INTERNATIONALBANK FOR WORLD BANK R E T C N O E N STRUCTION PM AND DEVELO April 2004 No. 45 A regular series of notes highlighting recent lessons emerging from the operational and analytical program of the World Bank`s Latin America and Caribbean Region TAKING DECISIVE ACTION THE BARBADOS HIV/AIDS PREVENTION PROJECT Patricio Marquez The first case of HIV/AIDS was detected in Barbados in 1984. countries separate loans and/or credits and grants for their At that time, HIV/AIDS was viewed more as a consequence of national HIV/AIDS Prevention and Control projects. A PHRD risky personal behavior by men who have sex with men than as Grant from the Government of Japan at the end of 2000 a public health issue that affects the general population. Since supported the preparation of country projects in the Dominican then the number of reported HIV cases has risen continuously Republic (total project cost US$30 million; approved June particularly among 15-49 year olds and the 2001); Jamaica (total project cost US$20 most economically active group, 25-49 year million; approved in 2002), Grenada (total olds. Today, prevalence among adults in project cost US$7 million, approved in Barbados is conservatively estimated at over 2002), St. Kitts and Nevis (total project cost 3%. But people who test positive are US$4 million, approved in 2003), and estimated to represent only one-fifth of the Trinidad and Tobago (total project cost infected population. US$25 million, approved in 2003). All of these projects are currently under Barbados has a window of opportunity to implementation. In addition, project prevent the spread of HIVAIDS, as its preparation is underway in Guyana (to be Government is now publicly committed to financed through a 100% grant), St. Lucia vigorous action. A National Commission on (25% grant), St. Vincent and the Grenadines HIV/AIDS (NACHA) was established in (25% grant) for approval in FY04, along the Prime Minister's Office in 2001 with a with an US$8 million Regional HIV/AIDS mandate to implement a broad program to IDA Grant to support regional institutions limit further spread of the epidemic into the and foster horizontal cooperation and general population, by preventing HIV infection among sharing of experiences among countries. vulnerable and high-risk groups, without stigmatizing them, and treating infected persons. The development of theAPL began with the report "HIV/AIDS in the Caribbean: Issues and Options," (World Bank, June 2000, "red cover" published March 2001). This report provided The Caribbean Multi-Country HIV/AIDS an overview of the HIV/AIDS epidemic in the Caribbean and Program the challenges and opportunities in addressing it. It compared country responses to the epidemic, and discussed options for In June 2001, the Barbados HIV/AIDS Prevention and Control addressing the crisis, highlighting strategies for donor project was the first approved under the US$155 million Multi- coordination and cooperation, including the World Bank's Country HIV/AIDS Prevention and ControlAdaptable Program proposal to finance a multi-country program. The report was Loan (APL) for the Caribbean. The APL offers individual presented to Prime Ministers, Finance Ministers, and other key 1 decision-makers from member countries at the Caribbean levels in the blood, enabling people living with AIDS to live Group on Cooperation in Economic Development (CGCED) healthier, longer lives. meeting, June 12-16, 2000. Participants, including senior representatives of other bilateral development partners and Project interventions include: (i) communication and advocacy international organizations, agreed to assign the highest priority to increase government commitment, attention and funding related to HIV/AIDS and to raise awareness, knowledge and Box 1 understanding among the population about HIV/AIDS; (ii) scaling up of "AIDS in the Caribbean has reached a watershed moment." intervention activities at the national Dr Peter Piot, Executive Director, Joint United Nations Programme on HIV/AIDS and community levels; (iii) scaling (UNAIDS), 2001 up of treatment, care and support at the national and community levels; "Without decisive action, the epidemic and its impact will cause untold harm for (iv) research and national decades ahead. Combating the epidemic in the region also requires focusing on the surveillance; and (v) capacity dignity of people already infected and living with HIV/AIDS, including improving building. their access to good quality, humane care and treatment." Former Director General of the Pan American Health Organization (PAHO/ WHO), Sir George Alleyne, 2001 Achievements "Millions of dollars that we now devote to care and treatment, especially behind the The Project, implemented through active anti-retroviral therapy programme, will be of no consequence unless there is a dramatic and drastic change in personal behavior, especially among members of the National HIV/AIDS society who are most at risk." Commission, has built working Barbados Prime Minister Owen Arthur, Second National Consultation on HIV/ partnerships with sector ministries, AIDS, 10/10/03 trade union representatives, business leaders, and persons living with AIDS. Substantial