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UNAIDS estimates that in Nigeria, around 3.9 percent of adults between ages 15-49 are living with HIV/AIDS¹. Although the HIV prevalence is much lower in Nigeria than in other African countries such as South Africa and Zambia, the size of Nigeria’s population (around 135 million) meant that by the end of 2006, there were an estimated 2,900,000 people infected with HIV.

Approximately 220,000 people died from AIDS in 2006 alone². With AIDS claiming so many people's lives, Nigeria’s life expectancy has declined. In 1991 the average life expectancy was 53.8 years for women and 52.6 years for men³. In 2007 these figures had fallen to 46 for women and 47 for men.

Despite being the largest oil producer in Africa and the 12th largest in the world⁴, Nigeria is ranked 158 out of 177 on the United Nations Development Programme (UNDP) Human Poverty Index⁵. This poor economic position has meant that Nigeria is faced with huge challenges in fighting its HIV/AIDS epidemic.

The history of HIV and AIDS in Nigeria

The first two HIV cases in Nigeria were identified in 1985 and were reported at an international AIDS conference in 1986⁶. In 1987 the Nigerian health sector established the National AIDS Advisory Committee, which was shortly followed by the establishment of the National Expert Advisory Committee on AIDS (NEACA).

At first the Nigerian government was slow to respond to the increasing rates of HIV transmission⁷ and it was only in 1991 that the Federal Ministry of Health made their first attempt to assess the Nigerian HIV/AIDS situation. The results showed that around 1.8 percent of the population of Nigeria were infected with HIV. Subsequent surveillance reports revealed that during the 1990s the HIV prevalence rose from 3.8% in 1993 to 4.5% in 1998⁸.

When Olusegun Obasanjo became the president of Nigeria in 1999, HIV/AIDS prevention, treatment and care became one of the government’s primary concerns. The President’s Committee on AIDS and the National Action Committee on AIDS (NACA) were created, and in 2001, the government set up a three-year HIV/AIDS Emergency Action Plan (HEAP). In the same year, Obasanjo hosted the Organisation of African Unity’s first African Summit on HIV/AIDS, Tuberculosis, and Other Related Infectious Diseases⁹.

Despite these positive intentions for tackling the epidemic, in 2006 it was estimated that just 7 percent of HIV-infected women and men were receiving antiretroviral therapy and only 0.2 percent of pregnant women were receiving treatment to reduce the risk of mother-to-child transmission of HIV¹⁰.

How is HIV transmitted in Nigeria?

Some 80% of HIV infections in Nigeria are transmitted through heterosexual sex. Factors contributing to this include a lack of information about sexual health and HIV, low levels of condom use and high levels of sexually transmitted infections (STIs) such as chlamydia and gonorrhoea, which make it easier for the virus to be transmitted.

It has been reported that blood transfusions account for up to 10 percent of new HIV infections in Nigeria¹¹. There is a high demand for blood because of blood loss from surgery and childbirth, road-traffic accidents and anaemia and malaria. Not all Nigerian hospitals have the technology to effectively screen blood and therefore contaminated blood is often used. The Nigerian Federal Ministry of Health have responded by backing legislation that requires hospitals to only use blood from the National Blood Transfusion Service, which has far more advanced blood-screening technology¹².

The other main transmission route is mother-to-child transmission. In 2005 it was estimated that 240,000 children were living with HIV, most of whom became infected from their mothers¹³.

Factors contributing to the spread of HIV in Nigeria

Lack of sexual health information and education

Sex is traditionally a very private subject in Nigeria and the discussion of sex with teenagers is often seen as inappropriate. Up until recently there was little or no sexual health education for young people and this has been a major barrier to reducing rates of HIV and other STDs. UNAIDS estimate that only 18 percent of women and 21 percent of men between the ages of 15 and 24 correctly identify ways to prevent HIV¹⁴. Lack of accurate information about sexual health has meant there are many myths and misconceptions about sex and HIV, contributing to increasing transmission rates as well as stigma and discrimination towards people living with HIV/AIDS.

