A bold shift is underway in how HIV care is delivered to young Nigerians. The focus is no longer just on treatment -- but on - but on building systems of support that reflect the complexities of adolescence -- uncertainty, transition, and vulnerability. This message was front and centre at the Nigerian Institute of Medical Research (NIMR) in Lagos during its monthly media engagement.
At the heart of this movement is Dr. Agatha David, Director of Research and Consultant Paediatrician at NIMR. With over two decades at the forefront of child and adolescent health, she is leading the charge to close persistent gaps in HIV care for young people -- gaps that have persisted despite national progress. "Adolescents and young adults living with HIV have the worst outcomes of all age groups," she says, pointing to low testing rates, weak adherence to medication, and staggering levels of mental health distress as critical barriers to success.
Globally, UNAIDS aims to end the HIV epidemic by 2030 through its 95-95-95 goal: 95per cent of people living with HIV should know their status, 95 per cent of those diagnosed should be on antiretroviral therapy, and 95 percent of those on treatment should have undetectable viral lods. But for adolescents in Nigeria, those targets remain far from reach. A study conducted by NIMR tested nearly 1,000 young people between the ages of 15 and 24 who had never previously been tested. Shockingly, 12 per cent tested positive -- nearly 10 times the national prevalence rate. "It was a wake-up call," Dr. David recalls. "These are young people walking around unaware they're living with HIV -- and potentially transmitting it."
The challenge doesn't end with diagnosis. Once enrolled in care, many adolescents struggle to consistently take their medication. To address this, NIMR introduced a series of interventions, starting with Directly Observed Antiretroviral Therapy (DOART). "We discovered that a number of patients thought to be failing second-line therapy weren't drug-resistant at all -- they just weren't taking their meds," she explains. Under DOART, caregivers were asked to watch adolescents take their pills daily, resulting in significant improvement in viral suppression. But sustainability remains a concern. "Parents are busy. Some young people are in boarding schools or universities. They need autonomy, but also support," Dr. David notes.
Enter digital health innovations. NIMR piloted both one-way and bi-directional SMS reminders -- coded messages like "Have you watched TV today?" -- to maintain discretion while prompting adherence. The bi-directional messages, which allow patients to respond, showed better results. Pairing this with peer navigation, where successfully suppressed youth mentor those struggling, further improved outcomes. Still, antiretroviral adherence isn't the only obstacle. Dr. David emphasises that sexual and reproductive health (SRH) is a critical, yet neglected, component. "Many HIV-positive girls are getting pregnant without understanding how or why. Some are kicked out of their homes. The stigma is overwhelming."
In one study, over 20 per cent of participants had initiated sex before age 15, with high rates of unprotected sex and transactional relationships. Pregnancies often ended in unsafe abortions, compounding health risks. "We found that many adolescents lack basic SRH knowledge and have no one to talk to -- neither parents nor trained professionals." Comprehensive sexuality education is key, says Dr. David, and it must extend beyond schools to reach out-of-school youth through community and faith-based initiatives. "We need to train health workers in adolescent care. Many so-called youth-friendly clinics offer little more than condoms -- and even those aren't always available."
Mental health is another pressing concern. NIMR's recent studies found that more than 20 per cent of adolescents living with HIV showed signs of depression, anxiety, or suicidal thoughts. A new clinical trial is set to examine the impact of routine mental health counseling as part of HIV care.
Meanwhile, at the frontier of prevention, Dr. Sabdat Ekama is leading research into a novel HIV microbicide vaginal gel designed to protect women during sex -- a demographic disproportionately affected by HIV. The gel is "smart," becoming viscous upon contact with body temperature to prevent leakage and incorporating targeted drug delivery triggered by natural enzymes. Having shown promise in lab tests and animal trials, the gel is entering pre-clinical stages, with its design shaped by feedback from women in high-risk groups. "We listened to their needs -- concerns about affordability, privacy, and ease of use. Co-creating this product with them is essential for future success," says Dr. Ekama.