West and Central Africa

World AIDS Day 2021 saw the authorities in the Central African Republic and others involved in the HIV response in the country come together to provide information on HIV, promote HIV prevention, treatment and care and show their solidarity in the face of the pandemic. This year, the President and Head of State of the Central African Republic, and President of the National AIDS Council, Faustin-Archange Touadéra, presided over the ceremony in the commune of Bégoua, near the capital, Bangui.

In line with the Dakar Call to Reinvent the Response to the HIV Pandemic, adopted at the recent High-Level Regional Summit on HIV/AIDS in Western and Central Africa, Mr Touadéra urged the Ministers of Health and Population and of Budget and Finance to ensure that 500 million central African francs is included in the government’s 2022 budget for the HIV response. He also tasked the Prime Minister to report on the actions taken in the HIV response. One of the four pillars of the Dakar Call to Action is to increase national and international resources devoted to HIV in the region by 33% by 2025.

Mr Touadéra also noted the importance of removing financial barriers to accessing health services for people living with HIV.

Bienvenu Gazalima, the President of the Network of People Living with HIV in the Central African Republic (RECAPEV), said that, “Access to antiretroviral drugs has improved, from 12% of all people living with HIV in 2013 to 58% by the end of 2020, but remains one of the lowest in the world. HIV treatment is available in only 10% of the country’s health facilities.”

On the eve of the World AIDS Day commemoration, messages from the Minister of Health and Population and UNAIDS were broadcast on major radio stations and national television. Information on preventing new HIV and COVID-19 infections was given out, especially to young people, in several provinces of the country. With the support of UNAIDS, sensitization caravans criss-crossed the streets of Bangui for several days to spread messages on HIV transmission, HIV prevention, vulnerability to HIV and HIV-related discrimination.

“We are at a crossroads. Leaders have a choice between bold actions and half measures. The transformative approach we need to end AIDS will also protect humanity from future pandemics,” said Marie Engel, UNAIDS Country Director for the Central African Republic, a.i. 

In a suburb of Nouakchott, Mauritania, a tent has gone up for an evening of counselling and HIV testing. Staff of the nongovernmental organization SOS Pairs Educateurs field questions, and people wanting to know their HIV status queue for a rapid test.

Mohammed Bilal, above, is supervising the evening event, along with peer educators, a nurse and a social worker. Pointing behind him to a small concrete house with a corrugated roof, he said that to keep all tests anonymous, people are given a number and they enter the makeshift office one by one. “We do counselling before the HIV test and after the person gets the results,” Mr Bilal said.

More than 70 men and women have opted to get a rapid test today.

In the El Mina neighbourhood, where the outreach event is taking place, Mr Bilal says that most people scrape by making a living, many women live alone raising children and most children don’t attend school. He grew up here and knows the community well. He and his team also know the needs of the people. For Mohammed Mouloid, above right, the Programme Coordinator at REMAP+, a network of people living with HIV, community outreach fills a big gap. During the COVID-19 restrictions, for example, they teamed up with SOS Pairs Educateurs, UNAIDS and others to distribute food kits.

Adjusting his glasses, Mr Mouloid said, “Before a person takes their medicine, they have two other priorities. The person has to eat first and find transportation to pick up their treatment. If both are not combined, then the third priority falls by the wayside and the person will never take their treatment.”

“Our biggest problem in Mauritania is stigma associated with HIV,” Mr Mouloid said, explaining that people living with HIV often drop out of treatment programmes. Only 40% of the 8500 people living with HIV in the country are on life-saving treatment. Mr Mouloid has lived with HIV for nearly 20 years and was one of the first people in Mauritania to take antiretroviral medicines, in 2004. “I have been married twice and have two children who are both HIV-negative, so I am a testament to living a healthy life, but things are tough in our society,” he said.

The HIV epidemic in Mauritania is concentrated in cities and among key populations. HIV prevalence among adults is around 0.3%, but is 9% among sex workers and 23% among gay men and other men who have sex with men. Mauritania criminalizes sex work and same-sex sexual relations, so people tend to hide. 

To reach out to key populations, SOS Pairs Educateurs, with the support of the United Nations and partners, recently opened a drop-in centre, above, in front of the bus station in the capital city (they have eight other drop-in centres around town). A television blasts in the corner as peer educators mill about chatting with a truck driver. A pilot project distributing HIV self-test kits that people can use in the privacy of their own home has also been undertaken. 

