Nigeria:

HIV/AIDS Epidemic and Progress Towards

Meeting 90-90-90 Goals
Honors 222 A: HIV and AIDS: Issues and Challenges

Nicole van Engelen

I. Background Information

Current Context

The Western African nation of Nigeria is seated in between Benin and Cameroon, with
the Niger river running from the northwest to the Gulf of Guinea in the south. The river
navigates through the arid regions in the North, the tropical rainforests in the center of Nigeria,
and the equatorial climate of the south. The country is accustomed to both occasional droughts,
but also floods. (The World) Recently, beginning in August of 2019, prolonged heavy rain
created flooding in Northeastern and Central states, causing the displacement of more than
42,000 individuals and the destruction of more than 2,700 houses. (FloodList) Other
environmental problems in the country can be attributed to the sheer number of people in the
country. Overpopulation has already led to many environmental problems, and if this growth
continues and Nigeria hits its forecasted population in 2050 of about 392 million, it will get
significantly worse. Air and water pollution, deforestation, soil degradation and oil spills have
stemmed from overpopulation, along with accelerated urbanization. Most of the major oil
companies operate in the Niger Delta Basin, helping to produce the nation’s 2.5 million barrels
of crude oil a day. (Oil)

Nigeria sits atop rich oil deposits that have historically been a primary export,
contributing significantly towards their economy. Yet instability has troubled the industry. A
2016 recession occurred due to lowered oil prices and production, made worse by attacks on oil
infrastructure and unfavorable policies that put more restrictions on foreign trade. Suffering
negative GDP growth that year, the real GDP growth rate became positive, at 0.8% in 2017.
According to 2017 figures, the GDP was $1.121 trillion U.S. dollars, which is ranked 24th
highest out of all nations. (The World) Despite this massive GDP, and an increasing GDP growth
rate which, as of January 2020 was 2.55%, unemployment remains high and is only growing
more. (Nigeria GDP) Between July 2017 and July 2018 alone, unemployment has grown from
16.2% to 22.7%. (Nigeria Unemployment) 70% of the population lived below the poverty line in
2017, and economic diversification efforts into agriculture, telecommunications, and services
haven’t seemed to alleviate this trend yet. (The World)

The aim of diversifying the economy is just one of current President Muhammadu
Buhari’s plans for the future. Since taking office in 2015, the president also hopes to increase
transparency and improve fiscal management, but due to his protectionist approach that taxes
imports, domestic producers rather than consumers are benefited. Buhari made some progress
towards his aims when he ran an anti-corruption platform that formed the Treasury Single
Account, a tool for managing government resources more efficiently and with more accuracy in
comparison to previous management which allowed “ghost workers” and duplicates to slip
through payroll systems. (The World) Though transparency may have improved in this way,
there are still the long-lasting concerns over corruption. In 2019, Transparency International gave
Nigeria a score of 26/100, meaning it has high levels of public sector corruption. (Corruptions)
Inequities stem from this corruption, including lower standards of living for most and conflict
between the people and the government, as administration members and government employees
are focused on their own financial wellbeing rather than the overall wellbeing of the general
public. (Musser)
 Buhari operates out of the Aso Rock Presidential Villa, a palatial estate located in the
country’s only territory, the Federal Capital Territory (FCT). (The Villa) The FCT is located
centrally, and additionally contains the densely populated capital city of Abuja. Other highly
populated cities include Lagos and Ibadan in the southwest and Kano in the North. The country
is currently divided into 36 states and one territory. With an exception being the capital, the
highest density areas tend to be in the south and southwestern regions of the country. (The
World)

In the North and Northeast, the Boko Haram and ISIS terrorist groups have recently been
a threat on Nigerian lives. Since 2009, members of Boko Haram have killed thousands of
Nigerians. To add on to this, they have disrupted trading and farming, which has the potential to
cause famine and displacement of many. Because they denounce actions associated with the
Western world, secular schools and voting are at risk despite being so crucial to future
development in the country. Political and communal violence hurt the country as well. Nigeria is
also a transit point for illicit drugs, like heroin and cocaine, and for forced labor and sex
trafficking, which puts even more lives at risk. (The World)

Historical Context and Major Events

A history of colonization has plagued Nigeria’s past, and can be attributed for some of
the issues the country suffers from today. Great Britain held control and influence over Nigeria
through the first half of the 20th century. The British implemented a system of indirect control,
which entailed traditional leaders keeping their positions of rule, but under the overarching rule
of the Crown. A 1951 constitution gave the balance of power to the Nigerians. Shortly after that,
in 1954, Nigeria became a federation, giving the people more autonomy from their colonizers.
With this change, independence in geographical regions began to follow by 1957, portions of the
East and West gained internal self-government. The North followed 2 years later. Elections to
the Federal House of Representatives in December of 1959 brought in a new government. At
their first meeting, the new House of Representatives requested full sovereignty from Great
Britain, and this request was officially granted in October 1960.

The independence government was led by the Northern People’s Congress and the
National Council of Nigerian citizens. Sir Abubakar Tafawa Balewa served as the prime
minister, and in 1963, the country’s first president Dr. Nnamdi Azikiwe was announced. Yet a
series of coups, beginning in January 1966, led to many rapid changes and a resulting instability
for the country. Ethnic tensions were elevating in this post-coup period. In May 1967, Lieutenant
Colonel Chukwuemeka Odumegwu Ojukwu declared Eastern Nigeria the independent Republic
of Biafra. This sparked an extremely deadly civil war that, in less than 3 years, ended the lives of
more than a million people.

