40649 The World Bank's Global HIV/AIDS Program of Action December 2005 THE WORLD BANK'S GLOBAL HIV/AIDS PROGRAM OF ACTION Copyright © 2005 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington, DC 20433 USA All rights reserved Manufactured in the United States of America If you have any questions or comments about this product, please contact: The Global HIV/AIDS Program The World Bank 1818 H Street NW Washington DC 20433, USA email: wbglobalHIVAIDS@worldbank.org Website: www.worldbank.org/aids CONTENTS Foreword v Acknowledgments vii Acronyms and Abbreviations ix Executive Summary 1 Introduction 8 PART 1: Overview 11 HIV/AIDS Today: Continuing and Emerging Challenges 13 An epidemic in transition 13 Continuing challenges 15 Emerging challenges: new issues for a changing epidemic 20 Notes 24 HIV/AIDS and the Bank: The Story Thus Far 26 Experience in analysis and policy advice 27 Experience in financing and supporting implementation 28 An uneven record 28 The Bank's comparative advantages 29 Diversity and commonality across regions 30 Notes 31 PART 2 33 The World Bank's Global HIV/AIDS Program of Action 35 Strengthening strategic, prioritized responses 36 Funding national and regional HIV/AIDS responses and strengthening health systems 37 Accelerating implementation 40 Strengthening country monitoring and evaluation systems and evidence-informed responses 41 Knowledge generation and sharing, impact evaluation and analysis 42 Working together 45 The broader perspective 46 Notes 47 iii Matrix 1: Global AIDS Program of Action--Matrix of Goals, Actions, Timing and Accountability 48 Appendix 1: Regional HIV/AIDS Strategies, and IFC and WBI HIV/AIDS Initiatives 51 Appendix 2: Country-Level HIV/AIDS Data 61 Figures 1. Estimated financial needs, commitments and disbursements 22 2. Cumulated new AIDS commitments, fiscal years 1989­2005 26 iv The World Bank's Global HIV/AIDS Program of Action FOREWORD The world has been fighting the relentless oping countries by 2005 has sparked march of HIV/AIDS for two decades now. momentum across the world to fight While there have been significant victories in HIV/AIDS. But there is still a long road Brazil,Thailand, and Uganda in turning back ahead. Today, about one million people in the disease, it continues to infect more peo- low- and middle-income countries are re- ple every day, and further strain the ability of ceiving treatment--more than double the governments to care for, and treat, the mil- number since the end of 2003--but it is still lions already suffering from its debilitating far short of the target and far short of the effects.Today there are more than 40 million need.With increasing numbers of people on people worldwide living with HIV/AIDS. treatment, AIDS is becoming a chronic dis- Over 15 million children--more than the ease, requiring long-term solutions and total number of children in France or Ger- sustained financing. It is also placing an ad- many or the United Kingdom--are orphans, ditional burden on the ability of health sys- their parents taken from them at the most tems to deliver the required services. vulnerable point in their young lives. But there is renewed hope as the world's re- Global efforts to reverse the spread of sponse to the epidemic enters a new phase. HIV/AIDS face a mixture of long-standing, We can see an unprecedented outpouring as well as newly emerging challenges in de- of resources, significant advances in the veloping and implementing sound strate- costs and science of treatment, and more gies to fight the disease. Even though effective `tried and true' lessons in preven- HIV/AIDS is a household word every- tion and treatment. AIDS is now acknowl- where, discrimination, denial, and silence edged as a central long-term development persist. issue backed by growing political commit- ment. It is an opportune time to take stock, I will never forget the woman in Nigeria who and do some careful strategic thinking-- told me"the stigma killed me before the dis- with our key partners and stakeholders-- ease."She described how she lost her job,her on the future direction of the Bank's work family, her home and her will to live after on AIDS. contracting HIV/AIDS from her husband. Fortunately, she regained her will to live This Global HIV/AIDS Program of Action from a remarkable support group for similar describes how the World Bank Group will victims of the disease.But it is important that work over the coming three years to she receives the treatment she needs to sus- strengthen the response to the HIV/AIDS tain life itself. And AIDS is not just an epidemic at country, regional, and global African epidemic. I heard similar heart- levels, through lending, grants, analysis, rending stories in China and India. Indeed, technical support and policy dialogue. The throughout the developing world, the com- Program links global and national efforts bination of AIDS and extreme poverty com- and builds partnerships with civil society, pounds the tragedy. and people living with HIV/AIDS. It builds on the"Three Ones"principles, agreed with The international `3 by 5' target to provide our development partners, which call treatment to three million people in devel- for one national HIV/AIDS authority, one v national strategic plan and one monitoring lives, and millions of children, so heart- and evaluation system lessly orphaned by the disease, being prop- erly cared for. There is an urgent need to do more and to do it better, so that the results of our efforts Paul Wolfowitz can be counted in millions of infec- President tions prevented, millions of people with World Bank HIV/AIDS living more productive, healthy November 2005 vi The World Bank's Global HIV/AIDS Program of Action ACKNOWLEDGMENTS Many people contributed to the develop- International), Joep Lange (University of ment of this program of action, and all are Amsterdam), Jeff O'Malley (PATH, India), thanked for generously sharing their time, Babatunde Osotimehin (National Action experience and thoughts. The regional Committee on AIDS, Nigeria) Nancy Padian HIV/AIDS focal points commented on vari- (University of California), Elizabeth Pisani ous drafts of the outline and text, and their (Family Health International), Peter Piot contributions were especially important in (UNAIDS) and Michel Sidibe (UNAIDS), shaping our thinking. A series of consulta- and for the many valuable insights we re- tive meetings were held, with the regional ceived from other representatives of UN- HIV/AIDS focal points in April 2004 and AIDS and its cosponsors (UNICEF, UNFPA, with an expanded group of Bank staff in UNDP, UNODC, UNHCR, UNESCO, ILO, September 2004.The first draft of the action WFP, WHO), other international organiza- plan was developed in January 2005 at a tions, bilateral and multilateral donors working meeting in Cuernavaca, Mexico, (United States Government, DFID, GFATM, and subsequently revised in the light of Government of Norway), governments of many constructive comments and sugges- recipient countries, faith-based and other tions, including from the HD Council. We civil society organizations, PLWHA, inter- especially thank the participants at a Con- national and national NGOs, foundations sultative Meeting in Washington DC, on and research institutions and the private May 17th, 2005, (several of whom travelled sector. long distances) who took time to read the document carefully and provided rich com- In alphabetical order, we thank the follow- mentary and input that helped shape the ing World Bank colleagues: Anabela Abreu final draft. (SAR), Olusoji Adeyi (HNP), Martha Ainsworth (OED),Yaw Ansu (AFTHD), Eliz- This Program of Action was discussed at a abeth Ashbourne (AFTHV), Jacques technical briefing for the World Bank Board Boudouy (HDNHE), Donald Bundy of Executive Directors on August 25th, 2005. (HDNED), Shiyan Chao (ECA), Mariam Speakers strongly endorsed the Program of Claeson (SAR), Kevin Cleaver (ARD), Cas- Action and asked Bank staff to present a plan sandra de Souza (AFTHV), Shantayan De- for its implementation to the Board (sched- varajan (SAR), Pamela Dudzik (HDNSP), uled for early January 2006). Ann Duncan, Sabine Durier (IFC),Armin Fi- dler (ECSHD), Paul Gertler (HDN), Keith We are very grateful for the input we re- Hansen (LAC), Roert Holtzmann (HDNSP), ceived from our external partners: Sakyi Evangeline Javier (LCSHD), Emmanuel Amoa (Ghana AIDS Commission), Stefano Jimenez (EASHD), Kees Kostermans (SAR), Bertozzi (National Institute of Public Nicholas Krafft (HDNVP), Patricio Marquez Health, Mexico), Suma Chakrabarti (DFID), (ECA), Nadeem Mohammad (AFTHV), Mark Dybul (PEPFAR), Robin Gorna Mary T. Mulusa (LAC), Adyline Waafas (DFID), Michel Kazatchkine (Ministry of Ofosu-Amaah (PREM), Patrick Osewe Foreign Affairs, France), Ricardo Kuchen- (WBI), Egbe Osifo-Dawodu (WBI), Isabel becker (Hospital de Clínicas de Porto Ale- Roche Pimenta (WBI), Sandra Rosenhouse gre, Brazil), Peter Lamptey (Family Health (SAR), Fadia M. Saadah (EAP), Jean-Louis vii Sarbib (HDNVP), Andreas Seiter (HNP), Program team for this effort was led by De- Bachir Souhlal (MNA), Susan Stout (OPCS), brework Zewdie, Director, Global HIV/AIDS and RudyVan Puymbroeck (LEG). Program, and included: Rene Bonnel, Jonathan Brown, Joy de Beyer, Phoebe Fol- The Program of Action was prepared under ger, Joan MacNeil, Elizabeth Mziray, Esra the guidance of Jean-Louis Sarbib, Senior Pelitozu, Joseph Valadez and David Wilson. Vice President and Head of the Human De- Support was provided by Ruth Kariuki and velopment Network. The Global HIV/AIDS Fatima-Ezzahra Mansouri. viii The World Bank's Global HIV/AIDS Program of Action ACRONYMS AND ABBREVIATIONS ACTAfrica AIDS Campaign Team for Africa (World Bank) AIDS Acquired immune deficiency syndrome ARD Agriculture and Rural Development Department (World Bank) ART Antiretroviral therapy ARV Antiretroviral drug CAS Country Assistance Strategy CSO Civil society organization CST Country Support Team DEC Development EconomicsVice Presidency (World Bank) DFID Department for International Development (U.K.) EAP East Asia and Pacific region ECA Europe and Central Asia region ESW Economic and sector work FBO Faith based organization GAMET Global HIV/AIDS Monitoring and Evaluation Team (World Bank) GFATM Global Fund to Fight AIDS,Tuberculosis and Malaria GHAP Global HIV/AIDS Program (World Bank) GTT Global Task Team on Improving AIDS Collaboration Among Multilateral Institutions and International Donors HDNED Education Team (World Bank) HDNSP Social Protection Team (World Bank) HIV Human immunodeficiency virus HNP Health, Nutrition and Population Team (World Bank) IAS Implementation Advisory Service IBRD International Bank for Reconstruction and Development IDA International Development Association IDF Institutional Development Fund IDU Injecting drug user IEC Information, education and communication IFC International Finance Corporation ILO International Labour Organization IMF International Monetary Fund JSDF Japanese Social Development Fund LAC Latin America and the Caribbean region LEG LegalVice Presidency (World Bank) M&E Monitoring and evaluation MAP Multi-Country AIDS Program MDG Millennium Development Goal MNA Middle East and North Africa region MSM Men who have sex with men NGO Non-governmental organization OED Operations Evaluation Department (World Bank) OPCS Operations Policy and Country Services (World Bank) PATH Program for Appropriate Technology in Health ix PEPFAR President's Emergency Program for HIV/AIDS Relief PEP Private Enterprise Partnership Program PLWHA People Living with HIV/AIDS PLWA People Living with AIDS PREM Poverty Reduction and Economic Management Network (World Bank) PRSP Poverty Reduction Strategy Paper SAR South Asia region SW Sex Workers TB Tuberculosis TF Trust fund TTL Task Team Leader UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session UNHCR Office of the United Nations High Commissioner for Refugees UNICEF United Nations Children's Fund UNODC United Nations Office on Drugs and Crime WBI World Bank Institute WFP World Food Programme WHO World Health Organization x The World Bank's Global HIV/AIDS Program of Action EXECUTIVE SUMMARY We have made a good start, but . . . we Operations Evaluation Department (OED) are only at the beginning of the efforts provided useful input.1 Discussions within that we really need to make on AIDS. the Bank, especially with regional HIV/AIDS The World Bank --James Wolfensohn focal points, managers and Task Team Lead- ers as well as with stakeholders outside the is committed to The World Bank is committed to long-term, Bank have led to a consensus on the priority long-term, strong support for comprehensive national actions in the Program of Action for the next strong support HIV/AIDS responses for effective preven- three years. tion, care and treatment, and mitigation.The for Bank works closely with client countries and comprehensive other development partners, including civil AIDS today: Continuing and national society and people living with HIV/AIDS emerging challenges HIV/AIDS (PLWHA).This Program of Action describes the steps the World Bank will take over the AIDS has been called "an unprecedented responses coming three years to strengthen the Bank's crisis . . . that demands an exceptional re- response to the HIV/AIDS epidemic at sponse".2 More than 40 million people are country, regional, and global levels, through now infected with HIV, over 20 million have lending, grants, analysis, technical support died, and there are more than 15 million and policy dialogue. The scope of this Pro- AIDS orphans.3 Yet prevention efforts re- gram of Action is Bank-wide and global, main small-scale and half-hearted in most drawing on and complementing the Bank's countries, new infections continue to grow regional HIV/AIDS strategies (summarized and treatment coverage is limited. In 2005 in Annex 1). This Program of Action sup- more people will become infected with HIV ports the "Three Ones" principles, and is and die from AIDS than in any previous aligned with the recommendations of the year. Despite international efforts to ex- Global Task Team on Improving AIDS Col- pand access to treatment and much lower laboration Among Multilateral Institutions prices for antiretroviral drugs, most people and International Donors (the GTT) and the living with AIDS (PLWA) are not being division of labor agreed among the UNAIDS treated. co-sponsors. The epidemic is evolving in diverse patterns The document was written for the World across countries and regions. In most coun- Bank's Executive Directors, management tries, overall adult prevalence is below 1 per- and staff, and for readers beyond the Bank, cent, with the epidemic concentrated in especially for our counterparts in client coun- sub-populations, notably injecting drug tries and partner organizations. It translates users, sex workers and men who have sex into concrete actions the Bank's commitment with men. In some countries, prevalence has to work with client countries and partner risen to as high as 80 percent of some sub- agencies, to more effectively prevent new in- populations. Ominously, in a growing num- fections and treat and care for people in- ber of countries, the epidemic is spreading fected and affected by HIV/AIDS. Several among the general population. In Sub- internal reviews of the Bank's HIV/AIDS Saharan Africa, adult prevalence is over 7 work and an independent evaluation by the percent, and in the next-hardest hit region, 1 the Caribbean, it is over 2 percent. Whether Continuing challenges concentrated or generalised, high and rising prevalence rates are of serious concern. Although much has been learned about Women--particularly young women and HIV/AIDS in two decades, there are major girls--are made especially vulnerable to in- obstacles to applying that knowledge sys- fection by physiological and social factors, tematically and effectively. National resulting in an increasing feminization of the HIV/AIDS planning tends to be poor: too little epidemic, particularly in Sub-Saharan Africa planning (in the rush to apply for funding and South Asia. Increasing HIV infection and then spend it),too many plans (to please rates among young people globally are also a variety of donors) with very little coordina- of great concern.4 tion, and an inability to plan effectively (es- pecially at the national level) because of a More than twenty years on, the AIDS epi- lack of good epidemiological surveillance and demic has entered a new phase. There has monitoring and evaluation information, mini- been an unprecedented outpouring of re- mal collaboration among government sec- sources, significant advances in treatment, tors, and donors bypassing "official" The AIDS accumulated understanding of how to im- planning mechanisms.This results in misal- epidemic has plement prevention efforts and deliver treat- located funds and little chance of impact; in entered a new ment and care, and growing political one country only 1 percent of program re- commitment to stop the spread of HIV.Once sources target the particular risk groups that phase seen as a health emergency, AIDS is now cause 75 percent of new infections. recognized as a broad, long-term develop- ment issue. There is also growing recogni- Even the best planned programs face imple- tion that international development mentation constraints: a lack of resources, es- partners and countries must address pecially skilled personnel; unpredictable or HIV/AIDS through harmonized, coordi- conditional funding; burdensome dis- nated actions, in order to promote common bursement and procurement processes; approaches. government reluctance to contract imple- mentation out to civil society or the private A number of longstanding challenges con- sector; and multiple management and tinue to undermine our efforts to confront monitoring and evaluation systems to meet the epidemic,jeopardizing the enormous in- differing donor requirements. One of the vestment of resources and blunting the im- most intractable problems is that in many pact of thousands of international, national, countries health systems are overwhelmed. and local initiatives. The growing emphasis Inadequate, understaffed and underfunded on treatment offers hope and healthy years health facilities, strained to the limits, are of life to those infected people who can ac- faced with rapidly rising numbers of people cess treatment, but also brings new chal- with AIDS who need treatment. Newly lenges. In developing this Program of available donor funding for antiretroviral Action, we have analyzed the continuing (ARV) drugs raises demand and expecta- and emerging threats and the most pressing tions, but also exacerbates pressures on needs of country HIV/AIDS programs for health care providers, especially if donors strengthening and support, and then identi- are reluctant to pay for salaries and other fied five priority action areas for the World essential operating costs. Bank's HIV/AIDS response.This Program of Action takes advantage of the Bank's partic- Many HIV/AIDS programs are too small in ular strengths, seeking to support country scale or too narrowly targeted to make a real and regional HIV/AIDS programs, to en- difference. And the social, political and legal hance their effectiveness in reducing new in- climate is often inimical to effective AIDS pro- fections and providing care and treatment, gramming. Populations at high risk of infec- and in working together in constructive and tion are overlooked/underserved because of harmonious ways with our partners. It also stigma, taboos and denial, or because gov- harnesses the Bank's capacity to address ernments shy from controversial services or HIV/AIDS through multisectoral and broad serving marginalised groups (such as clean developmental approaches. needle programs for drug users or promot- 2 The World Bank's Global HIV/AIDS Program of Action ing condom use among sex workers and stigma and improving community knowl- men who have sex with men). edge and treatment readiness. Integrated prevention and treatment ensures that pre- Donor demand for quick and visible results vention activities are not neglected and can discourages efforts to solve long-term, less provide important opportunities to address visible problems such as weak health sys- vulnerable groups more effectively. Treat- tems and lack of health personnel. Conflict- ment investments can help improve infra- ing donor demands frustrate coordinated structure and human resources for planning, and conditional funding reduces prevention and other health services, by efficiency and raises costs. strengthening health facilities and health worker training.As recognized by the Global Emerging challenges Task Team (GTT) and the Gleneagles G8 Communiqué, both prevention and treat- Much still remains to be done to provide life- ment and care are critical and related com- saving antiretroviral therapy (ART) on a large ponents for an effective response. scale in resource-poor settings. To do this, health system capacity and infrastructure The recent outpouring of AIDS funding has Prevention, need to be strengthened and long-term raised expectations among donors and af- treatment and funding is needed to make expanded treat- fected populations but overwhelmed weak care are all ment programs sustainable. Widespread ac- administrative systems and fragile infra- critical and cess to treatment could have enormous structures. This has caused an "implementa- benefits, prolonging healthy life, and en- tion gap"--a temporary resource bottleneck, related parts of abling infected parents to remain productive as financial resources arrive faster than they an effective and raise and care for their children. Treat- can be spent effectively, even though a"re- response ment adherence and the impact of wide ac- source gap" remains between available cess to treatment on risky behaviours need funding and what is needed for a compre- careful monitoring, and promoting safe be- hensive and adequate response. The UN haviours must be unrelenting. There are agencies, the Global Fund to Fight AIDS,TB huge unmet needs for treatment and care, at and Malaria (GFATM) and HIV/AIDS stake- the same time as prevention and mitigation holders have redefined the division of labor programs are still under-resourced and in- among agencies through the GTT in order to adequate. Preventing new infections should improve implementation and use of funds. still remain the highest priority for all coun- Harmonized and coordinated international tries--at all prevalence levels. Successful support will significantly reduce the imple- prevention relies on widespread efforts in mentation burden. many sectors and by many groups in society. The more successful countries are at pre- While the demographic consequences of venting new infections, the more feasible HIV are increasingly apparent in many they will find it to provide treatment and care countries, the extent of the economic and to those who are infected. social impact is only beginning to be under- stood. And yet HIV/AIDS is still largely Prevention and treatment have important being overlooked in the broader development synergies. Effective prevention makes treat- agenda, especially in countries with emerg- ment more affordable and sustainable by re- ing epidemics, whose poverty reduction ducing the number of new infections and strategies are often silent or cursory about hence the number of people who will need HIV/AIDS, including its links to gender, treatment. Availability of treatment and care youth and development. can bring large numbers of people into health care settings,providing new opportu- AIDS and the Bank nities for health care workers to deliver and reinforce HIV prevention messages and in- In two decades of involvement the Bank has terventions. Improved access to HIV testing learned important lessons about fighting provides an entry point for both prevention HIV, including the need for countries to own and treatment services. Prevention can en- and lead their individual campaigns,forAIDS hance access to treatment, by reducing efforts to be part of overall development 3 Executive Summary planning, for programs to be based on the the Global Task Team on Improving AIDS best available evidence, and for more effec- Collaboration among Multilateral Institu- tive monitoring and evaluation to add con- tions and International Donors (GTT) and tinually to that evidence and to guide the G8 Gleneagles communiqué.The Global program improvements. TaskTeam recognizes that the world must do more to effectively tackle AIDS. Strengthen- In recent years, the Bank has dramatically ing coordination, alignment and harmo- scaled up its financial support to countries, nization, in the context of the"Three Ones" helping jump-start expanded programs in principles, UN reform, the Millennium De- many of the hardest-hit places. Cumulative velopment Goals, and the OECD/DAC Paris lending for HIV since the first project in 1988 Declaration on Aid Effectiveness, is essential is now over US$2.5 billion, and commit- for rapid, effective scale-up of the AIDS ments in sub-Saharan Africa have grown response. from $10 million annually ten years ago to $250-300 million in each of the last four This Program of Action will contribute to years.5 these goals, through a range of activities, in- The Program of cluding lending and technical support, ana- Action describes The Bank has contributed more than financ- lytic work and policy engagement, that the five integrated ing to global efforts against HIV/AIDS. Bank's regional units plan for the coming Through strong economic and policy analy- three years in HIV/AIDS and health system action areas to sis it has helped countries identify the de- strengthening, as well as actions that will be focus Bank velopment implications of the epidemic and taken to support and facilitate the regional support for more the potentially high returns to investments and country plans. It also describes addi- effective AIDS in prevention, care and treatment and miti- tional cross-cutting activities led by the gation programs (and how to choose the Global HIV/AIDS Program, and actions responses best ones). And through policy dialogue it planned by other Bank units to mainstream has helped redefine AIDS as a development HIV/AIDS responses in key sectors and issue.This is not to suggest that the Bank and areas such as education, transport, infra- Bank-supported initiatives have done nearly structure, gender, youth, legal and the pri- enough--the Bank's record on HIV is, in vate sector. fact, uneven, and the Bank was slow to re- spond at the required scale. But the Bank The work will be done through partnerships does offer certain unique expertise which, if across Bank units, working closely with effectively applied, can contribute, along client countries, UNAIDS co-sponsors, with others, to turning the tide against the GFATM and other development partners to epidemic. achieve strong, well focused, concerted and harmonizedAIDS responses.The Bank's en- gagement across many different sectors is an The World Bank's Global HIV/AIDS important comparative advantage, espe- Program of Action cially in addressing the increasing feminiza- tion of the epidemic, which requires The Global HIV/AIDS Program of Action progress in many related areas, including will support more effective AIDS responses girls' education, poverty alleviation, and in five integrated action areas, which reflect: growth. country needs; the Bank's mandate, capacity and comparative advantage; the findings of The action areas are: reviews of the Bank's work in AIDS; the agreed division of labor among the major · Support for strengthening national HIV/ agencies working on HIV/AIDS; and the AIDS strategies, to ensure they are truly Bank's commitment to the"Three Ones"vi- prioritized and strategic, integrated into sion of one national strategic plan, one na- development planning and linked to gen- tional coordinating authority and one der and equity issues; national monitoring and evaluation system · Continued Bank funding for national and in each country.6 The Program of Action co- regional HIV/AIDS programs, and for incides with the publication of the report of strengthening health systems, to support 4 The World Bank's Global HIV/AIDS Program of Action responses that are of sufficient scale and ery, as part of HIV/AIDS program funding, scope; and/or within broader health sector support, · Accelerating implementation, to increase given the heavy demands that HIV/AIDS the scope and quality of priority activi- prevention and treatment makes on the ties, through harmonized, well aligned health sector and the weaknesses in health actions; services delivery in many countries. Areas · Strengthening country monitoring and that will receive particular emphasis include evaluation systems and evidence-in- human resources for health, health plan- formed responses, to enable countries to ning, key public health functions (including assess and improve their programs; surveillance and governance), procurement, · Knowledge generation and sharing and im- management and other logistics of drugs pact evaluation about what works, as well and other essential supplies, and enhancing as other analytical work to improve pro- laboratory and diagnostic capacity. gram performance. Ongoing work to mainstream HIV/AIDS Consistent with the Global Task Team into the work of key sectors in addition to process and the division of labor among health--including education, transport, Five focus areas: agencies, the World Bank will focus inten- legal, gender and youth--will continue, and national sively on improving national HIV/AIDS be expanded. The education sector has the strategies, strategies and annual action plans and on capacity to reach millions of children (and funding improving program implementation. their parents) and empower future genera- tions to protect themselves against HIV in- HIV/AIDS Practical guidelines, good practice notes and fection. Schoolchildren are a "window of programs and examples, technical training and support for hope" for the future. Nearly all school age health systems; a network of country practitioners will be children are free of HIV infection,even in the accelerating provided to help countries to develop strate- worst affected countries, and if they remain gic,prioritized national plans,soundly based so as they grow up, they could change the implementation; on epidemiology and evidence, with well- face of the epidemic within a generation. M&E; analysis defined priorities, goals and targets, time- and knowledge frames, responsible actors, cost estimates, To further accelerate and strengthen and plans for monitoring, evaluation and HIV/AIDS program implementation, the knowledge utilization.Analytic and advisory Bank will continue to provide financial and services and enhanced Country Assistance technical support through project/program Strategy (CAS) and Poverty Reduction Strat- support and IDF grants to enhance country egy (PRSP) guidelines and assessment crite- capacity and systems to implement national ria will aim to support better integration of HIV/AIDS plans; seek to ensure adequate HIV/AIDS into national development plan- funding for project supervision and addi- ning and better aligned national AIDS tional implementation support; work with responses. countries and Bank project teams to further improve planning, budgeting, program de- The Bank will remain one of the major fi- sign, financial management, disbursement nancers of AIDS activities globally, including and procurement, monitoring and evalua- using its flexibility to fund countries and ac- tion and expenditure tracking. Depending tivities that others cannot or will not finance. on individual country situations,appropriate Particular efforts will be made to work with actions will be taken to help make it possi- countries to ensure that program and fund- ble for the private sector, civil society organ- ing decisions are informed by evidence on izations including non-governmental risk behaviours, epidemiology, and effec- organizations (NGOs) and faith-based or- tiveness and impact of interventions, as well ganizations (FBOs) and communities to play as links to gender, youth, minorities and eq- a strong role in the HIV/AIDS response. uity issues. Good practice notes will capture and widely share knowledge about effective implemen- The Bank will continue to provide funding tation practices and promote more and support to strengthen health systems evidence-informed approaches. Networks and client country capacity for service deliv- of program practitioners will be supported, 5 Executive Summary to facilitate exchanges of experiences, channels, and especially targeting potential knowledge and practical advice on general users; and (ii) supporting coordinated coun- operational issues, fiduciary architecture, try efforts to translate evidence into im- and special programmatic themes. proved national programming. As a member of the Joint United Nations Partnerships are essential to ensure coordi- Programme on HIV/AIDS (UNAIDS) fam- nated and harmonized national AIDS re- ily, and in line with the implementation of sponses of sufficient focus, scope and quality the Three Ones, the Bank has particular re- to reduce HIV transmission, and achieve the sponsibility for strengthening country international AIDS targets outlined in the monitoring and evaluation systems. The United Nations General Assembly Special Global HIV/AIDS Monitoring and Evalua- Session (UNGASS) and the Millennium De- tion Team (GAMET) will continue to pro- velopment Goals (MDGs).7 The Bank will vide practical, in-country support to continue to work closely with other interna- country counterparts to develop and tional organizations and donors, with peo- strengthen their national monitoring and ple living with HIV/AIDS, with civil society The Program of evaluation (M&E) systems. The goal is to groups, with the private sector, and through Action endorses work with partners to build national capac- public-private partnerships. the Bank's ity to carry out M&E and to use the data for making decisions. Specific activities include In the end, HIV will be defeated one village approach to joint country support visits with other at a time, one household after another. But HIV/AIDS. But major M&E partners to ensure coordinated essential grassroots efforts will reach more we must do even country support, participatory collaborative people and save more lives if they are part of more and do it development of one national monitoring carefully coordinated national strategies, and evaluation framework in each country, with national programs being supported in better operational plans and indicators, trouble- a harmonized and coordinated way, to try to shooting, working closely with partners to guarantee the most effective use of all avail- harmonize, align and coordinate efforts, able resources. This Program of Action en- and preparing and sharing guidelines, good dorses the Bank's present approach to practice notes and training. HIV/AIDS. But we must do even more and do it better to prevent new infections and Building on lending and non-lending activ- treat and care for those who are infected and ities, the Bank will establish a continuous affected by HIV/AIDS. Millions of lives and and deliberate process of learning more the development gains and prospects of about what works and about the impact of many countries are at stake. AIDS programs, and will systematically share and apply this knowledge in program design. Bank project task teams will be sup- Notes ported to carry out impact evaluations of in- 1. World Bank. 2004. Interim Review of the terventions funded through projects, and Multi-Country HIV/AIDS Program for Africa. new HIV/AIDS projects will include Washington, DC. and World Bank 2005. prospective evaluations. Working with re- Committing to Results: Improving the Effectiveness searchers within the Bank and beyond, es- of HIV/AIDS Assistance. An OED Evaluation of pecially those with a strong client-country the World Bank's Assistance for HIV/AIDS presence, new analytical work will be sup- Control. Washington, D.C. Available on line at: ported in priority areas to supplement the www.worldbank.org/OED. analytic work included in regional and coun- 2. Peter Piot,"AIDS: The Need for an try work plans, and to focus on cross-cutting Exceptional Response to an Unprecedented Cri- and cross-country areas, and on research sis", Presidential fellows Lecture, delivered on that has "international public good" attrib- November 20, 2003 at the World Bank, and pub- utes, particularly in relation to impact evalu- lished by the World Bank, Global HIV/AIDS ation. More emphasis will be given to: (i) Program, Washington DC. sharing research findings and emerging les- 3. UNAIDS (Joint United Nations Program on sons of experience widely and quickly, using HIV/AIDS) 2004. 