‘No Nigerian child should be born with HIV’

• Inadequate domestic funding, insecurity, poor health workers attitude, stigmatization threaten elimination of mother-to-infant transmission of virus
• NACA begins decentralization of services to primary care facilities

In spite of the overwhelming evidence that women with Human Immuno-deficiency Virus (HIV) could have children free of the virus through free Prevention of Mother To Child Transmission (PMTCT) programme, positive couples in Nigeria are still having children with the virus.

Reasons: Daunting challenges remain including inadequate domestic funding in the face of declining support from donors; insufficient capacity (human resource 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 reluctance of pregnant women to deliver in health facilities.

Other reasons are: 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 care workers attitude to People Living with HIV (PLHIV), stigma and discrimination related to HIV and tuberculosis.

According to the latest statistics from the National Agency for Control of AIDS (NACA), in 2014, the coverage of PMTCT was estimated at 30 per cent, with 300,000 children aged zero to 14 living with HIV in the country due to Mother To Child Transmission (MTCT) of HIV; and 60,000 new child infections occurred during 2014 and over 30,000 AIDS-related deaths occurred among children. The situation is worrisome at a time where science and know how exist to prevent MTCT and mitigate its impact.

However, the Director General of NACA, Prof. John Idoko, told The Guardian that towards an AIDS free generation by 2030, Nigeria is committed to: increase domestic funding to achieve a fully funded AIDS response; fully operationalize 90-90-90 strategy to eliminate progression to AIDS, premature death and HIV transmission; ensure comprehensive combination prevention for all populations; expand HIV Counseling and Testing (HCT) antiretroviral treatment (ART) and PMTCT service points; pursue a policy of local manufacture of essential commodities- antiretroviral drugs, HIV test kits and condoms; and address barriers to access to HIV/Acquired Immune Deficiency Syndrome (AIDS) prevention and treatment services.

Idoko said the response to MTCT of HIV in Nigeria needs fast tracking and that services to provide PMTCT are being decentralized to the primary health care level thereby increasing significantly the number of PMTCT sites from 11 tertiary health facilities in 2002 to 6,533 facilities providing PMTCT services in 2014.

He said there has also been consistent improvement in the number of pregnant women tested and who know their result reaching 3,067,514 in 2014, a significant improvement from the 907,387 that were tested in 2010.

The NACA D.G. said there is also a steady increase in the number of HIV positive pregnant women who are receiving treatment- from 12,993 in 2006 to 63,350 in 2014- to prevent mother-to-child transmission of HIV and a transition of the PMCTC regimens from the single dose to multiple therapies. But, he said the roll of PMTCT has to be further fast tracked to match the needs. “There is need to quickly approve and implement option B plus- all HIV positive pregnant women on ART for life- as a national policy in Nigeria.

Idoko said the challenges remain important but not insurmountable including: preponderance of traditional and religious beliefs and practices which prevent women from going for ANC and from delivering in health facilities resulting in low utilization of maternal and child health-care services.

Other challenges include: Existing funds of PMTCT are largely from external donors because of a poor buy-in at national and state decision making levels; poor integration of HIV in reproductive health and mother and child health services; significant proportion of identified HIV positive pregnant women do not receive treatment because of stigma and discrimination; a sizeable proportion of the HIV positive women are receiving less than optimal drug regime and of children born to HIV positive women are not receiving antiretroviral treatment; limited access to early infant diagnosis testing; and limited health human resource particularly in rural areas

Idoko, however, said there is hope and elimination of mother-to-child transmission of HIV is not out of reach in Nigeria.

Despite these multiple challenges, the Joint United Nation Programme on AIDS (UNAIDS) estimates that by using an integrated and multipronged approach which includes measures to reduce the number of young women becoming infected with HIV, providing effective contraception to women living with HIV, providing lifelong ARV to HIV positive women, involving communities to reduce stigma and discrimination and increase demand for PMTCT services, Nigeria will eliminate MTCT of HIV by 2020.

UNAIDS estimates that eliminating MTCT of HIV by 2020 will resulting in the following health impact and net return on investment: 240,000 new HIV infection prevented among children; an additional 460,000 new HIV infections prevented in the adult population; a total of 700,000 new HIV infections prevented among adults and children; 340,000 AIDS-related deaths averted; 12 million life year gained; and a net return of $30 billion on investment.

