Report No. 15569-AFR AIDS Prevention and Mitigation in Sub-Saharan Africa An Updated World Bank Strategy April 20, 1996 Human Resources and Poverty Division Technical Department Africa Region Document of the World Bank AIDS Prevention and Mitigation in Africa: An Updated World Bank Strategy was written by Wendy Roseberry. Portions of this report draw from World Bank materials prepared by Martha Ainsworth, Jill Armstrong, Ed Bos, Rodolfo Bulatao, Siddarth Dube, A. Edward Elmendorf, Andrani Gupta, Mubina Kirmani, Jean Louis Lamboray, Jeannette Murphy, and Mead Over. Insights to understanding the epidemic's determinants and consequences are summarized from the works of many, most notably: Maxine Ankrah, Stefano Bertozzi, John and Pat Caldwell, Michel Carael, J. Cleland, Steve Moses, Karen Oppenheim Mason, Peter Piot, Frank Plummer, Elizabeth Reid, John Stover. Much of the epidemiological data was obtained from the Global Program on AIDS, World Health Organization and the Center for International Research, U.S. Bureau of Census. The paper was processed by Donna McGreevy, Chris Blanchard and Heather Imboden, edited by Paul Holtz, and written under the direction of Ishrat Z. Husain, Chief, and A. Edward Elmendorf, Principal Management Specialist of the Human Resources and Poverty Division of the Africa Technical Department. Ill TABLE OF CONTENTS A C R O N Y M S ............................................................................................................................................................... iv EXECUTIVE SUMMARY: CONFRONTING AIDS IN AFRICA ......................................................................V PREVENTING INFECTION AND MITIGATING THE CONSEQUENCES ............V............ .....................V THE BANK'S ROLE ....................................................................................Vii ADDITIONAL BANK STRATEGY ACTIONS 1996-2000 ....................................................ix THE BANK'S COMPARATIVE ADVANTAGE AND RISKS INVOLVED ............................................. xii I. AIDS IN AFRICA-THE RAPID SPREAD CONTINUES.................................................................................1 HIV PREVALENCE AND DISTRIBUTION ...................................................................... RISK FACTORS .........................................................................................4 2. AIDS UNDERMINES DEVELOPMENT-AND EXACERBATES POVERTY ..........................................8 THE IMPACT ON THE HEALTH SECTOR..........................................................................9 THE IMPACT ON THE EDUCATION SECTOR..................................................................10 THE IMPACT ON LABOR PRODUCTIVITY ...................................................................11 THE IMPACT ON HOUSEHOLDS ...........................................................................12 3. RESPONSES TO THE EPIDEMIC-IMPRESSIVE BUT LIMITED.........................................................15 PREVENTION AND CARE ................................................................................15 PROGRAMS AND PROGRESS ............................................................................. 18 4. BANK'S CONTRIBUTION TO THE RESPONSE-MAKING PROGRESS.......................................... 21 ECONOMIC AND SECTOR WORK .........................................................................21 POLICY DIALOGUE AND REGIONAL PROGRAMS ..................................................... ........25 LENDING OPERATIONS .................................................................................26 5. THE COLLECTIVE RESPONSE-BROADENING THE PARADIGM......................................................30 PREVENTION THAT WORKS ..............................................................................30 Direct efforts.. .....................................................................30 a.) Education on safe behaviors .......................................................................31 b.) Condom promotion.. ...................................................................32 c.) STD treatment .........................................................................32 d.) Safe blood supply..........................................................................32 Indirect efforts...........................................................................33 a.) Strengthening health systems... ...................................................................33 b.) Increasing girls' education ................................................................33 c.) Increasing economic opportunities for women..................................................34 MITIGATION THAT IS RESPONSIVE AND SUSTAINABLE.......................................................34 Improving care for AIDS patients.......................................................34 Caringfor AIDS-affectedfamilies, communities, and sectors......................................30 6. ENHANCING THE BANK'S STRATEGY-1996-2000......................................36 BUILD ON CURRENT STRENGTHS .......................................................... 36 ADDITIONAL AREAS FOR BANK ACTION.................................................... 36 Work more vigorously to change behaviors................................................ 37 Intensify national programs according to a typology of countries based on severity of prevalence levels................. 338 Increase the analysis of AIDS and its impact on development goals in economic and sector work... .............. 338 Improve the design and implementation of cost-effective approaches to mitigate the consequences of AIDS.......... 39 BANK COMPARATIVE ADVANTAGES AND RISKS IN UNDERTAKING THE NEW ACTIONS... ........................39 BIBLIOGRAPHY BANK.. S TRA0........................ ..................................................................................... 41 ANNEX: OAU MATRIX ON AIDS DECLARATIONS 1992 AND 1994 ...........................47 iv ACRONYMS AIDS Acquired Immunodeficiency Syndrome CARE Cooperative for Assistance and Relief Everywhere, U.S. FAO Food and Agriculture Organization GPA Global Programme on AIDS HIV Human Immunodeficiency Virus ICAPP Intensified County Action Planning Process NGOs Non-Governmental Organizations NIARSH Network for Improved Adolescent Reproductive and Sexual Health OAU Organization of African Unity PHN Population, Health & Nutrition STDs Sexually Transmitted Diseases TASO The AIDS Support Organization, Uganda NGO UNAIDS Joint United Nations Program on HIV/AIDS UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNICEF United Nations Children's Fund USAID United States Agency for International Development WAMATA Tanzania NGO to Assist People with AIDS WHO World Health Organization V Executive Summary: Confronting AIDS in Africa AIDS is taking a calamitous toll in human suffering, in reduced life expectancy and productivity, in disruption of social systems, and in increased poverty in Africa. AIDS is now believed to be the leading cause of adult death between the ages of fifteen and thirty-nine in Malawi, Tanzania, Uganda, Zambia, and Zimbabwe. Just as striking have been the escalating deaths from AIDS of children under the age of five in these same countries. Thus many Africans are witnessing the reversal of gains made over the past two decades in adult and child survival. Yet the full consequences of the epidemic are still to be felt. * Three-quarters of the estimated 8.5 million adults in Africa infected with HIV have not yet developed AIDS (World Health Organization 1995). Between 1995 and 2005 these 6.3 million HIV-infected people will succumb to illness, tripling the region's caseload of AIDS patients. This figure is the minimum, since more Africans are sure to become infected. With few exceptions, HIV infection continues to spread at alarming speed, particularly in Southern Africa. * Fraying health and welfare services in many countries will be overwhelmed--costs of caring for AIDS patients could consume Kenya's entire recurrent health budget by 2000 (Family Health International 1993). The burden of caring for the nine million Sub-Saharan children orphaned by the disease by 2000 will strain Africa's extended family network. * AIDS is thought to have lowered life expectancy in Uganda by eight years, and worst-case scenarios suggest a fall of eighteen years by 2005 (Armstrong 1995). * AIDS is projected to slow per capita income growth, through its effects on savings and productivity, by an average of 0.3 percentage point a year between now and 2025 in the ten Sub-Saharan countries with the most advanced epidemics (Over 1992). This is a potentially significant setback in countries that have experienced slow or even negative growth in per capita income over the past decade. Despite the adverse effects caused by the epidemic, the response from governments, nongovernmental organizations (NGOs), and others is commendable, and examples of human valor and strength among African HIV-infected communities are numerous. PREVENTING INFECTION AND MITIGATING THE CONSEQUENCES Because sexual transmission is the predominant mode of HIV transmission, preventing the epidemic's further spread requires fundamental changes in individual and communities' sexual attitudes and practices. The means by which to affect change are: education on safe behaviors, promotion of condoms and improved treatment of the other sexually transmitted diseases (STDs). Of lesser vi importance in slowing the transmission but still a necessity, is ensuring blood used in transfusions is safe from HIV contamination. Across the continent, many, but not enough health care providers, educators, and community leaders promote safer sexual behavior through person-to-person education and mass communication channels. Messages range from sexual abstinence to use of condoms. They are delivered to the general population as well as targeted to special groups: adolescents and youth (who make up the greatest number of new HIV infections), sex workers, military personnel, and truck drivers. All national programs provide condoms free of charge and condom social marketing programs in more than twenty countries sell condoms at affordable prices. These prevention activities also lower the rates of other STDs, since STDs are a consequence of the same sexual behaviors as HIV infection. Training of public and private health care providers in improved diagnosis and treatment of the other STDs is beginning to be included in primary health care services in urban areas throughout Africa. Among the many lessons learned in implementing these interventions, one is paramount: the messages and activities must be gender sensitive. Most African women infected with HIV have been infected by their husbands. The choices and actions they need to take to protect themselves from infection are different than those for most men. Understanding better the factors that influence sexual behavior in men and women is an ongoing challenge for both AIDS prevention and family planning programs. Nevertheless, research and pilot efforts promoting these cost-effective interventions-education, condom promotion, and STD care-against HIV across the continent show risky behavior has changed and rates of HIV infection and STDs have been significantly lowered in several groups and communities. The prevention interventions do work. For example, AIDS awareness among the African population is now high, many communities and families are talking about sexual roles and responsibilities, sex education in schools is leading to delayed and safer sexual behavior among adolescents, treatment of STDs has improved, condom sales have skyrocketed, and persons living with AIDS are involved in prevention