A-Al 36 g S -/ Document of The World Bank FOR OFFICIAL USE ONLY Report No. 11734-BR STAFF APPRAISAL REPORT BRAZIL AIDS & STD CONTROL PROJECT OCTOBER 8, 1993 MICROGRAPHICS Report No: 11734 BR Type: SAR Human Resources Division Country Department I This document has a restricted distnibution and may be used by redpients only in the performance of their offlcial duties. Its contents may not otherwise be disclosed without World Bank authodzaion. Currency Equivalents (as of July 1993) Currency Unit: Cruzeiro (Cr$) US$1.00 = Cr$ 48,107 US$1 million = Cr$ 48.1 billion Fiscal Year January I-December 31 Principal Acronyms AIDS Acquired Immune Deficiency Syndrome CAESA Coordina,co Geral de Assuntos Especiais de Saude CEME Centro de Medicamentos COAS Brazilian government's counseling and testing centers CSW commercial sex workers CT counseling and testing centers FIOCRUZ Fundac,o Oswaldo Cruz GPA Global Programme on AIDS, of WHO HIV Human Immunodeficiency Virus HIV+ Testing positive for HIV antibodies ICB International Competitive Bidding IEC Information, education and communications IRC Integrated Referral Centers (for HIV/AIDS) IVDU intravenous drug use LIB Limited International Bidding MEC Ministry of Education MOH Ministry of Health MRRL Macroregional Laboratory NASCP National AIDS and STD Control Program NGO non-governmental organization NRL National Reference Laboratory PFA Patient Flow Analysis POA Annual Operations Plan RSC Research Steering Committee SRL State Reference Laboratory STD sexually transmitted disease SOS Specialized Outpatient Services SUS Single Unified Health System TB tuberculosis UNDCP U.N. Drug Control Program WHO World Health Organization FOR OMCIA USE ONLY TABLE OF CONTENTS Pae DEFINMONS ................................................, iv BASICDATASHEET ........................................ v PROJBCr SUW9WAY ............................................. v iZ I. BACKGROUND,, ISSUES AND STRATBDY ........................ 1 A. Ba ud.. ... .......... 1 The Epemics AIDS and Sexualy Transmitted Diea . . ... .. 2 Institutoiona Arrngements . .. . ... .. .. . .. ... . .. . .. . . .. 0. . B. SectrLluesandlmplcatonsfforAidsandStds ................. 6 C. Government Stategy ........... . . . . a . ... . . . . . ... . .. 9 D. BankRoleandSSbrtegy .............................. . . 10 E. lessons amWd from Past PrjeM .......................... 10 HealthPrqecftin Brai ..................... .. ... ... 10 Bank AMS Pret .................. 12 11 THE PROJBCT ............... .......12 A. Proect Objectives ..................................... 12 D. P-jc opnmts......... ....O...... 13 C. Project Descriptm .............. .... . . . . ... 13 D. Projectnpm i M gemt ............... .. .. 23 M. PROJBCT COST3, FINANCING, PROCUREMENT AND DISBURSEMENS .. 25 A. ProJect Cosu ................. ... ... .. . 25 C. Procurement .2. ...................... . .... ...... 28 D. Dibursements ........32.so.........3 E. AccountsandAudits ................................... 34 This project i b d on the findings of a prpprail misson ta visted Brazil m Octber 1992 comprised of M Lewis (Mission Leader), M. Jacobs (Opeatis Andyst), R. Hoffmn (Operions Officer), J. Wlson (Consltant), I. Holmes (Consultant), M. Moore (Consultant), E. Ayres de CastUho (Consultant) and S. Dompieri (Cosdtant); and an appraisal mison tht visted Brazil in Januaty 1993 compised of M. Lew (Mison Leader), M. Jacobs (Opaion Analyst), i. Wison (Comutant), C. Betto (Seni Counsel), E. Ayres de Castllho (CoMutnt), S. Dompiei (Conmstant), D. SdWp (Consultant) and F. Zahauia (Cnsdtat). Tas AManager: M Lewis Divison Chief: Aim Coliou Diretor Rainer B. Steckhan Peer Reviewers: Mead Over and Julian Shete ThrRisdouent hadsa sue stbto a mye m b dpints onyin thepraa oft hek os i[c 4,uti,. Its sogemuts myX nio admis be dlooo wWut Wodd Bn auho !ci ii TABLE OF CONTENTS (contlnued) page IV. PROJECT BENEFIrS AND RISKS ........................... .............. . . 35 V. AGREEMENrT REACHED AND RECOMdMENDATION ....... ........ 36 Agreements Reached .................. . . ...... .. ..... 36 Recommendation ................. ............................... . 37 LIST OF TABLES Table 1: Summary of Project Costs by Component ....................... 26 Table 2: Summary of Project Costs by Category of Expenditure ............... 27 Table3: FincingPlan .......... .............. . 28 Tble 4: Summary of Proposed ProuememenA Arrrngemengem ....... ........... 29 Table 5: Disburseinent Projections . ......... . ........ . 32 LST OF ANNEXES ANNEX A: THE DISEASE OFADDS ...................... .. ........ . 39 Table A.1: Patterns of Transmission Modes ............... .. ...... 41 Table A.2: Reative Issues of Transmision Modes .................... 43 ANNEX B: HIV/AIDS SATISTICS FOR BRAZIL .................. 46 Table B. 1: Comparison of the Twelve Countiies With the Highest Number of Reported AIDS Cases as of March 1992 .................. 46 Table B.2: AIDS Cases Reported to WHO by LAC Member Counties . ..... 47 Table B.3: Incidence and Number of AI1DS Cases From the Macroregions of Brazf .............................................. 48 Table B.4: Selected HIRV Prevalence Study Results for Brazil, 1990-91 ...... 50 Figure B. 1: Reported Incidence of AIIDS for the Macroregions of Brazil, 19861991 ............................................. 51 Figure B.2: Exposure Categories of AIDS Cases accordng to Age: Brazil 1991 51 FigureB.3: ModesofT'nsissinBrazu ..................... . 52 Figure B.4: Trends in Exposr Categories Among Reported AIDS Cases: Brazi, 1988S1991 ............................ 0#*. . . ........ S 2 Figure B.5: Trends Observed in Transmission Routes Among Cases of Aids: FigpuB.6: NewCawseofAIDS andAssoateddDeaths, Brazil 1981-1991 .... 53 Figre B.7: Exposure Categories Among Cas of AIDS in Brazil Accrdin to Cknder ...................... .5............... 4 iii TABLE OF CONTENTS (continued) Page Figure B.8: Number of Male and Female AIDS Cases frow 1986 to 1991 .... 54 Figure B.9: Transmission Routes in Women, Brazil 1986-1991 ........... 55 Figure B1O: Incidence of AIDS Cases in Ptepant Women in Brazil, 1987-1990 . 55 Figure Bli: Incidence of AIDS Among Cidren .................... 56 Figure B12: Trends in Transnussion Routes in Children, Brai 1986-1991 .... 56 ANNEX C: NATURE, INCIDENCE AND TREATMENT OF SEXUALLY TRANShflTrED DISEASESIN BRAZL ............5 Table C. 1: Major STD Microbial Agents and the ConditionsThey Produce.... 58 Table C.2: Prevalence of Selected STs in Developing Countries ....... ... 59 Table C.3: Selected Prospective Studies on STDs as Risk Factrs for HV Trnsmiss!on ...................6 Table C.4: Summary of Brazin Studies Reporting Peretage of STDs in Selected Popwuations ............................ 62 ANNEX D: ECONOMIC ANALYSIS OF AIDS INVESTMENT IN BRAZIL ...... 68 ANNEX E: CRrTERIA FOR PARTICIPATION AND EVALUATION OF NGOs, AND PROFILE OF SELECTED NGOs ......................... 78 AiNNX F: STD DRUGS 83......83 ANNEX G: MUNICIPAL ELIGIBILITY CRITERIA AND SELECTION ......... 86 ANNEX H: TRAINING PROGRAMS UNDER THE ADS AND SD CONTROL PROJEC ......................8 ANNEX I: LIST OF PLANNED REFERENCE CENTERS: LABORATORY AND TRAINING .....................93 ANNEX J: ORG,ANIZATIONAL CHARTS ...... .............. ..... 95 ANNEX K: MONITORING ANDIMPACTINDICATORS ................. 97 ANNEXL: PROCUREMENTPRIORREVIEWTHRESHOLDS ............109 ANNEX M: DISBURSEMENT CATEGORIES AND PERCENTAGES ......... 110 ANNEX N: SUMMIARY COST TABLES ........................... 112 iv DEFINiONS AIDS Case Rate: Number of reported AIDS cases per 100,000 population. Incdence Rate: The number of new cases of a disea which occurs in a popuation during a spedfied period of time, usually expressed as the number of cases per 100,000 persons. Infant Mortality Rate: The number of deaths of infants under one year of age in a given year per 1,000 births in that year. Life Expectancy at Birth: The aveage number of years a newbo would live if age/sex - pecdfic moraityr ates prevailing at the time of birth were maltained. Prevalence Rate: The total number of people affected by a die esdtmted either at a specific dme (point prevalence) or over a stated period (pod pevalece) epessed per 1,000 population (n case of low figures, prevalence is expressed per 100,000 popuation). Surveillance: Systematic, regular collection of informaton on the incidence, distribution, and trends of a specific disease used to plan effective control of the disease.. Surveiance within the framework of the AIDS control program includes surveillance of HIV and AIDS. The AIDS case surveillance is carried out as a rouie pocedure by all medical instiutions serving in-and out- patients. HIV survelance consists of a series of surveys. Sentinel surveys, inital poin prvace suveys and repeated (periodically) point prevalence surveys in various groups of behavior, are designed to meet various objectives. Surveillance does not include mandatoy testing. HIV: Human Immunodeficiency Virus, a retovirus that causes the undedying damage to e huma immune system, which then permits 'opportunistic infectionse to caue virulent and fatal diseases in the HIV inected individ. v Oppor stic Infections: The many parasitic, bacterial, viral and funal infections which are able to cause disease in an individual once the human immunodeficiency virus has damaged the immune system. nTese are the most common presenting clinical manifaons tat establish a diagnosis of AIDS, and are chared by an agsive clinical course, resistance to thrp, and a high te of relapse. Progression Rate: Time from HIv infection to the development of 'full-blown0 AIDS. Sometimes expressed as the propordon of HIV infected individuals who will develop AIDS wituin a specified time period. Seroprevalence: Frequency of cass in which blood shows evidence of antibodies to a given infectious agent at a designated point in time. Serprevalence Rate: Proportion of a specified populaion whose blood shows evidence of antibodies to a given infectious agent at a specified time. vi BRAZIL AIDS & STD CONTROL PROJECT BASIC DATA A. Genea Total Area ('000 sq. Ian) 8,215 Density per sq.km 17 GNP per capita (US $) 2,680 B. Human Reources Population Size and Charactuistics Tota; Population in thousands (1990 est.) 150,000 14 and under (% population) ?,.4 15-64 (% popuation) 60.2 Age Dependency ratio (unit) 0.66 Females per 100 males Urban 103 Rurl 93 Populion Growth Rate (annual %) 2.1 Urban 3.1 Urban/rural growth differential 4.4 Percentage in urban areas (% popuation) 74.9 Fertility Crude brth rate (pe thousand popuWation) 26.7 Total fertility rate (births per woman) 3.2 Contraceptive prevalence (%of women 15-49) 65.0 Mortality Crude death rate (per thousand population) 7.3 infant mortalty rate (per thousand lve biths) 57.5 Life cpecancy at birth: (years) overall 66.2 female 69.3 C. Labor force (15 - 64) Total labor force (thousands) 55,026 Females per 100 males (number) Urban 104 Rural 90 vii D. BV/AIDS Icidence md Pevalence Number of Cumlative AIDS cases (mid 1992) 24,704 Number of AIDS Cases in 1990 6,177 AIDS case rate (1990) 4.1 stimated prevalence of HIV+ (1992) 300,00.450,000 MalelFemale incidence ratio (1992) 7/1 Modes of HIV/AIDS trtnsmissio (199): Sexual 66% Intravenous drugs 27% Blood transfusion 5% Peial 1% viii AiDS AND STD CONTROL PROJECT LOAN AN POJC SUAY Borrowen Federative Republic of Brazil benefcry: Ministry of Health LUn AmoUnt: US$160.0 Million equivalent Term: Payable in 15 years, including a five year grace perod at the Bak standard variable interest rate. tJject Objectives and Description: The overall objectives of the project are the following: (a) to reduce the incidence and tansmission of lilV and STDs; and (b) to strengthen public and pivate istituto responsible for SID and HIV/AIDs control. As a public health problem with seious negaive ei ties, te Bazilian govnment must mobilize resources for riing awr rehing groups engaged in high-risk behaviors to promote beaio change, and esling a functioning ias to cope with te epide-mic. The proposed project would put in pJace a set of insdtuons and actvities that: (I) define a basic program for EIV and STD prevention, and identify wbat inerventions work best; (U) dadvop an adequaty equipped and tec ay tained cadr of heath pr i able to diagnoe, treat and deliver social services to liV/AIDS ptients; (iii) establish efectve surveilce for HIY/AIDS and its collary illnesses (eg.,, STDs and tuberulosis); and, finaly, (tv) can be sustained by the states and municipalides. Te proposed proect has four components: (a) pvmeIon through: (i) informaton, education and communication (E prgms (u) expadig medical taff cacty for diagng HIV, AIDS and SThs; and (iii) broadening public sctor capbility in couselng and teng and early intervention to reduce the dak of tranmisson; ix (b) reatment servies including: (i) establishment of systems for identifying and treating STDs; and (ii) integrating HIV/AIDS prevention and medical services with long-term counseling to improve access and delivery of services and to direct patients to effective, low cost substitutes for hospitalizations; (c) institutional development to build capacity for dealing with HIV/AIDS and STD problems through (i) training of (mostly existEig) health workers in service delivery, quality control and monitoring at AIDS, for laboratory testing and quality control, and for counseling and treatment across the Single Health System (SUS), (ii) upgrading State Reference Laboratories to a basic standard in each macro-region to support HIV/AIDS and STD testing, and (iii) technical assistance for various elements of the project; and (d) surveillance. resarch and evaluation through (i) epidemiological surveillance, (ii) program evaluations in IEC, counseling and testing, services and laboratory quality assurance, and (iii) speci studies of: epidemiological analysis and projections; cost effectiveness of interventions; and the economic impact of HIV/AIIDS. Benefts: Without serious and concerted intervention now, there will be a growing epidemic with adverse consequences for Brazil. Building instutional capacity will be essential to managing the MV/AIDS crisis. This project is expected to save 300,000 lives over three years, with a savings in direct treatment costs of about US$594 million, and combined direct and indirect cost savings of US$ 1.2 billion. BEhanced expertise and infrastructm wiil have unmeasured future impacts on continued prevention. Risks: The major risk is associated with the fact that reducing HIV/AIDS requires behavior changes, and success is evaluated in terms of avoided infection, which cannot be measured directly. Achievement of project objectives entails convincing adults to modify accepted behavior to avoid the possibility of contracting or transmitting a disease that is asymptomatic in its early stages. The project encompasses multiple efforts through different avenues to reach adults. A second major risk is associated with the experimental nature of project interventions where effectiveness is not yet tested. To reduce this risk, a limited number of Specalized Outpatient Services and Counseling and Testing Centers will be established during the first year with a thorough evaluation after twelve months. The establishment of STD clinics in existing facilities will be evaluated during the course of the project. Annual reviews would provide an opportunity to monitor progress and x redesign aspects of the project as neded. A third major risk is possible delays in implementation due to bureaucratic difficulties, federal-state bottenecks or inadequate administrative capacity. The project's emphasis on building institutional capacity and technical assistance should mitigate this problem, and close Bank supervision should help to ensure dmely implementation. Estimated Costs: Local US$ 99.7 Foreign US$1I0.3 TOTAL US$250.0 Tuancicg Plan: Federal Government US$ 90.0 million IBRD US$ 160.0 million TOTAL US$ 250.0 million FAtImated IBRD Disbursements: -BankPFiscal Year- I224 l92S1996 1997I1 Annual 17.7 35.5 35.5 35.6 35.7 Cumulative 17.7 53.2 88.7 124.3 160.0 Rate of Return: Not applicable Poverty Category: Not specifically targeted BRAZEL AIS AND STD CONTROL PROJECT I. BACKGROUND, ISSUES AND STRATEGY A. BACKGROUND 1.1 AIDS (Acquired Immune Deficiency Syndrome) is a faal disease that affects all age groups, but predominantly adults, largely due to its modes of transmission. AIDS is the final stage of the Human Immn Vus infection (HIV+). It has reaed epidemic proportions in Brail and will have disastous oonsequences if left unchecked. Them is no vaccn, no effecdve treamt and the disse i spreading apidly among al classes, both sexes and all regions of fte country. Prevendon is the only efectdve intervention (see Annex A). 1.2 A classic public health problem, AIDS control rqires govenment attention and investment. AIDS i easily transmittabl, though tsmissio routes are not well understood by the popuion. Sexually transmited diseas (STDs) fcilitate HIV tansmission and increase the sverity of symptoms. Citizen need information on transmission and prevention, and access to voluntary tesing. Behavior change among those who have the virus and among those at risk of infecdon can arest transmission. Given the limited potential for profit in prevention or treatment of HIVWAIDS, the pnvate sector has litde interest or involvement. Only concerted government efforts can slow the spread of the disese and its devastating impact on govemnment budgets, economic growth, and human lives. 1.3 The economic Implications of this fatal disease are seve, both absolutely and in relation to other diseases. First, it dioptionately affect adults in the 25 to 40 year age group, when past human roure investments are being reaized and productivity is reaching its pak Second, victims are most likely to be the breadwinners or aetaks of families, and their death(s) often et into fmily poverty and/or neglc of offsprig. Third, the impac on overl ecnomic productivity may be greater than is the case with ote edndeic diseases because, especally in the early stages, it dispropionately affects the educated. Finaly, AIDS is emerging as the major cause of adult mortality, a circumst apparent in many African counties where the die is already well established and has infected over 6 million people.' AWwuih, M. nd Over, . -U Bonomic IEpt of AIDS: Shc, Resos ad oo,m" *Afic Tecni Dca PHN Divio Technio Wadcin Par No. , June 1992. 2 The Epidemies of AIDS and Seally Transmitted Dlseases 1.4 AIDS. AIDS is a set of infections that stem from a viral infection, that compromises the body's immune system. AIDS is the final and fatal stage of HIV infection, which can exist for up to 20 years with few if any symptoms. AIDS represents the stage of infection when the body's immune system has deteriorated to the point where the patient is prey to 'opportunistic infections," that is, diseases normally fought off by the body's defense mechanisms. It is the symptoms from these infections that usually lead victims to seek diagnosis and medical care. Internationally, AIDS patients on average survive for up to three years after diagnosis. In Brazil, the average is 5 months. 1.5 HIV transmission occurs in several ways. It is primarily transmitted: (i) during sexual contact; (ii) perinatally (from pregnant mother to the fetus); and (iii) parenterally (through blood transfusions and use of contaminated needles and syringes). The probability of transmitting EIV through any of these modes is tied to a set of co-factors. For sexual transmission, frequency of sexual contact, the number of different sexual partners, and presence of other sexually transmitted diseases2 enhance the 'efficiency" of transmission (see Annexes A and B). Only condoms prevent sexual transmission. Genital ulcers due to syphilis, gonorrhea or chancroid raise the probability of HIV transmission 5-10 times; transmission through infected blood or blood products increases the probability to about 100%; and children born to an HV-infected mother have a 30% chance of being bom HV positive (HIV+) (Annex A). 