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HIV & AIDS in Nigeria
Worldwide, Nigeria has the second highest number of new infections reported each year, and an estimated 3.7 percent of the population are living with HIV. 1 2 Although 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 166.6 million) means that by the end of 2011, there were an estimated 3.4 million people living with HIV. 3 4
Approximately 210,000 people died from AIDS in Nigeria in 2011 5 and, in 2012, the national life expectancy was 52 years. 6 Although national life expectancy remains low, this figure has been rising since access to antiretroviral therapy became available in the mid-2000s. 7
There are three main HIV transmission routes in Nigeria:
- Heterosexual sex. Approximately 80 percent of HIV infections in Nigeria are a result of heterosexual sex. 8 Women are particularly affected by HIV; in 2011 an estimated 1.7 million women were living with HIV and prevalence was 3 percent among young women aged 15-24. 9 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 diseases. However, gender inequality among women has been identified as a key driver of the HIV epidemic among women. 10
- Blood transfusions. HIV transmission through unsafe blood accounts for the second largest source of HIV infection in Nigeria. 11 12 Not all Nigerian hospitals have the technology to effectively screen blood and therefore there is a risk of using contaminated blood. 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 technology.
- Mother-to-child transmission. Most children infected with HIV aquire it from their mothers. An estimated 69,400 children were newly infected with HIV in 2011.
Key at-risk groups in Nigeria, include 13:
- Brothel and non-brothel based female sex workers (FSW). HIV prevalence is 24.5 percent.
- Men-who-have-sex-with-men (MSM). HIV prevalence is 17.2 percent.
- Injecting drug users (IDUs). HIV prevalence is 4.2 percent.
Transport workers and members of the Armed Forces and Police are also considered high-risk. It has been found that individuals that fall under these groups and their partners account for 40 percent of new HIV infections in Nigeria. 14
HIV prevention in Nigeria
Sex is traditionally a very private subject in Nigeria and the discussion of sex with teenagers is often seen as inappropriate. It is evident that some groups, particularly religious and cultural leaders, have acted as a barrier to previous attempts to provide sex education for young people in Nigeria. 15 However, successful delivery of sex education to young people is reliant on increasing the participation of these community leaders in the planning and implementation of such programmes. 16
- In 2009 only 23 percent of schools were providing life-skills based HIV education. 17
- Only 25 percent of men and women between the ages of 15 and 24 correctly identified ways to prevent sexual transmission of HIV, in 2010.
In some regions of Nigeria girls marry relatively young, often to much older men. Studies have found those who are married at a younger age have less knowledge about HIV and AIDS than unmarried women, and are more likely to believe they are low-risk for becoming infected with HIV. 18 HIV and AIDS education initiatives need to ensure they focus on married girls, as they are less likely to have access to health information than unmarried girls. 19 However, the need to improve knowledge about HIV among girls overall (both married and unmarried) remains, as HIV prevention knowledge is significantly less among girls (aged 15-19), compared to boys. 20 Addressing the social and cultural factors that contribute to early sexual debut among girls, notably gender inequality, in Nigeria is integral to successful HIV prevention among this group.
- In North Western Nigeria around half of girls are married by age 15 and four out of five girls are married by the time they are 18. 21
- Twice as many girls than boys are engaging in sexual activity before the age of 15 years.
Using a condom is the most effective way for a person to protect themselves from HIV, unless they practice abstinance. However, restrictions on condom promotion in Nigeria have hampered efforts to promote this form of HIV prevention. 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 used. 22 In 2006 APCON also started to enforce stricter regulations on condom advertisements that might encourage ‘indecency’. 23
Nevertheless, in their National Strategic Plan 2010-2012 Nigeria set the target of having 80 percent of sexually active men and women using condoms consistently and correctly with non-regular partners by 2015; indicating a positive change in attitude towards condom use. 24 However, nearly half (42 percent) of HIV infections occur among people considered to be having low-risk sex; those in cohabiting or married partnerships. This is a result of low condom use among regular sexual partners, but when one partner is engaging in high-risk behaviours outside of the relationship. 25
- More than 2 billion male condoms and 886,979 female condoms were distributed, both by NGOs and the Federal Ministry of Health, in 2010.
