Nigeria, with a population of 154.7 million (World Bank, 2009) is the most populous country in Africa and represents about 47% of the West African population (World Bank, 2010). The country is divided into six geo-political zones; North-West, North-East and North-Central as well as South-West, South-East and South-South (World Bank, 2010).
Being the biggest oil exporter in Africa and with the largest natural gas reserves in the continent (World Bank, 2010), one would think that (economically and in terms of human development) the country would be up in the ladder with the prosperous countries of the world. But one would be wrong. The country is classified as lower middle income with a GNI per capita, Atlas method of $1,170 (World Bank, 2009). The country ranks 158 out a possible 182 countries on the human development index table (UNDP, 2009). Life expectancy at birth is 48 years for men and 50 years for women (WHO, 2009), adult literacy rate is 60% (World Bank, 2008), urban population is 46% (World Bank, 2009) which indicates that the majority live in rural areas, while the total fertility rate (per woman) is 5.5 (WHO, 2009).
In terms of health indicators, the country does not fare any better. With an infant mortality rate of 85.5 per 1000 live births, a maternal mortality ratio of 1,100 per 100,000 live births and an under 5 mortality rate of 186 per 1000 live births (regional average- 142 per 1000 live births) (WHO, 2008), it will be safe to say that the country can and should do better. Table 1 (World Bank, 2009) is an overview of quick facts on Nigeria
Year 2009
Population, Total (millions)
154.7
Population growth (annual %)
2.3
GNI per capita, Atlas method (current US $)
1,170
Life expectancy at birth, total (years)
47.9
Mortality rate, infants (per 1000 live births)
85.8
Contraceptive prevalence (% of women ages 15-49)
15
Table 1. Source: World Bank: World Development Indicators, Nigeria: Quick facts, 2009
With economic and social indices poor in the worlds poorest countries, world leaders met in September 2000 under the canopy of the United Nations to set a roadmap to reduce extreme poverty with the aim of improving human and economic development through a global partnership (UN millennium declaration, 2000). Thus eight goals with 21 targets and 60 measurable indicators were set (UN, 2000).
Focussing on all the millennium development goals (MDGs) is beyond the scope of this paper. This paper aims to focus on one health problem that is a priority of the Nigerian nation. Therefore in the next few pages, you will be taken on a journey on the burden of the Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) in Nigeria, its current status and recent trends, issues of equity and spread in relation to income, gender and location (residence), national and sub-national policies to address the problems posed by HIV/AIDS, challenges to addressing these problems as well as recommendations for an improved strategic response.
GENERAL BACKGROUND/Current status and recent trends
HIV was first discovered in Nigeria in 1986 (DHS, 2008). By 1991, the prevalence rate was reported as 1.8% (DHS, 2008). The prevalence rate then progressively rose to 4.5% in 1996 and then 5.5% in 2001 (National HIV/AIDS prevention plan, 2007-9). However the prevalence rate dropped to 5% in 2003 and 4.4% in 2005 (National HIV/AIDS prevention plan, 2007-9). Notwithstanding the drop and as a consequence of Nigerias huge population, the disease has continued to pile an economic and health misery on the country as 2.86 million people had been infected by 2005 (IBBSS, 2008).
Currently, the HIV prevalence rate is 4.6% (NACA, 2009). Estimated number of people living with HIV/AIDS is 2.98 million, the annual HIV positive births is 56,681, while annual AIDS deaths is 192,000 with females bearing more of the death burden at 105,822 deaths to 86,178 deaths for males (NACA, 2009). The impact of the disease on children is particularly worrisome as evidenced by the annual HIV positive births. It gets worse. According to data released by the Federal Ministry of Health in 2009, 2,175,760 children have been orphaned due to factors relating to HIV/AIDS (FOMH, 2009).