Sharif (he did not want to give his last name) explains that he stops by regularly to pick up condoms and get information from the counsellor. “I came here to know more about COVID-19 and other health risks,” he said. He said he had never taken an HIV test, which are provided for free, but was thinking about it.

According to the UNAIDS Country Director for Mauritania, El Mustapha Attighie, community outreach like this is a way to support vulnerable groups.

“Stigma hinders our response to HIV and if human rights are not respected and people are left behind, this increases the risks of HIV,” he said. He added that UNAIDS’ mandate clearly states advocating for rights and treatment for all and as a trained doctor he focuses the debate on people accessing health care.

He believes that Mauritania could end AIDS by 2030. “We have the opportunity to make this objective a reality,” he said. “Channel more money and means where the epidemic is, to quash it and also stop it from reaching a broader population.”

SOS Pairs Educateurs has expanded its activities to reach different populations. It founded a school for street children and children who have dropped out of school and organized trainings for girls in sewing as well as a teen dance group. “Here for many the reality is that you have little hope so by having kids succeed in school or on the dance floor, it boosts them and impacts the entire family,” said the SOS Pairs Educateurs Director, Djibril Sy, above. He grew up in El Mina and still lives there, saying that countless people have benefitted from its work in the past 20 years. “Aside from hope, we really try to instil a sense of self-worth,” he added, explaining now that he wants to give young people trainings in entrepreneurship.

Despite progress, western and central Africa represents 8% of the world population but is home to 12% of all people living with HIV globally and experiences 22% of all AIDS-related deaths in the world.

On 11 November, a project to support the empowerment of nearly 400 people living with HIV through training and involvement in agropastoral activities was launched in the seventh arrondissement of Bangui, Central African Republic.

According to Joseph Tagbale, the Mayor of the seventh arrondissement, “This project is timely and comes as a breath of fresh air, as people living with HIV have paid a heavy price during the COVID-19 pandemic, firstly because of their high risk of infection due to their weak immune systems and secondly because of the collapse of their means of subsistence due to repeated confinements.”

The Multi-Partner Trust Fund granted the UNAIDS Country Office for the Central African Republic US$ 150 000 to support activities for people living with HIV in the context of COVID-19. These activities were chosen in collaboration with the Comité National de Lutte Contre le Sida (CLNS), the Ministry of Health and the Central African Network of People Living with HIV (RECAPEV) and will be implemented by the United Nations Food and Agriculture Organization and the international nongovernmental organization Solidarité pour la Paix et le Développement Intégré.

The activities consist of agropastoral activities (small-scale livestock farming and other farming activities), the production of face masks and income-generating activities, such as sewing, catering and the sale of soap and kitchen utensils. All these activities will enable people living with HIV to sustainably meet their needs and better adhere to their antiretroviral therapy, since due to the COVID-19 pandemic many people living with HIV have stopped taking their treatment because of problems in accessing food. “COVID-19 has destroyed all our progress in adherence to treatment, and people living with HIV have a lot of difficulty feeding themselves, as many are unemployed,” said Bienvenu Gazalima, the National Coordinator of RECAPEV.

The income-generating activities will be supported in four arrondissements of Bangui and in two surrounding communes, Bimbo and Bégoua, which were selected because they have large numbers of people on antiretroviral therapy.

Throughout the project, peer educators will educate people living with HIV on treatment adherence and other health issues, such as COVID-19 prevention and vaccination. Emphasis will be placed on involving women in the activities. “I am delighted that women living with HIV are so strongly integrated in this project, because it is they who have paid the highest price during this crisis,” said Marcelline Seremandji, adviser to civil society associations at CLNS.

“In the Central African Republic we are witnessing how structural inequalities and lack of income have direct impacts on health and HIV outcomes. The lower someone’s social and economic status, the poorer their health is likely to be. Addressing food insecurity and malnutrition, keeping adults earning an income and keeping children in school helps to ensure the efficacy of HIV treatment,” said Marie Engel, the Director, a.i., of the UNAIDS Country Office for the Central African Republic.

Leaders from governments, civil society and the United Nations have renewed their commitment to make urgent and strategic investments in adolescent girls’ and young women’s rights, education and health. At  a three-day regional summit on HIV/AIDS held in Dakar, Senegal that concluded with a call to action, the Education Plus initiative was applauded as a timely intervention to address the high number of adolescent girls and young women acquiring HIV in the Western and Central Africa region.

