AIDSTAR-One Nigeria's Mixed Epidemic: Balancing Prevention Priorities Between Populations


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Prompted by a growing knowledge of the complexity of HIV transmission, many countries are reassessing the nature of their HIV epidemics. "Mixed" epidemics, or concurrent epidemics experienced by both the general population and members of most-at-risk populations (MARPs), are of growing importance in HIV programming. Nigeria, a country with a range of regional and local epidemics, is now attempting to incorporate programming for MARPs into the national HIV response. This case study documents the country's analysis of its epidemics and the efforts of the Nigerian government to adjust their national strategic plan according to the results of the analysis.

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AIDSTAR-One Nigeria's Mixed Epidemic: Balancing Prevention Priorities Between Populations

  1. 1. AIDSTAR-One | CASE STUDY SERIES August 2011 Nigeria’s Mixed Epidemic Balancing Prevention Priorities Between Populations A way from the noisy, crowded streets of Lagos, the sun slowly sets over one of the city’s many beautiful white sand beaches. Hundreds of plastic tables and chairs are scattered across the beach, awaiting the arrival of the Friday night crowd. One of the bars that line the beach turns up the music as the crowd of mainly young males slowly grows. Aldo Spina As darkness approaches, a steady stream of young women emerges from the huts behind the cafes and bars, hovering in the darkness at theSunset at Lagos beach popular shoreline. As the night progresses, hundreds of women appear, all forwith sex workers. the same reason—to make money. The beach is one of the city’s many outdoor hot spots for female sex workers. What is not visible is just as significant. Do the young males fraternizing with the sex workers have girlfriends, wives, or other sex partners? The smell of marijuana wafts through the air, but are the men or women using other drugs, perhaps injecting them nearby? And what about men interested in having sex with other men? Although they may remain hidden to public gaze, they nevertheless manage to find each other. During the daytime, it is an entirely different scene. The crowds of young men are gone. Instead, outreach workers from a local organization educate female sex workers about HIV and the correct use of condoms, and refer them to the nearby health clinic for HIV testing. Although the program focuses primarily on sex workers, all of the groups that appear at night—people who inject drugs (PWIDs), men who have sex with men (MSM), and clients of sex workers—as well as the larger community By Aldo Spina need prevention programs. This beach is a microcosm of the challenges of HIV prevention in Nigeria, which—with almost 3 million people living with HIV—has one of the largest HIV burdens in Africa. AIDSTAR-One John Snow, Inc. 1616 North Ft. Myer Drive, 11th Floor This publication was produced by the AIDS Support and Technical Assistance Resources Arlington, VA 22209 USA (AIDSTAR-One) Project, Sector 1, Task Order 1. Tel.: +1 703-528-7474 USAID Contract # GHH-I-00-07-00059-00, funded January 31, 2008. Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
  2. 2. AIDSTAR-One | CASE STUDY SERIESKnowing Your EpidemicEach country confronts a different HIV epidemic, andmany face a range of regional and local epidemics.The call for countries to “know their epidemic” hasled to increasing recognition that in some places itis “mixed,” with epidemics occurring simultaneouslyamong both members of the general populationand members of most-at-risk populations (MARPs),including PWIDs, MSM, and sex workers, and often Aldo Spinawith significant geographical variations within thecountry, meaning that the populations at risk mayvary from state to state and at the local level. A rural brothel visited by Winrock implementing partners.Until recently, many countries did not have sufficientdata to determine whether or not their national to the epidemic throughout the 1990s has beenepidemic was mixed; routine HIV surveillance characterized largely as a period of denial. Theactivities often miss key at-risk populations, for first policy statement on HIV was developed bywhom targeted surveys are necessary. Countries the Federal Ministry of Health in 1997, but it wasmust work with the data they have available to accompanied by limited public awareness andmake difficult decisions about balancing resource mobilization campaigns. It wasn’t until the restorationallocation, carefully considering the unmet needs of democracy in 1999 that greater efforts wereof MARPs and the needs of the general population undertaken to respond to the epidemic, and theand youth, as well as considering variations in response moved from a health-centered response tothe epidemic in geographical regions. Moreover, a multisector response.countries already deeply engaged in preventionprogramming sometimes find it difficult to expand With a total population of over 153 million people,their work with MARPs or divert prevention the HIV epidemic in Nigeria is complex, and rates ofresources to them. Stigma and discrimination HIV and patterns of infection vary widely by region.also drive many individuals to hide their practices While several states are experiencing epidemics in(which in many countries are illegal) and not access the general population, epidemics in other statesservices. This can leave governments reluctant to are concentrated and driven by high-risk behaviors.acknowledge or address their needs. It has previously been suggested that youth and young adults in Nigeria are particularly vulnerable to HIV, with young women at higher risk than youngNigeria’s Early Response men. As a result, the first decade of HIV prevention programming tended to focus predominately onThe first two cases of HIV in Nigeria were identified preventing transmission among young people andin 1985 and were reported at an international AIDS the general population.conference in 1986. Quickly, HIV prevalence rosefrom 1.8 percent in 1991 to 4.5 percent in 1996. By Yet Nigeria’s experience is a good example of how2001, it peaked at 5.8 percent (National Agency for research led to an increased understanding that thethe Control of AIDS [NACA] 2010). The response HIV epidemic was spreading among MARPs, as2 AIDSTAR-One | August 2011
