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2008 PEPFAR Country Profile Update: Nigeria

 

Administered by the Office of the Global AIDS Coordinator, the President’s Emergency Plan for AIDS Relief (PEPFAR) provides $15 billion dollars over 5 years for AIDS, Malaria and Tuberculosis programs globally. A majority of funds are allocated to 15 focus countries: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.
 

 
 
(The following document is a 2008 update to the status of PEPFAR funding and related issues in Nigeria.  Click Here to Read Nigeria's 2005 Original Country Profile)
Introduction
 
In 2005, SIECUS published PEPFAR Country Profiles: Focusing on Prevention and Youth, an in-depth look at the then-new funding stream opened up through the President’s Emergency Plan for AIDS Relief (PEPFAR).  
 
PEPFAR directed $15 billion over five years, primarily to 15 focus countries and to a lesser extent to over one hundred other countries.  PEPFAR gave voice to the concern of the people of the United States to care for those around the world affected by HIV /AIDS and demonstrated the political will to put that concern into action.  At the outset, advocates were hopeful that this generous funding stream would offer a meaningful contribution to the fight against HIV/AIDS at a time when millions were dying.  Still, much of the language in the legislation gave advocates cause for concern, and it was unclear how the implementation of this program would play out.  
 
Advocates were particularly concerned with some of PEPFAR’s policies regarding prevention. First, a maximum of 20 percent of the funds could be spent on prevention efforts.  Moreover, 33 percent of those funds that were spent on prevention were earmarked for abstinence-until-marriage programs.  Together these made a glaring statement about the program’s priorities. PEPFAR also made funds available to faith-based organizations (FBOs), taking advantage of the vast social service networks already in place in many countries around the world. While these organizations often displayed expertise in areas such as care for orphans and hospice for the dying, they were, and still are, entitled to exclude information, particularly as relates to programs for the prevention of sexual transmission of HIV, that they believed to be inconsistent with their religious teachings. 
 
In the early years of PEPFAR very little was known about how these provisions, among others, impacted the efforts of national and international organizations. To fill this gap in information, SIECUS did what we have done in the United States for many years; we followed the money. For the original Country Profiles, we drew together information to create a more cohesive picture of the nature of each epidemic in the 15 focus countries and how PEPFAR responded to those epidemics, with a particular eye to the prevention and youth components. Specifically, we tracked prevention funds: how much money was distributed, who it went to, and how it was used. These were all elusive pieces of information at the time. 
 
Unfortunately, this type of information remains elusive. SIECUS conducted follow up research in 2008 to provide an update to those original Country Profiles. Each update features recent demographic data pertinent to the epidemic in that country, a breakdown of funding allocations for prevention, care, and treatment, and a list of those PEPFAR grantees that are implementing prevention programs. Wherever possible we also include additional information on grantees and the type of programs they are running with PEPFAR funds. 
 
In addition to this data, each update also offers further analysis on particular items of note in the country.  And, we follow this analysis with our recommendations for moving forward with PEPFAR to ensure truly comprehensive prevention strategies in the focus countries.  While these updates can be read independently of the original profiles, reading them together, affords an even richer perspective. 
 
 
Overview
 
The first case of AIDS in Nigeria was reported in 1986; since then prevalence of HIV has increased from 1 percent in 1990 to 3 percent in 2000 where it has roughly stabilized.[1] Prevalence differs dramatically among populations with the highest vulnerability to contracting HIV. For example, in Abuja, the capital city of Nigeria, it is estimated that 5.6 percent of injecting drug users (IDU) are infected with HIV, as are 13.5 percent of men who have sex with men (MSM), and 32.7 percent of female sex workers.[2] 
 
Despite the low prevalence, the total number of people living with HIV in Nigeria is quite high. Out of a total population of over 131 million people, 2.6 million people are living with HIV, the second highest number of people living with HIV in the world. Only South Africa has a higher total number of HIV-positive individuals, reported at 5.7 million.[3]  Since the start of the epidemic, at least two million Nigerians have died of AIDS-related illnesses.[4]  In 2007, 170,000 adults and children died from AIDS, and as of 2007 roughly 1.2 million children had been orphaned due to AIDS.[5] According to the World Health Statistics 2008, life expectancy in Nigeria is startlingly low at 48 years.[6]
 
While increased availability of antiretroviral therapy (ART) in recent years has helped to reduce the number of AIDS-related deaths in Nigeria, less than a quarter of people who are in need of ART are receiving it. The number of sites that provide ART has increased, from 71 in 2005 to 215 in 2007, however there remain hundreds of thousands of Nigerians who lack access to and coverage of ART.[7] 
 
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Nigeria. The stories behind the statistics are fleshed out in greater detail following the chart.
 
