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California state university, long beach

HIV/AIDS in Nigeria

Tolu Fashola

Joseph Francisco

Alexandra Madigan

Eresha

HSC 535

Spring 2011








In order to understand the journal articles enabling us to dissect the methods and theories being employed we must have a grasp on the current situation with social stigma, human rights and its correlation with HIV/AIDS in Nigeria, and then give an idea of the ideal situation in Nigeria using a behavioral model to implement this change. The current situation in Nigeria is that the HIV epidemic has continued to be on the rise, and in 1999, a cummulated total of 3.5 million cases had been reported with a national HIV prevalence rate of 5.7%. The issue that is being addressed is the social stigma on the society and community. “From the time HIV was discovered, social responses of fear, denial, stigma and discrimination have accompanied it. And although, its negative connotations have been acknowledged, research into its role in prevention methods has been dismal.” (Odimegwu, 2002)

2:1 Arranged Marriages for Couples Infected with HIV/AIDS in Nigeria

By arranging marriages with couples who are infected with HIV/AIDS, government officials in the state of Bauchi have the theory that this could be an effective way of controlling the spread of HIV/AIDS. Bauchi officials feel this can “promote the de-stigmatization” of those individuals infected with HIV and prevent the spread the spread of HIV/AIDS. In a country with a population size of 148 million, 3.1 percent tested positive for HIV/AIDS ranking Nigeria as the third highest population in the world infected with HIV/AIDS (Purefoy,2009) . Single males and females are viewed as the “spreaders” of HIV/AIDS, the Bauchi Agency for the Control of HIV/AIDS, Tuberculosis, Leprosy and Malaria (BACATMA) is the organization that arranges the marriages of the infected individuals. BACATMA encourages these individuals to mingle and meet with the purpose of getting engaged. BACATMA will also provide money toward a dowry and also finance the ceremony if the couples are arranged through the agency. As of 2009, there have been 110 arranged marriages by the agency (McCarthy, 2009).

The main issue with those infected by HIV/AIDS is the social stigmatization problems they face. Those that are open about being HIV-positive are often alienated in the communities. Family and friends tend to not associate with them as well as their employers do not allow them to keep their jobs. With this, infected individuals do not have the ability to maintain a steady income which makes it difficult for them to pay for housing. These individuals often times resort to becoming sex workers or prostitutes. Although prostitution is illegal in Nigeria, sex workers continue to work in their field in order to maintain a steady income. These individuals are highly vulnerable to becoming infected with HIV/AIDS and may be responsible for high rates for infection which could be passed from person to person.

Other organizations feel differently about BACATMA’s view and theory of arranged marriages. UNAIDS, the United Nations agency that deals with HIV and AIDS, disagrees with the concept of arranged marriages of HIV/AIDS infected couples because they feel this theory does not prevent the spread HIV and AIDS. UNAIDS theory of prevention of the spread of AIDS would be through “treatment and care” (BBC News, September 2008). It has not been proven that arranged marriages prevent the spread of HIV and AIDS, although it supports fight against the stigmatization that is brought upon by family, friends, and society. As reported by Amnesty International, in their report, “Nigeria: Rape – The Silent Weapon,” Nigerian police and security forces:

“intimidate communities in the Niger Delta… rape is used by the police as a means of torture to extract confessions from suspects in custody… women and girls rarely seek prosecution for fear of intimidation by the police and rejection by their families and community. When they do, widespread failures throughout the judicial system result in only an estimated 10% of cases ever being successfully prosecuted.” These instances of rape and sexual assault contribute to the spread of HIV/AIDS, yet BACTMA falsely assumes that married couples will have a degree of social protection against rape crimes”.

Also, UNAIDS advises that the arranged marriages should not have children due to the reduced possibility of the child being born with AIDS and the child may become an orphan because the parents may pass away from AIDS. The theory of arranged marriage of infected individuals allows those to escape the stigma that is associated with being HIV-positive but it does not solve the issue of HIV/AIDS prevention.

It appears the Communication Theory was being applied in the arranged marriage concept. The purpose of the arranged marriage was to try and control the spread of HIV and AIDS but at the same time it alters the attitudes that factor into the social norms of those individuals that are HIV positive. The people of Bauchi, who have HIV and AIDS are often alienated and singled out but the concept of being united with someone else in the same situation gives them the companionship they lack. The goal of setting up these arrangements targets a specific group of people and action was taken by 110 arranged couples. Some of those individuals do not have that stigma of HIV and AIDS and can relate with someone else. Although the thought of arranged marriages seems like a positive idea, the concept does not have the support from other organizations. UNAIDS does not agree with the idea because there is not enough evidence to support the cause. UNAIDS feels the best way to communicate the message of HIV/AIDS prevention is by way of treatment, care, and education. Without the support from other social groups and public health organizations, arranged marriages of individuals with HIV and AIDS will not be effective.

Activities & processes and Outcomes

What we did/How we did it?

The idea of arranged marriages of those individuals who were infected with HIV/AIDS was a theory that was an attempt to control the spread of HIV/AIDS and alleviate the negative stigma the disease creates. The marriage arrangement was a plan to control the spread of HIV/AIDS by bringing two infected individuals together and unite them so that others that do not have the disease would not become infected. The Bauchi State Agency for the Control of AIDS, Tuberculosis and Malaria (BACATMA) in Nigeria initiated and promoted a program that would help pay for the dowry and provide counseling as well as offer jobs within BACATMA. The theory of arranging marriages of infected individuals would confine the spread of HIV/AIDS amongst the couple because the HIV/AIDS is prevalent in Northern Nigeria from the polygamist culture. Dr. Lirwan Mohammed, executive director of the Bauchi Action Committee, states “Polygamy, as we have discovered, has become a potent source of spreading the HIV scourge in Nigeria” (Gutierrez-Folch, 2009). He also explains the arrangements are confidential and are based upon agreement of both parties. Dr. Mohammed also states “Suitors who have tested positive and are willing to wed each other, can reduce the spread of the virus and also cushion the psychological trauma of isolation,” (Gutierrez-Folch, 2009). Although the thought of controlling the spread of HIV/AIDS by taking those infected and partnering up as married couples does act as an agent to control the spread of the disease but there are drawbacks to the theory.

The arrangements do help by providing another person who is going through the same scenario which lifts the negative stigma of HIV/AIDS. The feeling of loneliness and isolation is not an issue as it was before because there is someone else by their side with the disease. The problem is that there is no evidence this method is effective in controlling the spread of HIV/AIDS. People of Nigeria are not provided with enough information about sexually transmitted diseases and the low use of condoms due to the Islamic laws which the state of Bauchi follows does not encourage the use of condoms. Many organizations, such as the United Nations does not approve of the arranged marriages due to the ineffectiveness and potential dangers. The UN fears that infected couples present the possibility of having children that may be born with the HIV or AIDS as well as children that may also become orphans as their parents succumb to the disease.

What do we need to change?

Rather than trying to contain the disease by having infected individuals marry one another, the state of Bauchi needs to emphasize education of sexual transmitted diseases and promote the importance of condom use. The United Nations emphasizes that treatment and care needs to be more accessible. There is no evidence that shows arranged marriages reduces the population of infected individuals. Instead it presents the possibility of growth due to the possibility of the infected couples barring children who may have the disease through birth. Sexual education needs to be promoted to the people of Nigeria with the emphasis on the risk of becoming infected with HIV or AIDS through unprotected sex. Although the arranged marriage aids in dealing with isolation and loneliness but that does not prove the spread of HIV/AIDS will be contained. BACATMA provides jobs and counseling for those who are infected by the disease. This can be an avenue for individuals to meet and discuss social issues they may be dealing with in their daily life as they speak with others who may have issues that relate. The key component in trying to slow down the spread of HIV and AIDS would be to educate and provide information of the risks of the disease. The importance of condom use needs to be emphasized as it can be a major component in controlling the spread of HIV/AIDS.

