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In Nigeria, an estimated 3.6 percent of the population are living with HIV and AIDS.

1. Although HIV prevalence is much lower in Nigeria than in other African countries such as South Africa and Zambia, the size of Nigeria’s population (around 149 million) means that by the end of 2009, there were 3.3 million people living with HIV.

2. Approximately 220,000 people died from AIDS in Nigeria in 2009.

3. With AIDS claiming so many lives, Nigeria’s life expectancy has declined significantly. In 1991 the average life expectancy was 54 years for women and 53 years for men.

4. In 2009 these figures had fallen to 48 for women and 46 for men.

The history of HIV in Nigeria

The first two cases of HIV and AIDS in Nigeria were identified in 1985 and were reported at an international AIDS conference in 1986. In 1987 the Nigerian health sector established the National AIDS Advisory Committee, which was shortly followed by the establishment of the National Expert Advisory Committee on AIDS (NEACA).

At first the Nigerian government was slow to respond to the increasing rates of HIV transmission and it was only in 1991 that the Federal Ministry of Health made their first attempt to assess Nigeria's AIDS situation. The results showed that around 1.8 percent of the population of Nigeria were infected with HIV. Subsequent surveillance reports revealed that during the 1990s HIV prevalence rose from 3.8% in 1993 to 4.5% in 1998.

When Olusegun Obasanjo became the president of Nigeria in 1999, HIV prevention, treatment and care became one of the government’s primary concerns. The President’s Committee on AIDS and the National Action Committee on AIDS (NACA) were created, and in 2001, the government set up a three-year HIV/AIDS Emergency Action Plan (HEAP). In the same year, Obasanjo hosted the Organisation of African Unity’s first African Summit on HIV/AIDS, Tuberculosis, and Other Related Infectious Diseases.

In 2005 a new framework was developed covering the period from 2005 to 2009.

Despite increased efforts to control the epidemic, by 2006 it was estimated that just 10 percent of HIV-infected women and men were receiving antiretroviral therapy and only 7 percent of pregnant women were receiving treatment to reduce the risk of mother-to-child transmission of HIV.

In 2010 NACA launched its comprehensive National Strategic Framework to cover 2010 to 2015, which requires an estimated N756 billion (around USD 5 billion) to implement.11 Some of the main aims included in the framework are to reach 80 percent of sexually active adults and 80 percent of most at-risk populations with HIV counselling and testing by 2015; ensure 80 percent of eligible adults and 100 percent of eligible children are receiving ART by 2015; and to improve access to quality care and support services to at least 50 percent of people living with HIV by 2015.

Despite being the largest oil producer in Africa and the 12th largest in the world, Nigeria is ranked 158 out of 177 on the United Nations Development Programme (UNDP) Human Poverty Index. This poor development position has meant that Nigeria is faced with huge challenges in fighting its HIV and AIDS epidemic.

How is HIV transmitted in Nigeria?

There are three main HIV transmission routes in Nigeria:

Heterosexual sex. Approximately 80-95 percent of HIV infections in Nigeria are a result of heterosexual sex. Factors contributing to this include a lack of information about sexual health and HIV, low levels of condom use, and high levels of sexually transmitted diseases. Women are particularly affected by HIV; in 2009 women accounted for 56 percent of all adults aged 15 and above living with the virus.

Blood transfusions. HIV transmission through unsafe blood accounts for the second largest source of HIV infection in Nigeria. Not all Nigerian hospitals have the technology to effectively screen blood and therefore there is a risk of using contaminated blood. The Nigerian Federal Ministry of Health have responded by backing legislation that requires hospitals to only use blood from the National Blood Transfusion Service, which has far more advanced blood-screening technology.

Mother-to-child transmission. Each year around 57,000 babies in Nigeria are born with HIV. It is estimated that 360,000 children are living with HIV in the country, most of whom became infected from their mothers. This has increased from 220,000 in 2007.

