Of all people living with HIV globally, 9% of them live in Nigeria.1 Although HIV prevalence among adults is remarkably small (3.2%) compared to other sub-Saharan African countries such as South Africa (19.1%) and Zambia (12.5%), the size of Nigeria's population means that there were 3.2 million people living with HIV in 2013.2
Nigeria, together with South Africa and Uganda, account for almost half of all annual new HIV infections in sub-Saharan Africa. This is despite achieving a 35% reduction in new infections between 2005 and 2013.1
Approximately 210,000 people died from AIDS-related illnesses in Nigeria in 2013, which is 14% of the global total. Since 2005, there has been no reduction in the number of annual deaths, indicative of the fact that only 20% of people living with HIV in Nigeria are accessing antiretroviral treatment (ART).1
Unprotected heterosexual sex accounts for about 80% of new HIV infections in Nigeria, with the majority of remaining HIV infections among key affected populations.3
Key affected populations and HIV in Nigeria
In response to this, the Nigerian National HIV/AIDS Strategic Plan (NSP) 2010-2015 calls for enhanced behaviour change communication for key affected populations. To deliver this, peer education systems are being scaled-up, alongside social media messaging that aims to reach those populations who tend not to present for HIV services.3
Sex workers and HIV in Nigeria
Half of all HIV infections in Nigeria among key populations are among sex workers, their partners and their clients. This is not surprising considering only 18% of sex workers were thought to have received HIV prevention information in 2010.4
19% of male sex workers and 25% of female sex workers in Nigeria are living with HIV.1 This is eight times higher than the general population. The 2012 National HIV/AIDS and Reproductive Health Survey found HIV prevalence to be even higher among female brothel-based sex workers, at 27.4%.5
One study found reasons for this high HIV prevalence including that many sex workers underestimated their risk of HIV and so didn't use necessary prevention methods. Others believed that their faith would protect them from infection.6 Many sex workers have also been found to not use condoms when they have sex with their partners, despite 88% using condoms with their most recent client.7 4
Men who have sex with men (MSM) and HIV in Nigeria
17% of men who have sex with men (MSM) are living with HIV in Nigeria.1 They are the only key affected population that actually experienced a rise in HIV prevalence between 2007 and 2010, now accounting for 10% of all new HIV infections in the country.3
2014 saw the signing into law of a bill that increased the punishment for homosexuality to 14 years in jail, despite same-sex activities already being illegal and worthy of a jail sentence.8 Homophobia discourages many MSM from testing for HIV. Indeed, only 17% of MSM were reached with HIV prevention programming in 2010.4
People who inject drugs (PWID) and HIV in Nigeria
It is thought that 9% of new HIV infections in Nigeria are among people who inject drugs (PWID) and yet there are no HIV prevention programmes that target this population.3 In 2010, only 19.4% of PWID knew their HIV status, so the reported HIV prevalence among this affected population of 4.2% is likely to be much higher.4
Reducing HIV infections among this population is reliant on Nigeria implementing harm reduction services that are not currently available, such as needle and syringe programmes and opioid substitution therapy.9 10
Young people and HIV in Nigeria
National data suggests that 1.3% of young women (15-24 years old) are living with HIV, and 0.7% of young men.1 Only 24% of young people in 2012 could correctly identify ways to prevent sexual transmission of HIV, and reject common myths.5
Early sexual debut is common in Nigeria, which begins at less than 15 years old for 15% of Nigeria's youth. This is one factor that increases HIV vulnerability among young people, alongside very low HIV testing rates - only 17% of young people know their HIV status.5 However, this is higher than the testing rate among adults.
Children and those orphaned by AIDS in Nigeria
400,000 children in Nigeria are living with HIV.11 HIV also has an indirect impact on children in Nigeria whereby they become the caregivers for parents who are living with HIV. Most often this responsibility lies with girls rather than boys.3 This reflects the imbalance in schooling between the two genders in Nigeria, with girls missing out on HIV education that could teach them how to protect themselves from infection.
