Nigeria is the most populous country in Africa with a population of over 140 million spread across a total land area of 923,768 km². Women constitute 48% of the population: an estimated two-thirds live in rural areas, while 44% are below 15 years old. Nigeria ranks 4^th of the 22 highest TB burden countries in the world. TB mostly affects women and men in their economically and reproductively active years (15-45). 

While the numbers of male and female patients under the age of 24 are nearly equal, there are significantly more cases among males over the age of 24 than females of this same age group (18,133 versus 11,242). Socio-economic and cultural factors play significant roles in determining gender differentials in rates of infection, progression to overt tuberculosis disease, health seeking behavior, case detection, access to treatment and care as well as treatment adherence, all of which have serious implications for successful TB control. 

The gender division of labor in Nigeria creates situations where women and girls are overburdened with care for sick relatives including their spouses and children with the attendant risks of getting infected and losing livelihood sources. Women face fear of rejection, stigma and discrimination associated with TB and are more likely to patronize alternative healthcare practitioners than men¹. Men’s heightened vulnerabilities may result from their masculine attitudes of being present in congregate social settings as well as genetic factors. Though case notifications for men are more than those for women, the treatment defaulter rate is higher among men.  

Several Nigerian studies have established that considerable delay exists between symptom onset and treatment initiation among pulmonary tuberculosis patients. A study by Okeibunor, et. al. 2007 reported that delay in seeking healthcare from DOTS clinics was mainly because most respondents (43.4%) did not consider TB as a serious health problem. Other important reasons for delay included unwelcome attitudes of health workers and the tendency of the respondents to prefer alternative medicine. Delays in seeking treatment among women were associated with ignorance (64%), negative attitude of health workers (16.0%) and the hidden costs associated with treatment (16.0%), especially transportation costs and initial diagnosis as well as seeking permission of their spouses to go for medical check up.  Poverty is a recurrent burden in the lives of most Nigerians.

The National Bureau of Statistics reported in 2005 that 54.4% of Nigerians live below the poverty line (US$1.0). Poor nutritional status and overcrowding increase the risk of transmitting and developing TB amongst family members. In addition to women, other vulnerable population groups that live in congregate settings including prison inmates, armed forces personnel, and socially marginalized and displaced persons pose special challenges for TB control. The emergence of the HIV epidemic has resulted in a fivefold increase in the number of TB cases registered by national TB programme in sub-Saharan Africa and have revealed new trends in TB prevalence among women especially female adolescents. In Nigeria, the HIV&AIDS epidemic is feminized and driven by poverty.Women are the poorest of the poor. Poverty, gender inequality, and illiteracy result in gendered vulnerabilities to HIV, the consequent progression of latent TB infection (TB is endemic in Nigeria) to overt disease and limits access to treatment and care in a vicious circle.

There is currently a strong National commitment for integration of HIV and TB programme. The National HIV/AIDS Strategic Framework (NSF) for Action, 2005-2009 incorporates gender sensitive strategies towards creating access to services for TB-HIV co-infected persons.  As part of learning to “know your epidemic”, the planned epidemiological surveys (prevalence of TB and MDR-TB) in the six geographical zones as planned under WHO and GFR5 grant support, will establish a sex-ratio standard, identify high risk groups and determine the gender and socio-economic barriers which prevent access to TB control services. The National Strategic Plan (2006 – 2010) and all related documents will be reviewed and updated with issues relating to the emerging realities around Gender and TB.

Gender equality modules are already being incorporated into all training curricula.  With increasing availability of computerized central data recording, processing and reporting systems at State and LGA level, the sex and gender disparities in TB control from case detection to successful recovery and rehabilitation will be captured in the monitoring and evaluation system (HMIS) of the NTBLCP, so that the magnitude of these disparities can be determined and addressed. All data collection tools would be reviewed to allow for disaggregation by sex, socio-economic status, and age. Data Managers and other key personnel will be trained on the interpretation and use of gender-sensitive data for planning. The R8 TB proposal takes into account the gender dimensions of TB and proposes strategies that create access to TB services for the poor and marginalized.

Among other things, this proposal emphasizes further and rapid expansion of TB and TB/HIV services to improve access with a special focus on hard to reach populations including women, children under five years of age, prison inmates, poor rural dwellers, TB-HIV co-infected persons, workers in confined areas and industries and other congregate settings. In the process of scaling up CTBC to an additional 200 LGAs ( 5 communities per LGA) under the HSS, community volunteers of both sexes would be involved to ensure proper health promotion, education, a pro-active approach for contact investigation and counseling in local dialects, with the aim of reaching children under five, the hard-to-reach groups, the illiterate and rural poor. Provision of incentives and enablers (social support, food packages, transport vouchers) for 60% of poor individuals infected with TB will improve access to DOTS services and enhance treatment outcomes.  

Where possible, employment processes and training of health workers will mainstream gender equality perspectives.  Male involvement in care for TB and TB/HIV co-infected patients will be promoted to reduce women’s burden of care. Also, an appropriate number of men and women will be employed and trained as healthcare providers in order to address certain norms, cultures and religious preferences that are made by patients. In addition, TB/HIV Support Groups and other key players will be sensitized to follow up with TB patients on treatment, especially males to ensure treatment adherence