Situation Analysis Report on STD/HIV/AIDS in Nigeria

The present Situation Analysis for STD/HIV/AIDS is the result of the work of many individuals and teams working under the leadership of the Hon. Minister of Health, the chairmanship of Prof. G.C Onyemelukwe who led the Team setup by NASCP and the Chairmanship of NACA.

We would like to commend the political commitment of President Olusegun Obasanjo, who is constantly lobbying for actions to be undertaken in the field of STD/HIV/AIDS for Nigeria, and who isclosely following the preparation of the Strategic Plan that will bring an expanded national response to the fight against the epidemic in the country.

We would like to thank the Hon. Minister of Health for his determination in sharing the Strategic Plan vision with his collaborators, and particularly in making multisectorality a reality.The situation analysis is the picture of what is happening in all the various fields and sectors involved in the alleviation of the HIV/AIDS epidemic in Nigeria, and not only in the health sector alone.

Our thanks also go to the Honorable Ministers of Information, Employment, Labor and Productivity, Culture and Tourism, Planning, Women and Youth, Education, Finance, Internal Affairs Agriculture and Sports, PLWHA, Governors of all the states, Commissioners of Health in all states, Chairmen of local governments, NGOs,
We would like to thank in particular the teams who have been working, sometimes under difficult situations, at States and local government levels to gather

The support at field levels are greatly appreciated, and our thanks go to all the persons whoaccepted to help, we unfortunately cannot enumerate all of them.

We also appreciate the contribution of DFID, WHO, UNICEF,USAID staff, who supported the various teams and also UNAIDS for their support of the revision of the situation analysis.
The situation analysis here presented will be widely distributed in order to obtain comments from all developmental partners at state, zonal, national and international levels. We therefore thank all those who will read this situation analysis

Prof. Ibironke Akinsete
NACA Chairman

Executive Summary

The situation analysis shows that STD/HIV/AIDS has unfortunately not been sufficiently addressed in the past decade. This is due to:

Unstable political situation in the country.
Lack of political will, commitment and involvement
Competing priorities in other areas.
lack of multisectoral approach as major interventions so far are in the area of healthcare delivery.
Centralization of the program, with little involvement of States and local governments.
Despite excellent intentions, programs are donor driven and often not sufficiently coordinated. Mostly “project oriented “ activities with little program approach Major donors had frozen their assistance for long periods of time
UN theme group had little impact during the period under review.
little recognition and lack of support for the work done by NGOs and CBOs
weaknesses in general planning and programming
absence of financial support for STD/HIV/AIDS activities in other sectors except for a minimal budget from the Ministry of Health
Weaknesses in management issues and management systems, including Information system management and poor data on the epidemic but also weaknesses in planning, programming, procurement, finance.
Insufficient nation wide awareness reflected by weak advocacy and information programs towards general populations and specific at risk groups: youth, women.
Persons living with AIDS were reluctant to actively participate in prevention and control activities.
The legal system has not been sufficiently adapted to the evolution of the situation, and the ethic committee on HIV/AIDS is not functional.

As a result of all these factors the situation analysis demonstrates that actions in the field of advocacy, information and awareness development have been scanty, and this has led the population to feel that STD/HIV/AIDS is not a major problem concerning them.In addition, AIDS is still regarded as a health problem and therefore is not sufficiently focused on behavioral change communication targeted at all Nigerians which would result in health seeking behaviors leading to early testing, and early treatment.

The available data, which is mostly based on sentinel surveys of adult pregnant women, shows that the sero prevalence rate for adult women is 5,4% as compared to 1.8% in 1992.

