Dr. Prosper Okonkwo
Dr. Prosper Okonkwo, Chief Executive Officer ofthe AIDS Prevention Initiative in Nigeria speaking with Adeola Akinremi about the challenges of HIV/AIDS prevention in Nigeria
Can you talk to us about the organization you lead and your efforts on the fight against HIV/AIDS?
Our organisation, AIDS Prevention Initiative in Nigeria came into existence in “ 2000, at the time as a project of the Harvard School of Public Health. The Harvard school of Public Health got a grant from the Bill Gate Foundation in 2000. That was what we used to start this project.
At that time, we were essentially working on a research that focused on capacity development for laboratory and human infrastructure, and we took on that till the end of 2003, when based on the gains of that we were able to apply to the United States’President’s Emergency Plan for AIDS Relief (PEPFAR).
Harvard School of Public Health at the time was working in three countries in Africa, Nigeria, Botswana and Tanzania. And one of the conditions for the plan to work is to be at least working in three of the countries that were eligible for application at the time.
So, in February of 2004, we got the grant though still as a project of the Harvard School of Public Health. We then began to implement HIV/AIDS care treatment support programmes, we started in three States, Lagos, Oyo and Plateau and eventually now we have up to 10 States in the country.
Another key landmark I could say is that the founders now got to a stage that they said they thought they wanted to begin funding directly in local organisations and Harvard helped APIN as a project to become registered as a local entity.
Right now we are working an organisation and that registration came in 2007 with all of the responsibilities of governance. When we started we put about 10,000 patients on treatment.
Currently now, we have about 73, 000 patients receiving treatment monthly from our Programme. One of the peculiarities of our Programme is also that we had worked because of the Harvard comparative advantage; we had worked more, especially at the tertiary facilities.
What has been the contribution of APIN to reducing HIV/AIDS in Nigeria?
I think if you put it in context, what we have in Nigeria is that the National Agency for the Control of AIDS (NACA) coordinates national response and there is a national strategic frame work that everybody is supposed to buy into. So whatever we are doing is to contribute to that bigger picture.
I think the easiest way to look at it is that if we know now that about 400, 000 people are on treatment in Nigeria and 73,000 of those are supported and I am very careful to use my words as are supported because some of them are supported by the federal government directly.
The other thing I want to say is that without sounding very immodest, because we work in teaching hospitals, most of the sites provide the leadership to most of the national task team of the anti-retroviral working group. And these are the bodies that try to translate evidence into policies.
Benue State has the highest prevalence of HIV/AIDS in Nigeria; what is your presence in Benue State?
Our biggest site in the country is Benue Federal Medical Center Markurdi. Presently, and I am talking not about the people that has been on treatment, at least 15, 000 receive treatment in Makurdi and it’s been like a nightmare because why we have 15, 000 is that services has not gone right down to the states. You find that there is a concentration of services and because of that we have been asked to open free General Hospitals in the three different parts of Benue.
What is the statistics for Nigeria. Those who are receiving treatment, either through your organisation or otherwise?
Generally, and it’s unfortunate that the numbers in Nigeria are very difficult to come by. For this World AIDS day, NACA projected that we have treatment in Nigeria today, I mean as at the last time we reported, 399, 000. But the US government because they support the Programme, and also has a way of getting their own data project that we have 450, 000 people on treatment.
But,it is safer to take what the government says, and from NACA what we have is like 400, 000 and that is 399, 000 something. And to also put it in context for now we know that 1.4million people are supposed to be on treatment in Nigeria and there is a big gap.
So how many people are out of treatment?
We just have like 10 per cent on treatment, just like one third of people who are supposed to be receiving treatment.
What is responsible?
Well, I think that will take us to the bigger concept of the bigger picture of what we call the health system, because it is not just to put drugs that will make service happen and I want to be also careful about what I say. But in most developing countries, the health system has been weak. The system involves the policy, the people, the hospital and everything. And when you now have this bigger burden of disease, you find out that it is even like weakening it the more.
There are places today, even if you take drugs, you can’t even find people to give them to, so there is multiplicity of reasons. But I think the good news is that our government is beginning to realise that this is our responsibility.
You know one of the things that is also coming out of the World AIDS Day is the so called Abuja declaration, which in 2001 the whole world came to Nigeria and said every country should at least make sure that their national budget for health should at least allocated 15% for Health, and maybe out of that 5% for HIV.
But only about seven countries have met that and Nigeria where we had the meeting has not implemented that decision. There is so much that the government can do for us.
The other big problem is that in Nigeria, health is on what we call the concurrent list. You know the federal government can do what it likes and the state government can do what it likes and the local government can do what it likes. And at the last count, the 36 states in Nigeria including Abuja contribute only 0.3 per cent budget to the national HIV/AIDS and that gives you the fact that even the 400, 000 we are doing today most of it is donor driven. It is a big challenge.