2:2 HIV/AIDS- Related Stigma and Discrimination in Nigeria

The stigma associated with HIV/AIDS in Nigeria is grave. It affects care, treatment and health-seeking behavior of those affected by the pandemic. “Stigma is often associated with discrimination and human rights has been defined in various ways.”(Emmanuel 2010) Freedom from discrimination is a fundamental human right founded on principles of natural justice that are universal and perpetual. Human rights inhere in individuals because they are human and apply to every individual. The principle of non-discrimination is central to human rights thinking and practice. Discrimination against people living with HIV/AIDS or those presumed to be infected with the virus is an obvious violation of the persons right.

Our main focus principle and value is human rights. “The way to tackle social oppression of any kind is to introduce strategies that address underlying conditions of poverty, racism, and sexism that support such oppression. To be effective, all HIV interventions should include an analysis of how stigma functions, how it enhances dominance and subordination in society. Enlightened HIV prevention and care interventions will empower the stigmatized through health education that lifts self-blame. While teaching respect for all through a more just society, these interventions will help people who are stigmatized to critique unjust societal dynamics and challenge assumptions and warrants of privilege.” (Rankin, 2005)

The ideal situation and our vision would be to see a decrease in social stigma related to HIV/AIDS in Nigeria throughout the rural and urban communities. We want to remove the barriers of social stigma and discrimination associated with HIV/AIDS in Nigeria. The ideal situation would be to tailor, document and grasp culturally appropriate and specific research on social stigma and discrimination to better equip current initiatives and prevention treatment programs. The best approach to implement strategies and effective ideas would be to emplore the use of the Social Cognitive theory because this theory asserts that more than information alone is needed to promote change

Our goal in regard to the associated social stigma related to HIV/AIDS in Nigeria is use the Social Cognitive Theory to first, increase awareness and knowledge of the health risk while convincing Nigerians that they have the power to change their behavior. Secondly, showing people what their risks are and how they can change it. Thirdly, to increase the individuals self-efficacy by showing them treatment is the way out and they are able to overcome social discrimination. Lastly, to build social support and provide a networking community to all infected individuals. Support groups are the way out to achieving self-efficacy. This is shown thorough this model. It is crucial that Nigerians are empowered to handle post-test status crisis to prevent suicide attempts and desperation to infect others. Campaigns combating social stigma, must be clear, direct and focused on the message they are trying to deliver and the population they are attempting to target.

behavior, rather sustained behavior change requires the skills to engage in the behavior and the ability to use these skills consistently and under difficult circumstances.” (Rankin, 2005)

This is a obviously a priority issue in Nigeria because of the increasing high incidence rates of HIV and continued barriers to treatment. Currently the fear of rejection and stigmatization is so high within the home and communities throughout Nigeria that it prevents people living with HIV/AIDS to reveal their status to family members. Religious affiliations interpret the pandemic to be a punishment from God for the sin of the infected. “To avoid stigma, discrimination and possible losses, HIV-positive individuals attempt to conceal their status, and this causes them to be cut off from social support and needed medical and social services. They may also delay in obtaining medical care or fail to adhere adequately to medical treatment regimens once they enter care.” (Odimegwu, 2002)

According to Odimegwu (2002), and Emmanuel (2010), the results showed that in regards to associated social stigma in these multi-cultural communities, not much has been done. The type of studies implemented consisted of; intervention programs, semi-structured interviews, and focus groups. Although no specific theory was directly mentioned or used, the term perceived susceptibility (from the Health Belief Model) was a common theme throughout the eight studies. The rural areas were involved in AIDS campaigns to educate about the disease and prevention steps, while the urban centers there are already a number of organizations active in HIV/AIDS prevention activities. In the urban sites a convenience sample design was used to select the samples for an interview.

The continued challenges illustrated in the articles are that, “Stigma remains a major roadblock to effective response to the AIDS pandemic; understanding and counteracting it is therefore a major public health challenge not only in Nigeria but the whole of sub-saharan African region.” (Odimegwu, 2002)

Implementation of interventions designed upon theoretical models such as the Social Cognitive Theory and The Labeling Theory are crucial in changing attitudes and demystifying the felt threat of HIV/AIDS. This must be done since most current intervention programs in the country lack theoretical foundation. We must put more effort and resources into care, support and treatment programs so the value of self worth and human rights can come out on top.

In this process it is important to know how do we get where we want to go. More specifically, who does what, when and how? We want to go in the direction of decreased social stigma associated with HIV/AIDS. This can be done through implementation of De-stigmatization programs which are a crucial focal point for prevention activities. An example of a de-stigmatization program would be to bring day hospitals to peoples homes. Some of the de-stigmatization phases would consist of recruiting and training local physicians and community health workers, publicizing HIV services and education, treatment beginning with home visits, and directly observed therapy, and lastly a follw-up period. These specifically tailored programs would aid in stigma reduction and be a different approach from previous programs because it hans’t been done on a large scale before. The literature that supports the effectiveness of reducing stigma is limited and not very conclusive. We also must present and design the information, education, and communication programs in such a way that they are able to aid stigma reduction not hinder it.

In order to get there and combat this pandemic a national program called the HIV/AIDS emergency Action Plan was put into effect from 2000-2003. The objectives consisted of; Increased awareness of the disease, the promotion of behavior change, empowering the public to initiate community-specific plans, creating networks of individuals already infected with the disease, establishing an effective surveillance system, and continuing HIV/ADIS research. (Odimegwu, 2002)

The evaluation plan to combat this epidemic and increase human rights for all is through documentation of experiences of stigma as well as the resistance to it. According to Emmanuel (2010), and Odimegwu (2002) it is apparent that we must examine the ways in which various media-electronic and print, have influenced AIDS stigma. Such as how media dissemination of HIV/AIDS information affects public stigma, and how the current national campaign to prevent HIV transmission engenders stigma.

The study done used “qualitative tools of in-depth interviews, key informants and focus groups to collect the required information from the communities.” (Odimegwu, 2002) Combining the findings from the articles the perceived challenges and the evaluation plan are the necessary steps in decreasing social stigma, increasing the value of improved human rights for all those affected and implementing a successful program based in the Social Cognitive Theory.



STEP 3: Document Implementation of Plan

What did we do?

According to Odimegwu (2002), a pilot survey was conducted to supplement a two-teared survey in the investigation of the impact of stigma on AIDS prevention, care and treatment programs in Nigeria. The first phase consisted of access to voluntary counseling and testing. Odimegwu states that it is essential to “provide a baseline to investigate the beliefs and values about HIV-related stigma in health care settings and families; how such stigma affects care, treatment and health-seeking behavior of those affected by the pandemic.”

A national program “HIV/AIDS Emergency Action Plan” (HEAP) was implemented which it’s objectives consisting of “ increasing Increasing awareness and sensitization of general population and key stakeholders, Promoting behavior change in both low risk and high risk populations; Ensuring the communities and individuals are empowered to design and initiate community-specific action plans; Creating networks of people living with HIV/AIDS and others affected by AIDS; Establishing an effective HIV /AIDS surveillance system;” (Odimegwu, 2002)

“The HEAP initiative intends to respond to the determinants of HIV/AIDS transmission such as social, behavioral and biological factors. Its strategies include preventive interventions, empowerment of women to negotiate safer sex, prevention of mother-to-child transmission, care and support for those infected and affected by HIV/AIDS (NACA, 2001).” (Odimegwu, 2002)



How did we do it?

