By Jon Cohen and Misha Friedman, Sciene Magazine, June 12, 2018<\/p>\n
NIGERIA\u2014On a January morning, 12-year-old Yusuf Adamu slumps in his father\u2019s lap, head pressed against his chest. Infected at birth with HIV, he is tiny for his age and has birdlike limbs. He has been feverish for 3 days, which is why his father, Ibrahim, brought him to the pediatric HIV\/AIDS clinic at Asokoro District Hospital in Abuja, Nigeria\u2019s capital. \u201cHe\u2019s been losing weight, he is not eating well, he\u2019s still taking his drugs, and he\u2019s complaining of chest pains and coughing,\u201d Ibrahim tells the nurse. Yusuf\u2019s records show that at his last blood check 6 months ago, HIV had already ravaged the boy\u2019s immune system, even though he was receiving antiretroviral (ARV) drugs. When the doctor, Oma Amadi, examines his mouth, it is filled with white sores from candidiasis, a fungal infection. \u201cThe boy has been sick for so long,\u201d she says. \u201cI\u2019m going to admit him.\u201d When Amadi removes Yusuf\u2019s\u00a0 shirt to listen to his chest, the boy winces at the touch of her stethoscope. Amadi suspects Yusuf has tuberculosis, and after x-raying his lungs, the doctors put him in an isolation room.<\/p>\n
Yusuf\u2019s mother was never tested for HIV before he was born: She received no prenatal care and delivered at home. Yusuf was not tested for the virus until she died of AIDS 3 years later. Ibrahim then learned that he, too, is HIV-positive, as are his two other wives. One ended up transmitting the virus to a second child, now 4.<\/p>\n
The entire family receives ARVs, but Yusuf has only had intermittent access to the drugs. Dosing is based on weight, and Yusuf\u2019s has fluctuated so much that he has required monthly hospital visits. Ibrahim, a security guard, earns the equivalent of only about $20 a month. The Adamus live 20 kilometers and three bus rides from the hospital. The round trip bus fare costs $2, and Ibrahim has to miss a day of work for each checkup, when he also picks up his son\u2019s ARVs. Ibrahim simply can\u2019t afford regular treatment for his son. \u201cThere is no food at home,\u201d Ibrahim says.<\/p>\n
Yet poverty alone does not explain the root of Yusuf\u2019s plight\u2014which hundreds of thousands of other Nigerian children living with HIV now face. At a time when rates of mother-to-child transmission of HIV have plummeted, even in far poorer countries, Nigeria accounted for 37,000 of the world\u2019s 160,000 new cases of babies born with HIV in 2016. The most populous country in Africa, Nigeria does have an exceptionally large HIV-infected population of 3.2 million people. But South Africa\u2014the hardest-hit country in the world, with 7.1 million people living with the virus\u2014had only 12,000 newly infected children in 2016. The high infection rate, along with the lack of access to ARVs\u2014coverage is just 30%\u2014helps explain why 24,000 children here died of AIDS in 2016, nearly three times as many as in South Africa.<\/p>\n
Mother-to-child transmission is only one part of Nigeria\u2019s HIV epidemic. But that route of transmission epitomizes the country\u2019s faltering response to the crisis, highlighting major gaps in HIV testing that allow infections to go untreated and the virus to spread. \u201cNigeria contributes the largest burden of babies born with HIV in the world\u2014it\u2019s close to one in every four babies [globally] being born with HIV\u2014and that\u2019s really not acceptable,\u201d says Sani Aliyu, who heads the National Agency for the Control of AIDS (NACA) in Abuja. And it is a solvable problem\u2014even here. The key is to find and treat the relatively small population of pregnant, HIV-infected women, because those who receive ARVs rarely transmit the virus to their babies. Like most countries, Nigeria has made mother-to-child transmission a priority for more than a decade, and it has seen a reduction in children born with HIV. Still, the country stands out for its slow progress. \u201cWhat we\u2019ve realized is that we need to think outside the box,\u201d Aliyu says.<\/p>\n
