October 7, 2019 On October 7, 2019, the Harvard Global Health Institute will host a one-day symposium to explore what enabled this visionary program, and to showcase how it has transformed not just the worldwide HIV/AIDS response but global health delivery more broadly. There are many lessons learned in PEPFAR’s story - from what it took to build a supply chain where there was none, to establishing the use of generic antiretroviral therapies (ARTs) and leveraging human capacity. This event convened the early architects of PEPFAR as well as experts and implementers currently leading the charge. We took a historically informed look at what it will take to stop global transmission, and shared tools useful for others hoping to move the needle on vexing problems in global health. For more information, visit our website at https://petrieflom.law.harvard.edu/events/details/15-years-of-pepfar

1. 15+ Years of PEPFAR –The
Nigeria Experience
Dr Prosper Okonkwo
APIN Public Health Initiatives, Nigeria

2. The Birth of PEPFAR in 2003
“HIV/AIDS is one of the great medical challenges of our
time…Across Africa, this disease is filling graveyards
and creating orphans and leaving millions in a
desperate fight for their own lives. They will not fight
alone…The legislation I sign today launches an
emergency effort that will provide $15 billion over the
next 5 years to fight AIDS abroad…In the face of
preventable death and suffering, we have a moral duty
to act, and we are acting”
-President George W. Bush

3. Pre-PEPFAR Era
• HIV diagnosis at the time was perceived as a death
sentence, with entire families and communities often falling
ill, and only few on any treatment .
• In 2001, President Obasanjo lunched the Nigeria’s national
HIV/AIDS program with an initial goal to provide treatment
for 10,000 people at 25 government sites
• ARVs were supplied to clients at these facilities at the cost
of $7 US per month
• ARVs from the private sector cost $350 per month ( GDP
per capita <$750, Health insurance coverage <5%, out of
pocket expenditure>75%)
• PLHIV were queuing to get enrolled and literarily praying for
others “to move on”, so they could be enrolled
HIV Prevalence in Sub-
Saharan AFRICA 2003

4. PEPFAR funding enabled a period of rapid expansion. JUTH for example
enrolled over 3000 patients within one year. New systems were created to
accommodate the huge numbers.
“ We had to move everybody on the waiting list into treatment……we had
to open up all the days of the week for consultation”
Clinician experience
With PEPFAR intervention, patients were receiving HIV/AIDS care at par with the
care in the US and Europe. Free treatment made a huge difference in the lives of
the patients.
“When PEPFAR fully came in , we started getting the drugs and the lab tests for
free……and that was when the patients started coming out”
- Igho Jefferson
Patient experience
PEPFAR Era: What
changed in Nigeria?

5. ….Massive Scale up of ART Services
1074 1046 1357
2391
7075
8114
690 675 959
1410
5622
6546
393 446 491 516 820 1057
2009 2010 2011 2012 2013 2014
HCT Sites PMTCT sites ART Sites
Number of HCT, PMTCT and ART sites in Nigeria (2009-2014)
From only 25 sites in Nigeria in 2001, number of ART sites have increased to more than 1000, PMTCT sites to more
than 6500. Majority of these sites are PEPFAR funded . Currently , APIN supports 664 sites (ART sites=339; PMTCT
sites 325) through PEPFAR/CDC in 8 States in Nigeria

6. Number of people on treatment continues to increase over the years with PEPFAR responsible for
75% of the treatment numbers. APIN supports more than 25% of the PLHIV in the PEPFAR program
in Nigeria
…..Improved Access to care and
treatment

7. PEPFAR-Supported PLHIV on
Treatment, Nigeria, 2004–18
Growth by
141x
5,702
871,843

8. HIV Prevalence in Nigeria- 2001-2019
5.8
5
4.4 4.6
4.1
3
1.4
2001 2003 2005 2008 2010 2014 2019(NAIIS
SURVEY)
HIVPrevalence%
Year
Birth of PEPFAR
Program in Nigeria

9. 5
NAIIS 2018 - HIV Prevalence by State
Benue
Akwa

10. Impact of PEPFAR on the Nigerian Health
System
• Nigeria’s is the third-largest U.S
President’s Emergency Plan for
AIDS Relief (PEPFAR) program
and has received over $5
billion since 2004.
• PEPFAR has positively
impacted all building blocks of
the Nigerian Health System

