Scope of Work for the:

Impact of the National Response on the HIV/AIDS Epidemic Study, the Socioeconomic Impact Studies of the AIDS Epidemic on Households, and selected Sectors in Nigeria

Prepared by: Joseph Nnorom Adegbenga Sunmola Wole Fajemisin Lisa Arrehag Stephen Kiirya

Coordinated by: Kayode Ogungbemi -NACA Susan Mshana - DFID Namaara Warren - UNAIDS Jerome Mafeni - ENHANSE Chidozie Ezechukwu - NEPHWAN Adaoha Akubuiro - NACA Muktar Mohammed - CDC Francis Agbo - NACA

For: National Agency for the Control of AIDS Federal Republic of Nigeria Abuja, Nigeria June 30, 2008

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TABLE OF CONTENTS LIST OF ACRONYMS.................................................................................................................. iii EXECUTIVE SUMMARY ............................................................................................................ iv INTRODUCTION........................................................................................................................... 1 1.1 Background .................................................................................................................... 1 1.2 Objectives ...................................................................................................................... 2 1.3 Justification .................................................................................................................... 3 1.4 Report Structure ............................................................................................................. 3 A1: IMPACT OF THE NATIONAL RESPONSE ON THE EPIDEMIC ...................................... 3 2.1 Problem Statement ......................................................................................................... 3 2.2 Methodology .................................................................................................................. 5 2.2 Data Sources .................................................................................................................. 6 2.3 Skills Mix....................................................................................................................... 7 2.4 Timeline ......................................................................................................................... 7 2.5 Budget ............................................................................................................................ 8 A2: COST-EFFECTIVENESS OF HIV/AIDS INTERVENTIONS .............................................. 9 2.1 Problem Statement ......................................................................................................... 9 2.2 Scope............................................................................................................................ 10 2.3 Methodology ................................................................................................................ 11 2.4 Data requirements ........................................................................................................ 12 2.5 Indicators...................................................................................................................... 13 2.6 Skills mix ..................................................................................................................... 14 2.7 Budget .......................................................................................................................... 15 B: SOCIOECONOMIC IMPACT OF HIV/AIDS ON HOUSEHOLDS ...................................... 16 3.1 Background .................................................................................................................. 13 3.2 Problem Statement ....................................................................................................... 13 3.3 Objective ...................................................................................................................... 15

3.3.1

Scope..15

3.4 Methodology ................................................................................................................ 16 3.5 Personnel...................................................................................................................... 20 3.6 Work Plan and Time Line ............................................................................................ 20 3.7 Budget .......................................................................................................................... 21 C: THE SECTOR-LEVEL IMPACT OF HIV/AIDS IN NIGERIA ............................................. 22 4.1 Introduction.................................................................................................................. 22 4.2 Problem Statement ....................................................................................................... 24 4.3 Objectives .................................................................................................................... 24 4.4 Scope............................................................................................................................ 24 4.5 Methodology ................................................................................................................ 25 4.6 Data Analysis ............................................................................................................... 28 4.7 Research Team and competencies ............................................................................... 28 4.8 Work-plan .................................................................................................................... 29 4.9 Budget .......................................................................................................................... 29 D: THE IMPACT OF HIV/AIDS ON THE MACRO-ECONOMY ............................................. 30 5.1 Problem Statement ....................................................................................................... 30 5.2 Scope............................................................................................................................ 31 5.3 Methodology ................................................................................................................ 31 5.4 Key macro economic indicators................................................................................... 33 5.5 Data Sources ................................................................................................................ 34 5.6 Skills mix ..................................................................................................................... 34 5.7 Work Plan .................................................................................................................... 34 5.8 Budget .......................................................................................................................... 34

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REFERENCES.............................................................................................................................. 35 ANNEX I: CHECKLIST FOR AVAILABITY OF IMPACT DATA .......................................... 38 A1: Impact of the National Response on the Epidemic ............................................................ 38 A2: Cost Effectiveness Analysis of Interventions..................................................................... 39 B: Some Socioeconomic Indicators for Impact of HIV/AIDS on Households......................... 39 C: Socioeconomic Indicators for Impact of HIV/AIDS on Sectors .......................................... 41 D: Macroeconomic Indicators for Impact of HIV/AIDS .......................................................... 42

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LIST OF ACRONYMS
AIDS ART CIDA CiSHAN FSWs DALY DFID ENHANSE FMOH GBV GDP HDI HIPC EPP FDI FGD IBBSS IDU KII LACA LGA MIS NACA NASCP NDES NDHS NEPWHAN NSF NPC M&E MSM PEPFAR PLWHA PMTCT OND OVC HCT HIV SACA SIDA STI TB TFP UN UNAIDS USAID WHO Acquired Immune Deficiency Syndrome Antiretroviral therapy Canadian International Development Agency Civil Society for HIV/AIDS in Nigeria Female Sex Workers Disability Adjusted Life Years Department for International Development Enabling HIV and AIDS Tuberculosis and Social Sector Environment Federal Ministry of Health Gender Based Violence Gross Domestic Product Human Development index Heavily Indebted Poor Countries Estimates and Projections Package Foreign Direct Investment Focus Group Discussion HIV/STI Integrated Biological and Behavioural Surveillance Survey Intravenous Drug Users Key Informant Interview Local Government Action Committee on AIDS Local Government Area Management Information System National Action Committee on AIDS National AIDS and STD Control Programme National DHS EdData Survey Nigerian Demographic and Health Survey Network of People Living with HIV/AIDS in Nigeria National Strategic Framework National Population Commission Monitoring and Evaluation Men who have Sex with Men Presidents Emergency Plan for AIDS Relief People Living with HIV/AIDS Prevention of mother to child transmission of HIV Ordinary National Diploma Orphan and Vulnerable Children HIV counseling and Testing Human Immunodeficiency Virus State Action Committee on AIDS Swedish International Development Agency Sexually transmitted Infections Tuberculosis Total Factor Productivity United Nations Joint United Nations Programme on AIDS United States Agency for International Development World Health Organisation

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EXECUTIVE SUMMARY Introduction Data on the surveillance, epidemiology and demography of HIV/AIDS is considerable in Nigeria. However, there is little data about the impact of the national response, cost effectiveness of interventions, and the effects of the epidemic on households, sectors and macroeconomic levels. This document entails the scope of work for studies to establish outstanding data gaps on impact and cost effectiveness of interventions related to the HIV/AIDS epidemic. The results will inform stakeholders about the strategic areas to direct interventions and resources. The scope of work is broken down into the following three interconnected components: A: B: C: The impact of the national response on the HIV/AIDS epidemic in Nigeria The social and economic impact of the epidemic on households and communities in Nigeria The social and economic impact of the epidemic on selected sectors in Nigeria (Education, Health, Petroleum, Transportation, Uniformed services)

Each component explains the rationale, methodology, timeline and resources required. A: Impact of the National Response on the HIV/AIDS Epidemic in Nigeria The sub-study on impact of the national response will examine issues relating to growth of public sector structures to coordinate and manage the national response, policies and legislations, platforms for collaboration and networking, funding levels, as well as services and their coverage by program area. It will also examine the future course of the epidemic over a time period of 1015 years, and make projections based on the assumptions that prevention and care/treatment have taken place at minimal, medium and optimal levels. Based on these scenarios, it will be possible to estimate the number of HIV infections averted, AIDS-related deaths prevented, orphans and other outcomes. It is recommended that the study of the national response on the epidemic be simultaneously awarded to at least two different organizations to assist the country determine the validity of the results It is also recognised that the national response consists of prevention, care/treatment and social support interventions. There is considerable inflow of resources for HIV/AIDS from various development partners that according to most stakeholders consulted, are skewed towards treatment interventions. Nevertheless, there are challenges regarding allocation and utilisation/expenditure of these resources due to inadequate data on cost and expenditure with regards to general programme and various interventions, and the limited quantifiable data about the impact and appropriate mix of interventions in view of scarcity of resources. For this reason, a sub-study on cost effectiveness is recommended. However, this sub-study on cost effectiveness of interventions should be carried out later when some planned surveys e.g. the National AIDS Spending Assessment and HIV/AIDS Program Sustainability Analysis Tool (HAPSAT) have been concluded since these studies will generate some data that will be needed to successfully carry out the cost effectiveness study. Aside from fiscal data, the cost effectiveness study will also use appropriate models such as the epidemiological model to determine the combination of interventions that will yield the maximum impact using least resources, then recommend future areas of investments.

B: Socioeconomic Impact of HIV/AIDS on Households and Communities Research in Nigeria is limited to explain the dynamic effects of AIDS on households and communities in ways that can be generalized countrywide or used to inform appropriate interventions at community level. A community-based cross sectional design that uses survey, focus group discussions and key informant interviews will be used to examine issues such as: illness and death of family members, consumption patterns, nature of dependent pattern and production of orphans, changes in household structure and size. Also to be examined are, household expenditure and income, sale of household assets and time spent on production, household livelihood strategies and coping mechanisms possibly through child labour and receipts of assistance. Furthermore, children school enrolment, attendance, and drop out, children malnutrition and health care will be examined. The relative impact of the epidemic on rural and urban households, burden of care on women, gender equality and impacts on women, nature of and who make decisions on important family issues will be examined. Other issues to be addressed include the nature of social exclusion of households through perception of stigma, how assets are consumed in caring for the sick, community redistribution of wealth pattern, regional differences of impact of the epidemic, the existence and strength of family (including extended), changes in cropping pattern, changes in community structure, institutions, networks, migration, political and administrative process. Data will be obtained from representative samples of households and communities in one of the six states located in each of the six geo-political zones. These states should be selected considering HIV prevalence rates, urban and rural characteristics and any other key inclusion criteria. The study data collection approach is adopted to ensure triangulation of information as data are simultaneously collected on a large-scale basis in each of the zones. The impacts of the epidemic on households will be discerned by comparing households with chronic illness and death with households without such cases, households with AIDS with households with other diseases different from AIDS, and households with at least one orphan with households without such cases. Data obtained through focus group discussions and key informant interviews will be qualitatively analysed and used to augment survey results. C: Impact of HIV/AIDS at Sector Level Available literature on sectoral-level impact of the epidemic is from research done in other countries. These countries differ from Nigeria in terms of the nature of epidemic and socioeconomic setup. Some institutions have data that are essential for measuring: changes in the pattern of expenditure, staff morbidity, absenteeism, death, workload, turnover, morale, experience, efficiency, trainability, welfare benefits; and the changes in supply and demand of services, infrastructure and associated cost/expenditures. However, this data is usually collated in a manner that does not substantiate AIDS-related impact on the internal (workforce) and external (people served) domains. The sectoral AIDS impact study will focus on the internal and external environments of the health, education, petroleum sectors, transportation and the uniformed services especially as these sectors are likely to be significantly affected by the HIV/AIDS epidemic both in terms of susceptibility to new infections and vulnerability to the impact of the epidemic. This study will use institutional audit checklist, review of existing service records/data and key informant interviews to determine mainly the sectors level of preparedness to prevent new HIV

vi
infections and mitigate the epidemics impact on the sector. If records are available, the study will determine changes in institutions expenditure pattern and why, the kinds of people employed, particular groups of staff particularly exposed to infection and why, feasible actions for reducing staff exposure, number of staff in each category expected to be ill or die, ease in terms of cost and time of training or replacing various staff, ill/dead staff who are difficult to replace, availability of other staff to be retrained or take-up work, availability of capital to replace sick/dead staff, possibility of giving multiple skills to existing staff, availability of sick and compassionate leave, provision of medical services and other benefits to staff, staff mobility and absence from home for long durations of time, staff involvement in high-risk situations like war and accidents, staff propensity of illness and absenteeism, and employment terms that allow infected staff to work. Exit poll interviews may also be used to establish the impact of the epidemic on the key people served by selected institutions. Representative samples of institutions, employees and key groups served will be selected in each sector in a proportionate manner to allow analysis and generalization of results.

