Nigeria Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

NIGERIA

Project Title: Nigeria Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

Budget Summary:

	Field Programs Funding by Account						Central Programs
	Notified November 2007			Notified February 2008			Notified as of February 2008	Allocations to Date
Implementing Agency	GAP	GHCS - State	Subtotal: Field Programs Funding	GAP	GHCS - State	Subtotal: Field Programs Funding	Subtotal: GHCS Central Programs	Grand Total:  Field & Central Funding
DOD	-	-	-	-	7,808,435	7,808,435	-	7,808,435
DOL	-	-	-	-	-	-	-	-
HHS	-	24,689,531	24,689,531	3,056,000	167,432,092	170,488,092	18,330,999	213,508,622
Peace Corps	-	-	-	-	-	-	-	-
State	-	-	-	-	65,000	65,000	-	65,000
USAID	-	30,825,000	30,825,000	-	163,490,808	163,490,808	5,973,130	200,288,938
TOTAL	-	55,514,531	55,514,531	3,056,000	338,796,335	341,852,335	24,304,129	421,670,995

HIV/AIDS Epidemic in Nigeria:
Adults (aged 15-49) HIV Prevalence Rate d– end 2005: 4.4% (National ANC Survey, 2005)
Estimated number of People Living with HIV: 3.9 Million (National ANC Survey, 2005)
Estimated number of Orphans due to AIDS: 930,000 (UNAIDS, 2006)

Country Targets and Projections to Achieve 2-7-10 Goals: Total Targets:

Nigeria	Total # Individuals Receiving Care and Support	Total # Individuals Receiving ART
End of FY 2004*	43,800	13,500
End of FY 2005**	67,900	28,500
End of FY 2006***	234,600	67,100
End of FY 2007****	282,000	126,400
End of FY 2008*****	1,216,243	196,625
End of FY 2009*****	1,802,449	327,250

^* "Engendering Bold Leadership: The President’s Emergency Plan for AIDS Relief.” First Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, March 2005.
^** “Action Today, a Foundation for Tomorrow: The President’s Emergency Plan for AIDS Relief.” Second Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, February 2006.
^*** "The Power of Partnerships: The President’s Emergency Plan for AIDS Relief.” Third Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, February 2007.
^**** "The Power of Partnerships: The President's Emergency Plan for AIDS Relief." 2008 Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, January 2008.
^***** Projections from FY 2008 Country Operational Plan

Program Description/Country Context:

Nigeria is not only populous (137 million), but also ethnically and culturally diverse. Under the federal system of government, Nigeria has six geo-political zones, 774 local government areas (LGAs), 36 states and a Federal Capital Territory (FCT). At an average of 3.2 million inhabitants, many states are larger than some African countries. The combination of Nigeria’s large population and estimated HIV prevalence of 4.4% (Federal Ministry of Health, 2005) result in an estimated 3.9 million inhabitants infected with HIV. In addition, Nigeria has one of the highest tuberculosis (TB) burdens (290/100,000 population, WHO 2006) in the world and the largest TB burden in Africa. Many TB cases go undetected despite increasing TB detection rates and TB program coverage.

Nigeria has a generalized HIV epidemic, however, prevalence varies widely across states and rural and urban areas. Concentrated HIV/AIDS epidemics occur in particular geographic regions and within certain segments of the population. The USG Nigeria program will support a population level prevalence survey in late 2007 to clearly define the variability in prevalence. Nigeria’s epidemic is largely fueled by heterosexual and mother-to-child transmission, but there are clearly identifiable risk groups that are similar to those in many other African countries. HIV prevalence peaks among 20 to 24 year olds, indicating people are becoming infected at an earlier age. While prevalence estimates imply that the stage is set for the next and larger wave of the epidemic to transpire over the next decade, the USG will work to counter such a situation with intensified and targeted prevention activities. By 2015, an estimated 16.2% of the total population under 15 years of age will be orphaned from any cause, up from only 5.2% in 2000.

In this context, PEPFAR funding will be focused on the following program areas that contribute to the 2-7-10 targets.

