HIV Prevention in Nigeria:
John Idoko MD
National Agency for Control of
AIDS (NACA)
Background on Nigeria
• Nigeria is a Federation with 36 semi autonomous
states and FCT and 774 LGAs
• At the end of October 2011, the population is
projected at about 168 million
• Birth rate is estimated at 41 per 1,000 while the
death rate is 15 per 1,000.
• Christianity and Islam are the two dominant
religions
• There are over 250 ethno linguistic groups with
different cultural practices
• Approximately two-thirds of the population live in
rural areas
• It has a relatively young population with a median
age of 17 years
National HIV Prevalence Trend 1991 – 2010 (FMOH)
Where we are now?....still far
away
•
•
•
•
•
•
•
•
Nigerian Population
No. of PLWIH
HCT coverage
PMTCT coverage
Annual HIV+ Birth
New infections
Number on ART
Total orphaned by AIDS
166 million
3.1 million
20%
21%
70,000
380,000/yr
432,000 (1.5m)
2.23 million
Strengths in the Nigeria prevention
programme
• Minimum Package of Prevention Interventions
(MPPI) is an innovative strategy for addressing
combination prevention
• Programs focusing on MARPs (FSW, MSM),
women and young girls exist
– Other vulnerable groups also being reached
• GON adapted tools for national roll-out of
PHDP
• Programs have created high demand for HCT
services
• GON supported policies at national level for
task shifting, implementation varies by site
Distribution of new HIV infections,
Nigeria, 2008
Casual
heterosexual
(CHS)
9.091%
Medical injections
1.199%
Blood transfusions
.500%
Partners of
CHS
14.785%
IDU
9.0%
FSW
3.397%
IDU-P 0.4%
High risk groups,
32.2
Low-risk
heterosexuals
42.258%
FSW clients
4.8%
FSW -P
3.4%
MSM
10.290%
Female
partners of
MSM
.899%
Broad AIDS Spending categories in 2010
Expenditure on beneficiary populations
2009
Beneficiary population
Amount (USD)
BP.01-People living with HIV
2010
%
Amount (USD)
%
207,110,810.00
49.87
187,424,838.00
37.72
378,255.00
0.09
557,700.00
0.11
20,332,659.00
4.90
22,744,908.00
4.58
BP.04-Specific accessible
population
1,130,254.00
0.27
3,118,459.00
0.63
BP.05-General population
23,452,982.00
5.65
62,125,892.00
12.50
162,882,470.00
39.22
220,787,650.00
44.43
0
415,287,430.00
0
100
158,024.00
496.917.471.00
0.03
100
BP.02-Most-at-risk populations
BP.03-Other key populations
BP.06-Non-targetted
interventions
BP.99-Specific targeted
populations not elsewhere
classified
Total
Financial Requirements (US$Mil)
for Universal Access Scenario
Scale-Up Scenario
Prevention
M: PMTCT
M: HCT
M: Other prevention
2010
5-yr Total
$5.0
$172.2
$16.4
$431.0
$180.0 $1,098.9
Treatment
M: ART
M: CSS - Pre-ART
$299.2 $3,049.9
$12.0
$360.9
C are
M: CSS - Non-ART
M: CSS - TB-HIV
$53.3 $1,539.2
$10.7
$58.8
Mitigation
M: OVC
M: Total Cost
M: Resources
M: Gap
HAPSAT, 2009
$16.7
$207.6
$593.2 $6,918.2
$601.3 $3,404.5
$0.0 $3,521.8
10
Total Expenditure Trend 2007-2010(USD) in Nigeria
NASA, 2012
National HIV/AIDS Strategic Frame
Work II(2010-2015)
• Overarching priority of NSF –Prevention of
new HIV infections (UA)
• Thematic Areas
– Promotion of Combination Prevention (Behaviour,
Biomedical and Structural Interventions)
– Treatment of HIV/related conditions
– C & S for people infected & affected and OVC
– Strengthening systems, coordination and resourcing
– Policy, Advocacy, HR and legal issues
– M & E, Research and Knowledge mgt
NSF II
• NSF II has an increased focus on:
country ownership, sustainability,
transition, and integration TB, Malaria,
MNCH and HSS/CSS
• Increased emphasis on evaluation, data
system strengthening & data use for
program improvement
INTEGRATED CLUSTER MODEL & ART DECENTRALIZATION
CBO/
NGO
CBO/
NGO
PHC
PHC
Comprehensive
PHC/GH
PHC
PHC
PHC
CBO/
NGO
†Comprehensive HIV services - PHASED
†Combination Prevention : MPPI
†Integration with MNCH, TB, Malaria, HSS
NGO/
CBO
Prevention under NSF II
• Shift away from “ABC” to comprehensive prevention
– A is ineffective and inappropriate for most populations;
“abstinence only” has negative impact
