How ASPIRE Project Fights HIV Surge in Nigeria
By Ojoma Akor
Dr. Stanley Abujah Idakwo is the Project Director of the Institute of Human Virology, Nigeria’s ASPIRE project. In this interview, he charted ways people living with HIV and other stakeholders, including the government, can boost Nigeria’s HIV prevention and care, as well as how IHVN’s response to the high burden of HIV in Rivers State, where about 4 out of every 100 people were living with the virus is helping to fight the disease.
Can you briefly tell us about the ASPIRE Project?
The ASPIRE Project—Action to Sustain Precision and Integrated HIV Response Towards Epidemic Control—is an initiative aimed at achieving HIV epidemic control. The intervention in Rivers State began in 2019, following the 2018 Nigeria AIDS Indicators and Impact Survey (NAIIS), which identified the state as a priority with the highest unmet need and low saturation of HIV services nationwide. The survey placed the HIV prevalence in Rivers State at 3.8%, which was significantly higher than the national average of 1.4%.
As a result, the Institute of Human Virology Nigeria (IHVN) was mandated by the Centers for Disease Control and Prevention (CDC), in collaboration with the Federal Ministry of Health (FMoH) through the National AIDS and STI Control Programme (NASCP), to address this unmet need and work toward flattening the curve of new HIV infections—that is, achieving epidemic control. This mandate gave rise to the SURGE Project, which commenced in April 2019.
Through robust stakeholder engagement, advocacy, partnerships, and collaboration with the Rivers State Government—particularly the Rivers State Ministry of Health—over 100,000 clients were initiated on treatment within the SURGE Project’s initial 18-month period.
Ongoing collaboration with stakeholders, especially the Rivers State Ministry of Health, continues to ensure delivery on this mandate and sustained efforts to flatten the curve of new infections in the state.
Achieving epidemic control remains critical and requires reducing new infections, scaling up prevention services, and identifying all clients so that everyone can live healthy and productive lives in line with the UNAIDS 95–95–95 targets.
These targets aim to ensure that 95% of people living with HIV know their status; 95% of those diagnosed are initiated, retained, and adherent to lifelong antiretroviral treatment; and 95% of those on treatment achieve viral suppression, with viral loads reduced to undetectable levels.
By achieving these goals, we improve overall wellness and well-being, reduce HIV-related morbidity and mortality, and mitigate the catastrophic economic effects associated with healthcare costs and lost productivity.
So, what specific strategies have you deployed to tackle the challenges you encountered in Rivers State?
Yes, several strategies were deployed. The SURGE Project was a moving train—we were essentially building the ship while sailing it, as we needed to identify clients quickly, initiate them on treatment, and ensure viral suppression for their well-being. Consequently, numerous structures were established within a relatively short period.
One of these strategies was the same-day test-and-start treatment policy, as outlined in the national guidelines for identifying clients, counselling them, and initiating treatment.
This significantly reduced HIV-related morbidity and mortality. Clients receive antiretroviral drugs at no cost, enabling them to start treatment on the same day as diagnosis. They are closely monitored, followed up, assessed, and treated for opportunistic infections such as tuberculosis. For clients diagnosed with tuberculosis, treatment is provided for two weeks before initiating antiretroviral therapy (ART).
When clients begin treatment, they are not left on their own. Continuous follow-up is conducted to reinforce adherence support. Clients are monitored through an initial 28-day period, with assessments on days 3, 7, 14, 21, and 28.
During these visits, we assess their concerns, including any adverse drug reactions, evaluate their overall well-being, and identify barriers to adherence. We work collaboratively with clients to deliver solutions, adopting a client-centred approach that treats each individual as an individual rather than as part of a group. Our focus is on identifying challenges and jointly developing practical, tailored solutions.
