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Background Despite a non-decreasing HIV epidemic, international donors are soon expected to withdraw funding from Kazakhstan. Here we analyze how allocative, implementation, and technical efficiencies could strengthen the national HIV response under assumptions of future budget levels. Methodology We used the Optima model to project future scenarios of the HIV epidemic in Kazakhstan that varied in future antiretroviral treatment unit costs and management expenditure—two areas identified for potential cost-reductions. We determined optimal allocations across HIV programs to satisfy either national targets or ambitious targets. For each scenario, we considered two cases of future HIV financing: the 2014 national budget maintained into the future and the 2014 budget without current international investment. Findings Kazakhstan can achieve its national HIV targets with the current budget by (1) optimally re-allocating resources across programs and (2) either securing a 35% [30%–39%] reduction in antiretroviral treatment drug costs or reducing management costs by 44% [36%–58%] of 2014 levels. Alternatively, a combination of antiretroviral treatment and management cost-reductions could be sufficient. Furthermore, Kazakhstan can achieve ambitious targets of halving new infections and AIDS-related deaths by 2020 compared to 2014 levels by attaining a 67% reduction in antiretroviral treatment costs, a 19% [14%–27%] reduction in management costs, and allocating resources optimally. Significance With Kazakhstan facing impending donor withdrawal, it is important for the HIV response to achieve more with available resources. This analysis can help to guide HIV response planners in directing available funding to achieve the greatest yield from investments. The key changes recommended were considered realistic by Kazakhstan country representatives.

Objectives: The objective was to assess improvement, or lack thereof, in the uptake of prevention of mother-to-child transmission (MTCT) services at selected sites supported sites by the Global HIV/AIDS Initiative Nigeria (GHAIN). Design: The study used aggregated monthly service statistics to evaluate service improvement efforts that were conducted before and after these were undertaken between July 2007-June 2008. Settings and subjects: The service improvement efforts took place in 60 public healthcare facilities. Outcome measures: The study measured changes in the number of pregnant women who attended antenatal clinics for the first time, the number of pregnant women tested for human immunodeficiency virus (HIV), the number of HIV-positive women receiving antiretroviral (ARV) prophylaxis, and the service ratio, an indicator of the relative uptake of ARV prophylaxis. An estimate of MTCT events that were averted through ARV prophylaxis taken by the pregnant women was also calculated. Results: One hundred and twenty thousand, five hundred and thirty-seven women attended an antenatal clinic (ANC) for the first time. There was an average of 167.4 monthly attendances per facility. ANC attendance increased per facility by 11.1 women monthly post-intervention (p-value < 0.01). The uptake of HIV testing was 87%, with a monthly average increase of 17.8 women tested per facility (p-value < 0.01). ARV prophylaxis uptake rose from 3.3-5.4 women per facility per month (p-value < 0.01). The service ratio per facility improved from 5.3 women receiving ARVs to 6.5 for every 10 women who tested positive for HIV (p-value < 0.01). Applying risk reduction estimates of different ARV regimens, it was estimated that between 88-169 MTCT events were averted pre-intervention, and 143-276 events, post-intervention. Conclusion: Service improvement intervention improved the utilisation of PMTCT services. It should be a key intervention that is used to close the PMTCT gap in Nigeria.Keywords: HIV, PMTCT, evaluation, Nigeria, service improvement, effectiveness

Author details Department of Operations Research, HIV/AIDS Program. Population Council, Nigeria. No. 16, Mafemi Crescent, Utako, Abuja, Nigeria. Department of Health Policy and Management, Diadem Consults Ltd, Abuja, Nigeria. Management Sciences for Health, Abuja, Nigeria. Howard University PACE Center, Washington, USA. Society for Family Health, Abuja, Nigeria. Family Health International 360, Pretoria, South Africa. UNDP Regional Center for Europe and Central Asia, Bratislavia, Slovakia.

Objective To evaluate HIV and syphilis prevalence among men who have sex with men (MSM) in Nigeria, and assess their HIV-related risk behaviours and exposure to HIV prevention interventions. Methods Cross-sectional study using respondent-driven sampling conducted in Lagos, Kano and Cross River states, Nigeria, between July and September 2007. Results A total of 879 MSM participated, 293 from each state. Eight participants (1.1%, CI 0.1% to 2.2%) in Cross River, 27 (9.3%, CI 5.7% to 15.4%) in Kano and 74 (17.4%, CI 12.3% to 23.2%) in Lagos tested positive for HIV. No syphilis was detected. The median age was 22 years. MSM reported an average of 4.2 male anal sex partners in the past 6 months. Between 24.4% (Lagos) and 36.0% (Kano) of MSM reported selling sex to other men. Up to 49.7% of MSM reported sex with a girlfriend and ≤6.5% purchased sex from female sex workers. Consistent condom use in commercial sex with other men over the past 6 months ranged from 28.0% (Cross River) to 34.3% (Kano), in contrast to between 23.9% (Kano) and 45.8% (Lagos) for non-commercial sex. Associations with HIV positivity included age in the three states, having been the receptive partner in anal sex in the past 6 months in Lagos and in Lagos and Kano feeling at risk of HIV. Conclusion Large differentials in HIV prevalence between states together with high mobility, inconsistent condom use and behavioural links with female sex partners, have the potential for further HIV transmission within MSM networks, and between MSM and the general population.

