Kayode Olanrewaju 
Despite efforts at eliminating the HIV pandemic in the country, indications have emerged that the current national prevalence in Nigeria is over two million people living with HIV across the country.
Though the rate of prevalence was 1.4 per cent in 2018, and 1.3 per cent as reported in 2022, the fight to eliminate HIV epidemic in Nigeria by 2030 World Health Organisation (WHO) target may be a forlorn, given the current posture of the country in failing to meet the UNAIDS 95-95-95 goal for 2025.
A Director of Research and Consultant Paediatrician at the Nigerian Institute of Medical Research (NIMR), Dr Agatha David, who disclosed this in her research or study, however, revealed that it would be impossible to achieve the SDG 3, Target 3.0 to end the HIV epidemic by 2030, if adolescents and young adults current testing rate in Nigeria is less than 25 per cent.
Dr David, the Coordinator of Child and Adolescent HIV Programme at NIMR said it was disheartening that the country is not on track to meet the United Nations Coalition on AIDS, UNAIDS 95-95-95 goal for 2025, which stipulates that 95 per cent of people living with HIV should know their status, 95 per cent of those who know their status should be on life-saving antiretroviral therapy, and 95 per cent of those on antiretroviral therapy should be virally suppressed.
The Director of Research, whose current study’s focus is in the area of adolescent and young adult health with emphasis on the challenges of adolescents and young adults living with HIV, noted that the challenges of focus in her study include those with adherence to Antiretroviral Therapy (ART), sexual and reproductive health (SRH), and mental health (MH).
Worst treatment outcomes
Raising the alarm, Dr David, who spoke during a media chat where she highlighted her research activities, expressed concern that adolescents and young adults living with HIV (AYLHIV) are one of the major problems for achieving this goal, because they have the worst treatment outcomes of all age groups.
With over 20 years’ clinical and research experience in child and adolescent health with special interest in infectious diseases and nutrition, she recalled that the HIV Programme in NIMR has a cumulative enrolment of over 25,000 patients since inception in 2002, including more than 3,000 children, adolescents, and young adults (ages 0-24 years).
Dr David, who noted that NIMR set up the first-ever adolescent and youth support group and special clinic for adolescents and young adults living with HIV (AYLHIV) in Nigeria, as well as an outreach HIV clinic at the Sisters of Charity Orphanage in Ketu, Lagos; said her research is also passionate about the well-being of children, adolescents and young adults, especially those living with, and affected by HIV. Speaking further, she explained that her study’s concern are those that are aged 0 to 24 years, as she and her team, Dr Sabdat Ekama, a Research Fellow at the Clinical Science Department of the institute, also look after children of mothers who are HIV positive.
“Children born to mothers with HIV, we look after them until we certify that they are HIV free at 18 months, or any time we find that they are HIV positive, we enroll them into the programme,” she stated, stressing that NIMR provides comprehensive care for them in terms of testing, treatment, checking for even resistance.
Dr David added: “NIMR set up an outreach clinic in that facility in 2009, which is still running. We were the first institution in Nigeria to set up an adolescent-friendly clinic for children living with HIV. “Adolescents and young adults living with HIV have the worst indices in terms of treatment outcomes for people living with HIV
Adherence to antiretroviral therapy
But, Dr David noted that this goal essentially is for meeting the United Nations SDG 3 of ending the HIV epidemic by 2030, stating that optimal adherence to antiretroviral therapy was necessary in order to achieve viral suppression, halt disease progression, prevent development of drug resistance, stop disease transmission and improve the quality of life of PLHIV.
Worried by the scourge, she recalled how 883 adolescents and young adults aged 15 to 24 years, who did not know their status and had never been tested before, were tested by NIMR and discovered that 106 of them, representing 12 per cent, were HIV positive. “But, you can imagine that in this study we did over a one-year period, testing about 1,000 people, 106 of them were HIV positive.
So, there are so many who are still out there who are positive that we are not getting to,” she stated. Dr David, however, wondered that antiretroviral therapy (ART) adherence is notoriously low among AYLHIV for various reasons, which she attributed to the peculiarities of adolescence, to avoid stigma and discrimination, and treatment fatigue.
“We have conducted several studies on, and made recommendations on ways to improve ART adherence and viral suppression among AYA,” she noted, adding that mental health challenges are prevalent among AYLHIV.
Studies from the Adolescents and Youth Programme of NIMR have shown a high prevalence of anxiety, depression and suicidal ideation
According to her, some of studies from the Adolescents and Youth Programme of NIMR have shown a high prevalence of anxiety, depression and suicidal ideation among these young people, which require the incorporation of mental health counseling into the routine care of AYLHIV on the mental health that is being developed.