A PORTRAIT OF NIGERIA IN NUMBERS
 
Total population (2006)[8]
131,530,000
Percentage of the population under the age of 24
N/A
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2005)[9]
$930
Per capita total expenditure on health (Int’l$, 2005)[10]
$13
Secondary school enrollment rate (19992005)[11]
31% Females
37% Males
Estimated number of people ages 15 and over living with HIV (2007)[12]
2,400,000
HIV prevalence in people ages 1549 (2007)[13]
3.1%
HIV prevalence in people ages 1524 (2007)[14]
3.3% Female upper estimate
1.2% Male upper estimate
 
1.2% Female lower estimate
0.3% Male lower estimate
Median age of first intercourse
N/A
Median age of first marriage
N/A
Young people ages 1524 who have had sex before age 15 (2005)[15]
15% Females
5% Males
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2005)[16]
2% Females
19% Males
Percentage of women and men ages 15–49 who had more than one sexual partner in the past 12 months reporting the use of a condom during their last sexual intercourse (2005)[17]
44% Females
62% Males
Contraceptive prevalence rate (2004)[18]
13% Any method
8% Modern methods
Percentage of couples using condoms for family planning (2005)[19]
1.9%
Number of births per 1,000 women ages 15–19(2005–2010)[20]
126
Percentage of females (2024) who have given birth by age 18 (2005)[21]
28%
Young people ages 15–24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission (2005)[22]
20% Females
25% Males
Schools with teachers trained in life-skills-based HIV/AIDS education who taught this during the last academic year (2007)[23]
34%
 
Nigeria’s initial response to the HIV/AIDS epidemic while under military rule in the 1990s was characterized by denial and delayed action. A democratic government was instituted in 1999, and it quickly reacted to the epidemic.  In 2000, the Presidential Committee on AIDS and the National Action Committee on AIDS (NACA) were created to develop the HIV/AIDS Emergency Action Plan (HEAP 2001–2003). HEAP 2001–2003 was a multi-sectoral approach which focused on the “removal of socio-cultural, informational and systemic barriers to community-based responses, prevention, care and support.”[24] The focus area of this program was behavior change, and its key messages revolved around abstinence, mutual fidelity, and condom use.
 
Due to a late initiation of HEAP, the initial implementation period was extended to cover 2004. Following the completion of this phase a review was conducted and a new plan, the HIV/AIDS National Strategic Framework for Action 2005–2009 (NSF), was created. The new framework targets women, youth, high-risk groups, and orphans and vulnerable children (OVC). The overall goal of the NSF 2005–2009 is to reduce HIV incidence and prevalence by at least 25 percent and provide prevention, care, treatment, and support while mitigating the impact on women and OVC by 2009.[25] The plan was officially launched on October 11, 2005. 
 
To ensure a sustainable response to the epidemic, NACA has been transformed into the Agency for the Control of AIDS through an Act of the Nigerian Parliament in 2007. The new agency will increase the amount of funds for HIV/AIDS in the national and state budgets in order to provide more effective coordination of the response. 
 
Nigeria has made some significant advances in addressing the HIV/AIDS epidemic.  As of 2006, the Nigerian government offered free antiretroviral therapy (ART) at all public institutions as well as free labor/delivery services to HIV-positive pregnant women seeking antenatal care at federal health institutions.[26]  Nigeria has also made great strides in improved monitoring and evaluating of the epidemic by implementing more innovative strategies. In 2007, the first Integrated Bio Behavioral Surveillance Survey was conducted among female sex workers, MSM, IDUs, transport workers, and uniformed officers to determine knowledge, sexual behaviors, and prevalence of HIV. The first national population based sero-prevalence survey was also conducted in 2007 and its findings are expected to be released in 2008. In addition, Nigeria organized the first national AIDS Summit in April 2007. It provided a platform for sharing information and best practices among all stakeholders in the country.[27]

Key Objectives and Strategies of the
 National Strategic Framework 20052009
1. Increase program implementation by 50%.
2. See appropriate behavioral changes in 95% of the population.
3. Increase access to comprehensive gender-sensitive prevention, care and treatment services.
4. To mitigate the impact of HIV/AIDS by 50%.
5. 100% implementation of the HIV/AIDS response.
6. To create and enable gender-sensitive and human rights friendly social, legal and policy environment.

Prevention areas, such as voluntary counseling and testing (VCT), prevention of mother-to-child transmission (PMTCT), and behavior change communication programs have become a priority under the national response. Since implementing these plans, Nigeria has seen some progress in fighting the epidemic. A framework to guide implementation of behavior change programs was created and provides direction for HIV/AIDS intervention activities using an “ABC” approach: Abstain, Be faithful and use Condoms. This approach has been utilized by civil society organizations, faith-based organizations (FBO), networks of people living with HIV/AIDS (PLWHA), and community leaders. There are nearly 350 PLWHA support groups nationwide, which have been integral in providing care and support to members and affected families.[28] Condom distribution may have also increased: over 4 million condoms were given to Nigeria by the United States from 2004–2007, however, follow-up information on how and if these condoms were distributed is unavailable.[29]  
 
The HIV/AIDS epidemic in Nigeria disproportionately affects women. The prevalence rate among young women ages 15–24 is at least three times higher than that of young men of the same age range.[30] Women make up roughly 60 percent of all people living with HIV in Nigeria.[31] It is estimated that 190,000 pregnant women are living with HIV and only 7 percent of HIV-positive mothers are receiving ART to prevent mother-to-child transmission.[32] Overall, only 58 percent of pregnant women received antenatal care during 2000–2006.[33] Women report lower levels of condom use during casual sex (44 percent of women versus 62 percent of men ages 15–49 in 2005), lower levels of knowledge about the virus (20 percent of women, versus 25 percent of men ages 15–24), and higher levels of having sexual intercourse before the age of 15 (15 percent versus 5 percent).[34] There are also a number of traditional religious and social practices which put women at a high risk of contracting the virus, including marriage practices where young girls marry older men as well as female circumcision/female genital mutilation (FGM). While Nigeria has made progress, more gender-friendly programs must be made available in order to truly bring about behavior change among these at-risk populations.
 
