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AIDS

On the Brink

Containing a potential HIV explosion in the strife-torn Niger delta is a tough job — but circumstances are forcing the oil and gas industries to confront it. Colin Macilwain reports.

Bonny Island's strategic location, at the mouth of the Niger River in west Africa, has always been a blessing and a curse. An important trading post for at least seven centuries, the island shipped hundreds of thousands of slaves from inland tribes to the Americas. Its Ibani people have retained good relations with foreign businesses ever since, even as the island's main export changed from people to oil and gas.

Slick solutions: the owners of the gas-liquefaction plant on Bonny Island are driving plans to improve public health on the island. Credit: L. LAPLACE

The traditional rulers of Bonny Island have helped to maintain a relative stability here in this oil-rich but desperately poor region. That is one reason why Bonny Island hosts the largest-ever industrial investment in Africa: a US$15-billion gas-liquefaction plant that compresses and exports millions of tonnes of natural gas — enough to feed half the gas needs of France.

The plant, run by a consortium of oil and gas companies known as Nigerian Liquefied Natural Gas (NLNG), expanded spectacularly after Nigeria's government decided that the gas that had previously been flared off should be compressed and exported. The plant now draws thousands of skilled workers from all over the world, as well as impoverished workers from the surrounding regions. Although accurate figures are hard to come by, the island's population has grown from perhaps 30,000 a decade ago to 100,000 or more today.

That influx has set the stage for a new menace. A combination of migration, fast money and rampant prostitution may be placing the island on the brink of an AIDS explosion. And so NLNG, with help from its sister oil companies, has chosen Bonny Island for an experiment that could change the face of public health in the entire Niger Delta: a partnership between the local community, government agencies and oil and gas companies that strives to study, test for and eventually control AIDS on the island.

Testing times: Bonny Island's run-down hospital will be the medical focus of the Ibani-se initiative. Credit: L. LAPLACE

The project is unusual in that it seeks to pull together industry and government money to support an initiative that will be built from the ground up, within the community of Bonny Island. It places great emphasis on self-help groups and other mechanisms that will involve all of the relevant groups in the community, from schoolteachers to sex workers, in the nitty-gritty of AIDS education and prevention.

“We are in Bonny Island because it is isolated and relatively secure,” says Donald de Korte, a veteran AIDS physician and consultant to the US drug giant Merck who is overseeing the project. Relatively is a key word here; in late December, the oil company Shell evacuated family members of expatriate staff from Bonny Island after car bombings and armed attacks elsewhere in the delta.

Money for nothing

The project, called Ibani-se after the local people and their word for 'energy', is the first of its kind in Nigeria. The country has an HIV prevalence of about 4% — much lower than that in southern or eastern Africa, perhaps because of western Africa's retained tradition of male circumcision. Still, an estimated 3 million adults in Nigeria are HIV-positive — more than anywhere else except South Africa and India.

With the exception of a few big city hospitals, little counselling and treatment are available; only about 5% of Nigerians who need antiretroviral treatment are getting it, says de Korte. Nigeria is awash with oil and cash, but not much of that makes it into basic health services for the country. Oil money has helped the Nigerian government to clear its $32 billion debt since 2004. But the economic activity generated by the production of oil and gas has inflated prices in the Niger Delta, fuelling social division.

The Ibani-se initiative is being supported initially by industry sponsors including NLNG, Shell and ExxonMobil, who have done other outreach programmes on the island. There is a discernable dichotomy here. On the one hand, the initiative hopes to achieve a sustainable partnership that is anchored in the community. But others have a more jaundiced view — grounded in past experience in the region — that nothing will function on Bonny Island unless NLNG does it, and pays for it.

Still, the project has a determined leader in de Korte, a Dutch physician who used to run Merck's business in Africa and then, from 2000 to 2004, led one of the continent's largest and most comprehensive AIDS treatment programmes, in Botswana. De Korte was tapped by officials from Shell and NLNG to chair the panel overseeing the initiative, after they heard him talk about his views on how AIDS should be fought. Since then de Korte has been working to constitute Ibani-se as a non-governmental organization (NGO), which would make it eligible for financial support from international bodies such as the Global Fund to fight AIDS, Tuberculosis and Malaria, or the US President's Emergency Plan For AIDS Relief (PEPFAR).

The key to the project is not to pour in drugs, money or equipment, which would in all likelihood be stolen, but rather to build something that is sustainable. To that end, de Korte and his team have painstakingly consulted a wide range of people on the island, including businessmen, sex workers, fishermen, the Navy, drivers, market traders, churches and mosques, and the twelve 'houses' of the Ibani people.

Reaching high

The initial goals of Ibani-se are, at first glance, quite modest. The project plans to have 50 patients on antiretroviral treatment by the end of the year, for example, and to have 800 patients — a third of those who could benefit — on treatment by the end of 2009. But given current conditions — with minimal public-health infrastructure, few people being tested or counselled, and practically no one getting drugs — these goals are much more ambitious than they initially appear.

