The hullabaloo the advent of the Human Immuno-deficiency Virus (HIV) that causes Acquired Immune Deficiency Syndrome (AIDS) generated may have petered considerably, but there is no denying the fact that the scourge is still ravaging. With no cure, or effective vaccine in sight yet, dwindling donor funds, and an alleged spike in prevalence at the behest of Key Populations (KP), etc., occupy the front burner as the world marks the 2023 World Aids Day. With a majority of the 1.9 million persons living with HIV being on treatment, CHUKWUMA MUANYA writes that poor domestic funding of the fight against the malaise remains an albatross as it threatens the sustainability of gains so far achieved, especially now that international funding, which is the highest contributor to the HIV and AIDS response in Africa is drying up due to pressures on international budgets.
As the world today marks the 2023 World Aids Day (WAD), with the theme: “Communities: Leadership to End AIDS by 2030,” a multitude of posers surrounding the scourge keeps reverberating across countries and territories, but without answers.
Be that as it may, the WAD is more than a celebration of the achievements of communities, it is also humanity uniting to show support for people living with, and affected by HIV, as well as a befitting remembrance for those who lost their lives to AIDS. Additionally, it is a call to action to enable and support communities in their leadership roles.
Sadly, studies have shown that progress made over the decades in a bid to eliminate the virus by 2030 is being challenged by a spike in new infections among key populations (KP), which include female sex workers, men who have sex with men (MSM), drug addicts, prison inmates, people who inject drugs (PWIDs), and transgender people, who are disproportionately affected by HIV.
Interestingly, the studies supported by some stakeholders indicate that 2.8 per cent of inmates of correctional centres, and nine per cent of PWIDs are infected with HIV and AIDS.
June 5, 2023, marked 42 years since the first cases of HIV and AIDS were reported in Los Angeles, United States, in five young homosexual men diagnosed with Pneumocystis carinii (a variant of pneumonia) and other opportunistic infections.
Back home, the first case of HIV and AIDS was reported in 1985. The first two cases as reported by the Federal Ministry of Health involved a sexually active 13-year-old girl and a female commercial sex worker from a neighboring West African country.
Without a doubt, tremendous progress has been made in treating HIV to the extent that the virus, with antiretroviral drugs, can become undetectable and non-transmittable, but a cure or an effective vaccine has remained elusive.
While stakeholders worry that there may not be a vaccine for the scourge by 2030, preventive treatments like Pre-Exposure Prophylaxis (PrEP), and Post Exposure Prophylaxis (PEP) are providing a sort of cover until a vaccine is developed.
Mutability, escapist tendency of virus
ONE major issue that has come up repeatedly since the advent of the disease, is the world’s inability to find a permanent cure or effective vaccine.
This failure is what stakeholders and experts have continued to express their views, even as they expressed the hope that it would happen someday soon given the sheer quantum of research so far carried out.
For instance, the Director of Research and Head, Centre for Reproduction and Population Health Studies, Nigerian Institute of Medical Research (NIMR), Lagos, Prof. Oliver C. Ezechi, explained that HIV is a highly mutable virus, capable of rapidly evolving and developing resistance to antiretroviral medications and immune responses.
“Additionally, the virus can establish long-lived reservoirs within the body, making it difficult to completely eradicate. Developing a safe and effective vaccine has proven challenging due to the virus’s ability to evade immune responses and the complexity of generating a broadly protective immune response against its diverse strains,” he said.
On the world soldiering on ending AIDS by 2030, Ezechi stated: “The journey since the first HIV case has been marked by significant progress, but challenges persist. The pursuit of a cure and an effective vaccine remains ongoing. To achieve the goal of ending AIDS by 2030, it is essential to address access barriers, stigma, discrimination, and the unique needs of key populations and vulnerable groups. By prioritising these efforts, we can work towards a future free from the burden of HIV/AIDS. Additionally, funding shortfalls and health system constraints pose significant challenges to achieving widespread HIV care and prevention efforts.”
Also offering his perspective on the absence of a vaccine thus far, Adviser to the Joint United Nations Programme on AIDS (UNAIDS) on Science Systems and Services, Dr Murphy Akpu, said that the elusive and ever-changing nature of HIV makes it difficult for traditional methods of vaccine development to work effectively.