  3. 3. AIDSTAR-One | CASE STUDY SERIESwell as the general population. This, in turn, led to a zone, urban prevalence was 7.1 percent and ruralnew emphasis on MARPs in the National Strategic prevalence was 4 percent.Framework and, with the support of donors, anincrease in programming for MARPs. Because much These state variations in HIV prevalence highlight theof the work with MARPs is still nascent, there are complexity of responding to the epidemic in Nigeria.challenges in the coverage, intensity, and duration Decisions regarding resource allocation for HIVof interventions, as well as the extent to which prevention requires not only balancing the needs ofgeographic variations in the epidemic have been MARPs and general populations, but also requiresrecognized and addressed. giving consideration to geographic variations in the epidemic. These geographical variations have beenOngoing political and financial commitment to recognized as important in a review of the nationalsustain activities is also required, particularly in response that highlighted that high-risk behaviors varylight of competing HIV demands and the less than in different communities and geographical settingssupportive cultural and legal environment. Even with within the country (NACA 2009a).these ongoing challenges, there are many valuablelessons from Nigeria’s experience that can be sharedwith countries facing a more mixed epidemic amongMARPs, other population groups, and the general Researching Nigeria’scommunity. Epidemic A range of surveys are regularly conducted toHIV Prevalence and State monitor HIV trends in Nigeria. One is the biannualVariations Integrated Biological and Behaviour Surveillance Survey (IBBSS), conducted by the Ministry of Health with support from a range of partners. FirstAdult HIV prevalence, based on a 2008 antenatal undertaken in 2000, the IBBSS focuses on groupssentinel survey, is estimated at 4.6 percent, with whose behavior or occupation is thought to placevariations across states ranging from 1 to 10.6 percent them at higher risk of HIV, such as sex workers,(NACA 2010). The survey found that Ekiti state in transport workers, and members of the armed forcessouthwest Nigeria had one of the lowest prevalence and police. In 2007, changes were made to therates at 1 percent, while Benue state in north central survey. For the first time, HIV and syphilis testingNigeria had the highest prevalence rate at 10.6 was included, and questions about risk behavior,percent. Benue, Nassarawa, Federal Capital Territory, knowledge, and beliefs were collected. MSM andAkwa-Ibom, Cross-rivers, and Rivers have the highest PWIDs were also included for the first time becauseprevalence rates, all reporting above 7 percent. they were also likely to be groups at higher risk of HIV infection.Further differences were identified among womenin urban and rural areas, with generally higher The 2007 survey was conducted across five statesprevalence among urban women found within the and the Federal Capital Territory, with a totalsix zones (geopolitical groupings of the states). sample size of 11,175 participants. Of these, 6,332For example, the north central zone had a higher participants were police, transport workers, or in theurban prevalence of 6.2 percent compared to armed forces. Of the remaining participants, 3,274rural prevalence of 4.7 percent. In the south-south were sex workers, both brothel- and non-brothel– Nigeria’s Mixed Epidemic: Balancing Prevention Priorities Between Populations 3
  4. 4. AIDSTAR-One | CASE STUDY SERIES based. Smaller sample sizes were achieved with MSM (879) and PWIDs MODES OF (690); recruitment of these populations was limited to only three states TRANSMISSION (Federal Ministry of Health 2007). (The small sample sizes of MSM and STUDIES PWIDs, as well as the limited number of regions where the survey was conducted, have been acknowledged as limitations of the study to be Modes of Transmission addressed in subsequent surveys.) (MoT) studies aim to improve HIV prevention by better understanding the drivers of the epidemic and the allocation of The Impact of the Integrated Biological prevention resources. and Behaviour Surveillance Survey MoT methods include: Findings 1. An epidemiological review to identify drivers of the epidemic The IBBSS found that HIV prevalence among high-risk groups was 2. ncidence modeling using HIV I significantly higher than the general population. The IBBSS found HIV prevalence and behavioral prevalence to be 34 percent for female sex workers, 13.5 percent for data to determine likely MSM, and 5.6 percent for PWIDs (Federal Ministry of Health 2007). distribution of HIV infection Lower levels of HIV prevalence were found among occupation groups: based on MoT 3.7 percent for transport workers, 3.5 percent for police, and 3.1 percent 3. nalysis of the scope A for armed forces. and scale of prevention interventions In many ways, this survey was an important turning point in the national response to HIV. It revealed that while Nigeria’s epidemic may 4. nalysis of the degree A be classified as generalized, the unequal distribution of HIV among of alignment of national different subpopulations means that the Nigerian epidemic also shares prevention resources with characteristics with the concentrated epidemics of other countries, priorities. indicating that the epidemic in Nigeria is more mixed than previously (Joint U.N. Programme on HIV/ assumed. AIDS 2007) While the IBBSS identified that MARPs have high HIV prevalence, it also found that knowledge about HIV and exposure to HIV interventions among MARPs were uniformly poor. This lack of knowledge as well as concern that MARPs can act as a “bridge” to the general population were factors considered in prioritizing MARPs for HIV interventions. For example, the survey revealed that a large proportion of MSM also had recent sex with women. Likewise, many of the clients of sex workers had other sexual partners, including wives and girlfriends. Understanding of the Nigerian epidemic improved further with the 2009 Modes of Transmission (MoT) study, supported by the Joint U.N. Programme on HIV/AIDS (UNAIDS) and the World Bank. The4 AIDSTAR-One | August 2011
