MANAGEMENT OF HIV / AIDS INFECTION IN NIGERIA



DEPARTMENT OF MEDICAL LABORATORY SCIENCE, FACULTY OF HEALTH SCIENCE AND TECHNOLOGY,
IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MEDICAL LABORATORY SCIENCE (BMLS)


ABSTRACT / SUMMARY
Research studies in Nigerian have been done primary in the areas of epidemiology, clinical practice. Virology, laboratory diagnosis and the management of the human immune deficiency virus. Therapy for infection  with human immunodeficiency virus (HIV) type 1 and type 2 has largely focused on the treatment and management of the HIV disease (AIDS) rather than the infection therefore opportunistic infection such as tuberculosis, diarrhea herpes zoster virus and other skin conditions, and tumors are essentially the targets for therapy. In the management of HIV 1 and HIV type 2, zalcitabine in combination with saquinavir mesylate is used (department of haematology, college of medicine of unilag, idi-araba Lagos) when the combined anti-retroviral drugs were evaluated into a patients with HIV infection the results was seen after six (6) months of therapy. Efficacy was evaluated by improvement in the CD4cell count and disappearance clinical signs and symptoms from the patient’s base line condition. Another way of managing immunodeficiency Virus (HIV) in Nigeria is by the funding of HIV and AIDS programmes, which promotes the treatment, care and education of HIV positive patients in Nigeria. This seminar also introduces the use of herbals in the management of human immunodeficiency virus by world health organization (WHO). The herbs alleviates AIDS symptoms.

TABLE OF CONTENT
Certification ……………………………………………………………….. i
Dedication …………………………...……………………………………. ii
Acknowledgement..………………………………………………………iii
Summary …………………………………………………………………..iv
Table of content...…………………………………………………………iv
Introduction…………………………………………………………......….1
The classification of HIV disease ………………………………………..2
Overview of the origin of HIV infection in Nigeria……………….……..3
Epidemiology of HIV infection in Nigeria ……………………………….5
Overview of the HIV epidemic……………………………………………6
Epidemiological factor………………………………………..………….11
Mode of transmission of HIV infection …………………...……………11
Major mode of transmission of HIV infection in Nigeria………….…..12
Control and HIV prevention of HIV infection in Nigeria………...…….14
Management of HIV infection in Nigeria……………………………….18
Role of drugs in the management of HIV/AIDS in Nigeria…………..18
The use of antiretroviral drugs in the management of
 HIV infection in Nigeria………………………………………………….20
Management of HIV infection in Nigeria with zalcitabine in combination with saquinavir mesylate- by akinsete et al; 2000…………………………...………….22
Management of HIV in Nigeria using herbals which alleviatesaids symptoms, by world health organization (who)……………………….23
Management of HIV infection in Nigeria by funding for
HIV and aids programmes………………………………………..……..26
Factors influencing the accessibility of HIV/AIDS-related
drugs in Nigeria……………………………………………………….….27
Challenges associated with the effective management
of HIV infection in Nigeria………………………………………...……..29
Conclusion………………………………...…………………….………..32
References……………………………………………………..…………33

INTRODUCTION
HIV was classified as member of the genus lentivirus, part of the family retroviridae. Many species are infected by lentiviruses which are characteristically responsible for long duration illnesses with a long incubation period (Jawtz,  et al; 2007).
Human immunodeficiency virus (HIV) causes progressive impairment of   the body’s cellular immune system, leading to increased susceptibility to infections and tumors and the fatal condition AIDS (Acquired immunodeficiency syndrome). In the management of the HIV infection, treatment initiated before advanced stage reduces plasma HIV RNA concentration to undetectable values in most motivated patients who have access to the antiretroviral drugs. Many HIV infected people remain unaware of their HIV infection, and they continue to transmit the infection to others and when diagnosed, have very advanced and often difficult-to-treatment late-stage disease.
            HIV/AIDS is a global crisis, a challenge to human life and dignity with ability to erode social and economic development. It has great influence on stability, life expectancy and economic development. It is a major public health problem with sub-Saharan Africa severely affected by the epidemic. HIV has the potential of hindering the realization of the Millennium Development Goals and its spread promotes poverty, and has unleashed immense suffering on different countries and communities worldwide. (UNGAS, 2001).
THE CLASSIFICATION OF HIV DISEASE
-           HIV-1
-           HIV-2        
The HIV-1
Based on the enveloped sequence, HIV-1 comprises three (3) distinct virus groups (M, N and O); the predominant M group contains at least ten subtypes  (Cheesbrough; 2000)

In Africa, subtype C is found in southern Africa (inducing zambia, zimbabwe, Malawi), subtype E is found in central Africa, Thailand and other counters of southern Asia while subtype E and B is found in south’s America. (Pope M. et al., 1997)
Differences in the case of transmission, virulence and disease progression may occur between strains. Group O containing a distinct F group of heterogeneous viruses, which are of low prevalence and have been found in west Africa, particularly Cameroon (cheesbrough; 2000).
HIV-2.
HIV-2 is found mostly in west Africa, including Senegal, Guinea Bissau, Ghana, Cotod’ ivore, Mali (cheesbrough; 2000).  Most HIV-2 infections reported from Brazil, Angola, and Portugal could usually be traced back to a west Africa contact. HIV-2 is less easily transmitted than HIV-1 and the period between initial infection and illness is longer in HIV-2. HIV-1 is more virulent and is the causes of the majority of HIV infections globally (cheesbrough; 2000).
Comparison of HIV Species
Species
Virulence
Infectivity
Prevalence
Inferred origin
HIV-1
High
High
Global
Common chimpanzee
HIV-2
Lower
Low
West Africa
Sooty management