The medical focal point of the initiative will be Bonny Island's dilapidated, 60-bed general hospital, where a team of 26 medical staff deal with 450 patients a week. The hospital is supposed to be being renovated; last month, the patients were crowded into just one of the four wards while they waited for the other wards to be fixed. “A lot needs be done” to upgrade the hospital, admits Douglas Pepple, the senior physician at the hospital, “but you have to start somewhere.”

Spreading the word: despite signs advising people of the risks, many are not aware of how real they are. Credit: MERCK

At present, the only people who can get AIDS drugs on Bonny Island are pregnant women, who are entitled to treatment until their baby is born. Everyone else has to go to a hospital in Port Harcourt — the sprawling capital of the delta, 50 kilometres up the pirate-ridden river. No one knows anyone on the island who has managed to complete the trip.

Ibani-se may help to change that situation. It was launched on 1 December 2006 — the last World AIDS Day. The day has a high, if ambiguous, profile in Nigeria. In the morning, local radio stations discuss the issue of AIDS, and O Network, MTV's popular African affiliate, broadcasts a question-and-answer session in which South African schoolchildren interrogate ex-US president Bill Clinton about AIDS. It also shows videos of ditties such as Put You On the Game, in which Los Angeles rapper The Game threatens women with a life of prostitution.

We need to rise up against the stigma and discrimination that surrounds AIDS. King Edward XI

Then, King Edward XI of Bonny Island and Peter Odili, the governor of Rivers State, arrive in the town of Akiama to officially launch Ibani-se. After a slow start the ceremony soon gathers steam, as about 500 schoolchildren and other islanders crowd into the community hall.

The king — who lives for most of the year in Nigeria's capital Abuja, where he chairs a confederation of Nigeria's traditional rulers — tells the crowd about an initial baseline study for the project. The survey, based on a representative sample of Bonny Island's adult population, found that an estimated 9,600 people on the island are now HIV-positive. “There's an urgent need to commence an HIV treatment programme,” the king says. “We need to rise up against the stigma and discrimination that surrounds AIDS.”

Empty gestures

For the event, Shell had shipped in a $40,000 machine to test CD4 counts — a measure of immune function — and dropped it, incongruously, on the floor of the hall. The gesture does not exactly thrill Ibani-se's organisers; nobody on the island knows how to use the machine. Thanking Shell for the gift, the king takes an adroit swipe at the donor: “$20,000 [sic] is nothing compared with what we will do have to do in the future to mount a project that must be sustainable,” he tells the community.

The community is yet to come to terms with the fact that AIDS is a big issue here. Samson Sunday

The budget of the programme has been modest so far, with about $600,000 donated by NLNG last year and $1.4 million set to be forthcoming in 2007. Merck has contributed the time of de Korte and other outside consultants, and plans to eventually supply drugs to the programme at a reduced rate.

The initiative's small group of permanent staff are Nigerian healthcare workers, hired mainly from other NGOs. “The community is yet to come to terms with the fact that AIDS is a big issue here,” says one of the team, Samson Sunday. “They know it exists, but they see it as a blight from the outside that only affects a small number of people. The first promising sign is that community leaders are accepting that they are sitting on a time bomb if they don't do something soon.”

The project's start-up has been much tougher than anticipated. Ibani-se still hasn't attained the legal status that it seeks as an NGO, despite trying for the past year and a half. Basic logistics are immensely problematic. Project managers didn't want new vehicles at first, as ostentatious transportation is the first thing that tends to divide community projects in Africa from the communities they purport to serve. But as a result, the project has become too dependent on NLNG for logistical support. Ibani-se's staff have found, to their frustration, that while they wait for transport and phone lines, staff at the gas company have other priorities.

The headquarters of the project is also still located on NLNG's fortified residential compound, whose manicured lawns and smart buildings look more like a retirement complex in Florida than the 'real' island outside the gates. Ibani-se is planning to move to one of the only concrete buildings in Bonny Town, the island's largest village. The building was constructed 20 years ago by Shell as a community library, but it has never been used and has stood derelict ever since.

Fighting fit: the Ibani-se project aims to protect the future of the children on Bonny Island. Credit: MERCK

It is palpable that local participants in the project are expecting some material gain. “There is hardly any volunteerism on the island,” says de Korte, who wants as many people as possible on Bonny Island to devote some of their own time to the project. But so far, “community engagement has only scratched the surface”. The whole exercise has been much more difficult than expected, he admits. “I underestimated the Nigerian environment.”

Platforms for success

On the other hand, de Korte is proud of the baseline survey done last summer by a Nigerian NGO, the Society for Family Health. The survey forms the basis for the project's action plan and provides the first detailed examination of sexual practices and HIV prevalence on Bonny Island. It shows that the prevalence of HIV is now 7.8% — double what it was five years ago. The study is not yet complete or cleared for release, but it is already identifying areas that Ibani-se could focus on, such as the sexual behaviour of the local sex workers and the 17,000 staff and contractors at the NLNG plant.

Not everyone on the island was surveyed, however. An extension to the liquefied gas plant, being built by an international consortium led by the US corporation Halliburton, employs another 1,700 workers. The consortium declined to participate in the survey, citing security concerns. Unlike the gas liquefaction plant itself — which is increasingly staffed by Nigerians — almost all the workers in the extension are white expatriates.

