Bringing the HIV epidemic in Nigeria to an end: A mixed methods study exploring why HIV remains an important public health challenge in Benue State and Nigeria. Inalegwu Precious OONO This thesis is submitted in partial fulfilment of the regulations for the degree of Doctor of Philosophy Institute of Health and Society Faculty of Medical Sciences Newcastle University. July, 2018 ii Abstract Introduction Human immune deficiency virus (HIV) remains a global public health challenge, with its burden varying steeply between rich and poorer nations. Despite advances in HIV diagnosis and treatment, certain populations continue to report high HIV prevalence and deaths. The main objective of this research is to explore variables that define HIV epidemiology in Benue State, Nigeria. HIV prevalence in Benue State is above the Nigeria national average of 3.2%. Methods An exploratory mixed methods research, incorporating a comparative analysis (of qualitative and quantitative data) and a systematic review (and meta-analyses) in the review of literature. Information generated from the literature review informed the content and direction of the empirical research. Data from qualitative and quantitative exercises were analysed and presented using standard techniques (for example thematic analysis for qualitative data and regression analyses for quantitative data). Results There is strong association between HIV burden and multiple deprivation. Variables associated with increased HIV risk in Benue State include female gender and low socioeconomic status. Religion, sex education and, local norms shape local HIV epidemiology through poor risk perception and social cognitive dissonance. Poor risk perception and social cognitive dissonance, in turn, lead to high HIV risk behaviours by reducing preparedness for safer sex practises. There was overwhelming local support for the passage of laws that criminalise deliberate transmission of HIV. Risk for HIV in Benue state vary significantly by places and areas of residence, with residents of rural and Idoma speaking areas being at increased HIV risk. Using condoms at first sex was significantly associated with lower HIV risk score (coefficient -0.25, P = 0.012, CI = -0.4458 - -0.0558). Tendency to stigmatise was significantly lower among those with tertiary education (coefficient = -0.88, P = 0.017, iii CI = -1.6009 - -0.1580). Predictors of consistent condom use include urban residence (OR = 3.68, P = 0.028, CI = 1.16 - 11.73), HIV knowledge scores (coefficient 1.66, P = 0.001, CI = 0.72 - 2.61) and condom use at first sex (OR = 5.61, P = 0.016, CI = 1.41 - 22.36). Inconsistent condom use was more likely among those who reported not having sex education at home in the past (OR = 0.32, P = 0.001, CI = 0.17 - 0.61). Marital status was not found to be protective against HIV risk in the meta- analysis (OR = 1.44, P = 0.44, CI = 0.57 - 3.63). Important epidemiological link between general population and known high HIV risk groups (like sex workers and MSM) was found, via Okada men. It was demonstrated, for the first time, that Okada riders may constitute an overlooked high HIV risk group locally – further research is needed to explore this finding. Conclusion There is need for comprehensive interventions that address individual and structural variables that influence local HIV epidemiology. The need for increased medication access cannot be overemphasised. Local interventions need to be decentralised, brought closer to the grassroots and, made sensitive to the needs of locals (especially among the older and less educated locals in rural settings). Mobile phone applications and, sex education (as part of schools curriculum), are some of the interventions and policy changes urgently needed. More controversial approaches such as criminalisation of deliberate HIV transmission are worth exploring further due to strong local support for such policies. Further research is needed to explore the relationship between local alcohol consumption and increased HIV risk as well as the role of “Okada men” in local HIV epidemiology. iv Dedication To my mother who never cease to inspire me. To all who live with HIV today. To the memory of all that have died from HIV related causes over the years. v vi Acknowledgement My unreserved appreciation goes to my supervisors (Professor Mark Stephen Pearce, Dr. Edmund Ong, Dr Katie Brittain and Dr Zaman Shahaduz). Many thanks for your immense support throughout my PhD years. Without your support and guidance, this project may never have been completed. This PhD journey began in the summer of 2012, when the proposed project (designed by the PhD candidate) was discussed with Professor Mark Pearce in his office. It was for the fact that Mark accepted to provide supervision that this project moved from the