A pregnant woman living with HIV has a 15% to 30% chance of transmitting the virus to her baby in utero or at birth, and breastfeeding will infect up to 15% more. In 1994, a study showed that one ARV drug, azidothymidine, cut transmission rates by two-thirds if given to the mother before and after delivery and to the baby for 6 weeks. But few poor countries used that regimen because it was expensive and complex, requiring an intravenous drip of the drug during labor. Five years later, a study in Uganda showed a single dose of another ARV, nevirapine, given to a mother in labor and a baby at birth, could reduce transmission by 50%, which soon became a standard of care. Countries all over the world began aggressive prevention campaigns. Nigeria launched a program in 2002 when it had 54,000 newly infected children, and transmissions began to slowly decline.<\/p>\n
Today, the standard of care is to treat all HIV-infected people, including pregnant women, with daily combinations of powerful ARVs. When treatment suppresses the virus in pregnant women and, as an additional safety measure, their newborn babies also receive ARVs for 6 weeks, transmission rates typically plummet to less than 1%. In the developed world and many developing countries, mother-to-child transmission is now rare. But the regimen can\u2019t be given if pregnant women don\u2019t know whether they are infected.<\/p>\n
According to estimates from the Joint United Nations Programme on HIV\/AIDS, 21.58% of HIV-infected, pregnant Nigerian women transmitted the virus to their children in 2016. Nigeria\u2019s central problem is that some 40% of women give birth at home or in makeshift clinics run by traditional birth attendants, where women are unlikely to get tested. The reasons women do not seek care at more formal health care facilities like Asokoro Hospital are many and overlapping: poverty, fear of stigma and discrimination for simply seeking an HIV test, lack of education, tradition, and husbands wary of health care.<\/p>\n
Another barrier is the \u201cformal\u201d fee that the government levies for care at a clinic. Deborah Birx, director of the U.S. President\u2019s Emergency Plan for AIDS Relief (PEPFAR) in Washington, D.C., which has invested more than $5 billion in preventing and treating HIV in Nigeria, says the fee \u201copens the door\u201d for others to tack on more insidious \u201cinformal\u201d fees. \u201cIf you want to get your lab results back or you want to get your blood drawn, that nurse may charge you,\u201d Birx explains. Those fees, she says, \u201care very hard to police.\u201d When one Nigerian state eliminated the formal fee, the number of women who came to clinics for antenatal care doubled, she says.<\/p>\n
Muktar Aliyu, an HIV\/AIDS researcher at Vanderbilt University in Nashville who is Sani\u2019s identical twin, says corruption is a major factor. \u201cIt\u2019s a big elephant in the room,\u201d says Muktar Aliyu, who still conducts studies in his home country. Scams such as informal fees are just part of the problem. The Global Fund to Fight AIDS, Tuberculosis and Malaria in 2016 suspended payment to the country after detecting what it called \u201csystematic embezzlement\u201d by Ministry of Health staff as well as improper auditing.<\/p>\n
Conducting large-scale HIV testing is also hard because the virus is dispersed unevenly across the country, with some states having a much lower prevalence than others. In Niger, a state in the central part of the country, it is just 1.7%, according to 2015 estimates. \u201cWe\u2019d test 1000, 2000 individuals and we\u2019d get barely 20, 30 positive,\u201d Muktar Aliyu says. But Benue, an east-central state that has been hardest hit, has an estimated adult prevalence of 15.4%.<\/p>\n
Several people at the front of Nigeria\u2019s HIV\/AIDS response link the\u00a0 shortcomings to the government\u2019s lack of \u201cownership\u201d of the epidemic. Foreign assistance\u2014mainly from PEPFAR and The Global Fund\u2014pays for nearly the entire HIV\/AIDS response. Health Minister Isaac Adewole, an OB-GYN who worked in HIV\/AIDS, says the \u201cNo. 1 challenge\u201d is for Nigeria to move \u201cfrom a donor-dependent program to a country-owned program.\u201d To give an example of the problem, Muktar Aliyu notes that foreign assistance often focuses on bolstering programs, including testing, at large treatment centers, not the 800 or so smaller clinics spread across the country. \u201cIn the next 5 years, at the most, country ownership will come through for HIV programs in Nigeria,\u201d Sani Aliyu promises. \u201cIt\u2019s my job to make sure that money is available.\u201d<\/p>\n
