Nigeria has the second largest HIV epidemic in the world. Although HIV prevalence among adults is much less (1.3%) than other sub-Saharan African countries such as South Africa (19%) and Zambia (11.5%), the size of Nigeria's population means 1.8 million people were living with HIV in 2019. Recent drops in prevalence estimates for the country has been attributed to better surveillance.

Nevertheless, UNAIDS estimates that around two-thirds of new HIV infections in West and Central Africa in 2019 occur in Nigeria. Together with South Africa and Uganda, the country accounts for around half of all new HIV infections in sub-Saharan Africa every year. This is despite achieving a 13% reduction in new infections between 2010 and 2019.

Unprotected heterosexual sex accounts for 80% of new HIV infections in Nigeria, with the majority of remaining HIV infections occurring in key affected populations such as sex workers.

Six states in Nigeria account for 41% of people living with HIV, including Kaduna, Akwa Ibom, Benue, Lagos, Oyo, and Kano. HIV prevalence is highest in Nigeria’s southern states (known as the South South Zone), and stands at 5.5%. It is lowest in the southeast (the South East Zone) where there is a prevalence of 1.8%. There are higher rates of HIV in rural areas (4%) than in urban ones (3%).

Approximately 45,000 people died from AIDS-related illnesses in Nigeria in 2019. Since 2010, AIDS-related deaths have decreased by 35% to 2019, and 89% of those with a positive diagnosis in Nigeria are accessing antiretroviral treatment (ART).

Nigeria has a mixed epidemic, meaning that while HIV prevalence among the general population is high, certain groups still carry a far greater HIV burden compared to the rest of the population. In Nigeria, Sex workers, men who have sex with men and people who inject drugs make up only 3.4% of the population, yet account for around 32% of new HIV infections.

Men who have sex with men (MSM)

Men who have sex with men are the only group in Nigeria where HIV prevalence is still rising. In 2017, prevalence in this group stood at 23%, significantly more than the next highest prevalence group - sex workers - at 14.4%. Of all new HIV infections in the country, 10% occur among men who have sex with men.

In 2014, the Nigerian government increased the punishment for homosexuality to 14 years in jail. Anyone ‘assisting couples’ may face up to 10 years in prison. Mass arrests of ‘suspected gay men’ in Nigeria have followed, for example in July 2017 the police arrested 40 men at a private house party.

Criminalising laws such as these have made it harder for civil society organisations to work with LGBT communities and have pushed men who have sex with men underground, making them more vulnerable to HIV. Although the NACA state that ‘no provision of this law will deny anybody in Nigeria access to HIV treatment and other medical services’, studies have shown that since the law came into action, more men who have sex with men report they are afraid to seek healthcare.

We just need good legal representation for lgbt people in Nigeria, right now, we don’t know who to contact when issues arise, [PrEP]… and antiretroviral drugs are difficult to get, you can’t tell your doctor about your sexuality so getting the right care is difficult, plus stigmatisation of gay and HIV positive people.

– Gay man living in Nigeria

Nevertheless recent years have seen an improvement in HIV prevention among men who have sex with men. In 2010, only 18% of men who have sex with men were reached with HIV prevention programming, while recent reports show 82% of men who have sex with men used a condom at last sex with male partner and 97% had tested for HIV in the last 12 months.

Homophobia is widespread in Nigeria. A recent survey found that 87% of respondents would not be willing to accept that a family member was homosexual and only 30% of those polled thought that homosexuals should have access to healthcare. Stigma such as this poses a major barrier to HIV prevention, as research has shown that HIV prevalence among men who have sex with men is directly correlated to their experiences of sexual stigma.

Bisi Alimi Foundation Founded by Bisi Alimi, the first man to come out as gay on public television in Nigeria, the foundation advocates for LGBTQ rights, and conducts research into public opinion on LGBTQ issues. In the following video Bisi Ailmi gives an insight into the life of a gay man living with HIV in Nigeria.

