Running head: NIGERIA’S HIV/AIDS EPIDEMIC

Nigeria’s HIV/AIDS Epidemic:

Prevention, Reduction, and Elimination by 2030

Rino Watanabe

University of Washington

HON 222A

Professor Danuta Kasprzyk

Professor Genya Shimkin

June 7, 2020
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Introduction: Background Information on Nigeria

The Federal Republic of Nigeria is a lower-middle income country in Western Africa that

is recognized for its large, diverse population and abundant oil reserves. With a growing

population of approximately 214 million people (July 2020 estimate), Nigeria is the most

populated country in Africa (Central Intelligence Agency [CIA], 2020). There are over 250

ethnic groups, including the Hausa, Igbo, Yoruba, and Fulani (CIA, 2020), and although English

is the official language of Nigeria, there are over 500 regional languages and dialects spoken in

the country (CIA, 2020). Approximately 49.66% of the population live in rural areas (The

World Bank, 2018), and the majority of people are between the ages of 15 and 54

(CIA, 2020). Nigeria’s birth rate is three times the mortality rate, resulting in the triangular-

shaped population pyramid (Figure 1). The birth rate is 37.905 per 1000, and the mortality rate is

11.86 per 1000 people (The World Bank, 2019). This population distribution typically correlates

to lower life expectancies. Correspondingly, life expectancies in Nigeria are the lowest in

Western Africa and thus some of the lowest in the world with females at 55.24 years and males

at 53.45 years (The World Bank, 2019); these low numbers can be attributed to socio-economic

issues, cultural practices, political instability, and health outcome disparities.

Figure 1. Nigeria’s 2020 population pyramid (CIA, 2020)

Despite facing collapsing oil prices, Nigeria has experienced considerable economic

growth over the decades due to their oil and gas exports. Nigeria is Africa’s largest exporter

of oil, and according to Nigeria’s National Agency for the Control of AIDS, around 75% of the

country’s budgetary revenue stems from these exports (NACA, 2017). As a result, Nigeria also

has the largest economy in Africa (The World Bank, 2019); however, Nigeria’s poverty levels,

unemployment rates, and underemployment rates are extremely high and disproportionately

impacting the youth and women in rural areas. Over 102 million people in Nigeria are in

extreme poverty (World Data Lab, 2020), primarily young women and youth living in rural areas

(NACA, 2017). Moreover, a combined 43.4% of the workforce are either unemployed or

underemployed, primarily burdening females between the ages of 16 and 64, rural residents, and

young people (National Bureau of Statistics, Nigeria, 2018). This social and economic inequity

ultimately amplifies the rampant gender inequalities and disparities between urban and rural

populations in Nigeria. For young people, women, and rural residents, this means that their food

security and educational stability are compromised, as well as their accessibility to basic services

and resources; this includes access to safe, affordable, and effective health care and treatments.

Because of the inefficient health care system, however, the lack of equitable access to resources

contribute to the growing disparities in health outcomes among the Nigerian population.

The major health issues in Nigeria include lower respiratory infections, malaria, neonatal

disorders, and HIV/AIDS (Centers for Disease Control and Prevention [CDC], 2019). In 2017

lower respiratory infections and malaria accounted for 19% and 20% of deaths, respectively,

primarily affecting children and infants (Muhammad, Abdulkareem, & Chowdhury, 2017).

Similarly, because of the poor health care infrastructure, the number of deaths from neonatal

disorders is increasing each year, resulting in over 267,000 neonatal deaths in 2019 (UN Inter-
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agency Group for Child Mortality Estimation [IGME], 2019). HIV and AIDS has also had a

significant impact on children and mothers due to the lack of PMTCT (prevention of mother-to-

child transmission) programs to support reproductive and maternal health. Consequently,

pregnant women have low HIV testing rates, and pregnant women living with HIV/AIDS do not

have secure access to antiretroviral therapy (ART) or early infant diagnosis services (Avert,

2020). The outcomes of these structural inequities are evident in Nigeria’s incidence rates for

mother-to-child-transmission of HIV, or MTCT (Avert, 2020). Because these pervasive health

issues target mothers and children in Nigeria, the rates for maternal and child mortality are

alarmingly high. The under-five mortality rate is approximately 119.9 deaths per 1000 live births

(IGME, 2019), which is staggering compared to the world average rate of 38.6 deaths per 1000

live births (The World Bank, 2018). In 2019, this amounted to over 866,000 under-five

deaths in Nigeria, excluding infant deaths and neonatal deaths (IGME, 2019).