In addition, stigma and discrimination against people living with HIV/AIDS (PLWHA) is still commonplace.  This creates an atmosphere where people are reluctant to be tested and receive proper treatment. The 2005 National AIDS and Reproductive Health Survey estimated that only 9 percent of men and 8 percent of women ages 15–49 were tested for HIV in 2005 or already knew his or her status (most recent data available).[35] The government has worked hard to scale up access to ART by increasing the number of ART sites to over 215 reaching over 165,000 people at the end of 2007.[36] Yet in 2007, only 26 percent of people that were in need of ART actually received it. In addition, there is no coordinated effort to deliver pediatric ART which is vital in order to meet the needs of HIV-positive young persons in the country.[37]
 
The NSF does not list any specific dollar amount that will be required to put this plan in to action. However Nigeria receives funds from multiple donors, including the World Bank, Global Fund, UK Department for International Development (DfID), and the President’s Emergency Plan for AIDS Relief (PEPFAR).
 
 
 
 President’s Emergency Plan for AIDS Relief (PEPFAR)
 

Key Terms to Understanding PEPFAR Prevention Programs and Funds
 
ABC: ABC stands for “Abstain, Be-Faithful, and Correct and Consistent Condom Use.” ABC is PEPFAR’s guiding principal for HIV-prevention programs. PEPFAR requires that a minimum of one-third of all prevention funds be spent on abstinence programs and it limits the promotion and marketing of condoms to specific groups outlined in PEPFAR’s ABC guidance. No discussion or promotion of condoms is permitted with youth under the age of 14 using PEPFAR funds.
 
Country Operation Plan (COP): A yearly program and budget plan developed for each PEPFAR focus country. The COP is developed by U.S. staff in conjunction with country governments. It divides programs into three main categories of prevention, care, and treatment: Abstinence-Be-Faithful (AB), Other Prevention (OP), and Prevention of Mother-to-Child Transmission (PMTCT). A country’s COP is not the same as its National Strategic Plan/Framework (NSP/F). Unlike a NSP/F, a COP is specific to PEPFAR programs and funds, and is developed annually. In comparison, the NSP/F is a multi-year, country-wide strategy on HIV/AIDS that is developed by each country’s government. Although the NSP/F may make reference to PEPFAR and other international donors, it is not limited to a description of activities funded by international donors, and an NSP/F may or may not be developed with input from the United States or other donors. 
 
Abstinence-Be-Faithful (AB): One category of prevention programs and funding under PEPFAR. Grantees that provide AB programs focus on education and promotion of abstinence-until-marriage and be-faithful messages. Grantees that receive OP funds, such as those to promote condom use, are listed in both sections of the COP.
 
Other Prevention (OP): One category of prevention programs and funding under PEPFAR. The OP category includes any prevention program that is not an AB program or a PMTCT program. This category includes surveillance programs, programs aimed at reducing stigma and discrimination, training for healthcare workers, and the promotion and marketing of correct and consistent condom use. Grantees that receive funds for OP programs in addition to AB funds are listed in both sections of the COP.
 
Prevention of Mother-to-Child Transmission (PMTCT): One category of prevention programs and funding under PEPFAR. The PMTCT category includes routine rapid HIV-testing in antenatal and maternity settings, counseling and support for infant feeding, and linking to care, treatment, and support services.
 

 
 
Funding
 
Nigeria is one of the most well-funded focus countries under PEPFAR. PEPFAR began implementing its programs in Nigeria with an initial grant of nearly $71 million. Since then, funding has dramatically increased each year, and in 2008, the budget was given its largest increase yet of over $100 million, making its current allocation $381,941,210 for the country.
 
The following chart details the allocated funds from PEPFAR to the different areas of funding. Within the prevention framework, PEPFAR promotes an ABC message, which signifies: Abstinence-only, Be faithful, and Correct and Consistent Condom Use. Abstinence-only/Be-faithful (AB) programming utilizes an AB-only message, while Other Prevention (OP) includes AB programming as well as messages that address correct and consistent condom use (ABC).
 
 
 
Allocated PEPFAR Funds 2004–2008*
 
2004[38]
2005[39]
2006[40]
2007[41]
2008[42]
Total Funds Allocated
$70,925,082
$94,021,494
$144,402,492
$271,449,414
$381,941,210
Total Prevention Funds Allocated
N/A
$21,143,134
$27,982,798
$52,917,884
$62,876,855
Total AB Funds Allocated
N/A
$5,938,234
$7,329,530
$17,594,781
$18,179,192
Total Other Prevention
Funds Allocated (includes condom funding)**
N/A
$2,581,794
$4,431,918
$9,277,500
$9,339,800
Total Treatment Funds Allocated
N/A
$53,777,753
$81,460,822
$152,084,765
$212,809,650
Total Care Funds Allocated
N/A
$19,100,607
$39,677,872
$80,003,825
$106,254,705
* The Office of the U.S. Global AIDS Coordinator (OGAC) only releases data on the funds that are allocated to each country. No data is available on the PEPFAR funds that are disbursed per country.  
** Total funding allocated to Field Programs only, excludes Agency costs.
 