2004 Report on the Global AIDS a range of distribution and dissemination Epidemic: 4th Global Report. Geneva: UNAIDS. 6 The World Bank's Global HIV/AIDS Program of Action 4. UNAIDS/UNFPA/UNIFEM 2004. Women gender, population, health systems, etc., and be- and HIV/AIDS: Confronting the Crisis. cause BW coding of HIV/AIDS components may 5. World Bank data prepared April 30, 2005 differ from the information provided directly to by the Global HIV/AIDS Program, World Bank. GHAP by TTLs. Washington, DC.These data include the total 6. UNAIDS (Joint United Nations Program committed amounts of HIV/AIDS projects, as on HIV/AIDS) 25 April 2004."Three Ones"Key well as HIV/AIDS components of over $1 Principles: Coordination of National Responses million in projects classified under other sectors, to HIV/AIDS: Guiding Principles for National using information provided by Task Team Lead- Authorities and their Partners. Conference Paper ers.The AIDS lending data recorded in the 1. Washington Consultation, Washington, DC. Bank's"Business Warehouse"(BW) differ 7. UN General Assembly 2000."United because part of HIV/AIDS projects may be Nations Millennium Declaration." coded and counted under other topics such as [www.un.org/] 7 Executive Summary INTRODUCTION The 40 million people now living with have scant evidence of what approaches HIV/AIDS, along with the families of the 20 work best when scaling up. million who have already died, are a stinging The Bank is indictment of the world's collective failure to The Bank is committed to a long-term re- committed to forestall a major--and preventable--epi- sponse to the pandemic--to staying the staying the demic.The human,social,and financial costs course in the fight against AIDS. We must are incalculable. In many countries, AIDS stem the tide of the epidemic, keeping the course in the has reversed the development achievements crucial focus on prevention to protect cur- fight against of the past generation and now jeopardizes rent and future generations. We must sup- AIDS the prospects of the next. In some countries port people who need a lifetime of treatment in sub-Saharan Africa AIDS has slashed life and care. We must protect and nurture mil- expectancy by half.1 It has closed schools and lions of orphans through to adulthood. We overwhelmed health care services. It has or- must ensure that our collective investments phaned 15 million children. in HIV are undertaken in coordination with investments in health, education, and social And this is only the beginning. More people protection systems and reinforce rather than were infected last year than ever before, and undermine them. more still will be infected in 2005. If this trend continues,the world will fail to achieve As recognized through the Global Task the Millennium Development Goal (MDG) Team process and by the G8 leaders, most of halting the spread of HIV by 2015, and recently at Gleneagles, strong productive other important MDGs also will not be met.2 partnerships with countries, with other funding organizations and with civil society In recent years, the world has finally come to are needed to overcome the formidable a firm consensus on the need to respond ag- challenges of the epidemic. Success will de- gressively to AIDS--to save lives, secure the pend on working together to build country future, and safeguard societies. Global fund- ownership and capacity, especially to de- ing grew twenty-fold between 1996 and velop strong strategies, implement them 2004. New global institutions have been cre- well and monitor and evaluate programs; ated. Programs to prevent new infections, leverage funds from client countries and provide care and treatment to those already the development community; and link the infected, and mitigate the impact of AIDS fight against HIV/AIDS to broader efforts to have proven effective in thousands of small alleviate poverty, reduce gender disparities, settings. increase equity and promote development. Yet despite these successes, our collective ef- In recent years, the World Bank has dramati- forts remain unequal to the task. More cally expanded its support for HIV/AIDS pro- money is on the table than ever before, but grams, and intensified its activities as a its promise has yet to be realized. Few coun- cosponsor of the Joint United Nations Pro- tries have programs of sufficient scale; too gramme on HIV/AIDS (UNAIDS).The Bank's few programs are evidence-informed or finance, influence, country presence, multi- carefully prioritized; too little of the money sector scope, analytic skills, and ability to sup- 8 is reaching those in greatest need; and we port effective implementation, provide a unique capacity to contribute to the global ef- Before describing the specific actions (in fort against AIDS. The mainstay of the World Part 2), this document reviews how the Bank's work in HIV/AIDS is of course the HIV/AIDS epidemic has evolved, and the lending,analysis and policy discussions led by persisting and emerging challenges we the six regions,and described in their regional face in addressing it. The Bank's response strategies and business plans (summarized in to HIV/AIDS so far is summarized as well Appendix 1).This Program of Action explains as the lessons of experience and joint (for internal and external audiences) the steps agency and bilateral work to harmonize the World Bank will take over the next three global and country efforts that have helped years,to strengthen the Bank's response to the guide the choice of priorities for this Pro- epidemic, and to complement and contribute gram of Action. to the work of our partners.These include the lending,analytic work and policy engagement led by the Regions,the actions that the Global Notes HIV/AIDS Program (GHAP) will take to sup- 1. UNAIDS. 2004 Report on the Global AIDS port, facilitate and augment country- and re- Epidemic: 4th Global Report. gion-specific operational work, additional 2. United Nations 4 April 2005. Progress Made cross-cutting activities, efforts to integrate in the Implementation of the Declaration of AIDS interventions into the work of other key Commitment on HIV/AIDS, Report of the sectors and the International Finance Corpo- Secretary-General to the fifty-ninth session of ration (IFC), and the capacity-building work the United Nations General Assembly. Agenda of the World Bank Institute (WBI). item 43. NewYork. 9 Introduction PART 1: OVERVIEW HIV/AIDS TODAY: CONTINUING AND EMERGING CHALLENGES An epidemic in transition There are regions, such as the Middle East and North Africa (MNA), where the pattern, Much has changed in the 24 years since the level and spread of the epidemic is not well first HIV infection was documented. The understood due to limited surveillance and The diversity of epidemic has evolved differently across re- behavioral risk data. the AIDS gions, and our ability to track and under- epidemic across stand it has grown markedly. While the In some countries--largely in Southern and and within epidemic is ever-evolving, in most of the Eastern Africa and in parts of the world HIV infections remain at low levels, Caribbean--the epidemic has spread widely regions and largely concentrated among sub-popula- into the general population, with adult countries poses tions: injecting drug users (IDU), sex work- prevalence over two percent in the challenges ers (SW), and men who have sex with men Caribbean and over seven percent in Sub- (MSM). In most countries, therefore, pre- Saharan Africa as a whole.A range of strate- venting new infections in these subgroups gies is required to prevent new infections, and their sexual partners through reducing ensure care and treatment for all those af- risk needs to be the main focus. fected, mitigate the sweeping impact, and support sustained programs. With so many The epidemic varies across and within re- people infected in these countries and in- gions, with some countries more affected creasing priority being given to treatment, than others. In Latin America and the efforts to prevent new infections still must be Caribbean, for example, 11 countries have sustained and enhanced. Even in countries an estimated national HIV prevalence of with the highest prevalence, the majority of one percent or more,while the rest of the re- the population is not infected, and adults gion has much lower general prevalence. and new generations of young people need Within countries, there are often wide vari- to be able to protect themselves from the risk ations among subgroups and geographic of infection. areas. Some of the most heavily populated countries in the world (e.g., China and The tremendous diversity across and within India) currently report an overall prevalence regions and countries poses its own set of of less than one percent, yet the infection challenges: the need for good surveillance, rate is much higher--and rapidly rising-- to understand the specific transmission dy- among a number of high-risk subpopula- namics in each context or country in order to tions. For example, in Chennai, India, HIV design effective interventions; the need to prevalence among drug injectors rose from ensure that interventions reach target 26 percent in 2000 to 64 percent in 2003. groups in concentrated or low-level epi- HIV among sex workers in Myanmar rose demics; the need for a comprehensive ap- from around 5 percent in 1992 to 31 percent proach in generalized epidemics; the in 2003, and from 1.7 percent in 2000 to 9 overarching need for strong political com- percent in 2004 among 70 sex workers in mitment and broad social mobilization to Tamanrasset, Algeria. Prevalence in a ran- end stigma, silence and denial no matter dom sample of inmates in aWest Java prison what the epidemic stage, and to change the went from one percent in 1999 to 21 percent cultural norms,beliefs,roles,and practices in in 2001 and 2003.1 which sexual behavior is deeply rooted. 13 There have been successful prevention pro- epidemic within a generation. Promoting grams, but they have rarely been of suffi- positive and safe behaviours must start be- cient scale or implemented widely around fore young people become sexually active or the world. We now have extensive experi- begin to use drugs. ence with prevention and, more recently, with treatment and mitigation programs, Many adolescents are sexually active and en- and we learn new lessons every day. It is gage in unprotected sex, and adolescence is more difficult to target individuals with risky also the time when drug use often begins.This behaviours when they are subject to social is a critical age to provide appropriate infor- taboos, or are marginalised, or not clearly mation, education and communication (IEC) identified--for example, widely dispersed interventions.3Yet many young people do not informal and part time sex workers who do have the knowledge or means to protect not work in establishments or "red-light" themselves from HIV/AIDS. For example, districts, injecting drug users, highly sexu- even in countries with generalized epidemics ally active men, and most of the MSM who such as Cameroon, Central African Republic do not identify themselves as gay. Preven- andLesotho,over80percentofyoungwomen The possibility of tion campaigns may have to address the en- have insufficient knowledge of HIV/AIDS. widespread tire population to reach those at most risk. treatment has Reaching people at highest risk of infection To prevent infections, young people need is also more complex, and less epidemiolog- youth-friendly and gender-specific informa- transformed the ically effective, in a generalized epidemic tion, health services and counselling and ac- epidemic but than in a concentrated one. cess to condoms. Providing HIV/AIDS access remains prevention in schools is critical but programs very limited The possibility of widespread treatment has must also reach youth living in the streets, transformed the epidemic, extending the and those involved in commercial sex work years of healthy life of people who have ac- or injecting drug use. Including young peo- cess to effective and affordable antiretroviral ple in the design and implementation of therapy. Access remains very limited, how- programs is an effective way to reach and re- ever, representing a missed opportunity to late to their peers. save lives and safeguard development. Greater access to treatment would give years As the epidemic and the worldwide re- of healthy life to people with scarce needed sponse to it continue to evolve, new chal- skills and expertise, and keep parents alive lenges and new obstacles are emerging. and well to care for their children, who Identifying these challenges and devising would otherwise join the millions of children appropriate responses must be part of any orphaned by AIDS. So the challenges in effort going forward. highly-affected countries are more varied: to build local capacity to manage a long-term, Unresolved longer-standing challenges also chronic disease; to ensure long-term main- remain, for which solutions are increasingly tenance of safer behaviors; to provide long- understood. The refrain--"We know what term support to survivors; and to plan for works!"--may be an exaggeration in some cohorts of young people who may begin cases, but in many others it is not. Our risky behaviors in the future. knowledge is incomplete, but it is substan- tial.The task with these recurring challenges Young people are increasingly at the center is not so much to figure out what needs to be of the HIV/AIDS epidemic. More than half done but to figure out how to do it. of those newly infected with HIV are aged 15-24, and there are more than 12 million As background to this Program of Action, an young people now living with HIV/AIDS. overview of the continuing and emerging But young people also represent the future challenges is presented below. This is not a and biggest hope in fighting the epidemic.2 list of problems the Bank intends to fix; it is, Nearly all school age children are free of HIV rather, a list of realities that the Bank, other infection, even in the worst affected coun- major donors, and countries need to be tries, and if they remain uninfected as they aware of in planning HIV/AIDS strategies in grow up, they could change the face of the the new millennium. 14 The World Bank's Global HIV/AIDS Program of Action Continuing challenges learn. But there are major obstacles that stand in the way of doing what works. If we really have learned so much about HIV over the last two decades, then why is the Limited strategic planning epidemic still growing? Why will more peo- ple be infected with HIV and die of AIDS in By and large, efforts against AIDS are not co- 2005 than in any previous year? In short, ordinated well at the national level and are why aren't we applying what we know? not part of an overall strategic plan.There are many plans,no plans,or different plans in dif- We are applying some of it, of course, al- ferent sectors; some efforts duplicate others, though not systematically nor on a scale some address problems that are not priorities commensurate with the need, and it is cer- (see box on Strategic Planning), and some tainly true that we have a great deal more to problems are ignored altogether. HIV/AIDS Many national plans do not Looking for the "strategic"in strategic planning strategically target the main ways HIV is Many countries have developed national plans,often through extensive consultation with stakeholders. These plans have helped to elevate national commitment,foster engagement and promote social transmitted openness about HIV/AIDS.But they have often not been truly strategic;that is,they have not identified and targeted the primary ways HIV is transmitted in a given country. One country inAfrica prepared a consultative and strategic plan which presupposed a highly generalized epidemic and emphasized the widest possible engagement of society and a broad range of interventions. HIV prevalence in the country's general adult population is 1.8 percent and antenatal data indicate that the epidemic has been stable for approximately a decade.The data also suggest that the peak age of HIV infec- tion is relatively high,between 35-39 years,for men and women.In contrast to relatively low rates in the general adult population and among youth in the country,HIV prevalence among sex workers is exception- ally high--78 percent and 82 percent in the two largest cities.The great difference between rates among sex workers and the general adult population suggests that a significant proportion of infections in this country arise from commercial sex.A recent study estimated that 75 percent of infections among sexually active men in the capital were acquired from sex workers.Yet a recent review indicated that only 0.8 percent of this country's HIV/AIDS investments were aimed at sex work interventions. This is not an isolated phenomenon.In oneAsian country,HIV infection in the general population remains low,at under 0.3 percent of pregnant women for example.In contrast,rates among injecting drug users approach 80 percent in the largest city,and rates of 30 percent have been reported among sex workers in selected sites.This country is clearly experiencing a concentrated epidemic,with exceptional vulnerability among marginalized populations.Epidemiological analyses indicate that injecting drug use contributes per- haps three-quarters of HIV infections,and injecting drug use and sex work together account for more than 90 percent.Despite these data,interventions to protect these two vulnerable groups are just one of this country's nine major strategic priorities. In one LatinAmerican country,the epidemic is largely concentrated among men who have sex with men. A study of over 7,500 such men between 1991 and 1997 found that more than 15 percent were HIV-pos- itive,against an overall adult prevalence of 0.3 percent.Given the likelihood that bisexual men are one route by whichAIDS enters the heterosexual community,low condom use among this population is wor- risome.In the survey cited above,85 percent of bisexual men in this country never used condoms during anal sex with their female partners,and 69 percent never used them during vaginal intercourse.Yet the majority of HIV prevention funds in the country are directed towards the"general population"and less than 10 percent are targeted towards men who have sex with men. 15 HIV/AIDS Today: Continuing and Emerging Challenges and its financing are often not integrated into them on to and"empower"those who ac- overall development and financial planning. tually carry out programs. · Systems of fiduciary accountability-- There are a number of reasons why countries financial management and disbursement do not plan more strategically or, if they do, and procurement of goods and services in why they do not always follow these plans: particular--that are more burdensome than relevant and do not take local con- · Missing data, especially on risky behav- ditions into account. iors, on the patterns and drivers of infec- · Implementation units with insufficient tion, on program effectiveness and on resources, skilled personnel, and regional economic and social impact. and international knowledge about what · Inadequate mechanisms to analyze and works, especially with regard to the chal- use data (when they are available), es- lenges of scaling up HIV prevention, care pecially for prioritizing HIV/AIDS and treatment, and mitigation programs. investments. · The reluctance of many in the public sec- · Reluctance to prioritize, because of the tor to contract program implementation HIV/AIDS makes difficult choices that must be made. and administration to existing civil society especially strong · Limited capacity to conduct regular plan- and private sector agencies in the country. demands on ning that involves many sectors of govern- · Unnecessary duplication of management ment and society,in particular to help each and monitoring and evaluation systems to health systems, sector assess realistically its comparative meet the requirements of different donors. which must be advantage in responding to HIV/AIDS. · Unpredictable, erratic, or narrowly tar- strengthened · Limited ability of governments to plan a geted disbursements of donor funding, national response when significant exter- often outside of national budgetary plan- nal resources are channeled directly to ning processes and cycles. non-government entities with limited consultation, and external resource flows Weak and overburdened health are unpredictable or uncertain. systems4 · Competition among stakeholders, in both the public sector and civil society, While the causes and consequences of HIV due to unclear roles and responsibilities affect many sectors, it makes especially and lack of ownership. strong demands on the health sector, which · Persistent knowledge gaps in some key has a central role in surveillance, preven- areas, such as effective prevention strate- tion, diagnosis and treatment of HIV/AIDS gies and how to scale up service delivery. and of opportunistic infections. Despite ef- forts over the years to improve health sys- Management and implementation tems, they remain very weak in many constraints countries, including some that are the worst affected by HIV/AIDS. Health systems must Even well-planned programs will have lim- be strengthened--to fight HIV/AIDS and to ited results if they are not well managed and address numerous other diseases and implemented. In many countries there is in- health problems. With the caveat that there sufficient support for implementation, espe- are significant variations across and within cially for scaling up programs in both the countries, the major obstacles to effective public sector and civil society. And where health system responses to HIV/AIDS, and, there has been support, programs rarely more broadly, to improved health outcomes benefit from lessons learned in other parts of and sustainability, include: the country or from other countries. Many countries, especially those hardest hit by · Not enough investment in health sys- HIV, and implementing agencies within tems. Donor and government efforts to countries face obstacles to successfully man- improve health systems generally--and aging and implementing their programs: human resources, provision of pharma- ceuticals and surveillance and other core · The tendency of management entities to public health functions specifically--have "control" resources rather than to pass been inadequate.5 Nor has adequate at- 16 The World Bank's Global HIV/AIDS Program of Action tention been paid to the coherence of in- · Resistance among public sector staff to vestments in health systems and their expanding the role of the private sector medium- to long-term sustainability. and civil society to deliver services. · Inadequate understanding of what works in health system development, and Limited reach of prevention, care and under-appreciation of the complexity of treatment services health systems and service delivery. The record of external efforts to support health The sense of emergency that has character- sector strengthening is mixed.While there ized much of the response to HIV has com- is evidence of improved capacity for pro- bined with the natural inclinations of many gram planning and local leadership in funding organizations to produce an explo- some contexts, these often do not trans- sion of pilot projects and other small-scale late into improved performance. activities. Large-scale, long-term sustained · To some extent, global initiatives may interventions, underpinned by reinforcing sometimes supplant rather than support developmental investments and actions are country-led strategies and work plans in what are needed now.Efforts to expand care, Large-scale, health. The High-Level Forum (HLF) on treatment and prevention programs have long-term the health MDGs is discussing ap- been frustrated by a number of obstacles: sustained care, proaches to harmonizing and coordinat- treatment and ing investments in health systems at the · HIV programs,particularly prevention ef- country and global levels.6 The prolifera- forts, have often focused on changing the prevention tion of initiatives on AIDS and other dis- behavior of a small group of individuals programs are eases has brought additional financing, rather than on designing comprehensive needed primarily for disease control efforts. or structural approaches to an entire at- Donor support for building the capacity risk group. of health systems has not kept pace with · Without clear HIV/AIDS communica- increasing demands to scale up the deliv- tions strategies, messages have not al- ery of services. The HLF Working Group ways been consistent or effective. has identified an urgent need for clear, · Too little effort and resources have been coherent guidance on how health initia- invested in HIV prevention. As access to tives can contribute to improving health treatment expands, care should be taken systems components. that prevention is not neglected, which · Inadequate numbers, skills and distribu- will result in an unsustainable growth in tion of health workers, due to weak incen- demand for treatment. tives, shortages of training facilities, brain · The effort to make treatment widely avail- drain and losses of health sector workers to able to the millions who need it,needs to be AIDS (see box on"People", p18). intensified,alongwithbuildingtherequired · Inequities in access to and utilization of infrastructure to make access possible. health services.7 · Stigma and denial deter people from · Restrictions on the use of some devel- coming forward and prevent programs opment assistance funds for recurrent from reaching many infected people, no- costs, including salaries. ARV drug costs tably men who have sex with men, inject- have declined, but other costs associ- ing drug users, and sex workers. ated with treatment--e. g., medical and · The staff available to deliver programs on support personnel, non-ARV drugs, a large scale is limited, especially in coun- biological monitoring--have remained tries where those most in need of services constant. Many donors traditionally are widely dispersed, highly mobile, in have been unwilling to pay for these rural areas or concealed. "local operating costs". · Many governments are reluctant to con- · Emphasis by donors on reaching many tract program management and service people with ARVs, without adequate at- delivery outside the public sector, even tention to the quality of care and to sus- where this would increase coverage, effi- tainability, given that ARV treatment is a ciency, and quality--and significantly lifelong commitment. close the implementation gap. 17 HIV/AIDS Today: Continuing and Emerging Challenges People: A key factor in the resource equation With new resources available for large-scale treatment,countries affected byAIDS confront a critical shortage of health workers,and expertise,including in epidemiology,virology,designing and managing pre- vention and treatment programs,and monitoring and evaluation.The severity and types of human resource constraints vary across countries.Africa has a quarter of the world's disease burden but only one percent of its health workers.1 Even if vacant posts could be filled,staffing levels still would not be adequate to meet the rising demand for care. The shortage of health workers has many causes.2Too few health workers are trained,too many die or move abroad,those in post are maldistributed relative to needs.Forty percent of the new graduate nurses in Zambia and Malawi each year are needed just to replace nurses who die ­ many ofAIDS.There are more Malawian nurses in Manchester,England than in all of Malawi.Tanzania has 26 times more nurses per capita in Dar es Salaam than in some rural areas.Weak public sector management and poor incentives and working environments erode productivity,and donors contribute by luring senior managers away from the Stigma, public sector.Kenya's civil service payroll was estimated to include 5,000"ghost"health workers.Doctors discrimination, in many developing countries earn as little as $50 per month.Low salaries sap morale and force health laws and social workers to undertake multiple jobs or activities. norms can Needs and solutions vary,but these options could help in many countries:Some countries have under-em- undermine ployed doctors and nurses,and other unemployed university graduates who,with appropriate training and HIV/AIDS supervision,could be deployed to meet shortfalls in program planning and management.More training prevention, care schools are needed,and rapid courses to train intermediate level para-professionals who can later upgrade their skills.Contracting private sector suppliers may help,but nursing agencies are rare inAfrica.Better and treatment salaries need to be arranged,and better working conditions and career development prospects are also needed.Staff could be distributed better,with incentives for rural service.Better public sector management is needed,combined in some cases with decentralization.All these are to be considered within a framework of sustainable financing. 