Nigeria

Context

Nigeria, situated in West Africa, was a British protectorate/colony from 1901 until 1960 and it was during this period (1914) that the modern Nigerian state was established. The country is made up of a multitude of ethnic groups (3 largest: Hausa, Igbo, and Yoruba), over 250 different language groups, and over 500 individual languages. It also consists of many diverse religions with Northern regions predominately Muslim and southern regions predominately Christian. Nigeria is the 7th most populous country in the world and home to over 210 million people.


Following independence in 1960, the country was ravaged by a civil war (Biafra War 1966-1970) and then by a succession of military dictatorships and democratic republican governments. While Nigeria has had democratically elected governments since 1999, the country continues to be torn by military insurgencies and conflicts, including the ongoing Boko Haram insurgency in North Western Nigeria, inter-communal violence between herdsmen and farming communities in North Central and Western Nigeria, and persistent unrest in the oil rich river delta region in South Nigeria. These and other smaller conflicts have led to more than 2 million internally  displaced people, increased gender-based violence and serious human rights abuses. 


The lasting impact of colonialism followed by decades of dictatorships, armed insurgencies, and instability has also led to deep poverty and persistent inequalities in the country. Over half of the population are aged 19 or younger and life expectancy in the country is only 54.6 years as of 2019 (1). Approximately 86 million people, or 41% of the population, live in extreme poverty (2) and there is only a 62% literacy rate as of 2018 (3).


With several large harbors, Nigeria has long played a significant role as a major international trafficking point for illegal drugs in West Africa, particularly for cocaine and heroin (4). In addition, the country is a major producer of cannabis, and has been increasing its capacity as a manufacturer of methamphetamine. In 2019 alone, over 600,000 kgs of cannabis and 146 kgs of methamphetamine were seized. 


The sociodemographic factors previously mentioned and Nigeria’s position as a hub for drug trade has contributed to the increased rates of drug use among the population (5). The latest data estimates over 14 million Nigerians aged 15-64 have used drugs during the past year.


The country has historically implemented a repressive drug policy, which has been described as a means of reinforcing state power (4). While restrictive and punitive policies are still the norm, in recent years some services for people who use drugs (PWUD), including harm reduction services, have been implemented. Unfortunately, these services are still very limited and the government and the media continue to stigmatize drug use and persons who use drugs. 


Data for this research was mainly gained via official government policies and documents as well as several academic research papers. However, large gaps remain in the available information  for several indicators.

policies

In 1989, the implementation of the National Drug Law Enforcement Agency Act (amended in 2004) gave rise to the National Drug Law Enforcement Agency (NDLEA) tasked with “eliminating the growing, processing, manufacturing, selling, exporting, and trafficking of hard drugs” (6). Under this Act the possession and use of drugs are criminalized and each carry a sentence of 15 to 25 years in prison. In practice, diversion to treatment and rehabilitation can be required in place of prison time but is often reserved for minors (7). The sentence for procurement, supply, trafficking and production of drugs which were once punishable by death were changed to life imprisonment around the same time. 


Since 1999, Nigeria has formulated and consolidated drug policy and strategies in the country’s National Drug Control Master Plan. The plan was compiled with support and funding from the EU and UNODC and developed by the Inter-Ministerial Drug Control Committee (IMC) which consists of the NDLEA, The Federal Ministry of Health (FMOH), The National Agency of Food and Drug Administration (NAFDAC), The National Agency for the Control of AIDS (NACA), and State Drug Control Committees (SDCCs). 


The country launched the fourth iteration of the National Drug Control Master Plan for the period 2021-2025 on December 06, 2021. Harm reduction has for the first time been specifically mentioned in this latest version. As strategy C of Pillar 2, under the title of “Harm Reduction Priorities”, the policy seeks to: implement a full package of harm reduction services, develop a drug overdose management programme, and strengthen data management systems. 


In 2018, Nigeria conducted its first comprehensive National Drug Use Survey based on data from the National Household Survey (~39,000 households), the National Survey on Problem Drug Use (over 9,000 interviews with problem drug users, and roughly 2,700 interviews conducted as part of the Key Informant Survey). This data became the catalyst for the National Programme on Drug Demand and Harm Reduction (NDDHR) which is closely linked to the Presidential Advisory Committee on the Elimination of Drug Abuse (PACEDA) established in May, 2019 with the mandate of coordinating the health sector response to drug use.