and care activities. Pilot projects in Nigeria, Rwanda, Tanzania, Uganda, Zaire, and Zimbabwe have lowered HIV infection and STD incidence among special population groups. Recently published data from two intervention projects in Uganda and Tanzania involving larger communities have shown encouraging results in increasing preventive behaviors (Uganda) and decreasing levels of HIV infection (Tanzania). Such efforts must now be expanded and the capacity to do so strengthened, for recent data suggest that the spread of the epidemic has yet to be significantly slowed. Attempts to mitigate the adverse affects of AIDS are challenging the health sector to provide quality care for the rapidly growing number of persons with AIDS. With health facilities already overburdened, particularly hospitals, the aim is to give as much quality care to the extent possible to AIDS patients in the home. Twenty-seven African countries have at least one community-based AIDS home care program, many of them managed by NGOs. In fact, NGOs have become instrumental in serving communities in AIDS-related activities. A formidable task vii for many community-based programs is to meet the many physical and psychosocial needs of AIDS patients for drugs, supplies, and counseling. Both prevention and mitigation strategies can be found in several sectors beyond the health sector. Ministries of education, defense, youth and women's affairs, and information are working closely with national AIDS control programs to integrate AIDS prevention and care activities with their program plans. Many-but not enough-innovative workplace programs among private industries reflect a strong commitment to educating employees on prevention and ensuring adequate care for those infected. Sectors and industries severely hit by the epidemic are attempting to secure adequate levels of financial resources to accord prevention efforts first priority while still meeting the costly needs of those already infected. About $100 million was spent in 1992 in Africa on prevention programs for AIDS and other STDs; 10 percent of this total came from African governments. A World Health Organization (WHO) study suggests that comprehensive prevention services would cost from $225 million to $435 million a year. Such spending would be two-and-a-half times 1992 spending, but it would yield enormous benefits, averting as many as 4.2 million new infections by 2000. About $183 million was spent on care for AIDS patients in 1992 by African countries. Although this is a small share of the $4.7 billion spent by industrial countries to care for their AIDS patients, it still exceeds what is spent on prevention in Africa. The cost-benefit relationship between prevention and 'cure' rings true for AIDS-it costs more to not prevent AIDS. By 2000 spending for care in Africa will nearly double, rising to $347 million a year. THE BANK'S ROLE In response to the ever-changing nature of the epidemic, this update is the second review of the World Bank's 1988 AIDS Strategy for Africa. The first review, in 1992, found that the six strategy actions from 1988 concerning economic and sector work, lending, and capacity-building had been initiated with progress. But the 1992 review identified four new areas requiring attention: * Concentrating on countries vulnerable to HIV because of their high prevalence rates of other STDs; * Promoting a core AIDS control strategy that recognizes AIDS as an STD and accentuates the prevention of the other STDs; * Reinforcing the key elements of the health infrastructure; * Developing multisectoral policies for coping with the economic and social impacts of AIDS. viii The first three of the four new areas have been addressed as the 1992 review intended. For example, ten of the twelve countries with high rates of STDs identified by the 1992 review have executed Bank-assisted projects with AIDS-related components. A core AIDS control strategy consisting of the main interventions for prevention (including STD care) and mitigation now exists in most African countries-and in all thirty-six Bank-assisted AIDS control projects. Twenty-five of the thirty-six Bank-assisted projects with AIDS-related components are strengthening key elements (such as pharmaceutical delivery and laboratory support) of the health infrastructure. Three projects have combined AIDS and population activities. Attention to the fourth area-developing multisectoral policies-while noteworthy, has not progressed beyond description and projection of the socioeconomic impacts of AIDS to actual development of multisectoral policies and interventions. For example, two innovative and comprehensive studies to assess the impact of AIDS on development have been sponsored by the Bank in Tanzania and Uganda. It is not evident, however, whether policies and interventions to mitigate the adverse socioeconomic effects of AIDS have been developed as a result of these studies' findings. A third study, a nearly complete Bank-sponsored survey of adult mortality in Tanzania will provide a closer look at the effects of AIDS at the household and community levels-and more specific recommendations on policy. Although eight more studies similar to those performed in Tanzania and Uganda are planned (in Botswana, Burundi, Central African Republic, Chad, Congo, C6te d'Ivoire, Madagascar, and Zambia), for a variety of reasons initiation has been slow. Overall, the implementation of the Bank's AIDS strategy since the 1992 review can be categorized into three domains: economic and sector analysis (including the socioeconomic impact studies discussed above), policy dialogue and regional programs, and lending operations. Each of the Country Departments and the Technical Department has developed an AIDS workplan that sets forth AIDS prevention and mitigation activities under these domains. Economic and Sector work specific to AIDS has focused on learning more about the prevalence of STDs and, as mentioned above, about the impact of AIDS on development. In all, ten studies have been performed and twelve more are ongoing or planned. A review of recent poverty assessments, policy framework papers, public expenditure reviews, country economic memoranda and country assistance strategies found that, although AIDS was frequently mentioned in these Bank documents, more consideration must be given to the epidemic's socioeconomic implications, how these implications will affect development goals, and what actions are required in the Bank's assistance strategy. Working closely with national and international organizations, the World Bank has increased the policy dialogue on AIDS by putting the subject on development agendas in a variety of African forums, from the annual meetings of the African Development Bank to a seminar on AIDS and the military. A high-level Organization of African Unity (OAU) delegation with Bank participation visited leaders of four African countries in August 1995 to discuss ways of expediting the response to AIDS. ix The Bank has also designed regional programs on AIDS and population to increase awareness, build commitment, and facilitate action. All three initiatives focus on demand-driven community services and on promoting healthy sexual behavior--goals shared by population programs. By 1995 Bank lending operations included thirty-six human resource development projects with cost-effective AIDS prevention and mitigation components in twenty-four African countries. And Burkina Faso, Chad, Kenya, Uganda, and Zimbabwe had initiated freestanding AIDS projects. Three additional projects focusing mainly on AIDS in Congo, Niger, and Tanzania are expected to be effective by the end of 1996. Total financing for AIDS-related lending exceeds $250 million. The freestanding AIDS projects in Burkina Faso, Chad, Kenya, Uganda, and Zimbabwe have several strengths. They support all the basic interventions, including AIDS and STD education, STD care, condom promotion, blood supply protection, and mitigation of AIDS consequences. In addition, they provide the resources necessary to expand successful pilot projects to scale, and create grant mechanisms to support community-based implementation of interventions that are more gender sensitive in their approach. They design and incorporate national evaluation strategies to measure the impact of interventions. Finally, they strengthen the skills of public and private personnel in program management. In brief, the governments of these countries ensure their AIDS control programs are comprehensive-all interventions are implemented simultaneously (depth) and all target groups are reached (breadth)-by including these elements in one large project. Few other national AIDS control programs in Africa contain these comprehensive elements. Because of high HIV and STD prevalence rates a number of countries-including Burundi, Cameroon, Central African Republic, C6te d'Ivoire, Ethiopia, Malawi, Namibia, Nigeria, Rwanda and Togo-are in great need of such comprehensive programs, whether Bank- assisted or not, and whether supported by AIDS-specific or integrated health projects. Implementation of the Bank-assisted projects has shown some progress, although frequent delays common to most projects have been experienced. Clinical management for the curable STDs has greatly improved in Lesotho and in Zimbabwe, where the availability of STD drugs among facilities has increased by 21 percent. National data on impact among the more recently designed AIDS projects will not be available for five to seven years. Eighteen additional projects are planned for fiscal 1996 and 1997, a reflection of government commitment to cost- effective interventions against AIDS and other STDs. ADDITIONAL BANK STRA TEGY ACTIONS 1996-2000 Africa's AIDS epidemic demands a collective, urgent response. A number of interventions have been identified as being highly effective, and many national and international partners have adopted these interventions-making up the Global AIDS Strategy-to save lives. The challenge now is to intensify the implementation of these interventions to significantly slow x the epidemic's rapid spread. The new Joint United Nations Programme on AIDS (UNAIDS) is envisioned to help meet the challenge, through improved coordination of UN assistance. Much of the Bank's work in assisting African countries to prevent HIV infection and mitigate the adverse effects of AIDS should continue. In addition, the Bank by updating its Country and Technical Department workplans on AIDS for the period 1996-2000 should undertake five new actions. The Bank should continue to support the cost-effective interventions-education, condom promotion, STD care, and safe blood-for prevention. Prevention efforts will have more impact on slowing the epidemic if they are backed with strong leadership, if knowledge on the determinants of behavioral change in Africa is increased and interventions are intensified. Thus the Bank will assist Africans to: * generate greater political commitment to the OAU declarations on AIDS * work more vigorously to change health behaviors * intensify national programs according to a typology of countries based on severity of prevalence levels Although AIDS is often referenced in Bank economic and sector documents, the adverse consequences of AIDS on development objectives such as decreased life expectancy and productivity is rarely factored in the analyses used to develop a severely affected country's assistance strategy. In addition, the 1992 review found that few policies and cost-effective interventions exist in mitigating the socio-economic effects of AIDS. Thus, the Bank should address these gaps by helping governments and NGO's: * increase the analysis of AIDS and its impact on development goals in economic and sector work, * improve