– B should be about partner reduction and knowing your
partner’s status, NOT fidelity
• Comprehensive prevention includes the use of
behavioral, biomedical, and structural interventions
(combination Prevention) to reduce HIV incidence
• National HIV/AIDS Prevention Plan being updated
• Updated combination prevention guidance for
programs will soon replace the former “ABC” Guidance
Prevention under NSF II
• Strengthen prevention services by providing
combination prevention
– Energize LACA & LACA-CSO partnership
– Use Minimum Package of Combination Prevention for key
population groups including MARPS and general population
– Targeted use of PrEP & T as P
– Community mobilization – LGA level (CMO) and ward level in
states with >10% prevalence
• Deal with following structural issues
– Stigma & discrimination
– Sexual violence & GBV
– HR violations
12/8/2010
12/8/2010
• Promote livelihood alternatives to transactional
sex
16
16
Prevention under NSF II
• Ensure universal HCT including scaling out
Provider Initiated Testing (PIT) and self testing
• Promote the full range of e-mtct services
• Promote joint HIV/TB services
• Partner with employers, employees & unions
to promote HIV prevention & treatment in the
workplace
• Ensure healthcare, law enforcement and
social services staff are trained on HIV issues
including gender & HR
12/8/2010
17
Prevention - TAG
• NPTWG inaugurated in 2007
– To promote the acceleration of HIV
prevention- elements of advocacy, policy,
resources and social mobilization, etc
– To coordinate and harmonize HIV
prevention- protocols, standards,
guidelines, coordination mechanisms,
HIV/RH Integration, etc
– To provide technical guidance and carry out
prevention-related tasks as commissioned
by the ETG
– Advice GON on current prevention
strategies
Key Attributes
 Builds on the 2007-2009 Prevention Plan and
lessons learned
 Informed by the most recent evidences on
HIV Issue in Nigeria
 NARHS-PLUS, IBBSS, NDHS, MoT, HSSS etc
 Policy Review & NSF Implementation Review
 Draws on the most recent policy frameworks
in Nigeria
 Reflects & responds to global developments
& directions in HIV prevention field
 Broadened approach to improve capacity for
practical interventions
Lessons From India
• Common Framework for National Response
• Investing & focusing on priorities
• Use of implementation science to guide programs
• Coordinated TSU
• Government ownership, leadership and effective
Coordination
• Partnerships, Innovation and Managed Networks
• Well organized CBO networks
• Standard Setting, Oversight and Accountability
• Scale up matters
• Well coordinated transitioning from donors to
government structures
In Summary: for effective response
Critical Factors:
•
•
•
•
•
•
Geographic Prioritisation
Population Sub Groups
Matching Investments with Drivers of the
Epidemic
Starting on Scale
Centrality of Leadership and Clear Common
Framework for Action
Quality Technical Assistance
This calls for rethinking current Elements of
Delivery and developing innovative
approaches and partnerships
WESA27: Africa-India HIV Learning
Exchange: Approaches to Achieving Scale:
The Ghana Experience
Richard Amenyah MD, MPH
Ghana AIDS Commission
Ramenyah@gmail.com
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Background
• In 2010, Ghana undertook a lot of initiatives to
develop an evidence informed National Strategic
Plan 2011-2015
• Evaluation of the previous 5-Year Plan
• Epidemic synthesis and response
• Implementation capacity assessment for a
sustainable response
• Costing models e.g. GOALS
• Development of a Technical Support Plan
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Our philosophy for Technical
Support
• Demand-driven Technical support needs to be
focused, strategic, flexible, responsive, efficient
and effective in building country systems to
scale up high impact HIV interventions and to
enhance the promotion of South-South
cooperation
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Why India for Technical
Support?