OVERVIEW OF THE ORIGIN OF HIV INFECTION IN NIGERIA
 Human immunodeficiency virus (HIV) in humans originated from cross-species infections by simian viruses in rural Africa probably due to direct contact with infected primate blood (Morgan et al; 2002)
Sequence evolution analysis, places the introduction of Simian immunodeficiency virus into humans that gives rise to HIV-I group at about 1930 presumably, such transmission occurred repeatedly over the ages, but particularly social, economic and  behavioral changes that occurred in the 20th century provided circumstance that allowed  these virus infection to expand and become well established in humans and reach epidemic proportions.
The first recognized cases of AIDS occurred in the USA in the early 1980s. a number of gaymen in New York city and California suddenly began to develop rare opportunistic infections and cancers that seemed stubbornly resistant to any treatment. At this time, AIDS did not yet have a name, but quickly became obvious that all the men were suffering from a common syndrome. The human immunodeficiency virus (HIV) causes acquired Immuno deficiency syndrome (AIDS) HIV attacks the Immune system, weakens it, and exposes the body to opportunistic infections, a variety of illnesses and cancers contracting several opportunistic infections (or one of a number of specific infections) often leads health care workers to suspect and test for HIV (UNAIDS, 2000)
            Most common symptoms of opportunistic infections in Nigeria
Symptoms
% of patients
Prolonged fever
73.12
Chronic diarrhea
53.05
Chronic cough
50.19
Tuberculosis
15.15
Dermatitis
25.03
Lymphadenopathy
39.92
Herpes zoster
9.88
Genital ulcers
8..03
Candidiasis
6.58

Source: Akinsette 1998 (43% according to Idigbe et al., 2000)
             
The first case of HIV/AIDS in Nigeria was reported in 1986. in 1991, the federal ministry of health conducted the first sentinel sero-prevalence survey in Nigeria. In this survey, and in subsequent surveys conducted in 1993,, 1999, and 2001, population selected to estimate HIV Sero-prevalence were pregnant women attending antenatal clinics (ANCs), patients with sexually transmitted infections (STIs), patients with Tuberculosis, and female commercial sex workers (UNAIDS, 2000).
EPIDEMIOLOGY OF HIV INFECTION IN NIGERIA
AIDS was discovered first in the united states in 1980s as a new disease entity in homosexual men: 20 years later, AIDS has become a world wide epidemic that continues to expand (Nester et al; 2004)
As of January 2006, the Joint united nations programme on HIV/AIDS (UNAIDS) and the world health organization (WHO) estimate that AIDS has killed more than 25 million people since it was first recognized on December 1981, making it one of the most destructive pandemics in recorded history. In 2005, AIDS claimed an estimated 3.3 million lives, of which more than, 570,000 were children. It is now estimated that about 0.6% of the world’s living population is infected with HIV (Jawetz; 2007, Nester; 2004).
In 2010, an estimated 48, 079 adults and adolescent were diagnosed with HIV infection; of these 79% of diagnoses among males and 21% were among females. HIV has remained localized primarily to West Africa ((Jawetz et al; 2007, Nester et al; 2007).

OVERVIEW OF THE HIV EPIDEMIC
            Nigeria has the second highest number of people living with HIV in the world after South Africa. (UNAIDS, 2009) UNAIDS estimated 33.4 million people living with HIV in 2008 in the world. Nigeria, with about 2.98 million people living with HIV, makes about 9% of the global HIV burden. However, there is gender inequality in the distribution with males accounting for 1.23million and female accounting for 1.72 million in the HIV estimates and projections for 2008. Women are more affected in the defining Feature of the epidemic with policy implications for prevention of mother to child transmission. Hence, addressing gender inequality is crucial in the control of the epidemic. Nigeria recorded the first case of acquired immunodeficiency syndrome (AIDS) in 1986. Heterosexual sex remains the primary mode of transmission for HIV and accounts for 80 – 95% of HIV infections in Nigeria. Tracking the course of HIV epidemic in Nigeria requires good reporting and surveillance system. Thus, Nigeria through the Federal Ministry of Health instituted regular surveillance system using clinical-based and population-based surveys to monitor the epidemic. This is needed to obtain reliable information about HIV prevalence and behaviors associated with HIV epidemic in relation to temporal changes, geographic distribution, magnitude, and mode of transmission. Furthermore, this surveillance system provides opportunities to monitor trend in prevalence, create awareness about early response, inform priority setting for new interventions and measure the effectiveness of public health interventions in the control of the epidemic. (Ainsworth M, Teokul W, 2000).
The federal Ministry of Health and National Commission with support from NACA and other relevant stakeholders conducts four main surveys namely:
-           National HIV/AIDS and Reproductive Health Survey Plus (NARHS Plus)- This is a population based survey that estimates HIV prevalence and obtains information on the associated factors in addition, it provides information on the sexual and reproductive health status in the country it is usually conducted every two years. (Jhap, et al., 20012).
-           HIV/STI Integrated Biological and Behavioral Surveillance Survey (IBBSS)- This survey is targeted at the most at risk populations whose behaviors or occupations often place them at higher risk of contracting sexually transmitted infections including HIV. It estimates HIV prevalence among the most at risk populations and provides information on drivers of the epidemic among these groups. It is usually conducted every two years. (Federal Ministry of Health, 2001).
-           Antenatal Care Survey- This is a clinic based sentinel survey to estimate HIV prevalence among pregnant women attending antenatal clinic. It is conducted every two to three years. (Federal Ministry of Health, 2004).
-           Nigeria Demographic and Health Survey (NDHS) – it is a nationally representative survey. Prior to 2008 survey, the last one was in 2003. It is conducted by National Population Commission with international support. HIV epidemic rose from 1.8% in 1991 and peaked at 5.8% in 2001. It is currently at 4.6% in 2008 antenatal survey. Figure 1 below shows a rapid rise in HIV prevalence in the sentinel surveys carried out from 1991 to 2001 (1.8% in 1991 to 4.5% in 1996 and then to 5.8% in 2001). Subsequently, the trend reversed and took a downward turn from 5.8% in 2001 to 5% in 2003 and then to 4.4% in 2005.
            Although a slight increase was observed in HIV prevalence from 4.4% in 2005 to 4.6% in 2008. However, in each of the sentinel survey there were significant variations in the different states of the federation.

