This post is by the Global Center’s Rabita Aziz.
At a forum hosted by the Brookings Institution yesterday, the Research Alliance to Combat HIV/AIDS (REACH) presented their findings from two studies that explored attitudes and behaviors related to HIV/AIDS prevention in Nigeria.
Nigeria, Africa’s most populous country, has 3 million living with HIV and a prevalence of 4.6 percent. Some areas, such as Benue, have a prevalence rate as high as 10 percent. 280,000 Nigerians die annually of the disease, and 370,000 new infections are reported each year. There are 2.2 million children orphaned by AIDS in the country, and 70,000 infants are born each year infected with the disease. There are also 244,000 pregnant women who are infected. According to REACH’s report, “Social Dimensions of HIV and AIDS Prevention: HIV/AIDS Related Risk Behaviors and Testing & Counseling in Nigeria,” four factors render African nations particularly vulnerable to HIV/AIDS: poor governance, weak institutions, poverty, and cultural norms and practices.
With funding from the Bill and Gates Melinda Foundation, REACH, a collaboration between Northwestern University and the University of Ibadan in Nigeria, began their studies in 2006 by engaging social scientists in community-based research in three Nigerian states: Benue, Lagos, and Oyo. A total of 2,453 Nigerians aged 15-59 years were surveyed through a variety of methods, including focus groups, key-informant interviews, and in-depth interviews with selected respondents.
One of the studies examined the rates of use of HIV counseling and testing, factors accounting for low acceptability and the use of counseling and testing facilities, and ways of enhancing testing uptake in Nigeria. The second study examined social, cultural, and contextual factors associated with HIV-related risk behaviors in low- and high-prevalence communities. Variables included demographics, migration patterns, cultural beliefs and practices, and power and communication structures.
The findings of the first study show that several factors play a role in a community’s use of voluntary counseling and testing centers (VCTs): stigma, fear, fatalism, center locations, HIV/AIDS misconceptions, health worker attitudes, confidentiality of results, and accuracy. Money and distance remain barriers in using centers, as centers can be miles away from many communities. There are only 998 health centers in the country, which has a population of 150 million. Only 14 percent of adults have access to testing and counseling.
Lack of knowledge and misconceptions are another barrier. Gbenga Sunmola, REACH principal researcher and research coordinator for the National Agency for the Control of AIDS in Nigeria, explained that most respondents did not know that using condoms can prevent HIV infection. Phillip Nieburg, senior associate at the CSIS and public health epidemiologist for REACH, added that many Nigerians fail to get tested due to superstitions, including one related to the drawing of blood. In addition, many do not get tested for fear that the results will be inaccurate or involuntarily disclosed to others, prompting stigmatization and discrimination. Sunmola explained that it is commonplace for a student to be dismissed from school and an employee to be dismissed from their job once their HIV-positive status is known to others. Sunmola emphasized this barrier to testing by stating that the issue of stigma is the biggest problem in the fight against HIV/AIDS, yet it is the most neglected issue as well.
The findings of the second study show that multiple high risk factors fuel HIV/AIDS in the studied communities: transactional sex, age of sexual debut, HIV/AIDS-related misconceptions, multiple sexual partnerships, marital problems, lack of parental oversight, high sexual needs, fatalism, low condom use, alcohol use, and the denial of AIDS as a pandemic. The panelists explained that gender inequalities play a major role in these risk factors. Transactional sex, in which women are often asked to trade sex for job offers, money, or other items, is identified as the most prominent problem in the report. In addition, because women are largely unable to negotiate the terms of sex, condom usage is low. Polygamy is also still common in Nigeria, with men having multiple sex partners. The report states that many men seek to “sample” multiple women, with one respondent stating that “nobody eats one type of soup.”
The researchers agreed that the media can play a very important role in spreading awareness of HIV/AIDS risk factors as well as reducing stigma. Many of the respondents who displayed some knowledge of HIV/AIDS prevention said they learned of those methods through the radio. In addition, new technologies can be put toward spreading awareness as well. For example, the panelists explained that a few cell phone companies routinely send their subscribers text messages about HIV-related issues, and such messages can be expanded to include information about testing sites and other critical pieces of information.
Susan Page, who oversees Central and Southern Africa issues in the State Department, spoke of the US commitment to fighting the HIV epidemic in Nigeria. Nigeria has received $2 billion in funding through PEPFAR since its inception and will continue to get PEPFAR funds. However, Page stated that the US government would like to see Nigeria increase its own funding toward fighting the disease to 50 percent of total expenditure by 2015, resulting in a sustainable, country-owned response to the epidemic. Page also suggested that Nigeria should create partnerships with private groups to address a large gap in treatment funding. The Center for Global Health Policy’s David Bryden suggested using oil revenues towards treatment efforts. Sunmola agreed that was something that needs to be taken into consideration.
Several researchers discussed policy recommendations and implications related to their findings. For example, HIV prevention planning can be integrated with local activities, such as within town meetings or incorporated into market days. Engaging community leaders to spread messages of awareness is also crucial. The researchers also state that addressing the key social and economic factors that disproportionately affect women is fundamental to addressing the epidemic. Richard Joseph, the principal investigator of REACH and a nonresident Senior Fellow at Brookings, said that the 50 social scientists who worked on the project agreed that policy recommendations, which have usually been influenced by biomedical studies, must be supplemented by studies conducted by social scientists in relation to social, cultural, and economic factors.