4 April 2018

Nigeria: Why U.S. Is Funding World's Largest HIV Survey in Nigeria - NACA Boss

Photo: The Guardian
A HIV positive woman posing with her antiretroviral drugs.

Sani Aliyu is the Director-General, National Agency for the Control of AIDS (NACA). In this exclusive interview with PREMIUM TIMES' Ayodamola Owoseye and Nike Adebowale, he speaks on why the largest survey of people living with HIV will be conducted from June in Nigeria and the reason why Nigeria still records high rate of Mother to Child HIV transmission of HIV.

PT - The world just celebrated World Tuberculosis Day to call attention to one of the deadest diseases affecting people living with HIV. What is your agency doing to prevent people with HIV from having Tuberculosis (TB) and providing treatment to those of them who already have TB?

Aliyu- You are quite right, HIV and TB are considered deadly twins and TB is the commonest cause of death in people living with HIV. And that is partly because of the prevalence of TB in our communities. Tuberculosis is so common, virtually most of us would have been exposed to tuberculosis at some point in our lives. What happens is that the disease becomes inactive in you and if your immune system drops, it becomes activated.

We at NACA have been working very closely with the federal ministry of health to design programmes that will reduce that frequency and incidence of TB in people living with HIV. For example, during the World TB Day, we engaged with the federal ministry of health, we were there, shoulder to shoulder with the minister, to show our solidarity.

Some years back, when there were issues with diagnosing TB, there is a new diagnostic tool which is based on PCR, which has been rolled out across a lot of sites in the country. NACA, actually worked with the Global Fund to deliver that and most of the machines that are currently used for Rapid Test in hospitals for TB were delivered through NACA.

There is also a very strong need that when people are diagnosed with HIV, an assessment is made as to whether they have been exposed to TB or not and if there is evidence that they have been exposed to TB and they have active Tuberculosis, then they need to be placed on full treatment. If there is evidence that they don't have active TB, then they can go on to prophylaxis, which will prevent them from developing active TB. Our approach nowadays is across the board. The first thing is to make sure you do not have active TB because if you have active TB and we put you on prophylaxis, (the drug for prophylaxis is only one drug) you will end up developing resistance. But if you don't have active TB, that Isoniazid which is the name of the drug, would stop it from activating from latent to active TB and it is only given for six months. So when people are placed on treatment for HIV, they will also be started on Isoniazid to prevent them from developing TB and it is now part of our national guideline across the board.

We are also doing a lot of works in the communities through other partners to make sure that people are aware of common symptoms of TB. So if you have cough that has lasted for more than two weeks, you have night sweat, losing weight, think of TB, because it is unlikely to be malaria. If you are having a cough that has been lasting for more than two weeks and losing weight, it is unlikely to be pneumonia, because if it is pneumonia for two weeks you will likely be in the hospital bed.

TB is a chronic illness, which takes a while before it actually brings a person down. You can continue to go to work for weeks, while you have TB and you are coughing before you realised you need to go the hospital.The awareness of the common symptoms of TB is important because if you know that you have TB, you will need to be put on treatment. Same way if diagnosed with TB, the next thing is to have an HIV test done. If you have HIV with TB, it is a different issue. We need to treat HIV as well to bring your immune system up so that as you are on treatment for the TB, the TB can be cured. If we give you treatment for TB without treating the HIV, work done is zero, because even if you are treated for TB, the first place the drug may not work very well. Secondly, the person might end up surviving from TB and dying from another opportunistic infection related to HIV.

There is a lot of work we have been doing and TB is really important. There are a lot more people with TB in the world than there is with HIV. It is estimated that there are up to 500 million people being exposed to TB in the world, while with HIV, about 30 million people living with the virus throughout the world. So you can see the

difference. Out of every one person with HIV, we have 20 people who have been exposed to TB, so it's a big problem.

PT- Do you have the statistics of people living with HIV and TB in Nigeria?

Aliyu- Yes we do, but I don't have the figures straight away. There are figures. I don't want to quote figures available in terms of active TB and people living with HIV. In estimate, we have about three million Nigerians living with HIV, probably up to five to ten per cent of them would have active TB at any point in time.

PT- How will you rate the success of the TB/HIV programme?

Aliyu- Definitely, there has been progress, but the progress is very slow. We have had major challenges both in terms of trying to get clinics to put people with HIV straightaway on prophylaxis for TB. There has been concern in the previous years that if you treat latent tuberculosis with Isoniazid, what you are doing is that you are increasing the risk of resistance to Isoniazid. That actually hasn't been proven and there is no evidence based for it. In fact, there is very good evidence based, that if you have HIV and you are put on Isoniazid for prevention, for prophylaxis, your outcome is much better. Because you can still develop TB, while on treatment for HIV because TB and HIV, TB usually tends to come in at much higher CD4 count, that is the level of the immune system. You can have TB when your CD4 count is about 400 to 500 for instance. A lot of people would have been on treatment for a year two years for a CD4 count of 400 to 500. So if they are not treated for latent tuberculosis, it means a year down the line and after taking HIV drugs, they could still come up with TB. And that is why it is so important to get rid of that latent TB infection in people living with HIV.