Accoring to Odimegwu (2002), the studies show that populations in both urban and rural areas were sampled. The first tear of the study consisted of qualitative tools consisting of complex interviews, key informants, and focus group discussions to collect the necessary information. In the urban communities, convenience sample designs were done asking there feelings toward individuals infected with the disease. Surveillance studies were also used. The results of the surveillance surveys done in Nigeria in the year 1999 indicated an increased level of regional variation of HIV/AIDS.



What were the results?

The results showed some variation throughout the urban versus the rural communities and Nigerians reactions to HIV/AIDS, it’s impact on social justice and how society views the infected individuals.

Accoring to Odimegwu (2002), it was found that the language that surrounds the epidemics aids in reinforcing negative stereotypes and prejudges. Odimegwu (2002), states that, “derogatory terms are used to describe those with the virus.” Since the majority of the population negatively associates the virus and the individuals affected, a grave problem begins with the way people living with the virus interact with the community and want to be a part of it. Odimegwu (2002), states “two-fifths of the respondents felt very or somewhat angry or disgusted toward persons living with HIV/AIDS, and more than half were afraid of them.”

There are also a lot of myths that Nigerians associate with the possible ways of contracting the virus. Accorinding to Odimegwu (2202), it was apparent that “one-fifth of the respondents thought that HIV could be contacted through mosquito bites. and 19% believed AIDS could be transmitted through sharing food.”



STEP 4: Revise

What do we need to change?

Focusing on social justice as our core value we were able to draw strong correlation between the negative social stigma associated with HIV positive Nigerians and the mistreatment the were receiving from their society. Social justice is based on the principles of equality and solidarity, which encompasses human rights, and recognizes the dignity of every human being. With that being said something has to change with the way Nigerians with the disease are treated. Social stigmatization must be combated. The misconceptions and myths associated with the disease must be changed in order to pave the way in convincing the infected individuals to seek treatment. “The surrounding community attacks or ostracizes them and the government balks at the prospect of enacting legislation; but even if enacted, implementation becomes difficult The mass media unabashedly publishes incendiary lies about the disease, and the medical community does little to combat the lies with their actions. All of these create an environment extremely unfriendly to the victims of the epidemic.” (Odimegwu, 2002)

A major issue within the country is that, the majority of interventions in Nigeria lack theoretical foundations. Theoretical models should be used to design interventions to change negative attitudes with the perceived threat of HIV/AIDS. Also in regards to campaigns, heath personnel at the local level should be targeted to change their fearful thoughts about providing services for the infected individuals. The campaigns against stigma and basic human right should also be upfront, clear and directed.

Throughout the articles it was suggested to find a way to do mandatory HIV testing. However, the individuals who participated in the surveys believed that knowing one’s sero-status posed more of a threat, than did good. Rejection would be high and infected individuals wouldn’t want to be negatively treated by the community by making their status known. Another issue is that of the saying that misery loves company. The population surveyed pointed out that some individuals will deliberately infect others because these people believe that “they too were infected by others and also that they would not be the only ones to die”(Odimegwu, 2002)

Another issue that must be changed is the models that are being used to combat social stigma around HIV/AIDS and improve the social justice and well being for Nigerians. In the multiple articles no definitive behavioral theories or models were used in these research studies. However, through careful examination, iIt is apparent that the most effective models to improve human rights through decreasing social stigma of HIV/AIDS were The social diffusion model and a model that assumes that social and environmental changes are necessary. For the diffusion of innovations to key component are; testability, and visibility. “One of the earliest successes in reducing HIV incidence comes from Uganda, where HIV incidence went into a sharp decline in the late 1980s. In other words, Low-Beer is arguing that the social diffusion model in which there is (a) a wide personal acquaintance with HIV/AIDS in the population and (b) the encouragement and willingness to speak about it and pass knowledge on in informal social networks is the method that has worked best to influence behavior change” (Emmanuel, 2010)

Furthermore, in regards to models that encompass social and environmental changes it is illustrated that the most effective way to use social change models with individuals is to develop ‘community pride’ programs which lead to the development of greater self-efficacy and the reduction of isolation among participants.

Lastly, it is important to address what needs to be assessed for future research imploring the use of implemented belief models that focus on social justice or implementing new models, and to understand the limitations of the studies to better assess what is needed for improvement in the future, and focus on the effect of persons living with HIV/AIDS as well as the individuals who are at risk for contracting the disease.

Concise research is needed in the evaluation of meticulously orchestrated intervention programs, that are ready and fully equipped for implementation. According to Odimegwu (2002), he states that “While its negative effects have been acknowledged, research into its role in prevention activities has been lacking in Nigeria. Only anecdotal evidence of stigma, reported by the news media, exist in Nigeria. A comprehensive search of published reports on HIV stigma in Nigeria using various electronic search engines yielded no result, except that in some studiesnot related to stigma, there are passing comments on the impact of AIDS stigma while no systematic study has actually investigated the relationship. Local non-governmental organizations admitted sigma issue is part of their intervention activities but were not able to show tangible on-going de-stigmatization activities in their programs.”

Although, there are numerous theories that have been associated with effectively decreasing the incidence rate of HIV/AIDS such as The Health Belief Model, and Stages of Change, theses models have little to no effectiveness in third-world underdeveloped countries. In first world nations the citizens have access to more resources for change and less risk associated with putting themselves at risk for he disease. However, in Nigeria as in other countries in Africa many individuals are exposed to the disease through lack of use of condoms (lack of resources), un-consensual sex, and blood transfusions.

2:3 HIV/AIDS Stigma among Healthcare Workers

STEPS 1 & 2

As a result of the increasing number of people living with HIV/AIDS, control and preventive strategies most not only focus on encouraging behavioral modification but also on respect of the rights to care of those infected. However, various research have shown that an unduly fear of contracting HIV/AIDS by the healthcare workers have mostly limited the efforts garnered towards combating the HIV epidemic in Nigeria. In this section, discussion focuses on Stigma towards PLWH/A among healthcare workers with the use of two research articles: (1) Attitudes of Health Care Providers to Persons Living with HIV/AIDS in Lagos State, Nigeria; (2) Discriminatory Attitudes & Practices by Health Workers Towards Patient with HIV/AIDS in Nigeria.