Timeline and estimated cost *The timeline and estimated cost of the four sub-studies is provided in the following table Timeline in Months Cost (US$) Study Component 1 2 3 4 5 6 7 8 9 10 11 12 A1: Impact of National Response A2: Cost Effectiveness of Interventions B: Impact on Households C: Impact on Sectors Total Estimate D: Study Coordination & Management (NACA) Meetings of the steering committee Meetings of the project advisory committee and project technical committee Hiring a data scout Periodic supervisory trips to the field E: Advocacy materials, Dissemination and Data use

669,300 145,236 501,500 363,836 1,679,872 88,993.6

5%

10%

167,987.2

*Steering Committee however approved 12 months

vii Next Steps Set up and inaugurate an SIS Management Committee(see TOR below) Set up and inaugurate a SIS Technical Committee. (see TOR below) Advert for RFP or B Set up Proposal Evaluation Committee: This will comprise of three members of the IRG, three members of the Scope of work development consultants, NACA, SFH, UNAIDS, NEPHWAN, CDC Contract preparation and Award Launch of Study Preparatory steps, Field work, Analysis, Report writing, validation, dissemination e.tc. MANAGEMENT AND COORDINATION OF THE SIS The SIS study will be managed by two key committees. A SIS study management committee (SMC) chaired by the NACA Director General and comprising of representation from the relevant key stakeholders (USAID, DFID, UNAIDS, UNDP, SFH, NEPWHAN, CISHNAN, relevant Federal line ministries and 2 SACAs) will be responsible for providing oversight for the study. The SMC will comprise of decision makers and heads of selected organizations. In addition, an SIS Technical Committee (SIS TC) that will be chaired by NACA will provide technical day-to-day management for the study. The SISTC will include technical leads and technical advisors of research/evaluation units of key stakeholders and implementing partners in the country e.g. FHI, APIN, ACTIONAID, NPOPC among others. Terms of reference for the SIS SMC Coordinate activities of the SIS Hold quarterly meetings or as the need arises and attend to issues pertaining to the study. To ensure that adequate advocacy is put in place for the study. Ensure that the study protocols and timelines are strictly adhered to Guide the technical committee and the SIS team on the conduct of the survey

Terms of reference for the SIS Technical Committee Provide oversight on technical issues related to the study Hold monthly meetings as contained in the study timeline or as the need arise and attend to issues pertaining to the study. Update the SIS management committee quarterly on progress made with the study Ensure strict adherence to the study protocol at all times Participate in the supervision of the data collection exercise Coordinate findings from the field and correct discrepancy where it exists

viii Ensure that a technical report on the survey is produced and disseminated

In addition to the above mentioned committees an SIS secretariat shall be established and domiciled in NACA to further provide logistic support and help with coordination of the study. The Research and Evaluation team in the Strategic Knowledge Directorate of NACA will man the SIS secretariat.

EVALUATION OF PROPOSALS FOR THE SIS Preparatory to award of contract to successful bidders a SIS Proposal Evaluation Committee will be set up to review all proposals received for the conduct of the study. The membership of the committee shall be as follows 3members of the International Review Group, 3 members from the team that developed the SIS Scope of work 1 representative each from NACA, SFH, UNAIDS, NEPHWAN and CDC Terms of Reference for the SIS Proposal Evaluation Committee Develop criteria for assessing proposals received for the SIS Assess the quality and merit of proposals submitted for the study Select successful organizations that will conduct the SIS

INTRODUCTION 1.1 Background Nigeria, lies between 416 and 1353 north latitude and between 240 and 1441 east longitude. The country is in the West Africa sub region and is bordered by Niger in the north, Chad in the northeast, Cameroon in the east and Benin in the west. To the south, Nigeria is bordered by approximately 800 kilometers of the Atlantic Ocean. Nigeria, the most populous country in sub-Saharan Africa has a land area of 923,768 square kilometers. The 2006 National Census estimates the countrys population to be 140 million. Approximately two-thirds of the population lives in rural areas that lack modern amenities in most cases. The National Population Commission defines rural areas as single geographic settings or communities with a population of less than 20,000 persons A case of AIDS was first reported in Nigeria in 1986 and the epidemic from thence had grown rapidly until 2001 when a decline in HIV prevalence was first noticed. The HIV prevalence in Nigeria rose from 1.8% in 1991, through 3.8% in 1994, 4.5% in 1996, 5.4% in 1999 to 5.8% in 2001. Thereafter, a decline was noticed as the prevalence dropped through 5.0% in 2003 to 4.4% in 2005 and currently stabilized at 4.6%. Using the estimates and projections package (EPP) 8, the number of people living in Nigeria with HIV infection was put at 3.86 million in 2005. About 296,000 new adult and 74,000 childhood HIV infections occurred in 2005, while 138,000 AIDS cases were estimated to have occurred during the same period. It was estimated that just over 500,000 persons living with HIV require ART while about 74,000 HIV+ births took place in 2005. The number of deaths due to AIDS was estimated to be 221,000 in 2005 while the cumulative deaths due to AIDS was estimated to be 1,450,000.8 Heterosexual intercourse constitutes the main mode of HIV transmission in Nigeria. At this stage of the HIV and AIDS epidemic in Nigeria, there are no obvious signs yet that the vibrancy and pulse of the countrys social and economic life is being affected by the epidemic. This lends credence to the fact that because the HIV and AIDS epidemic is a slow wave event which begins to exert its impact first at the individual and household levels and gradually but steadily walks its way up the sectoral and state levels, its impact on national life and its production processes and systems is not easy to see except one looks for it. As it is the case with many countries, Nigeria has and continues to respond to the epidemic. The national response to the epidemic has spanned over two decades and became particularly intense in the last five to six years. Just as no one can ascertain the socio-economic impact of HIV/AIDS in Nigeria at this point, the impact of the national response on the course of the epidemic is largely unknown.

2 However, regardless of the commendable efforts to date to control the HIV and AIDS epidemic in the country, we are yet to provide verifiable and convincing answers to the following three questions: Are we doing the right things? We need to look at our goals, objectives and targets both in terms of sub-population segments and service coverage. Do our goals and objective cover relevant areas in the entire spectrum of prevention to treatment/care continuum, and have we targeted those sub-populations that are most susceptible, most vulnerable and most at risk? These are some of the issues we need to look at with respect to the question above. Are we doing it right? If we are doing the right things, are we employing the right program design, implementation, monitoring and evaluation strategies and methods that enable us to reach as many people as possible in the shortest possible time frame and in the most cost effective manner? Are we doing enough to make a difference? If we are doing the right things and doing them right, are we doing them enough to halt and reverse the epidemic both in terms of preventing new HIV infections and mitigating its impact on individuals, families and communities? Are our interventions comprehensive and robust enough to achieve the desired results?

In order to fully understand the epidemic and respond appropriately to it, this study will be commissioned not only to assess the socio-economic impact of the epidemic at the household, sectoral and macroeconomic levels, but also to determine the impact of the national response on the course of the epidemic and the cost effectiveness of different combinations of preventive and care and treatment interventions. In other words, this study will help us answer the three questions above: Are we doing the right things, are we doing them right and are we doing enough to make a difference. 1.2 Objectives

The aim of the study is to fully describe the epidemic and the response with the view to improve future prevention and impact mitigation interventions using the most cost effective combination of preventive and care and treatment strategies; and generate persuasive advocacy materials for mobilization of more political support and commitment nationally and internationally. The specific objectives of the study are to: Assess the impact of the multisectoral national response towards achieving the goals of the National Strategic Framework for HIV and AIDS (NSF). Determine in broad terms the amount of resources spent on HIV and AIDS, including cost of different interventions Analyse the impact of the disease on Sectoral and National Development. Collate data and develop baseline impact indicators for future monitoring and evaluation.

3 1.3 Make recommendations to enhance the national response. Justification

Data on the surveillance, epidemiology and demography of HIV/AIDS is considerable in Nigeria. However, there is little data about the impact of the national response, cost effectiveness of interventions, and the effects of the epidemic on households, sectors and macroeconomic levels. This document entails the scope of work of studies that ought to be done to fill outstanding data gaps on impact and cost effectiveness of interventions related to the HIV/AIDS epidemic. The results will inform stakeholders about the strategic areas to direct interventions and resources. 1.4 Report Structure

This scope of work is broken down into the following three components: A1: The impact of the national response on the epidemic A2: Cost effectiveness of interventions B: The social and economic impact of the epidemic on households and Communities in Nigeria C: The social and economic impact of the epidemic on selected sectors in Nigeria Each component explains the rationale, methodology, timeline and resources required. Component A will consist of two interconnected sub-studies i.e. impact of the national response and cost effectiveness of interventions. A1: IMPACT OF THE NATIONAL RESPONSE ON THE EPIDEMIC 2.1 Problem Statement

It is recognized that the national response began in the early 80s and was health sector based. The National AIDS/STD Control Program (now the HIV/AIDS division of the Federal Ministry of Health) was established to coordinate the national response. In 2000, the National Agency for the Control of AIDS (NACA) was established to coordinate the countrys multisectoral response. States and Local Government Action Committees on AIDS (SACAs and LACAs respectively) were also established to coordinate respectively states and local government areas responses to HIV/AIDS. A national policy and several sectoral policies and guidelines have been developed to create the required enabling environment to address HIV/AIDS. All response inputs are guided by the National Strategic Framework for Action and the guidelines on the different thematic areas which include behaviour change interventions, HIV counseling and testing, prevention of mother to child transmission, palliative care, anti-retroviral therapy among others.