Successive coups followed in the next few decades. There was a brief period of
democracy following a 1976 coup. A previous ban on political activities was lifted in 1978,
followed by multiparty election in 1979. Yet this period ended following another coup in 1983.
General Sani Abacha went back and forth on his word concerning a return to democracy, but
eventually, in part due to a suspension from the Commonwealth Heads of Government, Abacha’s
replacement General Abdulsalami Abubakar finally allowed for full political activity and
published an election schedule. This effort eventually led to the election of Olusegun Obasanjo
and a 1999 constitution that allowed Muslims to practice Sharia law. While the constitution
caused outrage from Christian communities, it was eventually adopted and carried out beginning
in 2000. (Nigeria : History)

Demographics

Nigeria has not only the largest population of any African nation, which is estimated at
214,028,302, but also an extremely diverse population. More than 250 ethnic groups live in the
country. Hausa is the majority at 30%, followed by Yoruba (15.5%), Igbo (15.2%), Fulani (6%),
Tiv (2.4%), Kanuri/Beriberi (2.4%), Ibibio (1.8%), and those belonging to other groups (24.7%).
The Hausa and Fulani groups are predominantly Muslim, along with 53.5% of the country. The
Igbos are generally Roman Catholic and other types of Christianity. 10.6% of the population is
Roman Catholic and 35.3% is other types of Christianity, with only a small percentage, 0.6%
belonging to other religions.

Nigeria’s age structure is unique in how young most people are. In 2018, 41.7% of the
population was between 0 to 14 years old, followed by 20.27% between 15-24 years old, 30.6%
between 25 to 54 years old, only 4.13% of people 55 to 64 years old, and a small proportion,
3.3%, being 65 and over. The median age of a Nigerian in 2018 was only 18.6 years old. With
such a large youth population, there is a potential for major economic support and expansion, yet
in 2017, 16.5% of the total population was unemployed and 13.8% of youth between the ages of
15-24 were unemployed. The plentiful labor force of 60.08 million is unable to be fully utilized
due to a lack of opportunities. There is brain drain as a significant amount of highly skilled
workers emigrate west.

Another problem especially affecting younger generations is poor education. Though on

average men go to school for 9 years and women go to school for 8 years, only 62% of the
population is literate by the age of 15. The standard woman has the first of her average 4.27
children at the mean age of 20.3. Allowing people, especially women to obtain more education,
along with improvements in healthcare, would allow for smaller families and a growth rate less
than the steep 2.53%. In total, only 68.5% of the population has accessed to improved drinking
water sources and only 29% of the population has improved sanitation. 31.5% of children under
5 are underweight, showing another failure of the system that leaves 70% of the country
impoverished. These figures unfortunately justify Nigeria having a maternal mortality rate
ranked 4th highest in the world and an infant mortality rate ranked 12th. Yet, family planning
hasn’t been prioritized due to a lack of government financing, government will, and availability
of resources. Family planning will continue to be crucial, as the current dependency ratios have
proven to be unsustainable. The youth ratio is an extremely high 80.9. Losing a working-age
individual to an illness or other untimely death could be detrimental considering the high amount
of dependants involved in large families. (The World)

Morbidity and Mortality of Major In-country Health Issues

Many health issues are exasperated by a weak but improving healthcare system. In 2016,
the Lancet ranked Nigeria 142nd out of 195 countries using its Healthcare Access and Quality
Index (HAQ). The HAQ is based on the amenable mortality of 32 illnesses. This means they take
into account death rates from 32 causes of death that could be prevented by efficient and
effective medical treatment. (GBD) The degree of risk for major infectious diseases is very high.
Food or waterborne diseases like bacterial and protozoal diarrhea, hepatitis A and E, and typhoid
fever are significant. Vector borne diseases including malaria, dengue fever, and yellow fever are
a cause for concern. In fact, since 2017, an ongoing yellow fever outbreak has affected the
country. There are now cases in all 36 states. The CDC advises that anyone traveling to the
country gets vaccinated prior to visiting. Water-contact diseases like leptospirosis and
schistosomiasis, as well as the animal-contact disease rabies are also listed as very high risk.
Meningococcal meningitis, a respiratory disease, and Lassa fever, which can come from
aerosolized dust or soil contact, as well as infected rat excrement, are both major infectious
diseases in the region. However, arguably one of the most important health issues affecting the
country is the HIV and AIDS epidemic. Nigeria currently has the 2nd largest HIV/AIDS epidemic
in the world. (HIV and AIDS) In adults 15 to 49, the prevalence rate is 1.5%, ranking Nigeria
31st in the world. 1.9 million live with HIV/AIDS and in 2017 53,200 people died from it. Both
these statistics were ranked 4th in the world for their corresponding categories, which illustrates
the severity of the epidemic on this country. (The World)

II. History of HIV/AIDS Epidemic

First Cases and Initial Response

Women and youth have been at the center of Nigeria’s HIV/AIDS crisis since the
beginning. The first 2 cases were identified in 1985, and later reported on at an international
conference in Lagos in 1986. They consisted of a 13-year-old girl who was sexually active and
may have been a sex worker, though speculation should be avoided, and a female sex worker in
from a neighboring country. These cases began in Lagos and Enugu respectively.

The Nigerian government was slow to respond to the cases, which allowed for the virus
to be transmitted rapidly and without restriction. Initial responses were aimed at halting the
disease at its “prime age” (Balogun, A) The Federal Ministry of Health (FMoH) formed the
National Experts Advisory Committee of AIDS (NEACA) in 1986 and utilized World Health
Organization (WHO) assistance in instituting HIV testing centers. WHO also aided in creating a
plan to minimize the spread of HIV/AIDS. In 1988 the National AIDS Control Program (NACP)
replaced the NEACA. But at this stage, general public sentiment was that AIDS was a gay
American disease. Some were even convinced that their African blood would protect them from
this “Oyinbo,” meaning white person, disease. This mindset facilitated the spread of HIV from
the Southern states up northward. (Balogun, A)

