Nigeria Maps AIDS Epidemic, Future of HIV Fight

July 20, 2012 -Yellow, pink and green are the colors of promise in a country where 3.5 million people live with HIV.

In the suburbs of Abuja, Nigeria, dedicated implementers of HIV programs are meticulously mapping the area’s HIV epidemic with colorful dots, symbolizing the locations of most-at-risk populations. Nationwide, these populations—including female sex workers, injecting drug users and men who have sex with men—comprise about 3.4% of the national population but account for as much as 40% of new infections in the country.

The mapping of these at-risk populations is part of a first-time, nationwide effort supported by the World Bank to track a virus that infects close to 1,000 people a day in the West African country—the second highest number in the world.

The exercise is connecting the dots between health facilities and civil society organizations (CSOs) that provide services—including antiretroviral therapy, HIV counseling and therapy, and prevention of mother-to-child transmission (PMTCT) of HIV—and the most at-risk populations. It is also calculating the size of these populations, where they operate and their behaviors, which will expose programmatic gaps and help improve the design, implementation and evaluation of programs to prevent infections.

The task is daunting: Abuja, the Federal Capital Territory (FCT), is just one of more than 30 areas across the country that state agencies are mapping. The FCT Agency for the Control of AIDS is mapping 1,560 locations where female sex workers work, 116 linked to men who have sex with men and 43 linked to injecting drug users.

“We took this approach because we knew resources for HIV were limited,” says Uche Okoro, Program Manager for the FCT Agency for the Control of HIV/AIDS. “We wanted our programs for these populations to be based on facts.”

Big challenges, big investments

A quarter-century has passed since the first case of HIV was diagnosed in Nigeria. Before 2000, advocates, agencies and partners tried to keep pace with the deadly disease, but fell short in the absence of national coordination and detailed data that told the true story of the epidemic.

In 1999, Nigeria’s president moved HIV/AIDS to the top of the country’s agenda and a year later, created the National Action Committee on AIDS, which later became an agency. The same year, the World Bank scaled up its support to countries to improve the efficiency, effectiveness and sustainability of their national AIDS responses. Since then, the World Bank has committed $2 billion to 33 African countries—including $366 million toward HIV prevention efforts in Nigeria—and four regional, cross-border projects in Africa to expand national HIV/AIDS efforts.

Nigeria’s five-year strategic HIV/AIDS plan (2010-2015) is focusing on prevention for those most at risk (and including PMTCT), expanding access to treatment, and improving strategic knowledge and management of the epidemic to inform implementation programs. With less than one in five HIV-positive women with access to PMTCT services, and with only limited coverage of most at-risk populations, strengthening or establishing local and state AIDS control agencies and CSOs playing key roles in information and service delivery is essential to saving millions of lives.

Knowing your epidemic

To prevent HIV, the country needs to know and understand the main modes of transmission in each state, including the numbers, locations and service needs of those at greatest risk of infection and deliver the appropriate package of interventions designed for each at-risk group at a large enough scale to make a difference.

“The battle of AIDS will be won or lost in a small number of countries, and few are more important than Nigeria,” said David Wilson, World Bank Global HIV/AIDS Program Director. “We salute Nigeria’s leadership for rising to this immense challenge.”

The World Bank has worked with 120 countries, investing nearly $4.6 billion to better understand their epidemics and develop better prioritized, strategic plans, and is collaborating with high-incidence countries like Nigeria to determine the optimal mix of interventions to avert as many infections as possible. This means not only mapping at-risk populations, but also designing, implementing and evaluating nationwide responses based on the intelligence agencies are collecting across countries.

This work is part of a global initiative to improve HIV program science—and it’s not limited to Nigeria. Three other countries, including Kenya, India and Pakistan, are part of the first wave of an initiative sponsored by the World Bank and the U.S. government. (See box.)

World Bank investments in HIV/AIDS in Nigeria are strengthening health systems in the country, in line with the World Bank’s strategy for health, nutrition and population.

A rich tapestry

As a country, Nigeria is a rich tapestry, with 162 million people, more than 500 indigenous languages, 250 ethnic groups, two major religions, and 36 states and a Federal Capital Territory. Each community requires a tailored strategy. There is no panacea.

“Nigeria is a huge country and it is not possible for the government on its own to reach the key populations, especially those in the rural areas, with messages and interventions without the strong input and support of communities and civil society organizations,” says Francisca Ayodeji Akala, Task Team Leader of the World Bank’s HIV/AIDS project. “Studies in the country have shown the need to empower communities to reduce their HIV transmission risks.”

Data from communities and states is feeding into a national database that is shaping the country’s HIV strategy. The country is now establishing baselines and targets, which helps ensure that HIV funding isn’t wasted.

“Now we know the drivers of the epidemic and how we can target them with prevention interventions,” said Hajiya Maimuna Yakubu Mohammed, Director of Government Affairs, Coordinator and Support at the national HIV/AIDS coordination agency.

Country leaders are able to figure out where to implement programs for specific populations and measure the performance of programs to prevent new infections.

Celebrating progress

The project is also drawing on the experiences of a government effort in India—supported by the World Bank—that averted 3 million new infections through targeted prevention interventions among sex workers. Government program directors and key donor partners in Nigeria traveled to India in June 2012 to learn more about the government’s prevention program.

The World Bank is supporting the country’s efforts to map the epidemic in seven Nigerian states with the highest disease burden, and is working closely with the Global Fund, UNAIDS, U.S. Agency for International Development (USAID), the UK Department for International Development (DFID) and the Society for Family Health to map other states. Lessons from the first seven states will inform strategies to address epidemics in other states.

Nigeria is beginning to see results: The epidemic has stabilized and there has been a 40% reduction in the number of young people who were infected with HIV, down from 5.8% in 2001 to 4.1% in 2009.

In spite of these results, Nigeria has 18 states with prevalence rates above the national average and the second largest number of infected people in the world. It contributes close to one-third of global cases of HIV transmitted to newborn babies.

While celebrating the country’s achievements, there remains an urgent need to intensify efforts to reverse the epidemic by significantly reducing the number of new infections. The World Bank’s financial and technical assistance along with assistance from other partners is providing the government with the tools to more effectively and efficiently achieve this goal.

Improving HIV Program Science

This process of conducting a local epidemic appraisal through mapping, profiling venues, and interviewing at-risk populations to understand how to best implement programs that work, is part of a program to improve the science of HIV programs in Nigeria. The country is one of the four partner countries in the global HIV Program Science Consortium, which aims to bring the knowledge of the epidemic, the science of program delivery and the science of evaluation closer together for AIDS program performance improvement. The country is implementing the initiative in close partnership with the World Bank, U.S. government, DFID, the Global Fund, and academic partners such as the University of Manitoba.