Nigeria has the second largest HIV epidemic in the world.1 Although HIV prevalence among adults is remarkably small (3.1%) compared to other sub-Saharan African countries such as South Africa (19.2%) and Zambia (12.9%), the size of Nigeria's population means 3.5 million people were living with HIV in 2015.2
An estimated 60% of new HIV infections in western and central Africa in 2015 occurred in Nigeria
An estimated 60% of new HIV infections in western and central Africa in 2015 occurred in Nigeria,3 together with South Africa and Uganda, the country accounts for almost half of all new HIV infections in sub-Saharan Africa every year. This is despite achieving a 35% reduction in new infections between 2005 and 2013.4 Unprotected heterosexual sex accounts for 80% of new HIV infections in Nigeria, with the majority of remaining HIV infections occurring in key affected populations such as sex workers.5
HIV prevelance is highest in Nigeria’s southern states (known as the South South Zone), and stands at 5.5%. It is lowest in the southeast (the South East Zone) where there is a prevalence of 1.8%. There are higher rates of HIV in rural areas (4%) than in urban ones (3%).6
Approximately 180,000 people died from AIDS-related illnesses in Nigeria in 2015.7 Since 2005, the reduction in the number of annual AIDS-related deaths has been minimal, indicative of the fact that only half (51%) of those living with HIV in Nigeria are accessing antiretroviral treatment (ART).8
Key affected populations and HIV in Nigeria
The Nigerian National HIV/AIDS Strategic Plan (NSP) 2010-2015 included plans to introduce 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.10
Sex workers and HIV in Nigeria
18.6% of male sex workers and 24.5% of female sex workers in Nigeria are living with HIV. This is eight times higher than the general population.11 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%.12
Nigeria’s National Agency for the Control of AIDS (NACA) reports changes in risk behaviours among sex workers, particularly female sex workers. In July 2015, it found female sex workers to be using condoms regularly and increasingly aware of HIV risk. More were also testing for HIV although the testing rate remains low at 41.8%.13 There is marked difference between genders with only 17.5% of male sex workers testing for HIV compared to 44.8% of female sex workers. Similary, only 54.7% of male sex workers reported using a condom with their last client compared to 92.9% of female sex workers.14 Both genders reported low condom use with regular partners.15
Men who have sex with men (MSM) and HIV in Nigeria
The number of men who have sex with men (sometimes referred to as MSM) who are living with HIV in Nigeria is increasing. This group now bears the heaviest HIV burden in the country whereas, before 2013, sex workers were the worst affected group. In 2007, 13.5% of men who have sex with men were living with HIV. In 2015, prevelance had risen to 23%.16 Men who have sex with men are thought to account for 10% of all new HIV infections in the country.17
In 2014, the Nigerian government increased the punishment for homosexuality to 14 years in jail. Anyone “assisting couples” may face up to 10 years in prison.18
Despite NACA stating that “no provision of this law will deny anybody in Nigeria access to HIV treatment and other medical services”, many Nigerian men who have sex with men do not access HIV services. In 2010, only 18% of men who have sex with men were reached with HIV prevention programming .19 In the same year, 51% reported using a condom the last time they had sex and 25% reported testing for HIV in the past 12 months.20
People who inject drugs (PWID) and HIV in Nigeria
It is thought that 9% of new HIV infections in Nigeria every year are among people who inject drugs (sometimes referred to as PWID)21 Women who inject drugs are disproportionately affected; they are seven times more likely to be living with HIV than their male counterparts (14% compared to 3%).22
In 2015, NACA reported that around half (52.7%) of people who inject drugs share needles and syringes. 7.3% share needles and syringes all the time and more than a third (36.4%) shared needles some of the time. Although this is lower than in 2010, helped in part by efforts to reach people who inject drugs with HIV prevention services, these rates remain incredibly high.23
A key issue is that harm reduction services such as opioid substitution therapy and clean needle exchanges are currently not available in Nigeria. Available services are limited to targeted information, education and communication, condom distribution and hepatitis C treatment. However, discussions on developing a national harm reduction strategy began in 2015.24
In 2015, NACA began working with UNODC on a draft national HIV response strategy to target people who inject drugs. It has also begun to train staff from its National Drug Law Enforcement Agency and 11 civil society organisations working with people who use drugs on HIV responses targeted to this group’s needs.25
Young people and HIV in Nigeria
National data suggests that 4.2% of young people (ages 15-24) are living with HIV.26 Awareness of HIV prevention is higher among young men than women. In the 2013 Demographic and Health Survey (the most recent available), 70% of young men (ages 15-24) were aware that using a condom can reduce the risk of HIV transmission compared to 56% of their female peers.27
Young women have a higher HIV prevalence and are infected earlier in life than men of the same age group.28 In 2013, more than 34,700 young women were infected with HIV compared to 19,900 young men.29
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.30
Children and those orphaned by AIDS in Nigeria
An estimated 1.8 million children have been orphaned by AIDS, which has had a huge impact on thei health, safety and well being of these children.33 Around 20% of orphans and vulnerable children do not attend school regularly and around 18% have been sexually abused.34
HIV also has an indirect impact on children in Nigeria whereby they become the caregivers for parents who are living with HIV. Often, this responsibility lies with girls rather than boys.35 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.
