PROSPER OKONKWO: There is No Sickness Called AIDS

For Dr Prosper Okonkwo, the Chief Executive Officer of the APIN Public Health Initiative (former AIDS Prevention Initiative for Nigeria), fighting HIV/AIDS and intervening in public health is a way of life. Recently, the President, Muhammadu Buhari launched the Nigeria HIV/AIDS Indicator and Impact Survey, NAIIS, which showed that HIV/AIDS prevalence has dropped sharply in the country from 3.1 in 100 to 1.4 in 100. Speaking to Samuel Ajayi, Okonkwo says he is personally fulfilled that at last, their work of the last 17 years is now yielding positive results

Looking back, how old is APIN, that is the AIDS Prevention Initiative for Nigeria, though I am aware you have now changed your name?
I think we have to tell the whole story. We started in Nigeria in 2001 as a project of the Harvard School of Public Health in Boston, the United States of America. The School came to Nigeria and started an organisation called APIN. I joined in 2004. As we moved on and started doing different things, we saw the need to become an indigenous organisation on our own. In 2007, APIN became registered in Nigeria as a local entity with the Corporate Affairs Commission, CAC, and we had a board of directors. As a project, we have been here for 18 years but as an independent Nigerian organisation, we have been here for 12 years.

Can you say the mandate has been met?
I can say it is an ongoing mandate. I can say we are working towards achieving the objectives of the organisation which keep evolving. When Harvard set up in 2001, the objective was to build capacity in Nigeria which is to build infrastructure and research around the HIV/AIDS issue in Nigeria. We were only thinking about the treatment that time but in 2003 to 2004, the infrastructure, that is human resource and laboratory were in place and these became good launching pads for our treatment programme and today, we are one of the leaders in the treatment programme area. Today, we work in about eight states of the federations, managing about 250,000 cases which are about a quarter of the patients in Nigeria.

Why I cannot say the objectives have been met or not is that as we are doing things, new objectives are emerging but I can say we have built enough structures to deal with emerging trends. When we started, we were called the AIDS Prevention Initiative of Nigeria, APIN, and then as we evolved, we became APIN Public Health Initiative because we felt that one, the HIV programme we were doing has become a matured programme because patients are now living longer and also that we have built enough structures, systems, networks and collaborations that we felt we could use of other things. For instance, I wasn’t trained to do HIV but here I am. So when we wanted to do malaria or reproductive health, they would say no, your name is about HIV. But right now, we are working in the North-East on a World Bank project called N-SHIP (Nigerian State Health Investment Project). We are doing this in Gombe, Adamawa and Bauchi. There is also a programme called Save One Million Lives which has to do with childbirth-related issues. It is estimated that about a million women and children die in Nigeria from childbirth-related issues. So the World Bank and the Federal Ministry of Health came together and felt that if we could improve on some indicators, we can bring this down. The role we play there is called the Programme Support Unit, PSU. They have zoned the country into six zones and we PSU for South-east zone and Benue State. The states are being funded by the government but our work is to provide a technical assistant. So these are the reasons I can say we have achieved our mandate or not because things keep evolving and coming up. But we can say we are happy with what we have achieved.

Your operations are modelled after any reputable corporate organisation as your set-up is well organised and functional. But that cannot be said of governmental organisations which you have to deal with all the time. How have you been coping with governmental bureaucracy and the attendant lackadaisical attitude that goes with it?
I think this is very important. From day one, we have had to work with government institutions. I think one of the things that have worked is the fact that the government knows that most of the works we do come from founders who work with deadlines. And the option of not doing well does not even arise because it will cost a lot of things. Let me say that there will be issues but to get the good results that we all desire, we must do things differently. I can tell you that most of the states now know that there are ways we do our work and there are deadlines and if these deadlines are not met, it could affect the funding. We had difficulties in the beginning but things are shaping up.

Now, talking about governments at different levels, it could be different at different levels. At the federal level, things are much easier and in some states, things are better than other states. But what it has taken is persistence. We are working in six states and we need to do retreats but only two states have agreed that we come and do the retreats. Others are just saying well, you hold on till after this or that. It is there, but it is improving. In the same vein, a lot of people who work with us at the federal level are also part of the system and are beginning to understand.

Right now, the US government budget for this year for this country is being discussed in South Africa and the director-general of NACA is there. Segilola Areoye, who is the director of HIV, is also there. So everyone is becoming part of the language but as the level goes down, the knowledge decreases.

How do you deal with the myth around HIV/AIDS among Africans? I mean like someone saying, as in other African countries, that he has to sleep with an albino to get cured and stuff like that.
We have but let me bring more important things. If you do what is called Knowledge, Attitude and Practice, KAP, on 100 people, you find that about 95 people have knowledge about HIV, either he or she believes it is real or not. But where the challenge comes is the knowledge-behaviour gap, KBG. This means that people know but they don’t do. So what we discover that doctors are important but social scientists are also important: how could someone know that if he puts his hand in fire it will burn him and yet, still does it. For us, we felt that while we are doing well on the medical side, the social systems of poverty, education and so on must be dealt with.