HIV prevalence rate by state
State 
HIV Prevalence
(1999) 
Estimated HIV
Infection
HIV Prevalence
(2001)
Estimated HIV
Infection
Abia
3.0    
50,237
3.3
34,335
Adamawa
5.0                  
56,510
4.5
57,149
Akwa ibom
12.5
172,90
10.7
122,169
Anambra
6.0
106,721
6.5
134,325
Bauchi
3.0
26,488
6.8
114,288
Bayesa
4.3
17,675
7.2
49,935
Benue
16.8
279,466
13.5
245,066
Borno
4.5
67,633
4.5
52,140
Cross River                 
5.8
61,152
8.0
93,582
Delta 
4.2
61,141
5.8
15,842
Ebonyi
9.3
68,015
6.2
51,91
Edo 
5.9
69,772
5.7
54,828
Ekiti
2.2
15,132
3.2
31,326
Enugu 
4.7
52,172
5.2
51,639
FCT    
7.2
17,044
10.2
7,127
Gombe   
4.7
39,860
8.2
103,620
Imo  
7.8
73,305
4.3
79,865
Jigawa       
1.7
29,387
1.8
46,043
Kaduna   
11.6
151,007
5.6
199,723
Kano   
4.3
126,056
3.8
299,197
Katsina
2.3
63,075
3.5
76,544
Kebbi 
3.7
42,811
4.0
556,884
Kogi 
5.2
79,053
5.7
88,385
Kwara    
3.2
29,229
4.3
45,779
Lagos  
6.7
226,674
3.5
70,171
Nasawara       
10.8
63,077
8.1
49,275
Niger     
6.7
72,496
4.5
55,383
Ogun     
2.5
33,374
3.5
58,480
Ondo     
2.9
34,164
6.7
92,875
Osun   
3.7
39,462
4.3
52,125
Oyo
3.5
65,591
4.2
79,561
Plateau 
6.1
63,662
8.5
82,076
Rivers  
3.3
90,805
7.7
123, 233
Sokoto
2.7
45,505
2.8
45,229
Taraba  
5.5
38,773
6.2
60,460
Yobe   
1.9
7,106
3.5
24,280
Zamfara    
2.7
38,877
3.5
32,162

Source: National AIDS/ STD Control Programme/FMOH, 1999; 2001

EPIDEMOLOGICAL FACTOR
Travel:
International travel has undoubtedly played a major role in the spread of HIV in the U.S, international travel by young men making the most of the gay sexual revolution of the late 70s and early 80’s would certainly have played a large part in taking the virus world wide in Africa, the virus would probably have been spread along truck routes and between towns and cities within the content itself.

The blood Industry
As blood transfusions became a routine part of medical practice, an industry to meet this increased demand for blood began to develop rapidly. In some countries, donors are paid to give blood, a policy that often attracts those most desperate for cash; among them are intravenous drug users. In the early stages of the epidemic, doctors were unaware of how easily HIV could be spread and blood donations remained  unscreened.

MODE OF TRANSMISSION OF HIV INFECTION
Nigeria undertook modes of transmission modeling in 2009 the joint united nations program on aids (UNAIDS) mode of transmission model was undertaken by the National country team, with support from UNAIDS and the world bank, and was built on the world bank epidemiology and response synthesis project in Nigeria, the model estimates the distribution of new infections and identifies populations and highest risk for HIV infection. The mode shows that high-risk groups will significantly contribute to new HIV infections. These high risk groups are about 1% of the general population, and are men that have sex with men, female sex workers and injecting drug users. They will contribute almost 23% of no infections (UNAIDS, 2009). However, people practicing low-risk sex in the general population will contribute 42% of the infections due to low condom use and high sexual networking (UNAIDS, 2009)

MAJOR MODE OF TRANSMISSION OF HIV INFECTION IN NIGERIA
Sexual route:
The majority of HIV infections are acquired through unprotected sexual relation having vaginal or anal sex without a condom with someone who is infected.
Heterosexual spread of HIV is increasing and promises to become the dominant mode of transmission. In many African counties, sex with multiple partners, traumatic sex, anal sex, all increases the risk of sexual HIV transmission.

Blood Transfusion:
HIV transmission through unsafe blood accounts for the second largest source of HIV infection in Nigeria (Egesie J. and Egesie E, 2011). Not all Nigerian hospitals have the technology to effectively screen blood and therefore there is a risk of using contaminated blood. The Nigerian Federal Ministry of Health have responded by backing legislation that requires hospitals to only use blood from the National Blood transfusion services, which has far more advantaged blood-screening technology (Nigeria Exchange, 2008). It is also of concern for person receiving medical care in regions where there is prevalent substandard hygiene in the use of injection equipments, such as the reuse of needles in third world countries. (Reeves and Doms; 2002)   

Mother to child transmission:
The third most important mode of HIV spread is from mother to infant. The transmission from mother to child varies from 13% to 40% in untreated women Infact can become infected in uteri during birth process or more commonly through breast feeding. In the absence of breastfeeding, about 30% of infections occur uteri and 70% during delivery. Data indicate infection in Africa is due to breastfeeding (Bell 1997). High material viral loads are risk factors for viral transmission (Jawetz et al; 2007, Nester et al; 2007). HIV has been found at low concentration in saliva, tears and urine of infected individuals, but there are no recorded cases of infection by these secretions and the potentials risk of transmission is negligible (Bell, 1997).

