Global HIV/AIDS Program – Human Development Network – World Bank Technical Support to the Federal Government of Nigeria for a more Effective and Efficient HIV Prevention Response Aide-Memoire World Bank Mission February 24 – March 8 2011 Nigeria 1. This Aide-Memoire summarizes the conclusions and the understanding reached with the National Agency for the Control of AIDS (NACA) and their partners during a World Bank mission to Nigeria to commence implementation of three of the technical services that are part of a package of World Bank technical support package to improve the efficiency and effectiveness of HIV prevention in Nigeria. This package of technical support has been sub-divided into six tasks: (1) Collecting and categorizing existing HIV-related research and data in Nigeria, (2) Developing policy briefs for HIV prevention prioritisation, (3) Developing a Strategy, Study Designs and Cost Estimates for Most-At-Risk-Population Surveillance, (4) Modeling impact of HIV interventions and cost effectiveness, (5) Impact evaluation framework and implementation of an HIV prevention program science approach in some States, and (6) Impact evaluation of the community response to HIV and AIDS. 2. The mission took place from February 24th to March 8th 2011 and focused on Tasks 2, 4 and 5. The purpose of the mission was to: (a) initiate the process of developing HIV prevention policy briefs for every State in Nigeria (starting with high priority States, and States that have completed their Epidemiology Response Policy Synthesis (ERPS) studies); (b) investigate existing implementation support for HIV prevention and understand how the World Bank could be useful; (c) initiate the process of determining priorities in HIV prevention impact evaluation and designing appropriate HIV prevention impact evaluation strategies to evaluate the impact of prevention programmes; (d) investigate options for and agree on a final set of modelling questions relating to modeling the impact of HIV prevention interventions on the potential impact and cost effectiveness thereof. 3. The mission team members were: Marelize Gorgens (Senior M&E Specialist at the World Bank’s Global HIV/AIDS Program and Mission Team Leader), James Blanchard (World Bank Consultant focusing on concentrated epidemics, prevention policy brief development and implementation support), Wim Delva (World Bank consultant focusing on epidemiological and impact modelling) and Amaka Momah (World Bank research assistant). The mission team was also remotely supported by Dr Norman Hearst (World Bank consultant focusing on prevention policy brief development). The mission was supported and worked closely with the World Bank Nigeria Task Team (Francisca Ayodeji Akala, Task Team Leader; Michael O’Dwyer, Lead HIV/AIDS Specialist; Ugonne Eze, Team Assistant) that is supporting the implementation of the second HIV/AIDS Program Development Project (HPDP2) which recently became effective. 4. The mission team met with Professor John Idoko, Director General of the Nigeria National Agency for the Control of AIDS (NACA), Dr. Kayode Ogungbemi, Director of Strategic Knowledge Management (NACA) and members of the Research and M&E Units, Dr. Jennifer Ayanti, Director of Technical Services, SFH, Dr Omokhudu, Program Director ENR, Dr Kwame Ampomah UNAIDS Country Director, Lungi Okoko and Dr Kalada Green of USAID, Dr Wapada Balami, Director General of Nigerian AIDS and STI control program (NASCP). A field visit was undertaken to Benue State to initiate discussions on implementation support and impact evaluation. A full listing of the people met is in Annex 1 and the mission agenda is attached as Annex 2. Annex 3 contains a detailed agenda of the detailed scoping of Task 4 (modeling), which formed a basis for the modeling discussion during the mission can be found in Annex 4 and Annex 5 provides a detailed field report of the Benue State visit. 5. Financial support for executing the mission tasks was provided by the Global HIV/AIDS Program, the World Bank Nigeria Country Office, and DFID. It in envisaged that, since HPDP 2 has now become effective, it will also support future implementation of the remainder of the scope of work contained in the technical support tasks. 6. The mission teams wish to express their appreciation to the Federal Government of Nigeria for the strong leadership, commitment and partnership provided by NACA, and the strong partnership with DFID in supporting the Federal Government of Nigeria with their HIV response. In the following paragraphs, the mission findings, implementation arrangements, time frames and responsibilities agreed with NACA and partners, relating to the mission objectives and technical support Tasks, are summarized. MISSION FINDINGS Task 1: Development of an inventory of HIV research in Nigeria 7. The World Bank updated the inventory since the previous version was provided to NACA July 2010. Additional articles have been added, and State-level summaries of data have been prepared for 13 high prevalence States. These summaries (a) contain all quantitative data in the inventory as it relates to each of the 13 States, and (b) will eventually be completed for all 36 States. It was agreed that the World Bank would complete all State-level summaries by 31 March 2011. 