Published On: Wed, Nov 28th, 2018

World AIDS Day 2018 – time for reflection: Synopsis of selected HIV/AIDS Literature

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By Pharmacist Yusuf Babaye

World AIDS Day, designated on 1st December every year since 1988, is an international day dedicated to raising awareness of the human immune deficiency virus (HIV) pandemic and to remember those who have died of the disease. For healthcare workers and indeed government and other stakeholders, three decades is enough a period to reflect on our journey in the fight against the debilitating disease.
This year’s theme for World AIDS Day is: “Know your status,” which is a laudable effort towards achievement of the UNAIDS 90-90-90 targets. The aim of the UNAIDS targets is, by 2020, 90% of people living with HIV should know their status, 90% of identified HIV positive cases would be initiated on Anti-retroviral treatment (ART), and 90% of persons on ART would have achieved viral suppression.
The first case of HIV/AIDS in Nigeria was reported in 1986. Since then the number of people living with HIV or AIDS (PLWHA) has steadily increased with the epidemic moving into a ‘generalized’ state. The prevalence of HIV rose from 1.8% in 1991 to a peak of 5.8% in 2001, before declining to a nadir of 3.0% in 2014. Although the prevalence may be relatively low compared with other countries in sub-Saharan Africa, the country’s large population means that up to 3.2 million people are estimated to be living with HIV in Nigeria.
The HIV epidemic has further weakened and threatened to overwhelm the Nigerian health care system, increased the number of orphans and increased the cost of achieving set developmental goals by decreasing the size of the workforce, mainly adults in their most productive years of life (15-60 years). The high manpower-intensive sectors of the economy are mostly affected; including the agricultural, educational and health sectors as well as the rural economy. In summary, the impact of HIV/AIDS on Nigeria’s social fabric and on its economic development and well-being continue to be pervasive and, unless controlled, will continue to undermine the quality of life of Nigerians.
HIV is a virus that attacks cells in the immune system, which is our body’s natural defence against illness. The virus makes copies of itself inside a type of white blood cell called the T-helper cell (or CD4 cell) and in the process destroys these cells. As more and more CD4 cells are destroyed, the immune system is gradually weakened such that a person becomes increasingly more vulnerable to other infections. This means that someone who has HIV, and is not taking antiretroviral treatment, will find it harder and harder to fight off infections and diseases. If HIV is left untreated, the immune system can be severely damaged within a few years such that it can no longer defend itself at all. However, the rate at which HIV progresses varies depending on age, general health and background. AIDS (acquired immune deficiency syndrome) describes a set of symptoms and illnesses that happen at the final stage of HIV infection.
There is high commitment to fight HIV/AIDS in Nigeria, as evidenced by the initiation of the Presidential Council on AIDS, the National AIDS/STD Control Program (NASCP), and the National Agency for the Control of AIDS (NACA) which is a multi-sectoral agency including members from many government ministries and civil society. At the state level, State Action Committees on AIDS (SACA) have been established, while at the local level there are Local Action Committees on AIDS (LACA). The mission of NACA is to provide an enabling policy environment and a stable ongoing facilitation of proactive multisectoral planning, coordinated implementation, monitoring and evaluation of all HIV/AIDS prevention and impact mitigation activities in Nigeria.
In his speech during last year’s World AIDS Day commemoration, the Director General of NACA – Dr Sani Aliyu- stated that: in the last six years, we reduced new HIV infections by 56% and annual AIDS related death by 22%. He applauded President Muhammadu Buhari of Nigeria, for demonstrating strong political will to improve access to ART in Nigeria when, a year earlier, he launched the Fast Track Plan (FTP) to place additional 50,000 Nigerians living with HIV on ART each year. He also ensured that the 60,000 PLHIV receiving ART in Abia and Taraba States under the National Comprehensive AIDS Programme for States (NCAPS) continued to be served since the inception of his administration in 2015. In addition, the National Economic Council has committed to the implementation of an earlier resolution that committed 1% of the State’s monthly federal allocation to funding HIV programmes from 2018. Dr Aliyu emphasized that “While we commend ourselves for these achievements, we acknowledge the huge unmet need for ART; only about one third of the 36 states and FCT have surpassed 50% ART coverage. The rate of Mother to Child transmission of HIV in Nigeria is still unacceptably high. We certainly need to do more at the federal and state levels to take ownership of our HIV/AIDS response and close the gaps.”