He said: “HIV disguises itself so that even if our bodies make antibodies, the virus changes to escape them,” adding that integrating HIV into host genetic material, Deoxyribonucleic Acid (DNA), genome, makes it difficult for T-cells that kill infected cells to recognise the viruses as separate from hosts. This also limits the vaccine platforms that we can use.”
The public health physician explained that because there are different subgroups, or clades of HIV, “If you make a vaccine against Clade A, it may not work against Clade B or Clade C.”
One of the problems with mRNA vaccine technology (used for the COVID-19 vaccines), he said, is that there’s a limit to how much mRNA one can have in a vaccine. “So, we don’t know how many proteins we can express with this mRNA technology in a single vaccine, and that may be limiting for HIV vaccines.”
He informed that there have been more than 250 HIV vaccine trials, most of them early-stage, looking at whether the vaccine is safe and whether researchers mount an immune response following vaccination.
Despite these challenges, researchers are not discouraged. To Akpu, while he expressed pessimism that there will be an HIV vaccine by 2030, the medical practitioner added that preventive treatment like PrEP and PEP may provide a bridge until a vaccine is developed.
As humanity continues the search for a cure and effective vaccine for the scourge, the Director of Living Health International, Dr. Gbenga Adebayo, said that there is a need to be thankful for innovations that make living with the disease much easier.
Said he: “I think we first need to appreciate that HIV is not what it was 37 years ago. It is no longer the death sentence that it used to be. Whilst we don’t yet have a definitive cure (the inadvertent report cures following bone marrow transplant is not a sustainable approach to deploy for all) or vaccine to prevent the disease.”
Adebayo added that Anti-retrovirals (ARVs) available now make it possible to achieve such a level of control after diligent usage, as the virus will be undetectable by conventional testing methods.
He said, when this is so, the virus is untransferable, even as he explained that PREP and PEP are also biomedical tools available to help prevent transmission of the disease and these innovations alongside the behavioural prevention approaches make the goal of an AIDS-free Nigeria by 2030 an achievable goal.
Counselling and testing as entry points to treatment.Spike in HIV among key populations compounds woesBOTH Ezechi and Akpu recognise the important roles played by key populations and vulnerable groups in driving up the number of new HIV infections, not just in Nigeria, but globally.
According to the NIMR’s Director of Research and Head, Centre for Reproduction and Population Health Studies: “Key populations and vulnerable groups play a crucial role in the dynamics of new HIV infections. Factors such as social marginalisation, discrimination, and limited access to healthcare contribute to increased vulnerability among these populations. Stigma and criminalisation of certain behaviours further impede access to prevention and treatment services.
As a result, key populations, including men who have sex with men, transgender individuals, sex workers, and people who inject drugs, experience higher rates of new HIV infections. Addressing the unique needs of these groups is vital to effectively curbing the spread of HIV and achieving the goal of ending AIDS by 2030.
Akpu, who stressed that key populations are the major challenges in a plan to end AIDS by 2030, in corroborating Ezechi said: “In 2016, outside of sub-Saharan Africa, key populations and their sexual partners accounted for 80 per cent of new HIV infections. Even in sub-Saharan Africa, which includes Nigeria, key populations accounted for 25 per cent of new HIV infections in 2016.”
He also reiterated that these groups are often marginalised and face significant barriers to accessing HIV services, including stigma, discrimination, violence, human rights violations, and criminalisation.
He said these factors could prevent them from getting the care that they need, contributing to the spread of HIV within these communities and the general population.
A recent study on “Estimation of HIV Prevalence and Burden in Nigeria: A Bayesian Predictive Modelling Study, published in the journal eClinicalMedicine, in August 2023, by Dr Amobi Andrew Onovo et al, found that approximately two million people in Nigeria are living with HIV, adding that the HIV burden has increased by 7.2 percentage points since the last population-based survey in 2018, which is higher than the National Agency for the Control of AIDS (NACA) estimate of 1.9 million HIV-positive people.
The researchers said that their findings revealed that new HIV infections are on the rise, a development, which they also attributed to key populations, their clients, and sexual partners, who accounted for 64 per cent of all new HIV infections in West and Central Africa, and 25 per cent in the East and Southern African sub-region.