progress has been made toward the stated goal of to dealing with HIV/AIDS in the region. Prime Minister Arthur reducing HIV/AIDS mortality by 50% by 2004. The basic of Barbados thereafter became a "champion" of the regional physical and institutional infrastructure for scaling up HIV/ADS initiative. treatment and care is in place. The Government is committed to universal and free provision of antiretroviral therapy for all Barbados leads the way citizens living with AIDS who require treatment, and has Although Barbados graduated from the World Bank in 1993, allocated the required funds. the World Bank Team obtained approval from the Board of Directors to include Barbados in the APL loan as an A dedicated care and support out-patient facility, the exceptional case. This was justified on several grounds: Ladymeade Reference Unit, opened in early 2002 and staff for Barbados is one of the countries in the region most severely Ladymeade have been trained and deployed. Services include affected by HIV/AIDS; it plays a strong regional leadership voluntary HIV counseling and testing, family counseling, anti- role and provides a center for technical expertise and health retroviral therapy (HAART), medication adherence counseling, infrastructure; there would be transferable development medical diagnosis, assessment and monitoring, state-of-the-art lessons; and the funding would provide public goods and laboratory service including CD4 and Viral Load testing, and positive externalities. pharmacy services for storage, monitoring, and dispensing treatment. A Clinical Psychologist and Senior Counselor In 2001, Barbados became the first country to receive World provide psychological interventions and staff training. Bank funding for a multi-sectoral HIV/AIDS Prevention and Community involvement is emphasized and community nurses Control Project that includes scaling-up of antiretroviral follow-up non-attendee patients and defaulters. drug therapy (ARV), a cocktail of drugs that decreases HIV The procurement process for increased quantities of ARV drugs 2 has been clearly established at the Barbados Drug Service. · total hospital days fell by 59.4 percent, and average Evidence-based Treatment Guidelines developed by WHO are length of stay fell 30 percent, in use, and have proven easy to comply with; adherence to the · outpatient visits rose 228 percent from 4,727 visits per standard three drug regimes has been very good. year to 10,782, · inpatient cost post-HAART fell 41% (with an average length of stay of 27.8 days, inpatient costs for AIDS are Expanded laboratory services, including Elisa testing, CD4, over four times higher than for general medical care), CD8, and viral load estimations have been essential for offering · AIDS related events fell overall, and monitoring treatment. The Government of Barbados gave · deaths of clinic-registered patients fell by 56 percent this priority, since adequate monitoring allows earlier detection overall, of virological and treatment failure. · mother-to-child transmission fell six-fold, maintaining levels of less than 6 percent transmission over five A computerized HIV/AIDS case management, monitoring, years. evaluation, and surveillance system has been established, that Also: captures real-time comprehensive information on patient · the number of patients attending the clinic increased 56 treatment, care and social support of person living with HIV/ percent and uptake of the various services has been AIDS (PLWHA). It also collates comprehensive surveillance significant, data, including risk factor and transmission details for all · patient satisfaction is high and increasing. For example, persons tested for HIV whether positive or negative. It will be 90% of more than 1,000 people living with HIV/AIDS expanded to polyclinics to rated the quality of medical care re- capture data on sexually ceived as excellent or very good (HIV/ AIDS Social Services Utilization Study; transmitted infections (STIs). two-year survey using structured inter- views and focus groups, of needs, health status and experiences of PLWHA). Outcomes The number of AIDS patients Multi-sector activities being followed has grown to 520, including 260 patients on The Project has helped to HAART. Available data on institutionalize a multisectoral patient adherence to treatment approach to HIV/AIDS. For example, regimes and clinical outcomes led by Prime Minister Arthur, the (comparing May 2001-April National HIV/AIDS Commission has Mr.Owen S. Arthur, Prime Minister of Barbados 2002 before Ladymead Center organized two annual National opened, with 12 months of unit Consultations on HIV/AIDS. The operations May 2002-April 2003) indicate: 2003 Consultation theme was "The Expanded Response to HIV/AIDS: Get Involved!" It brought Ministers of · 85 percent of patients achieved an adherence rate Government and their core HIV/AIDS implementation greater than 95 percent of treatment regime recommen- groups together with strategic partners from international dations, and private and community organizations: PAHO, UNAIDS · 69 percent achieved virologic success, Caribbean, CDC, UNICEF, UNDP, CAREC, Barbados · baseline socio-demographic data are not correlated with