  5. 5. AIDSTAR-One | CASE STUDY SERIESresearchers used an MoT model recommended by continues the focus on MARPs, but drops youththe Reference Group on Estimates, Modelling and from the target groups. The document recognizesProjections of UNAIDS (UNAIDS 2007). The study MARPs as key drivers of the epidemic and identifiesestimated that MARPs (e.g., MSM, PWIDs, and a range of other key drivers, including low perceptionsex workers) account for almost 23 percent of new of risk, multiple concurrent partnerships, informalinfections, a figure that rises to 40 percent when the transactional and intergenerational sex, lack ofsexual partners of MARPs are included. The general effective services for sexually transmitted infectionspopulation accounts for 42 percent of new infections, (STIs), and poor quality of health services (NACAlargely due to low levels of condom use and high 2009b).levels of sexual networking (NACA 2010). A focus on MARPs is also evident in the National Policy on HIV/AIDS, October 2009 (NACA 2009c).Making Most-at-Risk It includes an explicit commitment to ensuring that MARPs have access to appropriate preventionPopulations a Priority in the interventions, as well as treatment, care, and support.National Policy Response The policy acknowledges the human rights and legal issues facing MARPs, while recognizing that efforts to reduce stigma and protect human rights “remain slowHow have both of these studies informed the national and hesitant.”policy response to HIV? In 2005, prior to the IBBSS,the National Strategic Framework for Action 2005–2009 was released to guide the national response While accurately representing the nature of the(NACA 2009b). The framework was produced by epidemic is important in the national HIV policyNACA, which is mandated by the National Assembly response, Nigeria is a federation, which meansto coordinate the national response to HIV. The ensuring a strong and appropriately targeted responseframework recognized the importance of scaling up at the state level is important. There has beenresponses to “groups with special needs,” a broad recognition that political commitment needs to bedefinition that included 11 different groups, including improved at state and local government levels, as wellPWIDs, sex workers, and MSM. Yet the strategy as the response more generally strengthened (NACAfell short of outlining major programmatic strategies 2010).to extend the reach of prevention activities to thesegroups. This acknowledgment of MARPs in national HIV policies represents a significant achievement forIn 2007, the National HIV/AIDS Prevention Plan the Nigerian government, a step many other African2007–2009 sharpened the focus on MARPs (NACA countries have not yet taken. While these efforts2007). The plan acknowledged that interventions for should be applauded, prevention programming forthe general population were important to sustain and MARPs has largely made progress because ofcalled for specific prevention efforts for MARPs, which donor support. The donor-dependent nature of thewere identified as female sex workers, PWIDs, and Nigerian response to HIV has meant that decisionsMSM, as well as transport workers, the uniformed regarding the allocation of resources have rested withservices, and youth both in and out of school. The donors. This raises an important question about thelatest National Strategic Framework 2010–2015 sustainability of prevention interventions for MARPs. Nigeria’s Mixed Epidemic: Balancing Prevention Priorities Between Populations 5
  6. 6. AIDSTAR-One | CASE STUDY SERIESCulture, Religion, and the HIV prevention needs of MARPs while still working within the constraints of the environment.Legal EnvironmentEven with MARPs recognized as a national HIVpriority, prevention programs encounter social Programming for Most-at-factors that present a hostile environment for Risk PopulationsMARPs. Religious and cultural beliefs have led towidespread denial that certain sexual practices With growing policy support, and despite the less thanoccur within Nigerian society. Homosexuality and supportive cultural, religious, and legal environment,sex work are prohibited. Illicit drug use is a criminal programming for MARPs has progressed in Nigeria.activity. Politically, there is often condemnation of and This has occurred in large part because of donorintolerance toward MARPs. The introduction of Sharia support and the efforts of civil society organizationslaw in many states may have driven sex workers even that undertake prevention programs. Programmingfurther underground. for sex workers has progressed furthest because of a long history of organizations working with thisOne immediate impact is that members of population. MSM prevention programming is moreMARPs remain hidden for fear of legal and social recent and still developing, while HIV preventionrepercussions, and even of their safety. Prevention programming specifically targeted for PWIDs has notprograms have thus had to work hard to identify yet emerged.and reach hidden populations and to build trustand rapport. MARPs may be reluctant to disclose How has programming developed? Pilottheir sexual practices to service providers or even and small-scale interventions have demonstratedaccess health services for fear they will experience the feasibility of working with MARPs and point tostigma and discrimination. The legal status of certain future directions for scaled-up prevention programs.practices, such as homosexual sex, also impedes For example, Family Health International (FHI) ran athe sustainability of support organizations. Because small-scale, time-limited men’s health project in 2008these organizations are not formally recognized by the and 2009 that elucidated a great deal about workinggovernment, their ability to organize and advocate is with MSM in Nigeria (FHI 2009). Such interventionslimited. are often accompanied by mapping of MARPs