HIV Testing and counselling (HTC)
HTC provides the first bio-medical contact for access to the prevention and treatment of HIV. In Nigeria, a lot has been invested in technical guidance, coordination and capacity building to implementers on HIV testing services across the states with the aim of enhancing HIV diagnosis in children, adolescents, pregnant women and breast-feeding women and adults.
Testing is the only way to know for sure if you have the virus. If you’ve already tested and your result is positive, you’ll be advised to start antiretroviral treatment as soon as possible. Treatment is the only way to manage HIV and prevent it from damaging your immune system. It also reduces the risk of passing HIV on to others.
WHO is supporting countries to address gaps in the cascade of prevention, testing and treatment services. HIV testing services include the full range of services that should be provided together with HIV testing: counselling (pre-test information and post-test counselling); linkage to appropriate HIV prevention, treatment and care services, and other clinical and support services; and coordination with laboratory services to support quality assurance and the delivery of correct results.

Prevention, treatment and care
National efforts coupled with support from various donors and development partners have contributed to a significant scale up of prevention, care, and treatment program aimed at combating the disease. Similarly, efforts have been made to strengthen monitoring and evaluation systems for HIV response activities as the country seeks to continue supporting evidence-based decision-making for a more efficient and effective response.
Prevention activities include prevention of mother-to-child (PMTCT), prevention of sexual transmission, prevention of medical transmission as well as prevention services within HIV counseling and testing. Treatment and care activities in Nigeria include; provision of antiretroviral drugs (ARVs) and services to eligible patients; laboratory support for diagnosis and monitoring for HIV-positive patients; adult and pediatric care and support; management of Tuberculosis and HIV co-infection (TB/HIV); and support for orphans and vulnerable children (OVCs). It also entails standardized training package for service providers, implementation of a quality pre-ART program, management of opportunistic infections and clinical mentoring.
There have been collective efforts in the implementation of the National framework on HIV & AIDS towards achievement of the set targets and scale up integrated HIV & AIDS services with specific focus on integrating ART/PMTCT into the Maternal, Neonatal and Child services to increase access to ART for HIV infected pregnant & breastfeeding women as well as increased uptake of pediatric ART through Early Infant Diagnosis and treatment utilizing an exposed infant follow-up program as well as promoting access for children under 5 years to ART.

Pharmaceutical care and supply chain
The focus of HIV Pharmaceutical care and supply chain is essentially on Pharmaceutical system strengthening to ensure access to quality pharmaceutical products, effective pharmaceutical services and uninterrupted availability of health commodities to achieve desired health outcomes. The country is implementing integrated supply chain management system (SCMS) for the management of HIV/AIDS medicines, laboratory commodities and consumables.
The greatest achievement of the HIV response to date has been the unprecedented global expansion of access to ART. Although only 680 000 people were receiving ART in 2000 (most of them in high income countries), by June 2017, this number had risen to 20•9 million people (18•4 million–21•7 million), or 57% of all people living with HIV worldwide. In Nigeria alone, 1,093,233 persons were accessing treatment at the end of June 2018. In 2016, an estimated 1•6 million deaths were averted worldwide as a result of ART.
Logistics data collected through the Logistics Management Information System (LMIS) should be utilized to inform decisions on forecasting and quantification, financial planning, procurement and order scheduling thus ensuring commodity availability at all times. Considering human resource constraints in the states, data capture needs to be strengthened through tools update, harmonization and continuous trainings of staff in Ministries of Health. It may be necessary to conduct comprehensive evaluation of health commodities transportation system with the view to selecting the best approach to distribution. It is expected that this endeavor will reduce cost and turnaround time for distribution of commodities which will result in timely and efficient drug supply and replenishment. Other areas for additional support include best pharmacy practice, rational use of drugs, pharmacovigilance, accountability in procurement, warehousing infrastructure and continuous quality improvement.

