2 l -/l ,VIONAL 8.1, ~'NAND June 2002 No.4 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 Patricio Marquez' In the Caribbean, HIV/AIDS has become the major cause of death among men under the age of 45 (see Figure 1). Figure 1 - Caribbean HIV/AIDS Official figures show more than 360,000 people living with Prevalence Rates AIDS, but estimates place the number at over 500,000 due to underreporting. More than 80,000 children have been orphaned by the epidemic, and the infection rate is Trinidad and Tobago 0.94% estimated to have reached 12 percent in some urban areas, Suriname 1.17% spreading in many countries from high-risk groups to the Jamaica 0.99% general population. Haiti 5.17% Guyana 2.13% The Caribbean Regional Strategic Plan of Action for Dominican Republic 1.89% H[V/AIDS, developed by the member governments of the . Caribbean Community (CARICOM) and the Dominican Belize 2.889 Republic, is backed by the World Bank2 other international Barbadoa 2.89% organizations such as PAHO/WHO, UNAIDS, CAREC, Bahamas 3.77% USAID, and the University of the West Indies, among others. It will support national programs based on the countries' own needs. While the general population will benefit from a reduction in the rate of new infections, the program will particularly benefit high-risk groups and the 300,000-500,000 people living with HIV/AIDS, by increasing their care quality and coverage. The program The five-year program includes: (see Table 1, on back page) will focus its support on a participatory approach to facilitate government work in Communications campaigns to raise awareness of partnership with patients, community groups, religious AIDS as a multi-sector development issue, not only organizations, NGOs, health professionals and the private a health concern and to provide information and sector. education on the disease. Cr6ter6 lor Countiry PanMefpatlons nn the M0an ofX Act6orn An approved National HIV/AIDS Strategy and Program; Readiness of national leadership (including a structured project management unit) Programming for multi-sector implementation; The use of sustainable business arrangements Defined institutional arrangements for monitoring and evaluation o Scaling up prevention activities, at the national and is the first country to receive Bank assistance (US$15.1 community levels, aimed at shifting away from high million) to finance the use of antiretrovirals - a cocktail of risk behaviors, promoting condom use, voluntary test- drugs that decreases HIV levels in the blood, enabling ing and counseling for vulnerable groups programs to carriers to live healthier and longer lives. reduce mother-to-child transmissions of HIV, and im- I proved screening of blood transfusions; It is estimated that the 2,415 documented cases of HIV- positive persons in Barbados is only one fifth of the o Strengthening care of people living with HIV/AIDS infected population, as the infection rates continue to by improving treatment, including sexually-transmitted increase among the economically productive age group of infections (STIs) and opportunistic infections such as 25-49 year olds. Therefore, the project aims to: tuberculosis, improving the availability and access to essential drugs; 0 Reduce reported cases from 1.5 percent to I percent iof positive HIV tests per year by 2006; o Support research and surveillance, including surveys | ofcpose HIV tser yercby 2006; of epidemiology, knowledge, behavior, and better cage 15 or olderc monitoring of the epidemic; I 0 Reduce mother-to-child HIV transmission to 12 per- o Capacity building to improve program coordination cent or less; and resource management. a Increase voluntary testing and counseling by 50 per- The IomWnca˘n Reputbc cent; , _ . -0 Treat 80 percent of AIDS patients with antiretrovirals; The $25 million loan to support HIV/AIDS l- Improve quality and coverage of clinical prevention and control in the Dominican F treatment and care through the public Republic will scale-up programs and ac- health system and improved community/ tivities targeting high-risk groups, expand home care.; awareness among the general population - I t . . . . ' v _ - _ °~~~~~~~~ Increase the life expectancy of AIDS and strengthen institutional capacity to en- patients by three or more years. sure that the effort is effective. In partner- pe b ship with the pharmaceutical industry, the w U project will also help expand the coverage I Jalma_ca of the mother-to-child prevention program. ,Ui l l. - - 7 a ;Using a multisectoral approach, the The HIV prevalence rate among the adult -~~~ ~project (US$15 million) would assist the population