Bringing the HIV epidemic in Nigeria to an end : a mixed methods study exploring why HIV remains an important public health challenge in Benue state and Nigeria

Abstract

Introduction Human immune deficiency virus (HIV) remains a global public health challenge, with its burden varying steeply between rich and poorer nations. Despite advances in HIV diagnosis and treatment, certain populations continue to report high HIV prevalence and deaths. The main objective of this research is to explore variables that define HIV epidemiology in Benue State, Nigeria. HIV prevalence in Benue State is above the Nigeria national average of 3.2%. Methods An exploratory mixed methods research, incorporating a comparative analysis (of qualitative and quantitative data) and a systematic review (and meta-analyses) in the review of literature. Information generated from the literature review informed the content and direction of the empirical research. Data from qualitative and quantitative exercises were analysed and presented using standard techniques (for example thematic analysis for qualitative data and regression analyses for quantitative data). Results There is strong association between HIV burden and multiple deprivation. Variables associated with increased HIV risk in Benue State include female gender and low socioeconomic status. Religion, sex education and, local norms shape local HIV epidemiology through poor risk perception and social cognitive dissonance. Poor risk perception and social cognitive dissonance, in turn, lead to high HIV risk behaviours by reducing preparedness for safer sex practises. There was overwhelming local support for the passage of laws that criminalise deliberate transmission of HIV. Risk for HIV in Benue state vary significantly by places and areas of residence, with residents of rural and Idoma speaking areas being at increased HIV risk. Using condoms at first sex was significantly associated with lower HIV risk score (coefficient -0.25, P = 0.012, CI = -0.4458 - -0.0558). Tendency to stigmatise was significantly lower among those with tertiary education (coefficient = -0.88, P = 0.017, iv CI = -1.6009 - -0.1580). Predictors of consistent condom use include urban residence (OR = 3.68, P = 0.028, CI = 1.16 - 11.73), HIV knowledge scores (coefficient 1.66, P = 0.001, CI = 0.72 - 2.61) and condom use at first sex (OR = 5.61, P = 0.016, CI = 1.41 - 22.36). Inconsistent condom use was more likely among those who reported not having sex education at home in the past (OR = 0.32, P = 0.001, CI = 0.17 - 0.61). Marital status was not found to be protective against HIV risk in the meta-analysis (OR = 1.44, P = 0.44, CI = 0.57 - 3.63). Important epidemiological link between general population and known high HIV risk groups (like sex workers and MSM) was found, via Okada men. It was demonstrated, for the first time, that Okada riders may constitute an overlooked high HIV risk group locally – further research is needed to explore this finding. Conclusion There is need for comprehensive interventions that address individual and structural variables that influence local HIV epidemiology. The need for increased medication access cannot be overemphasised. Local interventions need to be decentralised, brought closer to the grassroots and, made sensitive to the needs of locals (especially among the older and less educated locals in rural settings). Mobile phone applications and, sex education (as part of schools curriculum), are some of the interventions and policy changes urgently needed. More controversial approaches such as criminalisation of deliberate HIV transmission are worth exploring further due to strong local support for such policies. Further research is needed to explore the relationship between local alcohol consumption and increased HIV risk as well as the role of “Okada men” in local HIV epidemiology.