8. The World Bank handed over the inventory to the NACA Team, with a DVD containing all the articles that have been found in it. It was agreed that NACA would add this inventory to the HIV new knowledge, resource and information centre that NACA is creating. Task 2: Prevention Policy Briefs 9. The mission discussed the notion of improving the extent to which HIV evidence and science are used to improve implementation planning, coordination, implementation, implementation monitoring, results impact evaluations and measuring of HIV prevention results (i.e. an “HIV program science� approach to HIV response management). All parties agreed that this concept of HIV program science was essential in being successful with HIV prevention – a priority for the Government of Nigeria – response management in Nigeria. The World Bank team recommended to the Government that for such an approach to be successful and NACA to take the lead in it, it will be necessary for the Programs Coordination, Partnerships Coordination and Strategic Knowledge Management departments of NACA to work closely together in a symbiotic manner. 10. With support from the World Bank and the DFID-financed Enhancing the National Response (ENR) Program, NACA organized a workshop on Efficient and Effective HIV Prevention in Nigeria with relevant stakeholders to discuss the HIV prevention policy briefs and initiate their development. Representatives from 6 States (SACAs and SASCPs) that completed their ERPSs (HIV Epidemic, policy and Response Syntheses: Benue, Nasarawa, Ondo, Lagos, Akwa bom, and Cross River), ENR, the US Government, NACA, the Ministry of Health and the World Bank attended the workshop - a detailed agenda of the workshop can be found in Annex 3. During the workshop, participants developed draft policy briefs, based on the ERPSs and MOT studies completed for these States. It was noted that despite ERPSs and MOTs, still significant work needed to refine priorities to an extent where they are useful for programming, and that the HIV prevention policy briefs were therefore an essential tool for (a) State-level planning, (b) verification of the relevance of State-level work plans (by NACA and the World Bank) before final approval thereof, and (c) advocacy with state government officials and partners to strengthen the allocation and implementation of HIV prevention programs. It was agreed that the World Bank would support the 6 States to complete their HIV prevention policy briefs through (a) email and telephone based mentoring of the nominated State-level representatives, and (b) through a follow-up mission from 28 March – 6 April 2011. It was also agreed that NACA would commission the completion of the other ERPSs (not MOT studies, as insufficient data are available for MOT modeling in the other States) by June 2011 and that the World Bank would support these States to complete their policy briefs too, once the ERPSs have been developed. 11. Once these policy briefs have been developed, The World Bank and NACA agreed that they would be used to (i) inform and validate the HIV prevention sections of States’ HIV work plans and (ii) form a basis for the development and refinement of the performance framework for HPDP2 at State and (where possible) at LGA level – by clearly defining HIV prevention interventions, target populations, and service coverage for each of these target populations – as what the States should strive to achieve in HIV prevention. Task 4: Modelling of HIV Prevention Programme Impact Findings 12. During an initial meeting with NACA and partners, previous modeling and data triangulation work was discussed as important starting points for the envisaged modeling study, including the Modes of Transmission model, the EPP/Spectrum estimates and the US Government’s DATE (Data Analysis and Triangulation to improve Evaluation) study. Further, the relevance of the modeling questions, proposed in the scoping document, was confirmed, and attention was drawn to data gaps and potential bias in available behavioural and epidemiological data. Lastly, the need to verify internal consistency of reported behaviour with observed epidemic trends was established. Based on this discussion, the following four revised modeling questions were proposed during the meeting: a) How many new infections will the planned HIV prevention responses in Nigeria avert? b) What is the expected contribution of each of the HIV prevention interventions to averting new infection at the National and State level? c) Which interventions, geographical areas and populations should be prioritized if funding levels decrease? d) How plausible are the reported behavioural data, given the state of the epidemic(s)? 13. In the second half of the mission, the quality and availability of data to address these questions was explored, and an implementation plan was developed for executing the modeling, in consultation with NACA and selected partners: USAID, the Society for Family Health (SFH), the Network of People Living with HIV/AIDS in Nigeria (NEPWHAN), Measure Evaluation and CDC. 14. The mission found that: a) Behavioural data for both Key Target Populations (KTPs) and the general populations in selected States (IBBSS2010, NARHS, NDHS) could be confirmed to include: (i) Age differences between sexual partners; (ii) Number of partners by partner type; and (iii) Condom use by partner type b) Data on needle sharing practices and sexual behaviour of Men having Sex with Men are available for selected States. c) The available data on coverage and effectiveness of HIV prevention responses could only be confirmed for the distribution of male and female condoms through the Society for Family Health, which covers about 75% of the condom market in Nigeria. Data availability for the coverage and effectiveness of HIV Counseling and Testing, STI referral and management, Peer-education and Mass media campaigns, and other HIV prevention responses in Nigeria could not be assessed during the mission. The same is true for costing data for the above-mentioned HIV prevention responses. Consultation with the Federal Ministry of Health on this matter will be essential once modeling commences. 