INTERVIEW: The challenges faced, successes achieved in dealing with HIV in Nigeria – NACA DG

Director-General of the National Agency for the Control of HIV/AIDS, NACA, Sani Aliyu
Director-General of the National Agency for the Control of HIV/AIDS, NACA, Sani Aliyu

Sani Aliyu assumed office as the Director-General of the National Agency for the Control of HIV/AIDS, NACA, in November last year. He had his first degree at the Ahmadu Bello University, Zaria and worked for a few years in the State House Clinic, Abuja, before moving to the United Kingdom in 1998 for further studies, partly in London and Cambridge.

He became a consultant in infectious diseases and medical microbiology in 2007 and was a senior hospital consultant in Cambridge University Hospital for 10 years until his current appointment.

Mr. Aliyu acquired some managerial responsibility in addition to chairing the national UK infectious diseases exam board.

“My interest has always been in HIV. In fact, it was HIV that took me into infectious diseases. I have a strong interest and I feel strong with patients that have infectious diseases and the need for them to have good care”, he said in this interview with Ayodamola Owoseye and Nike Adebowale.

PT:  What is NACA’s position on the HIV self -test kit, can it be deployed in Nigeria to enable more Nigerians know their HIV status from the comfort of their homes?

Aliyu: It is important with epidemic like HIV that people know their status; they know whether they are HIV positive or negative and if they are positive, obviously they need to be linked to care.

The problem with some of the self-test kits is their performance. Whenever a new test assay is introduced into the market, we need to do field testing to make sure they work very well. In addition to that, some infections like HIV require some degree of counselling before the test. Imagine if you put yourself in a room and you are worried and you decided to do the test yourself and don’t do it properly and you get a false positive result, the psychological effect could be devastating.

So increasingly in the developed countries, there is a push towards the self test and I think it is the performance that has encouraged the use of the kit. It is actually a good idea but there can be problem about the handling and the storage of the kit. Even the storage of the test kits can affect the performance of the kit.

For a disease like HIV where the prevalence rate is very low, the lower the prevalence rate, that is the positive predictive valve is very high, and you are likely to get a false positive result. I will caution that any sort of intervention that we can do to get people tested is a good idea. But if you are buying a test kit or you are doing a test using a self-test kit, make sure that it is registered with the right authority such as NAFDAC etc. Make sure that you get it from a genuine and not just from the internet and make sure that you have appropriate counselling. More importantly, if it gives you a positive result, don’t rely on the result, go on and have a proper test so that you can know whether it is truly positive or not.

PT: NACA said less than 10 percent of Nigerians have had an HIV test done once, what is the agency doing to improve on this?

Aliyu: There is a huge scale out in the number of people that have been tested for HIV. In 2015 alone we had about 7.7 million people tested with HIV. So that is a lot. It is important that we keep the profile of HIV right at the front of people’s mind, especially young people. At the moment, a lot of people think HIV is no longer a problem because the medication are there and they work very well and people will remain healthy for life. If you are going to live to be 70 or 80 without HIV, you will live to be same age with HIV if you take your drugs.

But that sort of message at this time is to a certain extent increasing high risk behaviour and it is important that people really get tested. Particularly, certain groups that are higher prone, what we call key population. The female sex worker for example. And also pregnant women because the intervention that are available, the medication can actually stop transmission from mother to child. The risk of transmitting HIV from mother to child without treatment is about 30 per cent and reduces to about 1 percent if the medication is taken.

Health Minister, Isaac Adewole

In addition to that, if you are on medication and the amount of virus in your blood stream is very low, what we call virological suppression, you are even less likely to transmit the virus to your partner even when with un-protective sex. The risk significantly comes down. And in fact, one of the approaches that we are adopting is to start thinking of using treatment as prevention in itself, because the more people that are on treatment, the lower the number of highly infectious people living within the society and that way, the transmission rate will be much lesser. So we are talking of treatment and prevention in itself as a package to reduce transmission of HIV.

PT –Where and how do you collate the data of tested people and those with HIV?

Aliyu: You are probably aware that we have a lot of HIV counselling and testing centres across the country. We have over a thousand treatment sites as well.  And a lot of those sites upload the data when they do an HIV test to the database at the Federal Ministry of Health which is also linked up to our own database.

