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Ogbuabor D, Olwande C, Semini I, Onwujekwe O, Olaifa Y, Ukanwa C. Stakeholders’ Perspectives on the Financial Sustainability of the HIV Response in Nigeria: A Qualitative Study. Glob Health Sci Pract 2023; 11:GHSP-D-22-00430. [PMID: 37116920 PMCID: PMC10141423 DOI: 10.9745/ghsp-d-22-00430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/01/2023] [Indexed: 03/31/2023]
Abstract
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.
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Affiliation(s)
- Daniel Ogbuabor
- Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | | | - Iris Semini
- Equitable Financing Practice, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Obinna Onwujekwe
- Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | | | - Chioma Ukanwa
- National AIDS, Sexually Transmitted Infections, and Hepatitis Control Programme, Federal Ministry of Health, Abuja, Nigeria
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Ruffner M, Morrison L, Hijazi M, Semini I, McBain RK. A new initiative to track HIV resource allocation. Lancet HIV 2022; 9:e458-e459. [PMID: 35777406 DOI: 10.1016/s2352-3018(22)00159-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/18/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Michael Ruffner
- Office of the US Global AIDS Coordinator, Washington, DC, USA
| | | | | | | | - Ryan K McBain
- Partners In Health, Boston, MA, USA; RAND, Boston 02116, MA, USA.
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McBain R, Nandakumar AK, Ruffner M, Mann C, Hijazi M, Baker S, Morrison L, Chalkidou K, Zhang S, Semini I, Terris-Prestholt F, Forsythe S, Byakika S, Musinguzi J, Kaplan RS. A new initiative to track HIV resource allocation and costs. Bull World Health Organ 2022; 100:358-358A. [PMID: 35694617 PMCID: PMC9178425 DOI: 10.2471/blt.22.287818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ryan McBain
- Partners in Health, 800 Boylston Street, Boston, Massachusetts 02199, United States of America (USA)
| | - A K Nandakumar
- Office of the Global AIDS Coordinator at the United States Department of State, Washington, DC, USA
| | - Michael Ruffner
- Office of the Global AIDS Coordinator at the United States Department of State, Washington, DC, USA
| | - Carlyn Mann
- United States Agency for International Development, Washington, DC, USA
| | - Mai Hijazi
- United States Agency for International Development, Washington, DC, USA
| | - Susanna Baker
- United States Agency for International Development, Washington, DC, USA
| | - Linden Morrison
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Kalipso Chalkidou
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Shufang Zhang
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Iris Semini
- Fast Track Implementation Department, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Fern Terris-Prestholt
- Fast Track Implementation Department, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
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Hiebert L, Resch S, Schutte C, Turay M, Zekeng L, Matiku S, Semini I, Stover J, Forsythe S, Hecht R. Tanzania HIV Investment Case (IC) 2.0: Using modeling to explore optimization under severe resource constraints. Journal of Global Health Reports 2022. [DOI: 10.29392/001c.30063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Iris Semini
- Joint United Nations Program on HIV/AIDS (UNAIDS)
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Mc Lean R, Forsythe S, Semini I, Whiteside A. The next and last pandemics - The consequences of COVID-19 and its impact on the HIV/AIDS response. Afr J AIDS Res 2021; 20:255-258. [PMID: 34905455 DOI: 10.2989/16085906.2021.2015667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Roger Mc Lean
- The Health Economics Unit, Centre for Health Economics, The University of the West Indies, St. Augustine Campus, Trinidad and Tobago
| | | | - Iris Semini
- UNAIDS, Investment and Sustainability Team, Geneva, Switzerland
| | - Alan Whiteside
- Global Health Policy, School of International Policy and Governance, Wilfrid Laurier University and Balsillie School of International Affairs, Waterloo, Canada
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Stover J, Glaubius R, Teng Y, Kelly S, Brown T, Hallett TB, Revill P, Bärnighausen T, Phillips AN, Fontaine C, Frescura L, Izazola-Licea JA, Semini I, Godfrey-Faussett P, De Lay PR, Benzaken AS, Ghys PD. Modeling the epidemiological impact of the UNAIDS 2025 targets to end AIDS as a public health threat by 2030. PLoS Med 2021; 18:e1003831. [PMID: 34662333 PMCID: PMC8559943 DOI: 10.1371/journal.pmed.1003831] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 11/01/2021] [Accepted: 10/01/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND UNAIDS has established new program targets for 2025 to achieve the goal of eliminating AIDS as a public health threat by 2030. This study reports on efforts to use mathematical models to estimate the impact of achieving