1.6 AIDS first appeared in Brazil in 1980, about two years after emerging in developed countries. Endemic diseases in Brazil (malaria, schistosomiasis, Chagas disease, etc.), with symptoms often similar to AIDS, the range of multiple signs and symptoms of the disease, and the limited availability of diagnostic tests and equipment have led to misdiagnosis of AIDS and severe underreporting. Epidemiologically, Brazil conforms to the characteristics of countries where transmission has historically been due predominantly to homosexual transmission, intravenous drug use (IVDU), blood transfusions and limited peina transmission (as in the U.S. and Europe). However, AIDS is becoming more closely associate with all forms of sexual behavior and rising incidence of prinatal transmission (Annexes A and B). 1.7 The cumulative number of reported AIDS cases in Brazil is 24,704 as of mid 1992, ranldng Brazil first in Latin America and the Caribbean and fourth in the world behind the U.S. (218,301 cases), Uganda (30,190) and Tanzania (27,396). The estimated number of actual AIDS cases is between 40,000 and 70,000, and prevalence of HV infection is between 300,000 and 425,000. Both figures are based on reported AIDS cass, Brazil's epidemiological profile and patterns observed elsewhere. Between 1982 and 2 Technically AIDS is a sexually smitted dieas, but AIDS and STD8 are disinguished F &I Awificeti 800) per sentinel site (total 170 sudies), and HIV-2 semsurveillance in two different sites (total 6 studies); (iv) conduct annual supervisory visits to each of the 30 sentinel sites; and (v) produce and dstribute reports of HV sero-surveillance. 2.24 Surveillance for STDs other than HIV. This subcomponent relates to monitoring and surveillance of all STDs and is therefore closely lined to the STD service subcomponent. 2.25 This subcomponent would: (i) develop objectives, key indicators and standard methods for each type of surveillance activity; (ii) develop, and have validated by an advisory committee, all forms to be utilized in the system, and distribute forms to all STD Reference Centers; (iii) train 2 individuals from each of the 27 state SID Reference Centers in STD surveillance and syphilis screening, and tain personnel from new reference clinics each year in the use of forms; (iv) prcure and distribute al necessry reporting fom to all 300 STD sevice points, and VDRL (syphilis test) reagents to Refence Laboratories, antatal care units and materity clinics for about 28 million diagnostic and epidemiologic screnings; (v) stimulate passive case nodfication from public and private service providers other than the STD Reference Centers tirough mailings, support of professional organizations and other modes; and (vi) prepare and distribute 40 editions (20,000 copies each) of an STD Monthly Buletin. 20 2.26 Research and evaluation will figure prominendy in this acdvity. STDs are a new concen in Brazil and little is known about the effectiveness of alteive data gathering effors. Studies on syphilis screening, partner nodfication and eliability of incidence data will be undertaken. Evaluation of the new surveillance system during the fis 1-2 years of the project is also planned. 2.27 Surveillance for lHIV and Tuberculosb Co-infection. Of all the opportunistic infections that HIV/AIDS patients contact, none is as important and serious as TB. It is readily transmitted and can become a clinical problem in otherwise healthy people. HIV stimulates latent TB infections and mass TB symptoms because HIV is associated with non-pulmonary TB infections. Partially as a result, evidence on the nature, extent or prograsion of TB in Brazil is virtualy unknown. Tle world has seen a resuenc of TB during the era of MWAIMDS. Because of the close biological relationship between TB and HIV/AIDS, it is critical that control progams, traditionally quite separate, be closely coordinated. 2.28 Activities under the project would include: (i) 8 joint seminars to encourage coorinated SJAIDS and TB control program at the regional and stae levels, and developing, producing and distributing educational materials (d) 60 assessment consultations with states to develop and im=plement stategies for diagnosis and treatment of TB/HIV co-infection, (iii) taining for 60 professionals from state STD/AIDS programs in clinical treatment of TB/IV, 180 trainers in counseling for patients with TB/IV co-infection, and 60 professionals in surveillance for TB/HIV, (iv) production and disseminaton of TB/HIV surveillance data in monthly bulletins of TB and STD/AIDS, and (v) a research program to detmine the magnitude of the TB/MV problem in Brzil (10 studies), and optimal diagnostic (5 studies) and treatment (5 studies) modalities for TBIHIV. 2.29 rojectlons and Resear Related to HIV/AfDS and STD. This subcomponent would: (i) strengtien state and federl capacity to use the data, applying siical models to predict the spread of HIV/AIDS and STDs; and (h) suport research on model refinements, and analysis of economic, demographic and social implications. Specifically, it would: (i) train 3 national level professionals and two fiom each state in the use of projections models; (ii) provide technical assistance to sutaes and large municipalities in the use of the model and interpretation of results; and (iii) identify priority azs for reseach to be commissioned and carried out by universities and research instiutes (estimated 25 shtdies averaging between US$30,000 and 50,000 each). A list of participating municipalities and selection criteria are contained in Annex G. 21 Istitional Development (IUS$ 46.4 million lnluding contingencies; 18% of total costs) 2.30 ObJectIves. This component would strengthen vaious institutions and foster public capacity to meet the diverse needs of the AIDS epidemic. The subcomponents would include: (i) taining; (ii) reference laboratories for STDs and HIV; (iii) quality control to ensure blood safety; and (iv) measuring direct and indirect costs. 2.31 Traing for the National Program of STD/AIDS. Because AIDS is a relatively new disease and other STDs have only recently emerged as a priority, both federal, state and municipal planing capacity, and basic and specializd clinical expertise are inadequate. A significant training effort to: (i) bring clinicians and counselors up to functional levels, and (ii) fmi:iariz states and some key municipal officials with the approaches and management needed to address AIDS and other STDs is critical. Clinical and management skills among NGOs would also be strengthened. The full range of taining efforts and the training plan are descibed in Annex H. Under this plan, there would be over 550 workshops and courses with an expected attendance of over 7,000 participants. These will be launched in the first year and contnue through the hife of the project. Technical assistance needs of state and mmuicipal governments, and assisnce in setting up local-level rining will be determined in the first year of the project. This subcomponent would cost US$10.3 million. 2.32 Strengtheng the National Network of Reference Laboratories. The Brailian public laboratory network consists of one national reference, five macroregional, 26 central, 161 regional and 1,683 local laboratories. Coordination does not exist, functions are unclear, procedural guidelines are lacidng, laboratory methods are not standardized, training is often inadequate and there is no system of quality control. Maagerial weaknesses at the federal level, and erraic and delayed resource transfers no doubt contribute to the problem, but a better structure with clearly delineated functions would help improve the effectiveness and operation of the laawtory system. 2.33 Spedfically, activities would: (i) designate and acrdit 8 national (federal) reference labortories (NRL), each with a different specalty (V, syphilis, gonofrhea, hepatitis B, chancroid, chlamydia, TB and atypical mycobateria), 8 federal macrregional reference labs (MRRL), and 27 state (SRL) reference laborties that together will backup all public and private laboraories in their respective catchment areas and test for aU relevant organism (Annex 1); (Hi) institute a system of quality control from NRL. to MRRLs and from MRRLs (both federal) to SRLs (federal and state, rewecdvely) related to control of equipment, reagents, supplies/products, and proficiency testing; (iii) establish a standardized "National Record System of Laboratory Data' for monitoring project outputs and as a base for epidemioloical surveillance; and (iv) trn lbortory personnel at al reference laboratories in standardized procedures for diagnosis of HIV, TB and selected STDs: microbiology (gonorrhea, chancroid, chiamydia, TB); 22 serology (HIV, syphis, hepatitis B); and opportunistic infections (atypical mycobactia). 2.34 Qualty Control to Ensure Blood Safety. In close collaboration with the National Coordination of Blood and Blood Products (CONASHE), the subcomponent would help establish an effective National Blood Quality. Control Program, capable of overseeing blood collection, testing and other pre-transfusion services. 2.35 Specifically, activities would include: (i) needs assessment of public, private and philanthropic blood collection/testing centers in all states; (ii) providing 27 testing 'kits' for HIV and Hepatitis B and C to all public blood collection/testing centers; (iii) sensitivity/specificity test in conjunction with FIOCRUZ, of all blood transfusion screening reagents used in Brazil, and developing and distributing manuals and guidelines for reagent sensitivity and specificity testing; (iv) developing 50 "blood panels" for conducting the above-cited sensitivity/specificity testing, as well as overseeing the licensing of national/macroreional laboratories to conduct reagent sensitivity testing, and of blood collection/testing centers to conduct reagent specificity testing; (v) establishing agreements with four intrnational laboratories to conduct sWplementary "confirmatory testing' and quality control; (vi) domestic and interational training to attain standards established under Portaria No. 721/MS for public sector staff in blood collection/testing centers, State and M;ioregional Refence aboraties and FIOCRUZ; and (vii) providing necessary collection/testing equipment to selected blood collection/tesdng centers using citeria established by the MOH. In addition, research would be supported regarding: (i) patients who contracted HIV/AIDS through transfusions; and (ii) prevalence surveys for leading tansmissible diseases (WIV, syphilis, Chagas' disease, malaria and Hepatitis B and C) among the blood donor population (5 studies). The MOH has issued formal guidelines (Portaria) specifying the membership and functions of a Research Steering Committee for AIDS & SIDs to assure the technical excellence of these activities. 2.36 Dhrect and hidirect Costs of AIDS. The increase in HIV infection, the high case ftality rate, the high cost of treatment and the fact that the disease affects the economicaly active population makes AIDS a disease of economic concern. Very little work has been done on the direct and indirect costs of AIDS due to data constraints. This activity would entail an indepth study of direct costs and another of indirect costs. The study on direct costs would: (i) develop a methodology for estimating the costs of AIDS and selected other diagnoses; (d) design and prete an instrument; (ii) train data collectors and establish a collection system in selected hospitals; (iv) collect data for 24 months with continuing monitoring of results; and (v) analyze the data with a clear policy focus. Indirect costs would be measured using life table and hazard models and provide information on the social, economic and demograhic charactcs of the HIV+ populaion, and the economic losses assodated with HIV and AIDS. The work would be executed by the 23 Economics Insdttute of Sb Paulo (LSP/PUNDAP) in colabortion with the NASCP and the relevmt State Health Scretaies. D. PROJECT PME4TATION AND MANAGEMENT 2.37 liRtltutlonal Roles In Project ImplementatIo. The project will be executed by the MOH through the NASCP, which is directy subordinate to the Secretaia Nacional de Assistencia a Sadoe (SNAS), and will function as the project implementaion unit. The NASCP Coordinator will serve as geneal project nunager and will appoint an assistnt project manager. Both managers will share responsibility for technical coordination of the project. The project manager will also appoint a project administr and a team of at least four technicians who will be responsible for maintaining project accounts, preparing withdrawal requests, supervising procurement, preig annual reports and action plans and managing contacual agrements with states, municipalities, NGOs, consultants, researchers and international agencies. Project execution at the state and municipal levels will be supervised by the technical managers of the NASCP's various subprogams. The above implementation arrangements are embedded in the existing stuchre of the NASCP (see O ona Chart, Annex J). All project activities will be integraed with NASCP progmms. NASCP would also coordinate with but not be responsible to the Coodinao Geral de Assuntos Especa de Sadde (CAESA). The Bank received assrances at Negotatfions that the NASCP will maintain at all times manag t saff, structi're and functions acceptable to the Bank (Pam 5.1). 2.38 For each of the participating states and selected metopolitan areas, a unit would be esblished in each Sectara of Health to: (1) plan, promote and coordinate the execution of activities in their jurisdiction; (ii) rresent the state or municipality at the national level; (iii) monitor public and NGO activities within their jurisdiction, jointly with the feal govenment; (iv) prware annual reviews; and, (v) for large state prgams, issue periodic progr reports to MOH and, upon request, the World Ban1L In order to participate in the project, the MOH would require states and municipalities to: develop deiled plans for AIDS activities (with asistance from MOH when necessary); outline implementation jointly with the MOH; finance personnel costs; sae costs of some activities (eg., training). Established criteria (Annex 0) would detneine municipal participation. 2.39 The United Nations Development Programme (UNDP) will be contracted to asist in the pt of goods, services and consultants. WHO's Global Programme on AIDS, UNCEF and the U.N. Drug Control Program DCP) will assist in the pocuement of condoms and STD drugs, and in technical assistance for speiized program components. 2.40 Scpleatlo Shedule. The proposed project would be implemented over a period of four years. The project completion date would 24 be December 31, 1997, with a loan closing date of June 30, 1998. An it*lementation schedule, based on projected annual targets, is included in Annex K. Each year, beginning in 1993, paripatng tes and municipalites will present detailed annual plans and budgets for project activities, that the PIU will consolidate into an oveall annual operaions plan, or consolidated POA and budget. The implementation schedule will be revised annually to reflect these plans. At Negotiations, the Bank provided comments to the Borrower on the draft generic agreements between the Federal Government, states and municipalities. As a condition of effectiveness, the MOH would provide signed agreements with at least five states (para 5.3). 2.41 Reportng and Annual Reviews. By October 31st of each year the PIU will submit a draft consolidated POA and budget to the Bank, and a final version by December 31st incorporating any Bank comments. By March 31st of each year, the PIU will submit to the Bank a progress report on project implementation, using monitoring and impact indicators described in Annex K. Based on these documents, the Bank and MOH wiU hold a joint annual review of the project by June 30th of each year. These reviews will asses the progress under the project and any implementaion problems or other issues that may have arisen. 2.42 In particular, the reviews will focus on: (1) evaluation of progress in project execution; (ii) achievement of project objectives using the following indicators: o percent of population/patients by age group that know two or more means of preventing HIV tansmission; a number of condoms sold at subsidized and at market prices; o percent of target/survey poulation always/frequently/never using a condom except with the regular sex partner; * prevalence of HlV infection or syphilis among pregnant women; o number of HIV, STD and TB cases reported by state; o percent of AIDS deaths previously notified as AIDS cases; 0 number of people trained and percent stil working in ADS/STDs after six months; e percent of labs passing proficiency tests; * percent discrepancy between lab results and surveillance data 25 (iii) any changes in prcoect design and implementation that ma, be necessry (paa 5.1). The anual review of 1996 will serve as a mid-tern review and will make use of the various evaluation exercises supported under the project. 2.43 Sustalablity. The potendal for sustainability is built into the project. First, the federal government is requiring each state to prepare an acdon plan for addressing AIDS, and is providing technical assistance where necessary. Pato of that plan includes long term planning and budgeting for the delivery of services. Given ongoing HIV/AIDS activity, and the growing concern of municipal, state and federal officials, commitment is not likely to bw a problem, and the project will build the necessary institutional capacity. Second, the responsibility for exanding and/or upgrading medical staff will lie with states (and selected municipalities), with project activities reflecting state piorities. For example, states will pay staff to attend some types of training, provide logistic support, and support a coordinator who will liaise with the project and facilitate implementation. This will require shared state investments to promote their commitment and continued investment in AIDS and STD control efforts. Third, surveillance activities would be structured to assi states strengthen their activities. Surveilance is not envisioned as a federal requirement, but rather a joint process financed jointly by the federal (for start up costs) and state governments. Fourth, the largest elements of the project (IEC, laboratory upgrading and training) are one-time investnents that will not need to be financed at similar levels in subsequernt years. Fialy, all recurrent costs will be the responsibility of the fedeaal and state governments in year four. M. PROJECT COSTS, FINANCING, PROCUREM AND DISBURSEMENTS A. PROJECT COSTS 3.1 The total project costs including contingencies and taxes, is eStmated to be US$250.0 million equivalent, of which US$150.3 million (60%) would be foreign exchange costs. Tables 1 and 2 summarize the estimated costs by proect component and category of expenditure. Detailed cost estimates are presented in Annex N. 3.2 Base Costs, Taxes and Contingencies. Base costs of approximately US$226.5 million are expressed in January 1993 prices, and include taxes and duties of approximately 15%. Civil works costs were based on estimated costs for the type of minor remodeling proposed. Equipment costs were based on prices for similar imported or locally available items. The costs of vehicls, furniture, drugs, laboratory supplies, and instructional materials were based on the procurement experience of MOH. Overseas and domestic 26 Table 1: SUMMARY Of PROJECT COSTS BY COMPONENT gI (US$ Milion) . ... % 96Total Component Local Foteign Total Fop Bas I ______________________ __ _ iExchange Cost A. Prevention 40.4 53.5 93.6 57 41.4 B. Serices 22.3 53.4 75.7 71 33.4 C. Ifttuitioss DevelopmBn 21.8 20.5 42.3 49 18.7 D. Epidemiologlcal Suveillanc J J2 i l TOTAL BASE COSTS 90.8 135.7 226.5 60 100.0 Phydcal Contngecies 3.3 5.4 8.6 63 3.8 Price Contingencies U _ 1fi 6. S TOTAL 99.7 150.3 250.0 60 110.4 A/ tacludingtaxes of aproximately 15%. Note: Totas umay not sum exacty, due to rounding. training and costs of foreign and local consultants were based on curret standards. The costs of MEC services were based on MOH experience with dmiiar acvities. Incremental operaing costs were based on currt estimates of salarie and opang requirements. Total contngencies of US$23.4 million represent about 10% of base costs. Physical contingecies (US$8.6 million or 3.8% of base costs) and price contingencies (US$14.8 milion or 6.5% of base costs), were estimated on the basis of the Implementation schedule and expected annual price hncreases Cn US dollars) of 3.9% for the first year of the project and 3.8% thereafte. 