The situation analysis shows that:

There are indeed some weaknesses in the data as presented.It is mostly based on the sero prevalence of pregnant women. Infected women tend to have a lower chance of becoming pregnant, and therefore do not automatically frequent antenatal clinics where the surveys are taking place. Little data is available concerning youth, and pediatric HIV infection rate. Few other sero prevalence studies are available in other groups e.g. male adults with the exception of scanty data on the military and prisons.
Information concerning incidence rates is extremely scarce. The voluntary screening centers are still very few in the country, and besides the private sector, which is widely developed in Nigeria, does not share its data with the Public sector.
The association of STDs with HIV has not been sufficiently addressed throughout the period, and STD control (early detection, and early treatment) has been neglected as an essential part of the response to fight HIV.(Data on STD is scanty).
A substantial amount of planning has been undertaken, but what often fails is that these plans have not been implemented in most cases.Examples are numerous: for years Nigeria has worked on Blood safety guidelines, including how to ensure a National Blood Transfusion service, how to screen the blood to be transfused for HIV, Syphilis, and Hepatitis B, but while plans exist for the past years they still have not been implemented. Other examples can be cited: guidelines are available in almost all fields, but they are often not distributed or else the training of staff to utilize them is not undertaken.

The situation analysis has identified these fundamental weaknesses:

All linkages to health have been unsuccessful because there is a weak primary health care system. It shows that it has hindered even actions in the field of voluntary testing: Why tell a person that he is sero positive if the PHC back up cannot provide the essential support.
Past actions in the MTP l and ll have been project and action oriented instead of program oriented. The links between all these projects and actions were not evident.
Financial allocations have never been sufficient to support MTP I and MTP II
Past actions have lacked coordination – Most partners do what they want where they want, and this includes NGOS, CBOs and International organizations, the Private sector, etc. Past actions have lacked adequate monitoring and evaluation. Little is known about where one is starting from and of course it is difficult in such conditions to measure the results of any activities.
Much has been done, but with little impact as there have been insufficient efforts to share information, network and document information.
The medical field is far more advanced in reporting what is going on (although as mentioned above there are still lots of weaknesses) than the other sectors. In particular the social, economic and cultural sectors are not sufficiently involved. There is lack of behavioral, cultural and economic impact studies. Information about youth, women, labor force, the informal sectors, children in and out of schools, women and men working in the informal sector, are lacking.
NGOs and CBOs work has not been sufficiently documented. This is one of the gaps that will have to be addressed.
States and local government are not sufficiently aware of what is going on in their territories in terms of STD/HIV/AIDS alleviation, and they are not sufficiently sensitized to the importance of undertaking multisectoral approaches to fight the epidemic.

Besides this long list of obstacles, many opportunities have been detected at multisectoral levels. The analysis of the response will demonstrate if these opportunities have been sufficiently taken into account. Some of these are:

The recent commitment at the highest level and shared vision by government leaders under the new expanded National response initiative.
The Government’s determination to support a Multisectoral approach
The Government’s determination to involve a new Multisectoral Presidential Committee on AIDS (PCA)
The Government’s determination to support a new Multisectoral committee on AIDS (NACA) and to make sure that they have the personnel, the space and the financial support to execute the program.
The Government’s efforts to establish a National response through the Strategic Plan.
The willingness of the Ministries and political bodies (Senate, House of Representatives) the organized Private sector, NGOs, PLWAs to join and collaborate with NACA.
Several reforms in the various sectors to make STD/HIV/AIDS a priority (Education, Health, Women and Youth, Sports, Labor, Finance, Planning, Defense, etc.)
Poverty alleviation programs
Beginning of Strategic Social Sectors Policies
Community response and involvement triggered by the work of NGOs and CBOs. And various peer group associations e.g. youth clubs, artists joining hands, media – net, Journalist against AIDS
Social marketing of condoms
Information services are reaching more and more communities, and they are adapting the information to their needs, including utilization of local languages (Increasing media response)
There is an increasing consciousness among International organizations including donors are becoming more and more conscious that an integrated approach and more coordination is necessary to help the Government, States and Local government develop their national response.

The exercise has demonstrated that Nigeria is now in a position to analyze its past programs with a real desire not to destroy what has been done so far, but to positively criticize it. This is in order to find solutions to the various problems that have been encountered and to utilize all opportunities that have been developed during the period under review. The realities have not been hidden, and that in itself is an immense step forward.

