Reorienting the HIV response in Niger toward sex work interventions: from better evidence to targeted and expanded practice.
BACKGROUND
Niger's low-burden, sex-work-driven HIV epidemic is situated in a context of high economic and demographic growth. Resource availability of HIV/AIDS has been decreasing recently. In 2007-2012, only 1% of HIV expenditure was for sex work interventions, but an estimated 37% of HIV incidence was directly linked to sex work in 2012. The Government of Niger requested assistance to determine an efficient allocation of its HIV resources and to strengthen HIV programming for sex workers.


METHODS
Optima, an integrated epidemiologic and optimization tool, was applied using local HIV epidemic, demographic, programmatic, expenditure, and cost data. A mathematical optimization algorithm was used to determine the best resource allocation for minimizing HIV incidence and disability-adjusted life years (DALYs) over 10 years.


RESULTS
Efficient allocation of the available HIV resources, to minimize incidence and DALYs, would increase expenditure for sex work interventions from 1% to 4%-5%, almost double expenditure for antiretroviral treatment and for the prevention of mother-to-child transmission, and reduce expenditure for HIV programs focusing on the general population. Such an investment could prevent an additional 12% of new infections despite a budget of less than half of the 2012 reference year. Most averted infections would arise from increased funding for sex work interventions.


CONCLUSIONS
This allocative efficiency analysis makes the case for increased investment in sex work interventions to minimize future HIV incidence and DALYs. Optimal HIV resource allocation combined with improved program implementation could have even greater HIV impact. Technical assistance is being provided to make the money invested in sex work programs work better and help Niger to achieve a cost-effective and sustainable HIV response.
*Global HIV/AIDS Program, World Bank, Washington, DC; †Kirby Institute, University of New South Wales, Sydney, Australia; and ‡Coordination Intersectorielle de lutte contre les IST/VIH/SIDA, Niamey, Niger.
Nicole
N
Fraser
Cliff C
CC
Kerr
Zakou
Z
Harouna
Zeinabou
Z
Alhousseini
Nejma
N
Cheikh
Richard
R
Gray
Andrew
A
Shattock
David P
DP
Wilson
Markus
M
Haacker
Zara
Z
Shubber
Emiko
E
Masaki
Djibrilla
D
Karamoko
Marelize
M
Görgens
D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D058872:Epidemics; D005260:Female; D015658:HIV Infections / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*; D017048:Health Care Costs; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D009548:Niger / Q000453:epidemiology; D015995:Prevalence; D040841:Resource Allocation; D060386:Sex Workers; D055815:Young Adult