3.3 Forelg Exchange Costs. Direct and indirect foreign exchange costs are estimated at about US$150.3 million equivalent, including contingencies, based on Bank expeience with similar prqects in Brazil (see Table 2). 3.4 Recurat Costs. Incremental recurrent costs, including contingencies, are estimated at US$158.9 million. This total includes US$9.6 millon for supeison and maintenance (for bwldings, equipment and vehicles); US$95.4 million for laboratory supplies; US$20.2 million for drugs, US$17.4 million for condoms and US$16.3 million for other supplies and opeating costs (mainly fuel, salares, benefits and per diems). 27 Table 2: SUMMARY OF PROJECr COSTS BY CATEGORY OF EXPENDITURB (US$ Million) %, Foreip % Tota Category Local Foreigl Total Txchange Base Cost Investment Costs: Civil Works 0.4 0.0 0.4 . 0.2 Equipment 17.9 7.8 25.7 30 11.4 Vehicles 4.5 0.5 5.0 10 2.2 Training 18.9 5.S 24.4 20 10.8 Insbuctional Materials 3.9 2.1 6.0 30 2.7 Technical Assistance 1.5 1.5 3.0 50 1.3 Research 1.7 1.6 3.3 50 1.S EEC Services 7.5 7.5 15.0 S0 6.6 Project Management 1.0 0.1 1.1 10 0.5 Supervision 4.5 0.5 5.0 10 2.2 Recurnt Costs: Maintenance 2.2 1.0 3.2 30 1.4 Drugs 1.8 16.4 18.2 90 8.1 Laboty Supplies 8.S 76.3 84.8 90 37.4 Condoms 1.6 14.8 16.4 90 7.2 Other Supplies 6.1 0.0 6.1 - 2.7 Incremental Operating Costs 8.5 0.0 8.5 TOTAL BASE COSTS 90.8 135.7 226.5 60 100.0 Physical Contingencies 3.3 5.4 8.6 63 3.8 Price Contingencies 5 6 9 148 62 TOTAL 99.7 150.3 250.0 60 110.4 Note: Totals may not sum exactly, due to rounding. B. FINANCING 3.5 The proposed loan of US$160.0 million would finance the equivalent of 100% of the foreign exchange component of the project (approximately US$150.3 million) and about 10% of local expenditures. This large Bank share in the project is wanted by the Brailian fiscal crisis and the urgency of broad and immediate interventions to stem the AIDS epidemic. The Bank loan would be made to the Fedeaive Republic of Brazi which would provide countepart funds as necessary to complete the project. During Negotations the Borrower indicated that adequate funds were included in the approved 1993 federal budget to carry out the first year of the project. The loan would be for 15 years, with a five year grace period. Eligible expenditures made after October 31, 1993 in accordance with Bank procurement guidelines, up to an aggregate amount of US$16.0 million equivalent, would be eligible for retroactive financing. The need to initiate activities as soon as possible, combined with the fact that the NASCP has both prepared an acceptable twelve month plan and is able and ready to begin implementiaion indicate the apprpriate of retroactive financing. The 28 financing plan and loan allocations by category of expenditure are presented in Table 3. Table 3: FINANCING PLAN (US$ Million Equivalent) Proposed Category of Expenditure Government IBRD Total _BRD (%) Investment Civil Works 0.5 0.0 0.5 0 Vehicles 5.3 0.0 5.3 0 Equipment 0.0 27.1 27.1 100 Trining 8.9 18.4 27.3 67 Instructional Materials 0.0 4.5 6.7 67 Technical Assistance 0.0 3.4 3.4 100 Research 0.0 3.7 3.7 100 TEC Sevices 15.9 0.0 15.9 0 Project Management 0.0 1.2 1.2 100 Condoms 5.9 11.5 17.4 66 Laboratory Supplies 17.9 77.4 95.3 81 Supervision and Mainteane 9.6 0.0 9.6 0 Drugs 7.4 12.8 20.2 63 Other Supplies 6.8 0.0 6.8 0 Other Operating Costs ..2 ..2.Q .. 9 .Q TOTAL 90.0 160.0 250.0 65 c. PROCURE13T 3.6 Table 4 summarizes the proposed procurement arangements. The use of standard bidding documents for ICB, was agreed prior to Negotiations. 3.7 Other Bank projects implemented by the MOH have experienced procurement difficulties. In an effort to minimiz such problems, the NASCP will: (i) collaborate closely with the Coordenago Geral dos Auntos Especiais de Satide, the wordinator of interntonal financed activities (CABSA), to benefit from what it has learned in the past and ongoing procurement experience of other Bank financed MOH projects; and (*d) under an umbrella agreement with UNDP, receive technical assistance for project management, in particular, to strengten procurement capacity. 3.8 Civil Works. The cost of civil works under the project (about US$0.5 million, including contingencies) would involve minor remodeling of eidsdng facilities used for outpaient care and counseling activities (in the Casas de Apoio), and would be entirely financed by the Fedral Government. 29 Table 4: SUMMARY OF PROFOSED PROCUREMENT ARRANGEMS (US$ Million Equivalent) Procuremnt Method 111 Procurement Ement IC I _LCD O.e N.B.E. Total Cost 1. Civil Works 1.1 Remodeling - 0.5 0.5 __________________________ _________ (0.0) (0.0) 2. Goods 2.1 Laboatoy Supplies 46.0 . 49.4 c/ 95.4 (46.0) (31.4) (17.4) 2.2 Equipment 24.1 3.0 bJ 27.1 (24.1) (3.0) (7.1) 2.3 Instruction Materas 6.7 bl 6.7 (4.5) (4.S) 2.4 Vehicles S- .3 5.3 (0.0) (0.0) 2.5 Dmugs 20.2 S/ 20.2 (12.8) (12.8) 2.6 Other Supplies 6.8 6.8 (0.0) (6.8) 2.7 Condoms 17.4 g1 17.4 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (11.5) (11.5) 3. Conslties 3.1 Technical Assistance . 3.4 d/ 3.4 (3.4) (3.4) 3.2 Reseach 3.7 ./ 3.7 (3.7) (3.7) 3.3 TraininS 27.3 / _ 27.3 (18.4) (18.4) 3.4 Pioject M _anet 1.2 fV 1.2 -! _______________ ___ _ _ _ (1.2) (1.2) 4. IEC Services 15.9 15.9 i ________________________ ________ (0.0) (0.0) 5. Miscelaneous 5.1 Supevmion . 5.6 5.6 (0.0) (0.0) 5.2 Maintenane 4.0 4.0 (0.0) (0.0) 5.3 Opewting Costs 9.S 9.S (0.0) (0.0) TOTAL 70.1 132.3 47.6 250.0 _ _ __ _ (70.1) (89.9) (0.0) (160.0) 111 Rimbursemen of ozxndlwre on a declwni bass for al recurnt oosta. h/ Loal shopping on tho basi of quotations from at leat thdre wsu or contatrn. g/ US$41.4 million under m inite nationl biddig and US$7.9 milli In loca shopping. 4, Contracting of onsultnht and audion in accordance wib Dan guideli (AuS: 1981). /I Reimburemen of acp_ed s for trning including travel and per diens, and studies. p! Reinbursmmet of project manas and technichs under sho*tewm contws. XI Linited inte ona bidding based on prequaicatin fiomlhrougb WHO/UNIPAIUNDCP. Not Totsa repreent total _med coss per ctWyq including p and physical Numbes botwep p h eelect Dank financig. N.l.P. - Not Bank-financd. 30 3.9 Goods. The total cost of goods (including equipment, instructional materals, drugs, condoms, laboratory supplies and other supplies, and excluding IEC mateials) is esimated at US$178.8 million, including contingencies. Equipment and laboratory supplies grouped in packages of US$200,000 or more (about US$70.1 million), would be procured through internaional compettive bidding (ICB) procedures, in accordance with procedures consistent with those set forth in Sections I and II of the "Guidelines for Procurement under IBRD Loans and IDA Credits" (Mkay 1992). Goods that cannot be grouped in packages of US$200,000 or more, woul be procured through Limited io Bidding (B) and local shopping. Equipment procured in packages under $200,000 up to an agregate amount of US$3,000,000 would rely on local shopping. Laboratory supplies would be procured through LIB up to an aggregate of US$42.4 million, or, when procured in packages of less than US$200,000, through local shopping up to an aggregate of US$7.0 million. Mill instructional mateials, totaling US$6.7 million, would be selected on the basis of price quotations from at least thee suppliers. For the purpose of comparing foreign and local bids under ICB, domestic manufacturers would be allowed a margin of preference equal to the existing rate of customs duty and taxes applicable to competing imports or 15% of C.I.F. price at port of entry, whichever is lower. (See Annex L for the Summary of Procurement Thresholds). The total cost of vehicles included under the project is approximately US$5.3 million, including contingencies, and would be financed entirely by the Federal Government. 3.10 Condoms and Drugs. In light of the World Health Organization/Global Programme on AIDS' (WHO/GPA) experience in procurement of high quality-low cost condoms, and the need for expeditious condom acquisition under the project, the MOH will use WHO/GPA as a pocurement agent for condom purchase. An estimated US$17.4 million worth of condoms will be procured through Limited International Bidding procedures acceptable to the Bank, from prequalified manu that have met WHO standards and are from Bank-eligible countries. Condoms will be delivered in three equal insllments over the first three years of the project The total cost of drugs is atimated at US$20.2 million. Drugs will be procured through Limited Itenational Bidding based on prequalification from/through WHO/UNIPAK/UNU)CP. 3.11 Technical Assance. The total cost of technical assistance (consultants), including auditing, is esfimated at US$3.4 million including contingencies. The selection and appointment of consultants will be in accordance with the August 1981 "Bank Guidelines for the Use of Consultants." Foreign consultants would not be subject to prior registatio as a condition of teir participation in the selection process. Registration would be a pr-condition not of selection, but of contracting of consultants' services (Bkazilian procurement regulatons only require prior registration of engineering and architectual consulting firms). 31 3.12 Research. 'Me total cost of research, including contingencies, is estimated at US$3.7 million and would include funding for salaries, pe diems, travel and other field expense. Reseach proposals will be submitted to a Research Steering Committee which will follow guidelines established in a recently signed Research Regulaton (Portaria). The executing agency will make the final selection, taking into account the recommendations of the Research Steering Committee. 3.13 Information, Education, and Communication (IEC) Services. IEC services (US$15.9 million equivalent including contingencies) supported by the project (for development, production and dissemination of IEC materials) will be financed entirely by the Federal Government. 3.14 TraIning and Project Mana nt. The costs of taining are estimated at US$27.3 million equivalent, including contingencies, for courses, workshops, seminars, fellowships (domestic and internmational) and related travel and per diems. The costs of project magement are esnmted at US$1.2 miion equivalent, including contingencies, primarily for contracting of managers and technicians on fixed-term contacts for the life of the project. 3.15 Supervision and ance. Supevision costs estimated at US$5.6 million, including contingencies, would cover travel and per diems in connection with project supervison. Maintenance costs, including contingencies, are estimated at US$4.0 million equivalent and include the ,aintenance of buildings, equipment and vehicles financed under the proect. Supervision and maintenmce costs would be financed entirly by the Federa Government. 3.16 Other Operating Costs. About US$9.5 million equivalent for other operating costs (primarily salarie, benefits, per diems and fuel), including contingencies, would be financed entirely by the Federal Government. 3.17 Bank Review Requirements. The Bank would review and approve before contract award all procurement documentaion for all goods to be prcu through ICB and LEB. Prior Bank review of procurement documentation would cover about 55% of the total amount of goods and services financed by the Bank. For consulting firn contracts below US$100,000 equivalent, the Bank's prior review would cover only tem of reference. Given the simple but varied nature of the consultancies involved, the NASCP will use a standard model tenns of reference. Other conact and bid evaluations would be subject to selecfive post-ward review by Bank staff. It was agreed at Negotatons that all international procurement for goods and services will be made on the basis of sadard bidding documents, satisfacry to the Bank (para 5.1). In addition, the Government provided sanple documents for consultant selection, and sample terms of reference for consultants, as well as technical specifications for all equipment and supplies to be acquired through ICB. 32 3.18 Reporting. Procurement infonnation will be coUected and recorded as follows: (i) prompt reporting of contmct award information by the implementing agencies; and (ii) comprehensive semi-annual repots by the borrower, indicating any revision in cost estimates for individual concts and the total project; any revisions in the timing of procurement actions; and compliance with aggregate limits on specified methods of procurement. D<, lDIUBURSDENUSM 3.19 The proposed Bank loan of US$160.0 million would be disbursed over a period of about four and one half years (rable 5), based on the implementation schedule and a combination of relevant standard IBRD disbursement profiles for PHN projects in the LAC region. The Project Completion Date will be December 31, 1997 and the Loan Closing Date will be December 31, 1998. Table 5: DISBURSEIENT PRCJECTIONS IBRD FLsa Year Disbursements and Semestr Annual Cumulative % Semester 1994 2nd (Jan 94-Jun 94) 17.7 17.7 11 1 1995 lst (Jul 94-Dec 94) 17.8 35.5 22 2 2nd (Jan 95-Jun 95) 17.7 53.2 33 3 1996 lst (Jul 95-Dec 95) 17.8 71.0 44 4 2nd (Jan 96-Jun 96) 17.7 88.7 55 5 1997 lst (Jul 96-Dec 96) 17.9 106.6 66 6 2nd (Jan 97-Jun 97) 17.7 124.3 77 7 1998 1st (Jul 97-Dec 97) 17.9 142.2 88 8 2nd (Jan 98-Jun 98) 17.8 160.0 100 9 Closing Daft: December 31, 1998 33 3.20 The proceeds of the IBRD loan will be disbursed as follows: -Equipmet: 100% of foreign expendiue, and 100% of local expenditures (ex-factory cost); Laboratory Supples: * procured outside the territory of the Borrower: 100% of foreig expenditures; e procured locally: local expenditures (ex-factoIry cost) made on or before June 30, 1997: 100% up to an aggre,t amount equivalent to $12,700,000; and 50% with respect to the remaining amount; - Condoms: 3 prcured outside the territory of the Borrower: 100% of foreig expendiures; 3 procured locally: local expendiures made on or before June 30, 1997: 100% up to an aggregate amount equivalent to $1,600,000; and 50% with respect to the remaining amount; 3Drugs: * procured outside the teitory of the Borrower 100% of foreign expenditures; * procured locally: local expenditures made on or before June 30, 1997 100% up to an aggegate amount equivalent to $9,300,000; and 50% with respect to the remaining amount; cto Materials: * local expenditures made on or before June 30, 1997: 100% up to an aggrew amount equivalent to $3,140,000; and 50% with respect to the remaining amount; Cosa Services (excluding train, research and Ploject management: e 100%; - Tr,uaining:~ * 100% up to an aggregte amount equivalent to $12,600,000; 50% up to an aggregate amount equivalent to $16,200,000; and 25% with respect to the remaii4 amount. 34 3.21 D eto of Epditures. Withdrawal applications for goods with a contract value of US$200,000 or more, and for consulting firms with a contact value of US$25,000 or more would be supported by full documentation. Disburement under Contct valued below US$200,000 for goods, US$25,000 for consulting firms, and other activities not undertaken by contract, would be made on the basis of Statments of Expendius (SOEs), for which supporting documents would be mantained by the executing agency and made available for Bank staff reew. Selective review of SOB documenion, covering at least 20% of conta disbursed under these procedures, would be undertaken by visidng Bank missions. 3.22 As conditions of disbursement: no withdrawals shall be made for (i) expenditures under the project unless the expenditures are included in an annual opeations plan (POA) approved by the Bank; (i) expenditures for research unless the research activities have been approved by the Research Steeing Committee in accordance with the Research Regulation; and (iii) expenditures incurred by the states (other than the five states referred to in the conditions of effectiveness in para 5.3) or municipalities without a signed gement (para 5.4). E. ACCOUNTS AND AUDITS 3.23 A Special Account in US dollars would be opened at a commecal bank acceptable to the Bank with an initial deposit of US$14.0 mlion equivaient 3.24 lhe federa government, partiipating states and municipalities and other eecuting entities will keep separate project accounts for project epnditur in accordance with ionally accepted accounting prWedures. ITe accounts will show expenditures for each project component, subdivided by expenditures financed by the Bank and the Bower. Assuranoes to this effect were provided at Negotiations (pam 5.1). 3.25 All prect accounts and all disbursements against SOEs would be audited annually by an independent auditor acceptable to the Bank in accoance with the Bank's audiing gudeines. The executing agency would submit to the Bank the audit report of etur within six months of the losure of each fiscal year. The audit reports would cert that funds were used for the purposes for which they were provided. Assurances were obtined at Negotiations that e executing agencies will follow Bank rules in auditing of project accounts and procurement and submit audit reports witiin six months of the end of each fiscal year (cam S.1). 35 IV. PROJECT BENEFTIS AND RISKS leneats 4.1 Without serious and concrted interention, WHO and World Bank projectns indicate a growing epidemic with adverse consequences for Brazil. An adequately funded initiative ta builds insttutional capacity will be essential to mana&gi the HIV/AIDS risis. The project is expect to save 300,000 lives over three years, with savings in direct treatment costs of US$ 594 million, and combined direct and indirect cost savings of US$ 1.2 billion (Annex D). Estimates of future HIV infection resent informed guesses. They are grounded in assumptions for which there is incomplete dat (for epdemiological incidence) or Limited data (for ates of transmission). Furthermore, since declines in HIV/AIDS could ondy be attributed to changes in behavior, the estimates of possible decline are based on assumptions about shifts in behavior. Because of these important limitations on the available data, the most conservative scenarios have been used to develop these estimates. Rkks 4.2 The major risk is associated with the fact that AIDS is a difficult disease to control because it is based on behavior changes and success is evaluated in terms of avoided infection, which cannot be measured directly. Achdevement of project objectives entails convincing adults to modiy accepted behavior to avoid the possibility of contracting or transmitting a disease that is asympno c in its early stages. 4.3 A second major risk is associated with the experimental nature of prject interventions where effeciveness is not yet tested. Among these are tie integrated AIDS reference centers (SOSs), the counseling and testing centers (COAS), and SMT clinics. To reduce this risk a limited number of SOSs and COASs will be established during the first year with a thorough evaluation aftr 12 months. The establishment of STD clinics in existing facilities will be evaluated during the course of the project. Annual reviews will provide an pportunity to monitor progess and redeign aspects of the project as needed. 