HIV/AIDS INTERVENTIONS IN GOMBE STATE NIGERIA; CHALLENGES OF SUSTAINING THE GAINS

Oruonye, E. D¹⁺ Abubakar, H² Ahmed, M.Y³ Yakubu Dan⁴

^,3Department of Geography, Taraba State University, Jalingo, Taraba State Nigeria

²General Hospital Deba, Yamaltu Deba LGA, Gombe State, Nigeria.

⁴Department of Geography, Gombe State University, Gombe, Gombe State Nigeria.

Keywords: Challenges, GomSACA, HIV/AIDS, Intervention and Sustainability

Article History: Received: 24 February 2017, Revised: 6 April 2017, Accepted: 28 April 2017, Published: 4 May 2017

Contribution/Originality: This study is one of very few studies which have investigated the challenges of sustaining the gains made so far in the fight against HIV/AIDS. The findings present clearer picture of the enormity of the challenges of HIV/AIDS control and need for more proactive measures in the fight against the disease.

1. INTRODUCTION

HIV/AIDS is a global public health challenge and a major threat to socio-economic development in Nigeria and Gombe State in particular. Gombe state belongs to the most affected state in Nigeria (Usman, 2009). The first case of HIV/AIDS in the State was recorded in 1992. The HIV/AIDS prevalence rate was 4.7% in 1999 which rose to 8.2% in 2001, and decline to 4.9% in 2005, 4.2% in 2010 and 3.2% in 2016 (Gombe State Agency for the Control of AIDS (GomSACA), 2016). According to the 2013 National Reproductive Health Survey Report, Gombe state ranked 13^th position in the country with 3.4% prevalence rate. In 2005 there were 60,300 people living with HIV/AIDS in the state (10,200 of this were youth aged 15-24years), 16,200 children orphaned by the disease and 23,000 lives lost to the disease (NACA, 2013). There is a global drive to strengthen HIV/AIDS prevention efforts through understanding the disease transmission dynamics at all levels. The state population is highly mobile thereby increasing the risk of HIV/AIDS transmission and making the control of the spread of the disease very challenging. The state response to this challenge was initially guided by the 2006 – 2009 strategic plan and other national instruments (Usman, 2009). Later, new state HIV/AIDS policy documents were developed which included the 2012 and 2013 HIV/AIDS operational plans, 2012 GomSACA fact sheet and annual bulletin, 2013 coordination and partnership guidelines and 2016 GomSACA Fact Sheet.

The state has many high risk settings and increasing behavioural attitudes that enhance the spread of the virus. The high risk LGAs includes Gombe, Kaltungo, Billiri and Shongom LGAs. The spread of HIV/AIDS in the state is worsened by increasing rate of poverty and unemployment among youths which makes them indulge in risky sexual lifestyle. There is a great deal of complacency among the population. Most people do not care about the consequences of being infected by the virus and as such do not see any reason for taking preventive measures such as use of condom and sticking to single faithful sex partner. When eventually they are infected, they see it as an act of God destined to happen. This complacent attitude is further exhibited by the people when it comes to seeking for medication when they are sick. Most HIV/AIDS patient, despite being aware of their status prefers to deny the sickness rather than seek for medication. Many resort to traditional medicine for treatment because of fear of stigmatisation. Most patients prefer to die secretly with the HIV/AIDS rather than disclosing their status and receiving treatment. This was earlier observed by Usman (2009) who reported that even educated family members prefer to have the HIV/AIDS status of their relations kept secret. Thus, complacency about the need for HIV prevention may be among the strongest barriers communities face as they plan to meet the next century's prevention needs. Additionally, the State has been plagued with insecurity challenges since 2014. Thus, beyond the funding and provision of laboratory facilities and drugs, understanding the behavioural attitude influencing the spread is key to achieving success in the fight against HIV/AIDS in the state.