those targets. METHODS AND FINDINGS We simulated the impact of achieving the targets at country level using the Goals model, a mathematical simulation model of HIV epidemic dynamics that includes the impact of prevention and treatment interventions. For 77 high-burden countries, we fit the model to surveillance and survey data for 1970 to 2020 and then projected the impact of achieving the targets for the period 2019 to 2030. Results from these 77 countries were extrapolated to produce estimates for 96 others. Goals model results were checked by comparing against projections done with the Optima HIV model and the AIDS Epidemic Model (AEM) for selected countries. We included estimates of the impact of societal enablers (access to justice and law reform, stigma and discrimination elimination, and gender equality) and the impact of Coronavirus Disease 2019 (COVID-19). Results show that achieving the 2025 targets would reduce new annual infections by 83% (71% to 86% across regions) and AIDS-related deaths by 78% (67% to 81% across regions) by 2025 compared to 2010. Lack of progress on societal enablers could endanger these achievements and result in as many as 2.6 million (44%) cumulative additional new HIV infections and 440,000 (54%) more AIDS-related deaths between 2020 and 2030 compared to full achievement of all targets. COVID-19-related disruptions could increase new HIV infections and AIDS-related deaths by 10% in the next 2 years, but targets could still be achieved by 2025. Study limitations include the reliance on self-reports for most data on behaviors, the use of intervention effect sizes from published studies that may overstate intervention impacts outside of controlled study settings, and the use of proxy countries to estimate the impact in countries with fewer than 4,000 annual HIV infections. CONCLUSIONS The new targets for 2025 build on the progress made since 2010 and represent ambitious short-term goals. Achieving these targets would bring us close to the goals of reducing new HIV infections and AIDS-related deaths by 90% between 2010 and 2030. By 2025, global new infections and AIDS deaths would drop to 4.4 and 3.9 per 100,000 population, and the number of people living with HIV (PLHIV) would be declining. There would be 32 million people on treatment, and they would need continuing support for their lifetime. Incidence for the total global population would be below 0.15% everywhere. The number of PLHIV would start declining by 2023.
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Affiliation(s)
- John Stover
- Avenir Health, Glastonbury, Connecticut, United States of America
- * E-mail:
| | - Robert Glaubius
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - Yu Teng
- Avenir Health, Glastonbury, Connecticut, United States of America
| | | | - Tim Brown
- East-West Center, Honolulu, Hawaii, United States of America
| | - Timothy B. Hallett
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, United Kingdom
| | - Paul Revill
- Centre for Health Economics, University of York, York, United Kingdom
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Andrew N. Phillips
- Institute for Global Health, University College London, London, United Kingdom
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Abstract
This paper focusses on high-HIV middle-income countries termed the "risky middle", i.e. characterised by a typology based on HIV burden and gross national income (GNI), according to which seven countries - Lesotho, Eswatini, Kenya, Zimbabwe, Tanzania, Namibia and Zambia - are identified. There is particular concern for "people left behind", the factors determining a country's ability to mobilise resources in the context of multiple development needs - including economic disparities; the political economy of fiscal decision-making; levels of health investment; health and community systems; political will; and currency fluctuations. While donors will support lower-income countries and higher-income countries can compensate from domestic resources, there is a risk that some high-burden, lower middle-income countries will be unable to sustain a response. Continued growth means that there are countries transitioning to higher World Bank income classification - an important criterion for allocating development assistance for health. Our concern is that countries may face external funding reduction once their income category improves, and those in the risky middle will be unable to compensate from domestic resources. We conclude, with guidance from UNAIDS, the international community should step up support for "risky middle" countries. In addition these countries need to recognise the threat and develop measures to counter it, including improved accountability. Funding declines should be reversed through funding benchmarks that relate to both GDP and HIV prevalence. Finally, risky middle countries could constitute themselves as a special interest group, to protect their HIV funding and AIDS response.
