When the US Food and Drug Administration (FDA) approved the use of Truvada as an oral HIV Pre-Exposure Prophylaxis (PrEP) in 2012, global health experts had predicted the reduction in new HIV infection cases, especially among key populations.
But almost a decade after, the HIV epidemic retains a powerful grip with almost two million new infections recorded every year. In 2020 alone, 1.9 million new HIV infections were recorded globally, with key populations accounting for 65 per cent.
Key populations are people who inject drugs, men who have sex with men, transgender persons, sex workers and prisoners.
Around the world, key populations face much higher rates of HIV and AIDS than the general population and are most at risk of contracting HIV.
The joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that between 40 per cent and 50 per cent of all new HIV infections may occur between individuals in key populations and their immediate partner.
In Nigeria, sex workers, men who have sex with men (MSM), and people who inject drugs, make up only 3.4 per cent of the population, yet they account for about 32 per cent of new infections.
Similarly, a 2018 UNAIDS report showed that although MSM represents the smallest key target population for HIV services in Nigeria, at a little over 26,000 people, they account for the highest prevalence rate.
Health experts have attributed the prevalence rate to failure of these targeted populations to use the Oral PrEP and other HIV preventive methods like condoms.
About Oral PrEP
Oral PrEP is the use of pills to prevent the acquisition of HIV infection by uninfected persons.
For PrEP, the U.S. FDA approved the use of Truvada, a combination of two antiretroviral medications (Tenofovir + Emtricitabine). This combination is used in countries where PrEPs are accepted including Nigeria.
However, in recent times, Tenolam, a combination of Tenofovir and Lamivudine, is used for oral PrEP in Nigeria.
Studies have shown that these pills can prevent HIV infection in up to 90 per cent of cases if the pill is taken daily at more or less the same time.
In 2014, the World Health Organisation (WHO) first recommended PrEP to only men who have sex with men.
However, based on further evidence of its effectiveness and acceptability, in September 2015, WHO recommended that people at substantial risk of HIV infection be offered PrEP as an additional prevention choice, as part of comprehensive prevention.
These people include sex workers, discordant couple- a relationship where one partner is infected by HIV and the other is not, and MSM.
High prevalence rate
Health experts have attributed the high prevalence rate to low usage of the Oral PrEP and other HIV preventive methods like condoms.
George Ikaraoha, the PrEP advisor on the Reaching Impact, Saturation and Epidemic (RISE) Control project, said it is unacceptable to continuously record new HIV infections despite availability of various preventive methods.
“It’s sad to hear the number of infected persons is still on the rise despite the existence of different preventive methods including PrEP,” he said.
But Layla Abah (not real names), a sex worker who resides in Karu, a suburb in the Federal Capital Territory (FCT) said the fear of stigmatisation had prevented her from taking the Oral PrEP.
“The use of Oral PrEP is not new to me. I was on PrEP for about six months in 2017 due to risk involved in my line of work. But I had to stop after a rumour that I have a severe illness.
“My flatmate found my pills and told everyone around that I’m taking drugs for something serious. I tried to explain myself when the news got to me but by then, almost the entire neighbourhood knew,” Ms Abah said.
She said she is still living with stigmatisation caused by the use of PrEP till date.
Although sex trade and homosexuality, are illegal in Nigeria, there is no doubt that the trade continues to thrive in the country.
At least, roughly 25 other persons like Ms Abah, who spoke with PREMIUM TIMES on condition of anonymity, said stigma and lack of access to drugs frustrate their hopes of preventing the HIV infection using oral PrEP.
Lami Ogah, a 28-year-old sex worker residing in Gwarimpa area of Abuja, said such drugs will definitely push her clients away. Ms Ogah explained that PrEP is the same as drugs used in treating HIV infection, hence no explanation can prove otherwise.
Speaking in pidgin, Ms Ogah said “What if my customers find the drugs, how do I explain that I don’t have HIV? If such ever happens, the customer can even beat me to death or threaten my life.”
Similarly, Abdul Ibrahim, a drug user who resides in Kubwa, a suburb of Bwari Area Council of Abuja, said although he knows what PrEP is, he has never considered using it.
Mr Ibrahim said this is mainly due to the stigma associated with people using drugs connected with HIV.
“The drugs used for PrEP are the same antiretrovirals used in treating HIV. So why should I use that? Do I have HIV?,” he said.
Experts have said good adherence to an HIV prevention pill and or consistent use of condoms, can help HIV negative people protect themselves from infections.