the design and implementation of cost-effective approaches to mitigate the consequences of AIDS Generate greater commitment to the OAU declarations Attaining the required intensity of interventions to slow the epidemic's spread is a formidable goal for Africa-but one that must be achieved. African leaders have pledged to meet this goal, having made commitments to secure the resources needed to fight the epidemic in the 1992 and 1994 OAU declarations on AIDS. First, the Bank should help the OAU monitor country progress in implementing the activities contained in the two declarations through the development of a reporting system (see Annex). Second, the success of the OAU delegation tour of four countries in August 1995 suggests that the Bank should assist the OAU in undertaking xi undertaking tours of additional African countries to meet with Heads of State and accentuate their support in carrying out the OAU activities. Work vigorously to change behavior The Bank should also support Africans in the strengthening of programs leading to the adoption of safe sexual behaviors and practices. Three separate tasks would strengthen capacity in this field. First, a group called African Advisers on Behavioral Change would bring together spokespersons from various backgrounds to advise other Africans, international partners and the Bank on the many facets of adopting healthy behaviors. Second, a comprehensive review would be made of the progress to date and challenges ahead in adopting safe behaviors in Africa, with particular focus on lessons learned and shared sub-regionally. This study would be overseen by the African Advisers on Behavioral Change. Finally, African public and private institutions and community-based organizations currently involved in behavioral interventions would be strengthened. These organizations would serve as centers of expertise for building the capacity of professionals and community leaders in improving health practices. Intensify national programs in additional AIDS-affected countries selected from a typology of countries based on severity of prevalence levels. Of the forty-seven African countries, thirteen have HIV prevalence rates among adults greater than 5 percent, and another sixteen have adult prevalence rates greater than 1 percent. Intensified national AIDS control programs exist or are planned in twelve of these twenty-nine countries. Of the seventeen countries remaining, the Bank should first help about half-most likely-Burundi, Cameroon, the Central African Republic, Ethiopia, Malawi, Nigeria, Rwanda, and Togo-and the other half at a later date to secure the resources needed to have a substantial impact on the epidemic's spread. Within its new role as a cosponsor of the UNAIDS, and in collaboration with the Global Coalition for Africa, the Bank should initiate discussions in these countries to ascertain what is required to intensify program interventions and how resources can be mobilized and coordinated. If required, the Bank would provide additional resources to help these governments mount intensified national AIDS control programs, as donor of last resort. Increase the analysis of AIDS and its impact on development goals in economic and sector work The Country Departments serving the most severely affected countries should ensure that AIDS is addressed in relevant country analytical work both in and outside the PHN sector. Specifically, AIDS impact on adult and child morbidity, mortality and life expectancy, labor, productivity and savings should be assessed for several sectors, particularly PHN, education, agriculture, industry and transport. The findings of these assessments should be incorporated into the country assistance strategies. Thus, the country assistance strategy, country economic memorandum, policy framework paper, poverty assessment and public expenditure review xii should not only mention AIDS, as they often do now, but also factor the consequences of AIDS in their analyses and recommendations for improved development strategies. Improve the design and implementation of cost-effective approaches to mitigate the consequences of AIDS Because it is not yet clear which approaches best deliver community-based care or which policies best ease the adverse socioeconomic consequences of AIDS, the Bank should support African decisionmakers in designing and implementing mitigation policies. Increasing the cost- effectiveness of health care for AIDS patients is an obvious priority. Other priorities include the need to decrease the economic hardships confronting AIDS-affected households and communities, improve care and schooling of orphans and replace the skilled workers in industry and government lost to AIDS. The Bank should identify best practices and summarize lessons learned, define directions for future Bank and country policy, and design and implement interventions to help families, communities and sectors mitigate the adverse consequences of the epidemic. These policies and interventions will need to answer such questions as: How can quality care of AIDS patients be provided in facilities and homes at minimal cost to both the health system , other health system beneficiaries and home care givers? What components of AIDS patient care are the most likely to be sustained? What assistance is most needed by impoverished families and communities affected by AIDS and what criteria should be used to assess the most needy? What measures can families, industry and other sectors severely-affected by AIDS take to replace lost labor and productivity? THE BANK'S COMPARATIVE ADVANTAGE AND RIsKS INVOLVED Wha: are the Bank's comparative advantages to carrying out these new actions? The Bank's access to decision makers in government ministries such as finance and plan in addition to the ministry of health, gives the Bank the advantage in generating increased political commitment. Although traditionally, the Bank has not been seen as a lead player in supporting programs that strive to influence behavior change, this role is undoubtedly changing and becoming more visible as the Bank increases its involvement in human resource development, particularly in population, health and nutrition. The Bank's mobilization of funds for several regional programs (NIARSH and the West Africa Regional Program), the increase in demand for Bank support for AIDS activities and the Bank's new partnership with the UNAIDS program illustrate that the Bank has been and continues to be in a position to assist African governments secure the resources necessary to launch intensified AIDS-related activities. Few other agencies involved in AIDS work have the clear economic mandate in development as does the Bank. Of the six UNAIDS cosponsors, it is the Bank that is looked to, to provide the leadership in economic analyses of AIDS interventions and impact. As the UNAIDS Strategic Plan becomes operational, the request for Bank contribution to 'the economic side' of AIDS will increase. xiii The overwhelming risk to 'taking on AIDS' has been that of having only to rely on behavior change for success as opposed to a cure or vaccine. This risk remains. If the success of the collective response to AIDS is still most dependent on widespread adoption of safe behaviors, the risk in failing will have to be reduced by 'taking on' the subject of behavior. Few, but enough examples of successful behavior change exist in Africa and worldwide, as a knowledge base from which to expand. Thus, for the Bank to assist Africans in this endeavor, the Bank should strengthen its own understanding of what factors influence the adoption of safe behaviors and what improvements in project design, implementation and evaluation are required to attain healthy practices in Africa Figure 1 summarizes these new actions of the AIDS Strategy for Africa and those of previous reviews. Figure I Actions under the Bank's AIDS strategy for Africa Purpose: preventing HIV infection and mitigating the impact of AIDS in Sub-Sahoran Africa 188 AIDS strarag& f95Uda S rategy Inrovase Bank effort in rour pnontr areas: Additional &aons to help 9 Polic diogue: "ADSis a potential threat to development' * Generate greater cornitremto * Economic and sector wori: "Wha is the magnude of th the OAU declratkins proNem and how rVt it afect developren? *Inensify nabonal programs 9 Donor coorfinaton accordig to a typolog of couries * Training of Bank staff based on seveiy of IV prevalerce levels I srnthen proams leadrs to the adapkn of safs behwbrs to prevent 1992 Remew of AIDS sura HFIW5TDs New areas mwrtiganention. * Inoase the anayi of AIDS and its * Focus efforts or, courrtnes with a high prevatence of STDs impact on development goals it * Est.Oish a core strategy for NDS that reflects AIDS as ar STD econciic and sector work * Strenthen key elererts of hea nfrwsucture aMUic to * Improve the design and controlling ADS riplementation of cost-effecive * Develop muhiseacoral poaes for copng with approaches to rmiate the socioeconomc impact consequenest of ADS As indicated above, the evolving nature of the epidemic requires frequent assessment of the epidemiological situation and concurrent revision of the AIDS Strategy. This the Bank should continue to do, particularly as the response to the epidemic is fine-tuned. The effectiveness of the interventions to prevent HIV evidenced in small population groups thus far and the impressive response mobilized across the continent, suggest to the Bank that taking on AIDS in Africa is an achievable goal.  1 1. AIDS In Africa-The Rapid Spread Continues During the past decade more than 11 million adults and 1 million children-roughly two- thirds of the estimated global total-have been infected with the human immunodeficiency virus in Africa. Every day 1,800 more Africans are infected. Projections suggest that within five years the cumulative number of infected people in Africal will increase by a third, reaching 15 million (WHO 1995). Rapid increases in infection are occurring among adolescents and young adults, particularly females. The majority of HIV infections are in East and Central Africa, with the epidemic spreading to contiguous areas in Southern Africa, principally Botswana, South Africa, Swaziland, Zambia, and Zimbabwe (map 1.1, next page). The government of South Africa estimates that more than 500 black South Africans are infected with HIV each day. In Swaziland national AIDS control program managers expected the 1993 HIV infection prevalence rate among pregnant women to be twice the 1992 level of 3.9 percent, but instead the rate quintupled, to 21.9 percent (AIDS Analysis Africa 1994b). Rates of infection are also rising in limited areas of West Africa-Burkina Faso, C6te d'Ivoire, Guinea-Bissau, Niger, and Nigeria. The slow but steady increase in infection rates in Nigeria (from about 1.4 percent among pregnant women attending antenatal facilities in 1991 to 3.8 percent in 1994) is a cause of concern because of that country's large population and considerable internal and external migration (Federal Ministry of Health and Social Services 1995). HIV PREVALENCE AND DISTRIBUTION Throughout the continent, HIV has spread along the major migration routes. Several studies have shown that a change of residence is strongly associated with an increased risk of HIV infection. Thus, the extensive labor migration in Central and Southern Africa, the long- distance commercial transportation lines operating in both East and West Africa, and the mobilization and entrenchment of military forces are clearly tied to the spread and acceleration of the epidemic. Political and social instability gives rise to migration and thus to increased HIV transmission among both soldier and civilian populations. Some observers believe that HIV and AIDS were an important cause of the widespread despair and unrest in Rwanda before the recent upheavals. HIV prevalence among Rwandan soldiers was estimated to be as high as 65 percent in 1994 (AIDS Analysis Africa 1994b). Interviews with the military found fear, anxiety, and uncertainty in the ranks because AIDS was seen as "more dangerous than bombs," since it was invisible. The subsequent months of displacement and living in enclosed camps for the millions of Rwandan refugees will undoubtedly fuel the epidemic. Cooperative for Assistance and Relief Everywhere (CARE) estimates that 33 percent of sexually active adults in refugee camps in Tanzania are HIV positive. 