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Affiliation(s)
- Alan Whiteside
- Global Health Policy, School of International Policy and Governance, Wilfrid Laurier University and Balsillie School of International Affairs, Waterloo, Ontario, Canada
| | - Robert Greener
- Associate, Oxford Policy Management, Clarendon Centre, Oxford, United Kingdom
| | - Iris Semini
- Health Economics, UNAIDS, Geneva, Switzerland
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Forsythe S, Semini I. Editorial - A sustainable AIDS response: results in the era of shrinking donor funding. Afr J AIDS Res 2019; 18:iii-iv. [PMID: 31779579 DOI: 10.2989/16085906.2019.1698215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Steven Forsythe
- Avenir Health, Glastonbury CT, USA and The International AIDS Economics Network
| | - Iris Semini
- Joint United Nations Programme on HIV/AIDS (UNAIDS)
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Kripke K, Perales N, Lija J, Fimbo B, Mlanga E, Mahler H, Juma JM, Baingana E, Plotkin M, Kakiziba D, Semini I, Castor D, Njeuhmeli E. The Economic and Epidemiological Impact of Focusing Voluntary Medical Male Circumcision for HIV Prevention on Specific Age Groups and Regions in Tanzania. PLoS One 2016; 11:e0153363. [PMID: 27410384 PMCID: PMC4943708 DOI: 10.1371/journal.pone.0153363] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/29/2016] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Katharine Kripke
- Health Policy Project, Avenir Health, Glastonbury, Connecticut, United States of America
- * E-mail:
| | - Nicole Perales
- Health Policy Project, Futures Group, Washington, District of Columbia, United States of America
| | - Jackson Lija
- Tanzania National AIDS Control Program, Dar es Salaam, Tanzania
| | | | - Eric Mlanga
- U. S. Agency for International Development, Dar es Salaam, Tanzania
| | | | | | | | - Marya Plotkin
- U. S. Agency for International Development, Dar es Salaam, Tanzania
| | | | - Iris Semini
- Joint United Nations Programme on HIV/AIDS, Dar es Salaam, Tanzania
| | - Delivette Castor
- Office of the U.S. Global AIDS Coordinator, Washington, District of Columbia, United States of America
| | - Emmanuel Njeuhmeli
- U. S. Agency for International Development, Washington, District of Columbia, United States of America
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Mumtaz GR, Weiss HA, Thomas SL, Riome S, Setayesh H, Riedner G, Semini I, Tawil O, Akala FA, Wilson D, Abu-Raddad LJ. HIV among people who inject drugs in the Middle East and North Africa: systematic review and data synthesis. PLoS Med 2014; 11:e1001663. [PMID: 24937136 PMCID: PMC4061009 DOI: 10.1371/journal.pmed.1001663] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 05/08/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND It is perceived that little is known about the epidemiology of HIV infection among people who inject drugs (PWID) in the Middle East and North Africa (MENA). The primary objective of this study was to assess the status of the HIV epidemic among PWID in MENA by describing HIV prevalence and incidence. Secondary objectives were to describe the risk behavior environment and the HIV epidemic potential among PWID, and to estimate the prevalence of injecting drug use in MENA. METHODS AND FINDINGS This was a systematic review following the PRISMA guidelines and covering 23 MENA countries. PubMed, Embase, regional and international databases, as well as country-level reports were searched up to December 16, 2013. Primary studies reporting (1) the prevalence/incidence of HIV, other sexually transmitted infections, or hepatitis C virus (HCV) among PWIDs; or (2) the prevalence of injecting or sexual risk behaviors, or HIV knowledge among PWID; or (3) the number/proportion of PWID in MENA countries, were eligible for inclusion. The quality, quantity, and geographic coverage of the data were assessed at country level. Risk of bias in predefined quality domains was described to assess the quality of available HIV prevalence measures. After multiple level screening, 192 eligible reports were included in the review. There were 197 HIV prevalence measures on a total of 58,241 PWID extracted from reports, and an additional 226 HIV prevalence measures extracted from the databases. We estimated that there are 626,000 PWID in MENA (range: 335,000-1,635,000, prevalence of 0.24 per 100 adults). We found evidence of HIV epidemics among PWID in at least one-third of MENA countries, most of which are emerging concentrated epidemics and with HIV prevalence overall in the range of 10%-15%. Some of the epidemics have however already reached considerable levels including some of the highest HIV prevalence among PWID globally (87.1% in Tripoli, Libya). The relatively high prevalence of sharing needles/syringes (18%-28% in the last injection), the low levels of condom use (20%-54% ever condom use), the high levels of having sex with sex workers and of men having sex with men (15%-30% and 2%-10% in the last year, respectively), and of selling sex (5%-29% in the last year), indicate a high injecting and sexual risk environment. The prevalence of HCV (31%-64%) and of sexually transmitted infections suggest high levels of risk behavior indicative of the potential for more and larger HIV epidemics. CONCLUSIONS Our study identified a large volume of HIV-related biological and behavioral data among PWID in the MENA region. The coverage and quality of the data varied between countries. There is robust evidence for HIV epidemics among PWID in multiple countries, most of which have emerged within the last decade and continue to grow. The lack of sufficient evidence in some MENA countries does not preclude the possibility of hidden epidemics among PWID in these settings. With the HIV epidemic among PWID in overall a relatively early phase, there is a window of opportunity for prevention that should not be missed through the provision of comprehensive programs, including scale-up of harm reduction services and expansion of surveillance systems.