Prevention: $62,876,855 ($53,535,495 Field; $9,341,360 Central) (16.5% of prevention, care and treatment budget)

Prevention activities in Nigeria include prevention of mother to child transmission (PMTCT), abstinence and be faithful (AB) programs, blood and injection safety, and prevention initiatives focused on high risk populations. In FY 2008, the USG will expand support to PMTCT centers and will continue to dialogue with the Government of Nigeria (GON) to expand services to the rural areas where most women give birth. In six states, USG will reach every LGA (analogous to US counties), providing PMTCT services in at least one outlet. This expansion of services, not possible in Nigeria 3 years ago, builds on PEPFAR PMTCT networks and the GON National Scale-Up Plan. USG is leveraging resources for laboratory commodities for Early Infant Diagnosis (EID) and therapeutic feeding products for pregnant and lactating women. USG will continue training health workers to provide PMTCT services.

USG Nigeria will continue to support high-quality, targeted behavioral change programs to deliver abstinence and be faithful messages. USG implementing partners provide a range of services that target the specific needs of different risk groups, providing them with a meaningful set of prevention skills. to help further inform the prevention needs of the population and to quickly get essential sexual transmission prevention services to populations in need. USG will emphasize changing male norms and behaviors and “be faithful” messages. Mass media messages, such as the popular and successful national “ZIP UP” campaign will continue, coupled with other prevention activities to strengthen the overall messaging occurring in a geographic area and improve the effectiveness of the mass media messaging. USG will continue to provide institutional capacity building to local civil society organizations (CSOs), non-governmental organizations (NGOs) and faith based organizations (FBOs) to deliver accurate, high-quality AB messages.

Prevention activities will be incorporated into all care and treatment activities, particularly counseling and testing (CT) services. Strategies for discordant couples have been developed, and couples counseling will be expanded and will continue to provide targeted prevention messages. Efforts to reduce new infections among high-risk and high-transmission communities will continue, with messages specifically targeted for each individual risk group. USG will provide syndromic management services for sexually transmitted infections to persons engaged in high risk behaviors (PEHRBs), to help prevent HIV infection.

The blood supply in Nigeria remains a major source for the transmission of HIV and other pathogens despite great gains made by the National Blood Transfusion Service (NBTS) in 2007. In FY 2008, the USG continues its commitment towards ensuring that all clinical settings funded by the USG will have the capacity to screen all transfused blood for HIV. Additionally, all treatment partners will screen blood through the NBTS regional centers and reduce emergency transfusions at these sites. Clinical service outlets will benefit from safe injection activities, and USG partners will promote universal precautions in all clinical settings.

Principal Partners: Family Health International/GHAIN, Harvard University School of Public Health/APIN+, University of Maryland/ACTION, Partnership for Supply Chain Management, Catholic Relief Services/7 Dioceses, AIDSTAR, Project Search, PDHC, Society for Family Health, Management Sciences for Health (MSH)/Leadership Management and Sustainability (LMS), USAID/Annual Program Statement Solicitation, Center for Development and Population Activities, Population Council, U.S. Department of Defense, Columbia University/ICAP, John Snow Incorporated/MMIS, Nigerian Federal Ministry of Health, Safe Blood for Africa Foundation, NBTS

Care: $106,254,705 ($105,622,935 Field; $631,770 Central) (27.8% of prevention, care and treatment budget)

Care activities in Nigeria include CT, palliative care, TB/HIV, and support for orphans and vulnerable children (OVC). Meeting PEPFAR and GON goals for HIV clinical service provision requires providing CT services to millions of individuals in the coming years. In FY 2008, the USG will continue to support and expand all available modes of CT in a variety of settings including clinical service outlets, stand-alone voluntary CT sites, mobile testing services, and EID scale up. The national CT campaign, branded Heart-to-Heart, will continue to expand nationally recognized services beyond USG sites, and has been incorporated into all USG CT partner activities. All HIV testing represents an opportunity for both the delivery of prevention messages for all clients and referral to care and treatment for those found to be HIV infected. USG implementing partners will focus on integrating prevention messages and strengthening linkages to services in FY 2008. Provider-initiated, routine counseling and testing will be expanded in FY 2008.