PT- Currently, Nigeria has been using estimated data for people with HIV in the country and the federal government is planning to conduct a survey for a more accurate data. When will the survey be conducted and where? And what do you stand to achieve? How will this improve HIV campaign in the country?

Aliyu- The survey will be starting, hopefully, by June this year. The survey is partly sponsored by the United States government and Global Fund. It is the largest HIV survey ever done in the world. Partly because of the size of our population. We will be doing it across the country. We have gone very far in getting the initial stages of the survey. For instance, training is about to start and most of the guidelines have been written. From the Nigerian side, ethical approval have been given by the relevant government body and we are waiting for ethical approval from the U.S. side in order for us to get started. Equipment have also been procured and we are already starting to link up with state governments. We will be doing advocacy to state governors and also to traditional rulers.

The survey will cover the whole country, what it will show is where the issues are when it comes to HIV. At the moment, a lot of the surveys that are being done in the past have very wide confidence interval. Confidence interval means that they are not very precise because the sample sizes have been relatively small and the methodology has been different. This time around, we want to have more precise figures. We want to know right down to the state level and the sub states structures as well where people living with HIV are likely to be. So that, not only government but also our donors can target and channel resources towards those areas.

A common thing that is now happening over a year or two among our partners, is there has been challenges in getting people living with HIV. There are parts of the country that you will go to test people, and you will test and test, only few people will be positive. This increases the cost of delivering the programme because these test kits are expensive. If I have to test 10,000 people to get a handful that are positive, it is not good use of public resources. What we will prefer is to put resources in and get a high yield that will enable us to pick up a larger number of people having the disease and then linking them up to care. So that is what we are trying to do with the survey. The survey will tell us where the issues are, to enable us put in more resources in such areas. Nobody should be left behind. If you have HIV, it is important you are diagnosed. Don't forget we are talking about public health interventions, and with public health interventions, it goes beyond just the individual as we are looking at larger numbers. The more people we can pick up, the better for the overall response.

We are doing the survey to help us to channel public resources and use them more effectively, more efficiently and in an equitable manner. So you don't come to me and say, why am I funding HIV programmes in a state and not in another? Then I can say to you, we have saturated the other state with HIV testing last year and our survey shows there are maybe three or four times more people in the state we are funding, that is why we are channelling those resources there. It is a very important survey. I will like to appeal to our people and communities that when the survey comes, there will be a lot of publicity and they should please not be afraid and engage with us. We will be doing lots of testing, data for the overall good of the country and the overall good of the national response. And once we have the data, we will be able to have more robust national response to the HIV epidemic.

PT- What population size is the survey looking at?

Aliyu- You might say it's a small number, but the sample size will be about 3000 to 4000 per state. I think in total it is about 160,000 sample size that will be taken, including paediatrics and adults. You might say with a population of 180 million people, that is still a drop in the ocean. But it is not just the sample size that matters. It is also the methodology and the method of sampling.

We will be going down to enumeration areas, it will be right down to the ward levels. Enumeration areas will be selected in a scientific way and then they will be sampled. And it is not just HIV we will be looking for. We will also be looking for Hepatitis B and C. When we come to you and ask for your blood, you might think you don't have HIV, which by the way unless you are celibate or born before 1981, there is no way you can be 100 per cent sure you are HIV free. So it is important you all come out and get tested to know your Hepatitis B or C status. A lot more people die from Hepatitis than from HIV in Nigeria.

In a way it is a win, win situation for us all. We are grateful to our donors and supports of our principals in governments, particularly the federal government that has given us all the support we need to make sure that this survey becomes a reality. We hope that the survey will finish by the end of the year, just before the elections and results will be ready by early next year.

PT- Will the Nigerian government also fund the survey?

Aliyu- The government is supporting it, maybe not directly with money but with our resources and human capacity.

PT- How do you intend to harmonise the data from the private laboratories with the ones you will collect at the national survey?

Aliyu- The survey will determine HIV prevalence at community level, not at the facility level. What you raised is a very important issue. We increasingly know that a lot of HIV tests are being done in the private sector. In the past, we had been unable to pick up those results. More recently, the last time we collected data for HIV testing, we actually had to approach facilities directly and ask them how many people did you test and what is your result? That is a very inefficient way. The Federal Ministry of Health has been trying to roll out DHIS, that is the health information management system, and providing platforms for the private sector to make report. Particularly reporting mandatory diseases, which are communicable diseases like Lassa fever and other infectious diseases.

