IBADAN, Nigeria — Wasiu is well-known at his local HIV clinic in Ibadan, Southwest Nigeria. At 32 years old, he is a socialite with several wives — two in Nigeria and one in the United States. He is also HIV positive.
Health care providers at the health center knew his wives were at high risk of infection because Wasiu — whose name has been changed to protect his privacy — had openly talked about his dislike of condoms.
As expected, his two wives in Nigeria tested positive one after the other. But his wife in Florida has remained free of HIV.
That is because she could easily access a treatment to prevent infection — a pill called Truvada that combines two anti-HIV drugs to prevent the virus from spreading through the body. The World Health Organization recommends that people at high risk of exposure take it every day to lower their chances of infection — an approach known as pre-exposure prophylaxis, or PrEP.
PEPFAR's new strategy identifies 13 countries where it will accelerate efforts to achieve epidemic control. Nigeria, despite accounting for 9 percent of the global HIV burden, was not among them.
In Nigeria, more than 3 million people are living with HIV, but less than 400 people at the highest risk of infection are using PrEP, widely regarded as a key tool in the battle against the disease’s spread.
That is especially significant in a country where so-called “serodiscordant partnerships” — relationships where one partner is HIV-positive and the other is not — are a key contributor to the HIV burden.
That is true of many couples at Wasiu’s HIV clinic, according to the pharmacist in charge, Olubukola Akinlade. Under Nigerian government guidelines, the HIV-negative partners should be offered PrEP. But in most cases, Akinlade said, they are only offered HIV counseling, testing, and condoms.
“[The] Nigerian government does not have money for PrEP at present,” an official at the National Agency for the Control of AIDS told Devex. “If [the Bill & Melinda] Gates Foundation or any other major donor announces it will be providing PrEP for free, you will see them at the HIV clinics across Nigeria.”
In 2017, there were over 210,000 new cases of HIV in the country and about 150,000 HIV-related deaths. UNAIDS has acknowledged a “condom crisis” at the center of HIV prevention in sub-Saharan Africa, where the estimated condom need in 2015 dwarfed the number distributed. In Nigeria, they are still not widely adopted, due in part to religious opposition; reluctance from men like Wasiu, who say they make sex less enjoyable; and cultural norms that make it difficult for women to access them.
In serodiscordant couples, access to Truvada is therefore key. In Africa, a handful of countries have major PrEP access programs, while pilot projects are at different stages in countries across the continent. In Kenya, an estimated 28,000 people are taking PrEP, around 8,500 in South Africa, and 3,500 in Zimbabwe. But in Nigeria, only 364 people received PrEP drugs in 2017, according to UNAIDS — the lowest for any country that recommends PrEP in its national HIV guidelines, according to the Global PrEP Initiation Tracker.
Nigeria’s own PrEP pilot got underway in 2015, funded by the Gates Foundation, with the aim of figuring out how to offer the treatment in real-life situations, according to NACA’s then-director general, John Idoko. The pilot has finished collecting data, and is now undertaking analysis prior to a national consultation, he said.
NACA’s current director general, Dr. Sani Aliyu, told Devex the preliminary results of the pilot indicate a very positive uptake potential, but that PrEP will be expensive to provide. There are wide variations in PrEP pricing globally, but in the U.S, Truvada, which is made by Gilead Sciences in California, can cost up to $2,000 for a 30-day supply.
In Kenya, public financing, plus support from local and foreign partners, has made it possible for PrEP to be distributed for free to those most at risk. It is also available at private hospitals and pharmacies for about $36 a month. A similar arrangement in South Africa has seen PrEP access extended to university students.
But Nigeria’s government has offered no provision for PrEP financing since the 2016 HIV prevention guidelines became effective. Officials at the Ministry of Health and NACA told Devex this is a major reason why PrEP has not yet been rolled out.
Campaigner Morenike Ukpong pointed to a lack of political will. Beyond that, “there is nothing stopping PrEP roll-out in Nigeria,” she said. Aliyu, meanwhile, said the government does have the will but that there are other priorities.
“Of course, resources are limited and we still have a lot of people living with HIV that need treatment [first] ... PrEP will eventually come in,” he told Devex.
Almost a quarter of gay men in the country have HIV but most cannot access treatment.
Since it isn’t yet available at HIV clinics, advocacy groups are encouraging doctors to prescribe PrEP privately for patients who can afford it and to refer those who cannot to places where it might be available. For example, some men who have sex with men can access PrEP for free through a study being run by the U.S. Military HIV Research Program.
Still, the reliance on foreign donors for the diagnosis and treatment of HIV is a major concern for local health advocates. Former NACA head Idoko stressed the need for Nigeria to start investing in health care.
“We need domestic resources from government at all levels; involvement of the private sector; and most important, national, state, and community health insurance schemes,” he said.
Ikpeme Neto, founder of Wella Health Technologies, a Nigerian health technology company, said the private sector should be involved in setting up a model for PrEP access. “A company could aggregate demand and set up a payment plan, [then] connect this aggregated demand to a wholesale pharmacy that imports the generics from say India or China [once they become available]. We have millions of people that require HIV-related care. There's no reason why there wouldn't be a subset of those that … [could] pay for some form of care,” he said.
Although it is already possible to access PrEP privately in Nigeria, it isn’t widely available. NACA’s Aliyu said that the government will “strongly push for Truvada to be widely available in the private sector ... once we have a comprehensive plan available.”
Several experts told Devex that the key involvement of the government should be the provision of subsidies for those who cannot afford the treatment. That means upgrading its data capabilities to ensure that individuals such as Wasiu and his wives, who can afford to pay for PrEP, do, while those who cannot are still guaranteed access.
Editor’s Note: Research for this story was supported by the Africa Science Desk project of the African Academy of Sciences. Devex retains full editorial independence and responsibility.