A Decade of Monitoring HIV Epidemics in Nigeria: Positioning for Post-2015 Agenda.

BACKGROUND: Nigeria accounts for 9% of the global HIV burden and is a signatory to Millennium Development Goals as well as the post-2015 Sustainable Development Goals. This paper reviews maturation of her HIV M&E system and preparedness for monitoring of the post-2015 agenda. METHODS: Using the UNAIDS criteria for assessing a functional M&E system, a mixed-methods approach of desk review and expert consultations, was employed. RESULTS: Following adoption of a multi-sectoral M&E system, Nigeria experienced improved HIV coordination at the National and State levels, capacity building for epidemic appraisals, spectrum estimation and routine data quality assessments. National data and systems audit processes were instituted which informed harmonization of tools and indicators. The M&E achievements of the HIV response enhanced performance of the National Health Management Information System (NHMIS) using DHIS2 platform following its re-introduction by the Federal Ministry of Health, and also enabled decentralization of data management to the periphery. CONCLUSION: A decade of implementing National HIV M&E framework in Nigeria and the recent adoption of the DHIS2 provides a strong base for monitoring the Post 2015 agenda. There is however a need to strengthen inter-sectoral data linkages and reduce the rising burden of data collection at the global level.

It takes a village: community-based organizations and the availability and utilization of HIV/AIDS-related services in Nigeria.

Community-based organizations (CBOs) have emerged as a vital part of the response to HIV/AIDs in Nigeria. The evaluation, on which this article is based, conducted in 28 communities in 6 states and the Federal capital Territory in Nigeria, assessed the effects of the CBO engagement on a set of outcomes related to HIV/AIDS knowledge, attitudes, beliefs, and practices, stigma, service availably and utilization and social capital. It consisted of three components: a household survey conducted in all 28 communities, qualitative data collected from CBO staff and key informants (KIs), and a funding allocation study (qualitative interviews and the funding allocation study were conducted in a subset of 14 communities). This article focuses on the association between CBO engagement and reported availability and utilization of HIV/AIDS-related services. It shows that CBO engagement has a potential to add value to the national response to HIV/AIDS by increasing the awareness, availability, and utilization of HIV/AIDS-related services, especially in the area of prevention, care and support. The CBOs in the evaluation communities focused on prevention activities as well as on providing support for people living with HIV/AIDS (PLWHA) and prevention and care and support were the highest expenditure categories reported by CBOs. Respondents in communities with a stronger CBO engagement were more likely to: (1) be aware of any HIV/AIDs-related services, (2) report that prevention and care services were available in their communities, and (3) have used any HIV/AIDS related services, prevention-related and care-related services than respondents in communities where CBO engagement was weaker. The association between service awareness and service use and CBO engagement was stronger in rural than in urban areas.

Estimation of radiological impact of the activities of Olusosun Dump Site on workers and dwellers of Olusosun, in Lagos Southwest Nigeria.

This study assessed the potential radiological risks associated with the activities on Olusosun dump site on workers and dwellers of Olusosun community. The activity concentrations of 238U, 232Th and 40K from of soil and water samples were determined using High-Purity Germanium (HPGe) detector. The background radiation level of Olusosun dump site was measured using a portable Geiger-Müller counter-Radeye B20 survey meter. The mean value of background radiation was 1.46 mSv/yr. This value is about 46% higher than the recommended reference level of 1.0 mSv/yr for the public. The mean activity concentrations of 238U, 232Th and 40K in the soil samples were 19.1 ± 3.2, 29.1 ± 4.4 and 171.5 ± 6.1 Bq/kg respectively which are about 45.4%, 35.3% and 59.2% lower than the world's average levels. For the water samples, the mean activity concentrations obtained for 238U, 232Th and 40K are 0.4 ± 0.4, 0.8 ± 0.2 and 0.8 ± 0.3 Bq/l respectively. These are about 99.9% and 20% lower than WHO reference levels for 238U and 232Th. The mean absorbed dose rate in air (D), Annual effective dose (AED) outdoor, Radium Equivalent (Req), External hazard index (Hex) internal hazard index (Hin) and Excess lifetime cancer risk (ELCR) from soil samples were 33.6 nGy/h, 41.0 µSv/yr, 73.1 Bq/kg and 0.2, 0.3 and $1.4\times{10}^{-4}$, respectively. Absorbed dose in air D, AED outdoor, Req, Hex, Hin and ELCR are 41.1%, 41.4%, 80.3%, 80%, 75% and 50% lower than their corresponding world's average and references. The estimated AEDw from ingestion of water is 148.9 ± 50.4 µSv/yr, this is about 49% higher than the WHO reference level of 100.0 µSv/y from ingestion of water. The radiological hazard indices estimated from soil samples do not indicate any potential risks to the users. The elevated background radiation level of the dump site, and AEDw from ingestion of water, however, suggest that the activities on Olusosun dump site pose potential radiological risks on workers on the site and the public from consumption of water from Olusosun community.

