Kizito O. Akali, Pharm.D.

, HCMBA December 12, 2012 Call for Modification of the National Strategic Plan of the National Agency for the Control of AIDS (NACA) Executive Summary Nigeria is currently home to about 10 percent of the global population of people living with HIV, with about 3.5 million people currently infected. Infections keep going up each year, with about 400,000 new infections in 2012, and annual death from AIDS topping 200,000. The HIV prevalence has dropped from 4.6 percent in 2008 to 4.1 percent in 2012, however, this is misleading, as the population of the country has grown from 150 million to 162.5 million in the same period. This could mean a public health disaster of epic magnitude, with the population projected to double in 22 years, if the current policy on HIV/AIDS continues to be regurgitated. The National Agency for the Control of AIDS (NACA) has laid out a robust implementation plan in its 2010 National Strategic Plan (NSP), with set goals for 2015. This plan has demonstrated, from the 2005 Nationals Strategic Framework (NSF), that it will be ineffective without a total commitment from the government and proper collaboration among the various states and federal ministries, in addition to accountability to funds received. NACA should borrow a leaf from the United States National HIV/AIDS Strategy and Implementation plan, which employed a strategy of inter-agency coordination and collaboration from the federal down to the district level. This strategy has resulted in improved HIV counseling and testing, treatment, and support among the high risk groups, according to latest progress report. The funds approved and mobilized by The Global Fund is for the expansion of HIV/AIDS prevention, treatment, and care, decentralized at the community level. For the benefits of the fund to reach the intended recipients, it is imperative that the government of Nigeria and various ministries make the commitment to become involved toward this public health menace. The government should improve health access by expanding the public health insurance to accommodate all Nigerians, especially those unable to afford health services. More safety nets in the form of primary health centers should be built in all the local government areas (LGA), to decentralize services and improve coverage. Additionally, there should be a matching financial stake by the government toward the general funding of the HIV/AIDS prevention, treatment, and care that would show a more than decent improvement from the current stake. NACA should create a blueprint that details the coordination and collaboration among the ministries down to the LGAs. Implementation of these, coupled with support from The Global Fund and others, will result in increased HIV counseling and testing, as the issue of cost will no longer be a barrier, and there will be an improved access down to the community level. Mother to child transmission will be greatly reduced, as more pregnant women will have access to antenatal care, increasing the chance of HIV counseling and testing, and treatment, if necessary. Treatment and care will become better coordinated, as the distribution channels will become streamlined, reducing any chance of drug resistance due to insufficient supply of drugs. Combined, all these will help Nigeria avert a potential major public health disaster while leading her toward achieving the Millennium Development Goals (MDG).

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Thesis Nigeria should adopt a similar strategic and implementation plan used in the National HIV/AIDS Strategy (NHAS) of the United States of America, in order to reduce the prevalence of HIV infections and to improve access to care and outcomes for those living with the disease. Introduction Issue Nigeria, the most populous country in Africa, with an estimated population of 162,265,000, ranks third among countries with the highest HIV/AIDS burden in the world, after India and South Africa (NACA, 2012). It is estimated that about 3.5 million people in the country are living with HIV. Despite growing awareness of HIV/AIDS, risk taking behavior, poor access, and poor outcome are still rampant, leading to an increase of about 400,000 people infected in 2011 and more than 200,000 deaths attributed to AIDS (REACH, 2010) (NACA, 2012). The impact from HIV/AIDS, which accounts for 30% of the countrys morbidity (direct and indirectly), has caused Nigerias life expectancy to stagnate at 52 years (UNIDO, 2011) (Avert). As a result, the biggest public health issue in the country is HIV/AIDS. Efforts geared toward stalling the growth of this epidemic will go a long way to improve the life expectancy and productivity of the country, in addition to the reduced impact on children resulting from orphans due to AIDS and mother-to-child transmission of the infection. Background AIDS was first reported in Nigeria in 1986. Twenty six years later, 3.5 million Nigerians now live with HIV/AIDS. Though the national median HIV seroprevalence level has been on downturn in recent years, probably due to increase in population, the absolute number of people newly diagnosed and living with the disease has been increasing, in addition to AIDS related mortality (see table 1). Nigeria is a country that remains mostly underdeveloped despite Table 1- Epidemiology of HIV in Nigeria: Key Facts (NACA, 2012). National Median HIV Prevalence
Estimated Number of PLWHIV Annual AIDS Death Number requiring Antiretroviral Therapy New HIV Infections Total Number of AIDS Orphans

