Introduction and Background

Many papers have identified that several HIV based interventions have failed to yield impact because of a lack of structure or strength in the health system1, 2 and Nigeria is not an exception to this. On the long run, funds set aside for health systems are poorly distributed and when available are not well utilized. Globalization has several definitions but it is essential to note however, that it takes into consideration the nurturing of ideas and linkages which include but are not limited to series of actions systematically working on a political, economic and cultural sense globally or internationally3. Our lives are impacted to a large degree by exchange and communication and HIV/AIDS is therefore not an exception3. HIV/AIDS cannot be taken from an isolated or stand-alone point of view. It is not just an infectious disease but an international disease4. HIV/AIDS is without a doubt related to power dynamics, gender inequality and lack of wealth; these are intertwined with social maligning and poor economic power. Considering its traveling nature and the very nature of migration especially in the search for better life as is typically common within Nigeria, HIV/AIDS will definitely spread to different states in Nigeria. In addition, the situation is worsened because of the porous borders Nigeria has with neighboring countries29. Nigeria, whose cities are densely populated is the largest country in Sub-Saharan Africa and the tenth most populous country in the world. The World Bank and the US Census Bureau in 2013 estimated Nigeria’s population to be 173.6 million people5, 6. According to the US department of state, Nigeria accounts for more than half of the entire West African population7. Unfortunately, an estimated 60 % of the population lives below the poverty line. More than 90% earn less than $2 dollars a day even though Nigeria’s greatest source of revenue is crude oil8. Amongst all the countries in Africa, Nigeria is reported to be the greatest crude oil producer and exporter. Nigeria is the 12th greatest oil producer in the world. Unfortunately, however, these statistics do not translate to the latest ranking by the United Nations Development Program (UNDP) Human Poverty Index/Scale which suggests that Nigeria is down the ladder8. With a ranking as low as 158 out of 177, more pressing challenges than reducing HIV incidence and infection may have taken center stage.

Many reasons are responsible for the myriad of challenges Nigeria faces in tackling the spread of HIV. These have created unnecessary barriers to HIV interventions. Nigeria is a secular state, very diverse, and has over 300 ethnic groups and more than 250 languages, many cultures, and several religions9.

The spread of HIV/AIDS in Sub-Saharan Africa is interwoven in people and their relationships and environment in a complex web. When you have a significantly-on-the -move population, the spread of HIV is exacerbated10. There are significant regional variations in the HIV epidemic in Nigeria which is really interesting. The South western states in Nigeria report very low prevalence9. For example, a report from USAID suggests that Ekiti State in the southwest zone of Nigeria has 1% prevalence which is the lowest prevalence in Nigeria and Benue State in the north-central zone has the highest prevalence of 10.6 %9. It is very possible that prolific sexual practices in Benue State are responsible for this high prevalence. Women are more affected by HIV than their male counterparts: the prevalence amongst young women aged 15 to 24 is higher than the prevalence among young men (2.3 percent versus 0.8 percent, respectively) according to reports from UNAIDS and USAID.

Social, economic and psychological issues of HIV/AIDS and globalization in Nigeria

Social issues:

Unemployment and HIV/AIDS have a unique and unfortunate relationship which leaves much to be desired. Currently, many firms in Nigeria are very intolerant of people living with the disease. They believe that they have reduced work hours and increased financial burden for the firms. In addition, people living with HIV/AIDS treated unfairly are denied justice because of the stigma. Mandatory HIV/AIDS testing for newly hired workers increases the burden. A positive HIV test result is a death sentence. On a national scale, thousands of people are in the labor market without a job2, 12, 13 and 14. Some of the studies have shown that the death of teachers play a great role in reducing literacy levels because these teachers die of HIV/AIDS. Besides, when children become orphaned because of this disease in their parents, they are left with no choice but to drop out of school because of inadequate or inexistent funding for their education. The consequence of this is that many schools don’t have students. All of these factors have long-term consequences for economic and social development in Nigeria. Nigeria is already overburdened with social issues to have the consequences of HIV/AIDS worsen the situation. The end result is that these children will have lower levels of education because of lower literacy levels and they might become part of the labor force too early2, 12, 13, 14.

Economic effects:

