News

Research Alliance to Combat HIV/AIDS (REACH): Leading the Way for Bolder Action on HIV/AIDS Prevention

by Richard Joseph, REACH Principal Investigator, and Nkem Dike, REACH Associate Project Director

9/21/2010

In 2006, the Research Alliance to Combat HIV/AIDS (REACH) was launched at Northwestern University and the University of Ibadan, Nigeria, as a social science, community-based research program to address the HIV/AIDS epidemic in Nigeria. Current global data show that for every two infected persons started on antiretroviral treatment (ART), five are newly infected with HIV, and that Nigeria has the second largest number of persons living with the disease. Researching how prevention issues are perceived, understood, and practiced within communities in Nigeria is therefore critical to developing more effective means of combating the epidemic.

The current extent of the epidemic:

• 3 million Nigerians living with HIV and AIDS
• 339,000 new infections annually
• Only 14 percent have had HIV Counselling and Testing (HCT)
• 70,000 HIV positive births annually
• 182,000 AIDS deaths annually
• 911,000 Nigerians requiring ART (but 350,000 on treatment)
• 2.2 million AIDS-orphaned children
• 244,000 HIV positive pregnant women

Unless major advances are made in all aspects of the campaign, these alarming statistics will worsen. REACH, after almost four years of field staff training, protocol writing and data collection, began at the end of 2009 analyzing the research data. These findings have now been shared with national and local policymakers in Nigeria, members of the study communities, and a large number of researchers and policy officials in international meetings.

REACH researchers have returned to the twelve study communities to share site specific findings with them. Community members and leaders took part in one-day dissemination sessions and were given the opportunity to discuss how they could use the data to enhance HIV/AIDS prevention. In the Yoruba-speaking communities, a play was performed that helped convey messages more vividly. In addition to the community dissemination events, REACH held several larger dissemination meetings in May 2010 in Nigeria and the United States where the interim report was launched. At Nigeria’s Fifth National Conference on HIV/AIDS, May 2-5, 2010, a REACH forum was co-chaired by Professor John Idoko, Director General of Nigeria’s National Agency for the Control of AIDS (NACA). Another dissemination followed in Ibadan where REACH has had its offices. Both events were well attended. During the discussions, important points were raised that will be taken up in the course of further analysis of REACH data and in future research. In the United States, REACH findings were also presented at dissemination events at Northwestern University, the Chicago Council on Global Affairs, and the Brookings Institution, Washington, D.C.

REACH presentation, Brookings Institution, May 27, 2010.

In each of these events, highlights of the REACH program were presented: research objectives, methods, and instruments; information about study sites; insights on gender and high risk behavior; use of voluntary counseling and testing; and recommendations for curbing Nigeria’s epidemic. Audiences were provided detailed information about the quantitative and qualitative social science methodology used, including focus group discussions and in-depth interviews. A combined power-point presentation can be viewed here.

An example of many questions raised: “Why has only 14 percent of Nigerians taken advantage of available HIV counseling and testing?” According to REACH findings, there is stigma associated with just walking into a clinic for testing. Although testing centers may be in close proximity to the homes of residents, the fact of being seen walking into a clinic could lead to other persons assuming that an individual is infected with HIV. Some respondents mentioned the cost of testing as a disincentive. On average, it costs approximately $4.60 for a test, which is expensive for people in a country where the majority live on less than $2 a day. From the study findings, over 86 percent of those who never tested believe they would die soon if they were diagnosed with HIV infection, despite the widespread availability of drug treatment.

Less than 20 percent of those interviewed in REACH study sites had tested for HIV in the prior 12 months, compared to less than 7 percent reported in Nigeria’s demographic health survey. Sixty-five percent of adults had never tested and so had a surprisingly high 62 percent of pregnant women. About a third of pregnant women who were tested did not return for their results. Therefore, only a minority of HIV positive Nigerian women benefit from drug treatment that can greatly lower their chances of transmitting the virus to their babies. Education was found to be a significant factor in HCT uptake, with HIV testing increasing with education level. More respondents with post-secondary education were likely to get tested compared to those with only primary or no formal education. What these statistics suggest is the enormous advances that must be made for HIV testing and treatment to become a routine aspect of Nigeria’s health care and thereby serve as an incentive to reduce the current prevalence rate of 4.6%. The importance of community-based research is further demonstrated by the wide variation among Nigerian communities. In the case of REACH’s twelve study sites, HIV prevalence ranged from about 1% to over 10%.

With regards to sexual practices, the REACH study found that male study respondents are four times more likely to have more than one sexual partner outside marriage or regular sexual relationships. Persons aged 25-39 years are more likely to have more than one sexual partner outside a regular relationship. This age group is the one that shows the highest HIV prevalence in Nigeria. Transactional sexual networking was also found to be prevalent in some study communities amongst women driven by financial and other considerations.

In association with NACA and other organizations, REACH hopes to contribute to a substantially scaled-up HIV prevention program in Nigeria. A key component of this program would be expanding the community studies that REACH has conducted on the barriers to effective prevention and treatment. In so doing, REACH would generate a data set that better reflects Nigeria’s highly diverse population. Based on research already completed, REACH recommendations are as follows:

• Mobilize traditional and other community leaders to address community HIV/AIDS awareness/behavior change
• Provide incentives to groups, communities and health facilities to increase HCT levels
• Use myriad networks to disseminate more accurate information and confront stigma based on ignorance
• Target specific barriers to HCT using community surveys
• Reduce sharply the number of persons who have not had an HIV test in any 12 month period
• Provide HIV tests and appropriate counseling as routine aspects of healthcare services
• Engage communities and myriad public, private and religious institutions in action programs focused on achieving high and sustained HCT rates
• Take HCT door-to-door using rapid testing methods
• Target the specific barriers to HCT increase such as ignorance about risk, assumed costs of drug treatment, confidentiality concerns, and uncertainty about follow-up care
• Develop more effective ways to reach vulnerable youths, especially girls
• Engage political, religious, community and entertainment leaders in high-profile prevention events
• Design innovative approaches to combat stigma
• Commit Nigerian funds over several years to prevention and care so that a greater proportion of expenditures is covered domestically.

Professor Richard Joseph, REACH Principal Investigator (left) and Professor John Idoko, Director General of Nigeria’s National Agency for the Control of AIDS (NACA).

These recommendations complement ideas being advanced by NACA such as introducing routine testing, rapid tests, and mobile HIV/AIDS teams. In view of the low testing rates by respondents 15 years and younger, REACH will work with NACA to clarify current policies on the age of consent for HIV testing. Other issues to be addressed include overcoming known barriers such as travel costs and fees, house-to house testing, and the quality and availability of post-testing support.
In October 2010, NACA and REACH will jointly host a conference in Abuja to bring together representatives of national and international agencies for the purpose of exploring bolder action strategies. Highlights of this conference will be further discussions of REACH data and findings, the pursuit of greater synergy between biomedical and behavioral research and policy action, and the application of ideas distilled from the Vienna AIDS Conference of July 2010 to strengthening Nigeria’s response to the epidemic. It will also mark the start of REACH’s transition into a national entity after five years of pioneering social science research on HIV prevention.