We have a pretty good idea of the number of HIV tests that are going on. Obviously, we are unable to pick all of them but we have been able to pick a large number of them. Most of the test kits that are brought into the country either by our implementing partners, for example the NGOs, or they are brought in by NACA and those test kits are given out free and for free testing. We give them out free for testing and when we give them out free we expect results to be sent back.  If a thousand test kits is given out it is expected that after the outreach, the partners come back and give a report on the number of people tested and the number of positive gotten. We do have data collection regularly, but it is obviously not hundred percent data collection because it is impossible to have that. But our move is to have more accurate data and to have more real time data coming in using technology.

PT – Is NACA thinking of collaborating with private institutions to collate accurate data?

Aliyu: One of my main aims is to try and normalise HIV services because HIV is just like any other medical condition such as diabetes or hypertension, which are all chronic ailments. It is a chronic ailment that if managed well, people can live a normal life. And if we are able to take out the issues of prejudices, stigma and discrimination that still exist sadly in our society when it comes to people associated with HIV, then we should be able to start normalising treatment.

My vision is that one day you can walk into any hospital, have a HIV test done and be put on treatment and be followed up; and have choice, that is patient choice as to whether you want to have your HIV treatment and management in your local primary health care centre or in a general hospital or with private physician. And also improve the skill and the quality of handling the issue, as the quality is really important. For example, the Minister of Health, Isaac Adewole, has been trying to renovate primary healthcare centres across the country. He is taking at least 3 in every state and we are latching on this idea to push for the improvement in the quality of HIV services. So with each primary healthcare centre renovated, we will go in and build the capacity and the tools of the community health workers to deliver quality service, to deliver counselling and testing on HIV and also to initiate anti-retroviral therapy.

As the minister works towards improving the overall health of the country, we are latching on to him to improve the quality of HIV services. We are going to start moving from quantity to quality so that the overall standard of living for HIV patients improves and the number of HIV patients that are on treatments and that are biologically prepared goes down.

NACA Headquarters
NACA Headquarters

We really need to start thinking of HIV in this country in a different way. It is a chronic illness. The people who have it didn’t contact it deliberately. Nobody goes out deliberately to contact HIV. Anybody who has HIV should not be blamed or hated for having HIV because it can happen to anyone. It has no respect whether you are rich or poor, whether you are in the north or southern part of the country, whether you are educated or not. It has no respect for status or individuals and therefore people who have HIV have a right to good quality care and I am going to be a very strong advocate for that. I am here for them and NACA is here for all patients with HIV. People with HIV should be treated well, they should not be stigmatised, and they have the right to good quality life just like everybody else. It is simply a disease that needs to be treated.

PT -To what extent does the fight against HIV in Nigeria depend on international donors?

Aliyu: Things are changing, but we are certainly far away from the Promised Land. The Federal Government has been increasing investment in HIV care. For example, between 2013 and 2014, the contribution of the public sector to HIV had gone from 18 per cent to about 27 per cent. At the moment, the international donors contribute about 70 percent to the HIV programme. But an important point to make is that the only way we can achieve epidemic control and have sustainability is really by country ownership. That means all across the level of government, the Federal Government alone cannot do this.

If you look at estimate of people living with HIV infection, we have about nine hundred thousand people on treatment and there is an estimate of about three million people with HIV.  If all 3 million people are going to be tested and placed on treatment, it means we have a gap of about 2 million people requiring treatment. If the cost of giving treatment is about $150 million per month, that means we are taking about $450 million per year and this is more than 30 -40 per cent of our entire country budget.

We need the state government to come into it, we need the private institutions to come in and we also need agencies such as National Health Insurance Scheme (NHIS). I know some states have introduced HIV as one of their health indicator diseases for insurance, which is great. But there are some states that don’t even have HIV on their line budget. And that is unacceptable because you have patients with HIV that are in your state and you should budget for their welfare and health.

One of NACA’s main mandate is to make that possible for realisation. And we are very keen to work with our partners, with other state and local governments and federal government to make sure that the funding for HIV is adequate.

And the funding for HIV, especially the drugs and the commodity, cannot rely on the normal budget. We cannot wait until the next capital vote before we pay for anti-retroviral drugs. Remember when you are put on HIV treatment you need to be on it forever. You cannot wait until my drugs are about to run out in the next one month, but we just wait and see when the next one will be available.

We need full funding from our private sector, from the health insurance scheme, the federal and state governments and make sure that drugs are procured at the right time and made available where they need to be used. That is really important and that is something I intend to push. I am already having very good conversations with some of the state governments, the Minister of Health is very much in support of our move towards it, as he has been engaged in the HIV field for a very long time and he is a very strong advocate of people with HIV.

