The 2018 edition of the Civil Society Accountability Forum is scheduled to hold on the 14th and 15th of December, 2018 in Abuja, Nigeria. The theme for this year’s conference is “Domestic Resource Mobilisation: Public and Private Sector Investment”.The government – national, state and local – is expected to discuss domestic financing of the HIV response in Nigeria at the forum. This comes up closing on the heels of the commitment made by the Minister of Health, Prof Isaac Adewole at the PEPFAR 2018 COP meeting in Johannesburg, South Africa where he committed to performing a miracle by getting the Nigeria government to take substantial responsibility of the HIV treatment programme by funding procurement of commodities for the response.
He made this statement on the 22nd of February 2018 at the closing of the five days PEPFAR 2018 COP planning meeting.Adewole noted that like South Africa, Nigeria should be leading its National Response and donors should only be complimenting the response. Sadly, this is the reverse.
Nigeria currently funds less than 20% of the National HIV response. The country also has no strategic plans on how it plans to transit the currently heavily PEPFAR and Global Fund subsidized response.The country also has no annual plan that monitors how stakeholders strategically contribute to meeting set targets for the elimination of new HIV infections in the country.
Nigeria has one of the highest number of new HIV infection in Sub-Saharan Africa – in 2016, over 200,000 persons were infected with HIV (https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/nigeria).In an effort to reposition the country, the Ministry of Health (NASCP) conveyed a meeting in Lagos in March 2018, to begin preliminary discussions on national funding of the HIV treatment in Nigeria. This is essential as there are current efforts to phase out the use of Efavirenz and replace this with Dolutagravir.
PEPFAR is already going ahead with the plan to switch therapy. Dolutagravir is more user-friendly, with less side effects and cost effective. The Civil Society under the leadership of Treatment Action Movement in collaboration with Afrocab, had been very active with pushing the country to switch therapy. This was one of the agenda for discussion at the 2016 Civil Society Accountability Forum.
The NASCP meeting not only focused on how to re-establish the national HIV treatment programme, but it also developed a roadmap for the prevention of mother to child transmission of HIV in Nigeria. The roadmap was to have been presented to the Minister by the end of March 2018.
Unlike the Federal Ministry of Health, the National Agency for the Control of AIDS under the leadership of Dr Sani Aliyu, is focused not just on preventing mother to child transmission of HIV, but eliminating it in line with its 2017-2021 HIV and AIDS strategic plan. Nigeria contributes significantly to the global HIV epidemic having the highest number of babies born with HIV in the world. This is partly because only 30% of mothers living with HIV actually have access to HIV treatment programmes that can reduce the risk of mother to child transmission of HIV infection.
With the Minister committing to performing a miracle with the national HIV treatment programme before the coming in of a new government in 2019; and the National Agency for the Control of AIDS focusing its resources to eliminate mother to child transmission of HIV in Nigeria, it is critically important to listen to how the government has fared to date knowing 2020 is a miracle year for all – when AIDS should cease to be a global epidemic.Can Nigeria keep its global commitment to the 2020 goal? We look forward to answers at the 2018 Civil Society Accountability Forum.
Folayan is of New HIV Vaccine and Microbicide Advocacy Society
Any form of abuse meted out to adolescent girls may inflict in them negative consequences. It is therefore important not to prevent the abuser from facing the consequences of the law. Adolescents need not keep silent about abuses they face. It is your responsibility to voice out. Abuse is not anyone’s fault. People who abuse have a way of instilling fear and shutting the abused up. Forced sex is RAPE and it is a crime. There are also other forms of sexual harassment such as touching or grabbing intimate body parts for sexual gratification. Sexual assault is not just a crime of sex; it is also a crime of power and control, where sexual activity is used to dominate and hurt the victim. For adolescents and young adults, it can occur during a date. Prevention requires being proactive at social gathering to avoid molestation.
Join the #MeToo Campaign. Lets break the silence on sexual harassment
In the words of Professor Wafaa M. El-Sadir of the Columbia University, USA and the lead for the ICAP project, HIV management has passed through Trials, Travails and Triumphs with HIV epidemic evolving from an untreatable deadly disease to a chronic manageable condition.
As she discussed HIV prevention at the 25th anniversary of CROI held in Boston, USA from the 4th to the 7th of March 2018, she noted that despite the seeming success, new HIV infection continues and it is highly unlikely that the world would be able to reach the goal of less than half a million new infections per year by 2020. “This should compel us to think about how we can do better in terms of preventing new HIV infections,” she said.