The macroeconomic output of an economic/financial system that is already troubled is a significant problem. It becomes increasingly difficult to garner resources to fight the epidemic and this leads to an economic situation. GDP growth rates have significantly dropped in Nigeria as a result of this. UNAIDS estimates confirm this. We can only imagine the stress and strain on a significantly thin budget in Nigeria. Several resources are required to meet the individual needs of HIV/AIDS programs. The removal of the fuel subsidy in Nigeria though crippling will supposedly allow the country continue on more significant projects and these include HIV/AIDS programs. The government continues to divert resources towards coping with the impact of the disease. UNAIDS has estimated that by 2020, there will be at least 10-30% reduction in labor force if these people did not have the disease. These can be attributed to reduced productivity such that there is a disparity in public and private sectors. In addition, child labor increases because orphans have to fend for themselves. Family budgets suffer huge setbacks. The simple reason for this is that HIV/AIDS affects people in their 20s, 30s and 40s2, 12, 13, 14, 15, 16. At this stage of their lives, they are in their prime. These people are in charge of providing food for their families but are incapable because of lack of income. There is reduced economic power and agriculture reduces which in turn reduces food security. There are many burials to attend and so there is increased absence from work to attend multiple burial events. From an international standpoint, it has been found that HIV/AIDS has gotten worse with an increase in globalization. Debt relief and debt burden are major issues in this regard. Nigeria continues to receive aid from international agencies and from industrialized nations. The disease however continues to ravage Nigeria and Africa. Development aid may have reduced and not increased as may have been reported. Reports have shown that as AIDS became worse, financial assistance reduced from these countries. Contrary to this, the internationally acclaimed Zambian economist Dambisa Moyo’s quote: "Limitless development assistance to African governments has fostered dependency, encouraged corruption and ultimately perpetuated poor governance and poverty’’ speaks volumes. She argues that foreign aid helps perpetuate the cycle of poverty and hinders economic growth in Africa. Some other papers have suggested that despite the funding received to curtail the epidemic, there are discrepancies between those who need antiretroviral medications and the funds set apart for these people. Other studies have suggested that efforts are focused on treatment rather than prevention. The global fund to fight AIDS, Tuberculosis and Malaria; the World Bank, PEPFAR and the World Health Organization have made significant efforts to combat this disease via funding for treatment 15, 16 and 2. 

Psychological issues:

The stigmatization of HIV/AIDS patients; newly diagnosed patients as well as their families is a major problem. Families and family structures become disrupted and this results in women and children becoming heads of households and families. Furthermore, there is reduced motivation at work because work load is increased as a result of fewer staff which leads to significantly lower feedback and productivity. There is increased poverty which leads to psychological stress. When labor is reduced as a result of multiple grieving for dead family members and colleagues, there is a pervasion of fear because of the grief. Overall, there may be an increase in the weight of psychological health care 2, 14, 15, 16. 

Efforts by the Nigerian government to combat HIV/AIDS

The election of a civilian president was a welcome development for Nigeria as well as the heralding of a new civilian government in 1999 liberated Nigeria from several years of military dictatorship in which little governmental attention or funding was directed at addressing HIV/AIDS. The president made the incidence of HIV/AIDS in Nigeria a top government priority17, 18, 19, 20, 21, 22. Following the data from the 1999 sero-prevalence survey, the president swung into action and did the following: establishment of the Presidential Commission on AIDS (PCA) which he chaired; formation of a National Action Committee on AIDS (NACA). He emphasized a multi-sectorial approach in combating HIV/AIDS and these included the private sector, Non-governmental organizations (NGOs), State and Local Action Committees on AIDS (SACA and LACA) and Persons Living with HIV/AIDS. Approval for Nigeria’s first HIV/AIDS Emergency Action Plan was granted for a period of three years with a specific set of objectives. Their responsibilities included awareness creation; attitudinal change in high-risk populations; capacity building and community empowerment; creating enabling policies to help reduce the scourge of the disease; care and support for HIV/AIDS persons and their families; establishment and maintenance of networks of PLWHAS; creation and subsequent maintenance of an HIV/AIDS surveillance system and HIV/AIDS research17, 18, 19, 20, 21, 22 .To ensure exclusivity and autonomy from the government, National Action Committee on AIDS was transformed in 2007 into the National Agency for the Control of AIDS. Nigeria has worked tirelessly to continue in its maintenance of public-private partnerships in the bid to promote survival of a sustainable national response. Unfortunately, estimates from WHO, UNAIDS and UNICEF suggest that only 31% of patients or people living with HIV are actually receiving the antiretroviral medications despite the distribution to centers across the nation. Surveys worthy of mention include the National HIV/AIDS and Reproductive Health Survey Plus, the Integrated Biological and Behavioral Surveillance Survey (IBBSS), which is a clinic-based antenatal care survey. In the year 2006, a free antiretroviral therapy provision policy was instituted. Following this, there has been increased access and uptake to the medications17, 18, 19, 20, 21, and 22

Situation of HIV/AIDS in Nigeria compared to Sub-Saharan Africa

HIV/AIDS continues to remain an enormous challenge in Nigeria. Sub Saharan Africa has a little over 10% of the world’s population but millions of people with the disease live in these parts compared to the rest of the world. Nigeria has been identified as one of the top nine countries affected by the disease in Sub Saharan Africa, second to South Africa. For more than three decades, young people have remained the most vulnerable to HIV making them the most important targets for HIV/AIDS interventions 22 - 29.

