Many worries for persons living with HIV in Nigeria

Today is World AIDS Day, the day stakeholders adopted to raise awareness about HIV and AIDS, an epidemic that has killed millions of people across the world. Chukwuma Muanya, Assistant Editor, Writes that Nigeria government and other stakeholders need to step up action to end the epidemic.

Stella Wegba is 35 years old. She is married with five children. Her husband, Terwase, is dead. He died six months ago after a protracted illness. He was a long-distance driver. Stella was diagnosed with Human Immuno-deficiency Virus (HIV) that causes Acquired Immune Deficiency Syndrome (AIDS) two months ago after coming down with fever, diarrhea, oral thrush and skin rashes.

Three of Stella’s children age 4, 3 and 1 also tested positive to the virus. Stella, a cleaner at a local school, has also lost her job after being absent from work for long period due to illness. She now has no means of livelihood. Stella was also sent away from her husband’s house by his relatives who accused her of killing her husband, their brother. The lives of the children who are HIV positive are also threatened because of scarcity of paediatric HIV drugs in free treatment centres.

Bassey Etuk is 44 years old. Bassey, a bricklayer has been living with HIV for nine years. Bassey is married to Eno, 34, with three children. The children are all HIV negative because the couple is one of the beneficiaries of the free Prevention of Mother To Child Transmission (PMTCT) programme and Anti Retroviral (ARV) treatment of the federal government.

Our treatment sites now are becoming glorified prescription and dispensing centers where critical and core clinical care is fast disappearing. The quality of care to PLWHAN in most treatment centers is at its lowest ebb and worst of it is that clients are now made to pay for services.

But since this year, Bassey and Eno are being made to pay for drugs, consultation, drugs pick-up, screening of CD4 count (a marker for the immune system) and other baseline tests. The treatments are no longer free.

Umoru… has been living with HIV for more than 15 years.

Ibrahim Umoru, now in his fifties, has been living with HIV for over fifteen years. Umoru is one of the first Nigerians to make their HIV status public. Umoru is also a member, Community Delegation to the Board of Global Fund, Country Coordinating Mechanism (CCM) Nigeria to Global Fund, and Stop TB Partnership Nigeria.

Umoru in an exclusive interview with The Guardian ahead of the World AIDS Day said: “Having lived with this virus for over a decade and half and coming from an era when testing positive to HIV was a death sentence to when it has become a chronic manageable disease with people living healthier, longer and productive life, it now hurts deeply to see Nigeria as a country gradually loosing the gains made in the response to HIV as Person Living With HIV/AIDS in Nigeria (PLWHAN) now become more apprehensive of what tomorrow holds.

“Our treatment sites now are becoming glorified prescription and dispensing centres where critical and core clinical care is fast disappearing. The quality of care to PLWHAN in most treatment centres is at its lowest ebb and worst of it is that clients are now made to pay for services.

“As we discuss, many PLWHAN in Nigeria now pay for their laboratory monitoring, and for consultations in the United States President’s Emergency Preparedness Fund for AIDS Relief (PEPFAR) supported treatment sites. This is causing many to miss appointment and proper follow up. On the long run, we would have a deluge of people failing treatment and requiring second line treatment. Second line treatment is about 10 times or more expensive than the first line our poor system is messing up now. What is there to celebrate when the system in all sense is pushing many of my peers to their early graves?
“The whole scenario is made worst as the government of Nigeria, which has this high HIV burden with over three million of her citizens living with HIV contributes a paltry five per cent while Global Fund contributes 20 per cent and PEPFAR partners contribute 75 per cent to the national response to HIV. This is not a good level of responsibility for the government of Nigeria to be left at the bus stop watching the vehicle of the national response driven away by donors and also drifting our response away.”

Stella, Bassey and Ibrahim are three of the estimated 778,000 PLWHAN on Anti Retroviral; Therapy (ART) in the country.
Globally, it is estimated that there are about 34 million people living with HIV and Nigeria alone accounts for about 10 per cent of this global population with 3.5 million PLWHAN. As at 2014, there were 1,544,069 eligible for ART while only 747, 382 were on ART, which amounts to 48 per cent achievement.
In the same vein, it is projected that by the end of 2015, 2,345,303 would require ART thus at the present coverage there would be a treatment gap of 68 per cent.