or by small-scale research to inform program design.Although HIV policy efforts in Nigeria increasinglyacknowledge the needs of MARPs, there has been Who develops the programs? The hostile legallittle legislative action to better protect the human and political environment in Nigeria means MARPsrights of sexual minorities and other MARPs. As a often distrust government agencies. Civil societyresult, advocacy has been recognized as an important organizations are thus often better placed to providecomponent for many of the civil society organizations programs for MARPs, but most require capacityrunning prevention programs for MARPs. Since 1999, building to do so. To do this, well-known internationalAlliance Rights Nigeria has advocated for the rights of nongovernmental organizations experienced insexual minorities and people living with HIV, and has working with MARPs, such as Heartland Alliance,played an important role in increasing awareness of Winrock International, and FHI, have supportedthe issues. In the meantime, with little substantial legal civil society organizations to undertake this workor political progress, programs have had to meet the by providing technical assistance, developing staff6 AIDSTAR-One | August 2011
  7. 7. AIDSTAR-One | CASE STUDY SERIESknowledge about MARPs and the skills needed proposed that programming for MARPs be scaled-upto work with them, and providing access to donor in the same 10 survey regions.funds. What is the programming strategy? OneWhere has programming developed? overarching approach used by all HIV preventionTo some extent, programming for MARPs has programs in Nigeria is ensuring that a minimumdeveloped opportunistically in areas where donors package of services is delivered to the targetalready have implementing partners who are active audience. This became a priority when assessmentsin HIV prevention and are willing to expand their of prevention efforts showed that single interventionfocus to include MARPs. Although this approach can approaches had not produced the desired behaviorenable fast scale-up by employing existing program change required to prevent new infections (NACApresence, staff, and infrastructure, it may not ensure 2007).that services are located where they are neededmost, in locations where MARPs tend to congregate The minimum package approach requiresor where risk behaviors are most likely to occur. To implementing agencies to use a minimum of threesome extent, research efforts, such as the IBBSS, interventions to reach a target audience. A rangehave helped determine where interventions for of interventions was outlined in the National HIV/MARPs should be located. The next IBBSS, which AIDS Prevention Plan 2007–2009 (NACA 2007): awill increase the number of survey regions from 6 mixture of peer education, awareness raising, andto 10, will impact where programming for MARPs STI management, among others. The combinationoccurs. The successful Round 9 proposal to the of prevention interventions used may vary becauseGlobal Fund to Fight AIDS, Tuberculosis and Malaria implementing agencies choose the interventions MEN’S HEALTH NETWORK The Men’s Health Network (a project of the Center for the Right to Health, and Population Council Nigeria) works with men at higher risk, such as MSM, uniformed personnel, truck drivers, prisoners, and university students. Because of concerns that an MSM-only intervention could increase stigmatization, the network adopted the broader approach of working with men at “high risk.” “Man-friendly” clinics have been identified and supported Aldo Spina to provide services to high-risk men. Social networks were geographically and ethnographically mapped. Media coverage of Men’s Health Network Key opinion leaders have been trained to use social outreach to high-risk men. networking approaches to reach high-risk men to provide prevention messages and referal to the clinics and other services. They recruit by taking advantage of social networks—recruiting friends, acquaintances, and sexual partners—as well as using virtual and online social networks, such as chat rooms, websites, and text messaging services. Nigeria’s Mixed Epidemic: Balancing Prevention Priorities Between Populations 7
  8. 8. AIDSTAR-One | CASE STUDY SERIESmost appropriate for their population. One reason staff to create clinic environments that are friendlydifferent approaches are needed is because to MARPs. Ongoing training and support will helppopulations such as MSM cannot be assumed to be clinics remain inviting to MARPs.homogeneous. • Education outreach and service delivery: OutreachThe messaging developed will usually vary for each occurs at sites where MARPs are known toof the MARPs. For example, implementing agencies gather, including brothels, entertainment districts,working with sex workers do not tend to emphasize beaches, or other sites. Outreach can involve HIVabstinence or partner reduction messages but education, condom distribution, and referral toinstead focus their efforts on condom use and clinical services. Another way to improve accessregular HIV testing. to health services is to take those services directly to MARPs. Mobile counseling and testing servicesHow is prevention for MARPs have been shown to increase uptake of servicesimplemented? Even though the messages and among MARPs.combination of interventions may vary, there aremany common approaches used by implementing • Advocacy: Advocacy can create a moreagencies in their prevention efforts with MARPs in supportive environment for prevention programs.Nigeria. For implementing agencies, advocacy has meant working with local authorities to ensure supportThese approaches include the following: for prevention efforts, working with health services to ensure they are responsive to MARPs, and• Peer involvement: Members of MARPs are more facilitating the participation of MARPs in local HIV likely to be able to reach their peers and be trusted responses. by their peers. Peer educators are trained to provide formal and informal education sessions. • Information and education materials: For MSM and There are plans to harmonize current peer PWIDs, producing targeted resources