Before now, in Nigeria, the first HIV Sentinel Survey in 1991 showed a prevalence of 1.8 per cent. Subsequent sentinel surveys produced a prevalence of 3.8 per cent in 1993, 4.5 per cent in 1996, 5.4 per cent in 1999, 5.8 per cent in 2001, 5.0 per cent in 2003, 4.4 per cent in 2005, 4.6 per cent in 2008, 4.1 per cent in 2010 and 1.4 per cent in 2018.
This statistic shows that HIV prevalence in Nigeria has steadily declined between 1999 and 2018. But the researchers said their findings reveal that new HIV infections are on the rise, which could be attributed to key populations, their clients, and sexual partners, who accounted for 64 per cent of all new HIV infections in West and Central Africa and 25 per cent in the East and Southern African sub-region.
The study focused on the 15–49-year-old age range, which is considered the most sexually active age group in Nigeria. Compared to the 2018 Nigeria AIDS Indicator and Impact Survey (NAIIS) HIV prevalence data which focused solely on the general population, many of those at highest risk, such as partners of people with HIV, young people in high HIV prevalence settings, and KP are aggregated and included in the HIV seropositivity results from programme data.
According to data from Senegal, Gambia, Cote d’Ivoire, Ghana, and Nigeria, a large proportion of HIV infections occur among MSM, many of whom also report having intercourse with women.
NAIIS was a population-based survey that was conducted to track key national HIV-related indicators, such as progress toward the UNAIDS 95-95-95 targets, as well as, to guide policy and funding priorities. The President’s Emergency Plan for AIDS Relief (PEPFAR) mainly provided funding, and technical and logistic support for NAIIS implementation in Nigeria with some additional resources from the Global Fund.
According to UNAIDS 2021 data, in Nigeria, 90 per cent of people living with HIV know their status, 98 per cent are on treatment, and 95 per cent have a suppressed viral load, that is 90-98-95, while for South Africa, the numbers are 94-79-91.
They added: “Our estimated national HIV prevalence was 2.1 per cent among adults aged 15–49 years in Nigeria, which corresponds to approximately two million people living with HIV, compared to previous national HIV prevalence estimates of 1.4 per cent from the 2018 NAIIS and UNAIDS estimation and projection package People Living with HIV (PLHIV) estimation of 1.8 million in 2022.”
Also, according to a recent United Nations Office for Drug Control (UNODC) study on HIV prevalence in Nigerian prisons and drug use in Nigeria, 2.8 per cent of inmates and nine per cent of PWIDs are infected with HIV/AIDS. These figures are significantly higher than the 1.4 per cent national HIV prevalence rate among the general population, implying the importance of incorporating and utilising programme data, which includes both the general and priority populations.
‘Nigeria making significant strides in HIV/AIDS war’DESPITE skepticism among the populace regarding the country’s prosecution of the war against the malaise, the Director General of NACA, Dr Gambo Gumel Aliyu, insists that Nigeria, like many other countries, has made significant strides in the fight against HIV/AIDS.
He was, however, quick to add that there is still much to be done to achieve the goal of ending AIDS as a public health threat by 2030.
Aliyu, who said that the country has the second-largest burden of HIV infection in the world behind South Africa, added that of the 1.8 million persons estimated to be living with the virus, about 1.63 million are already on the lifesaving medication of ART.
Of this number, approximately 58 per cent are estimated to be female, 42 per cent male, and the national average mother-to-child transmission rate of 22 per cent is driven by a large number of states with transmission rates above 25 per cent, and few states with rates below 15 per cent. He further informed that Nigeria is responsible for about 30 per cent of the world’s gap in the Prevention of Mother to Child Transmission (PMTCT).NIGERIA’S seemingly impressive achievements on HIV /AIDS key performance indicators compared to other high-burden countries could be threatened by her over-dependence on dwindling donor funds.Presently, many are wondering what would happen to over 1.63 million people living with HIV that are currently on free national treatment when donors pull out of the programme.
The Guardian investigation revealed that donor agencies spend over $750 million (N750 billion), which is over 85 per cent of total funds spent yearly on HIV/AIDS programmes in the country.