However, the number of people on ART in 2015 has increased to 778,000, while the eligible people are about 1.5 million. Currently, the World Health Organization (WHO) has issued a guideline on treatment. The guideline has specifically stated that everybody living with HIV from the point of diagnosis should be tested and treated.

When former President Olusegun Obasanjo, in 2006, declared free comprehensive HIV care for 250,000 Nigerians, the largest rollout in Africa, all PLWHAN could not hold their joy. This policy came with free laboratory monitoring with viral loads test at many centers. ART drugs were made available at no cost, there was nothing like consultation fees and there was a large chunk of drugs for management of opportunistic infections coupled with robust clinical care from competent and willing healthcare workers. Nigeria was progressively increasing treatment centers as well as increasing ART coverage.

The HIV/AIDS Anti-Discrimination Act 2014 makes it illegal to discriminate against people based on their HIV status. It also prohibits any employer, individual or organization from requiring a person to take an HIV test as a precondition for employment or access to services. It is hoped that the new law will create a more supportive environment, allowing people living with HIV to carry on their lives as normally as possible.

Three million Nigerians are estimated to be living with HIV, with 750,000 on treatment.

Also, Nigeria in August 2010 signed a memorandum of understanding with the United States (US) government called the PEPFAR Partnership Framework promising to support the US government in her response to HIV epidemic in Nigeria with 50 per cent of the cost by 2015.

However, The Guardian investigation revealed that as at 2014, Nigeria has only met about 15 per cent of this which led to the PEPFAR team to reduce their funding support to the national response and the worst hit of the programme is the laboratory monitoring back up for HIV response.

The Guardian investigation also revealed that there are lots of challenges facing people living with HIV in the country. These include: lack of access to ART; and people living with HIV were made to start paying for drugs, consultation, drugs pick-up, screening of CD4 count and other baseline tests; shrinking donor funding and low domestic input; and continued discrimination against PLWHAN despite the fact that a law has been passed against stigmatization.
Persons with HIV protest

National Coordinator for Network of People Living with HIV/AIDS in Nigeria (NEPWHAN), Victor Olaore Omoshehin, told journalists: “… Another challenge facing us in the country is that in 2015, people living with HIV were made to start paying for drugs, consultation, drugs pick-up, screening of CD4 count and other baseline tests… Right now in 2015, people living with HIV have been charged. I can give you specific examples: Federal Medical Centre, Owerri, Imo State, Nigerian Institute of Medical Research (NIMR), in Lagos. They’ve been charging people to start paying for consultations and all series of tests. All of these are barriers that hinder people from accessing treatment.

Then, the dwindling funding. We know that a lot international donors are cutting their costs, including the United States (US) government. With all of that, we do not know where our fate lies; especially when it is a statement of fact that over 75 percent of the cost for treatment, prevention, care and support for HIV, malaria and tuberculosis, is being sponsored by international donors. So, what is Nigerian government going to do to salvage the situation? It means that our lives are hanging.
“Also, even though a law has been passed on discrimination, people still get stigmatized in the work place. People still do not get employed even though they are best candidates because the virus lives in their blood stream.”

World AIDS Day is held every December 1 since it was first held in 1988. It is a unique opportunity for the entire global population to unite in the fight against HIV, show their support for people living with HIV and to commemorate people who have died.
“For me, World AIDS Day means more than these facts stated above. Rather, there is an additional task of taking stock of what has been on ground; how has been my country and global response; what are the gaps and what should have been done better or not even done,” Umoru said.
Challenges and gaps

Director-General, National Agency for the Control of AIDS (NACA), John Idoko, has identified major challenges facing the HIV response as: Inadequate domestic funding in the face of declining support from donors; inadequate capacity (human and infrastructure) to effectively provide prevention, treatment and care programmes; poor health seeking habit among the rural population, particularly Ante Natal Care (ANC) attendance and delivery of pregnant women in health facilities; pockets of insecurity in some parts of the country which disrupts service delivery, commodity supply and overall coordination of interventions and programmes; and poor health workers attitude to PLWHAN, stigma and discrimination to HIV and Tuberculosis.