Treatment receives the most funding comprising over half of the entire budget at $212,809,650 in 2008. Care follows as a distant second, receiving nearly 30 percent, and prevention is the least funded area, receiving 16.5 percent of the total budget.  Though the prevention budget has tripled since its initial allocation of $21 million in 2004 (it’s currently at $63 million), both treatment and care have seen more dramatic increases in funding.  
 
AB programming has consistently seen double the amount of funding as OP and currently makes up nearly 30 percent of the prevention budget while OP makes up only 15 percent. Since there was little change in the allocation of the prevention budget, including AB and OP funding, in 2007–2008, the overall PEPFAR budget continues to reflect the prioritization of care and treatment programs. 
 
Prevention Programming
Prevention programming under PEPFAR utilizes an “Abstain, Be faithful, and when appropriate use Condoms” (ABC) approach. However, programs which promote abstinence and fidelity are the predominant intervention used with the general population. Programs addressing correct and consistent condom use are most often used with specific target populations that the PEPFAR guidance identifies as being most at-risk. Programs that support a comprehensive ABC approach are calculated into “Other Prevention” (OP) funding. 
 
The most comprehensive data available on PEPFAR funding for each focus country is in the 2007 Country Operational Plan (COP).  The COP delineates the total amount, according to program area, that each grantee or organization is given for that fiscal year. While general program descriptions are listed with the information about funding allocations, details on the specific activities that each grantee carried out and how these activities were executed are rarely included in the COP. This lack of detail on program content makes it difficult to conduct a thorough analysis of each program or of PEPFAR’s overall impact on prevention programming in the country. 
 
In 2007, there were a total of six AB-only grantees, six AB/OP grantees, and five OP-only grantees. The following is a list provided of PEPFAR grantees receiving prevention funding as reported by the Office of Global AIDS Coordinator in the 2007 Country Operational Plan for Nigeria. This list indicates whether grantees received only Abstinence-only/Be faithful (AB) funding, only Other Prevention (OP) funding or both. While there is a summary of funding projections available through 2008, the breakdown of funding according to recipient and amount granted in the full Country Operational Plan is only available for 2007.[43]
 
Organizations that received AB funding only:

  • Catholic Relief Services
  • Christian Aid
  • Food for the Hungry
  • Hope Worldwide South Africa
  • Population Council
  • U.S. Agency for International Development

 
Organizations that received AB and OP funding:

  • Centre for Development and Population Activities
  • Management Sciences for Health
  • Society for Family Health-Nigeria
  • U.S. Centers for Disease Control and Prevention (CDC)
  • U.S. Department of Defense
  • Winrock International

 
Organizations that received OP funding only:

  • Columbia University Mailman School of Public Health
  • Family Health International
  • Harvard University School of Public Health
  • Partnership for Supply Chain Management
  • University of Maryland

 
AB programs received $17,594,781 and targeted 3,653,144 people through community outreach in 2007.[44] AB programs promote abstinence, a return to “secondary abstinence,” and faithfulness as the most effective way to reduce HIV transmission.
 
Catholic Relief Services (CRS) received the most AB funds at $1,095,000 and targeted 1,110,000 people through community outreach in 2007.[45] CRS conducted “Sensitization Workshops” to Catholic clergy and laity to deliver “faith sensitive” AB messages which “encourage youth to adopt behaviors to reduce risk of HIV transmission, such as delaying sexual debut until marriage and promoting social/community norms which favor [abstinence-only-until marriage and being faithful]. Adults … will also be motivated to embrace the message of Being faithful to one partner as means of preventing HIV/AIDS.”[46] CRS was set to train 633 community “prayer leaders,” including couples counselors and youth peer educators, to deliver AB messages.   CRS’s AB activities also included prevention training for 192 people living with HIV/AIDS who lead support groups to “counsel and communicate information about AB prevention” within their faith communities.[47] CRS has delineated guidelines on which prevention messages to deliver to which populations: Primary abstinence is promoted to in school youth, secondary abstinence to out of school youth, and “accurate information about condoms” to groups that CRS has deemed “at-risk.”[48]
 
The largest AB and OP provider in 2007 was the Society for Family Health-Nigeria (SFH) at a total of $6,710,000 ($4.11 million in AB funding and $2.6 million in OP funding ).[49] SFH’s AB goal is to contribute to a reduction in HIV prevalence among young people ages 15–24 at the national level through a mass media campaign and in select sites in 19 states of Nigeria. SFH has operated in Nigeria since 1985 and has collaborated with NACA and the UK Department for International Development (DfID) to support the development of a national curriculum for ABC prevention interventions and the establishment of a national prevention technical working group for HIV/AIDS. One of SFH’s main AB activities is a social marketing campaign called “Focus on Youth.”  The campaign includes the popular Zip Up youth promotion, a radio and TV ad featured across the country that taught negotiating skills for practicing abstinence and served to affirm choosing abstinence as a popular lifestyle among teenagers.[50] One of SFH’s main OP activities is a community-based peer education program called “Peer Education Plus” or PEP. PEP holds sessions that include “condom and condom lubricant distribution, and referral for HIV testing and STI treatment.” The key messages in PEP are “partner reduction, consistent condom use in all sex acts, prompt and complete treatment of sexually transmitted infections (STI’s), and testing for HIV.”[51] PEP targeted 25 brothel-based female sex workers (FSW), 28 transport workers (TW), and 19 uniformed service men (USM) within support groups that SFH operated.
 