15. Based on the data available, it was agreed with NACA that the following was feasible in relation to the four potential modeling questions: a) At present, insufficient data from all States prohibits addressing the first question of the expected number of HIV infections averted by the planned HIV prevention responses in Nigeria at the national level. However, for selected States, data availability and data quality is good: data for the general population as well as Key Target Populations are available through the NDHS, NARHS and IBBSS2010 datasets for Anambra, Benue, Cross River, Edo, FCT, Kaduna, Kano, Lagos and Nassarawa States. Provided that model parameters can be obtained from these datasets (NARHSs and IBBSSs), the expected impact of the planned HIV prevention responses can be modeled for the above-mentioned States. Should sufficient data be collected for other States through future NARHS and IBBSS surveys, modeling can be done in future for other States as well. b) Similarly, the second question of the expected contribution of each of the HIV prevention interventions to averting new infections can be addressed for the States for which the first question will be modeled. The interventions to be considered are likely to depend on the epidemiological context, the Key Target Populations and the HIV prevention priorities identified in each of the selected States. For this modeling work to be done, access to the primary IBBSS 2010 data is essential, since key model parameters will need to be estimated based on additional primary data analyses, not yet reported upon in the report of the IBBSS 2010. c) The third question of prioritizing interventions, geographical areas and populations under decreasing levels of funding, can be addressed by a resource allocation optimization modeling tool, but this work crucially depends on the modeling results from previous two questions. This health economic modeling can therefore only be done once the first two modeling questions have been answered. d) Lastly, the plausibility of the reported behavioural data, given the state of the epidemics in selected States can be addressed using retrospective modeling studies to validate internal consistency or identify inconsistencies between reported behaviour and observed trends of HIV prevalence across time, age groups, genders, risk groups and geographical areas. This modelling question can immediately be answered. 16. The mission team noted that access to the IBBSS 2010 and NARHS 2007 primary datasets is a priority as key model parameters to address all modeling questions crucially depend on these data. It was agreed that NACA would support the mission team in obtaining these data sets, and send them electronically to the World Bank country office. 17. The mission recommended the establishment of a NACA-led interagency modeling task team, prior to commencing with the statistical and epidemiological modeling, as per the scope set out in paragraph 13 (a) to (d). It was agreed that the World Bank would send a draft Terms of Reference within the next two weeks and a recommended set of minimum skills to guide the establishment of the aforementioned task team. It was also agreed, at NACA’s request, that the World Bank team would prepare a list of online and hard copy resources on epidemiological modeling as reference materials for the modeling task team members and NACA staff who will be involved in the work by the end of March 2011. Further, it was agreed that NACA would nominate 2 staff members to work with the WB modeling team for local capacity building purposes by the end of March 2011. 18. In terms of working modalities, it was agreed that the World Bank team and NACA team would work through a combination of (i) email-based and telephonic mentoring technical support, and (ii) a working visit of active task team members (task team members who have attended at least 75% of task team meetings) to the South African Centre of Epidemiological Modeling and Analysis (SACEMA). Such a working visit was recommended because a larger critical mass of computing power and technical know-how is available at SACEMA. It was agreed that the working visit of active task team members could be funded from the proceeds of the World Bank credit, once it is operational. Task 5A: Impact Evaluation for HIV Prevention 19. The impact evaluation component of the mission focused on answering three related questions: (i) to identify key impact evaluation questions at the national level, in consultation with NACA; (ii) to develop common understanding and build capacity among state-level program officials and functionaries with respect to impact evaluation approaches; and (iii) to work with selected States to identify options and priorities for evaluating the impact of specific interventions at the State level. During the mission progress on these items were made through consultations with NACA and the workshop with NACA and selected States (see paragraph 9 and Annex 3 for more information about this workshop). 