On July 14, 2015, the United Nations Programme on HIV/AIDS (UNAIDS), released a report which shows that the global spread of HIV/AIDS has been reduced. Same time, media reports in Nigeria credited a statement to Dr. Bilali Camara, the UNAIDS Nigeria Country Director to the effect that ‘‘Nigeria is among countries which has reversed their HIV trend’’. But surprisingly Bilali gave no hint as to what extent the country has been able to reverse the disease epidemic.
Instructively, and precisely on July 16, 2014, the same UNAIDS had released a report it called the gap report. The gap report reveals that just 15 countries accounted for more than 75% of the 2.1 million new HIV infections that occurred in 2013. In every region of the world the report finds that there are three or four countries that bear the burden of the epidemic. In sub-Saharan Africa, just three countries: Nigeria, South Africa and Uganda account for 48% of all new HIV infections. Meanwhile, the report also shows that entire countries are being left behind. Instructively, six nations: Central African Republic, Democratic Republic of the Congo, Indonesia, Nigeria, Russian Federation and South Sudan are said to be facing the triple threat of high HIV burden, low treatment coverage and no or little decline in new HIV infections. In same period which this report covers, it gave a damning verdict on Nigeria as the country in the world with the highest HIV/AIDS mortality. Nigeria also accounts for one third of all new infections among children in the 20 worst hit countries in sub-Saharan Africa. While Nigeria’s HIV infection rate of 3.2 percent may appear considerably low in comparison to Southern Africa’s 12.2 %, with a population of 52.98 million (Human Sciences Research Council, HSRC), Nigeria’s estimated population of 173 million however guarantees that the reality is of huge implication to the country.
Correspondingly, in a 2014 fact sheet released on Nigeria by UNAIDS, the global HIV/AIDS body says 3.4 million Nigerians are living with HIV/AIDS, with only 593, 000 of them on antiretroviral drugs (ARVs) which represented a paltry 21% of total number who require treatment. New child infections in 2013 alone stood at 51, 000 while infections among all ages was put at 220, 000. According to that document, there are 190, 000 HIV positive pregnant women, with 52, 500 of the women on Anti retroviral drugs (ARVs). However, of this number of pregnant women needing treatment, Nigeria is unable to treat about 70%. The report says only 12%, 47, 300 of all infected children requiring treatments are able to access them, leaving out the majority 88%. In 2013, the year preceding the report release, the country lost 210, 000 to AIDS related deaths. The report concludes that there had been little decline in deaths to HIV/AIDS from 2005 up until 2013, and in 2012, UNAIDS verdict on Nigeria was that the country’s response was “stagnant” and requiring “a massive effort.” It is instructive to note that only Chad ranks lower than Nigeria in treatment coverage of HIV positive pregnant women in the world, while Nigeria accounts for 13% of all HIV positive people and 19% of all AIDS-related deaths in sub-Saharan Africa, according to the UN AIDS agency.
Nigeria’s semblance of success
We were asked to note an increased coverage in the prevention of mother to child transmission of HIV/AIDS (PMTCT) which went up to 27% in 2013 from the 19% that it stood in 2012, according to the United Nations Children’s Fund (UNICEF). UNICEF also said that some states doubled or tripled the number of clinics providing HIV services, bringing the number of PMTCT sites to 2,216, but still a far cry from the 16,400 needed to cover the 88% that the crucial services had left out. UNICEF reports that annual number of new child infections went down from 60,000 in 2012 to 51,000 in 2013. Meanwhile, it remains a fact that two in every three pregnant Nigerian women are not being catered for, so the 190, 000 figure quoted for pregnant women needing care might just be an outright understatement.
A national tragedy
What we must however note, which is quite troubling, is the fact that underlying these grim statistics is a gush of human tragedy that several Nigerian families have had to live with. A tragedy that could have been averted if the right thing had been done with the resources available to the HIV/AIDS response. That aside, with these incontrovertible facts, can we now ask, like several other concerned insiders familiar with the true status of the Nigerian HIV/AIDS intervention are asking about those measures that were put in place that could and had ensured that Nigeria is able to reverse the spread of HIV/AIDS in just one year like Bilali asserted? And when Nigerian officials go to town claiming that the country has met some MDG goals, especially pointing at successes in HIV/AIDS, should we not ask how and what those are?
