Africa: Getting Back on Track to Knock Out HIV – Dr. Sani Aliyu

17 July 2019

The pace of progress against HIV is slowing, says a report released 16 July by UNAIDS, the United Nations agency charged with" reducing new HIV infections, increasing access to treatment and ending AIDS-related deaths".

The warning comes as the global group is hiring a new executive director. After a search, the UNAIDS programme coordinating board, meeting in Geneva in late June, commended a short list of candidates as having "strong competencies'. The four Africans and an American are Ugandan Winnie Byanyima head of Oxfam International, who trained as an aeronautical engineer; Salim Abdool Karim, director of the South African Aids research centre, Caprisa; Johns Hopkins Bloomberg School of Public Health professor Chris Beyrer; former Namibian minister of health Bernard Haufiku; and Sani Aliyu, former director general of Nigeria's Aids control agency.

At a time when morale at UNAIDS is said to be low, and new energy and resources are needed to combat Aids, the choice – which will be made by UN Secretary-General António Guterres – is a critical one, says Richard Horton, editor-in-chief of the influential British medical journal The Lancet. Guterres' choice, Horton wrote in a 6 July column, "may determine the future fate of the AIDS epidemic".

Sani Aliyu, who has worked on HIV for his entire career - spoke to Bunmi Makinwa, the former Africa Regional Director of UNFPA, the UN population fund, in a lengthy interview probing Aliyu's qualifications for the position and the ideas that would guide his approach.

Who is Dr Sani Aliyu?

I graduated from Ahmadu Bello University, Zaria, Nigeria just over 25 years ago. I can recall quite vividly my fascination with HIV even in those early days. My community medicine project prior to graduation was on "Knowledge, attitude and belief on HIV/AIDS among university students in a northern Nigerian institution."

This dissertation was a real eye opener to the challenges of covert sexual relationships among young people in highly conservative societies and the link to cultural norms. My findings showed that young people were having sex, and potentially at risk of acquiring HIV, even in communities where social mixing among the sexes was taboo.  The need for increased awareness of HIV knowledge and prevention was quite clear.

My first proper job as a medical doctor was at the State House Clinic in Abuja, which was the first public health institution in the country to start providing free HIV treatment (Highly Active Antiretroviral Therapy of HAART). Abuja was a new federal capital then, blossoming with the influx of people from all over the country. The issue of stigma and discrimination was so rife then that patients would only come to collect their medications in the late evenings to avoid being identified as living with HIV.

I moved to the UK in 1998 to pursue a postgraduate programme in Internal Medicine. There, I was attracted once again to HIV medicine, after attaining dual membership of the Royal Colleges of Physician of the UK and Ireland.  I worked as a junior doctor at the Mortimer Market Centre, the largest National Health Service-funded sexual health clinic in the UK, this time experiencing HIV medicine in a resource-rich environment.

The clientele were very different. In Nigeria the epidemic was primarily in heterosexuals. In the UK it was a key population driven epidemic. When I moved to Cambridge a couple of years later, my heart was still in HIV medicine. I was appointed to the first joint training post in Microbiology and Infectious diseases, an experiment that was not only successful but also led to a consultant post being created some years later, which I subsequently took up.

My microbiology background strengthened the scientific platform for my infection practice, bridging the gap between the laboratory and clinical interface and providing me with the leadership skills necessary to run a large field exercise like the Nigeria AIDS Indicator and Impact Survey (NAIIS).

In July 2016, I was approached by the new administration of President Muhammadu Buhari to assist with restructuring the country's HIV response, which at the time was in deep crisis. To me, this was an opportunity to put back into a system that I had personally benefited from. I arranged for Special Leave with my institution and moved back to Nigeria to take up the post as the Director General of NACA. Prior to this, I had already agreed with government on a set of deliverables, which included a major restructuring of NACA to make it more efficient and effective.

You are a candidate for the post of Executive Director of UNAIDS. What specifically prepares and qualifies you for the job?

I have over two decades experience of working in the HIV/AIDS arena, both in clinical and laboratory settings and out in the field, as well as in the civil society space. I have the essential scientific understanding, a deep personal commitment to fostering quality teamwork and partnership, and the demonstrated courage and political skills to drive change in the most difficult environments.  I believe these are the key qualities required for this post today.

There has been tremendous progress in redefining the HIV response in Nigeria, working with the different arms of government, partners, civil society and the private sector to chart a new path for the country's response. I have worked hand-in-glove with my country's president, as his personal appointee and with his absolute support, to tangibly move policy and bring a new dynamism to the AIDS response in my country and region. I have led and successfully delivered in record time the NAIIS, the largest HIV survey of its kind in the world, to critical acclaim. I have significantly increased domestic resource allocation to the HIV response by both states and federal government as well as supported the establishment of a private sector led HIV Trust Fund. I have brought in-depth knowledge and intellectual capacity in the science and programmes for HIV prevention, treatment, service delivery and the challenges of reaching people living with HIV, women, adolescents and key populations. I am able to bring the science and politics of AIDS together for the benefit of the response.