20. It was acknowledged that due to heterogeneity of epidemics, the need for tailored prevention strategies at the State level, and limited data for some States, evaluating the overall impact of interventions in Nigeria would be difficult to achieve at the national level without the use of modeling, in combination with enhanced collection of intervention coverage, behavioural data and HIV prevalence trends in different sub-populations. However, it was agreed that the impact of specific interventions could be evaluated at the state level. Therefore, the mission found that there were two feasible HIV prevention impact evaluation options in Nigeria at this stage: (a) impact evaluation of specific, unproven interventions for Key Target Populations (KTPs), and (b) overall prevention impact of a combination of interventions at State level. 21. The impact evaluation component of the aforementioned HIV Prevention was well received by participants from the national and State levels. Emphasis was placed on: (i) focusing strategically on populations and interventions that are likely to have an impact on the epidemics in the states; (i) selecting impact evaluation design options that will yield valid findings regarding the impact of interventions at the population level, beyond measuring program outputs. During the workshop, through interactive sessions at the workshop teams from six States were each able to define two key interventions for which they developed basic designs and plans for impact evaluation. These ranged from evaluating comprehensive approaches to improving uptake of PMTCT services to evaluating the impact of focused HIV prevention programs in key transmission hot spots. Most proposed randomized intervention trials, often with a stepped- wedge design for scaling up interventions. Participants in the workshop demonstrated insight into key prevention priorities and a good grasp of the basic concepts and methods for impact evaluation. Several of the proposed impact evaluation activities hold promise and could yield important knowledge for HIV prevention strategies in Nigeria. Therefore, the mission recommended to the Government that it follow up on these initial plans with further design work and subsequent implementation through State-level programs. 22. At the workshop, it was agreed that State-level teams would take the responsibility for refining intervention plans and impact evaluation strategies to evaluate these interventions and that they would need to submit it to NACA within a given time frame. NACA, ENR and the World Bank would then jointly determine the IE priorities based on State submissions. It was further agreed that whilst the World Bank would provide technical support for the impact evaluation design, the funding for the interventions and impact evaluation implementation will need to be drawn out of existing funds available to States (WB, government, or other sources of funding). Task 5B: Implementation Support 23. Discussions with NACA reinforced and clarified the importance of ensuring a strong system of implementation support, particularly focusing on the State level. To facilitate this, it was recognized that it was essential that the Strategic Knowledge Management, Programmes Coordination, and Partnerships Coordination departments of NACA work closely together in relation to the technical support to be provided. It was noted that during this mission, interactions were mostly with the SKM team, and that in future missions, the other two units at NACA would need to play an equally-active role in the mission proceedings. 24. Discussions with NACA, FMOH, the ENR and US government program teams indicated that supporting the States to coordinate implementation well, and making sure that implementation was of the highest quality, was a priority for all parties concerned. In this regard, ENR and US government teams were already planning to provide some support: for the implementation support of good quality prevention interventions to work, it was essential that these support efforts be integrated, harmonized and mutually supportive of each other. 25. Critical areas of implementation support were identified in consultation with these partners, and confirmed through discussions with state level teams. These critical areas include: • Macro level intervention planning: - Mapping prevention needs at the local level and developing a blueprint for interventions and services accordingly. • Capacity building and learning systems for implementation, such as: - Micro-planning for the implementation of key interventions, focusing on local planning tools and processes. - Training systems and modules for key interventions. - Developing intervention guidelines and accreditation processes for implementing organizations. - Developing support resources for implementers: planning tools, job aids, monitoring forms and tools. - Developing supportive supervision systems to provide field level implementation and monitoring support. • Program monitoring and evaluation - Integrating the performance framework into implementation at all levels, from the field programs to the central program management. 26. So as to ensure above-mentioned integration, it was agreed during the mission that an integrated package of implementation support should be developed in consultation with key stakeholders, with clarification of roles and implementation arrangements. In relation to such a package of support, it was agreed that the next step would entail the development of a “briefing note� on implementation support in relation to the World Bank technical assistance. This will provide an overview of the background and principles of implementation support, including the approach to collaboration and partnerships, and define implementation support components. This briefing note will be used to initiate and facilitate discussion with NACA, SACAs and other key stakeholders. 