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 34. 26
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 people. 27
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 them. 28
Prevention of mother-to-child transmission of HIV
In Nigeria, a small proportion, only 18 percent, of pregnant women with HIV access antiretroviral therapy to protect their children. 29 As a result, Nigeria has achieved a small decline in new infections among children, since 2009; an estimated 69,400 children were newly infected with HIV in 2011. This has led to a rise in the total number of children living with HIV in the country to an unprecedented 440,000. 30
Over a quarter of pregnancies among women with HIV resulted in transmission to the child. Improvements in the uptake of HIV testing and counselling, and scaling up access to the most effective antiretroviral regimens (triple ARV regimens) among pregnant women are essential targets Nigeria must meet if they are to halt the rising numbers of children living with HIV. 31
- Less pregnant women are receiving single-dose nevirapine for PMTCT; 8.4 percent in 2011, compared with 24.5 percent in 2010.
- More pregnant women are receiving effective antiretroviral treatment for PMTCT; 33.2 percent received a triple ARV regimen in 2011, compared with 25.2 percent in 2010.
Preventing HIV among most-at-risk groups
The high HIV prevalence reported among high-risk groups, as well as their link to the general population should place these individuals at the centre of HIV prevention programmes. Nevertheless, HIV prevention messages are not sufficiently reaching people that fall within these groups. One of the major barriers to accessing HIV prevention programmes for MSM and sex workers are laws that prohibit their activities. For example, same-sex relations in Nigeria are criminalised with 14 years imprisonment, and in early 2014 a new law was passed to further criminalise the LGBT community. It states that people who participate in gay organisations or publically show same-sex affection will be imprisoned for 10 years; those that support gay organisations face the same conviction. There is concern that this will limit access for the LGBT community to HIV services. 32
Men who have sex with men (MSM)
MSM living in Nigeria are considered to have a high and increasing risk of becoming infected with HIV. 33 Despite the need for improvements in HIV knowledge and awareness among this group, less men who have sex with men were reached with HIV prevention programmes in 2011 (24 percent), than in 2009 (58 percent). 34 Condom use has remained generally unchanged since 2007, with only half of men reporting use of a condom. To prevent onward transmission of HIV men who have sex with men should know their HIV status. Yet, HIV testing among this group is low and declining, with only a quarter testing for HIV. 35
- HIV prevalence was reported as high as 17 percent in 2011, up from 14 percent in 2009.
- Only half of men used a condom, the last time they had anal sex with a male partner, in 2011.
People who receive money for sex (male and female sex workers) are considered at risk of HIV infection. This risk can be reduced by using condoms consistently and correctly. However, many sex workers in Nigeria are not being reached by HIV prevention programmes and therefore do not have the knowledge about how to protect themselves from HIV and other STDs. Considerably less sex workers were reached with HIV prevention messages in 2011 (26 percent), than in 2009 (80 percent).
Whilst consistent condom use has been found to be extremely high among sex workers with their clients, many are not using condoms consistently during sex with partners. However, expanding HIV prevention messages to male sex workers is of particular importance, as condom use with clients is extremely low among this group, particularly in comparison to female sex workers. 36
- A quarter of sex workers were living with HIV in 2011.
- Nearly all sex workers (89 percent) reported condom use with their most recent client, in 2011.
People who inject drugs
Sharing injecting equipment, such as a needle or syringe, can transmit HIV. People who use drugs must take precautions such as always using clean injecting equipment to prevent HIV infection. Although most people who inject drugs in Nigeria do so safely, this number is declining. 37 Reversing this trend should be a priority if HIV transmission through injecting drugs is to be minimised in Nigeria. Achieving this is reliant on Nigeria increasing existing harm reduction services and implementing new services, not currently available, such as needle exchanges. 38
- About 4 percent of people who inject drugs in Nigeria are living with HIV; a decline of about 2 percent since 2009. 39
- 71 percent of people who inject drugs, injected safely in 2011; less than in 2009.