Other important and relevant national policies for people who use drugs include those by the Nigeria Center for Disease Control (NCDC), NACA, the National Tuberculosis and Leprosy Control Programme, and the National AIDS, Viral Hepatitis, and STIs control programme. 


Youthrise Nigeria, a human rights-based advocacy organization, has drafted youth-centered drug policy recommendations based on stakeholder consultation during 2017. Key recommendations include the creation of a comprehensive harm reduction policy and strategies and programs specifically targeted towards children and their parents. These include: age-appropriate drug prevention education, improved monitoring, standardized treatment options including drop-in centers, and reducing stigma. 

drugs use and health

The latest data on drug use and health in Nigeria comes from the aforementioned National Drug Use Survey in 2018. According to the survey there was a 14.4% prevalence of drug use in the age group 15-64. This is approximately three times higher than the global prevalence rate of 5.6%. Drug use was the most prevalent in the age group of 24-39 years and the least prevalent in those younger than 24 years old. The most commonly used drugs are cannabis (10.8%), prescription opioids (4.7%), and cough syrup (2.4%). Among youth (school-aged children), the main drug used is cannabis.  


Injection and other drug use has been found across the country (8), but the areas with the highest prevalence of overall use are the megacity of Lagos, and Oyo State, both found in the Southwest region of Nigeria. Based on a scoping review published in 2021 (9), the main sources for drugs are: pharmacies, open drug markets, drug dealers, fellow drug users, and friends. 


Around 80,000 of the 14.3 million people who use drugs in Nigeria use intravenously. Of these high-risk drug users, approximately one in five are women. The most commonly injected substances are pharmaceutical opioids followed by heroin and crack (10). For young people (18 to 35 years) who inject drugs; heroin, cocaine, and methamphetamine are among the most widely reported substances used (11). The main sources of injection equipment are: pharmacies, friends, other injection drug users, and drug dealers. 


While the problem of drug-related deaths is referred to regularly in policy documents, information on drug-related deaths/overdose is extremely scarce. According to one uncorroborated online source reportedly using WHO data (12), drug use deaths were approximately 7,000 in 2018. The UNODC has no available data on drug-related deaths in Nigeria (13). 


NACA estimates that PWID and their partners make up 9% of the total HIV incidence annually. HIV prevalence among PWID in Nigeria has been estimated at 3.1% according to the Harm Reduction International annual report the Global State of Harm Reduction 2020. The report goes on to state that there is very low knowledge of the risks of HIV transmission among PWID, particularly around needle sharing. While those surveyed said that it was “quite easy” to obtain new syringes/needles, about 50% reported sharing injection equipment in the last 6 months. In addition, data from the Integrated Biological and Behavioral Surveillance Survey in 2014 indicated that only 60% of PWID knew where they could get testing. 


Nigeria is among countries with the highest burden of HCV with a national prevalence rate of 2.2% and those at highest risk for hepatitis infection are medical personnel. According to the report there is little known about HCV epidemiology in Nigeria due to a lack of data. However, PWID are identified as a key subpopulation. The rate of HCV among PWID in the country was estimated at 2.3% as per the Global State of Harm Reduction 2020 - 7th Edition. 

Harm reduction

Harm reduction has only recently been introduced in the country’s official drug policy document: The National Drug Control Master Plan 2021-2025. As such, resources for people who use drugs in Nigeria are extremely limited and difficult to access. The Master Plan outlines in detail harm reduction services that need to be implemented including: 1. Needle and Syringe Programmes (NSP); 2. Medically Assisted Therapy (MAT) and other evidence-based drug dependence treatment; 3. HIV Testing Services (HTS); 4. Antiretroviral Therapy (ART); 5. Prevention and treatment of sexually transmitted infections (STIs); 6. Condom distribution programmes for people who inject drugs and their sexual partners and 7. Targeted information, education and communication (IEC) for people who inject drugs and their sexual partners. 


The National Drug Use Survey found that 40% of high-risk drug users reported that they had an urgent need for treatment. However, many barriers impact access to such services including the lack of availability and cost of treatment options. Stigma and a lack of information are the two other major cited barriers to accessing drug treatment in the country (14). In 2021, standard policy and practice guidelines have been developed for NDLEA-run treatment centres (in partnership with the EU and UNODC) for the implementation of evidence-based and standardized interventions. 