Sex workers

In 2016, it was estimated that 14.4% of sex workers were living with HIV in Nigeria. This is a significant drop since 2013 when it was estimated that 24.5% of sex workers were living with HIV. HIV prevalence among sex workers is still eight times higher than the general population.

There are a number of factors that make sex workers more vulnerable to HIV. HIV prevalence is higher among female sex workers at 24.5% compared to male sex workers at 18.6%. Similarly, brothel-based sex workers face greater HIV risk in Nigeria, with a prevalence of 27.4%.

Progress in HIV prevention meant that, in 2016, 98.1% of sex workers reported using a condom with their last sexual partner and 97.1% of female sex workers had received an HIV test in the last 12 months.

Sex work is illegal in Nigeria. The law states that those wholly or partly supporting themselves through sex work can face two years imprisonment. There is no law that prevents healthcare workers from providing sex workers with health services, yet the criminalising law makes it difficult for individuals to disclose that they are sex workers to healthcare workers. The new law also makes sex workers more vulnerable to abuse from law enforcers.

When a sex worker’s hideout is raided, the law enforcers collect money from them and when there is no money to offer, they offer them sex. Some of these law enforcers don’t even use condoms and the sex worker don’t have much of a choice at that particular time.

– Ms. Anemo, National Coordinator of Nigerian Sex Workers Association, advocating for decriminalisation of sex work, 2017

People who inject drugs (PWID)

HIV prevalence among people who inject drugs (sometimes referred to as PWID) in Nigeria was 3.4% in 2017. Women who inject drugs are particularly affected with a prevalence of 13.9% compared to 2.6% among men. Female sex workers who inject drugs face the highest HIV prevalence at around 43%. It is thought that 9% of new HIV infections in Nigeria every year are among people who inject drugs.

In 2015, the National Agency for Control of AIDS (NACA) reported that around half (52.7%) of people who inject drugs share needles and syringes. Approximately 7.3% share needles and syringes all the time and more than a third (36.4%) shared needles some of the time. Although this is lower than in 2010, helped in part by efforts to reach people who inject drugs with HIV prevention services, these rates remain very high.

Harm reduction services such as opioid substitution therapy and clean needle exchanges are currently not available in Nigeria. Available services are limited to targeted information, education and communication, condom distribution and hepatitis C treatment. However, discussions on developing a national harm reduction strategy began in 2015.

The National Strategic Framework identifies providing people who inject drugs with harm reduction and needle exchanges as being a key goal in the coming years.

In addition to this in 2015 NACA began working with the United Nations Office on Drugs and Crime on a draft national HIV response strategy to target people who inject drugs. It has also begun to train staff from its National Drug Law Enforcement Agency and 11 civil society organisations working with people who use drugs on HIV responses targeted to this group’s needs.

Young people

In 2016, 240,000 adolescents (between the ages of 10-19) were living with HIV, making up 7% of the total number of people with HIV in Nigeria. HIV prevalence among this age group varies regionally, with 4.3% of 15-19 year olds living with HIV in the South South, compared to 1.3% in the South East. Health outcomes for adolescents living with HIV in Nigeria are poor, and Nigeria is the only country in the world where mortality in 10-14 year olds is rising.

Young women have a higher HIV prevalence and are infected earlier in life than men of the same age group. In 2016, more than 46,000 young women were infected with HIV compared to 33,900 young men.

There are a number of factors that increase HIV vulnerability among young people, including a lack of knowledge and appropriate sexual reproductive health services. Reports from a 2017 National Health Survey showed that only 29% of women and 27.9% of men between the ages of 15 to 24 could correctly identify ways of preventing sexual transmission of HIV, and reject major myths around transmission. Early sexual debut is common in Nigeria, with 15% of girls and 4% of boys having sex before they are 15 years old. Inter-generational relationships are also common in Nigeria. A 2017 survey found that 41.2% of women between the ages of 15 and 24 had had a sexual partner ten or more years older than them in the last 12 months. This increases HIV risk among this group as often the virus is passed from older men to younger women.

