Local Production for National Possession - Of HIV Medications and Tests Kits in Nigeria

On this 2024 World AIDS Day, please tell your neighbours, friends, family members, work colleagues and all other Nigerians that HIV is now like hypertension, diabetes mellitus, osteoarthritis – a mere chronic disease! Thanks to the efficacy of the Anti-Retroviral drugs externally sourced by Nigeria’s HIV program development partners and freely offered to Nigerian beneficiaries, with United States President’s Emergency Plan For AIDS Relief (PEPFAR) bearing the largest funding portfolio, trailed by the Global Fund, and then others. Apart from flickers of input-financing effort through salary payment to healthcare workers who man the HIV clinics and purchase of some units of condoms (and rarely, test kits), the national and subnational governments of Nigeria collectively contribute a meagre percentage to the overall annual financial burden of the program to cater to the estimated 1.63 million Nigerians on treatment for HIV. Overall, the unsaid words appear to accentuate a silent interpretation of Nigeria’s HIV program as ‘their’ (foreign partners’) response to ‘our’ (Nigeria’s) HIV burden.

Let me cast our minds back to World AIDS Day 2023 commemoration (on 1st December 2023) by taking a cue from the media summary broadcasted by Channels Television 24 hours later. I saw, on my television screen (and quickly screen-grabbed it), four key points out of which local production of Anti-Retrovirals (ARVs) featured among the calls to “Let communities Lead” – as the theme screamed.

Although financing (one of the six building blocks of the health system conceptualized by the World Health Organization - WHO) is an important element for national ownership & sustainability of the HIV program, there is another very important one too that has enormous potential to in fact stimulate government’s greater financial commitment to the program. As we may know, healthcare commodities are central to the delivery of clinical and public health interventions anywhere in the world. This article thus harps on the need to commence the “simplification” of the vertical HIV program in Nigeria with local production of medicines and medical kits. The ‘simplification’ phrase is one borrowed from the United States Centers for Disease Control & Prevention (US-CDC) - an organization that is an integral part of PEPFAR, as it was the highpoint of her 5th stakeholder engagement meeting held on 30th & 31st October 2024 at the Congress Hall, Transcorp Hilton Hotel, Abuja, Nigeria. 

In my humble opinion, which is in tandem with the presentation made on the first day of the aforementioned edition of the bi-annual US-CDC event by the Director-General (DG) of the National Agency for the Control AIDS (NACA), Dr Temitope Ilori, the local production of HIV commodities in Nigeria will align with the subject of that high-level HIV/Health sector stakeholders’ gathering. Themed “Strategic pivoting toward program simplification and sustainable public health interventions”, I had also been cordially invited to grace the podium on the second day to deliver a lecture titled “How health insurance can eliminate user fees in health facilities” as a significant contribution to the reverberating dialogue of HIV program sustainability in Nigeria. 

The production of HIV medications & test kits within the shores of Nigeria is the single most important medium- and long-term program re-design necessary to attract the Nigerian government to occupy the front seat in the current non-emergency phase of the HIV response, particularly as the country hinges towards epidemic control and the United Nations (UN) goal 95:95:95 by year 2030. Call local production of commodities the sustainability game-changer and you won’t be wrong. Call it a means to foster national “possession” (ownership) of the HIV program and you’ll be spot on. Many Nigerian participants at the US-CDC event were, accordingly, elated when Dr Ilori noted in her remarks that she, alongside other Nigerian government officials, were in India a few weeks earlier to commence discussions with some pharmaceutical industries on the possibility of establishing a manufacturing line on Nigerian soil for local production of commodities deployed for HIV response.

Today, as Nigeria joins the rest of the world to again commemorate the 2024 World AIDS Day with the theme “Collective Action: Sustain and Accelerate HIV Progress”, Dr Ilori’s notification of government’s medium- or long-term plan to “possess” (own & then sustain) her HIV program via local production is quite instructive. It may be strategic to dispassionately reflect on the detrimental implications of a continuous pulled purchasing, importation, and non-availability in Nigeria’s open market, of two critical commodities that form the “pivot” of our HIV program. Can Nigeria (national & subnational governments) truly “possess” a public health program whereby her humane and magnanimous development partners, who continuously commit billions of dollars to help Nigeria attain near-epidemic control of the HIV scourge persistently import and distribute in silo, “ARVs” (drugs for HIV treatment) and the “HIV test kits” (laboratory diagnostic & confirmatory tools)? Amid the harmonious melody of donor fatigue but cacophony of ‘timeline’ for their anticipated funding dip in HIV programming, shall we, therefore, examine the effects (beneficial or otherwise) of locally producing these commodities?