The situation analysis as conducted provides an excellent basis to map out what has been done so far and to spell out what were the difficulties and the opportunities in key sectors. It is essential to conduct the next step which is the analysis of the response which will show why it has not worked, or why it has worked in order to decide on what to prioritize in terms of efforts. What is working can be retained while strengthening what was not working so well, and also have the courage to drop all activities, which have hopelessly shown their failure to respond.

Introduction

Nigeria with a population of about 120Million people represents about 1/5 of the total African population. The result of the recently concluded November 1999 Sentinel Survey indicated that 5.4% of the adult population, which represents 50% of, total population are already infected with HIV. This means that 2.6 Million adults are living with the HIV (SOURCE, See Bibliography).

Nigerians in policy and academia in the early eighties denied the presence of HIV infection in Nigeria, which probably delayed the country from quickly, and appropriately reacting to the surging wave of the epidemic as was done in many other African countries. The first case of AIDS was reported in Nigeria 1986. Since then the trend has been on the increase as shown on fig 1-5.

The most severe impact has been on adults in their sexually active and economically reproductive years that is (15 – 45 years of age).

In certain areas like Enugu State, the mean HIV prevalence had increased from 2.3% in 1995 to 16.8% by 1999, an increase of more than 700%. Similarly eight other areas in the country had HIV prevalence rates greater than 10 percent.

The socio-economic impact of this epidemic on the Nigerian society has not been documented but it is becoming apparent that the already fragile health care delivery system is being overloaded. There are also more reported cases of monoparental families and orphans. Furthermore the Nigerian population continues to increase at an alarming rate of 2.83% or more. Hence, the projected impact will have disastrous consequence on the population of Nigeria and ultimately of Africa and the world. Despite all these, the Nigerian populace still continues to deny the existence of the disease.

HIV/AIDS/STD control program structures exist in the states and LGA but are confined to the Health sector alone. Although, many other partners have been involved (NGO, CBO, Religious organizations, Bilateral and multilateral organization), co-ordination of these efforts were weak and the program were very much donor driven and project oriented.

Objective of the Situation Analysis

The overall objective of this situation analysis conducted in Nigeria was to understand the background factors that will help developmental partners, government (National, State and LGA and Communities) identify the most important areas for action to be developed in the strategic plan and budgeted plans of action. The specific objectives were as follows:

Identify who is vulnerable to STD/HIV/AIDS and why.
Identify the most serious obstacles that affected the implementation of STD/HIV/AIDS control and prevention activities in the country.
Identify the most promising opportunities for expanding the response of Nigeria to the epidemic.

Scope

The scope of the situation analysis was to have a total picture of what has been done so far in the whole country, which involved developmental partners in this exercise. It also involved obtaining data and documentation of STD/HIV/AIDS on-going activities over the period. Research

Methods and Approaches

Methodology
Nigeria has 36 states and FCT with 774 LGA and communication systems are difficult. Also because the budget to support the strategic plan formulation was limited, the following methodology was chosen:

Advocacy meetings with Federal ministers, governors, commissioners, heads of hospitals, traditional / religious leaders and professionals associations.
Focus group discussions with youths, NGO, CBO and the organized private sector.
Questionnaires (quantitative and qualitative) to the general public, sex workers, hoteliers, laboratory scientist, heads of hospital, religious, traditional leaders and traditional healers, and NGO.

The multisectoral and multidisciplinary committee which carried out the situation analysis under the direction of NASCP, were representative of the following institutions:

States ministries of health
Federal ministries (Health, education, labor, defense, information, youth, women, sports) planning commission, National population commission.
The academia: universities, research institutions, and tertiary hospitals.
DFID, UNICEF, WHO, USAIDS
Organized private sector.
PLWHA
NGOs, CBOs

The situation analysis was originally planned to commence in January 1988. However due to various problems including non-availability of funds, it did not start until January 2000. The exercise was conducted over a period of 8 weeks.

Due to the short period for this exercise gaps have been identified and will be addressed in the strategic planning exercise and will be effected in the strategic planning activities.