We are raising concerns, now, because contrary to what officials will want us believe, facts suggests that today, Nigeria is perhaps in a more harrowing situation than July 2014 when the UNAIDS gap report which had first highlighted the drastic decline in the progress Nigeria is making was released, while claims to any level of considerable progress resulting in reversals might at best be dubious.
To be sure, and on January 23, 2015, a meeting held at the office of the National Agency for the Control of AIDS (NACA), chaired by the NACA Director General (DG) himself, Prof. John Idoko. This meeting was meant to have been held in late 2014, but according to the NACA DG, the meeting could not hold because of the tight schedule at the time. It is instructive to note that prior to that period, and in late October 2014, the Network of People Living with HIV/AIDS in Nigeria (NEPWHAN), had mobilised its members in Abuja to protest at the NACA office, shutting off business at the complex over perceived unresponsiveness of the agency to the dwindling fortunes of the HIV/AIDS treatment program in Nigeria. Victor Omoshein, NEPWHAN’s national secretary had then remarked ‘‘we are concerned with the miserable conditions of people living with HIV/AIDS in Nigeria, as well as the high number of people dying daily from AIDS related complications due in large part to lack of access to antiretroviral medications as a result of withdrawn support by donor agencies.’’ According to Omoshein, ‘‘only 649, 000 out of about 1.8 million in need of treatment have access to drugs.’’ That figure represented about 30% of treatment needs. Idoko had responded then that there were challenges, but reiterates government commitments to scaling up from 600, 000 to 1.4 million people on treatment (he did not give a time frame for government ambition). So at the resumed meeting of January 22, 2015 which was an offshoot of the earlier protest by NEPWHAN, aside the issues of access and quality of treatment, another issue had cropped up which to discerning observers and industry insiders is capable of truncating the treatment program and which may have ensured that the government figure of 600, 000 people that it said were on treatment by now have reduced drastically. That meeting had in attendance representatives of NEPWHAN, NACA, UNAIDS, of the President’s Emergency Plan for AIDS Relief (PEPFAR), National AIDS Control and Prevention Program (NASCP), and the Treatment Access Movement (TAM). By close of meeting, a singular agenda had dominated discussions by attendees.
Introduction of new regimes of fees to access HIV/AIDS services
Earlier on, Obatunde Oladapo, the national coordinator of the Treatment Access Movement (TAM) and member of UNAIDS Program Coordinating Board NGO delegate, had raised an alarm when individuals accessing their HIV/AIDS treatment at the PEPFAR site of the University College Hospital (UCH), Ibadan, suddenly woke up to series of levies to access treatment which were hitherto not there before. Quick checks to other sites across the country was soon to reveal that this was something not localised to only UCH!
Prior to now, a federal government circular had announced government policy of free treatment for HIV and has mandated that PLWHAs be treated free at all government hospitals covering HIV and other associated illnesses. All tests and examinations were also free weather HIV related or not. All a patient need do is to collect a waiver form which was made available by APIN, and they get the desired attention across the country. Now, all those have stopped.