The Nigeria HIV epidemic is a challenging and complex one, beset by accountability issues, barriers to accessing services, human rights abuses and social injustice. To succeed in such an environment requires resilience and strong negotiation skills.  I have successfully led the turnaround of the Nigeria HIV response, which over the years had defied progress. Prof Isaac Adewole, the immediate past Minister of Health in Nigeria, said I "have the necessary mix of skills, experience, and temperament to hit the ground running, bringing people together and getting people to do the greatest things."

I believe my work in transforming Nigeria's National Agency for the Control of AIDS (NACA), rebuilding credibility with our partners, bridging science and data to action, leading a collective national reappraisal and prioritization, and championing our cause at the highest political levels to move policy and mobilize resources, has transformed our AIDS response at a national level. Together with my broader curriculum, work history, and professional achievements, I believe I can leverage my experience to drive progress at the global level through UNAIDS. As a young, energetic and dynamic leader, I will bring new energy to the global HIV response. I have the grasp of the challenges, qualifications and directly relevant experience, not only to fill this position, but to hit the ground running, with passion.

What would UNAIDS look like under your leadership?

As an organisation, UNAIDS has been very successful in driving its mandate and maintaining the visibility of HIV globally as a public health threat.  Nevertheless, events of the last year have put a huge strain on the organisation and its stakeholders, creating the image of an organisation in deep crisis. UNAIDS finances have been under strain for a number of years, with the situation recently becoming more acute. In key technical areas, UNAIDS' several "realignments" appear to have hollowed out its technical capacity.

My priority will be to 'right the ship' starting by redeeming UNAIDS' public image of rectitude, instilling a renewed sense of pride, and refocusing on the serious issues of preventing new infections and reducing mortality. I will lead by example, encouraging quality teamwork and partnership, adopting a zero-tolerance approach to harassment, promoting gender equality and strengthen collegiality and harmonious working relationship among staff.

Clearly, some hard choices will need to be made and a meaningful consultation of stakeholders is the sine qua non. Pressing a strategic reset with co-sponsors would be key to building a new élan for the Joint Programme, building on the UN Secretary-General's on-going bold reform, especially at the country level and aligned with the 2030 Sustainable Development Goals. One of UNAIDS key strengths has been the unity and consensus of its Programme Coordinating Board (PCB). Anyone who serves next as Executive Director will need to work hard to preserve this approach.

I am determined to fully implement the management action plan arising from the events of the past year. I will also work jointly with the PCB members to make meetings more strategic and relevant to programmatic needs. I will promote inclusive governance and a country level approach to the joint programme based on agreed and robust joint planning, working and reporting. I will make sure the voices of key stakeholders are heard while promoting a system-wide mainstreaming of HIV as part of the wider Universal Health Care agenda. This will require the holistic needs of people living with HIV, key populations and vulnerable persons addressed within the SDG framework of poverty alleviation, gender/ human rights and economic empowerment. The approach to the use of data will be modified to include field data that goes beyond modelling and a stronger partnership developed with PEPFAR, Global Fund and other partners to share strategic information for action.

Within the context of the UN Secretary General's reform agenda to build a new-generation UN Country Team, I will work to refine the joint programme at country level, tailored to country priorities through an inclusive partnership and joint accountability with government, civil society, communities and international partners. There is a strong need to reinvigorate efforts in regions such as eastern Europe, Asia Pacific and the Middle East where we are seeing numerous countries with increasing infections. At the same time, the lagging response in west and central Africa is of major concern, and I will work to generate greater commitment.

We cannot afford to leave anybody behind.

We cannot afford to leave anybody behind. I will galvanize the political will and work with partners to mobilise the necessary resources to ensure we get back on track for 2030.

The issue of HIV prevention particularly among young persons, women and key populations becomes ever more urgent. We need a community health system which compliments and actively works with civil society who are organised to advocate and provide guidance and oversight to the programme. I will strengthen this partnership and ensure that prevention programmes are adequately resourced and pushed to the forefront of the HIV response, while also addressing human rights, stigma and social justice issues.

We have not invested to scale for eliminating stigma and discrimination. This has to change. The next Executive Director will need to fix, rejuvenate and revitalize UNAIDS. I am willing and able to do so.

The post of UNAIDS Exeutive Director was occupied by an African until a few months ago. Why would another African be the right choice for the international position?

While touching every continent, the epicenter of the HIV epidemic remains in Africa.