It is thought that 2 million children in Nigeria are currently orphaned by AIDS, with many caring for siblings alone, or being looked after by grandparents.11
HIV prevention programmes in Nigeria
Prevention of mother-to-child transmission of HIV
Of the 190,000 pregnant women living with HIV in 2013, only 27% of them received antiretroviral treatment to prevent the transmission of HIV to their child. Only 19% of these women are still taking their medication when breastfeeding, emphasising a lack of drug supply and a lack of knowledge of the transmission routes of HIV.1
22% of all new child HIV infections globally during 2013 were in Nigeria (51,000).12 With only a 19% decline in child HIV infections since 2009, it is clear that Nigeria is not progressing fast enough with its PMTCT programme. In fact, it is the second worst performing Global Plan priority country after Chad. Only 12% of children who are born HIV-positive are then receiving treatment to control their HIV infection.1
Improvements in the uptake of HIV testing and counselling, and scaling up access to the most effective antiretroviral regimens among pregnant women are essential targets Nigeria must meet if they are to halt the rising numbers of children born with HIV. More and more PMTCT sites are being set up around the country, so it is hoped the dramatic rise between 2012 (1,410) and 2013 (5,622) will lead to more promising PMTCT statistics in the near future.3
Testing men at PMTCT centres via couples testing and counselling is effective at getting more men to test for HIV and be involved in the PMTCT journey alongside his partner and child. In Benue State, a new incentive has been rolled out at PMTCT clinics whereby women who bring along their partner will be attended to first.3
In early 2015, the telecommunications company Etisalat started rolling out SMS messages to its subscribers about PMTCT and where people could seek HIV services. It is hoped that large-scale communications like this will encourage women to come forward for testing to prevent their babies being born with HIV.12
HIV and AIDS education
Family Life and HIV Education (LLHE) lessons are part of the Nigerian school curriculum.3 The requirements include a comprehensive list of topics related to HIV, including the basic facts about HIV transmission and prevention, alongside more complex issues such as stigma and gender-based violence.13
One study in 2013 evaluated the successes and failures of the curriculum, finding that pupil enrolment is increasing, teachers are mostly adequately trained, and learning is likely to reduce new HIV infections. However, there are not enough teachers for the number of pupils, and the number of classrooms and teachers are concentrated in certain areas.14
Preventing TB among people living with HIV
Nigeria is one of ten countries worldwide that together make up 80% of all people living with HIV who also have TB.1
The risk of developing TB infection declines dramatically if a person living with HIV is on antiretroviral treatment.1 In Nigeria, 88% of people diagnosed with TB are also living with HIV. However, the low uptake of HIV treatment in Nigeria could explain why so many people are developing TB, and why the country is not on track to meet the 2015 target of halving TB prevalence since 1990.15
In 2012, Nigeria conducted its first ever national survey to determine the extent of TB throughout the country. There is a greater commitment to improve TB case detection, improve access to treatment, roll out the use of new technologies to test for TB and engage all healthcare providers in TB care as a result.16
Multi-drug resistant TB (MDR-TB) is becoming an increasing problem, caused when treatment is started and not completed or taken incorrectly. Only 16% of TB cases in 2013 were diagnosed and treated successfully, Nigeria is experiencing a similar problem rolling out TB treatment as it is for HIV treatment.17
In 2012, a MDR-TB treatment centre was opened in Nigeria, with modern technology, specialised healthcare professionals, and the second-line drugs that are needed to treat MDR-TB. It was financed domestically, and it is hoped that this increased level of expertise and drug stocks within the country will help keep the number of TB cases under control and provide better care for those living with TB and HIV.18
Government commitment to HIV in Nigeria
As well as the National Strategic Plan (NSP) on HIV and AIDS 2010-2015, the country also initiated a Presidential Comprehensive Response Plan (PCRP) in 2013 as Nigeria was missing national targets in its HIV response.19 There are a number of priority interventions outlined in the PCRP, with particular focus on funding the response and ensuring that targeted interventions are in place. It aims to prevent 105,000 HIV infections during its two year duration.20
In early 2015, President Jonathan signed a new antidiscrimination bill into law which secured the rights of people living with HIV, protecting HIV-positive employees from unfair dismissal and from mandatory HIV testing.3
Barriers to HIV prevention in Nigeria
One of the major barriers to accessing HIV prevention programmes for MSM are laws that prohibit their activities. For example, same-sex relations in Nigeria are criminalised with 14 years imprisonment. This is not only limiting access for HIV prevention programming for this community, but causing nationwide stigma and discrimination against people based on their sexual orientation.21
Gender inequality is imbedded in Nigerian society and culture.11 Although women do have rights to land, the patriarchal society dictates that their rights are weaker than a man's.22 The result is a high fertility rate of six children per woman, due to the pressure on her to give birth to boys who can inherit and own land.