Despite their elevated risk, reports show that few adolescents test for HIV regularly. In 2017 only 2% of males between 15 and 19 and 4% of females had tested for HIV in the last 12 months.

National targets commit to a 90% treatment coverage and 50% testing rate among young people by 2020.

In addition to the National Strategic Framework, Nigeria released a National HIV Strategy for Adolescents and Young People in 2016, which provides a set of guidelines co-created with young people. This recognises negative provider attitudes towards young people and their sexual activities, limited access to youth-friendly services, low awareness of HIV and fear of stigma as being key challenges preventing young people from taking up sexual health services.

Children and orphans

In 2017, 220,000 children (0 to 14 years) in Nigeria were living with HIV However, only 26% were receiving antiretroviral treatment (ART). The UNAIDS Catch-Up Plan for West and Central Africa, outlines a target to enrol an additional 140,000 children across the region on ART by 2020.

In 2017, an estimated 1.8 million children were orphaned by AIDS, which can have a huge impact on their health, safety and wellbeing. Around 20% of orphans and vulnerable children do not attend school regularly and around 18% are sexually abused.

HIV also has an indirect impact on children in Nigeria, whereby often they become the caregivers for parents who are living with HIV. Normally, this responsibility lies with girls rather than boys and can contribute to the imbalance in schooling between the two genders in Nigeria, with girls missing out on HIV education that could teach them how to protect themselves from infection.

Women

In Nigeria it is estimated that 58% of the people living with HIV are women. Part of the reason why so many more women and girls are affected by HIV is the deep roots that gender inequality has in Nigerian society, culture and law.

In the most recent rankings, Nigeria was placed 122nd out of 144 for the size of its ‘gender gap’, meaning that it is has one of the most unequal balances of power between men and women in the world.

Gender power imbalances mean that women often face barriers in dictating their own sexual partner selection, use of contraception, number and spacing of children, and their own healthcare, all of which put them at greater risk of HIV.

Barriers to land ownership disadvantages women in particular. Although women have land rights, their rights are weaker than men’s. This is not only economically disempowering, but puts pressure on women to give birth to boys, leading to a high fertility rate of 5.5 children per woman. Women who have girls first, are likely to have more children, not use contraceptives, have short periods between pregnancies, and be subjected to polygamy. All of these increase a woman's vulnerability to HIV.

Women who have been formerly married are also more at risk of HIV, as they face a lack of economic opportunities and high rates of sexual exploitation. HIV prevalence among formerly married women is as high as 5.9% (almost double the prevalence of currently married and never married women – 3.4%). Recent studies have shown that being formerly married can be one of the strongest HIV risk factors among women.

Although Nigeria has several strategies on gender equality and HIV, less than 1% of spending on HIV goes towards them. In 2015, the National Agency for the Control of AIDS developed a set of Guidelines to help make gender part of the mainstream HIV response, aiming to raise awareness amongst health practitioners on issues around gender inequality and how to address these issues in their HIV programming. Reducing violence and coercion, and increasing legal protection for women and girls, are particular areas of focus for reducing HIV risk among women and girls.

In 2016, 34% of adults living with HIV were aware of their status. Across the country testing rates are low: only 15.1% of people between the ages of 15-49 had tested in the last 12 months and knew their results. Nigeria aims to reach the UNAIDS target, with 90% of people living with HIV knowing their status by 2021.

Surveys have also shown that only 60.4% of women and 70.8% of men knew where they could go to be tested for HIV.

There are a number of reasons why more people are not testing for HIV in Nigeria. These include supply problems with testing kits and logistic issues getting further supplies. There is also a common belief that HTC centres are where HIV-positive people go to access care, rather than them being testing centres for those who don't know their status.

A push on the number of sites providing HTC services has resulted in a huge increase, from around 1,000 in 2010 to more than 8,000 in 2014. However, this number is woefully short of the estimated 23,600 sites needed to provide universal coverage.

