HIV/AIDS - Getting Results These reports describe activities, challenges and lessons learned during the World Bank Global World Bank's HI/AIDS work with countries and other partners. HIV/AIDS Program Mozambique's battle against HIV/AIDS and the DREAM project Lucy Keough and Katherine Marshall transport routes to Malawi, Zambia and Zimbabwe. AIDS A partnership with the Catholic volunteer Community of affects a high proportion of economically active persons, Sant'Egidio in Mozambique is helping provide treatment, especially young workers, sapping the country's productive care and hope to thousands of people living with HIV and capacity. In the age group 15-49, prevalence is estimated AIDS. Much is being learnt and shared, sparking similar at 12.2% (UNAIDS, end 2003). Life expectancy is falling, initiatives in other countries, and spreading the benefits and deaths from AIDS are leaving many thousands of farther still. orphaned children. Mozambique and the Challenge of HIV/AIDS As in other severely affected countries, After a devastating civil war, Mozambique succeeded, as HIV/AIDS in few other African countries have, in resettlement and Mozambique reconciliation with speed and harmony. Although still one presents difficult of the poorest countries in the world, Mozambique's issues. Among the economic performance is strong. But now there is a new, most intractable are desperate struggle -- against HIV/AIDS. stigma and During its long civil war, Mozambique's social and discrimination; the economic isolation ironically protected it, at least to some lack or poor state of extent, from the HIV epidemic raging in neighboring health infrastructure; and weak legal and social protections countries, mainly because the war impeded population for people living with HIV/AIDS. The low literacy rate movement. However, after the war's end in 1992, presents special challenges for designing and vulnerability to HIV/AIDS increased dramatically, with the implementing effective HIV/AIDS education and behavior return of refugees from Malawi, Zimbabwe, and Tanzania, change campaigns. Women face huge social and where HIV/AIDS rates were much higher. Peacekeeping economic disadvantages; poverty and the pattern of forces from high prevalence countries and a marked intergenerational sexual relationships make young women increase in cross border trade also contributed. and girls particularly vulnerable. Other more specific, Mozambique's deep poverty, low levels of literacy (adult pragmatic issues include inadequate and unreliable literacy in 2001 was estimated at only 45 percent), and supplies of drugs to treat opportunistic infections, low rural-urban and cross-border movements, fueled the rapid condom availability, and Mozambique's chronic shortage spread of the epidemic. of doctors and nurses. Although costs of antiretroviral (ARV) drugs have dropped dramatically within the past few HIV/AIDS escalated drastically between 1992 and 2000 in years, at around US$300 a year they are still well beyond Mozambique. Currently, about 1.3 million people are the means of most Mozambicans. infected. The number of people newly infected each year is rising fast -- 61,000 in 2000, projected to reach 170,000 In recent years, the government of Mozambique has given in 2010. Youth aged 15-24 account for 60% of new steadily increasing priority to fighting HIV/AIDS. The first infections, and twice as many girls and women in this National Strategic Plan to combat sexually transmitted group are being infected as men. diseases and HIV/AIDS, 2000­2002 sought to make the HIV/AIDS fight a national priority. It put prevention at the The most affected parts of the country are Maputo (20.7%) heart of the strategy, and included interventions to provide and the central provinces of Manica (19.7%), Tete information about the disease widely, to develop voluntary (16.6%), and Sofala (26.5%),1 particularly along the counseling and testing programs, and specific activities geared to youth. The current National Strategic Plan 1 Ministry of Health, prevalence data for 2004, presentation covers the years 2005-2010. at Regional Advisory Panel Meeting, Dec. 2005, Addis Mozambique enjoys broad donor support for the HIV/AIDS Ababa, accessed 4/21/06 at: http://www.uneca.org/tap/ response. USAID provided US$6.6 million in 2001, the World Bank in 2003 approved $55 million in grant drug prices, inadequate budgets, weak health delivery financing through the Multi-Country AIDS Program (MAP), systems and few trained health personnel with experience and in 2004 the Global Fund to Fight AIDS, TB and in ARV. Only a small percentage of funding under the Malaria signed grant agreements for a total of nearly $30 World Bank's Multi-Country HIV/AIDS projects has gone million. UNAIDS and other UN agencies, the Clinton toward treatment. A protracted dialogue among the Foundation and the U.S. government's PEPFAR