Adebajo (2003) conducted a a descriptive study that evaluated the attitude of laboratory technicians and nurses towards people living with HIV/AIDS (PLWH/A) in Lagos state, Nigeria. The study examined the practioners knowledge, beliefs and attitudes towards PLWH/A and the factors that are responsible for this attitude like age, gender, religion, level of education, length of practice and attendance of refresher courses on HIV/AIDS. For the study, 254 nurses and lab techs were randomly selected from 15 government owned health facilities in Lagos State to elicit information through the use of a structured questionnaire. Of the 254 participants, 104 were laboratory technologist and 150 were clinical nurses. This 44-item self-administered questionnaire will assess the participants’ level of knowledge of the causes, modes of transmission and methods of preventing HIV/AIDS. The study was conducted from July to September 1999. In the results, data supported that 90% of the participants were able correctly to state the causes and mode of transmission of HIV/AIDS. However, in identifying the population that are most at risk of contracting HIV/AIDS, participates disproportionately listed patients admitted to the hospital and healthcare workers as a high risk population; neglecting IV drug users, adolescents and cab drivers (relevant to the country). Also, 87% of the respondents states that treating people living with HIV/AIDS (PLWH/A) put them at increased risk of contracting HIV and 34.7% of the respondents believed that PLWH/A should be isolated. Although 93% of the respondents agreed that they are duty bound to treat all patients, only 87% said they examine or touch a PLWH/A. The current situation in Nigeria with regards to Stigma associated with HIV/AIDS among health care workers is rooted in the unduly fear of contracting the disease by simply caring for this people. According to the first article stated in this discussion a staggering 40% of the participates listed patients admitted to the hospital and healthcare workers as a high risk population for contracting HIV/AIDS, neglecting IV drug users, adolescents and cab drivers (relevant to the country). Also that treating people with HIV/AIDS put the healthcare workers at great risk as listed by 87% of the respondents. (Adebajo, 2003) (Adebajo, 2003)

The second research article was conducted by Anyamale (2005) was conducted in the states of Abia, Oyo, Kano and Gombe, each representing a geographical area of the country. A total of 1,021 nurses, doctors and midwives were randomly selected from tertiary facilities both in the private and public sectors from the four states, and were administered a 104-item healthcare professional survey that included questions on demographics; practices regarding informed consent for HIV testing; testing and disclosure of HIV/AIDS; and attitudes and beliefs about treatment and care of PLWH/A. After this, an interview of the healthcare professionals lasting 20-30 minutes was conducted over a period of 5 weeks. With level of education, religion, and age accounted for, the results indicated that 49% believed that PLWH/A should be isolated when in hospital and 40% states that a person’s HIV status could be determined by physical appearance. Also, 40% of the respondents believed that healthcare professionals that are HIV positive should not be allowed to work in areas with patient contact and 20% of the respondents that the PLWH/A deserved the disease because of their immorality. As stated in previous section, our main focus and value is human rights. Promoting equality in human right is paramount to reducing the stigma and ridicule experienced by PLWH/A in Nigeria, especially when the stigma is stemming from those that are professionally obligated to do otherwise. As indicated in the second article, where 49% of respondents states that PLWH/A should be isolated when in hospital and 20% stating that the disease is deserved due to the patients’ life of immorality. (Anyamale, 2005)

STEPS 3 & 4

ACTIVITES (What we did & How we did it)

For the research articles utilized in the section of the project, interventions were targeted solely at healthcare workers in Nigeria as to cumulate attitudes toward PLWH/A. Various methodologies are being implemented countrywide to nourish the workers knowledge on care, development and management of the care of HV/AIDS patients.

As indicated in the “Attitudes of Health Care Providers to Persons Living with HIV/AIDS in Lagos State, Nigeria” by Adebajo and co., it is stated that Refresher course like certification exams, in-services, skills labs, educational conferences and professional advancement examination is a major medium for to increase knowledge among the healthcare workers community. Consequently, equipping the workers with knowledge will decreases unfounded fear in regards to their care of HIV/AIDS patient and reduce the stigma associated with this disease in the healthcare setting. (Adebajo, 2003)

The national governing body for the planning, medical and social management and surveillance of HIV/AIDS in Nigeria is the NACA (National Agency for the Control of AIDS) and was founded in 1999. The agency directly and indirectly fund state and local programs that provide care for HIV/AIDS patients and also educational opportunities for healthcare workers, outreach programs and community mobilization events. As evident in the third and fourth mission and vision statement of the National Agency for the Control of AIDS (NACA) that is:

· “Work together as a team supporting outstanding people-oriented services that will greatly reduce HIV/AIDS in Nigeria” ;

· “Work in the public interest, acting in good faith, shunning all divisive pressures to provide care and support to people affected by HIV/AIDS” (National Agency for the Control of AIDS, 1999)

To provide patient-centered care, shunning all divisive pressure (religious, social, financial or cultural) healthcare workers must overcoming any unfounded fear or stereotype about people living with HIV/AIDS. Continuing education and refresher courses that address these issues is one of the easiest ways to reduce stigma among healthcare workers and this will foster the growth and achievement of the goals set by NACA for the management of HIV/AIDS in Nigeria. (National Agency for the Control of AIDS, 1999)

The ideal situation will be absence of social stigma and health disparity, equal access to healthcare by all, and un-stigmatized delivery of care. Cultural competency aside, the best methodology to curbing the gangrenous stigma among healthcare workers is to implement theory advised practices utilizing models like the Health Belief Model, Social Learning Theory, Social Marketing Theory and the Diffusion of Innovation.

OUTCOME: (What were the Results?)

Although the results of the research articles used in the section are not all that encouraging, it is evidently an improvement from what the reaction to HIV/AIDS in Nigeria has being years back. The article “Attitudes of Health Care Providers to Persons Living with HIV/AIDS in Lagos State, Nigeria” shows 90% of healthcare providers that participated were able to correctly state the causes and mode of transmission of HIV/AIDS, but 34.7% of the respondents believed that PLWH/A should be isolated. Although 93% of the respondents agreed that they are duty bound to treat all patients, only 87% said they examine or touch a PLWH/A. (Adebajo, 2003). This result indicate a strong knowledge base of HIV/AIDS among the healthcare workers, but at the same time, it shows that variables other than knowledge are responsible to for the stigma associated with HIV/AIDS among healthcare workers.

The “Discriminatory Attitudes & Practices by Health Workers Towards Patient with HIV/AIDS in Nigeria” study showed that 49% of the healthcare workers that participated in this study believed that PLWH/A should be isolated when in hospital and 40% of them states that a person’s HIV status could be determined by physical appearance. This second statement clearly shows a staggering knowledge gap in the manifestation and testing of HIV/AIDS, and this is most likely rooted in the cultural believes as it mostly assumed especially among the population 50 years old and above that being robust is equivalent to being health and disease free while being skinny is indicative of a diseased body. Despite the fact that most of these healthcare professionals will theoretically states that HIV/AIDS can only be detected by a blood test, the stigma associated with the disease will cause them to claim that HIV/AIDS can be detected by merely looking at a person’s physical appearance. Also 20% of the respondents believe that the PLWH/A deserved the disease because of their immorality. (Anyamale, 2005)

REVISIONS: (What do we need to change?)

In a country as diverse and populous as Nigeria, culture, belief, religion, poverty, knowledge gap and communication network are a huge barrier to the implementation of an effective strategy to battle stigma from healthcare workers. Needless to say much, when the people that are trained and are professionally and ethically obligated to care for the sick regardless of what the disease or sickness is thinks that the patient is deserving of the disease because of a presumed or proven immorality, then the standard of care, access to care, and social support will be sub-standard

A recent report from the Center for Disease Control and Prevention (CDC) states that 50% of the people infected with HIV does not know that they are infected. As a result, they are not being treated or managed, and they are three times more likely to transmit HIV to an originally uninfected person than someone who knows his/her serostatus. The problem here is that despite the public awareness of HIV transmission, advancement in medications to manage symptoms and prevent transmission to AIDS as well as advancement in diagnosis; people still don’t want to get tested for HIV because of the associated stigma, and medical providers don’t readily perform HIV test on their patients even when a high risk lifestyle is sometimes presented. Note the above statement mostly apply to the United States where there is advancement in medical care. (CDC, 2010)

Now, compare this to Nigeria, a country where poverty, culture, religious oppression, polygamy and limited medical access provides little or choice of care. This combined with the associated stigma especially from healthcare workers that are suppose to provide refuge leaves the HIV/AIDS issue in Nigeria an eye sore. More alarming is the fact that to most Nigerians and even a significant amount of healthcare workers based of the resulted studies, HIV/AIDS = an immoral life style. With a belief as such, efforts should be targeted at de-stigmatizing HIV/AIDS is shapes and form in order to promote social justice