HIV testing

Another contributing factor to the spread of HIV in Nigeria is the distinct lack of voluntary and routine HIV testing. In a 2003 survey, just 6 percent of women and 14 percent of men had ever been tested for HIV and received the results¹⁵. In 2005, only around 1 percent of pregnant women were being tested for HIV¹⁶.

In 2006 president Obasanjo publicly received an HIV test and counselling on World AIDS Day in order to promote the services and information available to people in Nigeria. He stated on the day, “A great majority of Nigerians have now come to accept the reality of AIDS”¹⁷. However, the statistics show that the Nigerian government desperately need to scale up HIV testing rates in order to bring the epidemic under control.

Cultural practices

Women are particularly affected by the epidemic in Nigeria. In 2006 UNAIDS estimated that women accounted for 61.5 percent of all adults aged 15 and above living with HIV¹⁸.

Traditionally, women in Nigeria marry young, although the average age at which they marry varies between states. A 2007 study revealed that 54 percent of girls from the North West aged between 15-24 were married by age 15, and 81 percent were married by age 18¹⁹. The study showed that the younger married girls lacked knowledge on reproductive health, which included HIV/AIDS. They also tend to lack the power and education needed to insist upon the use of a condom during sex. Coupled with the high probability that the husband will be significantly older than the girl and therefore is more likely to have had more sexual partners in the past, young women are more vulnerable to HIV infection within marriage.

Poor healthcare system

Over the last two decades, Nigeria's healthcare system has deteriorated as a result of political instability, corruption and a mismanaged economy. Large parts of the country lack even basic healthcare provision, making it difficult to establish HIV testing and prevention services such as those for the prevention of mother-to-child transmission. Sexual health clinics providing contraception, testing and treatment for other STDs are also few and far between²⁰. This makes it particularly difficult to keep the spread of the epidemic under control.

Prevention

Condoms

The total number of condoms provided by international donors has been relatively low. One report showed that between 2000 and 2005, the average number of condoms distributed in Nigeria by donors was 5.9 per man, per year²¹. A study in 2002 found that 75 percent of health service facilities that had been visited did not have any condoms or contraceptive supplies²².

The number of female condoms sold in Nigeria has significantly increased, which indicates a greater awareness of sexual health issues. In 2003 only 25,000 female condoms had been sold, which increased to 375,000 in 2006²³. The female condom can potentially help in reducing the spread of HIV, as it does not rely upon the willingness of the man to use a condom himself. However, the female condom is more expensive than the traditional male condom, and is too pricey for the majority of Nigerians.

Restrictions on condom promotion have hampered HIV prevention efforts. In 2001, a radio advertisement was suspended by the Advertising Practitioners Council of Nigeria (APCON) for promoting messages suggesting that it is acceptable to engage in premarital sex as long as a condom is used²⁴. In 2006 APCON also started to enforce stricter regulations on condom advertisements that might encourage ‘indecency’²⁵.

Education

As the majority of new HIV infections occur in young people between the ages of 15 and 25, sex education at school is an important aspect of HIV prevention. In recent years a new curriculum has been introduced for comprehensive sex education for 10-18 year olds. It focuses on improving young people's knowledge and attitudes to sexual health and reducing sexual risk-taking behaviours.

In the past, attempts at providing sex education for young people were hampered by religious and cultural objections²⁶. However, the new curriculum was developed with consultation from religious and community leaders and is expected to remain in place in the future.

Media campaigns & public awareness

As Nigeria is such a large and diverse country, media campaigns to raise awareness of HIV are a practical way of reaching many people in different regions. Radio campaigns like the one created by the Society for Family Health are thought to have been successful in increasing knowledge and changing behaviour. "Future Dreams", was a radio serial broadcast in 2001 in nine languages on 42 radio channels. It focused on encouraging consistent condom use, increasing knowledge and increasing skills for condom negotiation in single men and women aged between 18 and 34²⁷.

In 2005, a campaign was launched in Nigeria in a bid to raise more public awareness of HIV/AIDS. This campaign took advantage of the recent increase in owners of mobile phones and sent text messages with information about HIV/AIDS to 9 million people²⁸.