Although tremendous success has been achieved in placing persons living with HIV on treatment, with significant reduction in AIDS related deaths, the number of new HIV infections is not falling fast enough in Africa. At the same time, Africa's population growth and youth bulge is like no other.

In west and central Africa (WCA) for instance, the HIV epidemic continues to grow, amid significant unmet treatment need. WCA accounts for a third of the 9.4 million undiagnosed persons living with HIV and nearly a quarter of the 19.4 million not virologically suppressed. Only 48% of persons living with HIV in the region know their status. Mother-to-child transmission rates in WCA is 20.2%. Eastern and Southern Africa (ESA) is home to more than half of the 37 million persons living with HIV globally. North Africa has one of the widest gaps in treatment and viral load suppression.

A 20% cut in donor funding to Mozambique's Aids programme would mean almost all its health budget would be needed to replace it.

There has been a progressive shift in political and capital commitment to HIV programmes in the last few years. This is particularly felt in African countries where sustainability is a major challenge and the bulk of HIV investment is from external donors. In Mozambique for instance, 17% of the total public health domestic budget goes to HIV. In the event that international donor support is cut by 20%, the country will have to accommodate HIV with 98% of their public health budget, which is clearly not sustainable. Other African countries are facing similar scenarios, including my own country, Nigeria.

An epidemic of this proportion requires a strong leader with the local experience of the terrain and the political sagacity to get things done. It requires a leader with local connections and the understanding of cultural norms and sensitivities that go with effective and effective advocacy. The new Executive Director will need to work in a dynamic and engaged way, not just at country level but also at the regional level. An African with sensitivity to the cultural and economic challenges is critical to advancing policies and investments required to accelerate and sustain the response.

You recently resigned from your post at NACA. Why?

I was appointed to the post of Director General of NACA by the Nigerian President in July 2016. I am grateful to President Buhari for giving me the opportunity. Indeed, there is no greater honor than to serve one's country.

At the time, I had been working at Cambridge University Hospitals (CUH) as a senior hospital consultant for almost a decade. The Government of Nigeria appointed me to this post with the understanding that I will restructure the national HIV response and get it back on track. I had identified and agreed a set of key priorities that I wanted to implement whilst in Nigeria. For this reason, I requested for Special Leave from CUH with the understanding that I will return to my post once I was able to achieve these deliverables within the first tenure of the Buhari administration.

I have been fortunate enough to deliver on almost all the priorities I set out to achieve during this period. I stepped down from the DG NACA post at the end of June 2019 following a structured handover process to ensure continuity of the programme.

How did your job at NACA prepare you to lead UNAIDS?

NACA is in many ways a microcosm of UNAIDS. The Agency was modelled after UNAIDS with a similar mandate for coordination, facilitating and mobilizing resources for the HIV response, promoting a data-driven strategic response, measuring impact and ensuring that key stakeholders are coordinated and  accountable for delivering agreed priorities.

Nigeria has a complex HIV epidemic with more than 1.9 million persons infected with HIV and about 1.1 million on treatment. As a large country with a population of almost 200 million and a federal system with health on the concurrent list, advocating for increased investment in HIV among 37 State Governors was not an easy task. There were also serious challenges with stigma and discrimination and a legal environment that was hostile to key populations. Internally, I faced a culture of high handedness, maltreatment and bullying of staff that I had to put a stop to.

I have led Nigeria to successfully conduct, in record time, the largest HIV population-based survey ever undertaken globally, the Nigeria AIDS Indicator and Impact Survey (NAIIS), which became a game-changer for the national response. At one point during the survey I had more than 6000 staff in the field. NACA itself has a staff strength of about 300. I have a firm grounding in resource mobilization, having successfully advocated for a significant increase in domestic investment for HIV in Nigeria.

The DG NACA post also provided me with the platform to engage at a high level with government, donors and implementing partners. I represented the President of Nigeria at two UN General Assembly events, and I have chaired the Abidjan-Lagos Corridor Organisation, a sub-regional body formed by five West African countries to deal with HIV and other health issues along a major west African highway.

I have restored donor confidence and engendered a spirit of collaboration and shared vision and responsibility for the response. I have developed a sound working knowledge of the UN system and have maintained an excellent working relationship, building on individual agencies' comparative advantage, and connecting UN partners in the right political space to move the UN agenda.

I believe I have served the Nigeria HIV response very well in a very short spate of time. I am ready to apply these skills and experience on a bigger scale for the benefit of our global HIV community.

My job at NACA may not have necessarily prepared me for this, but there can be no ending of AIDS as a public health threat if we fail our youth. I believe I can serve as a particularly good bridge for communicating and reaching out to this pivotal population group for the response.

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