Access to antiretroviral treatment should help expedite HIV prevention. In this case, treatment is used as prevention (TasP). Once antiretroviral therapy is adhered to, viral suppression occurs, and individuals living with the virus cannot transmit the virus. Similarly, adherence is required for antiretroviral used as pre-exposure prophylaxis (PrEP) to work.
Adherence to therapy can only be enhanced when supported with other intervention measures such as harm-reduction strategies for people who inject drugs, mental health service support for people who require this, access to regular HIV testing services, and empowerment programmes for adolescents and female sex workers.
Without these support, a population level effectiveness of treatment as prevention and pre-exposure prophylaxis would be limited in high HIV prevalence countries says Prof. Roel Coutinho from the University Medical centre Utrecht, Netherlands.
Meanwhile, mental health management of persons taking antiretroviral therapy for HIV infection management is also critical.
To control the epidemic, mental health care needs to be instituted as part of comprehensive HIV management, noted Dr. Robert H. Remien, a Professor of Clinical Psychology at the Columbia University, USA.
Poor mental health itself increases the risk of acquiring HIV infections for persons who are HIV negative as it negatively affects adherence to use of antiretroviral therapy as PrEP. It also doubles the risk of mortality for persons taking antiretroviral therapy for HIV infection management.
HIV prevention and treatment is best achieved through combination and integrated service delivery. All HIV management interventions proven effective need to be integrated into a combination of health-strengthening strategies to achieve effectiveness noted El-Sadir.
She also discussed the need for precision intervention by learning about WHERE to focus (geographic area), WHO to focus on (specific population), HOW to focus (models of prevention) and also WHAT type of tools we would use for the identified population(s).
The ability to learn how to conduct such precision interventions in Africa is limited by the capacity of local researchers to effectively oversee all aspects of the grant management cycle. Researchers in Africa have therefore had to depend on foreign partners for research administration, noted Dr. Elizabeth Bukusi of the Kenya Medical Research Institute, Nairobi, Kenya, during one of the breakfast sessions held at the conference.
“We don’t have strong management systems. Although we talk about issues of corruption, the systems are not robust enough to be able to manage research funds as we would want them; hence funds are being managed largely from the West,” Bukusi said.
“It is imperative to strengthen research administration through infrastructural, organizational, and human resource development to match the dynamic research environment and funding requirements.
“If we don’t address that capacity gap, it makes it difficult to grow the research to fit into our specific needs.”
“It was also identified that another issue we face is in infrastructural development. Facilities, resources and related services that are used by the scientific community are critical to conduct top-level research, without which, we will not be able to do the quality science that we desire,” she said.
Lots of changes have happened with the HIV prevention and treatment field over the last 35 years of the HIV epidemic. There have been indeed trials, travails and successes. The gain we have jointly made will require the sustained engagement and unique inputs from various communities, inclusive of small informal groups at the grass-roots and those of global coalitions. The struggle continues.
By Alaka Oluwatosin Bamidele
Oluwatosin,of New HIV Vaccine and Microbicide Advocacy Society (NHVMAS), writes in from Lagos.
Parents are the greatest assets for children. We are subject to the laws and mandates of our parents. I probably speak as such because I have very tough parents and I know what it is to live by their rules. and laws. I know what it is to grown up with different parents and I do have an insight into why adolescents may be considered rebellious. My father was extremely tough. He was had little accommodations for nonsense from we his children. He was very strict. He never wanted me to associate freely with anything outsde the christian world. He therefore restricted my knowledge and activities. Things were a lot easier because of my understanding mum. Sadly, this is the stage of life where adolescents are curious and want to explore. They will explore in these kind of gagged atmosphere but sadly, the exploration will be without parental guidance. Strict parents loose their children at this time as adolescents seek for knowledge from alternative sources. Parents should include early sex education for their children as part of the education they inculcate in the homes. Sex education should not be given in harsh manner. Just the way religion is taught to kids in the home, teach sex and sexuality to kids in the home. Home sexual education training is essential for adolescents as part of the love, care, correction and attention they need. Times are changing and parents also need to change with the changing times
Cults and Cabals exist in all societies. The research enterprise is not excluded. Fraternities exists in the research enterprise and many junior ones try to join these fraternities to enable them get privileged access to grants for their research work.
The lords of these fraternities try to sustain a rhythm of practice – they define research priority, and identify groups and individuals that get the choicest grants.
Sadly, the fear of the cabal makes many researchers silent –almost like coercive silence – and not push for changes that can otherwise improve the ethics of practice within the systems.
The HIV prevention research enterprise is not spared of this trait!