is important education manuals to create one national manual. because general education materials often do not make reference to the risk of HIV infection from• Community mobilization: Community mobilization anal intercourse or injecting drug use. This has left aims to create a more supportive environment. many MSM with the impression that anal sex is Community mobilization has meant working with not a high-risk behavior for HIV transmission. brothel owners and managers, health services, community leaders, state government, police, and • Innovative use of technology: Technological other key stakeholders to ensure their support for advances can contribute to HIV prevention HIV prevention efforts. interventions. One reason to use technology is to protect client confidentiality and anonymity. These• Access to HIV/STI clinics: MSM, sex workers, approaches are in their infancy in Nigeria and and PWIDs may be uncomfortable disclosing focus mainly on developing education websites for their behaviors to clinic staff, fearing judgmental MSM. attitudes, lack of confidentiality, and discrimination. This reluctance to disclose means that clinics • Distribution of condoms and water-based are unable to provide the most appropriate HIV/ lubricants: Male condoms are widely available STI services and prevention messages for these in Nigeria at affordable prices. Even so, MARPs. One way to address this is to train clinic implementing agencies that work with MARPs8 AIDSTAR-One | August 2011
  9. 9. AIDSTAR-One | CASE STUDY SERIES provide condoms to participants during peer education sessions and outreach. Some programs also distribute water-based lubricant, even FORTRESS FOR WOMEN though it is expensive and not readily available. Female condoms are not widely available and are costly. However, when they are available, Supported by the Global HIV/ there has been some limited distribution of female condoms to female AIDS Initiative Nigeria Project sex workers. A project is currently being planned to determine how to and FHI, Fortress for Women ensure reliable procurement and distribution of female condoms. trains female sex workers in Kano to become peer educators.How effective is programming for MARPs? In Nigeria, it Street rallies have been heldremains to be seen if the emphasis on MARPs generated by national involving volunteers, peerpolicy and strategic plans will result in prevention programming with educators, counselors, and othercoverage, intensity, and duration sufficient to meet the needs of Nigeria’s stakeholders to sensitize theMARPs. The next IBBSS will provide more information about whether public about HIV.the scale-up of prevention programming for MARPs over recent years Peer educators, brothel owners,has resulted in increased exposure to prevention information, improved and managers meet regularlyknowledge, and behavior change. to discuss advocacy strategies. One outcome was an agreement to adopt a “no condom, no sex”What Worked Well policy in all brothels. Key lessons learned include:After the critical first step of making MARPs a priority and increasing • The importance of buildingthe level of programming for them, a number of successes have helped trust with sex workersimprove Nigeria’s response to MARPs. • The need for strongResearch: Even within nations with highly generalized epidemics, relationships with brothelthere is increasing recognition that some groups are disproportionately owners and managersaffected by or uniquely vulnerable to HIV. Conducting qualitative and • Coordination among HIVquantitative research with MARPs can help target prevention responses prevention programs to avoidappropriately. Quantitative research with MARPs has been particularly duplicationimportant to the Nigerian response. Research findings that revealed thedisproportionately high level of HIV prevalence among MARPs led to • Advocacy with stakeholdersa re-examination of the epidemic and the recognition that it was more to create a supportivemixed than previously thought. This, in turn, led to a re-evaluation of environmentnational HIV prevention priorities. Since then, MARPs have become an • The transient nature of seximportant component of the national HIV prevention response. work means education needs to be ongoingIt is, however, important to recognize that in a country as populous • Working with sex workers isand diverse as Nigeria, further research is needed, in part because personally challenging butthe epidemic in each of the 36 states and the capital territory are ultimately very rewarding.different. While the IBBSS has been informative, it was conducted onlyin five states and the capital territory, so the results have geographiclimitations. In addition, while the IBBSS and MoT study providedvaluable information, they offer little insight into the often hidden lives of Nigeria’s Mixed Epidemic: Balancing Prevention Priorities Between Populations 9
  10. 10. AIDSTAR-One | CASE STUDY SERIESMARPs. Qualitative research is important to see the to deliver and implement programs to MARPs. Civilfull picture of the experiences and HIV prevention society organizations are considered best placedneeds of MARPs. Small-scale qualitative research to work with MARPs because they are capable ofactivities in Nigeria undertaken by FHI (funded building trust and rapport with MARPs in a wayby the U.S. President’s Emergency Plan for AIDS that often is not possible for government agenciesRelief through the U.S. Agency for International (particularly given the legal and political constraints).Development [USAID]) and the Center for the Right This capacity has largely been a result of donorto Health (funded by the American Foundation for financial support.AIDS Research) have provided initial direction forprevention programs for MARPs. One approach to developing national capacity has been to work with organizations that may alreadyStrategy and policy response: Even though be known to the target audience so that trust andthere is strong evidence globally that MARPs rapport between the implementing agency and thenearly always have a higher burden of HIV target audience already exist. For example, FHI’sinfection, research in