Furthermore, the maternal mortality ratio, or number of maternal deaths per 100,000

live births, is 917 deaths in Nigeria and 211 deaths in the world (The World Bank,

2017). In order to mitigate the impact of these health issues, particularly HIV/AIDS, the health

care system needs to be reformed to increase accessibility and distribution of resources,

particularly to communities across all economic, regional, and gender lines.

As a part of the UN, Nigeria has a responsibility to achieve the 17 Sustainable

Development Goals (SDGs) by 2030. These goals allow countries to further develop different

sectors of their government, environment, and society to promote peace and prosperity.

According to Nigeria’s 2020 Voluntary National Review (United Nations, 2020), which tracks

the country’s progress in fulfilling these SDGs, Nigeria has to focus on seven primary issues:

poverty (SDG-1), health and wellbeing (SDG-3), education (SDG-4), gender equality (SDG-5),
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an inclusive economy (SDG-8), an environment of peace and security (SDG-16), and

partnerships (SDG-17). Nigeria has integrated these SDGs into national policies and programs;

however, in order to achieve these SDGs by 2030, the Nigerian government has to specifically

address the country’s health inequities and how they intersect with political, social, economic,

and cultural barriers (United Nations, 2020). In the context of Nigeria’s major HIV/AIDS

epidemic, there are many of these barriers that prevent people, especially people living with

HIV/AIDS (PLWHA) and key populations, from achieving better health outcomes. Barriers

include socio-economic inequality, availability of sustainable and effective resources, political

unrest and violence, gender inequality and power imbalances, homophobia, and stigma and

discrimination against PLWHA.

These barriers all contribute to existing disparities, including health disparities, among

Nigeria’s populations. For example, a current crisis in Nigeria is the growing schism between the

North and South populations. A key player in this national crisis is the Boko Haram insurgency

which began in 2009 (Wikipedia, n.d.). With the goal of establishing an Islamic state, the Boko

Haram is a jihadist group that has rebelled against the Nigerian government and continues to

inflict massive violence, particularly in the North East region of Nigeria (Adamu et al., 2018).

This violence includes sexual violence, harmful cultural practices, and kidnapping, and as a

result, there are increasing STD incidences and HIV/AIDS incidences in the North East (Adamu

et al., 2018). Furthermore, because of the Boko Haram’s presence, people do not have

sustainable access to health care resources including antiretroviral drugs (ARVs), thus

contributing to the growing health disparities between people in the North and South. Nigeria’s

conservative cultural values are also a driving force in perpetuating these inequities and

disparities, particularly for men who have sex with men (MSM). The Same Sex Marriage
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(Prohibition) Act, 2013 [SSMPA] passed by Nigeria’s former president Goodluck Jonathan is a

prime example. The SSMPA “prohibits a marriage contract or civil union entered into between

persons of same sex and provides penalties for the solemnisation and witnessing of same

thereof” (2013). This Act demonstrated the political and social support of homophobia in

Nigeria, giving people the means to further ostracize this group. According to NOIPolls (2015),

92% of the Nigerian population supported the SSMPA in 2013, and this number decreased to

87% in 2015, indicating some change in attitudes towards LGB people. However, because the

overwhelming majority support the law, queer and LGB people in Nigeria have had to face more

stigma and discrimination. Consequently, the criminalization of same-sex relationships has

severely impaired their health, and it has instilled fear in them to go seek medical care or

socialize with other queer people in previously safe spaces (Schwartz et al., 2015). In the context

of HIV and AIDS, the SSMPA continues to impact the health outcomes, social networks, and

accessibility to prevention methods for MSM and MSM who are living with HIV/AIDS.

Although the Boko Haram insurgency and SSMPA have impacted health outcomes, especially in

regards to HIV/AIDS, there was less national control over the epidemic in the past. A critical

turning point in Nigeria’s history occurred when Nigeria shifted back to a democratic

government in 1999 (Gembu Center for HIV AIDS Advocacy Nigeria, 2020). For decades,

Nigeria had been under military rule, even after gaining independence on October 1, 1960 from

the UK (CIA, 2020). After the shift to democracy, the government was able to begin

coordinating a national response by creating programs, policies, and organizations that would

distribute resources and services to those who did not have access or where resources were not

available. Under the current President Muhammadu Buhari, the government needs to take more

action to address these inequities in order to eliminate the HIV/AIDS epidemic in Nigeria.
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History of HIV/AIDS in Nigeria: The Beginning of the Epidemic

When the HIV/AIDS epidemic initially began, Nigerians did not believe that HIV or

AIDS would ever be discovered in Nigeria, and this denial continued from 1981 to 1986

(Balogun, 2010). In 1985 the first two cases of HIV appeared in the urban, Southern cities of

Lagos and Enugu, both of which were not reported until at an international AIDS conference in