A breakdown, according to documents made available to The Guardian showed the United States (US) government and the Global Fund for AIDS, TB, and Malaria spent $400 million and $110 million on HIV response in Nigeria every year, while the remaining $240 million comes from Joint United Nations Programme on HIV and AIDS (UNAIDS) and other partners.
The investigation showed that the Federal Government’s contribution is, especially in terms of hospital infrastructure, healthcare workers, training, and re-training of medics.
According to sources at NACA, the Nigerian government increased its funding from about $44 million in 2007, to slightly more than $171 million in 2014. Since then, the government’s financial involvement has been largely under wraps.
To date, international funding remains the highest contributor to the HIV and AIDS response in Africa. This threatens the sustainability of HIV programmes, particularly with increasing pressures on international budgets. This is already being witnessed with decreased donor funding for Malaria, and tuberculosis (TB) in recent years.
To sustain the current progress, domestic financing and leadership are critical.
Recently, researchers from APIN Public Health Initiatives in Nigeria conducted a study comparing the funding sources for HIV between Nigeria and South Africa, which have the two largest economies in Africa.
While Nigeria has an HIV prevalence of 1.4 per cent among adults and an estimated 1.9 million people living with HIV, South Africa has an 18 per cent prevalence with over seven million people living with HIV.
The study analysed financial and programme performance data from UNAIDS and other sources to categorise funding contributions for HIV programming into domestic and international sources.
It, however, showed that between 2017 and 2020, the domestic funding contribution to HIV in South Africa (69-77 per cent) was about four to six times higher than that of Nigeria (12-17 per cent). Over 80 per cent of HIV funding in Nigeria was from international sources, compared to less than 30 per cent in South Africa. However, international funding has started to decline in Nigeria.
The researchers also pointed out that Nigeria’s seemingly higher achievements on HIV key performance indicators compared to South Africa could be threatened by the country’s over-dependence on dwindling donor funds.
The significant contribution of domestic funding to the total HIV expenditure in South Africa demonstrates a high level of local ownership that better positions South Africa for sustainability.
According to preliminary estimates, the National HIV Strategic Plan 2021-2025 will require $2.8 billion to finance the HIV response, with a significant funding gap close to $350 million if no further steps are taken. To address the funding gap, Nigeria must mobilise domestic resources through Federal and State Governments, as well as the private sector.
Commenting on reports that donor agencies spend over $750 million yearly on HIV programmes in Nigeria, Akpu, an advisor on Science Systems and Services, UNAIDS in Nigeria, told The Guardian: “So, without really focusing on the exact numbers, there are significant donor resources currently supporting the programme. From the US government, PEPFAR programme, to Global Fund and the Nigerian government, all these boils down to a significant amount of resources hence the need for the civil society, and beneficiaries of the programme to have their eyes on these resources that are available for the programme, and begin to ask questions about how the resources are being used; whether the right things are being done; whether people are using the resources appropriately, etc. Even governments at state levels also must ask questions. Should we begin to think about alternatives to how we are putting it together right now?
“Right now, we have non-governmental organisations (NGOs) kind of leading the implementation process, and the government is already trying to say that. You know, we should start to think forward about a time when, maybe the donors are not here anymore. What would we then do? So let’s begin to think about how we empower our local actors, our governments, our civil society organisations to take the lead in managing this programme…”
Many are wondering what would become of Nigeria as far as HIV response is concerned if donors were to withdraw their grants today. Akpu responded: “First thing is to say, there’s no concern about that per se. If everything goes away, our hospitals already know to manage this condition, and they are the ones doing it right now. So, that is progress in itself. We have a hospital system that can deal with HIV. We only have to contend with things like, how do we make sure that we continue to buy the drugs? How do we make sure that we continue to maintain supply? HIV treatment is a kind of uninterrupted treatment because if that happens, everything that we have built over the past 20 years could be jeopardised.”
Also aligning with the position that the government must take ownership of these programmes that are being funded and make them more sustainable, is the Associate Director, PEPFAR, HJFMRI Nigeria, Dooshima Uganden-Okonkwo. She went further: “Yes, our governments need to do more than they are doing now because these are Nigerians’ lives that are accessing these services. So, there needs to be some responsibility and accountability.”