realm of an idea into reality. “It is not very often that students come to us seeking supervision on projects they have designed” Mark would add. This statement served as a huge motivation to me and would remain in the back of my mind throughout my PhD. Mark constituted the supervisory team for my project and worked tirelessly throughout the project life (having to find a replacement supervisor when one of my initial supervisors, Dr Zaman Shahaduz, left Newcastle University and was no longer available to provide support) to ensure a timely completion. My PhD supervisory team has worked immensely to provide the best support possible. These efforts (in the form of guidance and supervision) have ultimately resulted in the successful completion of this timely and relevant piece of PhD research. Following conception of this PhD and discussion with Mark, came the funding hurdle. My profound gratitude to Commonwealth Scholarships Commission in the United Kingdom (CSC UK), through Newcastle University, who saw the promise in my candidature as well as the potential impact this project could make to lives far away in Nigeria (and Africa). The CSC UK demonstrated her faith in my potential by funding my research proposal, through the prestigious Commonwealth Scholarships studentship, awarded to me at Newcastle University. Without the support of CSC UK, it would not have been possible for me to fund this piece of research. The CSC UK scholarship offers more than a studentship: it was an unparalleled life changing experience for me. Through this studentship, I have experienced life in the UK in ways that may not have been possible otherwise: I have during my PhD seen the four remaining copies of the Magna Carta Libertatum (the documents that enshrine vii democracy, dating back to about 800 years); I have been to the Westminster Palace on the occasion of the birthday of Her Majesty, the Queen of England, HRH Queen Elizabeth II; attended a development module held at the serene Windsor Castle among other exciting experiences. My stipend was never late and funds were always available for field work and conference travels. A big thank you to the Federal Scholarships Board, Nigeria for nominating me for the CSC UK studentship - without this critical step I would never have enrolled on this PhD program as a Commonwealth Scholar. A million thanks to Benue State Ministry of Health for granting necessary approvals and support required for this research. I would also like to acknowledge the immense contributions of my assessment panel (Professor Richard Walker and Dr Louise Hayes). You were so good at the progress panel meetings that I never felt like I was being examined at any time: it felt like we were having intelligent conversations about how to improve my project. It was based on your recommendations that I summoned the courage to publish part of my PhD thesis. I do not wish for a different progress panel. Thank you so very much. I will like to acknowledge Katharine Kirton (Professor Mark Pearce’s secretary), Denise Heighton (IHS secretary), Mr. Richard Hardy (IHS computing officer), Marion Hancock (former Institute post graduate administrator, now retired) and Mr. Gabriel Ameh (Benue State Ministry of Health) for your immense support. I cannot thank you enough for ensuring that I had a smooth experience through your admin and clerical support. Many thanks. viii Awards, conferences and publications 1. A two part publication in Journal of Human Virology and Retrovirology (JHVRV): a. Oono IP, Ong E, Shahaduz Z, Pearce MS (2015) Understanding the Patterns of Spread of HIV/AIDS in Nigeria: A Systematic Review and Meta-Analysis of Primary Research Articles. J Hum Virol Retrovirol 2(4): 00047a. DOI: 10.15406/jhvrv.2015.02.00047a b. Oono IP, Ong E, Shahaduz Z, Pearce MS (2015) Understanding the Patterns of Spread of HIV/AIDS in Nigeria: A Systematic Review and Meta-Analysis of Primary Research Articles. J Hum Virol Retrovirol 2(4): 00047b. DOI: 10.15406/jhvrv.2015.02.00047b 2. Best poster award, applied epidemiology research day, Institute of Health and society, 2015. 3. Poster presentation at international association of providers of AIDS care (IAPAC) conference, Fort Lauderdale, Florida, United States of America. 2016. 4. Attendance at “controlling the HIV epidemic with antiretrovirals” - an IAPAC conference held at Geneva, Switzerland between 13th and 14th of October, 2016. ix x Table of Contents Abstract ...................................................................................................................... iii Dedication ................................................................................................................... v Acknowledgement ....................................................................................................