1. High Level Forum on the Health MDGs,"AddressingAfrica's HealthWorkforce Crisis:anAvenue forAction", Paper prepared for the meeting inAbuja,in December 2004.Accessed online on 06/03/05 at: http://www.hlfhealthmdgs.org/Documents/AfricasWorkforce-Final.pdf 2. High Level Forum on the Health MDGs,"HealthWorkforce Challenges:Lessons from Country Experiences", Paper prepared for the meeting inAbuja,in December 2004.Accessed online on 06/03/05 at: http://www.hlfhealthmdgs.org/Documents/HealthWorkforceChallenges-Final.pdf · There is still not enough money for cause of HIV/AIDS, they are less likely to salaries and operating costs and for some seek out prevention, testing, and treatment services, especially if the service is expen- services. If use of preventive methods such as sive (such as treatment) or politically un- condoms or clean injecting equipment is dis- popular (such as services for injecting couraged, prevention programs are weak- drug users or sexual health services for ened. Approaches that violate the rights of adolescent girls). people in need of services have also been shown to be counter-productive.Some social Social and political factors gender norms make girls and women more vulnerable and have resulted in women and Social and political circumstances and laws girls now being the most affected by the epi- can greatly influence the success of HIV pre- demic (see Box on Feminization of the vention, care and treatment services. Where HIV/AIDS Epidemic). Progress in changing people may be persecuted, for example, or social and political obstacles has been inhib- subjected to stigma and discrimination be- ited by: 18 The World Bank's Global HIV/AIDS Program of Action Feminization of the HIV/AIDS epidemic The HIV/AIDS epidemic is increasingly affecting women and young girls,especially where heterosexual sex is the main mode of transmission.In Sub-SaharanAfrica,57 percent of PLWHA are female,and in Russia, the proportion of women among newly infected people rose from 24 percent in 2001 to 38 percent in 2003. Several factors increase women's vulnerability to infection and limit their access to HIV care and treatment.These include biological and cultural factors,social and economic gender inequalities,violence against women,women's unequal access to information,education and services,and their role as caregivers.In addition,in many societies women take on most of the care of people infected with HIV/AIDS.InViet Nam,women make up 75 percent of all caregivers for PLWHA. Among adolescents (aged 15-19) in regions hardest hit by the epidemic,for every boy five or six girls are infected.Young girls are physiologically more at risk of infection,are often poor and powerless,and are fre- quently coerced or enticed into sexual activity with older men in exchange for money,gifts and favors.For many young women marriage does not provide protection either,as young brides often lack the power to negotiate safe sex practices. The feminization of the epidemic is an additional impetus for redressing the social,economic and legal inequalities women face and working to end violence against women.HIV/AIDS prevention and treatment programs must consider women and gender issues.Preventive methods that are controlled by women-- such as microbicides and female condoms--can help reduce their vulnerability.As antiretroviral treatment is scaled up,more than ever there is a need to ensure equal access to services.Integrating HIV/AIDS with reproductive health programs may help improve women's access,especially where stigma and discrimination against people with HIV make women reluctant to seek HIV/AIDS services. Source:UNAIDS 2004;UNAIDS/UNFPA/UNIFEM 2004,Women and HIV/AIDS:Confronting the Crisis. · Lack of effective tools to measure envi- · Frequent exclusion of security and correc- ronmental effects, obstacles and inter- tional services from the national dialogue ventions, and the related tendency of around HIV, despite the high vulnerability programs to neglect whatever cannot be of prisoners and military personnel and the measured or reported as a"deliverable." ease of reaching them. Law enforcement's · Insufficient assessment of social factors cooperation can also be helpful for inter- in planning and implementing pro- ventions targeting injecting drug users. grams to trigger ongoing feedback from · Focusing exclusively on women and stakeholders. working only with women's groups when · Lack of mechanisms to ensure that social considering gender issues, instead of also and political environments support ef- reaching out to men, recognizing that forts to prevent and reduce HIV/AIDS. most decision-makers are men. · Lack of empirical evidence and widely differing views on the relative roles of leg- Donor challenges islation and education in reducing stigma and protecting human rights. AIDS programs are funded by four broad · Political unwillingness of governments sources: countries themselves; bilateral and some donors to invest in potentially donors, especially the United States' Presi- effective but controversial interventions, dent's Emergency Plan for AIDS Relief such as harm reduction for drug users in (PEPFAR) and the United Kingdom's De- favor of more politically "acceptable" in- partment for International Development terventions that may have limited effect (DFID); private foundations, with the Bill & on the national epidemic. Melinda Gates Foundation and the Global 19 HIV/AIDS Today: Continuing and Emerging Challenges Fund to Fight AIDS, Tuberculosis and Emerging challenges: new issues Malaria (GFATM) being by far the largest; for a changing epidemic and multilateral donors including the re- gional development banks and the World Growing awareness of the devastating im- Bank. A number of agencies, in particular pact of HIV/AIDS has translated into greater UNAIDS and its cosponsors,provide techni- political commitment to confront the epi- cal assistance. Responses to HIV/AIDS have demic and its consequences. This commit- suffered from the distorting effect on pro- ment has resulted in an outpouring of new gram planning and implementation of the resources and initiatives, including the numerous policies and priorities of such a World Bank's Multi-Country HIV/AIDS Pro- wide variety of donors. Some of these dis- gram (MAP), the Global Fund, and major tortions occur out in the field and are the re- new commitments by government bilateral sponsibility of the countries themselves, but donors, such as DFID and PEPFAR. There others can be laid at the door of external are also significant funds from private insti- partners and the way they go about provid- tutions--notably the Bill & Melinda Gates ing assistance (and are common to many de- Foundation. Altogether, total HIV/AIDS Uncertain, short- velopment aid programs). funds available in developing countries grew term and tied from an estimated US$300 million in 1996 to funding; Problems include: US$6.1 billion in 2004, including about US$ 2 billion in domestic funding, and to US$8 duplication; and · Uncertainty about future funding, which billion in 2005.8 However, this is still $4-6 donor pressure discourages countries from making the billion short of what is needed for effective and politics can large up-front investments needed to prevention, care and treatment. create strengthen systems and leads to too much investment in short-term measures. This increase in funding is a dramatic change distortions and · Funding that is tied to specific sources of and poses new challenges with which the difficulties technical assistance or to a particular AIDS community is still grappling. product, which distorts allocations, raises prices and reduces efficiency. Providing large-scale antiretroviral · Diverting funds from other development therapy programs, undermining the AIDS effort in the long run by further weakening cru- Evidence from developed and developing cial sectors such as health and education. countries has shown that current treatment · Inadequate support to countries to inte- regimens can dramatically prolong the lives of grate HIV/AIDS programs into their na- persons living with HIV, enabling them to re- tional budget planning and management main productive and raise their children. But processes, including in Medium-Term only about one million of the six million peo- Expenditure Frameworks and Poverty Re- ple who currently need antiretroviral therapy duction Strategies (in countries that have in developing countries are receiving it.9 them). · Competition among donors and among The delivery of ART in resource-limited set- recipient agencies, leading to expensive tings, once thought impossible, has been duplication--or even conflicts--in pro- shown to be feasible. For example, universal gramming. access to ART in Brazil has, since 1996, en- · Pressure from donors to attribute con- abled the country to avert more than 60,000 crete,politically prominent results to their new cases of AIDS and 90,000 HIV-related specific funding, which can fragment na- deaths.10 To extend these benefits to other tional monitoring and evaluation systems parts of the world, the Bank supports a com- and discourage investment in less visible prehensive approach to care for people in- outcomes such as strengthening national fected with HIV which includes antiretroviral systems or infrastructure. treatment. The Bank provides technical and · Excessive influence of donor country do- financial support to national ARV treatment mestic politics in funding decisions can programs in several countries, has developed result in inappropriate prevention and a technical guide on procurement of AIDS care schemes in local settings. medicines and supplies which has been en- 20 The World Bank's Global HIV/AIDS Program of Action dorsed by UN agencies, and has entered into Staying the course on prevention an agreement with the Clinton Foundation to ensure that Bank funds may be used to Preventing HIV infections should remain a procure ARVs and diagnostics at the Foun- priority for all countries, whatever the level dation's negotiated reduced prices. of prevalence, while also treating and car- ing for people who are infected and af- Achieving the goal set by the World Health fected. Since HIV is invisible in its early Organization and UNAIDS of putting three stages, countries with low HIV prevalence million people on treatment by the end of are often slow to respond and especially 2005 ("3 by 5") will require much more than reluctant to use limited resources and money, and poses new challenges.11To max- budgets on prevention efforts. However, imize individual benefit and to minimize the inaction is costly in all contexts. It inhibits risk of patients developing resistance to response in low-prevalence countries at all ARVs, measures need to be taken to ensure levels: from policy formulation to preven- that treatment is made widely available, can tion planning, implementation and ulti- be sustained and that people adhere to their mately to individual behaviour change. regimen. The need to strengthen health Intervening early, however, and working Efforts to services is made even more urgent by the steadily and closely with key at-risk and prevent new greater emphasis on treatment. Health sys- vulnerable populations has proven effec- infections must tems are already overburdened and under- tive in many countries. be unrelenting, staffed. Expanding treatment will require substantial new resources, especially invest- Efforts to prevent new infections must be alongside ments in operational infrastructure, in train- unrelenting. Even in the highest prevalence activities to ing and retaining more health workers, and countries, the majority of people are unin- expand sustained additional funding. Staff need to fected, and need the information and treatment and be trained to prescribe ARVs appropriately means to remain uninfected. Effective pre- and to monitor patients and treatment out- vention may require changes in social care comes. Reliable, sustainable supplies of the norms, attitudes and behaviours which are drugs must be ensured; which may require difficult to achieve. Populations at high risk additional investments in the supply chain of infection may be overlooked or under- and its management and improved procure- served because of stigma, taboos and de- ment procedures. Additional laboratory ca- nial, or because governments shy away pacity is needed to support HIV testing and from controversial services or serving mar- management of ARV treatment. Much of ginalised groups (such as clean needle pro- this work will fall on the public sector, but grams for drug users or promoting condom private providers have an important role too, use by sex workers and men who have sex with appropriate stewardship from the pub- with men). Even with respect to prevention lic sector. in the general population, some institutions find it difficult to overcome the social barri- Another critical issue is to ensure equitable ers to dealing with sensitive issues sur- access to treatment programs. In some rounding AIDS. Sustained, strong political countries, gender inequalities already pre- commitment, effective multi-sectoral ef- vent many women from accessing care and forts and broad community engagement treatment services. The design and imple- are all needed for normative and behav- mentation of treatment programs need to ioural changes that prevent HIV infection. address gender and other dimensions of eq- uity such as access for poor and marginal- Integrating prevention and treatment ized groups and in rural areas. It will be important to make sure that the The "Gleneagles" G8 summit in July 2005 promise of treatment programs does not recognized the need for additional efforts slow momentum on prevention, especially and funding to implement a package for HIV as governments may find it easier to support prevention, treatment and care, and to strive treatment regimens than more controversial for universal access to treatment for all who measures such as condom distribution and need it.12 promoting clean needles. 21 HIV/AIDS Today: Continuing and Emerging Challenges The impact of widespread treatment on pre- ing community knowledge and treatment vention efforts is currently unknown: there readiness. Integrating prevention and treat- can be important synergies, but there are ment ensures that prevention activities are also concerns about unintended conse- not neglected and can provide important quences. For individuals, the possibility of opportunities to address vulnerable groups treatment may provide the incentive and ra- more effectively. tionale for being tested, and testing provides an entry point for delivering prevention and The funding paradox treatment services. An HIV-negative test re- sult could reinforce motivation to practice The recent surge of funding has created a safe behaviors. Availability of treatment and paradox: there is still not enough money care can bring large numbers of people into available for HIV/AIDS programs, but the health care settings, providing additional money that is available is not being spent as opportunities for health-care workers to de- fast as it is being committed. Figure 1 shows liver and reinforce HIV prevention messages the June 2005 UNAIDS estimate of annual and interventions. In some developed coun- needs for HIV/AIDS programs along with Funding tries, wide availability of treatment has coin- the best current estimate of available com- commitments cided with an increase in risky behavior, mitments and actual and projected dis- have surged perhaps because people are worrying less bursements.13 Funding commitments are about becoming infected. The impact of ex- still substantially below estimated needs, ahead of their panded treatment programs on risky behav- leaving a "resource gap". Disbursements use, but are still iours must be carefully monitored, and are increasing, but they are not keeping far below needs promotion of safe behaviours integrated into pace with commitments, resulting in an treatment programs. It would be a sad irony "implementation gap."There are not always if increased access to treatment came at the adequate systems in place--in recipient expense of a general lowering of vigilance countries as well as in donor institutions-- against infection and a greater number of to put increased funding to use in a timely new infections. Conversely, the more suc- and effective manner, creating disburse- cessfully countries prevent new infections, ment bottlenecks. Funding increases have the more feasible,affordable and sustainable raised expectations among donors and it will be for them to provide ARV and other people living with HIV/AIDS, but over- treatment to people who are infected. In ad- whelmed many of the in-country mecha- dition, prevention can enhance access to nisms through which those expectations treatment, by reducing stigma and improv- must be met. Figure 1. Estimated financial needs, commitments and disbursements US$ (billions) 20 Needs 15 10 Commitments 5 Disbursements 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 22 The World Bank's Global HIV/AIDS Program of Action This implementation gap threatens to dash trated epidemics may be invisible to the gen- rising expectations (to be treated with ART, eral public; and AIDS authorities may carry for example), and risks alienating donors little weight in government circles.This is ev- who assume that more money means more ident in some Poverty Reduction Strategy Pa- and faster results. In the rush to bridge the pers (PRSPs). A recent study of HIV/AIDS in gap and produce results, there is a real risk PRSPs in Africa showed that while it was ad- that planning will become even more neg- dressed by many--but not all--countries lected, that funds will be spent inefficiently, with a high prevalence,it was less likely to ap- and that accountability will be minimal.This pear in PRSPs in countries with emerging intensifies the need for donors and others epidemics.16 Moreover, even if HIV was working on HIV/AIDS to harmonize their ef- prominent in PRSPs, it was rarely costed, and forts and align their activities, to make the the institutional framework for implementa- most efficient use of resources and to support tion was detailed in only 10 percent of cases. country-owned and implemented strategies. Many hard-pressed governments find them- As a consequence, funding for HIV/AIDS selves spending more time managing com- can easily be ignored when donors pledge peting donor demands than establishing support for PRSP implementation. Country- AIDS needs to their own priorities and implementing their level stakeholders and international part- be better own programs. ners need to keep HIV on the agenda during integrated into the PRSP process and during other national broad national The Three Ones and the Global Task Team budgetary processes such as developing process is critical both in raising increased Medium-Term Expenditure Frameworks development resources and in ensuring that these re- (MTEF). National HIV/AIDS strategies need planning and sources are allocated well and used effec- to be embedded in national public expendi- budgeting tively to improve implementation and use of ture planning and taken into account during existing funds (See Box on The Three Ones). macroeconomic policy debate. With re- newed global focus on Africa, there is a To close the resources gap, more progress is pressing need to ensure that HIV/AIDS is needed towards closing the implementation addressed in the wider development agenda gap. This requires that donors and recipients and development instruments. do more to promote faster disbursements while at the same time maintaining high lev- PRSP and MTEF processes and macroeco- els of efficiency, effectiveness, transparency nomic policy dialogue also offer opportuni- and accountability. Neither recipients nor ties for considering broader policies and donors can continue to do "business as actions that are linked to a country's ability usual". Dr. Peter Piot, Executive Director of to respond to HIV/AIDS (for example, in- UNAIDS, has called AIDS "an exceptional vestments in the health sector including ex- epidemic . . . that demands exceptional ac- panding the health workforce and retaining tions."14The Bank has begun to use nonstan- health workers) and to gender factors such dard implementation arrangements in the as girls' access to education and women's Multi-country AIDS Program (MAP)15, and property rights, that can affect poverty and to change its procedures to speed up imple- vulnerability and women's ability to protect mentation.This flexibility has not always been themselves from infection. matched by governments, many of whom continue to address HIV through existing and Predicting the social impact of a still often rigid bureaucratic procedures. growing and diverse epidemic HIV is often overlooked in the poverty While the demographic impact of the HIV reduction strategy process and epidemic is becoming increasingly apparent medium term expenditure frameworks in much of Africa, we can only speculate about its full economic and social impact. At In many countries, AIDS has a disturbingly the household level, the main effect of AIDS low profile,for a number of reasons: stigma or is to increase poverty, especially among the denial may prevent political commitment or a poorest. Because AIDS affects mainly adults vocal civil society from materializing; concen- in the prime of their lives, it results both in a 23 HIV/AIDS Today: Continuing and Emerging Challenges Making the money work--"The Three Ones"in action InApril 2004,the UNAIDS co-sponsors,the Global Fund,theWorld Bank and key bilaterals including the U.K.and the U.S.agreed to support the"Three Ones"at country level in order to improve the efficiency and effectiveness of HIV/AIDS funding.1 The"Three Ones"are: · One agreed HIV/AIDS action framework to coordinate the work of all partners; · One nationalAIDS coordinating authority with a broad-based multi-sectoral mandate;and · One agreed country-level monitoring and evaluation system. Eleven months later donors and recipient countries met in London to assess the"Three Ones".While there was progress in some countries,not enough countries and donors were putting the"Three Ones" into practice.UNAIDS was asked to facilitate formation of a GlobalTaskTeam to issue within 80 days rec- ommendations on improvingAIDS coordination among multilateral institutions and international donors. Task forces were established on strategy and funding,technical assistance,and monitoring and evaluation. The Bank co-chaired the task force on strategy and funding and was a member of the group on monitor- ing and evaluation as well as the overall GlobalTaskTeam. The GlobalTaskTeam (GTT) presented its recommendations within the 80 day deadline.It also reached agreements on improved coordination between the Global Fund and theWorld Bank,and the division of labor among the UNAIDS co-sponsors,particularly with regard to rationalizing the provision of technical support.The division of labor suggested that theWorld Bank take the lead in assisting countries to enhance their HIV/AIDS strategies by making them more prioritized,evidence based and inclusive and by establishing annual actions plans for better implementation.Together with UNDP,the Bank will help coun- tries better integrate their HIV/AIDS programs into the broader development agenda,including in PRSPs and MediumTerm Expenditure Frameworks. TheWorld Bank is also participating in costing the implementation of the GTT recommendations with re- gard to technical support and in the creation of two new mechanisms for promoting coordination:(i) joint country support teams for monitoring and evaluation;and (ii) a UN system-Global Fund problem-solving team to operate at both country and global levels. 1. The"Three Ones"agreement was endorsed by representatives of the governments ofAustralia,Belgium,Brazil, Canada,Côte d'Ivoire,Denmark,Finland,France,India,Ireland,Italy,Japan,Luxembourg,Malawi,Netherlands,Norway, SouthAfrica,Sweden,UK and USA,and of the following organizations:UNAIDS,UNDP,WHO,World Bank,OECD, OECD/DAC,International Council ofAIDS Service Organizations (ICASO),and the Global Network of People Living with HIV/AIDS (GNP+).For more details on theThree Ones,see UNAIDS 2004,Coordination of National Responses to HIV/AIDS, Guiding principles for national authorities and their partners. rapid increase in the number of people patterns do change,andAIDS specialists have needing treatment and in the number of or- been wrong before in predicting the course of phans, who are often deprived of access to the epidemic. Even if current"worst case"sce- education. Even if governments are able to narios for large countries do not come to pass, provide long-term ARV treatment to rapidly at the very least, Eastern Europe and parts of growing numbers of people, many infected Asia are likely to see large, concentrated epi- adults will still die before their children reach demics affecting millions of people--and cre- maturity. ating vast new demands for prevention, care, support, and treatment. Given current trends, vulnerabilities and pat- terns of behavior, it seems unlikely that the large nations ofAsia will suffer HIV epidemics Notes in the general population such as those now 1. UNAIDS. 2004. seen in Southern Africa. However, behavioral 2. UNAIDS. 2004 24 The World Bank's Global HIV/AIDS Program of Action 3. World Health Organization Department of 9. WHO and UNAIDS, 2005,"The 3 by 5 Ini- Child and Adolescent Health and Development. tiative", report on progress as of June 2005, ac- The Talloires consultation to review the evidence cessed online on August 8, 2005 at: for policies and programmes to achieve the http://www.who.int/3by5/ global goals on young people and HIV/AIDS. In- progressreportJune2005/en/ formation Brief 11.10.04, http://www.who.int/ 10. Teixera, Paulo R., Marco A.Vitoria, and child-adolescent-health/New_Publications/ Jhoney Barcarolo. 2004."Antiretroviral treatment ADH/IB_SRG.pdf in resource-poor settings: the Brazilian 4. "Health systems"include a range of experience." AIDS 18(3): S5-S8. functions whose primary purpose is promoting, 11. WHO (World Health Organization). 2003. restoring and maintaining health.The areas of Treating 3 Million by 2005: Making It Happen: The concern most relevant to this Program of Action WHO Strategy. Geneva: WHO Department of are stewardship (oversight and the roles of the HIV/AIDS. [www.who.int/3by5/]. state); financing (revenue generation, collection, 12. Gleneagles Communiqué, Page 22, para- pooling, allocation, use and sustainability); graph 18 (d). epidemiological surveillance as an input into 13. UNAIDS 2005. Resource needs for an ex- evidence-informed planning, implementation and panded response to AIDS in low and middle-in- evaluation of programs; service delivery, including come countries. Presented at the Programme supply chains and the multiple dimensions of Coordinating Board; seventeenth meeting. quality care; human resources (quality, quantity Geneva, 27-29 June 2005. and performance incentives); and infrastructure 14. Piot, Peter. AIDS: The Need for an Exceptional for effective prevention and treatment, including Response to an Unprecedented Crisis. Presidential laboratory facilities and communications. Fellows Lecture delivered on November 20, 2003 5. Wagstaff A, and M. Claeson, 2004.The Mil- at the World Bank, Washington, D.C. lennium Development Goals for Health--Rising 15. As described in the MAP operations to the Challenges, World Bank, Washington DC. manual published as"Turning Bureaucrats into 6. UNAIDS 2005. Information Update. General Warriors", Brown, Ayvalikli and Mohammad, Assembly High Level Meeting on HIV/AIDS. World Bank, 2004. NewYork, 2 June 2005. 16. World Bank and UNICEF, 2004. Poverty 7. Wagstaff A, and M. Claeson, 2004. reduction strategy papers--Do they matter for 8. UNAIDS. 2005. "Resource Needs for an children and young people made vulnerable by Expanded Response to AIDS in Low and Middle HIV/AIDS? UNICEF, NewYork. On line at Income Countries", Discussion Paper:`Making http://www.unicef.org/publications/ the Money Work',The Three Ones in Action, index_24887.html United Kingdom, 9 March 2005. 25 HIV/AIDS Today: Continuing and Emerging Challenges HIV/AIDS AND THE BANK: THE STORY THUS FAR In the past 5 years, the World Bank has dra- make HIV a priority kept those results from matically increased its support for HIV/AIDS evoking or informing a broader institutional programs. Cumulative total Bank commit- response. Neither its shareholders nor its World Bank ments now exceed US$ 2.5 billion (Figure 2). managers gave AIDS the priority it war- support for Funding increases for AIDS in Africa have ranted, and few Bank clients asked for advice HIV/AIDS has been particularly impressive, from an aver- or funding for HIV/AIDS. Most other public age of US$ 10 million annually 10 years ago organizations were also slow to react in those increased to $250-300 million annually in each of the early years, but as a leader in development, dramatically, last four years.The Africa MAP has commit- the Bank bore a special responsibility-- with total ted US$1.12 billion for 29 countries and four which it failed to fulfil.2 commitments regional projects, and the Caribbean MAP has committed US$118 million for nine India and Brazil stand out in Bank lending: over US$ 2.5 countries and one regional project.1 they were among the first countries with billion dedicated HIV/AIDS projects (in 1992 and Although it started lending for HIV/AIDS in 1993), and in both, support has been sus- 1988, more than a decade passed before the tained, with second projects approved in Bank began to apply the full range of its tools 1999 and 1998, and a third project under im- and talents to confronting the epidemic. plementation in Brazil and being prepared in Some of the Bank's early work produced im- India. This support has helped build robust portant and lasting results, but the failure to HIV/AIDS institutions and capacity at na- Figure 2. Cumulated new AIDS commitments, fiscal years 1989­2005 US$ (millions) 3,000 2,500 2,000 1,500 1,000 500 0 FY89 FY90 FY91 FY92 FY93 FY94 FY95 FY96 FY97 FY98 FY99 FY00 FY01 FY02 FY03 FY04 FY05 26 tional and state level, engage NGOs in pre- Experience in analysis and policy vention and care efforts, build public aware- advice ness and bolster political commitment, and improve surveillance. Brazil is especially no- Through analysis, policy dialogue and advo- table for the focus on prevention among the cacy at the highest levels, the Bank has most marginalized groups helped put HIV/AIDS on the development agenda. Analytic efforts have identified the Since the late 1990s, Bank support for broader development dimensions of the epi- HIV/AIDS programs has risen fast, particu- demic, demonstrated the high returns from larly in the hardest hit regions. Regional investing in HIV/AIDS programs, and pro- HIV/AIDS strategies have been developed vided tools for selecting and costing appro- to guide the Bank's work (Appendix 1). Still priate interventions. In its policy dialogue, one of the three largest funders worldwide, the Bank has helped legitimise HIV/AIDS as the Bank also provides policy analysis and a development concern and a priority for advice, is a leading source of implementa- public action. tion support to countries, a cosponsor of UNAIDS and a core member of other major This work has helped convince many client Analysis, policy global partnerships.The Bank has deepened countries to increase funding for HIV/AIDS dialogue and its expertise, learned valuable lessons (see programs from domestic and external re- high level box), and become increasingly aware of its sources, and likewise prodded donor coun- advocacy have strengths and limitations. tries to commit billions more for HIV/AIDS-- two key developments that were especially helped raise These lessons, together with assessments of important in countries that had been reluc- political where programs most need strengthening tant to acknowledge or address their commitment and especially to overcome implementation bot- epidemics. funding for AIDS tlenecks, countries' most pressing needs for support, the Bank's particular strengths, and Since 1988 the Bank has published over two the directions set out in the regional strate- hundred analytical and research reports and gies, have determined which of the many papers on HIV/AIDS covering many different challenges described earlier the Bank has sectors, including education, transport, local chosen to focus on in this Program ofAction. government and the private sector.3 However, Twenty years--five lessons: What the Bank has learned from its HIV/AIDS programs In recent years,the Bank has carried out several studies of itsAIDS work.Five key lessons have emerged from these reviews and have guided the development of this global HIV/AIDS Program ofAction. · The Bank--by its acts and its omissions--influences both developed and developing countries in their actions on HIV/AIDS. · Country ownership,leadership,and capacity are crucial for successful action. Countries that have had success in fighting the epidemic have been supported to lead their own programs and build on local institutions.The Bank's policy advice and country-led approach are important assets to countries in pursuing these goals. · HIV/AIDS needs to be better integrated into development policy and planning--and the Bank is uniquely positioned to assist countries with this. · HIV/AIDS strategies,policies and programs should be evidence-informed,with priorities based on local epidemic conditions. Activities should also continually generate new evidence and channel it to managers to inform ongoing program refinements. · Monitoring and evaluation are essential--and consistently neglected. 