On a January morning, 12-year-old Yusuf Adamu slumps in his father’s lap, head pressed against his chest. Infected at birth with HIV, he is tiny for his age and has birdlike limbs. He has been feverish for three days, which is why his father, Ibrahim, brought him to the pediatric HIV/AIDS clinic at Asokoro District Hospital in Abuja, Nigeria’s capital. “He’s been losing weight, he is not eating well, he’s still taking his drugs, and he’s complaining of chest pains and coughing,” Ibrahim tells the nurse. Yusuf’s records show that at his last blood check 6 months ago, HIV had already ravaged the boy’s immune system, even though he was receiving antiretroviral (ARV) drugs. When the doctor, Oma Amadi, examines his mouth, it is filled with white sores from candidiasis, a fungal infection. “The boy has been sick for so long,” she says. “I’m going to admit him.” When Dr. Amadi removes Yusuf’s shirt to listen to his chest, the boy winces at the touch of her stethoscope. Amadi suspects Yusuf has tuberculosis, and after x-raying his lungs, the doctors put him in an isolation room.
Yusuf’s mother was never tested for HIV before he was born: She received no prenatal care and delivered at home. Yusuf was not tested for the virus until his mother died of AIDS 3 years later. Ibrahim then learned that he, too, is HIV-positive, as are his two other wives. One ended up transmitting the virus to a second child, now 4.
The entire family receives ARVs, but Yusuf has only had intermittent access to the drugs. Dosing is based on weight, and Yusuf’s has fluctuated so much that he has required monthly hospital visits. Ibrahim, a security guard, earns the equivalent of only about $20 a month. The Adamus live 20 kilometers and three bus rides from the hospital. The round trip bus fare costs $2, and Ibrahim has to miss a day of work for each checkup, when he also picks up his son’s ARVs. Ibrahim simply can’t afford regular treatment for his son. “There is no food at home,” Ibrahim says.
Yet poverty alone does not explain the root of Yusuf’s plight — which hundreds of thousands of other Nigerian children living with HIV now face. At a time when rates of mother-to-child transmission of HIV have plummeted, even in far poorer countries, Nigeria accounted for 37,000 of the world’s 160,000 new cases of babies born with HIV in 2016. The most populous country in Africa, Nigeria does have an exceptionally large HIV-infected population of 3.2 million people. But South Africa — the hardest-hit country in the world, with 7.1 million people living with the virus — had only 12,000 newly infected children in 2016. The high infection rate, along with the lack of access to ARVs — coverage is just 30 percent — helps explain why 24,000 children here died of AIDS in 2016, nearly three times as many as in South Africa.
Mother-to-child transmission is only one part of Nigeria’s HIV epidemic. But that route of transmission epitomizes the country’s faltering response to the crisis, highlighting major gaps in HIV testing that allow infections to go untreated and the virus to spread. “Nigeria contributes the largest burden of babies born with HIV in the world — it’s close to one in every four babies [globally] being born with HIV — and that’s really not acceptable,” says Dr. Sani Aliyu, who heads the National Agency for the Control of AIDS (NACA) in Abuja. And it is a solvable problem — even here. The key is to find and treat the relatively small population of pregnant, HIV-infected women, because those who receive ARVs rarely transmit the virus to their babies. Like most countries, Nigeria has made mother-to-child transmission a priority for more than a decade, and it has seen a reduction in children born with HIV. Still, the country stands out for its slow progress. “What we’ve realized is that we need to think outside the box,” Dr. Aliyu says.
Dr. Muktar Aliyu, an HIV/AIDS researcher at Vanderbilt University in Nashville who is Sani’s identical twin, says corruption is a major factor. “It’s a big elephant in the room,” says Dr. Muktar Aliyu, who still conducts studies in his home country. Scams such as informal fees are just part of the problem. The Global Fund to Fight AIDS, Tuberculosis and Malaria in 2016 suspended payment to the country after detecting what it called “systematic embezzlement” by Ministry of Health staff as well as improper auditing.
Conducting large-scale HIV testing is also hard because the virus is dispersed unevenly across the country, with some states having a much lower prevalence than others. In Niger, a state in the central part of the country, it is just 1.7 percent, according to 2015 estimates. “We’d test 1000, 2000 individuals and we’d get barely 20, 30 positive,” Dr. Muktar Aliyu says. But Benue, an east-central state that has been hardest hit, has an estimated adult prevalence of 15.4 percent.
Several people at the front of Nigeria’s HIV/AIDS response link the shortcomings to the government’s lack of “ownership” of the epidemic. Foreign assistance — mainly from PEPFAR and The Global Fund — pays for nearly the entire HIV/AIDS response. Health Minister Dr. Isaac Adewole, an OB-GYN who worked in HIV/AIDS, says the “No. 1 challenge” is for Nigeria to move “from a donor-dependent program to a country-owned program.” To give an example of the problem, Dr. Muktar Aliyu notes that foreign assistance often focuses on bolstering programs, including testing, at large treatment centers, not the 800 or so smaller clinics spread across the country. “In the next five years, at the most, country ownership will come through for HIV programs in Nigeria,” Dr. Sani Aliyu promises. “It’s my job to make sure that money is available.”
Since taking over NACA in 2016, Dr. Sani Aliyu has made some progress. For the first time, the federal government has been taking steps to prevent mother-to-child transmission, and state governments have devoted up to 1 percent of their budgets to efforts against HIV/AIDS. President Muhammadu Buhari, who appointed Sani Aliyu, authorized federal funds to pay for 60,000 new HIV-infected people to receive ARVs and vowed to add that same number to the treatment rolls each year. “The program, if successful, will serve as the exit gateway for PEPFAR as future programs acquire national ownership status,” Dr. Sani Aliyu says.