Former President, Goodluck Jonathan, had in February 2015 signed a new antidiscrimination bill into law that protects the rights and dignity of people living with HIV.

The HIV/AIDS Anti-Discrimination Act 2014 makes it illegal to discriminate against people based on their HIV status. It also prohibits any employer, individual or organization from requiring a person to take an HIV test as a precondition for employment or access to services.

It is hoped that the new law will create a more supportive environment, allowing people living with HIV to carry on their lives as normally as possible.

Omoshehin said: “In most of the facilities now, before you do your drug pick up, you pay like N1000. Remember, that drug has been paid for by the donor organizations. So, we don’t know why they are charging us this kind of fee. And, some people are just there to defraud the patients’ community.
They are not there to sympathize with the individual clients. They want to use the opportunity to defraud. Nigerian Institute of Medical Research, Lagos; Federal Medical Centre, Owerri, Imo State; Federal Medical Centre, Benin, Edo state are culprits. Each month you come to do drug pick-up, you pay N1000. When you come to do your consultation, you also pay a minimum of N3000. This is uncalled for.

These doctors have their salaries budgeted for by the government. Why should the patients be made to pay for consultation to see a doctor as if we were going to a private hospital? We also pay for CD4 counts and other baseline screenings. These are things the donors have budgeted for. They have provided the machines, the equipment for all of these facilities. We assume that is a bad situation and it will worsen the condition of HIV patients in the country.

He further stated: “Right now, HIV is becoming a death sentence with all of these barriers, challenges. In fact, they are killing a lot of people. And, with some policies that are not favorable to the patients’ community like that of the decision of Imo State governor to privatize the public health sector, it is becoming a death sentence.

This is because people will drop dead on a daily basis, if they cannot have free access to comprehensive treatment and care support services. It was in some ten years past, and maybe up till last year that we would say HIV was not a death sentence. But right now, it is becoming a death sentence if all of these barriers are not eliminated. To an individual, if you continue to have access to care, support and treatment, of course, you will live long. ARV will prolong your life, and you can be economically productive.”
Recommendations

To end HIV/AIDS in Nigeria by 2030, Idoko recommended among other things: increased domestic funding to achieve a fully funded AIDS response at all levels; fully operationalize 90-90-90 strategy to eliminate progression to AIDS, premature deaths and HIV transmission; ensure prevention for all populations; expand HIV Counseling and Testing (HCT), ART and PMTCT services; pursue a policy of local manufacture of essential commodities (antiretroviral drugs, test kits and condoms); and address barriers to access to HIV and AIDS prevention and treatment services.

The NACA boss said ending AIDS in Nigeria is possible by achieving universal access already by 2020 (front loading) which means: 80 per cent coverage for all key interventions; 81 per cent coverage for ART; 95 per cent PMTCT coverage; 90 per cent pediatric ART coverage; and sustaining these coverage rates until 2030.

Umoru said: “It is strongly recommended that treatment of HIV should be free, comprehensive, qualitative and accessible to all over the country. This way we would begin the regaining of already lost grounds and consolidating grounds still held. In working towards this, our government should take greater responsibility and lead the entire process. Health funding should be given priority. We all need to prove to the world that testing positive to HIV is not a death sentence.”

Omoshehin recommended: “The agenda of the new administration is to ensure that we are able to engage the government and private companies more to mobilize resources for domestic funding. We have a plan to launch Patient Trust Fund by December, which will be used as an opportunity to raise fund domestically to take care of the gaps and needs of the people living with HIV in the country, especially in the areas of income generating activities and empowerment, skills acquisition/training and empowerment.
“We know a lot of donors are concentrating their efforts in ensuring there is access to treatment. But, of course, we know that in the long run, sustainability is the major challenge for all interventions. There is a closing date for all human activities. If the patients’ community is empowered, if the patients have source of income, no matter what the challenges are, they will be able to stand on their own treatment plan, especially now that we are thinking of National Health Insurance Scheme to cover the people living with HIV.”