The Human Immunodeficiency Virus (HIV) is the biggest challenge to the contemporary biomedicine and social sphere. It has remained the topical disease condition that has afflicted man in recent times (Okechukwu, 2007). Understanding the prevalence and patterns of HIV infection and risk behaviors are important for every country irrespective of the stage of the epidemic or the level of HIV prevalence (Panchaud et al, 2002, pp11-29). Especially, a country like Nigeria which is classified as one of the most populous HIV/AIDS infected country in the world (Herek at el. 2002). Apart from the typical medical difficulties that the Nigerian HIV/AIDS infected patients suffer, like the devastating health condition of the patients, expensiveness of the treatment and lack of the availability of treatment facilities; social stigmas are also crucial factors in the deteriorating health condition of the HIV/AIDS patients. Because, HIV/AIDS- related stigma are directly linked to the delays in testing and the initiation of treatment (White et al. 2005 pp347-359). In this paper I will try to investigate that in a country like Nigeria, which is one of the world’s most infected region in terms of HIV/AIDS infection;the social norms and sexual behaviors of the people are hindering in collecting the correct records of the infected. Also instead of coping with the elimination of this epidemic the society is seem to be rather taking active part in discriminating the infected patients and then labeling them with social stigmas.
Nigeria is one of the developed countries of Africa (UNGASS, 2007). The country lies on Africa’s west coast and occupies 923,768 square kilometers of land bordering Niger, Chad, Cameroon and Benin (UNGASS, 2007). The country is currently under a democratic government for a third consecutive term of 4 years each after about 30years of military rule (UNGASS, 2007). In Nigeria, an estimated 3.6 percent of the population is living with HIV and AIDS (UNGASS, 2010). In 2003, 290,000 children in Nigeria were estimated to be living with HIV/AIDS. (UNAIDS, 2004) Its prevalence is high among young people in Nigeria, especially young women. Among those ages 15-24, the estimated number of young women living with HIV/AIDS was almost twice that of young men (US,NIC, 2002). Although HIV prevalence is much lower in
Nigeria than in other African countries such as South Africa and Zaia, the size of Nigeria’ population (around 149 million) means that by the end of 2009, there were 3.3 million people living with HIV/AIDS (UNGASS, 2010). The HIV/AIDS cases were first reported in 1986 by the international AIDS conference, shortly after which the Nigerian government established the National AIDS advisory committee which was then followed by the NEACA (Establishment of National Expert Advisory committee) on AIDS. The Nigerian government was slow in responding to the rapidly growing AIDS pandemic until 1991 when the Nigerian government finally established Federal Ministry of Health to abate the spread of HIV/AIDS. The result that it showed was astonishing, as 1.8% of the Nigerian population was infected with HIV/AIDS and it rose from 3.8% to 4.5% from 1993 to 1998 (Sofo et al. 2003). Health condition of the people of Nigeria started to get better when Olusegun Obasanjo became the president in 1999. His regime focused extensively on the health care facilities of the people and prevention strategies against HIV/AIDS. The government ruled out three-years HIV/AIDS Emergency Plan (HAEP) in 2001. In 2005 a new framework was developed covering the period from 2005 to 2009 (Adeyi et al. 2006).
Despite such influential strategies from the government side to control the epidemic, in 2006 it was estimated that only 10% of HIV infected men and women were receiving antiretroviral therapy and only 7% of pregnant women were receiving treatment to reduce the risk of mother-to-child transmission of HIV (UNAIDS, 2008). Therefore, another mega-scale project was launched to rule out the possible prevention and treatment expansion in general public of the Nigeria from 2010 to 2015 through comprehensive National Strategic Framework, which requires an estimate of 5 billion USD to implement (All Africa, 2010). This framework is supposed to reach 80% of sexually active adults and 100% of most-at-risk population through HIV counseling and testing, also to improve the access toquality care and support services to at least 50% of the people living with HIV by 2015 (NACA, 2009). The legal fight for resource control, the fight over the system of control (Sharia), the economical and political struggle to regulate the petroleum sector are considered to be the only crucial state issuesbut the vital issue regarding the control of overgrowth HIV/AIDS infection is sidelined (UNAIDS, 2008) This doubtful scenario of the Nigerian government put the battle against AIDS in jeopardy. This country is at verge of disastrous rate of infections and death, however, unless quick remedies are made sure.
