Why is Nigeria important?
Nigeria has the biggest population in Africa with 1 in 6 Africans being Nigerian. Although the HIV prevalence is much lower in Nigeria than in other African countries such as South Africa and Zambia, the size of Nigeria's population meant that by the end of 2005, there were an estimated 2,900,000 people living with HIV/AIDS. This is the largest number in the world after India and South Africa.1

Nigeria has a great deal of influence in West Africa. It is an important member of ECOWAS (the Economic Community of West African States) and plays a central role in ECOMOG's (the Economic Community of West African States Monitoring Group) peacekeeping operation. HIV/AIDS has already badly affected Nigeria society and its economy. If the epidemic continues at its current rate, or worsens, there could be knock on effects across the whole region.2

Background
Nigeria gained independence from Britain in 1960 and from 1966 to 1999 was controlled for the most part by various military governments. In May 1999, the democratically elected government of Olusegun Obasanjo, a former military dictator, assumed power. He was re-elected to a second term in 2003.

Nigeria has a population of around 140 million and life expectancy is around 50 years. It is an ethnically and religiously complex country with over 250 ethnic groups. More than 50% of the population belong to the Hausa-Fulani, Yoruba and Ibo ethnic groups.

Around 50% of the population are Muslim, 40% Christian and 10% hold indigenous beliefs. The official language is English, but over 250 other languages are spoken.

Nigeria is the 5th largest oil producer in the world and oil dominates the economy. The military governments in power between 1966 and 1999 failed to develop the economy in other areas. This, along with economic mismanagement and corruption, has contributed to Nigeria's poor economic performance and rising poverty. There is a highly unequal distribution of wealth in Nigeria with 66% of the population falling below the poverty line of $1 a day. This puts it among the 20 poorest countries in the world.3

HIV and AIDS in Nigeria

Celebrations for World AIDS Day 2001
The first case of AIDS was identified in Nigeria in 1986 and HIV prevalence rose from 1.8% in 1988 to 5.8% in 2001. Since 1991, the Federal Ministry of Health has carried out a National HIV/syphilis sentinel seroprevalence survey every 2 years. The 2003 survey estimated that there were 3,300,000 adults living with HIV/AIDS in Nigeria, and 1,900,000 (57%) of these were women.

In the 2003 survey, the national HIV prevalence had dropped to 5% from 5.8% in 2001. However, it found that state prevalence rates varied from as low as 1.2% in Osun state to as high as 12% in Cross River state. Overall, 13 of Nigeria's 36 states had an HIV prevalence over 5%. These figures give support to the claim that there are explosive, localized epidemics in some states.

At 5.6%, HIV/AIDS prevalence is highest among young people between the ages of 20 and 24 compared with other age groups. Nigeria's STD/HIV Control estimates that over 60% of new HIV infections are in the 15-25 year old age group.4

In 2005 it was estimated there were 220,000 deaths from AIDS, and 930,000 AIDS orphans living in Nigeria. There has been an alarming increase in the number of HIV positive children in recent years, 90% of whom contract the virus from their mothers.

Currently very few Nigerians have access to basic HIV/AIDS prevention, care, support or treatment services.

How is HIV transmitted in Nigeria?
Some 80% of HIV infections in Nigeria are transmitted by heterosexual sex. Factors contributing to this include a lack of information about sexual health and HIV, low levels of condom use and high levels of sexually transmitted infections (STIs) such as chlamydia and gonorrhoea, which make it easier for the virus to be transmitted.

Blood transfusions are responsible for about 10% of all HIV infections. There is a high demand for blood because of road traffic accidents, blood loss from surgery and childbirth, and anaemia from malaria. As there is no coordinated national blood supply system, blood isn't routinely tested for HIV, and a recent study found that 4% of blood donors in Lagos were HIV positive.

The remaining 10% of HIV infections are acquired through other routes such as mother-to-child transmission, homosexual sex and injecting drug use. The rate of mother-to-child transmission in Nigeria has gone up in recent years as the number of HIV positive women has increased.5

Factors contributing to the spread of HIV in Nigeria
Lack of sexual health information and education
Sex is traditionally a very private subject in Nigeria for cultural and religious reasons. The discussion of sex with teenagers, especially girls, is seen as indecent. Up until recently there was little or no sexual health education for young people and this has been a major barrier to reducing rates of HIV and other STIs. Lack of accurate information about sexual health has meant there are many myths and misconceptions about sex and HIV, contributing to increasing transmission rates as well as stigma and discrimination towards people living with HIV/AIDS.