In 1991, the Ministry of Health rolled out its first National Sentinel Survey. It was found
that about 1.8% of the population was infected with HIV, and this number was on the rise. By
1993 prevalence was at 3.8%. (History) A year before, in 1992, President Ibrahim Babangida had
launched the National War Against AIDS (NWAA). Under the NWAA, The Federal Ministry of
Health’s Sexually Transmitted Infection Control Program was combined with the NACP to form
the National AIDS and STI Control Program (NASCP). A state-level equivalent was created and
called the SASCP. (Balogun, A)
 The predominant method of prevention in the earlier years of the HIV/AIDS response
was scare tactics. At this time, AIDS was a death sentence in most places, and the treatment
available for the more economically developed countries was oftentimes harsh and ineffective.
For those who were HIV positive, there was a reality that they likely only had a few more years
to live. Campaigns in the 1980’s featured symbols of crosses and skulls, as well as skeletons, to
instill fear in the public. However this strategy proved to be ineffective. Adoption of AIDS
education methods later on were able to show changes in behavior. The ABC model, standing for
Abstinence, Be faithful, and Condom use, encouraged safer sex. The model led the way for other
HIV/AIDS campaigns that were focused more on informing the public rather than scaring them.
(Balogun, A)

Epidemiological Trends and Key Populations

As previously mentioned, though the HIV/AIDS epidemic began in the Southern states of
Lagos and Enugu, Northern Nigeria developed cases at an accelerated rate. The Plateau State had
prevalence rates of 6.2%, 8.2%, and 11.0% in the respective time periods of 1991/1992,
1993/1994, and 1995/1996. Another Northern state, Benue, had a 16.8% rate in 1997 and a
13.5% prevalence in 2007. There were a few exceptions to the higher prevalence North, with the
Cross River State in the South having a prevalence of 12.8% in 2003. Between 1986 and 2007,
data also showed that prevalence in cities was rising, alongside a spread from urban areas to rural
regions. (Balogun, A)

The rapid spread of HIV/AIDS throughout Nigeria can be attributed to biological, socio-
cultural, socio-economic, and political factors. Biologically, an already high prevalence of
untreated STIs, a high prevalence of tuberculosis, and a lack of male circumcision among certain
groups have contributed to transmission. Certain cultural practices have been associated with the
spread of HIV through skin cutting and through patriarchal values that put women at a higher
risk. Traditions like tribal marking tattooing, blood-letting, and female circumcision have
associated risks of HIV transmission, especially when unsterile equipment is used. (Balogun, A)
In fact, in 2012, female genital mutilation (FGM) had a prevalence of 41%. This process has
globally been deemed dangerous and discriminatory towards women, yet, as of 2012 the Yoruba,
Hausa, Igbo, and Kanuri ethnic groups generally practice some form of FGM. (Okeke et al.) In
addition to this practice, some customs addressing the roles of females in society tend to expose
women to a higher risk of infection. Child marriages, polygamy, and sharing partners all increase
the spread of HIV. (Balogun, A) According to a 2013 Demographic and Health Survey, despite
rates of polygamous relationships declining over the past decade, 1 in 3 Nigerian women
reported their husband having multiple wives. (Polygamy) Levirate marriages, when men marry
their brother’s widow, are also factor in the dispersion of HIV. Unfortunately, the virgin
cleansing myth that has plagued other countries has also played a role in transmission of HIV.
Stemming from this, rapes and attacks on young girls have occurred, especially earlier on in the
epidemic. Often these girls contract STIs, further increasing their risk of HIV in the future. Due
to a weak economic system, high levels of poverty and unemployment exacerbate exposure, as
people have to turn to hazardous situations to pay for necessities in certain cases. Finally, the
weak reaction and lack of responsibility by the Nigerian government delayed potential support
for those at higher risk of contracting HIV in the first place. (Balogun, A)
 Disproportionately affected groups early on included female sex workers, men who have
sex with men (MSM), people who inject drugs (PWIDs), females aged 25-29, and children
(through mother-to child transmission). In Lagos, by 1993 15% of sex workers were HIV
positive. By 1996, this number more than doubled to 31%. Years later, female sex workers still
remained extremely high risk. For comparison, in 2012 while prevalence for the general
population aged 15 to 49 was about 4%, female sex workers in the country had a prevalence of
25%. Men who have sex with men had a high prevalence rate of 17.2% in 2010 despite their
knowledge of HIV prevention information at the time. Other data attributed this higher
prevalence to risky sexual behavior like alcohol use and having sex with multiple male partners
concurrently. People who inject drugs had a slightly higher prevalence than average, at 4.2% in
2010. But in female IPWIDs, there was a prevalence 7 times higher than in males PWIDs. Lower
condom use between MSM and PWIDs in comparison to sex workers has allowed for increased
transmission. Women generally suffered, and continue to suffer, from the patriarchal society
which allows for gender violence and harmful traditions to continue to impact them. 2014 World
Bank research showed that if a woman gives birth to a daughter first, she is likely to have more
children, experience polygamy, and is less likely to use for of contraception, all increasing
chances of getting HIV. Females aged 25-29 were likely to be subjected to these conditions, as
they were at a reproductive age. Their children would suffer too, due to the possibility of
transmission from mother to infant, a detrimental issue still extremely relevant in Nigeria today.
(Awofala & Ogundele)

History of Governmental and Non-governmental Policies and Programs

Following the failure of scare tactics in decreasing HIV transmission, a period of