Checks made to several treatment centres across Nigeria indicate not a uniform scope of what is charged and for what it is being charged for. There are variations from one centre to the other. However, what was established, which is clear is a harrowing and troubling regime of fees ranging from consultation fee, to levies on drug pick up, to extra cost for routine tests and as well as the mandatory treatment monitoring done through CD 4 count checks and for those requesting viral load tracking. For instance, at UCH, clients confirmed to me that viral load testing is free, same for several other centres, but for the whole of Oyo and adjoining states, UCH is the only place the test can be conducted, while this usually result in backloads of cases with several people unable to get their test results for upward of three months! However, for haematology and chemistry tests, the regime of fees varies from one centre to the other. At UCH these are being charged at N12, 000 per annum. At the Nigerian Institute for Medical Research (NIMR), Lagos, which is an AIDS Prevention Initiative in Nigeria (APIN) site, among others, fee ranges from a monthly N1, 000 consultation charges and another N1, 000 for monthly drug pick up. At the Federal Medical Centre (FMC), Asaba, Delta State, user-fee is also being charged for pre-baseline tests such as renal function tests and lipid level test. In Borno, at the University of Maiduguri Teaching Hospital (UMTH), user fee is also being charged, as well as other monies for pre baseline tests such as full blood count, renal function tests, urine analysis and post baseline test like chest X-ray. The same situation is what is obtained in Kano state, at the Aminu Kano Teaching Hospital, and elsewhere, even where the burden bites the hardest.
Now, the immediate outcome is the fact of the reduction in clinic attendance by patients across the country, which is a cause of serious concern given its implication on the overall outlook of our HIV/AIDS burden. But considering the demographic information of majority population of those who are HIV positive in the country, there is need for serious concern by every right thinking member of our society. The way to look at it is to go back to why government in the first instance decided to make HIV/AIDS treatment free in the first place. Without doubt, there are no two reasons beyond the fact that the poorest of our people are the most affected. The social determinant of the disease has so ensured that the poor suffer the most. So, with what is happening now, what are we telling our most venerable? What are we telling our women, girls and children?
Issues of funding and accountability in Nigeria’s HIV/AIDS sector
From inception, funding for Nigeria’s HIV/AIDS intervention has been donor dependent and donor driven, to the extent that about 90% of available funds come from donor agencies like the United States President’s Emergency Plan for AIDS Relief (PEPFAR), Global Fund, World Bank and several other international organisations. Support ranges from training of personnel, provisions of technical knowhow, supply of lifesaving drugs and kits, and sundry. Nigeria’s government contribution was mainly reduced to the provision of physical infrastructures as hospital buildings and the payment of salaries of medical and other allied personnel employed in the hospitals while the core and major burden of intervention are borne by the donor agencies. Aside this anomaly, most donor organisations have had issues with the lack of accountability in the management of funds by Nigerian officials. In essence, a cardinal problem that has short-changed the success of the Nigerian intervention is corruption. This has ensured that on several occasion there were drugs stock-out, resulting in treatment truncation, we’ve had instances where expired drugs were dispensed, we’ve coped with fake and substandard testing kits deployed to testing centres, and while several thousand continue to lack access to life saving drugs, we’ve experienced instances where officials have had to destroy valuable supplies due to their expiration, with eyebrows raised as to why they were not supplied to those who require them before they gets bad. So, quite a number of disturbing logistical and management shortcomings have trailed our nation’s intervention.
With the global financial crisis and changes in the priority focus of donor agencies, the level of money available dwindled. Donor agencies mandated our government to contribute beyond just paying salaries and making available hospital spaces to actually invest in drugs purchase, in equipment, training etc. They wanted government to meet the treatment program half way. The Nigerian government agreed it will do more as usual, but the more never came. A presidential action plan on AIDS that the last administration agreed to fund and implement failed to kick off. So problems persist as demands for more investment from government and the corporate sector reverberates. However, with officials hardly able to justify how they have managed the vast resources made available to the HIV/AIDS intervention over the years, which has ensured that Nigeria remains where it is today; several people have questioned the rational for asking for more when considerable part of the funds keep ending in private pockets. It might help to put the picture in proper perspectives. PEPFAR, one of Nigeria’s main sources of funding for HIV/AIDS in Nigeria said it has committed over $3.4billion dollars to our HIV/AIDS program. Global Fund’s commitment stood at about $1.7billion dollars, while support from the World Bank, if not surpassing those of its other counterparts, is in the range of the other two major donors. These funds are outside of other smaller ones running into millions of dollars that has come from other sources, and is aside our own government scattered counterpart support overtime. Is it not troubling that with the huge allocation to this sector, the country is unable to treat half of those infected, unable to prevent new infections and has found it impossible to halt rising HIV/AIDS death? Will it be any surprise that less than 5% of Nigerians have ever tested for HIV/AIDS? No wonder then, that not a few are agreed that the HIV sector is one due for serious anti-corruption effort. According to one industry observer, the restrained phrase by official in charge of our HIVAIDS intervention is “thank God for HIV”, reflective of how officials are grateful for the robust and unhindered access to enriching themselves even if it is at the mercy of hundreds of Nigerians who lose their lives daily to AIDS complications.