Other limitations were insufficient time for training of all participants including members of the committee as well as poor utilization of guidelines. (UNAIDS Strategic Plan Guidelines)

Detailed Methodology

The various approaches included:

Formation of field teams.
Development and production of 15 sets of questionnaires for different target populations (Laboratory, Policy makers, Healthcare workers, General public, PLWHA, Traditional healers and Leaders, CSW, Hoteliers, Prisoners, NGOs, CBO SAPCs).
Training was minimally carried out for the field workers while the team leader carried out supervision. No pre-testing of the questionnaires were done as a result of the short time frame for the fieldwork.
Memoranda were invited from the general public through newspaper advertisement (New Nigeria and the Punch Newspapers); NTA and Federal Radio Coperation of Nigeria. Invitation letters were also delivered to The President of Nigeria Labor Congress and its 15 unions, including Health workers and NECA
One day visit per state
Random sampling of target population.
During the field visits data was collected through the following means: Direct administration of Questionnaires, Observation equipment, IEC materials, inferences drawn from Advocacy meetings with the Governors, community and Traditional Leaders; Moderation of FGD, in-depth interviews. Team members served as interviewers, reporters, moderators and key players in advocacy meetings. Where applicable tape recorders were used by the groups to record discussions.
Direct assessment of laboratory equipment, kit stock, equipment, personnel etc was also done to gather information.
The Staff of the secretariat of the AIDS Control Program were also used to assist in the data gathering process in each of the states. Evaluation process in the states involved situation and response analysis, which include the structure at the state and local Government, secondary and tertiary institutions and other facilities.
Team group were created to undergo situation analysis – the states level and LGA (See annex for constitution of the team).

Data Entry and Analysis

Quantitative and qualitative data were obtained. A team composed of an Epidemiologist and a Computer Analyst was constituted to analyze data obtained from questionnaires and the focus group discussions. The data was managed using MS Access and MS Excel. The results of the analysis were disseminated amongst the members of the Central Evaluation team and modified in line with the comment of the teams. A report was produced in limited quantity for the perusal of the Minister of health. Further work is being done in order to present this result for wider distribution locally and internationally.

Analysis of the situation in key areas
A decision was made to collect information in the following key areas:

Safe sexual behavior
STD management
Blood safety
STD/HIV/AIDS prevention in young people
STD/HIV/AIDS prevention in women
Care and support at Federal, state and community level
Labor force
Sexuality education
Psycho social help and counseling support
Human rights and ethics
Research

In addition some cross cutting issues were studied e.g.

Management
IEC
Monitoring and evaluation
Partnerships
Funding
Multisectoriality
Community involvement

Needs: Safe Sexual Behavior

Obstacles

Opportunities

Continued Denial of the existence of AIDS.

Education

Limited information in local languages
Limited information on STD/HIV/AIDS
Limited use of local channels of communications
Absence/limitation of sexual education in schools
General low enrolment of children at primary level and even higher in secondary and tertiary schools.
Girls attendance in school still low
Ignorance and illiteracy
Poor media interest and development

Culture

Negative cultural factors
Influence of religious factors
Youth cannot speak about sexual behavior with parents, teachers and they cannot publicly mention the subject
Myths and misconceptions and very strong beliefs of cures about STDs in general
Male sex behavior dominance
Sex freedom and acceptability of sexual behaviors such as multiplicity of partners, early sex, early marriages, child marriages, wife inheritance when widowed, etc. Youngsters have sex early resulting in many teenage pregnancies.
Social sexual networking

Social behaviour

Indifference shown to STD/HIV/AIDS by population in general and youths in particular
Lack of perception of risks especially among youths.
Prostitution
Poverty / affluence attraction to sex
Social pressures and peer examples
Crime
Lack of data on Homosexuality.

Condom

Lack of counseling and VCTs
Non acceptance of condom
No female condom
Low availability of condom
Poor quality of Condom
Cost of condom.