program Mozambique government, the World Bank, and the are also active in Mozambique. Community of Sant'Egidio considered funding treatment under the Mozambique MAP project, but this ultimately The Treatment Acceleration Project (TAP) proved unworkable. This dialogue, however, helped open the way for a World Bank grant for the Treatment In 2003­2004, the balance between prevention and Acceleration Project (TAP), an innovative three-year multi- treatment of people living with HIV/AIDS came increasingly country project, aimed specifically at testing and scaling up under scrutiny in Mozambique as in other countries. With different models of non-government delivery systems for continued increases in prevalence rates, plummeting costs holistic treatment programs. The three countries included for generic ART drugs, some expansion in the capacity to in the project are Burkina Faso, Ghana, and Mozambique, deliver them, and strong advocacy from a number of all of whom had promising non-government treatment groups, many countries in Africa were reconsidering the programs underway. feasibility of widespread access to lifesaving ART programs. In March 2004, only 3,228 people in The TAP builds on on-going NGO-managed public/NGO Mozambique were receiving antiretroviral treatment; less partnerships, and offers the three governments a than one percent of people clinically eligible for drug mechanism for testing and refining existing guidelines and therapy. Government plans aim for a sharp increase in this treatment protocols, for establishing reliable monitoring number to 132,000 by 2008, as outlined in the Ministry of and evaluation programs, ensuring compliance, minimizing Health Strategic Plan to Combat STIs and HIV/AIDS. resistance, increasing equitable access for the poor, and, Until recently, few developing countries were providing in keeping with the spirit of the TAP, for learning and public funding for HIV/AIDS treatment, deterred by high disseminating the important lessons from this experience. The Community of Sant'Egidio and Mozambique The Community of Sant'Egidio began as a student movement in the 1960's in Rome, committed to serving the poor and working for peace. Sant'Egidio's 40,000 member volunteers now work in more than 70 countries, on a wide array of community level interventions to alleviate poverty, provide social services, and foster peace and reconciliation. The Community's work touches many categories of the poor, the vulnerable, and the marginalized, including children, elderly, the handicapped, refugees, immigrants including the Roma people, people living with HIV/AIDS, prisoners, and the homeless. The Community of Sant'Egidio first became involved in Mozambique in 1976 through its work with very poor communities, and became more deeply engaged in drought relief efforts and the consequences of war. In 1984, responding to an appeal by the Catholic Archbishop of Beira, Sant'Edigio sent and distributed humanitarian relief aid, coordinated and monitored by volunteers, together with missionaries and Caritas Mozambique (a Catholic relief organization). As it became increasingly obvious that the problems of poverty could not be disentangled from the long, brutal civil war in Mozambique, the Community began to explore possible avenues to help bring peace. Persistent and creative efforts mobilized a network of political, religious and civil society actors, and promoted dialogue between the government and different factions -- a "two track" diplomacy approach of official negotiations and informal unofficial processes based on friendship, dialogue, patience, pluralism and inclusiveness. After 27 months of negotiations, a Peace Agreement was signed in Rome On October 4, 1992, ending 16 years of civil war. Through its work in many African countries, but particularly Mozambique where it has such strong roots, Sant'Egidio, has come to view the HIV/AIDS pandemic as the most serious threat to Africa's future. It has pressed hard first, to demonstrate through a practical program on the ground that a program of care can be implemented with the appropriate will, and second, to advocate for the rapid scaling-up of such programs. At a meeting in Rome on May 12, 2004, involving many leaders including 13 African ministers of health, the right to treatment and care for people with HIV/AIDS was presented as a fundamental human right. This was reflected in a joint declaration signed on May 13 by the Community of Sant'Egidio and the African ministers. 