Since taking over NACA in 2016, Sani Aliyu has made some progress. For the first time, the federal government has been taking steps to prevent mother-to-child transmission, and state governments have devoted up to 1% of their budgets to efforts against HIV\/AIDS. President Muhammadu Buhari, who appointed Sani Aliyu, authorized federal funds to pay for 60,000 new HIV-infected people to receive ARVs and vowed to add that same number to the treatment rolls each year. \u201cThe program, if successful, will serve as the exit gateway for PEPFAR as future programs acquire national ownership status,\u201d Sani Aliyu says.<\/p>\n
Perhaps most important, NACA\u2014with $120 million in funding from PEPFAR and The Global Fund\u2014now is working on a massive epidemiologic survey that many hope will bolster the country\u2019s efforts. Because HIV testing is so spotty, Birx explains, it\u2019s possible that official estimates of Nigeria\u2019s number of newly infected children are too high\u2014or too low\u2014and that HIV\/AIDS workers target the wrong regions. \u201cOur epidemic data from Nigeria is the weakest of all the countries,\u201d Birx says. The nationwide survey of HIV now underway, the largest ever done in the world, should be completed by the end of the year. \u201cI\u2019ll be frank: I used to be upset with Nigeria,\u201d she says. \u201cNow, I\u2019m just waiting for the data.\u201d<\/p>\n
Still, no one doubts that children are getting infected far too often. And some innovators are taking action.<\/p>\n
On a Sunday morning in mid-January, about 1000 parishioners fill the pews at the St. Vincent de Paul Catholic Church in Aliade, a remote, agricultural area in Benue state. Today, Reverend Emmanuel Dagi is leading celebrations called Baby Shower and Baby Reception, programs tailor-made to steer around the obstacles that keep so many pregnant women here from seeking an HIV test and receiving care.<\/p>\n
Near the end of the church service, Dagi asks women who are pregnant or who have recently given birth to come forward for a blessing with their husbands. More than 50 people cluster around the pulpit, some women with large pregnant bellies, others with swaddled babies in their arms. \u201cDefend these mothers and these fathers and their children from every evil,\u201d Dagi says. He walks from one end of the pulpit to the other, sprinkling the faithful with holy water.<\/p>\n
The priest then asks the expecting couples to attend Baby Shower, where they receive a gift bag and have blood drawn for tests for hepatitis B, sickle cell anemia, and HIV\u2014casually lumped into the mix to sidestep stigma. People with newborns attend a separate celebration, Baby Reception, where they, too, receive gift bags. At the same time, health workers discreetly check with all people who tested HIV positive at earlier services to make sure they\u2019ve been following proper procedures: taking ARVs for themselves, administering them to their newborns, and bringing the babies in for a blood test at 6 weeks of age, the earliest the virus can reliably and efficiently be detected.<\/p>\n
Those celebrations are part of the Healthy Beginning Initiative, funded by the U.S. National Institutes of Health and the Centers for Disease Control and Prevention. It has now expanded to more than 115 churches, some of which also test for malaria, syphilis, and anemia. Led by Echezona Ezeanolue, a pediatrician who works with the HealthySunrise Foundation based in Las Vegas, Nevada, the intervention takes advantage of the fact that some 90% of Nigerians regularly attend either church or mosque services. \u201cThat was a perfect place to test this,\u201d says Ezeanolue, a Nigerian who left the country 20 years ago. (Ezeanolue resigned from the University of Nevada in Las Vegas in March after a prolonged dispute with the school about what it alleged were financial irregularities with the maternal HIV program he ran there. He insists he did nothing wrong.)<\/p>\n
Sani Aliyu adds that Baby Shower has another advantage. \u201cThe religious leaders don\u2019t carry the burden of politicians,\u201d he says. \u201cPeople believe in what they say, and people follow them.\u201d<\/p>\n
