Nigeria's Hidden HIV Crisis

A patient has blood drawn for a HIV speed test in Benue state, Nigeria. Photo by: Kristian Buus / STARS Foundation / CC BY-NC-ND via DEVEX


— The myth about homosexuality in Nigeria goes thus: You are most likely to be gay if you are the youngest child and the only male child in the family. The odds are also increased if you attended a boarding school or Catholic seminary.

John does not belong to any of these groups. He has five siblings — four boys and one girl. He says he always knew he was attracted to men, in a country where homosexuality remains illegal. He is also HIV positive.

Like the 19 other HIV-positive gay men who spoke to Devex in Nigeria’s southeastern city of Owerri, John — whose name has been changed to protect his identity — only feels safe at home, and among those they refer to as fellow “CMs,” or community members. In the outside world, John and the rest of the group regularly suffer discrimination and physical attacks.

Though “sodomy” was already outlawed in Nigeria, the government introduced a law in 2014 that made homosexuality a crime punishable by up to 14 years in jail, or even death in parts of northern Nigeria that operate under Sharia law. Nonetheless, John said he knows at least 80 CMs in his city alone, and that there are undoubtedly many more who fly under the radar.

UNAIDS’ 2018 report showed that although gay men represent the smallest “key” target population for HIV services in Nigeria, at a little over 26,000 people, they account for the highest prevalence rate. Almost a quarter of them are thought to be HIV positive, compared with other key populations such as sex workers at 14.4 percent and people who inject drugs at 3.4 percent.

While this data is available, the enforced secrecy around the group means its reliability is limited. In Nigeria, UNAIDS has reported the number of gay men and other men who have sex with men at exactly 26,014 for two years running, which public health experts described as highly unusual. Some believe that HIV rates among this community are much higher than official figures suggest.

Despite the criminalization of homosexuality, health professionals in Nigeria are allowed to provide care. Advocates say that many practitioners are not aware of this, however, and also lack training in how to support gay patients or create a safe environment for them at clinics. In practice, this means that many HIV positive gay men do not have access to testing and treatment.

Onyekachi Onumara, who works for an NGO trying to tackle the issue, said that “while the national prevalence for HIV is less than 4 percent, it is as high as 30 percent among the gay population. In a month, I see at least 20 new cases [at the NGO’s specialist clinic] even though they rarely see up to 5 monthly at the major HIV centers across the country. There is a serious HIV crisis among Nigeria’s gay population that we cannot continue to ignore.”
Safe spaces

Onumara is a senior officer at the Owerri-based Rural Health Foundation, an NGO that trains health care providers on working with the gay community in Imo state and helps members gain access to treatment centers. Several similar projects are operated elsewhere in the country.

Part of the problem is that the emphasis on condom use in Nigeria is often around avoiding unintended pregnancy, Onumara explained, leading to a lack of understanding about their role in protecting from sexually transmitted infections. According to UNAIDS data, men who have sex with men are the key population with the lowest proportion of condom users at 51 percent, compared with 98.1 percent among sex workers.

As gay men are usually reluctant to come forward, RHF’s outreach relies on contact tracing — targeting those who may be at risk because of a relationship with an existing patient — and the ability of peer educators to identify fellow CMs.

John learned about his HIV status when a partner invited him to one of the peer sessions, after suspecting his wart-like growths could be caused by the human papillomavirus, a risk factor for HIV. He was offered testing, which came back positive, and has been receiving treatment since.

John and the other men who spoke to Devex emphasized that without the existence of a gay-friendly safe haven, they would never have gone for testing, nor commenced and adhered to the treatment.

RHF — which uses a combination HIV prevention strategy known as Minimum Prevention Package Intervention, advocated by the Nigerian government — has so far reached 500 CMs since 2015. Of those, 287 have been tested for HIV, of whom 115 tested positive, 87 were referred for treatment, and 67 completed referrals. The group says it struggled in its early stages, when CMs who tested positive for HIV refused to go to the hospitals they were referred to for treatment, fearing a hostile environment.

With no secure funding stream, however, it is unclear how long RHF will be able to keep running the program.

Devex contacted Nigeria’s Agency for the Control of Aids to comment on the issues in this story, and was directed to the country’s National HIV and AIDS Strategic Plan 2017-2021. This document promises to promote HIV testing among gay men; foster an enabling environment for gay men to access HIV services; and strengthen interventions targeted at reducing stigma and discrimination. It indicates the government’s support for the integration of gay men into the country’s HIV program.

But advocates say the reality is different, with problems often centering on making HIV clinics and their staff accommodating and welcoming of gay men.

Obinna Akamnonu, program coordinator of the Heart-to-Heart Clinic at Imo Specialists Hospital in Owerri, is one of the very few health professionals in Nigeria who have received training on working with gay community members. He told Devex that health care practitioners can often be the greatest obstacle to the emergence of safe spaces at hospitals.

“I had to restructure everything at my clinic. To make the community members comfortable and not feel they are being judged, I had to cut out some time-wasting protocols. I am the one that has direct conversations with them whenever they come for consultation and treatment,” he said.

One CM receiving treatment told Devex he would not have gone to a clinic that hadn’t received training. “Most people in the society do not really understand us,” he said. “They see us as sinners and devil incarnates … If it is not a desensitized environment, I wouldn’t go there for treatment.”

Onumara and Akamnonu believe the prevalence rate in the community is underestimated, and said that HIV-positive gay men are dying because they cannot access treatment.

“In the last four months, I’ve attended the burial of three community members,” Onumara said.
Need for integrated services

None of the men who spoke to Devex had told their family about their sexuality. Under heavy pressure, many are willing to marry women and have children to avoid suspicion.

For health care professionals, this is further reason why it is essential to integrate their care into the national HIV program. “Some of them are married to women who are not aware of their sexuality and HIV status,” and would have no reason to think they should go for testing themselves, said Onumara.

Akamnonu expressed frustration with the short-term nature of programs targeted at key populations in Nigeria, due to their reliance on foreign funds.

“The projects targeting [men who have sex with men] should be well integrated into existing programs and not be seen as a standalone initiative,” he said.

RHF’s outreach program was supported as a subrecipient of the Global Fund’s New Funding Model for most at-risk populations. The project ran from 2015-2017, but has not been renewed, nor integrated into the country’s national HIV program.

“The project has been suspended. The key population’s access to condoms and lubricants was stopped in January 2018,” Onumara told Devex.

For now, the peer sessions that have helped reach HIV-positive gay men and refer them for treatment are running on the generosity of caregivers at facilities attached to the hospital, but without new funding, they could soon end.

A spokesperson for the Global Fund told Devex that Nigeria’s initial application for renewal of the grant was not approved by its Technical Review Panel, but that the funding request has been resubmitted and is currently awaiting a decision.

Ultimately, Akamnonu would like to see the creation of a one-stop shop for HIV testing and treatment, for all patients, that would avoid unnecessary delays. He called for a government-driven inclusive program, and said it is time for the country’s leaders to come to terms with the burgeoning HIV crisis among the group.

“We cannot keep ignoring the population and denying it exists,” he said. “They are our fathers. They are our uncles. They are our brothers. They are our priests.”