Stigma and discrimination
Stigma and discrimination against people living with HIV/AIDS are commonplace in Nigeria. Both Christians and Muslims see immoral behaviour as being the cause of the HIV/AIDS epidemic. This affects attitudes towards people living with HIV/AIDS (PLWHA) and HIV prevention. PLWHA often lose their jobs or are denied healthcare services because of the ignorance and fear about HIV and AIDS. There is so much ignorance that 60% of healthcare workers think HIV positive patients should be isolated from other patients.6

Poor healthcare services
Over the last two decades, Nigeria's healthcare care system has deteriorated because of political instability, corruption and a mismanaged economy. Large parts of the country lack even basic healthcare provision, making it difficult to establish HIV testing and prevention services such as those for the prevention of mother-to-child transmission. Sexual health clinics providing contraception and testing and treatment for other STIs are also few and far between.7

Why are so many women being infected with HIV in Nigeria?
Nigeria is a male dominated society and women are seen as inferior to men. Women's traditional role is to have children and be responsible for the home. Their low status and lack of access to education increases their vulnerability to HIV infection. Certain social and cultural practices also make them vulnerable to HIV.

Marriage practices
Harmful marriage practices violate women's human rights and contribute to increasing HIV rates in women and girls. In Nigeria there is no legal minimum age for marriage and early marriage is still the norm in some areas. Parents see it as a way of protecting young girls from the outside world and maintaining their chastity.

Many girls get married between the ages of 12 and 13 and there is usually a large age gap between husband and wife. Young married girls are at risk of contracting HIV from their husbands as it is acceptable for men to have sexual partners outside marriage and some men have more than one wife (polygamy). Because of their age, lack of education and low status, young married girls are not able to negotiate condom use to protect themselves against HIV and STIs.8

Female circumcision
Female circumcision/female genital mutilation (FGM) is a cultural practice whereby all or part of the external female genitalia is removed by cutting. Around 60% of all Nigerian women experience FGM and it is most common in the south, where up to 85% of women undergo it at some point in their lives. FGM puts women and girls at risk of contracting HIV from unsterilized instruments, such as knives and broken glass that are used during the procedure.9

Sex work
Although prostitution is illegal in Nigeria there are more than a million female sex workers. HIV infection rates among sex workers have been estimated to be as high as 30% in some areas. There are low levels of condom use among sex workers because of a lack of knowledge about HIV transmission and poor acceptance by male clients.10

The Government response
It wasn't until the restoration of democracy in 1999 that a serious national effort was made in Nigeria to tackle HIV/AIDS. Since then, the Olesegun administration has placed high priority on prevention, treatment, care and support activities. It has established two key institutions - the Presidential Committee on AIDS and the National AIDS Action Committee on AIDS (NACA) to coordinate the various HIV/AIDS prevention, treatment and care activities in Nigeria.

NACA's main responsibility is the execution and implementation of activities under the HIV/AIDS Emergency Action Plan (HEAP), introduced in 1996 as a bridge to long-term strategic plan. HEAP had two main components: firstly to break down barriers to HIV prevention and support community based responses, and secondly to provide prevention, care and support interventions directly. HEAP has now been replaced with the National HIV/AIDS Strategic Framework, which will run until 2009.

So far there has been some progress towards the goals of HEAP but there are still huge gaps in HIV prevention, treatment and care services, particularly at community level.11

Prevention
Education
Nigeria's STD/HIV control estimates that 60% of all new HIV infection occurs in young people between the ages of 15 and 25. Last year a new curriculum was introduced for comprehensive sex education for 10-18 year olds. It focuses on improving young people's knowledge and attitudes to sexual health and reducing sexual risk taking behaviours. In the past attempts at providing sex education for young people were hampered by religious and cultural objections. The new curriculum was developed with consultation from religious and community leaders and hopefully will remain in place in the future.12

Condoms
Condoms have become nearly universally available in Nigeria because of efforts to increase coverage and subsidise prices. Uptake and use is affected by people's perceptions of how effective condoms are, perceived effects on sexual satisfaction and people not wanting to be seen as promiscuous as a result of buying them. These are all factors that are being overcome. More serious barriers are opposition from religious organisations and traditional societies, which are more difficult to break down, but with careful negotiation and consultation progress is being made.13