2008 4.6%
2.980,000 192,000 857,455 336,379 2,175,760

2012 4.2%
3,459,363 217,148 1,449,166 388,864 2,193,745

her oil wealth. 70.8% of the population lives below the poverty line, on less than $1 per day, making high quality healthcare unaffordable for most Nigerians, in the absence of government intervention (Osain, 2011). The negative trends are expected to worsen unless an appropriate strategy and implementation is adopted, as the population is projected to double in 22 years (REACH, 2010).
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The United States of America have more than 1.1 million people living with HIV infection. The number of new infection has remained stable at about 50,000 persons per year. An estimated 17,774 people died from AIDS in 2009 in the U.S. (CDC, 2012). These figures prompted the President to create the National HIV/AIDS Strategy (NHAS) in July 13, 2010, followed by the implementation plan. The purpose of this ambitious plan was to have a comprehensive coordinated roadmap for HIV/AIDS with clear and measurable targets (The White House, 2010). According to the plan, this will go a long way in achieving the vision where new HIV infections are rare, and when they do occur, patients will have unlimited access to high quality and life extending care, free from stigma and discrimination. The implementation of the NHAS involved a level of coordination and collaboration across agencies and the federal, states, and local governments. This coordination was spearheaded by the DHHS through tracking of federal programs implemented in each state, to ensure harmony between federal and state HIV/AIDS activities, and by establishing regular cross departmental meetings to coordinate program planning and administration of HIV/AIDS related issues (The White House, 2010). Highlights from the 2011 progress report showed improvements in several areas. For example, efforts were intensified more in communities where HIV is mostly concentrated. Also, recipients of public funds are held accountable for achieving results. This has resulted in more HIV testing and condom distribution for people at high risk of acquiring HIV. Additionally, HIV care was expanded and made available to the 8,100 community health centers across the nation, with continuous updates, and treatment and care guidelines disseminated to providers (DHHS, 2011). DHHS also improved the supply, capacity, and distribution of primary care providers able to provide HIV prevention, care, and treatment. The National Acton Committee on AIDS (NACA), the Nigerian agency in charge HIV/AIDS prevention, treatment and care, came up with its own action plan in 2010, dubbed the National Strategic Plan (NSP). The objectives of the NSP are to halt and begin the reversal of the spread of HIV infection, as well as lessen the impact of HIV/AIDS by 2015. According to NACA, this framework will cost about $5 billion to implement (Avert). Some of the aims included in the plan are: To reach 80 percent of sexually active adults and most at risk populations for HIV counseling and testing. To ensure 80 percent of eligible adults and 100 percent of eligible children are receiving ARV treatment. To improve access to quality care and support services to at least 50 percent of people living with HIV (PLHIV). To eliminate stigmatization of PLHIV. While NACA should be applauded for the goals posited in NSP, this new strategy looks more like a regurgitation of the national strategic plan (NSF) of 2005 -2009. The 2005 NSF called for accessibility of antiretroviral (ARV) drugs to 80 percent of adults and children with advanced HIV infection and to 80 percent of HIV-positive pregnant women by 2010. However, only 31 percent of those who needed treatment received ARV in 2009 (Avert). It got worse in 2010, when only 25% of adults and 7% of children in need of treatment had access to it. Currently, 1.4 million adults and 262,000 children eligible for ARV treatment are without it (NACA, 2012). How is it that such a well planned strategic framework resulted in an unsuccessful implementation? This is despite Nigeria being the largest oil producer in Africa and 12th largest in the world. Or was it?