The latest prevalence of HIV/AIDS in Nigeria for 2015 is 3.4% according to the Director-General of NACA. The president of the nation signed the HIV/AIDS Anti-Discrimination Bill in 2014 to prevent stigmatization. There was no response to the HIV/AIDS epidemic initially because of tyrant military dictatorship; however reports now indicate that awareness has helped to reduce the sero-prevalence rate in the country. Although significant reduction in the prevalence has been recorded, a crucial strategy to further reduce the crisis would be by the use of information, education and communication strategies that would remain for a long time 22 - 29. Adolescents in Sub Saharan Africa and indeed Nigeria are worse hit. About 88.2% of adolescents below 15 years of age living with HIV/AIDS in the world reside in Sub-Saharan Africa while 87% of infected adolescents are Africans. People aged between 15 and 24 years comprise about 20% of the world’s population and account for 60% of the new HIV infection each year 22 - 29.

An analysis of the epidemiological distribution of HIV/AIDS infection in Nigeria shows that young people take the greatest risks; HIV prevalence rates recorded in the 15- 19, 20 – 24 and 25  29 years age group amount to 4.9, 8.1 and 6.9 % respectively. HIV/AIDS continue to affect the economically active group in Nigeria causing considerable morbidity, mortality and socio-economic damage.

The focus on this group is because in Nigeria, they don’t have proper education about sex and sex related matters. Evidence has shown that even when they are aware of the disease, they have a poor knowledge base. In addition, cultural traditions, beliefs, fear and other inhibitions prevent adolescents from acquiring knowledge from their parents and teachers while poverty, parents’ unemployment and the desire to explore expose them to the risk of infection. High level of sexual relationships whether pre-marital or several short term relationships, vulnerability to sexual violence and a dearth of assertiveness skills could also be responsible for increased HIV/AIDS incidence 22 - 29.

In summary, the following may be plausible reasons why Nigeria has a high incidence of this disease; people living in denial especially among high risk group, high levels of stigma among people who do not have the disease (the fact that people have a moralistic view because it is sexually contracted), lack of women empowerment, poor assertiveness skills, polygamous marriages/relationships, high prevalence of untreated sexually transmitted infections (STIs), poor use of condoms, poverty and low literacy.

Many reports show that HIV medications were first introduced in the early 1990s. At that time, these drugs were very expensive. Many people infected with the disease could not afford them. This posed a big problem for majority of patients with the disease. Medications were imported from India and other countries and were sold at subsidized prices. However, several programs that have contributed with medication subsidies or donations have met bottlenecks such as issues of demand and supply and drug resistance. The contribution from the Nigerian government can significantly improve the situation 22 - 29.

Studies conducted in Nigeria have suggested that a priority for rural areas would be to increase the awareness of AIDS among people, ensure that available sources of information are effective. In cases where knowledge does not lead to a change in risky sexual behavior, it may seem that the AIDS awareness campaigns are not having the desired effect on reducing the incidence of the disease. Studies have also suggested that though there are available sources of information, general knowledge of these users may prevent them from using this information 22 - 29. The national policy about HIV/AIDS has not been shown to make use of person to person communication. The need to inculcate AIDS related topics into the curriculum may prove beneficial too. Intervention programs also need to be culturally sensitive.

On a national level, prevention programs will fail if the health and rights of women in the villages are not made a priority especially because of lack of access of the female child in many parts of Nigeria. Strategies that target social class or socio-economic status should be incorporated in the policy. It is also imperative that community leaders are trained in the area because community leaders are respected in the community. Interventions targeting culture and cultural inhibitions should be the focus instead of interventions that target individual behavior like in the case of cultural norms in Nigeria where there is approval of pre-marital and extra marital sexual intercourse for men irrespective of age. The AIDS literature is full of evidence suggesting stigma associated with HIV/AIDS. Discussing condoms as a means of prevention of HIV can be an obstacle because of the stigma transferred from the disease itself, but also because the disease is sexually transmitted, worse still is the fact that sexual relationships are in themselves objects of moral scrutiny 22 - 29. 

In Nigeria, studies have shown that there is a high awareness level and good attitude towards mandatory pre-marital HIV testing among study participants. Unfortunately, however, this creates stigmatization and issues of confidentiality for testers and those being tested. The international population conference in Cairo in 1994 was emphatic about the need for young people to be involved in planning, implementing and evaluating development activities, strategies and programs that impact their daily lives. For any program to reduce HIV/AIDS incidence in this group of people, it is imperative that they are involved in any program from inception to completion 22 - 29.

Conclusion

It is imperative that people’s attitudes about issues like stigmatization, counseling and testing and sex education change to significantly reduce HIV/AIDS incidence. Even though the Nigerian government has acted in great capacity to reduce the disease, there is still room for improvement in areas such as funding of programs directed towards providing medications and free testing centers in every state in the country. HIV/AIDS is a significant issue in the country and in a nation where culture and tradition play a great role in molding people’s behavior, interventions that target behavior change need to be implemented. It would be important to carry young people along in planning these HIV/AIDS prevention interventions. They should be involved in the interventions so that they can be successful. Non-governmental organizations should collaborate with the government at a micro level; by this they should target the rural areas especially because these areas still have HIV prone practices.

Globalization has proven to have made the poor poorer, people have had lower incomes and few have actually gained from supposed economic growth. It is important that we tackle the global pullers of the determinants of HIV/AIDS.