OP programs received $9,277,500 and targeted 899,535 people through community outreach and 543 outlets for the distribution of condoms.[52] The largest OP-only provider was Family Health International at $2,290,000 which was set to reach 130,000 people through community outreach and 12 service outlets to distribute condoms.[53] Family Health International partnered with SFH and the United Nations Fund for Population Activities (UNFPA) to obtain and distribute condoms in Nigeria though the number of condoms obtained or distributed is not stated in the Country Operational Plan. Family Health International also conducts condom use programs tailored to promote “the understanding that abstaining from sexual activity is the most effective and only certain way to avoid HIV infection…the importance of correctly and consistently using condoms during every sexual encounter with partners known to be HIV-positive (discordant couples) or partners whose status is unknown…the development of skills for vulnerable persons; and the knowledge that condoms do not protect against all STIs.”[54] 
 
In addition, there were three AB/OP providers and three OP-only providers that promoted the correct and consistent use of condoms. The Centre for Development and Population Activities, an AB/OP grantee that received $500,000, provided information and messages for correct and consistent condom use and reported that 10 million condoms would be distributed from 384 outlets targeting the most at-risk populations, including “long distance truck drivers, migrant workers, out of school youth, people living with HIV/AIDS (PLWHA) and clients of commercial sex workers.” [55] Columbia University Mailman School of Public Health, an OP-only provider that received $200,000, implemented a program that promoted the correct and consistent condom use of both male and female condoms to HIV-positive people through hospital networks.[56] 
 
Item of Note: Marginalization of Same-Sex Practicing People
 
Despite the generalization of HIV/AIDS into all sectors of the population there remains a disproportionate impact on same-sex practicing people, especially men who have sex with men (MSM), whose most recent prevalence estimate is 13.5 percent or at least four times higher than the prevalence rate of the general population. MSM may “cross-over” or engage in sexual practices with women as well as men, and inconsistent condom use and lack of HIV-prevention education among all populations puts everyone at higher risk. 
 
Lesbian, Gay, Bisexual, Transgender (LGBT) communities are currently experiencing discrimination not only in a lack of intervention activities, but also through laws which criminalize same-sex sexual practices. Off the Map: How HIV/AIDS Programming is Failing Same-Sex Practicing People in Africa, a recent report by the International Gay and Lesbian Human Rights Commission (IGLHRC), looks at the flaws in the current programs that are designed to fight the HIV/AIDS epidemic in Africa. IGLHRC found that less than $2 million has been devoted to funding HIV-prevention activities for LGBT and same-sex practicing populations. Programs focusing on these groups are being implemented in Latin America, Europe, and Asia, yet in Africa it seems that anti-gay discrimination remains a critical barrier to granting LGBT and same-sex practicing individuals’ access to such services.[57]
 
Statutes that criminalize homosexual activities, sometimes known as “sodomy laws” are currently in place in more than half of the countries in Africa, and some even extend the death penalty to such offenses. Nigeria is no exception; in certain parts of the country where the legal system is based on Sharia, or Islamic law, consensual same-sex acts may be punishable by death. Even within the Nigerian Parliament there exists great animosity and stigma toward LGBT same-sex practicing persons; the Same Sex Marriage (Prohibition) Act 2006 bans same-sex marriage and subjects “any person who is involved in the registration of gay clubs, societies and organizations, sustenance, procession or meetings, publicity and public show of same-sex amorous relationships” to five years in prison.[58]  Individuals caught having sex with anyone of the same sex are subject to arbitrary arrest, assault, verbal and physical attack, as well as murder. This practice of discrimination was supported by the country’s top leader at the time, in 2004 President Olusegun Obasanjo stated that homosexuality “is clearly un-Biblical, unnatural, and definitely un-African.”[59] The stigma that exists not only causes psychological and physical damage, but often leaves individuals reluctant to seek knowledge about and treatment and supplies for sexually transmitted diseases, including HIV/AIDS. 
 
In addition to these laws, numerous misconceptions also permeate the country. IGLHRC states that, “the overwhelmingly heterosexual imagery of HIV/AIDS in public health campaigns has led to ignorance and misinformation about same-sex transmission.”[60] One activist even reported that the billboards showing heterosexual couples create a misconception that it is safer to sleep with someone of the same sex.[61] And, throughout Africa there are myths that sexual activity between women poses no risk for transmission. While women who have sex with women (WSW) tend to have a lower prevalence rate than most women, they are still vulnerable to the disease. WSW are often forced into arranged marriages in order to “cure” their homosexual behavior, which can increase their risk contracting HIV.[62] Compounded by this are issues that all women in Africa face, including social and economic dependence on men, limited ability to negotiate condom use, and gender-based violence. There are no funds allocated to HIV-prevention programs focused on WSW in any of the PEPFAR focus countries according to their country operational plans.
 
