Stakeholders' Perspectives on the Financial Sustainability of the HIV Response in Nigeria: A Qualitative Study.

BACKGROUND: Countries in sub-Saharan Africa, including Nigeria, continue to depend on donor funding to achieve their national HIV response goals. The Government of Nigeria has made limited progress in translating political commitment to reduce donor dependency into increased domestic investment to ensure the sustainable impact of the HIV response. We explored the context-specific factors affecting the financial sustainability of the HIV response in Nigeria. METHODS: Between November 2021 and March 2022, we conducted document reviews (n=13) and semistructured interviews with purposively selected national and subnational stakeholders (n=35). Data were analyzed thematically using the framework of health financing functions comprising revenue generation, pooling, and purchasing. RESULTS: Stakeholders reported that there is a low level of government funding for the HIV response, which has been compounded by the weak engagement of Ministry of Finance officials and the unpredictable and untimely release of budgeted funds. Opportunities for domestic funding include philanthropy and an HIV Trust Fund led by the private sector. Integration of HIV treatment services into social health insurance schemes has been slow. Commodity purchasing has been inefficient due to ineffective coordination. Government stakeholders have been reluctant to support one-stop-shop facilities that target key and priority populations. CONCLUSION: Opportunities exist in the government and private sectors for improving domestic health financing to support transitioning from donor support and ensuring the financial sustainability of the HIV response in Nigeria. To ensure that domestic financing for the HIV response is stable and predictable, the amount of domestic funding needs to increase and a framework that incorporates donor transition milestones must be developed, implemented, and monitored.

Ending AIDS as a public health threat by 2030: Time to reset targets for 2025.

Paul De Lay and co-authors introduce a Collection on the design of targets for ending the AIDS epidemic.

The Economic and Epidemiological Impact of Focusing Voluntary Medical Male Circumcision for HIV Prevention on Specific Age Groups and Regions in Tanzania.

BACKGROUND: Since its launch in 2010, the Tanzania National Voluntary Medical Male Circumcision (VMMC) Program has focused efforts on males ages 10-34 in 11 priority regions. Implementers have noted that over 70% of VMMC clients are between the ages of 10 and 19, raising questions about whether additional efforts would be required to recruit men age 20 and above. This analysis uses mathematical modeling to examine the economic and epidemiological consequences of scaling up VMMC among specific age groups and priority regions in Tanzania. METHODS AND FINDINGS: Analyses were conducted using the Decision Makers' Program Planning Tool Version 2.0 (DMPPT 2.0), a compartmental model implemented in Microsoft Excel 2010. The model was populated with population, mortality, and HIV incidence and prevalence projections from external sources, including outputs from Spectrum/AIDS Impact Module (AIM). A separate DMPPT 2.0 model was created for each of the 11 priority regions. Tanzania can achieve the most immediate impact on HIV incidence by circumcising males ages 20-34. This strategy would also require the fewest VMMCs for each HIV infection averted. Circumcising men ages 10-24 will have the greatest impact on HIV incidence over a 15-year period. The most cost-effective approach (lowest cost per HIV infection averted) targets men ages 15-34. The model shows the VMMC program is cost saving in all 11 priority regions. VMMC program cost-effectiveness varies across regions due to differences in projected HIV incidence, with the most cost-effective programs in Njombe and Iringa. CONCLUSIONS: The DMPPT 2.0 results reinforce Tanzania's current VMMC strategy, providing newfound confidence in investing in circumcising adolescents. Tanzanian policy makers and program implementers will continue to focus scale-up of VMMC on men ages 10-34 years, seeking to maximize program impact and cost-effectiveness while acknowledging trends in demand among the younger and older age groups.

Implementing for results: program analysis of the HIV/STI interventions for sex workers in Benin.

HIV response has entered a new era shaped by evidence that the combination of interventions impacts the trajectory of the epidemic. Even proven interventions, however, can be ineffective if not to scale, appropriately implemented, and with the right combination. Benin is among the pioneering countries that prioritized HIV prevention for sex workers and clients early on. Effective implementation up to 2006 resulted in consistent condom use among sex workers increasing from 39% to 86.2% and a decline in prevalence of gonorrhea from 5.4% to 1.6%. This study responds to the growing concern that, although proven interventions for female sex workers (FSWs) were expanded in Benin since 2008, indicators of coverage and behaviors are far from satisfactory. The quest to better understand implementation and how to render service delivery efficient and effective resonates with increased emphasis in the international arena on return for investments. Quantitative and qualitative methods were utilized to collect data. The output measured is the number of sex workers seeking Sexually Transmitted Infection (STI) care at user-friendly STI Clinics (SCs). Data were collected for 2010-2011 in nine regions of Benin. While recognizing that commitment to scale up is commendable, the study revealed deficiencies in program design and implementation that undermine outcomes. The selected mix of interventions is not optimal. Allocation of funds is not proportionate to the needs of FSW across regions. Only 5 of 41 SCs were fully functional at time of study. Free distribution of condoms covers only 10% of needs of FSWs. Funding and financing gaps resulted in extended interruptions of services. Successful HIV prevention in Benin will depend on the effective and efficient implementation of well-funded programs in sex work setting. Resources should be aligned to local sex work typology and presence in communities. A national framework defining an appropriate mix of interventions, management structure, referral mechanisms, and operational standards is required to guide rigorous implementation. Health services, in particular functional and user-friendly SCs coupled with mechanisms that link community-based work and health facilities should be strengthened to ensure STI care/anti-retroviral treatment expansion. Without leadership of sex workers, any attempt to end HIV will be unsuccessful.