The Education Plus Initiative, a high-level political advocacy drive to accelerate actions and investments to prevent HIV, was launched as a joint commitment of UNAIDS, UNESCO, UNFPA, UNICEF and UN Women at the Generation Equality Forum in July this year. The Education Plus initiative is centred on the empowerment of adolescent girls and young women and the achievement of gender equality in sub-Saharan Africa—with secondary education as the strategic entry point for providing the multi-sectoral plus package.  The initiative calls for free and quality secondary education for all girls and boys in sub-Saharan Africa by 2025; universal access to comprehensive sexuality education; fulfilment of sexual and reproductive health and rights; freedom from gender-based and sexual violence; school-to-work transitions, and economic security and empowerment.  

While the Western and Central Africa region has progressed in girls’ education over the last two decades, the UNICEF 2019 report found that “the region still has the highest gender gaps in education in the world”. One in four adolescent girls aged 15-19 who have ever been married or in union, has experienced emotional, physical, or sexual violence at the hands of a husband or partner.

HIV/AIDS remains a major public health threat in the Western and Central Africa where 4.7 million people are living with HIV—12% of those living with HIV globally—but experiences 22% of all AIDS deaths in the world. Adolescent girls and young women (aged 15-24) in West and Central Africa are twice as likely to acquire HIV than their male peers.  Five in six new HIV infections (82% / 18,237 females) among adolescents 15-19 years are among females. Three-quarters (74%) of new HIV infections in the age group 15-24 in the region are in females (40,432 females / 13,860 males). Every week, approximately 800 adolescent girls and young women in WCA are newly infected with HIV. 

Secondary education offers protection to adolescent girls and young women from HIV—with reductions in HIV incidence among girls who complete secondary education by as much as one-third to one half in some countries.

However, most countries in Western and Central Africa are falling short of meeting the target of allocating 20 percent of government resources to education as required under the African Union’s Dakar Commitment on Education for All. Before the COVID19 pandemic, only Burkina Faso, São Tome and Principe, Senegal, Sierra Leone and Togo allocated at least 20 percent of their national budgets to education. As a percentage of GDP, education spending varies from 1.1 percent in Central African Republic to 7.7 percent in Sierra Leone.

Before COVID-19 struck, around 34 million secondary school-aged girls in sub-Saharan Africa were being denied a full 12-years of education and an estimated 24% of adolescent girls and young women (15–24 years) in the region were not in education, training or employed, compared to 14.6% of young men.  UNICEF estimates that in 2020 school closures due to COVID-19 impacted around 250 million students in the sub-Saharan Africa region, millions of whom may never return to the classroom-especially girls.

To date, five countries—Benin, Cameroon, Gabon, Lesotho and Sierra Leone—have signed on to champion the initiative with a wide range of commitments that will tackle the urgency of effectively addressing the alarming numbers of adolescent girls and young women acquiring HIV and dying from AIDS-related illnesses, among other threats to their survival, well-being, human rights and freedoms, including sexual and gender-based violence and teenage pregnancy. 

The Education Plus initiative is committed to advancing young women’s leadership as key to ending AIDS as a public health threat and in rebuilding communities and countries during and post pandemic.

During the West and Central Africa Summit on HIV in Dakar, several international partners and ministers gathered to discuss the pressing situation around health financing in the region, exacerbated by the economic crisis due to COVID-19. When it comes to funding HIV responses, WCA is facing a perfect storm: resources available for HIV in the region in 2020 were approximately three quarters of the amount needed. In addition, total HIV resources in the region declined by 11% in the last decade. While PEPFAR and the Global Fund have increased their commitments to the region, domestic resources have slowed down since 2018 and dropped dramatically in 2020.

COVID-19 epidemic did not help. Most African governments have responded to the economic shock by increasing government spending last year however, but with revenues hit by the slow-down, the pandemic will leave many countries with large deficits and unmanageable debts.

Winnie Byanyima, UNAIDS Executive Director, stressed the importance of focusing on these challenges by also re-thinking and reforming overall health systems. She urged countries, as did many other panellists, to use dwindling funds more efficiently, and to ensure additional resources be dedicated to health. “Healthy people means healthy economies,” she said.  She also called for more space to be given urgently to community-led services.