The ABC approach utilized by PEPFAR has also come under criticism for its lack of information and intolerance regarding same-sex relationships. Advocates note that an approach which emphasizes abstaining from sex until marriage has nothing to offer entire segments of the population who cannot be legally married. In fact, most AB-focused PEPFAR prevention programs are implemented by faith-based organizations whose religious views often condemn same-sex persons and relationships.
 
There are no statistics which detail what percentage of the population identifies as LGBT or acknowledges same-sex sexual practices. However, IGLHRC reports that if a conservative estimate of two percent of Nigeria’s population were predominantly attracted to members of the same-sex, there would be at least three million same-sex oriented citizens.[63] AIDS policy planning and resource allocation is driven by numbers, and if local governments and non-governmental organizations are unaware of an entire population in need, there is no way that they can be served.
 
LGBT and same-sex practicing individuals in Nigeria and throughout the entire African continent are failing to receive the attention and treatment that they require in order to effectively combat the HIV/AIDS epidemic and protect their health and lives. They are victims of institutionalized discrimination and are systematically ignored by the very organizations that could offer them the most help. Same-sex transmission of HIV in Africa has been under-counted, under-researched, and under-funded, and as a result people are less educated on how to prevent HIV infection. Nigeria stands as but one, concrete example of this larger issue.
 
Recommendations
 
In 2005, when SIECUS released the original PEPFAR Country Profiles publication, we made six recommendations: immediate actions necessary to remedy the problems in the PEPFAR legislation and its implementation. Sadly, although not surprisingly, three years and $19 billion in U.S. taxpayer funding later, little has been done. Lawmakers missed the opportunity to remedy the shortcomings of the original law in the reauthorization of PEPFAR in July 2008, despite ample evidence provided by researchers and advocates to guide them to create more sounds policy. Today, we reiterate each of these six recommendations as well as adding an additional one, and contribute evolving insight relevant to the current context:
 
1.  Abandon the Ideological Emphasis on Abstinence-Until-Marriage Programming
 
The newly reauthorized law brought about a technical change in the shape of the abstinence-until-marriage funding restrictions, although the impact is equally stifling. A hard earmark in the original legislation requiring that 1/3 of all prevention funding be spent on abstinence-until-marriage programming has been supplanted by an onerous reporting requirement. Despite the overwhelming evidence that abstinence-until-marriage programs are ineffective at preventing the transmission of HIV, they remain the cornerstone of the prevention policy. The new requirement states that if funding in this area falls below 50 percent of the total allocation for prevention of sexual transmission of HIV in any country, the Office of the Global AIDS Coordinator (OGAC) must issue a report to congress to explain the failure to prioritize abstinence and marriage promotion.  As long as there is a clear bias towards abstinence-until-marriage promotion programming in the law, countries will disproportionately seek to please the U.S. government and will funnel more monies into this failed approach. This wastes enormous resources on the ground and has created a situation that, if left unchecked much longer, will wholly destroy a comprehensive approach to HIV-prevention in many of the focus countries. Every attempt must be made to promote evidence-based strategies in prevention programming, not the ideological and hypermoralistic framework that characterizes the promotion of abstinence-until-marriage.
 
 
2. Increase Transparency of PEPFAR Prevention Funds
           
Since 2005, some progress has been made on the part of OGAC to provide more disaggregated prevention funding data in the 15 PEPFAR focus countries providing a somewhat clearer understanding of who is receiving the funds and what sort of programs are being carried out. For example, there is a greater delineation between prevention providers solely engaged in AB programming and those doing more comprehensive interventions. However, the substance of the actual initiatives being carried out remains elusive, particularly when it comes to entities receiving pass-through sub-grants from a primary agency. While there has been some improvement,  OGAC must provide a fuller documentation of the content and delivery of prevention initiatives. This recommendation should not prove unduly onerous to OGAC given the extensive grantmaking and reporting requirements imposed on implementers that have generated a wealth of information already in OGAC’s possession. 
 
3. Enact Appropriate Oversight Mechanisms of PEPFAR Prevention Grantees
 
In 2005, this recommendation cited two key concerns. First, we cited a lack of oversight regarding the use of funds by faith-based organizations to ensure they are not proselytizing in their work funded by PEPFAR. Given the escalation in PEPFAR funding and the increasing proportion of funding going to religious organizations, we reiterate that OGAC must provide for a systematic review of the prevention programs by these groups both including closely looking at the materials programs are using and on-the-ground monitoring of program delivery.
 
Second, we recommended then and reiterate now that OGAC collect data and report on the organizations taking advantage of a clause in the law that allows them to opt out of any condom/contraception education under the claim that to do so would be a violation of their religious beliefs. This information seems even more critical as abstinence and partner reduction programs have eclipsed those that include condom and contraceptive instruction. Tracking this information more closely would allow better analysis about the extent to which the clause is invoked and the extent to which condom related services are not being provided.
 
We also now add a third concern in this area and call on Congress to conduct a systematic review of the process by which countries are involved in the development of their annual Country Operational Plans. A great deal of evidence has emerged from individual countries that suggests that the Country Operational Plans are written by OGAC and U.S. personnel in the USAID missions of the countries to meet ideological mandates. As a result, Country Operational Plans too often fail to conform to the actual needs of the countries to combat their epidemics.  
 