11. Financing the Nigerian HIV response
$812,416,393 , 20%
$35,009,929 , 1%
$2,551,216,112 , 63%
$642,968,497 , 16%
National HIV/AIDS EXPENDITURE BY FUNDING SOURCE (2007-2014)
GON
Private
PEPFAR
Other Int'l agencies
Source: NASA 2007-2014
Between 2007 and
2014, PEPFAR
accounted for about
two-third of Nigeria
HIV/AIDS expenditure

12. Impact of PEPFAR-Leadership and
Governance
• Increasing political commitment and prioritization
of public health issues among state actors.
• More structured coordinating mechanisms.
• Improved fiduciary management systems to meet
the accountability standards required of such
funding.
• Emergence of formidable non-state actors now
responding to and managing many more
international grants and projects. Leadership, Governance

13. • Supported the establishment of logistic
management coordination units across the country,
building their capacity to track commodities across
all facilities.
• Integration of commodities supply across vertical
programs such AIDS, TB, Malaria and family
planning services
• HIV/AIDS supply chain unification project and
pooled procurement to drive down cost of ARVS
and other commodities
Impact of PEPFAR on Medicines and logistics
management
Logistics Management

14. Impact of PEPFAR on the Health Information
System
Nigeria
• PEPFAR supported GoN to improve data quality
and use for decision making
• Moving HIV program data from paper base to
electronic (EMR)
– Improve quality, accountability and
monitoring
– NDR is allowing real time assessment of
clinical experiences and outcomes.
– Other programs leveraging on these
successes.
• Patient biometric system (PBS) in EMR is
helping to avoid patients duplication and
misidentification. APIN is taking lead in PBS in
Nigeria
• Quality data supporting learning and
research
APIN Health informatics structure

15. Impact of PEPFAR’s HIV/AIDS program on the
Nigerian health system : Health work force
§ At the beginning of the epidemic in Nigeria, there were few
Health care workers with capacity to provide services for
PLHIV
§ PEPFAR supported massive capacity building initiatives
§ Training and re-training
§ On site technical assistance to health care workers
§ Curriculum development to address knowledge and skill gap
§ HRH policy development issues
§ New cadres of staff
§ Task shifting
§ Service integration post emergency phase of PEPFAR
Health Workers

16. Impact of PEPFAR program
Laboratory Support
• Laboratory infrastructure development
• Human capacity development
• Quality Management System
• Accreditation preparedness
• Laboratory information management
system

17. Laboratory Development
Before
After

18. PEPFAR Era: What changed? Leadership view
Prof. I. Adewole
- Former Minister of Health
“PEPFAR gave patients hope, it epitomizes really our
humanity, that compassion that comes with dealing
with people who are sick….to show people that actually
there is hope for the future”
“And then the game changer (PEPFAR) came in
2003 and massively we changed the landscape. It
has transformed the way we do business, the way
we do research, the way we manage our clients”
Dr Aliyu
- Former NACA DG

19. Impact of PEPFAR’s HIV/AIDS program. Moving
towards epidemic control: The unfinished business in
Nigeria

20. Unfinished Business- Progress towards
ownership and Sustainability
$812,416,
393 , 20%
$35,009,9
29 , 1%
$2,551,21
6,112 ,
63%
$642,968,
497 , 16%
National HIV/AIDS EXPENDITURE BY FUNDING
SOURCE (2007-2014)
GON
Private
PEPFAR
Other Int'l
agencies
Source: NASA 2007-2014
• Need for greater momentum towards
demonstrated state ownership and
promotion of program sustainability
• User fees for few services no longer
supported by PEPFAR is a barrier to
access of care, in the era of moving
towards Universal Health Coverage.

21. ......Summary Points
• The PEPFAR program, though not without some challenges, has truly
been transformative not only of the national HIV/AIDS program, but the
whole health sector in Nigeria.
• From stages of denial and of HIV diagnosis being synonymous with a
death sentence, the PEPFAR program now ensures high quality,
affordable, acceptable and accessible care to PLHIV.
• Non State actors that started off solely as PEPFAR implementing
partners, have developed robust management systems that now enable
them to apply for and manage many other grants.
• Using evidence from recent surveys, PEPFAR is supporting the last push
towards epidemic control of HIV in Nigeria.
• For all these gains to be sustained and improved upon , the pace of
assuming ownership by the government would need to be accelerated.

22. THANK YOU FOR LISTENING
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