The Nigerian cultural beliefs and attitudes, the gender related power differences, the Nigerian woman’s social status and social stigma towards the woman With HIV/AIDS



HIV/AIDS is one of the worst pandemic that has been experienced by humankind. This pandemic has killed so many people around the world, mostly in Sub-Saharan Africa. The nature of the pandemic led it to stigma and discrimination, which have made caring for People Living With HIV/AIDS (PLWHA) a big issue; it has also brought suffering on PLWHA around the world (Muoghalu 2010). Increased incidence of HIV/AIDs is a major health and economical problem in Nigeria as the third highest incidence of HIV in the world. Here, 2.9 million were diagnosed with HIV or AIDS in 2006 while 220,000 were kids, and 70% of the population were living with AIDS(LWAIDS) in Nigeria. Worst of all, 1.3 million of orphans are LWAIDs in Nigera (Ikecjebebulu IJ 2006). The society in Nigeria has been stigmaticing the PLWHA. Even the PLWHAs are entitled for a decent living with dignity; social justice without being stigmatizatised.There are local and international programs being implemented to achieve social justice to these populations by decreasing stigmatization by educating their population.

Nigeria is a country with mixed religion and beliefs. Religion wise, 50% of the population is Muslim, 26% are protestants and 14.8% are Roman Catholics. Christianity is mostly in Yoruba areas, and Catholicism predominated in the Igbo and closely related areas. In Nigerian villages, marriage is considered sacred. A church wedding is valued. In a marriage, the bride receives a bride price from the groom. Traditionally, parties are supposed to be virgins on the wedding night (unless it is not the groom's first marriage), Men are the most powerful members of Nigerian culture. The man is responsible for finances and he is the head of the family. In the Christian religion, abstinence before marriage is still preached. Polygamy is legal for the male in Nigeria even though, it is not encouraged in Christianity. In traditional beliefs, a man is allowed to have unlimited number of wives. Within marriage, women in Nigeria have an obligation to have children. Society blames the woman for marriage without children. Having many children in Nigeria is fashionable and a status symbol. Most families consist of 5 or more children. Female children are socialized to serve and be subordinate to males. Young boys are raised with the expectation of having a wife (or wives) to take care of them, and women are raised with the expectation that they will have a husband and children to take care of. Men are trained to be strong willed, powerful, and to bare leadership. Sexual activity is taken as the marker for masculinity (Ngozi2010). Women are raised to be gentle, caring, and subservient, and closely knit families are very important in the culture. Even though Polygamy is legal for male, the wives are supposed to be monogamous. Divorce in Nigeria is very uncommon. Divorced women are usually looked down upon and are condemned by society (Motherland Nigeria 2007). Nigerian culture believes that the most important thing in life is family and divorce should not be an option. In most neighborhoods, the neighbors take a part in taking care of a child. A lot of people feel like they were 'raised by the neighborhood (Akpan 2008). Again the rich men with jobs in urban areas fantasize having young women as a social status; the pretty, urban, educated young are the girlfriends provide not only sex but also the opportunity, or the fantasy, of having more exciting, stylish, and modern sex than what they have with their wives(Smith 2007). Furthermore, the man is superior to the woman in the Nigerian society and women are mostly dependants of the man (Smith 2007).

According to Mbonu Ngozi’s research paper on gender related power differences (2010), the social norms play a bigger role in the society. There is a strong gender related power difference in the Nigerian society. Woman is a man’s property and do not inherit anything by the Nigerian law making the women very dependant and placing the woman in a very disadvantaged position in economics. When a woman is diagnosed with HIV, she will be stigmatized. The woman become HIV positive due to infidelity but a man gets it from the barber. The woman will be sent away when she is found to be HIV positive but the sick man will be a taken care of the wife. The man will hide the HIV status from the society while he will broadcast his wife’s HIV status (Ngozi 2010). Female will be always stigmatized and blamed. According to the Nigerian society the man always got infected from the wife while the wife got it from another man due to her infidelity. Further, for the woman’s treatment needs the husbands consent while the man gives consent for his own. In Nigeria, the man makes decisions in the family; the wife is a subordinate helpless female to bear the burdens (Ngozi 2010).

HIV is transmitted by many ways, unprotected sex, needle sharing, mother to child transmission and blood transmissions. Unprotected sex with increased amount of partners, increase the risk of being HIV positive (CDC 2011). The Nigerian social norms, culture and beliefs make the woman vulnerable to HIV/AIDS as well as social stigma. Each human being needs dignity and deserves and entitled to social justice (Ngozi2010).

The ideal situation should be taking precaution to avoid HIV transmission, decrease the incidence of HIV/Aids or eradicate HIV/AIDS while providing social justice to the prevalent HIV/AIDs population. The PLWHA women should not be stigmatized more from the society than the counterparts. To avoid women being stigmatized, the Nigerian woman had to attain a financially secure position. The society needs to build a caring surrounding for PLWHA. The gender related stigma has to be eliminated by educating the society to attain to reduce the impact on HIV prevention and treatment. The health care system needs to develop proper

policies and programs to provide better care and patient provider confidentiality.

The specific objective to be ideal is to decrease incidence of HIV/AIDs and to decrease the stigmatization of HIV positive women. It is important to get equal treatment from the society despite the gender for the PLWHA. It is necessary to identify the gender related differences, and the social beliefs and reactions towards the HIV/AIDs, to analyze the impact on the problems of HIV infection, and care of PLWHA (Ngozi2010).

Activities and process; 40 people from the general public, 20 PLWHAs, and 40 Health care providers (HCP) were interviewed. The gender related differences at different levels were compared (Connell’s theory of gender and powers).The three levels were family level (PLWHAs), society level, (general public), and the health care system.The convenient sampling method was used to select the samples. The interview was structured on gender and social stigma about PLWHAs. The ethical committee’s approval was taken for the interview questions. Data analysis was done with Nvivo software system (Ngozi2010).

Outcomes.

The power differences were affecting on difference of care and reaction on male and female PLWHAs. Power differences were caused by structure of social norms, authority and financial inequality .These power differences were taking effect on the family, community and health care systems (Ngozi2010). The errors of the coding were eliminated by having two people code.

Challenges

In every process there are challenges. The cultural beliefs, attitudes, and behaviors will be the most difficult to overcome. There are number of social and cultural barriers. The programs should be built to change the cultural behaviors gradually and the programs should be culturally and linguistically appropriate. More research is needed to understand the policies, structural, and systemic focuses. There should be programs built to change the cultural differences, and develop proper policies (Ngozi2010).

Revisions

The policies should be changed to reduce the economical dependence of women, provide more authority for women in the family. The government should be increasing the ability of the woman to purchase medication and provide patient provider confidentiality. The government should help to reduce women’s vulnerability, increased stigmatization in society by developing and implementing of new policies that enhance and protect women’s access to health care and women’s rights. The government should find ways reduce the women’s financial dependence. Again, the government should change policies for women to be employed creating the financial stability, providing more power and authority for them. Interventions should be taken to educate women and hands on skills for a career. The legislation should be enacted to protect women from some effects of social norms, such as allowing men to have multiple partners. Further, the legislation should protect women from the stigmatization they face from husbands when diagnosed with HIV/AIDs. The women should assure of their safety, and fairness. The health insurance policies should be built for the PLWHA to have access for care and medication. The government should provide free health care for HIV/AIDs patients by changing the current policies, and providing equality for men and women. Furthermore, the ho

spital staff should be trained to treat patients equally, providing confidentiality. The providers should have an extended training to be culturally and linguistically competent, to the Nigerian society. The programs should have a vision to make an organizational development towards an organizational change in decreasing the stigmatization of the HIV/AIDs patients (Ngozi2010).

