Towards ending AIDS — Nigeria moves closer

As recently as 15 years ago, there was a sense of hopelessness for people living with HIV in Nigeria. Today, their lives are filled with countless tomorrows.

And by 2022, the AIDS epidemic is expected to no longer be a public health emergency in Nigeria.

What a difference a decade makes when there are changes in policy, investment and commitment — all of which were needed to make the life-changing antiretroviral treatment accessible to everyone.

The Nigeria story begins with making treatment available to people living with HIV, mostly through hospital HIV clinics, like this one in the Nigerian Institute of Medical Research in Lagos. In the early days of available antiretroviral treatment, the high price in Nigeria, at around 70 000 naira ($635) at that time, put it out of reach to most people. HIV testing and other related services also were not free. Consequently, people were not testing. People were not going for treatment because they couldn’t afford it. Plus, they were afraid: Afraid of dying. Afraid of family and friends knowing about them and rejecting them. Afraid of losing their job.

There came a point when the Government realized something had to change and committed to putting people on treatment, first with the U.S. President's Emergency Plan for AIDS Relief contributing the drugs. Then in 2015, with guidance from the World Health Organization and the supply of drugs also coming from The Global Fund to Fight AIDS, Malaria and Tuberculosis, the Government embraced the localizing of the global 90-90-90 goal: By 2020, 90% of the population living with HIV knows their status, 90% of those who know their status are placed on drugs, and 90% of those on drugs achieve viral suppression. As a result, the scaling up of people on treatment has been massive — Nigeria has tripled the number of people on HIV treatment since 2010.

Nigeria has the third-largest HIV burden in the world, and one of the highest rates of new HIV infections in the Africa region. Many people living with HIV in Nigeria are unaware of their status. There are many AIDS-related deaths. Nigeria contributes the largest burden of babies born with HIV in the world, close to one in every four babies globally are born with the disease each year. At the peak, HIV prevalence in Nigeria was 5.8% — nearly 10.5 million people in the population of more than 180 million persons. Today it is 1.4%. That means an estimated 1.9 million Nigerians are HIV positive. More than 1.1 million of them are now on treatment.

According to the National Agency for the Control of AIDS, the Government is working on user fees. A basic health care provision budget has been finalized, through which 1% of revenue will be used to create a basic health care provision fund. For the first time, money will be going directly to primary health care facilities; 50% of that will contribute to health insurance schemes, 45% will go to primary health care centres for their day-to-day operations and 5% for emergencies. Part of the money will be used to offset the user fees issue and part of that money will be used to help us improve maternal and neonatal outcomes.

“What am I most proud of? How we scaled up services,” praises Dr Araoye Segilola, Director of the National AIDS/STIs Control Programme in Nigerian Federal Ministry of Health. “We started saying, use data, look at prevalence and see where to put a facility. Our data isn’t perfect, it’s also a work in progress. We use a pool method for distributing the drugs. And we move commodities to all facilities.” Part of the prevalence reduction has to do with an exhaustive National AIDS Incidence and Impact Survey that led to the downward revision of the estimated numbers of people living with HIV.

“I hear you’re a fighter at school,” says the tender technician to the 6-year-old. “Yes, I beat everyone in school.” Oh, I’m scared of you now. You’re going to beat me up.” And so begins the simple step of drawing some blood from Isikong’s arm to check how well his system is responding to the treatment he has been on since birth. In the cramped Lagos hospital lab room, his mother stands to the side, terrified of what the results may say. “I am grateful to God for the medicine, says Esther, his mother. With antiretroviral treatment capable of suppressing HIV, an undetectable viral load means that the chance of transmission is significantly reduced.

“I am particularly proud of the adolescent clinic that I started and which has not only ensured retention of more adolescents in care in the Nigerian Institute of Medical Research than in other sites but also better drug adherence, viral suppression rates and improved quality of life among these adolescents, some of whom have gone on to become accomplished young adults,” says Dr Agatha David, Consultant Paediatrician and Head of Department of Clinical Sciences at NIMR in Lagos. Her institute is part of a study on HIV self-testing among adolescents and young people. Motorcycles, she adds, are used to transport samples to the NIMR reference laboratory and to take results back to the sending sites. This ensures that quality lab services can be provided to a much larger pool of clients outside the institute.

“I like this place because of the compassion they are giving”, says Idayat, 22 and five months pregnant with her first baby, in the Omolade Trado Clinic and Maternity in Lagos. Preventing transmission from mothers to children is a big focus of the Nigeria strategy. It is also the biggest challenge for the Government because only 38% of births take place in an institutional facility. In Lagos, the Government began working with the traditional birth attendants, training more than 100 of them so far to test for HIV. If a woman tests positive, she is referred to a hospital to begin the prevention-of-mother-to-child-transmission course. The future strategy for Nigeria’s prevention of mother-to-child transmission is still a work in progress. Many public hospitals are returning to charging for birth services, and women are finding it unaffordable, sending them to facilities that likely won’t test them for HIV.

“I enjoy helping people — I love to give them hope,” says Mosunmola Dosunmu, one of a small but growing group of “community pharmacists” in Lagos as well as elsewhere in the country who have been trained by the Government on the distribution of HIV treatment for people who want to avoid the hospital clinic or who find it difficult to take time off from work (which is a huge fear for many people on treatment—too much time for hospital visits may jeopardize their employment). Community pharmacists receive the medication from hospitals and earn nothing from distributing it. Stigma and discrimination remain palpable fears in Nigeria. Thirty-eight-year-old Noi, picking up her drugs in the photo, lives 90 minutes from Mosunmola’s pharmacy. Her husband died of AIDS nine years ago, and none of her four children know her status. Nor do her neighbours. She sells food stuff and she fears if they did discover her status, “They would avoid me, they would not buy from me.” She takes four buses and one motorcycle taxi every two months to protect her secret.

“I make sure people take their medication. I go to their homes, and I offer them phone support,” says peer counsellor Halima Gambo in Maiduguri. Her counselling comes from a place of knowing too well what others are going through. Although she was diagnosed 19 years ago with HIV, she could only access treatment in 2003. Three of her five children died in that time. Her two surviving sons, aged 25 and 30, attend university, and she is determined to give them a good education “so they can make a good life for themselves”. She works as a peer counsellor in the Maiduguri Hospital in Borno State. She also has spoken out on television and radio to destigmatize HIV. “We say in Nigeria, ‘the person who wears the shoes knows where it pinches the most’, says another peer counsellor and “mentor mother”, Abiola Ajani, 40, in Lagos, stressing that people with HIV talking with people with HIV makes all the difference. “Dignity is another key thing. I tell people to ‘stop looking down on yourself. HIV is not written on your face. Do you know I'm HIV-positive by looking at me? No!’”