The Director – General of the National Agency for the Control of AIDS (NACA), Dr. Gambo Aliyu, in this interview with Hope Magazine, expounded on his agenda for the Agency and enumerated the strategies for sustaining the National HIV response when development partners eventually exit. He also reiterated the strategic place of research – based intervention in the fight to contain the virus. The DG said NACA is currently working on establishing a Data Command Centre for the rapid generation of data to enhance coordination of its activities and monitor progress on epidemic control.
By: Toyin Aderibigbe, Abiodun Alabi, Shimsugh Chagbe, Oluwashola Idris
Sir, what is your agenda for the National Agency for the Control of AIDS (NACA)?
When I came on board, I made it clear that NACA at this material time should focus on controlling the HIV epidemic and chart a path to sustain it. What do we mean by epidemic control? Is a situation where new HIV infection is reduced to the lowest level, transmission has been interrupted and mortality from HIV is even greater than transmission. Once you reach that stage, it means that the disease is under check. It is not leaving people that have it to infect people that do not have it, and it is not killing those that have it as it would have before now. So, this is the focus: control the epidemic and sustain.
Control in terms of using the conventional term we use globally is to ensure the achievement of 90-90-90 and 95-95-95 UNAIDS global goal. Therefore, these are the metrics for epidemic control and ending AIDS by 2030.
By the time you identify 90 percent of people in Nigeria who have HIV and who know they have HIV; 90 percent of people who know they have HIV and take medication and stick with the medication; 90 percent of people who take the medication suppress the virus, transmission will drastically reduce to a very low level.
The next challenge is how to keep new infections at the barest minimum that is sustainability. How do we keep the tempo? How do we ensure new cases of HIV drop and HIV services continue to be available to those 90 per cent or more than 90 percent that are on medication, of all those that know their status? These are my goals.
What are your strategies for achieving these goals?
When I came on board I realised we needed to test more people, we need to go out into the communities to fight stigma and discrimination, to encourage people to demand for HIV services, demand for HIV testing, know about their status and do something about it.
We have said it before; we are saying it every day to every Nigerian wherever they are to know about their HIV status and do something. If your HIV status is negative, learn how to maintain that negative status for the rest of your life.
If your HIV status is unfortunately positive, we are saying it is no longer the end of the road and it is not a death sentence. You can manage it. We can keep the virus in check to make sure it does not destroy body defense mechanisms to give them the bad look that it used to give in the past, and HIV does not leave them to infect others.
How do we do that? We place and maintain them on treatment. So part of the strategy is to identify where the shoe is pinching, which we did with the NAIIS survey. We had identified areas that require aggressive intervention: areas where the epidemic is raging – areas with a high burden and low saturation of services. These are the areas that we are now collaborating with PEPFAR for special intervention. The programme is called ART Surge, and is happening in some States. However, what happens to States that are not on the ART surge?
Our strategy is to continue providing the level of services that currently exists, to making sure that all those we have identified and placed on treatment continue to be on treatment, with minimum default, minimum dropout. Those who drop out we will be tracked and brought back into treatment. We have groups that are doing that in communities and groups that are linking people from communities to health facilities to make sure that linkage is achieved. So identifying defaulters, identifying dropouts and bringing them back is important.
We test people in the communities, test people in facilities and link them up with our services. We want to rapidly identify those who have HIV in the communities but they do not know they have it, those who know they have the virus but don’t want to take medication, those who are taking medication but dropped out. The goal of treatment is to suppress the virus.
When we say to suppress the virus, people should know what we are saying is limiting the virus within the individual to a level that we don’t see it in the blood. If we don’t see it, we are confident that the virus will not leave a person with HIV to infect another person or persons. If we do not see it, we are confident that the virus will not destroy the body defense mechanism to make the individual vulnerable to other diseases. Because naturally, it is not the HIV that kills, it is the vulnerability, it is the destruction that HIV does to the body defense mechanism that exposes the victim to all sorts of infections that may end up claiming the person’s life if correct measures are not taken.
To monitor this closely we decentralized NACA services to now go closer to the States to monitor, evaluate and make sure we are having our hands, we are having our eyes, and we are having our books closer to the sites of action in the States.
