Strictly Confidential © 2014 WHY HIGH-QUALITY POPULATION SIZE ESTIMATES OF KEY POPULATIONS ARE IMPORTANT David Wilson HNP - GP World Bank

Strictly Confidential © 2014 ‘We Have Run Out Of Money; Now We Have to Think’ W.S. Churchill

Joint Program Competencies as Pillars of Strategic Planning Multisectoral approach NSP3G guidance Allocative efficiency studies Service delivery solutions Program efficiency Impact evaluation Multisectoral approach Evidence for strategic planning Epidemic appraisal Fiscal space analysis Sustainable financing research Investment cases SustainUnderstand DesignDeliver

What Does Success Look Like? What Does Success Look Like? India Joint Program Example Understand the epidemic Understand the epidemic Design: Implementation efficiency Design: Implementation efficiency Deliver: Effectiveness Deliver: Effectiveness Sustain: Sustainability Sustain: Sustainability Understand: Allocative Efficiency Understand: Allocative Efficiency 70% of transmission sex work in 4 states

Strictly Confidential © 2014 UNDERSTAND

Prevalence of Injecting Drug Use

Strictly Confidential © 2014 Prevalence of HIV among PWID

What we know Inaction is costly, and not the equivalent of nothing happening; It is hard to reverse epidemic once established Whereas harm reduction is -Effective - in terms of HIV cases averted -Cost-effective - in terms of healthy years gained and costs -Social benefits exceed treatment costs -And benefits the whole population

What is the global coverage of harm reduction services? Source: Authors’ literature review and estimates, using Mathers et al Few PWID access all three priority interventions Female PWID far lower access than males An estimated 10% access NSP About 14% of HIV+ PWID access ART An estimated 8% access OST

How much is spent on harm reduction? Sources: Stimson et al 2010 (three cents report), UNAIDS 2009; UNAIDS Progress report 2012; Global State of Harm Reduction, 2012; Bridge et al 2012  Estimated $160 million in LMIC in 2007 (3 cents per PWID per day): 90% from international donors  Global Fund largest HR funder (estimated $430 million ) > 50% to Eastern Europe and Central Asia

How much is needed to scale up priority harm reduction interventions? NSP coverage (%) Needles / PWID /year OST uptake (%) ART uptake of HIV+ PWID (%) Current estimated level Scenarios: Mid target High target  Very preliminary resource estimates based on regional estimates of current NSP /OST /ART coverage, population sizes and unit costs  Mid and high target scenarios costed

Summary: Estimated annual cost of scale-up of NSP, OST and ART for PWIDs Mid target 20% NSP coverage 20% OST coverage 25% ART coverage High target 60% NSP coverage 40% OST coverage 75% ART coverage South, East & South East Asia527M1,49B Latin America & Caribbean625M1,47B Middle East & North Africa26M55M W- Europe, N- America & Australasia17M1,19B Eastern Europe & Central Asia1.04B2,51B Sub-Saharan Africa414M901M Total per year2,65B7,62B 1: Mathers et al, Lancet (2010) 2: Scale-up calculations by UNSW

Annual scale-up costs by region and intervention  Costs dominated by Eastern Europe and Central Asia 1: Mathers et al, Lancet (2010) 2: Scale-up calculations by UNSW

Cost-effectiveness and relative return on investment ranges by region () number of studies in literature Western Europe, North America & Australasia CE 1 : ROI 2 : $402-$34,278 (9) $1.1-$5.5 (3) Sub-Saharan Africa Eastern Europe & Central Asia The Middle East & North Africa South, East & South East Asia Latin America & The Caribbean CE 1 : ROI 2 : $97-$564 (3) $1.4 (1) CE 1 :$1,456-$2,952 (1) CE 1 : ROI 2 : $71-$2,800 (7) $1.2-$8.0 (4) 1: Cost per HIV infection averted 2: Total future return per $1 invested (3% discount rate)

Harm Reduction Data Challenges Limited population size estimates Inconsistent service quality data Surveys miss hidden populations ATS increasingly used and injected but missed in surveys Significant but undocumented scale-down of services Sources: UNGASS country progress reports 2012; Mathers et al., 2010; Global State of Harm Reduction, 2012

Why we need reliable estimates of the size of populations at high risk Policy -Advocacy -Response planning and resource allocation -Estimates number of infected with HIV and projections of the burden diseaseProgramming -Intervention planning -Measurement of coverage -M & E interventions

Adjust for SW mobility with mathematical model to reduce double-counting of SW frequenting multiple spots Regression modelling to generate province- wide SW population size estimates from the towns mapped, with lower and upper bounds and Define Population Size and Program Targets Population Size Estimation with Modeling to Improve Estimates

Strictly Confidential © 2014 Using Evidence for Planning and Programming for PWID