4 Working through several collaborative platforms, both bilateral (PEPFAR, DFID, CIDA, JICA) and multilateral (the UN family including the World Bank) agencies as well as Foundations (Ford foundation, Clinton HIV/AIDS foundation, Bill and Melinda Gates foundation) continue to support Nigerias response to HIV and AIDS. The response consists of a battery of interventions that are aimed at reducing HIV incidence and prevalence, strengthening access to care and treatment, and mitigating the health and socioeconomic effects of the epidemic at various levels. But what have we achieved so far? What is the impact of our interventions so far? To directly answer these questions we need to use the current situation of the epidemic to make a projection of where we will be in the next 10-15 years and compare our findings with similar projections based on a no response and an optimum response scenarios. The difference between the projection based on our current situation and that based on a no response scenario represents the impact of the national response while the difference between the projection based on our current situation and that based on an optimum response scenario represents the window of opportunities for an improved national response. It has been noted that data on the surveillance, epidemiology and demography of HIV/AIDS is considerable in Nigeria. However, there is little data on the impact of the national response on the course of the HIV and AIDS epidemic, and cost effectiveness of interventions. This part of study will therefore examine issues relating to: Growth of public sector institutions to coordinate and manage the national response, policies and legislations, and platforms for collaboration and networking; How much funds are allocated to and spent on HIV/AIDS nationwide, financial inputs of the different key players and disaggregate funding by intervention category i.e. prevention, care and treatment and social support in order to give a sense of total spending on each category; Achievements on various aspects such as ART/PMTCT/HCT centers established and clients reached, number of persons reached with both AB and Non-AB prevention messages, and link these outputs to the recently observed progressive decline of the national median HIV prevalence. The factors that affect the susceptibility of individuals, families and communities to HIV infection Factors that affect the vulnerability of families, businesses and communities to HIV infection by considering the extent to which excess morbidity and mortality due to HIV/AIDS will have adverse effects to any social or economic entity; and Main challenges of the response especially in terms of resource gaps, little or no political support and commitments from the state and local government areas, the program mix and coverage between those targeting population segments considered low risk and those targeting most at risk populations continues to be a challenge, and the right balance between investments in prevention, care/treatment and social support

5 2.2 Methodology

The methodology will be mainly through desk review, secondary analysis of existing data, as well as interviews with key stakeholders at the federal, state and LGA levels. Where data does not exist the research work may also include primary collection of limited data. Data should be analyzed using both quantitative and qualitative methods. At the federal level, main stakeholders to interview will include, NACA, key federal line ministries, the HIV/AIDS division of the federal ministry of health, bilateral agencies (PEPFAR, DFID, JICA, CIDA,) and their implementing partners, multilateral agencies (the United Nations family group including the World Bank), Foundations (Ford Foundation, Clinton HIV/AIDS Foundation) and key civil society organizations (CiSHAN, NEPWHAN, ARN). The inclusion criteria for states and LGAs comprise the geopolitical zones, HIV Prevalence, urban/rural status and senatorial districts. Two states are to be selected from each geopolitical zone the state with the highest HIV prevalence and the one with the lowest HIV prevalence. In each state, two LGAs within the state capital representing the urban settings and three true rural LGAs, one from each of the three senatorial districts will be selected. Literature and materials relevant to these states and LGAs will be reviewed, their respective SACAs, LACAs and the development partners working in such states and LGAs interviewed to get a feel of the number, program focus and scope of HIV/AIDS projects/services being implemented/provided in the state and LGAs. The HIV/AIDS knowledge, attitude, behaviour and practices of different groups should be assessed through literature review and interviews with key stakeholders including PLWHAs and most at risk sub-populations. The state level work will also include interviews with organizations directly involved in implementing prevention, treatment, care and support interventions to determine their view points 2.3 Objectives

The study will use appropriate data to determine the effectiveness of the national response on the goals and targets of the NSF which include: Reduction in transmission of HIV infection Improved survival of persons with advanced HIV infection The study will also look at the above issues in-depth in a manner that will include: the tracking and disbursement of government and donor funds on HIV/AIDS programming; an understanding of the resource allocation to the various components/ programmes that constitute the national response

6 a broad mapping exercise designed to understand the scale of the national AIDS funding mechanism, equity of interventions and identify effective means of coordinating the several response inputs including donor activities. treatment success, adherence and resistance issues etc; and identifying the core drivers of the HIV/AIDS epidemic(s) in Nigeria

After reviewing the status of the HIV/AIDS epidemic from the standpoint of available hard data, it is important to utilize a projection model to generate more information and data on the disease burden and its epidemiologic and demographic impacts over a time period of 10-15 years. The study should therefore use appropriate data and projection packages to estimate the effects of the national response on the goals and targets of the NSF. By assuming that prevention and care/treatment have taken place at minimal and optimal levels and comparing such projections with the one based on our current situation, it will be possible to estimate the number of HIV infections averted, AIDS-related deaths prevented, orphans and other outcomes. In order to ensure that analysis captures sub-epidemics within the national epidemic, projections will need to be made for two states in each of the six geopolitical zones in addition to the national projection. The two states in each of the geopolitical zone will include the state with the highest HIV prevalence and that with the lowest prevalence. However, state selection will also depend on availability of data. The quality of the data generated through the projection models is only as good as the demographic and epidemiologic data inputs. Therefore sources of data must be credible, and as representative and reliable as possible. Some of the data usually needed to make epidemiologic and demographic projections include: 2.4 Current population size broken down by age and gender Current fertility, mortality and migration rates and assumptions on future trends Current HIV prevalence and assumptions about future trends Assumptions about variables such as HIV incubation period, perinatal transmission rates, age and sex distribution of new transmissions, and the start year of the epidemic. Size and risk profile of various high risk groups Data Sources

The sources of such data include the following: AIDS case data (HIV/AIDS Division, FMOH), The National HIV/STI Sentinel Surveillance Surveys Among Blood Donors, STI patients, TB Patients and Mothers Attending Ante-Natal Clinic (1991, 1994, 1996, 1999, 2001, 2003, 2005) The National behaviour surveillance survey (2005), NARHS+2008

7 2.5 The Integrated Bio-Behavioural Surveillance Survey (2007), the National HIV/AIDS and Reproductive Health Surveys (2003, 2005), The NDHS (2003 & 2005; 2008 will be shortly available), The Nigerian Population and Census Report (2006) The National HIV/STI Sentinel Surveillance Survey among Pregnant Mothers Attending Ante-Natal Clinic (2008). State level behavioral surveys amongst the general population and the high risk groups Skills Mix

The following expertise is required to execute this study: Epidemiologist with HIV/AIDS and Public Health expertise; Demographer; Social scientist and Economist. Provision should also be made for persons who will facilitate the collection of relevant data from various sources (Data scout or vanguard). The importance of anti-retroviral therapy in mitigating the impact of the epidemic on individuals, families and communities cannot be over-emphasized. However, emergence and significant levels of viral resistance can torpedo the noble objectives of ART, and make the ART programme in particular and the fight against the epidemic, unsustainable. As a result it is recommended that the ART programme in Nigeria be appraised to address such issues as coverage, drug availability, drug compliance/adherence, effects of rapid/slow expansion of the programme on emergence of viral resistance etc. Thorough literature search on ART best practices should be conducted and its findings be used not only as benchmarks for assessing the national ART programme but serve as guides for programme improvement

2.6 Activities

Timeline Months 1 2 3 4 5 6 7 8 9 10

11

12

Advocacy to increase stakeholder buy-in Advertisement and bidding for SIS and Implementation Selection and award of SIS and Implementation contract Training of interviewers Desk review including ART program appraisal, field visits and interviews Data management Report writing Report dissemination, advocacy and visits to mobilize more support

8 2.7 Budget

A2: COST-EFFECTIVENESS OF HIV/AIDS INTERVENTIONS Four Studies preparatory to A2 1. HAPSAT- USAID Health System 2020 2. NASA- UNAIDS/UNDP 3. Evaluation of National ART Program 4. Evaluation of National Prevention program To only be commenced after preliminary reports from the study on impact of the national response on the epidemic have been released and the national working group determines that there are enough data and information for a costeffectiveness study. Perhaps Nigeria may consider conducting this study when National AIDS spending Assessment (NASA) data becomes available

While it recommended that the cost effectiveness study be carried out later, it is important to determine at the moment: 1. The sustainability of current and planned interventions especially against the background of dwindling resources occasioned by the gradual shift of attention to other global issues like climate change, renewable energy, the recent global economic meltdown and donor fatigue 2. Funds flow and recommend mechanisms for improved allocation and utilization of both internally and externally generated resources. Since the cost effectiveness study will take place although later, its scope of work below has been deliberately preserved to serve as a ready guide and reference for the conduct of the study subsequently 2.1 Problem Statement

With the major burden of the HIV/AIDS epidemic falling on resource poor nations the necessity for low-cost, effective interventions are vital. However, to achieve costeffectiveness the costs and consequences of the initiatives proposed must be known to the decision-makers to make the best use of scarce resources. This is not only true for interventions in the same type of category, but also when it comes to the relative efficiency of a combination of prevention, care, treatment and impact mitigation interventions, to achieve an optimal mix that matches the stage of the countrys epidemic. Allocating limited resources among programmes often presents a challenge to policymakers and planners since a great number of factors except cost considerations influence priority setting and contribute to this decision. Such factors include concerns of sensitivity, acceptability, and equity and efficiency.1 For HIV/AIDS in particular, arguments have been made in support of general or specific interventions strategies based on ethical criteria and human rights. Other important requirements that need to be in
1

This challenge is many times also compounded by the fact that the resources provided are time-bound, whereby it might not be enough time to properly consider what is the most cost-effective strategy mix.

10 place for an efficient implementation of the national response to the epidemic include managerial structures, political commitment, infrastructure and human resources. In Nigeria, the national response to the epidemic consists of a wide range of interventions primarily focusing on prevention and treatment interventions, with the bulk of funding in 2007 coming from donors targeted at treatment interventions (Source: Key informant interviews and estimates from the costing of the National Strategic Framework (NSF)). However, previous research shows that an optimal allocation of resources requires a balanced combination of prevention and treatment interventions, which is true both from a strict cost-efficiency as well as a health perspective (e.g. Hogan et al., 2005 and 2004; Canning et al., Salomon et al., 2005). Nevertheless, exactly how this combination is to be balanced in Nigeria still remains to be answered. Literature focusing on low-income countries with a similar prevalence levels to Nigeria, however, suggests that there is a great need to address HIV prevention in Nigeria since the highest HIV incidence is found among the general population (e.g. Canning et al., 2004). As a result thereof a comprehensive and standardized analysis of available interventions, singly and in different combinations is necessary. Some of the major challenges facing the stakeholders responsible for the national response to HIV/AIDS in Nigeria when it comes to cost of interventions and efficient resource allocations are: Inadequate data on cost and expenditure regarding the programs and various interventions Quantitative impact measures of interventions are absent Attributing impact between a number of concurrent interventions to come up with the optimal and most cost-effective and health oriented mix of interventions, given the limited resources available.