education began. In 2000, the National Agency for the Control of AIDS (NACA) was
established. NACA began implementing multi-sectoral interventions in 2001 and was able to
create Nigeria’s first long-term strategic plan, called the HIV/AIDS Emergency Action Plan
(HEAP). The plan concerned 2001-2004, with a second plan called the National Strategic
Framework (NSF) following after. The National Ethics Board was created by NACA in 2001.
This allowed for the formation of National Ethics and Operational Guidelines for Research on
Human Subjects, which, although created specifically to address the AIDS epidemic, was
applied to all types of scientific research. It dictated how researchers and the press should report
on HIV/AIDS information, with aims of minimizing the spread of misinformation and harmful
stigma. Under these guidelines, terms like “AIDS patients” and “AIDS orphans” were replaced
with “people living with HIV/AIDS” (PLWHA) and “orphan and vulnerable children” (OVC).
NACA also adopted the principle of including PLWHA in their work, which they deemed crucial
to an ethical and competent response. In 2003, NACA, along with the Federal Government of
Nigeria, created the National Policy on HIV/AIDS, which updated and improved strategies for
the response. Adverse effects on national control of the epidemic due to stigma and
discrimination brought on the National Workplace Policy on HIV/AIDS. Created in-line with the
International Labor Organization’s (ILO) codes, social justice and equity were emphasized in all
workplaces.
 While the prevention of mother-to-child transmission of HIV was far from a priority
early on in the epidemic, by 2001 the federal government established the National Prevention of
Mother-to-Child Transmission (PMTCT) task team. The team began working in 8 sites across
the country in 2002. (Balogun, A) Yet significant barriers due to the presence of traditional birth
attendants (TBAs) have negatively impacted PMTCT. A 2010 study of TBAs in the Lagos State
showed that only 8.3% of TBAs had a proper knowledge of HIV and how to prevent
transmission between a mother and her infant. Even more frightening, 13% of these TBAs
claimed they could cure HIV with native remedies. (Balogun, M & Odeyemi) This type of
misinformation had the potential of impeding progress towards an HIV-free Nigeria. In more
recent times, a greater focus on ending PMTCT has helped to spread accurate information and
ensure more testing.

Despite these governmental programs and policies, the health sector received little help
for several years. External donors were depended on, and largely continue to be depended on,
especially in the area of antiretroviral (ARV) drugs. In fact, it took until 2001 for an
antiretroviral program to be introduced. Following this program’s implementation, access to
ARVs was nowhere near enough. High levels of poverty made it impossible for most people to
pay for transportation to the spread-out ARV centers and centers for testing. Additional issues
stemmed from certain civil society groups exaggerating on the epidemic to receive donations
which were misappropriated towards other uses. Thousands of these groups exist in Nigeria
today. Another issue that has damaged the effectiveness of the HIV/AIDS response in Nigeria
has been the persistent stigma that is still relevant today. Fear of discrimination means some HIV
positive individuals didn’t disclose their status, pursue treatment, or even get tested to learn of
their status. A lack of proactive responses to the earlier cases of HIV led to a full-blown
HIV/AIDS epidemic. (Balogun, A)

III. Current HIV/AIDS Epidemic

Prevalence

Current epidemic estimates show that HIV prevalence is 1.5% for the population between
the ages of 15 to 49. This roughly translates to 1,900,000 people of all ages living with AIDS.
Breaking down these figures, 140,000 are ages 0 to 14. This helps to illustrate the sheer number
of mother-to-child transmission cases unique to Nigeria’s epidemic. 7.3% of people living with
HIV are 14 and younger. Women continue to suffer from unsymmetrical prevalence. The most
recent estimates show that while there are 770,000 cases in men 15 and older, 1,000,000 women
15 and older live with HIV/AIDS. (Joint)

Incidence

Per every 1000 people in Nigeria, 0.65 were infected with HIV in 2018. For all ages, HIV
incidence was approximately 130,000. A significant proportion, 18.5% of new cases are in
children 0 to 14. With around 24,000 cases in these very young individuals, yet another example
of how MTCT is adversely affecting the population is shown. Successful prevention of mother-
to-child transmission will have a major impact on future generations. For women 15 and older,
there is again an unequal rate of new infection. Around 55,000 women contract HIV and 47,000
men 15 and older do. (Joint)

AIDS-related Deaths

In 2018, 53,000 people died of AIDS or related illnesses. Examining this statistic, 26.4%,
or 14,000 are in those aged 0 to 14. Another 14,000 come from women 15 and older.
Surprisingly, almost half (49%) of AIDS-related deaths are in men 15 and older. (Joint)

Trends in Overall Population

HIV/AIDS trends reveal a few successes and a few problematic results that will need to
be addressed by future programs and policies. Incidence is on the rise. Since 2010, there has
been a 5% rise in new cases of HIV. Though incidence rates have seen a slow decline since
2000, a small uptick in incidence between 2015 and 2018 is to fault for this rise. Data shows that
AIDS-related deaths have decreased by 26% between 2010 and 2018, which helps account for an
upwards trend prevalence, as some people living with HIV/AIDS are surviving longer. This
could, in part, be attributed to an increase in individuals using antiretroviral therapy (ART) in the
country, which has risen from 22% in 2010 to 53% in 2018. By 2019, Nigeria had tripled the
number of people on HIV treatment in comparison to 2010 figures. The incidence to prevalence
ratio has remained steadily declining. In 2000 it was at about 12%, however in 2018 it hit 7%,
emphasizing the increased life expectancy of many PLWHA, and semi-successful efforts over
the last 2 decades to lower the amount of new infections. Between 2013 and 2016, the percentage
of people aged 15 to 49 reporting discriminatory behavior towards PLWHA rose from 46.8% to
52.8% which is concerning, as stigma can be a major barrier to testing and treatment. (Nigeria
[unaids.org])