1The terms Africa and Sub-Saharan Africa will be used synonymously in this paper. 2 Map 1.1 High HIV infeetion rates are concentrated in East and Central Africa and along major migration Routes IBRD 27109 20' 7,7 47-_ - 50--k-& T- Co sorr n0 500 1,000 1,500 KILOMETERS MOROCCQ **".* a 0 500 1,000 MILES -r•.- A L GzE R| 30 LIBYA ARAB REP. OF S[EGYPT MAURITANLA sL u \ IgNouckchot \ ~j5% 1-5% >5% 1-5% >5% 1-5% >5% 1-5% HIV prevalence HIV prevalence HIV prevalence HIV prevalence HIV prevalence HIV prevalence HIV prevalence H/V prevalence Burkina Faso Chad Congo Gurnea-Bissau Burundi Benin Botswana South Africa Kenya C6te d'Ivoire Niger CAR Cameroon Swaziland Namibia Uganda Tanzania Lesotho Ethiopia Zimbabwe Malawi The Gambia Rwanda Guinea Zambia Mali Nigeria Senegal Togo Source World Bank data. The Bank has promoted both types of projects, those specifically geared toward AIDS (freestanding) and PHN projects with HIV prevention and AIDS mitigation components. Country circumstances should dictate which design will best support overall health goals and delivery systems. Ultimately, Bank staff, country decisionmakers, and other donors should work toward AIDS control programs that are comprehensive in their interventions and implemented in all geographical (including across borders) locations and all relevant sectors. Two limitations common in Bank lending practices inhibit a multisectoral response to the epidemic. First, PHN projects rarely deal with the issues from other sectors that influence health. For example, among thirty PHN projects with AIDS components, only four address exogenous variables, such as women's status, that influence the PHN sector. Second, most of Bank-assisted 29 projects with AIDS components still originate in the PHN sector-even in the most severely affected countries, where the impact of AIDS on other sectors is apparent. Only six projects with AIDS activities out of the total thirty-six originate outside the PHN sector. Five of these are in social sector development projects, and one is in the transport sector. (See Box 4 below for one example). Thus, the Bank and African governments have yet to fully integrate (a) the interventions that target the exogenous determinants into PHN projects and (b) AIDS prevention, mitigation, and planning into the other sector projects: education, transport, agriculture, and industry. Box 4 Widening the Health Sector Response to a Multisectoral Response: Supplementing the Health Interventions with Socio-economic Interventions The adverse impact of the disease on development calls for widening the response outside the health sector and supplementing the health interventions with interventions that address the socio-economic determinants and consequences of AIDS. Providing AIDS information in schools, workplaces, military bases and agricultural outreach programs is an example of widening the response outside the health sector. Programs that organize income-generating activities for women as alternatives to commercial sex work or provide care for orphans are examples of supplementing health interventions with interventions that address the socio-economic issues around AIDS. One Bank-assisted project in Uganda that consists of both these enhanced approaches to AIDS prevention and mitigation is the Program of Assistance to Orphans of AIDS (Gakuweekbwa, Munno) implemented by World Vision. The project focuses on empowering people within the Rakai and Masaka Districts to take the critical actions needed to respond to the AIDS crises. Visible outputs include 1) installation of 5 grinding mills providing daily income for the communities; clothing, food, and school tuition to 1,000 orphans, and provision of 234 loans to 237 clients (of which 60 were women) through the Small Scale Production Enterprise activity. Overall, 43,113 of the projected 58,241 orphans and 17,500 foster parents (6,500 more than the projected 11,000) are receiving assistance. 150 health workers have graduated and each given a drug kit and bicycle. 30 5. The Collective Response-Broadening the Paradigm The AIDS epidemic demands a collective, urgent response. This update of the World Bank's AIDS Strategy for Africa has reviewed the World Health Assembly's universally endorsed Global AIDS Strategy and the impressive progress made to date in mobilizing the resources to carry out the Global Strategy. A number of the strategy's interventions are highly effective, and many national and international partners have adopted these interventions to save lives. The challenge now is to intensify the implementation of these interventions to significantly slow the epidemic's rapid spread. This chapter summarizes the achievements and shortfalls of the global response, including that of the Bank. Based on this analysis, Chapter 6 suggests new actions to enhance the work currently supported under the Bank's AIDS Strategy for Africa. Figure 5.1 below introduces an AIDS response paradigm to assess the adequacy of prevention and mitigation. This paradigm broadens the response to include multisectorial and socio-economic concerns summarized previously in Box 4. Two types of prevention efforts, direct (square 1 in figure 5.1) and indirect (square 2), inhibit HIV transmission. Two types of mitigation efforts, those directed toward AIDS patients (square 3) and those directed toward AIDS-affected groups (square 4), help ease the adverse health and socioeconomic effects of AIDS. Figure 5.1 Efforts that prevent HIV infection and mitigate the impacts of AIDS Prevention Mitigation Indirect Infected Individuals Affected groups Humnai resource and Care of AJDS patents Care ofAJDS-aifeaed accinacnm development FaRs, coMmunities. and on safe * Treatment cf inecaons seaon Strenthenng helth * Alevia on of pain prOMot) s * Counseling * Counseling t Incwng girls eduaon - Fwianoal and in kind aid * Targeted interventions kIreasi" economic for the poo opportun6tes for women a Replcerrent oost labor PREVENTION THA T WORKS Direct prevention of HIV transmission is the first priority in the response to the epidemic. Direct efforts The four most effective HIV prevention interventions (education on safe behavior, condom promotion, STD treatment, and a safe blood supply) can be found in every African country (square 1). Studies in Rwanda, Tanzania, Zaire, Zambia and Zimbabwe have shown these interventions to be cost-effective in reducing the incidence of HIV and other STDs in certain target groups (the military and commercial sex workers) and in larger communities of the 31 general population. Still, these interventions have rarely attained the depth (all interventions in place at the same time) and breadth (reaching all target groups) required to substantially slow the epidemic's spread. For example, HIV prevalence rates among pregnant women continue to exceed more than 30 percent in several urban areas in southern Africa. The Bank's role. The Bank's new freestanding AIDS projects in Burkina Faso, Chad, Kenya, and Uganda were designed to intensify the depth and breadth of the four interventions. Bank-assisted projects containing AIDS-related activities with intensified interventions are being planned in Congo, C6te d'Ivoire, Guinea-Bissau, and Tanzania. But these nine countries are the exception. Many affected countries-among them Burundi, Cameroon, the Central African Republic, Ethiopia, Malawi, Nigeria, Rwanda, and Togo-lack the essential elements that intensify the depth and breadth of the interventions making up their national AIDS control programs. The progress of these interventions in preventing HIV infection is summarized below. a.) Education on safe behaviors Education on AIDS and safe sexual behaviors has substantially increased AIDS awareness throughout Africa. About 65 percent of rural populations and 100 percent of urban populations are aware of AIDS. How this knowledge influences the adoption of safe behaviors is less clear. Some African men are taking fewer sexual partners, and some men (about 25 percent of those surveyed in Burundi and Zambia) engaging in casual sex are regularly using condoms (Caral and Cleland 1993). Because the largest share of new HIV infections is among young adults and adolescents, this is one of the most important groups to target. Yet not all youth are being reached-sexual education courses in schools are often optional, and community activities targeting out-of-school youth are limited in number. And every year a larger cohort requires consistent and sustained messages on prevention. It is not yet widely known how Africa's high awareness of AIDS can be internalized by Africans into the adoption of safe sexual practices continent wide. The experience and best practices on how to bring about fundamental changes in social norms is thin in Africa and elsewhere. Several European donors, U.S. and Australian institutions, and United Nations agencies have recently acknowledged the role behavior plays in AIDS (and family planning), and have substantially increased grant funding in this area. And some African universities have increased the number of social research programs. Still, few NGO's and institutions in Africa have the capacity to expand the knowledge of which factors influence behavior. Technical and financial assistance is needed to increase the number of African organizations and institutions adept in the behavioral fields. The Bank's role: Through its regional programs, the Bank is expanding the efforts of three nongovernmental organizations and one institute in carrying out behavior research and interventions across country borders in East, Southern and West Africa. In addition, nearly two- thirds of thirty-six Bank-assisted projects with AIDS components promote safe sexual behaviors. 