It is important that we have a mechanism that allows the private sector deliver information to the main servers in the Federal Ministry of Health. I think what we need is incentives to allow the private sector to do

this because it will cost money to employ somebody to put in data and then send it. Externally, in countries like the UK, until recently, doctors were paid for every report made. I am not saying we should pay everybody, what I am saying is that we need to develop an incentive scheme that will support our private sector to provide us with relevant information that we can use to manage our health systems. 40-45 percent of Nigerians actually use private health facilities, which is a huge number. So it is a gap we have in data, that we really need to fill.

PT- Funding for HIV seems to be going down and Nigeria has been advised to own their campaign. With the health sector being under funded in this country, what do you think will be the future of HIV campaign in Nigeria, if the fund stops or reduces to the minimal?

Aliyu- We cannot sit down and allow this to happen. We know about one million people living with HIV and 95 per cent of them are being catered for by the U.S. Government and Global Fund, while five per cent by the government of Nigeria. We are working to reverse this with our principals. President Muhammadu Buhari has already made commitment that 50,000 people living with HIV will be put on treatment every year, consecutively. Though that is a drop in the ocean and will take a long time, but it is an excellent beginning. We already have 60,000 people in Taraba and Abia that are currently on treatment.

More importantly, what we have done with the Minister of Health, Isaac Adewole, we have put up a proposal for a national treatment programme for the country. The national treatment programme will be the future platform for delivering HIV services in the country. Essentially, what it will entail is, we will pull resources from the treatment budget of NACA and the treatment budget in the Federal Ministry of Health into the national treatment programme. The national treatment programme will work directly with state governments. So, just like we have in Taraba and Abia, where we channel funds to the state governments and they deliver the programmes, we will channel funds through the national treatment programmes to activate, beginning with five plus two states to start running HIV programmes. We will support those states with procurement of commodities, because everything you do at a large scale is much cheaper. For example, when it comes to HIV drugs, we know our partners, the U.S Government and others, they have easier access to markets at a lower rate because of their ability to negotiate costs.

We will build on that for the national treatment programme because we will have an economy of scale that will allow us to procure commodities and then deliver them to those states under the national treatment programme. If it works very well, what we plan is we start taking over sites that are currently not being used by our partners and deliver care to the people, and if in the next five years or 10 years, the US Government says to Nigeria 'we are done', it means we will have a platform that will allow us to continue the treatment programme.

Those one million on treatment for HIV, will continue to be around for another 30- 40- 50 years and they will continue to require drugs to allow them to live useful lives and somebody needs to look after them. Who would continue to do so? It is not going to be the U.S Government of Global Funds for the next 30-40 years. It would be Nigerian government and we need to work out a solution before it becomes a much larger problem that will be difficult to handle.

In the long term, what we are looking at is increased funding across the board for the health sector. We talk about Abuja Declaration, where we look at 15 per cent funding to the health sector. We cannot increase the pie for HIV funding in Nigeria, without increasing the overall health budget. The US government funding on average is about $400 million every year in Nigeria. Global Fund is about $110 million every year. The entire size of the HIV response in the country is about $700 million every year. How much is the budget for the Ministry of Health last year? It was less than $1billion. You cannot put all your money into one disease condition, so we need a different mechanism.

Let's increase the pie for the entire health sector and in that process, we will increase the HIV funding. We are trying to bring in the private sector, to help us set up a HIV Trust Fund and we are also building on our links with the states to encourage them to set up State Health Insurance Scheme that will allow people living with HIV to key in because if you are on treatment for HIV, you got to be on treatment for life. Certainly, at the moment there is no cure.

PT- On the state funding, the minister complained some weeks ago that some states have not contributed a kobo to HIV funding. How have you been working with them? What is the state of HIV in these states not providing counterpart funds and can you name some of them?

Aliyu- You want to put me in trouble with the states and be declared persona non-grata with them! We have only started advocacy visits, so rather than going to the states and be banned from landing at the airport. The term counterpart is wrong, what we are saying is that the state governments used their own money to fund the current structure that exists in the states through the State Agency for the Control of Aids to run HIV programmes. Most states have budgets but a lot of them don't release anything for it. Sometimes, you don't blame the governance but blame the budgeting process, the issue of finance and also the lack of awareness at an executive level that HIV is still an issue. Most governors I have I met, when I tell them they haven't released anything for HIV in three to four years are often shocked and don't know that is the case.