• Similarities in the nature of our epidemics
• Strong evidence that significant successes in
improving their HIV programming especially
among key populations
• Evidence of strong mechanism for coordination
of a decentralized response
• Willingness of the Government of India and its
key partners to share their experiences
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Our motivation
• Ghana believes that by strengthening SouthSouth partnership and collaboration, we can
enhance the relevance, quality and sustainability
of technical support provided in building
our local capacities and systems for a
sustainable programme response.
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
What did we do?
• The GoG had followed up with USG on capacity
enhancement of key institutions (public-private
partnerships plus CSOs) under our existing
partnership framework.
• The Need to learn from a success story: e.g
India (e.g. Avahan project etc)
• USAID, FHI 360 and GIZ were tasked to initiate
contact with their counterparts in India;
• GAC also contacted USAID and GIZ to consider
sharing cost of this learning tour which they
obliged to do
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
What Ghana was looking for?
• "How to do it"
• Improve on coordination arrangements at the
decentralized level
• Improve on high impact interventions being
implemented in Ghana especially among key
populations
• Build country capacity
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Specific areas of interest
• Unique identifiers for key populations
• Setting up Functioning Drop in Centres (DICs)
• Re-Structuring Peer Education system as well
as other approaches (micro-planning, clarifying
roles and responsibilities, rapid response system
-M-Friends and M-Watchers, SOPs)
• Strengthening national and decentralized
structures in coordination of HIV programmes
• Structured generation of "what works" and use
of strategic information
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
What did we learn to apply?
• Setting up 4 Technical Support Units to enhance
Ghana's decentralized HIV response
• Development of MARP Strategic Plan and it's
accompanying operational plan
• Setting up of DICs, rapid response systems, restructuring of Peer Education systems etc
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
What needs improvement?
• The need to reorganize the Unique identifier
systems set up for Key populations
• Strengthen micro planning for improved
programming
• Developing service standards and quality
assurance systems
• Sustain capacity building and
nurturing/mentoring of systems adapted from
south-to-South cooperation
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Conclusion
• We had a good exposure and great support
systems for adaptation which is tailor-made
• We were successful because USG/USAID, GIZ,
Danida bought into our country plan and helped
us to jump start the process with seed money
• We had a great return on our investment
– Excellent value for money
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Acknowledgements
•
•
•
•
•
•
•
•
Avahan project
USG/USAID
GIZ
Danida
FHI 360
WAPCAS
NACP
GAC
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Thank you
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
INTEGRATING LEARNING FROM
INDIA: THE SOUTH AFRICAN
EXPERIENCE
YOGAN PILLAY
DEPARTMENT OF HEALTH, SOUTH AFRICA
19TH IAS CONFERENCE, WASHINGTON DC,
25 APRIL 2012
THE SOUTH AFRICAN EPIDEMIC
• Generalised epidemic
• 5.6m people are HIV positive (total population
is 50m)
• 30% prevalence among women using ANC
clinics
• 17% prevalence in the general population
• Incidence is around 1%
38
KEY POPULATIONS IN SOUTH AFRICA
• Key Populations are key drivers of the
epidemic in South Africa include truckers,
men who have sex with men (MSM), female
sex workers (FSWs), and other high risk
groups
– 9.2% of and 19.8% of new HIV infections
are related to MSM and Sex work
respectively
39
South Africa National Strategic Plan for
HIV, STIs and TB - 2012-2016
• Built around a 20-year national vision of “Zero new
HIV infections”
• Reduce new HIV infections by at least 50% using
combination prevention approaches
• Ensures an enabling and accessible legal framework
that protects and promotes human rights
• Emphasis on evidence-based planning and
prioritization of interventions for implementation
• Recognition that HIV services should be provided for
Key Populations based on risk and need
40
South Africa Sex Worker Programs
• Few organizations supporting implementation
of services for sex workers
–
–
–
–
–
–
Sex Worker Education and Advocacy Task Force (SWEAT)
Wits Reproductive Health Institute (WRHI)
Center for Positive Care
Partners in Sexual Health
East London HTA
Women’s Legal Center
41
National HELPLINE
• National, toll-free helpline, staffed
by trained counsellors who were or
are sex workers
• Counselors receive weekly support
and supervision
• Common Issues addressed—Safe
sex, human rights, violence, police
harassment and arrest, substance
abuse, trafficking, emotional
wellness, and labour disputes (SW
agencies)
42
Creative Space
• A safe, stigma-free space for
sex workers to express
themselves,
• Opportunity to access legal
and counselling support,
