The theme of Zero Discrimination Day 2026 tells us to put people first. It is a deceptively simple formulation, one that should be the unremarkable baseline of any health system. That it still requires stating, twenty years into the era of effective antiretroviral therapy, reflects how far the structures we have built continue to fall short of the people they are meant to serve.
Nigeria’s HIV burden is significant and well-documented. According to Bayesian modelling using UNAIDS 2022 Spectrum data, approximately 1.87 million Nigerians are living with HIV, at an adult prevalence of 1.3%. Antiretroviral therapy coverage has climbed to roughly 70–75%, a genuine and hard-won achievement. Yet national viral suppression rates, the clearest indicator of whether treatment is actually working, range between 60% and 86% across populations and datasets. The distance between those figures and the UNAIDS 95-95-95 targets is not explained by a shortage of medicines or a failure of clinical knowledge. The 95-95-95 target is a benchmark which aims for 95% of people living with HIV to know their status, 95% of those diagnosed to be on treatment, and 95% of those on treatment to achieve viral suppression so they can live healthy lives and prevent transmission. Data from national surveys and multiple research studies consistently point to a different cause: the structural persistence of stigma and discrimination at every level of the health system.
Fear of disclosure, anticipated stigma, and discrimination within health facilities are each independently associated with lower HIV testing uptake, delayed linkage to antiretroviral therapy, and poor treatment continuity. To treat stigma as a social problem separate from health systems is to misunderstand the crisis. Discrimination is a systems failure, and like all systems failures, it demands a systems response.
Where discrimination enters the system
HIV-related stigma in Nigeria operates across multiple intersecting dimensions, each eroding a different point of the care continuum.
At the community level, anticipated stigma remains the single most significant barrier to first contact with HIV services. Among adolescents and young adults, who represent a disproportionate share of new infections, fear of social labelling is a documented driver of delayed testing. People who suspect they may be positive frequently know where to access testing. What stops them is a rational calculation about what disclosure, even accidental disclosure, would cost them in their families, workplaces, and communities.
Inside health facilities, the system itself can become the source of harm. Judgmental provider attitudes, breaches of confidentiality, and facility designs that offer no discretion create environments where seeking care is experienced as a threat to privacy and safety. In some settings, HIV services are delivered in isolated, clearly marked units, sometimes labelled in ways that make their purpose obvious. Anyone seen entering or leaving those spaces is immediately assumed to be living with HIV. The result of this is predictable: people would start delaying visits, missing appointments, or avoiding care altogether to escape unwanted attention. Evidence shows that these experiences correlate directly with treatment interruption and viral non-suppression. Missed appointments in HIV care frequently cluster not around travel distance or cost, but around periods when clients are most visible, when attending a clinic repeatedly risks exposing a status they have not chosen to disclose. When a health facility fails to protect a patient’s dignity, it does not simply lose that patient. It loses the community’s trust.
Key populations, including female sex workers, people who inject drugs, and other marginalised groups, face compounded discrimination that suppresses testing rates, reduces ART uptake, and undermines viral suppression. Legal and structural barriers further deepen their exclusion. Policing practices and the threat of legal exposure have been directly linked to disengagement from HIV prevention and treatment services among these groups. When entire populations cannot access care without fear of criminalisation, national targets become impossible to achieve, regardless of what the clinical protocols say.
Women and girls carry the burden of gender-based stigma that intersects with all of the above. Blame, intimate partner violence, and constrained decision-making autonomy restrict access to testing and treatment for millions of women, not as an isolated barrier, but as one layer within broader patterns of gendered disadvantage that the health system, in its current design, does not adequately address.
Health systems strengthening: What the evidence shows
Addressing stigma is not separate from strengthening health systems. It is one of its most important dimensions. Through the Action to Sustain Precision and Integrated HIV Response towards Epidemic Control (ASPIRE) programme, funded by the United States President’s Emergency Plan for AIDS (PEPFAR), through the Institute of Human Virology Nigeria (IHVN) and implemented by Solina Centre for International Development and Research (SCIDaR) across the Federal Capital Territory, Nasarawa, and Rivers States, we support 111 private for-profit health facilities to deliver comprehensive HIV services, including case finding, same-day treatment initiation, viral load monitoring, and data systems integration. The lessons this work has generated go directly to the question of what health systems strengthening must include if it is to close Nigeria’s remaining gaps.
The first lesson is that small system failures create large trust deficits. When a facility cannot protect a patient’s confidentiality, through a breach in records management, a poorly designed waiting area, or an offhand remark by a healthcare worker, the consequences extend far beyond the individual encounter. Communities talk. Reputation of facilities travel. Discreet service design is a clinical strategy. At ASPIRE-supported facilities, where patient flow has been redesigned to protect privacy, providers trained in respectful and confidential care, and same-day ART initiation implemented, we have observed measurable improvements in retention and viral suppression. For instance, in 2025 alone, the project supported 11,410 people living with HIV to remain on life-saving ART, tested 83,735 individuals, and initiated 671 new clients on treatment, demonstrating that health system architecture both physical and procedural, can either facilitate or undermine care.