Nigeria made it possible to men’s health project in 2009 chose to work withsuccessfully argue that MARPs needed greater Alliance Rights Nigeria and The Independent Projectpriority in the national response to HIV. It is a because of their familiarity with MSM. Even beforesignificant achievement that the new National MARPs became a national priority, some projects inStrategic Framework is committed to the scale-up of Nigeria were already working with high-risk groups.prevention among MARPs. One example is FHI’s USAID-funded IMPACT Project, which began in the late 1990s and targetedIn addition, recognition of MARPs in the national female sex workers.HIV response helps break the silence and liftthe taboos about these populations. In Nigeria, Over time, the number of civil society organizationswhere HIV prevention relies heavily on donor working with MARPs has steadily grown. In recentsupport, recognition of MARPs in national policies years, for example, USAID has progressed fromand strategies is an important step to ensuring having a few partners working with MARPs togovernment ownership of the HIV response. having most of its partners, excluding faith-based partners, implementing programs for MARPs,Including MARPs within the national response particularly for female sex workers.required strong leadership. For NACA, that meantbalancing an evidence-informed public health Improving access to services: In Decemberresponse with competing political and religious 2009, a review of the national response identifiedviews. An example of hostility that had to be an important challenge: HIV testing and counselingovercome was when religious leaders threatened not services were insufficiently targeted to MARPsto participate in the strategy consultation process (NACA 2009a). Even if individuals have access towhen they learned that MSM would be included in a health service, they are unlikely to disclose theirthe discussion. practices if they fear judgmental and discriminatory services. While all health care workers shouldCapacity building: Capacity building has meant provide confidential and non-judgmental services, insupporting civil society organizations to undertake reality it will be a long time before such a standardthis work. This requires ensuring there is good is achieved across all services. In the meantime, theknowledge about, understanding of, and empathy focus is on ensuring there are some existing healthwith MARPs, as well as developing skills in how best care services that meet these needs for MARPs.10 AIDSTAR-One | August 2011
  11. 11. AIDSTAR-One | CASE STUDY SERIESThis is a significant step in improving accessibility, are culturally appropriate for these groups. As workbut this may not always be easy to achieve because with MARPs continues to expand, the other importantproviders may not be able to expand services to research challenge will be to expand the evidenceMARPs without additional resources. base about how to create effective programming for MARPs.Health services that are willing to work withMARPs receive appropriate training and support Greater scale-up: Nigeria’s successful Roundto ensure they can meet the particular needs of 9 proposal to the Global Fund to Fight AIDS,MARPs. Prevention programs can then be confident Tuberculosis and Malaria included a gap analysisin referring MARPs to such services. This has that estimated that current MARP preventionmeant that these services are being developed in programs reach only 5 percent of the targetgeographic locations with proximity to implementing audience. Some stakeholders contest the reliabilityagencies working with MARPs. of this gap analysis (in fact, the proposal itself acknowledges that the number of MARPs in Nigeria is unknown); nevertheless, the analysis providesChallenges some indication that prevention programming for MARPs is not at sufficient scale.Has the right balance of HIV prevention programs forthe general population and MARPs been achieved? Programming for MARPs is varied in scope, scale,This remains an unanswered question. MARPs and intensity. Prevention programming with sexhave been given greater national priority in recent workers has progressed the furthest because ityears, with a corresponding increase in prevention has been implemented the longest. Preventionprogramming for MARPs. However, one of the programming with MSM is nascent and covers onlychallenges is that such programs probably have not a handful of cities; USAID has only four partnersyet reached appropriate scale and intensity. conducting programming for MSM in Nigeria. OneGetting better and broader research of the challenges to scaling up work with MSM isresults: One of the national strategic targets is to identifying how to expand the capacity of the fewreach at least 80 percent of MARPs with specific existing implementing agencies working in this areainterventions. Without estimates of the size of these or to facilitate the involvement of additional agencies.populations, it is difficult to identify when this target For PWIDs, a limited number of organizations workhas been met. Knowing this is critical to evaluating under the National Drug Law Enforcement Agency,whether programs are reaching MARPS in sufficient with a focus on reducing demand for drugs andnumbers and intensity to have an impact on behavior on HIV and drug use. However, these serviceschange. However, undertaking robust size estimations are thought to be underfunded and under-utilized.of the population group is difficult. MARPs can often Finally, there is no public sector needle and syringebe hidden, difficult to reach, and highly mobile. distribution program, although stakeholders report that syringes are widely available from pharmacies.While there has been some good qualitative researchdone for MSM, more qualitative research is needed Recognize geographic variations: Nigeriato better understand characteristics and behaviors has 36 states, a capital territory, and 774 localof all MARPs in Nigeria. Understanding how MARPs governments. In such a large and diverse nation,perceive their own behavior and the value they there is a need to recognize and address geographicascribe to it can assist in developing interventions that variations in the HIV epidemic. While it is important Nigeria’s Mixed Epidemic: Balancing Prevention Priorities Between Populations 11
