Tackling the HIV epidemic: we shall leave no one behind

Nigeria has the second largest HIV burden in the world, with an estimated 3.2 million people infected. The national HIV response has made substantial progress in the last few years with more than a million people currently on treatment. However, real challenges continue to exist in the delivery of the programme; it is heavily donor dependent with about 94% of those on treatment catered for by external sources. The country also contributes the largest number of babies infected with HIV at birth. New structures and funding streams are urgently required to safeguard the quality and long-term sustainability of the HIV programme in the country.

Nigeria has not been left behind in ensuring that its citizens living with the virus are able to access treatment. Through our partners, the United States-funded President’s Emergency Plan for AIDS Relief (PEPFAR) programme and the Global Fund for AIDS, TB and Malaria (GFATM), we now have just over 1 million Nigerians on ART. The Federal Government of Nigeria through the National Agency for the Control of AIDS (NACA) is currently delivering a treatment programme covering about 60,000 persons with HIV in Taraba and Abia States. Considerable progress is being made in increasing the number of people on treatment following the launch of the ‘Fast Track’ programme by President Muhammadu Buhari in December 2016, and a further commitment to putting an additional 50,000 PLHIV on treatment every year from 2018. However, with about 2 million Nigerians living with the virus not on treatment, we are still a long way from achieving ‘treatment saturation.’

There are significant challenges in the delivery of the HIV national programme. These challenges primarily relate to issues of sustainability and programme performance, particularly around Prevention of Mother-to-Child Transmission (PMTCT). Nigeria is a large and complex country with a healthcare system that is not only fragmented but also pyramidal in structure, with tertiary care dominating Federal funding to the detriment of primary health care programmes. Successful HIV programmes elsewhere have been modelled with a strong community component and delivered on a primary healthcare platform.

The cost of maintaining HIV care per person per year is about N50,000. With an estimated 1 million people on treatment and a further 2 million requiring treatment, it will cost about N50 billion naira to maintain the current numbers on treatment and a further N100 billion to get every infected person on treatment. This responsibility cannot be left to the Federal Government alone - all hands need to be on deck to find a long term sustainable funding model for the programme that will ensure national ownership. In June 2017, a National Economic Council meeting approved that 0.5% to1% of the monthly federal allocation to states be earmarked for financing the implementation of the HIV/ AIDS sustainability roadmap in their respective states. This arrangement will generate about N23 billion, which is sufficient to not only put an additional half a million Nigerians on treatment, but also fund free antenatal care and PMTCT services for pregnant women with HIV across the country. I am appealing to all State Governors to commit to this initiative and dedicate resources for the implementation of HIV programmes in their states. We cannot afford to continue mortgaging the future health of our citizens to external support - the challenge of domestic HIV funding needs to be addressed now and not left until later when donor fatigue sets in. Now is the time to right this anomaly.

Nigeria contributes the largest number of babies infected with HIV in the world. With a motherto-child transmission rate of 22% and HIV treatment coverage of only 32% of infected mothers, we are second only to Indonesia in failing to protect our future generation of citizens from HIV infection. It is unacceptable that we had more than 40,000 babies infected with HIV in 2016, despite the availability of treatment that can reduce the risk of transmission from mother to child to less than 1%.

In the first six months of 2017, 32,000 pregnant women were diagnosed with HIV and about 27,000 placed on treatment. The problem therefore is that of poor antenatal attendance; our inability to get pregnant women to visit the health facilities in the first place so that they can be tested for HIV. Almost half of all pregnant women in Nigeria deliver in non-formal community settings, including at home with traditional birth attendants, places of worship, etc. These pregnant women need to be found, tested and where positive, placed on HIV treatment.

The country’s ‘Fast Track Plan’ for PMTCT launched last year aims to test at least 3 million pregnant women for HIV by 2018 and put an additional 75,000 on treatment to eliminate mother-to-child transmission of HIV by 2021. This will not be possible unless we have innovative strategies that promote stronger advocacy and attitudinal change to antenatal care utilization at the community level. We also need to integrate current PMTCT programmes into the Reproductive, Maternal, Child and Adolescent Health programmes that are currently being implemented across the country.

Our last demographic survey in 2013 showed that awareness of HIV is higher among young men than women, with 70% of young men being aware that condom use protects against HIV when compared to only 56% of young women. Factors such as early onset of sexual activity, low literacy level, gender inequality, poverty and the inability to negotiate safe sex play a key role in driving the epidemic in young women. This vulnerability is substantially increased in communities facing social upheaval, such as the Internally Displaced Persons (IDPs) in the North East. To tackle this worrisome trend, we need to advance the young women and girls’ agenda and seriously address gender based issues including violence, school dropout and early marriage in our communities. How can we ensure that our girls remain in school? How do we empower our young women to improve their economic opportunities, ensure social mobility and remove barriers to accessing HIV prevention, treatment and care services? This is why HIV is not just a problem for the medical community alone but presents a substantial political, socio-cultural and human rights challenge to society.

To invest in our young women, we need to create structures and networks that provide qualitative platforms for economic and social empowerment. The role of strategic partnerships that can drive this initiative such as the First Ladies fora, faith-based organisations, community leaders and civil societies cannot be overemphasised.

In the same vein, we continue to engage with the Federal Government National Social Investment Programme, particularly as it relates to conditional cash transfers for vulnerable populations including persons with HIV. We are also working with the school feeding programme as a tool for engaging and keeping young people in school, and with other economic empowerment schemes such as N-Power. We need to give our adolescent girls and young women the full range of opportunities in order for them to maintain a fulfilling and HIV-free livelihood.

Prevention as they say, is better than cure. We realise that scaling up treatment alone will not end AIDS. Working collaboratively with our partners, civil society and all stakeholders, it is possible to achieve an HIV-free generation in Nigeria. This will require strong and committed partnership, transparent leadership and shared responsibility. The recent lifting of grant disbursement to NACA by the Global Fund reflects how far we have come in re-establishing trust and transparency with our partners. It is important that we continue to ensure that interventions are not only cost effective but also benefit those who matter most the people infected and affected by HIV. We must remove all barriers to accessing services and ensure that stigma and discrimination is addressed, particularly as it affects vulnerable and key populations. Achieving HIV epidemic control in Nigeria is a job that requires multistakeholder involvement. As we co-ordinate efforts to develop and create capacity nationwide, and increase domestic funding and accountability, all stakeholders, including civil society organisations must come together and work with government to enable realization of our collective vision of an AIDSfree generation. Government will continue to invest in building the capacity of civil societies as a bridge to stronger community involvement.

Dr. Aliyu is the Director-General, National Agency for the Control of AIDS (NACA), Abuja.