1986 (Balogun, 2010). One of the people diagnosed included a 13-year-old female sex-worker

from one of the West African countries (Balogun, 2010). Following these first cases, in 1987 the

Federal Ministry of Health in Nigeria established the National AIDS Advisory Committee

(NAAC) and the National Expert Advisory Committee on AIDS (NEACA) (Enwereji et al.,

2011). These were Nigeria’s first national responses against HIV and AIDS; however, no

effective preventative measures or policies were implemented to combat the epidemic. The lack

of social support also contributed to the epidemic’s growth between 1986 and 1997. Despite HIV

and AIDS being discovered in Nigeria, people still held a widespread disbelief in and

indifference to these first cases (Balogun, 2010) and even commonly referred to AIDS as an

“American Idea/Invention for Discouraging Sex” (Awofala & Ogundele, 2018). It was only after

the famous Nigerian musician and human rights activist Fela Anikulapo-Kuti died in 1997 from

AIDS-related complications that people realized that there was a national HIV/AIDS epidemic

(Balogun, 2010). Consequently, from 1986 to the majority of the 1990s, HIV/AIDS began to

become more prevalent, especially in urban areas, and gradually, HIV/AIDS disseminated across

the country from urban areas to rural areas (Balogun, 2010).

After the Federal Ministry of Health acknowledged that the Nigerian government was not

reacting urgently enough to increasing HIV transmission rates, in 1991 the first survey on

HIV/AIDS was conducted to gauge the state of the HIV/AIDS epidemic (Awofala & Ogundele,
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2018). According to this survey, HIV prevalence was 1.8% in 1991, and HIV prevalence

continued to increase to 3.8% in 1993, 4.5% in 1996, 5.4% in 1999, and 5.8% in 2001 (Awofala

& Ogundele, 2018). The key populations at this time were similar to that of the current epidemic:

pregnant women, female sex workers (FSW), men who have sex with men (MSM), and people

who inject drugs (PWID). Subsequently, HIV prevention and treatment began to escalate and

become a federal priority after the shift to a democracy in 1999 (Awofala & Ogundele, 2018).

The government collaborated with several international organizations to coordinate more

thorough surveys on HIV/AIDS in Nigeria, including the National HIV/AIDS and Reproductive

Health Survey (NARHS) and Behavioral Surveillance Surveys (BSS) (Awofala & Ogundele,

2018). These surveys were more extensive and inclusive than traditional household surveys,

allowing the government to gain more insight into which groups and what behaviors were at

higher risk for HIV and AIDS. The results indicated that HIV and AIDS were most prevalent

among urban residents, females in both urban and rural areas, and people between the ages of 25

and 29 (Balogun, 2010). Because HIV and AIDS disproportionately affected more females than

males, HIV prevalence increased to about 5.9 for 15 – 24-year-old females in 2001

(UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, 2004). HIV

prevalence among female sex workers also grew during the 1990s following the first HIV cases

in Nigeria. In Lagos State, for example, when HIV testing for sex workers initially began in 1988

– 1989, 2% of FSW tested had HIV (UNAIDS/WHO Working Group, 2004). This number

rapidly grew to 15% of FSW tested having HIV in 1993, and 33% of FSW tested having HIV in

1995 (UNAIDS/WHO Working Group, 2004). In Borno State, there was similar growth in HIV

cases, as less than 1% of FSW initially tested had HIV in 1986 – 1987; the data in following

years demonstrated tremendous growth with 24% of FSW tested having HIV, and 55% of FSW
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tested having HIV in 1996 (UNAIDS/WHO Working Group, 2004). As HIV prevalence

expanded in urban areas, HIV/AIDS spread to more regions and different populations outside of

urban centers. In 2000 the collected data presented that 11% of soldiers had HIV, and 4% of

truck drivers in Anambra State had HIV (UNAIDS/WHO Working Group, 2004).

History of HIV/AIDS in Nigeria: National Plans and Policies

Following the political shift in 1999, former President Olusegun Obasanjo created the

President’s Committee on AIDS (PCA) and the National Action Committee on AIDS (NACA)

(Gembu Center for HIV AIDS Advocacy Nigeria [GECHAAN], 2020). NACA, which was later

transformed into the National Agency for the Control of AIDS, continues to lead the national,

multi-sectoral campaign in eliminating the HIV/AIDS epidemic through coordinating programs,

influencing policy changes, and mobilizing resources (NACA, 2020). As the central coordinator

for Nigeria’s HIV programs and policies, NACA oversees the State Action Committee on AIDS

(SACA) and Local Government Action Committee on AIDS (LACA), which mitigate the

epidemic on a more region-specific level (NACA, 2014).