A number of small-scale studies have indicated towards a rise in HIV prevalence among injecting drug users. Although HIV transmission through injecting drug use is not one of the main transmission routes, it appears to be accounting for an increasing number of new HIV infections.

HIV prevention in Nigeria

HIV testing

In Nigeria there is a distinct lack of HIV testing programmes. In 2007, just 3 percent of health facilities had HIV testing and counselling services, and only 11.7 percent of women and men aged 15-49 had received an HIV test and found out the results. In 2009 there was only one HIV testing and counselling facility for approximately every 53,000 Nigerian adults, which shows how desperately the government needs to scale up HIV testing services.

Some reports have suggested that health care facilities offering HIV testing in Nigeria do not follow international standards about confidentiality and ethics. In one particular study, over half of people living with HIV reported that they did not know they were being tested for the virus and around one in seven health care professionals admitted to never receiving informed consent for HIV tests.

Education

Sex is traditionally a very private subject in Nigeria and the discussion of sex with teenagers is often seen as inappropriate. Attempts at providing sex education for young people have been hampered by religious and cultural objections. In 2009 only 23 percent of schools were providing life skills-based HIV education, and just 25 percent of men and women between the ages of 15 and 24 correctly identified ways to prevent sexual transmission of HIV and rejected major misconceptions about HIV transmission.

In some regions of Nigeria girls marry relatively young, often to much older men. In North Western Nigeria around half of girls are married by age 15 and four out of five girls are married by the time they are 18. Studies have found those who are married at a younger age have less knowledge about HIV and AIDS than unmarried women, and are more likely to believe they are low-risk for becoming infected with HIV. HIV and AIDS education initiatives need to focus on young married women, especially as these women are less likely to have access to health information than married women.

Condoms

The total number of condoms provided by international donors has been relatively low. Between 2000 and 2005, the average number of condoms distributed in Nigeria by donors was 5.9 per man, per year.

Restrictions on condom promotion have hampered HIV prevention efforts. In 2001, a radio advertisement was suspended by the Advertising Practitioners Council of Nigeria (APCON) for promoting messages suggesting that it is acceptable to engage in premarital sex as long as a condom is used. In 2006 APCON also started to enforce stricter regulations on condom advertisements that might encourage ‘indecency’.

The number of female condoms sold in Nigeria has significantly increased from 25,000 in 2003 to 375,000 in 2006.

Media campaigns & public awareness

As Nigeria is such a large and diverse country, media campaigns to raise awareness of HIV are a practical way of reaching many people in different regions. Radio campaigns like the one created by the Society for Family Health are thought to have been successful in increasing knowledge and changing behaviour. "Future Dreams", was a radio serial broadcast in 2001 in nine languages on 42 radio channels. It focused on encouraging consistent condom use, increasing knowledge and increasing skills for condom negotiation in single men and women aged between 18 and 34.

In 2005, a campaign was launched in Nigeria in a bid to raise more public awareness of HIV/AIDS. This campaign took advantage of the recent increase in owners of mobile phones and sent text messages with information about HIV/AIDS to 9 million people.

Another high profile media campaign is fronted by Femi Kuti, the son of Fela Kuti, the famous Afrobeat musician who died of AIDS in 1997. He appears on billboards alongside roads throughout Nigeria with the slogan 'AIDS: No dey show for face', which means you can't tell someone has AIDS by looking at them.

Prevention of mother-to-child transmission of HIV

Nigeria's programme to prevent the transmission of HIV from mother to child (PMTCT) started in July 2002. Despite efforts to strengthen PMTCT interventions, by 2007 only 5.3 percent of HIV positive women were receiving antiretroviral drugs to reduce the risk of mother-to-child transmission. This figure had risen to almost 22 percent by 2009, but still remains far short of universal access targets which aim for 80 percent coverage. Coverage for infants remains very low; in 2009 only 8 percent of children received antiretrovirals for PMTCT.