Laboratory System strengthening
Development of functional laboratory systems is a key component of sustainable health care systems. Global efforts to ameliorate the burden of HIV and associated infections as well as devastating outbreaks of infectious diseases such as Ebola, have illuminated the need for further support of global laboratory systems development. Effective laboratories and functioning national laboratory systems require a competent workforce, effective leadership and management, and an underpinning of laws and regulations that ensure quality of services. Good policies, shapes processes and mechanisms for optimal laboratory system performance and international cooperation as required by the International Health Regulations.
Over the years, investments by United States President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund, and other donors has significantly contributed to strengthening laboratory systems. This has been achieved through laboratory infrastructure upgrade, purchase of laboratory equipment, training of tens of thousands of laboratory professionals, and introducing laboratory information systems. The enforcement of biosafety practices has led to better waste management, use of personal protective equipment (PPE) and enhanced infection control measures. In addition, upgrading the degree of laboratory quality management systems (quality control, quality assurance, lab organization etc) has resulted in the accreditation of 3 medical laboratories in Nigeria by International Organization for Standardization (ISO).

Partnerships and community
In addition to treatment and prevention services, partners are supporting infrastructural improvement through the renovation of some facilities to create an environment that is conducive for clients and promote quality and best practice. Partners are putting in place mechanism for tracing clients who default in treatment and in collaboration with community minimizing stigma and discrimination.
Today, inclusion of civil society and people living with HIV is standard practice of many HIV related decision-making bodies. Non¬governmental representatives, including from organizations and networks of people living with HIV, are now routinely involved in national HIV related advisory bodies. Vigorous activism persists in many countries and regions. However, as the incidence of HIV infections and AIDS related mortality have decreased, and as funding for civil society activities has diminished, so have the magnitude and intensity of AIDS activism. In particular, the kind of cohesive activist voice that united the global north and south and laid the foundation for the HIV treatment revolution is no longer evident. In some cases, experiences in the HIV response have led some activists to concentrate more on broader health and human rights issues. For some, a focus on service delivery in their own communities has taken the place of activism for systemic change.
The majority of external funding for HIV/AIDS programs in Nigeria is coming from PEPFAR, the Global Fund, and the World Bank. As at 2018, Nigeria has so far received more than US$ 1.4 billion and US$ 4 billion from Global Fund and the United States PEPFAR programme respectively to deliver HIV programmes in the country.

Conclusion
The future course of national response to the HIV and AIDS epidemic depends on a number of factors including levels of HIV and AIDS-related knowledge among the general population; social stigmatization; risk behavior modification; access to quality services for sexually transmitted infections (STI); provision and uptake of HIV counseling and testing; and access to care and anti-retroviral therapy (ART), including prevention and treatment of opportunistic infections.
Good health services are those which deliver effective, safe, high quality health interventions to the people who need them, and where they need them, and with minimum waste of resources. These interventions may target individuals or entire populations, whether defined by geography (e.g. national, district or local) or characteristics (e.g. gender, age, nature of illness, occupation, behavior). In the case of HIV, health services need to take into account that people living with HIV or most-at-risk of infection often face stigma and discrimination because of their infection or because they may belong to groups with particular behavioral or disempowering characteristics.
The HIV response must make common cause with the broader global health field to herald a new era of global solidarity for health, and specific action is urgently needed to respond to the rapidly rising health toll associated with non-communicable diseases, including taking health into account in the development of public policies of all kinds. HIV services should, where feasible, be integrated with broader health services, in co-located sites where possible, with the aim of improving both HIV-related and non-HIV-specific health outcomes; greater integration of HIV and global health must preserve and build on key attributes of the HIV response, including participatory community and civil society engagement and an ironclad commitment to human rights, gender equality, and equitable access to health and social justice.
There should be renewed focus on surveillance and research for HIV integrated program in collection, reporting and use of data for evidence-based decision making. Stakeholders should facilitate dissemination of key findings, lessons learned and best practices through technical reports and peer reviewed publication.

Happy World AIDS Day!
Acknowledgement
I would like to acknowledge the source of this article, including excerpts from FMOH, NDHS, NACA, WHO, UNAIDS, PEPFAR, USAID, CDC, Lancet commission, I-TECH, AVERT and other reference materials.

Pharmacist Yusuf Babaye – Country Representative, International Training & Education Center for Health(I-TECH) Malawi (yusufbabaye@hotmail.com)

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