“The fact that something is hard to evaluate doesn’t make it impossible,” said Anna Downie, who leads on strategic information at Frontline AIDS. Reflecting on the challenge of evaluating advocacy, coalition-building, generating new partnerships and increasing the capacity of communities, she added, “To be successful, it is essential to allow space for innovation, to hear from communities about what is important to them and involve them from the outset so that you are looking for the same results and the evaluation is truly useful.”

Ms Downie was one of a number of experts who gathered in UNAIDS headquarters on 29 March in Geneva, Switzerland, for UNAIDS’ first consultation on evaluation. With the aim of informing the new UNAIDS evaluation policy, to be presented to the UNAIDS Programme Coordinating Board (PCB) meeting in June, the participants shared lessons they have learned while working on evaluation.

“Generating evaluations that are independent, credible and useful is the foundation of our work” said Susanne Frueh, the Chair of the United Nations Evaluation Group and Chair of the consultation.

The central role of countries in supporting a strong and independent evaluation function at UNAIDS was highlighted. The need for dedicated funding for evaluation, for the evaluation function to be independent and for transparency in the appointment of the head of the evaluation function were highlighted. The credibility and expertise of the staff of the office of evaluation, the establishment of an independent advisory committee and the need to protect the office from becoming politicized were also noted.

Michel Sidibé, UNAIDS Executive Director, highlighted the importance of the evaluation function. “We will not be able to transform or sustain our gains in the AIDS response if we don’t have clear learning from what we are doing. We will not be able to quicken the pace of action and help countries to scale up if we are not able to share our work and lessons learned,” he said.

The participants agreed that it is essential not only to ensure a strong gender and equity element in evaluations but also to measure what works and identify results in the areas of gender and human rights, which are cornerstones of the AIDS response. Triangulating data on human rights with civil society is a good way of ensuring that the evaluation provides a full picture. The importance of assessing the support provided by UNAIDS when major donors transition from countries was also highlighted.

In the medium to long term, the participants highlighted the need to build the capacity of young evaluators and to consider working with the growing number of evaluation companies from the global South.

The UNAIDS policy on evaluation is to receive a final round of comments from stakeholders soon. It will then undergo a peer review by the United Nations Evaluation Group before being presented to the UNAIDS PCB for endorsement. 

After six months of data collection and three months of data analysis, the President of Nigeria, Muhammadu Buhari, announced the results of the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) in March 2019. Costing approximately US$ 100 million and covering more than 200 000 people, 185 survey teams collected data for the NAIIS, the largest HIV-specific survey in the history of the global response to the epidemic.

In Nigeria, three types of survey have been conducted by the Federal Ministry of Health HIV/AIDS Division to determine HIV prevalence and to monitor the trends of the HIV epidemic in the country:

• The HIV Sentinel Survey (HSS), which is conducted typically every two to three years among women attending antenatal clinics, which determines HIV prevalence among pregnant women.
• The National Reproductive Health Survey (NARHS), which is conducted every five years among the general population.
• The Integrated Biological and Behavioural Surveillance Survey (IBBSS), which is mostly used to monitor prevalence and behavioural trends among key populations.

The last HSS and IBBSS took place in 2014, while the last NARHS took place in 2012. These data sources have served as the main survey data sources for the AIDS response in the country.

Between 2012 and 2014, significant progress was made in the AIDS response in Nigeria. The number of antiretroviral therapy sites doubled, prevention of mother-to-child transmission sites increased eightfold and HIV counselling and testing sites increased fourfold. According to government data, 6.7 million adults were counselled and tested for HIV in 2014, a 65% increase from the previous year. HIV testing among pregnant women also doubled in 2014 compared to 2013. Similarly, the number of people living with HIV on antiretroviral therapy increased significantly.

However, despite this progress, there was no commensurate improvement in the statistics on the coverage of antiretroviral therapy among people living with HIV. National achievements in the AIDS response were poor compared to the targets, and programme implementers reported difficulties in identifying people living with HIV in need of services. It was therefore suggested that the HIV burden was not as high as was estimated using the available HIV prevalence data.