We intend to work with the federal ministry of health, with the Budget Office and also with the state governments to make sure that there is enough money to keep this drugs coming in and to keep people on treatment and make them healthy and remain healthy.

A diagnostic room in primary healthcare, Kuchigoro, Abuja
A diagnostic room in primary healthcare, Kuchigoro, Abuja

PT – On non-availability of anti-retroviral drugs in some facilities in the country, what is the agency doing about this?

Aliyu: We have our procurement system and NACA contributes to the national procurement system. As I said earlier, about 70 per cent of responses are driven by our partners. A large bulk of the drugs that are consumed are actually brought in by our partners. We have been working very closely with our partners to make sure that our procurement logistics and the distribution network work very well.

We are also working extensively to ensure that the Federal Medical Store in Oshodi, Lagos State, has been improved, renovated and made to function very well. A lot of the challenges are the sort you will see in any developing country, particularly a developing country like Nigeria.

As far as I am concerned as the chief executive of NACA, I don’t want any patient going on treatment to stop because the drugs are not available. I will do anything in my power to make sure that once a patient is put on treatment they continue to be on treatment because it is not fair or right that they run out of their medication.

Running out of their medication increases the risk development. And as I said earlier I am a very strong advocate for patients with HIV. I have been interacting with the HIV field for more than 16 years and some of my closest friends and patients that are HIV positive for many years abroad have remained very healthy and the thing that applies for them outside the country is the quality of care of the HIV patient. That is what we should be aspiring to in this country. You start treatment, you are given HIV medication, we have every responsibility to make sure that you can access your medications when needed and continue to be on medication. This is the minimum standard that we should aspire to.

I know it will be challenging, mostly because of the issues facing any developing country and the issue is logistics, distribution among others and the nature of care, but we will push for it because quality is key, we will be moving from just quantity to quality.

The government currently has scaled up about 850,000 people on treatment and the government is looking at having about half a million people put on treatment in the next 18 months. Our next priority is to make sure that everyone placed on treatment is well cared for, remains healthy and they are able to go around with their normal activities and they don’t need to go through a lot of trouble in order to access the drugs or to take their drugs.

Our contract with them should be that we will give you the drugs but please comply and take your drugs. And if they are ready to pull through with the contract, we should fulfil our part and government is making every step to do so.

PT- How is NACA monitoring to know if drugs are disbursed to patients who need it?

Aliyu: They are disbursing the drugs and of course, it is to the right people because for you to have the drug you must have HIV, there is nothing you want to do with the drugs if you don’t have HIV. The approach now is no longer based on the CD4 count but an approach we call test and treat.

The moment the HIV test is done and it is positive, you need to go on treatment straight away. You don’t even have that need to have a decision on whether you need to be on treatment or not. You will be placed on treatment right away. The drugs available now, most of them are one pill by the day; the pills are extremely tolerable and easy to take. A lot of us take drugs on daily basis, especially people in the middle age with different sorts of medical complications. We end up on one pill or more once a day. So if you look at the burden in terms of taking the drugs, it really isn’t that difficult to take one pill by day.

New technologies are also emerging. For instance, new researches in UK are working on an exciting introduction of long term injectable and a lot of studies have been going on and it is looking promising. It is going to be a situation where you go to the clinic and you get an anti-retroviral jab that can last for three or six months. This will keep the patients off coming to the clinic except when necessary and also take them off the duty of taking the anti-retroviral pills. The injection will be enough to keep the patient virologically prepared.

The entrance of Kuchigoro Primary Healthcare

That is where medicine is progressing when it comes to HIV. But of course, in Nigeria we need to sort out the pill side first. Over time as medicine improves and the injection becomes available, it will help sort out the issues we have about compliance because our young people certainly don’t like taking medications. And because of the issue of stigma and discrimination, people don’t like going about with huge packages of drugs and tend to hide them from their peers and parents. The long terms injectable will certainly settle all issues relating with carrying the drugs and its usage. But we are very far from the cure; we are not there at all.

PT – What is your advice on HIV testing and treatment?

Aliyu: My advice is if you are HIV positive, you need to go on treatment and please do not be influenced by friends, relatives, or family to go to local herbalist for a cure because it does not work. Do not be influenced by local traditional healers that say they have a cure for HIV.

The only reason why HIV is no longer a death sentence is modern medicine and evidence based medicine is what we are canvassing and practicing and that is what we should be preaching.