Employers' Confederation, Congress of Trade Unions and adherence or virologic success, Staff Associations of Barbados, AIDS Society of Barbados, · mean Karnofsky scores increased 5.8 (-20 to 90), Barbados Family Planning Association, PAREDOS, Men's · AIDS patients showed a median CDS4 rise over 10 Educational Support Association, National Organization of cells/mm3, increasing their health status and decreasing the risk of getting sick or dying from an opportunistic Women, CARE Barbados, Artists Against AIDS Barbados, infection. National Cultural Foundation, Small Business Association, · Hospital admissions for treatment of opportunistic in- Barbados Chamber of Commerce and Industry, fections among HIV+ patients decreased by 442 per- representatives from 19 HIV/AIDS Community committees, cent from 316 to 183, Barbados Registered Nurses' Association, members of the 3 AIDS Management Team, and the National HIV/AIDS Lessons Learned Commission. The Barbados program provides evidence of the beneficial impact of ART on morbidity and mortality from HIV infec- tion, as has been reported in Europe, United States and "I was a bit wowed by the degree to which Barbados has truly institutionalized a multi-sector approach to Canada. ART effectively restores the immune system, reduc- addressing HIV/AIDS. You are not only a role model ing opportunistic infections and greatly improving patient for the Caribbean, truly and honestly Barbados is a management, costs, quality and length of life. ART has made global role model. (I've) worked on HIV/AIDS in it increasingly possible to consider HIV infection as a several countries in the former Soviet Union, south manageable chronic disease. Best practice is still evolving, Asia and East Africa....Barbados has surpassed all. In fact, Barbados has surpassed US and western so the inclusion of ART in the Barbados project, though European efforts in this area!". initially controversial, provides important lessons for others. Rebecca J. Rohrer, Director, USAID HIV/AIDS, Barbados was suitable as a pilot because of its small size, Caribbean Regional Program, 10/03 good fiscal management (making ART financially sustain- able), and superior procurement and financial management capacity. The Barbados HIV/AIDS Commission has led national Major difficulties, such as low compliance and drug resis- campaigns to dispel the myth that people with AIDS can be tance, have not arisen because ART was backed by well identified on sight, and to encourage condom use. These established infrastructure supported under the project: labo- have been well received by the general public, and survey ratory facilities and equipment, timely drug supply, ad- results demonstrate their impact. The Ministry of Health has equately trained staff for diagnosis and treatment, and ad- directed a condom social marketing campaign, and over the equate patient follow up in their communities and in hospi- past 6 months, condom distributors have noted a significant tal. increase in male condom sales. Recently the Ministry began promoting female condoms as part of the Commission's In summary, the results in Barbados indicate that ART drugs "Speak Sister" campaign, focusing on women's vulnerability significantly improve survival, treatment adherence is high, to HIV/AIDS. The Ministry of Tourism and other units have reducing the risk of HIV-drug resistance, and that the also conducted successful IEC programs, assessed through expanded program generated considerable client satisfaction surveys. The Ministry of Education, Youth Affairs and and increased health-seeking behavior. Barbados is a model Sports has sensitized one-third of teaching staff about HIV for enhanced HIV/AIDS treatment and care in developing transmission and prevention measures. The Commission's countries. abstinence program was launched in primary schools, with UNICEF funding. Moving Forward Sharing experiences Decriminalization of homosexuality and prostitution will soon be placed "on the front burner", if Attorney-General The Barbados National HIV/AIDS Commission is now Mia Mottley has her way. She is determined to remove the providing technical assistance to other Caribbean National "cancer of discrimination" that prevents "highly at risk" AIDS Programs (NAP), via peer-to-peer technical ex- people from benefiting from HIV/AIDS prevention. changes. For example, the Barbados NAP hosted a three-day study tour in August, 2003, comprising on-site visits to About the Authors observe Barbados' treatment and care capacity; visits and discussions with key actors such as local health clinics, Patricio V. Marquez is a Lead Health Specialist in the World community organizations and other service delivery provid- Bank's Latin America and Caribbean Region and Team ers; structured discussions on key topics; and development Leader for the Multi-Country HIV/AIDS Prevention and of individual action plans to implement lessons learned upon Control Program in the Caribbean. return. Officers from NAPs of The Bahamas, Suriname, About "en breve" Dominica, Dominican Republic, Jamaica, Trinidad and To- bago, and Grenada have benefited from Barbados' assis- Subscribe to "en breve" by sending an email to en_breve@worldbank.org tance. 4