Assessing Nigeria’s Efforts in Ending Mother-to-Child Transmission of HIV

By Moses Emorinken

Nigeria is on the fast lane and in the last mile push for HIV epidemic control, thanks to the human and financial resources invested over the years, especially in the last four years, by the federal government and development partners like President’s Emergency Plan for AIDS Relief (PEPFAR), Global Fund, the Joint United Nations Programme on HIV/AIDS (UNAIDS), and others.
As of today, out of 1.9 million people living with HIV in Nigeria, about 1.7 million of them have been placed on life saving antiretroviral therapy (ART). This represents 90 per cent of the estimated people living with HIV already identified and placed on treatment.

It is also very encouraging that the country’s HIV prevalence rate dropped from 5.8 per cent in 2001 to 1.3 per cent in 2021. Also, there has been a decline in new HIV infections from 103,404 in 2019 to 92,323 in 2021. All these are pointers that the country’s HIV programme is working. However, one critical area the country is still struggling with is in the Prevention of Mother-To-Child Transmission (PMTCT) of the virus.

Despite the country’s achievements, coverage for PMTCT is less than 50 per cent, leading to about 22,000 cases of mother-to-child transmission of HIV every year. Data obtained from the National Agency for the Control of AIDS (NACA) shows that Nigeria has the highest number of HIV new infections among children globally. One out of every 7 children born with HIV in the world is born in Nigeria.

This is worrisome as Nigeria, Africa’s most populous nation accounts for about one-third of all cases of mother-to-child transmission of HIV globally. If the country is not intentional and strategic in its interventions towards preventing and ultimately eliminating mother-to-child transmission of HIV, all its gains over the years in reducing new infections could easily be eroded. More importantly, not bridging the HIV infection gaps among newborns will totally flaw the country’s efforts towards achieving the United Nations 95-95-95 strategy of ending the AIDS epidemic by 2030. The strategy includes: 95 per cent diagnosed among all people living with HIV, 95 per cent on antiretroviral therapy among diagnosed, and 95 percent virally suppressed among treated.

Therefore, as Nigeria races towards the UNAIDS target of 2030, new infections must be seen to be on the decline and eventually tending towards zero. While the government focuses on preventing new infections among the key populations like female sex workers, men who have sex with men, and people who inject drugs, it must not lose sight of newborns, especially preventing them from contracting the disease from their mothers either before or during delivery. Hence, expectant mothers who are HIV positive must be identified and tested, placed on ART treatment, and virally suppressed. Most importantly, they must be followed up and encouraged to visit their preferred hospitals for antenatal care, delivery, and postnatal care. Among all the taps that need to stop running is the tap of new infections among newborns. If Nigeria does not halt the transmission among this population, then it will be very difficult to end AIDS within the 2030 window.

In 2015, former President Muhammadu Buhari launched the Elimination of Mother-To-Child Transmission (EMTCT) of HIV initiative at a sideline event of the United Nations General Assembly. Furthermore, in 2018, the government re-established the National Treatment and PMTCT programme, significantly strengthening national ownership of the response. In the same year, UNAIDS appointed Mrs. Aisha Buhari, former First Lady of Nigeria, as Special Ambassador for EMTCT. All these efforts have helped the country, to some extent, tackle the menace of HIV infection among newborns. However, other factors like lack of or inconsistent attendance of expectant mothers at hospitals for antenatal care and delivery continue to worsen the problem. Fixing gaps in antenatal care attendance, ART services, and engaging private hospitals.

Nigeria is presented with a unique opportunity to biologically end HIV infections for future generations. If current efforts towards ensuring that more people know their HIV status, are placed on treatment, and are virally suppressed, are sustained, and special attention is channeled towards PMTCT, then future generations will not have to contend with the threatening menace of HIV. As long as more expectant mothers fail to consistently visit health facilities for their antenatal care and delivery, even postnatal care, then, it would be hard to ensure that their unborn children and newborns are HIV-free. It is during antenatal care that many of these mothers who have HIV can be tested, identified, and placed on life-saving medications that ensure that the virus does not appear in their blood, hence it is not passed down to their off-spring. According to the 2021 Multiple Indicator Cluster Survey (MICS) & National Immunization Coverage Survey (NICS), the national coverage for delivery in health institutions is 49 percent.

The situation is worse in rural areas and further complicated by poverty and ignorance. While institutional delivery is 74 percent in urban areas, the coverage in rural areas is only 34 percent. Hence a lot needs to be done, as the majority of expectant mothers across the country still deliver without Skilled Birth Attendant (SBA). All these expose children to contracting HIV from their mothers who are positive for the virus.

