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A Fight on Two Fronts: How Nigeria is Successfully Combating HIV During the COVID-19 Pandemic
When former U.S. Global AIDS Coordinator Deborah Birx, MD, called for a 500,000 person increase in the number of HIV-positive persons initiated on antiretroviral therapy (ART) in Nigeria, the CDC PEPFAR country team was at a loss. Over 17 years of painstaking efforts had culminated in 450,000 HIV-positive persons connected to life-saving treatment. Now, they were tasked with exceeding this mark in a matter of 18 months.
Around the world, HIV remains a leading cause of death. In 2019, 38 million people were living with HIV globally and 690,000 people died from AIDS-related illness. Nigeria, the most densely populated country in Africa, has not escaped this devastation. In fact, HIV continues to elude control with millions of Nigerians forced to grapple with the consequences of infection on a daily basis.
Fortunately, effective strategies to prevent and control HIV are available. Early initiation of ART and long-term adherence have been proven to protect the health of HIV-positive individuals and reduce the risk of transmitting HIV to others. However, an estimated 320,921 of the total 1.8 million persons infected with HIV in Nigeria were not receiving life-saving treatment as of 2018.
To bridge this gap and chip away at the enormous goal set before them, CDC developed a strategic and operational platform to promote ART uptake. Implementation of this comprehensive framework in the course of ART Surge activities not only significantly increased the number of persons with HIV infection initiated on treatment in Nigeria, but also provided proof of concept for a novel approach to decreasing HIV transmission and mortality.
Success
Beginning in April of 2019, CDC, through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), initiated an 18-month ART Surge program across nine states in Nigeria. CDC and partners established incident command structures to effectively coordinate program operations across these different intervention areas. Site-level data was reported weekly and distributed to key stakeholders through an Excel-based dashboard. The Surge program’s operations were continually improved by routine data collection, site visits, and coordination with stakeholders.
Evaluation of ART Surge activities based on case detection, ART initiation, treatment continuity, and ART program growth revealed significant initial impacts. From May 4, 2019 to March 21, 2020, the weekly number of HIV tests increased 500% while the weekly number of newly diagnosed HIV-positive persons initiated on ART rose by 410%. Within the first year alone, approximately 97,387 people were started on life-saving treatment.
Unfortunately, these initial gains were threatened by the COVID-19 pandemic. From March to May of 2019, test frequency diminished, weekly positivity rates dropped, and fewer newly diagnosed HIV persons were enrolled in HIV services. However, CDC Epidemiologist Emilio Dirlikov, PhD, was determined to “frame this challenge as an opportunity.” Prior to the pandemic, fewer men than women reported to healthcare facilities for HIV testing and treatment. With everyone at home during lockdowns, mobile teams were able to diagnose and link more HIV-positive men to care. This shift away from facility-based case detection to direct contact with communities through mobile site visits helped restore rates of HIV diagnosis, ART initiation, and patient retention back to pre-pandemic levels.
At the conclusion of the 18-month intervention period, a total of 208,202 HIV-infected persons were initiated on ART and the weekly number of newly diagnosed HIV-positive individuals increased eight-fold. Despite pandemic restrictions, the number of viral load tests also expanded from 246,856 up to 407,312 per week, and viral suppression reached 89.3%.
Expansion
As part of the Fast-Track strategy to end the HIV epidemic, the Joint United Nations Programme on HIV/AIDS set targets calling for 95% of all people living with HIV to know their status, 95% of all people living with HIV to gain access to antiretroviral therapy, and 95% of all people on ART to achieve viral suppression by 2030. The success of the ART Surge Program suggests one potential strategy to achieve these aims in Nigeria and beyond.
CDC HIV Care and Treatment Branch Chief Tedd Ellerbrock, MD, attributes this success to the enormous synergy that exists between program components. The ART Surge program was built on the Comprehensive, Integrated, Resilient ART System (CIRAS) specifically designed and developed to increase ART coverage. The guiding principles of this platform, including autonomy and accountability, timeliness and accuracy, transparency, connectivity, and adaptability paved the way for the Surge program to be “almost unstoppable.”
The use of local community members is another linchpin. By training and supporting local individuals to run day-to-day program operations, Dr. Ellerbrock notes “you get real data, you get real people, you get real results.” Dr. Dirlikov expands on the utility of this approach even further, reporting that community workers “know the people who are sick.” In Enugu State, for example, this reliance on local knowledge and subsequent empowerment of community workers resulted in dozens of widows tested for HIV during a single visit outside a funeral parlor—the local gathering place for mourners whose spouses likely succumbed to HIV.
At the end of two years, the implementation of CIRAS through the ART Surge program allowed the CDC PEPFAR team in Nigeria to surpass Ambassador Birx’s benchmark of initiating 500,000 people on ART. What’s more, this herculanean effort was conducted with essentially the same amount of funding. “This is why CIRAS is so important, states Dr. Dirlikov, “It’s not about additional funding. It’s about management.”
As the program continues to expand across Nigeria, more and more evidence points to its tremendous potential to be scaled up worldwide. Because of the inherent flexibility and adaptability of the system, the impact of the ART Surge program does not end with HIV. Other diseases, like malaria, could tangentially be targeted through Surge activities. Thus, the possibilities, and utility, of this integration are endless.
Advancing Progress
HIV is one of the deadliest infectious diseases, and it continues to be a significant public health concern around the world. One of the most critical steps we can take to end the global epidemic is to provide treatment to people living with HIV. As evidenced by the ART Surge program launched in Nigeria, the use of data-driven, locally adapted interventions and incident command structures are effective strategies to achieve this aim.
However, there is still more work to be done. In Nigeria and other places throughout the world, many people remain unaware of their HIV status. Improvements in case detection, especially among those at high risk of infection, remain critical. Rapid linkage to treatment, patient retention, and sustained viral suppression are other top priorities to reduce HIV transmission and HIV-related mortality.
We stand at a tipping point. Studies forecast that AIDS will claim more lives in 2030 than it does today unless we accelerate efforts to prevent disease. Scaling up of the ART Surge Program could very well be the key to achieving this goal worldwide.
This novel approach could also generate momentum domestically. In the U.S., approximately 1.2 million people have been diagnosed with HIV and 37,968 become newly infected each year. This burden is not distributed equally, but rather, disproportionally impacts Black and Hispanic men. In reference to the limited effifcacy of over forty years of HIV programming in the US, Dr. Dirlikov notes, “We have better outcomes in Nigeria, than we do in the United States.” Fortunately, the number of HIV-positive persons not on ART is well below that of Nigeria. Adaptation of CIRAS, particularly the decentralization of case detection and empowerment of local community members, could narrow this gap even further.
To put it simply, the impact experienced in Nigeria as a result of the Surge is unparalleled. Dr. Ellerbrock said it best: “Very few of us in medicine and public health have the opportunity to do what we’ve done in Nigeria. The PEPFAR program in Nigeria has started over 500,000 people on lifesaving therapy. Try and put your arms around that…we just made an enormous difference in 500,000 souls.”
We have the right strategies, the right tools, and the right people working together to end HIV. It is time to leverage these systems and turn hundreds of thousands of lives saved into millions.