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Affiliation(s)
- Ghina R. Mumtaz
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Helen A. Weiss
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sara L. Thomas
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Suzanne Riome
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
| | - Hamidreza Setayesh
- Joint United Nations Programme on HIV/AIDS Regional Support Team, Middle East and North Africa, Cairo, Egypt
| | - Gabriele Riedner
- Regional Office of the Eastern Mediterranean, World Health Organization, Cairo, Egypt
| | - Iris Semini
- Joint United Nations Programme on HIV/AIDS Regional Support Team, Middle East and North Africa, Cairo, Egypt
| | - Oussama Tawil
- Joint United Nations Programme on HIV/AIDS Regional Support Team, Middle East and North Africa, Cairo, Egypt
| | - Francisca Ayodeji Akala
- Human Development Sector, Middle East and North Africa Region, World Bank, Washington (D.C.), United States of America
| | - David Wilson
- Global HIV/AIDS Program, World Bank, Washington (D.C.), United States of America
| | - Laith J. Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
- Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
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Wirtz AL, Pretorius C, Beyrer C, Baral S, Decker MR, Sherman SG, Sweat M, Poteat T, Butler J, Oelrichs R, Semini I, Kerrigan D. Epidemic impacts of a community empowerment intervention for HIV prevention among female sex workers in generalized and concentrated epidemics. PLoS One 2014; 9:e88047. [PMID: 24516580 PMCID: PMC3916392 DOI: 10.1371/journal.pone.0088047] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 12/20/2013] [Indexed: 11/19/2022] Open
Abstract
Introduction Sex workers have endured a high burden of HIV infection in and across HIV epidemics. A comprehensive, community empowerment-based HIV prevention intervention emphasizes sex worker organization and mobilization to address HIV risk and often includes community-led peer education, condom distribution, and other activities. Meta-analysis of such interventions suggests a potential 51% reduction in inconsistent condom use. Mathematical modeling exercises provide theoretical insight into potential impacts of the intervention on HIV incidence and burden in settings where interventions have not yet been implemented. Methods We used a deterministic model, Goals, to project the impact on HIV infections when the community empowerment interventions were scaled up among female sex workers in Kenya, Thailand, Brazil, and Ukraine. Modeling scenarios included expansion of the comprehensive community empowerment-based HIV prevention intervention from baseline coverage over a 5-year period (5–65% in Kenya and Ukraine; 10–70% in Thailand and Brazil), while other interventions were held at baseline levels. A second exercise increased the intervention coverage simultaneously with equitable access to ART for sex workers. Impacts on HIV outcomes among sex workers and adults are observed from 2012–2016 and, compared to status quo when all interventions are held constant. Results Optimistic but feasible coverage (65%–70%) of the intervention demonstrated a range of impacts on HIV: 220 infections averted over 5 yrs. among sex workers in Thailand, 1,830 in Brazil, 2,220 in Ukraine, and 10,800 infections in Kenya. Impacts of the intervention for female sex workers extend to the adult population, cumulatively averting 730 infections in Thailand to 20,700 adult infections in Kenya. Impacts vary by country, influenced by HIV prevalence in risk groups, risk behaviors, intervention use, and population size. Discussion A community empowerment approach to HIV prevention and access to universal ART for female sex workers is a promising human rights-based solution to overcoming the persistent burden of HIV among female sex workers across epidemic settings.
