The Nigerian Journey to Zero

A story about the journey to global HIV 95-95-95 target in Nigeria

Rukevwe Akpevwe Aliogo

Introduction

The United States President`s Emergency Plan for AIDS Relief (PEPFAR) is the largest health program created to respond solely to the HIV/AIDS pandemic globally. Population-based HIV Impact Assessment (PHIA) surveys are PEPFAR projects carried out in PEPFAR-supported countries that measure the reach and impact of HIV programs in these countries. Nigeria is one of the countries that PEPFAR funds.

In 2018, the HIV/AIDS Indicator and Impact Survey (NAIIS) was conducted in Nigeria. Before the survey, no national-level population-based studies were conducted, including viral load suppression, paediatric HIV prevalence, or ART coverage in Nigeria.  Population-based information was urgently needed to understand the current epidemic status and guide future interventions. The survey is the first to estimate Nigeria`s national HIV incidence and viral load suppression (VLS). The survey aimed to allow Nigeria to assess The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90/90/90 treatment targets nationally, thereby addressing this gap and providing greater clarity on the impact of the national HIV program and guiding policy and funding priorities. UNAIDS described NAIIS as the largest population-based cross-sectional survey ever conducted.

History of HIV in Nigeria

Nigeria first reported two cases of HIV/AIDS in 1985 at an International AIDS conference in 1986. The first HIV/AIDS sentinel survey was conducted in 1991 with a prevalence of 1.8% and gradually grew and peaked at 5.8% in 2001 before it began to decline. Despite its declining prevalence, HIV/AIDS remains a public health concern in Nigeria.

The Government of Nigeria (GoN) has over the years rolled out several initiatives guiding HIV/AIDS response. This was achieved with the support of donor agencies, civil societies and development partners.  In 1986, the National Expert Advisory Committee on AIDS (NEACA) was inaugurated. In 1988 the Federal Ministry of Health (FMoH) established the National AIDS and STI Control Program (NASCP). Subsequently, the President`s Committee on AIDS (PCA) was established in 1999, and the National Action Committee on AIDS (NACA) was created and renamed National Agency for the Control of AIDS in 2007 to coordinate and strengthen the multisectoral response. A 2017-2021 National Strategic Plan in line with the investment framework of UNAIDS has been implemented to accelerate the national response targeted at ending AIDS in Nigeria by 2030.

NAIIS Implementation

Three thousand five hundred and fifty-one (3,551) non-overlapping enumeration areas and ninety-five (95) healthcare facilities of the thirty-six states and the Federal Capital Territory of Nigeria were selected for the survey. Nearest neighbor analysis was used to map the EAs to the nearest health facilities, and network analysis was used to develop efficient travel routes for the samples to avoid freeze-thaw cycles.

Thiessen Polygons analysis was used to create a language, security and accessibility map. The language map guided the data enumerators, allowing them to plan their movements from one EA to another and assign the appropriate data enumerators to specific communities. Nigeria has over five hundred and twenty-five languages, and the predominant language in each region was considered. The security map served as a guide for the data enumerators on communities that may need security escorts and communities they may need to avoid due to high levels of insecurity.  Nigeria`s topography consists of valleys, highlands that are rugged, hills and mountains, and coastal plains. The accessibility map was used to plan effective routes for accessing the EAs. Some required special vehicles like Hilux for mountainous regions, boats for riverine areas, and in some cases, alternative means for non-motorable areas. 

Figure 1: Language Map for data enumerator distribution

Figure 2: Security Map for data enumerator`s movement

The data collection period was between July and December 2018. Survey participants received home-based HIV counseling and testing services. Survey participants who tested positive were linked to treatment services. 

Findings

The survey results revealed that HIV prevalence among adults 15-64 years was 1.4% and among children aged 0-14 was 0.2% with HIV prevalence being the highest among females aged 35-39 (3.3%).. Among adults aged 15-49 years, HIV prevalence was 1.3% with Akwa Ibom State having the highest prevalence (4.8%), followed by Benue State (4.3%) and Rivers State (3.6%). The prevalence also revealed that the prevalence of VLS among Nigerian adults living with HIV was 44.5%. These results showed the HIV prevalence in Nigeria is lower than previously thought. This has allowed the country to reprioritize its services to the areas needing to control the HIV epidemic the most. President Muhammadu Buhari released the NAIIS results on March 14 2019.

Figure 3: HIV prevalence among adults aged 15-64 years by state, NAIIS 2018

HIV Treatment and Prevention Progress

The Government of Nigeria (GoN) has over the years rolled out several initiatives guiding HIV/AIDS response. This was achieved with the support of donor agencies, civil societies and development partners.  In 1986, the National Expert Advisory Committee on AIDS (NEACA) was inaugurated. In 1988 the Federal Ministry of Health (FMoH) established the National AIDS and STI Control Program (NASCP). Subsequently, the President`s Committee on AIDS (PCA) was established in 1999, and the National Action Committee on AIDS (NACA) was created and renamed National Agency for the Control of AIDS in 2007 to coordinate and strengthen the multisectoral response. A 2017-2021 National Strategic Plan in line with the investment framework of UNAIDS has been implemented to accelerate the national response targeted at ending AIDS in Nigeria by 2030.

In the last five years, Nigeria has witnessed a remarkable expansion in its response to HIV due to the Nigerian Government and its partners implementing innovative interventions. The test and treat policy, utilization of differentiated care models and index partner testing, and decentralizing facilities that provide ART services are some of the successful strategies that have been set up to terminate the HIV epidemic. There was a concurrent increase in prevention of mother-to-child transmission, number of treatment, and HIV testing and counselling sites across the country. This resulted in 11.3 million adults receiving counselling and getting tested for HIV in 2016. People living with HIV (PLHIV) accessing antiretroviral treatment increased from 360,000 in 2010 to over one million in 2018.

Towards ending HIV

“For the first time, the end of AIDS as a public health threat by 2030 is truly in sight for our country. I urge all of us not to relent but to increase the momentum. Let us work collectively and push for the last mile.”  H.E. Muhammadu Buhari, President of Nigeria.

The success of NAIIS 2018 was a significant milestone, leading to the recalibration of HIV estimates. This recalibration prompted PEPFAR to initiate the surge strategy in 19 states of Nigeria, with 11 states being prioritized by the Government of Nigeria (GoN) for unmet need for ART. The emergence of GIS as a powerful tool in healthcare has revolutionized our understanding and management of health-related issues. It provides profound insights into health phenomena’ patterns, trends, and relationships, and has become essential in enhancing the quality of healthcare services, disease prevention, and public health management. Analyzing data such as infection rates, demographics, and mobility patterns empowers healthcare providers and policymakers to develop more effective disease control and prevention strategies, thereby improving data-driven decision-making and overall program efficiency.

Aliogo, Rukevwe Akpevwe is an Abuja based GIS Specialist.