A. Social Stigma Leads to Nonadherence to HIV/AIDS treatment

It is difficult to understand the current problem of resistance to antimicrobial agents, including drugs against AIDS such as, highly active antiretroviral therapy (HAART), since such agents have saved millions of lives and prevented infectious diseases. These agents have awarded Clinicians and Practitioners a sense of power over the host-pathogen interaction with these agents. Social factors endemic in developing countries, such as insufficient resources in health and education systems – can intensify inconsistent or “suboptimal” drug use. Economic and political factors, as well as ethical significance of antimicrobial promotion also constitute a major concern when trying to formulate public policies (Olivier, Williams-Jones, Doizé and Ozdemir, 2010).

The lack of participation in AntiRetroviral Therapy (ART) started by the Nigerian government from limited resources from the World Health Organization is mainly due to the cost of diagnosis of the disease and treatment. The stigma of HIV/AIDS plays a role in erratic drug cocktail use. Stigma associated with the disease intensifies the decreased participation in the ART program (Adeneye et al., 2006; Uzochukwu et al., 2009).

Stigma associated with the disease produces harsher negative reactions for females than males because of the medical and social consequences, as indicated by a study from the National Human Development Report. This study states that the burden of HIV/AIDS is borne primarily by the HAART program promotes viral suppression and deterrence of drug resistance in HIV/AIDS patients. HIV drug adherence promotion needs to tailor its approach to young women and children. (Salami, Fadeyi, Ogunmodede, and Desalu, 2010). Researchers have stressed the importance of conceptualizing stigma as part of power differences, theoretically supported by societal inequalities, such as gender (Link & Phelan, 2001; Parker & Aggleton, 2003).

Society endorses particular beliefs about HIV/AIDs and these beliefs affect the quality of life for people living with HIV/AIDS (PLWHA). Thus, the public reacts in a negative fashion towards PLWHA. The stigma associated with the disease dissuades and restrains PLWHA to seek proper care for HIV/AIDs (Mbonu, 2010). Following the Health Belief Model, one determinant of social stigma towards PLWHA is the general notion that PLWHA, in particular women, have transgressed the societal norm, leading to the social isolation of PLWHA. It has been shown that attitudes regarding HIV infection – the cultural interpretation of routes of contamination and assumption about the actions/activities of those with HIV are play a part as some determinants of social stigmatization (Mbonu, 2010).

Lack of knowledge about HIV/AIDs including the transmission of, physical signs, and effective treatment of HIV contribute to the stigmatization of said disease. It was shown that “knowledge of a person infected with HIV/AIDS based on information or physical body signs associated with HIV/AIDS, whether true or false, can generate negative reactions” Mbonu, 2010). Society makes judgments based upon any physical/noticeable characteristics, such as body weight and height; those with normal weight or heavy-weighted stature, as well as those on ART without noticeable HIV/AIDs heuristic signs do not experience social stigmatization because they are not believed to be HIV positive. It is sad to note that many PLWHA only divulge their HIV positive status when they are dying (Maughan Brown, 2010), thus reinforcing society’s image that HIV/AIDS is a rapidly fatal disease (Mbonu, 2010).

Stigma reduces self-efficacy, and self-efficacy increases protection behavior (Kalichman et al., 2006). Higher self-efficacy enables family and partners of PLWHA, whereas lower self-efficacy makes caretaking more difficult than what it really is. Bandura (1977, 1986) states that achievement of high or low self-efficacy depends on several components including performance accomplishments, vicarious experience, verbal persuasion and state of emotional/psychological arousal. For example, a motivational factor for caretakers would be the knowledge that ART in fact does help PLWHA feel better, pushing caretakers to work harder and empower PLWHA to seek care if it is known that treatment does have a positive impact (Mbonu, 2010).

There are several stigma-modifying factors such as gender, age, religion, policy and poverty[Sarita1] .

B. HIV Genome and Drug Resistance

The HIV genome is encoded on several genes on a long RNA strand. The free virus is has two RNA strand. In the provirus form of HIV, where the genome is incorporated into the cell’s DNA, the genome information is also encoded in DNA. The genes present in both the HIV-1 and HIV-2 strains are gag (coding for the viral capsid proteins), pol (reverse transcriptase), env (envelope-associated proteins); the regulatory genes are tat, rev, nef, vif, and vpr. Together, “gag-pol” represents the long strand of gag and pol together. The HIV-1 genome is characterized by the presence of vpu (not in HIV-2), and only HIV-2 has vpx. Long Terminal Repeats (LTRs) are at the end of the genome, serving structural and regulatory functions. LTRs are not genes per say, but are a specific sequence of RNA/DNA which is identical at either end of the genome.

C. Drug Resistance in Nigeria

Several drug resistant mutations in the HIV virus genome have been characterized as endemic to Nigeria. A study conducted in Jos, Nigeria noted the predominant variations in the antiretroviral mutations of the pol section of the HIV genome. Most of the HIV samples were either subtype G, CRF02_AG, or unique recombinant forms (URF) of the two. Six strains, four of subtype G and two of CRF02_AG, had nearly full genome sequencing performed. Several secondary mutations in drug naïve subjects were noted in seven codons of the protease gene, including PR K20I, M36I, L63A/P/V, V82I, L10M/I and I93L. A mutation, known as K283R, was identified in the reverse transcriptase gene of three viruses. In all strains, the mutation PR K201 and M36I was present. The L10M and V82I mutations appeared only in the subtype G strain of the HIV virus. In two women, the resistance-associated mutations RT M184V and K103N were archived in the proviral DNA months after their previous niverapine treatment ended (Lar, P., et al, 2007).

With this HIV intervention program, we will strive to reduce stigma by with education programs. The program will incorporate community leaders to play an active role in HIV education and prevention. We will use culturally proficient methods and integrate local folklore into the violence prevention curriculum to increase awareness about HIV, decreasing stigma associated with the disease. By decreasing the communication gap, we will truly stimulate the community to take action.

Another goal of the HIV intervention program is to increase resources for prevention, treatment and therapy, and intervention supplies. By increasing supplies available, our program will reduce nonadherence of HIV/AIDS patients to drug therapy because of cost. The program will also address the issue of HIV/AIDS in terms of prevention, reducing risky behaviors associated with the disease.

Regarding phylogenetic analysis of the gag gene of the HIV genome, an important number of the A sequences forms a distinct subcluster with the AG-IBNG prototype strain (a complex A/G mosaic virus): 12 of 17 (70.6%) in Nigeria. Potential implications include revolutionizing the future HIV vaccine, diagnostic, and treatment strategies. The actual and prospective role of these viruses in the universal pandemic must be observed in all new molecular epidemiologic research, a distinction between HIV subtype A and AG-IBNG-like viruses is essential (Montavon, et al. 2000).

Phylogenetic analyses of HIV 1 viruses that in various geographic locations have also revealed that this virus can be divided into 3 characteristic groups – M, N, and O. The prominent group that comprises most HIV-1 viruses that are the source for AIDs cases globally.

D. Implementation

The implementation of our program focuses on priority reasons as to why HIV/AIDs infected patients does not follow their treatment regiments, leading to drug resistant strains of the virus. Priority reasons include transportation to clinics, food security, stock-outs and substitutions, and stigma. Our intervention strategy will use a multi-intervention/multi-channel approach in order to effectively reduce stigma and gender equality; information-based approaches, coping skills acquisition, counseling approaches, and contact with affected groups will all be incorporated.

