Commonization of HIV/AIDS services in Nigeria: the need, the processes and the prospects

Introduction With the first case of Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome (HIV/AIDS) identified in 1986, the management of HIV/AIDS in Nigeria has evolved through the years. The emergency phase of the HIV/AIDS program, aimed at containing the HIV/AIDS epidemic within a short time frame, was carried out by international agencies that built structures separate from hospitals’ programs. It is imperative that Nigeria shifts from the previous paradigm to the concept of Commonization of HIV to achieve sustainability. Commonization ensures that HIV/AIDS is seen as a health condition like others. It involves making HIV services available at all levels of healthcare. Methods Excellence & Friends Management Consult (EFMC) undertook this process by conducting HIV tests in people's homes and work places, referring infected persons for treatment and follow up, establishing multiple HIV testing points and HIV services in private and public primary healthcare facilities. EFMC integrated HIV services within existing hospital care structures and trained all healthcare workers at all supported sites on HIV/AIDS prevention, care and treatment modalities. Results Commonization has improved the uptake of HIV testing and counseling and enrolment into HIV care as more people are aware that HIV services are available. It has integrated HIV services into general hospital services and minimized the cost of HIV programming as the existing structures and personnel in healthcare facilities are utilized for HIV services. Conclusion Commonization of HIV services i.e. integrating HIV care into the existing fabric of the healthcare system, is highly recommended for a sustainable and efficient healthcare system as it makes HIV services acceptable by all.


Introduction
With a national HIV prevalence of 3.4% as at 2012, HIV/AIDS is one of commonest causes of death in Nigeria [1]. It is estimated that 3,400,000 adults and children in 36 states and the Federal Capital Territory (FCT) of the Federation are living with HIV with about 260,000 new infections occurring annually [2]. Although the epidemic is now described as stable as a result of its prevalence hovering around 4% in the last five years [3], Nigeria has lost hundreds of thousands of bread winners to this epidemic. Over the past decade, there has been an unprecedented global response to the AIDS epidemic leading to a rapid scale-up of HIV treatment and prevention which has consequently saved millions of lives and transformed communities around the world. Since 1999, the year in which the epidemic is thought to have peaked globally, the number of new infections has decreased by 19% [4].The lowest levels of new HIV infections have been reported this century at 2.1 million.
In the last three years alone, new HIV infections have fallen by 13% [5]. More than 2.5 million deaths have been averted through treatment since 1995, and currently 6.6 million people are receiving treatment in low-income and middle-income countries [4]. Since 2004, when treatment of HIV/AIDS started effectively in Nigeria, it has been largely donor dependent. In 2007, 85.4% of all HIV expenditure was derived from external sources and this increased to 92.35% in 2008 [6]. Through these programs, 538,000HIV-infected people had received Anti-retroviral therapy (ART) as at 2013 [7].
However, the goal of universal access is limited by number and location of service delivery points. As at 2013, only 6,675,000 people were tested for HIV [7] and this represents about 4% of the total population of Nigeria while, only 17% of HIV positive women received Anti-retroviral (ARV) drugs for Prevention of Mother-to-Child Transmission (PMTCT) [8]. In existing treatment sites, HIV services are provided through vertical programs with specialized personnel, separate laboratories and specific clinic days. This programming model is expensive, unsustainable and fuels stigma and discrimination among HIV-infected and affected persons.
As demand for HIV treatment and care services increases, the health systems as currently supported will be increasingly stretched while resources available through donor agencies remain constant or decline. Therefore, there is the need to expand the capacity of health systems and personnel in a sustainable manner, compatible with existing mechanisms for managing chronic illnesses. Subject matter experts opine that key strategies that should be employed to sustain HIV treatment and care programs in high HIV-prevalence low and middle-income countries (like Nigeria) over the coming decade include further decentralization, task shifting, and integration of HIV services with other chronic disease treatment services [9]. In the long-term, the increased demand for HIV-care services can only be satisfied through increased decentralization to peripheral health units, with the role of each type of unit being appropriate to the human and material resources available to it [10]. Integration of HIV services is defined as co-location and sharing of services and resources for HIV care and primary care, such as clinic space, clinicians, health education, pharmacy, laboratory services, and training [11].
As a result of non-integration of HIV services into the fabric of the healthcare systems at all healthcare facilities, once there is cessation of funding by donor agencies, a collapse of the HIV program will result. However, this highlights the need for realistic budgeting by national governments [9]. While these strategies address the supply end of the HIV service chain, the demand can only be addressed by increasing client confidence through improved understanding of HIV and concerted efforts in eliminating stigma and discrimination. Despite the current decentralization, there is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers [12].
To address this, reduce cost of management and ensure sustainability of care -even post-funding era, Excellence and

Methods
With funding from US Government, the need to reach more in a unique project Christened "Reaching All with Care and Support To achieve sustainability and ownership of the HIV program by healthcare workers, all supported sites were encouraged to own their data, use their data to develop manuscripts as well as inform program review, strategy and improvement activities. Weekly reports of activities were required from all supported sites. Monthly meetings of PLHIV Support groups were encouraged and established. During these meetings, both clients and facilities' staff interact to discuss issues relating to their wellbeing and sustainable ways of managing HIV/AIDS and its effect.

Results
One hundred and twenty-one public and private healthcare facilities   Figure   2 shows the increase in HTC after integration of HIV services into the Immunization clinic at PHC Lugbe, one of EFMC's supported sites.
In a study carried out among TB cases in West Bengal, India, it was concluded that comprehensive strategies to change providers´ beliefs and practices, decentralization of HIV testing to all TB care centers, and improved HIV test kit supply chain management may increase the proportion of patients with TB who are tested for HIV [18].
HIV-care services can also naturally integrate with the care of chronic non-communicable diseases and with closely related services like mother and child health, and thus should promote a shift from vertical to integrated programming. Staff training and support around a set of evidence-based policies and guidelines and a reliable supply of essential medicines and supplies are further essential components for a successful program [10]. people where they live and work is an effective mechanism. People will access services if brought closer to them at free or cheaper rate.
A study in Malawi showed that household members in the lowestincome quartile were significantly less likely to have ever used facility-based HIV testing than the rest of the population but were 70% more likely to use the home-based rapid HIV testing program [20]. Most Nigerians, whether in urban or rural settings, are aware of the importance of immunization and this is as a result of the massive campaigns and outreaches carried out in communities. This process has been employed in National Immunization days and can also be replicated to HTC, as a national strategy.
In addition to the above strategies to de-centralize HIV services and provide services where people live and work, engagement of