27. It was further agreed that during the next mission (June 2011), NACA would convene a consultation with key stakeholders at the national and state levels to discuss and plan a comprehensive package of implementation support for the State level. The objectives of the consultation would be to (i) work towards consensus on elements of the support; (ii) define current roles and strengths, and identify key gaps; (iii) determine the priorities for World Bank implementation support; and (iv) discuss the methodology for providing support, emphasizing building capacity of existing functionaries and avoiding parallel systems. Following these consultations, the World Bank would support NACA to draft an implementation support plan to guide its technical assistance in this area. 28. As a result of the consultations and activities during the mission, the importance of local epidemic appraisal and mapping of key target populations and high risk localities was identified by NACA, state level officials and other key stakeholders. It was therefore agreed that during the next mission (June 2011) capacity building would be provided in local epidemic appraisal and mapping. This would involve key technical and program staff from the national and state levels and would be accompanied by the development of an implementation plan for local epidemic appraisals in selected states and localities. 29. Based on the Benue field visit (see Annex 5) where clear interest and political commitment from Benue State was shown in being part of the initiative, it was agreed that Benue State would be one of the States where integrated implementation support for prevention interventions for KTPs would be provided in the future. Details would be discussed and agreed with Benue State during the next World Bank technical support mission. Next Steps, Responsibilities and Timelines 30. Below please find a summary of the mission actions agreed on, responsibilities and timeframes for completing them: Activity Timeline Responsibility Actions Relating to Task 2 (Prevention Policy Briefs) Obtain new IBBSSs and ANC data and reports 31 March 2011 NACA Finalise State-level summaries for other States 31 March 2011 WB Update 13 State-level summaries 15 April 2011 WB Finalise policy briefs for 6 States, and disseminate Next mission: State reps with WB them for use in work planning May 2011 support Complete ERPSs for remaining States 31 May 2011 NACA Activity Timeline Responsibility Develop policy briefs for other 30 States Mission in June State reps with WB 2011; finished support by Jul 2011 Summary of key HIV prevention issues at the Nov 2011 WB national level for use during the subsequent Joint Annual Review Actions Relating to Task 4 (Modelling) Obtain access to IBBSS, NARHS and send 31 March 2011 NACA electronically to WB Send to NACA (a) TOR for Task Team and (b) 31 March 2011 WB epidemiological modeling reference materials Establish interagency, NACA-led modeling team and 15 April 2011 NACA convene inaugural meetings Obtain intervention coverage and costing data 15 May 2011 NACA Derive model parameters from survey data 30 June 2011 WB, with task team support Answer Modeling Question 1: Perform 30 August 2011 WB and task team epidemiological validity checks Impact and cost-effectiveness scenario modeling 30 Nov 2011 WB and task team Validation of modeling results 31 Dec 2011 NACA Actions Relating to Task 5A (Impact Evaluation) Obtain NARHS questionnaires 31 March 2011 WB Provide inputs into new NAHRS questionnaire 15 April 2011 WB State-level Impact Evaluation: After modelling discussions TBD Intervention-specific Impact Evaluation: States to submit expressions of interest 31 March 2011 6 States present at workshop, as per next steps agreed with States at workshop submit expressions to NACA Final selection based on data gaps May 2011 NACA and WB Activity Timeline Responsibility Support IE design Mission in June WB 2011 Secure funding for implementation 30 June 2011 States to include in WB or other partner w/plans Activities Relating to Task 5B (Implementation Support) Develop a briefing note on implementation support in relation to the WB technical assistance May 2011 Convene a consultation with key stakeholders at the June 2011 WB national and State levels to discuss the development of a comprehensive package of implementation support for States. Draft an implementation support plan for the WB June 2011 WB technical assistance to selected States, and finalise with key stakeholders during the next mission ANNEX I: GHAP Missions: List of Meeting Participants Name/Title Contact Details NACA Prof John Idoko idoko@naca.gov.ng Kayode Ogungbemi kogungbemi@naca.gov.ng Greg. Ashefor asheforgrego@yahoo.co.uk 08034032668 Idotayim Ezirim gend2teyin@yahoo.com 08069640051 Victor Vandi tvvandi@yahoo.com 08035961140 Anthony A. Bisong tony-bisong@yahoo.com 0806555153 Kemi Ladeinde oluwakemiladeinde@yahoo.com 08023419132 Ronke Adeoye ronadeoye@yahoo.com 08023859585 James Anenih anenihj15@yahoo.com 08074637339 Nsikak Ebong nsikakaebong@yahoo.com 08065588252 Maimuna Mohammed mymohd19@yahoo.co.uk 08037861653 Francis Agbo fagbo@naca..gov.ng 08036532548 Hakeem A.S. arkyymwise2@yahoo.com 08033162951 Okunade SK kayode_okunade@yahoo.com 08025788035 Dr Nnorom jnnorum@yahoo.com 08034080568 Udemezue Samuel samstays2002@yahoo.com 08067957641 Oshagbami Seun soshagbami@yahoo.com 08036473661 Oby Okwuonu obyokwuonu@yahoo.com 08033063117 Amuta Arinze Jude sontajude@yahoo.com 08036755783 World Bank Marelize Gorgens mgorgens@worldbank.org +1 202 560 4741 F. Ayo Akala fakala@worldbank.org 08066944805 James Blanchard James_blanchard@umanitoba.ca