2 The $60 million IDA grant for the TAP, approved in June Tanzania, Kenya, Guinea Conakry, Guinea Bissau and 2004, supports three components in each country: soon in Angola, Democratic Republic of Congo, Nigeria and Cameroon. ¡ Testing alternative approaches to scaling up delivery of the full continuum of HIV/AIDS care and The DREAM Project treatment: This includes all five areas of treatment ­ voluntary counseling and testing, home based patient With the collaboration and support of the Ministry of care and family support, treatment of opportunistic Health, Sant'Egidio launched its broadly based HIV/AIDS infections, antiretroviral drug therapy, and prevention treatment program in August, 2001, and began providing of mother to child transmission. treatment early in 2002. The program is called "Drug ¡ Strengthening public institutional capacity for Resources Enhancement against AIDS and Malnutrition", HIV/AIDS care and treatment: this includes building or DREAM, a name echoed in the appeal of young the capacity of each country's National Treatment Africans for access to treatment and care at a conference Committee to refine national policies and adapt WHO in Mozambique in 2003. protocols to their respective circumstances and evaluate and monitor non-governmental delivery "We turn to you, leaders of Africa who are gathered in programs; and building capacity in the Ministries of Maputo. We are young Africans. An heir of this Health to coordinate program expansion, and, in continent, Martin Luther King Jr, forty years ago has partnership with WHO, to monitor the quality and said: `I have a dream.' We too have dreams. Often disseminate the results and lessons of treatment only those. But dreams can become reality. . .Our programs. dream is that soon medical care may be accessible to ¡ Facilitating regional learning from the three- all the children of Africa, that AIDS may no more be a country experience under the TAP. WHO, through death sentence but an illness that can be treated and its headquarters and regional offices agreed to support prevented." in-country learning, helping refine and implement Youth Leaders Declaration, presented at the African Union treatment guidelines, developing national standards Conference, Maputo, Mozambique, July 10­12, 2003. and assessment tools for accrediting treatment programs, establishing quality control systems for drug The program began in Maputo Province, southern procurement, strengthening monitoring and evaluation, Mozambique, and expanded to two additional areas: training of health workers, devising methods for Sofala in the central region and Nampula (laboratory ensuring patient compliance and evaluating outcomes facilities) in the North. and potential drug resistance. The program provides broad-based support for people The primary focus of the TAP is learning by doing, affected by HIV/AIDS in the context of a comprehensive through comparing and sharing experiences among treatment approach. In addition to providing drugs free of the different kinds of programs delivering treatment in charge to eligible patients, treatment also involves different settings. To facilitate this, a regional advisory diagnostics, strategies to assure adherence to treatment, panel meets one or twice a year, bringing together monitoring for potential drug resistance, trained personnel, country TAP coordinators and National AIDS program and treatment of opportunistic infections and conditions staff, implementing partners and the other key that co-exist with HIV infection, including malaria, partners: WHO, the World Bank and United Nations tuberculosis, other sexually transmitted diseases and Economic Commission for Africa (UNECA provides the malnutrition. Secretariat). The meetings cover technical issues as well as managerial and administrative issues. A particular concern, shared by the Mozambican Parliament, is the need to define criteria that will ensure Mozambique received a grant of $21.7 under the TAP, and equitable access to publicly funded treatment programs. was the first of the three countries to get underway. The The TAP and the DREAM project emphasize targeting the first component of the Mozambique project -- scaling up poor in both urban and rural areas. HIV/AIDS care and treatment -- has thus far been on or ahead of schedule. Three non-profit organizations -- the Women receive special focus both through the mother- Community of Sant'Egidio, Health Alliance International, child transmission program, and also in Sant'Egidio's work and Pathfinder International, all with on-going treatment with households. DREAM aims to protect the health of projects deemed worth expanding, signed on as mothers and their children, providing drugs to pregnant implementing partners. The program being implemented women, both for prevention of mother-to-child transmission by the Community of Sant'Egidio under the TAP is part of (nevirapine), and also more broadly based full ARV a larger program, the Drug Resources Enhancement therapy, starting from the second trimester of pregnancy. against AIDS and Malnutrition (DREAM) project, which The program indicates that this reduces transmission of began in Mozambique, and is now operating in Malawi, the virus to about 3%, far below that of nevirapine monotherapy alone, and