reduce isolation, access
information, access HCT and
health checks
• Female, male and
transgender; separate spaces
• 100-150 participants per week
43
South Africa Truckers HIV Programs
•
Program by National Bargaining Council for Road
Freight Industry
•
Previously Trucking Against AIDS
•
Health & Wellbeing of industry
•
Since 1999, established 22 roadside wellness centres
and 5 mobile wellness centres
•
Donor Funding – services free
44
Roadside Wellness Centres
•
Major routes truck stops – all provinces
•
Open mostly at night
•
Primary Healthcare
•
STI testing & treatment
•
HCT & treatment programme
•
Care & Comfort to long-haul drivers
•
Condom distribution
•
HIV & AIDS Education
45
Wellness centres
46
Mobile Wellness Centres
 Five Mobile Wellness
Centres Nationally
 Similar services to
Roadside Wellness Centres
 Takes services to depot
level where all staff can be
trained and tested
 Treatment programme &
referrals
47
Learning from the Avahan Experience (1)
In September 2011, BMGF supported
Avahan learning visit by NDOH, NDOT,
KZN-DOH, CDC, SABCOHA, Trucking
Wellness and North Star Alliance
48
Learning from the Avahan Experience (2)
• Overall coordination and collaboration of stakeholders
involved in designing and implementing services for Key
Populations
• Standard package of HIV prevention services that is tailored to
different risk profiles for SWs--improved resource planning,
service delivery, and reduced looses to follow-up
• Volunteerism – enabled a seamless downward -upward
approach in policy planning and execution
• Advocacy at all levels of implementation (federal, state and
community)
• Branding and niche marketing including using appropriate IEC
material developed for specific Key Population
49
Learning from the Avahan Experience (3)
• Community ownership – through
empowerment of the community
in driving the Key Populations by
peer educators
• Health education and awareness
takes place in all health and nonhealth settings
• Emphasis on innovative ways to
create awareness for the key
populations
• Condom management community lead, demonstration
for all settings, increased
condom lubrication, condom
color and flavor
50
Priority NDOH Activities for Key Populations
2012-2013
• Developing of National Guidelines for HIV Prevention,
Care and Treatment for Key populations
• Standardization of the package of HIV Prevention
Services
• Convening a National Sex Worker Health Symposium
• Developing/Adapting program tools used for
implementing and monitoring Key Populations services
• Initiating routine HIV Surveillance and mapping
activities for Key Populations
• Collaboration with Transport Sector to scale-up
truckers HIV services
51
National Guideline for HIV Prevention, Care
and Treatment for Key Populations (1)
• Provide a framework to service providers to create an
enabling environment, empower key populations to
reduce their risk of HIV/STI acquisition and/or
transmission, and to seek early diagnosis and appropriate
treatment of HIV/STIs
• Create a benchmark against which the services provided
to key populations are monitored and evaluated regularly
to inform continuous improvement and improve access,
uptake and effective utilization of HIV prevention
activities
52
Developing/Adapting program tools for HIV
Services for Key Populations
• Leveraging on the established Key Populations TWG,
an Inventory of existing program tools currently
ongoing from June to July
• Aim is to identify a few tools that can be adapted for
use in the local context (HTA settings and others) -some examples
– Standard operation procedure for selection of
peer educators, clinical services etc
– Micro-planning and participatory mapping
activities
53
Routine HIV Surveillance and mapping for Key
Populations
• Strategic Information for Key Populations
TWG established under auspices of NDOH
and 1st meeting held in June 13
– Aim is to strengthen generation and reporting of
reliable information on the health and social welfare
needs of key populations in South Africa
– survey of sex workers will be conducted in Cape Town,
Johannesburg and Durban beginning later in 2012, with
results anticipated in the second half of 2013
– MSM surveillance in Cape Town, Durban and
Johannesburg is already underway by HSRC
– Discussion and agreement on minimum indicators for
monitoring and reporting (reference made to UNGASS
indicators)
54
Collaboration with Transport Sector to
Scale-up Truckers HIV Services
• NDOH is one of 24 members of the Transport Sector
HIV & AIDS and TB Coordinating Committee
established in March 2012
• 2 July 2012: Roundtable discussion on Truckers HIV
programme facilitated by BMGF project for key
stakeholders—SANAC, NDOT, NDOH and
implementing partners
– Agreement on a rapid mapping exercise in selected
hotspots along the N2/N3 in KZN (with support from
Transport Corporation of India Foundation)
– Discussion and agreement on the standardization of
Truck Stop Wellness Center services
55
Conclusions
• Key lessons from India:
– Role of NACO
– Importance of national budget
– Single implementation and monitoring strategy
– Business model (data driven for planning and
monitoring implementation)
– Local participation (community led)
56
I thank you!!!