Estimated per act risk for acquisition of HIV per exposure routes

S/N

Exposure Routes
Estimate Infection per
Chance of infection
A
Blood transmission
90%
B
Child birth
25%
C
Needle-sharing infection drug use
0.67%
D
Receptive and intercourse
0.04-3.0%
E
Percuteneous needle stick
0.30%
F
Receptive penile-vaginal intercourse
0.05-0.30%s
G
Insertive anal intercourse
0.06-0.056%
H
Receptive fellatio
0-0.04%
I
Insertive fellatio
0-00.5%
 
            Assuming no condom is used (Smith and Daniel, 2006)

CONTROL AND PREVENTION OF HIV INFECTION IN NIGERIA
HIV TESTING
Doctors seeing patients in an HIV clinic in Nigeria.
            In Nigeria there is a distinct lack of HIV testing programmes. In 2007, just 3 percent of health facilities had HIV testing and counseling services, (WHO et al., 2008) and only 11.7 percent of women and men aged 15-49 had received HIV test and found out the results (UNCASS, 2010). In 2010, there were only 1.4 HIV testing and counseling facilities for approximately every 100,000 Nigerian adults, which shows how desperately the government needs to scale up HIV testing services. (WHO et al, 2011) whilst an estimated 2.2 million people aged 15 years and above received HIV testing and counseling in 2010, this amounts to only around 31 people per 100,000 of the total adult population (WHO et al, 2011). Moreover, HIV testing and counseling of pregnant women is central to the prevention of mother-to-child transmission, yet this remains extremely low with only in 7 pregnant women receiving it in 2010.

EDUCATION
Sex is traditionally a very private subject in Nigeria, and the discussion of sex with teenagers is often seen as inappropriate. Attempts at providing sex education for young people have been hampered by religious and cultural objections (Odutolu, O et al, 2006). In 2009 only 23 percent of schools were provided life skills-based HIV education, and just about 25 percent of men and women between the ages of 15 and 24 correctly identified ways to prevent sexual transmission of HIV and rejected major misconceptions about HIV transmission (UNGASS, 2010). In some regions of Nigeria, girls marry relatively young, often to much older men in north western Nigeria around half of girls are married by age 15 and four out of five are married by the time they are 18 (the population council, 2007). Studies have found those who are married to younger age have less knowledge about HIV and AIDS than unmarried women and are more likely to believe they are low-risk for becoming infected with HIV. (the population council, 2007). HIV and AIDS education initiatives need to focus on young married women, especially as these women are not likely to have access to health information than unmarried women (the population council, 2007).

CONDOMS
            The total number of condoms provided by international donors has been relatively low. Between 2000 and 2005, the average number of condoms distributed in Nigeria by donors was 5.9per man, per year (UNFAA, 2005). Restrictions on condom promotion have hampered HIV prevention efforts. In 2001, a radio advertisement was suspended by the advertising practitioners council of Nigeria (APCON) for promoting messages suggesting that it is acceptable to engage in premarital sex as long as a condom is used (Population service international, 2003). In 2006, APCON also started to enforce stricter regulations on condom advertisements that might encourage indecency (UN Integrated Regional Information Networks, 2006). The number of female condoms sold in Nigeria has significantly increased from 25,000 in 2003 to 375,000 in 2006 (UNFPA, 2007)

MEDIA CAMPAIGNS AND PUBLIC AWARENESS
Addressing HIV- related issues in Nigeria through television drama as Nigeria is such a large and diverse country, media campaigns to raise awareness of HIV is a practical way of reaching many people in different regions. Radio campaigns like the one created by the society for family health is thought to have been successful in increasing knowledge and changing behavior. ‘Future dream,’’ was a radio serial broadcast in 2001 in nine languages on 42 radio channels. It focused on encouraging consistent condom use, increasing knowledge and increasing skills for condom negotiation in single man woman aged 18 and 34 (population services international, 2003). In 2005, a campaign was launched in Nigeria, in a bid to raise more public awareness of HIV/AIDS. This campaign took advantage of recent increase in owners of mobile phones and sent text massages with information about HIV/ AIDS to 9 million people (BBC News, 2009). Another high profile media campaign is fronted by Femi Kute, the son Fela Kuti, the famous Afro beat musician who died of AIDS in 1997. He appears on bill board a long side roads throughout Nigeria with slogan “AIDS: No dey show for face.‘’ which means you can’t tell someone has AIDS by looking at them (Reuters News Media, 2003 )

PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV
Nigeria’s programmes to prevent the transmission of HIV form mother to child (PMTCT) started in July 2002. (National Agency for the control of AIDS, 2010). Despite efforts to strengthen PMTCT interventions, by 2007 only 5.3 percent of HIV positive women were receiving antiretroviral drugs to reduce the risk of mother –to child transmission. This figure had risen to almost 22percent by 2009, but still remained for short of Universal access target which aim for 80 percent coverage.  (WHO et al, 2010). Single –dose nevirapine is no longer recommended for the prevention of mother-to-child transmission. Whildt 19, 733, or 9 percent, of HIV – infected pregnant women received the most effective antiretroviral treatment regimes for PMTCT in 2010, around 6, 505 pregnant women still only received single-dose neviroaine (WHO.. et al, 2011). Coverage for infants remains low; in 2009 only 8 percent of children received antiretroviral for PMTCT (UNICEF, 2010).