A study conducted in 2018-2019 in Enugu State in South-Eastern Nigeria found that additional barriers to the implementation of harm reduction services were a fear of promoting drug use, a lack of funding, staff resistance, poor training, community resistance, and lack of clear government policies (15). The study attributes improvements in awareness of harm reduction services to the efforts of NGO and drug user networks. 


Between July and December 2020, Nigeria piloted its first Needle and Syringe Programs. They were implemented in the states of Abia, Gombe, and Oyo. An assessment of the programs found that it was feasible, partially effective, and of good quality. While there is no available official information on the next steps, a key informant of the Drug Harm Reduction Advocacy Network (DHRAN), reported the pilot is being scaled up to include three more states and that a seventh NSP pilot is being conducted in Abuja, the capital of Nigeria, with a report to be released soon. Naloxone provision was originally included in the guidelines for the pilot NSPs. However, procurement issues led to the absence of the opioid antagonist being a part of the programs. This absence was highlighted as a major shortcoming according to a key informant from DHRAN, whose organization was involved in the development of the facilities. 


According to other Mainline informants, Nigeria currently receives funding for harm reduction from the Global Fund (GF) , PEPFAR and HiiV. Up to now, GF and PEPFAR have not funded services in the same cities/regions to avoid duplicating efforts. Services funded by PEPFAR, nevertheless, focus on screening and treatment for HIV for different key populations, and do not offer other harm reduction components such as NSP, overdose management or OAT. The NSP pilots were funded by GF, and it is under current negotiation by the GF the continuation of current NSPs and their scaling up to the other four states where PEPFAR is active. The total GF investment will be of two million dollars and will cover commodities, staff, training and M&E.  The grant from HiiV started in February 2022 and will last for two years. Actions will focus on increasing access to women who use drugs at the 3 states where NSPs currently exist plus Lagos and Abuja. 


Even with the scale up, there will still be gaps in terms of addressing Hepatitis C and Tuberculosis, besides a lack of service provision in all states without NSP or overdose management, and non-existence of OAT. According to a 2018 Youthrise policy brief and the Global State of Harm Reduction 2020, OAT remains unavailable in the country of Nigeria. However, in the 2019 National Guidelines for the treatment of Substance Use Disorders for Nigeria , information on methadone and buprenorphine prescribing is given in detail. There are no official government documents addressing drug testing/checking or drug consumption rooms. Other important gaps include lack of services for those using (and not-injecting) stimulants, and harm reduction services in prisons. Advocacy interventions for more enabling policies and government investment in harm reduction are also needed.  

peer involvement

Peer groups have been at the forefront of the fight to improve services for people who use drugs in Nigeria. Organizations like the aforementioned Drug Harm Reduction Advocacy Network (DHRAN) have been pivotal in increasing community support by bringing attention to the needs of people who use drugs and by providing a platform for advocacy. DHRAN chairperson highlighted the importance of formal organizations representing the needs of people who use drugs. 


DHRAN aims to “promote the health and rights of people who use drugs through drug user community mobilization and advocacy with stakeholders''. Services that DHRAN provide include: advocating for drug policy changes, collaboration and support for community organizations, using evidence-based health and social interventions, and reducing drug demand via harm reduction. DHRAN is highly organized and further details can be found in their Strategic Plan 2020-2025. 


The National Drug Use Survey reports that “community networks of drug users have been established in some states in Nigeria, and there are a few national networks but their influence on national policy making so far seems to be limited.” In 2019, DHRAN had been invited to the Global Fund Country Coordinating Meeting (CCM) for the first time regarding the inclusion of harm reduction services into National drug policy (16). Prior to this, people who use drugs had not been represented at the CCM. However, DHRAN was excluded from consultation for the country’s National Drug Control Master Plan. 


No governmentally-sourced information was found on peer involvement in harm reduction services in Nigeria. Despite this, a DHRAN representative clarified that peers have a huge role in current available services and estimates that they are involved in 70% of drug user-specific programs across the 12 states with such interventions. For example, lived-experience was a criteria for outreach workers who work with PWUD and that the NSP pilot project was also conducted with strong input from peers into its development and implementation. 