Trends in Key Populations

Men who have sex with men are the only key population in Nigeria that has not seen a
decline in prevalence. Between 2011 and 2015, prevalence rose from 17.2% to 23%. (The Key)
In 2019, the prevalence still remained at 23%. This statistic likely correlates to a homophobic
governmental system that has done little to help alleviate the HIV epidemic in this community.
In fact, in 2014 due to President Goodluck Jonathan signature of the Same Sex marriage
Prohibition Act, the punishment for being (or being accused of being) homosexual was increased
to 14 years imprisonment. Even people assisting homosexuals could be placed in jail for 10
years. Though the NACA claims that “no provision of this law will deny anybody in Nigeria
access to HIV treatment and other medical services,” mass arrests of anyone suspected to be gay
and widespread stigma are correlated with a higher HIV prevalence in this group. Disclosing
one’s sexual orientation could lead to more than a decade of jail time, so many homosexual
individuals are too afraid to seek healthcare. Additionally, the homophobia within the country
means that intervention efforts are rarely targeted at this community. In 2010, only 18% of MSM
were reached with HIV prevention programming. (HIV and AIDS) UNAIDS reported that in
2018 only 51% of MSM used condoms. Without safe and targeted interventions for the roughly
26,000 reported MSM in this key population, they may continue to see a high prevalence of HIV
cases in the future. (Nigeria [unaids.org])
 Sex workers have seen a significant decline in prevalence in recent years. For the group
of about 103,500, prevalence dropped from 24.5% in 2013 to 14.4% in 2018. (HIV and AIDS)
(Nigeria [unaids.org]) However, this percentage is still 8 times higher than the general
population, so efforts need to continue on. Prevalence is again dependent on gender. Female sex
workers suffer from a higher prevalence, being 24.5% in 2015 compared to 18.6% for men in the
same year. (HIV and AIDS) Sex workers do tend to have extremely high rates of condom use,
which has helped their HIV epidemic to slow. Between 2011 and 2015, condom use rose from
88.6% to 98.1%. (The Key) Yet, because sex work is illegal and being caught could entail 2
years in prison, sex workers can experience difficulties in receiving healthcare. They also tend to
fall victim to abuse by members of law enforcement. A 2017 quote from the National
Coordinator of Nigerian Sex Workers Association emphasizes this. Amaka Enemo said, “When a
sex worker’s hideout is raided, the law enforcers collect money from them and when there is no
money to offer, they offer them sex. Some of these law enforcers don’t even use condoms and
the sex worker don’t have much of a choice at that particular time.” (HIV and AIDS) This
horrifying statement illustrates another factor that plays into elevated HIV prevalence. Being
assaulted by a police officer for being a sex worker and then turning to a medical professional
where one could potentially again be outed as a sex worker and punished certainly justifies the
decision to not access healthcare.

For the estimated 44,500 individuals who inject drugs, a decline in prevalence has been
noted in the past decade. Between 2011 and 2015 prevalence dropped from 4.2% to 3.4%. (The
Key) For women drug injectors, the prevalence in 2017 was 13.9% compared to the dramatically
smaller 2.6% in men. For female sex workers who inject drugs, the 2017 prevalence was a
remarkable 43% in 2017. Though harm reduction services like needle exchanges are unavailable
in Nigeria, NACA and the UN Office on Drug and Crime began working on a plan to target
PWID in 2015. (HIV and AIDS) As of 2018, 70.9% used safe injecting practices and 83.2% used
condoms, helping to lower potential exposures to the virus.

The prevention of mother-to-child transmission has been an important target of recent

policy. The percentage of pregnant women with HIV accessing ART has risen from 27% in 2010
to 44% in 2018. Additionally, early infant diagnosis, meaning in the first 8 weeks of birth, has
risen from 9.7% in 2010 to 18.1% in 2018. In that year, 7,200 potential HIV infections were
averted. This data is promising, but much more is still needed to be done. ART treatment
coverage decreased from 63% to 44% between 2014 and 2018. At the same time, pregnant
women on ART also decreased from 60,000 to 44,000. (Joint) In 2017, 220,000 children aged 0-
14 years old were living with HIV but only 26% were receiving ART. UNAIDS created a Catch-
Up Plan for West and Central Africa which outlines their goal of enrolling an additional 140,000
children in the region on ART by the end of 2020. (HIV and AIDS) Because Nigeria held 41%
of the region’s HIV positive children in 2018, this plan could have a powerful positive impact on
the country. (Joint)

Additional Context

Gender has historically and today continues to play a major role in the way the
HIV/AIDS epidemic has played out in Nigeria. The World Economic Forum’s 2017 survey
ranked Nigeria 122nd out of 144 in gender equality. A massive gender gap has formed power
imbalances that all contribute in putting women at a higher risk of contracting HIV. Women have
little ability to choose their sexual partners, demand the use of a condom during a sexual
encounter, determine how many children they want to have, and receive their own healthcare.
Additionally, women who have been previously married are at and even higher of HIV, which
was as high as 5.9% in 2016, due to sexual exploitation and a lack of opportunities for economic
advancement. In 2015, NACA developed a set of guidelines to involve gender in the standard
HIV response. However, other strategies towards gender equality in the HIV response have been
notoriously underfunded, so the impact of these guidelines has been questionable. With women
disproportionately affected by HIV, the lives of infants, children, and adolescents have also felt
adverse effects. (HIV and AIDS) Nigeria is the only country in the world where mortality rates
in adolescents aged 10 to 14 is still rising. This is just one statistic that shows the poor health of
younger generations in Nigeria, which is especially threatening when considering the young
person-heavy age structure. A 2016 National HIV Strategy for Adolescents and Young People
recognizes the difficulties surrounding young people being sexually active, including lack of
access to youth-friendly services, lack of education, and intense stigma, yet in 2017 on 29.3
percent of girls and young women and 27.9% of boys and young men knew of appropriate
prevention measures for HIV. (HIV and AIDS) (Joint) Intersectionality comes into play with the
normalization of intergenerational relationships. In 2017, 41.2% of girls and young women aged
15-25 had a sexual partner who was 10 or more years older than them. This is risky, as an older
partner could expose the younger one to unsafe sexual behaviors and HIV that the older partner
has already contracted. For younger children living with a parent who is living with HIV/AIDS,
there are the added concerns of taking care of their parent. While young boys usually are able to
continue attending school, girls often have to take the responsibility of staying home as a
caretaker. Though Family Life and HIV Education (LLHE) education in schools since 2015 has
been teaching about important HIV prevention measures, these girls miss out on receiving the
information, which can put them at a higher risk of HIV infection in the future. When a parent or
both parents dies of AIDS, orphaned and vulnerable children (OVCs) suffer. About 20% stop
attending school regularly, again missing out on LLHE learning, and around 18% are sexually
abused. In 2017, an estimated 1.8 million children were orphaned by AIDS. Health, wellbeing,
and safety become sacrificed oftentimes in these situations. (HIV and AIDS)

IV. Control Efforts

Current Governmental and Non-governmental Policies and Programs

Many governmental and non-government programs have been implemented to address

the crisis. In 2016, a test and treat policy was adopted by the Nigerian government. This policy
had the intended purpose of providing early treatment to HIV positive individuals, regardless of
their CD4 count. (Nigeria adapts) The policy is not currently able to achieve its full aims but has
made some progress.