27 HIV/AIDS and the Bank: The Story Thus Far analyticalgapsremain,atboththemacro-and addition, the Bank has begun to integrate micro-levels. For instance, there has not been HIV/AIDS into other sectors, such as trans- enough attention to the links between port and education, and to require HIV safe- HIV/AIDS and poverty, which may explain in guards in projects where there are risks of HIV part the general neglect of HIV/AIDS in transmission.To help alleviate debt concerns, Poverty Reduction Strategy processes and it has increasingly used grants to finance other national development planning exer- HIV/AIDS projects in IDA countries. cises. At the micro-level, more economic and sector work is needed on a host of important The Bank has been among the foremost issues,such as the sector impact of HIV/AIDS, sources of support for implementation and the effectiveness of various HIV/AIDS inter- has reaffirmed its commitment to improving ventions, and the factors explaining house- implementation through the Global Task hold and individual behavior changes. In Team division of labor among agencies. It policy dialogue, Bank performance is uneven, has provided considerable support to coun- with HIV/AIDS emphasized with some tries in areas where their programs have tra- clients and overlooked with others. In addi- ditionally been weakest, especially financial The overall tion, in most cases the Bank has not done management and disbursement, procure- impact of Bank enough to help countries develop effective, ment, and monitoring and evaluation. This support for prioritized HIV/AIDS programs, or to absorb support has helped channel resources to an key findings from Bank projects as to which unparalleled number of stakeholders, and HIV/AIDS in 67 interventions work, under what circum- also strengthened the capacity of countries countries is stances, and at what scale. to carry out programs funded by other mixed, with donors.Internally,the Bank has created ded- successes and icated HIV/AIDS units in Africa, South Asia, Experience in financing and and the Human Development Network weaknesses supporting implementation (Global), and, recently, in the International Finance Corporation, the World Bank Insti- Since 1988, the Bank has funded HIV/AIDS tute and the Legal Department, as well as a projects and activities in 67 countries.4 In the Bank-wide HIV/AIDS Implementation Ac- early years, these projects supported coun- celeration Team, all of which share a key tries as different as Brazil, Cambodia, and mandate to ensure rapid and consistent sup- India in laying the foundations for effective port to project teams and clients. Some of national programs. The Africa MAP was the these units have sponsored broad initiatives first to fund African HIV programs on a bil- to disseminate lessons learned from ongo- lion-dollar scale. Responding to client de- ing programs, which has made it possible for mand, the MAP also introduced a set of new projects to benefit from earlier experi- innovations, including multisector reach, ence. These units have also helped develop funding for both operating and recurrent new policies to simplify project processing costs, flexible programming, simplified pro- and implementation. cedures, and direct flow of funds to civil so- ciety. These activities jump-started a rapid scaling up of HIV initiatives in Africa, where An uneven record today most national governments have pro- grams of unprecedented scope and where Overall, the impact of this work has been the Bank has funded more than 50,000 civil mixed.Within the portfolio,some operations society subprojects.5 Bank investments in have succeeded, while many others have HIV/AIDS initiatives have also climbed not. The reasons for the latter vary widely. steadily in most other regions. Some projects suffered from poor design and not enough analysis before being ap- The Bank has also developed new tools and proved; others foundered because of gov- practices to enhance its HIV/AIDS support.To ernment disinterest or neglect; and others address targets that individual country pro- were undermined by a weak strategic frame- gramscannotreach,ithasbegunfundingsub- work for AIDS.6 Other projects failed to per- regional HIV/AIDS projects in the Caribbean, form because of poor governance or because Central America, Central Asia and Africa. In governments were reluctant to pass on the 28 The World Bank's Global HIV/AIDS Program of Action flexibility of Bank funding to implementing Bank retains a special role and responsibil- agencies.Many projects had sound technical ity, which its partners are relying on it to ful- designs but stumbled when it came to im- fill. As the largest single provider of plementation, hampered by poor institu- development assistance and an important tional capacity and intra-governmental repository of knowledge and advisory serv- relationships or weak national ownership. ices, the Bank has a unique set of strengths Even some projects that succeeded (achiev- to bring to bear on the epidemic, as summa- ing their own specific objectives) were too rized below. small in scale to affect the country's epi- demic. Owing to a general neglect of moni- Advocacy and Access toring and evaluation, especially impact · The Bank has access to key decision mak- evaluation, opportunities have been missed ers, including in the area of finance, who to learn from previous projects. are critical to giving HIV/AIDS appropri- ate emphasis and putting it at the center While the Bank's support for implementa- of the development agenda, both globally tion has assisted countries to improve their and in individual countries. fiduciary architecture--financial manage- The Bank has a ment, disbursement of funds, and procure- A Longer-term, More Independent Perspective special role and ment of goods and services--the Bank has · Less fettered by national electoral politics responsibility done less well in supporting two other vital andbudgetcyclesthanothermajordonors, and set of areas: strategic planning and monitoring the Bank is in a position to take a sustained, and evaluation.Very few countries have de- long-term approach to the epidemic. strengths in the veloped a true strategic framework for · Bankfundingislongerterm,moreflexible, fight against HIV/AIDS based on the most recent country and better rooted in national ownership. AIDS level information about the epidemic, let · Gaps in human resources--the biggest alone viable and costed implementation obstacle to rapid scale-up of promising in- plans that have the support of national fun- terventions in the hardest-hit countries-- ders, especially Ministries of Finance and can best be addressed by long-term Planning. The Bank could do more to work investments across sectors, an approach with other UNAIDS partners to help coun- the Bank is particularly well suited to tries undertake a systematic, comprehensive support. and participatory process of strategic plan- ning that fits within the overall development Breadth of Action across Sectors and Countries framework, including the PRSP process. · The Bank engages across the full range of sectors and government ministries, from In supporting program monitoring and eval- health to education, transport and de- uation, no country, donor, or partner has fence, giving it unmatched advocacy and done an adequate job--the Bank included-- influence among external actors. and few countries have an adequate national · InsomecountriestheBankisstilltheonly system in place. Individual large-scale proj- major provider of funding for HIV/AIDS ects rarely include prospective evaluation of work. The Bank can provide funds to impact. With billions of dollars at stake, im- countries that are not able to access fund- proving monitoring and evaluation has be- ing from other major sources. come one of the highest priorities. At this · The Bank's privileged relationship with stage of the response to the epidemic, there the IMF and its central role in national de- can no longer be any excuse for not know- velopment planning in low-income ing whether and how AIDS activities are countries enable it to link HIV/AIDS making a difference. planning to broader development plan- ning and ensure that the latter address the epidemic. It is also well placed to as- The Bank's comparative sist Ministries of Finance and Planning to advantages improve their understanding of the epidemic. Although many global institutions are now · The Bank can easily finance projects with engaged in the fight against AIDS, the World multiple objectives. 29 HIV/AIDS and the Bank: The Story Thus Far Ability to Jointly Provide Funding,Analysis and severe--worsened poverty, millions of or- Technical Assistance phaned children and losses of productivity · The Bank provides access to highly con- and scarce skilled people. Implementation cessional IDA funding, in some cases di- and funding gaps are wide, and the differing rectly for HIV/AIDS programs. It provides requirements of funders make heavy de- this financial assistance in tandem with mands on hard-pressed managers. The analytical work, policy dialogue and mul- unmet need for treatment and care is vast, tisector convening power. while prevention remains the priority for the · The Bank has the capacity to support uninfected majority of the population. With multisector strategic planning to encour- increasing focus on development in Africa, age rational allocation of resources. HIV/AIDS plays a critical role because of its · The Bank has unique expertise in sup- devastating impact on development. porting program implementation around the world and in all the key economic and The epidemic is highly diverse across the social sectors; working with govern- East Asia and Pacific region, and Govern- ments, civil society and the private sector ment response has also varied, with decisive Bank regional from the community level to the national action in Thailand, Cambodia and Philip- HIV/AIDS level to develop a relevant and flexible fi- pines showing success in preventing infec- strategies are duciary architecture of appropriate finan- tions, whereas some countries still hesitate, cial management and procurement and political commitment remains low. tailored to systems and other structures that enable Other big issues include the difficulty of mo- address specific implementation of HIV/AIDS activities. bilizing multisectoral action and achieving and diverse · The Bank's extensive expertise in analy- the enabling legal environment needed to issues and sis, particularly in development econom- work effectively with high risk groups; poor ics, positions it uniquely to explore the surveillance especially of high risk groups; needs HIV/AIDS-poverty-gender-development high rates of TB; and changing social pat- dynamic and to support the design and terns that increase vulnerability to infection. analysis of the impact of large-scale, mul- tisector, multi-output programs. In Eastern Europe and Central Asia, prevalence is still fairly low, but new infec- Taken together, these strengths enable the tions are rising very fast, especially among Bank to play a central role in developing an ef- young people, with injecting drug use driv- fective and lasting response to the epidemic. ing the epidemic in many countries. TB has They also position the Bank as uniquely cred- emerged as a parallel epidemic in some ible to advise government and other partners countries, because HIV-positive people are on the proper emphasis to be given to HIV- especially vulnerable to TB. Growing num- relatedinitiativeswithinthecontextofacoun- bers of young women are infected, suggest- try's overall development agenda. ing an increase in heterosexual transmission. Much higher HIV prevalence in some Diversity and commonality across Caribbean countries than in most of the regions rest of the Latin America region makes it a very heterogeneous group of countries. Many of the challenges discussed earlier are Some of the low prevalence countries are common across many countries and regions. not doing enough to prevent infections, But there is also great diversity within each and program funding has been low and region, and even within countries, with re- poorly targeted in many countries. Al- spect to the epidemic, the country response though most Caribbean governments are and the barriers to effective action.The Bank now responding, donors tend to overesti- regional HIV/AIDS strategies7 are tailored to mate their implementation capacity. Inade- address specific issues and needs. quate government ownership of programs also hampers implementation progress. In African countries with very high preva- lence and generalized epidemics, the eco- Although general prevalence rates are low nomic and social impact of AIDS is in most of South Asia, large numbers of 30 The World Bank's Global HIV/AIDS Program of Action Diversity and commonality across regions AFR EAP ECA LAC MNA SAS HIV/AIDS Situation Adult Prevalence Rates 2004 7.4 0.1 0.8 0.6/2.3* 0.3 0.6 PLWHA (millions) 25.4 1.1 1.4 2.1 0.5 7.1 Main bottlenecks/issues National Program not strategic, focused X X X X X X Lack of donor harmonization X X X X X X Implementation capacity shortfall X X X Overwhelmed health systems X X X X* X Inadequate surveillance data X X X X X X Too little monitoring and evaluation X X X X X Denial ("not in our country") X X X X Stigma--IDU, SW, MSM X X X X X X High/growing prevalence among IDUs X X * Caribbean Source: UNAIDS December 2004 (for prevalence rates and numbers of PLWHA) people are infected in India, and many pop- Taking account of the commonalities and ulations are made vulnerable by structural differences across countries and regions, this and socio-economic factors, including global Program of Action complements and poverty and illiteracy, widespread denial, supports the regional strategies, focusing its stigma and discrimination against PLWHA, priority action areas on key common bottle- women's low status, and high levels of com- necks and barriers. mercial sex activity. Recent sharp rises in HIV among some groups with identified risky behaviors and in general adult preva- Notes lence in some Indian states are worrying. 1. World Bank data prepared April 30, 2005 Although there are some effective preven- by the Global HIV/AIDS Program, World Bank. tion efforts underway, better targeting, cov- Washington, D.C.These data include the total erage and quality are needed, and access to committed amounts of HIV/AIDS projects, as care and treatment is very low. Institutional well as HIV/AIDS components of over and governance weaknesses in AIDS pro- $1 million in projects classified under other sec- grams and health services delivery remain tors, using information provided by Task Team major challenges. Leaders.The AIDS lending data recorded in the Bank's"Business Warehouse"(BW) differ Data are so sparse that many countries in the because part of HIV/AIDS projects may be Middle East and North Africa do not re- coded and counted under other topics such as ally know what their HIV situation is. Preva- gender, population, health systems, etc., and be- lence is low in the general population, but cause coding of HIV/AIDS components may dif- appears to be climbing in some high risk fer from the information provided directly to groups for whom data are available. Strong GHAP by TTLs. social stigma attaches to high risk groups 2. World Bank 2005. Committing to Results: where HIV typically takes hold first (inject- Improving the Effectiveness of HIV/AIDS ing drug users, sex workers, men having sex Assistance. with men) and there are few programs that 3. World Bank 2005. address their needs.Vulnerability to the epi- 4. World Bank 2005. demic is increased by migration, high youth 5. World Bank, October 2005. ACTAfrica unemployment, conflict and security prob- internal project monitoring data. lems that make it difficult to implement pro- 6. World Bank 2005. grams, and cultural taboos against talking 7. See Annex 1 for summaries of the regional about sex that keep people ill-informed strategies and www.worldbank.org/aids for the about HIV/AIDS. full documents. 31 HIV/AIDS and the Bank: The Story Thus Far PART 2 THE WORLD BANK'S GLOBAL HIV/AIDS PROGRAM OF ACTION This Global HIV/AIDS Program of Action lytical work to improve program commits the Bank to supporting more effec- performance. tive and comprehensive AIDS responses in five integrated action areas, which reflect: These areas are closely interlinked. Bank support country needs; the Bank's mandate, capacity Strengthened strategic plans will require im- aims to be and comparative advantages; the findings of proved monitoring and evaluation systems comprehensive, reviews of the Bank's work in AIDS; and the and analytic work, and will guide the alloca- large scale, Bank's commitment to the"Three Ones"vi- tion of new funding.Accelerated implemen- sion of one national strategic plan, one na- tation requires more effective partnerships. flexible, tional coordinating authority and one Strengthened national monitoring and eval- grounded in national monitoring and evaluation system uation systems and more evidence-in- evidence, in each country. In addition to financial, formed programming requires rigorous complementary, technical and analytical support included in analytic work, which in turn, requires more the six Bank regional HIV/AIDS business comprehensive and timely data from na- coordinated and plans and strategies, and actions to main- tional monitoring and evaluation systems. aligned stream AIDS into sectors beyond health, there are also actions to complement and The key principles that underlie the Program support the regional operational work. Dis- of Action are: cussions with regional HIV/AIDS focal points, managers and Task Team Leaders in · The objective of the Bank's HIV/AIDS the Bank as well as with stakeholders out- work is to support client country efforts to side the Bank have led to a consensus on the prevent new infections, and to treat and priority actions chosen. care for people who are infected and af- fected by HIV/AIDS. The action areas endorsed are: · The Bank HIV/AIDS program needs to be at a scale capable of making a significant · Support for strengthening national impact on the HIV/AIDS epidemic and its HIV/AIDS strategies, to ensure they are consequences. truly prioritized and evidence-based ,and · Bank activities must be firmly grounded integrated into development planning; in available and emerging evidence. · Continued and sustained funding for na- · It is important to be flexible, adapting to tional and regional HIV/AIDS programs, meet different needs in different loca- and for strengthening health systems, to tions, and to adjust actions in the light of support effective HIV/AIDS responses that new evidence. are of sufficient scale and scope; · Bank resources will be used to comple- · Accelerating implementation, to increase ment funding available from other donor the scope and quality of priority activities; and national sources, in support of the ef- · Strengthening country monitoring and forts of the Global Task Team on Improv- evaluation systems and evidence- ing AIDS Collaboration Among informed responses, to enable countries Multilateral Institutions and Interna- to assess and improve their programs; tional Donors · Knowledge generation and impact evalua- · The Bank will focus its efforts in areas tion of what works, as well as other ana- where it has a comparative advantage and 35 can provide the most value-added.These strengthen strategic, prioritized national areas include the ability to respond across plans, which have: a sound epidemiological many sectors; to provide long-term in- foundation and evidence-informed ap- vestments in health system strengthen- proaches; well defined goals and targets; ex- ing; to access a wide range of policy plicit priorities; systematic planning; well makers including especially those re- identified timeframes; clear plans for moni- sponsible for finance, planning and toring, evaluation and knowledge utiliza- macroeconomics; experience and com- tion; clearly specified implementing actors mitment to participatory approaches that and responsibilities; detailed cost estimates; help empower communities; and exten- strategies for resource mobilization; and sive experience, know-how and lessons analysis of the institutional and human re- learned in program preparation and sources required for effective action. implementation. · Partnershipsareessential,toachievecon- The following activities will be undertaken certed, harmonized AIDS responses to strengthen national strategic planning as aligned around country systems. the basis for results-oriented actions: The goal is strategic, · develop practical guidelines for effective, prioritized, Strengthening strategic, prioritized strategic, prioritized planning that guides responses results-oriented actions costed national · prepare good practice notes, highlighting plans with clear The MAP Interim Review and OED review examples of sound national strategic targets, drew particular attention to national strate- planning timeframes and gic planning.1 Under the agreements flow- · develop strategic planning training ing from the GlobalTaskTeam on Improving courses and train Bank staff, consultants, accountability, AIDS Collaboration Among Multilateral In- development partners and national informed by stitutions and International Donors, the counterparts in multi-sectoral strategic evidence Bank, UNDP and UNAIDS have particular planning responsibility to assist countries to improve · provide technical support for national strategic and action planning. The MAP In- strategic planning terim and OED reviews note that few coun- · support the development of a network of tries have adequately incorporated AIDS country practitioners, enabling clients to into PRSPs or other overall national plan- develop and share national expertise in ning and budgeting processes. They ac- strategic planning knowledge that many countries have now · strengthen the links from knowledge prepared national strategic AIDS plans, generation and impact evaluation to pri- which have elevated commitment, broad- oritization of interventions and program ened the response, and increased stake- design holder engagement. However, they note · encourage and support countries to write that national plans do not serve as genuinely synthesis papers, analyzing their HIV strategic tools for guiding and prioritizing epidemiological data and responses, and action. Most plans are not informed by epi- identifying priorities, as a basis for better demiological information or rigorous analy- informed strategic planning. sis of effective approaches. They are all-encompassing and do not prioritize.They HIV/AIDS needs to be integrated into na- lack clear goals and responsibilities. They tional development planning efforts. The tend to be uncosted or unrealistically costed. Regions and the Global HIV/AIDS Program They seldom identify the specific actors and (GHAP) will continue working with PREM responsibilities required to realize their colleagues, client country counterparts, the strategic vision. IMF and other international partners such as UNDP and the UNAIDS Secretariat to bet- Under the aegis of the program of action of ter integrate HIV/AIDS planning into na- the GTT, the Bank, in collaboration with tional development planning and financing, UNDP and other partners,will make a major and especially in Poverty Reduction Strate- commitment to assist countries to gies (PRSPs), CASs and Medium-Term Ex- 36 The World Bank's Global HIV/AIDS Program of Action penditure Frameworks (MTEFs). An port HIV/AIDS efforts in countries that are HIV/AIDS dimension will be added to the ineligible for national assistance, and for Operational Guidelines for PRSPs and Joint cross-border activities. Predictable, multi- Staff Assessment criteria for PRSPs in coun- year Bank funding can help countries ensure tries with high or rapidly rising HIV levels. sustainability of their HIV/AIDS programs. The Global HIV/AIDS Program Monitoring and Evaluation Team (GAMET) will provide Within countries, the Bank will use its flexi- more analytical and advisory services to as- bility to finance major gaps in HIV/AIDS sist key stakeholders (especially Ministries programs that other funders cannot address of Finance and Planning and Bank Country as effectively. Specific examples include fi- Teams) to give appropriate priority to nancing long-term institutional and operat- HIV/AIDS interventions in PRSPs and ing costs, and activities and commodities MTEFs.CASs should make explicit (i) the ra- that may be controversial, including clean tionale for including or excluding interven- needle programs to reduce HIV transmis- tions to support the national AIDS response, sion among injecting drug users and con- and, where relevant, (ii) how Bank projects doms to prevent HIV transmission among and policy-based lending will help a country sex workers and their clients. Bank procure- AIDS financing attain its HIV/AIDS objectives. ment procedures that require countries to will increasingly purchase competitively at least cost can have reflect the Rigorous, genuinely strategic national plans positive spill-over into better use of other Bank's flexibility provide an essential platform for concerted, sources of funds as well. coordinated, effective AIDS responses that, with respect to along with the other action areas, will help The Bank will support country efforts to en- the countries the Bank to contribute to better success in sure that prevention and treatment inter- and activities it preventing new infections and increasing ventions are informed by the evidence on can fund the healthy years of life of people with AIDS. quality and outcomes. In prevention, the Bank's support will take into account the fact that epidemiological risks vary across and Funding national and regional within populations and age groups. The HIV/AIDS responses and Bank will support countries to address the strengthening health systems dual TB/HIV problem, particularly in sub- Saharan Africa and Eastern Europe and Bank funding for HIV/AIDS Central Asia. The Bank will remain a major financer of The Bank's ability to fund HIV/AIDS pro- AIDS activities globally, alongside the grams is subject to client countries'decisions Global Fund to Fight AIDS,Tuberculosis and to borrow. The Bank hopes to commit addi- Malaria, the United States Government and tional funding for HIV/AIDS programs in the United Kingdom (DFID) and other fi- the following countries in the coming three nancing partners. The Bank's financing role years (either in dedicated HIV/AIDS proj- increasingly will reflect its greater flexibility ects, or as part of broader support): Albania, with respect to both the countries and range Argentina, Benin, Bhutan, Burkina Faso, of activities it can finance. Thus the Bank is Cameroon, CapeVerde, Chad, Côte d'Ivoire, likely to remain a major source of finance for Ethiopia, Eritrea, the Gambia, Ghana, HIV/AIDS in many of the lowest income Guinea, Guinea Bissau, India, Kenya, Kyrgyz IDA countries, particularly those in central Republic, Madagascar, Mali (within a trans- and west Africa with limited access to other port project), Niger, Nigeria, Senegal, Sierra AIDS funding. The Bank can also lend to Leone, Suriname, Togo, Uganda, Zambia, middle-income IBRD countries that are in- and multi-country projects in the Abijan- eligible for other sources of financing. The Lagos Corridor, and in the Mercosur Bank has demonstrated an ability to estab- countries. lish AIDS programs in post-conflict coun- tries, often more rapidly than other major The current three-year round of conces- financing mechanisms. The ability to fund sional financing, IDA14, has no resources regional programs enables the Bank to sup- earmarked specifically for HIV/AIDS, and 37 The World Bank's Gloval HIV/AIDS Program of Action eligibility for grant funding (rather than re- epidemiological surveillance, reporting payable credits) has changed to depend pri- and response, (iii) standard setting and marily on each country's risk of debt regulation of the public and private sec- distress.2 Countries whose IDA funds are not tors and civil society organisations given as grants may be less willing to request (CSOs); (iv) improvement of local capac- IDA funding for investing in HIV/AIDS than ity in public health and epidemiology; (v) during the previous three years, when all monitoring social and geographic in- IDA funding for HIV/AIDS was provided as equities in outcomes that are amenable to grants. affordable services and to changes in in- dividual or household behaviour; and (vi) Strengthening health systems and the enhancing capacity for behaviour change capacity for service delivery communication. · Health human resources: Upgrading skills Given the demands that HIV/AIDS makes and expanding capacity for training dif- on the health sector in its key role in pre- ferent cadres of health care workers, and vention and treatment, and the weaknesses better incentives to retain and deploy Strengthening in health services delivery in many countries, health care workers where they are health systems the HIV/AIDS interventions that the Bank needed most. and services is a supports in the health sector need to be de- · The Bank will provide financing and ad- signed to help strengthen the health care de- visory services to improve local capacity crucial part of livery system. The Bank will continue to for managing logistics of pharmaceuticals HIV/AIDS provide funding and support to strengthen and other supplies, procurement and fi- programs and health systems and client country capacity nancial management, health manage- broader health for service delivery, as part of HIV/AIDS pro- ment information systems, and health gram funding, and/or within broader health care waste management systems. sector support sector support. · Upgrading of health care facilities, med- ical laboratory infrastructure and services Depending on country decisions, new to enhance diagnostic capacity. health sector funding may be committed in · Some countries are working with the the coming three years in Africa in Burundi, Bank to design incentives for better out- Cameroon, Democratic Republic of Congo, comes in the health sector; if successful, Côte d'Ivoire, the Gambia, Ghana, Lesotho, this approach could be expanded. Madagascar, Mali, Mauritania, Niger and Zambia; in the EastAsia and Pacific region in The Bank will continue to participate with Cambodia, Indonesia, Lao People's Democ- partners in efforts to seek common ap- ratic republic, the Philippines, Timor-Leste proaches and policies to key areas of health andVietnam; in Europe and Central Asia in system strengthening, and to take forward Albania, Azerbaijan, Croatia, Kyrgyz Repub- the work of the Global Task Team on Im- lic, Moldova, Poland, Tajikistan, Turkey and proving AIDS Collaboration Among Multi- Ukraine; in Latin America in Brazil, Colom- lateral Institutions and International bia, Ecuador, Panama, Paraguay, Peru, Donors, the High Level Forum, Joint Learn- Uruguay and Venezuela, as well as in India, ing Initiative, Global Health Council and the Lebanon and the West Bank and Gaza. recommendations of the World Health As- sembly, to strengthen key aspects of health Several key aspects of health systems are systems and health service delivery at coun- likely to receive particular attention: try level, within a sustainable fiscal framework. · To strengthen governments' capacity to perform key public health roles, in collabo- Supporting stronger HIV/AIDS ration with specialized institutions, the responses in other key sectors Bank will support the following cross- cutting issues that are relevant to The Bank is also working with client coun- HIV/AIDS: (i) formulation of public tries and other key partners to support health policies for disease control and stronger HV/AIDS responses in selected key services with positive externalities, (ii) sectors and areas (in addition to health), es- 38 The World Bank's Global HIV/AIDS Program of Action pecially in education, legal, gender, youth, jan-Lagos transport corridor is beginning to transport, infrastructure and the private sec- offer useful lessons that could be applied in tor. GHAP and other Bank staff working on other corridors, specifically in a proposed AIDS will support and encourage efforts to new HIV/AIDS transport corridor project in mainstream effective HIV/AIDS interven- Southern