Despite progress in HIV management, commitment must stay high—Okonkwo, CEO, APIN—Public Health Initiatives

Prosper Okonkwo is the founding CEO of APIN-Public Health Initiatives, a leading Nigerian NGO that emerged from Harvard T.H. Chan School of Public Health’s AIDS Prevention Initiative. Under his leadership, APIN supports over 300,000 clients on HIV treatment and addresses public health challenges, including malaria, TB, nutrition, and health systems strengthening. A 1982 graduate of the University of Ibadan, Dr Okonkwo is a visiting scientist at Harvard, an associate professor at Bingham University, and a fellow of both the Nigerian and West African postgraduate colleges. He has numerous research publications and has led Nigeria’s HIV/AIDS response for over two decades. A seasoned physician, he discusses APIN’s national impact, U.S. funding cuts, and why Nigeria must build sustainable health systems beyond foreign aid in this wide-ranging interview with BusinessDay. Excerpt

Can you briefly highlight APIN’s impact on HIV trends over the years?

We started in 2000 as AIDS Prevention Initiatives (APIN), a project of the Harvard School of Public Health in Boston, USA. So, we were just a project and not a full-fledged organisation at the time. The president at that time, President Obasanjo, wanted about 25,000 people to be put on HIV treatment. So, when the program came, it was just to help build systems and guidelines, train people, and build laboratories to manage those 25,000. When I say we, I mean the national HIV response.

We got initial funding from the Bill and Melinda Gates Foundation at that time, which served as a good foundation that helped us. So when the President’s Emergency Plan for AIDS Relief (PEPFAR) bid was announced in 2003, we were able to get funding based on the solid foundation that the Gates program had laid. Over the years, we have continued to be a significant part of the national HIV/AIDS programme. Now, we manage more than 310,000 patients, which is about 20 percent of the patients on treatment in Nigeria. Cumulatively, over the years, we have cared for more than 500,000 HIV patients. We are in Benue, which has over 160,000 patients on treatment, and also in Plateau, Oyo, Ondo, and Ogun States. In all of those years, we continue to manage what we call the comprehensive HIV program, which means we do prevention, treatment, and monitoring through the laboratory, and then, more importantly, we also manage the data. Modestly, we have contributed to the trend that we are seeing. We know, for example, that between 2010 and now, the rate of new infections has reduced by 48 percent, and the number of deaths has also reduced by 52 percent. So, we just really want to thank God that since 2000, we have been continuously one of the key implementing partners supporting the national response. We also work with several universities. A lot of the work we have done has also rubbed off on academics at institutions such as the University of Jos, the University of Lagos, Ahmadu Bello University, the University of Ibadan, etc. We have also collaborated with research institutions, such as the National Institute for Medical Research, and that has turned us into a learning organisation.

“With treatments, it was hoped that stigma would be reduced, but surprisingly, there is still stigma.”

HIV/AIDS gets less attention today than a decade ago. Has the infection rate dropped—and could declining focus risk a resurgence?

I don’t completely agree that attention has gone down. What has happened is that HIV management has matured, and things are changing. In the early days, a lot of money was spent on sensitisation and mobilisation. But now, it is believed that the tools are available, so people should know the right things to do. Studies and surveys have shown that more than 95 percent of Nigerians are familiar with HIV issues. But there’s what we call the knowledge-behaviour gap; people know, but they are not doing. And that’s why we are now emphasising the need for intensified behaviour change communication. Also, because drugs are now available, even for prevention, we see that people are laissez-faire. When we started this program in 2004, people were being wheeled in for treatment. But today, everybody looks healthy, even if one is positive. So that fear has come down a little bit. And because there are drugs, we’re no longer paying as much attention as we should to prevention. There are still more new infections than people dying, even though it has come down. There’s a gap in prevention. The other thing is the socioeconomic situation we find ourselves in, because HIV is not solely a medical disease; it’s a social disease. And we’re getting into a lot of wild behaviours. Lifestyle is also changing. Can you imagine that even today, drugs are free, but some people don’t have the money to go to the hospital? It’s a problem.

How will shifting global funding affect HIV treatment and your work—and how can the challenges be addressed?