4.4 A third major risk is possible delays in implementation due to bureaucratic difficulties, federal-state bottlenecks or inadequate administatve capacity, a serious problem in poorer states. The project's emphasis on bilding institutional capacity and technical assistance should migate this problem, and close Bank supervision should help to ensure timely implementation. Environmenta l pact 4.5 The only potential impact on the environment is through the generation of azadous waste. The government has developed specific guideines for disposal of hazardous waste, and these will be integrted into the project 36 training curricula. These exing safeuards are adequate to deal with the potenial environmental risks posed by project activities. Poverty Impac 4.6 The proect will affect all income groups equally, although outreach efort and social services are aimed at lower income groups. Currently AIDS dispprtionatly affects the bett off, but experence elsewhere suggests hat this will shift over time with the poor maldng up an increasingly larger share of the infected population. V. AGRFSM IREAC AND RlECOMUATl(ON Reached 5.1 At Negoions, the Bank received assurances that: (a) all project accounts would be aludited annually in accordance with appropriate auditing principles by independent auditors acceptable to the Bank (pam 3.25); and t t accounts would show expndiures for each projec component subdivided by expenditues financed by the Bank and the Borrower (pama 3.24); (b) by June 30th of each year, the MOH would conduct jointly with the Bank annual reviews to assess progress in project execution, any problems in implementation or other issues tat may have arisen (pam 2.41); (c) the NASCP will maintain at all management, staff, tructue and functions acceptable to the Bank (pam 2.37); (d) all procurement for goods and sevices will be made on the basis of standard bidding documents satisfactory to the Bank (pam 3.17). 5.2 The MOH fufiled the condition of Board presentation with: the formal ceation and appointment of the Reseh Steeing Committee and its publcation in the Diario Oficial; and (ii) formal government approval of a Research Regulation (Portasia) describing the procedures and criteria for submission and evaluation of propoals (pam. 2.35); 5.3 It was agreed at Negotiations that, as a condition of effectiveness, the MOH would provide signed agreements with five staes participating in the project (para 2.40). 5.4 The following conditions of disbursements were also agreed at Nego:tan: 37 (a) submission to the Bank of giged agreements with each state (other than those listed In pam 5.3 above) and municipality prior to project implementation in that jurisdicton (pama 3.22); (b) no disbursements would be made against expenditures not included in a consolidated annual opertions plan (POA) approved by the Bank (pam 3.22); (c) no disbursements would be made against research activities not approved by the RSC in accordance with the Research Regulation (pam 3.22). Recomedation 5.5 Subject to the above conditions, the proposed project constitutes a suitable basis for a Bank loan of US$160.0 million to the Federative Republic of Brazil repayable in 15 years with agrace period of five years at the Bank standard variable interest rate. 39 Annex A The Disease of AIDS 1. HIV belongs to a family of viruses called retroviruses, which are composed of the genetic matal RNA (ribonucleic acid) and have tumor- causing potental (Johnson and Vieira, 1987). HIV is infectious, transmitted by means of semen, vaginal fluid, or blood (WHO, 1988), usually during sexual contact or in blood transfusions. As a systemic infection, HIV mainly attacks and destroys white blood cells, especially T helper lymphocytes, in the blood and lymph system that cause an inability to resist infections. There are two reported strains of the virus. HIVI is the most common strain and serological evidence is found in those who acquire the disease. A second less prevalent strain, HIV2, is endemic in West Aftica, and present in Europe, and has been found in Brazil. HIV2 is less pathogenic' than HIV1. The modes of transmission are thought to be the same but to date all the reported cases of HIV2 involve sexual transmission. 2. The incubation period varies from carrier to carrier. It is beieved that the symptoms of AIDS can surfice anytime, normaly from one year to ten or more years after initial infection, but some have survived for as many as 20 years. The duration and intensity of infectiousness is also unknown; data have shown, however, that an HIV carrier can transmit the virus to others shortly after becoming infected and long before the onset of AIDS proper (Family Health Intemational 1987). The existence of such 'asymptomatic transmitters," many of whom may not be aware that they are even infected with HIV, makes the disease particularly difficult to control and interventions hard to target. 3. The body's initial response to HIV infection is to produce antibodies to the virus. However, the antibodies are ineffectual because they do not actually combat the virus but merely mark its presence (San Francisco AIDS Foundation, 1986, Glossary). The early symptoms of HIV infection may include a short-term illness, such as glandular fever, after 2-8 weeks. A common later effect is peristently enlarged lymph glands (PGL), which generally lasts three months or longer and may occur in conjunction with dianfhea, weight loss, fever, night sweats, fatigue and opportic infections (e.g. toxoplasmosis, cytomegalovirus and herpes simplex virus). 4. About 5-10 percent of patients with POL revert to an asymptomatic state for an indefinite period of time, but in most cases PGL is followed by the AIDS related complex (ARC) and then AIDS. In "full blown- AIDS the infected person contacts and later dies from opportunistic infections that a normally functioning immune system would repel. With the difficulty in identifying the symptoms, signs and infections associated with AIDS, WHO has developed a provisional clinical diagnostic profile for AIDS that is particularly relevant where diagnostic resources are limited: severe weight loss, chronic diarrhea, and prolonged fever. The following are mnmor signs: persistent cough, dermatitis, herpes zoster, candidiasis in the respiratory ' Defind as ca_g or capable of cauing disese. 40 Anex A tr, mouth and/or vagina, hrpes simplex infection and PGL. In the absence of other known causes of immunosuppression, such as cancer or malnutrition, AIDS is defined by the existence of at least two of the above major signs in conjunction with at least one minor sign. Modes of Trasnsmison 5. HIV transmission can occur several ways. It is primarily transmitted during sexual contact, perinatally (from pregnant mother to the fetus) and parenterally (through blood transfusions and use of contaminated needles and syringes). Transmission modes vary globally and WHO has developed three distinct patterns of HIV infections that are discussed in Table A. 1. 6. Pattem 1 closely corresponds to the observed epidemiology of AlDS in developed countries with the most common form of transmission being male homosexual intercourse, and the next most common being intravenous drug use. Pattern II is found in Africa, the Caribbean and some South Ameican countries, where heterosexuals are the main group afflicted. Pattern m is found in many countries in Eastern Europe and the Pacific Region. It involves both homosexual and heterosexual AIDS tansmsion, but at a much lower prevalence level and later itroduction date da observed in Pattern I and II countries. A hybrid of Pattern I and II is found in Brazi and may grow more important in other Caribbean and South American countries as it indicates the transitional stage of the epdemic where more and more women begin to be infected (Piot 1990). 7. Sexual traslon: Several forms of sexual transmission are observed. Non drug-related sexual transmission in the U.S. and a other few countries is traceable almost exclusively to male homosexuals. In LDCs, especially in Africa and the Caribbean, transmission is predominantly heterosexual.2 Evidence from Africa (and elsewhere) suggests a bidirectional transmission of the virus: whereas 93% of the AIDS patients in the U.S are men, the disease afflicts as many women as men in Africa (Center for Disease Control, 1987). The HIV virus can in principal be transmiutted through either anal or vaginal intercourse, and it is widely believed, (though less well documented) that the virus might be orally transmittable (Population Reports, 1986). Behavioral and culta factors appear to play a role in the relevance of the kinds of intercourse. 8. Parenteral transsion: The predominant mode of parenteral transmission in the West is intravenous drug use where needles and syringes are shared. Although transmission due to intravenous drug use (IVDU's) is 2 Exceptio to is rule among developins cutes include Taland, Haiti, Brazil and Pa. A sgnificant peretag of AIDS cases in Thailand have involved intaveaous dfug us amoog male homosexuals (Braian, 1985; Mann et al., 1988). Homosexual m havs constituted a subsantial shae of the AIDS cass in Hiti and Brazil (Mann et d., 1988). Of the nine cases of AIDS diagnosed in Peru, all but one w in homoseua mals (oj. et al, 1986). 41 Anne A rue in most LDC's, in Brzil, it is growing among both males and females due to the reuse of contaminated needles and syringes, as well as sexual activity. Table A.1: PAITERNS OF TRANSMISSION MODES Patt I Pattn I Pattern m Mqaor Affected Homosexualfbisexual Heterosexuals Pesons with l oaups men/intaveneus dtus multiple sex wusers parers Period Mid-1970s or early Early to late Early to mid- Identified 1980s 1970s 1980_ Sexa Predominantly Predominantly Homosexual and Transmission homexual. Limited heterosexual. heterosexual. hetrosexual Homosexual Low prevalence transison and transmision not among those with expected to increase a major factor multiple partnes and among prostitutes Panteral Intwavenous drug use, Transfsion of Not a significant Trnsmission contaminated blood liV infected problem at or blood products not blood and present. Some a continuing problem, related products infections in but existing cohort recipients of > 10,000 infected by imported blood or this mode before blood products 1985 Pedadal Primarly among Significant Currey not a Tsion hmble inwenous problem where problem dreg users, and S-lS% of women from HIV-1 women are IlV- endemic aeas 1 + Ditibution Weste Europe, Africa, Asia, (except North America, some Caribbean, some Australia and areas in South areas in South New Zealand), America, Auswtlia Ameica Middle East, and New 7Zand Eastern Europe, nuWal South America. Source: Piot et Si, 1988. 9. Blood trasfusions: In the US, Europe and Brazil, early cases of HIV were traceable to transfusions of contaminatd blood. The implementation of screening techniques for HIV antibodies has arrested this source of spread in industrialized countries. Blood contamination is slowly being controlled in Brail and has become a minor mode of transmission. The incidence of AIDS due to blood transfusions and associated derivatives was 7.1 % in 1988 and has dropped to 3.7 % since 1991/2. 42 Annex A 10. Pernatal Trausnson: HIV transmission occurs perinatally from the pregnant mother to the fetus. It is estimated that almost 10% of HIV infections are due to perinatal transmission in Tanzania (Ngaly 1990). The probability of perinatal trnsmission cannot be estimated with certainty as all newborns carry the mother's antibodies at birth. As the uninfected baby grows older, the maternal antibody levels will decrease, and HIV antibody tests will gradually show negative results. 11. Rates of vertical transmission are estimated to be around 25 - 50% (Ryder et al 1989) with mothers in advanced stages of disease showing higher transmission rates.3 With the increasing trend towards heterosexual transmission in Latin America and Africa, the incidence of perinatal transmission is likely to grow (Over and Piot, 1991). Relative Efficiency of Transmission Modes 12. Risk factors for HV infection are similar to those for sexually transmitted diseases and include a high number of sex partners, presence of STDs, history of contact with commercial sex workers4 (CSW) or being a CSW. Sexual transmission of HIV may be facilitated by the presence of other STDs, which partly explains the varying intensity of the HIV epidemic globally. SIDs and their consequences HIV infection is discussed in greater detail in Annex C. 13. The relative efficiency of the modes of transmission vary a great deal. Cofactolrs, such as the increased frequency of contacts, the use of condoms, and the presence of sexually transmitted diseases can exacerbate or retard the efficiency" of transmission, thereby raising the possibility of getting the RV infection. Genital ulcers due to Sexually Transmitted Diseases (STDs) from syphilis, gonorrhea or chancroid increase the efficiency of transmission 5-10 times (Bjorkman 1991, Pepin 1989). 14. Table A.2 summaizes the relative efficiency of alternative modes of transmission. Transfsed infected blood and its products are considered the most efficient tansmitter of HV approaching a 100% probability (Bulatao 1990). The probability of peinatal transmission is diffictdt to estimate, as all infants born of RV infected mothers will show antibodies against the RIV virus for the first 6-12 months. If a pregnant women is infected with NIV, studies indicate that the probability that her child will be born with RV ranges fom 12 - 50%. Mothers with more acute signs and symptoms of RIV 'Chin and Sonenberg eimt the rae of prinat tnmion rges from 12-39%, while Lalemont uses 8 0of 2 - 50%. 4 Gell includes male and female proStitutes. 43 Annex A Table A.2: RELATVE EFFICIENCY OF TRANSMLSSION MODES Infectivity Risk Risk (Multiple Auto, Dat (Sigle Enconter) and Loation Modes Transmittr Encounter) Sexual: _W + indvidual 0.2% 66.7% Hean and Hetero- no codom ( ian 500) 500 encounters I Hully sexual HIV + individual 0.2% 9.1% S00 Heawst and vaginal with condom encounte Hully, 1988 HIV + individual 53.6% Lui et au 1988, Ilian Male patients witb 71.4% Redfield at AIDS or ARC al., 1985, Washington D.C. basd _______ _______ ______ ______ t udy V + i-male 9.S% Krissetal., hemophiliace 1985; San Francisco ._______ ___ ____ _______ ba d study Sexual: IV + males 10.2% Gnt et eaL, Homo- 1987; (anlu) inter- Peinata NIV + modes 12-50% WHO, 1988, _ _ _ _ _ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ -d m te Tmns- HIV + blood 66.1% Ward et a., fusions of doors 89% 1987 Blood and Mosley et products al., 1987 Partea ParenJte exposue HIV + patients 0.9% CDC, Exposure (needle stick supplment, Inju.ies) 1987 Sour Lewis, M. at aL 1989. demonstate higher rates of transmsion to ther chiren.5 In Brazil, the probability is aoximately 35%. Approximately a quater to half of the infecte infants may beoome severdy ill in their fis year, otes may develop AIDS later on in their lives (WHO 1988). in Tanzada, the probabilities of perintal trnsmission range from 12-SO pement, with higher transmission rates observed in women who are at more advanced stages of HV infection. s WHO, 1988. Chin and Sooenberg _simt the prbability of petinal tnmdssion rnuges around 12-39%, (1991). Over and Piot use estimates of 25 -50%, citig Lai t (1989). 44 Annex A REFERENCES Brnigan, William, 'AIDS Scare Sweeping Asia Prompts Preventive Punitive Moves." TheWa gU (29 October 1985): A12. Bulatao, RA. 'The Demographic Impact of AIDs in Tanzania.- Background paper prepared for the Tanzania AIIDS Assessment and Planning Study. Washington D.C.: World Bank. June 1990. Center for Disease Control, _IS _ = _ _ Sa_ (28 December 1987). AIDs Program, Center for Infectious Diseases. Centers for Diseas Control, AIDS Weeld &une= Ras United (28 December 1987). AIDS Program, Center for Infectious Diseases. Chin, J. and Sonnenberg, F., *The Epidemilogy and Projected Mortality of AIDS in the United Republic of Tanzania," WHO, Cieneva, January 1991. Family Health International (FIl) Network (special issue, Spring 1987) Gant, R.M., Wiley J.A., Winkdestein, W., "Infectivity of the Human Immunodeficiency Virus: Estimates form a Prospecdve Study of Hiomosexual Men.' Journal of InfectousDiseases 156 (July 1987): 189- 93. Hearst, Norman and Hully, Stephen B, 'Preventing the Hetosexual Spread of AIDS.' lurmal of American Medical Aociatim 259 (April 1988): 2428-32 Johnson, Edward S., and Vieira, Je£fy, 'Causes of AIDS: Etiology." In AIDS: = nd I , odited by victr Gong and Nomnan Rudnick, 25 - 33. New Brnsick, NJ.: Rutgers University, 1987 Kriess, J.K., Kitchen, L. W., et al., 'Antibdy to Human T-Lymphotrophic Virus Type m in Woves of Hemophiliacs.' Ans gItesnaLMedn 102 (May 1985): 623-6 Lallemant, M.S., Lallemant-Le Coeur, Cheynier, D., et al 'Mother-child ransmisson of HIV-1 and infant survival in Brazaville, Congo.' AI 1989, 3:643-6. Lewis, M., Kenney, G., Dor A., et al., 'AIDS in DevetLging Countries: Cost Issuesnd Pd ISf.- 1989 Urban Institutoe Report 89-5 Luzi, G., Ensoli, B., et al,. 'Transmission of HTLV-M Infection by Heteroseual Contact' letter). 1 1 (2 November 1985): 1018. 45 Annex A Mann, I., Chin, James et al., "The Entenatioa Eideniology of AIDS." SDmt& A=dm (October 1988): 82-9 Mosley, James W., "Abstracts of the Third International Conference on AIDS' (1987): 160 Ngaly 1990, cited in Bjorkman, Anders. "Alternative Medical Interventions to Slow the Spread of HIV infection." Background Paper prepared for the Tanzania AIDs Assessment and Planning Study. Stockholm, Sweden: Department of Infectious Diseases, Karolinska Institute, Rolgstuli Hospital. Revised Draft, January 1991. Over, M., and Piot, P. Forthcoming in Dean T. Jamision and W. Heny Mosley (editors) Disease Control Pdorities in Delogging Countries (forthcoming). New York: Oxford Univerity Press for the World Ban Pepin, J., F.A. Plummer, R.C.Brunham et al "The inteaction between HIV infection and other sexually transmitted diseases: an opporunity for intervention." AM 1989, 3:3-9. Piot P., Plummer FA., *AIDS: An intnation Perspective. 239 (February 1988) 573-9 Piot P, Laga M, Ryder R et al - The global epidemiology of AIDs infection: continuity, herogeneity and change. J AIDS 1990; 403-12. Redfield, R., Marlkham, P.D., et al., "Frequent Transmission of HTLV-M among Spouses of Patients with AIDs Related Complex and AIDS." Jounal of the American Medical Association 253 (March 1985) 1571-3 Rojas, Gustavo, and Eduardo Gotuzzo, et al., "Acqired Immun Syndrome in Peru (letter)." Anns ofInlnma1 Midim 105 (Septmber 1986):465-6 Ryder, R.W., Nsa, W., Hassig, S., et al, "Pe l trnsmissnof l- to infants of seropositive women in Zaire", A1S,, 1990, 41: 725-32 San Francisco AIDS Foundation (SPAF), "AIDS; Fight the Fear with Facts." Public Education Campaip of the San Francisco AIDS Foundation, April 1986, Glossary Ward, J. W., Deppe, D. A., et al., wRisk of Human Immunodeficiency Virs nfecidon from Blood donors Who Later Developed the Acquired Immunodeficiency Syndrome. " Amls of IntenlM 106 (January 1987): 61-2 World Health Oganization (WHO), Global Program On AIDS. 91 AM E1fle, June 1988. 46 Annex B 9IVIAIDS Statistics for Brazil Unless ohierwise specified, the statistical data presented in this annex are aken from the e igdm ,da1dgi, the monthly publication of the Brazlian Ministry of Health that summarizes epidemiological incidence in the country. Projections of HIV and AIDS cases are not contained here but can be found in Annex D. Table B.1: COMPARISON OF THE TWELVE COUNTRIES W`IT THE HIGHEST NUMBER OF REPORTED AIDS CASES AS OF MARCH 19 Country Cumulative New Cases Last _____________ Casesm in 1990 Report USA 218,301 39,249 3/31192 Ugnda 30,190 8,441 12/31191 United Republic of Thbzania 27,396 7,948 7/31/91 Brazil 24,704 6,177 3/30/92 France 17,836 3,722 12/30/91 Zaire 14,762 2,425 12/31/90 Zimnbabwe 12,514 4,362 3/31/92 Malawi 12,074 4,226 10/31/90 Italy 11,609 2,955 12/30191 Spain 11,555 2,612 12/30/91 Cote d'Ivoire 10,792 3,189 12/31/91 Mexico 9,562 2,403 3/31/92 Source: WHO, Global Program on AIlDS, July 1992. 47 Annex B Table B.2: lIDS CASES REPORTED TO WHO BY ILC M BC COUNTRES (BASED ON REPORTS RECOEMVE THROUGH 6/30191) 1990 Mondh/Year of Cumulative Cas Country Lad Report to Mid-1992 # Case Cue Rate 1/ Anguila 06/30/92 4 1 10.0 Antigua Barbuda 12/31/90 6 3 3.7 Argentina 12/31/91 1,298 383 1.2 Bahamas 12/31/91 834 162 66.1 Barbados 03/31/92 280 61 23.9 Belize 03/31/90 12 1 0.6 Bennuda 03/31/92 199 33 57.9 Bolivia 03/31/92 43 7 0.1 BrazIl 03/31/92 24,704 6,177 4.1 British Virgin Idands 03/31/92 4 2 20.0 Canada 03/31/92 6,116 1,050 4.0 Cayman slands 03/31/91 10 2 11.8 Chile 12/31/91 500 117 0.9 Colombia 12/31/91 2,189 620 1.9 Costa Rica 03/31192 330 69 2.3 Cuba.. 03/31/92 112 10 0.1 Dominica 12/31/91 12 2 2.3 Dominican Rpublic 03/31/92 1,642 238 3.3 Ecuador 12131/91 179 42 0.4 El Salvador 03/31/92 323 54 1.0 French Guiana 09/30/90 232 41 46.6 Grenada 03/31192 32 5 4.8 Guadeloupe 04/24/90 195 6 1.7 uatemals 12/31/91 236 78 0.8 Guyana 03/31/92 258 61 7.7 Haiti 12/31/90 3,086 630 9.7 Honduras 12/31/91 1,595 586 11.4 Janaica 12/31/91 334 62 2.5 Martique 03/31/92 208 45 13.2 Mexico 03/31/92 9,562 2,403 2.7 Montsemt 12/31/91 1 0 0.0 Nediherlds Antilles 05/15/91 77 31 16.8 Nicargua 03/31/92 25 7 0.2 Panama 03131M92 337 73 3.0 Paraguay 12/31/91 36 12 0.3 Peru 03/31/92 614 141 0.7 Saint Kitts & Nevis 03/31/92 33 8 17.4 Saint Lucia 03/31/92 45 1S 10.5 Saint Vincen 03/31/92 39 4 3.6 Suriname 03/31/92 102 35 8.3 Trinidad & Tbbago 03/31/92 1,02S 173 13.5 Turks and Ciicos Isands 12/31/91 21 1 10.0 U.S.A. 03/31/92 218,301 39,249 15.7 Uruguay 04/30/92 278 76 2.5 Veneniela 12/31/91 1,573 426 2.2 Totl for the Region 277,042 S3,202 4 The 1990 figures are used due to incomplet reporting for 1991. 