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).
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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
Population, Total (millions)
Population growth (annual %)
GNI per capita, Atlas method (current US $)
Life expectancy at birth, total (years)
Mortality rate, infants (per 1000 live births)
Contraceptive prevalence (% of women ages 15-49)
Table 1. Source: World Bank: World Development Indicators, Nigeria: Quick facts, 2009
With economic and social indices poor in the world’s 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 Nigeria’s 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)
Progress towards target
HIV prevalence among 15-24 year old pregnant women (%)
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
Improving but slowly
% of young people aged 15-24 reporting the use of a condom during sexual intercourse with a non regular sexual partner
Ratio of school attendance of orphans to school attendance of non orphans aged 10-14 years
Number of children orphaned by AIDS (millions)
A, b, c, d are for 1999, 2001, 2003, 2005. NA- not available
Table 2. Source: MDG report, 2010
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).
Age in years
Ever had sex
Never had sex
More than secondary
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).
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The DHS, 2008 exposed a stratum of inequities in terms of coverage of HIV testing services (DHS, 2008). Living in urban areas increases one’s 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% were offered and accepted HIV tests during ANC and received the results (DHS, 2008) while only 13% were counselled, offered and accepted HIV tests and received the results. The women most likely to fall in the latter group were those who live in urban areas (35%), those from the south east ethnic origin (35%) and those with more than secondary education (54%) (DHS, 2008).
All of these imply that the HIV/AIDS challenge in Nigeria, as well the response to these challenges are in more ways than one determined by equity issues in relation to gender, poverty and location/residence.
NATIONAL AND SUB NATIONAL POLICIES AND STRATEGIES
After the HIV was first reported in Nigeria in 1986 (National HIV response analysis, 2009), the response was essentially health sector oriented to limit its spread (National HIV response analysis, 2009). However with the increasing spread of the epidemic and the advent of democracy in 1999, the focus shifted from a health sector based response to a multi-sectoral one (Country progress report, 2010).
This led to the establishment of the National Action Committee on HIV/AIDS to coordinate the multi-sectoral response (National HIV response analysis, 2009). To further strengthen its central coordinating role and the national response, this committee was transformed in 2007 by an act of the national assembly into full agency status, reporting directly to the presidency (National HIV response analysis, 2009). It became the National agency for the control of HIV/AIDS (NACA).
At the sub-national level, the coordination is done at each of the 36 states by the state action committee on HIV/AIDS (SACA) and at each of the 774 local governments by the local government action committee on HIV/AIDS (LACA) (National HIV response analysis, 2009). The plan was for the SACAs (just as NACA) to transform into full agencies to strengthen their contribution to the national response (NACA, 2009). However, only 20 states have transformed into full agencies (National response analysis, 2009). Weak political commitment as well as a lack of ownership at the state level has however continued to be identified as limiting factors for national HIV response (Idoko, 2009). Even the state committees that have transformed into full agencies have had problems ranging from poor funding to poor capacity with most of them working without constituted boards (Idoko, 2009).
NACA with the collaboration of relevant stakeholders developed an interim action plan in 2001, the HIV/AIDS emergency action plan (HEAP), a plan that focussed mainly on prevention, care and support (Country progress report, 2010). The need for a more comprehensive plan that includes treatment led to the development of the National strategic framework (NSF) in 2005. The NSF is the common framework for HIV/AIDS response in Nigeria (National HIV response analysis, 2009). All states also have state strategic plans (SSPs) sourced from the NSF and taking into account their peculiarities (Country progress report, 2007).
Nigeria developed her roadmap for universal access to HIV prevention, treatment, care and support in 2006 (Country progress report, 2010). This has been incorporated into the NSF and SSPs (Country progress report, 2010). The country has also developed key policy documents which factored in the development of the NSF including the National Workplace Policy on HIV/AIDS in 2005 to guide HIV programs in the workplace, the National Reproductive Health Policy, the National Gender Policy that ensures gender mainstreaming in the national response, the National Policy on Orphans and Vulnerable children (OVC), to guide OVC activities in the national plan, the National Policy on Injection Safety and Healthcare waste management as well as the National Prevention Plan and National HIV/AIDS Behaviour Change Communication (BCC) strategy to promote prevention and behavioural change activities (Country progress report, 2010).
With NACA as the central coordinating body, the NSF as the common strategic framework, there was the need to have a harmonized Monitoring and Evaluation (M&E) framework in line with the three ones principle (UNAIDS, 2004). This berthed the Nigerian National Response Information Management System (NNRIMS) with the development of the National M&E operational plan, 2007-2010 (National HIV response analysis, 2009).