HIV treatment and care in Nigeria

When antiretroviral drugs (ARVs) were introduced in Nigeria in the early 1990s, they were only available to those who paid for them. As the cost of the drugs was very high at this time and the overwhelming majority of Nigerians were living on less than $2 a day, only the wealthy minority were able to afford the treatment.

In 2002 the Nigerian government started an ambitious antiretroviral treatment programme, which aimed to supply 10,000 adults and 5,000 children with antiretroviral drugs within one year. An initial $3.5 million worth of ARVs were to be imported from India and delivered at a subsidized monthly cost of $7 per person. The programme was announced as 'Africa’s largest antiretroviral treatment programme'.

By 2004 the programme had suffered a major setback as too many patients were being recruited without a big enough supply of drugs to hand out. This resulted in an expanding waiting list and not enough drugs to supply the high demand. The patients who had already started the treatment then had to wait for up to three months for more drugs, which can not only reverse the progress the drugs have already made, but can also increase HIV drug resistance. Eventually, another $3.8 million worth of drugs were ordered and the programme resumed.

Pharmacy refrigerator with antiretroviral drugs in Nigeria

ARVs were being administered in only 25 treatment centres across the country which was a far from adequate attempt at helping the estimated 550,000 people requiring antiretroviral therapy. As a result, in 2006 Nigeria opened up 41 new AIDS treatment centres and started handing out free ARVs to those who needed them. Treatment scale-up between 2006-7 was impressive, rising from 81,000 people (15% of those in need) to 198,000 (26%) by the end of 2007.

Resources needed to provide sufficient treatment and care for those living with HIV in Nigeria are seriously lacking. A study of health care providers found many had not received sufficient training on HIV prevention and treatment and many of the health facilities had a shortage of medications, equipment and materials.

The government's National HIV/AIDS Strategic Framework for 2005 to 2009 set out to provide ARVs to 80 percent of adults and children with advanced HIV infection and to 80 percent of HIV-positive pregnant women, all by 2010. However, only 31 percent of people who needed treatment for advanced HIV infection received it in 2009. According to the latest WHO guidelines (2010), which advise starting treatment earlier, HIV treatment coverage is only 21%. As a result of this slow progress the treatment goals were set back to 2015 in the the revised framework (2010 to 2015).

Funding for HIV and AIDS in Nigeria

It has been estimated that the Nigerian government are contributing around 5 percent of the funds for the antiretroviral treatment programmes. The majority of the funding comes from development partners. The main donors are PEPFAR, the Global Fund and the World Bank.

In 2002, the World Bank loaned US$90 million to Nigeria to support the 5-year HIV/AIDS Programme Development Project. In May 2007 it was announced that the World Bank were to allocate a further US$50 million loan for the programme.

Through PEPFAR (the President's Emergency Plan for AIDS Relief) the United States has allocated a large amount of money to Nigeria. In 2008 PEPFAR provided approximately US$448 million to Nigeria for HIV/AIDS prevention, treatment and care, the third highest amount out of PEPFAR’s 15 focus countries.

By the end of 2008, the Global Fund had disbursed US$95 million in funds for Nigeria to expand treatment, prevention, and prevention of mother-to-child transmission programmes. Much of this was given to the Nigerian government to fund the expansion of antiretroviral treatment.

The future

In the 2007 general elections, Umaru Musa Yar’Adua of the People’s Democratic Party became the second president of Nigeria’s Fourth Republic. Following in Obasanjo’s footsteps, one of Yar’Adua’s priorities was tackling the Nigerian AIDS epidemic. Yar'Adua's successor, Goodluck Jonathan, has reiterated this commitment and has expressed particular concern about the low levels of HIV testing in Nigeria. With the large amounts of money being donated from international funds and a government dedicated to increasing prevention measures and treatment access, some are feeling slightly more optimistic.

However, according to the latest data from the Nigerian government, the country now accounts for around 10 percent of the global HIV burden. Nigeria therefore still has a long way to go in tackling its devastating AIDS epidemic. In 2011, the Nigerian Health Minister acknowledged the extent of the challenge that Nigeria faces when he stated...