By: Elizabeth Obigwe. Freelance Writer. With medical review and editorial support by the DLHA Team
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Image of an African woman holding a red ribbon for AIDS awareness. Click on image to enlarge
It’s 1985, and a new disease has been diagnosed in Lagos, the capital city of Nigeria. This disease was brought in by a 13-year-old female sex worker from a neighbouring West African country. However, the disease was not officially reported until 1986 and when people heard about it, they did not believe that it was real.
Fast forward to 38 years later, we are still fighting this disease that has now become a full-blown epidemic. Although HIV/AIDS was first identified in Europe and USA, it is now dominant in Africa and Nigeria is home to a significant number of people living with this disease (currently 1.9 million).
The key populations that have driven the transmission of HIV in Nigeria are men who have sex with men (MSM), people who inject drugs, and sex workers. Although the epidemic has spread across different demographics and regions in the country, the situation is not all bleak.
There have been consistent efforts in controlling HIV/AIDS in Nigeria and bringing it to an end and so far, the efforts are paying off.
This article will discuss:
When HIV first appeared in Nigeria in the 1980s, some people referred to it as a disease that affects only homosexuals because it was first identified in the West among men who have sex with men. Others believed it was a foreign disease that had no place in the country. This initial negligence and nonchalant attitude contributed to its rapid spread across the country.
Between 1985 and 1986, Nigeria had only two official cases of HIV. By 1987, there were additional two cases and by 1988, the number of new cases had risen to 33.
Ten years later, in 1998 alone, 18,490 cases were reported. The cases were continuously reported in thousands through the years, and in 2001, Nigeria experienced the peak of the epidemic with 3.5 million Nigerian adults and children living with HIV/AIDS (a 5.8% prevalence).
After 2001, the country started to notice a gradual decline in the disease burden. Starting with a 5.0% prevalence in 2003, the numbers decreased through the years to a 3.4% prevalence in 2013 and a 1.4% prevalence in 2019 among adults aged 15-49.
HIV prevalence in Nigeria from 1990 to 2012. Click on image to enlarge. Photo Credit: Awofala et al
The most recent report which is that of 2019 reveals that about 1.9 million Nigerians are still living with HIV. Hence, although there has been a decrease in the current HIV/AIDS prevalence in Nigeria, the population of people living with the disease is still high. This leaves the country with the second-highest population of people living with HIV/AIDS (PLWHA) across the globe.
Besides the general national burden, there are distinct differences in the prevalence of HIV in Nigeria across regions, gender, age and other demographics.
The 2019 statistics showed that females between ages 15 - 49 are twice as likely to have HIV than men (1.9% versus 0.9%.). While children between 0 – 14 years have a lesser prevalence of 0.2%. For regional differences, the South-South zone has the highest prevalence of 3.1% with the North Central zone following at 2.0%
One of the reasons why Nigeria still has a significant number of PLWHA is because of its large population. Nevertheless, there has been significant progress towards controlling HIV/AIDS in Nigeria. Between 2010 and 2019, the HIV infection rate in Nigeria declined by 21%.
As a country that ranks high among countries of PLWHA, the importance of adequate awareness and positive attitude of people towards HIV/AIDS cannot be overemphasised. However, Nigeria seems to be struggling with this.
Hence, there is a need for more public enlightenment about the disease. Better knowledge will help to check the transmission rate while also providing an accommodating society for those already infected.
In 2020, a study was done in Akwa Ibom State (a high prevalence state) using the state’s 2017 AIDS Indicator Survey to analyze the comprehensive knowledge, stigma, and HIV risk perceptions among young adolescents.
The results of the study were poor with only 9.4% of participants showing comprehensive knowledge. 81.5% of them reportedly showed discriminating tendencies and 93% believed they were not at risk.
Another study carried out in 2022 analyzed the trends of HIV/AIDS knowledge and attitudes among Nigerian women between 2007 and 2017. The data used were specifically from 2007, 2011, 2016 and 2017.
The knowledge of HIV/AIDS in Nigeria among these women was 64.6% in 2007. In 2011, it dropped to 45.6%, and in 2017 increased to 64.1%. Whereas their attitude towards PLWHA progressively increased from 40.5% in 2007 to 47.0% in 2011 and to 53.5% in 2017.
Several other studies have been conducted across the country and different demographics. Their results, like the one done by Nwimo et al., all point to the fact that there is a need for better awareness and enlightenment programs in Nigeria.
Treatment and Care Available for PLWHA
Generally, the treatment and care for PLWHA in Nigeria needs improvemrnt. The treatment constraints are mainly due to;
The major contributors to HIV treatment in Nigeria are the United States President's Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund.
A review of national expenditures on HIV in Nigeria between 2009 and 2016 showed that about 88% of total funding for HIV in the country came from these two sources. Other contributors include the government, philanthropists, and the private sector.