To combat the epidemic on a national level, NACA develops one National Strategic

Framework (NSF) and tracks the progress of it in alleviating the epidemic through the Nigeria

National Response Information Management System, otherwise known as NNRIMS (NACA,

2014). The NSF 2005-2009 was the first NSF that NACA created after the end of the HIV/AIDS

Emergency Plan (HEAP) in 2001 – 2004. Established by Obasanjo, HEAP was the first national

plan that aimed to mitigate the epidemic and to provide the necessary care, support, and

networks for PLWHA and AIDS orphans. Some of HEAP’s objectives included raising

awareness of HIV and AIDS, empowering and educating high-risk communities, reducing

stigma and discrimination against PLWHA, and increasing research and surveillance on
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HIV/AIDS (NACA, 2001). After HEAP, the NSF 2005 – 2009 focused on addressing the

interplay between gender and HIV/AIDS (particularly PMTCT), encouraging behavior change,

and providing universal access to treatment and care (Celentano & Beyrer, 2008). This plan also

integrated the different stakeholders including the government, Nigeria’s six geopolitical zones,

and various international partners (Celentano & Beyrer, 2008). The second NSF (NSF II) was the

National Strategic Plan (NSP) 2010 – 2015, and this targeted six thematic areas: behavior

change, treatment, care and support, policy and human rights, infrastructure and resources, and

monitoring systems (NACA, 2010). The NSP expanded HIV prevention efforts in prisons,

schools, and the workplace, and it encompassed more comprehensive guidelines to support

PLWHA, particularly among female key groups and PMTCT (NACA, 2010). For example, the

Plan included more programs to support networks of PLWHA and programs to alleviate poverty

for PLWHA (NACA, 2015). These programs were particularly effective in addressing the

intersectionality between HIV/AIDS and socio-economic status, while also making progress in

the SDGs. When the NSP was paired with the Minimum Package for Prevention Interventions

(MPPI) in 2013, HIV/AIDS prevention became more effective by extending to biomedical,

behavioral, and structural approaches (NACA, 2014). By the end of the Plan in 2015, the number

of health facilities that provided ART increased from 516 to 1057, and as a result, ART

accessibility and coverage had increased (NACA, 2015). Furthermore, the NSP led to the

development of the 2010 and 2014 PMTCT Guidelines and the 2012 National Guideline for the

Implementation of HIV Prevention Programs for Female Sex Workers (NACA, 2015). However,

the NSP 2010 – 2015 was not perfect, as it lacked interventions that would target and address the

needs of key populations such as men who have sex with men and transgender people (NACA,

2015). All of these national plans to implement interventions in multiple sectors were pivotal in
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preventing the epidemic from accelerating. They were also significant because they recognized

the impact of political, social, economic and cultural factors, including availability of resources,

stigma, accessibility, and gender inequality, on obtaining HIV testing and treatment.

Although the national plans included eliminating stigma and discrimination against

PLWHA, they did not specify how this was going to be executed. Therefore, the HIV and AIDS

Antidiscrimination Act, 2014 was a significant milestone because it was the first political

response in actively condemning discrimination and protecting the rights of PLWHA

(Odimegwu et al., 2017). In addition, it is significant because the Act was originally introduced

in 2005 and had not been officially approved for nine years, despite the insistence by PLWHA

(Odimegwu et al., 2017). Under the Antidiscrimination Act (2014), all Nigerians are obligated to

prevent any stigma and discrimination. PLWHA have the right to privacy about their HIV status,

employment, and welfare benefits, but they must disclose their status to their partner(s). All

employers, institutions, and communities are required to protect the rights of PLWHA, including

providing equal opportunities, ensuring confidentiality, and developing their own HIV/AIDS

antidiscrimination policy (HIV and AIDS Antidiscrimination Act, 2014). If the Act is violated,

penalties include fines and imprisonment; however, it is unclear how effective or ineffective this

Act is in protecting PLWHA from stigma and discrimination since state levels of enforcement

vary and level of awareness among Nigerians vary as well (Odimegwu et al., 2017). Following

this 2014 Act, the National HIV/AIDS Stigma Reduction Strategy, 2016 was developed, which

consisted of nine strategic objectives. These objectives collectively aimed to align the efforts of

various stakeholders within their jurisdiction and extent of influence to eliminate stigma and

discrimination against PLWHA (NACA, 2016). These stakeholders include community-based

organizations, faith-based organizations, the media, art and entertainment industry, health care
NIGERIA’S HIV/AIDS EPIDEMIC 12

and education institutions, and employers (NACA, 2016). The Stigma Reduction Strategy also

emphasized improving legal awareness of the policies on stigma and discrimination such as the

Antidiscrimination Act, 2014 (NACA, 2016). It is important to recognize the role of stigma and

discrimination in Nigeria’s HIV/AIDS epidemic because as indicated by the PLWHA Stigma

Index, it impacts accessibility to work and education, health and well-being, self-esteem, and

relationships with other people (Odimegwu et al., 2017). In 2015 approximately 72% of

Nigerians were willing to care for a relative living with HIV; 67% were willing to allow an HIV-

infected student in school or HIV-infected co-worker in the workplace; and 42% were willing to

buy food from a shopkeeper with HIV (NACA, 2015). Although there has been an overall

decreasing trend over the past decades, more research needs to be conducted to evaluate the

current state of stigma and discrimination against PLWHA.