The many implications of the rot in the Nigerian HIV sector
A cardinal aspect of HIV treatment is a robust monitoring of progress being made. Because, unlike other health conditions, what is at stake here is the body’s immunity, which is under furious attack from the virus, replicating in droves until one’s immunity is at their mercy. In the 34 years of the disease, there is still no known cure. But tremendous progress has been made in treatment, while today persons who test positive to the disease live healthier, longer lives. Despite this great stride, what is involved are different regimens of drugs taken at specified periods, daily, for life, and like every serious health condition, HIV also comes with very many daunting challenges. Key here is the issue of adherence to drugs. Drugs must be taken religiously. Most of these drugs which now come in single dosage combinations, an improvement, unlike before where countless numbers of pills must be swallowed daily, yet present peculiar challenges. One is the developments of side effects, the management of it and then dealing with various opportunistic infections. Here is where the progress being made becomes important. Meanwhile, the critical need for quality and effective treatment monitoring, especially for those newly commencing treatment is what has now become exclusive, out of reach of ordinary Nigerians who form majority of those accessing the government treatment program. As remarked by Morolake Odetoyinbo, Executive Director, Positive Action for Treatment Access (PATA), ‘‘pumping people with ARVs without monitoring can also send them to their grave.’’ According to her, ‘‘the challenge is that for many individuals, one test may be more important than for others, so it is crucial that most have unhindered access to what is crucial for their survival.’’ One of the biggest challenges at the moment has to do with those in the second line drugs. Developing resistance to drugs is a common thing, especially with a fertile environment that ensures that the predisposing factors are ever present. Meanwhile, being on the second line of drugs poses greater challenges because of the difficulties in accessing them, in fact the challenges of their storage (some require refrigeration), while failure on the second line drugs usually means the failure of the entire treatment program. Checks revealed that some drugs on the second line have not even been supplied for over one year. So for the few who can afford it, they source for it outside the system. This comes at no cheap cost. For the majority however, they wait on faith, only with HIV, more than faith is what is required. In some instance, health officials have been on record to improvise with cumbersome dosing. The scope of this is best understood when we consider that for some, the whole family is affected.
In another development, it has also become common for patients to get just two weeks dosing for no other reason but stock out. Normally, patients get monthly dosages. So the two-week situation ‘‘can only mean that they’re opening up pill boxes and splitting one between two people’’, says Ibrahim Umoru, activist and peer counsellor. Beyond that, it also equates multiple trips to the clinic, which can result in more days out of work for those employed and higher transportation costs for a majority who hardly can afford it. According to Bukola Ayinde, a pharmacist at one of the treatment centres, “the ideal situation is for those doing well on the same regimen, who are adherent to get enough meds to last 2-3 months.”
Aminat Alli, Lagos NEPWHAN Coordinator confirmed a meeting her association had with the management of a treatment centre in the city, which shows that if nothing is done by government, what is being charged currently might be further reviewed upward. According to her “the situation that stares us in the face is such that our people will continue dying. At the Center where we had gone on an advocacy visit, the director confided in us that unless government steps in they are helpless, as fees being charged are what they manage to run the centre.”