That is why we are working through the state health commissioners and through the commissioner of budget and commissioner of finance to make them aware of this issue. We agreed at the National Economic Council for states to put 0.5 to one per cent of their federal monthly allocation towards HIV in their states. We are not saying give us the money, we are saying use the current arrangement in your state and fund HIV programme properly. Most of the money could have gone principally into prevention, because at the moment I am not aware of any state government that is currently running treatment programmes.

Taraba and Abia, we run it through the federal government budget. I am not aware of any state government looking after people with HIV on treatment. They do not directly implement treatment programmes. What they do is provide services in terms of prevention, awareness, testing, and intervention in terms of key vulnerable population, that platform that is required to keep the epidemic in control. What we are saying is put your money into what will benefit your people most. HIV is important, they really need to fund HIV properly. There are states that are doing very well and am happy to name them. Kaduna State is exemplary in terms of their funding for HIV. Lagos State is also doing well. There are states that have State Agency for the Control of Aids (SACA) while they also have a governor chairing the agency. I will not mention states that are not doing well, but my challenge to the governors is, you did not object when we presented this to you so it is about time you put your money where your mouth is and fund HIV programmes properly in your states.

PT- It seems the world is missing the target of eliminating Aids by 2020. Going by the 2016 figure, we had about 160,000 new infections in children globally. Why is this and what can be done about it?

Aliyu- In Nigeria, we have a challenge with prevention of mother to child transmission of HIV. Other countries are doing well, like in Cuba, it has been eliminated. Belarus, not a problem, in Australia, it is no longer considered a public health emergency. In the UK, and in my almost 20 years of working in HIV field, I have not had a single patient who had a child born with HIV. We are having issues with Nigeria, partly because of the culture we approach ante-natal care and partly because of ignorance as well, especially among our pregnant mothers and lack of awareness. For instance, we know a large number of our women do not access ante natal care the normal way. If you look at our data for prevention of mother to child transmission, provided a pregnant mother goes to a facility for ante-natal care, nine out of 10 times is very likely to get a HIV test done. But when we have 45-55 percent of pregnant women not accessing facility care, maybe going to Traditional Birth Attendant or going to places of worship to deliver, then access to those mothers becomes really difficult.

What NACA has been doing is looking for a way of chasing those mothers and getting them to have an HIV test done and linking them up with treatment. That is the only way we can address prevention of mother to child transmission. We have to work outside the normal arrangement that the rest of the world had and we also need to integrate prevention of mother to child transmission into other maternal and child health services. We should not treat HIV as a separate issue in health care, it needs to be a holistic care. I am so delighted that the Saving One Million Lives has a component of prevention of mother to child transmission within it.

At the last meeting, which was chaired by the minister, directives were given that the Saving One Million Lives programme should invest in procuring test kits for testing pregnant mothers of HIV. We are also doing more work when it comes to maternal and child health week. Our aim is that for the two maternal health week that takes place every year, it provides us an opportunity to test all pregnant women within that period. Hopefully, we will pick up those women that need to go on HIV treatment because if you have HIV and you are pregnant and you deliver and you are on treatment and virological suppressed, there is less than one per cent chance that you will transmit the virus to your baby. But if you are pregnant with HIV and you do not do anything about it and you deliver, 3 to 4 out of 10 babies will get infected.

Nigeria contributes the largest number of babies born with HIV in the world. It is a burden, a sore on the nation's conscience and something that has to stop. The wife of the president, Aisha Buhari, has just been appointed by UNAIDS as a special ambassador on prevention of mother to child transmission and at that level, we hope to really key in and address this problem once and for all. It is a problem that can be solved. No Nigerian child should be born with HIV it is not right, we have the resources and the ability to stop it and we should not allow it to continue.

PT- Substance abuse is a problem Nigeria is tackling and this has been a major contributory factor to spread of HIV in many societies. What is NACA doing to stem the tide and control HIV transmission through drug use?

Aliyu- We have what we call key population. These are population that are at higher risk of having HIV, people who inject drugs, men who have sex with men, female sex workers etc. We have always had a programme that targets this vulnerable group of people. In Nigeria, injection drug use has never been a major issue in terms of transmission of HIV, but an issue in transmitting other viral infection like Hepatitis B and C.

The drug epidemic in Nigeria has not really been needle-based because most of it has been smoking. So the drugs were not being delivered in a way that transmits blood infections. Up north for instance, at the moment, there is an ongoing epidemic of codeine-related addiction. But we know that there are certain parts of the country, where as youths become more exposed to western culture, they start injecting drugs. That is really a safety issue. We are working very closely with NDLEA, we have had meetings and also attended some of their drugs-related conferences and we have been supporting the cause very closely. Drugs need to be controlled because if it is not controlled, epidemics like HIV and other blood-borne infections will rage and it mostly affects the youth. NACA will continue to work with other agencies of government, including how we can do programmes in addiction centres.


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