We don't want to end up with our workforce depleted, like the mines in South Africa. Brian Buckley

Brian Buckley, general manager for production at NLNG, says that the Ibani-se project is just one component of the gas company's plan to tackle social issues on the island. He says that he is hopeful that Halliburton workers will participate in the project later on. NLNG staff have already done so, he points out, although not many of the expatriates volunteered for testing. From the company's point of view, Buckley says, the Ibani-se programme is vital to the long-term future of the plant. “We don't want to end up with our workforce depleted, like the mines in South Africa,” he says. “The kids growing up on this island are the future of this community.”

World AIDS Day may have provided a glimpse of that future. Before and after the king's ceremony, long lines of people queued patiently to be counselled individually in a small interview cubicle, then give blood and be tested for AIDS. The four Ibani-se counsellors worked for hours and tested 100 people, but eventually ran out of time. They took down details of 121 more people for subsequent testing — taking the project some way towards its initial goal of testing 3,000 people by the end of the year.

If Ibani-se takes off as planned, its cost will rise significantly: thousands of islanders could end up on antiretroviral drugs priced at perhaps $60 per month. De Korte is confident that the Global Fund and other sources will help to foot the bill. But a spokesman for the fund, Jon Liden, says that public–private partnerships are “not as easy in practice as we had thought”. Efforts to fight AIDS in Nigeria, he says, have varied tremendously in quality; on several occasions, the fund has not renewed grants to Nigeria, “due to poor performance”.

Addressing the stigma

World AIDS Day saw the project off to an auspicious start though, and the king's words provided some assurance that the initiative has buy-in at the right levels. “We are pleased that the king has given his support,” says Ibiba Chidi, a project manager for Ibani-se.

For now, one of the project's focal points will be education. Stigma continues to surround AIDS on Bonny Island: health workers have uncovered very few people who admit to being HIV-positive. At the ceremony, a woman who was billed as speaking for people who are HIV-positive said she was, in fact, speaking out for a friend who is.

The other focal point, again reflecting data from the baseline survey, will be the activities of sex workers on the island. Project officials estimate that some 500 prostitutes work in Monkey village, on the main drag between the NLNG residential compound and the gas plant, where men gather at night to meet girls.

25-year old Joy Odudu runs a makeshift wooden bar in the ramshackle village. “I came to the island to work, but was looking for a job for a year and none was coming,” she says. She claims that site managers wanted a bribe of 40,000 naira (more than US$300) from women seeking employment there.

Odudu, whose arm was shot by river bandits, says that about half the men who frequent her bar after dark are expatriates, and that some of them will pay girls extra not to use condoms. She says she doesn't know how often this happens — “we can't follow them into their rooms” — but that arguments between clients and girls, and between girls, have exposed the practice. One Australian worker, she asserts, was paying girls $300 or $400 for nights of unprotected sex.

A nightly curfew, introduced after three oil workers were kidnapped on Bonny Island last August, is hurting business, Odudu says. But the expatriates are still coming, curfew or no curfew, says Peters Kunamon, headman of a section of Monkey village, Odudu's protector and a member of Ibani-se's community interface committee.

Asked about the project itself, both Odudu and Kunamon say it will win their support if it provides them with some material benefit. “It is supposed to be voluntary — but we need to eat,” says Kunamon, who also runs a pharmacy store in the village that will sell condoms. “The project is good if it gives us something.” Kunamon mentions something else that others are not keen to point out: women with day jobs on the site, he alleges, are also 'working' there at night.

Lucy, a girl at the bar, is just as direct. As she realizes that visitors are here for a chat, not for sex, her mood swings between charm and irritation. “You want jiggy-jiggy? Condoms or no condoms — what does it matter?” she asks sarcastically, voice rising. “We have to pay 100 naira here for water, to wash in the morning. We need to eat! We have nothing!”

Setting the scene

Back inside the compound at the close of World AIDS Day, the Sun goes down soon after six, as it does all year round so near the equator. Soon after, as the curfew takes effect, engineers converge on the open-air cocktail bar, where local musicians provide some outdoor entertainment. It's an attractive setting, with elegant log cabins and decks and an outdoor pool whose racing section is 49 metres long. If it were an olympian 50 metres, apparently, the law would require NLNG to open it to the public; in this intensely fortified zone, that wouldn't do at all.

Buckley is there, on what happens to be his last day as production manager. Next week, he is off to run an even larger (and more peaceable) liquefied-gas facility in Oman. He relaxes with a beer and a group of friends, most of whom sport polo shirts and chinos, the international uniform of the professional man at rest.

But all around the outer reaches of the extensive bar pavilion, smartly dressed Nigerian girls who don't look at all like petrochemical engineers are hanging out. Their teeth and eyes sparkle in the evening light, they have the great posture you only get from learning to balance ten litres of water on your head at the age of four, and they're keen to strike up conversation with strangers. “Five thousand naira,” one of them whispers, by way of introduction. “All night long!”

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Colin Macilwain writes for Nature from Edinburgh.

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Macilwain, C. On the Brink. Nature 445, 140–143 (2007). https://doi.org/10.1038/445140a

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