If a woman has a girl first, she is more likely to have more children, not use contraceptives, have short periods between pregnancies, and be subjected to polygamy. Each of these factors increases a woman's vulnerability to HIV. 1.6 million women are living with HIV in Nigeria.23
A simple lack of sites that deliver HIV services (testing sites, PMTCT sites, and treatment sites) presents problems for the Nigerian population. PMTCT coverage and sites that provide early infant diagnosis remain extremely low and results in many new HIV infections each year.3
HIV transmission via blood products is minimal in Nigeria, enhanced effort could almost eliminate this risk. Although there are guidelines for certain practices, the lack of universal precautions and failure to record blood safety information in all circumstances means HIV transmission via blood products remains a risk for patients and healthcare workers.3
Nigeria's funding of its HIV response remains challenging, but the PCRP launched in 2013 has committed to bridging the gap in funding by providing more domestic resources. It is hoped this will mobilise the response to HIV dramatically, as in 2012, only 21.4% was domestically financed.3
HIV testing and counselling (HTC) in Nigeria
The National HIV & AIDS and Reproductive Health Survey of 2012 found very low uptake of HIV testing in Nigeria - just 23% of males and 29% of females had tested in the last year. Less than 70% of these people had received their results.5
Since then, a huge number of new HTC sites have been built, bringing the total from 2,391 in 2012, to 7,075 in 2013. As a result, a 50% rise in the number of people tested was seen between those two years. Couples testing, and provider-initiated testing and counselling have been recommended throughout the country, but uptake at HTC sites is slow.5
There are a number of reasons why more people are not testing for HIV in Nigeria. These include supply problems with testing kits and logistic issues getting further supplies. There is also a common belief that HTC centres are where HIV-positive people go to access care, rather than them being testing centres for those who don't know their status.3
Antiretroviral treatment (ART) in Nigeria
Antiretroviral treatment (ART) provision in Nigeria is extremely low, with only 21% of adults living with HIV receiving treatment in 2013, and 12% of children. Only 19% of women who are living with HIV and breastfeeding are taking ART.1
Although the number of antiretroviral treatment (ART) sites increased between 2012 and 2013, it is still not enough. With only 820 sites in the whole of Nigeria, it is not surprising that people living with HIV are struggling to access clinics where they can get treatment. ART administration is being decentralised from hospitals to primary health centres, and from doctors to nurses and community health workers, although there is still a huge demand for more healthcare professionals.3
Certain weaknesses in the system exist, which mean many people who receive a positive HIV diagnosis are not referred on to treatment, or not retained in treatment for very long. Even when ART can be accessed, drug supplies are known to run out and lead to stock-outs.3
The future of HIV in Nigeria
Nigeria is an enormous country, and so it has a very high number of people living with HIV despite a relatively low HIV prevalence.
When reading the major statistics all together the situation is stark: 9% of all people living with HIV globally are in Nigeria, 14% of the global deaths from HIV-related illness are in Nigeria, only 20% of people living with HIV are on treatment, and only 27% of pregnant women are receiving treatment for PMTCT.
