…Ethiopia, Kenya, Namibia, others understudy Nigeria’s programme

By Sola Ogundipe

As Nigeria continues to make strides in its national HIV epidemic response efforts, the need to evaluate and deepen country ownership particularly at the state level cannot be overemphasised.

Since the fight against HIV started vigorously about 40 years ago, much progress has been achieved particularly since creation of the National AIDS & STDs Control and Prevention Programme, NASCP, within the Federal Ministry of Health.

This was followed by a multi-sectorial Presidential AIDS Commission in 1999 and the National Action Committee on AIDS, NACA, in 2000 – forerunner of the National Agency for AIDS Control, NACA.

Over the years, along with notable partners including The Global Fund, PEPFAR, UNAIDS, among others, Nigeria has maintained control of the epidemic and is gradually approaching a situation, where virtually everyone with HIV is identified, and HIV transmission has drastically reduced.

But with the challenge of depleting donor resources, the consideration for country ownership and sustainability, and sustainability of the response remains paramount.

In the views of the Director General of NACA, Dr Gambo Aliyu, Nigeria is gradually coming to the era of slowing down on new findings of HIV cases, because virtually all the cases that are there have been found.

Aliyu said in Nigeria, HIV is now being managed as a chronic illness without new cases of HIV transmission being recorded.

No new infections

“We are no longer seeing new infections, we are no longer seeing mother to child transmission, and the people that have HIV are living healthy and are having good life, and at the same time, the virus is not leaving them to affect other persons.  We are seeing the beginning of bye bye to the HIV epidemic.”

He stated that in the first alignment of the HIVresponse (Alignment 1.0) introduced three years ago, the idea was to have a common programme.

“There would be no collocation, which means we should not find PEPFAR Global Fund and Government of Nigeria implementing programmes in the same state.

“If PEPFAR is implementing programmes in this state, we allow PEPFAR to be in charge. If Global Fund is implementing programmes in another state, we allow Global Fund to be in charge. However, the treatment package should be standardised in such a way that the treatment a patient receives from a PEPFAR state is the same from a Global Fund state. Nothing changes in terms of the packaged standard of care.”

Pooling resources

The D-G said Nigeria should have a unified supply chain system.

“Instead of the government of Nigeria bringing commodities and moving them out to various locations, as well as Global Fund and PEPFAR doing it at the same time, we pool all the resources together in one place, and then now we move them together to various locations at the same time.

“We are effectively pooling all our resources in one place, we see what each of us contributes, and what each of us brings to the table, and now, we now move these resources to various locations where they are required throughout the country.

“We want to see more government investment, because we cannot talk of sustainability without government driving the entire team, whether it is at the centre or at the state level, and government cannot drive without making investment.”

On the features and benefits of Alignment 2.0, Aliyu said, “We started programmes that vigorously go after HIV in 2005, with the coming into existence of the PEPFAR programme.

“From that time, we have sustained this response till this moment, and what we are looking forward to is a situation where we control transmission, we control and limit HIV within individuals that have it, and now Nigerians can happily say HIV is no longer going to be an epidemic. It is going to be treated as a chronic illness.”

Alignment 1.0

Explaining further, Aliyu said, the alignment is essentially a process that looks at the country’s response and sees how gradually this country’s response belongs now only to the country, in terms of the country’s ownership and sustainability.

“We are now implementing everything under 1.0 and having successfully completed 1.0. We are beginning to realign to 2.0, under which where we are asking for more local resources for more ownership in terms of putting the states in the driver’s seat, and having more service integration with health insurance schemes and with primary health care at the grassroots.

 “Nigeria started this one. It is the only country that started this in the last three years, and with the success, Nigeria has recorded, the United States Government, is now advising countries across the globe to come to Nigeria to learn how Nigeria was able to do this and to learn what Nigeria is planning to do in Alignment 2.0.

 “Countries like Namibia came last year, and this year, just a month ago, Ethiopia and Kenya came. All of them were here to learn about the success of Nigeria’s HIV response, and to see what Nigeria is doing, and for them to learn and take back to their countries.”

The agreement was that the Federal government should support the treatment of at least 100,000 people for the next three years, and that promise has been fulfilled.