1/ Cs rate is number of rported cases/100,000 population. Tbe B.3: INCIDINCE AND NUMBER OF AIDS CASES FROM T1E MACROREGIONS AND STATES OF BRAZIL _ . ~~~~~~~~~Yew Mumoresiog, 1986 1987 1988 1989 1990 199111 Total No Incidence No |ncNdewc 1No ncdence No I1idee No |ncide No uasl 1,953 1.3 2,2 1.6 3,8 2.7 S,0 3.5 6,5 4.4 7,492 5.1 28,455 ?4ordas 0.1 17 0.2 32 0.4 54 *.6 60 0.6 83 0.9 280 ROwlonis - - 4 0.5 3 0.4 1 0.1 4 0.4 1 0.1 16 AMr , 3 0.8 1 0.3 4 1.0 3 0.7 8 1.9 20 Amnon 2 0.1 I 0.1 7 0.4 11 0.6 12 0.6 18 0.9 62 Ron_ - 1 0.9 . 7 6.0 6 4.9 10 8.2 27 Para 3 0.1 8 0.2 17 0.4 28 0.6 28 0.6 42 0.9 137 Auaa - - - - 3 1.3 2 0.8 1 0.4 2 0.% 8 Tantins I 0.1 I 0.1 6 0.6 2 0.2 10 Ns tA N88 0.2 1I 0.4 2s5 0.6 413 1.0. 462 1.1 5" 1.4 2,106 mA _nboo 6 0.1 S 0.1 IS 0.3 28 0.6 39 0.8 50 1.0 154 Piaui - 7 0.3 8 0.3 11 0.4 22 0.8 28 1.1 78 Cean 16 0.3 10 0.2 31 0.5 52 0.8 66 1.0 112 1.8 318 Rio Gnde do S 0.3 13 0.6 12 0.5 21 0.9 23 1.0 41 1.8 127 Node Paraiba 5 0.2 11 0.4 6 0.2 11 0.3 22 0.7 30 0.9 97 P a_vmdmo 27 0.4 60 0.9 81 1.1 133 1.9 127 1.8 135 1.9 m7 I Alagous 6 0.3 6 0.3 19 0.8 23 1.0 26 1.1 24 1.0 108 Seripe 1 0.1 8 0.6 11 0.8 16 1.2 13 0.9 16 1.1 69 Bahia 22 0.2 44 0.4 69 0.6 118 1.0 124 1.1 163 1.4 S83 CentrW-est 5D 0.9 71 1.1 10 1.6 13 25 212 3.7 318 S5. 997 Mat Groeo do Sol 9 0.6 IS 0.9 17 1.0 29 1.7 68 3.8 76 4.3 246 a - - I- - - - - - Mat Grosso 13 1.0 11 0.7 16 1.0 27 1.6 37 2.1 47 2.7 170 GIa02 22 0. I 1. G aoins 10 0.2 22 0.S 36 0.8 31 0.8 56 1.4 63 1.6 246 - - - - - - - - - - - w~~~~~~~~~~~~~~~~~~~~~t Table B.3: INCIDENCE AND NUMBEfR OF AIDS CASES FROM THE MACROREGIONS AND STATES OF BRAZIL Year Mwcrofegion 1986 1987 1988 1989 1990 1991 11 Total Distito Fodend 18 1.4 23 1.4 33 1.9 51 2.8 51 2.7 132 7.0 335 Xbr ffhe rZ 1418 3.5 1930 4.2 3172 6.7 4041 8.4 5219 10.6 S650 11.4 22.596 Mim Gerais 57 0.4 92 0.6 121 0.1 160 1.0 161 1.0 151 1.0 819 Espirito Santo 6 0.3 1S 0.6 31 1.3 43 1.8 44 1.8 69 2.8 238 Pio de Janeiro 385 3.3 504 3.8 812 6.1 914 6.7 987 7.1 687 5.0 4,386 Sao Pallo 970 3.7 1319 4.3 2208 7.0 2924 9.1 4027 122 4743 14.3 17,155 Sowut 92 O0S 102 0.5 254 1.2 354 1.6 S82 2.7 842 3.9 2,474 Paran, 20 0.3 27 0.3 67 0.8 83 1.0 133 1.6 232 2.8 659 Sta Catarina 8 0.2 14 0.3 37 0.9 62 14 145 3.3 176 4.0 481 Rio Grand dDo SWI 64 0.8 61 0.7 150 1.7 209 2.4 304 3.4 434 4.8 1,334 1/ PrEYimiy figures. NW Figmres am per 100,000 perope. SOUrc: Boaom de logiC, 23A 26192 50 Annex B Table BA: Sieted HV Pwaeu Study Reuts for BraA, 190-91 Hnt___ II Ar (Year) 11 Sub-Population Sample size Prevalence Rio de Janeiro (1991) Male Outpatients 3,600 34.6 Campinas, S.P. (1991) Volunteer blood donotes 22,954 0.2 Canipinas, S.P. (1989-90) IVDU 105 64.8 Campinas, S.P. (1988-91) Tet center attendees 2,096 22.6 Porto Aegle, RS (1988-91) Anonynous tesding atends Various 3.5-13.4 Rio de Janeiro, RJ (1992) TB Patents 1,398 2.9 Rio do Janeiro, RI (1991) Anonymous teting attendees 368 26.9 Rio de Janeiro, RU (1990-91) Partners of HIV+ persons 204 45.0 Santos, S.P. (1991) IVDU 160 59.0 Sao Paulo, S.P. (1990) Voluntee blood donors 403 0.7 Sao Palo, S.P. (1990-91) IVDU Prisoners 470 53.3 Sao Palo, S.P. (1990-91) Prsoners 982 16.1 Sao Palo, S.P. (1991) Cadavers 1,675 4.5 Brasiia, D.P. (1990-91) Surgical Pains 449 1.6 Three Urban Areas (1990-91) Prostutes: low income 300 0.0-14.3 high inonme 300 0.0-4.0 Unspecfied (1990) Street Boys 8,000 8.0 11 ities have stae abbreviations after thewi nanms. Source: U.S. Bueau of the Census compiation of Brzlian studies at the Vm International Conference on AJIDSISTD World Congres, Amstrdan, The Netheiands, July 19-24, 1992. 51 Anex B Figure 8.1 Reported Incidence of AIDS for the Maororegions of Brazil, 1986-1ig1 Intddno {paW 100.000 Inhabitants) 10 2 0 o,ntmo..tv Sul Sud0t Norts No dts Bral1 LEm w ias?O (3 tea 198 ls 1090 0 toit Figure B.2 Exposure Categories of AIDS Cases According to Age: Brazil, 1991 Thousands of cases 6 4- 3 2 0-4 5-14 16-19 20-24 25-29 90-34 S5-38 40-44 45-49 50-54 85-59 40 Ignorant IJ Homo/blaexuai NomoAVDU M IVOU ME Hemophilie M Transfusionl IMHetrosexual Perinstal MM Undefined 52 Annex B Figure B.3 Distribution of Transmission Modes In Brazil, 1980 - 1991 Homosexual 31% Blsexual 16% Perlnatal 2% Heterosexual 16% ther 10% Hemophillacs 2% Transfusions 4% IVDUs 21% Figure B.4 Trends In Exposure Categories Among Reported AIDS Cases: Brazil, 1988 - 1991 Number of Cases 2600 2000 _ 1600 1000 600 HemophIlles IVDU Transfusions Other Undefined Bisexual NomosexHeterosex. EJ 1988 1989 = 1990 P 1991 53 Annef B Figure B.6 Trends Observed In Transmission Routes Among Cases of AIDS: Brazil 1991 Percentage 6°= 10 10 1986 1987 1988 1989 1990 1991 - -lomosexual + BIsexual Heteroseual D rug Users - Hemophillacs ° Tranafusions Figure B.1 New Cases of AIDS and Associated Deaths Brazil 1981 -1991 Number of Cas" (thousands) 2 I. 1982 1983 1984 1986 1986 1987 1988 1989 1990 1991 IMNew cases of AIDS Deaiths due to AIDS 54 Annex B Figure 8.7 Exposure Categories Among Cases of AIDS In Brazil According to Gender Transfusions 14% Transfusions 3% Undefined 9% ,:.. Homosexual 36% Undfined 10% Perlnatal 7% erinstal 1% IVt@DnedSVDUV30% Heterosexual 3H Bisexual 18% emophillacs 2% Heterosexual 12% Females Males Figure B.8 Number of Male and Female AlDs Cases from 1986 to 1991 Number of Cases (thousands) 4 I 1982 1983 1984 1986 1986 1987 1988 1989 1990 1991 Male E Female| 55 Annex B Figure B.9 Transmission Routes in Women Brazil 1986 - 1991 Number of Cases 400 - 400 200 .C 300 1986 1987 1988 1989 1990 1991 _- Sexual -I- Drug Use -*- Transfusions Otherlnot defined Figure B.10 Incidence of AIDS Cases in Pregnant Women in Brazil, 1987 - 1990 Percentage 2 1.6 1 1987 1988 1989 1990 |-Incidence 56 Annex B Figure 8.11 Cases of AIDS Among Children Brazil, 1986 - 1991 Number of Cases 1S0 140 1 120 - 100 60 C 40 20 40 91- lJ: ' IT IVDU Hiemophliiac Blood Producsa Perinatal Undefined 1986 M 1987 E e 1908198 log99o~ 1991 1992 Figure 8.12 Trends In Transmission Routes in Children: Brazil 1986 - 1991 Number of Cases 140 120- 100 80 40 20 A 0 1986 1987 1988 1989 1990 1991 E~sexual 92IV DRug users Hemophillacs Blood/Derivatives ---- Perinstal EDother/undefined 57 Annei C Nature, Ilcddence and Treatment of Seuafy Transmitted Dieases In Brazl 1. Although historically considered relatively unimportant sets of diseases, sexually tansmitted diseases (STDs) have become of paramount importance due to the emergence of AIDS (a type of STD) and its interconnection with HIV transmission and its symptom severity. 2. STD are now the most common group of notiflable infectious diseases in most countries. Over 20 pathogens are known to be spread by sexual contact. Over the last 40 years the burden associated with traditional venereal diseases like syphilis, gonorrhea and chancroid has declined, particularly in industral countries, but they have been amply replaced by both bacterWial and viral syndromes including HIV. These agents are difficult to identify and beat and can cause serious complications resulting in chronic ill-health and even death. Typically, infections in men cause mild to severe genital or urinary tt problems and infertility can result. The consequences for women are fir mor severe. They include adverse outcomes of pregnancy for mothers and newborns; infections in newborns and infants like ophtamia and chlamydial pneumonia; pelvic inflammatory disease; inferlity; ectopic pregnancy; and cancers of the cervix. Table C.1 provides the outcomes of infection with STDs. 3. STDs are both a risk factor and a proxy for HIV infection. STDs are biologic evidence of unprotected sex, which is a key risk factor for HIV. Many STDs have acute clinical manifestaftons, which make them more Lily to be seen, diagnosed and reported than HIV. However, there are several important caveats, namely: (1) there are many different STDs, and diagnosis is based on clinical and laboratory methods that differ widely in complexity and avaibility; (2) many STDs are asymptomatic, particularly in women, and are unlikely to be detected because infected women don't seek diagnosis or treatment and (3) the infrastructure for diagnosing and managing STDs is poorly developed in most developing countries. Epidmology 4. A critical analysis of the relationship between H1V and STDs are compLcated by the fact that HIV itself is an STD (Laga 1992). It is beLieved that STDs influence the nat history of HIV. For example, HIV could conceivably give rise to atypical presentation of other STDs, including lager, more numerous and more persistent lesions, or acceleate its progression towards clinical symptoms. STDs could influence diagnosis or patient's response to treatment of other STDs, resulting in more frequent or more rapid complications, aberrant laboratory test results, and inadequate response to standard therapy (Mertens et al., 1990). HIV infection is thought to increase the susceptibility to other STDs. Research on the relationship with HIV and other STDs has revealed that STDs may enhane the sexual t_nsmission of HV by increasing the susceptibility in HIV-negative persons S8 Annex C and increasing infectvity in HIV-positive pess. This may partly explain the differing rztes of spread of HIV around the world. Table C.}: MAJOR SID MICROBIAL AGNtm MND THE CONDIMONS THEY PRODUCE Ago Acut Dism Penancy-Aciaed Chmnic coditions Nesounia ohm Uhitis Prematurity Infeilty Ceivicitis Septic abortion Ectopic pegancy Salpinitis oph0bami _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~Posipatun e dou etritis _ _ _ _ _ _ _ _ Caamydia tchmatis Uretut ophtMi Infilt Cuviitis Pneuona Ectovic prenany ____ ___ Salpiis Postatna e_domtl _ Teonma padlidum Pdrm and scnda Spontaneous abortan Neursphls Cneial"ds una Haemnophi ducreyi Gnital ulcer Non known I__ __ =-?av Mollonuceos8i PneDwity Silbtl AIS _~~~~~~ydo Perna IV |HPV Ganiw wau Laop aa"; canoe HPV HSV-2 Ge_it_ ulr Neonatal HSV Genil cancer _____ ___ _ .__ pemadty HBV Acte hopepaii Peinat aBV HYrnic hbetis Hqo s. Sl4die fom devdelping coutrie confim the endemicity (natve to a pMua locahty, Mpon of country) of STDSY. 'Me table below loolm at the emanc of v alu STDS. Gonorea is baeved to be thie mos oomon preventable cawe of Pelvic hiflammatory Diseas (PID)l and tuba hi ty worldwide. Prevlent in most Wese countries, gonoffhea is bemic in most parts of centml Africa (Waserheit and Dixon-Mueller, 1991). 6. The coflae of SID incidenoe include a large number of sexc paMr, a hisbogy of SIDs, urban residence, being single and betwee ffie 11/ A Std ill two E8yplniml mtdl ges cofim endmct of STD8. Mu; dudy fud tbat holf of S09 non- pMN wiom bdw di 8 of WMK bald reprt odctiv tb" . A study _odild in MWmd bWi of650 =Wwome mveWd t 92% of ll ad at kWoe 8 orsywlW dimmuo, wifh as avem> of 3.6 per wom (o_ W_addp Ng 7-7-. 59 AnnexC ages of 15 and 44. The highest rates of STs are found m urban women between the ages of 15 - 35 (Over M, and Piot P. 1992). Table C.2: PREVALENCE OF SELECMED STDS IN DEVELOPING COUNTRIES Infection Location Prevalence Africa 10% IGonorrhea l onorrhea Ladn Amenca 6% Africa 7% Chlamydia Asia 8% Africa 19% Trichomoniasis 11% Note: Puaon includes hmily planing clibt, gnecol patients, prwaa cliic patient, won giving in clical sidng and community based pultios Studies an female populatons present with PT) or pupere sess, and clen with STDs av bee excluded from this svey. Sorce Wasseheit, 1989. 7. The impact of HIV on the epidemiology of GUD (Genital Ulcer Disea) is distesng. If GUD facilitates the tr on of HIV, and HIV+ persons are more likely to have GUDs (assoiated with btetment failures due to antibiotic resistant strains), then these two infections are mutually reinforcing their spread, resulting in an increased prevalence of HIV and GUD in the community. Transmisson 8. STDs are highly communicable and can be trnsmitted prinataly, through sexual contact or intravenous drug use. Commcial sx worrs are cited as being the source of STDs in 20% of identfied cases in Europe and North America (D'Costa 1978) and in 80% of the cases in the Tbird Wod (Rajan 1978). They remain a reservoir for sustning the infection in the general population everywhere. 9. Biologically, the transmission of sveral STDs is more efficient from men to women and the consequences for women are more serious. For example, a man's risk of aquiring gonorrhea from an infcted woman during a single heterosexual encounter is apprximay 20 -25%. A woman n similar circumstances carries a 50% risk of acquiring gonorrhea from an infected male (Hatcher et al). 60 Anmex C 10. N. gonorrhoea and C. tmchomatis infections in the mother can be perinatally transmitted to children, and are manfestd as conjunctivitis and respiratory disease. Both, however, are treatble. The consequences of syphilis are well documented and cause swveral handicaps in 25 - 75% of exposed infants (Ingraham, 1951). Risk 11. As with AIDS, STD are sexually transmitted through genital mucosal contact. The presence of open ulcerative lesions increas the probability of transmission of HIV 3 - 10 times (Piot et al, 1988; and Pepin et al 1988). Genital ulceration such as chancroid, syphilis and herpes increases the risk of HIV infection. Trichomonal, chlamydia and gonoooccal infections in women also increase the risk of HIV transmission. Table C.3 summarizes studies conducted in several locations, demonstrating that the presence of STDs enhances the risk of HIV tansmission. Table C.3: SELECTED PROSPECTIE STUDIES ON STDS AS RISK FACTORS FOR HV TRANSMISSION Autor, Date and Risk of HV L.Ation Population Studied STD Tu_Annuzon Camewn, 1989 Htetorsu clien of Genitl Ulw Dias (GUD) 4.7 Kenya CSWs mainly oaci Daow, 1987, United St_a Homosexual _ _ Syiis 15 - 2.2 Kigley, 1990, _ United SWates HomExa m Herpes 2 Holmberg, 1988 3.5 United States Homosexual men Herpes 2 Lags 1990. GUD, Gaonorea 3.5 Zaire Female CSWs Cblamydia nction 3.2 _____________ Tuchomaniasis 2.7 Plummer, 1991, GUD 3.9 Kenya Femae CSWs Chlamydia infon 7.3 Sour:. Holmes, 1992. 12. Risk factors for STDs are the same as those for EIV and depend on the cultural and behavior pastt aesting in any given country. Although women are thought to be at low risk for STDs in many countries, recent evidence shows that India and Afdica have a urpisngly high prevalence of STDs (Bang 1989). In the absence of effeicdve disease control p ams, chiamydia rtes are 2-3 times higher than those in dweloped countries; gonorrea rates 10 - 15 tmes as high and syphilis occur 10 -100 times as much. In addon, gonorea is often ymptomatic and women are unaware 61 Ann= C that diagnosis and treatment are required. Women normally become infected at an earlier age than men (Holmes, 1992). 13. To illustrate the process of the transmission of STDs, Yorke, Hethoote and Nold (1978) proposed the existence of two separate groups: a core group of highly sexually active individuals and a noncore group of less sexually active persons. By definidon, highly sexually active persons are those with a new sexual partner every 5 days and those less sexually active were considered to have a new partner every 50 days. Individual show no preference in choice of partners and select among those who are available at any period. Individuals with STDs are usua}ly part of the core group of highly sexually active persons and by virtue of their infection, constitute a high risk group for contracting HIV infection. Surveillance 14. Because of the aforementioned circumstances, data on STD incidence is lacldng in most developing countries. Surveillance for many STDs may therefore be more effectively performed through sentinel surveillance rather than through routine passive surveillance. For example, surveilce of gonococcal antibiotic resistance through sampling of strains from patients seen at selected STD clinics may be sufficient to guide effective diagnosis and therapy for gonorrhea patients. 15. Treatment limits not only transmission but contraction of other STDs including AIDS. In spite of this benefit, few counties have accorded the surveillance, prevention or control of STDs a high priority. Sexuafly T ed D In Brazl Background 16. The paucity of information makes it difficult to esdmate the magitude of STD infection in Brazil. Only since 1986 have diseases like AIDS and congenital syphilis been reported to the fedeal Miistry of Health. Of the available literaure on STDs in Brazil, only 35% of recent studies look at the epidemiology patterns in the country. The absence of coordinated surveillance for any of the classic sexually transmitted diseases in Brai (e.g., syphilis, gononhiea, chlamydia) make estimates of STh incidence of limited value (Holmes 1992). There are a few narrower local studies that allow a partial view, but it is difficult to genealize for the entire country with nonrepresentative data. Table C.4 summarizes the studies available in Brazil. EpIdeiology 17. There are severa indications, however, tat SIDs are prvalent among high risk groups in Brazil. Studies of syphilis-specific antbodies among Table C.4: SUMMARY OF BRAZIUAN STUDIES REPORTING PERCENTAGE OF STDS IN SELECrED POPULAT[ONS .. ~ ~~~~~~ .. .s I ____~~~%Daaoe ____ Auhor Year Saple P lapoa Syil Chamydia Cuoina dian= d H_ e _e__ Fazah 1981 V tis - Maral 1982 Ma104m 5.10 - - 39.0 _ Poua 1983 GyeoL . S.18 . . .. T _mrnu 1983 Pdiemms _ 1S.S _ ' _ KM" 1985 PD . - 22.0 . rim 198S Vas0cusL . . 0.5 . 19.2 0.1 Paciomk 198S 0 13.0 M.0 6.14.0 _ BoLI.Un. 198 Wo 4.0 5.6 - 3.7 0.2 0.4 BdoI.LUn. 1985 Men &Won .3 - - Soon 1986 Acahsalp. 4.1 . redon 1987 Ptouite 20.0 19.0 6.0 5.0 _ Belda 1987 Popom 5.6 - M_ __ 1987 Vagin./_ysL - 0.3 _ _ _ PimI 1987 Po ..MM 0.9 0.7 1.4 0.2 1.7 Tomioka 1987 GyeccI 18.2 18.2 - Olirn 1988 Skin di. 0.5 0.2 d 1989 Cavicis - 10.0 _ _ _ DoLLUn. 1989 SID 17.4 11.4 . 14.6 14.1 2.9 BLLUn. 1990 SgD 12.1 9.6 S.1 0.9 3.0 Sour: FaPdes and Taka, 1992 0 63 Anne C female prostitutes have shown prece rates of 42% in Santos, 50% in Campinas, and 100% in Prsidento Prudente, Sao Paulo. A study of chlamydial antibodies among a sample of prostitutes in Santos owed a prevalence rate of 100% (U.S. Census Bureau, 1992). In 1991,,9% of patients presenting to the Sao Paulo STD clinic were found to be infected with gonorrhea, and another study showed that 40% were resistant to teracycline. With the exception of congenital syphilis, STDs are not routinely reported to the Brazilian Ministry of Health. Screening for syphilis is meant to be part of prenatal care, but data are not systemaically collected and reported, leading to serious underrporting. Data from the State of Rio de Janeiro for 1990 indicate that syphilis and gonorthea are the STDs most commonly reported to the Ministry of Health. STD treatnent guidelines currently in use in Brazil were developed by the MOH in 1985. 18. The uneven distribution of gonorrhea among Brazilian adults may be due to the asymptomatic nature of the disease in women and other difficulties encountered in diagnosing this disease in women. Limited data from Sao Paulo on ulcerative STDs suggests that chancroid may be responsible for as much as 60% of genital ulcers, with 5-10% due to primary syphilis, and the remanig being herpes simplex or atpical lesi. Of chancroid patients reently studied at the STD clnic in Sao Paulo, nearly all were found to be infected with HIV. Table C.4 summarizes data from avaiable selected stdies on STDs conducted in Brazil. While it is not possible to make statistically significant compadisons, it is clear that STDs such as syphilis and gonorrhea are an increasing problem. 