The Current HIV/AIDS Epidemic in Nigeria

Nigeria currently has the second largest HIV epidemic in the world, accounting for 9% of

all people living with HIV and 10% of HIV incidences (NACA, 2017). HIV prevalence among

adults between the ages of 15 and 49 is 1.5% (Joint United Nations Programme on HIV/AIDS

[UNAIDS], 2019); however, according to new survey results from the Nigeria National

HIV/AIDS Indicator and Impact Survey (NAISS) in March 2019, the prevalence was reported to

have decreased to 1.4% among adults (UNAIDS, 2019). Despite how relatively low Nigeria’s

HIV prevalence may appear to be, this percentage corresponds to approximately 3.6 million

people living with HIV/AIDS, or PLWHA (NACA, 2017). According to UNAIDS’s, however,

this percentage corresponds to 1.9 million PLWHA in Nigeria (2019). This discrepancy is a

result of many people living with HIV being unaware of their serostatus (Avert, 2019). As

reflected in the most recent 90-90-90 progress update in Figure 2, 67% of people living with HIV
NIGERIA’S HIV/AIDS EPIDEMIC 13

know their status; 53% of people living with HIV are on treatment; and 80% of people living

with HIV are virally suppressed (UNAIDS, 2019). This data can be misleading in portraying the

full extent of the HIV/AIDS epidemic in Nigeria since the second and third values of the 90-90-

90 target only represent 52% and 42%, respectively, of all PLWHA (UNAIDS, 2019).

Figure 2. Nigeria’s progress towards 90-90-90 targets (Avert, 2019)

The 2019 NAIIS found that HIV prevalence significantly varies across gender, age, and

region, among other categories. For example, HIV prevalence among females is 1.9%, which is

significantly higher than HIV prevalence among males, 0.9% (NAISS, 2019). Prevalence is also

concentrated in people between the ages of 15 and 49 (1.4% – 1.5%), as 75% of PLWHA are 15

– 49 years old, and 13% of PLWHA are 50 years old or older (NAISS, 2019). HIV prevalence

among children between 0 and 14 years old is 0.2%, accounting for 12% of PLWHA (NAISS,

2019). Among the six geopolitical zones of Nigeria (Figure 3), prevalence is greatest in the

South-South (3.1%) and North-Central (2.1%), while prevalence is lowest in the North-West

(0.6%) and North-East (1.1%) (NAISS, 2019). Currently, seven states have a high prevalence of

2.0% and above: Abia, Taraba, Benue, Enugu, Anambra, Akwa-Ibom and Rivers (NACA, 2019).

The PLWHA in these states account for 50% of all PLWHA in Nigeria. The Federal Capital
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Territory and 13 states have a medium prevalence between 1.0% and 1.9%, including Borno and

Lagos, and 16 states have a low prevalence below 1.0% (NACA, 2019).

Figure 3. HIV prevalence among people 15 – 64 years old by zone (NAISS, 2019)

While HIV/AIDS prevalence has been generally constant, HIV/AIDS incidence has been

growing each year, and in 2018, there were over 130,000 new cases with the majority of them

from key populations including females and children (UNAIDS, 2019). Female incidence is

significantly higher than male incidence among adolescents, young adults, and adults (NACA,

2019). The primary mode of HIV transmission in Nigeria is through heterosexual sex,

accounting for 80% of HIV incidences, and mother-to-child transmission (MTCT) and blood

transfusions are also common modes (NACA, 2014). In Nigeria, the key populations that

comprise the majority of HIV incidences include female sex workers (FSW), men who have sex

with me (MSM), and people who inject drugs (PWID) (NACA, 2019). Although these groups

represent 1% of the total adult population, they contribute around 23% of HIV incidences and

including their partners, 40% of HIV incidences (NACA, 2019). Young people, children, and
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females are also key populations of this epidemic who do not have access to stable health

services, among other barriers (Avert, 2019).