Former UNAIDS Country Director Dr Bilali Camara was a longstanding advocate for an expansion of the surveillance of the country’s epidemic.

“Working as UNAIDS Country Director in Nigeria, I realized early on that we did not have the full picture of the country’s AIDS epidemic,” said Dr Camara. “I was pushing for surveillance to be expanded for a long time―I am very happy that with this new survey we now have a better understanding of the AIDS epidemic in Nigeria and that it will allow us to better respond to the areas and people in most need.” 

Dr Camara’s persistence indeed paid off.

In July 2015, the National Agency for the Control of AIDS (NACA), under the leadership of its then Director-General, Professor John Idoko, decided that it was imperative to better understand Nigeria’s HIV epidemic. The NACA set up a National Stakeholder Committee, comprising the head of the National AIDS and STI Control Programme, the UNAIDS Country Director, the World Health Organization (WHO) representative, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) Coordinator, civil society and others, which decided to conduct a triangulation of data from various sources.

“The need for the survey was first initiated under my leadership, but we had overwhelming support from Dr Camara. UNAIDS headquarters was even willing to send its Strategic Information Director to Nigeria at the time,” said Professor Idoko.

Many countries have shifted to a location–population approach, which helps to ensure that HIV services reach the people and geographic areas with the greatest need. Location–population approaches require granular-level data, which were not typically available in Nigeria. In 2016, the UNAIDS Nigeria Strategic Information Team, led by Dr Gatien Ekanmian, was tasked to develop an evidence-informed methodology to estimate the HIV burden at the local level. During this process, a closer analysis of the results from the various surveys highlighted a series of issues with the HSS surveys:

• The sentinel sites were too limited in number to ensure nationally representative geographic coverage based on the demographics of the country.
• Urban sites were oversampled.
• Rural sites were usually under-sampled.
• There were often more urban sites than rural sites in many states, thus the HSS results reflect more the urban HIV epidemic than the rural epidemic among pregnant women.

The conclusion of the UNAIDS Nigeria epidemiological analysis was that the HSS and NARHS were no longer giving sufficiently precise epidemiological information. It was recommended that a comprehensive review of the HIV surveys being conducted in Nigeria be carried out in order to address the shortcomings in the existing survey approaches and methodology. 

Thereafter, the UNAIDS country office met with various stakeholders, including the Development Partners’ Group on HIV, and presented these observations and recommendations, effectively utilizing the Development Partners’ Group on HIV to galvanize support from PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) in particular.

In June 2016, the Director-General of the NACA raised an objection to the latest estimate of 3.5 million Nigerians living with HIV, believing that the figure was an overestimation. He had the opportunity to discuss his concerns with UNAIDS country directors, Dr Erasmus Morah and Dr Alti Zwandor at the International AIDS Conference in Durban, South Africa, in 2016. In July 2016, after advocacy from the UNAIDS country office, the new Minister for Health, Professor Isaac Adewole, and the new Director-General of the NACA, Dr Sani Aliyu, agreed on the need for an epidemiologically robust population-based HIV survey in Nigeria. They approved the recommendations for a population-based survey and committed to mobilize resources for it.

“When I resumed as Director-General of the National Agency for the Control of AIDS, a recurring issue that came up at every introductory meeting with partners was the difficulty in finding new cases. It was obvious that there was a problem with case-finding. Was this because we were looking in the wrong places? I had doubts on the quality data we had … and we can’t achieve epidemic control if we don’t even know where we are. Hence, the number one priority of my administration was born―establishing the true prevalence of HIV in Nigeria by employing the best scientific and technical survey tools available in the shortest possible time,” said Dr Aliyu.

