Without good data, we’re flying blind. If you can’t see it, you can’t solve it – Kofi Atta Annan
There are about 3.4 million Nigerians living with HIV- or at least that was what everyone thought. This figure was based on a prevalence estimate of close to 3%, derived from the last version of surveys conducted in Nigeria. This meant that despite finding and placing over one million people on treatment with antiretrovirals (ARVs), it was still estimated that over 50% of those infected with HIV did not know their status. As millions of dollars were spent by the Nigerian government and its partners to find more people living with HIV, the narrative was that “Nigeria was failing to live up to the challenge of HIV/AIDS”. But everyone working in the field believed something must be wrong. They were working hard, testing millions, yet not finding more cases, but the narrative of failure persisted.
Now, the results are in. Nigeria indeed does not have as many people infected as previously thought. The previous surveys were wrong!
The just-released results of the population-based HIV survey in Nigeria a prevalence of 1.5% among and viral suppression load of 44.5%.
Given Nigeria’s vast population, planning is critical for health systems to deliver. No system can deliver services appropriately if not well guided by data which requires an understanding of the factors driving the epidemic. In the absence of robust and accurate data, Nigeria’s response to HIV was said to be foundering. Uncertainty about Nigeria’s HIV prevalence was seen as a problem, especially given the significant resources that had been dedicated to testing for HIV cases and the budgets that have been allocated for treating people with HIV.
In Nigeria, as in most countries with generalised epidemics, these estimates of HIV prevalence were largely based on surveys for pregnant women who attended a selected number of antenatal clinics. While most countries moved away from these surveys or developed improved protocols, this change did not happen in Nigeria, despite the global criticism of this approach. The most recent national estimates were based on an antenatal clinic (ANC) survey conducted in 2014. In Kenya, HIV prevalence was calculated using the Kenya AIDS Indicator Survey, a nationally representative 2-stage cluster sample of households and South Africa previously used antenatal testing data, however as this was not representative of the country’s population, the HIV prevalence rate in the country has been calculated using a nationally representative population-based HIV survey for many years. Looking back, Nigeria really missed an opportunity by not building the national expertise required to deliver complex surveys, nor did we build a team sufficiently trained that can deliver on this over the years. We were the focus of debates at international conferences and there was not much confidence in the data that we produced. Yet, the response had to be funded- and if the surveys estimated 3.4 million people infected, we had to find the funds to treat 3.4 million people. So, when it became imperative to get the numbers right, we looked for an implementing partner to deliver in this critical survey for Nigeria.
Enter the new leadership of the National Agency for the Control of AIDS (NACA) in 2016, Sani Aliyu with a drive to improve the accuracy of data used to plan the allocation of resources for patients living with HV/AIDS in Nigeria. It was not long before he the scale of the challenge he faced. At the Nigeria Health Watch 2016 Health Watch Forum, themed ‘Does Leadership Matter?’, Dr. Sani Aliyu, Director General NACA stated that his major goal was to determine the actual number of people living people with HIV in Nigeria, diagnose and put them on treatment. It is against this background that the agency launched the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), the largest ever population-based HIV/AIDS survey carried out anywhere in the world. The results of the NAIIS have provided Nigeria with a better indication of its HIV prevalence rate and will now enable the country to plan properly to deliver services. The implication of this is that we have a better idea what the true burden of HIV is, which populations are most vulnerable so that we can now more accurately allocate funds from the government and donors to ensure that everybody living with HIV has access to treatment.
Putting together the largest survey in the world
The need for a nationwide population-based survey has been voiced by civil society . According to Dr. Aliyu, delivering the largest HIV survey cost about $91 million, funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Global Fund to Fight AIDS, Tuberculosis and Malaria, United Nations Programme on HIV/AIDS(UNAIDS), University of Maryland, Baltimore, Institute of Human Virology, University of Washington, the World Health Organisation, Inner City Fund (ICF) and African Field Epidemiology Network (AFENET). The survey was conducted in nine months with over 2,000 research enumerators collecting data from thousands of households across the country. Many of these enumerators were volunteers who put their lives at risk for the survey, visiting places that were termed as inaccessible. The survey reached more than 250,000 respondents, aged 15-64 years and 32,555 children, aged 0-14 years, in nearly 100,000 randomly-selected households. During the launch of the NAIIS results, Mr. David Young, Chargé d’Affaires, Embassy of the United States of America in Nigeria highlighted the “human angle” in the data collection. Households while being tested were on HIV prevention and where to seek care if needed.