HIV/AIDS in Nigeria is transmitted through three ways; heterosexual sex, blood transfusion and mother-to-child transfusion (UNGASS, 2010). Some small scale studies also show the transmission of HIV/AIDS through injecting drug users. In Nigeria there is a distinct lack of HIV testing programs. In 2007, just 3% of health facilities had HIV testing and counseling services (WHO, UNICEF, UNAIDS, 2008) and only 11.7 percent of women and men aged 15-49 had received an HIV test (UNGASS 2010). In 2009 there was only one HIV testing and counseling facility for approximately every 53,000 Nigerian adults (UNGASS, 2010).
Apart from management issues regarding the health facility in Nigeria, the collection of statistics and data regarding HIV/AIDS infection is problematic and sometimes unreachable. During the mid 1980s to the mid 1990s, most countries concentrated their resources on documenting the prevalence of the virus (UNAIDS, 2000). However, although HIV prevalence data provide some indication of the level of HIV in the general population, most existing HIV surveillance systems are yielding insufficient or unreliable data or data that are difficult to interpret and that do not capture the diversity of the epidemic in different population groups or do not adequately measure and explain changes over time (Ibid). First of all, the time of infection is difficult to detect, because the test that is used to determine the prevalence of HIV at some point will show a combination of different infections which may be recent or happened many years earlier (Ibid). Prevalence that is stable or decreasing may reflect past trends, may mean a recent decrease in new infections, may reflect omission of groups with an increasing rate of infection, or reflect changes in the likelihood of being tested or a combination of these factors (Ibid, 1998). In addition, current systems rarely monitor behaviors that provide early warning signs of the possible spread of HIV and do not help to identify subgroups most at risk of infection (Panchaud, 2002). In order to improve the existing methods of recording and tracing the infection WHO/UNAIDS proposed a method by adapting to the context of changing epidemic profiles (Ibid). With the international collaborative work to get an understanding of HIV surveillance led by WHO/UNAIDS resulted in a synthesis document; setting new guidelines for a second generation of HIV surveillance. This includes:
“(a) Tailoring the surveillance system to the pattern of the epidemic in each country.
(b) Concentrating data collection in population subgroups most at risk of becoming newly infected.
(c) Collecting more data on sexual behaviors.
(d) Making better use of other sources of information (for example sexually transmitted diseases “(Pachaud, 2002).
The goal of these assessments is to arrive at some interpretation about the usefulness of the literature that is currently in use and to provide insights into ways of improving HIV surveillance in a developing country like Nigeria with relatively few resources, so as to obtain, the best possible measurement of HIV prevalence and indications of future trends (Ibid, p12). There are different approaches to measure the prevalence of HIV/AIDS infection which range from a broad focus on the entire population through sentinel surveillance. That is the screening of donated blood known as sero-prevalence studies at the national level. On the other hand, at the micro level, studies focus on small targeted-group that is at high risk of transmitting HIV. Sentinel surveillance is usually based on unlinked screening of blood and measures HIV prevalence in selected population subgroups (usually women seeking prenatal care, STD clinic attendees, and commercial sex workers) (Ibid, p13). Although this type of study indicates national coverage, but due to its limited capacity associated with a particular sub-group, it is difficult to provide an overall statistics of the whole population. Sero-prevalence studies arean opportunity for testing and counseling. The main shortcoming in such studies is that they are costly and time consuming (Ibid).