Media campaigns

Femi Kuti billboard poster
As Nigeria is such a large and diverse country, media campaigns to raise awareness of HIV are a practical way of reaching many people in different regions. Radio campaigns like the one created by the Society for Family Health have been extremely successful at increasing knowledge and changing behaviour. "Future Dreams", was a radio serial broadcast in 2001 in nine languages on 42 radio channels. It focused on encouraging consistent condom use, increasing knowledge and increasing skills for condom negotiation in single men and women between 18 and 34 and was very successful.14

Another high profile media campaign is fronted by Femi Kuti, the son of Fela Kuti, the famous Afro beat musician who died of AIDS in 1997. He appears on billboards alongside roads throughout Nigeria with the slogan 'AIDS: No dey show for face' which translates as you can't tell someone has AIDS by looking at them.15

Treatment
National antiretroviral programme
In 2002 the Nigerian government started an ambitious antiretroviral (ARV) treatment programme to get 10,000 adults and 5,000 children onto ARVs within one year. An initial $3.5 million worth of ARVs were imported from India and delivered at a subsidized monthly cost of $7 per person.

In 2004 the programme suffered a major setback when it was hit by a shortage of drugs. This meant that some people didn't receive treatment for up to three months. Eventually, another $3.8 million worth of drugs were then ordered and the programme resumed. However, it took a long time to achieve the 2002 goal because of poor infrastructure and management.16

At the end of 2006, around 550,000 people were estimated to require antiretroviral therapy, of whom 81,000 (15%) were receiving the drugs.17 Although this is twice as many as were on treatment at the end of 2005, Nigeria's coverage rate is still only half of the average for sub-Saharan Africa.18

ARV production in Nigeria
In 2001, Ranbaxy Nigeria, a subsidiary of Ranbaxy India, India's largest pharmaceutical company, signed an agreement with the Nigerian Government to supply ARVs manufactured at its plant in Lagos. In 2004 Archy Pharmaceuticals, a Nigerian owned pharmaceutical company, also set up a new plant manufacturing ARVs in Lagos. This should increase the availability of ARVs to people in Nigeria and other West African countries.19

Funding
Government spending on HIV/AIDS
Government spending on HIV/AIDS has been very low. The WHO recently estimated that only 4 Naira ($0.03) is spent per person on HIV/AIDS prevention, treatment and care by the Nigerian government. To be effective, the UN estimates that 260-390 Naira ($2-3) needs to be spent per person.20

Sources of funding
Many NGOs and international organisations provide funding for HIV/AIDS in Nigeria. The main donors are PEPFAR, the Global Fund and the World Bank.

PEPFAR
In the past few years, Nigeria has received large amounts of money to target HIV/AIDS from the US as part of PEPFAR (the President's Emergency Plan for AIDS Relief). Some have suggested that part of the reason for this is US interest in Nigeria's oil and natural gas reserves. The US hopes to double the amount of oil imported from Nigeria in the next five years and is pressing Nigeria to withdraw from OPEC (the Organisation of Petroleum Exporting Countries) to give the US control over the oil market there.21

PEPFAR is expected to allocate $84 million to Nigeria in 2005 for HIV/AIDS prevention, treatment and care. It aims to provide antiretrovirals to HIV positive people, prevent over one million new infections and provide care and give support to people affected by HIV/AIDS, including AIDS orphans.

PEPFAR funds will focus on abstinence and fidelity education, mother-to-child transmission (MTCT) and blood safety. Existing sites will be scaled up and new ones created. Access to home-based care and voluntary counselling and testing services will be expanded too. Condom marketing will be improved, but only for those for those thought to be at high risk of being infected, such as prostitutes and truck drivers. Condoms will not be marketed to young people or married couples; this may or may not affect the general availability of condoms in Nigeria.22

An example of a PEPFAR funded project is the Global HIV/AIDS Initiative Nigeria (GHAIN). This is a five-year project aiming to provide ART and care to HIV positive people and to prevent 800,000 new infections by 2009.23

The Global Fund
The Global Fund is providing $28 million over two years to expand government ART, prevention and MTCT programmes to reach 20,000 people. Nearly $9 million of this will be given to the Nigerian government to fund the expansion of ART.24