also saves the mother and thus 3 protects her family. Other target subpopulations of practical experience through short internships in DREAM Sant'Egidio's program are health personnel and teachers. centers. Staff training includes a focus on the quality of The staff focuses on people whose viral loads are relationships with patients and stresses that patients must extremely high and are in need of immediate intervention. be welcomed at all times, politely, openly and with respect. Other people who seek help from the centers, and whose Sant'Egidio relies heavily on volunteers who maintain a viral load is lower, receive assistance ranging from home relay of people coming to Mozambique as well as care and medication for opportunistic infections to food members of the Mozambique communities. The core parcels to meet nutritional needs. program staff are qualified Mozambicans and are, of course, paid. Specifically, the DREAM program provides the following: Although the TAP project has only a three year duration, ¡ Voluntary counseling and testing for HIV status under a 10 year agreement with the government of ¡ Training of local staff (doctors, nurses, laboratory Mozambique, the DREAM project is providing health care technicians, health workers, and training staff) training (a top priority), personnel, laboratory equipment and supplies, and is importing, storing, and delivering ¡ Health education, especially for at-risk populations, ARVs for patients under its program. ARV therapy is with mothers with HIV playing a key role as peer provided at no cost to the patient, and it is a central educators premise of the approach and program that all services are ¡ Highly Active Antiretroviral (HAART)therapy for fully in line with WHO protocols as well as with western- preventing mother-to-child transmission of HIV level quality and standards. infection during pregnancy, birth, and breastfeeding The DREAM project is housed within existing public ¡ ARV drug therapy for people living with AIDS hospitals and maternity wards, reflecting the fact that the government of Mozambique is the central partner. Other ¡ Expandedlaboratoryfacilitiestomonitorpatients partners include universities in Italy and Mozambique, receiving ARV drug therapy pharmaceutical companies, communities, other ¡ Monitoring of blood donations nongovernmental organizations, and international development agencies. Reaching out to other institutions ¡ Prevention and care of diseases linked to AIDS and populations ­ business, local NGOs, religious (opportunistic infections, sexually transmitted organizations ­ helps further expand the network for diseases) HIV/AIDS services. ¡ Nutritionaleducationandsupplementsforpeopleliving with AIDS An innovative approach to support adherence ¡ Homecarefortheseriouslyill. Patients on treatment have become one of DREAM's best resources. Often, they form self-help groups to support Working within and strengthening the health one another. In the case of `Mulheres para o DREAM', system women have set up an association to support patients receiving treatment to adhere to treatment protocols. They The program is implemented entirely within the framework do so by sharing their own positive experiences with ARV of the Mozambican health system and is complementary to treatment. This peer education and emotional support is other on-going program interventions. Indeed, an early and profoundly encouraging and a crucial element of support valid concern expressed by some in the donor community for new patients, particularly in the first period of treatment, in Maputo was to avoid creating any new structures or and has contributed to very high adherence. vertical programs outside the Government's existing Special attention is devoted to support the treatment of Strategic Plan. A cornerstone of the TAP project, which is mothers with children and to help them administer drugs, reflected in the Sant'Egidio project, is to address a broad monitor their children's health conditions and provide range of constraints on the performance of the health care nutritional supplements. The `Mulheres" in the association system including training, remuneration, facilities and also provide health education to patients while they are logistics. Solutions for these systemic problems will greatly waiting to be seen at centers. enhance the chances of success of efforts to expand The holistic approach and strong focus on nutrition also access to treatment. The challenge of AIDS offers the contributes to high adherence and enhances the positive opportunity to reform and strengthen health infrastructure effects of ARV treatment. During pregnancy and for six in Sub-Saharan Africa. months afterwards, women receive beans, rice or maize, Training courses have been held for groups of doctors, oil, sugar and nuts as well as multi-vitamins and iron nurses, laboratory