The fight against HIV/AIDS is a complex and multi tasking undertaking which requires the collaboration of all stakeholders involved. This involved halting the further spread of the virus and providing care and support to people already infected or affected by the disease. The fight against HIV/AIDS requires huge capital investment, political will and commitment by the stakeholders. This is the reason why the effort of Gombe state government and stakeholders in the fight against the spread of HIV/AIDS is worth appraising.

So much gain has been achieved by Gombe State government and its international development partners interventions in the fight against HIV/AIDS in the state. However, sustaining these gains remains a serious problem. Not much has been done by previous studies to consider these gains and the challenges of sustaining the effort in the face of dwindling resources in the state and country. This paper attempts to fill this knowledge gap.

1.1. Description of Study Area

Gombe state is one of the six states of the North-east geo-political zone in Nigeria. The State shares boundaries with Yobe State to the North, Adamawa and Taraba States to the South, Borno State to the East, and Bauchi State to the West. It covers an area of 20,265km² with a population of 2,587,159 people (1,296,166 - 50.1% males and 1,290,993 - 49.9% females) according to the 2006 population census. The population of children aged 5years and below is 501,388 (19.4%) with an annual growth rate of 3.2%. The State was created from the old Bauchi state on 1st October 1996 with 11 local government areas. It is located in the Sahel Savannah with tropical continental type of climate characterised by long dry season and a short rainy season. The terrain is undulating with hills rising above 1200m above sea level. The State is drained by River Gongola, a tributary of the Upper Benue river basin. Its mineral resources include gypsum, limestone, silica, dolomite, talc, uranium and kaolin. The state is a multi-ethnic state, with some ethnic groups such as Tangale, Terawa, Waja, Kumo, Fulani, Kanuri, Bolewa, Jukun, Pero/Shonge, Tula, Cham, Lunguda, Dadiya, Bambuka, Hausa and Kamo/Awak. The people of Gombe state are primarily farmers producing food and cash crops such as cereals, legumes fruits, vegetables and tree crops (Mahmoud, 2016). Industries in the State include Ashaka Cement Plc, cotton ginneries and other small-scale industries.

Gombe state ranked 7^th in the list of Nigeria’s ten poorest states and over 80% of its population reside in the rural areas and engaged in subsistence farming as their predominant source of income (Usman, 2009). The state has high poverty incidence of 72.2% (National Demographic and Household Survey (NDHS), 2008) and a high index of out of pocket spending for illness (Gombe State Government (GSG), 2010).

Fig-1. Map of the Study Area

Source: Processed image 2017

There are 563 health facilities, of this, 14 general hospitals, 1 state owned specialist hospital, 1 Federal Medical Centre, 58 private health facilities, and 505 government owned primary health facilities. The bed capacity is between 11 and 14 beds /10000 of population (GSG, 2010). The public health care system like what is obtainable in the country is weak, poorly funded and overstretched especially with the challenges of HIV/AIDS. Poorly regulated private and traditional health sectors provide most health services involving unethical practices with HIV/AIDS consequences in the state (Ichoku and Fonta, 2006; Usman, 2009). There are over one hundred NGOs supporting HIV/AIDS prevention and care support for infected persons. The bulk of financing and technical assistance of the State’s HIV/AIDS programme comes from World Bank MAP, PEPFAR, UN System, CIDA and USAID (Usman, 2009).

2. MATERIAL AND METHODS

This study relied substantially on existing sources of data, journal articles and online materials. Interview schedules were used to elicit information from government officials and officials of some NGOs and donor support agencies involved in HIV/AIDS intervention in the state. The interview schedule were structured in such a way that it was used to generate information on the various HIV/AIDS interventions in the state, the impacts of such interventions, the challenges encountered during the intervention period and challenges of sustaining the gains made so far. The interviews were carried out to confirm or explain information from the literature reviewed and give clues where information is lacking in the literatures reviewed. The data generated were analysed using descriptive statistics.