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The major reason for the lackluster implementation is attributable to lack of political will, which leads to poor governance and weak institutions. In order for this major public health issue in Nigeria to be dealt with adequately, there should be a form of coordination and collaboration between all the ministries of the states and the federation that has even the slightest engagement with an HIV/AIDS adult or child. This form of collaboration will create a national web that will result in a more seamless execution. Additionally, ease of access for patients and high risk population to health facilities should be made possible. In this regard, the National Primary Health care Development Agency (NPHCDA), a government agency, has laid out a strategic plan to build primary health care (PHC) centers throughout all the Local Government Areas (LGA) (NPHCDA) (Abdulraheem, Olapipo, & Amodu, 2012). However, implementation of this plan has not yet materialized. Availability of these centers will improve the distribution channel for ARVs, condoms, testing, and counseling. Availability of these PHC centers will also increase the chances of pregnant women going for antenatal checks and subsequent testing for HIV. This is very pertinent, as 75,000 babies born in Nigeria annually have HIV, and about 360,000 children currently living with HIV mostly became infected from their mothers. Support Financial Sustainability Nigerias health system is ranked 187th out of 191 member states by the World Health Organization (WHO). The National Health Insurance Scheme (NHIS), touted to provide universal health insurance, covers only 5% of the population. Out of pocket expenditure represents 95.8% of all private health expenditures (Metiboba, 2011). The government provides only 30% of the health care delivered in the country, meaning that it will be impossible to afford the high cost of healthcare in a country where 70.8 percent of population lives below the poverty line, on about $1 per day (Osain, 2011). As a result of lack of government commitment to general heath and much less to the HIV/AIDS epidemic, there has been an overdependence on donor support. For example, only 7.6 percent of total funding came from the public sector in 2008 (NACA, 2012). The major international donors are the United States Presidents Emergency Plan For AIDS Relief (PEPFAR), The Global Fund, and World Bank. PEPFAR provided $448 million to Nigeria in 2008 for HIV/AIDS prevention, treatment, and care. The Global Fund, which has provided $275.5 million as at August 2012, wants to focus on decentralization of HIV treatment, testing, and support, to make it accessible in primary care facilities in the communities (Avert). With 10% of the world population of PLHIV in Nigeria, it requires more than international support to tackle this public health problem. More commitment from the government and better coordination among different ministries are needed to reach those with poor access and to disseminate information more effectively. Workforce The population of Nigeria was 131, 530,000 in 2003. The health care provider statistics at that period was 34,923 Physicians, 210, 306 Nurses, 6.344 Pharmacists, 690 Laboratory Technologists, and 115, 761 Community Health Workers (WHO Africa, 2006). To bring these figures into perspective, U.K., with less than half the population at that period, boasted of four times the number of physicians and nurses respectively. The figures might even be lower today due to incessant brain drain of physicians, nurses, and pharmacists to the U.S. and U.K (Nnamuchi, 2007). The few providers that are left are disproportionately concentrated in the
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urban areas, and a study found many of them with insufficient training on HIV prevention and treatment. Public Agenda Nigeria is currently home to about 10% of the global population PLHIV, with about 3.5 million people infected. New infections keep going up each year, with about 400,000 new infections in 2012, and annual death from AIDS topping 200,000 (NACA, 2012). The HIV prevalence has dropped from 4.6 percent in 2008 to 4.1 percent in 2012, but this is misleading, as the population of the country has grown from 150 million to 162.5 million in the same period. This rate of growth could mean a public health disaster of epic magnitude, with the population projected to double in 22 years, if the current policy on HIV/AIDS continues to be regurgitated (REACH, 2010). NACA has laid out robust implementation plan in its 2010 NSP, with set goals for 2015. This plan has demonstrated, from the 2005 NSF, that it will be ineffective unless a total commitment from the government and proper collaboration among the various states and federal ministries, in addition to accountability from any agency or