Soon after any pharmaco-industry willing to set up a manufacturing plant in Nigeria has been able to obtain the Active Pharmacological Ingredients (APIs) for local production of these ARVs, decisive “political, administrative and diplomatic” decisions will be required of the Federal Government. These will culminate in the termination of the country’s decades-long participation (active or passive) in the pulled purchase of HIV drugs & laboratory commodities from external sources in a manner that will not slight the benevolence of our development partners who have largely midwifed this process for two decades. Without discounting the need for requisite business climate incentivization of these interested local producers by government, the expected availability of these commodities in large quantities thereafter in Nigeria’s open market will foster their cost-efficiency. Also, there will be no need for a parallel or special logistics provision to ensure last mile distribution of these commodities because the multiple and seamless drug distribution network by drug wholesalers and retailers within the country’s open pharmaceutical market will organically assume that role.  

Furthermore, the reluctance of the country’s health insurance ecosystem to bear the financial risks of HIV-related services since 2004 that the National Health Insurance Agency – NHIA (formerly National Health Insurance Scheme – NHIS) commenced will gradually come to an end because the in-country production will be of immense benefit to ‘actuary’ analysis by ensuring a naira-denominated extrapolation of financial implications of coverage of a disease entity whose drugs & commodities will no longer be foreign exchange-dependent. The actual in-country prices will also significantly aid tariff projections that are compulsory elements of contracting between “purchasers” (NHIA; State Health Insurance Agencies – SHIAs; and Private health insurance companies/Health Maintenance Organizations - HMOs). Also likely is the stimulation of a greater interest of Nigeria’s political and bureaucratic leadership in the public funding (using multi-stream financing strategies) and integration of our parallel HIV program into the mainstream, knowing that both the funding and manufacture of drugs & commodities are no longer from & by some unknown, magnanimous and external sources. The positive consequence of HIV service integration and improved government funding can be summarized as demonstrated country ownership and sustainability of the program.

On the flip side, the beneficial decision of home production may (or may not) elicit quiet flashes of diplomatic discomfort between Nigeria –  a Low and Middle Income Country (LMIC) and her long time benefactor in the HIV response – the United States to the extent that existing bilateral trade agreements between the two may have to be reviewed while substantial external funding support by the latter to the former may (or may not) take a substantial dip. However, the extended benefits of foreign exchange conservation by switching from annual importation of manufactured ARVs and test kits in hundreds of millions of dollars to in-country production cannot be discarded. Of course, more jobs will be created by such envisaged pharmaceutical industrial complexes within strategic locations in the country.

As I conclude, if the crux of the ‘simplification’ mantra is the urgency of facilitating a ‘return’ of the HIV program to the mainstream public hospital services following its emergency ‘pull out’ two decades ago to allow for an urgent nationwide response to the public health threat posed by the virus at the beginning of the HIV pandemic in Nigeria, local production of routine & compulsory medications and test kits is germane. That is one sure way to initiate a sense of ‘our’ (Nigeria’s) response to ‘our’ (Nigeria’s) disease burden. Afterall, HIV is now a chronic disease like hypertension and if several antihypertensives are locally produced and available in Nigeria’s open market, ARVs and HIV test kits should not be any different.

In a nutshell, there is no smarter way to enhance “national possession” of Nigeria’s HIV program than for all stakeholders to encourage and support the government of President Bola Ahmed Tinubu in its backward integration strategy of the Sector Wide Approach (SWAP) agenda for Nigeria’s health sector in transitioning to local production of drugs and test kits used for HIV treatment as earlier echoed by Dr. Temitope Ilori. Of course, the onus of ensuring the standardization of these to-be-locally produced ARVs to prevent counterfeiting and its dire consequence of failed viral suppression in HIV-positive patients who ingest the drugs will then lie on the National Agency for Food and Drug Administration and Control (NAFDAC), Standards Organization of Nigeria (SON, and their likes. What is worth producing locally is worth being well produced, particularly for a highly infectious disease like HIV.

Dr. Adetolu Ademujimi is a Medical Doctor, Health Finance Specialist, Author, Reformer, Coach, Public Policy expert and social entrepreneur who can be reached in Abuja via adetoluademujimi@gmail.com