Costs of HIV prevention services provided by community-based organizations to female sex workers in Nigeria.

BACKGROUND: Nigeria has been consistently targeted in sub-Saharan Africa as an HIV-priority country. Its main mode of transmission is heterosexual, and consequently, a key population of interest is female sex workers (FSWs). While HIV prevention services are increasingly implemented by community-based organizations (CBOs) in Nigeria, there is a paucity of evidence on the implementation costs of these organizations. This study seeks to fill this gap by providing new evidence about service delivery unit cost for HIV education (HIVE), HIV counseling and testing (HCT), and sexually transmitted infection (STI) referral services. METHODS: In a sample of 31 CBOs across Nigeria, we calculated the costs of HIV prevention services for FSWs taking a provider-based perspective. We collected 2016 fiscal year data on tablet computers during a central data training in Abuja, Nigeria, in August 2017. Data collection was part of a cluster-randomized trial examining the effects of management practices in CBOs on HIV prevention service delivery. Staff costs, recurrent inputs, utilities, and training costs were aggregated and allocated to each intervention to produce total cost calculations, and then divided by the number of FSWs served to produce unit costs. Where costs were shared across interventions, a weight proportional to intervention outputs was applied. All cost data were converted to US dollars using the mid-year 2016 exchange rate. We also explored the cost variation across the CBOs, particularly the roles of service scale, geographic location, and time. RESULTS: The average annual number of services provided per CBO was 11,294 for HIVE, 3,326 for HCT, and 473 for STI referrals. The unit cost per FSW tested for HIV was 22 USD, the unit cost per FSW reached with HIV education services was 19 USD, and the unit cost per FSW reached by STI referrals was 3 USD. We found heterogeneity in total and unit costs across CBOs and geographic location. Results from the regression models show that total cost and service scale were positively correlated, while unit costs and scale were consistently negatively correlated; this indicates the presence of economies of scale. By increasing the annual number of services by 100 percent, the unit cost decreases by 50 percent for HIVE, 40 percent for HCT, and 10 percent for STI. There was also evidence that indicates that the level of service provision was not constant over time across the fiscal year. We also found unit costs and management to be negatively correlated, though results were not statistically significant. CONCLUSIONS: Estimates for HCT services are relatively similar to previous studies. There is substantial variation in unit costs across facilities, and evidence of a negative relationship between unit costs and scale for all services. This is one of the few studies to measure HIV prevention service delivery costs to female sex workers through CBOs. Furthermore, this study also looked at the relationship between costs and management practices-the first of its kind to do so in Nigeria. Results can be leveraged to strategically plan for future service delivery across similar settings.

HIV prevalence and risk behaviours among men having sex with men in Nigeria.

OBJECTIVE: To evaluate HIV and syphilis prevalence among men who have sex with men (MSM) in Nigeria, and assess their HIV-related risk behaviours and exposure to HIV prevention interventions. METHODS: Cross-sectional study using respondent-driven sampling conducted in Lagos, Kano and Cross River states, Nigeria, between July and September 2007. RESULTS: A total of 879 MSM participated, 293 from each state. Eight participants (1.1%, CI 0.1% to 2.2%) in Cross River, 27 (9.3%, CI 5.7% to 15.4%) in Kano and 74 (17.4%, CI 12.3% to 23.2%) in Lagos tested positive for HIV. No syphilis was detected. The median age was 22 years. MSM reported an average of 4.2 male anal sex partners in the past 6 months. Between 24.4% (Lagos) and 36.0% (Kano) of MSM reported selling sex to other men. Up to 49.7% of MSM reported sex with a girlfriend and ≤ 6.5% purchased sex from female sex workers. Consistent condom use in commercial sex with other men over the past 6 months ranged from 28.0% (Cross River) to 34.3% (Kano), in contrast to between 23.9% (Kano) and 45.8% (Lagos) for non-commercial sex. Associations with HIV positivity included age in the three states, having been the receptive partner in anal sex in the past 6 months in Lagos and in Lagos and Kano feeling at risk of HIV. CONCLUSION: Large differentials in HIV prevalence between states together with high mobility, inconsistent condom use and behavioural links with female sex partners, have the potential for further HIV transmission within MSM networks, and between MSM and the general population.

