Cover photo: UNICEF/C-79 15

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2 Preparation and printing of this document was made possible by funding and assistance from the POLICY Project The POLICY Project is funded by the United States Agency for international Development (USAIDj and implemented by the Futures Group International in collaboration with Research Triangle Institute (RTI) and the Centre for Development and Population Activities (CEDPA). Cover photo: UNICEF/C-79 15

3 What HIV/AIDS:

4 TABLE OF CONTENTS Section Page FOREWORD... vii PREFACE...viii ACKNOWLEDGEMENTS...

5 POLICY ENVIRONMENT

6 LIST OF FIGURES Figure Page 1. Transmission of HIV

7 FOREWORD There is no doubt that the greatest health problem threatening the human race in these times is

8 PREFACE Under the visionary leadership of President Olusegun Obasanjo, Nigeria has since 1999 instituted a vigorous and serious response for combating the HIV/AIDS epidemic. Commencing with the creation

9 When ACKNOWLEDGEMENTS

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11 LIST OF ABBREVIATIONS AIDS ANC ARV ARVs CBO CSW DFID ELJSA Acquired Immunodenfiency Syndrome Ante-natal Clinic Anti-rettoviral Anti-retroviral Drugs Community-Based: Organisation Commercial Sex Worker Department for International Development Enzyme-Linked Immunosorbent Assay

12 BACKGROUND What Is HIV/AIDS? Acquired Immunodeficiency Syndrome, or AIDS, is caused by the HIV virus. The virus acts by gradually weakening

13 Heterosexual

14 is no evidence to suggest that HIV can be transmitted through insect bites, the use of public toilets, sharing meals with HIV-infected persons, or even hugging them. Figure

15 becomes very infectious, but they are less likely to be sexually active. Therefore, the most important infective period is the period when the person is infected with HIV but does not yet manifest the disease. In children, progression of HIV infection is faster. Most children with HIV die of common diseases like malaria, diarrhoea, or acute respiratory infections, which occur more frequendy and are more severe in the HIV-infected child. About one-third of infants with HIV infection will die before their first birthday. Another third will die before they reach the age of 3 years. The others may live to be up to 10 years or older, and the disease may progress more like it does in adults. No one is quite sure why some infected individuals develop AIDS at a slower or faster pace than others. Countries where the overall health of the population is poor may have shorter incubation periods than countries with better health conditions. Figure 2. HIV incubation period for adults Not infected Infected Infectious AIDS Death Surveillance System years - -1 year - (on average without ARV drugs) Because most people in Nigeria do not know they are infected, a system had to be devised to monitor the trend of the epidemic over time. The Federal Ministry of Health (FMOH) operates a sentinel surveillance system that provides data for estimating the extent of HIV infection. The Joint United Nations Programme on HIV/AIDS (UNAIDS) suggests that the best way to understand the extent of the HIV/AIDS epidemic is to look at HIV prevalence among 15 to 49 year olds. Research has shown that the HIV prevalence among women from antenatal sites is a very good estimate for larger HIV prevalence among the total adult population aged 15 to 49. Sentinel surveys have been carried in Nigeria since The last, conducted in 2001, was the most elaborate. The sentinel population group covered during this survey was pregnant women aged 15 to 49 years who attended antenatal clinics in health facilities in all states of the Federation. A minimum of two sentinel sites was chosen in each state. Those states with 5

16 very large populations had three to five sentinel sites. A total of 85 sentinel sites, covering all the 36 states and the Federal Capital Territory (FCT), were used for the survey. Some of these sites were rural and others were urban. At these selected sites, health workers took blood samples from pregnant women as part of the standard antenatal care. These blood samples were then tested anonymously for HIV infection (i.e., the blood was tested for HIV after the routine laboratory tests, for which the blood

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18 quite sure why the epidemic has spread more slowly in Nigeria and in some other West African countries. However Nigeria's

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20 Figure 7. HIV prevalence by state, 2001 Source: FMOH, 2001 HIV/AIDS Sentinel Sen-Prevalence Survey 10

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22 Figure 9 shows the prevalence rates by age. It can be seen that those in the 15- to 29-year-old age brackets are at highest risk. This is consistent with data from other countries. Thus, young adults