Education

Curriculum for integrating STD/HIV/AIDS developed (1998) but not yet implemented
Plan to bring sexuality education into schools. But not yet put in place
Availability of communication channels at local levels
Efforts to raise attendance especially of girls in primary schools.
Media involvement
National video counseling board – multisectoral
Advocacy targeted at government at all levels.
Sporting events
Private T.V Stations

Social behavior

Poverty alleviation program
Involvement of NGO’s CBO’s and Religious organizations.

Condom

Social marketing of condoms

Political Commitment

Political commitment at the highest level.

Needs: STD MANAGEMENT

Obstacles

Opportunities

Early Detection

Not sufficiently integrated into PHC
Lack of information about where to go for diagnosis Lack of information about
STDs among population
Fear of Stigmatization
Lack of confidentiality at health services level Inadequate facilities at all levels of diagnosis
Cost of investigation
Non/poor availability of laboratory facilities for diagnosis
Lack of relevant skills for laboratory detection
Competition with alternative medical practitioners
Insufficient number of Health workers
Poorly distributed personnel Vulnerability of women
Unavailability of data systems and poor management information system.
Absence of information on private sector
Lack of youth friendly services
Paucity of relevant drugs
Private sector may not follow norms and guidelines
Difficulties in the application of syndromic guidelines

Early Treatment

Cost of care Self medication
Poor availability of drugs
Competition with quacks
Use of street/expired/fake drugs
Non compliance with treatment and self medication Poor availability of treatment guidelines
Poor distribution of available guidelines
Lack of appropriate skills for treatment Inaccessibility to PHC facilities in some areas
STD treatment assigned to special clinics Ineffective procurement of drugs
No information on cost/practices of private sector
Stigmatization
Cultural beliefs
Poor management of staff
High turnover of trained staff
Poverty (Staff and Clients)

Epidemiology and Prevalence

Poor Management Information System on STD
Institutional diagnosis and management systems of STIs are not available
Information sharing between Public and Private sectors non-existent.

Counseling and information

Paucity of counseling service/personnel at all levels
Poor utilization of condoms and counseling facilities
Limited number of trained counselors at all levels
Poor patronage of available facility
Limited use of available counseling services due to stigmatization.

Routine syphilis test for ANC
Available, recently reviewed guidelines on Syndromic management
Ongoing strategic plan on STD/HIV/AIDS
Renewed strength for PHC
Renewed strength for NHMIS
Availability of NGOs, CBOs and religious organization
Media favourable to HIV/STD problems
Existing essential drug list
Cost recovery system through drug revolving fund. Helping to lower the cost
Existing curricula in training institutions.
Early manifestation in Men leading to search for help.
National Health Plan

Needs : Blood Safety

Obstacles

Opportunities

National policy not yet implemented
No legislation to back up policy
No national blood transfusion services
Uncoordinated services at state level
Uncoordinated/ unsupervised private/ public laboratories
No application of norms by blood bank
Inadequate number of trained personnel
Lack of supervision at all level
No standard operating procedure
Lack of information and education on risks to public
Cultural and religious factors that impede blood Alternative Treatments.
Lack of voluntary non remunerated blood donor system
Non sustainable supply of consumables and reagents
High cost of processing blood for transfusion
Lack of blood substitute.
Lack of blood components
Lack of facilities to prepare blood components.
No standardized pricing system
Poor storage facility (Cold chain)
Poor packaging
Short expiry dates – reagents
Too many unnecessary transfusions prescribed (Anaemia - very common in women and children, Malaria, Sickle Cell)
Poor political and financial commitment

Availability of private laboratory (When coordinated/supervised)
Known prevalence of HIV due to transfusion
Edict in Lagos state against blood transfusion not screened
Availability of private blood banks
Existing institution/curriculum for training
Interest of donor (DFID, WB, WHO, EU)
NGO “blood for life” in Lagos
Availability of documents – workshop carried out e.g. appropriate use of blood.
Year 2000 WHO day theme – Safe Blood
Autotransfusion
Lagos and Oyo states have semblance of state level transfusion services.

