Access to SRH and HIV services for adolescent girls and women on the move living with or at high risk of HIV infection in Nigeria

Erik Lamontagne^1,2, Hasiya Yunusa Nyako³, Amaka Enemo⁴, Aaron Sunday⁵, Amira Muhammad⁶, Rilwan Mohammed Abdullah⁷, Henry Okiwu⁸, Veronica Akwenabuaye Undelikwo⁹, Pamela Adaobi Ogbozor¹⁰, Oluwaranmilowo Amusan¹¹, Oluwatoyin Adedoyin Alaba¹², Gabriel Undelikwo¹³, Takpa Koubagnine¹³, Greg Ashefor¹⁴, Matthew Kavanagh^1,15, Morẹ́nikẹ́ Oluwátóyìn Foláyan^16-19

Prepared for ICASA Conference in Harare, Zimbabwe, 07/12/2023

Session on Tuberculosis, HIV and the challenges with managing migrants, refugees and IDPs in Africa

Introduction

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• By June 2023, Nigeria was home to 98,645 refugees and asylum-seekers, 3.58 million internally displaced persons and more than 1.7 million unsettled returning migrants.
• Many were women returning from unsuccessful attempts to cross the Mediterranean from Libya, often destitute and may be economically worse off than before they left.
• In this study, women and girls on the move include migrants, refugees, asylum-seekers, returning migrants and internally displaced people.
• We assessed if women and girls on the move living with or at high risk of HIV faced increased health inequity and socioeconomic inequalities during the COVID-19 pandemic compared with other vulnerable women and girls.

Context and methods

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• The study engaged community representatives in its design & implementation.
• Recruitment was from June to December 2021 in the six geopolitical zones.
• Venue-based, and snowball and river sampling method (convenient sampling)
• Target populations were cisgender adolescent girls and women and transgender people living with or at high risk of acquiring HIV: women who sell sex, women who engage in transactional sex, women living with disability, women who use psychoactive substances, female migrants, refugees, displaced persons.
• The study protocol was approved: IPH/OAU/12/1692.

Who are these women and girls on the move?

• Sample: 3,442 participants living with or at risk of HIV including 700 women and girls on the move.

Among women and girls on the move (W&GoM)

• Majority (53.6%) were aged 25-44.
• Nearly half (46.5%) were unaware of their HIV serostatus
• More than half (62.4%) had no education or only completed primary degree
• More than three-quarters (79.6%) skip or reduce portions of their meals because there was not enough money when COVID-19 pandemic started.
• Almost 4 in 10 W&GoM (39.2%) reported SGBV.
• A quarter (24.6%) of HIV-positive W&GoM have no income compared to HIV-positive W&GnoM (17.2%)

The role of HIV status in the life of women and girls on the move

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Key findings

1: No disparities in health inequities and socioeconomic inequalities between HIV-negative W&GoM and HIV-negative W&GnoM

2: Differences in health inequities and socioeconomic inequalities between HIV-positive W&GoM and HIV-positive W&GnoM.

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=> The combination of being on the move and living with HIV exacerbates individual vulnerabilities

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Compared to HIV-positive W&GnoM, HIV-positive W&GoM had:

1. Lower odds of disrupted access to HIV services (aOR 0.54, 95%CI 0.36-0.82)
2. Lower odds of disrupted access to SRH services (aOR 0.55, 95%CI 0.34-0.90),
3. Lower odds of symptoms of anxiety & depression (aOR 0.91, 95%CI 0.86-0.96)
4. Lower odds of high HIV stigma index (aOR 0.94, 95%CI 0.91-0.97)

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Why were there weaker associations between the four measures of health inequity for HIV-positive W&GnoM compared to HIV-positive W&GoM?

Possibly HIV-positive W&GoM had learned to navigate challenges associated with poor health service access before the COVID-19 pandemic

Are HIV-positive W&GoM facing health inequity ?