2.2 Objectives The purpose of the study is to determine the combination of interventions in the national response that will yield the maximum impact using the least resources and recommend future areas of investments that will lead to the most desirable outputs both from a costefficiency and national health point of view. This part of the study analyses cost-effectiveness based on an epidemiological costeffectiveness model: 1. To identify the optimal mix of a number of selected prevention and treatment interventions, in both costs and health impacts; 2. Determine the sustainability of current and planned interventions especially against the background of dwindling resources occasioned by the gradual shift of attention to other global issues like climate change, renewable energy, the recent global economic meltdown and donor fatigue 3. Study Funds Flow and recommend mechanisms for improved allocation and utilization of both internally and externally generated resources

11

2B.3

Methodology

The following procedures will be followed to perform a cost-effectiveness analysis: Establish the appropriate level of analysis. For example, establish whether the analysis is going to be conducted at a national level, and/or on state and local levels, explaining the rationale for the chosen design and noting the advantages and disadvantages of the rejected and accepted scale of the proposed studies.. Define and select interventions to be included in the analysis, see Annex A Interventions. Assess all the interventions included and their combinations assuming that they are implemented for a preset number of years, for example ten years, set to a specific start year (base year). Include all resources used for each intervention, or a combination of interventions, and assign them with values. This assessment also needs to be based on a related assessment of the cost for each of the interventions or their combinations 2 . Classify and measure costs. Use a standardized approach to measure costs, requiring information on the quantities of physical inputs needed per intervention and their unit cost. Thereafter, total costs can be derived based on the quantities of inputs multiplied by their respective unit costs (Evans D.B et al., 2005). The unit costs for each input can in turn potentially be derived from the household survey described in a later section, key informant interviews as well as through a comparison with an existing database (e.g. www.who/int). In addition, make sure that costs are evaluated by assuming a percentage use of capacity for all interventions, which is to be based on epidemiological data. Moreover, standardized approaches for discounting future costs to the selected base year value should be applied. Establish plausible ranges for the epidemiological model parameters by reviewing relevant published studies and survey results for the Nigerian context. Potentially, use baseline prevalence projections from available sources (e.g. UNAIDS and WHO) to calibrate key parameter values for Nigeria. Undertake a number of epidemiological simulations by sampling values from each of the ranges. Thereafter, compare each simulation against the baseline projection of prevalence by gender and fit the model accordingly. It would be advisable for the researchers assigned to undertake this study mission to examine the usefulness of a number of comprehensive, tried and tested projection models. Thereafter, and in a second step, it would be suitable, based on this analysis of the existent models, to make a comparison of these to determine which of the models would be best to use for the purpose of this study. Assess the impact of interventions and their combinations (incrementally) against a no intervention scenario (defined by considering what would happen to the

When several interventions are combined it is important to identify possible shared costs to avoid double counting as some of the interventions may share available resources that should be reflected in a lower cost.

12 assessed populations health if they were put to zero today, i.e. setting the impact of all the key interventions to zero). This is called the null or do nothing scenario and is to be used as a baseline. After doing this, it is now possible to follow the impact of the population over time assuming that all interventions have ceased, using information on epidemiology and the assumed current coverage of interventions. Subsequently, trace the implications for the population health of adding all possible interventions, singly and in various combinations, against the baseline scenario. The difference experienced can thereafter be measured as the gain in health due to the reduction in disease burden from the interventions (DALY gained) (e.g. Evans DB. et al., 2005; Hogan et al., 2005). Next, the cost of each scenario is to be compared with the gain to identify the most cost-effective set of interventions at different levels of resource availability. Moreover, the comparison of the current mix against the optimal set for the resources currently available shows areas of inefficiency. Sensitivity and uncertainty analysis and the interpretation of results is the final step of this analysis. Given that a cost-effectiveness analysis is far from being an exact science it is vital that the results obtained are to be interpreted very carefully. This is particularly the case when the in-data used are limited or is otherwise deemed to be of poor quality. The rigorous sensitivity analysis should be performed as the last step of the exercise by adding varying uncertain assumptions for the parameters included in the model. Data requirements

2.4

Economic data: Yearly costs of interventions (assumed or preferably actual), data on the costs incurred by people to access the interventions such as travel costs (data gap), patient and programme level costs of each intervention based on available data and in the case of the patient cost (and potentially by the help of the household survey). The analysis need to include the unit level cost for each input at this level in addition to consultations with programme managers. In addition, for probability reasons a comparison can also be made with the unit costs in the existing database that is available at www.who.int/choice (Evans, et al., 2005). To obtain programme level costs data also needs to be collected on the physical inputs, such as human resources, office space, vehicles, electricity, other services and consumables. This information can perhaps be gathered in a survey and be supplemented by programme managers responsible for various interventions in Nigeria. Epidemiological data: The model needs to include information on (assumed or actual) coverage levels of the various interventions included in the model, underlying demographic data, statistics on the acquisition of HIV and other sexually transmitted infections (STIs), progression from HIV to AIDS and from AIDS to death, annual risks of HIV infection in each risk group to be studied (depending on the number of partnerships, sex acts per partnership, HIV prevalence among partners and condom use).

13

2.5

Indicators

Based on the desk review of strategic documents and consultations with key stakeholders it is recommended that a number of key interventions most relevant to the Nigerian setting, in terms of having a generalized epidemic where transmission occurs primarily through heterosexual contact. These interventions are separated into prevention and treatment respectively and are to be included in the combined cost-effectiveness analysis and epidemiological model. 2.6 Determine the sustainability of current and planned interventions especially against the background of dwindling resources occasioned by the gradual shift of attention to other global issues like climate change, renewable energy, the recent global economic meltdown and donor fatigue It is important to determine the scope of programs and interventions that could be fully supported with resources from government and indigenous communities alone (excluding donor funding). This entails the steady but gradual take over of donor supported activities, thus sources and mechanisms for the required budgetary increments need to be identified. Desk review of socio-economic, fiscal, programmatic, and other relevant data will be conducted as well as interview of key relevant personnel and individuals at the three tiers of government and communities including NGOs. Inclusion criteria for states and local government areas will be determined 2.7 Study Funds Flow and recommend mechanisms for improved allocation and utilization of both internally and externally generated resources. This study will be carried out at the Federal, State and Local Government Area levels. This will entail knowing how much funds come in, how they are allocated and spent and the bottlenecks that exist within the present funds flow system. Recommendations on how to improve the flow mechanisms/system are key deliverables Review of legislative, policy, fiscal and other relevant information and data will be carried out as well as interview of key relevant personnel and individuals at the three tiers of government, and communities including NGOs. Inclusion criteria for states and local government areas will be determined

14

2.8

Skills mix

Economist Education: M. Sc Degree in Economics, preferably higher. 5 years executive / consultancy report writing experience including technical writing preferably with previous experience of working with HIV/AIDS impact assessments. High level presentation, facilitating, communication and reporting skills Computer literate with skills in Microsoft Suite (Power Point, Word and Excel) and in performing projections (e.g. using SPECTRUM). Strong interpersonal skills and ability to work as a team player in a developing country Excellent written and verbal communication skills Capacity to deal with conflicting priorities and deliver high quality work on schedule Previous experience of and ability to work in a multicultural environment

Assistant Economist Education: M. Sc Degree in Economics. At least two years working experience, including searching, compilation and analysis of economic and financial data and report writing. Verbal and written communication skills. Strong interpersonal skills and experience to work in a focused and disciplined way according to a tight time plan and in developing countries, preferably in Nigeria. Additional: A person with an eye for detail, fluency in English and preferably in additional Nigerian languages.

Epidemiologist Experience: Over ten years of HIV/AIDS program design, implementation, and monitoring and evaluation experience. Strong analytic skills, using epidemiologic and bio- or medical statistic tools. High-level presentation, facilitating, communication and reporting skills. Computer literate with skills in Microsoft Suite (Power Point, Word and Excel) and in performing projections (e.g. using SPECTRUM). Strong interpersonal skills and ability to work as a team player in a developing country Excellent written and verbal communication skills. Capacity to deal with conflicting priorities and timely delivery of high quality work.

15 2B.7 Previous experience of and ability to work in a multicultural environment. Budget

16

B: SOCIOECONOMIC IMPACT OF HIV/AIDS ON HOUSEHOLDS 3.1 Background Standard AIDS response recommendations, and even Nigerian government national response strategy, explicitly indicate that an effective way to minimize the burden of the epidemic is to mitigate its impact on the population. The contents of such mitigation programmes will commonly include efforts that target PLWHAs and others that are affected by the epidemic especially at household and community levels. Available research conducted in Nigeria and elsewhere on the socio-economic impacts of HIV/AIDS on households has been limited to explain the dynamic effects of AIDS on households and communities in ways that can be generalized countrywide. Evidence of the epidemic impact on households is scanty in health and AIDS related official study reports in Nigeria. Results of national studies that include DHS, NARHS, IBBSS, and various HIV sero-prevalence surveillance studies are focussed mainly on individual-level risk and susceptibility indicators. They have shown impressive understanding of how factors such as knowledge, attitudes, beliefs and practices predispose individuals to contract HIV in various populations in the country. Even information is available on HIV prevalence in ways that explain trends over a period. It has become increasingly clear from the reports how the epidemic has unfolded over the past two decades and the likelihood that the effect of the epidemic will be massive in communities. However, the reports lack precise information about how the epidemic impacts on households and communities. Few unofficial studies supported by development partners are reported in three states in Nigeria- Oyo, Plateau and Benue - that examined the impact of HIV/AIDS on health care utilization and expenditure by comparing PLWHAs with non PLWHAs in households (Canning et. al, 2006; Hilhorst et. al., 2006). Findings showed a noticeable increase in morbidity, higher healthcare facility use mostly through out-of-pocket finances and increased time lost from work among PLWHAs compared with non PLWHAs. Similarly few studies elsewhere in sub-Saharan Africa and outside the continent have shown an impact of HIV on a wide variety of social and economic outcomes at the household level. The studies generally report a number of negative impacts such as: reduction in household income, severe difficulties in health care seeking that often culminate in increased expenditure on health consumption, lowering productivity, excess mortality in the most economically active age group, lost time due to mourning and funeral, strong tendency for households to transform from wealth to poverty, rapid changes in household composition, and various asset liquidation. 3.2 Problem Statement Although the previous studies offer interesting analytical and conceptual insights, these can be improved upon as they are currently limited for national planning and mitigation of HIV/ AIDS at the household and community levels in Nigeria. Below are highlights of some important data gap that necessitate the conduct of a study on the epidemic impact on households and communities.