“We need to properly fund community infrastructure and response to be strongly integrated with formal health systems. This is critical as we think about preparing and coping with future pandemics,” Ms Byanyima said.

PEPFAR Deputy Coordinator for Multi-Sector Relations Mamadi Yilla wholeheartedly agreed. "COVID-19 acted like a catalyst and everyone recognized civil society’s role in getting services to the people,” she said. Mentioning that PEPFAR has invested billions in Africa since 2003, she said that the partnerships have to be re-invented and urged governments to work hand in hand with civil society as well as deploy funds in a targeted fashion.

“We have to challenge ourselves to make each dollar count,” said Global Fund Executive Director Peter Sands, "COVID-19 has indeed highlighted the obvious: investing in health makes sense.” He added, “It is important to have finance and economic ministers as part of the answer because health ministers will not be able to solve this on their own.”

Recognizing the need for increased domestic spending on health, the Senegalese Minister of Economy, Planning and Cooperation, Amadou Hott, noted that the current economic slump limits countries' ability to invest more of their resources in the sector. He, like Ms Byanyima, said additional resources must be drawn from debt cancellation, additional international financing mechanisms such as augmenting international liquidity (Special Drawing Rights (SDRS) from the IMF), and fight tax evasion to help increase domestic tax collection.

The Sierra Leone Health Minister, Austin Demby, said that earmarking disease specific resources does not build sustainable health systems, citing an example of a recent measles outbreak in his country. He had to immediately deploy funds to contain it. “We have to create broader platforms to be more flexible,” he said. “Make sure some of the systems around community engagement, and services used every day for HIV, tuberculosis, and malaria can be used for other diseases.”

In addition, financing shouldn’t be tied to specific implementing partners. Both Ministers stressed that to transform health systems, they needed to be given more leeway to implement models that can be self-sustaining on domestic resources, which was not currently the case.

Finally, climate change must be taken into account as it impacts the planet and inevitably people’s wellbeing. The West and Central Africa region, hit hard by desertification and drought, will only feel more pressure on already overwrought health systems.

“Linking funding for climate change and health is crucial because one will inevitably impact the other and increase vulnerabilities to pandemics and diseases,” Mr Hott said in his closing remarks.

The President of Senegal, Macky Sall, pledges an additional $3.5 million to support the HIV response and the call for action

DAKAR/GENEVA, 3 November 2021—A three-day regional summit on HIV/AIDS held in Dakar, Senegal, has concluded with a call to action that urges stronger support for community-led responses, policies driven by science and data, increased investment in the HIV response and putting HIV at the centre of pandemic preparedness and response. In his closing remarks, the President of Senegal, Macky Sall, committed to advancing the call to action with the African Union and pledged additional funds to implement it in Senegal and across the region. 

Western and Central Africa is home to 4.7 million people living with HIV—12% of those living with HIV globally—but experiences 22% of all HIV deaths in the world. Countries in the region, on average, have seen slower declines in HIV infections than other countries on the continent and HIV prevalence in women is significantly higher than in men. Access to HIV testing and treatment reached 73% of people living with HIV in 2020, up from 38% in 2015, but short of the 81% goal that was set for 2020. The region has the world’s highest number of HIV-positive pregnant women still waiting for treatment, and just 24% of children living with HIV were virally suppressed.

The Dakar Call to Reinvent the Response to the HIV Pandemic calls for urgent action in four main areas:  

1. Expand community-led infrastructure and organizations to strengthen national systems for health and shift policies to enable sustained funding for community organizations. Too many of the most vulnerable people in Western and Central Africa region do not have access to conventional health systems. Evidence shows community-led organizations and networks are critical to filling the gaps. This includes expanding the provision of HIV treatment and prevention services by community-led organizations in partnership with the public health system, ensuring that organized civil society and affected communities are included as key partners in decision-making bodies, and building accountability structures such as community-led monitoring.

2. Update health policies to align with the latest HIV science and evidence. Countries that have aligned their HIV policies and programmes with the current science have made greater progress against HIV/AIDS. Governments are urged to review their health policies in consideration of the latest scientific data and evidence. This is as a key step to improve the HIV response, and particularly to address the needs of those most vulnerable to HIV.

3. Increase national and international resources for HIV in the region by 33% by 2025 and remove financial barriers to access health services by people living with HIV. UNAIDS studies show that $2.67 billion by 2025, representing a 33% increase, would ensure sufficient funding for a comprehensive response to HIV in the region. Insufficient progress in the response to the HIV pandemic is only increasing the long-term costs that will strain already overburdened health budgets.