32 b.) Condom promotion The explosive increase in sales of socially marketed condoms (from 2 million in 1988 to 120 million in 1994) suggests that consistent demand for condoms can be created if the condoms are affordable, accessible, and of good quality. With safer sexual behaviors becoming more common, condoms requirements in Africa are expected to reach 932 million condoms a year by 2000 (WHO 1993). Thus the twenty-five African countries without social marketing programs for condoms must immediately establish them to fill this projected need. In addition to socially marketed condoms, the demand for condoms will have to be met by free condoms procured internationally by the United Nations Fund for Population Activities, the U.S. Agency for International Development, the WHO, and governments with Bank financing, and possibly by condoms manufactured in Ghana and Nigeria and sold for profit regionally. On a parallel course, testing of the new female condom and research for a female controlled virucide must continue. The Bank's role. The freestanding Bank-assisted AIDS projects in Burkina Faso, Chad, Kenya, and Uganda and health projects in Benin and Guinea include procurement and distribution of free condoms for HIV/STD prevention. The projects in Burkina Faso and Chad also support social marketing programs. The proposed STD prevention project in Nigeria includes the plan to explore the profitability of manufacturing condoms locally. c.) STD treatment Many capital cities can boast one clinic providing quality STD care-but few countries have the drugs, training, and personnel to integrate STD care with their primary health care services. The importance of STD treatment was highlighted by the recent findings of a Mwanza, Tanzania study, which found that effective treatment of curable STDs lowered HIV incidence by 42 percent. The Bank's role. Studies assessing STD prevalence and related risk factors have been sponsored by the Bank in eight countries and are planned in three more, in Central and Western Africa. Working with the WHO, the Canadian International Development Agency, and the U.S. Agency for International Development (USAID), the Bank is increasing the University of Nairobi's ability to meet countries' needs for STD training. The Bank is also one of the few international organizations financing the procurement of drugs for STD care. d) Safe blood supply Although HIV transmission through blood products contributes only minimally to the African epidemic, safe blood is a necessary objective of any AIDS control program. Only ten countries in Africa screen all blood and blood products for HIV. Testing equipment is expensive and in short supply in most countries, especially in rural areas. The testing equipment that is available is usually supplied by the European Union, the WHO, and the Danish International Development Agency, in addition to the Bank. 33 The Bank's role. Fourteen Bank-assisted health projects support the screening of blood for HIV. This intervention includes procuring tests and testing equipment and setting up management and logistical systems for screening, referral, and reporting. Of critical importance is ensuring that confidential mechanisms exist to exclude blood donors of high risk to HIV and all persons are counseled before (and after if HIV-positive,) while donating blood. Indirect efforts Human resource and economic development efforts (square 2 in figure 5.1) are addressing many of the socioeconomic conditions that make people-especially women-more vulnerable to HIV. These prevention activities often require a longer time frame than the direct interventions just discussed. The United Nations Development Programme (UNDP), bilateral donors, and the African Development Bank are the main international actors, in addition to the Bank, assisting African governments with these development efforts. a.) Strengthening health systems A number of national and international organizations-public and private-have made tremendous strides toward improving the delivery of health services throughout Africa. The decreases in child and adult mortality witnessed in Africa over the past decades attest to this progress. But much more can be done. An additional $1.6 billion a year is needed to ensure a basic package of health services in the rural and periurban areas of low-income Africa. Strengthening the health system will involve improving the physical and managerial operations of health systems, with an emphasis on facility renovations, pharmaceutical procurement, and better management and training of personnel. The Bank's role. Bank-assisted health projects implemented in Angola, Burkina Faso, Guinea, Madagascar, Malawi, Mali, Mauritania, Niger, Nigeria, Uganda, and Zimbabwe. Bank assisted-health reform projects have recently begun in Ethiopia, Kenya, Mozambique, Tanzania, and Zambia. New lending in health to Sub-Saharan countries averaged more than $200 million a year during 1993-95. This total will rise to more than $400 million during 1996-98. b.) Increasing girls' education Educating girls is widely recognized as one of the most important steps in development. Education for girls has a catalytic effect on every dimension of development: lower child and maternal mortality rates, reduced fertility rates, increased educational attainment by daughters and sons, higher productivity, and better environmental management. Yet less than 70 percent of eligible African girls enroll in primary school, and only 68 percent of those girls enrolled in first grade complete primary school (Carr-Hill and King 1992). The United Nations Children's Fund, the United Nations Educational, Scientific, and Cultural Organization, and the African Development Bank follow the Bank as the leading multinational and bilateral supporters of education. 34 The Bank's role. Bank lending for education has increased significantly the past decade. Annual lending to Africa for education averaged $122.8 million during FY 1985-89, and reached $325.5 million in FY 1994. Since 1990, about 40 percent of Bank-assisted education projects in Africa have included female education components, from providing scholarships to training female teachers. c.) Increasing economic opportunities for women Improving women's productive capacity can contribute to growth, efficiency, and poverty alleviation-key development goals everywhere. Yet numerous barriers continue to shut out women and limit their opportunities. Effective strategies for reducing the barriers to women's economic participation have emerged over the past two decades through work performed by nongovernmental organizations, women's groups, and the Bank. The Bank's role. Since 1992, 57 percent of Bank lending to Africa has promoted macroeconomic adjustments that foster growth, and 17 percent is directed to narrowly targeted services whose main beneficiaries are the poor. Between 1987 and 1990 the Bank introduced eighty-one projects with enterprise development and financial services for women components- the majority of them in Africa-to raise incomes and generate new employment. These activities are found in agriculture, industry, and urban development projects. The Bank also supports through a regional program legal reforms (in land ownership and credit access) for women in Africa. Although these human resource and development efforts occur outside the health sector, they can be used to target populations specifically at risk of HIV infection. For example, programs to educate girls and increase women's access to credit could include female sex workers, orphans, and street children. More communication and collaboration between the sectors and among community leaders would strengthen the program linkages between development and HIV vulnerability. MITIGATION THAT IS RESPONSIVE AND SUSTAINABLE Although efforts to mitigate the consequences of AIDS (squares 3 and 4 in figure 5.1) are less urgently needed than those to prevent HIV, mitigation is still important. People living with AIDS can lead productive lives if they receive support from their families and communities. They can also contribute to prevention efforts in their communities, as agents of change and peer educators. In addition, families that are affected by AIDS suffer from personal loss, increased medical costs and burial fees, and reduced income. These larger socioeconomic impacts are significant-and should be addressed. Improving care for AIDS patients None of the thirteen countries most severely affected by HIV has experienced its peak of AIDS cases. Thus the number of AIDS patients requiring care in these countries is going to increase. Several NGO's (Tanzania NGO to assist People with AIDS-WAMATA and The 35 AIDS Support Organizatio-TASO) have shown that AIDS patients and their survivors can receive appropriate care and counseling away from the overburdened hospital systems. In fact, twenty-seven countries have some form of community-based care for AIDS patients. Questions regarding the cost-effectiveness and sustainability of these programs have yet to be answered, however. Thus, more information is needed on the costs of various approaches to service provision, and on who bears these costs. The Bank's role. Bank-assisted research into alternative, cost-effective modes of caring for the increasing number of AIDS patients has been performed in Tanzania and Uganda, and is planned in Botswana and C6te d'Ivoire. This research complements the work performed by others in Kenya and Zambia. A Bank-assisted project in Zimbabwe has increased the availability of drugs for tuberculosis and other opportunistic infections by 21 percent. Similar results are expected in Burkina Faso, Chad, Kenya, and Uganda. Caring for AIDS-affected families, communities, and sectors USAID, UNDP, the FAO, and several other international organizations have studied the consequences of AIDS, most recently in Kenya, Malawi, South Africa and Zambia. For example, the average Malawian family loses, in addition to a personal loss, a contribution of more than fifteen years of productive life when a male family member dies of AIDS (Family Health International 1994). The Bank's role. Three comprehensive Bank studies in Tanzania and Uganda and other analytical work sponsored by the Bank assess the socioeconomic impact AIDS is having or will have on African households and communities, as well as on the public and private sectors. This information helps convince policymakers of the need for a multisectoral response to AIDS and of the epidemic's dramatic impact on development. Still, few policies addressing these impacts have been developed as a result of such efforts. An abbreviated form of these studies, with better use of the data for policy and program decisionmaking, is planned for many of the other severely affected African countries, including Botswana, Burundi, Congo, C6te d'Ivoire, and Rwanda. Outside the health sector, integration of the findings of AIDS-related sector work with Bank operations has been limited. Among twelve most severely affected countries, the five poverty assessments and nine policy framework papers completed since 1991 make reference to AIDS. In addition, eight of ten Country Assistance Strategies and four of six public expenditure reviews mention the disease. But few of these documents factor the consequences of AIDS (for example, loss of skilled labor, increased economic hardship, and the impact on adult mortality) into their analyses of sector development or recommendations for poverty alleviation. 