Providing antiretroviral treatment for all people living with HIV doesn't only benefit those already living with HIV, it also dramatically reduces the chance of onwards HIV transmission to others. In a country like Nigeria where there are so many people not on treatment, it is hard to tackle the HIV epidemic. Considerable commitment, funding and resources need to be mobilised to expand access to treatment as a prevention method.
Despite government commitment to the HIV response in many ways, punitive laws such as the anti-homosexuality bill damage progress. They prevent key populations such as MSM seeking HIV services and make it extremely difficult to reach them with prevention messages. Engaging all members of society, and especially those who are most vulnerable to HIV, is key to a unified and considered HIV response.
Finally, encouraging HIV testing among the Nigerian population to ensure everyone knows their HIV status is key to any informed strategic plan. Without knowing the extent of how many people are living with HIV it is hard to mitigate new infections and provide HIV treatment to all.
- 1. a. b. c. d. e. f. g. h. i. j. k. UNAIDS (2014) 'The Gap Report'
- 2. UNAIDS (2014) 'Epidemiology Fact Sheet on HIV and AIDS in Nigeria'
- 3. a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. Nigeria National Agency for the Control of AIDS (2014) 'Country Progress Report 2014'
- 4. a. b. c. d. Nigeria Federal Ministry of Health (2010) 'HIV Integrated Biological and Behavioural Surveillance Survey (IBBSS)'
- 5. a. b. c. d. e. Nigeria Federal Ministry of Health (2013) 'National HIV & AIDS and Reproductive Health Survey 2012, (NARHS Plus II)'
- 6. Ankomah, A. (2011) 'HIV-related risk perception among female sex workers in Nigeria' HIV/AIDS - Research and Palliative Care 3:93-100
- 7. Eluwa, G. I. (2012) 'Sexual risk behaviours and HIV among female sex workers in Nigeria' Journal of Acquired Immune Deficiency Syndromes 61(4):507-514
- 8. Huffington Post (2014) 'Nigeria's Anti-Gay Bill Signed into Law by President Goodluck Jonathan'
- 9. Harm Reduction International (2014) ‘Global State of Harm Reduction 2014’
- 10. Eluwa, G. I. (2013) 'A profile on HIV prevalence and risk behaviours among injecting drug users in Nigeria: Should we be alarmed?' Drug and Alcohol Dependence 127(1-3):65-71
- 11. a. b. c. UNAIDS (2013) 'Nigeria'
- 12. a. b. UNAIDS (2015) 'UNAIDS and Etisalat join together to stop mother-to-child transmission of HIV in Nigeria'
- 13. Nigerian Educational Research and Development Council (2003) 'National Family Life and HIV Education Curriculum for Junior Secondary School in Nigeria'
- 14. Abah, R. C. (2013) 'The universal basic education programme and the family life HIV education in Nigeria' International Journal of Development and Sustainability 2(2)
- 15. World Health Organisation (WHO) (2014) 'Global Tuberculosis Report 2014'
- 16. World Health Organisation (WHO) (2012) 'Report - First National TB Prevalence Survey Nigera, 2012'
- 17. Stop TB Partnership (2015) 'Nigeria Spends Nearly US$1.5M for Procurement of Treatment for People with Multi-Drug Resistant TB'
- 18. FHI 360 (2012) 'Reducing the burden of tuberculosis and HIV in Nigeria'
- 19. UNAIDS (2013) 'President Goodluck Jonathan urges all Nigerians to "Take Charge" and take an HIV test'
- 20. UNAIDS (2013) 'The President's Comprehensive Response Plan - Summary'
- 21. UNAIDS (2014, January 14th) 'UNAIDS and the Global Fund express deep concern about the impact of a new law affecting the AIDS response and human rights of LGBT people in Nigeria'
- 22. The Economist (2014) 'Amid worries about kidnapped girls, Nigeria's traditions are unkind, too'
- 23. World Bank Policy Research Working Papers (2014) 'Son Preference, Fertility and Family Structure: Evidence from Reproductive Behaviour Among Nigerian Women'