MANAGEMENT OF HIV INFECTION IN NIGERIA
Role of drugs in the management of HIV/AIDS in Nigeria
            The classes of drugs most important to people living with HIV/AIDS (PLWHA) are
·                    Anti-infective agents to treat or prevent opportunistic infection.
·                    Anti-cancer drugs to treat malignancies, such as Kaposi Sarcome and Lymphoma;
·                    Palliative drugs to relieve pains and discomfort, both physical and mental;
·                    ARVS (Antiretrovirals to limit the damage that HIV dose to the immune system by reducing Viral load.
Based on extensive field research, MSF (Medicines) bans frontiers (doctors without Borders) asserts that the priority medicines for resources poor setting are:
(1)       Drugs for the prevention of opportunistic infection particularly Isoniazide and cotrimoxazole, which are recommended by WHO/UNAIDS;
(2)       Palliative drugs, such as analgesics and antidiarrheas, which have shown to improve the well being of patients
(3)       Antiretrovirals (ARVS) which can act as preventives of opportunistic infections and help to extend and improve the quality of live by reducing viral loads;
(4)       ARVs such as AZT and NVP, which can prevent MTCT and can be used as post-exposure Prophylaxis (Perez –casas and Boulet, 2000).
The use of antiretroviral drugs in the management of HIV infection in Nigeria.
There are two main types of antiretroviral drugs:
*          Nucleoside Reverse Transcriptase Inhibitors (NRTIS)
*          Non-nucleoside Reverse Transcriptase Inhibitors (NRTIS)
(Colebunders, et al…, 1997)
List of NRTIS
Drug
Manufacturing company
AZT,Z idovudide (Retrovir)
Glaxo Smith Kline
ddI, didanosine (VIdex)
Bristol Myers Squibo
Ddc, Zalcitabine (HIVid)
Roche
3TC, Lamivudine (Epivir)
Glaxo smith Kline
D4T, Stavudine (Zerit)
Bristol Myers Squibb
Abacavir (Ziagen)
Glaxo Smith Kline
Combine pill of AZT &3TC(combivir)
Glaxo Smith Kline
Combined pill of AZT, 3TC and Abacavir (Trizivir)
Glaxo Smith Kline
 (UNA IDS/ Nigeria, 2001)

List of NNRTI’s
drug
Manufacturing company
Neuirapirie (Varamune)
Boehringer ingelheim
Efavirenz (Sustiva)
DU pont in the U.S; Stocrin-Merck in the nest of the world
Delavirdine (REscripita)
Pharmacia and upjohn
(UNAIDS/ Nigeria, 2001).
The drugs selected for the survey in Nigeria, includes the following.
Antiretrovirals : delarvidine, Zindovudine CAZT, efavirenze, indinavir (ddi), saquinavir, nelfinavir, stavudine, nevirappine, ritonavir, lamiivudine, zalatabine, AZT/3TC combination.
Antibiotics: Amoxycillin /clavulanate, aproflaxacine, cotrimoxazole, ceftrioxone, azithromicine antifundals: fluconazole, ketoconazole, amphotericine B, Itraconazle.
Anti-TB: ISonizide, Rifampicin, Pyrazinamide.
(UNAIDS / Nigeria, 2001).

MANAGEMENT OF HIV INFECTION IN NIGERIA WITH ZALCITABINE IN COMBINATION WITH SAQUINAVIR MESYLATE- BY JEGEDE- EKPE ET AL, 2003
ZALCITABINE + SAQUINAVIR  MESYLATE
The anti-retroviral drug was evaluated in 24 adult Nigeria patients with HIV infection. The result of an interim analysis after a 6-months course of therapy is presented herein. Patients were given zalcitabine 2.25mg and saquinavir 1800mg per day. Efficacy was evaluated by improvement in the CD 4 cell count and disappearance or resolution of clinical signs and symptoms from the patent baseline condition. Tolerability and safety were assessed occurrence of adverse event and monitoring of biochemical parameters such as alanine, transminase, alkaline phosphatase and total bilirubin.  The haemogram profile of patients were also monitored, there was clinical improvement in 79.2% of the patients, a minimal increase in the CD4 cell count was observed, and the incidence of adverse event was 40%. The hematological and biochemical profile of the patients were not significantly affected by the treatment.
Therefore, a conclusion was made that the drug cocktail comprising zalcitabine and saquinavir dose posses good potentials for effective management of Nigeria patients with HIV infection (source, department of haematology, college of medicine Unilag, Idiaraba Lagos).

MANAGEMENT OF HIV IN NIGERIA USING HERBALS WHICH ALLEVIATES AIDS SYMPTOMS, BY WORLD HEALTH ORGANIZATION (WHO)
Though scientists are yet to find a cure for HIV and AIDS, certain traditional medicines have been shown to help treat many of the symptoms of opportunistic infection that are part of the disease.
According to living well with HIV/AIDS: A manual on nutritional care and support for people living with HIV/AIDS by FAO “The effect may not be the same for all people. People can try this herb and decide for themselves whether they are helpful.
The manual reads: “Remember that all herbs and spices should be used in moderate amounts. Exceeding these amounts may cause problems and have a toxic effect.
Aloe Vera
ALOE helps to relieve constipation: Use extract, boil and drink the concentrated water. To be used in limited amount; stop immediately if it causes cramps or diarrhea.  
C’alendula flower
It has anti septic, anti inflammatory and healing functions helps with infections of the upper digestive tract. Prepare as tea to help digestion.
Cayeme
Stimulates appetite; helps fight infection, heals ulcers and intestinal inflammation. Add a pinch to cooked or raw foods for energizing drink; add to fruit juice or water.
Eucalyptus
Has an antibacterial function, particularly for lungs and during bronchitis. Eucalyptus oil from leaves increases the blood low and reduces the symptoms of inflammation. Prepare tea from the leaves or extracts.
Garlic:
Has antibacterial, antiviral and antifungal function especially in the, intestine, lungs and vagina. Helps feeling of weakness, also for throat infections, herps and diarrhea. Prepare as tea or use in food.
Fennel:
Helps to increase appetite, combat flatulence and expel gas. Add as spice to food or prepare tea from the seeds.
Ginger:
Improve digestion, energies, relieves diarrhea, and stimulates appetite used for treatment of common cold flu and nausea, prepare as a ginger tea or use as spic.
Lemon:
Has antibacterial functions and helps digestion. Add lemon juice to food or drinks.
Peppermint:
May help nausea, reduces colic (Abdominal pain and cramps) helps to control diarrhea and stops vomiting, also used for relieving tension and sleeplessness. Prepare as tea, by boiling the leaves for about 10 minutes.
Thyme:
Has antiseptic and antifungal function. Relaxes nervous coughing and increases mucosal secretion. Stimulates digestion and the growth of the good intestinal flora in the guts. Use as mouth wash or as a vaginal douche.
Indeed, preliminary result on the evaluation of herbal preparations  used for the management of HIV/AIDS in many African countries have shown encouraging results that there have been improvements of quality of life and clinical conditions of patients treated with such herbal preparations.
Blood test to monitor their level of immunity (CD4 and CD8 counts) have also shown an improvement and in some cases there has been a significant decrease in viral load.    