19. While studies of STDs are scant, those petining to the intetion and effect of HIV infection in populations with STDs are even more infrequent. Three reports are available from three Brazilian cities but the small sample sie due to undeeporting render these of little value. Treatment of Paients with STD 20. The ability of health services and clinics in Brazil to deal with STDs is varied. No vertical STD clinics exist and only some gener cnics have specializd SID sewries. Dematology clinics (which also have reponibility for leprosy) handle SIOs, or, alteratively, geneal medicine clinics, urology clinics, community health posts and prel clinics are relied upon. About 80% of male paients self-treat through pharmacies (since antibioiics are obtainable over-the-counter). Women are genally asymptomatic and neither diagnosed nor treated. Except for syphilis serologies that are rouinely conducted on prenatal patients at pubi clinics, diagnosic laboratory tests are usualy not used in diagosis. 21. A few public clinics that provide generl medical care do have well- developed capabilities with specialized physicians and staff for providing care for patients with STDs. The STD clinic at the School of Public Health in Sao Paulo is one of the specilized STD clinics. Some cnics may have facilities for performing STAT laboratory tests (tests performed in on-site 64 Annex C clinical laboratories that are used for rapid diagosis). One public polyclinic in the Boca district in Santos is an example of a geneal purpose clinic rnu by a municipality dat lrovides STD cuae. Ambulaty services at Hospital Emilio Ribas (the spealized infecdous disease hospital in Sao Paulo), and at AIDS rfte centers in Sao Paulo, Rio de Janeiro, and Santos do not routinely perform gynecologic examiations on patients with newly diagnosed HIV infection, nor are they equipped to perform any STAT labotoy tests for SID. This poses problems since examinaions for SIDs should be routine in the initial evaluation of HIV+ patients, and because STD treatment in HIV+ patients may markedly reduce the sexual transmision of HIV. Survelilance 22. STD case definitions are not standardized and the lack of systematic reporting in Brazil makes the current surveillance system nonopertive. Because patients so frequendy self-treat at pharmacies, there is little incentive to report STDs. In addition, the private sector does not forward data on STDs to the government. All of these contribute to the lack of tandardiztion and undaerporting of cases. 23. Surveillance of STDs through partner notification exdsts in Brazil and is conducted in two ways: patient rferra of partners; or, preferably, prvder refral. In the latter the health department personnel elicit names of contacts from the patent, and actively seeks to locate, diagnose and subsequently inform the patients of the health status of the contacts. Each patient's anonymity is preserved in this process. Ideally, headth car providers and health departmet personnel request that steady parners of HIV+ persons be tested. No further follow-up is performed. Partner nodfication is antmpted in a limited way, reflecting resource constraints and the difficulty of identifying and reaching recent parners. 24. The implications for coordinated AIDS and STD Program are obvious for Brazil. * The major mode of tansmission for both HIV and SIDs is sexual, with matemo-fetal, parenteral transmission and IVDU transmission as secondary but also important. e There is a song association between the occurence of HIV infection and the presnce of other STDs, makdng early dgsi and effective tatment of STDs an important component in the pewntion of HIV transmission. * Taget groups and interventions for preventng HIV and SID transmiin are the same. e Moreover, STD carers are prune tarets for education (IMC), including counseing. 65 Annex C 0 Trends in SID incidence and prevalence are useful indicators of shifts in sexual behavior, reflecting the population's perception of its risk of contracting AIDS. 25. The synergy of a strong coordination of AIDS and STD programs in Brazil is important for the above reasons. STD testing, treatment and counselling need to be integrated with or closely linlkd to the prevention of HIV and AIDS. With the strong impact of STDs on the spd of HIVV, improving the capabiity of the Brzilian health care system to cormcy diagnose and manage patients with STDs is an important comporent of the AIDS prevention program. 66 Annex C REURENCES Bang R. An aproach to the gynecological problems of rural women: eidemiological study and intervention through primary health care. Pim Annual bla¢ig Cgmmuft 693pidemioloyHamt UVXU=n Ngtwgk, Kon Kaen, Thailand, February 14, 1988. D'Costa, LJ.,Plummer, PA., et al. "Prostitutes are a major reservoir of sexually transmitted diseases in Nairobi, Kenya". Sexually TXsmit E&CM, 1985, 12:64-7. Faundes A, and Tanaka AC. Rcmad9is Tract Infecions in Bmzi: Solutions in a diffiut eoomi climate", in Reproductive Tract Infecdons: Global hmpact and Priorities for Women's Reproductive Health, edited by Germain et al Plenum Press, New York 1992. B:e,RA. et al. '420:11fiv Technolog: International Edition" Adanta: Printed Matter, 1989, p96. Hethcote, HH. and Yorke IA. Gonorrhea T:nsmission Dnamics and Control, Lecture Notes in Biomathematics 1984, No 56, New York: Springer-Verlag. Holmes K, Reproductive Tract Infections: Global Impact and Priorities for Women's agBuyctive Health, edited by Germain et al Plenum Press, New York 1992. Inagraham, NR. 'The value of penicillin alone in the prevention and teatment of congenital syphilis" Acta Dennab VMol 1951; 31: (S24):60-88. Lap M. "HUman Immuoficey Virs Infection Prevention: The need for qm,emnoa SI control" in Reproductive Tract Infections: Globa Impact and Priorities for Women's Reproducdve Health, edited by Germain et al Plenum Pes, New York 1990. Mertens TE, Hayes RI, Smith PG. Epidemiologica methods to study the inteaction between HIV infection and other sexually transmitted diseases. AIDS 1990; 4:57-65. Mueller R, and Wasserheit J. The Culture of Silence: Reproductive Tra Infections among Women in the Third World. (New York:International Women's Health Coalition 1991). Over M and Piot P. HIV Infection and Sexually Tranitted Diseases. Forthcoming in Dean T. Jamison and W. Henry Mosley (eds) Disea CQnLP es in DevdgsQCuntris. New York: Oxford University Press for the World Bank, 1993. 67 Annex C Pepin, J., Pummer, FA., et al, -ne intacton btween HIlinfeton and otier sexualy transmitted diseaes: an oppmrt ty for interveition'. A 1989. V-39. Piot P., Plummer FA., 'AIDS: An te o Perspective.'N 239 (February 1988) 573-9. Piot P and Meheus A. "Epidemiologic des maladies sexuellement transmissibles danm les pays en developperrnet'. Anna de a societl 1ege d medecine :ale, 1983, 63:87-110. Rfjan, VS. 'Sexually transmitted diseases on a tropical island". Blrish Jonal of Ven Dies, 1978, 54:141-3. U.S. Bureau of Census, Summa . of gSrale Studies in Brazil, mimeo, 1992 Wasserheit L., 'The Significance and Soope of Reproductive Trc Infecions Among Third World Women, Int1ucatonal i JM Ld ag n1oxi and Qkalttic, Supplement 3, 1989, pp. 154-5. Wasserheit L., Dixon-Mueller R., 'The Culture of Silence: Reproductive Tract Infections Among Women in the Third World." 'nteniQna Women's Health Coalition. 1991, pp 5. 68 Annex D Economic Analyis of AIDS Investment In Brzil Ilnvestmeut In Prevention 1. Total project cost is US$250 million. These funds will be disbursed over a ftee y period begnning in 1993. The annual disbursements are epected to be US$50 million in 1993, US$100 million in 1994 and US$100 million in 1995. The investment is discounted using an eight percent discount rate. The present value of the futue investment is $228 million. AIDS Caes Prevented 2. Two scenarios of a Brznia AIDS epidemic are developed to estimate the number of AIDS cases prevented as a result of a substantial invetment in preventoln efforts. The first scenio is AIDS cases in Brazil with no intervention, using the Epi Model developed by James Chin and Steve Lwanga at WHO,, to project an HIV/AIDS epidemic based on the epidemiology of the disease. The assumptions for this scenario are: 0X) 425,000 people currently infected with HV in Brzil as of 1991; (ii) widespread transmission of HIV began in 1980; and (iii) annual new infcdons (mcidence) of HIV continue to increase until 1999. The number of people HIV+ was estimated by piecing together epidemiological data from trughout Brazil. The individual states in Brail were divided into three ctegories (high, medium and low risk of IIV transmission) based on avalable behavioral and HIV prevalence studies and the klowledge of Brailan AIDS experts. The adult populaton, ages 15-45 in each state of the states in each category was multiplied by a range of estimates of HIV prevaence rtes based on various seroprevalence surveys of the general ppulation from throughout the country. Using the current esdmate of HIV positive with the other Epimodel assumptions, implies in this scenario that the number of people currently infected with HIV grows from 425,000 to 1991 to 1.2 mi1ion by 2000. AIDS cases increase from 15,182 in 1991 to 77,576 by 2000. It should be pointed out that these estimates represent informed guesses, grounded in assumptions about which there is incomplete (epidemiologivca incidence) or limitd (rate of transmission) data. Hence at best they provide orders of magnitude. 3. The second scenario assumes that significant interventions are able to reduce the spread of tie AIDS epidemic. Assumptions (i) and (ii) above, on the number of HIV+ people in Brazil, and the introduction of HIV in Brazil, resptively, are the same for this scenario. Assumption (iii), on the number of new EIV infeions, is different, due to intervention programs that are eectd to slow the growth of Brazil's AIDS epidemic by changing people's behaviors. Under this scenario, annual new infections (incidence) of HIV incrase tugh 1995 and then begn to deea as behavior changes. This senario result in 900,000 people currendy inected with EHIV in 2000 and only 64,429 AIS cases by 2000. As in the first scenario, these estimates only indicate gal dicons. However, imuted behavior changes make 69 Annex D die projections more tenuous. Since declines in HIV/AIDS will only be attributable to behavior changes, we are makig assumptions based on little knowledge. Particularly weak is knowledge of sexual practies in Brazil, and the kinds of initiatves that stimulate behavior change. Hence, the most conservative scenarios have been reported and relied upon for this analysis. 4. Evidence on the impact of interventions on behavior and on HIV tansmission for developing countries is very limited. In Brazil, earlier IEC campaigns have raised awarenes of AIDS to dose to 90%. Subsequent campaigns under the project are aimed at infomaion to sdmulate behavior change, a much more difficult goal, and more difficult to quantify. 5. The one area where significant behavior shifts can be documented is among homosexual males in San Francisco, USA. HIV infections evidenced a dramatc decline when inmation and counseling expanded, and deaths among members of the communty rose. What role each of these ftors - information, counseling, deaths - played in changing behavior is not clear, but the s show that individuals can and do alter ther sexual practices under certai conditions. Given that the homosexual community was well educated, definable and meachable makes it unlike most sitatons in developing countries where educational levels are low, the target populton is diffused and how, when and where to reach them is not always apparent. Thus, the projects here implicitly assume that the planned program inrventions will have an edfct, but we cannot be more specific and achieve greater accuracy. In lieu of this, however, the project has built in research to try and measure some of the efecs, and indicators that support impact measures (see Annex K). 6. The two scenarios are illustated in Figures 1 and 2. The number of AIDS cases prevented is the difference in AIDS cases between scenario 1 and 2. Diret Costs of AIDS 7. Annual patient tretent costs of AIDS is esimated to be $16,700 in constant dollars. This esdmate includes both in-patient and out-patient costs and is derived from a peliminary cost study by Andre Medici and Kaiza Beltrao based on 1989 cost data from AIDS patients at Hospital Clementino Frago Filho in Rio de Jandro. These cob include labor, mateals, overhead and drugs. 8. Total direct cost savings are the sum of annual treamnt costs per AIDS patients multiplied by the annual number of AIDS cases prevented. These costs are then discounted at an 8% discount rate to calculate the present value. The present value of the cost savings increase from $2.1 million in 1994 to $146.7 million by 2001. Agegate savings are estimated to be $594 million. The present value of the investment costs, $228 million, are significantly outweighed by the present value of the potential direct costs savings, $594 million, a ratio of 2.6 to 1. Figure 3 illusas the diret cost 70 Annex D savings of an AIDS prevention program. Assuming that 75% of AIDS patients seek treatment due to their lower socio-eoomic status, the aggregate costs savings are $443 million, rther than $591 million. ldirect Costs of ADDS 9. The indirect costs of AIDS are a measure of the burden on society of an increase and redistibution of the morbidity and mortality due to AIDS. The prospecdve economic costs of illness and death of adults of worldng age include not only fte cost of medical care but also the product lost to the economy and society which these individuals would have otherwise contributed. This method assumes that the Brazilian labor market has excess capacity such that the marginal product does not rise due to a shift in the supply curve of labor. From the HIV/AIDS scenarios described above, estimates of AIDS deaths with and without interventions were developed. The difference between the two scenarios is the number of AIDS deaths which would have been prevented. Figure 2 illustrates the number of AIDS deaths resulting from both scenarios. 10. To estimate the present value of the indirect cost of AIDS, an average loss per AIDS death of 25 years is assmed and the gross national product per capita of $2,500 is used as the marginal product of labor. Per capita GNP is adjusted to account for the ct some AIDS deaths (injecting drug users) will be from the unproductive, unemployed sector. Thus, it is assumed that only 75% of AIDS deaths will be from the productive, employed sector. Moreover, about 27% of victims are from the upper middle clssm and above. The methodology used is the now conventional approach developed by Over, et al, of discounting prime adult years lost. A discount rate of 8% is used. Indirect costs prevented increase from $13.3 million in 1994 to $159.1 million in 2001. Another shortcoming of this method is that it omits any indirect effect of reduced savings due to households and governments diverting funds for AIDS treatment. Reduced level of savings impacts long run capital accumulation and economic growth. 11. Figure 4 illustrates the total direct and indirect cost savings of an AIDS intervention in Brazil. The aggregate savings of $1.2 billion outweigh the total investment of $228 million by 5.2 to 1 over the next nine years. The strong economic rational for prevention is further supported by the 300,000 HIV cases avoided through prevention efforts by 2000. Cost Benefi Anaysis 12. How much should be spent to control the spread of AIDS, and how this investnent compares with other development needs is difficult to detemine using standard techniques. This discussion focusses on the economic rationale fr imvesting in AIDS and SID Control. 13. Using the figures above, the prqectd cost per averted mV infection is estimated at US$833, ignoring discounting. Since each case of HIV 71 Annex D infecdon causes an avenge loss of at least 10 discounted 'disability adjusted life years," the project is buying a year of healthy life for about US$83. This too is an educated guess based on numerous assumptions that can nver be fully substantiated since even after the fact we will be estimating the counterfactual. This project rresents a first effort to stem the epidemic. Because retuns on similar types of investment are either not available or inapplicable, this investment should be seen as experimental, with a considerable evaluation and research agenda. 72 Annex D Brazil HIV/AIDS Epidemic I ~Figure 1 HI! New Infections 160,000 No Intervention 140,000 120,0Q00 . Number00 of 1 00,000 With Intervention People 80,000 60,000 *40,000 . 20,000 0 . I l 1992 93 94 95 96 97 98 99 2000 2001 1,400,000 HIV Currently Infected No Intervention 1,200,000 - . d 1,000,000 * - 0V With Intervention Number 800,000 Of People 600,000 400,000 200,000 1991 92 93 94 95 96 97 98 99 2000 2001 73 Annex D Brazil HIV/AIDS Epidemic Figure 2 AIDS Cases 90,000 - .80,000 - 70,000 - Number 60,000 - AIDS 509000 - Cases 40.000- 30,000 qJfll 20,000 10,000 92 939 95 9 97 98 99 20 2001 0 AIDS-With Interventin AIDS-No Intervention AIDS Deaths 100,000 Number 8,0 of 60,000- Deaths 40,000- 20,000- 92 93 94 95 96 97 98 99 20 2001 74 Annex D Brazil Direct Cost Savings bf AIDS Interventions Figure 3 $160MM[ $146.7 $140 $128.1 $120" $107.5 $100 * $85.5 $80 a . $62.9 $60a $40.7 $40 $20.1 $20 1994 ' 1995 ' 1996 1997 1998 1999 2 2001 o Aggregate direct cost savings = $591 Million o Direct Cost Savings outweigh Investment= 2.6 to 1 75 Annex D Brazil Direct and Indirect Cost Savings of AIDS Interventions Figure 4 $350MM $305.8 $300 $264.3 $250 Indirect Cost $219.4 $200 $171.7 $150 $1 23.2 $100 Direct $76.2 Cost $50 $33.4 1994 1995 1996 1997 1998 1999 2000 2001 o Aggregate direct and indirect cost savings - $ 1,193.2 Million * Total Savings outweigh Investment= 5.2 to 1 BRAZL National AIDS Control Project Financial Analysis of AIDS Prevetion Program Year 0 Year i Year 2 Year 3 Year 4 Year s Year 6 Year 7 Year 8 FY 1993 FY 1994 FY 1995 FY 109 Ft 1997 FY 1998 FY 199 FY 2000 FY 2001 Annual Inestmnt $50 $100 $100 Total Investnent $250 Present Vahle of Investment (1) $228 AIDS Cases No Inferantlon (2) 27.402 33,368 40,485 47,875 56,394 62.919 70.343 77.576 84,546 AIDS Cases With InbtVon (3) 9Z742 .Lm s9 4&SO 60D.27 £LIa2 60-128 64.429 88.2 AlDSCasesPrevnted 0 0 1,402 3.072 5.124 7,521 10.215 13.147 16,261 Oka Treatmnt Coat of AIDS And faleant emtsperAlDS $16,700 $16.700 $16.700 $16,700 $16,700 $16.700 $16,700 $16,700 $16,700 0v patIet (4) (In-pallent and Out-patI Tot Dect Costs Prmentd $0 S0 $23.413,400 $51.302.400 $85,670,800 $125,600,700 $170,590,500 $219,554,900 $271t5587100 Present Va, oDirectCst (1) $0 $0 $20.073.217 $40.725,499 $62,897,093 S8S,481,726 $107,500.952 $12%108,175 $146,714,718 rT piane Vha tg of Mud Iwetshnent $228,326,475 Direat Cot Prwwetd 691.501,377 RalIo 2.6 AIDS ggg PreweS AIDS Deaths No Invent 2) 24,591 30,316 36,927 44,180 51.635 59,157 66,f31 73,959 81,061 AIDS Dealtt With tenn (3) 24A1 I0Zh 3.1S7 41.94 47-536 i2 57-763 62 2Z8 66 Si X AIDS Deas Prevented 0 0 770 2,237 4.099 6,323 8,868 11,681 14,704 t Year o Year i Year2 Year 3 Year 4 Year s Year 6 Year 7 Year a FY 1993 FY s84 FY 1995 FY 1996 FY 1997 FY t998 FY 199 FY 2000 FY 2001 Inrdct Cost of AIDS Deat Average Years Lost 25 25 25 25 25 25 25 25 25 Gross Natonal Product per Capha $2.,00 $2,500 $2.500 $2,500 $2,500 $2,500 $2.500 $2,500 $2,500 Percent of Deaths from ProducIve 75% 75% 75% 75% 75% 75% 75% 75% 75% Sectw Discounted Years (5) 10.88 10.02 9.22 8.47 7.85 7.27 6.73 6.22 5.77 Tota Idirct Costs Preventd (6) $0 $0 $13.311.375 $35,526,3s6 $60,332,156 $86,190,394 $111,903,075 $136,229,663 $159,.078,900 Tobtl txdhxd Cost of AIDS Investment $228,326,475 Indiret Costs Prtented $602,671.919 Ratlo 2.6 Totl lhObd and hidM& Cost of AIDS Investment $228.326.475 Dir and Indirect Costs Prented $1 ,t94,073,296 Rato 5.2 - (1) lTh present value of bet bwestment and costs preentd Is calculated usd g 8% discount rate. (2) AIDS Cases No Intentin scenarIo asswnus 426.000 HIV infetod as ot 1991 and nw HIV infections peak In 1999. (3) AID6 Cases WIh Intervention scewao assumes 425,000 141V infted as ot 1991 and new HIV Intecdons peak In 1995. 