HIV-Positive W&GoM: No one-size-fits-all

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Among HIV-positive W&GnoM there were differences in experiences

• Migrants had higher HIV and SRH disrupted than IDP, refugees.
• 45.5% migrants vs 19.5% refugees vs 25.7% IDPs had disrupted HIV services.
• 38.6% migrants vs 9.8% refugees vs 10.2% IDPs had disrupted SRH services.
• 23.8% migrants vs 25.9% refugees vs 40.6% IDPs reported mental unwellness.
• Among migrants, returning migrants had worse mental health (23.8% vs 45%).

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Possible reasons?

• Health focused assistance provided to IDPs to minimise the impact of COVID-19 improved access to HIV and SRH services comparatively.
• Poor access to social support by IDPs had negative mental health impact

HIV-positive W&GoM faced a second epidemic: SGBV

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Compared to HIV-positive W&GnoM, HIV-positive W&GoM had:

• 5 times higher odds of facing gender-based violence (aOR 4.93, 95%CI 2.79-8.71).
• 5.6 times higher odds of facing more gender-based violence since the COVID-19 (aOR 5.61, 95%CI 3.01-10.47)
• Lower odds of engaging in sex work (aOR 0.44, 95%CI 0.21-0.89).
• No statistical difference between the two groups regarding transactional sex, after controlling for interactions.

The strenght of HIV-positive W&GoM

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Mental health of HIV positive vulnerable women and girls

• Symptoms of anxiety, depression and HIV self-stigma were high.
• HIV-positive W&GoM reported fewer symptoms of mental distress and a lower HIV-stigma score than their HIV-positive W&GnoM.

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Interpretation of findings

• It appears HIV-positive W&GoM had strong resilience capacity.
• Lessons from HIV-positive W&GoM in HIV programmes could help to reinforce and strengthen the resilience of HIV-positive W&GnoM.

Summary

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Among women and girls vulnerable to HIV

• No significant health & socioeconomic disparities between HIV -

Among HIV positive women and girls

• W&GoM had high socioeconomic inequality.
• W&GoM had lower health inequity than W&GnoM.
• W&GoM face five times higher odds of SGBV than W&GnoM.
• W&GoM had lower symptoms of mental unwellness than W&GnoM.
• W&GoM reported lower HIV self-stigma than W&GnoM.

Among HIV positive women and girls on the move

• Migrants had poorer access to HIV and SRH services
• IDPs, including returning migrants, had worse mental health.
• Take away message: treat populations distinctly.

Special thanks to the research teams

Nigeria Team

South Africa Team

Affiliations: ¹ Joint United Nations Programme on HIV/AIDS, Johannesburg, South Africa; ² Aix-Marseille University, School of Economics, Marseille, France; ³ Jami Al Hakeem Foundation Jimeta-Yola, Nigeria; ⁴ Nigeria Sex Workers Association, Kubwa, Nigeria; ⁵ African Network of Adolescent and Young Persons Development, Barnawa, Nigeria; ⁶ Northern Nigerian Transgender Initiative, Abuja, Nigeria, ⁷ National Association of Persons with Physical Disability, Abuja, Nigeria; ⁸ YouthRise, Abuja, Nigeria; ⁹ Department of Sociology, University of Calabar, Calabar, Cross River State, Nigeria; ¹⁰ Department of Psychology, Enugu State University of Science and Technology, Enugu, Nigeria; ¹¹ Data Quest, Makurdi, Benue State, Nigeria; ¹² Institute of Public Health, College of Health Sciences, Obafemi Awolowo University, Nigeria; ¹³ Joint United Nations Programme on HIV/AIDS, Abuja, Nigeria; ¹⁴ National Agency for the Control of AIDS, Abuja, Nigeria; ¹⁵ Global Health Policy and Politics Initiative, O'Neill Institute Global Health, Georgetown University; ¹⁶ Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria; ¹⁷ Nigeria Institute of Medical Research, Yaba, Lagos State, Nigeria; ¹⁸ Community Oral Health Department, Tehran University of Medical Sciences, Iran; ¹⁹ Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain.

Appendices

Giving a voice to those left behind

To measure the impact on COVID-19: exceptional mobilisation of networks to collect data for decision-making, advocacy and reprogramming to mitigate the impact of the epidemic and the required sanitary measures.

Context and methods