Today is World AIDS day 2015. All over the media in Nigeria, there have been reports on the new goal of the National Agency for the Control of AIDS (NACA) to “eliminate” AIDS in Nigeria by 2030. As there is no cure for AIDS, only treatment, the goal that NACA actually set was to reduce “new” infections to zero by 2030, but what it really hopes to achieve is to see HIV prevalence continue to decline. This lofty goal, which was widely and uncritically reported in the Nigerian press, is one that we fully and wholeheartedly support. But in order to set goals like this, we need to critically examine where we are, how we measure progress and what we will do differently in order to achieve our stated goal. We have not seen this in any of the reports or in any of NACA’s published activity plan for WAD2015.
Historically, HIV prevalence in Nigeria has been estimated by surveys among women attending antenatal services, known as ANC surveys, as in many other African countries. These surveys showed an evolution of HIV prevalence in Nigeria from 1.8% in 1991, to 3.8% in 1993, then 4.5% in 1995; it peaked at 5.8% in 2001 and started to decline to 5% in 2003, to 4.6% in 2008 and then 4.1% in 2010.
In recognition of the limitations of ANC surveys, the Nigerian Federal Ministry of Health (FMoH) and the National Agency for the Control of AIDS (NACA) in Nigeria carried out a nationally representative National HIV and AIDS and Reproductive Health (NARHS) Survey in 2007 and 2012, and the 2012 survey suggested that HIV prevalence in Nigeria was 3.4%.
So, the best estimate that we have as a country on World AIDS Day at the tail end of 2015 is data from 2012. Another ANC survey was carried out by the National AIDS and STIs Control and Prevention Programme of the Federal Ministry of Health in 2013, but to date, the results from this important survey have not been released, so we are in the dark on where we are at the end of 2015.
On the assumption that the data is about the same as it was in 2012, then we have about 3.5 million Nigerians living with the virus. By NACA’s estimates, there are about 750,000 thousand Nigerians on treatment, mostly funded by the taxpayers of the United States through the PEPFAR programme and the donors to the Global Fund. This means that we are only able to provide treatment to 20% of those in need of care, mostly donor funded.
Not surprising, stories have recently appeared in the press on the donors intention to withdraw funding from ART treatment to citizens of the largest economy in Africa. In September this year, following the synthesis of overwhelming scientific evidence, the World Health Organisation (WHO) recommended that everyone with a diagnosis of HIV should receive ARVs as soon as possible irrespective of CD4 count. This is beneficial to the patient, as it increases their life-expectancy, and to the community, as it drastically reduces the likelihood of transmission. This short video from the US CDC shows the importance of treatment to prevention. To their credit, NACA and its partners have intensified its activities to identify patients with HIV and get them into the care pathway, using free healthcare missions.
In the interview above, the Director General of NACA, Professor John Idoko explains why it took many months after WHO released its recommendations for NACA to accept and adopt the new WHO guidelines, commonly referred to “test and treat”.
Victor Omoshehin, the National Coordinator of the Network of People Living with HIV/AIDS in Nigeria (NEPHWAN), however painted a dire picture of the current Nigerian situation in an interview with Nigeria Health Watch. Lack of access to treatment, user fees, poverty, unemployment, and withdrawal of international funding are challenges facing those living with HIV in Nigeria, Omoshehin said. “A lot of people are eligible to access treatment but they are not being treated, the coverage is very low.”
The point that bothered him the most was that many facilities had recently introduced user fees for people living with HIV to access treatment, which discriminates against those who need access the most; the poor and unemployed. “Patients now pay for consultations, they pay for medical, they pay for drug pick-up, for card registration,” he said. “These barriers hinder people from picking up their drugs, which means they will default, develop resistance, and this leads to drug failure. We are just sitting on a time bomb that can go off at any time. User fees are unacceptable.”
When it comes to who foots the bill for ART provision, not much has changed, according to Omoshehin. “In the last 10 years I have been accessing my care on the budget and tax of foreign donors,” he said. “I work and pay my tax to the Nigerian government, but I am accessing my treatment with the tax payers of America’s money.”
As foreign donors gradually scale down their support, they are leaving a vacuum… and the inevitable question is, “Who will take over?” The obvious answer is the Nigerian government. “The Nigerian government needs to start putting their money where their mouth is, honouring the Abuja Declaration made in 2001 that agreed for 15% of the total budget to be dedicated to health,” Omoshehin said. “I want to see the health budget making provision for the purchase of ART drugs.”
Access to treatment for people living with HIV in conflict areas has been a struggle. “In places like the Northeast, insecurity has affected so many of our members,” Omoshehin said. “Care providers are running away. Too many people living with HIV in IDP camps do not have access to their therapy medications, especially children.” NEPHWAN is working in partnership with NACA and other partners to organize ART deliveries to those in IDP camps, he said.
Omoshehin’s main goal as he spearheads the new leadership of NEPHWAN is to push for more domestic funding that will support the majority who are still in dire need of antiretroviral therapy drugs. “We can start mobilising policy makers, the oil and gas industry, get companies to contribute a quota out of their Corporate Social Responsibility (CSR),” he said. “We need to take ownership and be responsible. I do not want to see more people die because they are waiting for a cure or a miracle.”
Ultimately Nigeria needs to take ownership of its ARV Treatment programme. It is only when it takes a firm decision in this regard that it can begin to make the tough decisions that are necessary to make this happen. In comparison, South Africa manages to treat 60% of its 5 million plus infected people, all paid for by their own government… and it is only the second largest economy on the continent.