4 Ep Model devod by Cf and Lwange used to dwelop the scea (4) Cost estimates based on preliminary stxdy by Andre Medi and Kalzo Befao based on 1989 cost data tromn Hosplad Clam o Fraga Flto In Rio de Janiro. Tota costs indie bI-paient and out-paltet ooss. (5) Dlsounted years base an Meid over , et t, mnehodology lo discownt yeas lost to present value In 1993 usIng dIsount rate of 8%, assung weage yeas bst due to AIDS orwbkdt -nd molrty of 25 years. (6) Indrect Cost PrNwetd is the sum o Dsourtd Yr mes AIDS Deat Prevened tms GNP per Capita times Percnt of Deaft bfrn Productive Seclor. x 78 Annex E Crita for Partcipation and Evalton of NGOs, and Profie of Selected NGOs I. Criteris for NGO Eligbility and Criteria for Evaluating Proposal 1. Criteria for determining eligibility: o structure of the organization; o legal sus (eg., NGOs must be wgistered in Brazil); o profile of the oganizaion and its activities; o organztion and staffing; o sources of support; o technical assessment of the NGO by municipal and state officials and its record worldng with those enitities. 2. Criteria for evaluating NGCO proposals: Technical Criteria o extent to which the proposal reflects national and project objectives; 3 l with local programs; o extent to which it addresses local needs; 3 technical quality of proposed activities; Management and Fmancial Criteria o admnstraive and managerial capacity; o acceptability and viability of cost proposal o co-financing potential; Epidemiological and Geographic Criteria o geographic distribution of pwposals (eg., undeserved areas will be given great weight); O degee to which activities would tget high incidence areas, places with high rates of rnsmission, or areas at risk of having the infecdon introduced; o extent to which project would build partnerships with other actors. EL Profile of Seleced NGOs Working In HIV/AIDS 1. NMOs exist throughout Brazil and have been at the forefront of social services for decades, especially in low income communities. AIDS has spawned considerable activism, spurred by the frution of educated Bilians hoping to prevent the spread of the disease. Since the identfication of the disease in 1983, an esimnated 120 NGOs devoted to controlling HIV/AIDS transmission have been registere with the federal 79 Annex E govemment. 2. Run largely by volunteers, these groups provide ideal vehicles for reaching potntit and acta HIVWAIDS victims. However, they suffer from a range of limitations, the most important being lack of adequate funds to support their activities. Other difficulties involve inadequate expertise of staff and volunteers, limited financial and managerial capacity and, sometimes, lack of staff. 3. Below is a short summary of the key features of 8 active AIDS NGOs. GAPA - SAo Paulo Background Data: GAPA (Grupo de Apoio a Prevenglo a AIDS) is an autonomous non-profit organization, without religious affiliation, government or paty political ideologies. Founded in 1985 to deal exclusively with issues related to AIDS. Volunteers: Approximately 50 Employees: 11; among the employees and volunteers are 2 doctors, 3 lawyers, 2 nurses, aad 3 social assstants. Estng Services: Lectures, communication courses for employees, production and distribution of informative material, oganization and pardcipation in events for AIDS, distribution of condoms. Social services for those with HIV/AIDS and their families. Includes assistance with medications, food, transport and other necessities, self-help groups, legal and psychological assistance, workshops for occupational therapy, counselling. Experience and Capacity: Help for persons with AIDS including social service; therapy; legal assistance; course to train communicators; course for employees; production of material specific to AIDS. Potential: good infrastructure compared to other NGOs. Dedicated membes and public recogniton of its work. Has accumulated experience in the area of prevention, especially in assistance. Grupo Pela Vida - Sbo Paulo Background Data: Non-profit organization witiout political and religious affiliaions. Founded formally August 1989 and expanded to Rio de Janeiro by June 1992. Its activities are essentally directed to persons with AIDS and HIV infection. Volunteers: Approximately 20 80 Annex E Employees: 2. Eaistng Sericos: Lectues, workshops for safe sex, production and distribution of informatve material. Services of assistance for persons with AIDS, HIV positives and their families: Iegal ces, counselling, organization of events for AIDS, groups for self help. Experience and Capacity: Workshops and brochures for safe sex. Good strucure wth members living with and counsllmg about living with AIDS. The group has established itself in less tan a year and has received aceptance and recogntion. GAPA - Rio Grade do Sul Background Data: Autonomous, non-profit organization, without religious affition, government or party political ideologies, founded april 1989 to deal exclusively with issues related to AIDS. Voluntees: 20 Employees: 7. Among the volunteers and employees are 7 psychologists, social workers, 2 nurses, and 1 lawyer Exsting Servkies: Lectures, production and distribution of informational material, distribution of condoms, organization and participation in events for AIDS. Experience and Capcity: Has access to general public and experience reaching high rsk groups; representing AIDS vicm in national debate; rahing the public with information; legal work; etc. Auoclagio des Pisttuas de Sergipe Background Data: Informaly founded August 1990. Non-profit organiation without politcal or ligious affiliaton, active with female prostitution mainly focusing in the areas of civil rights for prostitutes. Volunteers: 12 (2 doctors, 2 lawyers); 2000 prostitutes associated with the Employees: none Sex educaion for prostitutes, medical exanons for STDs, lectures, distribution of informational pamphlets, participation in media programs and ditibution of condoms. Services: Social services, legal services, psychological counselling erienc and Capacity. Political and socia leadershp to gain rights for 81 Annex E prostitutes through promotion of headth laws, human rights and non-violence. llost}t Superior dos Estudos da ReUlgo - Apolo Re*eso Contra a AIDS ARCA-lSER Background Data: ARCA was created in August 1987 as an internal program of ISER directed towards dealing with issues related to AIDS. Volunteers: None Employees: ISER - 120, ARCA - 4 Exsting Services: Workshops, courses, organization of events, information though the media, informaton by mail, production of informative material. Orientaion, counselling and assistce in prevention problems. Eperience and Capacity: A narrower focus enables more effective programs. Good iscture. Projects in existence are ODO-YA and Encontros Ecumenicos. Grupo Pela Vida - Rio de Janeiro Backrou Data: Autonomous NGO, without political or religious affilions, registered Sept 1989, to deal exclusively with issues related to AIDS. Has regional offices in five other Bazilian cities. Members consist mainly of persons with AIDS and HIV infection. Volunteers: 40 Employes 4. Among volunteers and employees are 3 doctors, 1 social worker, 2 lawyers, 2 nurses and 2 psychologists. Exting Services: Workshops, courses, production and distribution of material, organizatin and participation of events, consulting on behalf of workers, informaon by the media, distribution of condoms. Legal assistnce, counseling, self-help groups, social activities. Experience and Capacity: Institutional support, theater workshop, workshop for safe sex, workshop for physical expression, meetings on living with AIDS. The group has been establshed firmly in fte short period of extence. It not only characd is a self help group, but also is involved in civil and social rights activities. Has the ability to mpresent AIDS vicdms in legd deas. GAPA- BABIA Background Daft: non-profit autonomous ornzation, ithout politcal and religious affiliations, founded May 1989, dealing exclusively with issues related to AIDS. 82 Annex E Volunteers 12 Employees: 10 Exitg Services: Lectures, courses, organization and participation of AIDS related events, production and distribution of material, consulting for employees, information for the media, distribution of condoms. Also undertakes the distribution of food, drugs, clothes, rent and transport, counselling, psychological support, orientation on AIDS for the family, assistance in prevention. Experience and Capacity: Good mobilization and social penetration of the organization, good infrastructure and organization of work, good contact with other national and intional organizations. Involved with swveral projects associated with Institutional Support, AIDS and Communication, AlDs and Caring Mothers, psychological counselling, occupational therapy, publications. Projecto Esperanfa SIo MIguel Paulista Background Data: NGO linked to the catholic church, founded September 1989. Concerned with people living with AIDS and HIV infection. Volunteers: 12, 2 psychologists, 5 nurses. Employees: None Exsting Services: Lectures, courses, participation in events, and media. Provides support services by providing basic foods, drugs, clothes, other necessities, transport, social services, psychological assistance, home nurse assistance. Experience and Capacity: Good access to the community and assistance with the basic necessities of the patient at home. 83 Annex F STD Dps This annex provides details on the drugs of choice for treaing major categories of STDs, and the proposed drug therapies for use in health clbsics in Brazil under the AIDS and STD Control Project. The first table lists the drugs, dosage, total course rquired and estimated cost of the course of treatment for STDs based on etiological diagnosis. These are the most recent recommendations of the WHO's Global Programme on AIDS. The second table provides an estimate of the annual number of cases, drug quantities, and unit and total costs for an average health clinic in Brzil. These drugs will be made available to clinics in dkits" to facilitate distribution. If the prqject is successful, the number of STD visits should grow substantially, perhaps by as much as 10 fold. The actual distribution of diagnoses will become more clear as the project progresses. Thus, estimates of the actual type and amount of medication provided per kit are only rough guides that will need to be adjusted during project implementation. Table F.1: SELCTED SD DRUGS ThEATMNT COSTS BAE ON WHO RECO ____T AP _S _ _ _ _ _ Toadl Coons Codt ef Dnig Dbps DM Rout Dose Dwato p D_l ad T_etmt US$ _ _ _ _ _ =__ __ - Dm.. _____ Sypbi __ Ealy Bewzthine 2 4 nogs once 2.4 meg units .10 _ _ _ _ _ P NiQ U_ .nt _ _ _ _ _ _e S _ _weeky 3 wek 7.2 mog units 1.24 Cauganital S50,000 mu/k once _ __ variable _ _ _ _ G5o_rboe Ceflhnue 11 Oral 400 mg once 400 mg . Chalcoid. Ciproftoxacin ZI Ord S0 mg once 500_u 2.25 (or ofloxaci) I C bimydia and odher Doxycycline Oad 100 mg 2 x daily 7 days 1.4 Trichonos vagitis Mefonida_le O_al 2 g one 2 g 0.05 Cmad" Clotrimazoe I/ Intrvaga 200 mg daiy 3 days 600 mg 0.73 I .. ~~~~~~peay.I InPrgnancy Syphiis in E0yhrouycin Oral 500 mg 4 x daily 15 days 39 g 4.90 women Ciamydia Erydtoycin Oral 500 mg 4 x daily 15 days 30 g 4.90 C|ancroid Erytomycin oral SOO mg 4 x daily 7 days 14 g 2.45 * Tbese costs are drawn fom a number of lists and n WHO/SUP are prepang an authoritative List of drug costs. Adjusted tables will be nmde available as soon as possible for USe in estimaing drug costs. 11 Not on WHO Essential Drug List. x V, On WHO Essntal Drug complementary List.li Source. Core List of Essential Drugs for the Trtment of STDs,' B ound Paper No. STDJ4 of the WHO Advisory Group Meeting on STD Treatments, Februy 18-19,1993. 85 Annex F Table F.2: ESTIMTED QUTITY AND COST OF SWD TREATMENT DRUGS FOR DJIMIUTION BY HEALTH CLINCS UNDER THE ADS AND STD CONTROL PROJECTS Infecdon No. of Cam Dr| us $ costiunit Total Cost Gonorea 550 500 mg ciprolloxacin $2 $1,100 (or 4.8 million units APPO + Probenecid) 11 Chlamydia so8 SOO nig iterace z 28 $7 $4,060 Syphilis 400 2.4 milio units of $3 $1,200 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D nrthine p an 0 G_ _ _ Czanefoid 200 500 mg ciproflozacin $2 $ 400 Trichoms 100 2.0 mg atetoidale $1 $ 100 Cmdida 100.! Nystain or imWdaole $1 $ 100 Genital warts Podophylin $25 $ 100 . ___________ . _____________ 4 bottles/year Total_ _ $7,060 .=1 cost includes needls, syinges 3! actual cost of tetrccline on the glob madret should be less dtan $1 US per 7 day eatment; the $7 cost in Bgazil is excessive. -2 Tbe number of cases of trichomoniasis and cadidiasis is probably laer than showo in the estimate, but even if actal numbets are two or thuee times greater, the impact on total cost will be small. 86 Annex G Municipal EliibUty Criteria and Selection 1. The following citeria were used to determine municipal eligibility: o epidemiological profile of the population; o regional demographic profile; o size and scope of the health services network; and o management performance of existing programs. Weights on each of the four factors were used to select 41 municipalities out of the 100 that met the basic requirements. Below is the list of participating municipalities and the anticipated transfer amounts based on preliminary plans. Of the 41, 11 will receive transfers as consortiums. 87 Amnex G Table G.: MUNICIPALITIES RECEIVING TRANSFERS UNDER THE AIDS & STD CONTROL PROJECT Municipality (State) SAo Paulo (SP) Rio de Janeiro (RI) Santos (SP) Porto Alegre (RS) Sao Jose do Rio Preto (SP) Sio Vicente (SP) Sio Bernardo do Campo (SP) Ribeirio Preto (SP) GuarujA (SP) Itajaf (SC) Bel6m (PA) Sorocaba (SP) Niter6i (RJ) Guarulhos (SP) Osasco (SP) Campo Giinde (MS) Nova Igua9u (RI) Campinas (SP) Salvador (BA) Belo Hozizonte (MG) Recife (PE) Curitiba (PR) Santo Andrd (SP) Fortaleza (CE) Goionia (GO) Cuiaba (Ml) Taubat6 (SP) Floriandpolis (SC) Bauru (SP) Petpols () Juiz de Fora (MG Vitoria (ES) Sao Jose Dos Campos (SP) Sao Luis (MA) Piracicaba (SP) Jundiai (SP) Natal (RN) Presidente Prudente (SP) Joao Pessoa (PB) Londrina (PR) Manaus (AM FE I iii [fIT i1§ tu 1o8 i_ _" _ __ 8 _3 1{ 88 S K S 58 E g g - 8KE1 8 0 0 __. W _ b) _. _=P@ a 88'Ii ~~~~~~~~~~~~~~~~~~~~~~ o I l l i N o e r s N o r . d .,u . C a __ _ _ ___ Trang Aivy Cotrse Courses Ageua F4mik (OW Socidl wmet Basic uig in AIDS 80 6 60 MS MS 129.0 Nursing aids Tecicl trining in AIDS so 120 1.920 M MS/SW. 197.76 Mantal Healh profesioa CRE Tning in n and 40 9 108 MS Ms 8.S _ _ _ _ _ _ _ _ _ _ _ ~OUV cm cm ___ _ Had& pmfimio_s ffia oulladw Co _nsllg for ipatents and 40 72 8S MS MS 208.8 1~~~~~~ -_ ..-. - _ alcal Seics for 1lm! with MI/ADS Doctors and Nwses from CRNIDSI Upgrn ST dianosis and 480 . 42 bIntenai MS 338.0 Docos and Nurses nondary rod Control of STDs sod cogenta so 78 780 MS Ms 1,602.8 tertis_y can .__ ._ . . Nrsing s mand heat agets for STD contol and congal 80 56 560 MS MS 1,150.8s seoooduy and teriy cm s Doctos end nuresat ptiay cl cente LSD control and congenal s0 243 2,427 MS MS 4,847.85 Nusig and hath aget i STD control and cneni 80 173 1,733 MS MS 3,451.35 primy cau s Acquition and Dtri_ton o ndOms____ Phunsaists and exper in MS and NGOu Waehosing, control of dock, 40 3 60 TA from MS 92.4 ta spot, and regteriof in Heth srvwlae staff (INCQS and SES) Qulity Conol 480 5 TA f*om MS 40.0 . _ _- . _ - . Inir - TTmn Ad cou Coms Pai__ _ Agmey Fnds M" sesdor pvhwmb_ of Gesu & Social _skting 40 6 120 TA fiRm MS 32.6 ia ,cid NGOs & fnbd ors of -. ilona S&ior posins of st_a & Maoitor and evaation of 40 6 120 t MS 36.0 _EukHd N00 daoibua of socid b8 Inse NGO Grunts Senior MS pofesionalsGO mag Planning ad _ 40 8 60 ntemliona agemn MS 78.0 NGO pwbfesonals and AIDS volunteers Trainilgl d ip i DS so 6 6 1 _____ _______y MS 28.6 NGO prfsionalsand voluntem Intenational taiig in AIDS 8 8 8 Int tonl agency MS 14.4 N(O volteer C g aing for NGO 40 12 l08 MS MS 85.5 I___________ bries i.o pfevtm . HSV Among avonom Drug us WIg le profesms ls m IVDU wuk Pevntoa of MS 480 6 l at MS 18.0 ihr lve profesinas m IVDU wotk Moiorng prveti of IVDUs 40 2 10 MS Ms 120.0 IVDU wode Face to face IVDU conseing 40 8 240 MSJSES MS 120.0 E _ematr and S uodary School Teacheis School drug abuse prnon 40 12 360 MS/SES + SEE MS 244.8 AMDS in kheWorlae Profesiona of SES, SMS, NGO Monios im woraces 24 15 150 MSISES/SMSINGO MS 138.5 Officials, n goam dirhos wokers and Formin of itos to act in 24 190 1,520 MSISESISMSIGP MS 288.0 b!s_ _ _ _ __ pla ofwk 91 9 o~ 8 Sc h S i 4 M4 co co~~~~~~ co GO Wo,s of No. of No. of Soue Of CA_t I . T Cwrseing T us Adit q Co,e Comes hrtid.te A ymd g S|ior pS osmials in NRL Contrling blood quat 400 2 60 MS/lntn nlute MS 94.05 &.&nQd 9vdfw _ ___ ___ Sanor pmiol pro fomm MS Sureillane of HIV infti 60 2 40 MS MS 44.0 a anPedat Unes ,_ . . bmfesdob firom stnel posts eeraic Suxvelan Of HlV infctiom 40 70 4 SES MS 16.67 lab_nwe Seior edio_y pofssab fom MS AIDS eidogal sur_eIllane 24 2 60 SES MS 30.0 nd Fedea Uni y I_I_ I I I I I urv Serllame of SrDs, Sypi, and STD hfmal_ Systm Stdo coe_lrdningtm for AM/S1 9 anagenift Usining for STD md24 I 54 Ms MS 68.85 Team fiom PNC-DADS Use of palit flow mlyss m 20 8 I MS Intrat 10.98" S1D dhs __ hiw _ Teams fro PBC/SD Us of pedt low WAlysis 40 1 S4 MS MS 26.6 T|= fTan dto HV/SMh _ siles Use of pait flow anlsis 24 27 S40 SES MS 33.6 heacto betwm NW Ifedl. and Tuborads_ls Seawor ad W SES ii Tned_ of V/M infectIs 40 20 600 s MS 624.0 Saor pofeinabs Taing iwors for 40 2 30 MS MS 142.5 S pthmsionals and _OOWbwsm of BodEmicio_icat smvemw of 40 2 60 MS MS 563S8 stat promgu in STD and TB ool IIVmTB infections FJatmv Rsdoa o On AiDS Epidm _ Smniorlsvel fzomM8,SES jlnsrvleranngnh.sof I o 2f isi Study Cantr Ms j 3. senorlod oossontsfim s,Smdsis =_ _Ioa ands de "Raab......... . . 1nit , , ,,-, 1, Z,,,,S i,d =odd I , ,, 93 Anne I LIST OF PLANNED REFERENCE CENTERS: LABORATORY AND TRAINING Biomanguinhos and Advanced laboratory of Public Healti Rio de Janeiro. Oswaldo Cruz Institute - IOC/FIOCRUZ Rio de Janeiro Adolfo Lutz Institite Sfo Paulo/SP Federal District Healtfi Institute Brailia-DF Raphael de Paula Souza Hospital CuricicaR Nattonal Institute of Healti & Quality Control - INCQS Rio de Janeiro MACRQltR1GIONAL 1 RBPEREC D Evandro Chaas Insttute-FNS, Belwm/PA Amauri de Medeiros Healft Foundation (FUSAM) Central Labonrty of Public Healtfi - SUS, Recife / PE Public Health Labortory, Goncalo Muniz Invesdptigon Cte/FIOCRUZ and Central Public Health Laboratory-SUS, Salvador/BA Federal District of Health Institute - SUS, BrasilialDF Ezequiel Dias Foundation - FUNED-SUS, Belo Horzonte/MG Noel Nutelz Public Heali lAboratory - SUS, Rio de JanmoW Adolfo Lutz Instiut - SUS, 51o Paulo/SP Institute of Biological Investigadtion - SUS, Pot Alegre/RS 94 Anne I LOCATION OF NATIONAL REFERENCE CENTRES ON VIIVAIDS Professor Clemeatino Frgap FiLho Hospital end Universty of Rio de Janeiro, Rio de JaneiroRIR Professor Gaff&ee e Guinle UNIRIO, Rio de Janeio/RJ Emilio Ribas Institute of Infections Secrtary of Stae of Health in Sio Paulo, Sb PauloISP Maternal-Child Institute of Perambuco, Recife/PE Fenandes Figueira Institute/PIOCRUZ Rio de Janeiro/RJ Clinical Hospital of Porto Alegre Fedeal University of Rio Grande do Sul Porto ALkre/RS F1o | l- | | l ~ ~~g .5 a0 aI' fu giiir g I; 0L 96 Annex J 3RAZOL~ AIDS AND STD CONTROL PROJC OrganzatiDGal Chart of the Mistry of Health r Minister of - I . . lX~~~~~~ealth 8NAS | Chief of Cabinet r1 - Nationa AIIDS and STD Controt P am ( PI CAESA ca-7s 97 Anne K BRAZIL AIDS AND STD CONTROL PROJECT MONrTORING AND IMPACT MNDICATORS 1. Two sets of indicators will be used to monitor project implementation and assew project impact: xmitoring or "intermediae output" indicaors and final outcome (or input) indicators, 2. Monitoring Infteedate Output) Indicators. Tho fit set of indicaton in Table I measure tne physical execution of project acdvities. Spedficaly, they would be used to compare action taken against actions progmammed. 