Needs: Youth

Obstacles

Opportunities

Inadequate and non implementation of policy on integration of STD/HIV/AIDS into school curriculum
Many children and youth not in schools
Inadequate sensitization of policy makers and implementors
Inadequate funding of youths – related
STD/HIV/AIDS programs
Negative attitude of parents to sex and sexuality issues
Religious organizations attitude towards sexuality education
Inequality of opportunity for education between boys and girls
Poor role models of adults in society
Early marriage for girls
Poor perception of risks of STD/HIV/AIDS
Negative peer pressure
Influence of pornographic materials
Non implementation of censorship policy (videos, films)
Lack of youth friendly health care services – counseling facilities
Economic factors – desire to get rich quick Increasing drop out rates in school
Poverty Sexual harassment/abuse in school
Hawking
Increasing prevalence of street children and area boys
Declining moral standards Increasing moral decadence
Easy access of youth to alcohol, drugs, bars, nightclubs, etc.
Decreasing parental supervision of youths
Poor recreational facilities for youths
Non implementation of laws and rights of children/youths
Increasing unemployment
Lack of social welfare package
Increasing indiscipline in the society
Misplaced priorities
Paucity of channel of information targeted at youths
Increasing IV and non-IV drug use among youths.

Sexuality education policy
Poverty alleviation program
Creation of jobs
Availability of laws to protect children
Introduction of UBE (Universal Basic Education)
Existing institution
Availability of religious and traditional institutions
Family life education in schools
Existence of youth clubs and associations
Availability of youth friendly club and societies.

Needs: Care and Support

Obstacles

Opportunities

EARLY DIAGNOSIS

No facility for VCT
Expensive cost of diagnoses Inadequate facility for diagnosis
Poor health sector beheviour for prevention and diagnosis
Paucity of reagents and consumables
High cost of screening
Poor quality control of testing
Donor apathy in care and support
Care and support not linked to prevention

COUNSELLING

Inadequate facilities for pre/post test counseling
Inadequate skills of health care providers
Inadequate number of social workers.
Paucity of trained counselor at all levels
Poor selection of trainees
Inadequate peer counselors
Inadequate counseling by people living with HIV/AIDS
Intimidating procedure of the counseling service
Lack of hospital policy
Lack of motivation for trained counselors Inadequate guidelines on counseling

PATIENT MANAGEMENT

Inadequate facilities at all level.
Inadequate trained personnel
Inadequate supply of drugs
High cost of care and support
Stigmatization
Confidentiality not observed and human rights.
Poor referral system at all levels
Lack of logistic for follow-up and continuum of care
Limited funding for home care
Ineffective monitoring and evaluation
Competition with alternative medical practitioners and spiritual homes
Poor reporting system
Poor distribution of existing guidelines
High turnover of trained counselors.
High cost of care and support
Inadequate mobilization of community to support people with HIV/AIDS
Inadequate skills for social workers
Poverty to sustain treatment and appointment.
Increasing prevalence of TB
Increasing number of AIDS orphans
High cost of antiretroviral drugs (ARVD)
Unavailability of ARVD
Non - control of sale and prescription of ARVD
Lack of training in the usage of ARVD
Lack of monitoring of medical and paramedical
Lack of laboratory monitoring of those on ARVD
Pressure from pharmaceutical companies to sell drugs.

Extended family system
Existing training institution for care and support
Existing community based organization, NGOs
Existing manuals (Counseling, home care and case management)
Media involvement.
Political commitment and advocacy efforts
Ongoing strategic planning
The PHC structure (Multi-sect oral involvement)
Existing health facilities
Association of PLWHA
Interest of donor agencies, DFID, USAID, WHO, Pathfinder
Existing professional organizations
Poverty alleviation program
Pool of available trained counselors
Increasing community awareness.
TB/Leprosy program
Report of the orphan survey.
ARV on the essential drug list.