It takes about 30-50% of a PLWHA’s income in order to cover their HIV/AIDS medications. Forty percent of missed doses of treatment are due to insufficient funds for transportation. Other infrastructural resources that impede proper treatment are fewer treatment sites and increased distance to care. By providing cash transfers, mobile pharmacies, and accompagnteur/DOT thru our interventions, we would be able to prevent nonadherence to HIV/AIDs cocktails in terms of infrastructure and financial burden (Bangsberg, 2010).

Societal thinking also affects treatment for PLWHA, and this is where social structural resources come into play. Patterns of inequality, such as social stigma and gender inequality might persuade PLWHA to discontinue their prescribed HIV/AIDS treatments. It has been shown that if counseling or coping skills are provided along with standard care (information-based approach), behaviors and attitudes towards HIV/AIDS were successfully changed (Brown, Trujillo, and Macintyre 2001). Our interventional strategy will also attempt to inculcate in potential perpetrators the ability to prevent conflict at the individual or small group level. Previous studies have indicated that more instruction is required than mere presentation of facts. These types of approaches have been examined among small groups of psychology students and students of other majors. Some examples of coping skill acquisition methods include master imagery, where a person is given a hypothetical situation where they are in contact with a PLWHA and educated on how to use coping skills to appropriately resolve the situation. Group desensitization, another form of coping skill acquisition techniques, edifies participants about relaxation techniques and then gradually exposes the participant or group to several hypothetical situations with exposure to PLWHA. By utilizing the relaxation techniques presented in the intervention, there will be decreased tension between individuals and PLWHA in such real life circumstances (Brown, Trujillo, and Macintyre, 2001).

Gender inequality and myths about stereotypical gender roles will be dismissed using an inclusive intervention strategy. The intervention strategy will create opportunities for women to demonstrate their capability. Gender training will empower women and promote gender equality for PLWHA.

Individual beliefs and opinions also affect the nonadherence to HIV/AIDS therapy. Knowledge about HIV/AIDS, medication side effects, cognitive function, mental health, and alcohol use of PLWHA affect their adherence to prescribed drug treatment. Information-based approaches are the majority of interventions and with multiple target groups. This approach has been frequently used along with an additional stigma reducing strategy. The information will be conveyed in multiple ways, such as advertisement, leaflets/pamphlets, information packs or presentation thru class or lecture. The information communicated is usually didactic and includes an accurate explanation of the disease, transmission modes, and means of risk reduction (Brown, Trujillo, and Macintyre, 2001). Provision of psychiatrist and counselor services for those with mental health issues, as well as anonymous hotlines and programs for alcoholics will form a new support system, decreasing the chances of nonadherence to a PLWHA’s medication.

Cultural values and morals is the final priority reason for nonadherence to HIV/AIDS drugs. In has been noted in studies from multiple geographic areas that cultural factors, both individual beliefs and perceptions play an infamous role in the adherence to medication. The importance of having children, respect for authority, and religious beliefs are just few examples of the complex concept of culture.

Since there is no ‘one-size-fits-all’ perfect intervention that will produce equal results in all populations because of cultural diversity, UNESCO advises that researchers should listen to what the community has to say. Using a community-based participatory approach to increase the adherence to HIV/AIDS treatment, potentially reducing drug resistance in Nigeria, researchers, clinicians, grant and journal reviewers, university faculty, and community members will all contribute towards culturally proficient and congruent interventions that will be tested and implemented in the community (Williams, Wyatt, and Wingood, 2011). By including people from all parts of the community, the program will take in to consideration the needs of the under-represented (UNESCO).

It is important to invest time in the culture if the intervention is to be successful, according to UNESCO. Reaching out thru popular culture, for instance music, dance, or similar mediums for expression involve young people and communicate new ideas.

Conclusion

In conclusion, this HIV/AIDS program will be successful as it considers many evidence-based interventions while addressing social justice and how stigma plays a role in many issues faced by HIV/AIDS infected patients today in Nigeria. Multiple trends in HIV/AIDs patients such as drug resistance can be solved by tailoring the promotion approach to targeting stigma.

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Voluntary Counseling and Testing(VCT) in Enugu state Nigeria.

Increased prevalence of HIV/AIDS (Human Immuno Deficiency virus, /Acquired Immune Deficiency Syndrome) is a major health and economical problem in Nigeria

(Uzochukwu2010)) . In Nigeria, 2.9 million individuals were diagnosed with HIV or AIDS in 2006 while 220,000 were kids. 70% of the population was living with HIV /AIDS (LWHA) and worst of all, 1.3 million of orphans are LWAIDs in Nigeria. In the intention of educating the high risk, Nigerian population Voluntary Counseling and testing(VCT)program had been implemented by The World Health Organization(WHO) .VCT had been focusing on educating the high risk population on the differences of positive and negative tests of HIV ,how to decrease the risk to self and to others, why it is critical to prevent transmission disease, decrease the mother to child transmission, and as well as to improve the access to medical care and supportive care.

Implementation

In a research done by Uzochukwu(2010)) with a very large sample and a statistical significance (p value <0.05analyses )analyses the weaknesses of the study and points out the needed improvements. The ethical approval for the specific study was provided by Medical Research Ethics Committee, University of Nigeria Teaching Hospital, Enugu. Individual written informed consent was obtained from all participants prior to the interview following a verbal and written explanation of study aims and procedures.

The research explores the Southeastern Nigerian culture, beliefs, values of Christian religion, and the belief of the sacredness of a church marriage. The social network and culture strongly discourage the parental involvement in sex education and parent child communication on sex

In the intention of educating the high risk Nigerian population Voluntary Counseling and Testing (VCT)Program was implemented by the World Health Organization( WHO). VCT has helped millions of people, but more than 80% Nigerian adolescents are unaware of their HIV status. The population needs urgent efforts implemented to improve the amount of individuals getting the HIV status checked. The population needs to be educated on the procedures and techniques and the safety of the testing methods .The population has to be educated that Highly Active Anti Retro Viral Treatment(HAART)is not preventive ,or not curable for HIV status. Further that HAART treatment will only prolong and improve the quality of life. There is a need to educate that HAART treatment during pregnancy provides an assurance of a disease free new born. Due to the low cost of living in the country, the HAART seems to be expensive, making the treatment available only for a prestigious crowd. It can be judged with the terms used in the paper repeatedly that Uzochukwu(2010)) has used many models, including HBM, PRECEED, and PROCEED model, Tanstheoritical model ,and Theory of Planned behavior even though he does not specify the names of the models..Uzochukwu(2010) mentions the importance of target audiences knowledge and the gravity of disease; perceived susceptibility, perceived vulnerability, advantages, disadvantages, barriers of survival with AIDS or HIV, making strong grounds to conclude he had used Health belief model(HBM)) (2010)) research mentions the vitality of .Understanding the readiness to change, (with Model of trans theoretical) behavior, understanding beliefs, attitudes, and social norms in the population, highlighting the need of good models and theories implementation to create an organizational change. Implemented

Even if the specific term is not used by Uzochukwu(2010) mentions the stages of health belief Model( HBM )being implemented. The researcher specifies the need for cost effective programs in the high HIV prevalence population that could provide a service with an assurance of client provider confidentiality .Programs that motivate positive behavioral styles in the HIV positive and negative populations, are important. There is a need of reliable providers support to this high risk population to build their self esteem, self efficacy and to guide them towards their goals by helping them to build their expectations. Again, these populations need a strong supportive system to help them maintain the good behavior without relapse

The regression analysis of these statistical readings have shown a direct relationship on willingness to pay(WTP) for VCT programs with knowledge, men, sexually active, commercial sex workers, and higher number of years in Tertiary education. The high knowledge of VCT does not reflect on the attendance at VCT clinics. The Respondents seem ignorant about where the services can be obtained and they believe VCT should be free or adequately subsidized.(Uzochukwu2010) The cost of VCT is much higher than the mean WTP and Interested organizations should take subsidies in to consideration .More VCT centers should be created and widely publicized in various communities. There will be a need of successful innovation and social marketing models to promote the youth’s interest of visiting VCT.