In a study of the project in 40 churches, half of which received the intervention, Baby Shower increased HIV testing in pregnant women from 55% in the control churches to 92%, the researchers reported in the November 2015 issue of The Lancet Global Health. A study published in AIDS and Behavior last year shows that in women\u2019s male partners, testing jumped from 38% to 84%. \u201cWith Baby Shower, you don\u2019t have to go to the hospital for an HIV test\u2014you go to the church and nobody suspects anything,\u201d says Amaka Ogidi, coordinator of the project here. A follow-up study is assessing the actual impact on HIV transmission rates to the babies.<\/p>\n
Ogidi says she at first had reservations because the idea of a baby shower is a U.S. concept. \u201cWe\u2019re not used to celebrating pregnancy\u2014we\u2019re used to celebrating childbirth,\u201d she says. But the intervention has steadily grown in popularity, especially since the Baby Reception component was added. \u201cThe program is just like a sweet-smelling perfume,\u201d Ogidi says. \u201cYou smell it and say, \u2018Oooh, can I have some for myself?\u2019 You see smiles on faces and it\u2019s infectious.\u201d<\/p>\n
The Mama Metta Traditional Clinic and Maternity Home in the Iyana Ipaja neighborhood of Lagos also is introducing prevention of mother-to-child transmission into a familiar setting. The clinic, set on a street wide enough only for foot traffic, resembles a small house. Feyami Temilade, who runs the clinic, is a traditional birth attendant, and she is known as Mama Metta because she becomes something of a second mother to every woman in her care.<\/p>\n
This Friday morning, 16 big-bellied women sit on wooden benches in the waiting room. The walls are cluttered with framed certificates from courses Temilade has completed over the past 35 years, awards, fading photos of herself in celebratory garb, calendars, and pregnancy infographics. A poster above Temilade\u2019s desk says, \u201cKnow Your HIV Status\u201d in English, Yoruba, and Nigerian Pidgin. A certificate next to it notes that she participated in a training workshop for traditional birth attendants run by the Society for Women and AIDS in Africa in\u2014astonishingly\u20141991.<\/p>\n
The women wait their turn for checkups and to fill bottles with two herb concoctions she has prepared. The cost of the visit, says Temilade, who will listen to babies through a metal fetoscope called a Pinard horn, is a mere 200 nairas\u2014about $0.55.<\/p>\n
Birth attendants are unregulated in much of Nigeria. But Lagos state, which includes Nigeria\u2019s largest city, has a Traditional Medicine Board that accredits and monitors practitioners. Since 2012, the board has offered regular HIV\/AIDS training, which includes an internship at a hospital, for Temilade and some 2000 other birth attendants.<\/p>\n
Temilade has been in business here so long that two of the women here today were born in the facility, which has a birthing room with two beds. \u201cIf you\u2019re pregnant, you\u2019re eating for two people,\u201d Temilade tells the group. She also warns them to avoid high heels and not to sit in the same position for too long. \u201cCome here for HIV tests,\u201d she says, explaining that she\u2019ll link anyone who tests positive to a hospital.<\/p>\n
That\u2019s a start, Sani Aliyu says. But, ultimately, he believes, getting women to antenatal clinics in established health facilities will be key to stopping mother-to-child transmission here. \u201cIn most cases, at least 80% of them will get tested and commence treatment,\u201d he says. One state has experimented with paying incentives to traditional birth attendants to bring pregnant women to formal health care settings.<\/p>\n
Pregnant women make up only a fraction of Nigeria\u2019s huge HIV-infected population, and Sani Aliyu well recognizes that halting the epidemic here, as in other countries, depends on treating nearly everyone who is living with the virus\u2014not just mothers and babies. \u201cIt\u2019s going to be a lot of work to put everybody with HIV on treatment,\u201d he says. But protecting babies from infection, he says, \u201cshould be a low-hanging fruit that can be reached.\u201d<\/p>\n