Africa.The Africa Transport Group tions into the work of other sectors in the are working with key transport sector deci- Bank. sion makers in Anglophone and Francoph- one countries, to support development of In the education sector, HDNED's School policies on HIV/AIDS for transport workers, Health program will continue working, at implementation plans, and local networks the request of the regions, to support Africa, for sharing information and advice. LAC and SAR's efforts to accelerate and en- hance the education response to HIV/AIDS. The Urban Sector will continue to support This will be done by working through na- Local Government Responses to HIV/AIDS tional education systems, in the context of in several ways, including: (1) supporting efforts to achieve the MDG and Education urban operational units to mainstream for All goals.The country level work focuses HIV/AIDS responses into their policy dia- Work will on implementing activities in schools and logue and projects; (2) supporting local gov- continue to communities, and regional level work fo- ernments directly by providing them with mainstream cuses on strengthening leadership and shar- updated and enhanced training material and effective ing knowledge. The emphasis is on toolkits; (3) ensuring that local governments prevention--especially for girls--and en- and decentralized responses are adequately HIV/AIDS suring access to education for orphans and taken account of in the design and imple- interventions in vulnerable children, and addresses the re- mentation of multi-sectoral HIV/AIDS pro- key sectors in sponse at all educational levels. A key ele- grammes; and (4) supporting relevant addition to ment is to help the education sector make analytical work including analysis of the im- use of resources within the sector as well as pact of HIV/AIDS on the urban sector. In ad- health funds available specifically for HIV/AIDS ef- dition, the Bank will continue to coordinate forts. Good practice examples in school- and engage with external partners to share based prevention programs, in programs to best practice, knowledge and practical increase access to school for HIV/AIDS or- guidance. phans, and explaining the role that teachers can play in addressing HIV/AIDS will be In the legal sector, the work will focus documented and widely disseminated. This mainly on how to improve laws that could work benefits from the collaborative effort of protect PLWHA against discrimination and the Working Group of the UNAIDS Inter protect children orphaned or made vulnera- AgencyTeam for Education to accelerate the ble byAIDS; and advice on intellectual prop- education sector response to HIV/AIDS. erty rights (patents) and international trade law relating to pharmaceuticals (especially Transport and infrastructure: All con- generic ARV drugs). struction contracts with Bank funding should include HIV/AIDS activities (con- With respect to gender dimensions of dom distribution and IEC, and treatment HIV/AIDS, the PREM Gender and Develop- could also be included)."Good practices"will ment Group (PRMGE) will continue and ex- be highlighted to help companies do this in pand analytical and operational work to an effective way.TheTransport Sector Board, integrate a gender dimension into with GHAP and health sector colleagues, HIV/AIDS policy and operations, building will develop an action plan to ensure a more on the new Operational Guide on Gender proactive HIV/AIDS response in the trans- and HIV/AIDS.3 The main focus will be col- port sector across the Bank. In India and laboration with associations of judges and Africa, HIV/AIDS activities will be incorpo- women's lawyers, government agencies and rated into all new transport and infrastruc- civil society groups, to strengthen capacity ture projects, and added to existing projects among law, justice, medical and health sec- in Africa during mid-term reviews. In West tor institutions and professionals to address Africa, the HIV/AIDS project for the Abid- the gender and legal dimensions of 39 The World Bank's Gloval HIV/AIDS Program of Action HIV/AIDS. Relevant topics will include the management capacity building, including gender-responsiveness of existing legal holding national and regional training frameworks in the HIV/AIDS setting,in such workshops. areas as customary law/practices, religious · Based on learning and experience, con- laws, land law, inheritance and property tinue to simplify operational processes rights, family law, women's rights issues in and guidelines for HIV/AIDS projects and the context of gender-based violence, and encourage countries to use exceptional the links between HIV/AIDS and conflict, implementation procedures (such as out- post-conflict reconstruction and trafficking sourcing fiduciary management). in women and girls. · GHAP will continue to work with the re- gions to ensure that AIDS project super- vision is adequately funded, and to raise Accelerating implementation and use TF resources to provide the addi- tional implementation support needed to The GTT noted that improving program im- deliver the comprehensive, flexible and plementation at country level and ensuring adaptable "program support" on which Ongoing and better coordination and harmonization on the MAP approach is built. new efforts will the part of donors are essential to accelerat- · The Bank's Implementation Acceleration support faster, ing and maintaining the world's response to Team (IAT) comprises key staff from across the HIV/AIDS epidemic. The"implementa- the Bank working with OPCS andTTLs to more efficient, tion gap" can be substantially reduced if see where Bank policies need to be effective and countries and donors use exceptional poli- streamlined or simplified to facilitate MAP transparent cies and procedures commensurate with the implementation. This team will be implementation exceptional nature of the epidemic, and if strengthened, drawing on expertise from implementation by key stakeholders in the across the Bank, to become an AIDS Im- of HIV/AIDS public and private sector and in civil society plementation Advisory Service (IAS) that programs becomes faster, more efficient, effective and will work with countries and Bank project transparent. While the most flexible and teams, especially in the areas of planning, least bureaucratic Bank instrument--the budgeting, program design, financial Africa MAP--is disbursing at about 90 per- management, disbursement and procure- cent of original projections, higher than av- ment,expenditure tracking,and scaling up erage for Bank lending in general, this pace programs in the public and private sectors is still insufficient to deal with the challenges and in civil society. This will build on the in prevention, care and treatment and im- work of the IAT and of ACTAfrica, moving pact mitigation. The Bank has reaffirmed its into a new phase that goes beyond look- commitment to improving implementation ing at Bank policies and procedures to the as one of its areas of focus in the division of way they are in fact practiced, and work labor between agencies through the Global with Bank teams and country counterparts Task Team. to improve practice on-the-ground. We will use country, regional and global pub- To further accelerate and strengthen lications, workshops for regional learning, HIV/AIDS program implementation, the implementation advisory service missions Bank will: to countries, and operational guidelines for the Bank, and potentially for other · Continue to provide financial and techni- donors, to carry out this work. cal support through lending and Institu- · The private and non-profit sectors, civil tional Development Fund grants to society groups, communities and people countries to enhance capacity and sys- living with HIV/AIDS are essential part- tems, improve human resources, infra- ners in every country. The regions and structure and equipment, and fund GHAP will continue to support the active essential administrative and operating involvement of private sector and civil so- costs of their HIV/AIDS programs over ciety organizations, including FBOs, to the medium to long term. scale up and manage HIV programs. De- · Continue to support the global partner- pending on country needs, this may in- ship on ARV procurement and logistics clude (i) supporting policy changes to 40 The World Bank's Global HIV/AIDS Program of Action allow scaled-up contracting of services to pacity building and systems development, NGOs (e.g., legal frameworks, registering particularly in countries with limited public of NGOs); (ii) providing conditional cash sector capacity and human resources, chal- transfers to communities to help care for lenges exacerbated by poverty and AIDS those most affected by the epidemic and mortality. continuing to ensure wide access to MAP and other donor funds, through compet- Many countries have elements of an itive, transparent and results-based HIV/AIDS monitoring and evaluation sys- processes; (iii) encouraging governments tem in place, but few countries have com- to promote greater diversity in service de- prehensive monitoring and evaluation livery systems; (iv) hands-on in-country systems, which track both the epidemic and work with national AIDS commissions, national responses to the epidemic and use ministries, donors, business and labor or- the results for program improvement. A ganisations, civil society groups including comprehensive M&E system comprises the FBOs and communities to create mecha- following components: nisms and energize partnerships to ad- dress HIV/AIDS. · One overall national M&E system, with a Good monitoring · GHAP and the Bank's regional units will guiding flowchart, which specifies pre- and evaluation generate and capture knowledge about cisely how data flows from each M&E systems track good HIV/AIDS implementation prac- component and each level, to a single the epidemic tices, which GHAP will make widely and overall national data repository. readily available. GHAP will assist the · Biological surveillance (of HIV status), to and national Bank's regional units to create networks assist countries to implement sound, reg- response, of program practitioners to exchange ex- ular,credible,affordable,HIV surveillance informing periences, knowledge and practical ad- of the general population and vulnerable decisions to vice across countries and globally that will groups,in keeping with international best encompass general operational issues, practice. improve the fiduciary architecture, and special · Behavioral and social surveillance, to as- program impact programmatic themes. These efforts will sist countries to implement sound, regu- support the GTT's commitment to better lar, credible, affordable surveillance of key implementation of the Three Ones. behaviors among the general population and priority groups, based on interna- Accelerated implementation of AIDS proj- tional best practice.5 When combined, bi- ects and programs--especially care and ological and behavioral surveillance treatment for infected people--requires constitute a second generation surveil- strong health systems. The broader work of lance system, in which behavioral and bi- the Bank's HNP sector in strengthening ological data and trends are examined health care systems is crucially important, together, for reciprocal elucidation and and the GHAP will look for opportunities to greater understanding of the epidemic work with the HNP group and relevant units and behaviors contributing to it. in WHO to enhance and support this work. · Health facility surveillance,to continually assess the coverage and quality of essen- tial HIV related health services. Strengthening country monitoring · Research,to address keyAIDS prevention, and evaluation systems and care and treatment research questions. evidence-informed responses · Program activity monitoring, to assist countries to track HIV/AIDS related ac- AIDS resources have grown rapidly in recent tivities and services.The goal is for all im- years, from US$300 million in 1996 to US$8 plementing partners to submit regular, billion in 2005.4 As the GTT noted, the criti- structured program monitoring reports to cal need to ensure that available resources a well-functioning system, to enable na- are used effectively places unprecedented tional AIDS program coordinators con- responsibility upon country monitoring and tinuously to assess the scope and quality evaluation systems. Improved national sys- of key interventions and identify and ad- tems require a sustained commitment to ca- dress gaps and limitations promptly. 41 The World Bank's Gloval HIV/AIDS Program of Action · Financial monitoring, to enable countries · Working together to provide case-specific to track expenses, cost services and cor- assistance, including diagnosis and trou- roborate program activity reports. bleshooting, using the complementary · Program impact evaluation,to guide allo- strengths of major development partners. cation of resources and effort. Through these activities, GHAP and part- The GTT recently reaffirmed the Bank's par- ners will collectively and jointly assist a pro- ticular responsibility, in collaboration with gressively larger number of countries to the UNAIDS Secretariat, for strengthening develop comprehensive, functioning moni- country monitoring and evaluation systems.6 toring and evaluation systems. This work The Bank established the Global HIV/AIDS will be done in collaboration with technical Monitoring and Evaluation Team (GAMET) staff of other agencies who are also assigned to provide country support. In cooperation to help build country M&E capacity, to work with UNAIDS cosponsors and other part- together to realize this part of the "Three ners within the framework of the Monitoring Ones"vision at country level. and Evaluation Reference Group (MERG), The Global AIDS GAMET will continue to provide M&E sup- The Bank and partners will also assist coun- Monitoring and port through the following activities: tries to use their monitoring and evaluation Evaluation Team systems to promote effective, evidence-in- · Developing and regularly revising guide- formed prevention, care and treatment re- (GAMET) lines for national monitoring and evalua- sponses. Few countries base their responses provides tion systems. on a rigorous analysis of national HIV trans- practical, in- · Preparing good practice notes that high- mission dynamics and priorities for effective country support light examples of promising national interventions, or undertake rigorous impact responses. evaluation. Numerous reviews draw atten- · Co-facilitating global, regional and na- tion to the need for more selective,evidence- tional M&E training courses. informed national responses. By · Continuing to build one unified, multi- strengthening national monitoring and agency, global country support team evaluation systems as described above and (CST) of international monitoring and intensifying analytic work as outlined below, evaluation specialists, who provide inten- the Bank, working with specialized technical sive practical monitoring and evaluation agencies and research institutions, will assist field support to countries. countries to implement strategic, data- driven, evidence-informed approaches.This As a major source of practical, in-country will increase the impact of investments in M&E support, the country support team un- HIV/AIDS programs. dertakes the following activities in order to support the development of national moni- The Bank HD Network Chief Economist toring and evaluation systems: leads a team that provides advice and help to Bank staff for designing ways to generate · Coordinated, multi-agency country sup- knowledge about good practices and to eval- port visits, to understand monitoring and uate the impact of Bank-funded projects, evaluation needs and priorities. with the goal of learning what works, what · Harmonized and participatory develop- doesn't, and why. The regions and GHAP ment of national monitoring and evalua- will encourageTTLs of HIV/AIDS projects to tion frameworks, with indicators. take advantage of this support, and will doc- · Working with development partners and ument and share good practice examples countries to: develop operational plans,in- and evaluation results. cluding detailed descriptions of essential actions to strengthen biological,behavioral and health facility surveillance; enhance Knowledge generation and sharing, evaluation research; and develop program impact evaluation and analysis and financial monitoring systems. · Jointly training national AIDS authorities There are many aspects of the epidemic and implementing partners; and about which much remains to be learned. 42 The World Bank's Global HIV/AIDS Program of Action There is a need for country-specific analytic over 70 developing countries. The Bank work to help make important policy and will use this existing project infrastructure program decisions. The analytic work in- to carry out impact evaluations of its in- cluded in regional and country work plans terventions. To do this, additional re- will address key country-specific issues. sources and technical assistance will be GHAP will support cross-cutting and cross- provided to project task teams by GHAP country analytical work in priority areas, which will mobilize trust funds to support working with DEC, PREM, the IMF and this effort. other researchers, especially those with a · Carry out prospective evaluations of new strong client-country presence. Working HIV/AIDS projects. Prospective evalua- with specialized technical agencies,the Bank tions are time sensitive and need to be de- will sponsor or conduct operational research signed, and baseline data collected, on key issues related to large-scale anti- before the implementation of a project retroviral treatment in resource-limited set- begins. An expert consultative group will tings,including quality,effectiveness,impact be formed to help develop carefully and outcomes, and risk behaviors of people planned and scientifically sound prospec- on ARV treatment. tive evaluations of new HIV/AIDS New country- projects. specific and Knowledge generation and impact cross-cutting evaluation about what works Analytical and advisory activities analyses will The international community must signifi- Planned country-specific and regional ana- increase our cantly improve the effectiveness of lytic work covers the following areas: understanding HIV/AIDS responses in order to reduce new of HIV/AIDS and infections and meet the needs of people af- · HIV/AIDS country situational analyses in what works fected by and living with HIV/AIDS. Cur- Maldives, Afghanistan rently, there is insufficient evidence on"what · Analysis of treatment options in Nepal, works"when it comes to issues as diverse as Bhutan,Thailand fighting communicable diseases among · Evaluation of different prevention strategies groups with high-risk behavior or ensuring in Bangladesh, Pakistan, Bahamas, com- access to health care in resource-poor com- parative assessments of the Ukrainian munities.As a result, national strategic plans and Russian National HIV/AIDS Pro- and donor funding decisions are frequently grams, assessment of the HIV/AIDS pub- devised without the benefit of sound evi- lic information campaign in Russia dence-based analysis. · Estimates of the economic impact of HIV/AIDS or links with poverty in Ar- By virtue of its focus on long-term develop- gentina, India, Jamaica and Grenada ment, the World Bank is in a unique position · Studies on mobile populations in Caribbean to play a leading role in providing policy ad- and Central America vice and programs that are evidence-based. · Analysis of AIDS expenditures in India, By building upon its lending and non-lend- China, Cambodia ing activities, the World Bank can establish a · Local government, community or NGO re- continuous and deliberate process of learn- sponses to HIV/AIDS: Africa (local govern- ing and sharing information and applying ments) and Ethiopia (communities), the acquired knowledge to program design. Caribbean (NGOs and private sector) Establishing such a systematic process will · Assessments of legal and regulatory issues assist governments, the Bank and its devel- (including implications of trade agree- opment partners to devise increasingly ef- ments) relating to pharmaceuticals, dis- fective AIDS responses. To implement this, crimination against PLWHA, protection the Bank will do the following: of children orphaned by AIDS in Africa, Caribbean and Central America and in · Carryoutimpactevaluationsofdevelopment selected countries in South Asia. programs. Through its involvement in · Operationalizing the "Three Ones", joint HIV/AIDS projects, the Bank supports work with WHO, DFID, SIDA and UN- implementation of the AIDS response in AIDS in Russia 43 The World Bank's Gloval HIV/AIDS Program of Action · Analysis of health systems, health sector · Lessons from operational experience,includ- service delivery issues or institutional issues ing evidence of the effects of Bank sup- in Argentina, Azerbaijan, Bulgaria, Bu- port on service delivery, and on the rundi, Indonesia, Jordan, Madagascar, performance of key entities with the Mauritius, Nepal, Nigeria, Oman. biggest responsibility for aspects of · Analysis of implementation constraints in HIV/AIDS programs that depend on the Caribbean. health systems; comparisons of the effec- tiveness of different programs; and donor New global and cross-cutting analysis to be coordination and harmonization efforts funded or undertaken by GHAP, DEC, especially at country level. PREM, HDNED, LEGVP and other key units in the Bank is likely to include: Knowledge sharing, dissemination and use · Analysis of the links between poverty,gender and HIV, including the likely interaction Researchfindingsandemerginglessonsofex- between HIV programs and broader ef- perience need to be shared widely and Research forts to reduce poverty; and the long- quickly, so they can be incorporated into pro- findings and term impact of HIV and higher mortality. gramming decisions. More will be done to lessons of The work will assess the extent to which share analytic and program/project results public expenditures on HIV/AIDS treat- broadly and to target potential users during experience need ment, care and impact mitigation reach program/project planning and implementa- to be shared poor people, and mechanisms for im- tion.Full use will be made of existing distribu- widely and proving targeting. tion and dissemination channels, including quickly, to · Analysis of the economic and budgetary im- conferences and workshops, journals, plications and fiscal impact of HIV, looking at newsletters and list-serves and communities inform decisions expenditures and revenues, costing the of practice. State-of-the-art workshops, con- national HIV response, and assessing the ferences and debates will be convened as impact on economic performance and on needed, to discuss latest research and think- the skilled labor market in the public and ing, good practice and lessons of experience private sectors, notably health, education, on current controversial and cross-cutting is- agriculture and the civil service.GHAP will sues on HIV/AIDS prevention, care and offer funding to key sectors in the Bank treatment. (such as education and social protection) to analyze the impact of AIDS in specific The Bank will develop and implement a core sectors and actions to mitigate the effects. learning program for Bank staff on the epi- · Analysis of potential policy and program demiology of HIV/AIDS, with emphasis on trade-offs,including how to ensure enough the analytical basis for improved decisions in attention is given to prevention, care and program design, as well as appropriate indi- treatment and mitigation, the implications cators for monitoring and evaluation,and on of long-term and short-term responses, the "Three Ones" principles and how Bank the comparative costs and benefits of dif- staff can help realise the vision in the coun- ferent approaches, and operational re- tries where they work. search on quality and cost tradeoffs, and resource requirements for deploying new The Bank's AIDS website will be improved diagnostics and treatments. This research and used to provide quick and easy, user- will contribute to policy discussions and friendly access to information on Bank sup- decisions at the country level. ported HIV/AIDS project and Bank reports, · Analysis of institutional and structural fac- papers, manuals, etc. on HIV/AIDS.The"re- tors that influence program effectiveness and vamping"will ensure that the users will eas- response effectiveness of public sector agen- ily be able to find information on the Bank's cies, including decentralization, human work on HIV/AIDS. The country HIV/AIDS resource policies, service delivery capac- synthesis papers referred to earlier will be ity, means of delivery (whether public, published and posted on the website, and a private or CSOs, for example) and market new series of HIV/AIDS Discussion Papers incentives. will speed up publication and dissemination 44 The World Bank's Global HIV/AIDS Program of Action of new analysis.The Bank will make its work and harmonized national AIDS responses of available in a wider range of languages, to sufficient focus, scope and quality to reduce increase accessibility. HIV transmission, and achieve the interna- tional AIDS targets outlined in the MDGs A new series of short reports and notes high- and UNGASS. Strong working partnerships lighting examples of HIV/AIDS work will be at country level are also key to putting the developed in collaboration with UNAIDS, to "Three Ones" vision into practice. The im- share operationally useful information and portance of the"Three Ones"principles was experience.7These notes will help to publicize also reaffirmed in the G8 Gleneagles national and cross-country lessons of experi- Communiqué. ence quickly.The topics will include examples of GAMET's work on monitoring and evalua- Within the Bank, the Global HIV/AIDS Pro- tion, good examples of work with and being gram and regions will continue to work done by CBOs and NGOs; good examples of closely together, to ensure that the overall school-based HIV prevention programs and and regional AIDS strategies are coordi- efforts to ensure access to school for orphaned nated and complementary and reflect an op- children; and good examples of country-level timal division of responsibilities. GHAP will Strong global donor harmonization and coordination. intensify its cooperation with PREM, to and country- strengthen economic analysis of the epi- level New Guidelines to be developed and pub- demic and its links to poverty, gender and partnerships will lished include the following topics: vulnerability. With the IMF, the Bank will help countries to integrate HIV/AIDS into help realize the · preparing HIV/AIDS projects in a post- their overall budget planning and manage- "Three Ones" conflict setting ment processes, including MediumTerm Ex- and ensure · legal aspects of HIV/AIDS (primarily for penditure Frameworks and PRSPs. GHAP coordinated, Bank staff) will work closely with HNP, whose leader- · legal protection for children orphaned or ship in efforts to strengthen health systems harmonized, made vulnerable by HIV/AIDS (primarily and health services delivery and health fi- effective support for governments) nancing is crucial to country capacity to ad- · Guidelines on how India's new patent dress HIV/AIDS. Work with the Education law relates to HIV/AIDS drugs. group (HDNED) will continue, to promote a broader, more effective education sector re- The Bank will support opportunities for sponse, and to extract and build on what has countries to share their experiences, through been learned so far.GHAP will also continue networks of practitioners and"south-south" to work with the Legal Unit and Gender consultations on topics of shared impor- group. New work will be initiated with the tance, such as the consultation planned Transport Sector Board, to better integrate among Pakistan, Afghanistan and Iran on HIV/AIDS into transport activities, and with harm reduction and high risk groups. Other HDNDE, to understand how the Bank can examples of similar efforts being supported best work with religious and faith leaders by the Bank include technical cooperation and institutions on HIV/AIDS. GHAP and visits and virtual meetings among Moldova, the regions will also continue to work in the Ukraine, Russia and Brazil; "twinning" close concert with IFC Against AIDS, in arrangements between the Caribbean and order to strengthen private sector AIDS re- Central Asian regional HIV/AIDS organisa- sponses. The work led by WBI will continue tions, and between the Russian business to provide training to staff and clients in pri- council on HIV/AIDS and the European ority areas, especially program manage- Branch of the Global Business Council and ment, and ARV procurement and supply the Brazilian Business Council on HIV/AIDS. management. The World Bank's many external AIDS part- Working together nerships include the UNAIDS secretariat and other cosponsors, major international The GTT emphasizes that effective partner- financing agencies, PLWHA and other civil ships are essential to ensure coordinated society groups, and the private sector. The 45 The World Bank's Gloval HIV/AIDS Program of Action Bank's partnership with UNAIDS and other can diverge, so public-private partnerships cosponsors will continue to be of the utmost need to be structured well, to take advantage importance, particularly in light of joint ac- of potential synergies. tions recently agreed as part of the GTT. Within the UNAIDS family, the Bank has formal responsibility for economic analysis The broader perspective and the development of country monitoring and evaluation systems and is also recog- Recognizing that a "business as usual" re- nized for its leading role in strategic plan- sponse to HIV/AIDS was grossly inade- ning, institution building and quate, in the new Millennium the Bank implementation, which are all reflected in launched its innovative MAP program to the priority areas of this Program of Action.8 support quick, forceful, substantial and sus- tained action against the epidemic in as With respect to civil society, including peo- many client countries as possible. Many les- ple living with HIV/AIDS, a large and grow- sons have been learnt in the process and are ing literature attests to the importance of reflected in the priority actions in this pro- Civil society, continued strong Bank efforts to foster com- gram. Momentum must be maintained, be- including people munity leadership and engagement in AIDS cause millions of lives and the development living with prevention, care and treatment. The Bank gains and prospects of many countries are at will strengthen its partnerships and con- stake. The effect of AIDS in slowing or even HIV/AIDS, and tinue to provide financing, through national reversing progress towards many of the Mil- the private and structures, to civil society at all tiers, includ- lennium Development Goals (MDGs) is non-profit ing non-government, faith-based and com- clearly evident in Africa. sectors all have munity organizations, and local universities and researchers. The MDGs envision that by 2015 the world key roles will have halted and begun to reverse the The Bank will also strengthen its partner- AIDS epidemic.9 The Declaration of Commit- ships with the private sector to leverage in- ment on HIV/AIDS--unanimously adopted creased private sector resources for AIDS, by UN Member States at the unprecedented enlist the private sector's expertise and ca- UN General Assembly Special Session (UN- pacity in the fight against AIDS and utilize GASS) on HIV/AIDS in 2001--includes a the private sector's enormous reach to in- comprehensive set of concrete, time-bound crease the coverage of essential AIDS pre- targets to elicit effective global, regional and vention, treatment and care services. The national responses to the epidemic.10 This interests of private and public sector players Program of Action reflects and furthers the Civil society and communities play key roles in responding to AIDS Civil society plays a vital advocacy role,spurring countries to intensifyAIDS prevention,care and treatment programs.Widespread community engagement reduces stigma, pierces denial,promotes personal risk per- ception,and instils personal proximity to the epidemic,helping change community norms and individual behaviors in ways that reduce HIV transmission.In addition,civil society and community partners can play a critical role in implementingAIDS activities in both concentrated and generalized epidemics,and promoting interventions that reach marginalised groups at high risk and with high rates of HIV infection. In Brazil's concentrated epidemic,for example,vulnerable community members played a major role in mo- bilizing effective prevention,care and treatment responses among men having sex with men,injecting drug users and sex workers.In Uganda's generalized epidemic,the involvement of community and faith-based leaders played a major role in reducing stigma,increasing communication aboutAIDS,increasing personal risk perception,changing community norms and promoting safer sexual practices.InThailand and elsewhere,civil society and community partners have demonstrated an ability to motivate people with AIDS to seek antiretroviral therapy and to adhere to treatment regimens. 