17 Findings that emerge elsewhere outside the country are doubtful on how they can generally explain the impact in Nigeria. Many of the studies have populations with different household and community cultural disparities from many Nigerian population groups. The studies are also mostly conducted in countries with advanced epidemics and at intervention levels at a scale different from many Nigerian communities. The foreign countries have their own peculiar contexts, it may be misleading to use their epidemic impact findings to accurately plan for other countries such as Nigeria (Barnett & Whiteside, 2002). Existing studies within Nigeria also offer contributions in the area of HIV household impact analysis. However they have limited national coverage in their sample populations. The epidemic impact findings are predominantly restricted to information on adults in north central parts of the country and to a lesser extent to other culturally diverse localities of the country where the epidemic exists. The dearth of data on the impact of the epidemic in households in other parts of the country is worrisome given the twin knowledge that impact mitigation interventions are more effective when culturally sensitive, and that cultural characteristics are important variables in optimizing the prevention and treatment of HIV and AIDS. There is limited focus of existing studies on the epidemic impact on women. Given that the global burden of the epidemic is more on women, information is crucial about the impact of the epidemic on their livelihoods in the contexts of their greater vulnerabilities to HIV especially through various cultural factors and economic marginalization. Gender-based violence (GBV) is linked to the spread of HIV. It can also be a contributing factor to impact of HIV on women. It is crucial to assess the impact of the epidemic on women through GBV. Little information is also available about the impact of the epidemic on children. It is a priority to investigate how HIV impacts on children on such outcomes as their well-being, schooling, illness, and death. It is also crucial to understand livelihood strategies that are employed in caring for children and family survival in HIV infected households. It is not clear whether and how the children play economic roles to generate income for the family. Similar empirical concern is the dearth of information about the differential consequences of becoming an orphan from death of one or both parents. Another important area of impact where there is a little understanding in Nigeria is the viability of households where there are HIV infections. Studies are required to provide knowledge on the dynamics of household sustainability or dissolution in the event of HIV/AIDS. Of significant concern also is the lack of adequate data on community response to HIV and AIDS following an aggregate impact of the epidemic in such community households. Evidence currently suggests that the impact on households can be severe, it can be speculated that such impacts may threaten the social and economic structures of the community. This may even be more serious in rural communities and urban centres with fragile economies. Current data are uncertain in many respects such as on: how communities respond to share the burden of the epidemic that occur at household levels, the nature of social networks and solidarity that may emerge, and the viability of such communities especially in high prevalence epidemic areas. It is also recognized

18 that communities will adopt coping mechanisms to sustain the communal living and minimize the impacts of the epidemic. The nature of such mechanisms is unclear, especially with regard to how social structures and institutions are transformed in the face of accelerating illnesses and even death occurrences. Studies are yet required to give adequate picture of community institutional capacity and patterns of migration that occur in the event of AIDS impact. It is still unclear the kind of transformations that take place particularly in local community leaderships, availability of personnel to continue in administrative capacities, changes that take place to cropping systems, and impact of AIDS on political processes. 3.3 Goal The ultimate goal of the proposed study is to obtain a clear understanding of the impact of HIV and AIDS on households and communities in Nigeria. Accordingly the study will create a valid foundation of knowledge for informed policies and programmes that facilitate the capacity for appropriate national response to consequences of HIV and AIDS. To accomplish the goal, the aim of the proposed study is to obtain empirical evidence on the impact of HIV and AIDS on households especially as they affect the following: household expenditure; household income; household gender relationships, including women and children; household asset; household health and illness; and household and community viability. 3.3.1 Scope The proposed study will provide holistic picture of household and community impacts of the epidemic taking into consideration the practical value of data that have representative validity to diverse epidemic settings in six geo-political zones of the country, and that can inform appropriate HIV mitigation policy and programmatic actions. The study will describe, analyse and make inference about the interplay of indicators on how the epidemic impacts on households and communities in Nigeria. The study will seek evidence on how the epidemic affects households through such outcomes like: illness and death of family members, consumption patterns, nature of dependent pattern and production of orphans, household expenditure and income, sale of household assets and time spent on production, household livelihood strategies and coping mechanisms possibly through child labour and receipts of assistance, children school enrolment, attendance, and drop out, children malnutrition and health care, relative impact of the epidemic on rural and urban households, burden of care on women, role of GBV in the way HIV impacts on women, nature of and who make decisions on important family issues, nature of social exclusion of households through perception of stigma, how assets are consumed in caring for the sick, community redistribution of wealth pattern, regional differences of impact of the epidemic, the existence and strength of family (including extended) and community networks to cope with AIDS. 3.3.2 Objectives The objectives of the study amongst others will include:

19 1. To determine the present circumstances of persons infected or affected by HIV in comparison with persons not directly affected within households 2. To determine the effect of the epidemic and the national response to HIV and AIDS 3. To determine the effect of the HIV/AIDS epidemic on the communities with high HIV/AIDS burden 4. To identify community coping mechanisms developed as a response to their circumstances 5. To identify best practices in communities readjustment systems that may be replicable elsewhere Outcomes to be investigated will include poverty, orphaning, quality of life, stigma, education, further HIV transmission, vulnerability, role change, gender issues, and changes in communitys socio-economic balance and traditional wealth. They should also include any positive effects that may have occurred as a result of community coping mechanisms, community insurance mechanisms, fostering, adoption, social security structures, positive effects on harmful socio-cultural practices, and gender relations

3.4 Methodology
3.4.1 Community based cross sectional design The outline of the study method was developed in close consultations with national HIV and AIDS stakeholders, sector officials, and development partners. Most of them already work in states and local communities, and have participated in various health related research in the country. The study design in addition was developed on the basis of empirical literature on impact studies within and outside the country. The study will combine both quantitative and qualitative approaches to examine the impact of the epidemic on households and communities in six geo-political zones of the country. The study data collection approach is adopted to ensure triangulation of information as data are simultaneously collected on a large scale basis in each of the zones. A community-based cross sectional design that consists of a survey will be used to collect data in the quantitative component while focus group discussions and key informant interviews will be used to obtain data in the qualitative component. Study Area and Sampling A total of six states Benue, Lagos, Enugu, Akwa Ibom, Taraba, and Kano- are purposively selected. They are selected on the basis of an inclusion criterion of one state with high HIV prevalence from each of the six geopolitical zones. Study LGAs, communities, and households will be randomly selected from the states on the basis of other criteria as urban-rural, socio-economic, and burden of AIDS characteristics. The survey will be conducted in the six states. A stratified multistage clustered probability sampling will be adopted to obtain a representative sampling of households in the selected states. The multistage sampling process is described below. In stage 1, a sampling frame of all the LGAs in each of the states will be obtained and stratified into urban and rural areas. Three rural and two urban LGAs will be obtained.

20 States are statutorily divided into three senatorial districts. One rural LGA will be selected from each of the senatorial districts, and at least one or both of the two urban LGAs will be selected from the capital city of the states. All the LGAs will be purposively selected on the basis of evidence of burden of AIDS. Undoubtedly AIDS is still being stigmatised in many Nigerian communities. Three proxy indicators will be used that will be indicative of AIDS burden. The indicators are 1) Recent deaths of young adults (15-49 years in the previous 5years), 2) Cases of chronic illness of adults that impairs occupational functioning, 3) number of orphans (one or two parents). The proxy indicators will be used to elicit responses from State Health Management Boards and relevant stakeholders who work in communities. LGAs will be selected when observation shows that they have preponderance of populations of inhabitants according to the three indicators. The proxy indicators are found useful in previous impact studies in Benue Nigeria. In stage 2, enumeration areas (EAs) will be randomly selected from each LGA. This will be consistent with the National Population Commission (NPC) record of enumeration areas. In stage 3, houses will be numbered within the EAs. Systematic random sampling will be employed to select from the houses in the EAs. In stage 4, one household in each of the houses selected will be recruited to the study. In stage 5, the target respondent is the head of household who will be identified. All residents aged 15 years and above who have resided in the household for at least 6 months will also be interviewed. It is important that the sample size for the proposed study be decided at the outset of the study, with appropriate level of precision and degree of confidence. A sample size in the neighbourhood of 3000 may be considered appropriate in the light of previous household surveys in Nigeria involving zonal and national level analyses. Data Collection: Measures and Indicators A structured questionnaire will be developed to obtain survey data that allows an understanding about the epidemic impacts on households and communities as follows: 1. Establish a picture of the current socio-demographic constitution of households in the community and to identify recent changes. 2. Describe household expenditure with data on costs of : funeral, memorial, food, meat and related protein, clothing, rent, durable household goods, drug and medical, hospital admission, hospital consultation, hospital admission, transportation, recreation and entertainment, education and the like 3. Quantify household income with data on: income from rent, gifts, dividends, interests, life insurance, pensions, sickness benefits, health insurance, occupation, land lease and the like. 4. Describe household gender relationships, women and children circumstances with data on: nature of decision making on important family issues, children of school age ever been to school, children of school age currently enrolled and attending schools, children who have dropped out of school, children who trade or do other business to support family income, children who live in household due to loss of their own parents, children who have left household to live in other places, women who are in gained employment, women who have lost employment,

21 women who own land property, women who are primary caregiver to a sick member of household, women who are absent from work because they have to care for a sick person, and other related indicators. Provide information on household asset with data on ownership of land, livestock, bicycle, motorcycle, car, sewing machine, TV, radio, refrigerator, iron, electric fan, gas cooker, telephone and the like. Quantify household health and illness characteristics with data on nature of minor and chronic illness, period of hospital admission, length of illness, weight of household member, number of days unable to carry out normal activity on account of illness, death, sex of member of household who die, age of member of household who die, and similar indicators. Describe urban and rural household and community viability in addition to coping mechanisms through data on changes in social structure in response to AIDS, community social groups and networks, community social solidarity, household dissolution, migration patterns in response to AIDS, and the like. In rural communities where farming is usually the main means of livelihood, the effects of the epidemic on food production and consumption should be explored. This will include effects of HIV on Size of arable land owned and cultivated overtime Types and size of livestock owned overtime Main types of crops cultivated and volume harvested overtime (changes in cropping pattern and yield due to various reasons) Volume of crop harvested and sale Types of agricultural assets acquired and sold overtime such as land, crop, livestock, oxen, equipment/plough, etc Evidence of adoption of less labour intensive crops and farming techniques

5. 6.

7.

8.

Data Collection Procedure, including Fieldwork, Training and Pilot Study The study will be conducted using an interviewer administered structured questionnaire. The instrument will be translated into local languages for administration and translated back translated to English to ensure accuracy. Research assistants will be recruited and trained to administer the questionnaires. The research assistants will be recruited based on minimum qualification of OND certificate. They will be fluent in both English and the local language. They will also be trained on how to obtain information relevant to the research work and through both English and local languages and they will be required to conduct interview in the preferred language of the respondent. They will be trained on sampling, interview technique and ethical issues including issues of confidentiality. Training will also involve how to establish rapport with respondents, and reduce under reporting of sensitive information particularly on sexual behavior and confidentiality. In a pilot survey, the questionnaire will be conducted to revise the procedures and instruments of the survey. The questionnaire will be pre-tested on a small sample of

22 respondents from similar communities as intended for the present study, but with respondents who will not participate in the main study. The aim is to ascertain feasibility and reliability of the questionnaire, especially to correct any possible gaps and redundancies in the questionnaire in the light of cultural conditions and sensitivities, and to check if the language is appropriate. The questionnaire will be amended accordingly and administered in ways that no identifying information is collected, to allow for completely anonymous responses. The survey will be conducted with the support of local officials who will assist in the sampling procedures and in the introduction of the survey team to household members. The research assistants will work in pairs of a female and a male. Participants will be informed about the approximate time of the interview before the study commences. Data Analysis For the household survey, analysis will take place at multiple levels to depict the impact of the epidemic on households in ways such as: Comparison between households affected by chronic illness and death and households not affected by chronic illness and death Comparison between households affected by AIDS and those affected by diseases due to other causes Comparisons between households with at least one orphan and households without any orphan. For 1-3 above, comparisons will take place on outcome variables such as: household expenditure, household income, household gender relationships, women and children circumstances, household asset, household health and illness characteristics, and household livelihood characteristics, (see detailed indicator characteristics in measure and indicator section). All the comparisons will be segregated for socio demographic and state level analysis. To assess the impact of predictor variables (1-3 above) on outcome variables, data will be segregated as mentioned. Bivariate analyses will be performed followed by multivariable analysis using a stepwise binary logistic regression model and likelihood ratio tests will be used to compare various models. Performance of the model will be reported through the model chi-square and goodness-of-fit as assessed by the Hosmer and Lemeshow test (goodness-of-fit chi-square). The values obtained from the multivariate model will be presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI) and p-values to the 95% CI. Other models can as well be considered that is valid to make inference of impact and permit statistical control of relevant indicators. 3.4.2 Qualitative Focus Group Discussions Focus group discussions (FGDs) will be conducted to provide in-depth qualitative description of impact of the epidemic in households and communities. FGDs are expected to help provide situations where information about sensitive topics like sexuality and HIV can be freely discussed as less inhibited persons in the group often