If you had come here in early February, you wouldn’t have met anybody because we’ve closed shop. In Nigeria, the U.S. government funds HIV work through USAID, the CDC, and the DOD, which is their military arm. We happen to be fortunate that we are funded by the CDC, and that is partly why some of us are still here. Even though we are still funded, some executive orders have stopped us from doing certain programs that do not align with the policies and priorities of the new US administration. One of the things that has happened and worked well for us in APIN is that we leverage all the good things and all the resources that we got from PEPFAR over the years, and we have built systems. When we started in 2004, we were called AIDS Prevention Initiative in Nigeria (APIN). But we got to a stage that we felt we had built systems, so we got into other public health initiatives. In 2016, we became the APIN Public Health Initiative. We kept ‘APIN’ because it had become like a brand. Right now, we’re doing maternal and child health, nutrition, and consulting because we have built systems such as data management.

We used the advantage of Harvard that we started with and set up our programme as a service delivery programme.

We have an electronic medical record (EMR) system, and that has drawn attention to us. As I speak to you, we have the National Institute of Health Collaborations with Emory, Harvard, and Vanderbilt Universities, as well as many Nigerian academic and research institutions. We continue to spread our tentacles. Even now, we have a “for-profit” lab, APIN Medical Laboratory, in town. For the program’s sustainability, I believe that if Nigeria can get assured access to drugs and test kits, say by local production, even if the U.S. government funding ceases, the program will continue. I would also hope that this is a good warning signal for us. It is believed that we have the resources as a nation. At the national level, the government is working with some groups to see if we can certify some of these plants for drug and test kits. I hope this will be a final push. We knew that PEPFAR would leave one day. But we didn’t know that one week after a new president came, this shaking would happen. But it shows again the fragility of the dependence on donor funding.

Is federal funding a possibility for your project? Have you engaged the government?

Yes, but just to say that we have built some capacities. For example, we have another project funded by the US government that takes care of all the data in Nigeria. We call it the Public Health Information, Surveillance, Solutions, and Systems (PHIS 3) Project. It manages the National Data Repository. In 2018, a National AIDS Indicator and Impact Survey (NAIIS) was conducted, among other things, to ascertain the prevalence of HIV in Nigeria. So, they have started another one now, which PHIS 3 is doing, in selected states. They started in Akwa Ibom, Lagos, and Rivers State. This survey was paused, as it didn’t fall within the list of activities approved during this review period. This is just an example of experience that we can “market.” We are doing our due diligence to see if the government of Nigeria has plans with other funding for such activities so we can apply.

Do you own your medical facilities? How do you work with patients and these facilities?

We are middlemen, an implementing agency. The U.S. government has a relationship with the government of Nigeria; they are executing that relationship through us.

We work with the federal and state governments, a few private sector facilities, and faith-based organisations, and that also has a little challenge because now that stakeholders are talking about sustainability and moving on, the faith-based organisations are not directly involved in such transitions because they don’t get any subvention. And it’s a challenge for us because in Benue State, for example, we have a lot of faith-based institutions, and their health facilities account for a significant proportion of the places we work. But, we don’t own sites, and we’re not allowed. That also poses its own sustainability challenge.

Cancer care is costly in Nigeria. What is APIN doing to improve early diagnosis and affordable access, especially for HIV-positive women?

HIV-positive women are about 4 to 5 times more at risk of cervical cancer than the general population. So, it’s a low-hanging fruit. If we can use the HIV system to also implement cervical cancer screening, we will be getting them early and at not much extra cost. About five or seven years ago, we began to look at HIV-positive women and how we can assess their cervical cancer risks. We set a target to screen 40,000 HIV-positive women. We did the basic test, which they call VIA, to examine their cervix. We leveraged our very extensive infrastructure to start the screening program and avert cancers by early detection. We trained more than 400 health workers to be able to deliver this service. But this training was not enough. We developed an app called AVIVA that enabled us to increase the sensitivity of these results, get people’s consent, take a picture of the cervix the way it is, and send it in real time to get an expert opinion. This is patented with the ministry of trade now. The percentage of those who are positive is high. CDC then began to fund us, but a gap remains because of the large proportion of women who are not HIV positive without access to this particular service.