Sex workers have been one of the key populations since the beginning of the HIV/AIDS

epidemic in Nigeria. Since 2016, HIV prevalence among sex workers has been 14.4%, which is a

significant decrease from the HIV prevalence in 2013, 24.5% (UNAIDS, 2017). Female sex

workers and brothel-based FSW, in particular, are a key population since 20% of HIV/AIDS

incidences can be attributed to FSW, their clients, and their clients’ partners (NACA, 2019). HIV

prevalence is also higher among female sex workers, 24.5%, than male sex workers, 18.6%

(NACA, 2015). Although prevalence is still high, the decrease in recent years can be attributed to

increase condom use and condom distribution, as 98.1% of sex workers reported using a condom

with their last sexual partner (UNAIDS, 2017). Furthermore, more sex workers are receiving

HIV tests, and in 2017, 97.1% of FSW reported receiving an HIV test in the last 12 months

(UNAIDS, 2017). Some barriers, however, that are preventing sex workers from negotiating safe

sex and from obtaining the necessary resources, such as medical care, to test for, prevent, and

treat HIV/AIDS are politics and power imbalances. Because sex work is illegal in Nigeria and

punishable by imprisonment, it is a challenge for sex workers to seek health care and disclose

their job to healthcare workers (Global Network of Sex Work Projects, 2015). Fear of stigma and

discrimination is also a factor that prevents sex workers from seeking care because stigma and

discrimination are widespread in Nigeria. They are also more vulnerable to human rights

violations, so sex workers face more violence, including sexual violence, from clients, law

enforcement, and community members (Global Network of Sex Work Projects, 2015). As a

result, they are not always able to negotiate safe sex practices like using condoms, which would

increase their risk for acquiring HIV.

Men who have sex with men, MSM, are the only key population in Nigeria whose HIV

prevalence is continuing to rise. Currently, the HIV/AIDS prevalence among MSM is about 23%

(UNAIDS, 2018), and MSM and their partners account for about 10% of HIV/AIDS incidences

(NACA, 2019). Condom use among MSM is particularly low, as only 51% reported using a

condom with their last sexual partner (UNAIDS, 2018). However, there has been an increase in

MSM who are receiving HIV tests, and in 2017, 97% of MSM reported receiving an HIV test in

the last 12 months (Avert, 2019). Compared to females, there have been fewer prevention

measures targeted towards men and MSM because of the significant disparity in prevalence

between males and females. This lack of programs has contributed to greater incidences among

MSM; however, the greatest barriers against reducing the burden of the epidemic on this key

population are stigma, discrimination, and homophobia. The Same Sex Marriage (Prohibition)

Act, 2013 has played a prominent role in impairing the health outcomes for MSM because it

reinforced the homophobia that has already been very pervasive in Nigeria. Although NACA

stated, “Nothing in the Same Sex Marriage (Prohibition) Act 2013 refers to or prohibits

programs targeted at prevention, treatment, care and support for people living with HIV or

affected by AIDS in Nigeria” (NACA, 2014), this Act has had a detrimental impact on MSM and

the LGB community at large (Schwartz et al., 2015). The SSMPA has led to several

consequences including increased fear among MSM to seek healthcare, increased avoidance of

seeking healthcare or attending follow-ups, increased blackmail, and increased verbal harassment

(Schwartz et al., 2015). Law enforcement officials have also used it as an excuse to harass and

occasionally incarcerate MSM (NACA, 2015).

People who inject drugs, PWID, are another key population of this epidemic that require

more targeted approaches. The HIV prevalence among PWID is 3.4% with females having a
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higher prevalence of 13.9% than males with a prevalence of 2.6% (UNAIDS, 2018).

Furthermore, a female sex worker who inject drugs has the highest prevalence of around 43%

(NACA, 2019). According to NACA (2019), PWID and their partners contribute 9% of annual

HIV/AIDS incidences. HIV is spread through sharing needles, so this particular groups requires

more effective harm reduction strategies and services such as opioid substitution therapy and

clean needle exchanges (Avert, 2019). However, these harm reduction approaches are not

available yet in Nigeria; they are currently in the Revised National HIV and AIDS Strategic

Framework for 2019 – 2021.

In addition to these key populations, young people, children, and females are burdened by

the epidemic. For young people, especially young females, they are at higher risk of acquiring

HIV because of lack of knowledge and lack of appropriate sexual health services. In 2018 only

28.86% of young people between the ages of 15 and 24 had knowledge about HIV prevention

(UNAIDS). Coupled with having sex at a younger age and having a sexual partner who is much

older, which is common for young females in Nigeria, young people are very vulnerable to

HIV/AIDS (Avert, 2019). HIV/AIDS also has a direct and indirect impact on children under 14

years old. In 2017 about 220,000 children were living with HIV/AIDS, and only 26% were

receiving antiretroviral therapy, ART (UNAIDS, 2018). The incidence rate for children is also

alarmingly high, accounting for around 17% of HIV incidences in 2017 (NACA, 2019). The

indirect impact is evident in the increasing number of AIDS orphans in Nigeria, impacting the

children’s health (NACA, 2019). Furthermore, in the case of a child with a parent living with