Despite the contributions towards funding, only 78% of PLWHIV have access to ART, leaving out 22%. Moreover, the already feeble healthcare structure became further stretched following the WHO’s “Treat All” guideline.
2018 NAIIS report for UNAIDS 90-90-90 target. Click on image to enlarge. Photo Credit: 2018 NAIIS report
In 2016, the World Health Organization launched the "Treat All" guidelines. This guideline allows treatment with antiretroviral therapy (ART) for all individuals with HIV regardless of their CD4+ cell count.
Consequently, in 2016, Nigeria adopted this guideline as the "Test and Treat" strategy. Changes were effected on the national HIV prevention and treatment guidelines which included removal of CD4+ cell count thresholds for ART initiation and allowing initiation of ART within two weeks of testing.
This strategy aimed to achieve the UNAIDS 90-90-90 target for 2020. This entails that 90% of people infected with HIV should know their status, 90% of these should be on ART and 90% of those on ART should have attained durable viral suppression. However, this target was clearly not achieved.
From the 2018 NAIIS (Nigeria HIV/AIDS Indicator and Impact Survey) report, Nigeria only achieved 46.9-96.4-80.9 of the expected 90-90-90. Even though the last two 90s seem close to target, given the mode of calculation, the default in the first negatively impacts their significance.
In 2020, UNAIDS set a new 95-95-95 target for 2025, intending to end AIDS as a public health threat by 2030. However, the chances of achieving this in Nigeria are slim as Dr Ebuka Onyegiri shares.
Dr. Onyegiri is a Nigerian-based Doctor of Internal Medicine with a special interest in HIV. According to him, the COVID-19 pandemic and the recent political activities in the country have slowed down progress. He said, "With this change in government, people have not settled to even know what are the main challenges health-wise for Nigeria".
From his experience working in the field, Dr Onyegiri also shares that Nigeria, alongside other African countries, has lost some progress due to COVID-19.
"So, we're still very far. In fact, what I was writing at that time was about what we have lost. You know the integrated services we had lost due to Covid disruption. So, even most countries that were really edging it getting closer to 70, 75 per cent in all of these three bands, they actually still had a loss from 2019 to 2022, most of them had a dip. So even for Nigeria, the figures are not yet out."
However, CDC reported a surge in the treatment of HIV/AIDS in Nigeria between 2019 and 2021. This was following the NAIIS national household survey which provided the data that fostered the surge in treatment.
According to the CDC, between 2019 and 2021, the number of PLWHIV in the 18 states which were involved in the treatment surge increased from 454000 to 903000. Hence, increasing the number of people who are aware of their status as well as the number of people receiving treatment.
Hopefully, when these figures are out, we will have a clearer picture of how far we have come and if there has been any progress or regression from the initial 46.9-96.4-80.9 statistic.
The main preventive care available for HIV is PrEP (pre-exposure prophylaxis) coupled with abstinence, needle replacement policy and/or use of barrier contraceptives during sexual intercourse.
PrEP treatment prevents you from getting HIV, especially if you are a person at high risk. Unfortunately, Nigeria is faced with both a lack of awareness and a lack of access to treatment with PrEP.
Nonetheless, studies show that people at high risk (MSM and sexual workers) indicated high interest in using and even paying for the drug after they were enlightened about its benefits. Therefore, there is a need to scale up both awareness and access to PrEP.
Challenges Faced by HIV/AIDS Patients in Nigeria
The challenges that Dr. Onyegiri stated to be common to PLWHA include;
Stigma remains an important challenge facing people living with HIVAIDS in Nigeria although awareness of the condition and the mechanism of spread and access to treatment and care are improving.
“The concept of integrated care is getting all you need for that treatment in one place. That's like a one-stop shop. So, most times what you see, is you get one from here, you get one from there. You do CD4+ count in one facility, you do viral load in another and all these disruptions increase cost and lead to people defaulting on follow-up or investigations, or even being lost to follow-up. So, that's a real serious challenge.” Dr. Onyegiri said.
Nigeria is currently facing an economic downturn and PLWHA are not spared. Although they receive significant coverage for treatment, there are other hidden costs of receiving treatment including transportation to the treatment facility.
Dr. Onyegiri pointed out not enough research is being conducted on gays and homosexuals to drive policy towards their care. This will influence the overall progress in the fight against HIV/AIDS given that men who have sex with men have been identified as part of the key populations at a higher risk of HIV infection.
Although Nigeria has made significant progress in combating HIV since it first appeared in the country, there is still a lot of work to be done. Nigeria has a large population which in turn reflects on the population of people infected with HIV/AIDS in Nigeria. To be able to eliminate the epidemic, Nigeria has to strengthen its preventive strategies and adopt new ones where necessary.
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Published: October 26,, 2023
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