UM's HIV effort offers ray of hope in Nigeria


GWAGWALADA, Nigeria -- Fired by her boss and evicted by her landlord after she received a diagnosis of HIV, 30-year-old Felicia Nimji retreated to a sweltering, windowless, concrete room better suited for a jail cell.

Without money, she had little to eat, and there were no friends or family members to help. She had quit taking her antiretroviral pills. For weeks, she had been slipping away in the dim light, barely able to see, let alone believe, the sticker on the wall: "God who lifted me up will not let me down."

It was in this bleak setting that a University of Maryland-trained outreach team found her lying disconsolately on a blanket one afternoon.

"I don't have anyone to help me," she said, crying.

"We're here to help you," said Emily Umaru, an outreach coordinator.

Combating human immunodeficiency virus requires more than doling out pills. When it comes to treatment and care, it also means training health workers, fighting stigma, equipping laboratories, emphasizing testing, stressing adherence for those on pills and seeking out the scorned, people such as Nimji.

All of those elements are part of a federally funded program run here by UM's Institute of Human Virology. The success of such efforts is critical. Nigeria's HIV rate is still much lower than southern Africa's. But experts say an explosion of the disease in Nigeria, Africa's most populous nation with more than 130 million people, would be catastrophic.

Nigeria has the world's third-highest number of people with the AIDS virus, after India and South Africa. Despite an apparent drop in the national rate, to 4.4 percent of adults from 5.8 percent in 2001, few think the battle is anywhere near over in this teeming West African nation.

Since it began in early 2005, the Maryland program, with $31 million from the U.S. government this year, has pushed hard to make headway at seven locations around Nigeria, including this dusty town south of the capital, Abuja, in the country's center.

"It has given a lot of hope to the downtrodden," said Dr. Nandul Durfa, chairman of the sprawling government-run Gwagwalada Specialist Hospital.

Eighteen months ago, his hospital was treating 400 people for HIV, and patients had to pay $7 a month plus the costs of lab tests, large sums in a country with extreme poverty. Since then, enrollment has shot up, with nearly 4,000 patients receiving the life-extending pills and related lab services free.

Across Nigeria, the Maryland program was treating more than 16,000 patients by July, a third of the 50,000 who are receiving drugs paid for by the United States. Another 50,000 are getting pills from the Nigerian government with help from the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

With 3.6 million Nigerians infected, according to a United Nations estimate, even the rising number of patients being treated accounts for a small fraction of those who need antiretrovirals.

"We're getting there, slowly," said Dr. John Farley, a pediatric AIDS specialist and leader of the Institute of Human Virology-Nigeria.

Pills are only part of the solution, he said. The institute's program - called ACTION and funded through the Bush administration's $15 billion, five-year AIDS venture - has had to start with the basics to build up the public health infrastructure.

Before the program began, the Nigerian government had no machines to measure CD4 cells, basic devices that gauge when patients need to begin antiretrovirals and monitor their progress. At a cost of $100,000 each, the program has outfitted several new labs with advanced equipment, but not too advanced.

"It's very important that we don't bring in technology that is absolutely useless in terms of the future for Nigeria," said the institute's Dr. Alash'le Abimiku, who is from Nigeria. "We can't import engineers from the U.S. for repairs."

Training has focused on ensuring rudimentary standards in those labs, she said, adding, "If you do not make sure the temperature is right for the test, I'm sorry, you're going to get it wrong. They're very simple, very basic, but we spend a lot of time on that."

In part because the U.S.-funded program will not last forever - the Bush plan is halfway finished, though it could be extended - Nigerian doctors are being trained in how to identify and treat HIV-related ailments.

One morning, Dr. James Shepherd, a University of Maryland infectious-disease specialist, sat in an examination room as Dr. Oluokun Young, 32, pondered how to treat a man named Mohammed. The patient had advanced HIV and possibly tuberculosis. He was not eating much because of a painful oral thrush condition common in HIV sufferers.