Patterns of condom acquisition and its association with consistent use among young men in Nigeria.

There is limited information about the influence of condom acquisition patterns on consistent condom use. Research is required to identify the relative extent of consistent condom use among individuals who always obtain condoms free, or who always have mixed procurement of free and purchased condoms or who always purchase condoms. The study analysed condom acquisition and sexual behaviour practices of 372 young men and logistic regression was analysed to determine whether condom acquisition practice was a predictor of consistent condom use. Results showed that most participants (41%) had mixed procurement of free and purchased condoms, 31% always bought condoms while 28% always purchased condoms. Majority of individuals (71%) who always purchased condoms, 23% who had mixed procurement, and 12% who had free condoms consistently used condoms. The results also showed that having 2 or more partners and always purchasing condoms increased the likelihood of consistent condom use. It is recommended that programmes of free condom supply should also incorporate in it education that emphasizes consistent condom use with a partner whose HIV sero status is not known.

Explaining the heterogeneity in average costs per HIV/AIDS patient in Nigeria: The role of supply-side and service delivery characteristics.

OBJECTIVE: We estimated the average annual cost per patient of ART per facility (unit cost) in Nigeria, described the variation in costs across facilities, and identified factors associated with this variation. METHODS: We used facility-level data of 80 facilities in Nigeria, collected between December 2014 and May 2015. We estimated unit costs at each facility as the ratio of total costs (the sum of costs of staff, recurrent inputs and services, capital, training, laboratory tests, and antiretroviral and TB treatment drugs) divided by the annual number of patients. We applied linear regressions to estimate factors associated with ART cost per patient. RESULTS: The unit ART cost in Nigeria was $157 USD nationally and the facility-level mean was $231 USD. The study found a wide variability in unit costs across facilities. Variations in costs were explained by number of patients, level of care, task shifting (shifting tasks from doctors to less specialized staff, mainly nurses, to provide ART) and provider´s competence. The study illuminated the potentially important role that management practices can play in improving the efficiency of ART services. CONCLUSIONS: Our study identifies characteristics of services associated with the most efficient implementation of ART services in Nigeria. These results will help design efficient program scale-up to deliver comprehensive HIV services in Nigeria by distinguishing features linked to lower unit costs.

Efficiency of HIV services in Nigeria: Determinants of unit cost variation of HIV counseling and testing and prevention of mother-to-child transmission interventions.

BACKGROUND: Like most countries with a substantial HIV burden, Nigeria continues to face challenges in reaching coverage targets of HIV services. A fundamental problem is stagnated funding in recent years. Improving efficiency is therefore paramount to effectively scale-up HIV services. In this study, we estimated the facility-level average costs (or unit costs) of HIV Counseling and Testing (HCT) and Prevention of Mother-to-Child Transmission (PMTCT) services and characterized determinants of unit cost variation. We investigated the role of service delivery modalities and the link between facility-level management practices and unit cost variability along both services' cascades. METHODS: We conducted a cross-sectional, observational, micro-costing study in Nigeria between December 2014 and May 2015 in 141 HCT, and 137 PMTCT facilities, respectively. We retrospectively collected relevant input quantities (personnel, supplies, utilities, capital, and training), input prices, and output data for the year 2013. Staff costs were adjusted using time-motion methods. We estimated the facility-level average cost per service along the HCT and PMTCT service cascades and analyzed their composition and variability. Through linear regressions analysis, we identified aspects of service delivery and management practices associated with unit costs variations. RESULTS: The weighted average cost per HIV-positive client diagnosed through HCT services was US$130. The weighted average cost per HIV-positive woman on prophylaxis in PMTCT services was US$858. These weighted values are estimates of nationally representative unit costs in Nigeria. For HCT, the facility-level unit costs per client tested and per HIV-positive client diagnosed were US$30 and US$1,364, respectively; and the median unit costs were US$17 and US$245 respectively. For PMTCT, the facility-level unit costs per woman tested, per HIV-positive woman diagnosed, and per HIV-positive woman on prophylaxis were US$46, US$2,932, and US$3,647, respectively, and the median unit costs were US$24, US$1,013 and US$1,448, respectively. Variability in costs across facilities was principally explained by the number of patients, integration of HIV services, task shifting, and the level of care. DISCUSSION: Our findings demonstrate variability in unit costs across facilities. We found evidence consistent with economies of scale and scope, and efficiency gains in facilities implementing task-shifting. Our results could inform program design by suggesting ways to improve resource allocation and efficiently scale-up the HIV response in Nigeria. Some of our findings might also be relevant for other settings.