With PEPFAR support, the GON has made progress in establishing a basic package of services for HIV positive people and their relatives. In FY 2008, care services, including opportunistic infection management, laboratory follow up, management of sexually transmitted infections, and referral to a care network will be provided to all HIV positive patients identified in USG programs. People affected by HIV/AIDS will receive support services, home based care kits, and access to psychosocial support. USG Nigeria will promote access to home-based care and strengthen networks of health care personnel, community health workers and promoters to provide nursing care and psychosocial support and to link OVC to specialized services.

TB/HIV activities have been prioritized in FY 2008, and the USG will implement provider-initiated routine HIV testing within TB facilities for all individuals, regardless of their TB status. As part of the LGA Coverage strategy, at least one TB service outlet in each LGA in six states will provide HIV testing services. USG Nigeria believes that this initiative will greatly increase access to services for adults and children co-infected with HIV and tuberculosis, expanding services from secondary to primary level facilities and from urban/semi-urban to rural establishments. In FY 2008, USG will continue working with implementing partners to ensure that all facilities offering antiretroviral treatment (ART) also have co-located government TB services available. USG will also conduct a national TB resistance and HIV survey to assess tuberculosis diagnostics and service provision.

Children have been identified as a priority in FY 2008, with increased focus on PMTCT outcomes; provision of EID; prioritization of scale up of treatment services to children; the provision of pediatric tuberculosis services; prevention initiatives focused on school aged children; nutrition and education programs, and direct services for OVCs and their care providers. The USG will continue to support the Federal Ministry of Women Affairs and Youth Development to disseminate national guidelines and policies which address the needs of OVC and their caretakers. Improved access to a variety of educational choices, based on need, will be available to OVCs building on a broad USAID educational program being implemented in Nigeria. Nutritional supplements consisting of high protein, locally produced crops will be distributed to children with the highest need. The USG will also support interventions to advocate among, and to mobilize, a broad range of stakeholders to raise awareness of OVC issues. In FY 2008, USG Nigeria will continue to scale up clinical care services for OVCs that include prevention and management of opportunistic infections as well as ART for eligible children.

Principal Partners: Society for Family Health, Catholic Relief Services, USAID Annual Program Statement Solicitation, Christian Aid, Winrock, Family Health International/GHAIN, Harvard University School of Public Health/APIN+ and University of Maryland/ACTION, ABE/Link, MARKETS, AIDSTAR, Partnership for Supply Chain Management, Department of Defense, Center for Development and Population Activities, Christian Aid, and Federal Ministry of Women Affairs and Youth Development

Treatment: $212,809,650 ($198,478,651 Field; $14,330,999 Central) (55.7% of prevention, care and treatment budget)

Treatment activities in Nigeria include the provision of antiretroviral drugs and services to eligible patients, as well as laboratory support for the diagnosis and monitoring of HIV positive patients identified through USG Nigeria activities. Funds will be used to purchase FDA approved or tentatively approved generic antiretroviral drugs, whenever possible, in an effort to maximize the number of Nigerians receiving treatment, and the USG leverages GON and other development partners for pediatric drugs. Pediatric treatment services have been prioritized in FY 2008. Harmonization, quality of service, reduced target costs and cost leveraging continue to be mainstays of the Nigeria treatment program, with standardized services and health care worker training provided across all implementing partners. .

In FY 2007, PEPFAR supported a revision of the Nigeria National Treatment Guidelines to provide more durable first line treatment options, which will be employed in FY 2008. The USG supports logistics management activities, a key component of antiretroviral drugs delivery, through the on-going development of a Logistics Management Information System and an Inventory Control System. Staff in all sites will be trained in all aspects necessary to maintain a safe and secure supply of high-quality pharmaceutical products in a cost-effective and accountable way.

