Author: Dr. Gloria Sangiwa During the last four decades we’ve seen stunning achievements in the global and local responses to HIV. We’ve…
Authors: Jenny Mwanza is a Senior Technical Advisor for the Data for Implementation (Data.FI) project. She leads Data.FI’s Data Use for Improvement workstream, which operates across eight countries. With over 20 years of experience designing and scaling domestic and international public health projects, her areas of expertise include health service delivery, health management information system strengthening, and monitoring & evaluation.
Aniebietabasi (Anie) Etokakpan serves as Data.FI’s Strategic Information Associate in Akwa Ibom State, Nigeria. A monitoring & evaluation expert with a master’s degree in public health, she serves a vital role expanding the project’s data use initiatives and collaborating with local stakeholders in Akwa Ibom.
The theme of World AIDS Day 2023 is “Let Communities Lead.” Given the growing body of evidence that substantial localization is crucial for achieving the UNAIDS 95-95-95 goals and ensuring the sustainability of HIV epidemic control, this is a timely and laudable priority. However, “letting communities lead” is often easier said than done, as the balance between local leadership and sufficient external support is difficult to strike.
Recent efforts in Akwa Ibom, a state in south-eastern Nigeria with more than 5.5 million inhabitants, offer lessons on how this balance might be achieved.
The 2018 Nigeria HIV/AIDS Indicator and Impact Survey identified Akwa Ibom State as having the highest prevalence of HIV in the country (5.5%) and a significant unmet need for HIV services, with only 36,234 individuals receiving treatment out of an estimated 178,000 people living with HIV. Women of reproductive age experienced HIV infection at twice the rate of their male counterparts and were at risk of being left behind if no action was taken. Akwa Ibom, alongside nine other states, was prioritized by the national AIDS response with support from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) to receive intensified “surge” support over the subsequent five years.
With advances in treatment, it is possible for an individual taking antiretroviral therapy daily to achieve viral load suppression in as little as six months, continue a relatively healthy life, and become unable to transmit the virus. Breaking the chain of transmission through “treatment saturation” became a possibility with the surge in financial resources and technical assistance.
So, to curb the epidemic, Nigerian healthcare workers needed to link undiagnosed HIV-positive individuals to comprehensive, patient-centered care and treatment. To make the most of these investments, healthcare workers and key decision makers needed access to complete, real-time information on HIV testing and service delivery, which was not available at that time. HIV data was collected across public and private facilities, supported by a myriad of donors, and stored in more than a dozen disconnected information systems.
Mr. Uduak Umo-Udofia, Monitoring and Evaluation Officer of the Akwa Ibom State AIDS and STD Control Programme, noted that in 2019, “regular data review was a challenge because routine data were collected in parallel systems and…data was only made available on a quarterly basis. This did not allow for effective decision-making processes and the response the HIV epidemic in the state was not optimal.”
In was in this context that, in mid-2019, the Data for Implementation (Data.FI) project was invited to work with local leaders to strengthen the linkages between disparate information systems and create spaces for enhanced data review called “Situation Rooms.”
With United States Agency for International Development (USAID) funding, and in service of the Director of Public Health of Akwa Ibom, Data.FI launched the Automated Partner Performance Reporting (APPR) system designed to bring real-time, granular analysis of patient level outcomes to state-level decision makers for review. Data Use Advisors mentored government officials to conduct the standardized Data.FI approach to frequent, fast-paced data review to identify inefficiencies, understand reasons for under-performance, and course-correct to improve service delivery. Between April 2019-March 2023, Data.FI worked with the State Ministry of Health (SMOH) leaders to mobilize implementing partners (IPs) and in close coordination achieved results across the 95-95-95 cascade:
- More than 4 million individuals were provided counseling and testing services; 165,767 individuals were newly diagnosed with HIV and linked to treatment. This represents a nearly seven-fold increase in the number of people living with HIV (PLHIV) diagnosed and on antiretroviral therapy (ART) from 28,481 in 2019 to 194,248 in 2023.
- An improvement in viral load testing coverage (from 47% to 94%) and suppression (from 78% to 99%) among those tested, thereby breaking the chain of HIV transmission for the majority of PLHIV on ART treatment.
- Approximately 10% of newly diagnosed individuals were a member of a key population group: men who have sex with men people who inject drugs, female sex workers, people in prisons and other enclosed settings as well as transgender; the number of individuals on treatment in key population groups more than tripled from 7,500 to 27,500.
