By Eloke Onyebuchi
In the twelve years, since the 2001 Declaration of Commitment on HIV/AIDS, the world has seen an unprecedented mobilization of resources for HIV. Innovative partnerships have been created to support an elevated response to the epidemic. There has been a corresponding, dramatic increase in the numbers of people in low and middle income countries with access to treatment, up to 42% in the last four years. If this increase can be maintained, the goal of universal access to treatment is almost within our grasp. But what of universal access to prevention?
As the Secretary General of United Nations has reported, the number of new infections is 2.5 times higher than the number of people receiving antiretrovirals. USD1 invested in prevention can save up to USD8 in treatment costs. It is obvious to us all that treatment gains will be rapidly undermined unless prevention is the mainstay of our response.
In Asia and the Pacific nearly 5 million people are living with HIV. The epidemic is expanding in many countries in nearby regions including the populous countries of China, Indonesia and Vietnam. In Papua New Guinea adult HIV prevalence is estimated to rise over 4 per cent by this year without an enhanced response. In the neighboring Indonesian province of Papua, a population survey confirmed adult prevalence of 2.4 per cent in 2006. This data from Australia’s nearest neighbors is sobering. The epidemic is outpacing the response.
UNAIDS and its co-sponsors have led the world in researching, tracking and analysing the drivers of the epidemic, knowledge that is crucial to our efforts to stop the spread of HIV. We commend their efforts. It is up to us to apply that knowledge.
This is no time for half-measures. For the first time ever, we have the resources and knowledge to halt the spread of HIV. What is needed now is the political courage and leadership to take effective action. Nigeria endorses the call of the Secretary General to scale up focused HIV-prevention for populations most at risk. This is especially important for those of us in the African region with high prevalence and concentrated epidemics. In these settings, providing targeted services for people who inject drugs, sex workers and their clients and men who have sex with men will prevent the spread of HIV.
Injecting drug use has proved highly efficient in initiating and fuelling epidemics across Europe and Asia. The epidemic is dynamic and evolving. New data (from the Commission on AIDS in Africa and Asia) demonstrates that men who buy sex will be the most powerful driving force in African and Asia’s epidemic over the next decade. Male to male sex will also become one of the main sources of new HIV infections in Africa and Asia by 2020. Yet coverage of these key populations with prevention services remains very low, often less than 5 per cent. That is a far cry from universal access.
Nigeria has been heralded as a success in the global fight against HIV/AIDS for its innovative and effective approaches to prevention and care. A number of factors have contributed to this success, including strong political commitment by the Government of Nigeria and a coordinated effort between the Government of Nigeria, international and local non-governmental organizations to deliver prevention, care, and support services; voluntary counseling and testing; and programs for children affected by AIDS. Another important factor is the substantial financial investments of the U.S Government – through the U.S. President’s Emergency Plan for AIDS Relief (PEP FAR) – and other donors in the effort. Yet numerous program implementation challenges remain, and the sharp declines in HIV prevalence that occurred during the past decade have leveled up.
Nigeria’s own experience in this area testifies to the success of focused and evidence based prevention efforts. We reversed our epidemic in the middle of 2000. Our rates of new infections are far lower than most comparable countries, with approximately more than 10,000 cases diagnosed per year in a population of 140 million. Central to Nigeria’s success in HIV prevention has been social mobilisation of affected communities. People living with HIV, people who use drugs and sex workers have helped to lead the national response, working in partnership with the government, health sector private sector and researchers.
This partnership has ensured that community based prevention remains at the forefront of our strategy. Affected communities have been involved in the planning and provision of targeted services such as peer education and outreach, and have helped shape the research agendas. We have adopted a pragmatic approach which has been highly cost effective. Our national needle and syringe program averted an estimated 25,000 infections over a nine year period, saving up millions of dollars in treatment costs. Together with our partners, we have pioneered harm reduction approaches to HIV prevention in Africa.
In the lead up to this article, there has been a vigorous debate about how HIV fits within the context of broader efforts to strengthen health systems and to address neglected issues such as child and maternal health and cancerous infections that is now becoming a scourge across the globe. These are not competing interests. HIV has forced the world to think differently about public health and its relationship to communities including the most marginalised. Our learning from HIV needs to inform our approaches to public health across the board.
Increasingly it is our responsibility to ensure HIV responses, complement and support broader efforts to improve the health of our nations and to mobilise the resources required to sustain equitable access to all essential health services, particularly for the poor and vulnerable.