As treatment services continue to increase in FY 2008, laboratories will focus on maintaining high quality services. In addition, the USG will continue to emphasize actualization of networks of care with a tiered approach to service delivery. Discussions with GON counterparts on improving cost efficiencies have been very successful to date and will continue in FY 2008, with the hope of further reducing overall treatment costs and making routine monitoring available to all antiretroviral treatment patients.

Principal Partners: Management Systems for Health/LMS, Family Health International/GHAIN, Harvard University School of Public Health/APIN+, CRS/AIDS Relief, University of Maryland/ACTION, Columbia University/ICAP and U.S. Department of Defense.

Other Costs: $39,729,785

In the FY 2008 Country PEPFAR Operational Plan, USG Nigeria will continue to strengthen the capacity of the GON to provide comprehensive antiretroviral treatment and to build the systems and structures that will support this countrywide effort. A key component of this effort includes improving the policy environment underpinning the provision of prevention, care and treatment services. Monitoring and evaluation practices will also be strengthened to effectively measure progress in these program areas.

Activities to strengthen the GON’s provision of comprehensive antiretroviral treatment will include improving antiretroviral commodity forecasting and procurement in the national system, surveillance, patient management and monitoring systems, targeted evaluations and population-based surveys. In addition to supporting the development and dissemination of guidelines and policies necessary to direct the provision of prevention, care, and treatment, specific legislation influencing HIV/AIDS activities (such as those dealing with stigma and discrimination and the transformation of the National and State Action Committees on AIDS into a Federal Agency) will be supported in the National Assembly. Other national agencies, such as the National Agency for Food, Drug Administration and Control, Medical Laboratory Science Counsel of Nigeria, the National Central Public Health Laboratory and the Nigerian Institute for Medical Research will be supported in their AIDS related activities. The Global Fund Country Coordinating Mechanism (CCM) will also be supported with this funding.

USG Nigeria will also utilize funds in this program area to collect qualitative and quantitative data to monitor all partners’ performance. Information necessary to report on PEPFAR indicators will be collected, compiled, analyzed and used for programmatic decision making.

Principal Partners: Family Health International/GHAIN, University of Maryland/ACTION and The Futures Group/ENHANSE.

Management and staffing funds will support the in-country personnel needed for USAID, HHS/CDC, Department of State, and DOD. Funds will ensure effective program management, monitoring and accountability; adherence to USG policy while working under the leadership of the Nigerian national response, and cover office and administrative costs.

Other Donors, Global Fund Activities, Coordination Mechanisms:

The United States is the largest bilateral donor to the Nigeria health sector, having provided a total of $339 million in support during FY07, the majority of which is for HIV/AIDS prevention, care, and treatment. The USG in-country agencies include USAID, HHS/CDC, HHS/NIH, Department of State, and Department of Defense. In addition to USG agencies, development partners include the Global Fund; World Bank; the Clinton Foundation and UNITAID; UNAIDS; DFID; JICA; CIDA; WHO; and UNICEF. Others include the African Development Bank, International Labour Organisation (ILO), Italian Cooperation, UNDP, UNDCP, UNFPA, and UNIFEM. The primary HIV/AIDS coordinating body is the National Agency for the Control of AIDS (NACA). In addition to regular planning with NACA and the Federal Ministry of Health, the USG team holds one of two bilateral seats on the Country Coordinating Mechanism for the GF. The USG is also the current Chair of the Development Partners Group for HIV/AIDS, which is the primary donor coordination body for multilateral and bilateral organizations providing HIV support.

The USG will continue to leverage funding from both the Global Fund and the Clinton Foundation. The Global Fund has approved five HIV/AIDS and TB grants for Nigeria, totaling approximately $100 million in lifetime awards to support the expansion of TB services, ART, PMTCT and the promotion of civil society’s role in the HIV/AIDS response.

Program Contact: PEPFAR Coordinator, Jennifer Graetz

Time Frame: FY 2008 – FY 2009

Approved Funding by Program Area: Nigeria