If you don’t know your HIV status, please go and have a test done. There is a call centre and the number is 6222. So if you are worried about HIV for whatever reason you can give a call between 8 am to 8 pm. We can tell you where the closest centre is for testing and if you are tested positive, we can tell you where you can go for treatment and access your drugs as well.

We are currently working to further develop our website so that we can have more interactive sessions with people with HIV on Facebook and Twitter accounts where people can actually send me a message. Because over the last few weeks since Worlds AIDS day, I have had a lot of messages coming from people with HIV, some concerns with medications, confidentiality and we are always happy to help. People should contact us, we have many resources available and we can certainly tell you a lot more about the disease.

It is important that HIV continues to be at the fore front of our health agenda.

PT-Why the emphasis on HIV?

Aliyu: People ask me why we are too worried about people with HIV, what about the people with diabetes, hypertension? More people have these ailments.

The reasons are two- HIV affects the most reproductive parts of any society. It affects young people and those between 20 and 40, these are the people that provide food on the table for their families. They are the people that run the country’s GDP. If you treat HIV, you normalise the lifetime. In every low and middle income economy, for every one year of life expectancy gained, you have an increase of one per cent GDP. So if money is put into the prevention and control of HIV, it is like an investment, you won’t have many people with the disease and those infected will still be able to live a normal life, go out, work and generate money for the economy.

That is why it has a strategic place in the overall health system of the country and that is why organisations like NACA exist to coordinate the entire HIV response across the board.

The second reason is because HIV is a transmittable disease that can be transmitted to an unborn child, partner or loved ones. HIV is an infection that has an ability to go on and have serious impact on the community. In the early 80’s when the disease first came, there were entire communities that were wiped out. Because of the transition, most children are orphans, and because of the transmission to children, you have more children coming up with it. But gradually, we are making huge progress to reduce this.

Internationally, we have made huge progress. Now if you go to the UK, a lot of the HIV wards are closed. Many of the patients in my clinic in Cambridge do not come in to the hospital nor get admitted. It is only those that are diagnosed late. Things have changed and HIV is no longer what it used to be. You are much better off knowing your HIV status than not. If the status is known on time, the better because the treatment takes a while. The virological suppression takes several months and if your immune system is down, it will take months or a year or two before your CD4 count recovers.

Irrespective of your sexual life, have an HIV test done. It will not hurt to know your status. It is a win-win situation irrespective of the outcome because if you don’t do the test and you are positive, it’s risky. It can take up to ten years before you fall sick, then it might be too late and you end up dying from a disease that is treatable.

PT – How often or soon should the test be done after suspected exposure?

The test can be done as often; there is no strict rule on how often it can be done, especially depending on the risk factor the individual is exposed to. New test kits are available that can detect early infections. This assay has shortened the waiting windows to about three weeks, between four weeks you will have a pretty sure answer; but six weeks after exposure will be the best and reliable. So there is no need to stay for a long time after suspected risk to confirm status.

PT: What is the success rate of mother to child transmission programme of the agency?

For every pregnant woman, there is a need to do a HIV test to prevent transmission to the unborn child. Every pregnant woman in this country needs to know their HIV status, it is really important. You don’t get pregnant without sex; there must be a degree of exposure.

If you are pregnant and you have HIV, we can do something about it. It is very sad that we continue to have children born with HIV in this country. We have about 55,000 pregnant women currently on treatment; we estimate that about 177,000 women at any point in time are HIV positive.

Pregnant women who do not know their HIV status are causing harm to their baby. Every pregnant mother when they go for their antenatal visit should be tested for HIV.

Part of my priorities coming to this organisation is to improve the uptake of what we call Prevention of Mother to Child Transmission (PMTCT) rate in the country, because currently it is only about 30 per cent of pregnant women tested and put on treatment. We need to up that to about 90 per cent. We are working closely with maternal and child health services and we are going to try and introduce PMTCT teaching services across the board for every Primary Health Care Centre across the country and for every antenatal clinic.

The highest rate when it comes to transmitting HIV to the child is at the point of delivery, because that is when you have the mixture of maternal blood with foetal blood. Doctors can reduce the transmission rate by doing a caesarean section if the mother is not virologically suppressed.

They should insist on knowing their HIV status. If they are positive, they will be put on treatment and they will have a healthy child and they don’t need to have a hassle of a child growing up with HIV and having to force down drugs in the child’s throat every single day because the child does not know the importance of it.