  12. 12. AIDSTAR-One | CASE STUDY SERIESthat MARPs are nationally recognized as a priority, the ability of HIV prevention programs to reach andthis may not sufficiently reflect priorities at the state provide appropriate services to these groups.and local level. The challenges in identifying state andlocal priorities is exacerbated by the lack of specific When MARPs fear they will be subject to stigma,research: for example, the IBBSS is only conducted in discrimination, public exposure, blackmail, ora small number of states. Each state and the capital physical violence, and when their activities areterritory will need to be responsive to the particular criminalized, this affects their willingness toepidemic it faces and ensure that it balances priorities approach HIV prevention programs. Stakeholdersappropriately. Even within states, there may often report, for example, that the imposition of Shariabe variations based on geographical location, such law often had the impact of driving sex workersas urban compared to rural populations. Overall, underground, making HIV prevention programmingthe response and priorities in each state will need to for these women even harder to undertake. Thisvary while still working within the National Strategic is why advocacy to protect the human rights ofFramework. marginalized groups is an important HIV issue.Avoiding further stigmatization: A key Achieving legislative and cultural change will notchallenge is ensuring that prevention programs do happen overnight. Stakeholders often expressednot further stigmatize or put the physical safety of a fear of a backlash among political, religious,MARPs at risk. Homosexuality, sex work, and illicit and other community leaders against HIVdrug use are prohibited behaviors. Fear of stigma prevention with MARPs. It is a legitimate fear, givenand discrimination means MARPs will conceal developments in some African countries. This hastheir behaviors. Survey data show that less than 10 meant that caution and wise political judgment arepercent of MSM fully or partially disclose their sexual critical skills for those working with and advocatingorientation to others (Federal Ministry of Health on behalf of MARPs.2007). Maintaining the focus on MARPs: In light of competing demands for treatment and preventionFear of stigmatization is one of the reasons the programs for the general population and youngMen’s Health Network, for example, works to ensure people, there is a legitimate concern that the focustheir services are not identified as MSM-only, but are on MARPs could waver. Maintaining the focus onfor all high-risk men. Concerns about stigmatization MARPs and ensuring appropriate scale-up willalso mean that intervention strategies that enable continue to require strong political leadership,MSM to protect their confidentiality and remain advocacy from civil society organizations, andanonymous are being explored, such as telephone continued support from donors. Research provedinformation or support services, mobile messaging, critical to driving the issue onto the national agenda,and the Internet. and further research on population size, resource gaps, and the effectiveness of programming can aidAdvocacy and human rights: Even with the efforts to maintain the focus on MARPs.inclusion of MARPs in the national HIV response,the overall legal, political, and cultural environmentremains largely unsupportive of and, in some Recommendationscases, hostile to MARPs. As noted in the NationalPolicy on HIV/AIDS, October 2009, progress is slow Efforts in Nigeria to launch and expand prevention(NACA 2009c). This has a significant impact on programming for MARPs are still in progress, and12 AIDSTAR-One | August 2011
  13. 13. AIDSTAR-One | CASE STUDY SERIES Promote ownership: If the HIV response is largely donor-driven and donor-dependent, it becomes even more important to promote government ownership of the response. Ensuring that appropriate evidence is available can facilitate government ownership, as well as demonstrate the feasibility of working with MARPs through pilot projects. Despite the difficulties of promoting government ownership, particularly if there is political, social, and religious opposition, prevention efforts for MARPs may not be sustainable without support from government agencies. Also Spina Build the capacity of civil society: The criminalization of homosexuality, sex work, andBrothel signage. illicit drug use in many countries means civil society organizations are normally best placed to work with MARPs. The role of government inhow they will unfold over the coming years remains providing health services is still important, butto be seen. However, there is cause for optimism that civil society organizations are often best placed toin mixed epidemics, the HIV prevention needs of the reach, educate, support, and advocate on behalf ofgeneral population can be balanced with the need to MARPs. Currently, donors largely support the workensure targeted programming for MARPs. of civil society organizations; in the long-term, the government needs to recognize and invest in theDo the research: Even though there is strong work of civil evidence that MARPs have a higherHIV burden and significant HIV risk factors, this Ensure coordination of multiple partners:does not always act as a persuasive argument for Because there are often many civil societytheir inclusion in the national response. Sometimes, organizations active in HIV prevention, ensuringthere is a disbelief that such groups even exist coordination of activities and areas of work iswithin society. Country-level research estimating important to eliminate duplication of services andHIV prevalence and examining HIV risk factors for to provide high-quality services to all regions ofMARPs is critical. Such evidence can be used to importance.argue that an effective public health response to HIVrequires that MARPs be included in any national Undertake advocacy: The legal, political, cultural,strategy. and religious environment has an enormous impact on the ability of HIV prevention programs to functionImplement pilot projects: In an unsupportive effectively. This requires ensuring the human and civilenvironment, pilot projects can usefully demonstrate rights of MARPs. In Nigeria, the immediate focus hasthat it is possible to reach and implement programs successfully been on ensuring that issues related towith MARPs. Such projects can pave the way for the MARPs are addressed in the HIV response, as wellfurther scale-up of programs and demonstrate ways as on ensuring health services are provided to meetto strengthen later interventions. the needs of MARPs. Nigeria’s Mixed Epidemic: Balancing Prevention Priorities Between Populations 13
