In 2014, an estimated 36.9 million people were living with HIV worldwide of which 3.2 million were estimated to be in Nigeria. The figures were daunting, but the challenge was accepted under what is now known as the 90-90-90 goal. With this started an ambitious plan to ensure that by 2020, 90% of the world population living with HIV know their status, 90% of those who know their status are placed on drugs and 90% of those on drugs have achieved viral suppression. But even this herculean task was not the end-vision. The ultimate goal is that by 2030, the world would see an end to the AIDS epidemic. The work to mobilise governments, institutions and people around this goal started immediately.
2020 is barely 3 years away and the question to be asked is, what improvements have been made across board towards achieving the 90-90-90 goal? So far, the mission has seen significant progress with access to HIV treatment accelerating in the past three years. Globally, it is estimated more than two thirds of all people living with HIV knew their HIV status in 2016: 77% of these were accessing antiretroviral therapy, and viral suppression occurred in 82% of people on treatment. This translates to a progress of 70 – 77 – 82 as a global average: not bad.
Between 2010 and 2016, due to a comprehensive strategy that included condoms, voluntary medical male circumcision, pre-exposure prophylaxis (PrEP), and efforts to protect human rights and establish an enabling environment for service delivery, there was a 32% decline in AIDS related deaths, and a 16% drop in new HIV infections.
Countries like Botswana which have already achieved the 90-90-90 targets, with its very aggressive and comprehensive prevention and care programmes serve as a signpost for the rest of the world that global attainment of all three 90s by 2020 is both feasible and achievable if existing gaps in the HIV testing and treatment cascade are addressed. This requires much more than the technical capacity, but also political will and requisite funding.
Nigeria presently has an estimated 3.2 million people living with HIV, the second largest burden in the world after South Africa, but only an estimated 1.1 million of these know their status (just over 30%). Though 88% of those who know their status are on treatment and 81% of those have achieved viral suppression, the statistics look worse when put in the perspective of the total number of people living with HIV, revealing that only 30% of people living with HIV in Nigeria are on treatment. This means that we still have a long way to go in ending AIDS in Nigeria despite the 90-90-90 target.
Between 2010 and 2016 new infections in Nigeria reduced by just 5% and the total number of people living with AIDS increased slightly. Most new infections are among the heterosexual population but key populations like men who have sex with men, sex workers and people who inject drugs are estimated to contribute about 40% of the total HIV burden in Nigeria. Only 24.4% of people aged 15-24 have knowledge of HIV prevention, the report also showed a low to average usage of condom at last higher-risk sex (with a non-marital or co-habiting partner) among individuals aged 15 – 49 years.
There has been long-standing controversy on the validity of the estimates from Nigeria. But most of the questions will be answered when Nigeria carries out its cross sectional, representative, population based survey of adults and children, scheduled to start in 2018. This survey, which will be the largest ever conducted in the world is already being supported by the United States (US) government with $85 million.
However, we cannot afford to gloss over or ignore these data because they provide the best current evidence that there are still gaps to be filled in order for Nigeria to achieve the 90-90-90 goal. For many of the necessary steps, we do not need to wait for the data. We must address harmful masculine gender norms, which contribute to greater risk-taking and poorer uptake of health services among men as well as criminalization and high levels of stigma and discrimination of members of key populations. Consent laws and insufficient access to comprehensive sexuality education deny young people the services and knowledge they need.
2020 is less than 3 years away, and if there are any lessons to be learnt from Southern and Eastern Africa, it is that a lot of progress can be achieved in a very short period. This was demonstrated in the results from the Sustainable East Africa Research in Community Health (SEARCH) study, which showed an increased proportion of HIV-positive people with viral suppression from 45% at baseline to 81% within two years. This was based on the use of a multi-disease community-based approach with streamlined patient care.
We must continue to aggressively work towards ensuring that 90% of those who are living with HIV know their status, and improve on linkage of newly detected positives to sites where they can access treatment. This must also be coupled with increased capacity for offering treatment especially in underserved areas and locations. The prospect of achieving this goal has increased with new deals on more effective and cheaper dolutegravir, a medication used for HIV treatment, which will be made available next year in African countries, as well as the ongoing test and start strategy.
But according to Michel Sidibé, Executive Director of UNAIDS, “Scaling up treatment alone will not end AIDS”. The new HIV Prevention 2020 Road Map which is meant to Fast-Track countries to reduce new HIV infections, contains a 10-point action plan that outlines effective steps countries can take to accelerate progress. Some of these steps are conducting up-to-date analysis to assess where the opportunities are for maximum impact, developing or revising national targets and road maps for HIV prevention, training to develop expertise in HIV prevention and on developing networks and addressing legal and policy barriers to reach the people most affected by HIV, including young people and key populations.
The road map identifies gaps in political leadership, policy, in HIV prevention financing, and lack of systematic implementation at scale as the four main reasons for lack of progress. It encourages countries to develop a 100-day plan for immediate actions, including setting national targets, reviewing the progress made against the plan after 100 days, reassessing their national prevention programmes and taking immediate remedial action. It outlines how different partners can contribute and includes actions for civil society, development partners, philanthropic institutions and the business community. By reaching these targets, progress in reducing new HIV infections should accelerate significantly, setting countries firmly on the path towards ending their AIDS epidemics.
“UNAIDS is urging commitment and leadership for measurable results,” said Mr Sidibé, adding, “Leadership to address sensitive political issues and leadership in mobilizing adequate funding of HIV prevention programmes.”
Achieving 90-90-90 and ultimately zero AIDS involves community effort. We must all work together to push for behavioural change for men to reject harmful versions of masculinity, prioritizing and protecting key populations, empowering women and girls. It is also key that stigma and discrimination are addressed, as these serve as barriers to people who need access. More work also needs to be done on educating and informing Nigerians on safe sexual practices especially condom usage and other HIV prevention strategies.
Most importantly, we must hold our government accountable to increase its funding to tackle AIDS and quit relying only on external donor funding.
90-90-90 is possible in Nigeria. Together we can end AIDS.