in the Dominican Republic is - Government of Jamaica (GOJ) in (a) estimated at 2-3 percent, suggesting that curbing the spread of the HIV epidemic this disease now threatens to become a by scaling up preventive programs widespread epidemic. Therefore the targeted to high-risk groups, and project's main objectives are: prjet' m oexpanding awareness about HIV/AIDS o Reduce by perct the rate of re- among the general population; (b) oRedby 5 percent -- improving treatment, care and support; ported HIV cases and (c) strengthening Jamaica's o Increase the number of people using condoms from 30 multisectoral capacity to respond to the epidemic. to 50 percent; 0 Ante-Natal Clinic (ANC) prevalence rate to be held o Decrease HIV-prevalence among women of child-bea below 2 percent and among young army recruits less ing age attending prenatal care services to less than than I percent one percent by 2004; • Increase by 40 percent the number of orphaned chil- . A decrease among commercial sex workers from 20 to dInreaseby 40 percent the number of orphaned chtl- 10 percent in Montego Bay and 10 to 7 percent in dren receiving care and support. Kingston l3arbados 0 25 percent reduction of syphilis prevalence rate in - -- - ---=--=---- ------=-- - - | ANC attendees aged 15-24 Although most Bank assistance focuses on prevention, o Delay median age at first sex by at least 0.5 years some loans also support improvement in treatment and care for people living with HIV/AIDS. Barbados for example 0 25 percent reduction in the proportion of men/women who report having sex with a non-regular partner 2 * Increase in proportion of men/women age 15-49 re- therefore has to indicate its willingness to collaborate porting using a condom in their last sexual intercourse with NGOs, CBOs other line ministries and the private with a non-regular partner. sector in program design and implementation. * Increase the life expectancy of AIDS patients by three 3 The response to the epidemic must include care and or more years. support. There are known and relatively inexpensive * Increase from 75 to 85 percent of the propprtion of means to improve the quality and life expectancy of commercial sex workers reporting condom use with persons who are HIV positive. Providing care and their last clients. support to them would convey to the public that HIV is a health problem rather than a moral one. Providing * 100% of all district health facilities to have at least one care would require that the health system and health trained counselor providing specialized HIV/AIDS workers begin to manage the disease rather than the counseling. death of reprehensible people. The inclusion of care and support in the response to HIV/AIDS are thus ex- Grenada pected to contribute to diminish the stigma and dis- crimination. Project activities (US$6 million) target the whole 4 Prevention must remain at the core of the response: population, with particular emphasis on high-risk groups this is most cost-effective way of managing the epi- such as HIV/AIDS-infected pregnant women, children born demic. Among possible prevention interventions, be- from HIV/AIDS infected mothers, adolescents, sex havior change among high risk groups is key. Even workers, MSM, uniformed personnel, and hotel and tourism though the epidemic is now generalized in Jamaica, workers. About 35% of the population lives in St. George those in high risk groups are still more likely to con- (the capital), and the remainder can be reached within 15 tract and spread HIV to others. Prevention among minutes to one hour by road. This population distribution those at higher risk prevents many more infections in in a small country makes less difficult to reach target the general population indirectly. groups. The activities selected for project support have been grouped into four components: (i) promotion and 5 Sufficient emphasis has to be placed on strengthening behavior change; (ii) prevention and control; (iii) access to the HIV/AIDS/STI surveillance system as a tool for treatment and care; and (iv) institutional development, effective program monitoring and evaluation. The sur- management and surveillance. veillance system must give policymakers timely infor- mation on the direction of the epidemic, as well as * In 5 years, reduce reported HIV/AIDS cases by 50%, knowledge of the behaviors that continue driving the and reduce mortality and morbidity attributed to HIV/ epidemic. AIDS, by 40%; epidemic. * Improve the quality of life for People Living With 6 Strategies for dealing with the epidemic are bound to AIDSs (PLWAs); change as new information becomes