  14. 14. AIDSTAR-One | CASE STUDY SERIESFuture Programming behavior. The next IBBSS should shed some light on whether prevention programs are reaching MARPs and have been successful in increasing theirFuture programming in Nigeria should build on the knowledge and improving behaviors. gwork that has occurred to date. While maintaininga focus on prevention for the general populationand youth, Nigeria has proved that it is possible to RESOURCESintroduce a much-needed focus on prevention forMARPs. NACA has taken ownership of the issue National Agency for the Control of AIDS (NACA), Nigeria:by giving priority to MARPs in national strategic and prevention frameworks. The responseso far demonstrates that it is possible to introduce National AIDS Control Council of Kenya, and Population Council. 2009. The Overlooked Epidemic: Addressinginterventions with MARPs in a less than supportive HIV Prevention and Treatment Among Men whopolitical, cultural, and religious environment. Also Have Sex with Men in Sub-Saharan Africa, Reportimportantly, while the focus on MARPs nationally of a Consultation, Nairobi, Kenya, 14–15 May 2008,remains important, state and local governments Consultation Report. Available at to understand and be responsive to their local pdfs/HIV_KenyaMSMMeetingReport.pdf.priorities, given there are significant geographicvariations in the nature of the epidemic. REFERENCESThe focus on prevention for MARPs is beginning Family Health International. 2009. HIV/AIDSto result in a full range of program activities for Prevention Services Among Men Who Have SexMARPs implemented by agencies largely through with Men: Report of the Men’s Health Project.the support of international donors. Many of the Abuja, Nigeria: Family Health International.prevention activities for MARPs are relatively newand opportunistically take advantage of existing Federal Ministry of Health. 2007. HIV/STIprogram activities. Future efforts should concentrate Integrated Biological and Behavioral Surveillanceon settings where MARPs reside or congregate, and Survey (IBBSS) 2007. Abuja, Nigeria: Federalshould also expand to ensure sufficient scale and Ministry of Health.intensity. Joint U.N. Programme on HIV/AIDS. 2007.One of the challenges in scaling up programs is Modeling the Expected Short Term Distributionsecuring adequate financial resources and identifying of Incidence of HIV Infections by Exposureimplementing agencies with sufficient capacity and Group. Geneva: UNAIDS. Available at http://experience in this area. Funding of HIV prevention for MARPs is largely donor-dependent. modeoftransmission_manual2007_en.pdfOverall government funding of HIV prevention (accessed July 2011)remains low, and prevention efforts for MARPs National Agency for the Control of AIDS. 2007.compete with those for the general population. This National HIV/AIDS Prevention Plan 2007-2009.may pose challenges for the ongoing sustainability Abuja, Nigeria: National Agency for the Control ofand ownership of the response to MARPs. AIDS.There will also need to be a focus on whether National Agency for the Control of AIDS. 2009a.interventions are having the desired impact on National HIV/AIDS Response Review 2005-2009.14 AIDSTAR-One | August 2011
  15. 15. AIDSTAR-One | CASE STUDY SERIESAbuja, Nigeria: National Agency for the Control of for Family Health; the U.S. Department of HealthAIDS. and Human Services, Centers for Disease Control and Prevention Nigeria; the National Agency for theNational Agency for the Control of AIDS. 2009b. Control of AIDS; the Ministry of Health; the World Bank;National HIV/AIDS Strategic Framework 2010- Fortress for Women; Winrock; the Center for the Right2015. Abuja, Nigeria: National Agency for the to Health; FHI 360; Population Council; the IndependentControl of AIDS. Project; Heartland Alliance; the National AIDS/STI Control Program; and members of the U.S. President’sNational Agency for the Control of AIDS. 2009c. Emergency Plan for AIDS Relief General Population andNational Policy on HIV/AIDS, October 2009. Abuja, Youth Prevention Technical Working Group.Nigeria: National Agency for the Control of AIDS.National Agency for the Control of AIDS. 2010. RECOMMENDED CITATIONUNGASS Country Progress Report Nigeria. Abuja,Nigeria: National Agency for the Control of AIDS. Spina, Aldo. 2010. Nigeria’s Mixed Epidemic: Balancing Prevention Priorities Between Populations. Case Study Series. Arlington, VA: USAID’s AIDS Support andACKNOWLEDGMENTS Technical Assistance Resources, AIDSTAR-One, Task Order 1.The author would like to thank the U.S. Agency forInternational Development (USAID)/Nigeria for theirassistance and support in undertaking this case study. Please visit forThanks go to a variety of stakeholders who shared additional AIDSTAR-One case studies and othertheir thoughts and experiences, including the Society HIV- and AIDS-related resources. Nigeria’s Mixed Epidemic: Balancing Prevention Priorities Between Populations 15
  16. 16. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approachesaround the world. These engaging case studies are designed for HIV program planners andimplementers, documenting the steps from idea to intervention and from research to practice.Please sign up at to receive notification of HIV-related resources,including additional case studies focused on emerging issues in HIV prevention, treatment,testing and counseling, care and support, gender integration and more.