3. RESULT OF FINDINGS

To ensure a proactive approach to the challenges of HIV/AIDS, the State Action Committee on AIDS (SACA) was transformed into agency backed up by law on 9^th February, 2010. The 11 LGAs in the state have Local Action Committee on AIDS (LACAs) and Critical Mass Unit was established in all lined up ministries in the state. This is to ensure effective coordination and sustainability of HIV/AIDS control activities in the state.

The state government and its development partners provided modern machines and equipments for HIV/AIDS test to various health facilities in the state (plates 1). This includes HIV/AIDS test kits and chemical reagents for all HIV/AIDS and related baseline tests. HIV/AIDS support facilities provided in the state (Table 1) included HIV/AIDS Counselling and Testing (HCT), Prevention of Mother to Child Transmission (PMTCT) and Anti retroviral Therapy (ART). There was mass media enlightenment programme sponsored by UNICEF Nigeria, Starwood of United Kingdom and the National Youth Service Corps. Religious leaders and clergy men from both religion (Islam and Christianity) were integrated in the awareness creation exercise in the state.

Plates-1&2. New HIV/AIDS testing equipments procured

Source: (Fieldwork, 2017)

Table-1. HIV/AIDS Support Facilities in Gombe State (2016)

Source: GomSACA (2017)

The Action Committee on HIV/AIDS in 2014 planned to conduct free test to 500,000 persons in the state to ascertain their HIV status. ₦15million was required to purchase 1 million test kits for this exercise. Suggestion was made to LGAs in the state to devote ₦200,000 of their monthly subvention to HIV/AIDS control in their domain. This is part of the effort to queue into the Presidential Comprehensive Responsive Plan by the Federal government aimed at having 80million Nigerians tested for HIV/AIDS in the country. 85 persons from SDPs have been trained on Nigerian National Response Information Management System (NNRIMS) and are collecting data on PMTCT, ART, VCT, HIV/TB, HBC, OVC and BOC using NNRIMS tools. There are about 226,021 persons that needs HIV/AIDS counselling and test in the state out of which 101,136 were counselled, tested and received their results in 2013 (Gombe State SHEIA, 2013) which rose to 155,519 in 2014 (National AIDS & STIS Control Programme (NASCP), 2014). 5,390 of those counselled and tested in 2013 are positive which increased to 5,431 in 2014.

The state HIV/AIDS prevention approach involves the use of Family Life Health Education (FLHE) training curriculum and peer education as a co-curricular strategy. During the intervention period, FLHE was mainstreamed into the teachers training curriculum. In 2013, 520 were trained to teach FLHE and 32,803 pupils/students were reached with FLHE. Between January to June 2016, about 28 schools were implementing FLHE curriculum, 82 teachers trained to teach FLHE and 694 pupils/students were reached with FLHE (Table 2).

Table-2. HIV/AIDS Knowledge and Awareness Creation Exercise in Gombe State (Jan.-Jun. 2016)

Source: (NASCP, 2014; GomSACA, 2017)

As people are counselled and tested for HIV/AIDS, those that tested positive are subjected to baseline test before been placed on ART. The costs of the baseline test are shouldered by the intervention fund. NASCP 2014 report shows that there are 58,517 persons living with HIV/AIDS in the state. The ART need based on CD4 350 eligibility was 24,724, out of which 19,160 persons were placed on ART giving 77% coverage. 90,000 HIV/AIDS patient are currently on ARV drugs in Gombe State.

Table-3. HCT Services in Gombe State

Source: (NASCP, 2014; GomSACA, 2017)

Despite increase in the number of HIV/AIDS Counselling and Test (HCT) sites to 201 in the state (Table 1), the proportion of the general population who have accessed HCT services is still low (Table 3). HCT is still low because people are afraid of knowing their HIV status and new infection as at 2015 is about 5,306 persons.

Table-4. ART Services in Gombe State

Source: GomSACA (2017).