Females constitute almost three-fifths (58.3%) of the infected persons in Nigeria (National HIV response Analysis, 2009). Also worthy of mention is the fact that young adults are disproportionately affected with a sero-prevalence of 5.6% in the 25-29 age-group, the highest of any age group (National HIV response Analysis, 2009). As this is part of the productive age group of any country (UNAIDS, 2008), the impact on socio economic development can only be imagined.
The millennium development goal 6, target 6 A&B is to halt by 2010 and begin to reverse by 2015 the spread of HIV/AIDS and to achieve universal access to treatment for all those who need it by 2010 (UNDP, 2010). The indicators to measure these include: HIV prevalence among pregnant women aged 15-24, condom use at last high risk sex, proportion of population aged 15-24 with comprehensive knowledge of HIV/AIDS, ratio of school attendance of orphans to non orphans and the proportion of population with advanced HIV with access to antiretroviral therapy (ART) (UNDP, 2010).
The demographic health survey (DHS) implemented by the Nigerian population commission (NPC) and supported and funded by PEPFAR, USAID and UNFPA was carried out in 2008 (DHS, 2008). It showed that 23% of women and 36% of men in Nigeria have what is a comprehensive knowledge of HIV/AIDS (DHS, 2008). Comprehensive knowledge is considered to be the knowledge that condom use and faithfulness to one partner can prevent HIV infection, knowing that a healthy appearance does not rule out HIV and the rejection of two commonest myths that HIV can be transmitted through voodoo or mosquito bites (DHS, 2008). Using the above criteria as the definition of comprehensive knowledge is a bit thin. A better term would be basic knowledge as the popular acronym ABC (abstinence, be faithful and condom use) constitutes the basics of HIV prevention. The percentage of adults and children with advanced HIV with access to treatment is 32% (DHS, 2008). As the target is universal access to treatment, this shows clearly that Nigeria is lagging behind on treatment despite its preponderance over prevention (Idoko, 2010). The prevalence of HIV among pregnant women between ages 15 and 24 in Nigeria has decreased from 5.8% in 2001 and 2002 to 5.0% in 2003 and 2004 and has steadied at 4.3% in 2005 through 2007 (NACA, M&E unit, 2007). The percentage of the population who used condom at last high risk sex has markedly increased from 43.9% in 2003 to 63.8% in 2007 (NACA, M&E unit, 2007) while the Federal Ministry of Health reported in 2009 that the number of children orphaned by AIDS increased from 1.97 million in 2007 to 2.18 million in 2009. The ratio of school attendance of orphans to non orphans is said to be 0.86:1 (FMOH, 2009).
Prevention of mother to child transmission (PMTCT) of HIV constitutes a huge gap in HIV prevention in Nigeria (Idoko, 2010). With only 12.5% of pregnant women having access to PMTCT services, Nigeria represents 30% of the global gap of PMTCT of HIV (Idoko. 2010).
The progress Nigeria has made in her fight against HIV/AIDS is illustrated in table 2 which compares estimates and data compiled by NACA from 2000 through 2007. It shows a mixed bag of results as the improvements made have either been slow or dawdling (Mid- point assessment, 2010).
Target 7: Have halted and begun to reverse the spread of HIV&AIDS (UN Millennium Declaration, 2000)
Indicators
1990
2000*a
2001
2002*b
2003
2004*c
2005
2006*d
2007*d
2008
2015
Progress towards target
HIV prevalence among 15-24 year old pregnant women (%)
5.4
5.8
5.8
5.0
5.0
4.3
4.3
4.3
4.2
To be halted
Improving but slowly
% of young people aged 15-24 who both correctly identify ways to preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission
18.3
18.3
25.9
25.9
25.9
NA
100
Improving but slowly
% of young people aged 15-24 reporting the use of a condom during sexual intercourse with a non regular sexual partner
43.9
43.9
63.8
63.8
63.8
NA
100
Improving
Ratio of school attendance of orphans to school attendance of non orphans aged 10-14 years
NA
NA
NA
NA
NA
NA
NA
NA
NA
1.2
Number of children orphaned by AIDS (millions)
1.8
1.97
1.97
1.97
1.97
worsening
A, b, c, d are for 1999, 2001, 2003, 2005. NA- not available
Table 2. Source: MDG report, 2010
EQUITY
Empowering women and girls has a plethora of positive effects on all MDGs (UNDP, 2010). HIV/AIDS is no exception. Despite the fact that HIV/AIDS knows no gender, clear disparities are visible in the way men and women with HIV/AIDS are responded to and cared for (Mbonu, et al, 2010).