From UNAIDS estimates Nigeria has the second highest burden of HIV in the world – second to South Africa. At the end of 2013, 3.2 million persons were living with HIV with the national HIV prevalence rate being 3.2 per cent. At the end of 2014, Nigeria had placed over 747,382 people on ART. A large population of new HIV infections is also through mother to child transmission: the mother to child transmission rate for MTCT was estimated at 27.3 per cent.

The response to HIV in Nigeria is coordinated through a three-tier system of administration. NACA, under the Presidency, leads the coordination at national level. At the state level, the State Agencies for the control of AIDS (SACAs), under the Office of the Governor, are responsible for the coordination of the multi sectorial response on HIV and AIDS.

NACA and SACAs coordinate joint planning, implementation, monitoring and evaluation of HIV/AIDS programmes at the national and state levels respectively. At the LGA level the Local action committee on AIDS (LACA) have similar broad mandate as NACA and SACAs to coordinate the HIV/AIDS response. The coordination of HIV response across the national and state levels is guided by the “Three Ones” framework thereby promoting effective coordination and efficiency of the response.

The first multi-sectorial action plan developed by NACA was the HIV/AIDS Emergency Action Plan (HEAP). The HEAP aimed to break down barriers to HIV prevention at the community level and support community- based responses, and provide prevention, care, and support interventions. As a result of developments in the global AIDS response, the National HIV/AIDS Policy (2005) and National HIV/AIDS Strategic Framework (NSF 2005–2009) were developed to engender a more robust response.

Based on national response review findings and recommendations, these two strategic documents were revised in 2010 and in addition, the National HIV/AIDS Strategic Plan (NSP 2010 – 2015) was developed.

The World Health Organisation (WHO) indicators were recently used by UNAIDS, Columbia University/Millennium Village Project and Local Health Authorities to validate elimination of mother to child transmission (eMTCT) in Pampaida community (“UN Millennium village”, Kaduna State). This is the first community in Nigeria to report no HIV transmission from mother to child in four consecutive years.

The success of Pampaida with elimination of mother to child transmission of HIV is largely due to the use of ‘development-centred’ approach rather than a ‘project-based’ approach to address the need of the community. With a ‘development-centred’ approach, Pampaida was able to address structural problems, which are critical and central to HIV control – poverty, education, and gender empowerment.

Access to health care was enhanced through girl child education, increased community awareness and male involvement in health decision-making processes. Improved access to cash also improved access to health commodities including food. Gender empowerment increased access of the girl child to school, reduced rate of early girl child marriage. Increased uptake of contraception-increased child spacing, reduced maternal mortality and increased child survival.

An on-going manifestation of the President’s commitment to the welfare of Nigerians was the launching of the President’s Comprehensive Response Plan (PCRP) for HIV/AIDS, which aims to accelerate the implementation of key interventions against HIV, including PMTCT. However, achieving an AIDS free generation will not be possible without eMTCT.

The President clearly recognizes this and emphasizes: “No child deserves to be born with HIV and no mother deserves to die of AIDS, we are equal to the task”. Therefore, in order to increase the momentum in the effort to achieve eMTCT, there is need to enhance political commitment at all levels of government – from the Ward level to the National government. Therefore, this concept note proposes a high level process involving political and other key stakeholders in Nigeria to deliberate on how to advance the eMTCT agenda as articulated in the PCRP and beyond.

This high level process undertaken by the Presidents aims at a political and social mobilization to end the AIDS epidemic among children and it will start with the launching of a National Action Plan to end Mother to Child Transformation of HIV in Nigeria by 2020 to conform to vision 202020 and the transformation agenda, and progress into a vigorous one week long nationwide campaign of accelerated access to PMTCT services.

The key activities include: development of a Comprehensive National Plan of Action to end Mother to child transmission of HIV in Nigeria by 2020; nationwide HIV testing campaign among pregnant women for a week; publicity and media in support of the campaign; media briefing and press conference; and national launch of eMTCT plan of action.

Former President, Dr. Goodluck Ebele Jonathan, said: “Looking back one will remember that under my stewardship Nigeria has become the first economic power of Africa and through our transformation agenda there has been an improvement in many other development indicators in this country. In my whole political life, HIV/AIDS has been a scourge I passionately tackled and moving forward, I will lead a transformative movement to end the AIDS Epidemic among children in our Country, because it is my clear conviction that no child deserves to be born with HIV in Nigeria. Join me in this fight for AIDS-free generations in our Nation.”