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24 Knowledge of AIDS and Perception of Risk Information about personal knowledge of AIDS and risk behaviours was collected in the 1999 Nigeria Demographic and Health Survey (NDHS, 1999) conducted by the National Population Commission. The results from this nationally representative survey can be seen in the Figures 11 and 12 below. Figure 11. Knowledge and perceptions of risk of AIDS and behavioural changes made to avoid HIV/AIDS Source: National Population Commission, Nigeria Demographic and Health Survey A total of 8,199 women and 2,680 men were interviewed in both rural and urban areas of the country. Of those interviewed, 74.4% of women and 89.5% of men had heard of HIV/AIDS before. The respondents were more likely to have heard of it if they were more educated, living in an urban area, or younger than 40 years of age. Persons in the southern part of Nigeria were also more likely to have heard of the disease. The most common source of information was the radio, followed by friends and relations. Of those who had heard of AIDS, 51.8% of women and 43.1% of men mentioned keeping faithful to one sexual partner as a way of avoiding HIV/AIDS. Other methods mentioned were abstinence and the avoidance of commercial sex workers (CSWs). The use of condoms was mentioned by 13.8% of women and by 29.4% of men. Women (25.7%) were more likely than men (14.1%) to lack knowledge of how to prevent HIV/AIDS. The least known fact about AIDS was the possibility of transmission from mother to child; only 54.3% of women and 46.5% of men were aware of this fact. 14

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26 frequently than women, though only 37.7%

27 PROJECTIONS OF THE EPIDEMIC Projected HIV Prevalence

28 The HIV prevalence in many other African countries, especially in the southern and eastern parts of Africa, is much higher than in Nigeria. For example, as was shown in Figure 13, South Africa's prevalence rate is 20%, Kenya's is 15%, Zambia's is 21.5% and Zimbabwe's is nearly 34%. The higher prevalence in these countries may be due to an earlier start of the epidemic in those countries, different behaviour patterns, the presence of higher levels of other risk factors, the presence of different strains of HIV, a difference in susceptibility, or a combination

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30 Figure 15. Projection of number of HIV positive persons (1990 to 2015) Projected Number

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32 Annual Deaths Among Persons Aged 15 to 49 Years The epidemic will increase the death rate at all ages. The impact will be most severe among adults in the prime working ages and among children under the age of 5. Without AIDS, we should expect only a slight increase in the number of deaths per year, mainly due to the increase in the size of the population. The crude death rate in Nigeria is 14 per 1,000, which implies approximately 1.65 million deaths annually. However the number of deaths amongst persons in the 15- to 49-year-old age group is usually small, because this is usually the healthiest fraction of the population. The impact of the epidemic will be especially severe among adults in the prime working ages, 15 to 49. Figure 18 shows the yearly number of expected deaths in the 15- to 49-year-old age group in the absence of HIV/AIDS and compares it with the number of yearly deaths in the two scenarios. The difference between the lower curve and the two upper curves is due to AIDS. It can be seen that the number of deaths without HIV/AIDS does not increase very much over time. The increase is due to a rise in the total population size, rather than to an increase in mortality. Figure 18. Deaths of young adults (15 to 49 years of age) 22

33 With the effect of HIV/AIDS, the number of deaths due to AIDS increases markedly. In the year 2000, an excess of over 100,000 deaths occurred due to AIDS. This can be expected to rise

34 If persons expected to die from the disease in the next 10 years, the majority are already infected.

35 DEMOGRAPHIC AND SOCIAL IMPACTS OF AIDS Life Expectancy One dramatic impact of AIDS deaths is the resulting decline in life expectancy. Life expectancy

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38 Figure 22. Projection of expected number of AIDS orphans by 2015 At the community level, there will be an increased need to provide services for these children, including orphanages, health care, and school fees. The avoidance of an increasing number of orphans created

39 Child Survival AIDS is not only affecting young adults, but is also becoming a child survival issue; one that threatens to reverse many of the recent gains of child survival programs. About 25 to 40% of infants born to infected mothers will be infected with HIV. Most of these babies will develop AIDS

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41 HIV and Tuberculosis

42 Figure Figure 26. Effect of HIV/AIDS on tuberculosis in Nigeria

43 Costs of Health Care As has been shown, there are today more than 3.1 million people in Nigeria who are infected with HIV.