Targets set in the most recent National Strategic Framework commit to 60% of the general population and 100% of key populations and children of mothers living with HIV to have access to HIV testing services. The plan also hopes to integrate screening for other co-infections into HIV testing and counselling services.

The Minister of Health in Nigeria recently released a statement in support of self-testing. Nigeria has put in place policies that allow for self-testing, but these testing kits are not yet available across the country.

Nigeria accounted for 59% of all new HIV infections in West and Central Africa in 2016. This rate of new infections has remained relatively stable in recent years, with only a 5% decrease between 2017 and 2010.

The National Strategic Framework laid out by the NACA, outlined key targets for the next five years: aiming to provide 90% of the general population with HIV prevention interventions by 2021 and for 90% of key populations to be adopting HIV risk reduction behaviours by 2021. They identify strengthening community structures as being a main way to achieve this.

Condom use

According to 2017 data, 57.6% of men between the ages of 15-49 reported using a condom when they last had sex, compared to 39.8% of women. Condom use varies across different groups, and is lowest among people who inject drugs at 83.2%.

The end of term review of the 2010-2015 national HIV strategy identified condom uptake as having been a major area of challenge, identifying cost, low availability and resistance to condom promotion from certain key religious and cultural groups to have been some of the main barriers to progress.

The review also identified low uptake of lubricants, as having been a key failing, with only 45.9% of participants reporting using lubricants consistently.

The National Strategic Framework aims to increase condom use, particularly among young people and those who have never been married. It aims for 90% of people to be using condoms regularly by 2021.

Pre-exposure prophylaxis (PrEP)

PrEP is not available to the general public in Nigeria, however some serodiscordant couples have been able to access the drug through demonstration projects. In 2016, 242 people were on PrEP in Nigeria. It is hoped that the results of the study will be used to inform a nation-wide scale-up of PrEP as part of a comprehensive HIV-prevention package.

According to the new national guidelines for HIV prevention and care, future expansion of PrEP will include serodiscordant couples, commercial sex workers, people who inject drugs, and ‘individuals who engage in anal sex on a prolonged and regular basis’.

HIV education

Family Life and HIV Education (LLHE) lessons are part of the Nigerian school curriculum. In 2015, more than 48,500 schools were providing LLHE lessons, where they were required to teach a comprehensive list of topics relating to HIV, including basic facts about HIV transmission and prevention, alongside more complex issues such as stigma and gender-based violence. The NSF outlines plans to expand access to this education in the coming years.

Prevention of mother-to-child transmission (PMTCT)

Just over a quarter (26.9%) of all cases of mother-to-child transmission (MTCT) of HIV in the world happen in Nigeria. In 2016, just 32% of pregnant women living with HIV received antiretroviral treatment to prevent mother-to-child transmission and only 34.7% were tested for HIV as part of their antenatal care. As a result the rate of mother-to-child transmission has remained high, at an estimated at 22% in 2016. . Only 18,556 infants born to mothers living with HIV were tested after two months.

As such, reducing mother-to-child transmission remains a major target area. Nigeria was selected as one of UNAIDS’ 23 priority countries for PMTCT – being one of the nations with the highest HIV burden yet low levels of treatment coverage during pregnancy. Of these 23 countries, Nigeria has the second lowest level of ART coverage in pregnant women.

The number of pregnant women visiting health facilities remains low, as does the number of health facilities providing PMTCT services, with only 7,265 health facilities providing PMTCT in 2015. To address this, Nigeria aims to have 95% of health facilities providing PMTCT services by 2021.

SMS Communications In early 2015, the telecommunications company Etisalat started rolling out SMS messages to its subscribers about PMTCT and where people could seek HIV services. It is hoped that large-scale communications like this will encourage women to come forward for testing to prevent their babies being born with HIV.

Nigeria is a long way off meeting the global target of enrolling 90% of people diagnosed with HIV on antiretroviral treatment (ART). Just 33% of all people living with HIV were receiving treatment in 2017. Among children this is even lower, with just 26% on ART. Of the people on HIV treatment, only 24% had achieved viral suppression in 2016.