4.  Rescind the Anti-Prostitution Pledge
 
As the United States Congress began debate in 2008 on the reauthorization of PEPFAR, one message was sent loud and clear from social conservatives and the Bush White House: the anti-prostitution pledge was non-negotiable.  The anti-prostitution pledge requires all recipients of PEPFAR funds to denounce commercial sex work in order to receive U.S. government funding. SIECUS’ own research in Zambia has documented that the anti-prostitution pledge is more than just a piece of paper. It has manifested itself as the strongest of ideological weapons to shut down any outreach to women engaged in sex work, leaving them at an even greater risk for infection. The lack of political courage in Congress has meant the continuation of this dangerous policy as the reauthorization passed in July 2008 made no efforts to reverse this requirement. Congress must request an inquiry by the General Accounting Office (GAO) to undertake a survey in each of the 15 focus countries to determine the impact of the anti-prostitution pledge on HIV-prevention program delivery to women engaged in sex work. Further, a new administration in 2009 should provide leadership in directing OGAC to work with focus country governments to scale-up HIV-prevention programming to this population and actively engage in mobilizing non-U.S. government resources to fill this vital need. And of course, when the opportunity presents itself in the next reauthorization, this provision must be removed from the law itself.
 
5. Work with the International Community to Implement Programming and Policy that Connects HIV/AIDS to other Issues of Sexual and Reproductive Health
 
The current trend of separating public-health foreign aid into disease-specific silos, such as HIV/AIDS, malaria, and tuberculosis, purports to create a strong enough resource flow to significantly reduce the manifestations of each disease.  However, such segmentation has also led to too narrow a framework/conceptualization.  Sexual transmission is the most widespread driver of the epidemic globally, and women, particularly women in committed relationships, often including marriage, and the children they bear are increasingly becoming infected with HIV. Curbing the epidemic requires greater integration of sexual and reproductive health services to provide the education and commodities needed to prevent the spread of HIV, whether through sexual transmission between partners, or mother to child transmission. Sexual and reproductive health service delivery sites are often the only interface a woman has with healthcare, offering of the opportunity to engage with and gain access to someone who may not seek out information and services elsewhere. For reasons of stigma and discrimination, a woman may not be able to seek out services at healthcare delivery sites specifically oriented towards HIV/AIDS.
 
While OGAC has promoted “wraparound” with reproductive health services funded through funding streams outside of that authorized by PEPFAR, this has not proved sufficiently adequate. Such a narrow focus on HIV/AIDS specific health services has actually meant less money, not just a comparatively lower amount to the PEPFAR funding, on the ground for general sexual and reproductive health services. Due to this reality, the “wraparound,” while it may seem sound in theory, is not, in fact, a solution on the ground. 
 
From a public health perspective, integration of sexual and reproductive health with HIV/AIDS is simply good medicine, but on the policy end, the individual ideologies of policymakers have interfered with the creation of strong policy to support this end. OGAC needs to work with the international community to implement programming and policy that connects HIV/AIDS to other issues of sexual and reproductive health.
 
6.  On-the-Ground Monitoring of Funded Activities
 
Over the past four years of PEFAR funding, it has become disturbingly clear that PEPFAR has transformed the landscape of HIV-prevention programming in each of the 15 focus countries in worrisome ways.  Not the least of these is that the vast majority of PEFAR funding is going to international or U.S.-based NGOs and, in the process, indigenous NGOs in the focus countries are failing to benefit from this record investment. A quick look at the list of grantees in each country testifies to a lack of investment in building up the capacity for prevention programming among local NGOs, and distributing funds so that they may also carry out HIV-prevention programming.  PEPFAR’s largesse will not continue in perpetuity and therefore, investments in local capacity in this area seem among the wisest of investments in a long-term strategy to assist these countries. OGAC should be directed to begin an immediate scaling up of investment in indigenous prevention program providers and to set escalating targets over the next five years that will ensure than at least 50 percent of prevention program funding goes directly to indigenous NGOs.  We have a responsibility to these countries and to U.S. taxpayers to invest in system change in these countries, and that begins with building and investing in NGOs on the ground.
 
7. Eliminate the Clause Which Opens the Door for Implementers to Discriminate Against Certain Populations
 
 
The original law included a provision permitting implementers of prevention and treatment programs to opt out of delivery of services that they deemed to go against their religious beliefs. This provision offered a loophole which benefited the implementer more than those in need of prevention and treatment services, deferring to moral frameworks of the implementers instead of championing the evidence-based strategies. It granted the authority to the implementer to pick and choose which elements of a comprehensive approach to utilize, even when doing so undermines the integrity and effectiveness of the overall program. This troublesome provision raised the concerns of advocates early on whether ideology would trump evidence. In the time that has unfolded since the initial roll-out of PEPFAR programs, this provision has shown to be particularly problematic regarding the implementation of HIV-prevention interventions addressing sexual transmission. Many faith-based organizations have experienced a “moral panic” over the delivery of comprehensive prevention services, fearing a contradiction with the moral frameworks on sexuality derived from their faith traditions. The new law expanded this provision to apply to care services in addition to prevention and treatment services. This move is clearly a step in the wrong direction and must be remedied by fully repealing this clause in the next authorization of this law.
 