44 While less than 20% of patients make use of government health facilities, a larger percentage will make use of them in the years ahead, especially if subsidised therapy becomes available, since the cost of maintaining healthcare is usually beyond the ability of most persons living with HIV/AIDS. Estimates

45 By 2015, the amount spent on AIDS alone could reach 35 to 45% of the health budget (Figure 29). This will mean that other diseases might not be provided for, or that increased prioritisation will occur to the detriment of the health of Nigerians. Without a strong health programme to address the preventive aspect of the HIV/AIDS epidemic, the costs required for treatment of AIDS patients will continue to increase and gradually approximate the expected health budget Figure 29. AIDS needs as ppercentage of MOH budget AIDS is extremely worrisome for a country such as Nigeria with a GNP per capita income of only US$310, especially as drugs for its treatment have to be imported with scarce foreign exchange reserves. Hospital Bed Utilisation The money spent on AIDS directly is only a fraction of the burden made on the health system by the epidermic. Another is the bed requirements needed to treat the disease. Current estimates show that Nigeria has a person-to-hospital-bed rate of about 1, Over the years, Nigeria has been able to stabilise at about this figure by continuing to build new hospitals and provide new beds to make up for the increase in population. If the person-tobed, rate were to remain the same in the next 10 years, the effects on the bed availability would be critical. An AIDS case usually requires about 15 to 40 days of hospitalisation, from time of diagnosis to death, when no ARV or specific treatment is available. If the epidemic continues, and 12 FMOH, 2001, Department of Research, Planning and Statistics, Report of Notification of HIV/AIDS Cases.-.

46 more AIDS victims make

47 is a large gap in funding to meet the full needs of a scaled-up care and prevention programme. This would cost approximately US$2 to US$3 per capita or approximately 0.8% of GDP. In education, a model developed by UNAIDS and the United Nations Children's Fund (UNICEF) shows how increasing mortality rates have led to discontinuity, with many pupils losing or having a change in their teachers. The potential impact on other sectors, including agriculture, households, and firms, shown in other African nations to lead to increased costs and expenditure, labour losses, reductions in savings, and shifting productivity patterns, need to be carefully monitored in future studies. 13 Because the HIV virus is slow acting, with an incubation period of many years, an HIV/AIDS epidemic is a long, slow event. By the time that even a few people with AIDS are recognised by clinical services, many more exist, and the epidemic is well advanced. This usually means that actions are taken more slowly than necessary and responses are many times reactive rather than-proactive. Once the HIV epidemic Begins in the society, certain consequences are inevitable, although initially invisible. The extent of these consequences and the speed with which they occur will depend on the effectiveness of prevention programmes and the degree to which the society is willing and able to plan for the impact. The following stages of impact apply to an HIV/AIDS epidemic: Stage 1. Stage 2. Stage 3. Stage 4. Stage 5. Stage 6. Number of people with AIDS are visible to medical services; some people are infected with HIV. A few cases of AIDS are seen by medical services; more people are infected with HIV. Medical services see many people with AIDS. There is some awareness among policy makers of HIV infection and AIDS. The incidence of reported tuberculosis cases increases. The number of AIDS cases may threaten to overwhelm existing health services. There is widespread awareness among the general population of HIV infection and AIDS. Unusual levels of severe illness and death in those aged 15 to 50 produce coping problems, a significant number of orphans, and the loss of key household and community members. Tuberculosis is a major killer. Loss of human resources in specialised roles in production and in economic and social reproduction decreases the ability of households, communities, enterprises, and even districts to govern and manage, themselves effectively. These difficulties elicit various responses, which may include creative and innovative ways of coping or the failure of social and economic entities. Both types of response may be observed in the same country, region, enterprise, or household. 13 African Development Forum - October 2000 AIDS in Nigeria (epidemiological summary). 37

48 Although some countries have reached stages 4 or 5, little evidence exists that any country as

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50 Reduced supply of labour Loss of skilled and experienced workers Changes in composition of labour force and early entry of children into employment Increased pressure on women to earn income as well as care for the sick Mismatch between human resources and labour requirements

51 orphaned children, many

52 Right to information Citizens have the riglit to information and education relating to sexual health

53 PREVENTING THE TRANSMISSION OF HIV The predominant modes of transmission of HIV in Nigeria are heterosexual intercourse, mother-to-child transmission (MTCT), and parenteral transmission. Interventions

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57 In January 2000, President Obasanjo, in response to a PowerPoint presentation developed using data from the 1999 Sentinel Survey on the possible impacts of the AIDS epidemic in Nigeria, and in recognition of the need for and creation of a multisectoral approach, followed through by establishing a Presidential Committee on AIDS (PCA) and a National Action Committee

58 Since these segments

59 REFERENCES African Development Forum - October 2000 AIDS in Nigeria (epidemiological summary). C. Akway,