HIV/AIDS patient on ART are given some incentives to encourage them to take their drugs promptly. These incentives include package of gifts (soap and detergents among others) and transport fee back home. Without these incentives, some of them will not come to the hospital to pick their drugs. Gombe State increased the number of Prevention of Mother to Child Transmission (PMTCT) centres from 185 to 203 centres in the state. The aim is to make sure that every woman that was tested positive in the state has access to the service. The PMTCT sites were supported by UNICEF, MTN, ICAP, FHI, GHAIN and IHVN. The State provides free PMTCT services in eight secondary and nine primary health care facilities owned by the state government. NASCP 2014 report shows that PMTCT need in the state in 2013 was 4,294 and achievement of the state in this regard as 1,488 given 35%. In 2014 the PMTCT need was 4,771 and the achievement was 747 (16%). On the other hand, Gombe State SHEIA (2013) report shows that the number of new ANC client was 86,875 (Table 5) and the number of pregnant women counselled, tested and received results was 79,137 (Table 5). Of this, 1,226 persons tested positive and 1,087 of them were placed on ART prophylaxis. The intervention also involves provision of incentives to women attending anti natal care (e.g. they are given token packages such as soaps and detergents and transport money back home).

Table-5. PMTCT Services in Gombe State

Source: GomSACA (2017).

Intervention measure to reduce HIV/AIDS stigmatization in the state includes the drafting of a bill on stigmatization against persons living with the disease presently pending in the State House of Assembly. This is because people are not coming forth for the voluntary counselling and testing (VCT) to know their status.

The State was the first to introduce electronic medical records for people living with HIV/AIDS to make it easy to access care through mobile phones. This include the establishment of database room with IT connectivity. This allows them to track HIV/AIDS patients back home to ensure they pick their drugs in good time and promptly. This is important because compliance to the drugs regulation helps to reduce the spread of the virus.

In the areas of awareness creation through Behavioral Change Communication (BCC), GomSACA collaborated with NGOs and CBOs in organising and conducting advocacy programme in public places such as hotels and brothels to educate commercial sex workers and other MARP groups on preventive measures against HIV and AIDS. Tunfure Resort was selected as the first site for Priority for Local AIDS Control Effort (PLACE) intervention in the state. This intervention is part of the cycle 1 of the Strengthening HIV/AIDS Prevention Services (SHIP) for the Most at Risk Population (MARP) project.

An alternative to this was the ‘‘Table for Table’’ innovative approach to PLACE night activities. It was introduced and adopted in July 2013 after a fire incident that disrupted night activities at the Resort. As low music played in the background, variety of questions on HIV/AIDS, sexual and reproductive health previously compiled and written in ballot forms were passed around in bags for people from Table to Table to pick and answer questions and discuss the selected theme. There is usually active participation by the sweet Moms and male sex clients. Branded gift items were usually given out to all who answered questions correctly. This strategy was adopted in other parts of the state. SHIP for MARPs is a flagship USAID prevention programme implemented by Society for Family Health, Federal Ministry of Health and Population Services International in the state. About 11,295 MARPs were reached with individual and or small group level Minimum Prevention Plan (MPP) intervention in the state (Gombe State SHEIA, 2013).

Table-6. HIV/AIDS Sexual Behavior Intervention in Gombe State

Source: GomSACA (2017)

HIV/AIDS Care and support involves the provision of palliative care and support to PLHIV and their families and the provision of social protection to OVC. About 604 orphans and vulnerable children have benefitted from social services and improved quality of life package (Table 7) and 226 OVC households received free basic external support in caring for the child in 2016 alone.

Table-7. Orphans and Vulnerable Children Care Support in (GomSACA) (2016)

Source: GomSACA (2017)

The interventions have helped reduced HIV/AIDS related death from 3,652 in 2012 to 1,210 in 2014 (NASCP, 2014). The number of death averted by HIV/AIDS intervention in the state from a baseline at 2013 to 2015 is estimated at 2,341 while the number of infections averted by PMTCT from baseline at 2013 to 2015 is 209 (Gombe State SHEIA, 2013).