Another peer-led group, The Nigeria Network of People Who Use Drugs (NNPUD) was formed in 2015 with the help of INPUD (International Network of People who Use Drugs) and the AfricanNPUD. The organization has members in several states and cities in Nigeria and a private facebook group, but has not yet been officially/legally registered.  NNPUD representatives consulted for this database had a less positive perspective on peer involvement in Nigeria. According to them, the community of PWUD currently does not have input in the planning of services, and NSPs remain unknown to a large proportion of the population who inject drugs. Moreover, NNPUD finds that PWUD lack official representativity in the country, as those usually representing the community in official meetings do not have lived experience of drug use.  

human rights

Amnesty International Report 2020/21 lists arbitrary arrest and detentions, torture, exessive use of force, enforced disappearences, failure to investigate human rights violations, and violations of freedom of expression. It also lists widespread gender based violence and failure to secure the right to health and housing. While some of the worst human rights abuses relate to the ongoing armed conflicts in the country, they are by no means isolated to these conflicts or regions.


People who use drugs are affected by many of these general and wide-spread human rights abuses, not least the failure to secure health and housing. However, they are also the victim of targeted human rights abuses. A Youthrise Nigeria report looking at the effect of Nigerian Drug Laws on human rights of PWUD also found the occurrence of regular police violence against PWUD. This include: arrest and detention, extortion, physical assualt, sexual assault, and neglect among other human rights violations. 


Qualitative research on violence on drug users in Nigeria found that while the NDLEA are mainly responsible for drug violations, the Nigerian Police Force (NPF) are also often involved in making drug arrests (17). Findings from the study found that the NPF tend to use more excessive force than the NDLEA and interactions with police have involved threats, beatings, confiscation of personal items, and extortion. 


Information on human rights violations in Nigeria can also be found from the Nigeria National Human Rights Commission (NNHRC). Complaints about human rights violations for PWUD in private and government treatment facilities were to be brought to the UN this past July around “the cruel inhuman and degrading treatment meted on drug users.” A response to a questionnaire from the UN Working Group on Arbitrary Detention Relating to Drugs based on 2018 NDLEA data was published by the NNHRC, although the original questionnaire and/or data could not be found. From this response, it was found that “there are no compulsory treatment centers in Nigeria ''. However, in the same document, it is also reported that the federal court can “make an order requiring an offender to undergo measures such as treatment”. 


From a recent news article from guardian.ng website, the headline from October 4, 2021 reads: “NDLEA proposes mandatory drug test for Nigerians getting married”. No official documentation around this proposal was found. Clearly if this were to pass, it would be a violation of privacy but it is unclear how serious this proposal actually is.

prison

The USAID-funded and UNODC-implemented HIV and Health in Nigerian Prisons and for people who use drugs project has a stated aim to “achieve access to HIV prevention, treatment, care and support services for people in prisons and people who use drugs”. This project led to a comprehensive National Situation and Needs Assessment of HIV and AIDS, Drug Use and Related Health Services in Nigerian Prisons survey conducted by NACA and NPS. The survey consisted of both qualitative and quantitative measures of over 2500 prisoners from 12 prisons across the six geopolitical zones in Nigeria. 


Based on the survey, it was found that the percentage of prisoners who are injection drug users is 2.5%, a rate 25 times higher than that of the general population. Furthermore, 40% of PWID in prison reported sharing needles. The same report states that HIV prevalence is twice the rate of the general population (2.8% among prisoners vs 1.4%). There are also high rates of lifetime history of using drugs among people in prisons including three times that of the general population for non-medical opioid use (16% vs. 5%). 


The survey also highlights an almost complete lack of harm reduction services available for PWUD in Nigerian Prisons, high levels of stigma for those with HIV/HCV in prison along with poor knowledge of disease transmission, low levels of information specific to harm reduction, an absence of NSPs, and almost no availability of condoms. Lack of services in prison is confirmed by NNPUD key informants, who highlighted the urgent need for condom distribution, PrEP, and other harm reduction services such as NSP and OAT in prison. 


Rates of HIV and TB vary between prisons across the country with the highest prevalence of HIV being 7.1% in the North Central region and TB 71% in the South-South region. The same survey showed that less than two-thirds of the prison population had access to HIV and other health services for transmissible diseases (18). Only slightly more than half of the survey respondents reported having HIV testing and TB screening available, and approximately 40% had ART and 60% had TB treatment. 


A pilot project consisting of treatment and counselling for people in prison who used drugs was scheduled to begin in one prison in Nigeria in September 2015. The project aimed to provide standardized and evidence-based treatment adapted to the Nigerian context to combat concerns about high rates of drug abuse. This was a UNODC coordinated intervention in partnership with NPS and FMOH, however, there is no further available information on if it was implemented and what the results may have been.


