For women, the risk is increased due to difficulty in diagnosing STIs, which are often asymptomatic in presentation, thus making treatment difficult.”

More than 3, 000 field staff did data collection from household members ages zero to 64 years old, and participants were asked about knowledge of HIV/AIDS, their behaviours, risks that may predispose them to HIV, health-seeking behaviour, and stigma and discrimination against people living with HIV/AIDS.

Confidential HIV counselling and testing services were provided and blood samples tested for HIV, Hepatitis B, Hepatitis C, and other biomarkers.

All participants that were found to be HIV positive were linked to a health facility to help them access HIV services. HIV confirmation tests were done, and viral load measured to determine the degree of viral suppression among those taking HIV medications.
Pace Of Decline In New Adult HIV Infections Remains Short Of Ambition.

According to a new report, despite progress made in control of HIV/AIDS, some coalition countries, however, experience increase in new adult HIV infections, including Nigeria, where new adult HIV infections increased by eight per cent, and Pakistan, which is experiencing a rapidly growing HIV epidemic among key populations, where new adult HIV infections rose by a staggering 56 per cent. On average, new HIV infections in non-coalition countries remained relatively stable between 2010 and 2018.

The new report on progress made in reducing new HIV infections, across 28 countries that have been particularly affected by HIV, was launched by co-conveners of the Global HIV Prevention Coalition, Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations Population Fund. The report was launched at the High-Level Meeting of the Global HIV Prevention Coalition, held on November 12 on the sidelines of the Nairobi Summit on ICPD25.

Together, the 28 countries account for 75 per cent of all new HIV infections globally—1.2 million of the 1.7 million new HIV infections among adults in 2018. The report, Implementation of the HIV prevention 2020 road map, shows that among the coalition countries new HIV infections among adults declined on average by 17 per cent since 2010, slightly higher than the global decline of 13 per cent, but far short of the 60 per cent decline needed in 2018 to meet global HIV prevention targets.

Executive Director of UNAIDS, Winnie Byanyima, said: “We are nearly 40 years into the HIV epidemic and it is unacceptable that governments and leadership are still shying away from sensitive issues.

“Investments in HIV prevention do not match the needs of our people; in some countries, even the basic commodities like condoms are not available, accessible or affordable in rural areas, for young people or key populations.”

The report shows that some countries have made significant progress, with 12 countries reducing new adult HIV infections by 26 per cent or more since 2010. They include countries with major epidemics, such as South Africa, with a 39 per cent decline, the Democratic Republic of the Congo, with a 37 per cent decline, Uganda, with a 36 per cent decline, and Zimbabwe, with a 28 per cent decline.

The report shows that while there has been some progress in developing programmes for adolescent girls and young women, the Global HIV Prevention Coalition estimates that in 2018 only 34 per cent of the areas with high HIV prevalence had dedicated comprehensive HIV prevention programmes for women and girls—far short of the global target of reaching 90 per cent of adolescent girls and women with these services by 2020. During the meeting, Nyasha Sithole, from the Athena Network, made a strong call for investment and engagement of adolescent girls and young women in HIV prevention and sexual and reproductive health programming.

The Global HIV Prevention Coalition was established in 2017 to galvanize greater commitment and investment in HIV prevention to achieve the 2020 prevention target of reducing new HIV infections among adults by 75 per cent by 2020 (against the 2010 baseline). Its added value is visible in several focus countries and beyond. Countries confirm that it has promoted a more systematic and structured approach to HIV prevention programming and built momentum in most of the 28 countries; however, much more needs to be done to meet global commitments.

To accelerate progress in stopping new HIV infections, momentum urgently needs to be stepped up by increasing investment, addressing HIV-related stigma and discrimination, addressing the legal, policy and structural barriers to HIV prevention, especially for adolescent girls and young women, key populations and their sexual partners, and taking measures to expand community-based responses.

By taking these critical steps and increasing efforts to address persistent gaps in programme coverage and ensuring that services and community programmes are available to everyone in need, significant progress can be made towards ending AIDS.
Govt Scaling Up Interventions To End Scourge

The Minister of Health, Dr. Osagie Emmanuel Ehanire, told The Guardian that, “there is something to cheer about in the just-released “National Aids Indicator and Impact Survey (NAIIS) of 2018, which is the largest such survey conducted, which now shows that Nigeria has HIV/AIDS prevalence of 1.4 per cent, down from three a few years ago.

“It gives us an idea of our problem, so we can target and scale up interventions to the 90-90-90 target, which is to detect 90 per cent of all HIV cases, treat 90 per cent and ensure 90 per cent are suppressed virally. We can build on that achievement.”

Osagie said about 1.9 million Nigerians are infected with HIV, and about one million get treatment free. Many of the rest do not even know their status. “Know your status,” “test and treat,” are part of the strategy of the Federal Ministry of Health (FMoH).

On the country’s poor paediatric HIV treatment statistics, Ehanire said: “Paediatric HIV derives largely from mother to child transmission during delivery. Prevention of Mother To Child Transmission (PMTCT) is an important item in our HIV elimination strategy. Detecting the mother’s HIV status during antenatal care visits, putting positive ones on treatment at once to defeat most transmissions does it. To scale this and such intervention up to rural and underserved areas, we advocate the need for functional Primary Healthcare Centres (PHCs) in every ward in Nigeria.”

On what the government was doing to improve a situation where over 70 per cent of HIV activities in the country are funded by the United States, he described the U.S. government as a great partner, not just in fighting HIV/AIDS, but in other challenges. “We also get support from the Global Fund and other partners, without whom it would not be easy. The government of Nigeria does its best within the circumstances that it finds itself. But all must work together to eliminate diseases of global concern by 2030,” he said.

While enumerating challenges facing HIV control in the country, the surgeon said funding challenges are the topmost. “I hope it improves as public revenue increases and pressure on the budget from security, food, and energy agencies are satisfied. Behaviour risk communication needs to be stepped up, with high priority to youths in age-appropriate and culture-sensitive HIV education. Key groups need to be addressed too,” he said.

Commenting on the alleged neglect of persons living with HIV in prisons, Ehanire said Nigerian prisons have medical units to take care of persons in custody, adding that the Ministry of Health was not directly in charge of these units, but is ready to support correctional institutions to meet their medical needs, including HIV treatment.