Naomi: a new modelling tool for estimating HIV epidemic indicators at the district level in sub-Saharan Africa.

INTRODUCTION: HIV planning requires granular estimates for the number of people living with HIV (PLHIV), antiretroviral treatment (ART) coverage and unmet need, and new HIV infections by district, or equivalent subnational administrative level. We developed a Bayesian small-area estimation model, called Naomi, to estimate these quantities stratified by subnational administrative units, sex, and five-year age groups. METHODS: Small-area regressions for HIV prevalence, ART coverage and HIV incidence were jointly calibrated using subnational household survey data on all three indicators, routine antenatal service delivery data on HIV prevalence and ART coverage among pregnant women, and service delivery data on the number of PLHIV receiving ART. Incidence was modelled by district-level HIV prevalence and ART coverage. Model outputs of counts and rates for each indicator were aggregated to multiple geographic and demographic stratifications of interest. The model was estimated in an empirical Bayes framework, furnishing probabilistic uncertainty ranges for all output indicators. Example results were presented using data from Malawi during 2016-2018. RESULTS: Adult HIV prevalence in September 2018 ranged from 3.2% to 17.1% across Malawi's districts and was higher in southern districts and in metropolitan areas. ART coverage was more homogenous, ranging from 75% to 82%. The largest number of PLHIV was among ages 35 to 39 for both women and men, while the most untreated PLHIV were among ages 25 to 29 for women and 30 to 34 for men. Relative uncertainty was larger for the untreated PLHIV than the number on ART or total PLHIV. Among clients receiving ART at facilities in Lilongwe city, an estimated 71% (95% CI, 61% to 79%) resided in Lilongwe city, 20% (14% to 27%) in Lilongwe district outside the metropolis, and 9% (6% to 12%) in neighbouring Dowa district. Thirty-eight percent (26% to 50%) of Lilongwe rural residents and 39% (27% to 50%) of Dowa residents received treatment at facilities in Lilongwe city. CONCLUSIONS: The Naomi model synthesizes multiple subnational data sources to furnish estimates of key indicators for HIV programme planning, resource allocation, and target setting. Further model development to meet evolving HIV policy priorities and programme need should be accompanied by continued strengthening and understanding of routine health system data.

Development and use of a master health facility list: Haiti's experience during the 2010 earthquake response.

Master health facility lists (MHFLs) are gaining attention as a standards-based means to uniquely identify health facilities and to link facility-level data. The ability to reliably communicate information about specific health facilities can support an array of health system functions, such as routine reporting and emergency response operations. MHFLs support the alignment of donor-supported health information systems with county-owned systems. Recent World Health Organization draft guidance promotes the utility of MHFLs and outlines a process for list development and governance. Although the potential benefits of MHFLs are numerous and may seem obvious, there are few documented cases of MHFL construction and use. The international response to the 2010 Haiti earthquake provides an example of how governments, nongovernmental organizations, and others can collaborate within a framework of standards to build a more complete and accurate list of health facilities. Prior to the earthquake, the Haitian Ministry of Health (Ministère de la Santé Publique et de la Population [MSPP]) maintained a list of public-sector health facilities but lacked information on privately managed facilities. Following the earthquake, the MSPP worked with a multinational group to expand the completeness and accuracy of the list of health facilities, including information on post-quake operational status. This list later proved useful in the response to the cholera epidemic and is now incorporated into the MSPP's routine health information system. Haiti's experience demonstrates the utility of MHFL formation and use in crisis as well as in the routine function of the health information system.

Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa.

BACKGROUND: There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data. METHODS AND FINDINGS: We use the Decision Makers' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization's considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion. CONCLUSIONS: This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs.

Social factors, social support and condom use behavior among young urban slum inhabitants in southwest Nigeria.

OBJECTIVES: Despite widespread knowledge that condoms offer protection against STIs/HIV when used correctly and consistently, many young people do not regularly use condoms, thus leading to new sexually transmitted infections, including HIV and AIDS. This study explored condom use behaviour, specifically the extent to which beliefs, self efficacy, risk perception and perceived social support act as predictors of use or non-use of condoms among sexually active young people aged 15-24 years. METHODS: Data was obtained from sexually active 448 boys and 338 girls, who were selected through multistage sampling techniques. Analysis of data, which was done with EPI Info and SPSS version 12, focused on predictors of condom use or non-use. RESULT: Generally, there is widespread knowledge and low levels of condoms use, despite high levels of risky sexual behaviour. Although, half of boys and one third of girls report ever using condoms, a considerably lower proportion of male and female adolescents regularly use condoms. Logistic regression models show that among girls, those who perceived social support from peers and non-parental figures were more likely to use condoms while among boys, earning an income, high risk perception and self efficacy were associated with higher odds of condom use. CONCLUSIONS: Programs aiming to increase condom use among young people need to address these factors through community-based strategies.

Extramarital sex among Nigerian men: polygyny and other risk factors.

The AIDS epidemic in Nigeria is generalized, with infection primarily occurring through heterosexual transmission. It is important to understand patterns of sexual behavior to assess their impact on the epidemic and to design appropriate intervention strategies. This study examined risk factors for extramarital sex among Nigerian men, with a particular focus on polygyny and peri- and postpartum abstinence. Data from the 2003 Nigeria Demographic and Health Survey were analyzed for 1153 men and their wives. Eleven percent of men reported extramarital sex in the previous year. Logistic regression models showed that men with 3 or more wives were at the greatest risk for extramarital sex, followed by monogamous men, when compared with men with 2 wives. Other significant predictors included region, religion, wealth, age at sexual debut, and self-perceived risk of HIV infection. Peri- and postpartum abstinence was not significant. Based on these findings, HIV prevention programs should include men with 3 or more wives and those living in the southwest region, in addition to activities targeting men of all ages. Given the heterogeneity within Nigeria, further in-depth studies should be undertaken to explore the relation between number of wives, peri- and postpartum abstinence, and extramarital sex within specific communities.

Investigating access to reproductive health services using GIS: proximity to services and the use of modern contraceptives in Malawi.

This paper attempted to identify whether access to reproductive health services partly explains use of modern contraception in Malawi. Recent changes in Malawi's population policy have brought the state's population ambitions into alignment with the consensus reached at the International Conference on Population and Development held in Cairo in 1994. Concurrently, Malawi witnessed a large increase in the use of modern contraceptives from 7% in 1992 to 26% in 2000. A geographic information system (GIS) was employed to integrate health facility data from the Malawi health facilities inventory and global positioning data from the 2000 Malawi demographic and health survey. An effort to detect a plausible causal pathway was made by using distance to health services as a proxy variable for access to services. In a multivariate logistic regression analysis, after controlling for background variables traditionally associated with use of modern contraception, access could not be shown to explain use of modern contraception in Malawi.