Very few Nigerians know their HIV status. This can place people at risk of becomming ill, as they do not access timely HIV treatment and care. It also increases the risk of onward transmission to sexual partners. People who want to get tested for HIV often have to travel long distances, and into rural centres, as there is a distinct lack of HIV testing and counselling facilities. 40 In 2011 there were only 1357 HIV testing and counselling facilities nationwide and only 12 percent of women and men aged 15-49 had received an HIV test and found out the results. 41 42 This shows how desperately the government needs to scale up HIV testing services. Moreover, HIV testing and counselling of pregnant women is central to the prevention of mother-to-child transmission, yet this remains extremely low with only 1 in 6 pregnant women receiving it in 2011. 43
The uptake of HIV testing among most-at-risk individuals, such as sex workers, injecting drug users (IDUs) and men who have sex with men (MSM), must increase if Nigeria is to see a decline in the currently high levels of HIV prevalence reported among these groups. 44
- HIV testing among sex workers has increased, but remains low, with only 42 percent receiving an HIV test and the results within the previous 12 months, in 2011.
- Uptake of HIV testing is poor among MSM, only a quarter had received a test in 2011, less than in previous years.
- Few IDUs know their HIV status, only one in five reported to have received a test in 2011.
Some reports have suggested that health care facilities offering HIV testing in Nigeria do not follow international standards about confidentiality and ethics. 45 In one particular study, over half of people living with HIV reported that they did not know they were being tested for the virus and around one in seven health care professionals admitted to never receiving informed consent for HIV tests. 46 Implementing these standards will go someway towards improving the uptake of HIV testing. However, if HIV testing is to improve among most-at-risk individuals legislation, that criminalises their activities, must be replaced by legislation that enables them to access health services free from the risk of discrimination and arrest. 47
HIV treatment and care in Nigeria
Resources needed to provide sufficient treatment and care for those living with HIV in Nigeria remain seriously lacking. A study of health care providers found many had not received sufficient training on HIV prevention and treatment and many of the health facilities had a shortage of medications, equipment and materials. 48
The government's National HIV/AIDS Strategic Framework for 2005 to 2009 set out to provide ARVs to 80 percent of adults and children with advanced HIV infection and to 80 percent of HIV-positive pregnant women, all by 2010. 49 However, only 31 percent of people who needed treatment for advanced HIV infection received it in 2009. 50 As a result of this slow progress the treatment goals were set back to 2015 in the revised framework (2010 to 2015). 51
- Only a third of people in need of treatment are receiving it. 52
- 1.4 million adults need treatment, whilst only 432,285 adults were receiving treatment in 2011. 53
- The number of children who need treatment has increased since 2009, to 280,000. 54
- 36,716 children are receiving treatment. 55
Funding for HIV and AIDS in Nigeria
- Total available funding for HIV/AIDS was $497,817,471 in 2010
- Funding from international sources totalled $370,927,328 in 2010
- In 2008 only 7.6 percent of total domestic HIV funding was from public sources ($30,082,451), compared with 45.5 percent ($125,139,584) in 2010
- Funding available for HIV prevention activities increased in 2010, whereas funding for HIV treatment and care declined by 28.5 percent in 2010
In 2002, the World Bank loaned US$90.3 million to Nigeria to support the 5-year HIV/AIDS Programme Development Project. 58 In May 2007 it was announced that the World Bank were to allocate a further US$50 million loan for the programme. 59 Following the success of this programme, the World Bank went on to contribute a further US$225 million towards an HIV/AIDS Programme Development Project II (2009-2013) set to run until 2015, due to delays signing the credit agreement. 60 61
Through PEPFAR (the President's Emergency Plan for AIDS Relief) the United States has allocated a large amount of money to Nigeria. In financial year 2011, PEPFAR provided approximately US$488.6 million to Nigeria for HIV/AIDS prevention, treatment and care. 62
By August 2012, the Global Fund had approved US$360,454,493, and disbursed US$275,586,635 in funds for Nigeria to expand HIV/AIDS treatment, prevention, and care programmes. 63 Most recent funding has been focused on decentralising HIV prevention, support and care to make it available in primary care facilities and at a community level, to increase gender sensitive prevention interventions and to expand antiretroviral treatment access across secondary health facilities. 64
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 was tackling the Nigerian AIDS epidemic. Yar'Adua's successor, Goodluck Jonathan, has reiterated this commitment and has expressed particular concern about the low levels of HIV testing in Nigeria. 65 With the large amounts of money now being sourced from both international and domestic sources and a government dedicated to increasing prevention measures and treatment access, Nigeria seems set to make a lasting impact on its HIV epidemic.