HIV prevention programmes in Nigeria
Prevention of mother-to-child transmission (PMTCT) of HIV
A third (32%) of all cases of mother to child transmission (MTCT) of HIV in the world happen in Nigeria. In 2013, just 30% of pregnant women living with HIV received antiretroviral treatment. As a result, MTCT is high at 26.5%.36
Despite yearly increases, the number of pregnant women visiting health facilities remains low, as does the number of health facilities providing PMTCT services. To improve the situation, programmes designed to actively engage the private-health sector and traditional-birth attendants (TBAs) on HIV have been implemented. For example, the Agbebiye programme in Ondo State set out to incentivise TBAs to refer women to public health facilities that provide quality mother and child care services. In 2014, the programme resulted in 91% of the 45,000 pregnant women in the state accessing antenatal services in public health facilities.37
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.38
HIV and AIDS education
Family Life and HIV Education (LLHE) lessons are part of the Nigerian school curriculum.39 In 2014, more than 1 million pupils attended LLHE lessons. The requirements include a comprehensive list of topics relating to HIV, including the basic facts about HIV transmission and prevention, alongside more complex issues such as stigma and gender-based violence.40
Preventing tuberculosis (TB) among people living with HIV
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 its target of halving TB prevalence.45
Multi-drug resistant TB is becoming an increasing problem, caused when treatment is started and not completed or taken incorrectly. Only 15% of TB cases in 2015 were diagnosed and treated successfully.46
Government commitment to HIV in Nigeria
As well as the National Strategic Plan (NSP) on HIV and AIDS 2010-2015, the country initiated a Presidential Comprehensive Response Plan (PCRP) in 2013 as Nigeria was missing national targets in its HIV response.47
As of 2016, whether the PCRP has achieved its stated goal of preventing 105,000 new HIV infections in two years has not yet been reported. However, the PCRP initially led to a significant increase in government spending on its HIV response.48
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.49 However, in 2016 UNAIDS reported that 21% of people living with HIV had been denied access to health services and reproductive health services due to their status.50
Nigerian cities Abuja and Lagos are among 50 cities with high HIV burdens in the world to be included in the International Association of Providers of AIDS Care’s Fast-Track Cities initiative. The initiative is led by each city’s mayor and local administration to help cities become “more sustainable, secure, smart and healthy”. 51 As part of the initiative, Microsoft is implementing a programme to that will help cities provide remote clinical services and other e-health initiatives. This will enable health centres to reduce costs without reducing services and provide real-time information to patients.52
Barriers to HIV prevention in Nigeria
One of the major barriers to accessing HIV prevention programmes for men who have sex with men 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.53
1.9 million women are living with HIV compared to 1.3 million men. Women also experience higher infection rates, accounting for 54% of new infections in 2014.54 The feminisation of Nigeria’s HIV epidemic is in part due to the gender inequality that is embedded in its society, culture and law.55
Although women do have land rights, their rights are weaker than men’s.56 The result is a high fertility rate of 5.5 children per woman, due to the pressure on her to give birth to boys who can inherit and own land, although this rate is slowly declining.57
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.58
Although Nigeria had several strategies on gender equality and HIV, less than 1% of spending on HIV goes towards them.59
A simple lack of sites that deliver HIV services (testing sites, PMTCT sites, and treatment sites) presents problems for the Nigerian population.
Blood transfusion and unsafe medical injections do result in some new cases of HIV but the rates are minimal (0.5% and 1.2% of new HIV infections in 2010 respectively).60 As a result, enhanced efforts 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 this transmission route remains.61
The funding of Nigeria’s HIV response remains challenging. The vast proportion of money comes from international donors. Despite the PCRP initially leading to a boost to domestic funding this continues to fluctuate.62
Funding problems arose in 2016 following an audit of NACA by the Global Fund to Fight AIDS, Malaria and Tuberculosis. The audit found evidence of “fraud and collusion in the amount of US$3.8 million”, causing the Global Fund to suspend its funds.63
The Global Fund has committed more than US$1.4 billion to Nigeria since 2003, with over US$800 million disbursed between 2012 and 2016. (US $545m on HIV, US $708m for malaria and US $155m for TB).64
In recent years, sustaining domestic funding for HIV responses has become a priority of donors. Pilot schemes on innovative financing mechanisms, such as taxes on imports and levies on telephone calls, are currently underway in countries including Nigeria. 65
Nigeria has also begun developing investment cases for its six most affected states to mobilise domestic resources and make state-level responses more effective.66
HIV testing and counselling (HTC) in Nigeria
The National HIV & AIDS and Reproductive Health Survey of 2012, the most recent available, 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.67
A push on the number of sites providing HTC services has resulted in a huge increase, from around 1000 in 2010 to more than 8000 in 2014.68 However, this number is woefully short of the estimated 23,600 sites needed to provide universal coverage.
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.69
Antiretroviral treatment (ART) in Nigeria
Antiretroviral treatment (ART) provision in Nigeria is low, with 51% of all people living with HIV receiving treatment in 2014. This figure includes children. When considered in isolation, only 12% of children living with HIV are receiving ART. Only 30% of pregnant women living with HIV are on ART.70
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.71
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.
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 such as Nigeria, where so many people are 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, punitive laws such as the 2014 anti-homosexuality bill damage progress. Indeed, a worrying rise in HIV prevalence is emerging among men who have sex with men just as punishments for homosexual acts increase, suggesting this group is finding it more and more difficult to access HIV services. Engaging all members of society, 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.
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