“The problem is not the second or third 90 but the first 90” – Dr. Sunday Agbochenu Aboje, National Coordinator, HIV/AIDS & STIs Control Program, Federal Ministry of Health.
When there is a big public health problem, fiddling around at the edges hardly changes anything, neither does hiding our heads in the sand. The world still has a big HIV challenge, and most of this is with us in Africa. By current estimates, there are over 3 million Nigerians living with HIV, second in absolute numbers only to South Africa.
The World Health Organization recommends that everyone with HIV should have access to antiretroviral therapy (ART). However, in its 2016 progress report on HIV/AIDS, the lack of diagnosis across many countries in the world remains a major obstacle. The report stated that about 40% of the estimated 36.7 million people living with HIV at the end of 2015 were unaware of being infected. The gap in HIV diagnosis is a major stumbling block for HIV programmes.
In 2014, an ambitious new 90-90-90 target to end AIDS was launched by the United Nations AIDS Programme on HIV/AIDS. The goal is to ensure that by the year 2020, 90% of people living with HIV worldwide know their HIV status, 90% of those diagnosed with HIV infection receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy have viral suppression. Dr Aboje, who leads the team focusing on HIV/AIDS in the Nigerian Ministry of Health is not happy with progress towards reaching the first 90%, which he described as critical during the recent dissemination of results of an HIV Self-Testing study conducted by the Population Council Nigeria. It is estimated that only 34% of those infected with HIV in Nigeria know their status. Meanwhile, South Africa, despite the much larger burden of disease, at 86% is closing in on the 90% target.
Two years away from the target year agreed to by many countries including Nigeria, this goal still seems very ambitious, especially in Nigeria. Yet, reaching this target is not actually the end goal in the battle against HIV. It is hoped, rather, that if this three-part target is achieved, at least 73% of all people living with HIV worldwide will have viral suppression leading to the eventual end of the epidemic by 2030 and resulting in several health and economic benefits for the world.
Can a radical change in our approach to testing be a game-changer?
To improve access to and uptake of HIV treatment, WHO issued new guidance on HIV self-testing (HIVST) in November 2016. This means that people can use oral fluid or blood from finger-pricks to check their own HIV status in a private and convenient setting. Results are ready within 20 minutes. Those with positive results are advised to seek confirmatory tests at health clinics. WHO also recommends that they receive further information and links to counselling as well as rapid referral to prevention, treatment and care services.
Key populations such as Men who have sex with Men, Female Sex Workers, and injecting drug users are most vulnerable to HIV and often have the least access to life-saving HIV prevention, treatment, care and support services. After the WHO guideline was issued, the Population Council, in 2016-2017, conducted a multi-method research study to gain insights on HIV self-testing among men who engage in same sex activities in Lagos State. This was the first study of its kind ever conducted on a key population in Nigeria. During the result dissemination event, the Population Council’s Country Director Dr. Sylvia Adebajo hoped that the study will provide evidence on the acceptability of HIV self-testing strategy to improve uptake of HIV testing and treatment among MSM in Nigeria. The study, which targeted MSM aged 17-59, was conducted in two phases.
Results from the first phase revealed high acceptance among the 18 participants. In-depth interviews revealed that majority of the participants were willing to use the oral HIVST because it addressed key concerns like privacy, convenience and it didn’t require any needle pricks. Participants were however, curious about the science behind this new test and concerned about the linkage to a health institution for follow up after the test.
The second and main phase of the research included 319 participants found that the HIVST was highly acceptable to participants, who perceived it as easy to use. They also suggested that peer educators or Key Opinion Leaders could distribute the kits within their networks easily and recommended a 24/7 helpline be made available to help connect those who are positive to care after testing.
Mr. Alex Ogundipe, Director of Community Prevention Care and Support Services at the National Agency for the Control of AIDS (NACA) was also hopeful about the study’s findings, saying that it supports existing evidence of people’s attitude towards self-testing. “We know that stigma is still high. A lot of people will like to receive news of their status in a private, confidential place where they can manage their emotions without revealing it to people,”.
Despite Nigeria’s strong stance against same-sex relationships, Dr. Adebajo believes the Federal Government needs to come to terms with the reality that Nigerians are a diverse, non-homogenous group and programmes should take this into account in their efforts to control HIV/AIDS.
There were some reservations expressed about self-testing, most centered around concerns about counselling people in key populations, especially before and after they take an HIV test. “Positive clients naturally become emotional, these emotions are best handled in a key population friendly facility” Mr. Onumara Onyekachi, a Programme Manager for a CSO implementing a Global Fund HIV intervention for Key Populations, said.
Achieving the 90-90-90 target and all development goals is anchored on the principle of inclusion and ensuring no one is left behind. Despite this, key populations, especially Men who have Sex with Men (MSM), Female Sex Workers (FSWs) and Injecting Drug Users (IDUs) have a hard time accessing life-saving interventions. They are also part of the general population and often have relationships with other people in the general population. Ignoring their needs is counter-productive to efforts aimed at curbing the HIV epidemic in Nigeria.
In considering the need to adopt innovative approaches to ensure more people access HIV diagnosis and get into treatment, HIVST is an effective new way to reach more people than what is currently available through normal facility visits and testing. If we want to get to 90%, courage is required.