Nigeria: World Aids Day - Why Nigeria Missed 2020 HIV/Aids Target

1 December 2020

The 90-90-90 target was to achieve three major HIV/AIDS target by 2020.

COVID-19 has been largely blamed for disrupting several global health targets including the HIV/AIDS goal set for 2020 by UNAIDS, a United Nations agency dedicated to tackling the virus.

But Nigeria, among several other countries, was not even on track to reach the target before the COVID-19 pandemic hit due to a mix of factors, such as the high prevalence of mother-to-child transmission and isolation of key populations such as sex workers and gay communities.

That is not to say Nigeria did not make progress towards reaching the target.

In 2014, the joint United Nations Programme on HIV/AIDS - UNAIDS - and other foreign partners launched the 90-90-90 strategy which is an ambitious target to help end the AIDS epidemic by 2030. The aim was to diagnose 90 per cent of all HIV positive persons, provide Antiretroviral Therapy (ARTs) for 90 per cent of those diagnosed, and achieve viral load suppression for 90 per cent of those treated by 2020.

Two years later, in April 2016, Nigerian authorities adopted 'the testing and treatment policies' in line with WHO latest treatment guidelines and subsequently the 'UNAID 90-90-90 fast track initiative' was launched by President Muhammadu Buhari to accelerate the plan to end the AIDS epidemic by 2030 in the nation.

As Nigeria joins the rest of the world to commemorate the World's AIDS Day (WAD) on December 1, PREMIUM TIMES analyses some factors that have shaped HIV response in the country.

HIV/AIDS Census

One key initiative that highlights Nigeria's response to the HIV/AIDS epidemic was the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS). Conducted in March 2018 and released in 2019, the survey, which was the country's largest, cost about $100 million, involved 185 survey teams, and covered more than 200,000 people.

Preliminary results indicated that there are 1.9 million people living with HIV (PLHIV) in the country -- a 40 per cent reduction from the country's official national HIV prevalence estimates for 2017.

"The result reflected the progress Nigeria has made in scaling up HIV treatment and prevention services in recent years. The end of AIDS as a public health threat by 2030 is truly in sight for our country," President Muhammadu Buhari had said when the result was first released.

Health advocates also believe the new data will allow Nigeria to better target its HIV interventions in pursuit of the 90-90-90 goals.

This led to record gains; about 60 per cent of the people living with the virus in Nigeria are now on treatment, recent data from the World Health Organisation (WHO) shows.

While the 60 per cent is already showing a deficit of about 30 percentage points going by the 2020 target, Nigeria is off-track in other focus areas such as 90 per cent of the population knowing their status at the end of the deadline.

One major concern raised about the 2018 survey was that it did not give a focused coverage of key populations -- those most at risk of HIV infection, including men who have sex with men, sex workers, and people who inject drugs.

According to Devex, NAIIS field workers said that although some members of key populations were likely covered by the survey, they were not specifically targeted.

Almost a quarter of gay men in the country have HIV but most cannot access treatment due to laws against same-sex relationships and rampant discrimination, the Devex report stated.

Nigeria still accounts for the second-largest HIV population after South Africa. This is because of some of the factors highlighted below, which includes COVID-19 but not restricted to it.

Prevalence of Mother to Child Transmission

Despite efforts and progress made in reducing the scourge of HIV/AIDS, Nigeria is still holding the unenviable position of the country with the most HIV-infected babies in the world.

When rates of Mother to Child Transmission (MTCT) of HIV are dropping, even in far poorer countries, Nigeria still accounted for 37,000 of the world's 160,000 new cases of babies born with HIV in 2016 - the highest in the continent.

Even South Africa, with 7.1 million people living with the virus, had only 12,000 newly infected children in 2016.

"Nigeria contributes the largest burden of babies born with HIV in the world. It's close to one in four babies (globally) being born with HIV and that's really not acceptable," Sani Aliyu, the former head of NACA had said, according to an investigation by Sciencemag.org.

The high rate of MTCT in Nigeria highlights major gaps in HIV testing. This allows HIV infections to go untreated and the virus to spread.

This is despite an increased number of states providing services to prevent mother-to-child transmission, following billions of naira spent in providing test kits for pregnant women through initiatives such as the Save One Million Lives (SOML) programme.

Gambo Aliyu, the Director-General of the National Agency for the Control of AIDS (NACA) said the only way to eliminate MTCT is to take these services to the community level. A step he said the government has already made.

"Nigeria has struggled on PMTCT for several years and for the umpteenth time, we have not been able to make a single progress on this," Walter Ugwocha, executive secretary of Civil Society for HIV/AIDs in Nigeria (CISHAN), told PREMIUM TIMES.

COVID-19 PANDEMIC & AIDS

While Nigeria, just like other countries, was making efforts to end the AIDS epidemic, the COVID-19 pandemic struck, resulting in massive disruptions of health services globally.

The novel coronavirus, which was first reported in Wuhan, China last December and has since spread to over 200 countries, has caused major setbacks in gains already made in the health sectors, according to a UNAIDS report.

This has also led to funding and resources being diverted away from HIV, as all efforts are geared towards ending the COVID-19 pandemic.

"We cannot take money from one disease to treat another. Both HIV and COVID-19 must be fully funded if we are to avoid massive loss of life," Winnie Byanyima, executive director of UNAIDS said.

The UNAIDS had in its report 'Seizing the Moments', warned that the HIV targets set for 2020 will not be reached due to unequal access to antiretroviral therapy and service disruptions caused by the pandemic.