In the UK, we have eliminated mother to child transmission because the doctors go to any length to monitor non-compliant mothers and even admit them at the late stages of their pregnancy to curtail mother to child transmission of the disease. And that should be the approach we have in this country. No matter who the pregnant woman is seeing, a local midwife, a doctor, nurse or matron, or traditional birth worker, the message is if you are pregnant, get a HIV test done and know your status because it is important for your unborn child and long term health.

PT-Some patients are still paying for anti-retroviral drugs‎, what is the agency doing about it?

Aliyu: My position here is all patients with HIV should have free medications. As far as I know, 99 per cent of drugs brought into this country are brought in by either our partner donor agencies or by the government of Nigeria, and those drugs are brought in for the purpose of free distribution. They are not brought in for the purpose of being sold. If you have HIV and we link you to a site for treatment, we expect you to get that treatment for free.  There are certain sites which charge for laboratory, for example like National Bank Blood and Promotion Agency and we are working with them because really, the laboratory aspect increases the cost of HIV delivery.

The best way to sustain national response is to bring down the cost of anti-retroviral medication and distribution and to push the HIV care into the main health sector.

HIV medications are free as far as I am concerned, and it should be given out free. We are working on the long term that patients will be able to have a choice. And this will include the private sector so that the private sector can be part of the treatment. Even then, it is very likely that the drugs will be given out free and people will just be charged for the consultation of the doctor.

PT – Why has NACA not been able to establish state and zonal offices as stipulated by the ACT 2007 to strengthen its coordination efforts?

That is a valid question. We don’t have the resources to open zonal offices. But we realise the importance of having zonal offices and we will look into it. 2017 budget is already late, but certainly 2018 budget we will be leveraging with the National Assembly and also with the Executive to make a case for zonal offices.

This is important because we want the state governments to start taking more ownership of the HIV response. So we are trying to push the HIV response from the national level back to the state and the local government. But that can only happen if we have zonal offices. Our intention is to create zonal offices in the six geopolitical zones and we are already in very close discussion with one of our major funders going into 2018. One of our major strategies to be used is our major donor in terms of resources we will be getting is to have them at zonal level.

I am someone who believes in addressing issues little at a time, not taking too much bite but taking enough that can be chewed to work with.

PT- On the Global Fund International scandal, what has been done about it and are there any NACA staff indicted?

Aliyu: This all happened before I came in so I will just give a brief background. The Global fund contributes to national response. It contributes a large sum of money not only to HIV but also to tuberculosis and malaria. Even in the aspect of HIV, they work not only for NACA but also for other departments of government. The problem they had had with judiciary arrangement had to do with department for public research and this is in the public domain. I know investigations have been done and still ongoing, so I wouldn’t want to comment too much on that. All I will say is that we know that we had our own weakness in terms of providing oversight and we have strengthened our oversight power system.

No NACA staff has been indicted as far as I know, and all investigations that are currently going on do not relate to NACA staff. And we have strengthened our power oversight. NACA got dragged into it because we were supervising the place where they had problem. It won’t happen again, it certainly will not happen on my watch. On my watch, one of the key things I am going to push for and I intend to make sure it happens is to have to conclusive, cohesive account and good governance structure.

We are going to be transparent. The HIV response team will be very transparent. It has to be in line with the Federal Government’s anti-corruption. And NACA is not welcoming contractors that are not willing to work at all, and we are going to reduce our financial strength in terms of exposure. Things like procurement and logistics for instance, we are pushing our partners to do that.

Our job is to know how many antiretroviral and test kits a particular state needs and we get them delivered. How they do it has nothing to do with me. I am not interested. All I want is to get the commodity delivered so that patients can be tested and placed on medication when necessary

Remember my main job as NACA Chief Executive is to get as many people tested, and to get as many people who tested positive put on treatment.  That is my job and it is pretty straight forward and that is what we intend to do. We are not contractors and we have over time began to reduce our financial strength to exposure to large sum.

PT- How has the failure to constitute the NACA board affected the operations of the agency, especially in terms of appointments, promotion and discipline of senior staff?

As we know, the Federal Government is in the process of constituting boards and I am sure this will be done in an appropriate time. NACA is not alone in not having a board. Having a board of course is very important, but operationally, it hasn’t affected our function. We have ministerial oversight so we report to the presidency through the Secretary to the Government of the Federation.

When it comes to appointment and promotion, we have a committee which has members to look into issues.

We have been doing our proper work without a board but for the purpose of providing the necessary rules and regulation, a board is important and I am sure that will be constituted at the right time.

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