By Morenike Oluwatoyin Folayan
The HIV prevalence in Nigeria has been reported to be stable at 3.0% for several years by UNAIDS. The National Agency for the control of AIDS under the leadership of Prof John Idoko had however continued to highlight that the HIV prevalence estimate for Nigeria was exaggerated; and that the national prevalence had likely reduced to something in the range of 1.5% to 1.8% over the years.
He derived this evidence from series of national HIV testing programmes conducted during the period he was the Director General of the Agency.
However, he could not establish this evidence. His justification for making the assertions were also fraught with bias – public HIV testing without a defined sampling framework makes recruitment of study participants skewed as people who know their HIV status may not join public HIV testing campaigns readily.
In addition, making a case that the HIV treatment programmes were failing to identify new cases in large numbers is not substantive evidence for the absence of HIV positive cases: it is public knowledge that there are many rural and hard-to-reach communities that have not been effectively reached with HIV programmes.
The planned National HIV indicator survey to be funded by PEPFAR, the largest indicator survey to be conducted in the world, will put an end to the debate. It is anticipated that data on HIV prevalence in a number of states in Nigeria will start rolling in by the end of the year. The national report should be out by 2019.
What does this however mean for adolescent girls 15 – 19 years of age?
Aboki et al, in a prior publication, had shown that the HIV prevalence among adolescents had continued to increase in Nigeria. This may be a result of an harvesting phenomenon though, as many children born with HIV are now reaching adolescence.
But more than that, it may also be an indication that a number of HIV negative sexually active adolescents are not receiving adequate HIV prevention interventions.
Ezechi et al had once provided evidence from their clinic data from the National Institute of Medical Research, Yaba, Lagos, that a significant number of adolescents receiving HIV treatment at the center were infected through sexual transmission in adolescence.
HIV prevention intervention for adolescents in Nigeria has been poorly planned and had received poor attention. The effectiveness of models to reach adolescents in Nigeria is not known and have not been properly studied.
The DREAMS project supported by PEPFAR in other countries in Africa is a structured HIV prevention programme targeting adolescents and young women. The focus of the programme was mainly to address structural barriers to accessing HIV prevention services. The project led to a reduction of HIV incidence by 12% to 40%. This suggests very clearly that to succeed with HIV prevention for adolescents and young women, national HIV prevention programmes need to address structural barriers – barriers to access to education, barriers to access to economic empowerment.
We also see very clearly from global evidence that a focus on biomedical interventions for adolescent girls will not turn the tide around. Reports of results from microbicide studies and PrEP access studies that disaggregate data show that adherence to use of biomedical HIV prevention products is challenging for adolescents. The same is the case with the use of antiretroviral drugs for adolescents living with HIV. Success with programmes on treatment as prevention focusing on adolescents may also be limited.
Evolving evidence suggest very strongly that for HIV prevention programmes designed to address the needs of adolescent girls in Nigeria to succeed, the programmes need to address structural drivers of the epidemic. The programmes need to improve their social life: HIV prevention access should be situated in a comprehensive intervention model that empowers then with skills for life and living; and with skills to improve their independency.
The A360 programme in Nigeria is a good example of a programme to model a comprehensive HIV prevention intervention programme for adolescents after.
The A360 programme, hosted by the Society for Family Health and funded by Bill and Melinda Gates and the Children Investment Fund Foundation, promotes access of adolescents 15-19 years to contraception.
This is a new project in Nigeria with all the potentials for community uproar and resistance due to religious and cultural upheavals about adolescents’ access to sexual and reproductive health services. Despite these risks, the project is working and working well.
The project learnt to integrate contraception access within a model that addresses the social risk for adolescents’ pregnancy – economic empowerment; active engagement of adolescents during their spare time; and motivation for change through intense peer group education and one-on-one counselling.
The planning and implementation of the entire programme within communities and states allow for excellent community engagement and stakeholder involvement including involvement and project ownership by policy makers. Contraception services is introduced and provided for girls who understand the need for this having undertaken skills building and motivational classes. Those who access services also become the ones who recruit peers for the services. The model allows for fast recruitment of peers to access services. Multiple success stories about how lives have changed have been documented on the project.
Designers and implementers of HIV prevention programmes in Nigeria can learn from this experience.
There is little need to reinvent the wheel.
Formative research needs to be conducted so that HIV prevention projects targeting adolescents can understand the specific community context needs of the adolescents.
It is important to understand that adolescent girls are not homogenous. There are interventions appropriate for adolescents based on their culture, geographical locations, age segmentation, marital status and a whole lot more confounders. Understanding these confounders and addressing them through the mix of a combination of interventions identified using a human centre design approach will result in meaningful impact.
The global goal for eliminating HIV as a global crisis by 2030 is near the corner. Nigeria will fail to meet this target if drastic changes are not made to the way it manages its HIV programmes – treatment and prevention.
We can make it if we try.
Morenike Oluwatoyin Folayan, is of New HIV Vaccine and Microbicide Advocacy Society.
