World's largest HIV survey to begin in 2018

Nigeria is Africa’s most populous country: about 190 million people live there, and it’s growing rapidly. But millions of people there are also infected with HIV, and Nigeria has received billions of Dollars in international aid to help them to control the spread of the disease.

No one knows, though, how many people are actually infected, or where, so it’s hard to ensure that these resources are properly used. Last year Sani Aliyu, who’s an infectious diseases consultant from Addenbrooke’s Hospital in Cambridge, was seconded to Nigeria to help, and he’s now setting up the largest HIV survey in the world. He told Chris Smith how they're going to do it...

Sani - What’s happening in Nigeria is the country is one of a handful of countries facing the triple threat of a high HIV burden, a treatment programme that doesn’t really cover the majority of patients with HIV, and also a very slow decline in the number of new infections. So when I started, one of the key problems we had was being able to assess the impact of the programme. We were having targets that were clearly not achievable. We had issues with prevention of mother to child transmission where, on average, one in every three babies born in the world with HIV is a Nigerian child. But the targets set up for the implementing partners was really not achievable.

So we decided that the best way to go about dealing with this is to establish the true prevalence of HIV in the country to find out how many people have we got, and what we are planning to do is do a two stage cluster survey of households. It will be the largest HIV survey ever done in the world. Our sample frame constitutes about 30 million households.

Chris - That’s geographically dotted across Nigeria? So what are you doing, dividing the country into sectors so that you’re taking a representative cross-section of each of these geographies?

Sani - That’s right. We have what we call enumeration areas, so first of all we will take up enumeration areas within every sampling frame. And within each enumeration area you will have 25 households. We have 60 geopolitical zones across the country so that makes it much easier and we’ll be taking states at a time, so national entities at a time. As we go through, we’ll not only be providing HIV counselling and testing, we’ll also be looking at incidence of HIV, and for those who are already HIV positive are they virologically suppressed and do they have any resistance issues, are there issues with quality of services? So a whole range of things but it’s going to be a huge exercise. The US government through the Presidential Emergency Fund for AIDS relief is funding this to the tune of about 85 million US Dollars. It makes it, by far, the largest investment on a survey ever done on HIV.

Chris - But why will this help to get a handle on what’s going on in the country and achieving the decline in the spread of HIV in Nigeria?

Sani - A lot of money has gone into the HIV national programme in Nigeria. We really need clarity on the impact of the programme. Are we doing well in the first instance and, if we’re not doing well, why is that we’re not doing well? My feeling is that a lot of the problems arise from the difficulty in really targeting high prevalence areas, being able to identify parts of the population that have a high prevalence of HIV. This survey will give us an answer to that because we’ll be able to channel those resources effectively.

The US government have spent about 4.3 billion US Dollars since the beginning of the HIV programme in Nigeria alone. Global fund has spent about 1.3 billion US Dollars. And even as I speak, the US government are spending between  350 to 400 million US Dollars every year on more than a million people on treatment. But, as we get more and more people on treatment, it’s going to become more and more difficult to find those positives left.

Chris - The law of vanishing return?

Sani - Exactly. And we need to be more cost effective in terms of how are using their resources to find those positives.

Chris - Some people may say that why are we spending so much money on one country and there are lots of needy situations, lots of deserving cases and causes - what’s the value of investing such prodigious sums in one country? Admittedly, there are a lot of people there, why should we be spending this money in Nigeria?

Sani - We talk about trying to eliminate HIV in the long run; having epidemic control globally. You cannot have epidemic control of HIV in the world without having epidemic control in Nigeria. It will just not happen because we estimate about 3 million people have HIV. We have the second largest HIV burden in the world. We need to able to get on top of the HIV situation in Nigeria otherwise it will be like throwing good money after bad money. A lot of the East African countries have very done well based on similar surveys that have been done, but because they are smaller countries, it’s cheaper to get these surveys done whereas in Nigeria it’s a completely different issue. The answer we will get from Nigeria will enable us to target where the resources need to go to and we’ll be able to know what additional resources we need to get on top of the 1990 targets set by the United Nations.