Funding for HIV/AIDS programs in Nigeria is both internal and external (Country progress report, 2008). Internal funding is from the national, state and local government budgets, which has substantially increased as a result of the debt relief gain (DRG). There is also some funding from the private sector. However, bureaucratic bottlenecks in the release of funds, continues to be identified as one of the key problems militating against the response performance at state and local government levels (Idoko, 2009).
Figure 1 (National response analysis, 2009) shows the organogram, the institutional structural design of the country’s national response and how it links with sub-national and other non state actors. NACA is at the apex of the response architecture and from this vantage point provides political, program and technical leadership while linking with state and non state actors (National HIV response analysis, 2009). In the same fashion, state and local responses are led by SACAs and LACAs. Together these bodies interface with line ministries, the private sector, civil and human rights groups including faith based organisations and local and international development partners (National HIV response analysis, 2009).
HEALTH SECTOR, LINE MINISTRIES
LOCAL&INT. DEVELOPMENT PARTNERS
CONSTITUENTS AND COMMUNITIES
CONSTITUENTS AND COMMUNITIES
SACAs, LACAs, LINE MINISTRIES
CSO, PRIVATE SECTOR, DEVELOPMENT PARTNERS
COMMUNITIES AND CONSTITUENTS
COMMUNITIES AND CONSTITUENTS
Figure 1. (Source: National HIV Response Analysis, 2009)
In addition to the entrenchment of the ‘three ones’ principle, the development of the National Strategic Framework and the correct implementation of all other policy documents by NACA, other specific strategies to achieving Goal 6 of the MDGs in relation to HIV/AIDS in Nigeria include the local production of condoms and ARVs to drive down cost, increasing the number of HCT and ART sites as well as making them free and accessible, providing social security for AIDS orphans and children with HIV/AIDS, strengthening BCC programs, broadening prevention efforts in line with the National prevention plan, getting the MOHs to dedicate more funds to HIV/AIDS at the state and local levels, increased advocacy to states and LGs to drive SACAs and LACAs, as well as support for research on HIV/AIDS (MDG Mid-point Assessment, 2000-7).
While significant progress has been recorded as earlier detailed, significant challenges also exist (National HIV response analysis, 2009). There is an imbalance in the attention given to prevention as opposed to treatment as the focus has been more on treatment than prevention (Shehu, 2007). This is a surprising misplacement of priorities since at least 95% of Nigerians are HIV negative thus requiring concrete preventive measures to make them remain so (Shehu, 2007). By 2007, only 3% of health facilities in Nigeria provided HCT services (WHO, UNAIDS & UNICEF, 2008). In 2008, it was estimated that there was only one HCT facility to 80,000 Nigerians (WHO, UNAIDS & UNICEF, 2009). This might be related to suggestions that facilities providing HIV testing in Nigeria do not follow international standards about ethics and confidentiality (Physicians for Human Rights, 2006). Also, condom distribution and promotion has been hampered by poor resources and political interference (AVERT, 2010). Between 2000 and 2005, the average number of condoms distributed in Nigeria by donors was approximately 5.9 per man per year (UNFPA, 2005) while in a 2002 survey, only 25% of health facilities had any condoms (Human Rights Watch, 2004). In 2006, the Advertising Practitioners Council of Nigeria (APCON) started to restrict condom advertisements that might encourage ‘indecency’ (UN Integrated Regional Information Networks, 2006). Though APCON may have softened her stand, the view that condom advertisements promote indecency has to be balanced with the clear dangers posed by unprotected sex as a main driver of the spread of HIV/AIDS.
Other challenges include the inadequate and inequitable distribution of drugs, the high prevalence of stigma and discrimination, violation of the human rights of people living with HIV/AIDS (PLWHA), poor funding and low capacity at all levels but especially at the sub-national levels, inadequate monitoring of the quality of intervention, insufficient and inadequate responsive data bases, challenges in program coordination (National HIV response analysis, 2009) as well as the slow involvement of civil society and private sector groups in HIV/AIDS planning and budgeting (Country Midpoint assessment, 2000-7).
Poor accessibility and uptake of intervention services is a major problem affecting the national response (Coker, 2009). An example of that is in PMTCT (Coker, 2009). The National AIDS and STD control program (NASCP) reported uptake of PMTCT nationally as 11% as of July 2009 (Coker, 2009). While there were 908 functional HCT sites scattered across the country as at 2007 (NACA, 2007), there appears to be little awareness of the location of these sites (DHS, 2008), hence poor access especially at the community and hard to reach areas (National HIV response analysis, 2009).