4. Put HIV and COVID-19 at the centre of pandemic preparedness and response. Many of the measures needed to accelerate the HIV response will also help prevent future pandemics.  These measures include strengthening and protecting the formal and informal health workforce, collecting quality epidemic data to inform decision-making, implementing rights-based responses, and ensuring equitable access to new medical technologies.

These four actions are achievable in the next three years and would move the region closer to the 2025 global target of 95% of people knowing their HIV status; 95% of people who know their HIV status initiating treatment; 95% of people on treatment being virally suppressed. They would contribute to a dramatic reduction in the number of AIDS-related deaths and new HIV infections in the region.

Western and Central Africa has been at the forefront of some of the most innovative and successful efforts in the global response to HIV. Ending the AIDS epidemic as part of the 2030 Sustainable Development Agenda remains a priority even though the region faces multiple challenges including the response to the COVID-19 pandemic, numerous economic and security crises, and climate change.  

During the summit governments, civil society actors, community-led organizations, scientists, and other partners reviewed new data and progress against HIV in the last 5 years and took note of the new UNAIDS Global AIDS Strategy 2021-2026 and the United Nations General Assembly Political Declaration on HIV and AIDS: Ending Inequalities and Getting on Track to End AIDS by 2030. The summit was co-organized by UNAIDS and the Civil Society Institute of HIV and Health in Western and Central Africa and hosted by the President of Senegal, Macky Sall. It was held with the support of Luxembourg and the Bill and Melinda Gates Foundation.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

In the lead up to the West and Central Africa Summit on HIV/AIDS taking place in Dakar from 31 October to 2 November 2021, UNAIDS asked its country directors across the region five questions about the AIDS response in their country. Here are the replies of Ms. Sirra NDOW, UNAIDS country director in the Gambia

Similar to other western African countries, the Gambia has a low but highly concentrated HIV epidemic, affecting heavily key populations such as men who have sex with men and female sex workers. While impressive progress towards reducing new adult and paediatric infections have been observed in recent years, COVID-19 has caused a lot of complications. Repurposing HIV medical equipment and health personnel to address the fast-rising epidemic was necessary to limit COVID-19 related deaths. It also came with a cost—reducing the capacity to deliver HIV prevention and treatment services.

Lessons must be learned from the dual HIV/COVID-19 epidemics. Effort must be invested in better prevention services, especially tailored to key populations. Health personnel must be better trained and better supported to manage their workload and prevent bottlenecks. The approach of task shifting/sharing must continue and be further complemented by the strengthening of community health workers and decentralization of services. Finally, no progress will be truly radical unless stigma, discrimination and violence against people living with HIV and other marginalized groups are eradicated.  

1.  What are the main areas of progress in your country’s response to the HIV epidemic in the last five years?

The HIV epidemic in The Gambia mirrors those prevailing in other West African countries: the epidemic is overall low—less than 2% of the general population—but highly concentrated among key populations. The most recent Integrated Biological Behavioural Surveillance Study (IBBS.2018) estimates that prevalence is over 35% among men who have sex with men (MSM) and over 10% among female sex workers (IBBS 2018).

In 2018, the Gambia started implementing WHO’s recommendation to provide all people living with HIV with lifelong antiretroviral therapy (ART) regardless of clinical status or CD4 cell count. Between 2015 and 2020, impressive progress happened as new infections were cut by half and new infections among children were reduced by 75% (National AIDS Strategic Plan,2020-2025). All pregnant women attending antenatal clinics are routinely offered HIV tests, and all pregnant women living with HIV are eligible for ART (Option B+). Until the COVID-19 epidemic started, ART uptake had increased significantly. The country also adopted task shifting for HIV/AIDS and malaria—typically enabling nurses to dispense ART and capacitating community health workers to deliver a range of HIV services.

2. What are the main challenges that still need to be addressed?

Despite increased outreach activities, the testing coverage remains very low with less than 40% of the estimated PLHIV knowing their status. Inadequate investment in HIV prevention programmes and lack of access to prevention services, especially among key population groups, continue to impede progress in the national HIV response. HIV prevalence has increased more than three-fold among MSM from less than 10% in 2011 to over 35% in 2018 (IBBS, 2018) and no program have been designed to accelerate the uptake of pre-exposure prophylaxis as a prevention strategy among MSM.