In November 2016, a review and triangulation of HIV data in Nigeria was commissioned by the NACA, in collaboration with UNAIDS, the findings of which gave further support for a national survey to develop more precise estimates of HIV prevalence. Firm support for the survey came from the Government of the United States of America (the Centers for Disease Control and Prevention, PEPFAR, USAID and the Department of Defense) and the Global Fund, which committed funding to the NAISS.

“It was easy to see that getting the data situation in Nigeria right was not only the right thing to do but also the dream of so many people. Fortunately, Nigeria had great partners to help turn this dream into reality. Programming and accounting for HIV results in the country will never be the same,” said Dr Morah, the current UNAIDS Country Director for Nigeria.

The United Nations system’s contributions in the NAIIS Technical Committee were anchored by UNAIDS, WHO and the United Nations Children’s Fund. Before the results of the survey were announced, Peter Ghys, UNAIDS Director of the Strategic Information Department, led a multi-group technical mission to Nigeria. The team gave advice on the use of the survey results, on the trends and the geographic locations of the epidemic, at the national and subnational levels. They also gave technical guidance to national partners on data management and governance, including on a strategy for country ownership and leadership of the survey results and support on how to communicate the changes in the epidemiological profile of HIV in the country.

“The road to NAIIS is a wonderful and brilliant story to tell, because it actually tells the story of the HIV response in Nigeria,” said Professor Adewole.

This feature is adapted from an article written by Erasmus U. Morah, Gatien K. Ekanmian and Doris, A.Ogbang

While the incidence of HIV infection globally for all ages declined by 22% between 2011 and 2017, HIV infections among people who inject drugs appear to be rising. HIV incidence—the number of new HIV infections among a susceptible population during a certain time—among people who inject drugs rose from an estimated 1.2% in 2011 to 1.4% in 2017.

There is compelling and comprehensive evidence that harm reduction—including opioid substitution therapy and needle–syringe programmes—prevents HIV infections among people who inject drugs. However, criminalization of drug use and possession for personal use and the widespread stigma, discrimination and violence faced by people who use drugs hampers access to health and harm reduction services.

In its new report, Health, rights and drugs: harm reduction, decriminalization and zero discrimination for people who use drugs, UNAIDS has outlined a set of recommendations for countries to adopt for a public health and human rights response to drug use.

Expanded data collection and analysis provides better understanding of HIV epidemic in Nigeria

ABUJA/GENEVA, 14 March 2019—Results released today by the Government of Nigeria indicate a national HIV prevalence in Nigeria of 1.4% among adults aged 15–49 years. Previous estimates had indicated a national HIV prevalence of 2.8%. UNAIDS and the National Agency for the Control of AIDS estimate that there are 1.9 million people living with HIV in Nigeria.

Speaking in Abuja, Nigeria, the President of Nigeria, Muhammadu Buhari, welcomed the news that there are fewer people living with HIV in the country than previously estimated and launched the Revised National HIV and AIDS Strategic Framework 2019–2021, which will guide the country’s future response to the epidemic. Nigeria has made good progress in scaling up HIV treatment and prevention services in recent years.

"For the first time, the end of AIDS as a public health threat by 2030 is truly in sight for our country,” said H.E. Muhammadu Buhari, President of Nigeria. “I urge all of us not to relent but to increase the momentum. Let us work collectively and push for the last mile.”

The data from the Nigeria National HIV/AIDS Indicator and Impact Survey (NAIIS) are based a revised and enhanced methodology. The survey provides a clearer understanding of Nigeria’s HIV epidemic and shines a light on progress and the remaining gaps and challenges.

The Executive Director of UNAIDS, Michel Sidibé, welcomed the new estimates and said the improved understanding of the country’s HIV epidemic would allow Nigeria to better reach people living with HIV and people at higher risk of acquiring HIV.  

“I commend the Government of Nigeria and its partners for conducting this ambitious survey, which provides us with a much better understanding of the country’s HIV epidemic,” said Mr Sidibé. “While it is fantastic news that there are fewer people living with HIV in Nigeria than previously thought, we must not let down our guard. Let us use the results of this survey to better focus our delivery of HIV prevention, treatment and care services to the people in the greatest need and ensure that Nigeria gets on track to end the AIDS epidemic by 2030.”