46 The World Bank's Global HIV/AIDS Program of Action Millennium Development Goal Africa Progress AIDS effect Reduce poverty/hunger Stagnant at best Large Universal primary education Lagging Moderate Gender equality Lagging Large Child & infant mortality Worsening Large Maternal health Worsening Large Combat AIDS & diseases Worsening Large Environmental sustainability On track Minimal Improve global partnerships On track Favorable Bank's commitment to support national Results: Improving the Effectiveness of governments and programs as they strive to- HIV/AIDS Assistance. wards these important goals. 2. The changes in criteria for financing terms (all grant, half grant/half credit, or all credit) are The fight against HIV/AIDS has entered a summarized and explained in a note issued to new phase. In the 24 years since the virus Word Bank staff in March 2005:"Summary of was identified,much has been learned about IDA14 Policies for Operational Staff". IDA14 re- its epidemiology and about prevention, sources for grant funding are 20% greater than treatment and care.The recent enormous in- under IDA13.The net effect on funding that will crease in funding offers new potential to put be extended for HIV/AIDS as grants under our accumulated knowledge into action, on IDA14 remains to be seen, although it is an unprecedented scale. HIV/AIDS used to expected that about 30% of all IDA14 funding be seen as a health problem, now it is recog- will be provided as grants. Only the 81 poorest nized as a broad development problem. countries with per capita GNI below $895 are What started as an emergency response has eligible for IDA funding; these changes have no become a long-term commitment. The ini- effect on Bank financing on IBRD terms tial few agencies working on HIV/AIDS have available to higher-income countries. More been joined by many more, and the efforts information is available at: www.worldbank.org/ and resources of all are desperately needed. IDA But these efforts must be harmonized and 3. Integrating Gender Issues into HIV/AIDS, coordinated to provide efficient and effective An Operational Guide. 2004, Gender and support to countries, instead of deluging Development Group (PREM), World Bank. countries with multiple demands and http://www.worldbank.org/afr/aids/map/ pulling them in many different directions. Gender_and_HIV-AIDS_Guide_Nov-04.pdf 4. UNAIDS. 2004 Report on the Global AIDS This Program of Action embodies the World Epidemic. Bank's commitment to work with our col- 5. Key behaviors to monitor are: age of sexual leagues, partner agencies and client coun- debut, multiple partners, commercial sex and tries, doing all we can, as best we can, to condoms use. prevent new infections and treat and care for 6. UNAIDS. 8 April 2002. Convening Agencies: people infected and affected by HIV/AIDS, Role and Responsibilities. Geneva: UNAIDS. guided in each country by one strong na- 7. These would complement the UNAIDS tional HIV/AIDS program, coordinated by "Best Practice"collection. one national authority, and monitored and 8. UNAIDS. 8 April 2002. Convening Agencies: evaluated within one national system. Role and Responsibilities. 9. United Nations General Assembly. 2000. "United Nations Millennium Declaration." Notes [www.un.org/]. 1. World Bank. October, 2004. Interim Review 10. United Nations General Assembly 2001. of the Multi-Country HIV/AIDS Program for "Declaration of Commitment on HIV/AIDS." Africa, and World Bank. 2005. Committing to NewYork. 47 The World Bank's Gloval HIV/AIDS Program of Action Matrix 1: Global AIDS Program of Action--Matrix of goals, actions, timing and accountability Goal Specific Actions Timeline Key Accountability Action Area: Assist countries to strengthen strategic, prioritized costed national planning, as agreed by the GTT Countries develop Develop practical guidelines for effective, strategic, FY06 GHAP, UNAIDS strategic, prioritized, prioritized planning costed national Prepare good practice notes, highlighting examples of FY06-FY08 GHAP, Regions HIV/AIDS plans sound national strategic planning Develop strategic planning training courses and train FY06-FY08 GHAP, WBI National counterparts, Bank staff, development partners and consultants in strategic planning Provide technical support for national strategic planning FY06-FY08 GHAP, Regions Support the development of a network of country FY06-FY08 GHAP, Regions practitioners, enabling clients to develop and share national expertise in strategic planning Strengthen links from knowledge generation and impact FY06-FY08 GHAP, Regions, DEC evaluation to improve prioritization and program design Assist countries to write synthesis papers, analyzing their FY06-FY08 GHAP, Regions epidemics and optimal responses, as a basis for better informed strategic planning. HIV/AIDS is better Add HIV/AIDS to Operational Guidelines for PRSPs and FY06 UNDP,OPCS,PREM, integrated into Joint Staff Assessment criteria for PRSPs in countries GHAP, HDNHE national development with high or rapidly rising HIV levels. planning Expand GAMET's mandate to assist countries to give FY06-FY08 UNAIDS, UNDP, appropriate priority to HIV/AIDS in PRSPs GHAP, GAMET Incorporate HIV/AIDS into guidelines and process for FY06-FY07 GHAP, PREM, IMF, UNDP, HDNHE preparing Medium Term Expenditure Frameworks Build MOH and MOF capacity to address macroeconomic FY06-FY08 WBI, UNDP policies that might impede rapid scale-up of HIV/AIDS activities Engage high-level policy makers to advocate for HIV/AIDS response FY06-FY08 Regions, HDNHE, WBI, UNDP, UNAIDS CAS's to provide, when relevant, rationale for including FY06-FY08 OPCS, PREM, GHAP, UNDP or excluding support for HIV/AIDS, and how the Bank program will help the country attain its HIV/AIDS goals. Action Area: Fund national and regional HIV/AIDS programs and health sector strengthening The Bank remains a Lend and provide grants to countries and for regional FY06-FY08 Regions, GF and other major and flexible HIV/AIDS response major funders, GHAP financer for HIV/AIDS Health systems are Provide long-term funding and support for health FY06-FY08 Regions, HDNHE, WHO, strengthened, i.a. system strengthening GHAP to improve capacity Take forward, in practical ways, the work on health FY06-FY08 HDHNE, Regions, partners, to handle HIV/AIDS system strengthening of the High Level Forum and GHAP prevention and treatment other global initiatives Support Education: strengthen school health programs in Africa, SAR, FY06-FY08 HDNED (at request of mainstreamed LAC; disseminate good practice examples in school-based Regions), UNESCO, GHAP HIV/AIDS prevention programs, programs to increase access to school response in of HIV/AIDS orphans and role of teachers in addressing HIV/AIDS; key sectors coordinate with partners and local experts. Transport and infrastructure: Develop plan for mainstreaming FY06-FY08 AFTTR, SASHD and SASEI, HIV/AIDS in Bank transport work, include HIV/AIDS activities Transport Sector Board, in new transport and infrastructure projects in India and Africa, GHAP and add to existing projects in Africa during mid-term reviews. Work with transport policy makers in Anglophone and Francophone Africa to develop HIV/AIDS policies and implementation plans. Prepare HIV/AIDS Transport Corridor project in Southern Africa. Construction contracts with Bank-funding to incorporate IEC and condom distribution. Urban: continue ongoing work to support local governments' FY06-FY08 TUDUR, regions, Urban response to HIV/AIDS, including developing and updating Sector Board, key partners training tools for municipalities; providing support to Bank including Cities Alliance, operational units to incorporate HIV/AIDS response in Urban GHAP operational work, and to involve local governments in HIV/AIDS programs; and working with external partners to share knowledge, good practices, and practical suggestions. Gender and Law: learning dialogues, operational FY06-FY08 Gender and Law TG, GHAP, guidelines and training to improve capacity to address UNAIDS gender and legal dimensions of AIDS among law, justice, medical and health professionals. Legal: review and advise on improving laws to protect FY06-FY08 LEGVP, Regions, GHAP, PLWHA and orphaned children. Give advice on laws UNAIDS relating to ARV patents and trade. 48 The World Bank's Global HIV/AIDS Program of Action Goal Specific Actions Timeline Key Accountability Action Area: Support to accelerate project implementation HIV/AIDS projects Provide financial and technical support through FY06-FY08 GHAP, Regions, WBI, GIST, and programs lending, IDF grants, seminars and training to WHO are well enhance country capacity and systems to implement implemented national HIV/AIDS plans. and disburse Ensure adequate BB funding for AIDS project FY06-FY08 GHAP, Regions, UNAIDS on schedule supervision, and make available TF resources for additional implementation support. Continue to support the global partnership on ARV FY06-FY08 WBI, GHAP, WHO, UNICEF procurement and logistics management capacity building Build on the Implementation Acceleration team, and FY06 GHAP, WBI, GIST, Regions work of ACTAfrica, to set up a Bank-wide AIDS implementation advisory service (IAS) to work with countries and Bank project teams to further improve planning, budgeting, program design, financial management, disbursement and procurement, expenditure tracking. Based on learning, experience and need, further FY06-FY08 GHAP, Regions, OPCS, GIST simplify operational processes and guidelines for HIV/AIDS projects, and encourage countries to use exceptional processes for more rapid and effective implementation Private sector, civil Actions depend on country needs, and may include FY06-FY08 GHAP, Regions, partners, IFC society organizations, (i) supporting policy changes; (ii) establishing and and UNAIDS NGOs and funding transparent, results-based processes to channel communities funds to communities; (iii) encouraging governments play strong role to work more with other service delivery systems; in HIV/AIDS (iv) in-country work to create mechanisms and energize response partnerships to address HIV/AIDS. Knowledge on good Use networks of program practitioners to exchange FY06-FY08 GHAP, Regions, UNAIDS implementation experiences, knowledge and practical advice on practices is captured general operational issues, fiduciary architecture, and and shared widely special programmatic themes. and influences practice Action Area: Strengthen country monitoring and evaluation systems and evidence-informed responses Countries gain Develop and regularly revise guidelines for national FY06-FY08 GAMET, UNAIDS GF, PEPFAR capacity to monitor monitoring and evaluation systems and evaluate their Prepare good practice notes that highlight examples of FY06-FY08 GHAP, Regions, UNAIDS programs, setting promising national responses to HIV/AIDS up sound HIV/AIDS Hold global, regional and national M&E training FY06-FY08 GHAP, Regions, WBI, UNAIDS, M&E systems and courses GF, PEPFAR using the data in Work as tasked by the GTT with key partners to FY06-FY08 GHAP/GAMET, UNAIDS program planning harmonize and strengthen national M&E systems Continue to build and train unified, multi-agency FY06-FY08 GHAP/GAMET, UNAIDS global country support team (CST) of international monitoring and evaluation specialists, who provide intensive practical M&E field support to countries. Train M&E specialists in each country, building national FY06-FY08 GAMET/CST, UNAIDS, GF, capacity, gradually reducing the need for CST support. PEPFAR Action Area: Knowledge generation and sharing, impact evaluation and analytic work, to improve program performance Knowledge Carry out outcome, impact and operational evaluations FY06-FY08 Regions, DEC, GAMET, HDN generation and of HIV/AIDS programs and establish a system for Chief Economist, UNAIDS, impact evaluation prospective evaluations of new HIV/AIDS projects URGE New analytical work Work with DEC, PREM, IMF and researchers with FY06-FY08 PREM, DEC, IMF, URGE, in priority areas is strong country knowledge to define and carry out new GHAP, researchers carried out. analysis in key cross-cutting and cross-country areas. Research findings Distribute reports etc widely using a range of FY06-FY08 GHAP and lessons of distribution and dissemination channels. experience are Improve and continuously add content to the Bank FY06-FY08 GHAP easy to access HIV/AIDS website, to provide quick, easy access to all and shared widely Bank reports, papers, manual etc on HIV/AIDS. Produce new publication series: (i) short reports and notes FY06-FY08 GHAP on HIV/AIDS work in the field, (ii) HIV/AIDS analytic reports. Publish country HIV/AIDS synthesis papers. Convene state-of-the-art workshops, conferences and FY06-FY08 GHAP, WBI and partners debates to discuss current controversial and cross- cutting issues on HIV/AIDS prevention, care and treatment. 49 Matrix 1: Global AIDS Program of Action--Matrix of Goals, Actions, Timing and Accountability Goal Specific Actions Timeline Key Accountability Work closely with partners to achieve concerted and harmonized AIDS responses, in keeping with the GTT vision GHAP, regions and Work closely with regions, supporting their HIV/AIDS FY06-FY08 GHAP, Regions other Bank units strategies and work programs. work closely Work more closely with PREM and DEC on economic FY06-FY08 GHAP, HDNHE, PREM, DEC, together, for analysis, links between AIDS and poverty, gender and WBI, IFC, URGE stronger Bank vulnerability; with HNP on health systems and health impact on HIV/AIDS services delivery and health financing issues. Continue ongoing work with WBI on training, and IFC on private sector initiatives. Develop new HIV/AIDS work with Education, transport, FY06-FY08 GHAP, HDNED, Transport & urban and other sectors. Urban units, partners, others tbd Bank engagement in Fulfill UNAIDS cosponsor role tasks and GFATM Board FY06-FY08 GHAP external partnerships and Committee Meetings contributes to a more effective global response and complements, and/or strengthens Bank's own HIV/AIDS work 50 The World Bank's Global HIV/AIDS Program of Action APPENDIX 1: REGIONAL HIV/AIDS STRATEGIES, AND IFC AND WBI HIV/AIDS INITIATIVES The mainstay of the World Bank's work in ACTAfrica, to provide operational support in HIV/AIDS is of course the lending, analysis all sectors. ACTAfrica's role includes (i) and policy discussions led by the six regions. equipping and supporting Bank country This Appendix briefly summarizes the re- teams to mobilize African leaders, civil soci- gional HIV/AIDS strategies or business ety, and the private sector to intensify action plans, and the IFC and WBI programs to ad- against HIV/AIDS; (ii) retrofitting projects dress AIDS. with HIV/AIDS components where possi- ble, helping develop new dedicated HIV/AIDS projects, and building AIDS-mit- Africa (AFR) igation measures into other projects where necessary; and (iii) supporting Bank country The 1999 Africa regional strategy, Intensify- teams in addressing HIV/AIDS in their ing Action Against HIV/AIDS in Africa; Re- country assistance strategies. sponding to a Development Crisis1 notes the inadequacy of Bank efforts against the fero- When the Africa region strategy was devel- cious spread of the epidemic in Africa and its oped, Bank lending and economic and sec- unprecedented impact on regional develop- tor work (ESW) for HIV/AIDS had ment. It states that HIV/AIDS must become diminished to a trickle, many governments a central element of the Bank's development lacked the political commitment to tackle agenda in Africa and called on African lead- HIV/AIDS, and resources and capacity were ers, civil society and the private sector also to sparse. put HIV/AIDS at the center of their agendas. UNAIDS had recently been created and al- The strategy rests on four pillars: though the Bank was a cosponsor, it was not as active as it could have been. 1 Advocacy to position HIV/AIDS as a cen- tral development issue and to increase The strategy was innovative in the central and sustain an intensified response; role it saw for HIV/AIDS in the Bank's de- 2 Increased resources and technical sup- velopment agenda for sub-Saharan Africa. It port for African partners and Bank coun- also broke new ground in advocating multi- try teams to mainstream HIV/AIDS sectoral approaches, with country AIDS activities in all sectors; Control Programs coordinated from outside 3 Prevention efforts targeted to both gen- the Ministry of Health; flexible financing of eral and specific audiences, and activities programs that were open-ended, client to enhance HIV/AIDS treatment and driven and collaborative; and innovative care; and mechanisms for channeling resources to the 4 An expanded knowledge base to help private sector, civil society and communities. countries design and manage prevention, The innovative, intensive new efforts incor- care, and treatment programs based on porated a process of learning from experi- epidemic trends, impact forecasts, and ence, adapting and improving. identified best practices. Since 2000, when the Bank's first Multi- To help realize the strategy, Africa estab- Country HIV/AIDS Program was approved, lished a multisectoralAIDS CampaignTeam, the Bank has committed US $1.2 billion to 29 51 countries and 4 sub-regional projects in of projects. A study of community re- Africa. Of this, approximately US $440 mil- sponse to HIVAIDS is being done in lion has been disbursed, about forty percent Ethiopia. channeled directly to implementing organi- zations in the public and private sectors, civil society and communities in over 30,000 sub- Latin America and the Caribbean projects. In 2002, IDA rules were changed to (LAC) allow 100 percent grant financing for HIV/AIDS in IDA-only countries, and up to In 2001, the Bank was supporting three 25 percent in blend (IDA/IBRD) countries. HIV/AIDS projects in the Latin America and HIV/AIDS was also made a priority for Insti- the Caribbean region: a Brazil HIV/AIDS tutional Development Fund (IDF) grants project loan approved in 1993, a health and that allow the Bank to provide up to US disease project loan in Argentina approved $500,000 for capacity building in IDA and in 1997, a Haiti health project that included IBRD countries. HIV/AIDS activities, and a small regional LatinAmerican and Caribbean initiative that An interim review of the MAP program in was being integrated into UNAIDS'regional 20042 recommended that it do more to help technical support. realize the "Three Ones" goals of one na- tional authority for HIV/AIDS, one strategic Recognizing that intensified efforts were framework and one M&E system; help gov- needed, a strategy was developed for the ernments to develop stronger national Caribbean sub-region, where the epidemic HIV/AIDS strategies; help improve gover- was most advanced.3The strategy suggested nance and accountability; incorporate in- five key steps to intensify national responses centives for performance; support to HIV/AIDS: (i) increase national govern- differentiated projects as a flexible donor of ment commitment, attention and funding to last resort; and better address the overall combat the HIV/AIDS epidemic; (ii) scale up needs of the health sector. The review also HIV/AIDS prevention activities at national suggested that the Bank improve its own ef- and community levels using communica- fectiveness and technical capacity to support tions to induce behavior change; make con- MAP projects, particularly in the areas of doms, treatment of STIs and VCT more M&E, communications and institutional de- accessible; ensure a safe blood supply and sign. In addition to responsive actions by the reduce MTCT; (iii) scale up national and Africa region and ACTAfrica, the key recom- community level HIV/AIDS care activities; mendations of the interim review have (iv) support more HIV/AIDS-related re- guided this Global Program of Action. search at national level, and (v) strengthen regional responses to the epidemic in the Outputs targets for the near future include Caribbean. the following: The Bank acted upon the Caribbean strategy · Lending: Second MAP projects are ex- by approving a US$155 million Caribbean pected to begin implementation soon in Multi-Country HIV/AIDS Adaptable Lend- Ghana and Ethiopia, preparation is un- ing Program in 2001. Since then, US$117.6 derway in Kenya and Eritrea. MAP fol- million has been committed to nine country low-on projects are also likely to be programs and one regional project using the needed in the following countries: Nige- multisectoral approach outlined in the ria, Benin, Burkina Faso, Burundi, strategy. Cameroon, Cape Verde, Madagascar, Sierra Leone, Uganda, Senegal, Guinea The region also has HIV/AIDS projects in Bissau, Zambia, Niger and Guinea. Su- Brazil, where a third loan in 2003 brought pervision of programs will have high total AIDS lending to US$425 million.4 A priority. number of health and other projects in Ar- · Analytic and advisory services: Policy di- gentina, Venezuela, Honduras, Mexico and alogue and analytic work will be inte- El Salvador include significant funding for grated with supervision and preparation HIV/AIDS. These projects follow a broadly 52 The World Bank's Global HIV/AIDS Program of Action similar strategy: prevention activities imple- sources among HIV prevention interven- mented by NGOs and the government, tions in Argentina". services for AIDS patients, and institutional development and monitoring and evalua- The region intends to develop a new tion. A US$8 million HIV/AIDS regional HIV/AIDS strategy in 2005 that will build grant was approved in March, 2005 for a ca- upon the earlier response, and take account pacity strengthening project for Central of the diverse nature of the epidemic across America (El Salvador, Costa Rica, sub-regions and countries and within coun- Guatemala, Honduras, Nicaragua and tries; the specific needs of low prevalence Panama). countries with epidemics concentrated in small high risk population groups; the need In 2003, the region published two reports for different responses by the Bank given that review the state of the epidemic and that middle income countries may seek country responses and suggest priority ac- technical rather than investment support tions. HIV/AIDS in Latin America: The Chal- from the Bank; and the rapidly changing ex- lenges Ahead5 notes that although many ternal funding scenario. Latin American countries are not faced with full-scale HIV/AIDS epidemics, in several Outputs targets for the near future include countries the epidemic appears to be ex- the following: panding beyond the highest risk groups (MSMs and IDUs) into the general popula- · Lending: The region will seek additional tion. It warns that the epidemic may become opportunities to take advantage of scale generalized unless appropriate strong pre- economies using sub-regional projects ventive measures are taken in the very near and programs that support HIV/AIDS future.The priority areas in low endemic set- and strengthen health system capacity. A tings are suggested to be: (i) strong efforts to specific effort will be made to strengthen prevent new infections in high risk groups; the implementation of existing projects in (ii) epidemiological surveillance; and (iii) the Caribbean. A health project for Ar- care and support for PLWHA. gentina (FY06) will include support for HIV/AIDS. The region may also consider "HIV/AIDS in Central America: An support for HIV/AIDS in Dominica and Overview of the Epidemic and Priorities for Suriname. Prevention" reports the work and conclu- · Analytic and advisory services: Policy di- sions of three country workshops (in Hon- alogue will continue in the course of proj- duras, Panama and Guatemala) in which ect supervision and developing and teams of local and international experts ex- discussing a new regional HIV/AIDS plored the likely impact on new infections of strategy.The recently published report on different resource allocations across application of the Allocation by Cost-Ef- HIV/AIDS activities, using a modelling tool fectiveness (ABC) Model in Argentina designed to help strategic planning. will be discussed with the government. The model will be applied to a number of In all three countries, the most cost-effective other countries in the region. Other ana- preventive interventions were condom so- lytic and advisory work envisaged in- cial marketing, free condom distribution to cludes: an assessment of implementation high risk groups, IEC for high-risk groups weaknesses of Bank-financed and other including MSM, sex workers and prisoners, donor projects in the Caribbean; analysis and voluntary counselling and testing. The of the private sector response to difficulty of reaching high risk groups was a HIV/AIDS (focusing on the tourism sec- strong constraint on preventing infections, tor); assessment of interventions for pointing to the importance of going beyond reaching mobile populations; assessment traditional prevention interventions. The of experience in the use of NGOs and modelling showed that existing funding lev- community based groups to deliver inter- els were inadequate and poorly targeted. In ventions to target populations. In addi- 2005, similar analysis was published for Ar- tion, analytic work will be conducted gentina: "Optimizing the allocation of re- through the two regional HIV/AIDS proj- 53 Appendix 1: Regional HIV/AIDS Strategies, and IFC and WBI HIV/AIDS Initiatives ects for the Caribbean and for Central Europe and Central Asia (ECA) America that will include studies on the following areas: linkages between The 2003 regional HIV/AIDS strategy6 notes HIV/AIDS and poverty in the Caribbean the rapid speed at which the HIV/AIDS and (with Jamaica and Grenada as case stud- TB epidemics are growing in some parts of ies); lessons from the Bahamas experi- the region, threatening to undermine eco- ence on HIV/AIDS; HIV risk factors in nomic growth, drive up health expenditures mobile populations; and an assessment and worsen dependency ratios. New cases of the pharmaceuticals patent and regis- are heavily concentrated among young peo- tration systems of the CARICOM coun- ple, chiefly injecting drug users, commercial tries. The Central American regional sex workers and mobile populations. The project will support a review of the strategy sees a compelling case for reducing HIV/AIDS legal framework for civil vulnerability to infection especially among rights, integrated treatment and drug and "high risk core transmitters and bridge pop- laboratory supplies regulation. Two ulations", and supporting targeted, nonstig- GDLN dialogues are scheduled in FY06 matizing prevention programs on a much to discuss regional cooperation and the larger scale than most existing pilot projects. potential for a new regional operation in the Mercosur countries (Chile,Argentina, The strategy commits the Bank to efforts to Bolivia, Brazil, Paraguay and Uruguay). raise social and political commitment to ad- · Accelerating AIDS response in selected dressing the epidemics of HIV/AIDS and TB sectors: The LAC region plans to in the region. It gives priority to helping strengthen the multi-sectoral response to countries to generate and use essential infor- the HIV/AIDS epidemic.A process has al- mation in program design, implementation ready been initiated for strengthening the and evaluation, including: epidemiological role of the education sector in the and behavioral surveillance as the basis for Caribbean.This effort will be a collabora- effective prevention; identifying the inter- tion of the Caribbean Management Unit ventions that yield the most value in terms of HIV/AIDS and Education team, the Edu- preventing new infections; estimates and cation team at the Human Development projections of the economic and social im- Network, UNESCO, the Pan-Caribbean pacts of HIV/IDS and TB and of the resource HIV/AIDS Partnership (PANCAP) Secre- requirements for prevention and treatment. tariat and other members of PANCAP. · Capacity Building. The LAC region will The strategy emphasizes that preventing continue to provide technical support for new infections is`the ultimate priority for the cross-cutting areas through the two re- Bank's work on HIV/AIDS"in the region. It gional projects in a number of areas in- identifies key actions as: programs to pre- cluding: monitoring and evaluation; legal vent transmission among sex workers and and regulatory aspects; and strengthen- their clients; harm reduction among inject- ing the education sector response. ing drug users; interventions among prison · Donor Coordination/Partnerships. The inmates and ex-inmates; and increasing region will help strengthen ongoing col- blood safety. It calls for ensuring affordable, laboration with bilateral donors and good quality care and support for PLWHA, multi-lateral agencies including: the Pan- but cautions that use ofARVs should be sub- American Health Organization ject to international peer review and im- (PAHO/WHO); the Inter-American De- provement of health systems to ensure velopment Bank,the Global Fund and the quality and reduce the emergence of drug- Clinton Foundation.The region will con- resistant strains of HIV. It offers Bank sup- tinue to contribute to regional partner- port to increase country capacity for ships and provide technical support for implementing large-scale HIV/AIDS and TB strengthening regional agencies includ- programs. ing the Pan-Caribbean Partnership against HIV/AIDS of CARICOM and the At the time the ECA strategy was produced, Central American Secretariat for Social the Bank had completed a country Integration (SISCA). HIV/AIDS study in Georgia, and sub-re- 54 The World Bank's Global HIV/AIDS Program of Action gional studies in Poland and the Baltic States low overall regional HIV prevalence rate. and in south-eastern Europe, and a sub-re- There are significant intra and inter-country gional study in Central Asia was underway variations,with some geographic pockets al- (now completed). In 2003 the Bank also co- ready experiencing a generalized epidemic7 financed two regional studies with UNAIDS, and some a concentrated epidemic.8 The including an inventory of resources for prevalence of risk behaviors is significant in HIV/AIDS programs in the region. Bank the region; unprotected commercial sex re- lending currently supports HIV/AIDS pro- mains the most risky behavior but HIV has grams in the Ukraine, Russian Federation, also been increasing among IDUs and Moldova, and a new regional Central Asia MSMs. The regional HIV/AIDS business HIV/AIDS project. There are grant financed plan points out that the window of opportu- projects for Moldova and Central Asia. nity exists now to prevent concentrated epi- demics from generalizing further and that Outputs targets for the coming 2-3 years in- there is urgent need to scale up support to clude the following: country responses.9 · Lending: Supervision of programs in The region's strategic approach emphasizes Moldova, Russia, Ukraine and Central (i) focusing on high impact preventive serv- Asia. New operations in Azerbaijan and ices targeting the right people and influenc- Albania will include activities to ing the multi-sector determinants that strengthen the health sector, including create an enabling environment, facilitate capacity to respond to HIV/AIDS. and reinforce safe practices, and de-stigma- · Analytic and advisory services: Analysis tize HIV/AIDS; and (ii) using country spe- and policy dialogue will focus on: TB and cific approaches, taking into account the HIV/AIDS in Central Asia; a regional dynamics of the epidemic in each country HIV/AIDS assessment of South Eastern and the high level of risk and vulnerability Europe; in Russia, assessment of patents throughout the region. It also recognizes the and registration systems for ARV drugs, need for harmonization and donor coordi- the public information campaign on nation, and ensuring that the Bank's contri- HIV/AIDS, and a comparative evaluation bution is strategic, considering the changing of the Russian and Ukrainian HIV/AIDS donor landscape. programs. · Capacity Building: ECA will support part- Outputs targets in the current three-year nerships, twinning and technical cooper- work program include the following: ation visits, meetings and other activities to support program implementation · Lending: National programs will be among countries in the region (especially strengthened and expanded in India, those with a common language), as well Bangladesh,Bhutan10,Sri Lanka and Pak- as between countries in the region and istan and supervision of programs will be Brazil, between the Central Asian and improved. Caribbean regional organisations for · Analytic and advisory services: Policy di- HIV/AIDS, and between the Business alogue will be initiated in Afghanistan Councils for HIV/AIDS in Russia, Brazil and Maldives. Treatment options and and Europe. plans will be developed in Sri Lanka and · Donor coordination: ECA will work with Nepal. WHO, UNAIDS, DFID and SIDA on an · Capacity Building: HIV/AIDS prevention assessment and activities to operational- will be incorporated into education and ize the"Three Ones"in Russia. transport, private and rural development sector operations, and second generation surveillance and M&E systems will be de- South Asia (SAR) veloped in all countries. · Donorcoordination:Partnershipswiththe The South Asia region, with its immense Global Fund and Gates Foundation will be population, has the second highest number established and the Bank's collaboration of newly infected cases per year despite the with UN partners will be strengthened. 