But real and perceived stigma has continued to undermine all efforts to reduce the transmission of HIV infection.
“Because PrEP falls under the same categories of ARV used in treating HIV positive persons, it creates what is called the PrEP stigma,” Mr Ikaraoha said, adding: “Especially in a community where HIV positive stigma is already existing.”
Mr Ikaraoha said stigma decreases the demand for PrEP because they perceive people take PrEP as promiscuous rather than a good health seeking behaviour.
He explained that stigma not only prevents people from using PrEP, it also prevents them from getting tested and staying on their treatment if positive.
“Unless stigma is addressed, the aim of ending the AIDs epidemic by 2030– one of the United Nations’ Sustainable Development Goals – is unlikely to become a reality,” the Director-General of the National Agency for the Control of AIDS (NACA), Aliyu Gambo, said.
Mr Gambo said stigmatisation against persons living with HIV or trying to prevent HIV is not helping to stop transmission against the virus.
“We have spent over two decades fighting HIV but we have not yet controlled the virus largely because of fears people have which comes from stigma and discrimination,” Mr Aliyu said.
Aside stigma, non-availability of PrEP is a major challenge facing persons willing with HIV to take the medications. In countries where the drugs are available, the costs are high, making it difficult for average persons to afford.
For instance, in Nigeria, PrEP is rarely available even in general hospitals.
A PREMIUM TIMES’ visit to, at least, three general hospitals shows that such drugs are not readily available.
Fortunately, PrEP is available in some top pharmacies across the city of Abuja but it comes at a huge cost. In some of the pharmacies, a pack of PrEP costs as much as N35,000 and above. This means that average Nigerians, which include key populations, may not be able to afford such drugs.
Mr Aliyu, NACA’s head, said PrEP is not as accessible as the conventional HIV drugs because the cost is a little bit prohibited for the donors.
“We get these drugs mostly as donations but at the moment, they are given at one stop shops.
“These are places where key affected populations are seen and are provided medication, including PrEP to those that are HIV negative,” he said.
He also said efforts are ongoing to reduce the cost of PrEP in the country.
“For other places that provide medication, there is an ongoing review of the guideline by WHO and hopefully, after the review cost of PrEP may be less than what it is at the moment. And at the time, the donors may find it feasible to make money available so that the medication could be available on the open market,” he said.
Mr Ikaraoha said PrEP is readily available only in some supported facilities.
“There are some PEPFAR supported facilities across the country. For RISE supported facilities in five states, we provide these drugs free of charge.
“Anyone willing to take PrEP is subjected to some screening to see how eligible they are for the medication,” he said.
HIV continues to be a major global public health issue. Data from WHO stated that in 2020, an estimated 37.7 million people were living with HIV, including 1.8 million children. Of these statistics, 6.1 million people did not know they were HIV positive.
The data also shows that 680,000 people died from HIV-related causes in 2020. It indicates that 1.5 million people were newly infected in 2020.
Since the start of the epidemic, an estimated 75.7 million people have become infected with HIV, according to data from UNAIDS.
Data also shows that the vast majority of people living with HIV are located in low and middle income countries. Of the 4,500 people who contract HIV every day in the world, 59 per cent live in sub-Saharan Africa.
East and Southern Africa remains the region most affected by HIV in the world, with 20.7 million people living with HIV and 730,000 new HIV infections in 2019.
In Nigeria, about 1.9 million people are currently living with the disease, according to the Nigeria HIV/AIDs Indicator and Impact Survey (NAIIS).
World AIDS Day
The World AIDS Day (WAD) is celebrated December 1 every year to honour the people who have fallen to the disease as well as people living with HIV.
It is also celebrated to raise awareness on the disease and the need for people to know their status.
The theme of WAD 2021 is “End inequalities, End AIDS.” Ahead of the day, WHO said the theme is meant to highlight the growing inequalities in access to essential HIV services.
The international health agency urges global leaders and citizens to confront the inequalities that drive AIDS and to reach people who are currently not receiving essential HIV services.
In a briefing ahead of the WAD, the country director, UNAIDS Nigeria, Erasmus Morah, said tackling inequalities is a long-standing global promise, the urgency of which has only increased.
“As well as being central to ending AIDS, tackling inequalities will advance the human rights of key populations and people who are living with HIV, make societies better prepared to beat COVID-19 and other pandemics and support economic recovery and stability,” he said.
To celebrate WAD 2021, Nigeria has adopted the theme; “End inequalities, End AIDS through sustainable HIV financing in Nigeria.”
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