technicians, chemists, biologists, supplements. The program also offers treatment for computer programmers and coordinators from tuberculosis, malaria, and sexually transmitted diseases. Mozambique, and also from many other countries in Africa. The courses combine theoretical training with 4 Results A pilot study that compared 40 women treated under the DREAM project for three months before and after they The Community of Sant'Egidio reported in a January 2006 gave birth, with 40 other (untreated) women found a meeting on the DREAM program, that it had to date dramatically lower viral load in breastmilk of the treated provided voluntary counseling and testing (VCT) to close women, and a significantly higher proportion of women to 14,000 people in eight centers. The number of with undetectable breastmilk viral loads. This raises the HIV/AIDS-positive people in care had reached 9,371, a hope that ARV treatment may allow HIV-positive women to significant increase (58 percent) from the 2,731 reported in breastfeed their babies with little risk of HIV transmission, September, and a very significant scaling up from the 412 but this will need to be tested in future clinical studies in April 2003. Over 4,800 people were receiving ARV (Giuliano et al, 2006). treatment through eight sites operated by Sant'Egidio, of whom about 3,200 are women. Most fall into the 25-49 age The results from the DREAM program have been widely cohort, while some 155 children under the age of four were reported at leading medical conferences and in peer also being treated. The Community operates three reviewed journals. Detailed monitoring and program laboratories for diagnostic monitoring of ARV recipients. evaluation is an integral and important part of the work. The ARV therapy results are excellent, with over 90 Sant'Egidio puts considerable emphasis on cost efficiency. percent adherence to treatment programs and a The annual cost of caring for an HIV/AIDS patient in 2005 remarkable "Lazarus" effect of people recovering from averaged $600, including drugs, diagnostic work, and near death to happy and productive lives when on the ARV nutritional supplements, plus all costs for personnel; therapy. No increase in drug resistance has been found construction and depreciation of facilities. To lower costs, under the program. Careful monitoring has shown a limited Sant'Egidio is engaging with large pharmaceutical rate of liver toxicity, which has been able to be controlled companies such as GlaxoSmithKline, Merck, and by changing or stopping treatment in all but one case Boehringer Ingelheim, seeking better deals on drugs and (Liotta et al, 2005). test kits. Of more than 1,500 babies born to HIV/AIDS-positive Broader perspectives mothers in the program, 97 percent have tested negative for the virus. Results are especially good for women who Scaling up access to treatment stay on treatment for the full duration of the protocol: the vertical transmission rate was just 1.9% a year after The DREAM project and other partners in the TAP delivery for women who received more than 60 days of program are helping develop more effective strategies for HAART teatment before delivery, as well as nutritional fighting the HIV/AIDS pandemic, demonstrating that it is supplementation, multivitamins and who fed their babies feasible to provide high quality care for HIV/AIDS positive were on formula (Liotta et al, 2005). Figure 1 shows that people, including life-prolonging ARV drug therapy, even in birth outcomes are significantly better for women who start resource-constrained settings, and to scale up access to ARV therapy more than 15 days before their babies are that care through effective private/public partnerships. born, with nearly 90% fewer stillbirths and abortions. Sant'Egidio ­ and others who advocate and are working to Children born to mothers in the program had a somewhat expand access to treatment ­ argue that first, no disease lower low birth-weight rate than the general population and in history has been fought successfully with prevention comparable infant mortality rate during the first year. alone; second, the fact that drug therapy is successfully These are important indications of the positive impact of used in richer countries makes it morally imperative to the intervention. apply similar standards of care in poorer countries; and Figure 1: Abortion and Stillbirth (cumulative number third, that prevention will only succeed if there is hope held per 100 observation months) by length of pre-delivery out for HIV/AIDS-positive people. This applies above all for HAART testing, where the possibility of treatment and care is a powerful incentive to being tested. 