That would avert more than , HIV infections by The initiative's fate will depend on Congress, which will decide whether to fund the new proposal and, if so, by how much. In a press call Wednesday, Dr. Brett Giroir , assistant secretary for health, declined to specify how much money the president would request from Congress for the program.
Those details will be included in the administration's overall budget request, he said. The new plan echoes "targeted" prevention campaigns of decades past. These have focused on people at highest risk of HIV, such as men who have sex with men, injection-drug users and commercial sex workers. Or they have concentrated resources on specific geographic areas, where the spread of HIV was greatest. The rate of new infections has hovered around the 40, mark, more or less, for years despite the targeted programs. Anthony Fauci of the National Institutes of Health said on the press call.
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That means they essentially can't pass the virus to others. Some 90 percent of new HIV infections can be attributed to people who either don't know they are infected or aren't getting treatment, or both. Second, people who are at high risk of getting HIV — including men who have sex with men, commercial sex workers and people who use drugs intravenously — can protect themselves from HIV by taking an anti-HIV pill once a day.
It's called pre-exposure prophylaxis , or PrEP. Also, studies have shown that providing injection-drug users with clean equipment can dramatically reduce the risk of HIV spread. Condoms can too. But she also said it runs counter to actions by the administration so far. Indeed, the cost of the administration's new program could be quite substantial. We found a study conducted among MSM in North Central Nigeria which investigated the impact of the law prohibiting such relationship in Nigeria [ 52 ].
The authors argued that there was increased fear of stigma and discrimination among this key population and as a result, access to care was affected. Policies are usually formulated at the national level and domesticated by the states. Though the administrative structure in Nigeria stipulates that states are federating units with autonomy to develop their own policies and programmes on issues such as health and education, there is a lot of synergy and cooperation among the federal and state government agencies.
In this review, only policies and programmes enacted by the national government are reviewed because they apply across the entire country. Also, in order not to lose sight of the aim of this paper, we focused on the policy and programme components related to HIV-stigma. Prior to that, similar policies have been formulated in and The policy document adopted a multisectoral approach to the fight against HIV in Nigeria.
Therefore, its formulation involved extensive stakeholder engagement across public sector, private sector, and international development partners.
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Among the guiding principles of the policy was protection of rights of PLHIV and reduction of stigma and discrimination. The six strategic thrusts of the policy were 1 behaviour change and prevention of new infections; 2 treatment; 3 care and support for infected and affected persons; 4 institutional architecture and resourcing; 5 advocacy, legal issues, and rights; 6 monitoring and evaluation; 7 research and knowledge management.
Stigma and discrimination were part of several policy objectives under strategic thrusts 1, 2, 3, and 5.
Surprisingly, the policy document was silent on specific strategies to reduce stigma and discrimination under treatment, care, and support services. This was the third in a series of plans to combat HIV epidemic in Nigeria. It served as blueprint on implementation for different stakeholders. In the NSP, stigma and discrimination featured as an objective under care and support services. Furthermore, S and D reduction was also listed among the activities to be carried out under policies, rights, and legal issues. The latest review was adopted and published in [ 55 ].
Such a policy became necessary because the population most affected by HIV in Nigeria are youths and those who are in the reproductive age groups. These also constitute the workforce of the country. Nigeria is a signatory to several ILO recommendations and conventions. Curiously, implementation and action plans which were to be developed by different stakeholders are still being awaited.
First introduced to the National Legislature in , the bill was passed and signed into law in April and November , respectively. This is because the nonpassage of the bill was a recurrent comment in the PLHIV stigma index and gender assessment report which are both reviewed in the next sections.
The antidiscrimination act was very clear on rights of individuals [ 57 ]; their responsibilities; institutional obligations; and penalties for violations. It stipulates that PLHIV have rights to privacy about their serostatus, employment, welfare benefits, compensation, appeal, and recourse to courts as well as occupational safety. All Nigerians have responsibility to prevent stigma and discrimination.
The responsibilities of PLHIV were disclosure of status to partner, demand for their right, and reporting of violations. Available information from the legal unit of NACA is that the act has been domesticated in 17 states across Nigeria. Two years after the law became active, there is a need for empirical evidence on the level of awareness; compliance; and the impact of the law on different aspects of the national HIV response in Nigeria.
This is very crucial for the development of the next strategic response plan. Anecdotal evidence shows that lack of laws is not the main problem. In response to the formidable threats posed by stigma and discrimination to the success of HIV prevention and treatment programmes, NACA in collaboration with other stakeholders developed the stigma reduction strategy for Nigeria [ 58 ].