Management of HIV infection in Nigeria by funding for HIV and AIDS Programmes.
            It has been estimated that the Nigerian government are contributing around 5 percent of the funds for the antiretroviral treatment programmes (Health Reform foundation of Nigeria 2007). The majority of the funding comes from development partners. The main donors are PEPFAR, the Global Fund and the World Bank. In 2002, the World Bank loaned US $90.3 million to Nigeria to support the 5-year HIV/AIDS programme development project (Health Reform Foundation of Nigeria, 2007). In May 2007, it was announced that the World Bank were to allocate a further US $ 50 Million loan for the programme. (The World Bank, 2008).
            Through the President’s Emergency Plan For AIDS Relief (PEPFAR), the United States has allocated a large amount of money to Nigeria. In 2008 PEPFAR provided approximately US$ 448million to Nigeria for HIV/AIDS prevention, treatment and care (PEPFAR< 2008) the third highest amount out of PEPFAR’s is to focus countries. By the end of 2008, the Global Fund had disbursed US $ 95million in funds for Nigeria to expand treatment/management, prevention and prevention of mother-to-child transmission programmes, (the Global Fund, 2009). Much of this were given to the Nigeria government to fund the expansion of antiretroviral treatment.

FACTORS INFLUENCING THE ACCESSIBILITY OF HIV/AIDS-RELATED DRUGS IN NIGERIA
1.         Generic production. The presence or absence of generic competition in the open market is a key determinant of pricing levels. Competition brings down prices dramatically. For example, fluconazole is not patented in Thailand. Before fluconazole was produced as a generic in 1998, Pfizer sold it for US$7 per 200mg capsule. Then, three Thai companies began production and Pfizer dropped its price to US$3.6, even though generic companies were charging much less (Biolab was charging US$0.6). After initially responding to generic competition, Pfizer increased its price in Thailand to US$6.2 in March 2000, while Biolab’s price decreased its price to US$0.3 (20.7 times cheaper than Pfizer’s price). Multinational 20 companies have had to contend with similar competition from CIPLA in India. Glaxo Welcome’s lamivudine (3TC) 150mg tablet costs 78 percent less in India than in the United States. Brazil generically manufactures a great deal of its ARV drug supply, which is sold at a fraction of the price globally. A generic form of zidovudine is 14 times cheaper in Brazil than in the United States (Per├ęz-Casas and Boulet, 2000a).
2.         Cost-drivers, tariffs, and taxation. In addition to multinational monopoly pricing regimes, costs within a country make essential drugs even more out of reach for Nigerians. The executive secretary of the Nigerian Pharmaceutical Group, Kunle Okelola, noted that the following add-ons create substantially higher drug costs:
A.        Shipping and handling usually is about 20—30 percent of the drug price.
B.        Additional costs exist for shipping to health facilities (inland transportation cost).
C.        Taxes paid on imported drugs are 25 percent.
D.        Imported raw materials are 5 percent.
E.         There should be no value-added tax (VAT) on pharmaceuticals; however, some are still made to pay 5 percent (a cost that is now in the process of being eliminated).
F.         Prices are marked up by manufacturers, importers, suppliers, and retailers to ensure profits for everyone.
G.        There is no excise duty on locally made products (Ikoro, 2001).
3.         Differential pricing: Comparing prices between countries is inherently difficult because of the problem of comparing official exchange rates and real currency values; differences in pharmaceutical distribution channels (private versus public sector, retail versus wholesale); different strengths and pharmaceutical dosages; price fluctuations overtime, and so forth. However, companies often price the same drugs in different countries at different prices.  (UNICEF et al., 2000)

