New Funding for Nigeria HIV Grants will focus on Treatment.
Global Fund Observer (Nairobi)
By David Gamaise
Nigeria plans to use the bulk of the $121 million in interim applicant funding for three HIV grants (first announced in this GFO article) to pay for drugs and other health products. The Global Fund Board approved the funding request from the country coordinating mechanism, but with some modifications.
With three million people currently living with HIV, Nigeria has an HIV prevalence of 4.1%, constituting 9% of the global HIV burden. In addition, Nigeria has one of the highest TB burdens in the world and the largest TB burden in Africa (311 per 100,000 population). Nigeria's HIV epidemic is generalised; however, prevalence varies widely among states and between rural and urban areas. Nigeria's epidemic is largely fuelled by heterosexual and mother-to-child transmission, but key affected populations (KAPs), who constitute about 1% of the adult population, play a crucial role in driving the epidemic and account for 40% of annual new infections.
When the transition phase of the new funding model (NFM) was launched, $121 million was identified for Nigeria as an interim applicant (for HIV). The Nigeria country coordinating mechanism (CCM) submitted a proposal for $119.6 million. The CCM requested that the funds be added to three existing single-stream-of-funding (SSF) grants - NGA-H-NACA, for which the principal recipient (PR) is the National Agency for the Control of AIDS (NACA); NGA-H-ARFH, for which the PR is the Association for Reproductive and Family Health; and NGA-H-SFHNG, for which the PR is the Society for Family Health.
The CCM's proposal focused on the need to address critical commodity gaps; 97% of the proposed budget was earmarked for drugs and other health products. In addition to scaling up the provision of antiretroviral treatment and the prevention of mother-to-child transmission of HIV (PMTCT), the proposal included activities to (a) enhance the diagnosis of TB among people living with HIV; (b) enhance the coordination of TB and HIV programmes; (c) provide additional funding for the Integrated Biological and Behavioural Surveillance (IBBS) survey for KAPs; and (d) reduce barriers to accessing services, and support community mobilisation to improve service utilisation and adherence to treatment in 16 states not already targeted under the current SSF grants. The current grants are implementing activities to reduce barriers etc. in 21 states. The funding request also called for increasing the efforts underway in the 21 states.
The Grant Approvals Committee (GAC) recommended that the proposal be approved with some changes, and that the budget be increased to the full $121 million earmarked for Nigeria.
The most significant change is that the GAC recommended that Nigeria concentrate on strengthening efforts to reduce barriers etc. in the 21 states where these activities are already underway. The GAC said that although reducing barriers to access, increasing service utilisation and improving adherence are critical, there is no evidence available yet on the effectiveness of the approaches currently being used or of the proposed activities (scale-up of support groups, community dialogue and Mentor Mothers).
The GAC recommended that the money that the CCM had planned to use to expand these efforts into 16 new states be used instead to evaluate the effectiveness of the existing efforts. The GAC said that these evaluations could form the basis for a proposal under the full roll-out of the new funding model to expand into new states.
The GAC recommended changes in two other areas: (a) support for KAPs interventions and enabling environment; and (b) support for the implementation of ongoing scale-up.
Support for KAPs interventions and enabling environment
The GAC noted that the proposal for interim applicant funding contained no funding for KAPs in addition to the $14 million already available for the second implementation period of the SSF grants for behaviour change communication activities, mobile HIV counselling and testing, advocacy, condom distribution and treatment referral strengthening. The GAC recommended that $6 million be set aside for expanding interventions to female sex workers working outside brothels, their clients and communities; for STI treatment and management among KAPs; and for further strengthening of the current approach to working with men who have sex with men.
The GAC further recommended that a portion of this $6 million be reserved for legal aid and core funding of HIV programmes for KAPs. The GAC said that the precise use of this budget should be determined during grant negotiations.
Finally, the GAC recommended that future applications under the NFM include funding for additional interventions targeting KAPs, once the KAPs and IBBS surveys are completed. The GAC said that future funding should also cover additional advocacy activities at different levels to further support an enabling environment for most-at-risk populations.
The GAC said that the existing NACA SSF grant budget for supporting activities related to the PMTCT scale-up plans and implementation at state level should be assessed to determine if savings are available under the grant to support ad-hoc state-level strategy and planning workshops. If such savings are not available, the GAC said, then some funds from the $121 million approved for Nigeria should be used for these such activities to keep the momentum going.
All of the recommendations of the GAC will be addressed during final grant-making and in grant implementation.
When it reviewed the request for funding, the Technical Review Panel (TRP) noted what it called the "relatively low performance" of PMTCT initiatives and stressed the need for the Secretariat to seek greater clarity on additional steps the HIV programme is taking to increase PMTCT coverage beyond trying to reduce barriers to access. The TRP also stressed the need for PMTCT initiatives to be integrated in public health centres and maternal, new-born and child health programmes in order sustain these initiatives and to reduce fragmentation in Nigeria's health system. The Secretariat, CCM and PRs will attempt to address these issues during final grant-making.
The GAC underlined the need in future to continue coordination efforts with partners and to step up prevention efforts. The GAC added that there is a need to start thinking about further prioritisation, mapping and drilling down to geographic hot spots at the sub-state level.
Acknowledging ongoing efforts to more effectively reach KAPs, the GAC said that there is a need to look at all options in support of KAPS, including a potential multi-country proposal or non-CCM proposal.