available. Imple- mentation procedures must therefore favor flexibility, * Consolidate sustainable organizational and institu- learning and innovation, and responsiveness to oppor- tional framework for managing HIV/AIDS. tunities and demand. Lessons Learned Next Steps I There needs to be a clear demonstration that govern- ment, at the highest level, is committed to the issue With the Jamaica loan becoming effective in June 2002, the and ready to provide leadership. This means that the multi-country program is moving forward to its goal of government is committed to discussing the epidemic encompassing all Caribbean nations by mid-2003. The openly, accepting that a problem exists and that the project in Grenada was negotiated at the end of May 2002, means of transmission are known. The government and is expected to be approved by June 2002. Projects in should also indicate its willingness to strive to reduce Dominica, Guyana, and St. Kitts and Nevis are currently the stigma and discrimination associated with HIV in- under preparation; a project in Trinidad and Tobago was fection. identified in early May 2002 and preparation has began; St. Vincent and the Grenadines and St. Lucia have expressed 2 There has to be a clear recognition that reversing the interest. An important aspect of future work will be to HIV/AIDS epidemic is ultimately an issue of behavior identify grant sources for Haiti and regional-level change and that strategic partners (community leaders, activities. youth leaders, peers, etc.) have to be involved in the planning and implementation process. Government, 3 Table 1 - Caribbean Regional Strategic Plan of Action for HIV/AIDS 1999-2004 Priority Areas for Action Strategic Actions Promote human rights and non-discrimination Advocacy, Poficy Developnbent and Target leadership in critical sectors Advocacy, Polcy Development and HIV/AIDS and health reform Legislation Conduct research on impacts Conduct vaccine trials Conduct situational analysis on access and quality of case lCarm and Support for People Living with Develop regional standards of care C HIV/AIDS uPLt fr P Extend counseling and diagnostic facilities HJv/AIDS (PLWHA) Extend networks of persons living with HIV/AIDS and support them Support the implementation of the Health and Family Life Education (HFLE) initiative Integrate into adolescent programs, including reproductive Prevention of HIV Transmission Among health programs Young People Condom prornotion Research and innovation in methodology Peer counseling Sexual health education for youth in and out of school Support developmrent of regional networks Prevention of ElV Transmission Among Support research and development to defne best practices - Vulnerable Populations Support implementation of UNDCP plan of action - Men having sex with men (MSM) Integrate HIV/AIDS prevention and care into prison health - Sex workers care programs - Drug users Targeted information, education and communication (IEC) - Institutional populations programs - Uniformed populations Conduct situational analyses Mobile populations (e.g., migrarit workers, Include HV AID issues in tourism and health initiatives sex workers, tourists) :.. Develop regional policy and operational guidelines Identify and support field traiinig sites/models Target women for IEC programs Prevention of Mother-to-Child MV Negotiate with pharmaceutical companies for access.to antiviral Prensntssiono o drugs fbr prevention of mother-to-child HIV transmission Transmission Close colaboration with UNICEF for program development and implementation Network with regional agencies and NGOs Support capacity building in key agencies Upgrade HIV/AIDS surveiDlance Develop a comprehensive IEC strategy and program Strengthening Regional and National Develop research agenda and promote implementation Promote technical cooperation among countries Develop coordinated approach to resource mobilization Target the private sector Strengthen monitoring and evaluation capacity About the Author Notes 1 - Patricio Marquez is a Lead Health Specialist in the Hu- 2 - This program is supported through a US$155.0 million man Development Department of the Latin America and the Multi-Country HIV/AIDS Prevention and Control Adaptable Caribbean Region of the World Bank. Program Lending (APL) for the Caribbean Region approved by the World Bank's Board of Directors on June 28, 2001 More on this Topic c -- - ~~~~~~~~About "en breve' See "Health, Nutrition and Population" under http:H/ www.worldbank.org/lac To Subscribe to "en breve" please send an email to and... "en breve@worldbank.org" http://www.worldbank.org/AIDS 4~~~~~~~~~~~~~~