While Nigeria’s national HIV prevalence is 1.4% among adults aged 15–49 years, women aged 15–49 years are more than twice as likely to be living with HIV than men (1.9% versus 0.9%.) The difference in HIV prevalence between women and men is greatest among younger adults, with young women aged 20–24 years more than three times as likely to be living with HIV as young men in the same age group. Among children aged 0–14 years, HIV prevalence according to the new data is 0.2%. Significant efforts have been made in recent years to stop new HIV infections among children.

At the national level, viral suppression among people living with HIV aged 15–49 years stands at 42.3% (45.3% among women and 34.5% among men). When people living with HIV are virally suppressed they remain healthy and transmission of the virus is prevented.  

The improved understanding of the country’s HIV epidemic will allow for more efficient investments in the response to HIV and more effective planning for the provision of HIV prevention, care and treatment services, including a focus on key populations, such as female sex workers. It will permit the adoption of a population–location approach to deliver services to the people and areas where they are most needed.

The new data differentiate HIV prevalence by state, indicating an epidemic that is having a greater impact in certain areas of the country. The South-South zone of the country has the highest HIV prevalence, at 3.1% among adults aged 15–49 years. HIV prevalence is also high in the North Central zone (2.0%) and in the South East zone (1.9%). HIV prevalence is lower in the South West zone (1.1%), the North East zone (1.1%) and the North West zone (0.6%).  

“The Nigeria National HIV/AIDS Indicator and Impact Survey (NAISS) findings provide Nigeria with an accurate national HIV prevalence measure of 1.4%. NAIIS also showed we are able to effectively provide antiretroviral treatment,” said Isaac F. Adewole, Nigeria’s Minister of Health. “Everyone infected with HIV needs to get treatment so they can achieve viral suppression, especially pregnant women. We must ensure pregnant women have access to antenatal services and are tested during every pregnancy. We know we can support HIV-positive mothers, hence ensuring the next generation is free from HIV.”

Nigeria has shown steady progress on increasing access to treatment for people living with HIV, with the adoption of a test and treat policy in 2016. This measure has further accelerated referrals to treatment facilities for people who test positive for the virus. From 2010 to 2017, the country almost tripled the number of people living with HIV having access to antiretroviral therapy, up from 360 000 people in 2010 to more than 1 million people in 2018. However, the new estimates released today indicate that more than half of people living with HIV still do not have suppressed viral loads.

The new data are more accurate as they are based on an expanded surveillance system and a revised and enhanced methodology. In recent years, there has been a significant expansion in the country’s response to HIV. The number of sites providing treatment has more than tripled, the number of sites providing services to prevent mother-to-child transmission of HIV has increased eightfold and the number of HIV counselling and testing sites has increased fourfold. A total of 11.3 million adults were counselled and tested for HIV in 2016, four times as many as in 2012.  

“It is important that all people living with HIV get treatment and achieve viral suppression. To halt the epidemic, we need to act now,” said Sani Aliyu, Director-General of the National Agency for the Control of AIDS. “As a government working with our partners, we have what it takes to support people who are HIV-positive, to provide treatment, to protect their families and to help people live long and healthy lives.”

The NAIIS was led by the Government of Nigeria through the Federal Ministry of Health and the National Agency for the Control of AIDS. UNAIDS, the United States President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria provided support for the work on the survey, which was overseen by the United States Centers for Disease Control and Prevention and implemented by the University of Maryland, Baltimore, with a scope that included all 36 states and the Federal Capital Territory of Nigeria. The survey reached around 220 000 people in about 100 000 households. Fieldwork was conducted between July and December 2018.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Federal Ministry of Health (FMOH)