Differences in Sexual Practices, Sexual Behavior and HIV Risk Profile between Adolescents and Young Persons in Rural and Urban Nigeria.

INTRODUCTION: We aimed to determine differences in sexual practices, HIV sexual risk behaviors, and HIV risk profile of adolescents and young persons' in rural and urban Nigeria. METHODOLOGY: We recruited 772 participants 15 to 24 years old from urban and rural townships in Nigeria through a household survey. Information on participants' socio-demographic profile (age sex, residential area, number of meals taken per day), sexual practices (vagina, oral and anal sex; heterosexual and homosexual sex; sex with spouse, casual acquaintances, boy/girlfriend and commercial sex workers), sexual behavior (age of sexual debut, use of condom, multiple sex partners, transactional sex and age of sexual partner), and other HIV risk factors (use of alcohol and psychoactive substances, reason for sexual debut, knowledge of HIV prevention and HIV transmission, report of STI symptoms) were collected through an interviewer administered questionnaire. Differences in sexual behavior and sexual practices of adolescents and HIV risk profile of adolescents and young persons resident in urban and rural areas were determined. RESULTS: More than half (53.5%) of the respondents were sexually active, with more residing in the rural than urban areas (64.9% vs 44.1%; p<0.001) and more resident in the rural area reporting having more than one sexual partner (29.5% vs 20.4%; p = 0.04). Also, 97.3% of sexually active respondents reported having vaginal sex, 8.7% reported oral sex and 1.9% reported anal sex. More male than female respondents in the urban area used condoms during the last vaginal sexual intercourse (69.1% vs 51.9%; p = 0.02), and reported sex with casual partners (7.0% vs 15.3%; p = 0.007). More female than male respondents residing in the rural area engaged in transactional sex (1.0% vs 6.7%; p = 0.005). More females than males in both rural (3.6% vs 10.2%; p = 0.04) and urban (4.7% vs 26.6%; p<0.001) areas self-reported a history of discharge. More females than males in both rural (1.4% vs 17.0%; p = 0.04) and urban (15.0% vs 29.1%; p<0.001) areas self-reported a history of itching. CONCLUSION: There are differences in the sexual behavior and practices of adolescents and young persons' residing in the urban and rural area with implication for HIV prevention programming.

An appraisal of female sex work in Nigeria--implications for designing and scaling up HIV prevention programmes.

BACKGROUND: The HIV epidemic in Nigeria is complex with diverse factors driving the epidemic. Accordingly, Nigeria's National Agency for the Control of AIDS is coordinating a large-scale initiative to conduct HIV epidemic appraisals across all states. These appraisals will help to better characterize the drivers of the epidemic and ensure that the HIV prevention programmes match the local epidemic context, with resources allocated to interventions that have the greatest impact locally. Currently, the mapping and size estimation of Female Sex Workers (FSWs)--a major component of the appraisal has been completed in seven states. These states are using the data generated to plan, prioritize and scale-up sub-national HIV prevention programmes. METHODOLOGY: It involved a two-level process of identifying and validating locations where FSWs solicit and/or meet clients ("hotspots"). In the first level, secondary key informants were interviewed to collect information about the geographic location and description of the hotspots. For the second level, FSWs were interviewed at each hotspot and information on population size estimates, typologies and operational dynamics of the FSWs were collected. RESULTS: Across the seven states, a total of 17,266 secondary key informants and 5,732 FSWs were interviewed. 10,233 hotspots were identified with an estimated 126,489 FSWs ranging from 5,920 in Anambra to 46,691 in Lagos. The most common hotspots were bars/nightclubs (30%), hotels/lodges (29.6%), streets (16.6%), and brothels (14.6%). Furthermore, the population density of FSWs (per thousand adult men) across the states ranged from 2 in Anambra to 17 in the Federal Capital Territory. CONCLUSION: FSW populations in Nigeria are large and diverse, with substantial differences between and within states. Improved understanding of the location, population size, density, organizational typologies and clients of sex work has informed and is central to Nigeria's planning process for scaling up focused HIV prevention programmes.