23 initiate and open up discussion. Furthermore, FGDs will strengthen the survey as they facilitate revelations about impact at community level. The FGDs will be conducted in venues within the same communities chosen for the cross sectional survey. Forty-eight FGDs will be conducted in total. Four will be conducted in the rural and four in the urban LGAs from the study states. Participants will be recruited through local community organizations such as religious institutions, markets, and neighborhood groups. About 6-8 discussants separated by gender and two age groups (25 years and younger and 26 years and older) will participate in each FGD. Research assistants will be trained to facilitate the FGDs with the assistance of one note taker. The facilitators and note takers will be similar to participants in terms of gender and age. FGDs will be conducted in the language participants prefer. Facilitators will tape, transcribe and translate discussions for analysis. Participants will discuss major issues especially that the survey may not capture in comprehensive depth. These include: dynamics of household sustainability or dissolution, women and children livelihood pattern, changes in social and economic structures in communities, re-distribution of wealth in communities, how communities share the affects of AIDS on households, viability of affected communities, community institutional capacity, patterns of migration, and impact on community leadership. Key Informant Interviews Key informants will be purposively selected because they are knowledgeable about HIV/ AIDS and its impact on household and communities. Key Informant Interviews (KIIs) conducted with local policy makers in various line ministries, opinion leaders, health care practitioners, and religious leaders. Overall, ten KIIs will be conducted in sampled states. Trained interviewers will conduct interviews with the aid of question guides that elicit responses on various aspects of AIDS impact in the communities. Interviewers will meet the participant in a place convenient for them. The interviews are expected to last about one hour. Attempts will be made to audiotape record all interviews. In cases where informants do not allow such recording, interviewers will make detailed notes of the responses of the informants. Taped responses will be later transcribed. All the transcripts will be carefully checked for accuracy and consistency and major themes will be identified that relate to the purpose of the study. Analysis FGD & KII data All recordings of FGD and KII interviews will be transcribed. Analysts will read transcripts to depict the embedded themes relating impacts of HIV/AIDS on households and communities. Based on these readings, a set of codes will be developed and then applied to the full set of qualitative data. To ensure consistency of coding, a team of researchers will code several transcripts and then discuss points of consensus and disagreement to develop general principles for assigning codes. This process will continue until there is 90% consistency across coders, and then each transcript will be coded fully. Analysis will proceed by pulling all text associated with codes of interest,

24 and then research teams will discuss the themes emerging from the texts. Software packages such as Atlas-ti may be considered for analysis of FGD and key informant interviews. 3.5 Personnel

In conducting this study, the following personnel will be required: 1 Sociologist/Social Psychologist or related field consultant, 6 NPC officials (to participate in activity 5), 12 Supervisors (Researchers with experience of community based studies), 36 data collectors, 1 Public Health specialist or related field consultant, 1 Economist and 1 Medical Epidemiologist or statistician experience in national survey. 3.6 Activity 1 2 3 4 5 6 7 8 3.7 Work Plan and Time Line Months 1 2 3 4 5 6 Familiarization and planning meetings with stakeholders in national, states, and LGAs Development of survey, FGD, KII instruments Finalization of Scope of work s for study & IRB Approvals Pilot Investigation and Preparation- Recruitment of personnel, training finalization of instruments Community and household enumeration and listing Data Collection (KII, FGDs & Survey) Data Analysis and Report Writing Publication & Dissemination of Report Budget 7 8 9 10 11 12

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C: THE SECTOR-LEVEL IMPACT OF HIV/AIDS IN NIGERIA 4.1 Introduction

The HIV/AIDS epidemic is growing in various localities and population groups in Nigeria. While the national HIV prevalence rate appears to be decreasing, about 3.5 million Nigerians are living with HIV/AIDS (IBBS, 2007). Apart from human illness, death and suffering, this epidemic is affecting virtually all sections of society - the community, public and private sector. In Nigeria, the public sector undertakes functions that are essential for development and employs a significant proportion of those with technical skills, professional qualifications and management expertise. Loss of human resources due to AIDS is therefore especially debilitating to the capacity of sectors to supply essential goods and services. Studies done in eastern and southern African countries indicate that HIV/AIDS is generating more demand for services especially in the health, education, uniformed, petroleum and transport sectors. This is indirectly weakening the human, infrastructural and financial resources of these sectors to facilitate national development. Studies in sub-Saharan Africa show that HIV/AIDS impacts sectors in unique ways. In the health sector, there is shortage of healthcare workers, large numbers of health workers are being infected and dying due to HIV, those who die are not immediately replaced because of the long time it takes to train a health worker, the workload of health workers is increasing and affecting their morale and efficiency in service provision, the number of people living with HIV who are demanding care is growing, more than half of all hospital beds are occupied by people with HIV-related diseases, HIV-positive patients are hospitalized for a longer duration than other patients, and there is increased infrastructure modifications and spending to cope with the new demands that are emerging due to the epidemic such as overtime wages, medical and insurance bills, pension fees and funeral expenses. A study done in one region of Zambia found that about 40% of midwives were HIV-positive. In Botswana, 17% of the healthcare workforce died due to AIDS between 1999 and 2005. It is also noted that the direct medical costs of AIDS without antiretroviral therapy for every person infected per year is about US$30 compared to US$10 per capita public spending on health (UNAIDS, 2002 & 2006). These impacts pose a huge challenge not only to the capacity of the sector to carryout its functions effectively but also on the overall health of the people and economic development of countries. In the education sector the epidemic weakens staffing levels, teacher efficiency, and the OVC school enrollment, attendance and completion. Teachers and support staff who are HIV infected or affected are likely to spend less time on work because of stigma, intermittent illness, caring for sick and attending funerals of family members. In case of death, the teacher is not easily replaced immediately due to the duration and cost of training. The class may be taken on by another teacher, combined with another class or left untaught especially in schools where the staffing levels are already low hence negatively affecting the quality of education the students get. Some vulnerable children are withdrawn from school to care for the sick parents and relatives or due to intermittent

26 illness and inability of the family to generate income or provide fees. Children who dropout of school are two times more susceptible to HIV infection than those who complete primary education since some of them engage in sex prematurely (NDES, 2004; RTI, 2004). The Petroleum Industry 3 , being one of the sectors that employ many people who earn relatively higher income in Nigeria, it may also be vulnerable to the epidemic in ways that are similar to other sectors. However, there is scanty information on how the epidemic is affecting the internal and external domains of this particular sector. There is need to understand the socioeconomic impact of the epidemic on the ministry and company workforce including station attendants. Transport sector & Uniformed Services, From the IBBSS 2007 report, the prevalence of HIV amongst Transport workers was the highest among all the predominantly male occupational groups (i.e. Police, Armed Force and TW) with a value of 3.75%. Multiple partnerships are quite common among predominantly male occupational groups. Of these three groups, 37.9% of transport workers as against 37.3% of armed forces and 29.4% of police reported sex with more than one partner in the previous 12 months. Based on these findings it would be essential to note the socio economic impact of the epidemic on the transport workers and the services they provide, on the Uniformed Service men and women, and their quality of service.

4.2

Problem Statement

Research in sub-Saharan Africa indicates that the HIV/AIDS epidemic affects the public sector in terms of increasing staff morbidity, absenteeism, death, workload and turnover. It reduces staff morale, experience and efficiency. It increases the costs on staff medical bills and expenses on death benefits and funerals. There is also increase in pressure on particular infrastructure that results to structural transformations and increased spending in an attempt to respond to the ever-changing demand for services. The worst hit sectors are health, education, agriculture, the military and households (Barnett & Blaikie, 2002). In the case of Nigeria, there is a huge body of literature about HIV/AIDS sero-behavioral surveillance and programs. Studies indicate that the programs are contributing to the decline in the national prevalence and alleviating suffering of those infected/affected. However, data to substantiate how the epidemic is impacting on the various sectors and special groups is limited. The visible literature on socioeconomic impacts of the epidemic at sector level is from research done in other countries. In view of the differences in the nature of the epidemic and the socioeconomic set up in Nigeria, the epidemic may be impacting on sectors and special groups in a manner that is not similar to results of
3 This includes the ministry of energy itself and the companies drilling and selling oil products such as Chevron, Total, Shell, Mobil, Elf, etc.

27 research done elsewhere. It is therefore necessary to understand the socioeconomic effects of the epidemic on sectors. Nigeria has adopted a multi-sectoral response to the epidemic that supports the various sectors responding to the epidemic in line with their areas of comparative advantage. In doing this they are expected to utilize the advantages occasioned by their unique positions and some capabilities to respond to the epidemic Undocumented evidence suggests that while Nigeria professes a multi-sectoral response, most sectors are yet to fully develop and deploy mechanisms to mitigate the impacts of the epidemic on them. This study will also aim to determine the preparedness of the various sectors to adequately respond to the epidemic and the various factors that could affect the level of preparedness 4.3 Objectives

The objectives of this study are to: Find out the impact of the epidemic on the internal and external environments of the health, education, and petroleum , uniformed and transport sectors; Recommend strategies for alleviating impact on the sectors Determine the level of preparedness of the various institutions/units to respond to HIV/AIDS epidemic a. Private organizations i. Civil society ii. Commercial sector b. Public institutions i. Health system (Federal and state ministries of health, primary , secondary and tertiary health facilities) ii. NACA, SACA, iii. FMOWA, FMOE Compare the level of preparedness of public institutions' in low and high prevalence states 4.4 Scope

The study should assess the sector-level impacts of the epidemic particularly in terms of changes in spending patterns e.g. sick leave claims and death benefits, changes in demand and supply of services e.g. of the health sector. As noted above the main sectors to be assessed should include health, education, and the petroleum industry, uniformed services and transport sector. Groups of people to be interviewed should include respective ministry and extension staff, as well as the key people served such as patients/carers, teachers, students, petroleum workers, human resources and medical departments of institutions, Transport owner and passengers, unions, drivers, motor part operators The sectors will also be studied in terms of levels their preparedness to respond to the epidemic prevention and impact mitigation.