At first Shepherd suggested starting with medication to ease the thrush, followed by TB pills and then antiretrovirals for the HIV. Young came to a different conclusion: Because the TB was not yet "well founded" and the primary antiretroviral treatment could have worsened his anemia, he prescribed a different HIV medication right away along with something for his throat.

Shepherd approved. "I think he's got a good plan for you," he told Mohammed.

Prevention, which is critical to slowing an epidemic such as HIV, is not a core focus of the Maryland program. Those running it speak little about the relative merits of condoms, abstinence and monogamy, for example.

One key exception is in trying to prevent babies from being born with the virus. At Gwagwalada Hospital's HIV clinic, pregnant women can receive free tests. Those who test positive can be given Nevirapine to minimize the chances of passing on the virus during delivery. They are also told about the risks of transmission through breast feeding.

Kadijat Audu, who at age 20 has an infant son and is five months pregnant with her second child, had learned of her status for the first time. As she sat with nurse counselor Naomi Mgbami, she looked nervous beneath her colorful maroon and yellow scarf.

"The result is ready," Mbgami said, spilling out the words as quickly as she could. "It's negative. You're doing fine. You don't have HIV."

Audu did not react at first. Then she smiled and said, "Thank God for that" before walking out with advice from the nurse to stay faithful to her husband and to refuse injections outside a clinic setting.

Affecting everything the University of Maryland doctors do is the stigma surrounding HIV. Here, as in many parts of Africa, HIV is seen as having a moral component because, unlike, say, tuberculosis, it is transmitted sexually.

Patients will bolt from waiting rooms for fear of being spotted by someone they know. Churches send busloads of people to clinics hours away to keep knowledge of their status within a small circle of people.

"It's a huge barrier to speedy treatment and even prevention," Shepherd said.

So the Maryland program has tried to enlist as allies Gwagwalada's local leaders, most of them Muslim, who command great respect.

One afternoon, the traditional king, Alhaji Mohammed Magaji, received a delegation from the hospital. The meeting took place in an octagonal room staffed by men-in-waiting who wore flowing red and green tops and held whiplike switches. As the king sat on a raised platform, two dozen community leaders, all men, sat on the carpeted floor.

The king expressed thanks for the Maryland program and said he hoped that growing awareness of HIV would reduce the stigma attached to it. When the community leaders were asked who among them had been tested, there were murmurs and smiles, but no raised hands.

"Nobody raises his hand because they were not tested," the king explained. "They were not aware these services were available."

He has tried to set an example by supporting the volunteer outreach program and by taking volunteers to the hospital for the weeklong training.

That training is led by Asabe Gomwalk, who was animatedly addressing more than 50 new volunteers one Thursday morning. She elicited several ideas, including alarm clocks and morning and evening prayers, for giving people cues to remember their twice-a-day pills.

"If I don't take the drugs," Gomwalk asked, "will I be better?" The crowd replied with a chorus of "no."

Mindful that adherence to pill regimens is a big challenge because erratic use can create resistance to medication, Gomwalk asked what a volunteer would tell someone who wants to stop the pills because of nausea or rashes.

"Tell him to continue," one woman said.

"Thank you," Gomwalk said, beaming. "With time the body gets used to these drugs."

The next day, volunteer Queen Olekaibe put her training to use. Sweating in Felicia Nimji's dark room, she asked the ill woman, "Don't you think stopping these drugs results in illness?"

Nodding, Nimji mumbled that she could not take the pills without food and that she had no money for food. Olekaibe and Emily Umaru swept into action. They fetched water and showed Nimji how to use water-purification tablets. Olekaibe said she would return to set up an insecticide-treated mosquito net. They pledged to ask Nimji's pastor for food donations.

Nimji's condition has since taken a turn for the better. Because of the institute's intervention, her spirits have risen. And she is back on her medication.

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