WHO/UNAIDS has formulated a rather extensive approach to measure and indicate the behaviors attached to HIV infection-transmission (UNAIDS, 1998). The indicators contain number ofsexual partners, engaging in casual or commercial sex, usage of condom, availability of condom at national level as well as local level and the quality of awareness about HIV/AIDS among general population (Panchaud et al, 2002, p14). And to carry on with such strategies, cross-sectional behavioral surveys are conducted. That, usually, includes socio-demographic information. Panchaud et al. conducted such surveys which included 35 studies on HIV prevalence and methodology. Of which, 34 studies were conducted to indicate the sexual behavior of Nigerian people. Half of these studies contained samples greater than 300 (Ibid). Although, different strategies were used to indicate the prevalence of HIV in the same population sample, but the data which were collected, indicate that those behaviors which are associated with sexual transmission of HIV /AIDS are, somehow, similar (Ibid, p20). Studies which constituted number of sexual partners indicate that males (aged 15 years and above) are more likely to have two or more partners (17%) than females in that same age group (Rossem et al. 2000). Panchaud indicated that people who are classified as occupational group (those who are employed), are more commonly engaged in multiple sexual partners. This indicates high cases of sexuality in work places (Panchaud et al. 2002, p21).
Much effort has been done by the Nigerian government to get realistic and useful data regarding the prevalence of HIV/AIDS infection which resulted in some substantial outcomes (Ibid, p25). A lot of such data were made possible using the sentinel system which is, somehow, considered a backbone of HIV/AIDS surveillance in Nigeria and also in many developing countries (Ibid). However, a lot of improvement in the collection of such data has been reported, but on the other hand, it posits many challenges particularly in many developing countries like Nigeria.
“Testing of blood is required by most methods used to determine HIV status,
a procedure that may be too expensive and difficult to perform at the necessary
scale in countries where health systems are insufficiently developed and that
lack resources to make testing facilities widely available” (Ibid, p26).
Not only the accessibility of drug in treating HIV is the issue, the reduced incentive to be tested is also one of the crucial factors which hinders in broad scale treatment of this epidemic. One of the major factors in the reduced-incentive to be treated is the ‘stigma’ attached to HIV/AIDS in Nigeria. Also, the lack of confidentiality is considered to be an undeniable factor which often discourages people from adopting treatment procedure and take advantage of medical facilities (Panchaud et al. 2002, p26).
HIV/AIDS has been associated with negative connotation, and it is especially prevalent among those who suffer from devastating illnesses. Particularly, those patients who suffer from HIV/AIDS infection are usually the worst victims of social stigmatization. Erving Goffman defined stigma as a ‘deeply discrediting’ attribute in the context of a set of relationships (Goffman, 1963, p3). Stigma, is therefore, an undesirable potential that an individual posses which decreases the status of the individual in the eyes of the society. Under Goffman’s definition, an individual is thus labeled as deviant by the society (Goffman, 1963, p 5). The same kind of concept was presented by Jones et al, who said that stigma is any attribute that links a person to undesirable characteristics. Discrimination, on other hand, is an aspect of stigma which can also be called as marginalization by the society due to stigmatization.
Stigma is expressed in three ways (Okechukwu, 2007).
(a) Instrumental expression: it involves the individual’s concern and perception about the risk of his having the disease. In short it is manifested by the infected individual.
(b) Symbolic expression: it is expressed on a broader scale by the political and religious setup of that particular region. It also includes the cultural and social valves that play a vital role in creating an environment that breeds stereotypical trait in individuals.
(c) Courtesy expression: it includes the manifestation at the organizational and nongovernmental level which are associated with the HIV/AIDS (Ibid).
Discrimination against the HIV/AIDS patients make them ostracized. The infected people choose to live a life a rejection and avoidance. These prejudices, expressions and manifestations have been reported through different surveys (ibid, p2).