HIV-related human rights and gender situation in the Gambia has not improved in the past five years. Key populations suffer multiple burden of frequent human rights violations, systematic disenfranchisement, stigma, and discrimination. The existence of punitive laws perpetuates barriers to accessing HIV services for key populations and further contributes to their social and economic marginalization. There remains lots to be done on promoting human rights literacy, putting in place mechanisms to monitor and report human rights violations, and advocate for policy reform and sensitization of lawmakers on human rights and gender-related issues.

Inadequately trained human resources for health coupled with frequent transfers of experienced and trained staff continue to threaten the national response. Decentralizing services, engaging community health services sites should be prioritized to further expand prevention, treatment, and care services. Finally, tracking patients at ART centres is a challenge due to inadequate cross-border programmes. There is need to strengthen cross-border initiatives to enhance follow-ups, defaulter tracing and referral of patients on treatment.

3. How has COVID-19 affected the HIV response in your country?

In the Gambia, there was no public health facility adequately equipped to treat COVID-19 cases and patients were treated at the Medical Research Council. There was no public health laboratory for COVID-19 testing, so health professionals repurposed PCR machines, which were originally intended for HIV testing, to test for COVID-19. HIV laboratory staff were also requested to provide COVID-19 services in addition to routine HIV and TB services While such urgent actions were required by the emerging pandemic, it led to a severe disruption in HIV diagnosis and the delivery of HIV and TB treatment services.

Social unrest caused by the COVID-19 pandemic also impeded access to regular healthcare, including for people living with HIV (PLHIV) and resulted in disruptions of ART availability. Rapidly, a multi-month dispensation of ARVs was initiated to try to maintain continued availability of treatment for all stable PLHIVs. During this period, a sharp decline in the number of PLHIV on ART was observed as well as a decline in HIV testing services in the general population.

4. Who are the unsung leaders of the AIDS response in your country?

We commend the admirable work delivered by community health workers in the Gambia, and the outstanding solidarity displayed by the community of people living with HIV.

5. If you could ask your Head of State to change one thing to strengthen the HIV response, what would it be?

To be a champion for the AIDS responses and to commit to mobilize adequate resources for the response.

In the lead up to the West and Central Africa Summit on HIV/AIDS taking place in Dakar from 31 October to 2 November 2021, UNAIDS asked its country directors across the region five questions about the AIDS response in their country. Here are the replies of Dr. Erasmus Morah, UNAIDS country director in Nigeria

The National response in Nigeria is growing more ambitious and efficient—better information and high-level political commitment have led to increased antiretroviral therapy coverage. Communities, networks of people living with HIV and key populations are given more space to be actors in the response. The private sector is stepping up to play its part in funding the response.

Despite such effort, Nigeria is failing children living with HIV and vertical transmission is on the rise. Violent arrests are still routinely carried out against key populations. And user fees continue to impede access to HIV care and hinder adherence to treatment. Resilience in times of the COVID-19 epidemics gives hope that more effort will be invested to address these systemic barriers to truly turn the tide on HIV and end AIDS.

1.  What are the main areas of progress in your country’s response to the HIV epidemic in the last five years?

First, the availability of data has expanded to enable the country to truly know its epidemic and its response. Several surveys took place since 2017 which provided precious support to national decision-makers to prioritize, track program performance and mobilize resources to end the epidemic.

In 2017, the Nigerian President committed to treating 50,000 Nigerians annually and has since honored his commitment. HIV treatment coverage has leapt from 55% in 2016 to over 85% in 2020. Currently, we estimated that 90% of people living with HIV (PLHIV) know their status, 86% of them receive antiretroviral therapy (ART), and among those, 72% have a suppressed viral load—meaning they have no risk of transmitting it.

To put communities at the centre of the response, the network of persons living with HIV and key populations are engaged in community-led monitoring to assess the quality of services they are receiving and to use data to influence policy and lead to programmatic changes.

To reduce Nigeria’s over reliance on international resources, the Nigeria Business Coalition Against AIDS has worked with the National Agency for the Control of AIDS (NACA) and UNAIDS to set up a trust fund of 150 million US dollars for HIV to be launched on World AIDS Day 2021. A sustainability plan is also being developed for HIV, tuberculosis and malaria.