10.0 The experience in Mozambique is a testament to how the perspectives, energies, and dedication of a community 8.0 motivated by their faith and their commitment to equity and N/100 6.0 months friendship with the poor, and working together with the 4.0 government and other development partners, has 2.0 pioneered new approaches to caring for people with 0.0 <15 16-30 31-60 61-90 >90 HIV/AIDS in places where many, until very recently, % 8.5 2.8 1.7 0.5 0.5 argued that care was impossible to provide at reasonable cost. Source: Liotta et al, 2005. 5 HIV/AIDS and the Catholic Church Meeting global commitments There is another broad perspective within which to view Sant'Egidio describes its greatest challenge now as the project. Sant'Egidio is an important movement within mobilizing sustainable sources of funding to scale up the the Catholic Church and thus the dialogue, deliberations present scope of the project while ensuring that those and actions can be viewed as part of the Catholic Church's receiving ARVs have the assurance of a reliable and response to the HIV/AIDS crisis and, still more broadly, of continuing source of care and drugs. This reflects the faith communities. broader global challenge of realizing the commitment by The Catholic Church has considerable influence through a world leaders at the G8 Meeting in Gleneagles in July large network of communities across the world, as well as 2005, reiterated by the United Nations General Assembly an extensive health system infrastructure, and is a strong in September 2005, to scale up HIV prevention, treatment, voice on many core issues around the prevention, care care and support, with the aim of coming as close as and treatment of HIV/AIDS. There has been much possible to the goal of universal access to treatment by prominence given to the Church's opposition to the use of 2010 for all those who need it. condoms, even as a means to prevent the spread of HIV, and the related stigmatization that results when HIV/AIDS References, further information is linked, implicitly or explicitly, to sin. The Sant'Egidio experience highlights additional dimensions. ¡ Marazzi MC, Guidotti G, Liotta G and Palombi L. 2005. "DREAM: An Integrated Faith-Based Initiative to Treat The Catholic Church is emerging as an increasingly HIV/AIDS in Mozambique, Case Study." Perspectives dynamic actor on HIV/AIDS. Within the Vatican as well as and Practice in Antiretroviral Treatment. Community of within Catholic based relief and development organizations Sant' Egidio and World Health Organization, Geneva. (like Caritas), there is growing recognition of the urgency http://www.who.int/hiv/pub/casestudies/mozambiquedr of addressing the complex issues around HIV/AIDS. The eam.pdf DREAM project, for example, has helped to draw out the links between care and treatment and prevention, thereby ¡ Liotta G, Liotta G, Palombi L, Guidotti G, Scarcella P, increasing the scope and the depth of the dialogue on Mancinelli S, Bartolo M, Narciso P, Perno CF, Valls prevention strategies. The program has strong support Balsquez M, Loureiro S, Abdul Magid N, Da Cruz from many in Vatican circles and is widely publicized and Gomez A, and Marazzi MC, 2005. Mother-to Child praised in Italy. Transmission in Limited-Resource Settings: The role of the DREAM Programme. Presentation at the 14th Complementing the work of implementing and expanding International Conference on HIV/AIDS and Sexually the DREAM program, Sant'Egidio is a forceful advocate on Transmitted Infections in Africa (ICASA), Abuja, HIV/AIDS ­ sometimes beyond the faith communities, as Nigeria, December 2005, and Treatment Acceleration for example, convening African health ministers. At every Program Regional Advisory Panel meeting, Addis international event where they are present, Sant'Egidio Ababa, Deember 12-13, 2005. Accessed 4/24/06 on puts a spotlight on HIV/AIDS. The most prominent line at: http://www.uneca.org/tap/ (Resources page) example is a major annual interfaith event, the "Prayer for Peace" that the Community runs on behalf of the Catholic ¡ Giuliano M, Guidotti G, AndreottiM, LiottaG, Cusato Church. Each year, there a major panel on HIV/AIDS and M, Cristina Marazzi M, Loureiro S, Regazzi M, Palombi L, and Vella S. 2006. Triple antiretroviral therapy all plenary sessions stress the importance of working to administered during pregnancy and after delivery fight AIDS. significantly reduces breast milk viral load. Poster at 13th Conference on Retroviruses and Opportunistic Infections (CROI 2006), Denver. Accessed on 4/20/06 at http://www.retroconference.org/2006/PDFs/727.pdf ¡ http://dream.santegidio.com/Homep.asp ¡ http://www.uneca.org/tap/ About the authors: Katherine Marshall (Director) and Lucy Keough (Senior Operations Officer), of the World Bank Development Dialogue on Values and Ethics unit, engage with faith institutions around development issues. This note draws on "A DREAM? Sant'Egidio Fighting HIV/AIDS in Mozambique", Chapter 10 in K. Marshall and L. Keough (eds), Mind, Heart and Soul in the Fight Against Poverty, World Bank, Washington DC, 2004. April 2006 6