55 Appendix 1: Regional HIV/AIDS Strategies, and IFC and WBI HIV/AIDS Initiatives A regional multisectoral team has been es- This requires regular behavioral surveys, re- tablished to support this action agenda, with search on sexual and drug-using behaviors, a regional AIDS program coordinator in and increased local capacity to conduct re- place since January 2005. search. Monitoring and evaluation systems are needed to collect information on inter- ventions for prevention and care, support, East Asia and Pacific Region (EAP) and treatment. The strategy note,"Addressing HIV/AIDS in Larger scale prevention interventions must East Asia and the Pacific" (2004) describes be established,maintained and strengthened the diversity of the epidemic in the world's based on sound local knowledge.Access to a most populous region.11 It points out lessons range of care, support and treatment services learned from successful and unsuccessful at- for people infected and affected will require tempts to curb the epidemic in the region. better policies for the public and the private The strategy notes that even where commit- sectors, and analytic work to understand ment has been strong, government funding how best to provide ARV therapy in the con- for HIV/AIDS has been low, with a key role text of relatively weak health systems. for the Bank and other development agen- Strengthening health care systems and ab- cies. New sources of external funding make sorptive capacity within the broader govern- future demand for Bank lending uncertain, ment are both key for implementing but there is likely to be an important role for successful HIV/AIDS interventions. the Bank in mobilizing resources, providing analytic and advisory services and capacity Cumulative regional lending for HIV/AIDS building, helping ensure a multi-sectoral re- is US$138 million, as components of ten sponse and perhaps as donor of last resort. broader health project and two projects ex- clusively for HIV/AIDS (Indonesia andViet- Five key challenges every country faces in nam).12 Projects currently under combating the epidemic are outlined: (i) po- implementation are a project in four target litical commitment and multisectoral sup- provinces in China--Fujian, Guangxi, port; (ii) public health surveillance and Shanxi, and Xinjiang (US$ 25 million), a safe monitoring and evaluation, (iii) prevention; blood project in Vietnam (US$ 47.5 million) (iv) care, support and treatment; and (v) and the newly approvedVietnam HIV/AIDS health services delivery. It proposes to de- Project (US $35 million), and support for velop country-specific strategies to respond ARVs under a health program in Cambodia. to these challenges based on each country's needs and stage of the epidemic, national Looking ahead, planned activities include strategic HIV/AIDS plans developed by gov- the following: ernments, and World Bank Country Assis- tance Strategies. The country HIV/AIDS · Lending: Efforts will focus on strong im- strategy notes will outline flexible and inno- plementation of the existing portfolio, vative specific work plans that incorporate and preparation of new HIV/AIDS proj- some mix of analytic and advisory work, ects, depending on country demand. lending, and regional activities in focusing · Analytic and advisory services: In China, on the five key challenges. new analytic work focuses on policy op- tions to address HIV/AIDS in China. In The strategy outlines critical actions for ad- Papua New Guinea, a joint strategy for dressing each of the key challenges. Political HIV/AIDS is being developed, as part of a commitment and multisectoral support broader human development strategy to- across a broad spectrum of sectors can be gether with AusAID and the ADB. In built using communications that increase Thailand,a recently completed analysis of public awareness and support. Modern policy options for treatment while pro- methods of public health surveillance are moting effective prevention will generate needed to gather information on the num- various follow-up activities, and several bers of people practicing high-risk behavior knowledge sharing activities are planned and their interactions with other groups. forVietnam and PNG. Proposed new an- 56 The World Bank's Global HIV/AIDS Program of Action alytical work is under discussion with the levels of the society to participate in pre- Indonesian government. venting HIV/AIDS, and raise the effective- · Capacity Building: In Vietnam, there is a ness of programs. strong focus on monitoring and evalua- tion in close collaboration with other Four areas are identified where the World partners as part of the newly approved Bank could support MNA countries in pre- project on HIV prevention. The lending venting the epidemic and expanding access operations inVietnam and China also in- to information on HIV/AIDS: clude capacity building efforts.All the an- alytic work listed above also involves · Engage political leaders, policy makers specific capacity building efforts. and key stakeholders to raise awareness · Donor coordination:The region will keep and priority given to HIV/AIDS programs on strengthening collaboration with within national development agenda other key players in the region, such as · Support upgrading of surveillance sys- UNAIDS,AusAID, the ADB and UN.This tems and strengthening research and is an integral part of the approach and the evaluation of epidemiological, economic, regional strategy highlights this. and behavioral aspects of HIV/AIDS · Support the development of National HIV/AIDS strategy and programs, based Middle East and Northern Africa on country-specific epidemiological, so- (MNA) cial and economic conditions and contexts The MNA region strategy13 notes that al- · Support capacity building and knowl- though adult prevalence in the region is es- edge sharing for comprehensive manage- timated at only 0.3 percent and appears to be ment of HIV/AIDS programs. concentrated among high risk groups such as injecting drug users,sex workers and pris- The Bank supports one HIV/AIDS project in oners, the absence of reliable surveillance the region, the Djibouti HIV/AIDS,Tubercu- data among these groups makes the actual losis and Malaria Control Project which is a level of infection uncertain. It notes that low grant for US$ 12 million for capacity build- prevalence does not mean a low risk of an ing, prevention and support to community- epidemic. Despite social and cultural values based initiatives. In addition, the Djibouti that have helped prevent rapid spread of International Road Corridor Rehabilitation HIV/AIDS in MNA countries, there are Project (approved in 2000) includes some many vulnerabilities that could lead to in- HIV/AIDS activities.The Bank has also sup- creased transmission: widespread migra- ported the development of national AIDS tion; silence and stigma; civil conflicts and plans in Morocco and Lebanon, held re- security problems that could undermine gional workshops to raise awareness, and government ability to respond effectively; engaged in advocacy. and a large youth population that bears the brunt of unemployment. Outputs targets for the coming years include the following: The strategy calls for decisive action in four areas: (i) establish a reliable surveillance sys- · Lending: No new lending specifically fo- tem to identify and target support to the cused on HIV/AIDS is expected, but most vulnerable groups; (ii) vigorously pur- HIV/AIDS prevention programs will be sue cost-effective public health measures to incorporated in new lending projects with stem the spread of HIV/AIDS, targeted at in- a high degree of community-based and jecting drug users and their sex partners, sex NGO activities (e.g., Egypt Social Fund, workers, prison inmates, males who have Iran Local Development Project and sex with males and youth; (iii) expand pub- Yemen Population project). MNA also lic information and education, and encour- plans to identify specific components and age greater public discourse on HIV/AIDS; investment activities related to HIV/AIDS and (iv) promote cooperation between gov- prevention and selected priority health ernments and civil society to mobilize all and social services which should be inte- 57 Appendix 1: Regional HIV/AIDS Strategies, and IFC and WBI HIV/AIDS Initiatives grated into new lending operations in ed- teams; community leaders and NGO repre- ucation, health and social protection. sentatives; managers from the private sector; · Regional Technical Assistance: (i) Advo- staff from international organizations, cacy and Building Partnership for Preven- HIV/AIDS program staff and trainers and tion of HIV/AIDS activities will include academicians. WBI develops and delivers launching the Regional HIV/AIDS Strat- more than half of its activities with partners egy,follow up consultative processes with in client countries and has formal partner- key partners, and identification of and ship agreements with nearly 200 organiza- preparation of priority investment and tions that provide expertise, content, analytical work to be undertaken by the facilities, staff, funding and other inputs. Bank in partnership with other stake- holders, including the Global Fund. (ii) To respond to country demand, in the com- An Inter-regional Program on HIV/AIDS ing 3-5 years,WBI will focus on building im- Prevention among High Risk Groups will plementation capacity for HIV/AIDS involve cooperation with SAR and ECA programs by: i) building the management ca- for countries bordering Afghanistan and pacity of the public sector and civil society or- affected by the rapid expansion of drug ganizations to overcome the current trafficking and IDU use. In the first phase, planning, management and implementation a conference is proposed to be held in constraints, ii) continued collaboration with Tehran in 2006, to discuss how to address WHO, UNAIDS, Global Fund and PEPFAR drug trafficking, drug addiction and the to harmonize ARV procurement and supply spread of HIV/AIDS in Afghanistan, Pak- management efforts at country level, iii) con- istan, Iran,Tajikistan and Uzbekistan. tinuing to hold training workshops on pro- · Capacity Building: Under a new Lebanon curement and supply management at IDF Grant project, NGO-based regional and country level, iv) building the HIV/AIDS projects will be promoted. technical capacity of program managers Funds (JSDF or IDF) will be sought for using technology to rapidly disseminate evi- local capacity building grant projects to dence-informed knowledge across geo- complement Global Fund activities, in se- graphical borders, v) engaging high level lected countries in the region (to be se- policy makers to advocate for HIV/AIDS,and lected based on readiness and political vi) building the capacity of ministry of health will) in FY07-FY08. Capacity building ac- and ministry of finance officials to address tivities will be identified based on the out- the macroeconomic polices that might im- come of theAdvocacy and PartnershipTA. pede rapid scaling-up of HIV/AIDS activities. The World Bank Institute Business and HIV: IFC against Leadership Program on AIDS AIDS The Leadership Program on AIDS supports Businesses feel the impact of the AIDS epi- the World Bank's intensified efforts in demic most clearly through their workforce, HIV/AIDS lending and research and con- with direct consequences for a company's tributes to a critically important but still neg- bottom line. These include increased med- lected need for leadership and capacity ical expenditures and health insurance costs, building. The Program focuses on: building funeral and death benefits, higher recruit- capacity of clients including local institu- ment and training needs due to lost person- tions to strengthen implementation; mobi- nel, higher absenteeism and staff turnover, lizing policy makers to focus on HIV/AIDS; reduced productivity, declining morale and a sharing knowledge of best practices within shrinking consumer base. and between counties; and using technology to create mass awareness and to share The International Finance Corporation, the knowledge. The Program targets a wide private sector investment arm of the World range of stakeholders including policy-mak- Bank Group, recognizes that HIV/AIDS is as ers and analysts in government ministries much a business issue as a development and and other public institutions; national PRSP humanitarian concern. Since 2000, the IFC 58 The World Bank's Global HIV/AIDS Program of Action AIDS program--IFC Against AIDS--has 3 Training: IFC Against AIDS will deliver a worked to increase the private sector's role 3-year training program inAfrica for small in fighting the epidemic. The overarching and medium enterprises (SMEs), which goal is to accelerate the role of the private can be just as affected by HIV/AIDS as sector in the fight against HIV/AIDS. The larger companies. A package of tools and program has honed its approach and tools approaches is being developed that will be and worked with over 30 client companies, able to be used by others in the field, in- of which 25 are in sub-Saharan Africa. The creasing reach to this important part of the program has also included companies in the private sector.The strategy includes build- Caribbean and South Asia. ing capacity of local trainers and NGOs to deliver the training program, which Africa will remain a priority for the program, should increase the ability of SMEs to re- in moving forward to intensify existing ac- spond to HIV/AIDS. This program has tivities (facilitated by increased staff capacity been developed in cooperation with the in the Africa region), and to launch an inno- IFC Private Enterprise Partnership pro- vative program to reach small and medium- gram (PEP Africa), and will be managed sized enterprises (SMEs). jointly with PEP Africa from October 2005 till September 2008. IFC Against AIDS has four areas of activity: 4 Financing:ClosecollaborationwiththeIFC Corporate Citizenship Facility (CCF) has 1 Raising awareness: IFC Against AIDS enabled IFC Against AIDS to leverage fi- works with IFC clients to help them ana- nancing on a cost-sharing basis for clients lyze and acknowledge the risks that AIDS for whom a compelling case for support poses to their companies, making the can be made.Financing will be provided to business case for action. This work will clients that can show a demonstration ef- continue inAfrican countries,and expand fect for a particular sector, such as tourism, to countries in other regions, including or a particular geographic area or country, India, Russia, and China. Tools are being such as Nigeria. These examples will be developed and used, and a communica- used to capture lessons learned that can be tions strategy guides activities to demon- replicated internally with other IFC clients strate how private companies can and externally, and add to the body of respond to the challenge of HIV/AIDS. knowledge within the field.This collabora- 2 Guidance: Once companies are aware of tion with the CCF is expected to continue, the risk that HIV/AIDS poses to their op- but there is also the possibility of estab- erations, they typically do not know lishing an IFC Against AIDS Facility in the where to start. Through one-on-one in- future if warranted. teraction with clients, IFC Against AIDS helps companies develop an appropriate IFC Against AIDS has been working in and tailored response, working with closer cooperation with AIDS units in the clients to design and implement pro- Bank, seeking ways to concretely partner, grams that include HIV/AIDS education, such as in Kenya with IDA to jointly promote prevention, and care interventions for the the role of private companies in the National workforce and/or communities in which HIV/AIDS Strategic Plan and in the imple- they operate. This demand-driven sup- mentation of coordinated activities.Another port is expected to expand to more com- example is the work with the World Bank In- panies in future. stitute in Africa and India. This cooperation In the coming year, IFC Against should intensify in future. AIDS will pilot a more systematic and client-based monitoring and evaluation Considerable attention will be focused on (M&E) tool with selected clients in sub- India in the coming years. Proactive engage- Saharan Africa. This tool will help clients ment in HIV/AIDS in the private sector in to assess the relative success of activities India remains piecemeal. After evaluation of and interventions and enable them to what IFC could do to bring value to its clients make more informed decisions concern- and contribute to India's response to the epi- ing their HIV/AIDS workplace programs. demic, IFC Against AIDS and the IFC South 59 Appendix 1: Regional HIV/AIDS Strategies, and IFC and WBI HIV/AIDS Initiatives Asia department launched a program in Jan- Notes uary 2005 that aims at increasing the ability 1. World Bank 1999. Intensifying action against of clients to proactively address HIV/AIDS in HIV/AIDS in Africa: Responding to a development three possible areas: crisis. Washington, DC: The World Bank, Africa Region. · workplaces--by raising awareness about 2. World Bank. 2004. Interim Review of the HIV/AIDS and promoting prevention MAP. across company operations, and by ex- 3. World Bank. 2001. HIV/AIDS in the tending education programs throughout Caribbean: Issues and Options. Washington, DC. their groups and to supply chain partners; 4. This includes $255.05 million committed · company clinical facilities--by training under the three AIDS projects as well as funding medical and clinical staff on HIV/AIDS for HIV/AIDS activities in other projects. and sexually transmitted infections 5. Anabela Garcia-Abreu, Isabel Noguer and (STIs), i.e. modes of transmission, pre- Karen Cowgill. 2003. HIV/AIDS in Latin America vention (with a special focus on universal The Challenges Ahead. HNP Discussion Paper, precautions related to HIV infection in Washington, DC: The World Bank. clinical settings), basic counseling skills, 6. "Averting AIDS Crises in Eastern Europe syndromic management of STIs, oppor- and Central Asia"2003, Eastern Europe and tunistic infections related to HIV and Central Asia Region, World Bank. anti-retroviral treatment therapies; 7. Generalized: greater than 1 percent HIV · their communities--by supporting or prevalence among women attending antenatal scaling-up the awareness and prevention clinics. efforts around their operations, particu- 8. Concentrated: greater than 5 percent larly among migrant workers and truck- among STD patients and other groups whose ing communities with whom companies behavior places them at risk e.g. sex workers, in- interact. jecting drug users. 9. South Asia Human Development Sector. This project is financed from FY05 to FY07 by (2004). HIV/AIDS Business Plan South Asia the CCF: clients may submit project propos- FY04-FY06. als that address any one, two or three com- 10. The first ever Bhutan HIV/AIDS project ponents, IFC supporting up to half of the was approved with grant financing in 2004. eligible costs incurred for up to 18 months. 11. Borowitz, Michael,Wiley, Elizabeth, Sadaah, The goal is to involve about five major cor- Fadia and Enis Baris. December 2003. Responding porates under this scheme, and to develop to HIV/AIDS in theEast Asia and Pacific Region: A the capacity of local organizations to play an Strategy Note for the World Bank. HNP Discussion intermediary role in local capacity building, Paper, Washington, DC: The World Bank. which would enable the project to be ex- 12. Lending data supplied by the EAP region, tended later to smaller companies or SMEs which may differ from data in the"Business in the supply chains of larger clients. IFC Warehouse"database because of differences in clients already involved in HIV/AIDS in- coding. clude Apollo Tyres, Ambuja Cement, L&T, 13. The World Bank. (2005). Preventing the Usha Martin and Ashok Leyland. Spread of HIV/AIDS in the Middle East and North Africa: The World Bank Regional Strategy. www.ifc.org/ifcagainstaids Washington, DC. 60 The World Bank's Global HIV/AIDS Program of Action APPENDIX 2: COUNTRY-LEVEL HIV/AIDS DATA Table of country-specific HIV and AIDS estimates and data, end 2003 (UNAIDS, July 2004) 1. Estimated number of people living with HIV Adults and Children end 2003 Adults and Children end 2001 Adults (15-49) end 2003 [low estimate - high [low estimate - high [low estimate - high Country Estimate estimate] Estimate estimate] Estimate estimate] Global Total 37,800,000 [34,600,000 - 42,300,000] 34,900,000 [32,000,000 - 39,000,000] 35,700,000 [32,700,000 - 39,800,000] Sub-Saharan Africa 25,000,000 [23,100,000 - 27,900,000] 23,800,000 [22,000,000 - 26,600,000] 23,100,000 [21,400,000 - 25,700,000] Angola 240,000 [97,000 - 600,000] 220,000 [86,000 - 550,000] 220,000 [88,000 - 540,000] Benin 68,000 [38,000 - 120,000] 65,000 [36,000 - 110,000] 62,000 [35,000 - 110,000] Botswana * 350,000 [330,000 - 380,000] 350,000 [330,000 - 380,000] 330,000 [310,000 - 340,000] Burkina Faso * 300,000 [190,000 - 470,000] 280,000 [180,000 - 440,000] 270,000 [170,000 - 420,000] Burundi 250,000 [170,000 - 370,000] 240,000 [160,000 - 360,000] 220,000 [150,000 - 320,000] Cameroon * 560,000 [390,000 - 810,000] 530,000 [370,000 - 770,000] 520,000 [360,000 - 740,000] Central African Republic 260,000 [160,000 - 410,000] 250,000 [150,000 - 400,000] 240,000 [150,000 - 380,000] Chad 200,000 [130,000 - 300,000] 190,000 [120,000 - 290,000] 180,000 [120,000 - 270,000] Comoros ... ... ... ... ... ... Congo, Republic of 90,000 [39,000 - 200,000] 90,000 [39,000 - 200,000] 80,000 [34,000 - 180,000] Côte d'Ivoire 570,000 [390,000 - 820,000] 510,000 [350,000 - 740,000] 530,000 [370,000 - 750,000] Dem. Republic of Congo ** 1,100,000 [450,000 - 2,600,000] 1,100,000 [430,000 - 2,500,000] 1,000,000 [410,000 - 2,400,000] Djibouti 9,100 [2,300 - 24,000] 8,100 [2,400 - 23,000] 8,400 [2,100 - 21,000] Equatorial Guinea ... ... ... ... ... ... Eritrea 60,000 [21,000 - 170,000] 61,000 [22,000 - 160,000] 55,000 [19,000 - 150,000] Ethiopia 1,500,000 [950,000 - 2,300,000] 1,300,000 [820,000 - 2,000,000] 1,400,000 [890,000 - 2,100,000] Gabon 48,000 [24,000 - 91,000] 39,000 [19,000 - 78,000] 45,000 [23,000 - 86,000] Gambia 6,800 [1,800 - 24,000] 6,700 [1,800 - 24,000] 6,300 [1,700 - 23,000] Ghana * 350,000 [210,000 - 560,000] 330,000 [200,000 - 540,000] 320,000 [200,000 - 520,000] Guinea * 140,000 [51,000 - 360,000] 110,000 [40,000 - 310,000] 130,000 [48,000 - 330,000] Guinea-Bissau ... ... ... ... ... ... Kenya 1,200,000 [820,000 - 1,700,000] 1,300,000 [890,000 - 1,800,000] 1,100,000 [760,000 - 1,600,000] Lesotho * 320,000 [290,000 - 360,000] 320,000 [290,000 - 360,000] 300,000 [270,000 - 330,000] Liberia 100,000 [47,000 - 220,000] 86,000 [37,000 - 190,000] 96,000 [44,000 - 200,000] Madagascar 140,000 [68,000 - 250,000] 100,000 [50,000 - 180,000] 130,000 [66,000 - 220,000] Malawi * 900,000 [700,000 - 1,100,000] 850,000 [660,000 - 1,100,000] 810,000 [650,000 - 1,000,000] Mali 140,000 [44,000 - 420,000] 130,000 [40,000 - 390,000] 120,000 [40,000 - 380,000] Mauritania 9,500 [4,500 - 17,000] 6,300 [3,000 - 11,000] 8,900 [4,400 - 15,000] Mauritius ... ... ... ... ... ... Mozambique 1,300,000 [980,000 - 1,700,000] 1,200,000 [930,000 - 1,600,000] 1,200,000 [910,000 - 1,500,000] Namibia 210,000 [180,000 - 250,000] 200,000 [170,000 - 230,000] 200,000 [170,000 - 230,000] Niger 70,000 [36,000 - 130,000] 56,000 [28,000 - 110,000] 64,000 [34,000 - 120,000] Nigeria 3,600,000 [2,400,000 - 5,400,000] 3,400,000 [2,200,000 - 5,000,000] 3,300,000 [2,200,000 - 4,900,000] Rwanda * 250,000 [170,000 - 380,000] 240,000 [160,000 - 360,000] 230,000 [150,000 - 350,000] Senegal * 44,000 [22,000 - 89,000] 40,000 [20,000 - 81,000] 41,000 [21,000 - 83,000] Sierra Leone ... ... ... ... ... ... Somalia ... ... ... ... ... ... South Africa * 5,300,000 [4,500,000 - 6,200,000] 5,000,000 [4,200,000 - 5,900,000] 5,100,000 [4,300,000 - 5,900,000] Swaziland ** 220,000 [210,000 - 230,000] 210,000 [190,000 - 220,000] 200,000 [190,000 - 210,000] Togo 110,000 [67,000 - 170,000] 100,000 [65,000 - 160,000] 96,000 [61,000 - 150,000] Uganda * 530,000 [350,000 - 880,000] 620,000 [420,000 - 980,000] 450,000 [300,000 - 730,000] United Rep. of Tanzania * 1,600,000 [1,200,000 - 2,300,000] 1,600,000 [1,100,000 - 2,200,000] 1,500,000 [1,100,000 - 2,000,000] Zambia 920,000 [730,000 - 1,100,000] 890,000 [710,000 - 1,100,000] 830,000 [680,000 - 1,000,000] Zimbabwe 1,800,000 [1,500,000 - 2,000,000] 1,700,000 [1,500,000 - 2,000,000] 1,600,000 [1,400,000 - 1,900,000] East Asia 900,000 [450,000 - 1,500,000] 680,000 [340,000 - 1,100,000] 900,000 [450,000 - 1,500,000] China 840,000 [430,000 - 1,500,000] 660,000 [320,000 - 1,100,000] 830,000 [430,000 - 1,400,000] Hong Kong SAR 2,600 [1,300 - 4,400] 2,700 [1,300 - 4,400] 2,600 [1,300 - 4,300] Dem. Peo. Rep. of Korea ... ... ... ... ... ... Japan 12,000 [5,700 - 19,000] 12,000 [5,800 - 20,000] 12,000 [5,700 - 19,000] Mongolia <500 [<1,000] <200 [<400] <500 [<1,000] Republic of Korea 8,300 [2,700 - 16,000] 5,600 [1,800 - 11,000] 8,300 [2,700 - 16,000] Oceania 32,000 [21,000 - 46,000] 24,000 [16,000 - 35,000] 31,000 [21,000 - 45,000] Australia 14,000 [6,800 - 22,000] 12,000 [6,000 - 20,000] 14,000 [6,600 - 22,000] Fiji 600 [200 - 1,300] <500 [<1,000] 600 [200 - 1,200] New Zealand 1,400 [480 - 2,800] 1,200 [420 - 2,400] 1,400 [500 - 2,800] Papua New Guinea 16,000 [7,800 - 28,000] 10,000 [4,900 - 17,000] 16,000 [7,700 - 26,000] 61 1. Estimated number of people living with HIV Adults and Children end 2003 Adults and Children end 2001 Adults (15-49) end 2003 Country Estimate [low estimate - high estimate] Estimate [low estimate - high estimate] Estimate [low estimate - high estimate] South & South-East Asia 6,500,000 [4,100,000 - 9,600,000] 5,900,000 [3,700,000 - 8,700,000] 6,300,000 [4,000,000 - 9,300,000] Afghanistan ... ... ... ... ... ... Bangladesh ** ... [2,500 - 15,000] ... [2,200 - 13,000] ... [2,400 - 15,000] Bhutan ... ... ... ... ... ... Brunei Darussalam <200 [<400] <200 [<400] <200 [<400] Cambodia 170,000 [100,000 - 290,000] 170,000 [100,000 - 270,000] 170,000 [99,000 - 280,000] India 5,100,000 [2,500,000 - 8,500,000] 3,970,000 [2,100,000 - 7,100,000] 5,000,000 [2,500,000 - 8,200,000] Indonesia 110,000 [53,000 - 180,000] 58,000 [28,000 - 95,000] 110,000 [53,000 - 180,000] Iran (Islamic Republic of) 31,000 [10,000 - 61,000] 18,000 [6,000 - 36,000] 31,000 [10,000 - 60,000] Lao People's Dem. Rep. 1,700 [600 - 3,600] 800 [300 - 1,600] 1,700 [550 - 3,300] Malaysia 52,000 [25,000 - 86,000] 42,000 [20,000 - 70,000] 51,000 [25,000 - 84,000] Maldives ... ... ... ... ... ... Myanmar ** 330,000 [170,000 - 620,000] 280,000 [150,000 - 510,000] 320,000 [170,000 - 610,000] Nepal 61,000 [29,000 - 110,000] 45,000 [22,000 - 78,000] 60,000 [29,000 - 98,000] Pakistan 74,000 [24,000 - 150,000] 63,000 [21,000 - 130,000] 73,000 [24,000 - 140,000] Philippines 9,000 [3,000 - 18,000] 4,400 [1,400 - 8,700] 8,900 [2,900 - 18,000] Singapore 4,100 [1,300 - 8,000] 3,400 [1,100 - 6,700] 4,100 [1,300 - 8,000] Sri Lanka 3,500 [1,200 - 6,900] 2,200 [700 - 4,300] 3,500 [1,100 - 6,800] Thailand 570,000 [310,000 - 1,000,000] 630,000 [360,000 - 1,100,000] 560,000 [310,000 - 1,000,000] Vietnam 220,000 [110,000 - 360,000] 150,000 [75,000 - 250,000] 200,000 [100,000 - 350,000] Eastern Europe & Central Asia 1,300,000 [860,000 - 1,900,000] 890,000 [570,000 - 1,300,000] 1,300,000 [850,000 - 1,900,000] Armenia 2,600 [1,200 - 4,300] 2,000 [990 - 3,400] 2,500 [1,200 - 4,100] Azerbaijan 1,400 [500 - 2,800] ... ... 1,400 [500 - 2,800] Belarus ... [12,000 - 42,000] ... [10,000 - 39,000] ... [12,000 - 40,000] Bosnia and Herzegovina 900 [300 - 1,800] ... ... 900 [300 - 1,800] Bulgaria <500 [<1,000] ... ... <500 [<1,000] Croatia <200 [<400] ... ... <200 [<400] Czech Republic 2,500 [800 - 4,900] 2,100 [750 - 4,700] 2,500 [820 - 4,900] Estonia 7,800 [2,600 - 15,000] 5,100 [1,700 - 10,000] 7,700 [2,500 - 15,000] Georgia 3,000 [2,000 - 12,000] 1,500 [660 - 4,000] 3,000 [2,000 - 12,000] Hungary 2,800 [900 - 5,500] ... ... 2,800 [900 - 5,500] Kazakhstan 16,500 [5,800 - 35,000] 10,400 [5,000 - 30,000] 16,400 [5,700 - 34,000] Kyrgyz Republic 3,900 [1,500 - 8,000] 1,500 [700 - 4,000] 3,900 [1,500 - 8,000] Latvia 7,600 [3,700 - 12,000] 6,000 [2,900 - 9,800] 7,500 [3,700 - 12,000] Lithuania 1,300 [400 - 2,600] 1,100 [400 - 2,200] 1,300 [400 - 2,600] Poland 14,000 [6,900 - 23,000] ... ... 14,000 [6,900 - 23,000] Republic of Moldova 5,500 [2,700 - 9,000] ... ... 5,500 [2,700 - 9,000] Romania 6,500 [4,800 - 8,900] 4,000 [4,000 - 4,000] 2,500 [800 - 4,900] Russian Federation 860,000 [420,000 - 1,400,000] 530,000 [260,000 - 870,000] 860,000 [420,000 - 1,400,000] Slovak Republic <200 [<400] ... ... <200 [<400] Tajikistan <200 [<400] ... ... <200 [<400] Turkmenistan <200 [<400] ... ... <200 [<400] Ukraine 360,000 [180,000 - 590,000] 300,000 [150,000 - 490,000] 360,000 [170,000 - 580,000] Uzbekistan 11,000 [4,900 - 30,000] 3,000 [1,900 - 12,000] 11,000 [4,900 - 29,000] Western Europe 580,000 [460,000 - 730,000] 540,000 [430,000 - 690,000] 570,000 [450,000 - 720,000] Albania ... ... ... ... ... ... Austria 10,000 [5,000 - 16,000] 10,000 [4,900 - 16,000] 10,000 [4,900 - 16,000] Belgium 10,000 [5,300 - 17,000] 8,400 [4,300 - 14,000] 10,000 [4,900 - 16,000] Denmark 5,000 [2,500 - 8,200] 4,600 [2,300 - 7,600] 5,000 [2,500 - 8,200] Finland 1,500 [500 - 3,000] 1,200 [400 - 2,400] 1,500 [500 - 3,000] France 120,000 [60,000 - 200,000] 110,000 [56,000 - 190,000] 120,000 [59,000 - 200,000] Germany 43,000 [21,000 - 71,000] 41,000 [20,000 - 68,000] 43,000 [21,000 - 71,000] Greece 9,100 [4,500 - 15,000] 8,900 [4,400 - 14,000] 9,000 [4,400 - 15,000] Iceland <500 [<1,000] <500 [<1,000] <200 [<400] Ireland 2,800 [1,100 - 5,300] 2,400 [800 - 4,900] 2,600 [900 - 5,100] Italy 140,000 [67,000 - 220,000] 130,000 [65,000 - 210,000] 140,000 [66,000 - 220,000] Luxembourg <500 [<1,000] <500 [<1,000] <500 [<1,000] Malta <500 [<1,000] <500 [<1,000] <500 [<1,000] Netherlands 19,000 [9,500 - 31,000] 17,000 [8,500 - 28,000] 19,000 [9,300 - 31,000] Norway 2,100 [700 - 4,000] 1,900 [600 - 3,600] 2,000 [700 - 3,900] Portugal 22,000 [11,000 - 36,000] 21,000 [11,000 - 35,000] 22,000 [11,000 - 35,000] Serbia and Montenegro 10,000 [3,400 - 20,000] 10,000 [3,400 - 20,000] 10,000 [3,300 - 20,000] Slovenia <500 [<1,000] <500 [<1,000] <500 [<1,000] Spain 140,000 [67,000 - 220,000] 130,000 [65,000 - 210,000] 130,000 [66,000 - 220,000] Sweden 3,600 [1,200 - 6,900] 3,400 [1,100 - 6,600] 3,500 [1,200 - 6,900] Switzerland 13,000 [6,500 - 21,000] 12,000 [6,000 - 20,000] 13,000 [6,400 - 21,000] Macedonia, FYR <200 [<400] <200 [<400] <200 [<400] United Kingdom 51,000 [25,000 - 82,000] 43,000 [21,000 - 69,000] 47,000 [24,000 - 81,000] 62 The World Bank's Global HIV/AIDS Program of Action Adults and Children end 2003 Adults and Children end 2001 Adults (15-49) end 2003 [low estimate - high [low estimate - high [low estimate - high Country Estimate estimate] Estimate estimate] Estimate estimate] North Africa & Middle East 480,000 [200,000 - 1,400,000] 340,000 [130,000 - 910,000] 460,000 [190,000 - 1,300,000] Algeria 9,100 [3,000 - 18,000] 6,800 [2,200 - 14,000] 9,000 [3,000 - 18,000] Bahrain <600 [200 - 1,100] <500 [<1,000] <600 [200 - 1,100] Cyprus ... ... ... ... ... ... Egypt, Arab Republic of 12,000 [5,000 - 31,000] 11,000 [3,600 - 22,000] 12,000 [5,000 - 30,000] Iraq <500 [<1,000] ... ... <500 [<1,000] Israel 3,000 [1,500 - 4,900] ... ... 3,000 [1,500 - 4,900] Jordan 600 [<1,000] 600 [<1,000] <500 [<1,000] Kuwait ... ... ... ... ... ... Lebanon 2,800 [700 - 4,100] 2,000 [400 - 2,500] 2,800 [700 - 4,000] Libyan Arab Jamahiriya 10,000 [3,300 - 20,000] ... ... 10,000 [3,300 - 20,000] Morocco 15,000 [5,000 - 30,000] ... ... 15,000 [5,000 - 30,000] Oman 1,300 [500 - 3,000] 1,000 [300 - 2,100] 1,300 [500 - 2,900] Qatar ... ... ... ... ... ... Saudi Arabia ... ... ... ... ... ... Sudan 400,000 [120,000 - 1,300,000] 320,000 [110,000 - 890,000] 380,000 [120,000 - 1,200,000] Syrian Arab Republic <500 [300 - 2,100] ... ... <500 [300 - 2,100] Tunisia 1,000 [400 - 2,400] 600 [200 - 1,200] 1,000 [400 - 2,300] Turkey ... ... ... ... ... ... United Arab Emirates ... ... ... ... ... ... Yemen, the Republic of 12,000 [4,000 - 24,000] ... ... 