“For the last three years, every year we’ve treated 100,000 people yearly. This is the beginning and gradually with time, we will begin to add more patients, which means the patients that would now be under the care of our development partners, would continue to reduce going forward.                                       

Benefits of Alignment 2.0

“With Alignment 2.0 we now want to see more local investment, more local resources coming to support HIV response. The local resources must not only come from the government, it can come from the private sector and that was the reason for launching HIV Trust Fund of Nigerians in February this year.

“Under Alignment 2.0, we would want to see more of these investments from the Federal government, private sector, as well as from the states.  And under Alignment 2.0, we want to give the states more responsibility, to put the states in the driver’s seat.

“Instead of having implementing partners implementing programmes at the state, using state structures, we now want each state to use its own structure to implement the programme, which we believe is doable.”

Aliyu explained that the implementing partners would now become teachers, teaching, training and showing the state what they do and what they have been doing over the past 20 years to sustain the response and to provide treatment services to people in different locations throughout the state.

Integrating services

“So now the state uses its internal structures to now drive that response which the implementing partners would be doing it together with the state.

 At the first instance they would do it together, after one year, the implementing partner would now step aside and serve as technical advisers or technical assistants, providing the state technical guidance and technical services for the state to continue to drive the response.

“This would continue until we are satisfied that the states are now driving the response and we are getting positive outcomes.  Once we have done this, then we would want to see more service integration.

“So we want to integrate these services and see that the structures remain the same. But in terms of the catchment areas, the diseases that are covered now cut across to malaria, TB or HIV.         

“This is the essence of alignment 2.0 and we believe that by the time we arrive at that, and then the country is fully structured for ownership. 

“We are working now with PEPFAR and Global Fund to come up with a framework, in the first or second week of November and we expect to converge in Geneva to scrutinse discussion, and now produce a document that would provide both the policy guideline and the structure that would guide country ownership and sustainability. That is what the alignment is all about.”

The D-G assured that the new Alignment 2.0 will kick start in the country as soon as relevant documents are finalised.

“In fact, it has already started because the HIV Trust Fund that we launched early this year is meant to kick start it, and we have kick-started it. 

We are bringing the states into the driver’s seat. In two of the 36 states, we have already signed an agreement about where the states now would be leading, so it has already started in a way.

“In November we will get more direction in terms of policy, moderation in terms of how we are going to navigate the Alignment 2.0 terrain for the next three to four years, after which we believe the country would be well-positioned in terms of our ability to own the programme and to sustain it.

 NEPHWAN reacts

Abdulkadir Ibrahim, the National Coordinator of the Network of People Living With HIV/AIDS in Nigeria, NEPWHAN, said with Alignment 2.0, the Federal government will be better positioned to lead the National HIV response where the Global Fund is still putting some level of resources for treatment.

“About 30 per cent goes to the community response which is of more benefit to people living with HIV; where issues around monitoring the quality of services are issues around gender and human rights and in terms of prevention of stigma and discrimination against people living with HIV and other marginalised group is really improved.”

  Ibrahim said there were issues with the first realignment because most of the community components and intervention targeted at empowering NEPHWAN or organisations of living with HIV and other vulnerable groups has not really being prioritised.

“What we want to see now in the alignment 2.0 is to ensure that priorities are given to other interventions such as sensitisation, rights protection, prevention of stigma and also sensitising people more about their HIV status and people are taking their medications as when appropriate and also to ensure that community programmes like NEPHWAN and our subordinates are really empowered and adequately supported in terms of funding and systems strengthening.”

 He said even though the resources have been there in alignment 1.0, it has not really gone down to the communities, for instance on the issue of prevention of mother-to-child HIV transmission.

“It is a serious issue, we are still lagging and our indicator survey is still showing we are less than 45 per cent, which shows that a lot of HIV-positive pregnant women are not on treatment.”

Ibrahim regretted that many women don’t even know they have HIV, noting that what was expected was to see real change.

Assuring that ending HIV is possible, he stated, “Allow our PMTCT programme to continue the way it is going because most of these international partners have reduced their funding in terms of community intervention and only focus on tertiary institutions or specialist hospitals,” he asserted.