Over the last decades, we have greatly improved our fight against the HIV epidemic. From NAIIS (results), we can see that fewer Nigerians are living with HIV. We cannot celebrate yet, because many of them are not on treatment– President Muhammadu Buhari at the Presidential announcement of the results
We applaud the government’s effort in capturing key and timely HIV data in Nigeria, given the logistical challenges in the country. These survey results contain critical information for planning HIV response and treatment and scaling-up interventions. They have also provided an opportunity to better allocate resources. Given that we do not have as many people living with HIV in Nigeria as had been estimated, what are the implications for donor agencies who have so far funded over 90% of our HIV response? Will PEPFAR or the Global Fund to fund our HIV response as they have done? Who will now take responsibility for the estimated 1.9million Nigerians living with HIV when these donors exit Nigeria? South Africa, with the largest HIV prevalence rate in the world, has made considerable progress in its HIV/AIDS response in the past decade, with about 80% of their response funded by the South African government. Nigeria must step up, it is critical now that we have sustainability in funding for HIV interventions. HIV has its largest impact on the most productive part of our population and it is about time Nigeria stops relying on outside donors to solve the HIV prevention, detection treatment.
Women overwhelmingly bear the burden of HIV infection rates
According to the NAIIS result, HIV prevalence among women in Nigeria aged 15-64 is 1.9% and 1.1% among men. This prevalence figure is the same for women aged 15-49 years, however, for men, it is 0.9%. This implies that HIV disproportionally affects women in Nigeria. Could this be because of the inequalities that are driven by gender norms related to masculinity and feminism, violence against women, barriers of access to health services, poor education or lack of economic security? We would need to address some of these possible factors that put women at risk of HIV infections. For pregnant women who are living with HIV, it is important that we prevent the transmission of the virus from the mother to the baby. There is an urgent need for Nigeria to scale up prevention of mother-to-child transmission (PMTCT) services to be offered before conception, throughout pregnancy, delivery and breastfeeding. Family planning is one of the most vital PMTCT measures. Reducing the number of unintended pregnancies among women living with HIV would reduce the number of children born with HIV. States can play a large role in this by ensuring family planning services are provided in primary and secondary health facilities. In addition, now that we have state-specific prevalence data, state governments need to take more responsibility to employ better strategies that are needed to improve the accessibility, acceptability, affordability and uptake of HIV and reproductive health services, particularly for young women.
So where does HIV prevalence stand in Nigeria?
International donors and partners have dedicated significant resources to treating the previously estimated 3.4 million Nigerians living with HIV in Nigeria. The US government and the Global Fund spend $400 million and $110 million respectively every year funding the HIV response in Nigeria. Results from NAIIS have shown that HIV prevalence in Nigeria is 1.5% among people aged 1-64 years. This means that detailed discussions will now have to take place on what level of funding will come from our partners. For Nigeria to take greater responsibility for funding the treatment of people living with HIV in Nigeria, we must increase our total health budget. It costs about N50, 000 to treat a person living with HIV in Nigeria, for a year. In 2018, a total expenditure of N340.46bn was proposed for the Federal Ministry of Health. In order to accommodate the treatment of Nigerians living with HIV, it will most likely cost about two-fifths of the total health budget. If Nigeria is to develop a sustainable mechanism for funding HIV, we must consider integrating HIV treatment into national, state and community health insurance schemes. Our target should be for health insurance schemes to cover HIV treatment for its enrollees. Also, state governments need to take greater ownership for the HIV response in their states. If states could dedicate no less than 1% of their monthly federal government allocation to HIV treatment, it would go a long way in putting more patients on treatment.
Was it worthwhile spending $91million to have a clear idea of the number of people living with HIV in Nigeria? Absolutely, especially if we use this data to improve the response. The Government can now plan, develop and implement more effective programs to control HIV and Hepatitis in Nigeria, leading to healthier individuals and families. Since we now have a better estimate of HIV prevalence, we now call on our government to take greater ownership of the response. The next time we need to carry out a survey, we hope that we will not need an implementing partner to deliver on it.
How close are we to achieving the 90-90-90 goal?
UNAIDS has set the 90-90-90 target which would mean that by 2020, 90% of people living with HIV will know their status, 90% of people living with HIV will be on anti-retroviral therapy and 90% of people on anti-retroviral therapy will have viral suppression. These targets will all increase to 95% by 2030. However, the current viral load suppression among 15-64 is 44.5%, but given that population level viral suppression is essential, to say we have made progress in meeting the 90-90-90 goal, the viral suppression load should be closer to 73%. So, is there a silver lining? Given that the HIV prevalence rates are not as high as previous estimates, the country was failing to show the progress that had been made in tackling the HIV epidemic proportionate to the effort that had been put in preventing new infections. We are much closer to the first 90% than previously thought.
See photos from the presidential announcement of the NAIIS results here