CHALLENGES ASSOCIATED WITH THE EFFECTIVE MANAGEMENT OF HIV INFECTION IN NIGERIA
1.         Challenges of availability of affordable laboratory-monitoring tests and trained manpower required for the implementation of HIV therapy
Few laboratories in resource-constrained countries can afford to perform laboratory- monitoring tests required for the implementation of HIV therapy. Flow cytometric techniques are expensive and require a significant infrastructure to perform. In addition, the measurement of quantities of virus in the blood known as viral load is an important clinical parameter to evaluate the severity of disease and to monitor the efficacy of therapy. These expensive laboratory tests require complex technologies not previously used in much of the developing world. Scientists are devising new methodologies that they hope will be as sensitive as existing methodologies yet more cost effective. The laboratory infrastructure is the most expensive and specialized part of any institutional framework for HIV/ AIDS cares (Stephenson, 2002). In Nigeria, policymakers and decision makers have tended to view laboratories in the narrow context of HIV screening. At the onset of the ART program no laboratory in the country had the full capacity needed to monitor treatment response and toxicity properly. Only a handful of institutions had the capacity to perform CD4+ counts, a necessary test for decision-making in HIV therapy. The federal government program provided the training and technical capacity for CD4+ tests to be performed in the 25 treatment centers using a manual microscopic technique, This technology is labour intensive, and one laboratory scientist cannot reliably perform more than 10 tests a day. This pace cannot accommodate the expansion of ART in these centers and in other centers that would rely on them for laboratory support. Through a generous donation from MTN Nigeria, a telecommunications company, APIN was able to equip two federal treatment centers—at University College Hospital and Jos University Teaching Hospital—with flowcytometry—based instruments (Imade et al., 2005), which allow technicians to process more than 100 CD4÷ tests daily. The instruments cut the cost of the tests four- to fivefold. All Harvard PEPFAR program sites are now equipped with these instruments. Many other programs in Nigeria, particularly the other PEPFAR programs, have opted for that investment as well. Similarly, when the ART program started in Nigeria, only one centre had the capacity to perform viral load tests routinely; these tests are used to measure the virus level in the blood of infected individuals and thereby allow clinicians to assess treatment efficacy. This centre, the Nigerian Institute of Medical Research, had been upgraded and equipped by a grant from the Ford Foundation. APIN, a project based at the Harvard School of Public Health (HSPH) and sponsore1d by the Bill & M1inda Gates (Stephenson et al., 2002)
2. Challenges of deciding the optimal time to start antiretroviral treatment
Highly Active Antiretroviral Therapy (HAART) has changed the landscape of HIV- related care in the developed world with marked reduction in mortality and morbidity (Cameron et al., 1998). This possibility however is beyond the reach of a vast majority of HIV-infected in sub Saharan Africa. Following the development of HAART, many physicians were quite aggressive in treating patients at virtually any stage of this human retroviral disease. Increasing concern related to drug toxicities, pill burden, cost and ability of patients to adhere to strict and complicated regimens, have complicated the decision-making process for physicians and patients alike (Volberding, 2000). Despite promised price-reduction and increased availability of generic drugs in some countries, cost remains a major factor in deciding when to start therapy.

CONCLUSION
HIV which was classified as member of the genus lentivirus, part of the family retroviridae, when properly managed with some cocktails of antiretroviral drugs, anti-infective agent, anti-cancer drugs, palliative drugs can promote the effective suppression of viral replication, the reconstitution of the immune system, and improvement of the physical well being of the study population. The management of HIV can also reduce the rapid spread of the infection through sexual route, blood transfusion, mother-to-child transmission e.t.c.
            Finally, a lot of care is also required for already positive individuals, because it keeps them happy and healthy.  

REFERENCES
Abuja National AIDS/STIs control program 9NASCP) Nigeria (IBBSS 2007).
Adeyi O. et al., editors. 2006. AIDS in Nigeria, a nation, a nation on the threshold (Harvard university press Harvard series on population and international health).
Ainsworth M. Teokulw. Breaking the silence: setting realistic priorities for AIDS control in less developed countries 2000; 356: 55-60.
Bell, 1997 Transmission of Human Immunodeficiency Virus from mother to-child.
Carrol, G. Rooney G, VIllar J (2001). How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence paediatr periant Epidemiol, 15 (1): 1-42.
Cheesbrough M (2000): HIV in: Cheesbrough M (ed) District Laboratory practice in tropical countries. Cambridge University Press, Cape Town, south Africa. Part two Pp 253-255.
Colebunders, R. E. Karita, H. Taclman, and Pmugy enyi. 1997. “ Antiretroviral treatment in Africa” AIDS 11(Suppl B): S 107- S 113.
De Cock Km, fowler MG, Mercies E, et al (2000) Prevention of mother –to – child HIV transmission in resources –poor countries. Translating research into policy and Practice. JAMA, 283 (9): 1175-1182.
Egesie J. & Egesie E. (2011) Seroprevalence of Human Immunodeficiency Virus (HIV) Among Blood Donors in Jos-Nigeria” cited in Barros E. (2011) ‘HIV-infection: Impact, Awareness and Social Implication of living with HIV/AIDS’. InTech.
Erhabor, O ukoek, Adias T (2006). Absolute Lymphocyte counts as a marker for CD4T-lymphocyte count: criterion for initiating antiretroviral therapy in HIC infected Nigerians. Niger Jmed, 15(1): 56-59.
European collagorative study (2005) mother to child transmission of HIV infection in the Era of hidiply active antiretroviral therapy. Clin infect Dis, 40(3): 458-457.
Ezumah NE. Gender Issues in the prevention and control of STIs and HIV/AIDS; lessons form Awka and Agulu, Anambra state, Nigeria. Africa Journal of reproductive health, 2003: 7: 89(99)
Federal ministry of health (2001) A Technical report on 2001 natinal HIV/Syphilis Sero Prevalence sentinel Survey among pregnant women attending antenatal clinics in Nigeria. Abuja National AIDS/STIs control program Nigeria.
Federal ministry of health (2005) Technical report on the 2005 national HIV/Syphilis sero-prevalence sentinel survey among pregnant women attending antenatal clinics in Nigeria department of public Health National AIDS/STIs control Programme: Abuja: Nigeria
Federal ministry of health (2005) the national situation Analysis of the health sector response to HIV/AIDS in Nigeria. Abuja: FMH Nigeria.
Federal ministry of Health (2009) National HIV/AIDS and reproductive health survey. Abuja (NARHS 2007).
Geographical: The Complete Atlas of the world, “Nigeria”, (Random House, 2002).
Health Reform Foundation of Nigeria (HERFON) (2007, August) “Impact, challenges and long term implications of antiretroviral therapy programme in Nigeria,
Human Development Report 2009.
IF{A (2005) “Donor Support for contraceptives and condoms for STI/HIV prevention 2005”
Jawetz, Melnick, Adeberg’s (2007): AIDS and Lentiviruses in: Geo F. B, Butal J. S, Stephen AM, Karen C.C (eds), Medical Microbiology McGraw Hill New York 24th ed. Pg 604-616.
Jegede-Ekpe, Bolman and Deals. 2003. The management of HIV infection using cocktail of Zalatabine in combination with saquinavir mesylate
Jhap, Nagelkerke NJD, Ngugi, Arasada Rao JVR, will bond B, Moses S, et al. Reducing HIV transmission in developing countries. Science 2001; 292: 224-5.
Lallement M(2005) response to the therapy after prior exposure to nevirapine. 3rd IAS conference on HIV pathogesis and treatment, Rio de Janeiro, Brazil, July 24-27. (Abstract FUFO 205).
Lawn SD (2004). “AIDS in Africa. The impact of CO-Infetions on the pathogenesis of HIV-1 infection” J. Infect. Dis-48 (1)” 1-12.
Mofenson Lm (1999)- Mofenson L.M Larmbert JS, Stihm ER, et al., (1999). Risk factors for perinatla tramsission of human immuno deficiency Virus type 1 in women treated with Zidovadines N Engl J med, 321: 385-393.
Mofenson LM (2003) Advances in the prevention of vertical transmission of human immuno deficiency virus. Semin pediatr infect Did, 4(4): 295-308.
National Agency for the control of AIDS (2010) “National HIV/AIDS response review 2005-09”
National Agency for the control of AIDS (NAACA): National Strategy framework (NSF) 2005-2009.
National agency for the control of AIDS (NACA):  National Strategic Frame work (NSF) 2005-2009.
National Agency for the control of AIDS: HIV/AIDS NNRIMS operational plan 2007-2010.
National Economic Empowerment and Development Strategy (NEEDS) 2006, HIV/AIDS in Nigeria National planning commission. 
Nester WE, Anderson. G, Roberts C.E Jr., Pearsall N.N, Nester M.T (2004). HIV infection and AIDS in Colins H.W (ed). Microbiology, A Human Perspective McGraw Hill New York 4th edition Pg 740-748.
Nigeria Exchange (2008, 6th February) ‘Ministry of Health alerts Nigerians to the transfusion of unsafe blood in hospitals’
Nnadozie, Kent 2001, Trips Agreement and Access to essential Medicine in Nigeria.