Nigeria is strongly committed to working in partnership with the United Nations, donor agencies, the private sector and affected communities across all regions to achieve universal access to HIV services, to halt the spread of HIV and to achieve the health Millennium Development Goals.
However, one of the lessons of the epidemic over the last twenty five years is that none of us can afford to be complacent. In Nigeria we are starting to see rises in new cases of HIV in some of our cities. The Government is working with communities and researchers to understand the reasons for new trends and to respond accordingly. This is a great opportunity to adjust our global, regional and national responses to make them more effective, so that we can meet our agreed targets. To do so requires the leadership, courage, concerted efforts and mobilization skills to advocate more programme strategies in our country and beyond to inform its roll out and expansion.
The purpose of this action is to implement HIV/AIDS Evaluation, Assessment, and Formative Research Task Order to take stock of key programs at various stages of implementation in order to extract lessons learned, best practices, and remaining challenges. Undertaking this capacity evaluation strategy will help examine the effectiveness of the program implementation in order to inform its roll out and expansion. It will also explore which elements of the current implementation are most effective and should be continued, where the gaps are, how the successful elements can be adapted for the post-primary target groups, and, given the accomplishments, how the program should develop and evolve.
Also, this will avail opportunities to underscore the country commitment and dedication in applying professional technical expertise to address key drivers to primary prevention behaviours to this virus, underlying societal factors and support to biomedical prevention methods. This opportunity will also enable the system improve on the technical expertise and finesse in existing policy project design, formulation of policy evaluation proposals to previous strategies designed against this virus, and methodologies in applying these practical policies locally.
The complexity of the HIV/AIDS epidemic stem from its links with all aspects of society and culture. Social and cultural factors determine the viral transmission, the outcome of prevention strategies and the compassion of Health care workers in treating their HIV/AIDS patients. A clear understanding of these factors, therefore, becomes a determinant for planning the control of the epidemic. Although, it is now globally known and accepted that antiretroviral can help people with HIV achieve long term survival, the slight distinction between managing and curing the disease evades the understanding of most people, especially policy makers and urban poor and rural populations. Hence, the rationale for this initiative, to strengthen country activities by taking the fight against the disease to the door step of this often, neglected segment of the population.
Benefit of this country action:
Community empowerment for free mobile testing to increase HIV testing at the community level would reduce HIV infection and possibly spot subsequent undiagnosed HIV infections. This mobile testing strategy has been confirmed to be effective from a randomised control trial, carried out in four countries in the developing world. An acceptable level of reduction on HIV infection were recorded in these countries.
This is because many people, especially the urban poor and rural populations, who are at increased risk of transmitting this virus to others, due to lack of formative empowerment on the virus would want to voluntarily know their status by being tested, therefore, increasing the awareness and prevention of the disease among the local populations. This is the most effective way to enhance Voluntary Counselling and Testing (VCT) as this strategy easily identifies people at probable risk with no community harm, stigma and discrimination.
To explore designs and strategies for implementation of policy research and tackling the remaining challenges on HIV/AIDS. This strategy will determine the development of policy measures, health impact assessment and evaluation of policy adoption and implementation. The purpose is to improve the quality and quantity of policy research and to translate to action, positive healthy behaviours against this viral menace in our population.
Exploring surveillance research to track changes in organisational activities with the potential to influence control and enhance prevention of HIV/AIDS. This would enable researchers policy makers and practioners to (1) Identify opportunities for natural experiments (2) Examine the influence of organisational activities on ensuring effective service delivery, and (3) To determine how organisational activity shift in response to policy changes, and how this can affect the behaviours of our health care staffs.
…. At the end, the fight against HIV/AIDS will stand or fall on the willingness of Governments to implement creative ideas to manage the virus. It is 2013. Two years to the year, we agreed in our millennium development goals promise of universal access to prevention and seven years to 2020, the set date to halt the spread of HIV. Let us resolve to seize the moment and re-commit ourselves to do what we know it takes to reach these goals and hopefully create a model that other countries will not hesitate to emulate from us. hence the need to continue to re – model our approaches in tackling the challenges posed by this disease in our population. Therefore, the need to adopt this country action, with its important commitments, goals and targets, will be a hopeful sign that the global response to HIV/AIDS and that a generation without HIV/AIDS in Nigeria could be a reality.
Eloke Onyebuchi, a public health specialist is on firstname.lastname@example.org