Amaka Momah momah_amaka@yahoo.com 08033326449 Wim Delva Wim.delva@ugent.be ENR Augustine Ankomah aankomah@sfhnigeria.org 09-4618823 Jennifer Anyanti janyanti@sfhnigeria.org 08023289518 Olufemi Faweya ofaweya@enrnigeria.org 07063337606 Omokhudu Idogho oidogho@enrnigeria.org 08023006631 Ipoade Omilaju Ipoade.omolaju@actionaid.org 08023370724 Olusola Onifade sonifade@gmail.com 08033234210 USAID Lungi Okoko lokolo@usaid.gov 0813231112 Isa Iyortim iiyortim@usaid.gov 08037876998 Jerry Gwamna gwamnas@ng.cdc.gov 07034119818 Kalada Green kagreen@usaid.gov 08036271914 UNAIDS Kwame Ampomah ampomahk@unaids.org 08036591753 Job Sagbohan sagbohanj@unaids.org 0807057779481 NASCAP Dr Balami wapaiabalami@yahoo.com 08023667183 Dr Aderemi Azzez zzaderemi@yahoo.co.uk 08033299779 Benue State agency for the Control of AIDS Ahile Rhoda ahilerhoda@yahoo.com 08069103851 E.S Kyaaaba shimkyaagba@yahoo.com 08065599194 S.I Ityo ityosim@yahoo.co.uk 08064194919 Dr Aida 08035783010 Regina Ameh ginameh@yahoo.com 08037413236 Uba .E ednangusonon@yahoo.com 07036913403 Ioron M.C zertiev@yahoo.com 08064733030 Awai G.M.G awaigmg@yahoo.com Esther Igwue essigwue@yahoo.com 08054443940 Tarhembah Joe 07036882260 Edwin M.E maryedwin@yahoo.com 08026703360 Beatrice Shomkegh bshomkegh@yahoo.com 080245262934 Ivande Denen-Igundunasse Ivande4real@yahoo.com Agbede T.L linaagbede@yahoo.com 07033257426 Tyovenda . J jivenda@yahoo.com 08035982924 Idoko Rebecca beckyogah@hotmail.com Sonia Ezia soniascolumn@yahoo.com 08036549274 Amate Sam 0805534113 Dr Godwin Achinge godwinachinge@yahoo.com 08035778786 Grace Wende Ashiwende@yahoo.com 08036804737 Dr Ochenjeles ochenjelesumila@yahoo.com 08063359347 Dr Kumba 08065947928 Rosemary Hua Cishan.benue@gmail.com Gabriel Awah Gabriel_awah@yahoo.com Daniel Shintindi 08033710537 Yongo Stephen benuenetnigeria@yahoo.com 08036137681 Mrs Ajonye aajonye@yahoo.com Ona Ode onaode@gmail.com 08032597816 Jonah Abah docjoab@yahoo.com 0803689357 Dr Akpe Tarvishia tatakpe@yahoo.com 08051528968 Nyulaku Mwuese 08065550409 Bridget Ahungwa Ngutor1@yahoo.com 080651716127 Odeh Roselyn 08037054413 ENR Consultants Odeh Roselyn rosesuung@yahoo.com 08037054416 Dr Musa Kana Musakana77@yahoo,com 08035909560 Aniete Moses Amoses204@yahoo.com 07037582865 Emmanuel Udoh udohcaca@yahoo.com Michael Pedro mpedro@insighthc.org Segun Oyedeji segunoyedeji@gmail.com Oyo_Ita A Oyo_Ita@yahoo.com Farouk Musa Famusa2000@yahoo.com Olusola Onifade sonifade@gmail.com Nassarawa state workshop representatives Aisha Hadi Kasim nnikeisha@yahoo.com Baw I Azara Ibrahimaza2002@yahoo.com 08033559058 Halimata Musa goshimusa@yahoo.com 08068705333 Akwa-Ibom state workshop representatives Nseobong Bassey nsebassey@yahoo.com 08023512466 Dr Aniete Moses Amoses204@yahoo.com 070337582865 Mr Uduak Umo Udofia udyumoudofia@yahoo.com 08023783355 Lagos state workshop representatives Dr Ogboye dr_ogboye@yahoo.com 0802309070 Dr Lajide dayolaja@yahoo.co.uk 08033027089 Cross-River workshop representatives Rev Michael Edu enyogo@yahoo.com 07056470011 Loveth Chukwurah lovethchukwurah@yahoo.com 08037102576 Gabriel Undelikwo gundelikwo@yahoo.com 08037237692 Mbukpa Mary mgmbukpa@yahoo.com 08037097908 Ondo state workshop representatives Dr Adegbulu Capong95@yahoo.com 08034711136 Kola Olaoye Oloyemike2002@yahoo.com 08037208218 Imo state workshop representatives Eke Rita 07038039367 Dr Anyanwu alonzoan@yahoo.com 08030873400 Moneme Judith judymoneme@yahoo.com 08034071809 Dr Nwankwo osondubobo@yahoo.com 08033441418 Kaduna state workshop representatives Mark Anthony gaiyamimo@yahoo.co.uk 0803597204 Juliana Joseph Julie_hab@yahoo.com 08033837025 Adams John Call4adams@yahoo.co.uk 08028186737 NGO representatives Danesi Ismaed Maeel2001@yahoo.com 0055608856 Yemisi Ogunbiyi oogunbiyi@ghain.org 08023023185 Are-Shodeinde Aderonke areshodeinde@unaids.org 08025186134 ANNEX II: GHAP Mission Agenda February 25 – March 4, 2011 25 Feb 2011 Meeting with NACA 28 Feb 2011 Meeting with UNAIDS country Coordinator and M&E advisor Meeting at ENR 1 March 2011 Meeting with Director General of NASCAP Meeting with US government (USAID and CDC) 2 March 2011 Conducting workshop with state level representatives 3 March 2011 Conducting workshop with state level representatives 4 March 2011 Meeting with NACA to discuss modelling End of mission debrief between World Bank, NACA, UNAIDS and ENR 7 March 2011 Modeling meetings (individually) with Measure Evaluation, SFH and USAID 8 March 2011 Modeling meetings (individually) with NEPWHAN and CDC Modelling debriefing session with NACA ANNEX III – Detailed agenda of HIV Prevention workshop Towards more efficient and effective HIV prevention in Nigeria: Evidence, Implementation Support and Impact Evaluation 2 – 3 March 2011 Abuja, Nigeria Workshop Objectives: a) To provide an overview of what it takes to improve HIV prevention b) To develop HIV prevention priorities for 6 States c) To prioritize HIV prevention impact evaluation questions, methodologies and focus areas in Nigeria Workshop Deliverables: a) Outlines of prevention priority policy briefs for 6 States b) HIV prevention impact evaluation priorities and methodologies Workshop Programme: 2 March 2011 08:30 – 09:00 Registration 09:00 – 09:15 Welcome by NACA NACA 09:15 – 09:30 Current HIV prevention priorities in Nigeria HIV prevention Nigeria TWG 09:30 – 10:30 Overview: How evidence, implementation World Bank Resource materials: support and impact evaluation work PPT 1 together to improve HIV prevention 10:30 – 10:50 Tea 10:50 – 11:15 Discussion relating to overview NACA presentation 11:15 – 12:00 Evidence – doing the right interventions World Bank Resource