We have created six Zonal Offices and have decentralized our services to these six zonal offices for effective coordination, evaluation, monitoring and making sure that we are on course to control HIV epidemic in the next two to three years. It is not an easy task but it is a task that must be done if Nigeria must control this epidemic, and if the global community is to benefit from the sustained investment of over 15 years for HIV in Nigeria, which today has gulped over 5 billion US Dollars. Thus, our strategies to control the epidemic include ART surge, creating awareness at the grassroots to fight stigma and discrimination and encouraging people to come up to test for HIV; bringing people (defaulters) back to treatment and decentralizing NACA services to go closer to the States.
Many people have expressed concern about the sustainability of HIV and AIDS programme in Nigeria when major partners exit. Against this backdrop, what are your strategies for sustaining HIV services and scaling up intervention to meet the 90-90-90 global target timely?
Let me make it clear, the major partner we are talking about here is PEPFAR, and I doubt if PEPFAR will leave us before we achieve this goal of controlling the HIV epidemic in the country. And because of that, now the challenge for NACA is to make sure we double up in our coordination, to make sure we do everything possible to move trajectories towards achieving epidemic control. Our strategy for sustainability is not sleeping until PEPFAR leaves the country. We have started working with PEPFAR and the Global Fund on a sustainability model. This sustainability model looks at what PEPFAR does now and figuring out ways to keep same services with States in the driver seat.
The model, as it’s operated by PEPFAR now is unlikely to be sustained. What the government of Nigeria is looking at is bringing in a sustainability model that will largely be financed and implemented internally.
In the absence of PEPFAR, how do we come up with a model where the government at the Centre and the government at the States share responsibilities? How do we ensure that existing gaps are filled; to make sure H I V services remain uninterrupted even when PEPFAR exits because the country has reached a critical milestone and is now ready to take full responsibility?
We know the help and assistance we are getting from outside is not going to remain with us forever. We know at a certain stage and at a certain level of the response, the government of Nigeria would be invited to take full responsibility. Instead of waiting until that time comes, we have already started taking responsibility. We have already started doubling on the number of people we treat. This year we are on course to treating 100,000, people double of what we treated last year. Next year we will be exploring how to increase that margin by another 50,000, to treat 150,000 persons.
The question now is how is HIV control going to be sustained in the long- run using domestic resources?
The answer here is government alone is unlikely to be able to do that. So what is the plan?
Our plan is to look at the private sector; to get the private sector also to invest in HIV the same way we are seeing an encouraging response of the private sector investing today in the COVID-19.
When I say organized private sector here I mean a plan that has been developed between NACA and coalition of business sector against HIV, the NiBUCAA.
We came up with an idea of HIV Trust Fund, which has reached an advanced stage. We were just at the verge of launching this Trust Fund when COVID-19 struck.
We know the COVID -19 is likely going to go and we are praying that it goes soon so that we have our energy and our time to concentrate on controlling HIV pandemic. Getting to establish this HIV Trust Fund, which in the long-run will finance a significant part of our commitment for medication, consumables plus logistics. The HIV Trust Fund is one area we are looking at.
Another area is mobilizing resources at the States level. We had a commitment by State Governors all over the country in 2018. In 2019, some Governors lived up to these pledges or commitments. Our hope is that in 2020 more Governors will key in to fulfil the pledge to commit 0.5- 1% of their monthly allocation to HIV control.
This will bring significant resources at the State levels for HIV programme response to be coordinated by the States agencies for the control of AIDS (SACAs). Bringing these three together, private sectored and State Government resources is key to sustainability.
Sir, you are very passionate about data and have on each opportunity underscored the importance of data in HIV programme. How prepared is NACA in terms of having up-to-date data to support any emerging intervention programme?
Data are everything to a programme. Without data, you would not know how much you have achieved with your programme or where you are going. Without data, you will not know how far you need to go to achieve what you want to achieve. Without data, you cannot evaluate the impact of your investment on anything. Without data, you cannot know when you reach the Promised Land or arrive at your destination.