28 The health sector has been chosen mainly because most of the aspects related to the epidemic are handled within the health systems, most of its staff work in situations (health facilities) that makes them susceptible to infections and illnesses, and because the epidemic appears to be increasing the pressure on health systems and families of patients. The education sector is chosen due to the central role it plays in skilled manpower development, and because it has a huge workforce that deals with a huge population of children and youth (.. percent of the population).This population experiences high HIV infection due to risky behaviour. This sector is also responsible for the education welfare of orphans and other vulnerable children whose number is ever increasing. Similarly most of the workforce in the petroleum sector is usually deployed away from home for long periods of time and have more disposable income, which encourages them to engage in casual and commercial sex. This seems to be common particularly among drill oil workers who work on oil rigs away from settlements for long periods of time. The Transport workers and Uniformed services were likewise selected because of their degree of mobility which encourages them to engage also in casual and commercial sex. 4.5 Methodology

This section describes the research design, methods, sample size and sampling techniques, instruments and data analysis that may be used to carryout the socioeconomic impact of HIV/AIDS at sector level. 4.5.1 Design and methods

The study may employ a research design that uses institutional audit and special survey techniques. This design has been chosen because it ensures validity of results especially in circumstances where there is no appropriate baseline data on how institutions, employees and people served or relate with various sectors are being impacted by the epidemic. It also allows for triangulation, which regulates biases or wrongful attribution of results. Sector level impact data will be collected primarily through administering an institutional audit checklist to selected institutions, reviewing existing service records/ MIS data, interviewing heads and employees in selected institution, interviewing people that receive services in respective sectors, and administering survey questionnaire to special groups especially. 4.5.2 Sample size

A sample frame that captures categories and numbers of institutions, employees and population groups served in the respective sectors should be constructed, and used to compute the proportion for each category of institutions, employees served and special

29 groups. Based on this frame, determine the suitable sample sizes for each category in a proportionate manner. The sample sizes should fall within the minimum required size on which statistical tests could be meaningfully conducted within and/or across categories at an estimated sampling error of +/-3.0 percent or a confidence level exceeding 95%. 4.5.3 Sampling strategy

Study areas We recommend this study to employ multi-stage stratified random sampling technique in selecting the states, local government areas, institutions/companies and respondents to involve in the study. The first strata should be constructed along the 6 geopolitical zones to ensure inclusion of states in each geopolitical area, the second strata should be constructed along state level to allow in-depth understanding of AIDS impacts within the state, and third strata should be constructed along the local government level. In selecting the states and local government areas, we recommend the following inclusion criteria; high HIV prevalence, urban-rural locality and high-low income level. A list of states and local government areas with the corresponding socioeconomic and demographic characteristics should be obtained from the National Population Commission and arranged according to the geopolitical zones and the above inclusion criteria. Based on this list, the researchers should purposely or randomly select the states and local government areas in intervals of 2 - N for the study. Respondents At each sector stratum, identify types of institutions/companies/facilities eligible for institutional audit be they government or private owned, categorize them and randomly select the suitable number based on the likelihood of finding sizeable employees and key people served. We recommend separate questions for employees and the key people served. The researcher should also interview heads of institutions and gather relevant service records for review. As for special groups, the study may use a unique sampling method that is similar to one used in the IBBS (2007). In this study, PLWHA, truck drivers, IDUs, MSMs, FSWs and their clients were selected and reached through their umbrella organizations. 4.5.4 Instruments

We recommend design and validation of three main data collection instruments: 1. Semi-structured tool for assessing institutional vulnerability.

30 This may be administered to heads of institutions or staff in-charge of administrative and service records/data on staff health, welfare, training and costs. This tool will entail questions that seek data on the following issues: The kinds of people employed, The particular groups of staff exposed to infection and reasons, Workplace programs in for reducing exposure, Organizational benefit of program for reducing staff exposure, Types of employees to be included in programme, Number of staff in each category expected to be ill or die, Staff ill/dead whom are difficult to replace, Ease in terms of cost and time of training/replacing various staff, Availability of alternative staff to be retrained/take-up work, Availability of capital to replace sick/dead staff, Possibility of giving multiple skills to existing staff, Availability of sick and compassionate leave, Availability of free medical services for staff Staff death and other benefits (funeral costs, insurance, pensions, etc Staff mobility and absence from home for long durations of time Staff involvement in high-risk situations like war and accidents Staff propensity of illness and absenteeism, Availability of employment policies that allow infected staff to continue work. Spending on HIV/AIDS supplies, activities and services in workplace over time. Infrastructural changes due to AIDS overtime (rehabilitation and equipment, counseling space, HIV/AIDS training for sickbay staff, etc 2. An instrument will also be designed to ascertain the level of preparedness of the institutions to respond to HIV and AIDS as it affects both the internal and external environment of the sector The level of HIV/AIDS programming taking place in the sector The adequacy of the programming in the sector and the effects on the recipients The sustainability of programs - comparing government and donor support The awareness of the threat that the HIV/AIDS epidemic may have on the sector The existence of any plans to overcome such threats The level preparedness and political support shown to address HIV and AIDs within the sector 3. Interview guide for employees to assess workload, susceptibility/vulnerability levels; 4. Exit polls with people served by sectors to determine how epidemic impacts on them. In the health sector, patients/care givers seeking service or admitted in the sampled health facilities may be interviewed on: Frequency and duration of illness and admission,

31 Quality of service received Expense incurred on illness/admission Payment for the medical bills, and How the money for medical bills is obtained.

In the education sector, some orphaned students in selected schools may be asked about: School attendance in last week in orphans and non-orphans (proxy measure) Susceptible/vulnerability to illness, stigma, etc Membership in anti-AIDS school clubs, societies, etc Access to levy waiver/scholarship scheme for OVC

4.5.5

Data Sources

The data sources for this study will include secondary data obtained from existing management information systems (MIS) in federal, state and LGA institutions; administrative and service records of the sampled institutions at federal, state and LGA level; and primary data from key informants in sampled institutions. 4.6 Data Analysis

Data may be analyzed by computing percentages for distribution of responses. Some responses may be tabulated cross types of workforce to establish the categories of staff that could be especially susceptible to infection and vulnerable to effects of AIDS. Qualitative data should be in such a way that the required content under each discussion and interview theme is extracted and synthesized with the quantitative results. 4.7 Research Team and competencies

We recommend that a team of researchers who are experienced in institutional audit and service-level research conduct the study. The team may comprise one (1) principal investigator, one (1) co-investigator, six (6) research coordinators (one for each state), and 24 data collectors (four per state), one (1) statistician, and two (2) data clerks. 4.8 Work-plan Days 1 7 6 Months 1 2 3 1. Preparations and contracting (PI and Co-Investigator) 2. Develop& present technical proposal including the work plan and survey instruments (PI, CI and Statistician) 3. Constitute and train research coordinators and assistants (PI, CI, RCs, Statistician and 24 RAs) 4 5

Activities and Personnel involved

32 4. Pre-test, revise & reproduce instruments (PI, CI, RC, RA) 5. Data Collection (PI, CI, 6 RCs, 24 RAs) 6. Transcribe, code, check, enter, clean, and analyse data (PI, CI, Statistician, 2 data clerks, 6RCs & few RAs). 7. Report writing (PR, NR) 8. Dissemination of results to stakeholders Total 4.9 Budget 3 23 40 X 21 1 82

D: THE IMPACT OF HIV/AIDS ON THE MACRO-ECONOMY Based on the realities on ground, a relatively low HIV prevalence (compared to levels found in Eastern and Southern Africa regions), preponderance of skilled manpower, unemployment level etc, it is recommended that this study be shelved as it is unlikely that any significant impact at the macroeconomic level will be seen at this point in time.

33

REFERENCES 1. Arrehag, L., De Vylder, S., Durevall, D. & Sjblom, M. (2006) The impact of HIV/AIDS on the Livelihoods, Poverty and the Economy of Malawi. Sida Studies No. 18. Edita. 2. Barnett, T. & Blaikie, P. (1992) AIDS in Africa: Its Present And Future Impacts. London and New York: Belhaven Press and Guilford Press. 3. Barnett, T. & Grellier, R. (2003). Mitigation of the Impact of HIV/AIDS on Rural Livelihoods through Low-Labour Input Agriculture and Related Activities. Norwich: Overseas Development Group, University of East Anglia for the UK Department for International Development, UK. 4. Barnett, T., & Whiteside, A. (2002) AIDS in the twenty-first century: disease and globalisation. Hampshire and New York: Palgrave Macmillan. 5. Barnett, T., Whiteside, A. (2000). Guidelines for Studies of Social and Economic Impact of HIV/AIDS. A UNAIDS Publication 6. Bollinger, L., Stover, J. & Nwaorgu O. (1999) The Economic Impact of AIDS in Nigeria. The POLICY Project of The Futures Group International. 7. Bosworth, B. & Colllins, S. M. (2003) The Empirics of Economic Growth: An Update unpublished, Brookings Institution. 8. Canning D, Mahal A, Odumosu K & Okonkwo P. (2006) Assessing the Economic Impact of HIV/AIDS on Nigerian Households: A Propensity Score Matching Approach, Program of the Global demography of Aging. Harvard Initiative for Global Health, PGDA Working Paper Series No 16, 9. Canning, D., Mahal, A., Odumosu, O., Okonkwo, P. & Soyibo, A. (2004) Expenditure on HIV/AIDS and Their Policy Implications. Chapter 22 of AIDS in Nigeria: A Nation on the Threshold, 2006. Cambridge: Harvard Centre for population and Development Studies, USA. 10. Casale, M. (2005). The Impact of HIV/AIDS on Poverty, Inequality and Economic Growth, mimeo, HEARD, University of Kwazulu-Natal, Durban, South Africa. 11. Ekong, E., HIV/AIDS and the Military. AIDS in Nigeria: A Nation on the Threshold, 2006. Cambridge: Harvard Centre for population and Development Studies, USA. 12. Evans, D.B., Tan-Torres Edejer, T., Adam, T. & Lim S. S. (2005) Methods to Assess the Costs And Health Effects of Interventions for Improving Health in Developing Countries. British Medical Journal, 2005; 331: 1137-1140. 13. Federal Ministry of Health (2001) A Technical Report on 2001 National HIV/Syphilis Sero-Prevalence Sentinel Survey among Pregnant Women Attending Antenatal Clinics in Nigeria. Abuja: NASCP, Nigeria. 14. Federal Ministry of Health (2003) National HIV/AIDS And Reproductive Health Survey. Abuja: FMH, Nigeria. 15. Federal Ministry of Health (2004) A Technical Report on 2003 National HIV/Syphilis Sero-Prevalence Sentinel Survey among Pregnant Women Attending Antenatal clinics in Nigeria. Abuja: National AIDS/STIs Control Programme, Nigeria. 16. Federal Ministry of Health (2005) National HIV/AIDS & Reproductive Health Survey, Abuja: FMH, Nigeria.