materials: right PPT2 12:00 – 12:15 Discussion relating to evidence NACA presentation 12:15 – 12:30 Overview: ERPS and MOT processes in NACA consultant Nigeria 12:30 – 12:45 Orientation to afternoon’s groupwork NACA Resource materials: PPT3 12:45 – 13:45 Lunch 13:45 – 14:00 Policy brief overview ENR 14:00 – 17:00 Groupwork in the 6 States – preparing Groups Resource materials: policy briefs with HIV prevention Groupwork priorities assignment sheets Group work will be interspersed with feedback opportunities 17:00 Tea and workshop closure 3 March 2011 08:30 – 09:00 Recap from Day 1 NACA 09:00 – 10:30 Impact evaluation overview and World Bank Resource materials: definitions Plenary discussions PPT4 Types of Impact Evaluation designs – part A 10:30 – 10:50 Tea 10:50 – 11:45 Types of Impact Evaluation designs World Bank Resource materials: – part B Plenary discussions PPT5 11:45 – 12:15 Unique additional factors in HIV Group work and plenary prevention impact evaluation design feedback 12:15 – 12:45 Using modeling as part of impact World Bank Resource materials: PPT6 evaluation efforts: an example and principles 12:45 – 13:45 Lunch 13:45 – 14:00 Nigeria’s HIV research priorities: an NACA overview 14:00 – 14:10 Orientation to afternoon’s groupwork NACA Resource materials: PPT7 14:10 – 17:15 Impact evaluation for HIV Groups Resource materials: prevention in Nigeria – questions and Groupwork assignment methods sheets Group work will be interspersed with feedback opportunities 17:15 Next steps and timeline NACA Tea ANNEX IV – Detailed Scoping of Potential Scope of Modelling Tasks (used as a basis for discussion and verification during the mission) Overview and Scoping of Task 4 Support NACA to model the impact of the HIV prevention interventions outlined in the NSP on the number of new HIV infections in Nigeria, and their cost-effectiveness 1. Introduction Task 4 aims to answer the follow questions: • How many new infections will the planned HIV responses in Nigeria, if implemented fully to scale as intended, avert? • At different future points in time, how would the different interventions (including the new Bank- supported project) have contributed to achieving the goals of the national and state level HIV responses? • What is the future of HIV funding in Nigeria and which interventions, geographic areas and populations should be prioritized if funding levels (particularly from development partner assistance) decrease? To address these questions, an epidemiological model with "add-on" health economic features will be developed for national and State level use (deliverable 1). Secondly, scenarios of impact and cost- effectiveness for the ongoing and planned HIV responses will be modeled (deliverable 2). The development of both models is subject to the availability of a set of parameter data. It may not be possible to model at the national level, for example, but only in some States. Or, it may not be possible to model all of the questions presented above. As one moves through the different steps, the feasibility of the modeling questions, or possible adaptations thereof, will be considered. 2. Proposed incremental modeling approach and methodology The first step is to provide answers to the questions below through literature review and consultation with NACA, WB Nigeria office, other development partners, the technical support project team, MOH and other stakeholders. This step will also entail a brief investigation into past and current modeling efforts in Nigeria, and their limitations. The answers to these questions will guide a final decision as to whether the modeling can be undertaken, how it will link to existing or planned modeling efforts, refine the modeling questions, as well as guide the development and parameterization of the epidemiological model. Should it not be possible to do any modeling in Nigeria because of a lack of data, the focus of this task will change: it will focus on defining the minimum data requirements needed to undertake modeling in future, and suggest which survey questions could be added to existing surveys so as to collect the data needed for an effective modeling process. a) Questions related to Nigeria’s HIV response 1. What are the planned HIV responses in Nigeria? 2. Over what period of time will these HIV responses by rolled-out / scaled up? 3. What is the current coverage of theses HIV responses? 4. What is the expected coverage of these HIV responses under a scenario of scaling up, and under a scenario of universal access by the end of the roll-out / scale-up period? 5. What is the expected effect size of these HIV responses in exposed individuals or couples (e.g. reduction in per sex act transmission probability, reduction in rate of acquiring concurrent partners, reduction in age difference between sexual partners)? 6. Are there any interactions to be expected between HIV responses? (e.g. scaling up VCT may lead to higher ART coverage and higher CD4 count (i.e. shorter time since infection) at the time of ART initiation; scaling up male circumcision may lead to increased partner turnover in a subgroup of men. b) Questions to support impact estimation over time 1. What are the time horizons to be considered in the impact estimations? (e.g. impact after 3 years, 5 years, 10 years) 2. What are the end points to be considered in the impact estimations? (e.g. HIV incidence rate, crude number of averted infections, HIV mortality rate , number of HIV-related deaths averted, number of (quality-adjusted) life years saved) c) Questions related to Nigeria’s sexual behaviour and network structure 1. What does the degree distribution of sexual partners in the last year and lifetime sexual partners currently look like? 2. What does the age mixing pattern currently look like (average age difference and variability around that average)? 