A year later, the 2017 National Strategic Framework (NSF), created by NACA, outlined
key goals for its next 5 years. By 2021, the NSF aims to provide 90% of the general public with
HIV prevention interventions and aims for 90% of key populations to adopt risk reduction
behaviors (Balogun, A)
 In 2019, following the results from that year’s Nigeria National HV/AIDS Indicator and
Impact Survey (NAIIS), the country adopted a Revised National HIV and AIDS Strategic
Framework lasting from 2019 to 2021 to steer future responses to HIV. (Nigeria adapts) The
NAIIS, conducted with the assistance of the U.S. President’s Emergency Plan for AIDS Relief
(PEPFAR) and the University of Maryland School of Medicine, this survey appears to be reliable
due to its comprehensive structure and its almost 100,000 respondents. (Large) The Strategic
Framework allowed for a population-location approach to service distribution. Areas with the
most need for services would have a greater amount of services than those with less of a need.
While this plan was being presented, the UNAIDS Executive Director Michel Sidibé visited
Nigeria. He signed a cooperation agreement that reinforced UNAIDS’s relationship with the
Nigerian government. Also while in the country, Sidibé appointed first lady Aisha Buhari to the
position of UNAIDS Special Ambassador for the Elimination of Mother-to-Child Transmission
of HIV and the Promotion of Treatment for Children Living with HIV in Nigeria. During this
trip, Sidibé was also able to meet with the national coordinator of the Network of People Living
with HIV/AIDS in Nigeria. Coordinator Abdulkadir Ibrahim asked for UNAIDS support in
ensuring that the national response would be include PLWHA, especially younger individuals
living with HIV/AIDS, so they could help design policies and programs for their own wellbeing.
(Nigeria adapts)

Substantial aid from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)
program has helped Nigeria manage their epidemic. Nigeria currently has the 3rd largest
PEPFAR program and has received more than 4 billion U.S. dollars in relief since 2004. One of
the branches of the PEPFAR response, the CDC-Nigeria, has been working closely with the
Nigerian FMoH, to internally strengthen Nigeria’s laboratories, disease surveillance, and
monitoring systems. The ultimate goal is for Nigeria to independently run their own sustainable
programs to combat HIV/AIDS. With CDC-Nigeria’s help, they are working to scale up testing
and treatment, developed customized prevention plans for key populations, aid PMTCT efforts,
and transition HIV/AIDS treatment programs towards long-tern management under the Nigerian
government. (HIV/AIDS) Possible budget cuts to PEPFAR under Donald Trump could be
detrimental to PEPFAR-based responses in Nigeria.

APIN Public Health Initiatives, a non-government organization (NGO), created in 2007

is a direct implementing partner of the CDC. Since inception, the NGO has worked with the
federal government to provide ART to more that 250,000 people in Nigeria in more than 570
treatment sites across 8 states. Their services account for 25% of the patients currently on
antiretroviral therapy in Nigeria. Additionally, as they have a strong focus in evidence-based
prevention, they have stat-of-the-art labs that have the capabilities of monitoring CD4 levels,
DNA PCR levels, and drug resistance monitoring (DRM). (About Us)

The AIDS Healthcare Foundation (AHF) began work in Nigeria in 2011. They operate in
65 clinics in 6 states currently but hope to expand to an additional 80 clinics under the Nigerian
government’s Fast Track Initiative, which aims to get 100,000 more Nigerians on ARV
treatment. To date, they have conducted more than 2 million HIV tests and distributed more than
8 million condoms. The services they offer include ART, counseling, STI diagnosis, diagnosis of
opportunistic infections, and training for healthcare workers. In the states of Abuja and Benue,
AHF has Wellness Hubs that focus on youth, adolescent, and women’s health. (Nigeria
[aidshealth.org])

Health System

The current healthcare system in Nigeria has been notoriously weak, thus failing millions
of people. The country still follows its 2004 National Health Insurance Scheme, which is said to
ensure easy access to healthcare and universal health coverage (UHC) but falls extremely short
of its promises. (About Company) In 2015, less than 5% of Nigerians had healthcare coverage.
(Awosusi et al.) To make matters worse, the majority of those that do have healthcare are
employees of the federal government or their dependents. (Aregbeshola) Equitable access to
healthcare has not been achieved and likely will not be achieved until policy makers commit to
it, according to the Director General of the WHO, Dr. Tedros Adhanom Ghebreyesus. The
scheme is poorly led, poorly planned out, and poorly structured, translating to difficulties in
achieving this universal healthcare coverage by 2030, a goal for the country. In 2018, the
National Health Account revealed that only a sliver of government expenditure, 5.3%, has been
spent on health, leading to many out-of-pocket costs for individuals who have limited ability to
pay for health services. (Aregbeshola)

Treatment Access and Prevalence

Access to treatment has improved but still has a long way to go to meet the needs of
everyone in this incredibly large HIV/AIDS epidemic. In the 2017 financial year, 7.7 million
Nigerians received HIV counseling and testing services, according to PEPFAR figures. Of these
7.7 million, 1.6 million were pregnant women hoping to prevent MTCT. Also in this year 1.1
million orphans and other vulnerable children received services aimed at their care. However
statistics like these, and the statistic that an estimated 772,000 children, women, and men are
currently on HIV treatment, don’t account for the extensive numbers of people will no access to
these types of treatment (PEPFAR) Also in 2017, 33% of PLWHA were receiving ART. Even
smaller, only 26% of children living with HIV were receiving ART. (HIV and AIDS) In 2019,
the percentage of PLWHA on ART was at 53%. (Nigeria 90-90-90) This shows progress, yet it is
still imperative that this number grows. Of those on treatment in 2016, only 24% had achieved
viral suppression. Despite the enrollment of 212,000 more people on ART between 2016 and
early 2017, the aforementioned test and treat policy is nowhere near an actuality. (HIV and
AIDS)

