Despite Progress, More Work is Needed to Control Infectious Diseases in Nigeria
November 5, 2010
Senior Associate, Global Health Policy Center, CSIS
A recent visit to an HIV/AIDS conference in Nigeria gave me an opportunity to discuss with colleagues and to review recent reports on several important infectious diseases in that very large and diverse country. The progress report was decidedly mixed.
On the bright side, Nigeria, a country with a population greater than 140 million, appears to have made excellent progress in regaining control over paralytic polio. It had previously been the only African country that had not eliminated polio from within its borders, and as a consequence over the last several years, polio viruses spread from Nigeria to several other countries, some of which have not yet brought their polio outbreaks under control. However, the most recent data from Nigeria indicating few recent polio cases means that Nigeria has not only brought its own outbreak under control but also, there is now a lower risk of the spread of polio from Nigeria.
On the other hand, Nigeria is now experiencing a large outbreak of cholera, a severe and sometimes fatal bacterial infection that spreads person-to-person through contaminated water and food, most often in areas where adequate sanitation is lacking. As of October 26th, reports indicated that more than 40,000 Nigerians have been sickened and more than 1,500 have already died of the disease. Although cholera cases are usually reported in Nigeria during its rainy season, the magnitude of this year’s outbreak is unprecedented, said to be the largest in 20 years. The reason for this outbreak appears to be flooding from the unusually heavy rains that have fallen in this year’s rainy season. Authorities are hopeful that the oncoming dry season will help their ongoing disease control efforts.
Malaria remains another problematic disease burden for Nigeria. Data from the World Health Organization and from the global Roll Back Malaria Program indicate that in 2008, the most recent year with global data available, Nigerians experienced nearly one of every six malaria infections in the world. Because malaria is a major cause of infant and young child mortality, it seems clear that better malaria control is a pre-requisite for further reducing the country’s infant mortality and child mortality rates. Equally concerning is a recent report that reveals a large proportion of blood donors in Nigeria are infected with malaria and that Nigeria’s current malaria screening practices may not be adequate to prevent malaria transmission through blood transfusions.
Nigeria’s HIV/AIDS Conference
Nigeria has an estimated 3 million HIV-infected people, more than half of whom are women. The HIV/AIDS conference I attended, co-sponsored by Nigeria’s National Agency for the Control of AIDS, focused largely on options for increasing HIV testing and counseling (HTC) rates in that country. HTC represents both a gateway to AIDS treatment for those found to be infected and a gateway to more focused HIV prevention efforts for those found to be uninfected. Yet only 6-14% of Nigerians over 15 years old have been tested and counseled for HIV, meaning that more than four out of every five HIV-infected Nigerians are unaware that they are infected.
Preliminary results were presented from HIV prevention awareness surveys carried out by the Research Alliance to Control HIV/AIDS (REACH), a multi-year collaboration between Northwestern University (Evanston, IL) and Nigeria’s University of Ibadan. Data from these community studies confirmed the low HTC uptake and identified associated factors such as lower income levels and lower levels of completed schooling. Other factors linked to low HTC uptake included lack of awareness of nearby HTC sites, fear of stigma and fear of having to disclose results to family members and/or sexual partners. The youngest survey respondents, i.e., those 15-17 years old, had HTC rates much lower than older respondents, possibly because they were at lower actual risk of being HIV-infected. Another possible reason for this, though, could be that Nigerian law – requiring parental consent for medical procedures for those under 18 years – had been an obstacle to their seeking HTC.
Among the options for moving forward discussed at the conference were an explicit focus on testing and counseling of couples (a technique already in use in several other African countries), use of mobile testing teams that would allow HTC to be done outside of formal health facilities, and a greater use of “opt out” HTC, in which people coming to hospitals and clinics for almost any reason are routinely told about the program and tested and counseled for HIV unless they ask not to be included. REACH survey respondents had been very positive (>80% acceptance rate) about accepting each of these options.
The conference also marked the beginning of a transition for REACH from a formal collaboration between Northwestern and the University of Ibadan to a project totally under the control of Nigerian institutions. Although Nigeria still has a long way to go to get HIV/AIDS under optimal control, I was impressed by the determination expressed at the conference by Nigerians in both government and academia; these leaders are committed to addressing outstanding HIV/AIDS challenges by using available data to make necessary policy changes.