3.1. Challenges to Sustaining These Gains or Successes

The cost of HIV/AIDS treatment such as laboratory cost for baseline tests, prophylaxis and ARTs is far beyond the affordability of most people in the state. The above scenario makes HIV/AIDS control very complex and financially demanding. Thus it cannot rely on the normal budget of the state. The funds used in providing the above services were provided by NGOs involved in the fight against HIV/AIDS in Gombe State. State government counterpart funds were small and not regular (Table 8).

The various donor agencies intervention in the state are for specified period well defined from the onset. These NGOs are already running out their time of intervention and are in the final process of disengagement. This stage involves reduction in the funds for HIV/AIDS control and support activities before the final termination of the program.

The reduction in the funding of the programme is already affecting the HIV/AIDS support services in the state. The state government are already finding it difficult to procure the test reagents for the baseline test before placement on ARV and maintenance of some of the equipments (Interview, 2017).

Table-8. Funding Landscape of HIV/AIDS in Gombe state (2011-2013)

Source: Gombe State SHEIA (2013).

Gombe state appropriated Nl0million for its 2006 HIV programme on the ground that it was rendering support through other means. The state has been getting support of UNFPA, UNICEF and UNDP in fighting HIV and 172million dollars World Bank grant. Out of ₦51.6 billion total budget of the state in 2009, the budgetary allocation for health is N1.4billion, which accounts for 2.7% of Government expenditure. The Government total per capita expenditure on health then was ₦342.66 which is far below WHO recommended level of $34/person (GSG, 2010). The current budgetary allocation to health accounts for 2.7% of the budget which is grossly inadequate for effective health care delivery in the state.

Table 8 shows that Gombe state government’s total budget for HIV/AIDS programme is only (15.1%) of the donors/partners expenditure on HIV/AIDS in the state. Out of ₦162,100,000 total state budget for HIV, only ₦33,675,000 (20.8%) was actually expended on HIV/AIDS in the state. This amount declined to ₦9,370,000 in 2012 and ₦500,000 in 2013, while the funds from donor/partner agency increased to ₦1,075,009,630 in 2012 (Gombe State SHEIA, 2013). Table 8 shows clearly that funding for HIV/AIDS in the state is far beyond the normal budget of the state.

Newly infected persons are placed on ARV immediately after confirmation without going through the process of undergoing the baseline test to determine the potential effects of drugs that will be administered to the patient. The incentives given to patients on ARV are not forthcoming, thereby discouraging many people from coming out to pick their drugs as at when due. This has the tendency of eroding the gains that have been achieved over these years, with a potential of worsening the situation more than it was at the commencement of the programme. This was the case in Taraba state. Following the withdrawal of NGOs and various support groups in the fight against HIV/AIDS in 2008, the prevalence has risen from 5.5% in 2011 to 10.5% in 2013, making Taraba state the second highest prevalence rate in the country.

Following the withdrawal of funding and support intervention by international donor agencies and NGOs in Taraba State, the HIV/AIDS control and prevention activities declined. This is because the state government refused to take ownership of the problem and programme. The State government funding stopped or declined drastically, HIV/AIDS enlightenment campaign in media houses and public places stopped or were left in the hands of few community based organizations (CBOs) and Faith based organizations (FBOs) in the state. All the effort and successes recorded in reducing the spread of HIV/AIDS during the intervention period were lost and the spread of the disease increased from 5.5% at the time of withdrawal to 10.5% four years later in 2013. This resulted in the increase in the number of new cases of HIV/AIDS infection and HIV/AIDS related mortality and the number of children orphaned by the disease in the state.