Although there are areas where ART can be accessed, supplies are known to run out.
Because of this, NACA has put enhancing supply chains and distribution in high regard. ART is
technically free, however added-on fees can get in the way between a person living with
HIV/AIDS and proper treatment. UNAIDS plans to help remove these fees in the future, which
would dramatically increase access for some, but additional barriers including high travel costs
to properly equipped facilities could still cause issues. (HIV and AIDS) A 2019 study showed
that stigma in Nigeria presently remains moderately high according to 77.2% of PLWHA, which
will remain to be a key player in certain PLWHA receiving treatment. (Oke et al.) Unique
circumstances in the Borno State have put strains on access to antiretroviral therapy. Especially
between 2013 and 2016, Boko Haram uprisings led to an 18% fall in ART coverage. (HIV and
AIDS)

Prevention Policies and Strategies

HIV prevention programs recently have targeted condom use, access to PrEP, HIV
education, and PMTCT. 2017 data showed that 57.6% of men between age 15-49 reported using
condom last time they had sex. In comparison, only 39.8% of women had, which could be
attributed to socio-cultural determinants, like a male-dominant society. Barriers such as cost, low
availability, and the rejection of condoms by certain religious groups have blocked progress. Pre-
exposure Prophylaxis (PrEP) is currently unavailable for the general public, yet small studies
gave 242 people access to the medicine in 2016. HIV education was first infused in school
curriculums in 2015. Family Life and HIV Education (LLHE) is in place today. Lessons about
transmission and prevention of HIV, as well as issues of gender violence and stigma are subjects
covered. (HIV and AIDS)

As of 2019, national HIV policies lave laid the groundwork for future progress towards
the end of the HIV/AIDS epidemic. HIV self-testing is approved in Nigeria, and is generally
available in hospitals, pharmacies, counselling and testing centers, and through community
distributors. The test is simple to use and comes with visual instructions to clearly show what
steps the user should take. (HIV self-testing) Treatment of all PLWHA, including children,
regardless of CD4 count has been implemented countrywide, potentially preventing the further
transmission of HIV drastically.

In the Revised National HIV and AIDS Strategic Framework, prevention strategies to
address the different epidemics within the general population, as well as key populations, are
defined to guide the next steps for NACA. For the general public, subsidized and completely free
condoms and lubricants are planned on being distributed based on socio-economic
considerations. Commercial and social marketing campaigns to encourage condom use will be
created. Provider initiated testing and more access to self-testing materials are also part of the
plan. Additionally, the diagnosis and treatment of STIs, as well as sexual health interventions
will be scaled up. In key populations, finding ways to provide services without intense
discrimination or stigma is a goal of NACA. To prevent MTCT, increased education for pregnant
women, along with early infant diagnosis are planned. Assuring that health facilities have
comprehensive services is another element of the Framework which will make it simpler for
individuals, especially those in key populations to get the support they need in a straightforward
way. For PWID, harm reduction interventions like needle and syringe programs and opioid
substitution therapy is another key target. The expansion of PrEP to male sex workers and their
clients as well as community mobilization efforts are important in the HIV response. If these
prevention strategies are able to be effectively implemented into communities at high levels, the
epidemic could slow significantly. (Revised)

V. Status of 90-90-90 Goals

Status of 90-90-90 Goals

 While the NAIIS survey has helped immensely in understanding the HIV/AIDS epidemic
in Nigeria, the initial delayed and ineffective response has set the country behind many other in
controlling their respective epidemics. Created by UNAIDS, the 90-90-90 targets are challenging
but attainable targets that anticipate an HIV- and AIDS-free world in the future. The first 90 in
the 90-90-90 model represents targets of 90% of people living with HIV being aware of their
status. The second is that 90% of the people diagnosed with HIV are on treatment. The final 90 is
people on treatment who a virally suppressed. While the 90-90-90 goals were originally
scheduled to be completed in 2020, it is more realistic for some countries to achieve these goals
by 2030. According to the most recent estimates, from 2019, 67% of people are aware of their
HIV status. 53% of PLWHA are being treated for their HIV. Of the 53%, 42% have achieved
viral suppression. To close the first 90-90-90 target, 448,000 more people would need to learn of
their status. To close the first and second gap, an 530,000 more people would need to be on
treatment. To close all three gaps, 583,000 would need to be virally suppressed. (Joint)

Plans for Achieving 90-90-90 Goals

Clearly outlined in the Revised National HIV and AIDS Strategic Framework,
interventions specific to each of the 90-90-90 goals are listed. The first target, enabling 90% of
PLWHA to know their status, has many strategic interventions aimed at scaling up testing.
Provider Initiated Testing and Counseling (PITC) in high prevalence settings and in cases such
as TB and STIs is one method to meeting this goal. Community-based testing strategies,
including the use of self-testing are deemed necessary in high prevalence communities with
underserved populations. In fact, creating partnerships with businesses to commercialize low-
cost test kits is also included. Another tactic of scaling up youth involvement to increase testing
especially in younger people is listed. Improvements in encouraging testing, offering greater
access to testing, and involving the economic sector have the potentially of dramatically shifting
towards the first 90 if properly implemented. (Revised)

To reach the second 90, assuring that the test and treaty policy could actually treat all
PLWHA, no matter their viral load is a major concern. Developing effective but cheaper ART,
possibly through relationships with the private sector is included on the list. Adopting World
Health Organization (WHO) strategies to monitor drug resistance will ideally allow for most
PLWHA to stick to the most effective first-line treatments rather than back-up options. Also,
there is a focus on scaling-up models to ensure adherence to treatment regimes, which helps in
preventing drug resistance. To address socio-cultural factors that can traditionally be barriers to
receiving treatment, the Framework mentions integrating cultural elements like religious
organizations and traditional birth attendants (TBAs) into the formal health responses. Finally,
addressing the additional costs associated with receiving treatment, like user fees will eliminate
select affordability barriers to getting PLWHA on treatment. (Revised)

