NIGERIA—On a January morning, 12-year-old Yusuf Adamu slumps in his father’s lap, head pressed against his chest. Infected at birth with HIV, he is tiny for his age and has birdlike limbs. He has been feverish for 3 days, which is why his father, Ibrahim, brought him to the pediatric HIV/AIDS clinic at Asokoro District Hospital in Abuja, Nigeria’s capital. “He’s been losing weight, he is not eating well, he’s still taking his drugs, and he’s complaining of chest pains and coughing,” Ibrahim tells the nurse. Yusuf’s records show that at his last blood check 6 months ago, HIV had already ravaged the boy’s immune system, even though he was receiving antiretroviral (ARV) drugs. When the doctor, Oma Amadi, examines his mouth, it is filled with white sores from candidiasis, a fungal infection. “The boy has been sick for so long,” she says. “I’m going to admit him.” When Amadi removes Yusuf’s shirt to listen to his chest, the boy winces at the touch of her stethoscope. Amadi suspects Yusuf has tuberculosis, and after x-raying his lungs, the doctors put him in an isolation room.

Yusuf’s mother was never tested for HIV before he was born: She received no prenatal care and delivered at home. Yusuf was not tested for the virus until she died of AIDS 3 years later. Ibrahim then learned that he, too, is HIV-positive, as are his two other wives. One ended up transmitting the virus to a second child, now 4.

The entire family receives ARVs, but Yusuf has only had intermittent access to the drugs. Dosing is based on weight, and Yusuf’s has fluctuated so much that he has required monthly hospital visits. Ibrahim, a security guard, earns the equivalent of only about $20 a month. The Adamus live 20 kilometers and three bus rides from the hospital. The round trip bus fare costs $2, and Ibrahim has to miss a day of work for each checkup, when he also picks up his son’s ARVs. Ibrahim simply can’t afford regular treatment for his son. “There is no food at home,” Ibrahim says

Yet poverty alone does not explain the root of Yusuf’s plight—which hundreds of thousands of other Nigerian children living with HIV now face. At a time when rates of mother-to-child transmission of HIV have plummeted, even in far poorer countries, Nigeria accounted for 37,000 of the world’s 160,000 new cases of babies born with HIV in 2016. The most populous country in Africa, Nigeria does have an exceptionally large HIV-infected population of 3.2 million people. But South Africa—the hardest-hit country in the world, with 7.1 million people living with the virus—had only 12,000 newly infected children in 2016. The high infection rate, along with the lack of access to ARVs—coverage is just 30%—helps explain why 24,000 children here died of AIDS in 2016, nearly three times as many as in South Africa.

Mother-to-child transmission is only one part of Nigeria’s HIV epidemic. But that route of transmission epitomizes the country’s faltering response to the crisis, highlighting major gaps in HIV testing that allow infections to go untreated and the virus to spread. “Nigeria contributes the largest burden of babies born with HIV in the world—it’s close to one in every four babies [globally] being born with HIV—and that’s really not acceptable,” says Sani Aliyu, who heads the National Agency for the Control of AIDS (NACA) in Abuja. And it is a solvable problem—even here. The key is to find and treat the relatively small population of pregnant, HIV-infected women, because those who receive ARVs rarely transmit the virus to their babies. Like most countries, Nigeria has made mother-to-child transmission a priority for more than a decade, and it has seen a reduction in children born with HIV. Still, the country stands out for its slow progress. “What we’ve realized is that we need to think outside the box,” Aliyu says.

Ibrahim Adamu sits with his son Yusuf in an isolation room at Asokoro District Hospital in Abuja. MISHA FRIEDMAN
A pregnant woman living with HIV has a 15% to 30% chance of transmitting the virus to her baby in utero or at birth, and breastfeeding will infect up to 15% more. In 1994, a study showed that one ARV drug, azidothymidine, cut transmission rates by two-thirds if given to the mother before and after delivery and to the baby for 6 weeks. But few poor countries used that regimen because it was expensive and complex, requiring an intravenous drip of the drug during labor. Five years later, a study in Uganda showed a single dose of another ARV, nevirapine, given to a mother in labor and a baby at birth, could reduce transmission by 50%, which soon became a standard of care. Countries all over the world began aggressive prevention campaigns. Nigeria launched a program in 2002 when it had 54,000 newly infected children, and transmissions began to slowly decline.

Today, the standard of care is to treat all HIV-infected people, including pregnant women, with daily combinations of powerful ARVs. When treatment suppresses the virus in pregnant women and, as an additional safety measure, their newborn babies also receive ARVs for 6 weeks, transmission rates typically plummet to less than 1%. In the developed world and many developing countries, mother-to-child transmission is now rare. But the regimen can’t be given if pregnant women don’t know whether they are infected.

According to estimates from the Joint United Nations Programme on HIV/AIDS, 21.58% of HIV-infected, pregnant Nigerian women transmitted the virus to their children in 2016. Nigeria’s central problem is that some 40% of women give birth at home or in makeshift clinics run by traditional birth attendants, where women are unlikely to get tested. The reasons women do not seek care at more formal health care facilities like Asokoro Hospital are many and overlapping: poverty, fear of stigma and discrimination for simply seeking an HIV test, lack of education, tradition, and husbands wary of health care.

Another barrier is the “formal” fee that the government levies for care at a clinic. Deborah Birx, director of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in Washington, D.C., which has invested more than $5 billion in preventing and treating HIV in Nigeria, says the fee “opens the door” for others to tack on more insidious “informal” fees. “If you want to get your lab results back or you want to get your blood drawn, that nurse may charge you,” Birx explains. Those fees, she says, “are very hard to police.” When one Nigerian state eliminated the formal fee, the number of women who came to clinics for antenatal care doubled, she says.

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