Like a female sex worker who knows she must insist the client must use protection but will still allow someone without protection but who is willing to pay double the fee. She has to do this because of economic reasons: she has bills to pay. So what am I saying? What we know at times is different from what we do. So most programmes we do now, you bring eight professors but someone will be looking and asking: where is the social scientist? Doctors will say this is twenty percent but the social scientist will ask: why is it twenty percent?

So are you achieving anything in that regard? I mean the knowledge-behaviour gap issue.
Well, HIV prevention work is not Jack of all trade. Everyone is funded to do different things. We are interested in prevention but there are people who are in qualitative work on HIV.

How is your work in areas of malaria, tuberculosis, maternal health and so on?
Tuberculosis and HIV are like husband and wife; the two cannot be separated.

How?
AIDS means Acquired Immune Deficiency Syndrome. The syndrome is a collection of diseases. There is no sickness called AIDS. Tuberculosis is the number one killer of patients that have HIV. Let me explain this way. If we take chest x-ray of two of us here, there is a small, whitish thing that looks like chalk there. If we are okay, it remains like that until the rest of our lives. Different infections come into our body but our natural immune systems keep them at bay. Once we have HIV, those abilities are lost and all sorts of things will manifest. We deal with TB because most of our HIV works involve TB. For reproductive health, a lot of things that have to do with family planning are happening in the Save One Million Lives project.

There are six things used to measure this: family planning and that is about contraceptive prevalence rate; immunisation coverage for children, third is still-birth, nutrition, long-lasting insecticide net and percentage of pregnant women attended to. To answer your question, we are still open to opportunities. There is another grant from a university in the United States we are working on to deal with infant mortality rate. You find out that for children under the age of five, 45 of their deaths happen within the first 28 days. So if we can manage the first 28 days of life, you have dealt with 45 percent of death before the age of five. And we know that three things: premature births, infections around birth and complications are the greatest causes of these deaths. So there is some bio-medical equipment they are bringing into Nigeria and we are looking to partner them to make these things available, not free but at a very little cost.

Recently, you launched the National HIV/AIDS Indicator and Impact Survey, NAISS. It was a major event in the fight against HIV/AIDS in Nigeria. Can you throw light on this?
What has happened is that before now, estimates have been used to say this was the number of patients we needed to treat in Nigeria and these estimates were based on what we have done before. The idea was that every other year, they took samples of pregnant women at ante-natal clinics to determine the number of people that needed treatment across Nigeria. But over the years, the numbers were increasing and we were asking: with what we were doing, numbers supposed to be decreasing. And even the people funding us, they were asking if nothing was asking. What we did now is a household population-based survey. It was like the way we do the census. About 200,000 houses were surveyed and we were sure that the statistical methodology for this was very sound. And to make sure that it was reliable, the United Nations Agency for AIDS had to send their chief statistician to validate this result. So it was not a result that was inconclusive. One thing they found out was that prevalence was reducing. That is the proportion of people like say, out of 100, we now have 1.4. That is 14 out of 1000 people. Before, it was 3.1 which was 31 out of 1000 people. That was very good, but in Nigeria, there is what is called the burden of disease. And this means knowing how many people have the disease. Prevalence is low but in the area of the burden of disease, Nigerian just moved to number four from number two.

And it is a question of population. A country that has a prevalence of 20 per cent but has a population of two million, only 400,000 people need to be treated. But Nigeria with 160 million people and 1.4 per cent will be about 2.2 million people. So we moved to number four in prevalence behind South Africa, Mozambique and India. For treatment, we thought before that 3.1 million needed to be treated but now, it is 1.4 million people. So what we need to cater for now is 1.7 million. So this is good for the government because now the issue is now tractable. The slogan now is ‘Let’s go for the last man’. It now shows that the efforts are no yielding results and even, God forbid, the funders want to go, Nigeria can cope. And secondly, we are no longer planning blind; we now plan with facts and figures.

You are having a book launch in a couple of weeks. Can you tell us the significance of the event vis-à-vis the recent achievement from the survey?
I am excited to talk about the book. One of the things APIN has done which we have not taken credit for is that from the beginning we have been associated with the academic community and most of our works have been directed in that direction. When we started, we tagged our work: ‘AIDS in Nigeria: A Nation at Threshold. 13 years after, we say, ‘Turning the Tide: AIDS in Nigeria’. It would have indicted us if the result of this survey had come and there was no indication that the tide was indeed turning. We are very happy that this book, which is 551 pages, is coming at this time because it documents what the national response has been which led to this reduction. It has been widely received and the launch would be on April 11 and we are expecting a huge government presence.

And wasn’t it instructive that the book is being launched when this survey came out?
Ironically, we started the book three years ago and the survey was from July to December last year. So there was no connection but the result of the survey has shown that we have indeed made some impact on HIV/AIDS reduction in Nigeria. We knew that on the field, things are happening but the figures we are getting were not congruent with our efforts.

You are doing well in your work but grossly under-reported. Why?
At the board of directors’ meeting, this issue always comes up but we always felt our works should always speak for us. But what we found out is that HIV/AIDS community, they know us but outside, we are not. So we want to wean ourselves off that because we were an offshoot of the academic community and we didn’t have to shout but now, it is time to gradually change that. We want to get more visible.