Poor treatment coverage and adherence means that the number of AIDS-related deaths in the country has remained high with 150,000 deaths in 2017.

Although Nigeria adopted a 'test and treat' policy in 2015, which means that anyone with a positive diagnosis is eligible for treatment, this is far from a reality. Nevertheless, efforts have been made to scale-up treatment access, and 212,000 more people were enrolled on antiretroviral treatment between 2016 and March 2017.

Yet weaknesses in the health system exist and create a barrier to many people accessing or staying on treatment. Even when ART can be accessed, drug supplies are known to run out and cause stockouts. In an attempt to address this, the National Strategic Framework for the HIV response has made strengthening supply chains and improving logistics around treatment a priority.

The UNAIDS catch-up plan for Nigeria, also identifies removing ‘user-fees’ as being a key next step in expanding treatment coverage. Although accessing the antiretroviral drugs themselves is free, often patients will be asked to pay for other services, for example running other tests. Studies have shown that these fees and high costs of travel to clinics can be a barrier to many people accessing care.

Nigeria aims to triple treatment coverage in the next three years, ensuring that 90% of the population living with HIV are on treatment by 2021. To do this they will also need to address stigma and discrimination around the virus, and have committed to work to foster an enabling environment for people living with HIV to come forwards.

Nigeria was also selected as a key focus country for the World Health Organization’s drug resistance strategy in 2017. Results from 2008, the most recent data available, showed that in some clinics levels of drug resistance mutations had reached 2.1% among new patients and 50% among those who had been exposed to ARVs before.

Treatment coverage during conflict North-Eastern, Borno State has been the centre of Boko Haram’s insurgency in Nigeria over the last decade. Previously a front-runner in antiretroviral treatment coverage, the area has seen ART coverage fall by 18% between 2013 and 2016, with annual drops in the number of people accessing antiretrovirals (ARVs) of 41.2%. Services offering HIV care have become more scarce in the midst of the conflict. The following podcast, discusses some of the difficulties in providing antiretroviral treatment in the midst of ongoing conflict in Nigeria.

Recent research into the role of civil society in the HIV response in Nigeria revealed that while civil society organisations (CSOs) play a key role in service delivery and HIV education, they rarely are given the opportunity to directly impact on policy or play a central role in democratic processes.

Although 30% of the organisations included in the study identified advocacy as being a key area of their work, many faced difficulty in getting funding for the more political areas of their work and few had influence beyond their local village and community. CSOs working with men who have sex with men face further difficulties in even registering as an organisation

Although NACA claimed to seek civil society input in the formulation of their last National Strategic Framework, there is currently no civil society forum. This was identified by the African Commission as being a key action to further protect and promote the human rights of key groups. One of the actions of this proposed group would be the monitoring of the anti-HIV discrimination and stigma bill.

Nigeria has the fourth biggest tuberculosis (TB) epidemic in the world. Approximately 4% of global TB cases occur in Nigeria.

The TB epidemic in Nigeria is closely linked to HIV. Nigeria is one of ten countries that together are home to 80% of people living with HIV and TB co-infection. Low antiretroviral treatment coverage (30%) contributes to the high rates of HIV-associated TB in the country, as being on antiretroviral treatment dramatically reduces a person living with HIV’s risk of TB.

Nigeria also falls behind when it comes to providing preventative TB treatment. It is advised that those living with HIV are enrolled on the TB drug Isoniazid for preventative therapy, yet in Nigeria only 29% of people living with HIV have access to this medicine.

Cases of TB are underreported in Nigeria, and the country accounts for 8% of the gap between TB incident cases and notifications. When cases of TB are not reported, active TB is more likely to spread, as more people go untreated. fn]World Health Organisation (2017) ‘Global Tuberculosis Report’[pdf]

Between 2015 and 2016 cases of multi drug resistant TB increased by 30% in Nigeria. TB can become resistant to drugs when people start treatment, but fail to complete their course or take their medication incorrectly. This is why counselling around TB treatment is so important. In 2016 it was estimated that 4.3% of new cases of TB in Nigeria were resistant to multiple drugs and 25% of previously treated cases.

