What I Have Learned About AIDS As a Doctor in Nigeria, My Country

[This text has been written Ebenezer Agbana, a physician with 6 years of experience in General practice and Infectious disease prevention and control especially in low resource settings. He is currently studying Master of Clinical Research: International Health Track at ISGlobal, University of Barcelona.]

The health systems in HIV case management in Nigeria is not without many challenges. I worked as an infectious disease physician and I’m quite familiar with the issues of concern in this regard.

Nigeria is a country located in west Africa with a population size of about 218 million (adjudged to be the most populous country in Africa). As of 2021, 1.9 million people were living with HIV (with the prevalence of 1.4%) women were the most affected group, counting 1.1 million individuals. Also, children up to age 14 who were HIV positive equaled 170 thousand [UNAID, 2021]. Nigeria is ranked 4^th on the global disease burden of HIV in the world.

The country is currently suffering from workforce crisis among healthcare professionals, there has been an unusual surge in brain drain in recent years. Doctor: patient ratio is 1:10,000 as against WHO’s recommendation of 1:600. This has led to lack of specialists at various level of healthcare. Majority of HIV patients present to the hospital with opportunistic infections and even multiple organ failure (most times due to intake of herbal concoction) which most times require specialist intervention, this is one of the leading causes of mortality among HIV patients.

Nigeria is currently suffering from workforce crisis among healthcare professionals, there has been an unusual surge in brain drain in recent years. Doctor: patient ratio is 1:10,000 as against WHO’s recommendation of 1:600

Trust in the healthcare system among the general population has been compromised. Most patients present late to the hospital with serious complications because they’ve been with traditional healers, religious leaders, for weeks and even sometimes months. A whole lot of these patients have been poorly treated and given false hope. One of the reasons for this lack of trust is closely related to the first point, long hospital waiting hours due to shortage of healthcare workers. The traditional healers are easily accessible to them, most of the religious leaders are influential people in the society who easily convince them not to seek conventional therapy.

Trust in the healthcare system among the general population has been compromised. Most patients present late to the hospital with serious complications because they’ve been with traditional healers, religious leaders, for weeks and even sometimes months

Loss of retention in care is due to out of pocket spending on transportation, hospital admission fees and baseline blood investigations prior to commencement of antiretroviral therapy. Patients who already have the advanced form of the disease or complications are always advised to stay in the hospital for proper investigation, care, and monitoring. Most of them turn down such offer because of financial constraint leading to poor health outcomes and avoidable deaths. A case that readily comes to mind was when a 65 years old woman came to the emergency department at 12 midnight with breathing difficulties, she’s been on antiretroviral therapy for eight years with obvious facial and limb swelling. She will benefit from hospital admission, oxygen therapy and further investigations and treatment. She’s a widow and unemployed, for obvious reasons she turned down the hospital admission. This woman deserves dignity, love, and care.

Loss of retention in care is due to out of pocket spending on transportation, hospital admission fees and baseline blood investigations prior to commencement of antiretroviral therapy

There’s an increasing trend of abandonment among people living with HIV. This is common among those on hospital admission. Patient’s relative sometimes fail to visit them, some follow them to the hospital and “dump” them. This is traceable to stigmatization, discrimination and sometimes lack of funds. Most patient death didn’t really come from the virus itself but from issues related to mental health, while healthcare workers are expected to provide counselling and support, it shouldn’t replace empathy that comes from friends and loved ones in times of despair.

Strategies should be developed based on cultural and epidemiological peculiarities. It’s not enough to adopt programs and strategies designed by international organizations. The Nigerian government must be curious enough to know what exactly works for them by carrying out local studies and apply such to practice

If Nigeria must achieve the 95-95-95 target by 2030 (95% of people living with HIV will know their HIV status, 95% of people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART) and 95% of people receiving ART will achieve viral suppression), evidence-based medicine must be prioritized. One- size- fits- all approach should be avoided; strategies should be developed based on cultural and epidemiological peculiarities. It’s not enough to adopt programs and strategies designed by international organizations. The Nigerian government must be curious enough to know what exactly works for them by carrying out local studies and apply such to practice. That way new knowledge is generated. People living with HIV should not be victims of fragmentation in care delivery, the issues raised above should be critically examined when designing interventions.