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Affiliation(s)
- Andrea L. Wirtz
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Emergency Medicine, Johns Hopkins Medical Institute, Baltimore, Maryland, United States of America
- * E-mail:
| | - Carel Pretorius
- Futures Institute, Glastonbury, Connecticut, United States of America
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Michele R. Decker
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Population, Family, and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Susan G. Sherman
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Michael Sweat
- Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Tonia Poteat
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jennifer Butler
- HIV and Key Populations, United Nations Population Fund, New York, New York, United States of America
| | - Robert Oelrichs
- Human Development Network, The World Bank, Washington, District of Columbia, United States of America
| | - Iris Semini
- Human Development Network, The World Bank, Washington, District of Columbia, United States of America
| | - Deanna Kerrigan
- Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Health, Behavior & Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Semini I, Batona G, Lafrance C, Kessou L, Gbedji E, Anani H, Alary M. Implementing for results: program analysis of the HIV/STI interventions for sex workers in Benin. AIDS Care 2013; 25 Suppl 1:S30-9. [PMID: 23745627 PMCID: PMC4003579 DOI: 10.1080/09540121.2013.784392] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Mumtaz G, Hilmi N, Akala FA, Semini I, Riedner G, Wilson D, Abu-Raddad L. P1-S1.17 HIV-1 molecular epidemiology in the Middle East and North Africa. Br J Vener Dis 2011. [DOI: 10.1136/sextrans-2011-050108.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Mumtaz G, Hilmi N, Akala FA, Semini I, Riedner G, Wilson D, Abu-Raddad LJ. HIV-1 molecular epidemiology evidence and transmission patterns in the Middle East and North Africa. Sex Transm Infect 2010; 87:101-6. [PMID: 21036790 DOI: 10.1136/sti.2010.043711] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The distribution of HIV-1 subtypes in a population tracks the spread and evolution of the epidemic. This study is a systematic review of all available evidence on HIV-1 molecular epidemiology and subtype distribution in the Middle East and North Africa. Sources of data included Medline and various institutional documents and databases. In several countries, a diverse distribution of HIV-1 subtypes was observed principally reflecting travel-related exogenous exposures. A trend for a dominant HIV-1 subtype was observed in a few other settings and was often linked to HIV transmission within specific high-risk groups such as subtype A and CRF35_AD among injecting drug users and subtype C among commercial sex networks. Multiple exogenous introductions of HIV-1 variants seemed common to all countries, as observed from the high diversity in subtypes, or the high genetic divergence among any specific subtype even if predominant. In several countries though, epidemic-type clustering of specific subtypes suggests established or nascent HIV epidemics among classic core risk groups for HIV infection. HIV prevention efforts in MENA must be prioritized for these high-risk groups.
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Affiliation(s)
- Ghina Mumtaz
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Qatar Foundation, Education City, P.O. Box 24144, Doha, Qatar
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Abu-Raddad LJ, Schiffer JT, Ashley R, Mumtaz G, Alsallaq RA, Akala FA, Semini I, Riedner G, Wilson D. HSV-2 serology can be predictive of HIV epidemic potential and hidden sexual risk behavior in the Middle East and North Africa. Epidemics 2010; 2:173-82. [PMID: 21352788 DOI: 10.1016/j.epidem.2010.08.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Revised: 08/26/2010] [Accepted: 08/31/2010] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND HIV prevalence is low in the Middle East and North Africa (MENA) region, though the risk or potential for further spread in the future is not well understood. Behavioral surveys are limited in this region and when available have serious limitations in assessing the risk of HIV acquisition. We demonstrate the potential use of herpes simplex virus-2 (HSV-2) seroprevalence as a marker for HIV risk within MENA. METHODS We designed a mathematical model to assess whether HSV-2 prevalence can be predictive of future HIV spread. We also conducted a systematic literature review of HSV-2 seroprevalence studies within MENA. RESULTS We found that HSV-2 prevalence data are rather limited in this region. Prevalence is typically low among the general population but high in established core groups prone to sexually transmitted infections such as men who have sex with men and female sex workers. Our model predicts that if HSV-2 prevalence is low and stable, then the risk of future HIV epidemics is low. However, expanding or high HSV-2 prevalence (greater than about 20%), implies a risk for a considerable HIV epidemic. Based on available HSV-2 prevalence data, it is not likely that the general population in MENA is experiencing or will experience such a considerable HIV epidemic. Nevertheless, the risk for concentrated HIV epidemics among several high-risk core groups is present. CONCLUSIONS HSV-2 prevalence surveys provide a useful mechanism for identifying and corroborating populations at risk for HIV within MENA. HSV-2 serology offers an effective tool for probing hidden sexual risk behaviors in a region where quality behavioral data are limited.
