This has been an increasingly controversial question recently. Understanding the burden of HIV in Nigeria is more important now than ever before, because, aside from Nigeria having the second largest population of people living with HIV, and only being able to find about 750,000 people to put on treatment, we are also the subject of an embarrassing Global Fund investigation.
In July this year, many Nigerians working on HIV/AIDS will attend the next International Conference on AIDS holding in South Africa, only the second time ever it’s being held in Africa, with the inevitable scrutiny this will bring the HIV response in Nigeria. Your Nigeria Health Watch team will make sure that you do not miss a thing from the conference in Durban.
The official HIV prevalence by UNAIDS in Nigeria is 3.2% among the adult population, giving a total estimate of 3.4 million Nigerians living with HIV, and not 5 million as widely reported by Nigerian newspapers recently. The most recent national prevalence survey for HIV carried out in Nigeria in 2013/14, undertaken by the National AIDS and STI Control Programme of the Federal Ministry of Health, put overall HIV prevalence among women attending antenatal clinics in Nigeria at 3.0%. In Nigeria, as in most countries with generalized epidemics, national HIV estimates are based on surveillance systems that focus on pregnant women who attend a selected number of sentinel antenatal clinics. The major assumption here is that prevalence among pregnant women is a good approximation of prevalence among the adult population of men and women (15-49 years). Since the first case of AIDS in Nigeria was reported in 1986, Nigeria adopted ANC sentinel surveillance as the system for monitoring the epidemic, in line with WHO guidelines. The first HIV Sentinel Survey in 1991 showed a prevalence of 1.8%. Subsequent sentinel surveys produced results as illustrated in the graph below. The epidemic appears to have peaked in about 2001 and has been on the decline since then.
In addition to the sentinel surveys, two population-based surveys for HIV were also conducted in Nigeria in 2007 and 2012. These put the overall HIV prevalence at 3.6% in 2007 and 3.4 in 2012, broadly similar to the estimates based on ANC surveys, although the sub-national estimates varied from those of the ANC surveys in terms of high prevalence states. In summary, neither the ANC surveys nor the population-based surveys have produced a national prevalence estimate of below 3%.
Despite the surveys above, there have been comments by some people working on HIV in Nigeria that HIV prevalence may not be as high as the surveys have persistently shown. In a recent interview in Calabar, the Director, Partnerships Coordination of National Agency for the Control of AIDS, Dr. Emmanuel Alhassan, gave the national HIV prevalence, as understood by NACA, as “way below 2%”, referring to NACA’s programmatic data. Some newspapers gave his comments their uncritical coverage with the headline, “HIV prevalence rate below 2% in Nigeria – NACA”. By boldly making these comments in public and on camera, he opened up a debate that has been taking place behind the scenes for months: What really is the prevalence of HIV in Nigeria?
The estimation of the number of people infected with HIV is a very important process for purposes of advocacy, programme planning and evaluation. We cannot manage what we do not measure properly. With a population as large as ours, these things matter, as a 1% difference in HIV prevalence equates to about 1 million people. For instance, treating 750,000 people with antiretroviral drugs out of 2.5 million people would appear a lot better than out of 3.5 million people. An accurate estimate of prevalence, therefore matters for everything from resource allocation to measurement of impact.
The limitations of antenatal surveys for the estimation of HIV prevalence have long been recognised. The primary purpose of antenatal clinic-based surveillance is the assessment of trends in HIV prevalence, but it can also be used to estimate the level of HIV prevalence as well. There are several factors that can affect the extent to which pregnant women attending antenatal clinics in the surveillance system are representative of all pregnant women in the country, including non-attendance at antenatal clinics, the use of private clinics, and the location of participating clinics. These are important variables that we should be measuring, especially how they have changed over time. Some countries, like South Africa, have improved the quality of ANC-based surveillance by using probability proportional to size (PPS) sampling to select 400 clinics in the nine provinces of South Africa to carry out annual rounds of surveillance, which yield data on about 16,000 pregnant women on which surveillance is based. These annual surveys in South Africa are carried out as part of the government-funded HIV response activities, and analyses are done in a few weeks after the surveys.
At the International Conference on AIDS in South Africa, the focus will inevitably be on the countries with the two highest disease burdens in Africa; Nigeria and South Africa. South Africa will be reporting significant progress achieved in the last 10 years. It will report the largest ARV treatment programme in the world with over 3 million people on treatment funded by the government; it will report an increase in life expectancy from 52 years in 2003 to 63 years in 2015, the most rapid increase ever reported. From Nigeria, we head to the conference in Durban, uncertain about the size of the epidemic.
It has become obvious that there is a lack of confidence among stakeholders regarding prevalence estimates in Nigeria, and it is hurting the country’s capacity to focus on the response. Achieving consensus on the prevalence of HIV in Nigeria has to be the priority of the government. If the relevant government agencies cannot agree on the process to measure this, then competent independent organisations should be commissioned to carry out the appropriate analysis to arrive at a prevalence estimate that we can all confidently work with. Once this is done, we can focus on why nearly all indicators assessed on HIV in Nigeria show stagnation and suggest that Nigeria is still facing significant hurdles, despite all the resources invested. This will be the question on the minds of most people attending the International Conference on AIDS in South Africa this July.
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