Aside the issue of fees being charged, another problem common to most treatment sites is the dwindling number of trained hands available to attend to patients. According to several sources in several locations who confirmed this, ‘there are days that there are no doctors to see patients, so if you have complaints you are asked to come back another time.’ This problem has extended to services available to pregnant women, with clear impact on outcomes of the prevention of mother to child transmission of HIV (PMTCT). For several other reasons, cultural and faith based, coupled with the inability to cope with the number of women who are turning up for PMTCT services, more work seems to be needed at the traditional birth attendants (TBA) centres and faith based delivery points. According to Olayide Akanni, Executive Director at Journalists Against AIDS (JAAIDS), ‘‘our project with the Lagos State AIDS Control Agency (LSACA) recognises that many women don’t go to government facilities, so we are offering HIV counselling and testing (HCT) in the TBA centres. We started testing in October 2014, and till date we have recorded considerable number of HIV positive cases. And you will be surprised at the women who come to these TBAs, educated women’’, she says. Olayide also indicated that work is covering the faith community because several women don’t end up delivering at the hospitals even for some that had earlier registered. For most women who opted out of the hospitals, overcrowded facilities and a lack of focused care are some of the reasons for opting out. For others, it’s the cost. But for the majority, the TBAs are the closest to them. These comes with obvious challenges of its own because the TBAs are mostly not covered by our HIV services, which simply means that there is no way to determine the scope of the incidences of HIV outside of healthcare settings if we practically depend on pregnant women who only turn up at government facilities which has excluded the majority to determine what our HIV situation is in the country.
Most at risk population
In January 2014, Nigeria further criminalises homosexuality, and places sanctions on those providing services targeting the community. This compounded the situation for the majority LGBT population affected by HIV/AIDS. Prevalence rate stood at over 12% in the LGBT community, to the 3.2% in the general population, while there are hardly services directly focusing on the needs of the community in the country. Several community members went underground with the escalation of hostility, while this has had a drastic effect on the access they have to treatment. Interestingly, data suggests a robust interaction between the LGBT community and the general population in aligning to societal pressure to conform. About 50% of members of the LGBT community are said to also involve in heterosexual liaisons to gain acceptance while also keeping a healthy gay lifestyle even if in the closet. Therefore the HIV/AIDS intersection is high with obvious impacts on the overall reality of what we are ready to admit. These facts are what John Idoko, NACA DG, is not comfortable with when he denied that the law has had any negative impact on the LGBT community, a fact confirmed by couple of centres offering HIV services to the community. According to Dorothy Aken ’Nova, Executive Director at the International Centre for Sexual and Reproductive Rights (INCRESE), ‘‘in several instances what we have experienced is outright treatment stoppage by members of the LGBT community as a result of the violence and rejection they experienced once their sexuality becomes public knowledge.’’ Dorothy is of the view that the full scope of the impact of that law on the HIV burden of the country may not be known for now, but she is convinced it does not looks good.
There is also not a strictly defined prevention policy and strategy targeting sex workers and injection drug users, while the country is currently also experiencing an exponential dimension to the scope and occurrence of sex work. The network of sex work today has become so sophisticated with the influx of mobile telephony while the smart phones places access in the palms of our youths, while the social media makes that sector more accessible with a variety of options that makes targeted services all the more difficult. And a fact which must be accepted is that the country has failed its most vulnerable. Across our schools, sex work thrives beyond imagination, while new recruits come in droves on a daily basis. Sadly, the levels of awareness remain unable to impact a knowledge shift that comes with tangible results while services targeting our youths are non-functional, anywhere. The reality is indeed quite grim.
Stigma and discrimination
At home, hospital settings, on the faith arena, school and at work, being HIV positive comes with dire consequences. On a daily basis, dreams are shattered for lack of compassion mainly as a result of ignorance, still, about this disease since the first incidence in the country in 1986. Several people cannot change jobs for fear of the mandatory tests for HIV, even when a positive status today has got little to do with one’s productivity. Thousands face the prospect of loneliness from a lack of life partner and stagnation from shrinking spaces for expansion of life’s opportunities. With majority poor and unable to shoulder the challenges of managing their health alone, many have had to confide in loved ones with most cases ending in rejection and isolation. Nigeria now has an anti HIV discrimination law, but like most of our laws, they exist only in name. In the first major legal test for the rights of an HIV positive person in Nigerian to seek redress, Georgina Ahamefule had to endure 12 harrowing years of legal tussle. Even after the court gave a landmark judgement in her favour, it seems the waiting period has just started with the defendants back in court on appeal. Mr. Emmanuel Nwaghodoh of the Social and Economic Rights Action (SERAC) who took the case to court said the Appeal Court up till now is yet to set a date to commence hearing. If the trend in the Nigeria judicial system is factored in, it might take another five years before the case is discharged with. Which means for Georgina, it might be a waiting game of about 17 years before justice finally comes.