Needs: Women

Obstacles

Opportunities

Social/Religious status of women
Poor access to information and treatment
Poor economic power
Cultural bias against women
Religious bias against women
No empowerment – economically, socially, politically
No reproductive rights
Physiological factors
Early marriage
Inability to negotiate safe sex
Poor education
High level of illiteracy of women especially in the northern states
Violence – rape abuse of women
Migration
Rural to urban areas
Poor legislation on women’s rights
Prostitution
No female condom
Religious/Social upheavals
Poor decision making power in sexual matters
Polygamy
Wife inheritance and wife sharing
Widowhood and inheritance rights
Non implementation of laws that apply to women
Poor/inadequate reproductive health issues
Poor distribution of NGOs especially to rural areas
Multiparity and large families
Lack of confidence in self and other women
Lack of channel of information
Women have little time for leisure and information

Women community organization
Women targeted programmes
Ministry of women affairs
Religious organizations
NGOs, CBOs, Donors Agencies dealing with reproductive issues
More and more gender issues up-coming
Head of NACA, Minister of state of Health, Transport
Adult education Program
Female functional literacy program
Educated children
Plan to start Social marketing of female condom.

Needs: Labor

Obstacles

Opportunities

INFORMAL SECTOR

More than 50% of labor force in the informal sector – no social safety nets for illness and disability
Mobility of the informal sector
Poor organizational structure Inadequate provision for prevention of STD/HIV/AIDS among staff and workers
Poor reporting system
Migration of workers
Inadequate remuneration
Poor education
Poor health seeking behavior

FORMAL SECTOR

Managers not sufficiently informed about STD/HIV/AIDS to help in prevention for their staff and workers
Little response from management
Lack of commitment of management towards STD/HIV/AIDS prevention and control
Inadequate welfare package for those with STD/HIV/AIDS
Little or no funds committed to STD/HIV/AIDS prevention and control
No reporting system to the central data on incidence and prevention rates
Inadequate and sustained information on STD/HIV/AIDS within the companies
Breach of confidentiality of HIV status
Mandatory pre-employment screening for HIV
Poor implementation of international, national laws on employment and labor
Breach of human rights of HIV positive staff
Inadequate provision for care and support
Unions not utilized for prevention of HIV
Lack of policy on HIV/AIDS/STD in most organizations
Frequent duty travel away from home which exposes them to risk
Disposable cash predisposes to leisure activities – alcohol, multiple sexual partners, drugs, casual sex, etc.
Poor enforcement of occupational safety and health regulations.

Existence of Unions and Associations
Training department within organizations
Existence of health structures
Availability of funds
Organizational structure within the sectors
Potential to produce STD/HIV/AIDS education materials
Existing international and national laws, codes, ordinances
Existing social clubs within organizations
Networking among organizations and companies

Needs: Sexual Education

Obstacles

Opportunities

Sex not discussed openly in families and with adults
Sexual issues are taboos
Sex education not well addressed in school curricula
Sex education materials insufficiently produced
Sex education materials not widely distributed
Resistance of parents to introduction of sexuality education
Lack of skills of teachers/parents for sexual education
Resistance from religious leaders – Islam/Christianity/Traditionalist
Low level of sexuality education among school children at all levels
Inappropriate peer education on sexuality

CONCEPTION OF EDUCATION (Production, distribution, Dissemination and evaluation)
CONCEPTION

Insufficient number of trained personnel at conception level
Insufficient material in local languages – funds for translation of materials in local languages
Insufficient trained IEC personnel at all levels Insufficient training of staff
Lack of equipment, inadequate facilities for production of IEC materials
Inadequate information sharing between different sectors
No supervision and regulation of quality and relevance of materials produced
Insufficient facilities to evaluate conception programs
Not all the sectors are covered in the conception
No supervision and regulation of quality and relevance of materials produced

IEC PRODUCTION
(Lack of Production Facilities)

Inadequate funds for production of materials Inadequate quantity of materials produced due to lack of funds

DISTRIBUTION

Difficulties with distribution of materials to states and LGAs due to inadequate funds, poor communication and networks
Poor logistics
Poor organization of distribution at all levels
No evaluation of distribution patterns at all levels