Despite establishing digital record system for HIV/AIDS data management in the state, accessing these data remains a serious challenge in the state. Some data for HIV/AIDS related cases for some years are either missing or are non-existent. This affected the present study greatly and explained the much dependence on published materials in the internet.

4. CONCLUSION

This study has examined the challenges of sustaining HIV/AIDS interventions in Gombe state. The study appraised the gains made so far and the challenges of sustaining this effort. The findings of the study show that the tripartite collaboration between UNICEF, Gombe state government and some NGOs has led to drop in the spread of HIV/AIDS in the state from 8.2% in 2001 to 3.2% in 2016. The study also reveals the gains so far made in reducing the spread of the disease in the state. Despite all the gains, the optimum prevention returns on the fight against HIV/AIDS is rather low. HIV/AIDS constitute significant burden on the already stressed and declining resources and weakened infrastructure available to fight the spread of the disease in the state. The study shows that HIV/AIDS control and support services require huge capital and human resources that are far beyond the normal state budget. Thus as the international donor agencies winds up their support and intervention in the state, there is urgent need for the state to come up with measures to sustain the ongoing HIV/AIDS control and support activities to ensure that the gains made are not loss.

5. RECOMMENDATION

Based on the findings of this study the following recommendations are suggested;

1. The state government should be more proactive by taking ownership of the problem of HIV/AIDS and ensure increase funding.

2. Maximize all resources available for HIV/AIDS control activities in the state.

3. Given the enormity of the challenges of HIV/AIDS control, Government at all levels should endeavour to increase their budgetary allocation and prompt release of funds for HIV/AIDS control in order to consolidate the gains so far recorded towards meeting the rising need for HIV/AIDS service delivery.

4. Effort should be made to promote long-term sustainability of the gains so far made in HIV/AIDS control in the state by exploring innovative financing methods such as dedicated tax levies and HIV/AIDS trust funds among other options.

5. Effort should be made to get the private sectors involved in the fight against the spread of HIV/AIDS in the state because the challenge is beyond the capacity of the state government.

6. The state should intensify new prevention technologies and innovation in HIV/AIDS control while the search for vaccine continued.

7. There is need to optimize the logistics system for ART procurement, distribution and utilization in the state. Effort should be made to minimize loss to follow up, poor adherence and consequent development of HIV drug resistance in the state.

REFERENCES

Gombe State Agency for the Control of AIDS (GomSACA), 2016. Fact sheet.

Gombe State Government (GSG), 2010. Strategic health development plan (2010 - 2015).

Gombe State SHEIA, 2013. HIV epidemiological and impact analysis Gombe State. Power point Presentation.pdf

GomSACA, 2017. Fact sheet.

Ichoku, E.H. and W. Fonta, 2006. The distributional impact of health care financing in Nigeria: A Case Study of Enugu State. PMMA Working Paper.

Interview, 2017. Interview with Mal. Haruna Bose on 13th February, 2017 at GomSACA office, Gombe, Gombe State.

Mahmoud, U., 2016. Security and governance in Gombe State. In Hussaini Abduand Chigozirim Okoro (Eds.) Security and Governance in North –East Nigeria. Lagos Nigeria: Malthouse Press Limited. pp: 113-153.

NACA, 2013. HIV Epidemic Appraisals in Nigeria: Evidence for prevention programme planning and implementation data From the First Eight States.

National AIDS & STIS Control Programme (NASCP), 2014. Annual Report on HIV/AIDS Health Sector Response in Nigeria. Federal Ministry of Health. Abuja, Nigeria.

National Demographic and Household Survey (NDHS), 2008. National population Commission, Abuja, Nigeria.

Usman, A.U., 2009. Analysis of knowledge, attitude, behavioural and structural factors driving HIV epidemics in Gombe State. A Thesis Submitted for the Award of Master Degree in Public Health of Royal Tropical Institute, Vrije Universiteit Amsterdam (45 International Course in Health Development).