The World Bank
A World Bank Multi-country HIV/AIDS Program (MAP) loan of $90.3 million was allocated to Nigeria in 2002. This was to support national programmes already in place. The Nigerian government was allocated the money as they agreed to channel it quickly to community programmes and NGOs. However, by 2004, only $9.62 million had been accessed, due to delays at national and state level. Because of this, it was reported last year that the Nigerian Government could lose the unspent World Bank money.25

WHERE NEXT ? AVERT.org has more about:
HIV & AIDS in Africa
HIV prevention
providing AIDS treatment in poor countries
women, HIV & AIDS
HIV & AIDS elsewhere in the world
Author Jane Pennington

References
UNAIDS/WHO 2006 Report on the global AIDS epidemic
Institute for Security Studies, Profile: Economic Community of West African States (ECOWAS) www.iss.co.za/AF/RegOrg/unity_to_union/ecowasprof.htm/
The World Factbook: Nigeria Country Information, www.cia.gov/cia/publications/factbook/geos/ni.html
Nigeria Country Profile (HIV/AIDS), USAID, July 2003, www.usaid.gov/locations/sub-saharan_africa/countries/nigeria
'Hospitals to pay N.5 fine for transfusing HIV-infected blood, Sola Ogundipe, The Vanguard, 22 April 2005, www.vanguardngr.com
Reducing stigma and discrimination surrounding HIV and AIDS in Nigeria, EngenderHealth, www.engenderhealth.org/itf/nigeria-2.html
Social development and poverty in Nigeria, Chapter 3 in Measuring poverty in Nigeria', Sofo, C.A. Ali-Akpajiak and Toni Pyke 2003, Oxfam Working Paper www.oxfam.org.uk/what_we_do/where_we_work/nigeria/resources.htm
Child Marriage Briefing Nigeria, Population Council. September 2004 www.phishare.org/documents/PopCouncil/2478?
Nigeria: Report on Female Genital Mutilation (FGM) or Female Genital Cutting (FGC), US Department of State, www.state.gov/g/wi/rls/rep/crfgm/
'A job to die for', www.news24.com/News24/Africa/Features/0,,2-11-37_1456450,00.html
Nigeria: Rapid Assessment of HIV/AIDS Care in the Public and Private Sectors, August 2004, Partners for Health Reformplus (PHRplus), www.phishare.org/documents/PHRplus/2708/
'Proposed sex education for schools: Who will accept it?, Farooq Adamu Kperogi, The Weekly Trust.
Access to Condoms and HIV/AIDS Information: A Global Health and Human Rights Concern, Human Rights Watch, December 2004 hrw.org/backgrounder/hivaids/condoms1204/
'Nigerian Radio Campaign Generates Safer Behaviour', March 2003, Population Services International, www.psi.org/resources/profiles.html
www.firstuniversal.clara.net/femi-kuti.htm
ARV Treatment in Africa, A. Odutola, Centre for Health Policy and Strategic Studies, Lagos, Nigeria, 2004, http:/academic.udayton.edu/health/06world/africa04.htm
WHO, Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector, 17th April 2007
WHO, Progress in scaling up access to HIV treatment in low and middle-income countries, June 2006, 16th August 2006
'Nigeria to begin making HIV/AIDS generic drugs', Reuters NewMedia, Tuesday, July 27, 2004 www.aegis.com
APIN Summary Report of Presidential Forum, www.hsph.harvard.edu/apin/report-forum.html
The New Gulf Oil States, Servant,J.-C., Le Monde Diplomatique, January 2003, MondeDiplo.com/2003/01/08oil?var_recherche=jean-christophe+servant
PEPFAR Fiscal Year 2005 Operational Plan, US Department of State, February 2005 www.state.gov/s/gac/rl/or/44471.htm
'FHI 'GHAINS' new funds for HIV/AIDS, TB services in Nigeria', Family Health International, 2004, www.fhi.org/en/HIVAIDS/country/Nigeria/nigernews.htm
The Global Fund, Portfolio of Grants in Nigeria, www.theglobalfund.org/search/portfolio.aspx?lang=en&countryID=NGA
'Nigeria may lose N11.2956 World Bank Grant' ThisDay, June 28, 2004 www.naijapost.com/news/publish/article_980.shtml