Thorough studies done by Emmanuel Monjok, Andrea Smesny and E. James Essien on the Nigerian population have further classified the affects of S&D (stigma and discrimination) on individual patients who suffer from HIV/AIDS into three levels. At individual level S&D leads to identity crisis,isolation, loneliness, low self esteem and lack of interest in containing HIV/AIDS (Valdiserri, 2000). That can further lead to lack of motivation to carry on with the prescribed prevention procedure and reduced care taking behavior (Parker, 2003). At the community level, the families who take care of the patients are also prone to stigma and discrimination. Therefore, open support from the community is highly reduced. At the institutional level, the patients can lose their jobs by forced termination or resignation, and, therefore, are treated with hostility. Discriminative acts among healthcare workers include, delivery of poor quality treatment and counseling services, early discharge from hospital, segregation of hospital wards, isolation, the marking or labeling of patients beds, files and ward, selective application of “universal” precautions and lack of confidentiality (Ehiri, Anyanwu, Donath, kanu, Jolly, 2005). Discrimination against the HIV/AIDS patients is so intense that at some point in time in their lives many infected individuals become suicidal when they get their diagnosis done for the first time. Because they know that they will face a discriminatory attention of the society. Such thoughts become the source of their mental illnesses like post traumatic disorder, generalized anxiety disorder insomnia and panic attacks (NYSDH, 2006, p. 1-8). Unluckily, the association of HIV/AIDS with sexual relationship, this disease is looked down upon through different lenses. Cancer is too a life threatening disease but the accompanying and social support of the family and sympathy of the society make the patients to at least hold on to their healthy conception of their self. Such a notion of the society makes the cancer patients to engage in health seeking behaviors and at least they are emotionally willing to do so. On the other hand, HIV/AIDS patients try to hide their disease from the society because they are afraid of the response they will get from the peers. They know that they will never get the support of the family or friends. They won’t even seek forgiveness or engage in religious activities. They perceive themselves as the cursed ones.
It can be argued that it’s the society of Nigeria which associates stigma to the patients who suffer from HIV/AIDS. These social norms are more lethal than the medical malfunctioning itself as in case of HIV/AIDS patients, if the care and surveillance is failed to remove the unwillingness to be treated then they can become the direct cause of the increase in HIV/AIDS rates. As AIDS related stigmas can cause a delay in treatment, poor treatment adherence, and greater number of new infections (Goudge etal, 2009). Goudge et al. through case studies on the Nigerian population illustrated various response to diagnosis, like anger, violence, blame, shame, withdrawal, grief and depression. Most of the patients areneglected, and sometimes are verbally abused. These conditions expedite signs of betrayal, and disappointment of fractured relationship and fear of a potential fatal disease.
The risk of transmitting HIV/AIDS is also increased due the false conception about sexual practices. Jordan Smith conducted a survey and recorded many case studies regarding the faulty conception which in turn increase the risk of spreading the HIV infection. He presented a case study of a 23 years old boy named Ike, who sold electrical appliances in Aba, a southern region of Nigeria. When he was asked about the usage of condom, his remarks showed carelessness about the inherent risk that they seem to accept. His remarks were, somehow, same as were shared by many other young adults of his age (Smith, 2007, p 228).
“I use condoms with loose girls, you know, the ones who have
Sex anyhow. They could give you something a man has to
protect himself. But if a relationship is serious like being in love,
then I can trust My partner and we would not have to use them.
You have to know your Partner’s character” (Ibid).
Same kinds of remarks were made by the females of Nigeria. Smith (2007) mentions one case study where a 20 years old girl, named Chinwe, who works as receptionist in her uncle’s Business in Kano.
“You have to respect yourself, or no one else will respect you. It's
dangerous to sleep around here and there. If a girl is going to have
sex, she should know her partner and be able to trust him.
Some guys go about putting the thing here and there.
For me to have sex, I have to love the man and know that he
loves me. ... I think it's always good to use condoms, but
with a partner that you love, who you can trust, it's not as necessary.
My boyfriend and I don't always use condoms because
I know I can trust him” (Smith et al, 2007, p. 228).
Many Nigerian men, usually, think of those girls who ask their boyfriends to use condom that they have already been engaged in sexual behaviors before or have many sexual partners which make the girls to keep silent about the usage of condom. Otherwise, their relationship would be jeopardized (Smith, 2004, p. 230). “Oneyebuchi, a 24-year old apprentice learning to repair electrical generators in Kano, reflected some young men’s attitudes”:
“if a girl keeps a condom in her room, you will feel somehow,
like she is professional.” (Ibid)
In such circumstances the behavior of the women’s reluctance to initiate discussions of condom use is understandable (Ibib).