Federal Ministry of Health is one of the Ministries in the Federal Republic of Nigeria. It is concerned with the formulation and implementation of policies related to health. The Ministry has several departments focusing on different aspects of health care. The Department of Public Health’s National HIV and STI Control Program (NASCP) participated in the conduct of NAIIS and guided its implementation. More information can be found at http://www.health.gov.ng/

National Agency for the Control of AIDS (NACA)

The National Agency for the Control of AIDS was established to coordinate the various activities of HIV/AIDS in the country. The Agency among several functions coordinate and sustain advocacy by all sectors and at all levels for HIV/AIDS/STDs Expanded Responses in Nigeria. The Agency in collaboration with the FMoH guided the implementation of NAIIS. More information can be found at https://naca.gov.ng/ for more information about NACA.

The number of new HIV infections globally continues to fall. Modelled estimates show that new infections (all ages) declined from a peak of 3.4 million [2.6 million–4.4 million] in 1996 to 1.8 million [1.4 million–2.4 million] in 2017—the year for which the most recent data are available. However, progress is far slower than that required to reach the 2020 target of fewer than 500 000 new HIV infections (see graph below).

Women are disproportionality affected by HIV, particularly in sub-Saharan Africa. However, in some countries the imbalance is severe.

According to data collected in the Demographic and Health Surveys 2009–2017—a programme that collects and disseminates data on health and populations in developing countries—in the past decade HIV prevalence has been up to three times higher among 20–29-year-old women than men in some of the countries with the highest HIV burden in western and central Africa: Cameroon, Côte d’Ivoire and Ghana (see graph below). 

Data for 20–29-year-olds show the importance of HIV transmission through sex. Since men tend to start having sex at an older age than women, data for people who are 20–29 years old better cover both sexually active women and sexually active men. It is clear that women in the region are not being reached with the range of HIV prevention options they need to stop them becoming infected with HIV through sex.

With the ongoing drive in western and central Africa to match the progress made against HIV in eastern and southern Africa, there is a vital need for awareness of the disproportionate impact that the HIV epidemic has had, and continues to have, on women in the region. 

A new data dashboard to enhance the HIV strategic information products that were already available on the AIDS Data Hub for the Asia and the Pacific region was launched on 30 October.

Developed by UNAIDS, the platform allows users to visualize data and indicators related to HIV epidemiology and the AIDS response in the region through customizable maps, graphs, tables and fact sheets by indicator, country and key population. It also facilitates integrated analysis and gives access to granular data. The data dashboard is a one-stop shop that offers HIV-related strategic information, data analysis products and reference documents.

“With concrete targets to be met on the way to end the AIDS epidemic by 2030, it is vital to have the right data tracking whether the Asia and the Pacific region is on course to meet the commitments made in the 2016 United Nations Political Declaration on Ending AIDS. Data show us how far we have come and how far we have to go,” said Eamonn Murphy, Director of the UNAIDS Regional Support Team for Asia and the Pacific.

Accurate and credible data on the HIV epidemic are the cornerstone of the AIDS response. Over the years, a detailed understanding of the HIV epidemic has been built up through the collection, analysis and dissemination of data, helping programmes to reach the right people in the right place and at the right time. Having high-quality data on the AIDS response coupled with cutting-edge analysis has been critical for countries to track their progress towards ending the AIDS epidemic.

UNAIDS and the Data Hub team work with all the countries in the region to collect and analyse data on their AIDS responses and to help build their capacity to generate and use strategic information. In the region, no major report, speech or policy initiative on HIV is launched or made without referring to data collected and released by UNAIDS.

The Data Hub team works closely with civil society, particularly on strengthening the capacity of young community members on data literacy and the interpretation and use of data. “Research and data, coupled with the lived experience of our community, provide the evidence we need for an effective response to HIV. The AIDS Data Hub is an essential tool for helping community-based HIV workers across the Asia–Pacific region access relevant research and data to amplify their advocacy for better services, more funding and the scaling up of programming,” said Midnight Poonkasetwattana, the Executive Director of APCOM.