There had been organizations (Uzochukwu2010) trying to make communication model such as social marketing or Diffusion of innovation. The study shows that 75% of the Tertiary education populations were aware Of VCT program. To have such a high population75%) with the awareness after implementation of the program, it had been a very successful innovation

Revision

According the author, (Uzochukwu2010)) the study on VCT was conducted with only students so it difficult to extrapolate the results to the general population (external validity is poor). However, this study has set a base on which future studies can be built in which the different population groups can be researched. The socio-economic characteristics of the respondents during the survey which would have enabled them to run a regression analysis of what socio-economic variables explain WTP, knowledge and awareness. However, the researcher mentions that some of the socio-demographic characteristics explain WTP for VCT.

According to the author(Uzochukwu2010)), the knowledge of VCT for HIV/AIDS among youths in tertiary institutions in Enugu State is adequate. However, the awareness of where these services provided seems an issue, so also is the cost of VCT which all contribute to the underutilization of these services. To improve the utilization of these services it is important that the service should be subsidized or free in all health facilities for youths to access this service freely. The VCT centers should be widely publicized and made available to the youths in order to create awareness. Stand alone VCT centers should be established in the communities, and educational institutions to increase access to the services.

There should also be an increased emphasis on the training of medical personnel as VCT counselors. It is equally important that teaching on HIV AIDS and VCT be incorporated into the school curriculum in order to increase awareness and create the right attitude towards the utilization of VCT services and WTP for the services. In addition, there should be community enlightenment programmes in churches, market places and other public places in order to inform the parents who also have a responsibility to also educate their children

Benjamin Uzochukwu et al. (2010) Voluntary Counseling and Testing (VCT) for HIV/AIDS: A study of the knowledge, awareness and willingness to pay for VCT among students in tertiary institutions in Enugu State Nigeria Retrieved from, http://www.sciencedirect.com.mcc1.library.csulb.edu/science

Models and theories

Health Belief Model (HBM) applied to in the same city mentions the sufficient awareness on HIV infection, protection and the importance of not having multiple partners in youth .Further there is a significant increase in the risky behaviors with increasing age. With the implementation of HBM, although the HIV status check increased in the rural suburb area the study was conducted, a reduction of risky behaviors did not show a significant change (Peltzer K 2004. The study strongly recommends integration of health studies into Nigerian elementary school curriculum's, provision of adequate facilities for free HIV test in rural areas, among others (Oyakals As 2010).A combination of HBM, Theory of Reasoned Action,(TRA) in sexually active first year Nigerian students(n=213)concluded that they need a good education of proper and effective use of condoms((Peltzer K 2004).

Obugi QC( 2010)implemented ,Health belief model in Ibadan Nigeria.The large research sample selected with Systematic random sampling from three HIV/AIDS centers ,(n=514) HBM was implemented to increase and assess the life style in People Living with HIV and AIDS (PLWHA). Qualitative data showed stigmatization and discrimination against PLWHAs by family and community members regardless of age and gender, exposing them to a deep feeling of sadness, dejection, hopelessness, anxiety and fear thereby affecting negatively towards their quality of life. However, majority of the participants (67.3%) had coped with the infection through life style adjustment by dedicating more time to religious activities and resorting to spiritual help, developing self coping mechanism, and seeking psychosocial support from nongovernmental organization (NGO) support groups and faith-based organizations. Discrimination towards them by family, friends and the community affected negatively their quality of life. The study concludes the need of Combinations of strategies--health education, psycho--social interventions in addressing the needs of people living with HIV/AIDS (Ogbuji QC 2010).This suggests another area that relevant models and theories should be implemented.

There is an increase in the number of children infected with HIV in recent years. However, more than 90% of HIV infections in children aged less than 15 years are due to mother-to-child transmission of HIV. The most effective way to reduce childhood HIV infection is to prevent the infection in mothers and for already infected mothers use appropriate strategies to prevent transmission to their children. A was conducted to determine the level of awareness and acceptability of strategies for preventing mother to child transmission of HIV. Majority of the respondents (94.7%) were aware of transmission of HIV from an infected mother to her child. Respondents were more aware of the use of antiretroviral drugs in pregnancy (63.2%) than they were of avoiding breastfeeding (58.5%) and Cesarean delivery (22.8%) as strategies for preventing mother to child transmission. They were also more likely to accept the use of antiretroviral drugs (78.2%) than they would avoid breastfeeding (69.0%) and accept Cesarean delivery (38.0%) for preventing mother to child transmission of HIV High educational status was significantly associated with a positive attitude to these strategies. There is need for more educational programs and social support to bridge the gap between the levels of awareness and acceptability of strategies for preventing mother to child transmission of HIV among the population (.Ogaji DS) .Here using the models and theories,HBM, TPB, social marketing, Diffusion of innovation or Social marketing with mass media had been affective. Most HIV-positive women chose and practiced formula feeding. With the desire to reduce the risk of transmission, but took the major challenge as social stigmatization and criticism (Oladokun RE 2010). This is another issue that has to be addressed with new models to build self efficacy of the mothers to cope up with the society when they avoid the breast feeding for the newborns best interest.

There have been many models and theories implemented to increase the Knowledge, skills and attitudes of the Nigerian population. The programs have been successful, up to a considerable extent but still need target and tailored interventions to the specific populations for specific behavioral patterns. There is a need to focus and improve the used models and behaviors to improve the social justice towards the Nigerian population.

Peltzer K, Oladimeji Y.(2004 Apr;)Some factors in condom use amongst first-year Nigerian University students and black and white South Africans. Psychol Rep.Retrieved from, http://www.ncbi.nlm.nih.gov.mcc1.library.csulb.edu/pubmed/15154190

Oyekale AS, Oyekale TO.(2010June);Application of health belief model for promoting behaviour change among Nigerian single youth. Afr J Reprod Health. Retrieved from, http://www.ncbi.nlm.nih.gov.mcc1.library.csulb.edu/pubmed/21243920

Ogbuji QC, Oke AE. (2010 Jun;)Quality of life among persons living with HIV infection in Ibadan, Nigeria.Afr J Med Med Sci. retrieved ''from,http://www.ncbi.nlm.nih.gov.mcc1.library.csulb.edu/pubmed/21117409

Ogaji DS etal(. 2008 Jan-Mar)Awareness and acceptability of strategies for preventing mother to child transmission of HIV among antenatal clients in Calabar, retrieved ''from,http://www.ncbi.nlm.nih.gov.mcc1.library.csulb.edu/pubmed/18390128

Oladokun RE et al. (2010 Sep). Infant-feeding pattern of HIV-positive women in a prevention of mother-to-child transmission (PMTCT) programmed. AIDS Care Retrieved ''from,http://www.ncbi.nlm.nih.gov.mcc1.library.csulb.edu/pubmed/20229369

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