"With COVID-19 dislocating supply chain, affecting antiretrovirals and kits manufacturing, with COVID-19 competing with HIV in terms of health care personnel time, in terms of services being provided to patients, there may be an increase of almost 100 per cent fall of mortality and morbidity in the HIV community," Mr Aliyu told PREMIUM TIMES.

Ms Byanyima said that every day in the next decade, decisive action is needed to get the world back on track to end the AIDS epidemic by 2030.

Stigma and discrimination

People living with HIV often experience stigma, hostility, denial of gainful employment, forced resignation or retirement, delivery of poor quality treatment, and segregation in hospitals wards.

A PREMIUM TIMES finding revealed that the fear of rejection is rife amongst persons living with the virus in Nigeria.

"Over two decades of HIV response in Nigeria, there are people who are still not bold to say I am HIV positive, people who will not subject themselves to HIV test and when these two behaviours persist, then it is difficult to achieve that target," Country Director of Christian AID, Charles Usie, said.

Studies have repeatedly shown that, when HIV-infected persons take their treatment properly, their viral loads become suppressed. This makes it almost impossible for them to transmit the virus to others.

But the fear of stigma is creating barriers to accessing HIV prevention, testing and treatment services and putting lives at risk.

"If stigma prevents HIV-infected people from getting on treatment, the virus will be allowed to flourish. People who don't know they are infected with HIV would not know that they require treatment," National Coordinator of Nigeria Network of Religious Leaders Living with HIV/AIDS (NINERELA+), Amber Erinmwinhe said.

Although Nigeria's Anti-Discrimination Act of 2014 frowns against the ill-treatment of PLHIV, the Act has not been fully implemented as cases of stigmatisation still go unpunished.

"There have been improvements over the years but a lot of work is still needed to breach the knowledge gap. We need to address the knowledge gap within faith congregations to ensure the passage of right information," Ms Erinmwinhe said.

AIDS/HIV FUNDING

Nigeria's HIV programme, just like many other key health interventions, is largely dependent on foreign donors.

At the presentation of the 2020 HIV Quarterly Fact Sheet, Mr Aliyu said about $6.2 billion was spent to identify and treat 60 per cent (1,080,000) of the estimated PLHIV in Nigeria between 2005 and 2018. However, international donations account for over 70 per cent of the amount.

"Interestingly, over $5bn (N2.1trn) of the above sum comes from international donors - US Govt., PEPFAR program or from Global Funds," Aliyu said.

With the global and national economic effects of COVID-19, donor funding, domestic public financing, and private out-of-pocket spending for HIV could all be under threat.

As donor money starts to shift away, and time runs out to establish a locally backed replacement, health experts say the government should source for local production of antiretrovirals.

"There is a one-way solution for Nigeria, the local manufacturing of ARV. We have WHO prequalified companies in Nigeria but the government is yet to patronise them," Mr Ugwocha, the CISHAN head, said.

To breach the funding gap, the NACA chief, Mr Aliyu, said, "We are building up the HIV Trust Fund, which will enable us to buy drugs that will at a minimum provide medications for about 40 per cent of people living with the virus."

He also said plans are underway to put state governments in the driver's seat in response to the epidemic.

Underserving LGBT AIDS community

In Nigeria, sex workers, men who have sex with men, and people who inject drugs make up only 3.4 per cent of the population, yet they account for about 32 per cent of new infections.

The Nigerian government had in 2014 increased the punishment for homosexuality to 14 years in jail. Anyone "assisting couples" may face up to 10 years in prison.

"Criminalising laws such as these have made it harder to work with LGBT communities and have pushed men who have sex with men underground, making them more vulnerable to HIV," Mr Ugwocha said.

Although Nigeria's AIDS agency states that "no provision of this law will deny anybody in Nigeria access to HIV treatment and other medical services", studies have shown that since the law came into action, more men who have sex with men report they are afraid to seek healthcare.

"If we ramp up testing amongst high-risk

That is not to say Nigeria did not make progress towards reaching the target.

groups, then we would be able to reach our target easily," the head of the Institute of Human Virology Nigeria (IHVN), Patrick Dakum, said.

Poor AIDS Awareness

A previous story by PREMIUM TIMES coupled with a recent check shows there is still low awareness about HIV/AIDS.

Importantly, most Nigerians have never heard of Post Exposure Prophylaxis (PEP) for HIV and Pre-exposure prophylaxis (PrEP).

PEP for HIV is a short-term treatment with antiretroviral medicine to reduce one's chance of becoming infected with HIV after a potentially high-risk situation.

The 30-day medication helps prevent HIV from replicating and spreading in the body as long as it is first taken within 72 hours after exposure.

While PrEP is the use of a pill called Truvada to prevent the acquisition of HIV infection by uninfected persons.

2030: Where do we go from here?

The 2020 target was only but a roadmap to ending the scourge of HIV/AIDS by 2030.

While acknowledging that the 2020 target was far from reach in July, the UNAIDS said stigma and discrimination were major obstacles that stood in the way of reaching these goals.

The health agency said it developed a new strategy that will address many of the challenges the 2020 target faced and further drive the quest to end the AIDS epidemic by 2030 as part of the Sustainable Development Goals.

Continued advances in science and treatment access have made HIV a long-term yet manageable chronic disease for more people than ever before. The agency said more investment will be made in dealing with the scourge of HIV/AIDS by leveraging on technology.

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