According to a news article, sensitization training with the goal of highlighting a medical approach to drug use has been implemented to some extent for Custodian Centre Officers in Enugu State (19). A second article from a different news source reports that Gombe state has partnered with NDLEA to offer counselling to inmates with drug use problems (20). 

women who use drugs

It is estimated that women account for 25 percent of all drug users (approximately 3.4 million people) in Nigeria. Of the estimated 80,000 injection drug users in the country, around one in five are women (17,000). However, only a small fraction of people who use drugs that access treatment are women (approximately 6 percent). Women face the double stigma of being a woman as well as being a person who uses drugs. 


There are also gender-based inequalities at play in initiating injection drug use in Nigeria and other drug use-related behaviors. Women are often introduced to using drugs intravenously by their intimate partners as a “means of bonding” and often feel obligated to their male partners to share drug injecting equipment. They are more likely to report using their partner’s needles than men according to the National Drug Use Survey. It also found that women have higher rates of injecting heroin compared to men and that they are more often engage in high-risk sexual behaviors. They also report less control in how they have acquired their drugs which often come from their male partner(s). 


Qualitative studies on female sex workers in Nigeria have found very high rates of drug use among them and has been attributed to various reasons from being an expected behavior, to acting as a tool for coping with trauma, stigma, and violecnce (21,22).


Gender-sensitive services have been mentioned as important and necessary in both the National Drug Use Survey and the NDCMP, and during the recent launch of the Master Plan, the Minister of Women Affairs highlighted the importance of these services. It appears that government-funded, gender-specific services for women who use drugs are extremely rare in the country. In response to the Drug Use Survey, the FMOH has opened a women-specific drug treatment programme in Sokoto State in 2019. There is no available data on further expansion of these services across Nigeria or additional gender-specific programming.  


Youthrise Nigeria operates a drop-in centre in Abuja providing comprehensive services for women who use drugs. Used as a case study for the NGO Frontline Aids, the centre is “for women who use drugs which provides social and health care. They offer a range of services including information on SRHR in a locally produced manual; as well as condoms, hygiene kits, family planning, HIV tests, STI screening and legal support for gender-based violence cases.” They have thus far offered over 200 women drug treatment services, provided drug education to over 1000 people, provided 275 females with HIV testing and counselling, and increased the reporting of gender-based violence. 


Outlook Humanitarian Care Initiative (OHCI), a Nigerian NGO, has the mission to “empower women, improve gender equality, and fight malaria and HIV and AIDS among women and children. Support reform on the use of drugs and reduction of harm in the developing world” via advocacy and research. Unfortunately, a request for specific details on the organization's activities were unanswered in time for this report. 

social issues and inequalities

Most treatment services available in Nigeria are private and thus quite costly. According to 2018 World Bank data, Nigeria had the highest out-of-pocket spending on health care (76.6%) and is in the bottom third of all African countries in public spending on health care as a percentage of GDP (3.89%) (23,24). The inability to pay for treatment is one of the most common cited reasons for not accessing treatment . Furthermore, economic inequalities have also been found to be a driver for the adoption of injecting drug use to offset the lack of availability, lower purity, and high cost of substances (10). 


Stigma is another significant barrier for people trying to access support for their drug use. In response, targeted sensitization around drug use issues has been recommended for the Nigerian Police Force and the National Drug Law Enforcement Agency as well as for other stakeholders and the general population. 


However, the media, such as Vanguard newspaper, continue to publish sensational headlines and perpetuate damaging stereotypes about drugs and the people that use them. The role of the media in the fight against drugs was explicitly highlighted in an article published in the Journal of Communication titled, “Decongesting the Dodgy Hub: The Role of Mass Media in Curtailing Illicit Drug Trafficking and Use in Nigeria”. This divide between expectations and reality highlights the need for further efforts in stigma reduction.


Stigma around injection drug use in particular was found to increase negative attitudes amongst healthcare workers who care for people living with HIV/AIDS (25). 

Recommendations

Based on data gathered via desk research and key informants, and on the validation meeting with Love Alliance grantees and other key stakeholders from Nigeria, we propose the following recommendations:

 

Advocacy & policy reform

 

Awareness raising

 

Community-based research and assessments

 

Harm Reduction services

 

Learning needs

A policy brief summarising Nigeria's data can be found here.

Nigeria Key Indicators

References