3. What is the point prevalence of concurrent relationships? 4. What does the distribution of the duration of sexual relationships look like? 5. What does the distribution of the duration of overlap of sexual relationships look like? 6. What is known about demographical or behavioral correlates of engaging in age-disparate or concurrent relationships? d) Questions related to costing of interventions 1. Which costs are to be included in the cost-effectiveness analysis (direct health-care costs only? indirect opportunity costs?) 2. What is the per capita cost for each of the HIV responses (potentially different for different levels of scale up)? 3. What are the averted costs associated with averted infections and averted deaths? 4. What rate should be applied to discount future costs and savings? Once the extent to which these data are available has been assessed (it is planned that this be done during the mission), the modelling question/s can be refined and agreed on. This will be followed by the development of a detailed timeline for the modeling, as well as specific activities to support in-country capacity building during the modeling process (a local counterpart will have to be identified and contracted1 to support the process). The second step is to develop the epidemiological model with add-on health economic analysis modules to simulate the impact and cost-effectiveness of ongoing and planned HIV responses at national and State level. SIMPACT, a stochastic, individual-based model, is proposed as the modeling platform for this task. SIMPACT is developed specifically with simulation of HIV prevention and treatment interventions in mind. As sexual relationships are explicitly modeled in SIMPACT, it allows for the simulation of behavioral interventions that act on the dynamics of relationship formation and dissolution, including the formation of concurrent and age-disparate relationships. Other interventions that can be simulated using SIMPACT include scaling up of male circumcision, VCT, condom use and ART.A base case analysis will be performed based on the evidence generated in step one, possibly complemented with educated guesses where questions could not be answered definitively. The third step is to perform an uncertainty analysis to explore how the outcome measures of interest may vary for alternative choices of parameter values. The range of parameter values included in the uncertainty analysis will be based on the uncertainty around the parameter values as estimated in the first step. The fourth step then entails the presentation, validation and dissemination of the modeling results. This will be led by NACA, in partnership with the M&E TWG and the Prevention TWGs. The purpose of the dissemination2 will entail ensuring that stakeholders understand the modeling results, assumptions and limitations, and that the modeling efforts support better programming and decision-making in Nigeria. 1 The World Bank GHAP team will not be able to support this local counterpart financially, and it is expected that the government will use funds from the current credit to fund such a person. 2 As agreed in the original Terms of Reference for the work, the World Bank GHAP team will not be able to fund these activities (validation and dissemination costs, which entails bringing a number of stakeholders to a central venue for a short period of time). It is expected that the Government will use the proceeds from the latest WB HIV project to fund the dissemination costs. ANNEX V – Report on Field Visit to Benue State On February 27th, 2011 Dr. Blanchard traveled to Makurdi for meetings the following day with the Benue SACA and its partners in the government and non-government sectors. The objectives of this meeting were: • To apprise Benue SACA and its partners about the purpose and scope of the World Bank’s technical support initiative. • To discuss key technical issues, challenges and opportunities related to planning, implementing and evaluating HIV prevention programs at the state and local level. • To explore the potential for establishing a Program Science initiative in partnership with Benue, and if so, to begin discussions regarding the potential areas of focus. A total of 34 individuals participated in the meeting, including key stakeholders from the HIV response and from other key health and government departments. Findings 1) BENSACA and its partners have considerable interest in improving the technical aspects of their programs, and would like to pursue further technical support to achieve this. 2) Priority areas for technical support identified by stakeholders include: • Local assessments, including rapid assessments of behaviours and networks, and strategically planning a mix of preventive interventions (LGA level). • Effective implementation of interventions, including program management, field implementation and monitoring. • Impact evaluation of specific interventions and intervention packages. 3) It was agreed that an integrated approach to knowledge management and program implementation needed to be developed to optimize the technical quality and impact of interventions, using a “program science� approach (as described by J. Blanchard). 4) It was further agreed that BENSACA, the ENR team and the World Bank team could work together, in consultation with NACA, to develop a technical support model in Benue.