The researcher, who said AYLHIV testing rates are very low and adherence to treatment is very low, and hence their viral suppression is low, lamented that with this position it is going to be impossible to meet the SDG of ending AIDS by 2030. She said: “In Nigeria, studies have shown that for adolescents and young adults the testing rate is less than 25 per cent.
Besides, several studies across the country have shown that when you ask young people, have you ever tested for HIV, approximately 23 per cent will say they have ever tested, but far less than that will say that they tested in the last one year. “So, if they are not tested, how do we know how many of them are positive? In one study we did, the astonishing figures we found of new HIV cases among these adolescents and young adults is alarming. “We have a lot of work on our hands to reach this population.
But, then when we reach them, and they are enrolled into care, for various reasons they do not take their drugs. And, if they do not take their drugs, they cannot be virally suppressed.” Based on this, Dr David worried that if they are not suppressed, the chances of continuing the chain of transmission is far higher, saying this is the reason this age group is of concern, globally.
Mental health challenges
The other challenges of AYLHIV, according to her, include Mental Health, which are prevalent among them as some of studies from NIMR’s Adolescents and Youth Programme showed a high prevalence of anxiety, depression and suicidal ideation among these young people. Currently, a study which will evaluate the effect of the incorporation of mental health counselling into the routine care of AYLHIV on mental health is being developed,” she stressed.
The other one, Dr David pointed out, is the Sexual and Reproductive Health (SRH) as it concerns the spate of unplanned pregnancies among female AYLHIV and a dearth of information on the SRH of AYLHIV nationally, which prompted a study on the sexual and reproductive health (SRH) needs of AYLHIV in Lagos State.
Findings in the study, she noted, revealed poor knowledge of SRH, engagement in risky sexual behaviour, which resulted in poor SRH outcomes as well as poorly staffed and equipped adolescent friendly centres “Lack of comprehensive sexuality education, poor economic status, and poor parent-child SRH communication were significantly associated with the negative SRH findings, highlighting the need for sexuality education, parental counselling, improvement in economic status for the populace and provision of comprehensive and accessible SRH services for adolescents and young adults with HIV,” she added.
As part of moves to ensure that AYLHIV take their drugs regularly, Dr David insisted that to curb or eliminate HIV there is the need for optimal adherence to Antiretroviral Drug Adherence and Viral Suppression among this group.
This, she said, had become necessary in order to achieve viral suppression, halt disease progression, prevent development of drug resistance, stop disease transmission and improve the quality of life of PLHIV. “ART adherence is notoriously low among AYLHIV for various reasons, including the peculiarities of adolescence, to avoid stigma and discrimination, and treatment fatigue.
We have conducted several studies on, and made recommendations on ways to improve, ART adherence and viral suppression among AYA,” she said. She spoke about Directly Observed Antiretroviral Therapy (DOART), which recommendation followed HIV resistance testing among some of the adolescents, who were failing 2nd line ART, which revealed that they were sensitive to all tested ARVs including first-line drugs (meaning they had not been taking their drugs).
The recommendation, she explained, stipulated that the drugs must be taken in the presence of a caregiver/treatment supporter led to a drastic reduction in supposed drug resistance and improvement in viral suppression.
Other step taken, is the SMS Reminders for Drug Adherence, where they assessed the effectiveness of oneway SMS reminders to take drugs at the right time, and bi-directional SMS reminders by sending an SMS and to get acknowledgement that drug has been taken, and where the bidirectional SMS reminder was more effective than the one-direction SMS. Similarly, Dr David also spoke of Peer Navigation and bi-directional SMS reminders, which involved the combination of bi-directional SMS reminders trained peer navigators to support AYLHIV and encourage ART adherence among them.
“This was effective in improving adherence and significantly improved viral suppression below 1000 copies/mL,” she noted, saying however, more effort is needed to achieve viral suppression below 50 copies/mL. On repeated test in six months, given their high risk, as they could get infected, they were introduced to what she called “pre-exposure prophylaxis for HIV,” he said the pre-exposure prophylaxis is a tablet they can be swallowed once a day, with between 98 and 99 per cent efficacy for preventing HIV infection.
“What we found is that young people are not ready to take these medicines, because the uptake for that was only six per cent. Indeed, even those who take the first dose, when they collect the first amount, they do not come back to collect the other. So we need to do a lot more,” Dr David added.