In another similar instance, little Kehinde Babalola, whose hand was amputated in a case of criminal negligence due to suspected HIV status is still battling for justice almost 10 years after she was amputated from the negligence she suffered at birth on assumption that she must be born HIV positive due to the fact that her parent are positive. Kehinde other sister, Taiwo, died in the process.
We can take a quick journey into our recent history with few instances of how these have continued to play out:
On July 8, 2003, Chinasa Nwapu-Okereke, a nursing sister in Owerri, South-West Nigeria, committed suicide two weeks after she was told she is HIV positive. In 2006, Abigail Atirene who also lost her daughter to AIDS was left with no option but to pack out of her family house because her siblings said they could no longer stay with someone who is HIV positive. Abigail before then lost her young marriage and was stopped from worshipping in her church. Abigail too has now since also lost the battle to AIDS and to the stigma she was subjected to. Theresa is a young woman living with HIV in Benin City, South West Nigeria. She lost her job, and her aunt with whom she stays asked her to pack out and her parent in the village said it is better they don’t set their eyes on her again. Not long ago, Frederick Adegboye, then student at the Nigerian Institute of journalism (NIJ) and now a staff of a national newspaper was relieved of his admission at NIJ based on his HIV status; it took coordinated protests before the school authority agreed to reinstate him. A hostess with one of the local airlines was sacked because she was bold enough to reveal in a confidential update on staff that she was HIV positive. Also recently, a Nigerian university asked her graduating set to all undergo HIV test with the proviso that only those who test negative will be allowed to graduate.
Other manifested trends of discrimination and stigmatization experienced by positive persons include denial of health services because of HIV status. On suspicion of HIV infection alone, services have been refused, and patients have been neglected. There are several recorded instances of verbal assaults and harassment of PLWHAs in Nigeria, which sadly has remained on the rise. Often, there is total lack of confidentiality as regards health records. On several occasions, the results of HIV/AIDS testing have been divulged to outsiders without consent, while family members have first-hand information about a test result even before the person involved is aware.
A civil society in disarray
UNAIDS report shows that 19 million of the 35 million people living with HIV today do not know that they have the virus, while interestingly, the total number of Nigerians who have ever summoned the courage to test for HIV is well less than 5% of our total population. Meanwhile, data continues to suggest that for every 10% increase in treatment coverage there is a 1% decline in the percentage of new infections among people living with HIV, according to the AIDS Healthcare Foundation (AHF). The AHF report analyses the reasons for the widening gap between people gaining access to HIV prevention, treatment, care and support, and people being left behind. It shows how focusing on populations that are underserved and at higher risk of HIV will be key to ending the AIDS epidemic. Yet, in Nigeria today, efforts in this regard remains stagnated. The civil society complimentary effort that normally should aid that has been halted to infighting between personalities coordinating the national network in charge of that effort. The Civil Society for AIDS in Nigeria (CiSHAN) secretariat remain under key and lock for disputes arising from who controls what which all points to one factor – corruption, as the fight has nothing to do with the work but the money, and what each faction can get. Till this moment, the Global Fund projects being implemented across the states by these organisations have been disrupted. Meanwhile Africa’s most populous country, and home to the second largest number of persons living with HIV/ AIDS in the world is buckling to greed, poverty, stigma, discrimination, and a poorly coordinated HIV treatment and prevention effort.
Who will safe this giant of Africa from its self-inflicted pains? The time for action is now, as the country can hardly afford another wait.