Importantly, Nigeria must sustain and increase present funding and investment levels, if access to HIV testing and treatment is to reach all Nigerians. Moreover, HIV education and knowledge must be expanded and gender inequality issues addressed to lower current levels of new HIV infections, particularly among young women and children.
Nigeria continues to be home to 10 percent of the global population of people living with HIV, and still has a long way to go in tackling its devastating HIV and AIDS epidemic. In 2011, the Nigerian Health Minister acknowledged the extent of the challenge that Nigeria faces when he stated...
The HIV and AIDS epidemic in Nigeria remains a public health problem of enormous magnitude that must be given priority attention 66
The History of AIDS in Nigeria
The first two cases of HIV and AIDS in Nigeria were identified in 1985 and were reported at an international AIDS conference in 1986. 67 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 transmission 68 and it was only in 1991 that the Federal Ministry of Health made their first attempt to assess the situation with HIV and AIDS in Nigeria. 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 HIV prevalence rose from 3.8 percent in 1993 to 5.4 percent in 1999. Following a peak of 5.8 percent in 2001, HIV prevalence then declined steadily throughout the decade. 69 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.
When Olusegun Obasanjo became the president of Nigeria in 1999, HIV 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 Diseases. 70
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 person. 71 The programme was announced as 'Africa’s largest antiretroviral treatment programme'.
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 HIV drug resistance. Eventually, another $3.8 million worth of drugs were ordered and the programme resumed.
ARVs were being administered in only 25 treatment centres across the country which was a far from adequate attempt at helping the estimated 550,000 people requiring antiretroviral therapy. Despite increased efforts to control the epidemic, by 2006 it was estimated that just 10 percent of HIV-infected women and men were receiving antiretroviral therapy and only 7 percent of pregnant women were receiving treatment to reduce the risk of mother-to-child transmission of HIV. 72 As a result, in 2006 Nigeria opened up 41 new AIDS treatment centres and started handing out free ARVs to those who needed them. 73 Treatment scale-up between 2006-7 was impressive, rising from 81,000 people (15 percent of those in need) to 198,000 (26 percent) by the end of 2007.
Nigeria's programme to prevent the transmission of HIV from mother to child ( PMTCT) started in July 2002. 74 Despite efforts to strengthen PMTCT interventions, by 2007 only 5.3 percent of HIV positive women were receiving antiretroviral drugs to reduce the risk of mother-to-child transmission. This figure had risen to almost 22 percent by 2009, but still remained far short of universal access targets which aim for 80 percent coverage. 75
In 2010 NACA launched its comprehensive National Strategic Framework to cover 2010 to 2015, which required an estimated N756 billion (around US$ 5 billion) to implement. 76 Some of the main aims included in the framework are to reach 80 percent of sexually active adults and 80 percent of most at-risk populations with HIV counselling and testing by 2015, ensure 80 percent of eligible adults and 100 percent of eligible children are receiving ART by 2015; and to improve access to quality care and support services to at least 50 percent of people living with HIV by 2015. 77
Despite being the largest oil producer in Africa and the 12th largest in the world, 78 Nigeria is ranked 156 out of 187 on the United Nations Development Programme (UNDP) Human Poverty Index. 79 This poor development position has meant that Nigeria is faced with huge challenges in fighting its HIV and AIDS epidemic.
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