Collection on: Stigma Research and Global Health
Several strategic actions were listed including survey on behavioural, biomedical, and structural drivers of stigma and discrimination at different levels, increasing awareness about related laws. This national stigma reduction strategy actually integrated many of the UNAIDS suggestions on programmes and initiatives to promote stigma reduction at individual, community, structural, and institutional levels [ 2 , 59 ].
The commonest programme targeted at HIV-stigma and discrimination reduction in Nigeria is media and awareness campaigns aimed at educating the populace about HIV and ultimately reduce stigma and discrimination. Other approaches include the strategies deployed for universal counselling, testing, and treatment. The main philosophy of the approach was that if HIV is seen as a chronic condition just like hypertension or any other, then the infection would be better humanized thereby reducing stigma and discrimination against those infected and affected by HIV.
The stigma index was designed to collect data on stigma, discrimination, and rights of people living with HIV. As of September , it has been used in more than 50 countries including Nigeria. Further details on the development and processes involved in using the index are available on its dedicated website www. Data was collected from persons living with HIV selected from support groups in 12 states of the federation. Report from the assessment documented several experiences of stigma and discrimination across three themes: exclusion, access to work, health, and educational services; internalised stigma; and fears [ 60 ].
Nearly one-third of respondents reported that they have been excluded from family and religious or other social functions due to their HIV status. A similar percentage also reported that they have experienced denial to health and educational services. It is noted that the stigma assessment was done before the enactment of antidiscrimination law. Also, several programmes and initiatives have been implemented which must have influenced the narratives about HIV S and D in Nigeria.
A repeat application of the stigma index is necessary to empirically assess the impacts of these various interventions. There has been a drive at international and regional levels to use laws as tools for HIV elimination. Particularly, to improve equity in access to services among key populations, law and regulatory environment must not be prohibitive. For instance, in Nigeria, HIV prevalence is higher among brothel-based female sex workers Incidentally, there is a law prohibiting same-sex relationships in Nigeria.
Empirical investigation of the effect of this law showed that it increased the incidence of stigma and discrimination against MSM such that they are afraid of accessing HIV care and treatment from public health facilities [ 52 ]. Stigma and discrimination are a main driver of inadequate access to care and treatment among these key populations. This would constitute a weak link in the HIV prevention efforts if an enabling environment is not created to protect this group against marginalisation and stigma.
The LEA in Nigeria was therefore designed to identify and review existing laws, regulations, and policies that could impact the national HIV response. Varieties of qualitative research methodologies desk review, focus group discussion, in-depth interview, and key informant interview were employed for the exercise. Even though the constitution amended guaranteed rights of individuals against stigma and discrimination in any form, the institutional mechanisms for seeking redress could be easily exploited to the disadvantage of those in lower socioeconomic strata.
Some of the legal provisions under different laws such as the criminal codes which operates in Southern regions , penal codes in the Muslim dominated northern regions , and same-sex marriage laws were found inconsistent [ 61 ].
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While advocating for review of many of the existing laws related to stigma and discrimination, the LEA report also called for legal literacy among key populations and stakeholders in the justice sector. Although the measures used have not been consistent, there is evidence to show that the level of HIV-stigma in Nigeria has declined in the past two decades.
This is demonstrated in results from analysis of attitudinal questions about people living with HIV in nationally representative surveys such as the NARHS , , , and and NDHS [ 21 , 23 , 29 , 63 ]. At least, early stories of isolation, abandonment, avoidance, and so forth have reduced drastically while uptake of HIV counselling and testing have improved [ 4 ]. HIV-stigma exists beyond the individual level and persists in families, communities, workplace, and other institutional contexts.
Forms of HIV-stigma and discriminatory practices vary from one setting to another and this contextual difference is driven by economic and sociocultural diversity characteristic of Nigeria. At the base of this is the problem of power and inequality which visibly manifests as gender differences in HIV-stigma.
Apart from the effect of stigma on testing, treatment uptake, adherence, care, and support, there is emerging evidence of a negative effect on treatment outcomes quality of life and mental health. Example of a positive response is by choosing to maintain good adherence so that physical health and overall quality of life can be like that of HIV-negative individuals. Another one is their family formation behaviour which is strongly motivated by a desire to demystify the misconceptions that fuel HIV-stigma and discrimination.
