HIV Prevention in Nigeria:

1. HIV Prevention in Nigeria: John Idoko MD National Agency for Control of AIDS (NACA)

2. 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

3. National HIV Prevalence Trend 1991 – 2010 (FMOH)

4. Where we are now?....still far away • Nigerian Population 166 million • No. of PLWIH 3.1 million • HCT coverage 20% • PMTCT coverage 21% • Annual HIV+ Birth 70,000 • New infections 380,000/yr • Number on ART 432,000 (1.5m) • Total orphaned by AIDS 2.23 million

5. 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

7. Distribution of new HIV infections, Nigeria, 2008

8. Broad AIDS Spending categories in 2010

9. Expenditure on beneficiary populations

10. Financial Requirements (US$Mil)for Universal Access Scenario HAPSAT, 2009

11. Total Expenditure Trend 2007-2010(USD) in Nigeria NASA, 2012

12. 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

13. 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

14. INTEGRATED CLUSTER MODEL & ART DECENTRALIZATION CBO/NGO CBO/ NGO PHC PHC Comprehensive PHC/GH PHC PHC PHC CBO/ NGO NGO/ CBO †Comprehensive HIV services - PHASED †Combination Prevention : MPPI †Integration with MNCH, TB, Malaria, HSS

15. 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

16. 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 • Promote livelihood alternatives to transactional sex 12/8/2010 16

17. 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

18. 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

19. 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

20. 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

21. 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

23. WESA27: Africa-India HIV Learning Exchange: Approaches to Achieving Scale:The Ghana Experience Richard Amenyah MD, MPH Ghana AIDS Commission Ramenyah@gmail.com

24. 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

25. 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

26. 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

27. Our motivation • Ghana believes that by strengthening South-South 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.

28. 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

29. 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

30. 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

31. 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, re-structuring of Peer Education systems etc

32. 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

33. 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

34. Acknowledgements • Avahan project • USG/USAID • GIZ • Danida • FHI 360 • WAPCAS • NACP • GAC

35. Thank you

37. INTEGRATING LEARNING FROM INDIA: THE SOUTH AFRICAN EXPERIENCE YOGAN PILLAY DEPARTMENT OF HEALTH, SOUTH AFRICA 19TH IAS CONFERENCE, WASHINGTON DC, 25 APRIL 2012

38. 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%

39. 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

40. 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

41. 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

42. 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)

43. 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

44. 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

45. 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

46. Wellness centres

47. 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

48. 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

49. 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

50. 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 non-health 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