Strictly Confidential © 2014 Total Sex Work Volume (denominator) Sex Workers Contacted SWs “Involved” SW STI Services Behaviour Change Opportunity Gaps Outreach Rapport STI Services Peer Education Community Mobilization Defining the Denominator to Enhance Targeting: Sex Work Programs Forming Group Norms MARPS (Sex Worker) Mapping

Programmatic Mapping for the Purpose of HIV Program Implementation Planning in Kenya Secondary key informants SW spots in each zone/town Estimated SW populations Sex workers Validation of spots (incl. adding spots) Validation of population sizes and ranges Existing location/si ze data Comparison to previous studies Local/national level SW per capita estimates Comparison across cities/towns and countries for plausibility

Geographic, Programmatic Mapping: Why it is Essential for Strategic and Operational Planning 1.Multisectoral programme planning & costing (national, sub- national) 2.Implementation/service delivery planning, including micro- planning at site level 3.Identification and allocation of peer educators in KP sites 4.Facilitating the setting up of individualized tracking systems for KPs 5.Baseline for monitoring progress 6.Informing design of evaluation strategy The Kenya AIDS Control Project and Hope World Wide Kenya rapidly used the data to offer peer education at known and newly recognized hot spots, and to set programme performance targets

Work with UN Joint Team members – UNAIDS, UNFPA, UNODC, WHO – to Validate and Finalise Data Correction for SW mobility (58% visiting more than one spot) Extrapolate to non-mapped towns with 5,000+ population Extrapolate to towns with <5,000 population Considering female urban population aged only Mapping not possible

Kenya National Adjusted Sex Worker Estimates ProvinceUrban population (2009 Census)Per capita FSW estimates Total urban and peri-urban pop. Total female pop. (15+ years) Total female pop. (15-49 years) % adult women 15+ years sex workers % of women years sex workers Nairobi3,138,369889,221735,9073%4% Central4,383,743491,124368,3433%4% Coast3,325,307415,929346,0075%6% Eastern5,668,123354,256292,1705%6% North Eastern2,310,75790,45489,8922% Nyanza5,442,711375,965333,5735%6% Rift Valley10,006,805645,647566,5644% Western4,334,282192,213174,4088%9% Overall 38,610,0973,454,8082,906,8644%5%

Kenya Urban Adjusted Sex Worker Estimates POPULATIO N PROVINCEESTIMATED NUMBERS MinimumMaximumAverage FSWNairobi 21,08134,16027,620 Central 5,7439,4007,572 Eastern 7,61613,51710,567 Coast 12,42220,50816,465 Nyanza 11,04217,70814,375 Western 10,05016,58813,319 Rift Valley 9,92316,83713,380 Grand total 77,878128,717103,298

Nigeria Program Understanding: Urban FSW at Hotspots by State Abuja FCT Ondo Nasarawa Gombe Cross River Benue Anambra Lagos NACA, 2013

Nigeria Program Understanding: Urban FSW at Hotspots by State NACA, 2013

Establishes overall objectives, strategy, planning processes, implementation mechanisms National Prevention Strategy MARPs Other urban populations Rural prevention programs Implementation Guidelines Specifying geographic focus, coverage targets, intervention components, measurement framework Terms of Reference for Implementers Nigeria Program Understanding: The Bridge From Understanding to Design and Delivery NACA, 2013

World Bank, Global Fund and USAID SACA and NGOs National Prevention Technical Working Group and M&E TWG Donors and Implementers Program implemented through grants to CBOs/CSOs LGA unit of program management Hot spot unit of program delivery Cluster implementation model Implementation Arrangement Macro level planning at national and state level. Meso level planning at state and LGA level Micro level planning at hot spot, cluster and LGA level Program management NACA, 2013 Nigeria Program Understanding: The Bridge From Understanding to Design and Delivery

Plan and Implement Scaled Program Scaling up strategy to provide efficiency and effectiveness Set outcome objectives e.g. Consistent condom use 80% Set specific objectives for project reach (micro level) e.g. 80% of FSWs reached by peer education Set coverage targets (macro level) e.g. Programs to cover 60% of estimated FSWs Define the Intervention Package Segmented by Population Group Specify the Population Focus (e.g. FSW) Develop rationale for selection NACA, 2013 Nigeria Program Understanding: The Bridge From Understanding to Design and Delivery

Pakistan Joint Program Understanding The joint program provided a better understanding of epidemic dynamics, drivers and typologies UN Wome n UNDP WB UNHC R WFP ILO UNOD C Secretaria t AIDS plan UNICE F UNFP A WHO HIV prevalence Hot-spot mapping Karachi Population size estimation

Know Your Epidemic: Epidemic, Response and Policy Syntheses Know Your Epidemic: Epidemic, Response and Policy Syntheses