The second lesson concerns the strategic value of the private sector both for service delivery and for data integrity. A consistent pattern across ASPIRE’s implementation is that many clients actively seek private health facilities because they perceive them as more discreet than public alternatives. This preference is itself a system’s signal: it tells us that the public health system, in certain contexts, has not earned the trust of the people it most needs to reach. But the implications extend beyond service access. When private facilities operate outside national reporting structures, a significant portion of HIV service delivery becomes invisible in official data. Incomplete reporting distorts estimates of coverage, viral suppression, and treatment continuity and weakens the precision of policy and resource allocation decisions. Properly integrated and supervised, private health facilities are not a peripheral addition to the HIV response. They are essential both to reaching populations who might otherwise remain outside formal care and to ensuring that national databases reflect the full reality of service delivery. ASPIRE’s model of integrating private providers into national reporting systems, while equipping them with the quality standards and commodity security, demonstrates that trust, accountability, and data integrity can be strengthened simultaneously.
The third lesson is that stigma reduction must be institutionalised and measured. In facilities where dignity and confidentiality are embedded as performance standards, service uptake and viral suppression improve. But these principles must move beyond value statements to measurable indicators. Dignity and confidentiality can be assessed through routine patient satisfaction surveys, anonymous feedback mechanisms, and community-led monitoring. They can be reflected in audit checks on privacy safeguards such as secure records management, discreet patient flow design, and consultation spaces that prevent unintended disclosure. They can also be tracked through retention data: sudden treatment interruption patterns often signal breakdowns in trust. Where respectful care is monitored, reviewed in supervision visits, and tied to quality improvement processes, outcomes strengthen. Where it remains aspirational, without accountability structures, gaps persist. Culture follows structure. If non-discriminatory care is not measured, it is not guaranteed.
A policy agenda, not a wish list
The practical actions required are known. What has proven difficult is translating policy commitments into consistent, system-wide implementation.
For policymakers: anti-discrimination protections within health facilities must move from policy text to monitored, enforced practice. Nigeria’s national HIV performance framework must include stigma-reduction indicators alongside the clinical metrics that currently dominate accountability systems. Healthcare worker training on confidentiality and patient rights must be mandatory and recurrent, not a one-cycle intervention. And domestic HIV financing must be treated as a national security priority. With over 96% of Nigeria’s HIV resources currently drawn from external donors, the recent volatility in global health financing is not an abstraction. It is an immediate threat to the continuity of care for nearly two million Nigerians. The government must act accordingly.
For health institutions: service delivery must be redesigned with privacy as a structural principle. Grievance mechanisms for patients who experience discrimination must be visible, trusted, and safe to use. Supportive supervision, not punitive oversight, must become the standard approach for identifying and addressing discriminatory conduct. Facilities that deliver dignified, confidential care should be recognised; those that do not must be supported to change.
For development partners and civil society, funding ought to be aligned with quality-of-care standards that treat stigma reduction as a measurable outcome. Community-led monitoring, which surfaces the lived experience of discrimination that routine health data systems miss, must be adequately resourced. And the translation of evidence into policy must be accelerated: the research based on what works is robust. The gap is in systems that act on it.
The goal is within reach
There are clear and honest grounds for optimism. HIV testing coverage has expanded. The number of Nigerians on treatment has grown substantially. Viral suppression rates are trending upward. Same-day ART initiation is becoming more common. Integration of HIV services into antenatal care and primary health care is reducing missed opportunities for early diagnosis. More private facilities are delivering structured HIV services than at any point in the epidemic’s history. These gains are real, and they are the product of deliberate investment in health systems, guided by evidence and executed by skilled, committed professionals across the public and private sectors.
Meaningful success, in the next three to five years, looks like three concrete things:
● Viral suppression rates consistently above 95% among those on treatment, with narrow variation across states and population groups
● Measurable, survey-documented declines in stigma at both community and facility levels
● HIV services are thoroughly normalised within primary health care that testing is routine, confidentiality is trusted, and no Nigerian remains outside the care system because they fear what entering it would cost them.
People First is not a slogan. It is a design specification. It tells us what health systems must prioritise, what policies must protect, and what accountability structures must enforce. The science of ending AIDS is not in question. The clinical tools exist. The epidemiological roadmap is clear. What Zero Discrimination Day asks of us, of policymakers, health institutions, development partners, and practitioners, is the institutional seriousness to build systems that place every person’s dignity at the centre of every interaction.
At SCIDaR, this is not an abstract commitment. It is what the work demands. And on this Zero Discrimination Day, it is what Nigeria’s 1.87 million people living with HIV, and every person at risk, deserve.
Salisu, principal, Solina Centre for International Development and Research (SCIDaR).