HIV/AIDS, this can have an indirect impact on the child’s educational stability. Because of the

gender inequality in Nigeria, girls are more likely to have to care for the parent and sacrifice their

education and their opportunity to learn about HIV prevention in school (Avert, 2019). The
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gender inequality and resulting power imbalances that exist in Nigeria also explain why females,

specifically pregnant women, are key populations of this epidemic. As women are pressured by

the patriarchal society to birth boys, women who have girls first are likely to give birth to more

children and not use contraceptives (Milazzo, 2014). Because of the power imbalance, they

would have less control over these decisions and other decisions including time between

pregnancies. Consequently, they would likely have shorter periods between pregnancies, which

is a health risk in itself, and be subjected to polygamy (Milazzo, 2014). All of these effects

increase pregnant women’s risk for HIV/AIDS. Furthermore, there is poor antenatal care in

Nigeria, so pregnant women have less access to HIV tests and follow-up appointments; in 2017

only 35% of pregnant women received an HIV test (Avert, 2020). There are also few PMTCT

programs, so pregnant women living with HIV/AIDS have less resources to take preventative

measures against transmission and have an early infant diagnosis (Avert, 2020). As a result,

MTC transmission of HIV account for 90% of HIV incidences in children (NACA, 2019).

Recent HIV/AIDS Control Efforts

Following the National Strategic Plan (NSP) 2010 – 2015, the Nigerian government

implemented new plans, programs, and policies that aligned the national goal of eliminating the

HIV/AIDS epidemic with the global goal of achieving the SDGs. The plans stated at NACA’s 5th

National Council on AIDS (2019), for example, encapsulates some of the new efforts made to

target the third SDG regarding health and wellbeing. The Council specifically addressed issues

including accessibility to treatment, quality of treatment, and allocation of funds to better combat

the HIV/AIDS epidemic. At this meeting, a policy was supported to lower the age of consent for

adolescents and young people living with HIV (AYPLHIV) to access HIV and sexual and

reproductive health services (NACA, 2019). This would increase accessibility to treatment and
NIGERIA’S HIV/AIDS EPIDEMIC 19

prevention measures for a high-risk group. The Council also supported increasing HIV self-

testing, especially among high-risk populations (NACA, 2019); therefore, people who typically

avoid seeking healthcare because of fear and discrimination, such as sex workers and MSM, can

achieve better health outcomes. Other plans that were approved include improving client

adherence to ART through building better provider-client relationships and mobilizing funds to

increase HIV testing and PMTCT services (NACA, 2019). There was also an effort to increase

availability of viral load testing for PLWHA in all states, but this was denied due to lack of

funding; instead, the Council approved of increasing support for existing laboratories that

provide viral load testing services. (NACA, 2019). In 2016 the National HIV and AIDS Strategic

Framework (NSF) 2017-2021 was also created, which was later replaced by the Revised NSF for

2019 – 2021 (RNSF).

The HIV/AIDS Epidemic in Nigeria in 2030

Under the Revised National HIV and AIDS Strategic Framework for 2019 – 2021,

Nigeria aims to completely eliminate its HIV/AIDS epidemic by achieving the 90-90-90 targets

by 2020 and 95-95-95 targets by 2030. The goal for the RNSF was the same goal stated in the

NSF 2017 – 2021: “An AIDS-free Nigeria, with zero new infection, zero AIDS-related

discrimination and stigma, with a broad goal to ‘Fast-track the national response towards ending

AIDS in Nigeria by 2030’” (NACA, 2019). Through implementing new policies and generating

more funding, Nigeria aims to completely eliminate HIV incidences and MTCT of HIV by 2030.

Furthermore, the other objectives for 2030 include ensuring that 95% of the population,

especially key groups, have access to HIV combination prevention intervention; 95% of people

living with HIV know their status; 95% of people living with HIV are on sustainable ART; and

95% of people living with HIV who are on ART are virally suppressed (NACA, 2019).
NIGERIA’S HIV/AIDS EPIDEMIC 20

Developing a Plan to Achieve the HIV/AIDS Goals by 2030

In order to meet the 95-95-95 target by 2030, Nigeria’s government is focusing on

implementing specific prevention and intervention strategies for the general population and key

populations as well as for low, medium, and high HIV prevalence states. Regarding prevention

for the general population, the primary strategies include increasing negotiation behavior for

condom usage, emphasizing HIV testing, increasing HIV awareness and knowledge, and

implementing sexual and reproductive health interventions (NACA, 2019). For key populations,

NACA (2019) emphasizes reducing stigma and discrimination, implementing harm reduction

interventions for PWID, distributing PrEP to male sex workers, and implementing sexual and

reproductive health interventions. The RNSF also aims to incorporate the use of media and

HIV/AIDS education to increase the number of “HIV Competent” individuals (NACA, 2019).