The demographic health survey (DHS) carried out in 2008 revealed disparities based on gender, ethnicity, location and income quintile in the knowledge of HIV/AIDS, attitudes towards HIV/AIDS and coverage of testing (DHS, 2008).
Table 3 (DHS, 2008) shows a variation in the knowledge of HIV/AIDS according to age, residence, ethnicity, level of education and income (DHS, 2008). Of note is the trend that reveals that HIV awareness while almost universal in urban areas (98% and 95% among men and women respectively), is lower among rural men and women at 91% and 84% respectively (DHS, 2008). Awareness of HIV/AIDS was also found to be lower in the Northern region compared to the South, being lowest in women of North-central origin (76%) and men of North-eastern origin (88%)(DHS, 2008).
Background characteristics
Women
Men
Age in years
15-24
87.1
91.4
15-19
85.3
88.3
20-24
89.1
94.8
25-29
89.8
94.6
30-39
89.4
94.7
40-49
87.2
94.4
Marital Status
Never married
92.9
93.4
Ever had sex
96.5
98.0
Never had sex
90.0
89.0
Married/living together
86.4
93.6
Divorced/separated/widowed
91.3
92.0
Residence
Urban
95.3
97.9
Rural
84.3
90.8
Zone
North central
75.9
90.7
North east
81.4
87.8
North west
87.8
90.9
South east
97.1
96.4
South South
92.0
96.1
South west
93.4
97.8
Education
No education
76.6
80.7
Primary
90.2
92.4
Secondary
96.0
97.1
More than secondary
99.3
99.7
Wealth quintile
Lowest
75.5
83.5
Second
81.7
89.9
Middle
88.8
93.8
Fourth
94.5
97.0
Highest
97.6
98.9
Table 3. Source: Nigeria DHS, 2008
In Nigeria, there are clear differences in the proportion of the population with the knowledge of preventive measures of HIV by age, gender, ethnicity and income quintile (DHS, 2008). Overall women were found to be more knowledgeable in urban areas than in rural areas (DHS, 2008). The same trend was also found to apply for men. Most worrying is the fact that those in the lowest wealth quintile have a rather poor knowledge of HIV prevention measures with only 31.3% of women and 53.2% of men knowing that using condoms at every sexual encounter can protect them from contracting HIV (DHS, 2008). The DHS, 2008 also found that respondents in urban areas are more likely to have a comprehensive knowledge of HIV/AIDS compared to rural areas (DHS, 2008). This proportion rises with an increasing level of education and income among both men and women (DHS, 2008).
The DHS, 2008 exposed a stratum of inequities in terms of coverage of HIV testing services (DHS, 2008). Living in urban areas increases ones chances of knowing where to test for HIV with 66% of women and 78% of men knowing where to test for HIV compared to 39% for women and 57% for men in rural areas (DHS, 2008). Zonal disparities are also evident as women and men in the North-east are least likely to know where to test for HIV (27% for women and 54% for men) (DHS, 2008). Worryingly however, of the people who were tested for HIV in the 12 months preceding the survey, only 7% of men and 7% of women came back for the results (DHS, 2008). Further studies might be required to find out why this is the case.
As stated earlier in this paper, there is a huge gap in PMTCT services in Nigeria. The DHS, 2008 made known that only 24% of women who gave birth in the 2 years preceding the DHS received HIV counselling (DHS, 2008). Only 16