34 17. Federal Ministry of Health (2005) The National Situation Analysis of the Health Sector Response to HIV & AIDS in Nigeria. Abuja: FMH Nigeria. 18. Federal Ministry of Health (2005) Technical Report on the 2005 National HIV/Syphilis Sero-prevalence Sentinel Survey Among Pregnant Women Attending Antenatal Clinics in Nigeria. Department of Public Health National AIDS/STI Control Programme. Abuja: Nigeria. 19. Federal Ministry of Health (2007) The Behavioural Surveillance Survey of 2005. Abuja, Nigeria. 20. Federal Ministry of Health (2007) Integrated Bio-Behavioural Surveillance Survey Among Most at Risk Populations in Nigeria. Abuja: National AIDS/STIs Control Programme (NASCP), Nigeria 21. Hilhorst T, van Liere MJ, Ode AV, de Koning K. (2006) Impact of AIDS on rural livelihoods in Benue State, Nigeria. Journal of Social Aspects of HIV/AIDS, 3, 1, 382393. 22. Hogan, D. R., Baltussen R., Hayashi C., Lauer J. A. & Salomon J. A. (2005) Achieving the Millennium Development Goals for Health. Cost effectiveness Analysis of Strategies to Combat HIV/AIDS in Developing Countries. BMJ, doi: 10.1136/bmj.38643.368692.68 (published 10 November 2005). 23. Hogan, D. R. & Salomon, J. A. (2004) Prevention and Treatment of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome in Resource-Limited Settings. Public Health Reviews. Bulletin of the World Health Organization 2005; 83: 135-143. Ref. No. 03-010082. 24. Jianhua, Y., Yi X., Tao, J., Mei, W., Yaqing, L., Kejun, L., Shuquan, Q., Yue, B., Linqyun, W., Bollinger, L., Walker, N., Jingling, H. & Ionita, G. (2002) The Socioeconomic Impact of HIV/AIDS in China. 25. McPherson, M. F. (2003) Macroeconomic Models of the Impact of HIV/AIDS, Cambridge, Centre for Business and Government, John F. Kennedy School of Government, Harvard University. 26. Mtika, M. (2003) Family Transfers in a Subsistence Economy under a High Incidence of HIV/AIDS: The Case of Rural Malawi, Journal of Contemporary African Studies, Vol. 21, No. 1. 27. National Action Committee on AIDS (2005) HIV/AIDS National Strategic Framework for Action 2005-2009. Society for Family Health/NACA, Abuja: Nigeria. 28. National Population Commission (2002) National Population Census 1991 Analysis. National and State Population Projections. Abuja: NPC, Nigeria. 29. Natrass, N. (2002) AIDS, Growth and Distribution in South Africa, Centre for Social Science Research, AIDS and Society Research Unit, CSSR Working Paper. 30. Odutolo, N., Mafeni, J. O., Okonkwo, K., Fajemisin, O. A. (2004) Monitoring and Evaluation of HIV/AIDS in Nigeria. Chapter 23 in AIDS in Nigeria: A Nation on the Threshold, 2006. Cambridge: Harvard Centre for population and Development Studies, USA. 31. Rosen S, Macloed W, Vincent J, Thea D, Simon J. Why do Nigerian Manufacturing firms Take Action on AIDS? Discussion Paper No. 3 Boston: Centre for International Health and Development, Boston University of Public Health. 32. Salomon, J. A., Hogan, D. R., Stover, J., Stanecki, K. A., Walker, N., Ghys, P. D. & Schwartlnder, B. (2005) Integrating HIV Prevention and Treatment: From Slogans

35 to Impact. Open access, freely available online PLOS Medicine http://www.plosmedicine.org. 33. UNAIDS (1998) Cost-effectiveness Analysis and HIV/AIDS. UNAIDS Technical update. August 1998. 34. USAID (2001) HIV/AIDS in Southern Africa: Background, Projections, Impacts, and Interventions, The POLICY Project for Bureau for Africa, Office of Sustainable Development, USAID. 35. Van Liere, de Koning, K., Hilhorst, T., (2003) The Impact of AIDS in Benue State: Implications For Rural Livelihoods. Amsterdam: Royal Tropical Institute for the UK Department for International Development. 36. Walker, D. (2003) Cost and Cost-effectiveness on HIV/AIDS Prevention Strategies in Developing Countries: Is There And Evidence Base? Health Policy and Planning; 18 (1): 4-17. Oxford University Press. 37. Webpage: http://www.who/int. 38. Weil, D. N (2005) Economic Growth, Pearson Education, Addison Wesley.

36

ANNEX I: CHECKLIST FOR AVAILABITY OF IMPACT DATA A1: Impact of the National Response on the Epidemic
Response Impact: Modelling the Epidemiologic/Demographic Impact of HIV/AIDS Minimum data required Available (source) Shortly available Unavailable Current population size by Yes: National Population age and gender Census Report, 2006 Fertility & mortality rates Yes: NDHS 1999, 2003; Yes: NDHS 2008; NARHS 2003, 2005 NARHS plus 2008 Migration rate Yes Current HIV Prevalence Yes: ANC HIV prevalence Yes: ANC HIV 2005 in MARP, IBBSS 2007 prevalence, 2008 HIV incubation period Yes: National ART guidelines Perinatal transmission rate Yes: National PMTCT guideline Age and sex distribution of Yes new transmissions Start year of the epidemic Yes: ANC HIV prevalence reports Response Impact: Modelling for Cost effectiveness of Interventions Minimum data required Available (source) Shortly available Unavailable General demographic Yes: National Population Yes: National Pop information Census report, 1991 Census, 2006 Yes: NARHS plus Yes: National BSS, 2005; Data regarding sexual 2008; National Pop NARHS 2003, 2005; IBBSS, behaviour by risk groups, census report, 2006 2007; NDHS 1999, 2003 including condom use HIV-STI prevalence Yes: ANC HIV prevalence Yes: ANC HIV 1991,1994, 1996, 1999, 2001, prevalence survey, 2003, 2005; IBBSS, 2007) 2008 Unit costs for prevention Yes activities Percent of the population Yes: National Health Council covered prevention and Meeting reports care activities in public sector Yes: To estimate it Information about care and mitigation activities, plus data and assumptions on levels of activities to be provided Assumptions on cost of Yes providing types of care Budget allocation by item Yes Proportion succeeding and Yes: National ART guidelines failing on HAART per yr

37 A2: Cost Effectiveness Analysis of Interventions

Data Availability Yes Soon No

Economic data Size of funding for various interventions Actual or assumed yearly costs of interventions Costs incurred by people to access the interventions (travel, etc) Program-level costs of each intervention (in MIS, etc) Patient cost on each intervention (from MIS or survey) Unit level cost for each input obtained from programme managers Unit costs in the existing database to facilitate comparison Physical inputs for various interventions: human resources, office space, vehicles, electricity, consumables (survey, programs MIS) Intervention mix Outcome data on of various mixes of interventions Epidemiologic data Actual or assumed coverage of the various interventions Underlying demographic data Data on the acquisition of HIV and other STIs Data on progression from HIV to AIDS and from AIDS to death, Annual risks of HIV infection in each risk group based on: Number of partnerships and sex acts per partnership HIV prevalence among partners Condom use among partners

B: Some Socioeconomic Indicators for Impact of HIV/AIDS on Households

Indicators Male and female children in the household Male and female children who make important family decisions Male and female children of school age currently living in household Male and female children who: Dropped out of school Left the household to live with other relatives Left the household to live in an unknown place Trade or do other business outside the household Earn incomes to support the family Earn incomes to support the family Died recently in the household Women and men who: Are in gainful employment Lost employment Own land property Give care to a sick member of household Absent from work due to care for a sick person in the household, and days of no work Total household income from: Data Availability Yes Soon No

* * *

38
Rent Gifts Dividends Interests Life insurance Pensions Sickness benefits Health insurance benefits Loans Other sources Total household expenditure on: Agricultural food items Manufactured food items Meat etc Clothing and footwear Rent, fuel and lighting Durable household goods e.g. furniture Drugs and medical expenses Funerals Transportation Recreation and entertainment Education Cultural services Gifts and donations Total household expenditure from on other sources Ownership of assets/property like: Land Livestock Bicycle, car, etc Sewing machine Television Refrigerator Ironing box Air conditioner/fan Gas cooker Telephone Status of owned or rented house: No of rooms in house Whether electricity in house Type of water supply system Self report of health status of member of household Weight of member of household (adult only) Whether member of household ill in the last four weeks Type of illness of member of household in the last four weeks Type of illness of member of household in the last four weeks Whether member of household die in the last one year Male and female member of household who died in the last one year Age of member of household who died in the last one year Percent ill for over 6 months * * *

* * *

* * * *

39
Percent dead due to chronic illness among 15-49 year olds in past 5 yrs *

* This data is from localized studies in Benue, Oyo, and Plateau by Hilhorst., et al (2006) and Canning., et al (2006)

C: Socioeconomic Indicators for Impact of HIV/AIDS on Sectors

Institutional Level (on employees, demand, supply of services) The kinds of people employed, The particular groups of staff exposed to infection and reasons, Workplace programs in for reducing exposure, Organizational benefit of program for reducing staff exposure, Types of employees to be included in programme, Number of staff in each category expected to be ill or die, Staff ill/dead whom are difficult to replace, Ease in terms of cost and time of training/replacing various staff, Availability of alternative staff to be retrained/take-up work, Availability of capital to replace sick/dead staff, Possibility of giving multiple skills to existing staff, Availability of sick and compassionate leave, Availability of free medical services for staff Staff death and other benefits (funeral costs, insurance, pensions, Staff mobility and absence from home for long durations of time Staff involvement in high-risk situations like war and accidents Staff propensity of illness and absenteeism, Availability of employment policies allowing infected staff to work Spending on AIDS supplies, activities and services overtime. Infrastructural changes due to AIDS overtime (rehabilitation and equipment, counselling space, HIV/AIDS training for sickbay staff, Patients or Caregivers at health facilities Frequency and duration of illness and admission, Quality of service received Expense incurred on illness/admission Payment for the medical bills, and How the money for medical bills is obtained. Orphaned students in selected schools School attendance in last week in orphans and non-orphans Susceptible/vulnerability to illness, stigma, etc Membership in anti-AIDS school clubs, societies, etc Access to levy waiver/scholarship scheme for OVC PLWHAs and susceptible Farmers in selected Associations Size of arable land owned and cultivated overtime Types and size of livestock owned overtime Main types of crops cultivated and volume harvested overtime = changes in crop pattern and yield due to various reasons Volume of crop harvest and sale Types of agricultural assets acquired and sold overtime such as land, crop, livestock, oxen, equipment/plough, etc Evidence of adoption of less labour intensive crops or farming Data Availability Yes Soon No

40 D: Macroeconomic Indicators for Impact of HIV/AIDS

Indicators GDP GDP per capita GDP growth rate Consumption per capita Public and private savings Investments Competitiveness and implications for Foreign Direct Investment Labour force: human resources, productivity, potential skills shortages HDI and the impact on gender roles, dependency rations and fertility Environment Technological development Data Availability Yes Soon No * * * * * * * * * * *

* The data available is not up-to-date and specific to HIV/AIDS. Identifying impact due to the HIV/AIDS epidemic at the macroeconomic level requires very rigorous analysis.