So, is the government failing in this direction?
I won’t use that word. I think it’s being impressed on them more. I think it’s a question of prioritisation because there are many competing needs for these resources. But I think it is becoming more and more obvious with the highest level of advocacy, you have to have a healthy nation for you to move on.
Will there ever be a cure for HIV/AIDS?
That will be the earnest expectation of everybody, but I think HIV has been with us now for 31 years, and the amount of money that is pumped into it, one would expect that significant milestones would have been reached. But unfortunately, even for vaccines we haven’t gotten as fast as we thought we would. In medicine we never say never so it’s not impossible. So I think it’s possible but it’s still a long way.
HIV/AIDS campaign has been controversial right from the start till now. So as a leader in HIV/AIDS campaign, how do you react to this kind of controversy?
I think the controversies are understandable because from my perspective it’s like it just came from the blues so, it’s like what is this disease we are talking about. The only thing I want to say now is that evidence abound now of things that work or of things that don’t work.
For the controversy, I think it’s getting less because it is obvious people now see that some people have been on drugs for over five years now and they have been living normal lives. It’s now seen that we have used good mechanisms to prevent mother to child transmission so many women who are HIV positive today would have their babies and they are negative.
It has also been seen today that we don’t need to be told that there are some high risk groups like men who have sex with men and the commercial sex workers. The rate of HIV in those people is much higher, so the area of controversy that I think is still existing is not because people don’t have the awareness, but the big problem is that a lot of people still have this belief that maybe the white man just brought this disease to harm us so there is still that apathy.
I also truly believe if we subject a lot of our herbal preparations to scientifically rigorous processes, there is a chance that we might get some treatment that will do what ART’s are doing. But the challenges are that because there is a lot of mis-trust, you don’t want to bring what you think is your game changer and give it to me as a scientist to subject to test.
And for the scientific communities, we cannot accept and believe totally that it works unless it goes true that rigour. I think that’s where the bigger issues are.
If you look at the issue of stigmatisation, is it still there?
Definitely it is still there, the only thing I can say is that it has reduced. And, because people now find that many people have been on treatment for like 10 years and they are living their normal lives, HIV is no longer seen as a killer disease but is seen as that of chronic disease that you can just live your normal life with like diabetes.
But from the work we do apart from the fact that some people who are positive have not come out, one practical example of stigmatisation we found in the work we do is that people are not comfortable getting their drugs and treatment from within their location. They will prefer to pay transport and travel far for their drugs. This is because they don’t want people that know them to find out their status. So there is still stigmatisation.
As we talk, there is anti-discrimination bill that the National Assembly has passed a while ago, which we still believe the President will accent to. It’s one of the things that will come up during this World AIDS Day because you know that the broad theme for the 4 years is counting to zero. Because we expect that by 2015 we would have reached the Millennium Development Goal and so we are saying zero new infection, zero discrimination, and zero HIV-related death.
Again I noticed that when we talk about discrimination and stigmatisation there are also some self-induced stigmatisation, which has resulted in the early days where some health workers even till today will not touch a patient who is HIV positive. So it now makes the patient to recoil and overreact occasionally. To answer your question straight, there is still a lot of it.
What’s the statistics of those who are orphaned by AIDS in Nigeria?
I won’t have the exact figure of it, but the first thing I want to say is that the definition for orphans you know is for one or both parents and we find that it was neglected for a long time. But I think it’s being considered. For instance in our programme, the number of orphans and vulnerable children that we are given a target to manage last year was 12,000. And when I saw that number I’m like where will you get 12,000 but as we began to work with the NGOs, in like nine months we over-shot that target.
Another thing right now is that the ministry of women affairs and social development at the federal level is seeing to it. So if we are giving funding for all those people it now goes through them. Like in Lagos now, there is a ministry call ministry of women affairs and poverty alleviation, that is where the programme now stays. When we put it under ministry of health we neglected it. So now it’s been given some more relevance. It’s coming on but for the real figures I don’t think I have the national figures but I can get it for you.
In the HIV/AIDS campaign what are you looking forward to?
The first thing I want to say is that as we get closer, we get to the magical 2015, and we expect universal access and by universal access we mean that at least 80 per cent of those who need ART should have gotten them, 80 per cent of pregnant women who need PMTC services should have gotten them.
But we find out unfortunately that we are still far from a lot of those things. So I think there’s a new sense of urgency. And when we are saying to bring down to zero death, the people are talking about the international solidarity that we need to ask our government both Nigeria and other governments to live to the responsibility of what they have pledged together in 2001 to put more into HIV/AIDS. A country like South Africa started very slowly.
In fact the South African president didn’t even believe that HIV causes AIDS until like five years ago, but today two thirds of the total money for HIV in South Africa is from the government and this year alone they put in $1.2 billion. So it’s just an awakening that our government should see.