Control Of HIV Through Interventions Directed At The Reservoir

Several large multi-national studies have established that transmission of HIV does not occur between sexual partners when the viral load is undetectable (<200copies/ mL). Hence the United Nations set overly ambitious treatment targets of ensuring that globally by 2020, 90% of PLHIV will know their HIV status, 90% of diagnosed PLHIV will have uninterrupted access to ART and 90% of PLHIV will have suppressed viral loads. This is important since HIV is transmissible from a reservoir to others only in the presence of high viral loads. Similarly, studies have shown combination ART to be highly effective in preventing MTCT of HIV, making effective administration of ART key in the prevention and control of HIV. Control of HIV through interventions directed at susceptible hosts.

To protect susceptible hosts, several prevention strategies are currently employed by the United Nations with the target of ensuring that by 2020, new HIV infections will be limited to 500, 000. These include health education on behavioral modification such as use of sterile syringes and needles by IDUs, use of condoms and limiting number of sexual partners. Also, medical interventions such as provision of ART to at risk population as pre-exposure prophylaxis (PrEP) and voluntary male medical circumcision. 22 Ecology, epidemiology and burden of HIV in Nigeria.

Nigeria is a country located in sub-Saharan Africa with a culturally and religiously diverse population which was estimated at about 190 million in 2017. Nigeria is divided into 37 states and further into 774 Local Government Areas for administrative purposes. Both HIV 1 and 2 circulate widely in Nigeria with some reported cases of dual infection. Globally, Nigeria is the second only to South Africa in terms of highest number of PLHIV, estimated at 3. 1 million in 2017. In 2013, Nigeria contributed 9. 0%, 10. 0% and 14% respectively of PLHIV, new HIV infections and HIV-related mortality to global HIV burden. According to a nationally representative household survey, there has been a marginal decline of HIV among Nigerian adults from 3. 6% in 2007 to 3. 4% in 2013. Also, the National sentinel sero-prevalent surveys (antenatal clinic surveys) revealed an initial increase of HIV prevalence from 1. 8% in 1991 to a peak of 5. 8% in 2005, HIV prevalence then declined over the next decade to 3. 0% in 2014. However, HIV prevalence is as diverse as the different states being lowest in Zamfara state (0. 9%) and highest in Benue state (15. 4%) in 2014. HIV epidemic in Nigeria is complex and mixed with a concentrated epidemic among key populations (MSM, IDUs and sex workers) and a generalised epidemic in the general population. For example while an estimated majority (≈ 80%) of new adult HIV infections occur via heterosexual sex relationships, about 20% of such new infections occur in key populations. This is quite alarming because these key populations are about only 1% of Nigerian adult population. In addition, poverty as well as religious and cultural practices (polygamy, girl child marriage to old men in the community, female genital mutilation) make HIV control difficult in Nigeria. Furthermore, there are punitive policies against sex workers and same sexual relationships attracts up to 14 years imprisonment. This creates fear among these key population, preventing them from accessing care, possibly accounting for why they remain major drivers in HIV transmission in Nigeria. Stigmatisation and discrimination of PLHIV is also a challenge to HIV control in Nigeria with about 46. 8% of individuals aged 15 – 49 years reported to have exhibited discriminatory behaviors against PLHIV in 2013.

Prevention and control of HIV in Nigeria

With the highly ambitious vision of a Nigeria with zero new HIV infections, zero AIDS-associated stigma and discrimination in a AIDS free Nigeria by 2030, the National Action Committee against AIDS (NACA) have developed HIV control strategic plans. They include encouraging behavior change thus preventing new HIV infection through education on HIV, HIV counseling and testing (HCT), encouraging condom use in non-marital sexual relationships and among key populations (MSM, sex workers, IDUs). These strategies have been largely unsuccessful because strategy evaluation in 2015 (five years into plan implementation) revealed that only about 25% of young people and adults had adequate knowledge on HIV. Also, among key populations, approximately 25% of them still had gross misconception on mode of HIV transmission and only 26. 3% of the general population had had HCT.

Another strategic pillar was ensuring that all individuals with HIV had prompt treatment for HIV/AIDS and associated illnesses. Again, in 2015, only 25% of individuals eligible for ART had treatment while 76. 3% and 68% respectively were on co-trimoxazole and had been screened for Tuberculosis. Furthermore, advocacy and legislations to uphold the rights of PLHIV is also included in the strategic planning, thus, HIV/AIDS anti-discriminatory law enacted in 2014. Unfortunately, this law has been domesticated in only eight of the 37 states in Nigeria.

Also in 2014, MSM was criminalized in Nigeria. This law was adjudged by HIV control experts as counterproductive for HIV control. In addition, intrinsic to this plan was elimination of MTCT of HIV and care and support for PLHIV as well as orphans and vulnerable children (OVC) by enrolling them into care and ensuring education for all OVC. Sadly by the end of 2014, a fifth of OVC had irregular school attendance and 18% of them had been abused sexually. While the strengths of this strategic plan lie in its robust and multifaceted nature, the weaknesses are that the strategies are coordinated via a highly centralised body (NACA) and not particularly tailored to high risk populations. This is because the local and state arms of NACA are virtually non-functional, in the background of an underperforming health system characterised by gross systemic weaknesses.