The joint United Nations program on HIV/AIDS identified four major challenges of the HIV/AIDS response in Nigeria (UNAIDS, 2009). They include but not limited to: challenges due to empowerment of National leadership and ownership, challenges of alignment and harmonization, reform challenges for a more multi-sectoral response, and challenges with accountability and oversight (Country Midpoint assessment, 2000-7). NACA’s organisational effectiveness is still considerably weak with capacity constraints overwhelming at state and local government levels (National HIV response analysis, 2009). There also is a disparity in programs and coordination systems at all levels due to poor dissemination and use of policy instruments (National HIN response analysis, 2009). In terms of ownership and alignment, there is an excessive fragmentation of donor activities, poor collaboration between NACA-donor while donor approaches are not always aligned with national priorities thereby undermining ownership (National HIV response analysis, 2009). This may be due to the fact that the majority of funding for HIV programs is donor driven (HERFON, 2007). For instance, Nigeria contributes an only an estimated 5% of the funds for antiretroviral therapy programmes (HERFON, 2007). While this may be due to a country desire to concentrate more and rightly so on prevention, it may also explain why there is a tilt towards treatment.
The 2010 country progress report while acknowledging the successes and achievements of the HIV/AIDS response in Nigeria also identified key challenges that needed to be addressed. They include: incommensurate funding of the prevention, treatment, care and support programs compared to the complexity of the epidemic, overdependence on donor support, weak political and financial support especially at states and local governments, the lack of a National HIV/AIDS research agenda, poor coverage and quality of PMTCT, limited knowledge of the drivers of the epidemic, low risk perception at policy making and community levels, inadequate supportive legislation to guide and boost the national and state response, inadequate implementation of the National M&E system, the overwhelming focus on intervention monitoring rather than impact evaluation, as well as poverty and gender equality (Country progress report, 2010).
Above all, there is the challenge of maintaining current levels and scaling up a sustainable HIV/AIDS response that will tackle demand challenges like increasing new infections and declining livelihoods due to poverty, and supply challenges like inadequate infrastructure, low motivation of health workers and brain drain, governance challenges like poor health, communications and power infrastructure, inadequate health financing, inadequate logistics and procurement as well as declining human resources (Ogunlayi, et al, 2007). The requirement for this is a health systems strengthening approach with a target of improving the health supply chain efficiency and effectiveness, training more people with adequate incentives to man and manage those systems, developing policies that will support national and sub-national sustainability plans including the provision of physical infrastructure as well as mobilizing a responsible, responsive and equitable health financing (National HIV response analysis, 2009).
That Nigeria has made positive strides in her fight against HIV/AIDS is not in doubt. What is in doubt is if the current levels can be maintained and scaled up. It is instructive that of the 7 point agenda for action at the inception of the current political leadership, there was no health component.
This paper will bring to the front burner the need for greater political commitment from the top on health matters in general and the HIV/AIDS issue in particular.
As the evidence in this paper has shown, the impact of HIV/AIDS has been enormous particularly on women and children. While gender has been mainstreamed into the national response in Nigeria (National response analysis, 2009), there is clearly still a lot more to be done. It is particularly sad that Nigeria records annual HIV-positive births of 56,681. There is the need for all stakeholders to speak with one voice and declare this trend as unacceptable. And indeed it is. It should be unacceptable for pure and innocent neonates, infants and children to bear the brunt of the epidemic in a scale as seen in Nigeria. This paper strongly advocates the scale up of both the access and quality of all HIV/AIDS services including but not limited to HCT, PMTCT as well as other prevention, treatment, care and support services and especially for those disadvantaged due to location, income or gender.
This paper will bring to the fore the poor state of the response at the state and local government levels. There is the need to strengthen technical, financial and management capacity not just at NACA but at the SACAs and LACAs (National HIV response analysis, 2009).
There is a greater need for Prevention programs to be at the heart of the HIV/AIDS response. This need is reinforced (as shown in page 5) by the declining difference in the proportion of people with an awareness of HIV/AIDS compared to those with a comprehensive knowledge of HIV/AIDS (DHS, 2008). There is a further decline in the proportion of the latter group with the awareness of where to get tested (DHS, 2008). While treatment, care and support programs are indispensable, there is the need for a scale up of prevention programs to cater to the over 95% of the population that are currently HIV negative. While donors should be praised for the huge financial and human resources they have committed to the HIV/AIDS response, there is the need for country ownership as well as the alignment and harmonization of donor priorities in line with country plans and strategies.
Health systems strengthening needs to be accelerated for a health systems response that is based on improved infrastructure for an integrated package of care, a functional forecasting system based on verified data, built capacity of human resources, adequate health financing and a strong leadership (Country progress report, 2010).
Finally, the MDGs and its targets for HIV/AIDS should not be seen as a destination but a process. A process that ”emphasizes urgency, quality and equity, and involves the development of a comprehensive package of prevention, treatment, care and support relevant to the country (UNAIDS, 2006).
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