 
 
 


[1] Nigeria UNGASS Report 2007, (31 January 2008), National Agency for the Control of AIDS, Nigeria, http://data.unaids.org 14
[2] 2008 Report on the Global AIDS Epidemic Annex 1: HIV and AIDS estimates and data, 2007 and 2001, UNAIDS, (New York, NY), accessed 19 August 2008, http://data.unaids.org 218
[3] Ibid., 214-219
[4] Ibid., 6
[5] 2008 Report on the Global AIDS Epidemic Annex 1: HIV and AIDS estimates and data, 2007 and 2001, UNAIDS, (New York, NY) accessed 19 August 2008, http://data.unaids.org 217-218
[6] Epidemiological Country Profile on HIV and AIDS, UNAIDS, (New York, NY), accessed 12 August 2008, http://www.who.int 4
[7] Ibid., 12
[8] 2006 UNAIDS Report: Country profiles annex 1, UNAIDS, (New York, NY), accessed 19 August 2008,
[9] Ibid., 25
According to the World Bank, “GNI PPP is measured in current international dollars which, in principal, have the same purchasing power as a dollar spent on GNI in the US economy.”
[10] Ibid., 25
[11] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY) accessed 19 August 2008, http://www.unfpa.org/swp/2007/english/notes/indicators/e_indicator1.pdf 87
[12] 2008 Report on the Global AIDS Epidemic Annex 1, 214
[13]Ibid., 215
[14] Ibid., 217
[15] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 19 August 2008,http://data.unaids.org301
[16] Ibid., 307
[17] Ibid., 313
[18] Monitoring ICPD Goals – Selected Indicators, 87
According to UNFPA, “Modern or clinic and supply ­methods include male and female sterilization, IUD, the pill, injectables, hormonal implants, condoms and female barrier methods.” 
[19] 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY), accessed 19 August 2008,
[20] Monitoring ICPD Goals – Selected Indicators, 87
[21] The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC) accessed 5 August 2008, http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf 13
[22] 2008 Report on the Global AIDS Epidemic Annex 2, 296
[23] Ibid., 292
[24] HIV/AIDS National Strategic Framework for Action (2005-2009), National Action Committee on AIDS (NACA), September 2005, accessed 25 June 2008, http://www.nigeria-aids.org 17
[25] Ibid., 34
[26] Nigeria UNGASS Report 2007, 18
[27] Ibid., 19
[28] HIV/AIDS National Strategic Framework for Action, 90
[29] 2008 Country Profile: Nigeria, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 26 August 2008, http://www.pepfar.gov/documents/organization/81638.pdf
[30] 2008 Report on the Global AIDS Epidemic Annex 1, 217
[31] Ibid., 214-215
[32] 2008 Report on the Global AIDS Epidemic Annex 2, 279
[33] Epidemiological Fact Sheet on HIV and AIDS, 16
[34] 2008 Report on the Global AIDS Epidemic Annex 1; See Epidemiological Fact Sheet on HIV and AIDS, 15 for surveys pre-2005
[35] 2008 Report on the Global AIDS Epidemic Annex 2, 284
[36] Nigeria UNGASS Report 2007, 20
[37] HIV/AIDS National Strategic Framework for Action, 25
[38] Nigeria FY 2004 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 8 August 2008,
[39] Total Dollars Planned for FY 2005 by Program Area, U.S. State Department. (Washington, DC), accessed 19 August 2008, http://www.state.gov/s/gac/progress/other/data/program/59798.htm
[40] Approved Funding by Program Area: Nigeria: FY 2006, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 19 August 2008 http://www.pepfar.gov/about/77684.htm
[41] Approved Funding by Program Area: Nigeria: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 19 August 2008, http://www.pepfar.gov/about/82460.htm
[42] Approved Funding by Program Area: Nigeria: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 25 August 2008, http://www.pepfar.gov/about/opplan08/102028.htm
[43] Nigeria FY 2007 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 26 August 2008 http://www.pepfar.gov/documents/organization/103938.pdf
[44] Ibid., 139
[45] Ibid., 140-143
[46] Ibid., 142
[47] Ibid., 141
[48] Ibid., 141
[49] Ibid., 158, 282
[50] Ibid., 159-160
[51] Ibid., 283
[52] Ibid., 276
[53] Ibid., 277
[54] Ibid., 278
[55] Ibid., 309
[56] Ibid., 298
[57] Cary Alan Johnson, Off the Map: How HIV/AIDS Programming is Failing Same-Sex Practicing People in Africa, International Gay and Lesbian Human Rights Commission, 2007, accessed 25 June 2008, http://www.iglhrc.org
[58] Nigeria: Anti-Gay Bill Threatens Democratic Reforms: Homophobic Legislation Restricts Free Speech, Association, Assembly, Human Rights Watch, 28 February 2007, accessed 25 June 2008, http://www.hrw.org/english/docs/2007/02/28/nigeri15431.htm
[59] Off the Map: How HIV/AIDS Programming is Failing Same-Sex Practicing People in Africa, 14
[60] Ibid., 51
[61] Ibid., 68
[62] Ibid., 40
[63] Ibid., 16
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