3. Final Outome InIdkators. The second set of indicators provided in Table 2 measure the "final outcome" of the project in tms of impact on health, behaviar and institutional strengthening. Some important indicators are listed below. Many of the indicators wl requie baselie surveys, aganst which to measure project impact trough a later follow-up Isurvey. Tabl . BvaD: AIDS and rD Contol Wrqet indlcatos i 1 TOW _ _ _ _ ___ Yowl Year2 Yar3 Year4 {70mpont A. Pgevention EEC Caipakm # mpaigs luhed 1 1 2 2 Ting and Co _eig Cents (COAS) # COAS iniplanuted 20 20 45 40 Condoms PmearauenuaDbisIbutl # codoms distributed (millios) 15 1S 30 30 Clommunty Outreach/Ph'ventlo # behvioml intvetion proects ppmord 20 22 42 43 # indeedent poects ogand 6 6 24 36 NGO hoines oranied 4 4 8 8 suwveys, canS and fbrmaive studies 3 4 8 7 Pklevtion among IVDUS # studies undetake (epiant/bi wv) 4 5 2 # cass de spoio establse I 1 2 2 # litu bleach distibuted (milions) 3 3 6 6 AIDS in the Workple # NGO pojects inidated 5 5 10 5 I business/comnty proecs initiad 1 2 2 .- -. - -. 98 Annex K Table 1. Bradl: AiDS and SID Control Pject !uunplenetalst Schedlde/MolItorIng Incdkcaors 1/ Targets ____________________. _______ _ Y ar I Year 2 Year 3 Year 4 HIV/AIDS Treatment # SOSs implemented 5 5 27 5 A Pay Hospital established S0 S0 |SD Treabnt # new pnimary centers 30 30 80 76 # now seondary centers 12 13 20 19 # new refere cente"s 10 10 20 24 # new secondary refes-ence centers Commudty Outeach 2 3 s s # cas de apoio establisbed 5 S 20 20 # community projects initiated I 1 2 2 # reearch projects initiated 12 12 25 25 j X~~mponent Q-'gd,d INX4MMIt DreDc and Indir Cests indirect cost study completed mtetodology developed for AIDS cost-benefit analyis 1 National cost-benefit study completed # hospital cost tracwing tems set up I Reerene L6oratories 9 9 # reference laboratories established 4 4 # macroregional reference labs established 4 4 Blood Supply # blood centers establishepded 1 2 # prevalence and other sudies 3 16 0 TtaiIng 4 6 Y of higher level laboratory profssionals trained rAMMoneM 1). Snedlbnce HIVIAIIS SurveiLanoe # suveillance systems implemented in sentinel posts 40 10 # surveillance systems implemented in sentinel labs 10 10 SrD Swveillance # sveillance systems implemented in treatment centers 105 195 # partner notification systems implemented in treatment centes 105 195 # HIV/SI'D ceotres using PPA software 105 109 EvrrB # stdies initiated 5 5 10 10 A couselors trsined 30 30 60 60 w state level profesdonals trained 100 110 210 180 # iuct. pamphlets printed/distributed 5,000 5,000 25,000 25,000 AIDS/V FPJections # studies to develop emprica models initiated 2 99 Annex K Table 1. Brazil: AIDS and SrD Cnol Pkject Impaentaton ddIndtm 1/ j Year I yewzYea I 3 Yew 4 M toinldicttnd s for use by Comnity Pres V/ D of talk given # of couses given by Wains to commuties & of educaotoa marials produced # of condoms distributed to designated poesons # of AIDS hoties ornized I of AIDS boine telephone calls received of sa organized I of peraons counseled I of education camwaigs wtken # of basic food baskeht distributed # of drugs distibuted I of clothing and other goods ditibuted # of rasot fiunished # of csas de apoio establisbed of hou Visits Mde U of houe and hoital visits made # of counelings and refenals to AIDS services made # of psychological counseling seions provided # of lel oumseling sessiDons provided # of self help groups organized # of recreional activides orgized # of counseling ssions for beatmts provided ,LI TI following tables reflect only dte major project actities. A _ v impletion schedule is available in the proect file. Progress in ptrect impl_ eation will be msurd inst the tare dwn inu thes ables. Targes may be modified in the coumse of proect impdemeion I/ Targets to be specified during poe implIea. Note: A sewate Tnining Plan is included as Anex H. 100 Annex K Table 2. Brzil AIDS and STD Control Project Final Outcome/Impact Indicators * A. p IEC Campaigns % of persons in 15-49 year age group cidng 2 or more acceptable means of self- protection from HIV infecdon % of sexually active persons in 15-49 year age group stating that they have had sex with one person who is not their regular sexual partner % of persons at risk of HIV infection stating they used a condom during their most rcent sexual inecourse AIDS in the Workplace % of tained employees who have agood grasp of the basic concepts of AIDSIHV and SM tansmission % of trained persons willing to work with persons withE HIV/AIDS % of trained persons who know how to live corectly (conviver coretamente) with HIV positives % of large and medium businesses offering AIDS education in the workplace Intravenous Drug Users (IVDUs) % of recovering users stating they used a condom in their most recent intcourse with their a) principal sexual partner, and b) last sexual partner % of recovering users who are also prostitutes and who state they used a condom in ter most recent sexual intecourse with a client % of users who know where to obtain free clean synnges % of users who did not share a syringe on the previous day % of users who know where to obtain free bleach * Adeoiaks reflect kdey ndhcato for mmnorng. 101 Annex K % of users who visited a cm de apoio or other project supported location/group at least one dme % of (casa de apoio) clients who state they ae satisfied with the services provided COAS % of persons receiving pre-test counseling who subsequently are tested % of persons who are tested % of persons who are tested who seek the results % of COAS clients who receive condoms % of COAS clients who state they used a condom during their most recent sexual intercourse % of HIV positive cients who klow the location of support seices for HIV positive individuals % of persons receiving post-test counseling who acually visit the institutions to whom they are referred % of persons assisted by institutions supporing HIV positive perons who learned of their HIV positive stats fom a COAS decline in number of people tested at blood banks Condom Procurement and Distribution % of free distribution locations which did not run out of stock in the previous month % of locations selling subsidized condoms which did not run out of stock in the previous month # of condoms sold at subsidized or market price % of condoms distnbuted for subsidized sale which were actually sold * Asteddsds seflect key indicats for moitg. 102 Annex K % of persons engaging in high risk behavior reporting condom failure during the previous month % of persons stating they are satisfied with condom quality Mean retail price of condoms % of persons stating they are satisfied with the availability of condoms % of persons who state that the price of condoms is accessible % of persons who state they purchased the condoms they needed in the previous month B. Sendioes Clinical Services for AIDSISTDS # of centers with 3 fully tmined full time physicians # of centers with 1 fully trained full time nurse # of centers with 4 fully trained full time auxiliaes de enfermagem (nurse assistants) # of centers with 2 fully trained full time health agents % of centers with regular case notification % of cases notified, by centers implemented by the project, which are treated % of cases notfied, by other centers, which are treated % of patients who seek follow up treatment ( a. for prcject centers and b. for other centers) % of patients who can cite 2 ways to avoid AIDS % of patients stating that they used a condom during their most recent sexual inteourse * AsterAsks reflect key incatowi fbr mnitoi. 103 Annex K % of patients in the project implemented centers who state they receive adequate counseling and services % annual increase/decrease in demand in the centers implemented by the project in 1993, 1994, and 1995 Clinical Services for HIV/AIDS # of users of SOS # of SOS users referred by COAS overall and per capita cost of SOS frequency of hospital use by HIV/AIDS patients # of fully staffed SOS, and # of users/staff in each % reduction of the TMP (by group of origin) in locations with SOSs in contwst to locations without SOSs % of the locations with SOSs which fully apply standard treatments (aplicando plenamente as normas terapeuticas) % of the locations without SOSs which fully apply standard treatments (aplicando plenamente as normas terapeuticas) size and nature of increase in average special drug consumption by AIDS patients (in relation to 1993) Community Outreach for Treatment Services # of support groups established and functioning C. Institutional Delopmn Trining * 9i% of persons trained, in all areas, still worling in AIDS or STDs: a) 6 months later and b) 2 years later * AteAsks reflec ky ixdcatoi for montorng. 104 Annem K % of pons trained stating that the training was useful to their work Reference Laboratories % of Reference Labs and Macroregional Reference Labs eaperiencing a shortge of reagents in previous 3 months # of LtN and LRMR furnishing epidemiological data on HIV and STDs average number of days to notify client of test results % of labs with 100% proficiency of tests * % of labs with 80% proficiency of tests * % of labs with 60% proficiency of tests Blood Supply/Quality Control % of units which undertake HIV prevalence studies among donors % of units where 80% of HIV positive cases or SID cases are monitored % of reference labs and unidade hemoterapicas that do triage and quality control of blood and reagents % of transfusion recipients who develop 11V, syphilis or hepatitis B Costs and Indirect Costs same as per monitoring (see implem.sched/monitoring indicators) D. Epidemiological Surveillance Epidemiological SurveifLance/V-AIDS * # of HIV, STD and TB cases reported by state X % of AIDS deaths which were previously notified as AIDS cases * AAtedsks rflect key i&dicatos for mtng. 105 Annex K % of AIDS case notifications made during the same year that the case was diagnosed % of monthly state bulletins published on time (within 4 weeks of date) % of montly epidemiological bulletins (informes) published on time (within 4 weeks of date) % of HIV prevalence studies completed and quality of those studies Epidemiological Sutveiance/ STDs % of cases notified that receive treaent % of cases treated that are treated with the appropriate drugs average number of days between appearnce of STD symptoms and seeling of treatment aveae number of days between appernce of STD symptoms and final diaposis average number of months between day examined and the day of notification averge waiting time (minutes) for medical exam number of atnding units which utilize patient flow analysis (PFA) sIV and Tuberulosis % of TB patients taing voluntary HI-V test % of persons who received the complete training in HIV/TB who are still woring in this area a) 6 months later and b) 2 years later % of persons trained stating that the taining assisted them in their job % of prposed studies in execution Projections * Aseridwkd ioflect key indicaton8 f mitoring. 106 Annex K estblishment and use of models developed for estimating conventional and non- conventional indicators of AIDS dsk E. gCenoa Impat Indicators Epidemiology * estimated prevalence of HIV infection among pregnant women, 15-24 year age group * estimated pwralence of syphilis infection among pregnant women, 15-24 year age group estimated incidence of genital ulcers and urethritis among patients in STD chnics % change in incidence of genital ulcers and urethritis among patients in STD clics incidence of congenital syphilis in the general population % of recipients of blood and blood derivatives who develop HIV, syphilis or hepatitis B Behavior % of the population 15-49 citing 2 acceptable ways to avoid HIV infection % of women 15-49 at risk or with a partner at risk who "always" use a condom % of women 15-49 at risk or with a partner at risk who used a condom during their last sexual intercourse % of the population that kmows its HIV status and/or knows the risk behaviors of their regular sexual partner % of those who know the risk of infecton, who always use a condom, or who avoid sex with a partner who is HIV positive and/or who engaes in high risk behavior * Asterisks reflect key indicaton for mtoing. 107 Annex K % men 10-19 who do not begin engaging in high risk sexual behaviors (either by not engaging in sexual relations, always using a condom, or remaining monogamous with a partner that does not engage in high risk behavior) % women 10-19 who do not begin engaging in high risk sexual behaviors (either by not engaging in sexual relations, always using a condom, or remaining monogamous with a partner that does not engage in high risk behavior) % of adolescents 10-19 who do not begin using intravenous drugs % of men, practicing anal sex with male partners, who always use a condom % of men, practicing anal sex with women, who always use a condom * # of condoms sold in the country (fonnal market) Community Outreach % of the target/survey population that always uses a condom except with the regular sex partner % of the target population that uses a condom sometimes or always, except with the regular sex partner % of the target population that knows their HIV status and or the risk behaviors of their regular sex partner % of the target population that uses condoms or avoids sexual relations with a partner who is HIV positive and/or who engages in high risk behavior Treatment and Quality of Life % of persons with AIDS who survive longer than (a) 6 months and (b) 2 years after diagnosis % of HIV positive children or children of mothers with AIDS, without ote family support, who are cared for in casas de apoio % of HIV negative children in casas de apoio who are reintegated with their family or adopted * JAterks reflect key indicators for monitoring. 108 Anmex K % of HIV positive persons who maintain a job after diagnosis is revealed to the employer % of persons with HIVVAIDS who feel discriminated agaist in school or at work % of HIV/AIDS patients who believe treatment seices are adequate % of labs and blood supply units funcdoning fuly and adequately * % disctepancy between lab results and surveillance data % LRE with proficient systems % of COAS and clinics with zero suppressed demand for laboratory diagnosis for specific populatons in the geographic area % of public labs and public blood bank with Quality Control (CC) panels in adequate use % of private labs and public blood supply units (setor produtivo e usuario) with Quality Control (CQ) panels in adequate use % of blood donated under guidelines Quality Control guidelines * Aerisk ,eflkot key indicto for mm A iI- A A }0 igAi V A V i b! t#!irF o N - _ m- .0 t l_ VA VVA| t X~~~ XU221 110 Annex M BAR AS AND $IM COEIOL PROQC 11 Da$BWA3MS CAOR1E AND- PERC13N rM} Disbursement ya~gQr~ Amount - 1. Equipment 25.4 100% of foreign expenditues and 100% of local expendiures (ex- fatoy cost); 2. Labortory Supplies: foeign 56.4 100% of foreign expenditre; local 16.2 local ewendit made on or before June 30, 1997: 100% up to an aggregate amount equivalent to $3,140,000; and 50% with respect to the remaining amount; 3l. Condoms: foreign 8.8 100% of foreign expenditures; local 2.0 local expenditures made on or before June 30, 1997: 100% up to an aggregate amount equivalent to $3,600,000; and 50% with respect to the remaining amount; 4. Drgs: foreig 1.0 100% of foreign expendiures; local 11.0 local expenditures made on or before June 30, 1997 100% up to an aggregate amount equivalent to $9,300,000; and 50% with respect to the remaning amount; 5. nsbtional Mateials 4.2 local expenditu made on or before June 30, 1997: 100% up to an aggregate amount equivalent to $3,140,000; and 50% with respect to the remaining amount; 6. Technical Assistance, Research and Project M g t 7.8 100%; 7. Thining 17.2 100% up to an aggate amount equivalent to $12,600,000; 50% up to an agpgegate amount equivalent to $16,200,000; and 25% with respect to the remaining amount. 111 AnnexM 8. Unallocated 10.0 rotal 160.0 Estimated IBRD ,Diasbursmet Bank Fiscal Year 1994 195 n2 -$US Millio_o- Annual 35.5 35.5 35.5 35.6 35.7 Cumulative 17.7 53.2 88.7 124.2 160.0 112 Annex N Table N.1: Brad AIDS and SlD Cono Plojec Sunna Aconts by Yar With Contn " CM) ____________ _ rYear l Year 2 Year 3 year4 Total A. Pmention Testing/Counseing Cente 3,466 12,491 17,592 3,466 37,015 Condomns 3,527 6,338 7,352 3,527 20,744 Community Outech 1gv. 692 2,653 2,714 692 6,751 IV Din Use8r 1,156 2,4 3,314 1,156 8,471 Behavior Chag 1,476 3,067 3,243 1,476 9,261 AIDS in the Wodkplace 976 1,831 821 976 4,605 I'f o/EduclCommunicaioD 2,549 5,296 S,500 2,S48 15,894 SubTotal 13,842 34,521 40,536 -13,842 102,742 B. Sevices Clincal Sevices - AIDS 2,261 7,927 10,606 2,261 23,055 Clnieal Serices - SgmS 6,780 16,742 27,234 6,780 57,536 Community Outreach Service 386 I,500 1,723 386 3,995 Sub-Totd 9,427 26,169 39,562 9,427 84,586 C Iutiona DevelopmIn Rdefeence Laboratories 4,153 5,936 6,164 4,153 20,406 Truaing 1,687 3,488 3,458 1,687 10,320 Tesing and Blood Supply 3,034 884 1,278 3,034 8,229 Costs ant Indibre Coadt 420 67S 511 420 2,026 Project Supevision 811 1,685 2,148 811 5,455 Sub-Tota 10,104 12,669 13,559 10,104 46,437 D. Epidi Sureilnc Smeninld Swveilanco 436 907 942 436 2,723 dsn4aioogicl Surveillance 1,750 3,643 3,789 1,750 10,933 HIVftB Iteaction 321 588 572 321 1,804 Prodectons of AIDS 214 190 IS3 214 771 Sub-Total 2,722 5,330 5,458 2,722 16,232 TOTCAL PROJECr COSTS 36,096 78,689 99,116 36,096 250,000 of which-_ Fog Exchange 19,866 47,244 63,338 19,866 150,314 113 Anme N Table N2: BraD AIDS and 5D Contol Prjet "adc Components by Year, Base Cost ('C0) YearI yew2 Year 3 Y u.4 Total A. Prevention Testing/Counsellng Centers 3,290 11,327 15,307 3,290 33,215 Condoms 3,420 5,900 6,600 3,420 19,341 Community Outreach Pev. 64S 2,380 2,345 645 6,017 IV Dmg Users 1,113 2,625 2,938 1,113 7,789 Behavior Chanm 1,380 2,760 2,810 1,380 8,330 AIDS in the Wokplace 913 1,647 71S 913 4,188 Info/Educ/Comunnication 2,500 S,000 5,000 2,SOO 15,000 Sub-Totd 13,262 31,641 35,715 13,262 93,881 B. Services Clncd Services - AIDS 2,145 7,219 9,259 2,145 20,767 Clinic Services - SMDS 6,344 15,072 23,595 6,344 S1,356 Community Oubreach Serv. 360 1,350 1,490 360 3,S60 Sub-Totd 8,849 23,641 34,344 8,S49 75,683 C Institutional Dvelopment Rdfernce Labofaories 3,943 5,327 5,327 3,943 18,540 Training 1,576 3,137 2,994 1,576 9,281 Testig and Blood Supply 2,970 779 1,064 2,970 7,783 Costs and Indrect Costs 395 607 443 39S 1,840 Project Superision 758 1,515 1,860 758 4,890 Sub-Total 9,641 11,365 11,687 9,641 42,334 D. Epideaiologied SurveiH Sentind SurveUlance 408 817 817 407 2,449 Epidemiological Surveill 1,641 3,286 3,291 1,641 9,859 i ImvnB interacion 301 532 498 301 1,632 Projecions of AIDS 203 171 131 203 708 Sub-Totd 2,553 4,805 4,736 2,553 14,647 TOTrAL BASELINE COSTS 36,096 71,452 86,482 34,306 226,545 Physical Continagnies 1,099 2,836 3,621 1,099 8,6SS Price C(oi ingecies 690 4,402 9,013 690 14,796 TOTAL PROJCTS COSTS 36,096 78,689 99,116 36,095 250,000 Forign Echange 19,866 47,244 63,338 19,866 150,314 114 Annex N Table N.3: DrauJI AIDS and SlI) Control Prject Summay Aecounts by Year With Contingenci ('000) Yuur I Year 2 Year 3 Year 4 Total L hnstment Costs Civil Worlc 68 167 200 68 505 EIpmen 7,020 6,510 6,538 7.020 27,089 Vehicles 980 1,635 1,722 980 5,317 Trining 3,910 9,519 9,926 3,910 27,266 instuctional Materias 931 2,419 2,422 931 6,705 Teohical istance 590 1,139 1,052 590 3,371 Research 581 1,241 1,288 581 3,691 IIC 2550 5,296 5,500 2550 15,894 Project Managemet 193 400 416 193 1,201 Total Investent Costs 16,822 28,329 29,068 16,822 91,042 H. Recurrent Costs SUpWrviion 836 1,743 2,221 836 5,636 Maintenance 222 1,375 2,197 222 4,016 Laborakty Supplies 8,816 30,720 47,002 8,816 95,354 Drugs 4,515 5,377 5,775 4,S15 20,182 Condoms 2,666 5,540 6,545 2,666 17,417 Other Supplies 837 2,263 2,902 837 6,840 Operating Costs 1,381 3,342 3,404 1,381 9,510 Tota Recurnt Cost 19,273 50,360 70,048 19,273 158,955 TOTAL PROJECr COSTS 36,096 78,689 99,116 36,096 250,000 Forign Exchange 19,866 47,244 63,338 19,866 150,314 VENEZUELA COLOMBIA \ A M P COtOMBIA ''< i'n \dtQGU UYANA' )GUIANU ' AMA S -~~t7 ARI GRANE DONORTEINA -o5l N.W~~~~~~~~~~~~~~~0 Bein Pa ve CR~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~vv Pacific~ e Stat <@-Uuur;Mbde Capialy_saont ROND6NA SERGN Stt Bou9dariem Ocean ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~T Cc pi IternatonalBd dre ARGENTINA 0 sns~s SNTOBeri Pav00 40. ~ ~ ~ ~ ee.*.in0Una0o 20'~~~~~~~~\ Under A5st u198