This review also revealed that the Government of Nigeria with support from development partners have done a lot to confront HIV-stigma. National policies and strategic plans have been revised about three times to align with international best practices as well as respond to the epidemiological and structural dynamics of the HIV epidemic in the country. A robust multisectoral approach with stakeholders involvement, political will, and policy advocacy at national and state levels have all contributed to general awareness about the urgent need to eliminate stigma and curtail HIV spread.
To further improve on the successes recorded so far, some recommendations are made which could strengthen the stigma reduction programmes in the country. There is a need for reliable, validated empirical measures of HIV-stigma. Even though the Berger HIV-stigma scale was applied at a facility in SW Nigeria [ 46 ], its internal consistency reliability was just average. Measures already validated in other SSA settings [ 12 ] can be revalidated in the country.
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Availability of reliable and validated measures will facilitate objective assessment which is very important for the monitoring of the recent stigma reduction strategy in the country. The need to monitor the impact of the antidiscrimination law also makes this necessary. Another reason for new measures of stigma stems from the scale-up of ART services to secondary and primary healthcare facilities.
It is expected that a deeper population penetration of ART would help correct the wrong belief that HIV is a death sentence. This misconception has been responsible for abandonment in the early s. It also heightened the fear of casual transmission via mere physical contact. Now that treatment is closer to the grassroots, it ought to have indirectly mitigated some of the stigma.
Operational research studies need to be undertaken to explore this proposition. Considering the evidence about the dynamic sociocultural nature of stigma, there is need for complimentary evidence from the North East and North West regions. The case for the North East is even more sacrosanct because of the internal population displacement occasioned by the Boko Haram insurgency. Although some of these internally displaced persons are being resettled in their communities, the level of HIV-stigma in IDP camps must have been enormous.
The experiences of those affected and how they coped with the challenges would provide useful lessons for stigma reduction programmes in Nigeria. Another implication of the preponderance of HIV-stigma studies in Nigeria being domiciled in tertiary health facilities is that they also provide information about urban areas.
Could stigma be higher in rural areas? Evidence from population-based surveys suggests that stigmatizing attitudes towards PLHIV was associated with lower education, poverty, and poor knowledge of HIV [ 23 , 63 ]. These features are characteristic of rural settings in Nigeria. In addition, the only facility-based study among health workers in primary health centres also showed that stigma was high among this cadre of health workforce [ 38 ].
These are kinds of facilities that exist in most rural areas. Therefore, it can be expected that stigma will be higher in rural areas. This may also explain why investigation of HIV-stigma in this population is rare. The only study among this group showed that enactment of the law prohibiting same-sex partnership in Nigeria has contributed to higher level of fear [ 52 ], although, prior to the legislation, the existing social environment cannot be claimed to be conducive to MSM. Therefore, it is difficult to draw a definitive conclusion about the effect of the new law. Without prejudice to other strategies aimed at eliminating HIV by year , stigma and discrimination reduction is a priority.
Research, policies, and programmes in the past decade have made tremendous contributions to this drive. Newer approaches tailored to the epidemiological and social contexts of individual countries would continue to evolve. In this regard, this paper reviewed research studies, policies, and programmes related to HIV stigma in Nigeria, the country with the second largest number of people living with HIV in the world.
This review identified the need for a consistent valid and objective measure of stigma at different levels of the HIV response. Empirical evidence on the awareness and effect of anti-HIV discrimination law and other interventions are urgently needed. Nigeria is not lacking in policies as this review shows that the country is nearly up to date in compliance with UNAIDS guidelines on several policy requirements.
What need to be strengthened are programmes design, planning, monitoring, and evaluation.
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It is necessary to intensify advocacy, awareness, and enforcement of the anti-HIV discrimination law. It is also very important to develop systems for evaluating the impact of stigma and discrimination reduction programmes at national and subnational levels. The authors declare that there are no conflicts of interest regarding the publication of this paper. Indexed in Web of Science. Journal Menu. Special Issues Menu. Subscribe to Table of Contents Alerts. Table of Contents Alerts. Clifford O. Odimegwu , 1 Joshua O. Akinyemi , 1,2 and Olatunji O.
Alabi 1,3. Abstract Nigeria has about 3. Introduction One of the successes recorded in the Millennium Development Goals was target 6A which aimed to halt HIV by and begin to reverse its spread. Yahaya, A. Jimoh, and O. Okareh, O. Akpa, J. Okunlola, and T. Okoronkwo, U. Okeke, A. Azar expressed a similar view last month at a conference on H. It is, he said, wrong to stigmatize those with H. The officials include Dr. Brett P. Robert R. Anthony S. In his speech, Mr.