group that receive funds. Men having sex with men (MSM) contribute up to 10% of new infections in the country. Yet a same-sex prohibition bill passed by the country Senate propose up to 14 years imprisonment each for same-sex couples that decide to get married, and 10 years each for anyone that assist them (NACA, 2012). This bill, if passed into law, will criminalize homosexual groups and promote discrimination of such persons. The law will become an obstacle to effective prevention, treatment, care, and support for MSMs, rising HIV prevalence contributor. Rather than criminalizing same-sex union, the government should show commitment toward reversing the growth PLHIV by encouraging homosexuals to undergo HIV counseling and testing through the passage of a strong anti-discrimination bill that will be recognized in all states. The NSP should be re-evaluated to involve a level of coordination and collaboration. This coordination should be spearheaded by either NACA or the Ministry of Health, which tracks the programs implemented in each state. This cross network of collaboration will result in improved access for those individuals in the rural areas, and it will yield an improved monitoring and evaluation environment. The money approved by the Global Fund is for the expansion of HIV/AIDS treatment, prevention, and care decentralized at the community level. For the benefit of the fund to reach the intended recipients, the government of Nigeria and various ministries has to make the commitment to be involved. This include making available, PHC centers in all the LGAs, a blueprint detailing the coordination and collaboration among the ministries down to the LGAs, and a matching financial contribution from the government by allocating a specific percentage in the annual budget HIV/AIDS prevention, treatment, and support. Counter Argument Testing Sites Advocates of the NSP and NSF might come up with an argument that the implementation plan of NACA is already working, as survey has shown that most people knew of the testing sites, but only a third had ever been tested. This shows that the program is reaching the individuals intended, but for one reason or the other people decide not to come in for HIV counseling and testing (REACH, 2010). This argument, instead, should raise the question of
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barrier to testing and which should be addressed by NACA. The fact that people are not testing means ineffective implementation plan, as the goal is to have 80% know their status. Removing barriers, such as high perceived cost, difficulty in disclosing status by clinics, and belief that HIV-positive individuals will die soon, can improve testing percentage. This can be achieved by adequate training of health care providers in HIV prevention and treatment. High Prevalence to Transactional Sex Another argument might be that the continued prevalence and growth of PLHIV is due to the high rate of transactional sex across the board. As a result, the full impact of the implementation plan of NACA in spreading the level of awareness about HIV/AIDS is undermined (REACH, 2010). In reaction to this argument, it is a fact that financial and material greed could be a strong motivation for transactional sex, especially in a country where three quarter of the population subsists on $1 per day. While NACA cannot reduce this pervasion, it has the opportunity to target and reach out to the groups prone to this kind of act, such as the university students and commercial sex workers, to promote HIV counseling and testing (HCT) and eventual distribution of condoms. As at 2011, results show that about 2 million individuals are aware of their HIV status within the last 12 months, with women constituting 71 percent of those tested (probably through antenatal care). This means that HCT uptake is still very low among Nigerians, something NACA should focus on through coordination and collaboration. Argument HIV Testing There is a lack of HIV testing programs and facilities in Nigeria, with about 1.4 HCT facilities for approximately every 100,000 Nigerian adults as at 2010. This results in only 31 individuals per 100,000 of the adult population that have received HIV testing (Avert). Cost Cost is a critical factor determining the ability to go for HIV testing in majority of the available centers (REACH, 2010). In Nigeria, 70 percent of the health care delivered is provided by private vendors, with only 30 percent provided by the government (Osain, 2011). With the rate poverty in the country, affording the cost of such service, which can range from $5 to $$7, becomes a luxury for most people. The National Health Insurance Scheme, which is supposed to provide a social health security system to the different segments of the society, currently covers only 5 percent of the population (Metiboba, 2011).