We operate a team-of-teams approach. This concept involves both facility-led and community-led teams, each managed by designated leads. These teams develop strategies to identify clients, retain them in treatment, and provide follow-up as needed. Known as cascade management teams, they work collaboratively to identify clients and address barriers to treatment, such as access to medications, stigma, and other challenges that may lead to missed appointments. Follow-up is continuous to ensure sustained engagement in care.
Another strategy we have employed is closer collaboration with community structures, such as ward and village committees. We engage in ongoing advocacy with these groups, who help spread awareness by encouraging people to know their HIV status. As a result, individuals come forward willingly for HIV testing, and those who test positive are promptly linked to care and followed up accordingly.
We also work closely with the supply chain team to ensure uninterrupted commodity availability, preventing treatment interruptions. Clients can access their treatment at no cost and remain healthy and stable as a result of the long-term therapy they are currently receiving.
How have you collaborated with the government and other stakeholders in Rivers State to drive program sustainability?
IHVN has aligned with the Federal Government’s sector-wide approach to health and is working collaboratively with all stakeholders in the state. To ensure sustainability and foster a strong sense of ownership, we have partnered closely with the Rivers State Government and the Rivers State Ministry of Health, represented by the Honourable Commissioner for Health. Our strategies and implementation plans are aligned with national priorities as articulated by the Federal Ministry of Health and Social Welfare. These partnerships have been instrumental to our success.
When the SURGE Project commenced, a SURGE Consortium was established, comprising government agencies, private-sector organizations, community leaders, multinational partners, and academia. This platform enabled robust discussions and feedback, which contributed significantly to the project’s unprecedented outcomes. The consortium also served as a framework for developing sustainability plans.
We continue to work with the Rivers State Government by building institutional capacity, providing technical assistance, supporting skills transfer, and advancing sustainability and local ownership. In addition, we are advocating for the integration of the current ad hoc human resource support into the state system to strengthen program continuity further.
IHVN has, over time, supported the Rivers State Government in developing its Annual Operational Plan. We were also instrumental in supporting the establishment of the Rivers State Health Insurance Scheme, now known as the Rivers Contributory Health Protection Programme (RIVCHPP). In addition, we conduct joint monitoring, evaluation, and supervisory visits to strengthen state systems and support frontline healthcare workers.
Regarding ownership, we have assisted in developing state policies, strategic plans, and guidelines aligned with national HIV priorities. Regarding sustainability and ownership, we are driving these efforts collaboratively by appropriately transferring skills and enabling the state to assume program implementation gradually. As mentioned earlier, we are also advocating for the absorption of some ad hoc staff into the mainstream workforce as part of the human resource sustainability strategy.
The necessary structures—both physical infrastructure and technical skills—are already in place; what remains is continuous alignment through mentorship and capacity-building support. I can confidently say that these efforts are yielding positive results.
What are the key breakthroughs of the project in Rivers State?
We have recorded several notable breakthroughs, but I would like to highlight a few. When the SURGE Project began, only about 24,000 clients were on treatment. With support from the Rivers State Government, implementing partners, and our funders—and through the collective efforts of all stakeholders—we identified and initiated treatment for over 100,000 clients within 18 months. This represents a breakthrough, even though pockets of new infections persist. Nonetheless, this achievement was significant and helped popularize the SURGE Project.
Over the past four years, we have also improved treatment outcomes by identifying clients, retaining them in care, and ensuring viral suppression. We supported health facilities in strengthening service delivery, enhancing data management, and improving commodity management systems. At the onset of the project, we encountered challenges with data and commodity management. However, with support from our funders and the government, we established robust data and commodity management systems.
We now routinely analyze data and use it to make informed and robust programmatic decisions. We have clear visibility of the number of clients in care and plan appropriately with stakeholders across the state. Having all stakeholders aligned and working collaboratively is a breakthrough in itself.
We have also made progress in integrating services. Previously, many facilities operated as standalone HIV service points, which often reinforced stigma. Through sustained advocacy, we have achieved a level of service integration in which any doctor or nurse sees clients, routinely triages, and provides holistic care. This approach has significantly reduced stigma by delivering services seamlessly alongside other healthcare services.