It is, therefore, evident that the young males and females of Nigeria associate the issue of HIV/AIDS with morality and conceive it on religious grounds. The idea that the relative risk of acquiring HIV/AIDS isassociated with the morality of a sexual relationship is further reinforced by religious interpretations of the AIDS pandemic and religious discourses about premarital sexuality (Green 2001; Takyi 2003; Smith 2004). Most of them are Christian and religiosity is increasing in the youth (Marshall 1993; Marshall-Frantani1998; Smith 2004). Therefore, religious understanding of this pandemic promotes the morality of the issues related to HIV/AIDS; many religious as well social figures depict HIV/AIDS as a consequence of the immorality of the society. People tend to associate this pandemic with God by saying its God’s curse onthe people who have lost the right path of glory. Several other believe that AIDS is God’s punishment for their sin. The words of Nnenna, a 19 years old girl living in Kano (Nigeria) illustrate such proposition. “AIDS is a terrible thing. But this place is like Sodom and Gomorrah. Nigerians are being punished for their sins. If people did not have sex here and there, if the society were not so corrupt, there would be no AIDS.... Yes, it is God's punishment, but we have brought it on ourselves” (Smith, 2007, p. 229). So it is quite clear that the general perception of AIDS is more than just a pandemic. It is considered to be an evil sign and those who are inflicted have been morally as well as religiously degraded. So the societal valves of the infected patients are reduced and therefore stigmatized. Not only are that, the discussion regarding safe sex and usage of condoms during intercourse sidelined. As religion convince people that their misery is because of their deviation from the true path and when they return to right path by waiting and holding their sexual desires till their marriage, will make them clean in God’s eye and therefore, they will no longer be affected by HIV (Ibid). Chidi, a 21 year old, living in Aba expressed his thoughts in the same way. “I know that condoms are supposed to prevent AIDS. But you cannot count on them. They could be old or have a hole or break. If God wants you to get AIDS, it will not matter how you try to protect yourself. The best thing is to have faith in God“(Ibid). This behavior of abstinence until marriage or finding true love projects their thoughts about the importance of morality. Growing emphasis on notions of love as the basis for acceptable pre-marital sexuality when fused with religious interpretations of AIDS as punishment for sin creates a context where open discussion of condom use can be seen as suggesting that one, one's partner, or one's relationship is immoral and risky. Religious interpretations of sex and of AIDS decrease the perceived need for condoms within "moral partnerships," (Ibid). Such model of conception sidelines the risk of getting infected which cannot be argued within the circle of their conception. Ifeoma, a 23-year-old woman who braided hair in the Sabon Gari market in Kano, offered a common description of couples' negotiations concerning condom use (smith, 2007, p. 229):
“You use a condom because you do not want to get pregnant. How could you tell a guy that you want him to use a condom because you fear he might have AIDS? If I thought a guy had AIDS, I would never agree [to have sex with him] even with ten condoms. Tofiakwa! [God forbid such an abomination!] Even if you want to be careful, you know, and you do not know the guy very well, can you imagine asking him to put on a condom and telling him it is because you fear he has AIDS? Besides the insult, I mean, that would ruin the whole thing” (Ibid).
Not surprisingly, things like condom which is used as a prevention technique of getting infected from HIV/AIDS are infected with the stigma. (taylor, 1990; Hillier et al, 1998). The stigma that surrounds HIV/AIDS infection is due to its association with sexual relationship which in Nigeria is considered the object of intense moral scrutiny (Smith, 2007, p. 230). To talk about the risk that this infection entails and to take decision for the usage of condom is like bringing the consciousness into account when young people engage in having premarital sex which is more likely to be avoided by these young Nigerians (Caldwell et al, 1989). Additionally, with the rise of the idea of love in this context makes it even more complex to create awareness on purely rational grounds as people make decisions which go against medical serenity and these people are more likely not concerned about that at all. Even, premarital sex is not discussed as sinful, religiously, if the couples are found out to be engaged in romantic love and they consider it as a moral partnership. It is because, the conception of morality regarding premarital sex, particularly for a woman, depends on the notion that the relationship is a romantic relationship and therefore don’t need any worldly ideas to hinder in its way (Ibid).