Therefore, there is an urgent need to not only encourage pregnant women to visit health facilities, but the government needs to build the capacity of local and Traditional Birth Attendants (TBAs) whom these rural women mostly visit for their delivery. The TBAs can be trained and linked with hospitals where they can send their clients for HIV testing, childbirth registration, and other health services. Private hospitals located in rural areas where the government does not have facilities can be partnered with for free HIV testing and treatment for pregnant women.

In a chat, Dr. Patrick Ezie, Chief Medical Director of Silver Cross Hospital in Abuja explained that beyond PMTCT, there is a higher level, which is Elimination of Transmission of Mother-to-child transmission (EMTCT). According to him, once the country is at the level of elimination, it means that it has been able to successfully stop transmission from mother to child.

He said, “It is all about scale. Inherently in that scale are a lot of health interventions, donor support, and facility empowerment. How many ART clinics are available in each state and community, how many pregnant women are tested for HIV, and how many are put on medications so that they carry their babies for nine months and do not transmit HIV to their babies? If you have these figures at every centre, you will be able to know for a fact what the country’s response is like.

“For you to eliminate mother-to-child transmission, it means that in every facility that has a pregnant woman that has HIV, we must make sure that the woman is virally suppressed during pregnancy, and make sure that they follow up the child for the next 18 months after delivery, and do the relevant tests for that baby to make sure that the baby does not carry the virus. Therefore, there is a lot of burden on facilities.

“As a country, we know that our facilities are not given the kind of support that we would like for them to have. A lot of the support they are getting comes from donor support. If tomorrow the donors are not there or the drugs are not available, or for some reason, the funds that the facility needs to aggressively combat or track a woman that is HIV positive, they are not getting it, what happens is that you start having gaps in the treatment programme.”

He added, “There is a danger. The danger is that if we are not successful in preventing the transmission of HIV from mother to child, it means that HIV is going to get into the next generation. That would have been a misstep because it is a vital point where we would have been able to wrap the epidemic of HIV in the bud in this generation. “If we prevent transmission into the next generation, then the virus dies. That is the easiest way to kill the virus. People who already have the virus will be on medication and can live as long as they can, then the newborns are not getting the infection. Hence, there won’t be HIV in that generation.

“If we miss it, we will have children who are born with HIV, and they carry it to the next generation and the epidemic continues. Whereas, this would have been a moment to biologically eradicate HIV as a virus by preventing transmission to the next generation.” Dr. Celestine Okorie, Executive Secretary, Health Reform Foundation of Nigeria (HERFON), in an interview, said, “I think the HIV control programme in Nigeria, has done well because, for a while, the rate was very high. But we have been able to stabilize it and the rate of infection has been coming down. We need to sustain the success that has been achieved, which again boils down to political will, commitment, and funding.”

To guarantee a generation of HIV-free babies should be the top priority for the Federal Government, especially now that the country has a new Coordinating Minister of Health and Social Welfare, Prof. Muhammad Ali Pate, who has a very strong international experience and record of achieving results in the public health space. About US$500 million per annum is deployed towards prevention of HIV/AIDS in Nigeria (with a funding shortfall of approximately US$108 Million per annum) and a significant amount of this funding comes from donor partner agencies. However, donor fatigue is setting in as the country is on the verge of controlling the epidemic and taking full ownership of HIV prevention. A shortfall in HIV programme funding can affect the ability of the country to address the bottlenecks in PMTCT. Inadequate funding will erode the gains Nigeria has made over the last 20 years in the fight against HIV/AIDS.

Thanks to the timely partnership between the Federal Government through NACA and the private sector coalition, the HIV Trust Fund of Nigeria (HTFN) was launched in February last year. The purpose of the HTFN is to bridge the projected funding shortfalls once the donor funding begins to exit. The private sector-led N62.1 billion (US$150 Million) Trust Fund, driven by the Nigeria Business Coalition Against AIDS(NiBUCAA) will ensure a sustainable financing mechanism for the mobilization and deployment of domestic private sector resources to address PMTCT in Nigeria.

While this is underway, there is need for approximate governance and accountability frameworks and processes to be put in place to ensure that the fund is properly targeted towards addressing PMTCT and other HIV programme concerns. Dr. Ezie added, “There is a lot of funding going on, but the problem is that when people donate funds, does the fund get to the end beneficiaries? Does the money go into the hands of the people who really understand the problem and are intentional about solving it?” He said this is the point where the government needs to be very intentional about funding. “The reason is because donor partners are getting fatigued. So, any funding that you get must be channeled to those who maximally require that service’’.