As a public health physician, I don’t think we are doing all we should do, but we are restrained by what we are funded to do.

How does APIN tackle stigma and cultural barriers to boost testing and treatment in underserved areas?

I think it’s a problem. In the early days, people just tested and found they were positive, and that was the end of the story. In those early days, the billboards you would see read “AIDS, no dey show for face.” We have done what we call community engagement. For example, in our prevention of mother-to-child transmission programme, we use positive clients as mentor mothers. And these are people who have become champions who are not hiding their status anymore. But there’s also a lot of self-stigma. If you go to a typical HIV clinic, they now give clients drugs for six months if they’re stable. When they come out, some of them take their drugs in sachets and trash the pack. So, stigma is still there, but what we have done is to try to integrate tailored health approaches in community services. For example, young people and adolescents can’t freely come to the regular clinic, so we have weekend clinics for them. We also have adolescent hubs so that they can have those safe spaces. There’s also stigmatisation in the health system, because many of us are not culturally sensitive and empathetic. Maybe because a health worker sees 20 patients a day and believes that every patient is increasing the workload and pressure. So, it’s a multifaceted thing that needs a multifaceted approach.

With treatments, it was hoped that stigma would be reduced, but surprisingly, there is still stigma.

With increasing drug resistance in tuberculosis treatment, how is APIN adapting its clinical protocols and capacity to manage multidrug-resistant tuberculosis?

It’s even gone beyond multi-drug to multi-multi-drug now. But to start, APIN does not on its own manage multi-drug-resistant tuberculosis directly. Our work is a collaboration on the national TB control programme. What we have continued to do is improve systems so that people can get treatment early. We do prompt and effective referral and linkage of suspected patients. Before, it took six weeks to do a culture, but now we have GeneXpert machines. Our funders have supported us with 75 GeneXpert machines in many states where the sputum can get you the result on whether it’s multi-drug in hours.

We are using that to prevent it because early diagnosis is important. The other important thing we are doing, which we are funded for and working with NCDC on, is infection prevention and control. TB is what kills most HIV patients. Hi, infection prevention control is something that we think we need to do. If we prove that somebody has multi-drug-resistant TB, there’s a protocol before the person can get treatment, which is supplied by the National TB Control Programme. They want to regulate it. Because if we throw it up like the regular treatment, again we’ll abuse it because any treatment for multi-drug resistant TB is at least 20 times more expensive than a regular TB course. So we try to ensure that if there are such cases, they are picked up early. We are collaborating with NCDC on its microbial resistance project, but we don’t have a multidrug TB programme.

To answer your question, if we don’t control things at the national level, we will worsen the situation. So we assist the national TB control program to ensure that we do the needful. Multidrug resistant TB is increasing; again, we cannot remove socioeconomic circumstances. If, for example, you tell a patient to come for a test, and he/she has just N1,000 in the house, you can imagine. Those things are some of the issues, and the situation is very bad. You must have heard about universal health coverage, where insurers can pay for your treatment so that you don’t get into financial catastrophe. But we’re already in financial catastrophe, even before we get sick.

What’s the most difficult challenge you face in your job?

For us, we’ve been fortunate. I joined APIN in 2004 as a project manager for Harvard. In 2007, when we were asked to become an indigenous CAC-registered entity, I assumed the role of chief executive officer. That’s why I’m proudly leaving soon because I think I’ve overstayed my welcome. But in all of those years, we have been blessed with a very committed workforce. God has helped us in that respect. We have an alumnus in Canada, and we have sufficiently trained ad hoc staff. The specific challenge, to which I think we’ve grown immunity, is uncertainty of funding. It didn’t start with this Trump thing. Every day you wake up, you’re not sure whether these people will fund you next year. That, for me, is the biggest challenge. And then the size of the organisation keeps increasing, so you have a burden. These young people are working hard, and they see their future here, and you are not sure what is going to happen. That burden for me is the greatest. And I don’t blame our funders because they are represented here by CDC Nigeria. So to answer your question, my greatest challenge is the fluidity and uncertainty of the funding environment. The more we begin to use our skills to do some innovative things that can bring resources—albeit that those resources will not be able to manage this big crowd that we have—I think we will be better.