Objective: To measure changes in service utilization of a model integrating family planning with HIV counselling and testing (HCT) antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) in the Nigerian public health facilities. Design: It is a retrospective survey of attendance and family planning commodity uptake in 71 health facilities in Nigeria that analyzes the preintegration and postintegration periods between March 2007 and January 2009. Methods: A prepost retrospective comparison of mean attendance at family planning clinics and couple-years of protection (CYP) compared 6 months preintegration with 9 months postintegration period. An analysis of service ratios was conducted relating completed referrals at family planning clinics to service utilization at the referring HIV clinics. Results: Mean attendance at family planning clinics increased significantly from 67.6 in preintegration to 87.0 in postintegration. Themean CYP increased significantly from32.3 preintegration to 38.2 postintegration. Service ratio of referrals from each of the HIV clinics was low but increased in the postintegration period by 4 34 and 42 per 1000 clients from HCT ART and PMTCT clinics respectively. Service ratios were higher in primary healthcare settings than in secondary or tertiary hospitals. Attendance by men at family planning clinics was significantly higher among clients referred from HIV clinics. Conclusion: Family planning-HIV integration using the referral model improved family planning service utilization by clients accessing HIV services but further improvement is possible. Male utilization of family planning services also improved. The government of Nigeria should review the family planning user fee policy and scale up the integration in primary healthcare facilities.

Background. Human infections with the tissue nematode Onchocerca volvulus show strong interindividual variation in intensity, which cannot be explained by differences in exposure alone. Several lines of evidence suggest a relevant influence of human genetics. Methods. In a genome-wide search for genetic determinants of resistance, we studied 196 siblings from 51 families exposed to endemic O. volvulus transmission in the forest zone of Ghana, West Africa. The numbers of worm larvae in the skin (i.e., microfilariae), which are the established measure of O. volvulus infection intensity, were counted in 4 small skin biopsy specimens (i.e., skin snips), and the numbers of palpable subcutaneous worm nodules (i.e., onchocercomata) were assessed. Numbers were corrected for age and exposure and were analyzed for linkage to 377 autosomal microsatellite markers and additional markers in genomic regions of interest. Results. Linkage was detected between the numbers of microfilariae and chromosome 2p21-p14 (maximum multipoint log 10 of odds (LOD) score of 3.80 at marker position D2S2378; empirical P = 2.9 X 10 -5 ). Conclusions. This finding provides strong evidence that a human genetic factor influences the intensity of O. volvulus infection. The strength of the linkage signal may facilitate the identification of the decisive genetic variants.

Summary Background Of 18 million people world-wide who are infested with the tissue nematode Onchocerca volvulus, more than 30% are considered to have skin lesions, the pathomechanisms of which are poorly understood. Objectives To relate skin changes associated with onchocerciasis to parasitological findings and systemic cellular immune responses. Methods In the course of a genetic study, 691 members of 241 families exposed to hyperendemic O. volvulus transmission and free of other filarial or schistosomal infestations were studied clinically, by counting palpable Onchocerca nodules and skin microfilariae, by measuring peripheral blood cell (PBC) counts and total serum IgE, and by determining PBC in vitro proliferation and cytokine secretion in response to O. volvulus antigen. Results Of 691 individuals studied, 219 presented with onchocerciasis-associated skin changes. The groups of individuals with and without skin lesions neither differed in prevalences nor in average numbers of microfilariae. Compared with individuals without skin lesions, pronounced systemic T-helper (Th) 2-type responses were found with a trend of increasing intensity in the order of depigmentation, papular dermatitis, atrophy and lichenified dermatitis. Differences between the groups were most pronounced for serum IgE, less so for eosinophilia, and relatively weak for PBC proliferation and interleukin-5 secretion. Conclusions Skin lesions in onchocerciasis are associated with a spectrum of increasing generalized Th2-type responses ranging from low reactivities in cases of depigmentation alone to strong reactivities in cases of lichenification.

Endosymbiotic bacteria living in plasmodia or worm parasites are required for the homoeostasis of their host and should be excellent targets for chemotherapy of certain parasitic diseases. We show that targeting of Wolbachia spp bacteria in Onchocerca volvulus filariae by doxycycline leads to sterility of adult worms to an extent not seen with drugs used against onchocerciasis, a leading cause of blindness in African countries.