What were the challenges of the project?
One of the key challenges relates to clients themselves. While treatment is provided free of charge, some clients lack transportation or the means to access adequate nutrition. As a result, some clients drop out of treatment. However, program funding does not cover these support services.
Nonetheless, we work closely with client-based groups and peer networks, including NEPWHAN—the Network of People Living with HIV/AIDS in Nigeria—and the Association of Positive Youths in Nigeria. We also engage expert clients who are employed within the system. These expert clients serve as peer mentors, facilitating discussions among clients and promoting ownership of their health and treatment.
Regarding access and distance between clients’ residences and health facilities, we engage volunteers within the system, many of whom are drawn from the facilities themselves. This enables them to identify where clients live and provide differentiated service delivery. Adherence counsellors also follow up closely to support continued engagement in care.
Stigma remains a persistent challenge. As mentioned earlier, we continue to work with HIV support groups to develop focused messages to address stigma and discrimination. In addition, we advocate for the strengthening of existing legislation and the development of effective policies to protect the rights of people living with HIV.
In summary, the major challenges include stigma and discrimination, access barriers, retention and adherence issues, and occasional supply shortfalls. However, moving forward, we anticipate improved commodity forecasting and supply systems to ensure uninterrupted treatment and continuous monitoring of clients’ well-being.
So, how has capacity building supported your project implementation and HIV programming?
If you want people to do the right thing, you build capacity. We train, mentor, and transfer skills, strengthening capacity across all service delivery points. Our focus is on strengthening health facility systems, including patient tracking, supply chain management, and quality improvement processes, to ensure consistent, efficient treatment and care.
We have also sustained advocacy with government authorities and health workers to promote ownership through task shifting, whereby healthcare workers integrate HIV service delivery into their routine responsibilities. Through these efforts, we have built the capacity of healthcare workers, making IHVN a trusted and well-recognized partner across multiple facilities.
As a result of this work, we are now at a point where transition is feasible. Government staff who have been trained are well-positioned to sustain the system, particularly the clinical and service-delivery leads who have been mentored over time. These responsibilities have become part of their routine practice rather than being treated as IHVN-led activities. Increasingly, they are taking ownership of the program, and we have observed significant improvements across health facilities.
What is your advice for people living with HIV and other stakeholders, including the government, involved in the response?
For people living with HIV, the first message I would share is that, with the many interventions now available, HIV and AIDS are no longer a death sentence. In the past, many lives were lost to HIV and AIDS, but today this is no longer the case. What is essential is for clients to take responsibility for adhering to their treatment and maintaining their health. These medications are available at no cost.
Secondly, my advice to stakeholders and government actors is to sustain the gains already made, particularly in terms of ownership and sustainability plans. The government must continue to take responsibility, while clients and other stakeholders also play their respective roles. This collective effort will ultimately lead to an AIDS-free generation.
Finally, I strongly recommend increased government funding for service delivery and human resources for health to ensure the continuity and long-term success of the HIV response.
How has the ASPIRE Project impacted the workforce in Rivers State?
The IHVN Rivers ASPIRE Project has significantly strengthened the capacity of ad hoc staff across the state. When the SURGE Project began, we had over 3,000 ad hoc staff; however, due to funding constraints, this number gradually decreased. Currently, more than 700 ad hoc staff remain active in the system.
The support that IHVN has provided over time has had a considerable impact. As mentioned earlier, we are working with the state government to explore ways to integrate eligible individuals from this pool into the civil service, leveraging their extensive experience in HIV programming.
At present, there is still a heavy reliance on ad hoc staff to perform critical work across state health facilities. These staff are funded through U.S. government resources. If they were withdrawn, the consequences would be catastrophic. Through ongoing advocacy and integration efforts, some facility staff are beginning to take greater ownership and responsibility. While progress is being made, there remains a degree of dependence on IHVN-supported staff, given that the program is still largely donor-funded.