2. What are the main challenges that still need to be addressed?

Unfortunately, children are still being left behind, and their treatment coverage remains much lower compared with adults. Only 45% of children living with HIV know their status, 45% of them receive antiretroviral therapy (ART), and among those, 31% have a suppressed viral load.  It is sad to note that prevention of mother-to-child-transmission has been less effective over the past five years. 

We continue to deplore the frequent arrest of key populations. Criminalization of the behaviour of key populations, violence and widespread stigma and discrimination continues to feed their avoidance of health care centers.

Finally, some health facilities are still demanding user fees from patient—despite evidence from western and central Africa showing that user charges undermine uptake of antiretroviral therapy, hinders the retention of people in care and reduce the quality of care. Studies specifically carried out in Nigeria have also shown that user fees undermine adherence to HIV treatment (Global AIDS report, 2020).

3. How has COVID-19 affected the HIV response in your country?

Despite the initial negative impact of lockdowns, the contingency measures put in place has ensured that Nigeria was able to successfully put about 300,000 people on treatment by the end of 2020. Through the one UN Basket Fund, about 10,000 households of PLHIV in needs were provided with cash transfers, personal protective equipment, and hygiene products to help prevent and mitigate the impact of COVID-19.

To ensure service continuity, the National AIDS and STI Control Program (NASCP) issued a policy directive from the Minister of Health for multi-month dispensing of ART, meaning that all clinically stable patients were provided with 3 months of treatment at once. NASCP set up a situation room to track HIV commodity stocks. Furthermore, NASCP regularly updated the UNAIDS HIV service disruption portal with programmatic data to monitor HIV service delivery during the COVID-19 pandemic. PLHIV networks provided home delivery ART services for their peers who could not access health services.

4.  Who are the unsung leaders of the AIDS response in your country?

First, we need to recognize the outstanding work delivered by communities of key populations and networks of Persons Living with HIV in Nigeria. They truly are unsung heroes of the AIDS response. We also need to laud the support and commitment of international partners such as PEPFAR and the Global Fund.

5. If you could ask your Head of State to change one thing to strengthen the HIV response, what would it be?

I would call on Nigeria to take forward its commitments by investing its fair share in the AIDS response and by increasing domestic financing.

To counter the low level of people living with HIV in Central African Republic (CAR) on treatment, the country has been testing new treatment approaches.

One is distributing up to 6 months of medicine, known as multi-month dispensing. The other is community ARV dispensation. CAR’s 2021-2025 National HIV Strategic Plan, identified these differentiated approaches at the community and hospital level and has been trying it out.

In the capital, Bangui, four pilots opened and 15 sites will progressively offer MMD (multi-month dispensing), health check-ups and community outreach thanks to funding from the Global Fund. This follows on the success of community-based treatment groups (CAGs) introduced by the Ministry of Public Health and Population and the National AIDS Control Council (CNLS) in 2015, with the support of the NGO Médecins Sans Frontières.

Certain community members deliver antiretroviral treatment to people living with HIV, especially in rural or conflict-stricken areas. Results showed that treatment intake was much more regular and people living with HIV had a rate of 75% viral suppression.

In addition, with UNAIDS support under a Luxembourg grant, the country has set up a steering committee to oversee the scale up of differentiated services, developed and validated national guidelines on the provision of differentiated services and two guides on multi month dispensing and the possibility of getting refills in a non-hospital setting.

At the end of October, clinicians, lab technicians, health care providers, community health care workers from the four pilot health centers participated in a workshop to go over the new approaches and guidelines. The CNLS and the country’s Division of Communicable Disease Control (DLMT) were confident adapting to the HIV epidemic in this way was a right step to keep patients on treatment. Currently, less than half of the people living with HIV take life-saving medicine (88,000-100,000 people live with HIV in CAR.)

Dr Marie-Charlotte Banthas from the DLMT said that "differentiated treatment models have demonstrated consistent improvement in patient engagement and retention of care, while freeing up time for the care of people with advanced disease.” She then added, ”It's a model of care for people living with HIV and staff working in the HIV field, a model of life."

These approaches came at the right time considering the lockdowns due to COVID-19, remarked UNAIDS CAR Country Director a.i. Marie Engel.

"With the long projected trajectory of the Covid pandemic, there is an even greater need to adapt the system to reduce service disruptions and not have recent gains in the HIV response stymied,” she said.