There are cults controlling every aspect of the life of the HIV prevention research enterprise – vaccine research, PrEP research, microbicide research, research involving adolescents. Some cults control the funding and some control the practice. Some cult members are more powerful than others. Some cult members are threats while others are work engines.
One group that can cause disruption in the norms of practice of the HIV prevention research practice is the activists. They can and should identify those practices in the research enterprises that are inimical to the safety and welfare of study participants, of communities that hosts research, and for governments that should institute practices that ensure access of its citizens to medicines and vaccines.
One area where disruption is needed is the issue of post-trial access to HIV prevention research products. Paul et al ( https://www.ncbi.nlm.nih.gov/pubmed/29487116) in their article published in the Journal of Medical Ethics showed clearly that over the years, the HIV prevention research enterprise has not done well to ensure sustained access to beneficial interventions for trial participants.
Sadly, without a disruption in the practice, the unsuccessful model will continue to be perpetuated. While research is not meant to address country level problems, it is expected that the huge resources invested in HIV prevention research could do more than providing tokenistic research outcomes.
Also of importance is the need to change perception about power dynamics and what partners can bring to the table.
Advocates have asked continuously for communities to engage with researchers in the design and implementation of research because they can add value to the research process.
Recently, Folayan et al (https://www.ncbi.nlm.nih.gov/pubmed/29490667) provided evidence that a structured engagement of community members can facilitate discussions about research designs. Community members consulted and engaged with HIV prevention research should not be limited to low literate members of the community. There are highly intellectual members of all communities who are educated enough to make critical inputs into the decision making process.
Community members engaged during research processes could be Professors, doctors, lawyers and a whole cadre of highly-educated persons who had spoken up for their community in the past and will willingly be glad to engage in conversations about research design and implementation for their community. We can do more by investing wisely the dollars spent in researching for products acceptable by community members.
Disruptions will come with unease, threats, funding cuts and a whole lot more for activists. There is nothing new about these phenomena. But we all as activists must and should be ready to cause the needed disruption to end an era of tokenism in the way community members are engaged in the design and implementation of HIV prevention research.
As the cabal members justify their gains in the enterprise – and justly so – we need to see that participants, communities and countries who are invested in the HIV prevention research enterprise equally benefit from their investment: respect for their persons, assurance of long term safety of their health, community benefits for study participation, and post trial access to study products by countries involved in the research. Anything less is tokenism.
Morenike Oluwatoyin Folayan, is of New HIV Vaccine and Microbicide Advocacy Society.
HIV prevention intervention for any target population requires comprehensive programming. Programmes need to address biomedical, behavioural and structural risk factors. For adolescent girls, there is very little addressing a high HIV risk factor – rape.
The risk of rape is extremely high for girls in Nigeria. A study showed that about 34.1% of sexually active adolescent girls have their first sexual experience through rape. In Nigeria, rape increases the risk of girls to HIV infection just like it does in South Africa.
The mental distress associated with rape is not often managed due to the culture of silence about rape. This culture increases the high risk behavior of rape survivors – unprotected anal and vaginal intercourse, having multiple sex partners and increased engagement in transactional sex.
Rape survivors also suffer depression and low self esteem. In Nigeria, they often use coping strategies that limit their interactions with people and the public further increasing their risk of mental distress.
The risk for HIV infection for adolescent girls is further heightened if they get unwanted pregnancies, and continue to have sex with an infected partner during pregnancy and immediately post delivery.
The risk of engaging in sex during and immediately after delivery is high due to the need to get source for money to support themselves and their child. Pregnancy increases the risk of being a school dropout, having no skills to provide financially for self and a family suddenly trust into her care. Resorting to transactional sex as a way for making income during pregnancy and post delivery is therefore high.
Sadly, the national government does not recognize rape as a risk factor for HIV infection for adolescent girls in Nigeria. Neither does the country have a HIV prevention programme designed to acknowledge that unwanted/unplanned pregnancy is a risk factor for HIV infection for adolescent girls.
The HIV prevention programme in Nigeria should address rape as a structural risk factor for HIV in Nigeria. The risk for rape is high for adolescent girls in Nigeria. Rape increases the risk for pregnancy. Pregnant girls are often forced to marry identified sex partners – rapist or others. They drop out of school, become economically insecured, and are less able to negotiate safe sex.
Not having education beyond secondary school is one of the greatest structural risk factors for HIV infection for women and young girls. Sadly, 49% of females living in rural Nigeria and 22% of those in urban Nigeria have no education.
We need to break the vicious cycle of HIV risk resulting from unwanted adolescents’ pregnancy. Establishing programmes that empower young girls to make decisions about preventing unwanted pregnancy is highly needed in Nigeria.