57
HIV Prevention/Care Program with Most At
Risk Populations, Nairobi, Kenya
Reflections on Africa – India
HIV Learning Exchange:Approaches to Achieving
Scale
Kenya AIDS Control Project
Dr. .Joshua Kimani
Prevention works -The results of 25 years of
interventions with sex workers – Majengo Clinic
100%
90%
PERCENT (%)
80%
70%
60%
50%
40%
30%
20%
10%
0%
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10
YEAR
HIV Incidence
Condom use with Casual client
Gonorrhea Infection rate/visit
Chlamydia Infection rate/visit
Mobilization and Health Education
MARPs outreach, testing and Enrolment
MARPS
50000
44853
43855
45000
40533
37571
40000
43087
32222
35000
Number
49221
47494
28744
30000
24121
25000
18989
20000
14843
15000
10717
0
7928
6790
10000
5000
13390
2313
1144
582
3192
1565
901
4883
2221
1366
4060 5033
2979
1785
2515
9402
10746
8910
4190
5400
6446
7237
Month
Tested
Contacts
16281
12195
6376
3196
14625
Enrolled
8191
9509
9766
15257
18753
17528
11470
10784
10206
A minimum HIV prevention, Care and Treatment
package for sex workers
• Information on safer sex practices
• Condom information, demonstration on use and provision.
• HIV testing and counseling (VCT/PICT)
• STI screening and treatment
• Risk reduction counseling services
• ARV and HIV basic care
• Family planning information
• TB screening and referral
• PEP
• Psychosocial support and referral
But…..
Key Gaps in Programming
•
•
•
•
•
•
Number of sex workers unknown
Coverage unknown
Mapping of catchment area not done
Number and typology of hot -spots unknown
Required number of peer educators unknown
Outreach activities not evaluated as a core function of
our program
• Program biased towards biomedical interventions
• Retention a major challenge
Nov 2011- Mar 2012
National geographic mapping of
populations most-at-risk of HIV (MARPs) in
Kenya
Nairobi County - Zoned
Participatory Zoning Process
Peer Led Mapping and Spot Analysis
Hot Spot Analysis - Nairobi
Results
Estimates of active FSW spots in Nairobi,
by Districts
Total: 2,539
Estimates of FSWs in Nairobi County, by districts
Total Ave.: 27,620
Total Min.: 21,081; Max.: 34,160
Estimates of MSW/MSM population in NAIROBI, by
districts
Total Ave.: 1,570
Min.: 1,140; Max.: 2,000
Distribution of FSW by Typology of Hot Spots
in Nairobi
NAIROBI - (N=27,620)
Total: 2,539
KACP Program – April 2012
“The Way Forward”
Hotspot Focused –
peer educator led
model
Acknowledgements
•
•
•
•
•
•
•
CDC-PEPFAR - Funding
UON-UOM Hosts
NASCOP Team –MOH Support
BMGF- Avahan
World Bank
KACP staff
MARPs (Clients)
Asante sana/ Thank You