36 6. Enhancing the Bank's Strategy-1996-2000 This last chapter sets the scene for the Bank's AIDS strategy for the near future. Simply stated, the Bank will continue to support what works, plus undertake several additional actions to enhance its Strategy. BUILD ON CURRENT STRENGTHS Through its sector work and lending operations with African countries and in collaboration with UNAIDS, the Bank should continue to support cost-effective HIV prevention measures, both directly (through education on sexual behavior, condom promotion, STD treatment, and a safe blood supply) and indirectly (through better health services, education for girls, and economic opportunities for women). The Bank should also continue to support facility and community-based mitigation efforts, that alleviate the adverse health effects of AIDS on patients, and the adverse socioeconomic effects on their families, and their communities. Five new actions are required from the Bank. The Bank should help Africa to * generate greater political commitment to the activities contained in the two recent OAU declarations, * intensify national AIDS control programs in additional countries, * work more vigorously on the adoption of safe sexual behaviors, * increase the analysis of AIDS and its impact on development goals in economic and sector work, and * improve the design and implementation of cost-effective approaches to mitigate the consequences of AIDS. ADDITIONAL AREAS FOR BANK ACTION The Bank should continue to support the cost-effective interventions-education, condom promotion, STD care, and safe blood-for prevention. Prevention efforts would, however, have more impact on slowing the epidemic if the interventions were backed with strong leadership, if knowledge on the determinants of behavioral change in Africa is increased, and the interventions are intensified. Thus the Bank will assist Africans to: * generate greater political commitment to the OAU declarations on AIDS * work more vigorously to change health behaviors * intensify national programs according to a typology of countries based on severity of prevalence levels Although AIDS is often referenced in Bank economic and sector documents, the adverse consequences of AIDS on development objectives in severely affected countries such as decreased life expectancy and productivity is rarely factored in the analyses used to develop a country's assistance strategy. In addition, the review found that few policies and cost-effective interventions exist in mitigating the socio-economic effects of AIDS. Thus, the Bank should address these gaps by helping governments and NGO's: 37 * increase the analysis of AIDS and its impact on development goals in economic and sector work, and * improve the design and implementation of cost-effective approaches to mitigate the consequences of AIDS Generate greater political commitment to the OAU declarations Attaining the required intensity of interventions is a formidable goal for Africa-but one that must be achieved. African leaders have pledged to meet this goal, having made personal and political commitments to carry out the activities in the 1992 and 1994 OAU declarations on AIDS. Through the Bank's close working relationship with the OAU, the Bank should help the OAU monitor country progress in implementing the activities contained in the two declarations. A reporting instrument and system should be devised to track progress and report back periodically to the OAU Assembly. Furthermore, the success of the OAU delegation tour of four countries in August 1995 suggests that additional tours should be undertaken with Bank assistance. Based on criteria that includes geographical representation and needs, suggested countries for the next tour include the Central African Republic, Gabon, Mozambique, and Namibia. The findings of these country visits and of the reporting instrument circulated to all African country should be the subject of a report to be presented at the OAU Assembly in June 1996. Work more vigorously to change behaviors The Bank should support Africans in strengthening of programs leading to the adoption of healthy sexual behaviors and practices. Three separate tasks built on the Bank's cooperative advantage in policy dialogue and sector work are proposed to strengthen capacity in this field: * Establish a group called African Advisers on Behavioral Change to organize analytical work and behavioral change programs in Africa for better health. The group will bring together prominent spokespersons from various backgrounds to explore, promote, and give direction to other Africans, the Bank and international partners on the many facets of changing behavior. Sub-regional lessons learned will be emphasized. * Design and undertake a comprehensive review of the progress to date and challenges ahead in changing risky practices and adopting safe behaviors in Africa. The terms of reference and work for this study will be commissioned by the African Advisers on Behavioral Change, and its findings will shape the Bank's regional lending activities. * Augment Bank initiatives to strengthen African public and private institutions, and community-based organizations currently involved in behavioral interventions. These 38 organizations will serve as national and regional centers of expertise for building the capacity of professionals and community leaders in improving health practices. Intensify national programs according to a typology of countries based on severity of prevalence levels Of the forty-seven African countries, thirteen have HIV prevalence rates among adults greater than 5 percent, and another sixteen have adult prevalence rates greater than 1 percent. Among these twenty-nine countries, intensified AIDS control programs exist or are planned in twelve. Of the seventeen countries remaining, the Bank should first help eight-Burundi, Cameroon, the Central African Republic, Ethiopia, Malawi, Nigeria, Rwanda, and Togo-secure the human and financial resources needed to attain the intensity in depth and breadth required to have a substantial impact on the epidemic's spread. The last nine countries should be assisted in a later phase. The financial resources required to prevent HIV and mitigate the consequences of AIDS are estimated at $1.9 per capita annually-about 15 percent of the $13 per capita needed to supply a basic package of health care services in low-income African countries. Less is known about the human resources required to support a comprehensive AIDS response, although the health personnel and community mobilization needs are extensive. As grant money becomes more scarce-and the direct and indirect costs of HIV and AIDS increase-the need for borrowing is becoming more apparent for the severely affected countries. Within its new role as a cosponsor of UNAIDS, and in collaboration with the Global Coalition for Africa and the Organization of African Unity, the Bank should initiate discussions with government leaders in these countries to ascertain what is needed to intensify AIDS control program interventions and how resources can be mobilized and coordinated. If required the Bank should provide additional resources to help these governments mount intensified national AIDS control programs. Increase the analysis of AIDS and its impact on development goals in economic and sector work The country departments serving the most severely affected countries should ensure that AIDS is addressed in relevant country analytical work both in and outside the PHN sector. Specifically, AIDS impact on adult and child morbidity, mortality and life expectancy, and on labor, productivity and savings should be assessed for several sectors, particularly PHN, education, agriculture, industry and transport in the severely-affected countries. The findings of these assessments should be incorporated into the country assistance strategies. Thus, the country assistance strategy, country economic memorandum, policy framework papers, poverty assessment and public expenditure reviews should not only mention AIDS as they often do now, but also factor the consequences of AIDS in their analyses and recommendations for improved development strategies. 39 Improve the design and implementation of cost-effective approaches to mitigate the consequences of AIDS Because it is not yet clear which approaches best deliver community-based care or which policies best ease the adverse socioeconomic consequences of AIDS, the Bank should support African decisionmakers in designing and implementing mitigation policies. Many of the donors supporting AIDS work look to the Bank to provide specific support to these socio-economic aspects of the epidemic. Increasing the cost-effectiveness of health care for AIDS patients is an obvious priority. Other priorities include the need to decrease the economic hardships confronting AIDS-affected households and communities, improve care and schooling of orphans and replace the skilled workers in industry and government lost to AIDS. The Bank should identify best practices and summarize lessons learned, define directions for future Bank and country policy and design and implement policies and interventions to help families, communities and sectors mitigate the adverse consequences of the epidemic. These policies and interventions will need to answer such questions as: How can quality care of AIDS patients be provided in facilities and homes at minimal cost to both the health system, other health system beneficiaries and home care givers? What components of AIDS patient care are the most likely to be sustained? What assistance is most needed by impoverished families and communities affected by AIDS and what criteria should be used to assess the most needy? What measures can families, industry and other sectors severely-affected by AIDS take to replace lost labor and productivity? BANK COmPARATIVE ADVANTAGES AND RISKS Lv UNDERTAKING THE NEW ACTIONs What are the Bank's comparative advantages to carrying out the first three new actions for prevention? The Bank's access to decision makers in government ministries such as finance and plan in addition to the ministry of health, gives the Bank the advantage in the first action regarding increased political commitment. Although traditionally the Bank has not been seen as a lead player in supporting programs that strive to influence behavior change-the second action---this role is undoubtedly changing and becoming more visible, as the Bank increases its involvement in human resource development. Three reasons justify the third action. The Bank's mobilizing of funds for several regional programs (NIARSH and West Africa Regional Program), the increase in demand for Bank support for AIDS activities and the Bank's new partnership with the UNAIDS program, illustrate that the Bank has been and continues to be in a position to assist African governments secure the resources necessary to launch intensified AIDS-related activities, the third action. The Bank's comparative advantage in the last two actions for mitigation is that few other agencies involved in AIDS work have the clear economic mandate in development as does the Bank. Of the six UNAIDS cosponsors, it is the Bank that is looked to, to provide the leadership in economic analyses of AIDS interventions and impact. As the UNAIDS Strategic Plan becomes operational, the request for Bank contribution to 'the economic side' of AIDS will increase. 40 The overwhelming risk to 'taking on AIDS' has been that of having only to rely on behavior change for success as opposed to a cure or vaccine. This risk remains. If the success of the collective response to AIDS is still most dependent on widespread adoption of safe behaviors, the risk in failing will have to be reduced by 'taking on the subject of behavior'. Few, but enough examples of successful behavior change exist in Africa and worldwide, as a knowledge base from which to expand. Thus, for the Bank to assist Africans in this endeavor, the Bank should strengthen its own knowledge of what factors influence the adoption of safe behaviors and what improvements in project design, implementation and evaluation are required to attain healthy practices in Africa. Figure 6 below summarizes the updated AIDS Strategy for Africa. Figure 6 Implementation of the Bank's Updated AIDS Strategy for Africa 1996-2000 Purpose: Preventing HIV Infection and Mitigating the Impact of AIDS in Sub-Saharan Africa Activity: Economic and Sector Work Outcome: Learning more about STDs/HIV and the impact on development Performed On-going Planned STD Rapid Assessment Studies 8 1 2 AIDS Impact Studies 2 1 8 New actions: Assist Africans to * Increase the analysis of AIDS and its impact on development goals in collaborative economic and sector work * Improve the design and implementation of cost-effective approaches (care and coping) to mitigate the consequences of AIDS Activity: Policy Dialogue and Regional Programs Outcome: Increasing awareness, linking AIDS and population activities and building capacity Putting the subject of AIDS and development on Agendas Combining Population and AIDS projects in countries, where appropriate Developing regional programs to intensify national AIDS and population plans, identify the determinants of sexual behavior, and assess service demands among beneficiaries. 