- Near complete (99%) transition to the Tenofovir, Lamivudine, and Dolutegravir (TLD) drug regimen, a game-changing one pill per-day known for accelerating viral suppression, was attained in 2021.
- PEPFAR programs served more than 160,000 orphans and vulnerable children in 2023 with community services to ensure that the 5,000 pediatric HIV-positive children in Akwa Ibom have attained high viral load testing coverage (95%) and suppression (97%).
Aniebietabasi (Anie) Etokakpan, Data.FI’s Data Use Advisor, prepares analyses and identifies priorities for stakeholder discussion at the weekly Situation Room meetings. She has observed that the emphasis on capacity-building and local partnerships is paying off, allowing state and community officials to lead the effort to curb the HIV epidemic. When asked what the role of the Situation Room has been over the last four years, she replies: “The Situation Room has brought about strong collaboration between stakeholders and implementing partners in the state. It has ensured real time data review which has led to prompt decision making in addressing service or reporting challenges across the facilities and LGAs [local government authorities] where HIV response is ongoing. It’s the combination of data access and strong methods that have transformed the culture of data use. In the past, the data was incomplete, and decisions were made top-down. Now we invest the time to triangulate data, seek explanations, and develop careful solutions to stubborn problems. I’m amazed by the progress the SMOH is making towards our HIV epidemic control goals.
The situation in Akwa Ibom is evolving, though, and challenges remain.
One particular challenge involves identifying undiagnosed PLHIV through index testing, the method of eliciting contacts from recently diagnosed HIV-positive clients.
Since early 2021, when index testing yielded a positivity rate of 26%, the index yield has steadily decreased (see the graph below). When Anie presented the data to Situation Room stakeholders in mid-2022, the group mobilized to reactivate the strategy: existing HIV patient files were reviewed, a refresher training on sexual partner elicitation was provided, and follow-up client sexual contact elicitation interviews were conducted. As a result, the number of index partners who were tested in the following quarter more than doubled to an all-time high of 59,000 people. The proportion of new HIV-positives identified, however, remained largely unchanged.
Stakeholders are optimistic that Akwa Ibom is reaching treatment saturation, suggesting that the pace of HIV transmission is slowing given the high rates of viral load suppression among PLHIV on treatment. However, there are many factors at play and further investigation is needed to better understand the decreasing index testing test positivity. As Nigeria makes progress towards national goals, it will become more difficult to identify and link undiagnosed, HIV-positive individuals and to return clients experiencing adherence challenges to treatment.
To achieve the final milestones towards epidemic control, the Situation Room in Akwa Ibom will continue to analyze, review and discuss real-time, more-granular data to focus HIV resources where they will most effectively diagnose new cases.
Akwa Ibom presents a case study of what it means to “Let Communities Lead” – an emphasis on systematic changes rather than isolated interventions, a focus on local needs rather than external expectations, and a commitment to better data use rather than a desire to import technology for its own sake. In this way, local leadership coupled with international funding and expertise can accelerate and maintain HIV epidemic control. And as we draw closer to 2025, the target date for UNAIDS 95-95-95, the international community can do more to foster initiatives like those unfolding in Akwa Ibom.
 PEPFAR. Strategy for Accelerating HIV/AIDS Epidemic Control, 2017-2020. https://www.state.gov/wp-content/uploads/2019/08/PEPFAR-Strategy-for-Accelerating-HIVAIDS-Epidemic-Control-2017-2020.pdfpdf iconexternal icon
 https://www.state.gov/wp-content/uploads/2019/09/Nigeria_COP19-Strategic-Directional-Summary_public.pdf; The 2018 Nigeria HIV/AIDS indicator and impact survey (NAIIS). NAIIS website. https://www.naiis.ng; https://www.datim.org/dhis-web-commons/security/login.action. Accessed 19 April 2021.
 The HIV prevalence gender disparity between females and males was greatest among younger adults, with females age 35-39 years (3.1%) having 2 times the prevalence of males in the same age group (1.4%). https://www.naiis.ng/resource/factsheet/NAIIS%20National%20Summary%20Sheet.pdf
 DATIM accessed on date of September 25, 2023.
 Tenofovir, Lamivudine and Dolutegravir.