Regarding efforts to completely eliminate MTCT, NACA describes 4 key points: providing

prevention resources for young women, preventing unintended pregnancies among women with

HIV, preventing HIV transmission from women with HIV to their infants, and providing the

necessary treatment and support to women with HIV (2019). However, PMTCT services first

have to be integrated into health services for children and newborns.

By targeting the low, medium, and high prevalence states with different plans

corresponding to their location and population, the RNSF is implementing a Location-Population

strategy. For the seven high prevalence states, the strategies to achieve the 2030 target include

implementing more community-based services, expanding services for HIV and sexual and

reproductive health, increasing HIV testing and treatment (specifically for MSM), and increasing

PMTCT services such as early infant diagnosis (NACA, 2019). This plan would focus on

targeting groups, such as FSW, MSM and pregnant women, that carry the greatest burden of the
NIGERIA’S HIV/AIDS EPIDEMIC 21

epidemic. For the 13 medium prevalence states, the primary strategies include expanding

combination HIV prevention, tailoring prevention methods for adolescent girls and young

women, establishing community distribution centers for ART, increasing HIV testing and other

health services, and implementing programs that target “mobile and cash-rich workers” such as

truck drivers and female sex workers (NACA, 2019). These strategies would specifically

decrease HIV/AIDS incidences among key populations and high-risk groups. For the 16 low

prevalence states, the main strategy is increasing prevention programs that target key populations

since most HIV incidences in low prevalence states are from high-risk groups (NACA, 2019).

Other strategies for these states include increasing HIV and other health services, extending the

plan to young populations, implementing more harm reduction services and PMTCT services,

increasing PrEP distribution, and increasing funding for prevention programs (NACA, 2019).

The Reality of Achieving the HIV/AIDS Goals by 2030

Considering Nigeria’s history and current barriers against achieving the 95-95-95 target,

more time and work are necessary for Nigeria to achieve its HIV/AIDS goals. A primary reason

why the 2030 target is currently unachievable is that Nigeria has yet to make significant and

consistent progress in achieving the SDGs. Until issues of poverty, healthcare, and gender

inequality are directly tackled by the government, it will be challenging to alleviate any singular

issue because these issues often intersect with each other. A major barrier in addressing these

issues are Nigeria’s cultural values that are passed down each generation. Just as the patriarchal

society and corresponding power imbalances have continued, rampant homophobia and stigma

and discrimination against PLWHA maintain their power in society as well. Therefore, if Nigeria

wants to eliminate their HIV/AIDS epidemic and make progress in their SDGs, eliminating

stigma and discrimination should be a greater national priority. There needs to be an increase in
NIGERIA’S HIV/AIDS EPIDEMIC 22

awareness and enforcement of the HIV and AIDS Antidiscrimination Act, 2014 and the National

HIV/AIDS Stigma Reduction Strategy, 2016 (Odimegwu et al., 2017). In addition, there needs to

be more surveillance systems that accurately track and evaluate the impact of these reduction

programs on the national and regional level (Odimegwu et al., 2017). Because stigma and

discrimination are so culturally-ingrained and widespread, more active measures need to be

taken to effectively eliminate them. According to a study in Southwestern Nigeria, for example,

even though respondents had a high level of awareness and knowledge about HIV/AIDS and

PMTCT, around 71% had negative attitudes towards PMTCT because of the social stigma

surrounding HIV and PMTCT (Olugbenga-Bello, 2013). This study demonstrated how efforts

needs to be made to bridge the gap between HIV knowledge and HIV perception in order to

increase prevention. Some strategies to address and reduce stigma around HIV/AIDS include

incorporating de-stigmatization programs into the media, integrating HIV/AIDS education into

school curriculums at all levels of education, and collaborating with PLWHA and high-risk

groups to design and to implement prevention policies and programs (Monjok et al., 2009).

Stigma should also be reduced in the healthcare sector by encouraging healthcare professionals

to empathize and understand the needs of PLWHA (Monjok et al., 2009). On a larger scale,

people need to reduce stigma by addressing the cultural, religious, and social influences in the

country that fuel people’s stigma and discrimination. Until Nigeria’s government and people

have the political and social will to eliminate the stigma and discrimination against people living

with HIV/AIDS, and in effect make progress towards the SDGs, it is going to take more time

than by 2030 to achieve either the 90-90-90 or 95-95-95 target.

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