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Affiliation(s)
- Laith J Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College-Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar.
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Mumtaz G, Hilmi N, McFarland W, Kaplan RL, Akala FA, Semini I, Riedner G, Tawil O, Wilson D, Abu-Raddad LJ. Are HIV epidemics among men who have sex with men emerging in the Middle East and North Africa?: a systematic review and data synthesis. PLoS Med 2010; 8:e1000444. [PMID: 21829329 PMCID: PMC3149074 DOI: 10.1371/journal.pmed.1000444] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 06/13/2011] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Men who have sex with men (MSM) bear a disproportionately higher burden of HIV infection than the general population. MSM in the Middle East and North Africa (MENA) are a largely hidden population because of a prevailing stigma towards this type of sexual behavior, thereby limiting the ability to assess infection transmission patterns among them. It is widely perceived that data are virtually nonexistent on MSM and HIV in this region. The objective of this review was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA. METHODS AND FINDINGS This was a systematic review of all biological, behavioral, and other related data on HIV and MSM in MENA. Sources of data included PubMed (Medline), international organizations' reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and various other institutional documents. This review showed that onsiderable data are available on MSM and HIV in MENA. While HIV prevalence continues at low levels among different MSM groups, HIV epidemics appear to be emerging in at least few countries, with a prevalence reaching up to 28% among certain MSM groups. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in several countries. The high levels of risk behavior (4-14 partners on average in the last six months among different MSM populations) and of biomarkers of risks (such as herpes simplex virus type 2 at 3%-54%), the overall low rate of consistent condom use (generally below 25%), the relative frequency of male sex work (20%-76%), and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread. CONCLUSIONS This systematic review and data synthesis indicate that HIV epidemics appear to be emerging among MSM in at least a few MENA countries and could already be in a concentrated state among several MSM groups. There is an urgent need to expand HIV surveillance and access to HIV testing, prevention, and treatment services in a rapidly narrowing window of opportunity to prevent the worst of HIV transmission among MSM in the Middle East and North Africa. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Ghina Mumtaz
- Infectious Disease Epidemiology Group, Weill Cornell Medical College-Qatar, Cornell University, Qatar Foundation-Education City, Doha, Qatar
| | - Nahla Hilmi
- Infectious Disease Epidemiology Group, Weill Cornell Medical College-Qatar, Cornell University, Qatar Foundation-Education City, Doha, Qatar
- Human Development Sector, Middle East and North Africa Region, World Bank, Washington (D. C.), United States of America
| | - Willi McFarland
- HIV Research Section, San Francisco Department of Public Heath, San Francisco, California, United States of America
| | - Rachel L. Kaplan
- Department of Social Welfare, School of Public Affairs, University of California, Los Angeles (UCLA), Los Angeles, California, United States of America
| | - Francisca Ayodeji Akala
- Human Development Sector, Middle East and North Africa Region, World Bank, Washington (D. C.), United States of America
| | - Iris Semini
- Joint United Nations Programme on HIV/AIDS Regional Support Team, Middle East and North Africa, Cairo, Egypt
| | - Gabriele Riedner
- Regional Office of the Eastern Mediterranean, World Health Organization, Cairo, Egypt
| | - Oussama Tawil
- Joint United Nations Programme on HIV/AIDS Regional Support Team, Middle East and North Africa, Cairo, Egypt
| | - David Wilson
- Global HIV/AIDS Program, World Bank, Washington (D. C.), United States of America
| | - Laith J. Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College-Qatar, Cornell University, Qatar Foundation-Education City, Doha, Qatar
- Department of Public Health, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
- Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- * E-mail:
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