Access Health care access in Nigeria is only about 43.3 percent (Osain, 2011). Part of the reason may be attributed to 55 percent of the population living in the rural areas. Testing centers are mostly located in the urban areas, and cases where they are located in the rural areas, they usually turn out to be miles away from the community, resulting in the lack of knowledge of their existence. This is why it is imperative for the government to complete the strategic plan of building and equipping a PHC center in all the LGAs (NPHCDA).

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Prevention of Mother to Child Transmission of HIV (MTCT) About 75,000 babies in Nigeria are born with HIV annually. Most of the 360,000 children living with HIV in the country became infected from their mothers (Avert). In fact, Nigeria contributes 32 percent to the world gap of achieving the global target of eradicating MTCT. This makes it the highest in the world (NACA, 2012). This is not unconnected to the fact that about 50 percent of pregnant women do not access antenatal care nor deliver in health facilities. In 2011, only 1,120,178 (16.9%) of pregnant women received HCT. Though an improvement from the 2010 data of 907,387 pregnant women, it still remains far short of the universal access target of the NSF and NSP. In 2011, about 37,868 (17.1%) received ARVs to reduce MTCT, out of the estimated 221,129 HIV-infected pregnant women. HIV Treatment and Care Resources needed to provide sufficient treatment and care in Nigeria is lacking. In 2009, only 31 percent of people who needed treatment for advanced HIV infection received it. In a lot of cases, patients who had already started the treatment had to suddenly stop due to insufficient supply of drugs. They may have to wait for up to three months to resume treatment, thereby reversing the progress already made and possible increase in HIV drug resistance (Avert). This affects mostly the poor, who are not in a position to pay for the drugs from private vendors. By 2010, ARV treatment coverage remains low in the country, with only 25 percent of adults and 7 percent of children in need of treatment getting it. Moreover, many health care providers had not received the proper training on HIV prevention and treatment, and may alienate, albeit ignorantly, the patients. Conclusion There has been a huge transformation in the efforts to control the prevalence of HIV infection in Nigeria since the first few cases were identified in 1985. However, much still need to be done in order to control this epidemic, which currently has infected about 3.6 percent of the population and where only a quarter of adults and 7 percent of children infected with HIV have unfettered access to care and treatment. To stall and eventually reverse the growth trend of HIV infections in the country and to improve the access to care, the National Agency for the Control of AIDS (NACA) has developed the National Strategic Plan (NSP) in 2010. This framework has the audacious goals of a universal access of at least 80 percent of sexually active adults receiving HCT, 100 percent of Children, and 80 percent of adults and pregnant women with HIV infection receiving ARVs by 2015. However, this looks like a reincarnation of the 2005 NSF, which from available data was not successful. The NSF failed despite the flow funds from international donors. While the NSF and currently the NSP looks very colorful, and from a casual glance, have the potential to succeed, it lacks the proper implementation framework to succeed. It was actually designed to fail. This is because, for a disease that has about 3.5 million infected, the NSP lacks the proper coordination and collaboration needed to reach all the corners of the federation. It is imperative that the federal and state governments recognize the gravity of the situation and subsequently champion the effort to reduce the prevalence of this disease. International donations to the HIV/AIDS cause continue to outstrip that of the government by a ratio of three to one. This calls for a reversal in the policy of the country toward this public health menace. To improve access, the government needs to expand the public health insurance
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to accommodate all Nigerians, especially those that are unable to afford health services. Since the success of prevention, treatment, and care of HIV/AIDS depends on available sites, government needs to build more safety nets in the form of primary health centers, to decentralize services and improve coverage. NACA should revise the NSP to include a comprehensive coordinated road map that should involve a level of collaboration across federal and state ministries, in addition to local government agencies. There should be in place, a tracking formula to ascertain the progress of the implementation program in each state. There should be regular cross departmental meetings to coordinate program planning. Finally, there should be accountability for each fund disbursed. The aim is for service to reach the disenfranchised poor in the rural communities. The Global Fund has approved $$360,454, 493 and disbursed $275,586,635 to expand HIV/AIDS treatment, prevention, and care in 2012. The main purpose of this approved fund is to focus on decentralization by making care available in primary health care facilities at the community level. While the Global Fund is determined in its quest to stall the growth of HIV infection in Nigeria, it wants a show of total commitment from the Nigerian government in the form of a blueprint that shows willingness to join in the fight against HIV/AIDS for her citizens.

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NPHCDA. (n.d.). Home. Retrieved November 17, 2012, from National Primary Healthcare Development agency: http://nphcda.org/ Osain, M. (2011). The Nigerian health care system: Need for integrating adequate medical intelligence and surveillance systems. J Pharm Bioallied Sci., 3(4), 470-478. REACH. (2010). Social Dimensions of HIV and AIDS Prevention in Nigeria:Risk Behaviour Testing, and Counselling. Evanston: Research Alliance to Combat HIV and AIDS. The White House. (2010). NATIONAL HIV/AIDS STRATEGY FOR THE UNITED STATES. Washington: Office of The PResident of the United States of AMerica. The White House. (2010). NHAS Federal Implementation Plan. Washington: Office of the President of the United States of America. UNIDO. (2011). Pharmaceutical Sector Profile: Nigeria. Vienna: United Nations Industrial Development Organization. WHO Africa. (2006). Country Health System Fact Sheet 2006:Nigeria. Geneva: WHO. WHO. (n.d.). Country Statistics and Information: Nigeria. Retrieved November 4, 2012, from World Health Organization: http://www.who.int/countries/nga/en/index.html

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