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THE TUNIS DECLARATION ON AIDS AND THE CHILD IN AFRICA, JUNE 1994 ADOPTED BY THE OAU HEADS OF STATE AND GOVERNMENT Agenda for Action: Point One Point One of the Dakar Declaration: Agreement of giving our fullest political commitment to mobilizing society as a whole for the fight against HIV/AIDS No corresponding point in Tunis Declaration Timeframe: Within 3-12 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments 1. Heads of State and Government to confirm publicly 1. Make a public declaration by Heads of State and Written public * Ministry of Health with personal commitment to mobilize society to fight against Government to mobilize the nation against AIDS in declaration submitted to Office of President and HIV/AIDS and reduce isolation of people living with AIDS. general, and its impact on specific groups at risk, OAU Secretariat Ministries of especially children. Information, Foreign Affairs and National Planning/Finance 2. Heads of State and Government will establish multisectoral AIDS Advisory Committee and encourage 2a. Prepare the necessary legislation for establishment of a . Head of State and preparation and processing of necessary legislation. National AIDS Advisory Committee within 3-5 months. Government 2b. Form a multisectoral, multi-disciplinary National AIDS Advisory Committee within Committee established * Head of State and *_Example: 6 months - I year. and a list of members Government yes; committee formed within I provided to OAU * Office of the President year, June 1994. Secretariat 2 of 13 Agenda for Action: Point Two Point One of Tunis Declaration: Commitment to elaborate a national policy framework for the needs of HIV/AIDS-affected children No corresponding point in Dakar Declaration: Timeframe: Within 8 to 24 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments 1. Elaborate a'national policy framework' to guide and Ia. Form a multisectoral multi-disciplinary team (as a sub- Committee established Head of State and support appropriate responses to the needs of affected group) of the National AIDS Committee to develop a Goverment children covering social, legal, ethical, medical and human national policy framework' to guide and support Office ofthe President rights issues. responses to the needs of children affected by HIV/AIDS National AIDS within 8 months - 1 year. Advisory Committee lb. Develop a 'National policy framework' on children ofJHealth with active NGO participation which takes into account National policy issues related to food and nutrition, education problems of framework developed - Ministry of Social orphans, medical care and social services for HIV-infected Affairs persons and their families within 24 months. - Ministry of Education * Ministry of Local Government * National AIDS Advisory Committee 3 of 13 Agenda for Action: Point Three Point Two of Dakar Declaration: Commitment to stepping up action to prevent the sexual transmission of HIV Point Two of Tunis Declaration: Commitment to protect young people from HIV infection Timeframe: Within 6 months to 24 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments 1. A multisectoral team (including Ministries of Health, Ia. Form a multisectoral, multi-disciplinary team (as a Sub-committee * National AIDS Finance, Information, private sector and NGOs) will initiate sub-group of the National AIDS Advisory Committee) established and Advisory Committee on-going nationwide professionally designed and sustained responsible for designing media campaigns and other campaigns designed and media campaigns using television, radio, films, video and information, education and communication campaigns messages developed audio-music cassettes, concerts and sporting events, with (IEC) within 6 months. inputs from professional or advertising sectors. lb. Develop a schedule for repeated nationwide media Schedule developed coverage and public events to mobilize the nation against AIDS within 6 months. Ic. Expose urban and rural residents aged 15-49 to media Media messages messages, at least once weekly, on safer sex, condom use broadcast to residents at and compassion for people with HIV/AIDS within IS least once weekly months. Id. Develop media messages to reach out-of-school youth Youth exposed to media on prevention of HIV/AIDS and to inform them of health messages regularly and care services available within 18 months. aware of services available 2a. A multisectoral team (including Ministries of Health, Education, Finance, NGOs and Parent-Teacher 2a. Form a multisectoral team (as a sub-group of National Sub-group on training National AIDS Associations) to intensify nationwide training for Sex and AIDS Advisory Committee) responsible for intensifying formed and list including Advisory Committee HIV/AIDS-specific education for primary and secondary nationwide training for the development and conduct of terms ofreference Ministry of Education schools. sex HIV/AIDS educational programmes within I year, provided to OAU Ministry of Local including development of training materials and training Secretariat. Goverment of trainers. Materials developed. Ministry of Culture Trainers trained. 4 of 13 Agenda for Action: Point Three (cont'd) Timeframe: Within 6 months to 24 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments 2b. A multi-disciplinary team (including Ministries of 2b. Provide intensified education training for primary and Training programmes - Ministry ofHealth Health, Social Welfare, Youth, Labour, Agriculture, secondary school teachers, including skills straining, developed and teacher - Ministry of Education Transport, Defense and Finance, private sector and NGOs) within 2 years training on-going will initiate nationwide HIV/AIDS education programmes for target communities, youth and groups at high risk to 2c. Develop culturally appropriate sex education Sexualeducation * Ministry of Education HIV infection (e.g. prostitutes/clients, truckers, traders, programmes for youth in schools to help increase their programmes developed - Ministry of Social military, migrant labourers, STD patients). knowledge and skills to avoid sexual exploitation and for for youth and youth Affairs prevention of HIV infection and other STDs within 24 training on-going - Ministry of Health moMinistr National AIDS Advisory Committee 2d. Develop and introduce community and person-to- Person-to-person and person AIDS education for target communities (e.g. community programmes * Ministry of Health prostitutes/clients, truckers, traders, military, migrant for AIDS education * Ministry of Education labourers, STD patients) in at least 70% of urban and 50% designed and target of rural areas within 2 years. communities being educated 3. Legal protection of young people from HIV infection. 3a. Review laws and policies that affect the welfare and Laws and policies economic status of young people and their families; e.g. reviewed and revised and - Head of State and laws that criminalize destitute children; laws of copies provided to OAU Government inheritance; laws that regulate age of consent, and policies Secretariat - Government on employment, education and child care and policies of Ministry ofSocial HIV testing of children within 24 months. Affairs * Ministry of Justice 3b. Develop national policies and guidelines to prevent Policy and guidelines parental transmission of HIV through infected blood on developed and copies a Ministry of Health the use of contaminated needles/syringes or traditional provided to OAU G National AIDS surgical manipulation, also introduce legislation to Secretariat Advisory Committee discourage potentially harmful traditional practices withinMal 24 months. affS Government 5 of 13 Agenda for Action: Point Three (cont'd) Timeframe: Within 6 months to 24 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments 4. A favourable policy climate will be created to promote 4a. Develop and issue a policy statement on needs and Policy statement * National AIDS gender issues geared towards strengthening women's needs rights of women as groups sexually vulnerable to developed and issued to Advisory Committee and rights as groups sexually vulnerable to HIV/AIDS. HIV/AIDS, within 6 months. public and copy provided with Government to OAU Secretariat Ministries Sub-committee on 4b. Establish a multisectoral subgroup on women and women established and AIDS, responsible for promoting gender issues and list and terms of creating a policy climate geared towards strengthening the reference submitted to rights of women within 6 months. OAU Secretariat Policy developed and 4c. Develop a policy to decrease the cases of issued publicly and in . Multisectoral team discrimination against the rights of women so that a international fora, copy under the direction of the reduction in the number of cases is evident within 2 provided to OAU National AIDS Advisory years. Secretariat Committee Press reports released 4d. Increase media attention (eg. press reports) to support * Ministry of Information the policy statement on women within 6-12 months, with with National AIDs the support and involvement of the sub-group on media. Advisory Committee * Media sub-group 6 of 13 Agenda for Action: Point Four Point Three of Dakar Declaration: Commitment to planning for the care of people with HIV infection and AIDS and the support of their families and survivors No corresponding point in the Tunis Declaration Timeframe: Within 12 to 24 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments 1. The Ministry of Health will formulate policies and Ia. Formulate National Policy guidelines for HIV tcsting. National policies and - Ministry of Social national guidelines on HIV testing, and care of AIDS lb. Formulate National Policy guidelines for care ofAIDS guidelines formulated Affairs and Ministry of orphans. orphans within I year. and copy submitted to Local Government OAU Secretaiat 2a. Develop national guidelines for comprehensive AIDS 2. The Ministry of Health will formulate policies and care including guidelines for ensuring the access of all as above *Ministry ofHe-Ialth, national guidelines for comprehensive AIDS care, e.g. young people and women to reproductive health care, Ministry of Social clinical management, nursing care, counselling and counselling and medical care services within IS months. Affairs, Ministry of Local community-based care, and a referral system for those with Government HIV infection and AIDS. - Health Training Institutions 3. National policies formulated and guidelines initiated - Ministry of Health 3. The Ministry of Health will formulate policies and for integration of HIV/AIDS and specified health as above guidelines for integration of HIV/AIDS with other specific programmes within I year. health programmes, e.g. TB, MCH and Family Planning, - Health Training EPI, CDD, STDs. Institutions 4a. Hold workshops of national experts to identify types 4. The Ministry of Health, with the Essential Drug ofprevalent HIV/AIDS-related infections, TB and STDs, Workshops held; types of Programme, will identify' and ensure availability of basic define treatment and identify basic drugs lo be included in infections identified; *Ministry of Health and essential drugs related to AIDS-related infections, TB and National Essential Drugs List (EDL) within I year. treatment schedules Ministry ofPlanning STDs. defined and basic drugs included in EDL 4b. Increase the availability of essential drugs for TB, ST s and HIV-related infections at 50% of urban and Mechanisms established 50% rural health service facilities within 24 months. to increase availability of Ministry ot Health drugs and drugs made available on a sustainable basis. 