PEPFAR (2008) ‘ FY2008 Country Profile: Nigeria’ Annual report to congress.
Pettifor AE, Rees HV, Kleinschmidit I, et al. Young people’s sexual health in south Africa: HIV Prevalence and sexual behaviours from a nationally representative house hold survey AIDS 2005; 19: 1525-34.
Physicians for Human Rights (2006) ‘Nigeria Access to Health Care for People Living with HIV and AIDS’
Pope M et al., (1997, October) Human immuno deficiency virus type 1 strains of subtypes B and E replicate in Cutameous dendritic cell-T-Cell mixtures without displaying subtype-specific tropism J virol 71(10).
Population Services International (2003, March) “Nigerian radio campaign generates safer behaviour”
QuinnTc, overbaugh J. HIV/AIDS in women; and expanding epidemic. Science 2005; 308:1582-83.
Reeves J.D, Doms R.W (2002) HIV tupe – 2 J. Gen. Virol, 83 (Pt6): 1253- 1265.
Reuters New Media (2003, 9th November) “Nigeria Grammy nominee fights to win for the poor”
Rhodes T, Simic M. Transition and the HIV risk environment. BMJ 2005; 331: 220-3.
Shisana O. Davids A. Correcting a gender inequalities is central to controlling HIV/AIDS Bull World Health Organ 2004; 82: 812.
Simon V. HIV/AIDs epidemiology, pathogenesis, prevention, and treatment 2006; 3 68: 489-504.
Stephenson J (2002) cheaper HIV drugs for poor nations bring a new challenge: monitoring treatment. JAMA, 288 (2): 151-153.
The Global Fund (2009) “Nigeria and the Global Fund’
The population council, Inc (2007) “The experience of married adolescent girls in Northern Nigeria’
The World Bank (2008) ‘Nigeria receives US million additional funding for HIV/AIDS project program
Thorne, CN and Patel, Dand Fiore, sand peckham, C and Newell, MC (2005) mother-to child transmission of HIV-1 in the era of highly active antiretroviral therapy. Clinical infectious diseases, 40 (3), 458-465.
UN Integrated Regional Information Networks/All Africa (2006, 27th March) “Condom ads stir passionate debate”
UNAIDS 2009 AIDS epidemic update: Global summary of the AIDS epidemic.
UNAIDS 2009 Report: modern of transmission in Nigeria: Analysis of the distribution of New HIV infection in Nigeria and recommendations for prevention.
UNAIDS Action frame work: Addressing Women, Girls, Gender Equality and HIV. August 2009
UNFPA (2007, 30tj November) “A right to choose: expanding access to the female condom in Nigeria.
UNGASS (2010) ‘UNGASS Country Progress Report: Nigeria’
UNGASS (2010) ‘UNGASS Country Report: Nigeria’
UNICEF, UNAIDS, WHO and MSF 2002. selected drugs and diagnostics for people living with HIV/AIDS Geneva: WHO.
UNICEF, UNAIDS, WHO/EDM and MSF. 2000  selected drugs used in the care of people living with HIV: sources and prices. Geneva: WHO.
UNICEFF (2010) “Nigeria: PMTCT”
United Nations Development Program 2009
United Nations General Assembly Session on HIV/AIDS 25-27 June 2001: Declaration of Commitment on HIV/AIDS. Global Crisis –Global Action.
WHO, UNAIDS and UNICEF (2008) “Towards universal access: scaling up priority HIV/AIDS Interventions in the health sector.
WHO/UNAIDS/UNICEF (2010) “Towards Universal Access: Scaling up priority HIV/AIDS Interventions in the health sector”
WHO/UNAIDS/UNICEF (2011). “Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011”
WHO/UNAIDS/UNICEF (2011)’ Global HIV/AIDS Response: Epidemic update and health sector Progress towards Universal Access 2011’
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