DISSEMINATION

Insufficient trained IEC personnel at all levels
Inadequate funding
Inadequate facilities for dissemination.
Poor logistics at all levels

EVALUATION

Irregular evaluation of materials and activities due to lack of funds
Inadequate personnel
Poor logistics
Poor communication network

CONDOMS

Religious opposition
Cultural opposition
Parental opposition
Unavailability of female condom
Poor decision making power of women in reproductive health issues
Poor standard of condoms
Gross ignorance about use of condoms
Inefficient social marketing
Perceived reduction of sexual pleasure
Low acceptance of condom usage
Quality control assurance of condom is low
No faith in condom
Condoms perceived as a method of family planning.
Cost of condom – poor affordability
Inaccessibility of condom in rural areas
Lack of co-ordination and procurement of condoms
Tariffs on condoms
Inadequate information on condom utilization
Absence of local production of condom.

Introduction of Sexuality education in schools
Existing information on HIV/AIDS/STI for IEC teams
Lack of production capacity within private sectors
Existence of marketing distribution networks
Existence of one condom quality assurance lab in Lagos.

Needs: Psychosocial Help and Counseling Support

Obstacles

Opportunities

MEDICAL

Ignorance (Health Care and clients)
Inadequate number of trained personnel
Poor health seeking beheviour
Inadequate and misdistribution of health facilities
Inadequate protective devices for health workers
Poor infection control
Lack of infection control policies in various institutions
Fear and stigma of healthcare workers
No continuum of care
Inadequate facilities for diagnosis of opportunistic infections
Inadequate drugs for treatment of opportunistic infections
Poor access to ARV drugs for opportunistic infections
High cost of drugs
No monitoring facilities for disease markers.

PSYCHOSOCIAL HELP AND COUNSELLING SUPPORT

Inadequate number of trained counselors at all levels
Counselors not part of curriculum in training institution
No organized training institution for HIV/AIDS/STD counseling
Inadequate number of guidelines for counseling
No monitoring/evaluation of counseling that is going on.
No networking between trained personals
Inadequate psychosocial help
Lack of sustainability (Inadequate funding for psychosocial support)
Poor referral systems
Poor logistics for follow up
Stigmatization.
Lack of confidentiality
Poor continuing education facilities
Competition with spiritual healers
Competition with traditional healers
Negative medical effects.

SOCIAL

Religious barriers
Cultural practices
Fear of the unknown Ignorance
Poverty
Access to information, diagnostic and treatment facility
Gender inequality

PSYCHOSOCIAL HELP AND COUNSELLING SUPPORT

Existing health facilities
Existing NGOs, CBOs, religious organizations involvement
Existing commitment
Existing guidelines
Existing association of PLWHAs

MEDICAL

Existing medical facilities
Existing NGOs, CBOs etc
Existing health facilities
Existing NGOs, CBOs, religious organizations involvement
Existing commitment
Existing guidelines
Existing association of PLWHAs
Private medical practitioners
Pharmaceutical companies

SOCIAL

Existing health facilities
Existing NGOs, CBOs, religious organizations involvement
Existing commitment
Existing guidelines
Existing association of PLWHAs
Poverty alleviation program

Needs: Human Rights and Ethics

Obstacles

Opportunities

Legal department staff not sensitized enough on the importance of HIV/AIDS
Conservatism
Laws are not following all new issues related to the HIV/AIDS epidemic and the profound changes that may have an impact on society as a whole
Non compliance with existing laws
Poor monitoring and implementation of existing laws
Gaps in existing laws on rights
Non enforcement of laws
Poor involvement of the legal profession on HIV/AIDS/STI issues
Poor circulation of documents
Populations are not sufficiently aware about existing laws on HIV/AIDS
Poor institutional backup at state and LGAs
Not enough political drive
Traditional/Religious laws do not address HIV/AIDS
Strong Traditional/Religious laws which may be contrary to HIV/AIDS
Stigmatization
Ignorance
Prisons not protected enough

Existing laws
Existing human rights organizations