7 of 13 Agenda for Action: Point Five Point Four of Dakar Declaration: Commitment to supporting of appropriate and relevant AIDS research Point Three of Tunis Declaration: Commitment to promote and support applied research Timeframe: Within 12 to 36 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments Ia. Research needs will be assessed and research Ia. Assess AIDS research needs and develop research Research needs assessed * Ministry of Health achievements or gaps identified through consultancies or capability inventory within I year. and inventory developed . National AIDS national workshops. Local or collaborative research studies Coalition Programme needed will be identified. * medical research committee lb. Promote research efforts based on African experience lb. give support to or conduct studies to establish the Research issues - National AIDS and tradition and support institutes of research in Africa scale and nature of the problem of AIDS-affected identified and high working mainly in the field of determining the magnitude children. The numbers, where they are, the circumstances priority given to studies and extent of HIV infection in children and women and the oftheir lives, and the nature oftheir needs within 12 in this area underlying factors to HIV infection in order to prevent the months. - Ministry ofSocial spread of infection and alleviate its consequences on Affairs children and women. -mdclrsac committee Ic. Give support to or conduct studies to determine the Research issues factors underlying the spread of IV infection in children identified and high ANatiottal AIDS within 24-26 months priority given to studies Advisory Committee in this area Ministry of Health Id. Establish a research committee and develop a national Committee established; consensus on priority research areas including human and meeting held to develop financial resources required within I year. a national consensus and human financial resource needs identified 2. National research guidelines to be drawn up, and AIDS 2a. Develop and endorse National AIDS policy Research policy Research Plan and Programme to be established and guidelines within i year. developed, endorsed and * Ministry of Health promoted among potential donors and partners. disseminated widely for - medical research researchers and research committee institutions nationally and intemationally 8 of 13 Agenda for Action: Point Five (cont'd) Timeframe: Within 12 to 36 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments 2b. Design and endorse National AIDS Research Plan and National Research Plan , National AIDS Control Programme within I year. and Programme Programme designated and endorsed, - Medical Research plan disseminated and Council funding sources identified or being sought; plan provided to OAU Secretariat 2c. National AIDS Research policy guidelines, and Mechanism to promote * medical research research plan and programme promoted among national research plan and policy committee research institutions and potential donors and partners designated and * National AIDS Control within 18 months. implemented Programme * Ministry of Health 3. Research capacity will be promoted and strengthened 3. Promote and strengthen national and regional research Ways of promoting and and a mechanism established to ensure coordination of networks, e.g. by registration of national and regional strengthening regional * Ministry of Health AIDS research between African countries. branches of African research networks within 18 months. research networks * Medical Research identified including Council with National registration of national AIDS Control and regional branches of Programme African research networks 9 of 13 Agenda for Action: Point Six Point Five of Dakar Declaration: Commitment to using our leadership position to ensure that all sectors of society work together to tackle the AIDS pandemic No corresponding point in Tunis Declaration Timeframe: Within 6 to 12 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments 1. The Head of State and Government will present the I a. Make a presentation and debate of Dakar Declaration Presentation made and * Cabinet Dakar Declaration for debate in Cabinet and strive to in Cabinet within 6 months. debate held in Cabinet . Head of State and achieve consensus on the need for a multisectoral strategy. Government lb. Achieve consensus on need for multisectoral strategy * National AIDS within 6 months. Advisory Committee 2. Cabinet, will establish a Master Plan defining the 2. Establish a Master Plan defining process for building Master Plan established * Head of State and process for building a multisectoral strategy for the national multisectoral strategy for the national plan for HIV/AIDS. and submitted to OAU Government plan for HIV/AIDS. Secretariat, and partners G Cabinet for endorsement * National AIDS 3. Prepare sector-specific budgeted plans of action within Advisory Committee 3. Individual Ministries will prepare according to the individual Ministries within 6 months. Sector-specific plan master plan sector-specific budgeted plans of action. prepared and submitted * Ministry of Health to OAU Secretariat * Individual other Ministries , National AIDS Control 4. Identify' and initiate collaboration between individual Programme 4. Each sector-specific plan of action prepared by Ministries with partners in relevant Ministries, NGOs and Areas of collaboration individual Ministries will identify partners, e.g., in other agencies in order to achieve planned objectives within 6 identified and initiated a Ministry ofHealth Ministries, NGOs and agencies, for collaboration to achieve months, with partners , Individual Ministries planned objectives. " National AIDS Control 5a. National AIDS Advisory Committee monitors Pograme 5. The Head of State and Government will set up a progress of Master Plan of sector-specific action plans and Monitoring ofaction multidisciplinary mechanism to monitor the Master Plan of mobilizes necessary resources, within 13 months. plans ongoing and Head of State or sector-specific action plans, and to mobilize necessary resources being identified Government resources. 5b. Produce progress report within I year (and progress Natinal AIDS reports produced annually thereafter). Advisory Committee S National AIDS Control Programme 10 of 13 Agenda for Action: Point Seven Point Five of Tunis Declaration: Commitment to monitoring the epidemiological situation and impact of the action programme and evaluate its implementation No corresponding point in Dakar Declaration Timeframe: Ongoing activity Action Steps Activities and Target Output National Responsibility Action Performed? Comments 1. Continuously monitor the epidemiological situation and Ia. Monitor (with the support of collanorating agencies) Reports developed and * Ministry of Health the impact of the action programme (NAP) and regularly the epidemiological situation of children infected with circulated annually to . Collaborating Agencies evaluate its implementation in order to effect any necessary HIV and develop reports annually for circulation to all collaborators modifications or reorientation, collaborators (ongoing). * National AIDS Control lb. Develop and agree on selected programme indicators Progress indicators Programme to measure progress to enable reporting and at regular detected and * Ministry of Health intervals within I year. disseminated; * Collaborating Agencies information provided to OAU Secretariat * Ministry of Health Ic. Develop a report to consolidate the findings ofthe Annual reports developed * National AIDS Control annual NAP reviews to be shared with all collaborators and disseminated to Programme (ongoing). collaborators and OAU Secretariat Plan refined/revised * Ministry of Health Id. On the basis of the reviews, refine/revise the overall annually and update * National AIDS Control national AIDS plan annually (ongoing). submitted to OAU Programme Secretariat 11 of 13 Agenda for Action: Point Eight Point Six of Dakar Declaration: Commitment to make AIDS a top prioriiy for external resource allocation so that our continent benefits from maximum international cooperation and solidarity in overcoming the pandemic and its impact Point Four of Tunis Declaration: Commitment to make definite and substantial budgetary provisions to meet identified requirements for preventive programmes among children Timeframe: Within 6 to 18 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments 1. Reviews will be carried out of existing national 1. Conduct review of existing national HIV/AIDS Reviews conducted and National AIDS Advisory HIV/AIDS programmes; of the effectiveness of specific programmes of effectiveness of specific preventive information disseminated Committee preventive programmes including those for children; and of programmes and capability of health service infrastructure to all partners and National AIDS Prog. the capability for health service infrastructure and and communities to cope with the epidemic within 18 donors, programmes Ministries of Health and communities to cope with the epidemic. months. revised accordingly National Planning 2. A review will be carried out of national manpower 2a. Conduct a national manpower review within I year. National manpower CoNat As capabilities and needs in relation to national HIV/AIDS review conducted and National AIDS Prog. programmes and manpower training prepared and mechanisms identified to conducted where necessary. strengthen resources; information shared with National Planning 3. A review will be carried out of national and international partners to support resource allocations to the health and social sector for training HIV/AIDS, including the budgetary provisions for preventive programmes among children and for the care and 2b. Identify training needs and preparation and support of those affected by HIV/AIDS. implementation of relevant training begun within 18 months. 3a. Conduct a review of national and international Review conducted and Ministry of Finance resource allocations to health and social sectors and gaps identified, (MOF) with National AIDS identify' gaps within 6 months, mechanisms proposed to Advisory Committee improve funding situation and share with partners t upr trnMinis of Finance with 3b. Policies defined for increasing national and National AIDS Advisory international contributions within 6 montha. Committee 12 of 13 Agenda for Action: Point Eight (cont'd) Timeframe: Within 6 to 8 months of 1994 Action Steps Activities and Target Output National Responsibility Action Performed? Comments 4. On the basis of the reviews (1-3) the National Plans of 4a. Formulate and refine National Plans for Action based National Plans of Action * National AIDS Action will be formulated/refined. Based on those plans, on a rational use of resources with the help of a formulated and shared Advisory Committee the overall Plan for Africa will be prepared. coordinating group to avoid duplication of efforts and to with partners and OAU . National AIDS Control consider the development of umbrella projects within 12 Secretariat Programme months. * Ministry of Health 4b. Make definite substantial and budgetary provisions to Budget developed and * National AIDS meet identified requirements for preventive programmes provisions made to Advisory Committee among children and for the care and support of those support activities in A Ministry of Health affected by IUV/AIDS. collaboration with - Ministry of Health partners * Ministry of Finance 4c. Develop an overall Plan for Africa prepared within I Plan of Action for Africa year. developed with * National Governments involvement of all partners 5. The overall Plan for Africa will be promoted at 5. Promote the overall Plan for Africa at international and Plan promoted at relevant international and donor fora. donor fora. international and donor * National Governments fora 13 of 13  IMAGING Report No: 15569 AFR Type: SR