In reaching the final 90, structural changes to managing and recording systems of viral
load are imperative. The development of stronger electronic record systems to help manage
patients and help communicate their results in a timely manner, when necessary will insure
progress towards the third 90. In remote communities, the Framework plans on scaling up dried
blood spot specimen testing. Strategies to encourage follow- up appointments and promote
adherence to treatment will also aid in achieving 90% viral suppression in those on ART,
according to NACA, PEPFAR, and the University of Maryland School of Medicine analysis.
(Revised)

VI. Progress and Recommendations to Meeting 90-90-90 Goals

Though the Revised National HIV and AIDS Strategic Framework has high goals in
ending the HIV/AIDS epidemic, these targets may be too lofty to reach in the next 10 years,
especially considering Nigeria’s lack of progress in many areas up until very recently. Despite
President Buhari’s bold proclamation that, “For the first time, the end of AIDS as a public health
threat by 2030 is truly in sight for our country,” (UNAIDS) The reality is that significant barriers
need to be surmounted for this ambitious result. Issues of gender inequality, the criminalization
of homosexuality, funding, and a weak health system have played a major role in diminishing
Nigeria’s HIV/AIDS response.

Due to the huge gap in gender equality women suffer from less economic opportunities,
educational opportunities, and decision-making opportunities. (Gender) Forced to be extremely
submissive in many aspects of their lives, women unfortunately are exposed to more areas for
HIV transmission. In Nigeria, women make 77 cents for every dollar that a man makes. (Goal)
Considering that in 2017 70% of the Nigeria population live in poverty, these 77 cents per every
man’s dollar play and even larger role than would be expected. (The World) In 2017, Nigeria had
the most girls out of school in comparison to any other nation on the globe. (UNICEF) When
girls miss out on LLHE lessons offered in some schools, they don’t hear as much about the HIV
epidemic and tools for prevention. They also miss out on information regarding gender violence
and stigma. This effectively oppresses young women and places them at a higher risk for
contraction of HIV and other STIs. Finally, women, due to a lack of empowerment, are generally
unable to make their own choices in regard to important life events and daily life situations. Of
the Nigerian female population alive today, about 750 million were married before turning 18.
(Goal) While the risk of HIV transmission is increased when a young woman marries an older
man out of her age group, this effect is amplified in cases of polygamy. It is viewed as acceptable
for men to have multiple wives, and concurrent sexual partners mean more chances and more
vulnerable people for the spread of HIV. As women are for the most part hit harder by the
HIV/AIDS epidemic in Nigeria, achieving equality will be crucial to fighting off this illness.
Despite the acknowledgement of gender inequality in the Revised National HIV and AIDS
Strategic Framework, NACA does little to address how this will be combatted other than saying
they will align with the pre-established Guidelines for Gender Mainstreaming in the National
HIV/AIDS Response and Training Manual for Capacity Building for Gender Mainstreaming in
the National HIV/AIDS Response and run unspecific gender-sensitive programming. (Revised)
Created in 2015, the guidelines haven’t contributed drastically to any sort of women’s rights, so
adopting them may not alleviate any issues for women living with HIV/AIDS at all. (National)

The criminalization of homosexuality in Nigeria is another huge area of concern when

anticipating 90-90-90 goals. Little, both historically and currently, has been done to address
extremely high rates of prevalence in men who have sex with men. Without approaching topics
of decriminalization or other legal methods, it is likely that many MSM will remain fearful of
seeking treatment, for risk of being outed and possibly imprisoned. While the Framework aims
for access to treatment for all, with hopes of eliminating stigma that could get in the way of
attaining help, national laws as well as rampant homophobia emphasize that these populations
are not priorities. If Nigeria actually aims for 90-90-90 by 2030 and an end to the epidemic in the
near future, the Same Sex Marriage Prohibition Act would need to be repealed.

95% of funding for the end to the Nigerian HIV epidemic has come from external donors
like PEPFAR and the Global Fund. (Revised) Though internal government budget allocations
towards the HIV response have risen recently, proposed cuts to PEPFAR and the Global Fund by
1.35 billion and 392 million dollars respectively could hurt Nigeria, as most of their major
successes have been made through the support of these groups. (Herrick) The Revised National
HIV and AIDS Strategic Framework includes multiple methods of increasing funding and better
utilizing funding, yet these hits may create an insurmountable barrier towards widespread testing
and treatment access. The expansion of antiretroviral production into local sectors could cut costs
considerably, especially as treatment costs currently make up about 60% of funding
requirements, but financial insecurity could continue to plague response efforts. (Revised)

The incredibly poor healthcare system that promises universal healthcare coverage but
fell remarkably short at less than 5% in 2015 will not be sufficient in securing 90-90-90 targets
by 2030. The Revised National HIV and AIDS Strategic Framework recognizes the failure of the
current health system but provides no concrete solution. A small blurb that concludes with a few
general modifications for the system is all that is done to address the topic. The strengthening of
“Leadership and Governance; Human Resource for Health; Health Financing; Service Delivery;
Medical products, Vaccines and Technologies and Health Information System” (Revised) are
mentioned, but not strategy as to how to do this is included. A major overhaul of the healthcare
system is required, yet from the Framework it appears as though NACA doesn’t have to slightest
clue in actually achieving this.

The NAIIS and resulting Revised National HIV and AIDS Strategic Framework have
greatly redefined the course of action for HIV prevention and intervention, yet improbable aims,
exasperated by considerable barriers, such as gender disparities, homophobia and stigma, an
uncertain future of financing, and inadequate healthcare coverage. Progress is certain further
along than it was a decade ago, but until these failures of the system are addressed, likely taking
substantial additional effort in governmental, economical, and social sectors, Nigeria’s 90-90-90
goals may not be achievable.

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