So data are your lights: They are your eyes, they are your ears. Data are everything in terms of helping you to monitor where you are, where you are going or whether you have reached, where you are going. And if you are yet to reach how long or how much time you need to reach your promised land or if you are unlikely to reach, what are the factors preventing you from reaching the Promised Land? You need data for all these.
If you implement a programme without solid data, you are likely wasting resources; it is very likely you are wasting time; it is very likely you are not reaping much or you are not reaping much or you are not getting value for money. So data helps you to do all these; it helps you to get value for money, keeps you knowledgeable about the programme and progress made.
We are operating with a budget and in an environment where every bit of money we have should be accounted for and we should see the value for every investment made in HIV response.
HIV has taken many lives; it has taken many resources and is a threat to our national security and economy. It is high time keep our eyes on the big prize to suppress, control, and make sure HIV does not continue to be a threat to our economy, development and security. We can never do that without good data.
With the help of data, we now know our investment for the past 15 years has paid off largely and we are on our way to control the epidemic. We did not know these before 2018 when NACA decided to do the NAIIS survey.
From the NAIIS data, we learnt that we have done well in controlling the epidemic and we are on course to control it if we can sustain certain things:
If we can increase testing, if we can continue to fight stigma and discrimination to encourage people to demand for HIV services; and if we continue to encourage people after demanding for HIV services and knowing their status, they should also be responsible to do something about it.
One thing people do not see or they do not want to see is that if you climb a ladder, assuming that there is anything you can call pyramid of epidemic control, the tip of the pyramid is 100 per cent, the base is zero. You look at the base it is always broad, so to climb to go to 50 percent does not take y o u m u c h e n e r g y compared to climbing from 50 percent to 100 per cent.
Reaching the tip of the pyramid is not easy; it is going to cost you more money, energy and resources. Therefore achieving HIV control in Nigeria is going to be tough in the next two, three years.
People who are yet to take HIV test may largely belong to the group that don’t want to discuss HIV issues with you; groups that are very afraid to take the test – they don’t want anybody to know they have HIV. They are a group that do not want to seek for HIV services at facilities. Some of them do not even believe that they have HIV, and if they know that they have HIV they may be reluctant to take medication. Even when they begin to take medication, they may prefer traditional than conventional medicine. Going out to get these people and convincing them to test, to know their HIV status and come and take medication is not easy; we have not found it easy in the last one year. We know that in the next two or three years we aim to put this epidemic under control, so we are bracing up for the challenge.
That is why we decentralized our office closer to the grassroots to be on ground to monitor and to aggressively as well as vigorously ensure that the momentum is sustained.
What mechanism have you put in place to generate data rapidly to meet the need for an emerging intervention?
Every data on HIV in this country belongs to NACA wherever it is generated. NACA is creating a Data Command Centre. That Data Command Centre. When fully operational the Centre should have capacity to access data from all sectors to bring them together, analyze to inform the national response monitoring and evaluation and decision-making in terms of how Nigeria is controlling the epidemic and how the country would sustain the epidemic after it is controlled. We attach so much importance to data that we prioritize getting the Data Command Centre up and running.
Sir, how would you describe NACA’s relationship with global development partners?
You know that NACA coordinates activities of development partners and all sectors, in the government or outside the government.
We work with development partners and the relevant sectors they serve. Remember in the government we have activities in schools in the Ministry of Health and Education, we have activities to do with orphans and vulnerable children (OVC), that has to do with Women Affairs. We have activities with the Ministry of Youth and Sports, that is targeting the youths; and we have activities that look at the treatment that are taking place at the facilities – medical treatment that is taking place at health facilities.
Our relationship is very cordial. They understand our roles, and we give them space and support needed to operate and succeed.
What is the government of Nigeria doing in terms of funding the national HIV response?
I told you, last year we were treating 50,000; this year we are treating 100,000 PLHIV. You can do the math yourself 50,000 and now 100,000, it has doubled and it is likely to go up next year as we add more.
Sir, how do you foresee HIV response in the next five years?
I see the course very, encouraging in terms of getting to the Promised Land as long as we keep the current tempo and momentum going, NACA coordinating at the center and at the zonal offices coordinating and monitoring activities at individual States, making sure each State is on course. If we keep this momentum, we are likely to get HIV epidemic under control in the next three years.