Another high profile media campaign is fronted by Femi Kuti, the son of Fela Kuti, the famous Afrobeat musician who died of AIDS in 1997. He appears on billboards alongside roads throughout Nigeria with the slogan 'AIDS: No dey show for face', which means you can't tell someone has AIDS by looking at them²⁹.

Treatment

When antiretroviral drugs (ARVs) were introduced in Nigeria in the early 1990s, they were only available to those who paid for them. As the cost of the drugs was very high at this time and the overwhelming majority of Nigerians were living on less than $2 a day, only the wealthy minority were able to afford the treatment.

In 2002 the Nigerian government started an ambitious antiretroviral treatment programme, which aimed to supply 10,000 adults and 5,000 children with antiretroviral drugs within one year. An initial $3.5 million worth of ARVs were to be imported from India and delivered at a subsidized monthly cost of $7 per person³⁰. The programme was announced as “Africa’s largest antiretroviral treatment program”.

By 2004 the programme had suffered a major setback as too many patients were being recruited without a big enough supply of drugs to hand out. This resulted in an expanding waiting list and not enough drugs to supply the high demand. The patients who had already started the treatment then had to wait for up to three months for more drugs, which can not only reverse the progress the drugs have already made, but can also increase the risk of HIV becoming resistant to the ARVs. Eventually, another $3.8 million worth of drugs were ordered and the programme resumed.

ARVs were being administered in only 25 treatment centres across the country which was a far from adequate attempt at helping the estimated 550,000 people requiring antiretroviral therapy. As a result, in 2006 Nigeria opened up 41 new AIDS treatment centres and started handing out free ARVs to those who needed them³¹. In spite of this effort, it was estimated that at the end of 2006, only 81,000 people living with HIV/AIDS were receiving treatment³².

The government has set up the National HIV/AIDS Strategic Framework to manage the nation’s response from 2005 to 2009. There are a number of targets that have been integrated into the framework. By 2010 Nigeria aims to provide ARVs to 80 percent of adults and children with advanced HIV infection and to 80 percent of HIV-positive pregnant women³³. The government also aims to test 80 percent of the population for HIV.

These targets could be viewed as over-optimistic, when looking at the situation in Nigeria today. In 2007 only 22 percent of people needing treatment were receiving it³⁴. Although this figure has increased from 2.3 percent in 2003, it is still below the average for sub-Saharan Africa.

Funding

It has been estimated that the Nigerian government are contributing around 5 percent of the funds for the antiretroviral treatment programmes³⁵. The majority of the funding comes from development partners. The main donors are PEPFAR, the Global Fund and the World Bank.

In 2002, the World Bank loaned US$90.3 million to Nigeria to support the 5-year HIV/AIDS Programme Development Project³⁶. In May 2007 it was announced that the World Bank were to allocate a further US$50 million loan for the programme³⁷.

From America, PEPFAR (the President's Emergency Plan for AIDS Relief) has allocated a large amount of money to Nigeria. In 2006 PEPFAR gave approximately US$164 million to Nigeria for HIV/AIDS prevention, treatment and care³⁸. The planned funding for treatment alone in Nigeria for 2007 was US$138.9, the third highest out of PEPFAR’s 15 focus countries.

As of November 2007, the Global Fund has approved nearly US$200 million in funds for Nigeria to expand treatment, prevention, and prevention of mother-to-child transmission programmes. Much of this will be given to the Nigerian government to fund the expansion of antiretroviral treatment³⁹.

The future

In the 2007 general elections, Umaru Musa Yar’Adua of the People’s Democratic Party became the second president of Nigeria’s Fourth Republic. Following in Obasanjo’s footsteps, one of Yar’Adua’s priorities is tackling the Nigerian HIV/AIDS epidemic.

With the large amounts of money being donated from international funds and a government dedicated to increasing prevention measures and treatment access, some are feeling slightly more optimistic about the future of HIV/AIDS in Nigeria. However, it remains to be seen whether the target of providing universal access to HIV prevention, treatment, care and support by 2010, will be reached.

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