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Cultural barriers

The national strategic framework identifies certain cultural practices that increase HIV vulnerability among the general population in Nigeria. These include female genital mutilation (FGM), denial of women's access to inheritance, widowhood rites, encouragement of multiple sexual partners for males, and marriage of young girls to much older men.

In addition to these stigma remains a key barrier to the HIV response in Nigeria, with 46.8% of people reporting that they would not buy vegetables from a shopkeeper living with HIV, in 2016. As such reducing stigma and discrimination has been identified as being a key action point for the country in the West and Central Africa catch-up plan.

Legal barriers

In early 2015, President Jonathan signed a new antidiscrimination bill into law which secured the rights of people living with HIV, protecting HIV-positive employees from unfair dismissal and from mandatory HIV testing. However, in 2016 UNAIDS reported that 21% of people living with HIV had been denied access to health services and reproductive health services due to their status.

One of the major barriers to accessing HIV prevention programmes for men who have sex with men are laws that criminalise their activities. For example, same-sex relations in Nigeria can be punished with 14 years imprisonment. This is not only limiting access to HIV prevention programming for this community, but causing nationwide stigma and discrimination against people based on their sexual orientation.

Structural barriers

A simple lack of sites that deliver HIV services (testing sites, PMTCT sites, and treatment sites) presents problems for the Nigerian population. In 2015 there were only 1,078 facilities providing HIV treatment, according to the national strategic framework.

Although rates are low (0.5% and 1.2% of new HIV infections in 2010 respectively) blood transfusions and unsafe medical injections do result in some new cases of HIV. As a result, enhanced efforts could almost eliminate this risk. Although there are guidelines for certain practices, the lack of universal precautions and failure to record blood safety information in all circumstances means this transmission route remains. By 2021, the NACA aims to ensure that 100% of blood transfusions and blood products are safe.

Despite an additional US$17 million of domestic funds having been allocated to the HIV response for 2017, the vast majority of funding still comes from international donors.

To increase domestic funding further, Nigeria has launched a new initiative to make each of the 36 states contribute up to 1% of their monthly allocations from the federal government to the HIV response. Nigeria also aims to increase private sector investment in the response from 2.1% in 2014 to 10% in 2018.

Funding problems arose in 2016 following an audit of NACA by the Global Fund to Fight AIDS, Malaria and Tuberculosis. The audit found evidence of “fraud and collusion in the amount of US$3.8 million”, causing the Global Fund to suspend its funds. However, the Global Fund has reinstated its support following the creation of the West and Central Africa Catch up Plan, which saw the fund commit to providing another US$214 million to cover an additional 215,000 treatments.

Nigeria is working hard to reverse the trend of a donor-driven approach to our national HIV programmes, as more financial resources are being allocated for the procurement of medicines.

- Isaac Adewolfe, Federal Minister of Health, Nigeria

Nigeria is an enormous, populous country, and so it has a very high number of people living with HIV despite a relatively low HIV prevalence.

Providing antiretroviral treatment for all people living with HIV not only benefits those already living with HIV, it also dramatically reduces the chance of onwards HIV transmission to others. In a country such as Nigeria, where so many people are not on treatment, it is hard to tackle the HIV epidemic. Considerable commitment, funding and resources need to be mobilised to expand access to treatment as a prevention method.

Despite government commitment to the HIV response, punitive laws such as the 2014 anti-homosexuality bill damage progress. Indeed, a worrying rise in HIV prevalence is emerging among men who have sex with men just as punishments for homosexual acts increase, suggesting this group is finding it more and more difficult to access HIV services. Engaging all members of society, especially those who are most vulnerable to HIV, is key to a unified and considered HIV response.

Finally, encouraging HIV testing among the Nigerian population to ensure everyone knows their HIV status is key to any informed strategic plan. Without knowing the extent of how many people are living with HIV it is hard to mitigate new infections and provide HIV treatment to all.