12,000 [4,000 - 24,000] North America 1,000,000 [520,000 - 1,600,000] 950,000 [490,000 - 1,500,000] 990,000 [510,000 - 1,600,000] Canada 56,000 [26,000 - 86,000] 49,000 [24,000 - 79,000] 55,000 [25,000 - 85,000] United States of America 950,000 [470,000 - 1,600,000] 900,000 [450,000 - 1,500,000] 940,000 [460,000 - 1,500,000] Caribbean 430,000 [270,000 - 760,000] 400,000 [270,000 - 650,000] 410,000 [260,000 - 720,000] Bahamas 5,600 [3,200 - 8,700] 5,200 [3,300 - 8,300] 5,200 [3,100 - 8,400] Barbados 2,500 [700 - 9,200] 2,500 [800 - 7,300] 2,500 [700 - 9,100] Cuba 3,300 [1,100 - 6,600] 3,200 [1,100 - 6,500] 3,300 [1,100 - 6,400] Dominican Republic 88,000 [48,000 - 160,000] 90,000 [52,000 - 150,000] 85,000 [47,000 - 150,000] Haiti 280,000 [120,000 - 600,000] 260,000 [130,000 - 500,000] 260,000 [120,000 - 560,000] Jamaica 22,000 [11,000 - 41,000] 15,000 [7,700 - 28,000] 21,000 [11,000 - 40,000] Trinidad and Tobago 29,000 [11,000 - 74,000] 26,000 [11,000 - 59,000] 28,000 [10,000 - 72,000] Latin America 1,600,000 [1,200,000 - 2,100,000] 1,400,000 [1,100,000 - 1,800,000] 1,600,000 [1,200,000 - 2,000,000] Argentina 130,000 [61,000 - 210,000] 120,000 [59,000 - 200,000] 120,000 [61,000 - 200,000] Belize 3,600 [1,200 - 10,000] 2,900 [1,100 - 7,200] 3,500 [1,200 - 9,800] Bolivia 4,900 [1,600 - 11,000] 4,200 [1,300 - 9,000] 4,800 [1,600 - 9,400] Brazil 660,000 [320,000 - 1,100,000] 630,000 [310,000 - 1,000,000] 650,000 [320,000 - 1,100,000] Chile 26,000 [13,000 - 44,000] 25,000 [12,000 - 42,000] 26,000 [13,000 - 43,000] Colombia 190,000 [90,000 - 310,000] 130,000 [61,000 - 210,000] 180,000 [90,000 - 300,000] Costa Rica 12,000 [6,000 - 21,000] 11,000 [5,500 - 19,000] 12,000 [6,000 - 20,000] Ecuador 21,000 [10,000 - 38,000] 20,000 [9,700 - 36,000] 20,000 [10,000 - 34,000] El Salvador 29,000 [14,000 - 50,000] 24,000 [12,000 - 43,000] 28,000 [14,000 - 46,000] Guatemala 78,000 [38,000 - 130,000] 69,000 [34,000 - 110,000] 74,000 [36,000 - 120,000] Guyana * 11,000 [3,500 - 35,000] 11,000 [4,300 - 30,000] 11,000 [3,300 - 33,000] Honduras 63,000 [35,000 - 110,000] 51,000 [29,000 - 90,000] 59,000 [33,000 - 100,000] Mexico 160,000 [78,000 - 260,000] 150,000 [74,000 - 250,000] 160,000 [78,000 - 260,000] Nicaragua 6,400 [3,100 - 12,000] 5,800 [2,700 - 10,000] 6,200 [3,000 - 10,000] Panama 16,000 [7,700 - 26,000] 11,000 [5,500 - 19,000] 15,000 [7,500 - 25,000] Paraguay 15,000 [7,300 - 25,000] 10,000 [5,000 - 17,000] 15,000 [7,300 - 24,000] Peru 82,000 [40,000 - 140,000] 53,000 [26,000 - 88,000] 80,000 [39,000 - 130,000] Suriname 5,200 [1,400 - 18,000] 4,100 [1,300 - 13,000] 5,000 [1,400 - 18,000] Uruguay 6,000 [2,800 - 9,700] 5,600 [2,700 - 9,500] 5,800 [2,800 - 9,400] Venezuela, R.B. de 110,000 [47,000 - 170,000] 73,000 [35,000 - 120,000] 100,000 [47,000 - 160,000] Global Total 37,800,000 [34,600,000 - 42,300,000] 34,900,000 [32,000,000 - 39,000,000] 35,700,000 [32,700,000 - 39,800,000] 63 Appendix 2: Country-Level HIV/AIDS Data 1. Estimated number of people living with HIV (continued) Adult (15-49) Adult (15-49) Adults (15-49) end 2001 rate (%) end 2003 rate (%) end 2001 Women (15-49) end 2003 [low estimate - [low estimate - [low estimate - [low estimate - Country Estimate high estimate] Estimate high estimate] Estimate high estimate] Estimate high estimate] Global Total 32,900,000 [30,200,000 - 36,700,000] 1.1 [1.0 - 1.2] 1.0 [0.9 - 1.1] 17,000,000 [15,800,000 - 18,800,000] Sub-Saharan Africa 22,000,000 [20,400,000 - 24,500,000] 7.5 [6.9 - 8.3] 7.6 [7.0 - 8.5] 13,100,000 [12,200,000 - 14,600,000] Angola 200,000 [78,000 - 490,000] 3.9 [1.6 - 9.4] 3.7 [1.5 - 9.1] 130,000 [50,000 - 300,000] Benin 59,000 [34,000 - 100,000] 1.9 [1.1 - 3.3] 1.9 [1.1 - 3.4] 35,000 [20,000 - 62,000] Botswana * 330,000 [320,000 - 340,000] 37.3 [35.5 - 39.1] 38.0 [36.3 - 39.7] 190,000 [180,000 - 190,000] Burkina Faso * 250,000 [160,000 - 390,000] 4.2 [2.7 - 6.5] 4.2 [2.7 - 6.5] 150,000 [98,000 - 240,000] Burundi 220,000 [150,000 - 310,000] 6.0 [4.1 - 8.8] 6.2 [4.3 - 9.0] 130,000 [85,000 - 180,000] Cameroon * 500,000 [350,000 - 700,000] 6.9 [4.8 - 9.8] 7.0 [4.9 - 9.9] 290,000 [200,000 - 420,000] Central African Republic 230,000 [140,000 - 360,000] 13.5 [8.3 - 21.2] 13.5 [8.3 - 21.2] 130,000 [83,000 - 210,000] Chad 170,000 [110,000 - 260,000] 4.8 [3.1 - 7.2] 4.9 [3.2 - 7.4] 100,000 [66,000 - 150,000] Comoros ... ... ... ... ... ... ... ... Congo, Republic of 80,000 [35,000 - 170,000] 4.9 [2.1 - 11.0] 5.3 [2.3 - 11.5] 45,000 [19,000 - 100,000] Côte d'Ivoire 480,000 [330,000 - 680,000] 7.0 [4.9 - 10.0] 6.7 [4.7 - 9.6] 300,000 [210,000 - 420,000] Dem. Republic of Congo ** 950,000 [390,000 - 2,200,000] 4.2 [1.7 - 9.9] 4.2 [1.7 - 10.0] 570,000 [230,000 - 1,300,000] Djibouti 7,500 [2,200 - 21,000] 2.9 [0.7 - 7.5] 2.8 [0.8 - 7.9] 4,700 [1,200 - 12,000] Equatorial Guinea ... ... ... ... ... ... ... ... Eritrea 55,000 [20,000 - 150,000] 2.7 [0.9 - 7.3] 2.8 [1.0 - 7.6] 31,000 [11,000 - 85,000] Ethiopia 1,200,000 [760,000 - 1,900,000] 4.4 [2.8 - 6.7] 4.1 [2.6 - 6.3] 770,000 [500,000 - 1,200,000] Gabon 37,000 [18,000 - 73,000] 8.1 [4.1 - 15.3] 6.9 [3.3 - 13.7] 26,000 [13,000 - 48,000] Gambia 6,300 [1,700 - 22,000] 1.2 [0.3 - 4.2] 1.2 [0.3 - 4.3] 3,600 [970 - 13,000] Ghana * 310,000 [190,000 - 500,000] 3.1 [1.9 - 5.0] 3.1 [1.9 - 5.1] 180,000 [110,000 - 300,000] Guinea * 100,000 [37,000 - 280,000] 3.2 [1.2 - 8.2] 2.8 [1.0 - 7.5] 72,000 [27,000 - 190,000] Guinea-Bissau ... ... ... ... ... ... ... ... Kenya 1,200,000 [830,000 - 1,600,000] 6.7 [4.7 - 9.6] 8.0 [5.8 - 11.1] 720,000 [500,000 - 1,000,000] Lesotho * 300,000 [270,000 - 330,000] 28.9 [26.3 - 31.7] 29.6 [27.0 - 32.3] 170,000 [150,000 - 190,000] Liberia 80,000 [35,000 - 180,000] 5.9 [2.7 - 12.4] 5.1 [2.2 - 11.3] 54,000 [25,000 - 110,000] Madagascar 98,000 [48,000 - 160,000] 1.7 [0.8 - 2.7] 1.3 [0.6 - 2.1] 76,000 [37,000 - 120,000] Malawi * 770,000 [610,000 - 960,000] 14.2 [11.3 - 17.7] 14.3 [11.4 - 17.9] 460,000 [370,000 - 570,000] Mali 120,000 [37,000 - 350,000] 1.9 [0.6 - 5.9] 1.9 [0.6 - 5.8] 71,000 [23,000 - 210,000] Mauritania 5,900 [2,900 - 9,700] 0.6 [0.3 - 1.1] 0.5 [0.2 - 0.7] 5,100 [2,500 - 8,300] Mauritius ... ... ... ... ... ... ... ... Mozambique 1,100,000 [870,000 - 1,500,000] 12.2 [9.4 - 15.7] 12.1 [9.4 - 15.6] 670,000 [520,000 - 860,000] Namibia 190,000 [160,000 - 220,000] 21.3 [18.2 - 24.7] 21.3 [18.2 - 24.7] 110,000 [94,000 - 130,000] Niger 51,000 [26,000 - 98,000] 1.2 [0.7 - 2.3] 1.1 [0.5 - 2.0] 36,000 [19,000 - 68,000] Nigeria 3,100,000 [2,100,000 - 4,600,000] 5.4 [3.6 - 8.0] 5.5 [3.7 - 8.1] 1,900,000 [1,200,000 - 2,700,000] Rwanda * 220,000 [140,000 - 320,000] 5.1 [3.4 - 7.6] 5.1 [3.4 - 7.6] 130,000 [86,000 - 200,000] Senegal * 38,000 [19,000 - 76,000] 0.8 [0.4 - 1.7] 0.8 [0.4 - 1.6] 23,000 [12,000 - 47,000] Sierra Leone ... ... ... ... ... ... ... ... Somalia ... ... ... ... ... ... ... ... South Africa * 4,800,000 [4,100,000 - 5,600,000] 21.5 [18.5 - 24.9] 20.9 [17.8 - 24.3] 2,900,000 [2,500,000 - 3,300,000] Swaziland ** 190,000 [180,000 - 200,000] 38.8 [37.2 - 40.4] 38.2 [36.5 - 39.8] 110,000 [110,000 - 120,000] Togo 94,000 [61,000 - 140,000] 4.1 [2.7 - 6.4] 4.3 [2.8 - 6.6] 54,000 [35,000 - 84,000] Uganda * 520,000 [370,000 - 810,000] 4.1 [2.8 - 6.6] 5.1 [3.5 - 7.9] 270,000 [170,000 - 410,000] United Rep. of Tanzania * 1,400,000 [1,100,000 - 2,000,000] 8.8 [6.4 - 11.9] 9.0 [6.6 - 12.2] 840,000 [610,000 - 1,100,000] Zambia 800,000 [660,000 - 970,000] 16.5 [13.5 - 20.0] 16.7 [13.6 - 20.2] 470,000 [380,000 - 570,000] Zimbabwe 1,600,000 [1,400,000 - 1,800,000] 24.6 [21.7 - 27.8] 24.9 [22.0 - 28.1] 930,000 [820,000 - 1,000,000] East Asia 670,000 [340,000 - 1,100,000] 0.1 [0.1 - 0.2] 0.1 [0.1 - 0.2] 200,000 [100,000 - 320,000] China 650,000 [320,000 - 1,100,000] 0.1 [0.1 - 0.2] 0.1 [0.0 - 0.2] 190,000 [95,000 - 320,000] Hong Kong SAR 2,600 [1,300 - 4,300] 0.1 [<0.2] 0.1 [<0.2] 900 [400 - 1,400] Dem. Peo. Rep. of Korea ... ... ... ... ... ... ... ... Japan 12,000 [5,800 - 19,000] <0.1 [<0.2] <0.1 [<0.2] 2,900 [1,400 - 4,800] Mongolia <200 [<400] <0.1 [<0.2] <0.1 [<0.2] <200 [<400] Republic of Korea 5,600 [1,800 - 11,000] <0.1 [<0.2] <0.1 [<0.2] 900 [300 - 1,800] Oceania 24,000 [16,000 - 34,000] 0.2 [0.1 - 0.3] 0.2 [0.1 - 0.3] 6,100 [3,600 - 9,200] Australia 12,000 [5,900 - 20,000] 0.1 [0.1 - 0.2] 0.1 [0.1 - 0.2] 1,000 [500 - 1,600] Fiji 500 [200 - 900] 0.1 [0.0 - 0.2] 0.1 [0.0 - 0.2] <200 [<400] New Zealand 1,200 [400 - 2,400] 0.1 [<0.2] 0.1 [<0.2] <200 [<400] Papua New Guinea 10,000 [4,900 - 16,000] 0.6 [0.3 - 1.0] 0.4 [0.2 - 0.7] 4,800 [2,400 - 7,900] 64 The World Bank's Global HIV/AIDS Program of Action 1. Estimated number of people living with HIV (continued) Adult (15-49) rate (%) Adult (15-49) rate (%) Adults (15-49) end 2001 end 2003 end 2001 Women (15-49) end 2003 [low estimate - [low estimate - [low estimate - [low estimate - Country Estimate high estimate] Estimate high estimate] Estimate high estimate] Estimate high estimate] South & South-East Asia 5,800,000 [3,700,000 - 8,400,000] 0.6 [0.4 - 0.9] 0.6 [0.4 - 0.9] 1,800,000 [1,200,000 - 2,700,000] Afghanistan ... ... ... ... ... ... ... ... Bangladesh ** ... [2,200 - 13,000] ... [<0.2] ... [<0.2] ... [400 - 2,500] Bhutan ... ... ... ... ... ... ... ... Brunei Darussalam <200 [<400] <0.1 [<0.2] <0.1 [<0.2] <200 [<400] Cambodia 160,000 [100,000 - 260,000] 2.6 [1.5 - 4.4] 2.7 [1.7 - 4.3] 51,000 [31,000 - 86,000] India 3,800,000 [2,100,000 - 6,900,000] 0.9 [0.5 - 1.5] 0.8 [0.4 - 1.3] 1,900,000 [710,000 - 2,400,000] Indonesia 57,000 [28,000 - 94,000] 0.1 [0.0 - 0.2] 0.1 [<0.2] 15,000 [7,100 - 24,000] Iran (Islamic Republic of) 18,000 [6,000 - 36,000] 0.1 [0.0 - 0.2] 0.1 [<0.2] 3,800 [1,200 - 7,400] Lao People's Dem. Rep. 800 [300 - 1,500] 0.1 [<0.2] <0.1 <0.2 <500 [<1,000] Malaysia 41,000 [20,000 - 68,000] 0.4 [0.2 - 0.7] 0.4 [0.2 - 0.6] 8,500 [4,100 - 14,000] Maldives ... ... ... ... ... ... ... ... Myanmar ** 270,000 [140,000 - 500,000] 1.2 [0.6 - 2.2] 1.0 [0.6 - 1.9] 97,000 [51,000 - 180,000] Nepal 44,000 [22,000 - 72,000] 0.5 [0.3 - 0.9] 0.4 [0.2 - 0.6] 16,000 [7,200 - 24,000] Pakistan 62,000 [20,000 - 120,000] 0.1 [0.0 - 0.2] 0.1 [0.0 - 0.2] 8,900 [3,000 - 18,000] Philippines 4,300 [1,400 - 8,500] <0.1 [<0.2] <0.1 [<0.2] 2,000 [700 - 4,000] Singapore 3,400 [1,100 - 6,600] 0.2 [0.1 - 0.5] 0.2 [0.1 - 0.4] 1,000 [300 - 2,000] Sri Lanka 2,200 [700 - 4,300] <0.1 [<0.2] <0.1 [<0.2] 600 [200 - 1,200] Thailand 620,000 [360,000 - 1,100,000] 1.5 [0.8 - 2.8] 1.7 [1.0 - 2.9] 200,000 [110,000 - 370,000] Vietnam 150,000 [75,000 - 250,000] 0.4 [0.2 - 0.8] 0.3 [0.2 - 0.6] 65,000 [31,000 - 110,000] Eastern Europe & Central Asia 880,000 [570,000 - 1,300,000] 0.6 [0.4 - 0.9] 0.4 [0.3 - 0.6] 440,000 [280,000 - 650,000] Armenia 2,000 [1,000 - 3,300] 0.1 [0.1 - 0.2] 0.1 [0.0 - 0.2] 900 [400 - 1,400] Azerbaijan ... ... <0.1 [<0.2] ... ... ... ... Belarus ... [10,000 - 38,000] ... [0.2 - 0.8] ... [0.2 - 0.7] ... [3,100 - 14,000] Bosnia and Herzegovina ... ... <0.1 [<0.2] ... ... ... ... Bulgaria ... ... <0.1 [<0.2] ... ... ... ... Croatia ... ... <0.1 [<0.2] ... ... ... ... Czech Republic 2,100 [750 - 4,700] 0.1 [<0.2] <0.1 [<0.2] 800 [300 - 1,700] Estonia 5,000 [1,700 - 9,900] 1.1 [0.4 - 2.1] 0.7 [0.2 - 1.3] 2,600 [900 - 5,200] Georgia 1,500 [700 - 3,900] 0.1 [0.1 - 0.4] <0.1 [<0.2] 1,000 [700 - 4,000] Hungary ... ... 0.1 [0.0 - 0.2] ... ... ... ... Kazakhstan 10,300 [5,000 - 30,000] 0.2 [0.1 - 0.3] 0.1 [<0.2] 5,500 [2,000 - 12,000] Kyrgyz Republic 1,500 [700 - 4,000] 0.1 [<0.2] <0.1 [<0.2] <800 [<1,500] Latvia 5,900 [2,900 - 9,700] 0.6 [0.3 - 1.0] 0.5 [0.2 - 0.8] 2,500 [1,200 - 4,100] Lithuania 1,100 [400 - 2,200] 0.1 [<0.2] 0.1 [<0.2] <500 [<1,000] Poland ... ... 0.1 [0.1 - 0.2] ... ... ... ... Republic of Moldova ... ... 0.2 [0.1 - 0.3] ... ... ... ... Romania ... ... <0.1 [<0.2] ... ... ... ... Russian Federation 530,000 [260,000 - 870,000] 1.1 [0.6 - 1.9] 0.7 [0.3 - 1.2] 290,000 [140,000 - 480,000] Slovak Republic ... ... <0.1 [<0.2] ... ... ... ... Tajikistan ... ... <0.1 [<0.2] ... ... ... ... Turkmenistan ... ... <0.1 [<0.2] ... ... ... ... Ukraine 300,000 [150,000 - 490,000] 1.4 [0.7 - 2.3] 1.2 [0.6 - 1.9] 120,000 [59,000 - 200,000] Uzbekistan 3,000 [1,900 - 11,000] 0.1 [0.0 - 0.2] <0.1 <0.2 3,700 [1,700 - 9,900] Western Europe 540,000 [420,000 - 680,000] 0.3 [0.2 - 0.4] 0.3 [0.2 - 0.4] 150,000 [110,000 - 190,000] Albania ... ... ... ... ... ... ... ... Austria 9,900 [4,900 - 16,000] 0.3 [0.1 - 0.4] 0.2 [0.1 - 0.4] 2,200 [1,100 - 3,600] Belgium 8,100 [4,000 - 13,000] 0.2 [0.1 - 0.3] 0.2 [0.1 - 0.3] 3,500 [1,700 - 5,700] Denmark 4,600 [2,300 - 7,500] 0.2 [0.1 - 0.3] 0.2 [0.1 - 0.3] 900 [400 - 1,500] Finland 1,200 [400 - 2,400] 0.1 [<0.2] 0.1 [<0.2] <500 [<1,000] France 110,000 [55,000 - 180,000] 0.4 [0.2 - 0.7] 0.4 [0.2 - 0.6] 32,000 [16,000 - 52,000] Germany 41,000 [20,000 - 67,000] 0.1 [0.1 - 0.2] 0.1 [0.1 - 0.2] 9,500 [4,700 - 16,000] Greece 8,800 [4,300 - 14,000] 0.2 [0.1 - 0.3] 0.2 [0.1 - 0.3] 1,800 [900 - 3,000] Iceland <200 [<400] 0.2 [0.1 - 0.3] 0.2 [0.1 - 0.3] <200 [<400] Ireland 2,200 [700 - 4,300] 0.1 [0.0 - 0.3] 0.1 [0.0 - 0.2] 800 [300 - 1,500] Italy 130,000 [64,000 - 210,000] 0.5 [0.2 - 0.8] 0.5 [0.2 - 0.8] 45,000 [22,000 - 74,000] Luxembourg <500 [<1,000] 0.2 [0.1 - 0.4] 0.2 [0.1 - 0.3] ... ... Malta <500 [<1,000] 0.2 [0.1 - 0.3] 0.1 [0.0 - 0.2] ... ... Netherlands 17,000 [8,300 - 28,000] 0.2 [0.1 - 0.4] 0.2 [0.1 - 0.3] 3,800 [1,900 - 6,200] Norway 1,800 [600 - 3,500] 0.1 [0.0 - 0.2] 0.1 [0.0 - 0.2] <500 [<1,000] Portugal 21,000 [10,000 - 34,000] 0.4 [0.2 - 0.7] 0.4 [0.2 - 0.7] 4,300 [2,100 - 7,100] Serbia and Montenegro 10,000 [3,300 - 20,000] 0.2 [0.1 - 0.4] 0.2 [0.1 - 0.4] 2,000 [700 - 3,900] Slovenia <500 [<1,000] <0.1 [<0.2] <0.1 [<0.2] ... ... Spain 130,000 [64,000 - 210,000] 0.7 [0.3 - 1.1] 0.6 [0.3 - 1.0] 27,000 [13,000 - 44,000] Sweden 3,300 [1,100 - 6,500] 0.1 [0.0 - 0.2] 0.1 [0.0 - 0.2] 900 [300 - 1,800] Switzerland 12,000 [5,900 - 20,000] 0.4 [0.2 - 0.6] 0.4 [0.2 - 0.6] 3,900 [1,900 - 6,400] Macedonia, FYR <200 [<400] <0.1 [<0.2] <0.1 [<0.2] ... ... United Kingdom 39,000 [20,000 - 68,000] 0.2 [0.1 - 0.3] 0.2 [0.1 - 0.3] 14,000 [7,100 - 24,000] 65 Appendix 2: Country-Level HIV/AIDS Data 1. Estimated number of people living with HIV (continued) Adult (15-49) rate (%) Adult (15-49) rate (%) Adults (15-49) end 2001 end 2003 end 2001 Women (15-49) end 2003 [low estimate - [low estimate - [low estimate - [low estimate - Country Estimate high estimate] Estimate high estimate] Estimate high estimate] Estimate high estimate] North Africa & Middle East 320,000 [130,000 - 860,000] 0.2 [0.1 - 0.6] 0.2 [0.1 - 0.5] 220,000 [70,000 - 690,000] Algeria 6,800 [2,200 - 13,000] 0.1 [<0.2] <0.1 [<0.2] 1,400 [500 - 2,700] Bahrain <500 [<1,000] 0.2 [0.1 - 0.3] 0.1 [0.0 - 0.2] <500 [<1,000] Cyprus ... ... ... ... ... ... ... ... Egypt, Arab Republic of 11,000 [3,600 - 21,000] <0.1 [<0.2] <0.1 [<0.2] 1,600 [500 - 3,200] Iraq ... ... <0.1 [<0.2] ... ... ... ... Israel ... ... 0.1 [0.1 - 0.2] ... ... ... ... Jordan <500 [<1,000] <0.1 [<0.2] <0.1 [<0.2] ... ... Kuwait ... ... ... ... ... ... ... ... Lebanon 2,000 [400 - 2,400] 0.1 [0.0 - 0.2] 0.1 [<0.2] <500 [<1,000] Libyan Arab Jamahiriya ... ... 0.3 [0.1 - 0.6] ... ... ... ... Morocco ... ... 0.1 [0.0 - 0.2] ... ... ... ... Oman 1,000 [300 - 2,000] 0.1 [0.0 - 0.2] 0.1 [0.0 - 0.2] <500 [<1,000] Qatar ... ... ... ... ... ... ... ... Saudi Arabia ... ... ... ... ... ... ... ... Sudan 300,000 [100,000 - 840,000] 2.3 [0.7 - 7.2] 1.9 [0.7 - 5.2] 220,000 [66,000 - 690,000] Syrian Arab Republic ... ... <0.1 [<0.2] ... ... <200 [<1,000] Tunisia 500 [200 - 1,100] <0.1 [<0.2] <0.1 [<0.2] <500 [<1,000] Turkey ... ... ... ... ... ... ... ... United Arab Emirates ... ... ... ... ... ... ... ... Yemen, the Republic of ... ... 0.1 [0.0 - 0.2] ... ... ... ... North America 940,000 [480,000 - 1,500,000] 0.6 [0.3 - 1.0] 0.6 [0.3 - 1.0] 250,000 [130,000 - 400,000] Canada 48,000 [24,000 - 79,000] 0.3 [0.2 - 0.5] 0.3 [0.2 - 0.5] 13,000 [6,400 - 21,000] United States of America 890,000 [440,000 - 1,500,000] 0.6 [0.3 - 1.1] 0.6 [0.3 - 1.0] 240,000 [120,000 - 390,000] Caribbean 380,000 [260,000 - 610,000] 2.3 [1.4 - 4.1] 2.2 [1.5 - 3.5] 200,000 [120,000 - 370,000] Bahamas 4,900 [3,200 - 8,000] 3.0 [1.8 - 4.9] 3.0 [1.9 - 4.8] 2,500 [1,500 - 4,200] Barbados 2,500 [800 - 7,300] 1.5 [0.4 - 5.4] 1.5 [0.5 - 4.4] 800 [200 - 3,100] Cuba 3,200 [1,100 - 6,300] 0.1 [<0.2] 0.1 [<0.2] 1,100 [400 - 2,100] Dominican Republic 87,000 [51,000 - 150,000] 1.7 [0.9 - 3.0] 1.8 [1.1 - 3.1] 23,000 [13,000 - 41,000] Haiti 240,000 [130,000 - 460,000] 5.6 [2.5 - 11.9] 5.5 [2.8 - 10.4] 150,000 [66,000 - 320,000] Jamaica 14,000 [7,500 - 27,000] 1.2 [0.6 - 2.2] 0.8 [0.4 - 1.6] 10,000 [5,500 - 20,000] Trinidad and Tobago 26,000 [11,000 - 57,000] 3.2 [1.2 - 8.3] 3.0 [1.3 - 6.8] 14,000 [5,200 - 36,000] Latin America 1,400,000 [1,000,000 - 1,800,000] 0.6 [0.5 - 0.8] 0.5 [0.4 - 0.7] 560,000 [420,000 - 730,000] Argentina 120,000 [59,000 - 200,000] 0.7 [0.3 - 1.1] 0.7 [0.3 - 1.1] 24,000 [12,000 - 39,000] Belize 2,800 [1,100 - 6,900] 2.4 [0.8 - 6.9] 2.1 [0.8 - 5.2] 1,300 [400 - 3,600] Bolivia 4,000 [1,300 - 7,900] 0.1 [0.0 - 0.2] 0.1 [0.0 - 0.2] 1,300 [400 - 2,500] Brazil 620,000 [300,000 - 1,000,000] 0.7 [0.3 - 1.1] 0.6 [0.3 - 1.1] 240,000 [120,000 - 400,000] Chile 25,000 [12,000 - 41,000] 0.3 [0.2 - 0.5] 0.3 [0.2 - 0.5] 8,700 [4,300 - 14,000] Colombia 120,000 [61,000 - 200,000] 0.7 [0.4 - 1.2] 0.5 [0.3 - 0.8] 62,000 [30,000 - 100,000] Costa Rica 11,000 [5,400 - 18,000] 0.6 [0.3 - 1.0] 0.6 [0.3 - 0.9] 4,000 [2,000 - 6,600] Ecuador 19,000 [9,500 - 32,000] 0.3 [0.1 - 0.5] 0.3 [0.1 - 0.5] 6,800 [3,400 - 11,000] El Salvador 24,000 [12,000 - 39,000] 0.7 [0.3 - 1.1] 0.6 [0.3 - 1.0] 9,600 [4,700 - 16,000] Guatemala 65,000 [32,000 - 110,000] 1.1 [0.6 - 1.8] 1.1 [0.5 - 1.7] 31,000 [15,000 - 51,000] Guyana * 11,000 [4,000 - 28,000] 2.5 [0.8 - 7.7] 2.5 [0.9 - 6.4] 6,100 [1,900 - 19,000] Honduras 48,000 [27,000 - 84,000] 1.8 [1.0 - 3.2] 1.6 [0.9 - 2.8] 33,000 [19,000 - 59,000] Mexico 150,000 [74,000 - 250,000] 0.3 [0.1 - 0.4] 0.3 [0.1 - 0.4] 53,000 [26,000 - 87,000] Nicaragua 5,500 [2,700 - 9,100] 0.2 [0.1 - 0.3] 0.2 [0.1 - 0.3] 2,100 [1,000 - 3,400] Panama 11,000 [5,400 - 18,000] 0.9 [0.5 - 1.5] 0.7 [0.3 - 1.1] 6,200 [3,100 - 10,000] Paraguay 10,000 [5,000 - 17,000] 0.5 [0.2 - 0.8] 0.4 [0.2 - 0.6] 3,900 [1,900 - 6,400] Peru 51,000 [25,000 - 84,000] 0.5 [0.3 - 0.9] 0.4 [0.2 - 0.6] 27,000 [13,000 - 44,000] Suriname 4,000 [1,300 - 12,000] 1.7 [0.5 - 5.8] 1.3 [0.4 - 4.1] 1,700 [500 - 6,100] Uruguay 5,500 [2,700 - 9,100] 0.3 [0.2 - 0.5] 0.3 [0.2 - 0.5] 1,900 [900 - 3,200] Venezuela, R.B. de 71,000 [35,000 - 120,000] 0.7 [0.4 - 1.2] 0.6 [0.3 - 0.9] 32,000 [16,000 - 53,000] Global Total 32,900,000 [30,200,000 - 36,700,000] 1.1 [1.0 - 1.2] 1.0 [0.9 - 1.1] 17,000,000 [15,800,000 - 18,800,000] 66 The World Bank's Global HIV/AIDS Program of Action 1. Estimated number of people living with HIV (continued) Women (15-49) end 2001 Children (0-14) end 2003 Children (0-14) end 2001 [low estimate - high [low estimate - high [low estimate - high Country Estimate estimate] Estimate estimate] Estimate estimate] Global Total 15,700,000 [14,600,000 - 17,400,000] 2,100,000 [1,900,000 - 2,500,000] 2,000,000 [1,800,000 - 2,300,000] Sub-Saharan Africa 12,500,000 [11,600,000 - 13,900,000] 1,900,000 [1,700,000 - 2,200,000] 1,800,000 [1,600,000 - 2,100,000] Angola 110,000 [44,000 - 280,000] 23,000 [8,600 - 61,000] 20,000 [7,500 - 54,000] Benin 34,000 [19,000 - 59,000] 5,700 [2,900 - 11,000] 5,100 [2,600 - 10,000] Botswana * 190,000 [180,000 - 190,000] 25,000 [17,000 - 36,000] 22,000 [15,000 - 33,000] Burkina Faso * 140,000 [91,000 - 220,000] 31,000 [18,000 - 56,000] 31,000 [18,000 - 56,000] Burundi 120,000 [84,000 - 180,000] 27,000 [16,000 - 45,000] 26,000 [15,000 - 44,000] Cameroon * 280,000 [200,000 - 400,000] 43,000 [26,000 - 72,000] 39,000 [23,000 - 64,000] Central African Republic 130,000 [80,000 - 200,000] 21,000 [11,000 - 38,000] 19,000 [10,000 - 35,000] Chad 97,000 [64,000 - 150,000] 18,000 [10,000 - 32,000] 16,000 [9,400 - 29,000] Comoros ... ... ... ... ... ... Congo, Republic of 45,000 [20,000 - 99,000] 10,000 [4,200 - 26,000] 11,000 [4,400 - 26,000] Côte d'Ivoire 270,000 [190,000 - 380,000] 40,000 [24,000 - 67,000] 38,000 [23,000 - 64,000] Dem. Republic of Congo ** 540,000 [220,000 - 1,300,000] 110,000 [42,000 - 280,000] 100,000 [40,000 - 270,000] Djibouti 4,200 [1,200 - 12,000] 680 [210 - 2,400] 570 [200 - 2,300] Equatorial Guinea ... ... ... ... ... ... Eritrea 31,000 [11,000 - 84,000] 5,600 [1,900 - 17,000] 5,400 [1,800 - 16,000] Ethiopia 670,000 [430,000 - 1,000,000] 120,000 [69,000 - 220,000] 110,000 [60,000 - 190,000] Gabon 21,000 [10,000 - 41,000] 2,500 [1,200 - 5,300] 2,000 [900 - 4,400] Gambia 3,500 [1,000 - 12,000] 500 [100 - 1,900] <500 [<1,600] Ghana * 170,000 [110,000 - 280,000] 24,000 [9,600 - 36,000] 22,000 [12,000 - 41,000] Guinea * 59,000 [21,000 - 160,000] 9,200 [3,300 - 26,000] 7,300 [2,500 - 22,000] Guinea-Bissau ... ... ... ... ... ... Kenya 750,000 [540,000 - 1,000,000] 100,000 [61,000 - 170,000] 100,000 [63,000 - 170,000] Lesotho * 170,000 [150,000 - 180,000] 22,000 [15,000 - 32,000] 20,000 [13,000 - 29,000] Liberia 45,000 [20,000 - 99,000] 8,000 [3,400 - 19,000] 6,400 [2,600 - 16,000] Madagascar 55,000 [27,000 - 91,000] 8,600 [2,500 - 30,000] 6,000 [1,600 - 22,000] Malawi * 440,000 [350,000 - 540,000] 83,000 [54,000 - 130,000] 77,000 [50,000 - 120,000] Mali 65,000 [21,000 - 200,000] 13,000 [3,900 - 42,000] 12,000 [3,500 - 38,000] Mauritania 3,300 [1,600 - 5,500] ... ... ... ... Mauritius ... ... ... ... ... ... Mozambique 640,000 [490,000 - 820,000] 99,000 [63,000 - 160,000] 87,000 [55,000 - 140,000] Namibia 100,000 [90,000 - 120,000] 15,000 [10,000 - 22,000] 12,000 [8,200 - 18,000] Niger 29,000 [15,000 - 56,000] 5,900 [2,800 - 12,000] 4,500 [2,100 - 9,700] Nigeria 1,800,000 [1,200,000 - 2,600,000] 290,000 [170,000 - 500,000] 260,000 [150,000 - 450,000] Rwanda * 120,000 [81,000 - 180,000] 22,000 [12,000 - 37,000] 20,000 [12,000 - 35,000] Senegal * 21,000 [10,000 - 43,000] 3,100 [1,400 - 6,800] 2,700 [1,200 - 5,900] Sierra Leone ... ... ... ... ... ... Somalia ... ... ... ... ... ... South Africa * 2,700,000 [2,300,000 - 3,200,000] 230,000 [150,000 - 340,000] 190,000 [130,000 - 280,000] Swaziland ** 110,000 [100,000 - 110,000] 16,000 [11,000 - 23,000] 14,000 [9,400 - 20,000] Togo 53,000 [34,000 - 82,000] 9,300 [5,200 - 17,000] 8,700 [4,900 - 15,000] Uganda * 310,000 [210,000 - 460,000] 84,000 [46,000 - 150,000] 97,000 [54,000 - 160,000] United Rep. of Tanzania * 820,000 [600,000 - 1,100,000] 140,000 [85,000 - 230,000] 130,000 [83,000 - 220,000] Zambia 450,000 [370,000 - 550,000] 85,000 [56,000 - 130,000] 84,000 [55,000 - 130,000] Zimbabwe 900,000 [790,000 - 1,000,000] 120,000 [84,000 - 180,000] 120,000 [83,000 - 180,000] East Asia 140,000 [69,000 - 220,000] 7,700 [2,700 - 22,000] 5,300 [1,800 - 16,000] China 130,000 [65,000 - 220,000] ... ... ... ... Hong Kong SAR 800 [400 - 1,300] ... ... ... ... Dem. Peo. Rep. of Korea ... ... ... ... ... ... Japan 2,700 [1,300 - 4,500] ... ... ... ... Mongolia <200 [<400] ... ... ... ... Republic of Korea 600 [200 - 1,100] ... ... ... ... Oceania 4,000 [2,400 - 5,900] 600 [<2,000] 400 [<1,200] Australia 800 [400 - 1,300] ... ... ... ... Fiji <200 [<400] ... ... ... ... New Zealand <200 [<400] ... ... ... ... Papua New Guinea 2,900 [1,400 - 4,800] ... ... ... ... 67 Appendix 2: Country-Level HIV/AIDS Data 1. Estimated number of people living with HIV (continued) Women (15-49) end 2001 Children (0-14) end 2003 Children (0-14) end 2001 [low estimate - high [low estimate - high [low estimate - high Country Estimate estimate] Estimate estimate] Estimate estimate] South & South-East Asia 1,600,000 [1,000,000 - 2,300,000] 160,000 [91,000 - 300,000] 130,000 [77,000 - 260,000] Afghanistan ... ... ... ... ... ... Bangladesh ** ... [300 - 2,100] ... ... ... ... Bhutan ... ... ... ... ... ... Brunei Darussalam <200 [<400] ... ... ... ... Cambodia 48,000 [30,000 - 77,000] 7,300 [3,800 - 14,000] 6,400 [3,500 - 12,000] India 1,500,000 [570,000 - 1,900,000] 120,000 [55,000 - 260,000] 100,000 [45,000 - 220,000] Indonesia 6,900 [3,400 - 11,000] ... ... ... ... Iran (Islamic Republic of) 1,900 [600 - 3,800] ... ... ... ... Lao People's Dem. Rep. <200 [<400] ... ... ... ... Malaysia 6,300 [3,100 - 10,000] ... ... ... ... Maldives ... ... ... ... ... ... Myanmar ** 78,000 [42,000 - 140,000] 7,600 [3,600 - 16,000] 5,700 [2,800 - 12,000] Nepal 9,100 [4,500 - 15,000] ... ... ... ... Pakistan 4,300 [1,400 - 8,500] ... ... ... ... Philippines 900 [300 - 1,800] ... ... ... ... Singapore 800 [300 - 1,500] ... ... ... ... Sri Lanka <500 [<1,000] ... ... ... ... Thailand 200,000 [110,000 - 340,000] 12,000 [5,700 - 24,000] 12,000 [6,200 - 23,000] Vietnam 41,000 [21,000 - 69,000] ... ... ... ... Eastern Europe & Central Asia 280,000 [180,000 - 410,000] 8,100 [6,600 - 12,000] 7,000 [5,800 - 9,700] Armenia 700 [300 - 1,100] ... ... ... ... Azerbaijan ... ... ... ... ... ... Belarus ... [2,800 - 12,000] ... ... ... ... Bosnia and Herzegovina ... ... ... ... ... ... Bulgaria ... ... ... ... ... ... Croatia ... ... ... ... ... ... Czech Republic 750 [300 - 1,600] ... ... ... ... Estonia 1,600 [500 - 3,200] ... ... ... ... Georgia <600 [200 - 1,300] ... ... ... ... Hungary ... ... ... ... ... ... Kazakhstan 3,500 [1,000 - 7,000] ... ... ... ... Kyrgyz Republic <500 [<1,000] ... ... ... ... Latvia 1,900 [900 - 3,100] ... ... ... ... Lithuania <500 [<1,000] ... ... ... ... Poland ... ... ... ... ... ... Republic of Moldova ... ... ... ... ... ... Romania ... ... ... ... ... ... Russian Federation 170,000 [85,000 - 280,000] ... ... ... ... Slovak Republic ... ... ... ... ... ... Tajikistan ... ... ... ... ... ... Turkmenistan ... ... ... ... ... ... Ukraine 96,000 [47,000 - 160,000] ... ... ... ... Uzbekistan 1,000 [600 - 3,600] ... ... ... ... Western Europe 130,000 [100,000 - 170,000] 6,200 [4,900 - 7,900] 5,800 [4,600 - 7,400] Albania ... ... ... ... ... ... Austria 2,200 [1,100 - 3,600] ... ... ... ... Belgium 2,900 [1,400 - 4,800] ... ... ... ... Denmark 800 [400 - 1,300] ... ... ... ... Finland <500 [<1,000] ... ... ... ... France 30,000 [15,000 - 49,000] ... ... ... ... Germany 8,100 [4,000 - 13,000] ... ... ... ... Greece 1,800 [900 - 3,000] ... ... ... ... Iceland <200 [<400] ... ... ... ... Ireland 700 [200 - 1,300] ... ... ... ... Italy 42,000 [21,000 - 69,000] ... ... ... ... Luxembourg ... ... ... ... ... ... Malta ... ... ... ... ... ... Netherlands 3,300 [1,600 - 5,400] ... ... ... ... Norway <500 [<1,000] ... ... ... ... Portugal 4,200 [2,100 - 6,900] ... ... ... ... Serbia and Montenegro 2,000 [700 - 3,900] ... ... ... ... Slovenia ... ... ... ... ... ... Spain 26,000 [13,000 - 43,000] ... ... ... ... Sweden 900 [300 - 1,700] ... ... ... ... Switzerland 3,600 [1,800 - 5,900] ... ... ... ... Macedonia, FYR ... ... ... ... ... ... United Kingdom 11,000 [5,500 - 19,000] ... ... ... ... 68 The World Bank's Global HIV/AIDS Program of Action 1. Estimated number of people living with HIV (continued) Women (15-49) end 2001 Children (0-14) end 2003 Children (0-14) end 2001 [low estimate - high [low estimate - high [low estimate - high Country Estimate estimate] Estimate estimate] Estimate estimate] North Africa & Middle East 170,000 [62,000 - 480,000] 21,000 [6,300 - 72,000] 16,000 [5,400 - 48,000] Algeria 800 [300 - 1,600] ... ... ... ... Bahrain <200 [<400] ... ... ... ... Cyprus ... ... ... ... ... ... Egypt, Arab Republic of 1,200 [400 - 2,300] ... ... ... ... Iraq ... ... ... ... ... ... Israel ... ... ... ... ... ... Jordan ... ... ... ... ... ... Kuwait ... ... ... ... ... ... Lebanon <500 [<1,000] ... ... ... ... Libyan Arab Jamahiriya ... ... ... ... ... ... Morocco ... ... ... ... ... ... Oman <200 [<400] ... ... ... ... Qatar ... ... ... ... ... ... Saudi Arabia ... ... ... ... ... ... Sudan 170,000 [59,000 - 470,000] 21,000 [6,000 - 72,000] 16,000 [5,200 - 48,000] Syrian Arab Republic ... ... ... ... ... ... Tunisia <200 [<400] ... ... ... ... Turkey ... ... ... ... ... ... United Arab Emirates ... ... ... ... ... ... Yemen, the Republic of ... ... ... ... ... ... North America 190,000 [100,000 - 310,000] 11,000 [5,600 - 17,300] 11,000 [5,500 - 17,200] Canada 12,000 [5,900 - 20,000] ... ... ... ... United States of America 180,000 [88,000 - 300,000] ... ... ... ... Caribbean 180,000 [120,000 - 310,000] 22,000 [11,000 - 48,000] 22,000 [12,000 - 42,000] Bahamas 2,500 [1,600 - 4,000] <200 [<400] <200 [<400] Barbados 800 [300 - 2,400] <200 [<400] <200 [<400] Cuba 1,000 [300 - 2,000] ... ... ... ... Dominican Republic 23,000 [13,000 - 39,000] 2,200 [1,100 - 4,400] 2,100 [1,100 - 4,100] Haiti 140,000 [71,000 - 260,000] 19,000 [7,900 - 45,000] 18,000 [8,700 - 39,000] Jamaica 7,200 [3,700 - 14,000] <500 [<1,000] <500 [<1,000] Trinidad and Tobago 13,000 [5,600 - 28,000] 700 [300 - 2,100] 600 [300 - 1,500] Latin America 480,000 [360,000 - 640,000] 25,000 [20,000 - 41,000] 24,000 [19,000 - 40,000] Argentina 23,000 [11,000 - 37,000] ... ... ... ... Belize 1,000 [400 - 2,500] <200 [<400] <200 [<400] Bolivia 1,100 [300 - 2,100] ... ... ... ... Brazil 230,000 [110,000 - 380,000] ... ... ... ... Chile 8,000 [3,900 - 13,000] ... ... ... ... Colombia 40,000 [20,000 - 65,000] ... ... ... ... Costa Rica 3,500 [1,700 - 5,700] ... ... ... ... Ecuador 6,200 [3,000 - 10,000] ... ... ... ... El Salvador 7,700 [3,800 - 13,000] ... ... ... ... Guatemala 27,000 [13,000 - 45,000] ... ... ... ... Guyana * 6,100 [2,300 - 16,000] 600 [200 - 2,000] 700 [200 - 1,900] Honduras 27,000 [15,000 - 47,000] 3,900 [2,000 - 7,800] 3,200 [1,600 - 6,200] Mexico 49,000 [24,000 - 80,000] ... ... ... ... Nicaragua 1,800 [900 - 2,900] ... ... ... ... Panama 4,100 [2,000 - 6,700] ... ... ... ... Paraguay 2,700 [1,300 - 4,400] ... ... ... ... Peru 16,000 [8,000 - 27,000] ... ... ... ... Suriname 1,300 [400 - 3,900] <200 [<800] <200 [<800] Uruguay 1,800 [900 - 2,900] ... ... ... ... Venezuela, R.B. de 23,000 [11,000 - 37,000] ... ... ... ... Global Total 15,700,000 [14,600,000 - 17,400,000] 2,100,000 [1,900,000 - 2,500,000] 2,000,000 [1,800,000 - 2,300,000] 69 Appendix 2: Country-Level HIV/AIDS Data 2. AIDS Deaths 3. Orphans due to AIDS Deaths in adults and Deaths in adults and Orphans (0-17), Orphans (0-17), children end 2003 children end 2001 currently living 2003 living in 2001 [low estimate - [low estimate - [low estimate - [low estimate - Country Estimate high estimate] Estimate high estimate] Estimate high estimate] Estimate high estimate] [2,600,000 - [2,300,000 - [13,000,000 - [10,000,000 - Global Total 2,900,000 3,300,000] 2,500,000 2,800,000] 15,000,000 18,000,000] 11,500,000 14,000,000] [2,000,000 - [1,700,000 - [11,000,000 - [8,800,000 - Sub-Saharan Africa 2,200,000 2,500,000] 1,900,000 2,200,000] 12,100,000 13,400,000] 9,600,000 10,700,000] Angola 21,000 [9,600 - 45,000] 18,000 [8,500 - 40,000] 110,000 [74,000 - 160,000] 87,000 [58,000 - 120,000] Benin 5,800 [3,400 - 10,000] 4,900 [2,800 - 8,600] 34,000 [23,000 - 48,000] 25,000 [17,000 - 36,000] Botswana * 33,000 [25,000 - 43,000] 28,000 [21,000 - 37,000] 120,000 [84,000 - 180,000] 95,000 [63,000 - 140,000] Burkina Faso * 29,000 [18,000 - 47,000] 30,000 [19,000 - 48,000] 260,000 [180,000 - 370,000] 240,000 [160,000 - 340,000] Burundi 25,000 [16,000 - 39,000] 25,000 [16,000 - 38,000] 200,000 [130,000 - 280,000] 170,000 [120,000 - 250,000] Cameroon * 49,000 [32,000 - 74,000] 41,000 [26,000 - 63,000] 240,000 [160,000 - 340,000] 170,000 [110,000 - 240,000] Central African Republic 23,000 [13,000 - 40,000] 20,000 [12,000 - 35,000] 110,000 [77,000 - 160,000] 90,000 [60,000 - 130,000] Chad 18,000 [11,000 - 28,000] 16,000 [9,900 - 25,000] 96,000 [64,000 - 140,000] 73,000 [49,000 - 100,000] Comoros ... ... ... ... ... ... ... ... Congo, Republic of 9,700 [4,900 - 20,000] 10,000 [5,100 - 20,000] 97,000 [65,000 - 140,000] 87,000 [59,000 - 120,000] Côte d'Ivoire 47,000 [30,000 - 72,000] 43,000 [28,000 - 66,000] 310,000 [200,000 - 440,000] 270,000 [180,000 - 390,000] Dem. Republic of Congo ** 100,000 [50,000 - 220,000] 100,000 [48,000 - 210,000] 770,000 [520,000 - 1,100,000] 680,000 [450,000 - 970,000] Djibouti 690 [320 - 1,900] 550 [300 - 1,800] 5,000 [3,400 - 7,200] 4,100 [2,700 - 5,800] Equatorial Guinea ... ... ... ... ... ... ... ... Eritrea 6,300 [2,900 - 14,000] 5,800 [2,700 - 13,000] 39,000 [26,000 - 55,000] 28,000 [19,000 - 41,000] Ethiopia 120,000 [74,000 - 190,000] 100,000 [58,000 - 180,000] 720,000 [480,000 - 1,000,000] 560,000 [370,000 - 790,000] Gabon 3,000 [1,500 - 5,700] 2,200 [1,100 - 4,500] 14,000 [9,300 - 20,000] 10,000 [6,900 - 15,000] Gambia 600 [200 - 1,500] <500 [<1,200] 2,000 [1,500 - 3,200] 1,500 [990 - 2,100] Ghana * 30,000 [18,000 - 49,000] 26,000 [16,000 - 42,000] 170,000 [120,000 - 250,000] 140,000 [91,000 - 190,000] Guinea * 9,000 [4,000 - 20,000] 6,900 [3,000 - 16,000] 35,000 [23,000 - 50,000] 25,000 [17,000 - 35,000] Guinea-Bissau ... ... ... ... ... ... ... ... Kenya 150,000 [89,000 - 200,000] 140,000 [87,000 - 190,000] 650,000 [430,000 - 930,000] 500,000 [340,000 - 720,000] Lesotho * 29,000 [22,000 - 39,000] 24,000 [18,000 - 33,000] 100,000 [68,000 - 150,000] 68,000 [46,000 - 97,000] Liberia 7,200 [3,500 - 15,000] 5,900 [2,800 - 12,000] 36,000 [24,000 - 52,000] 28,000 [19,000 - 40,000] Madagascar 7,500 [3,200 - 16,000] 4,900 [2,100 - 11,000] 30,000 [20,000 - 42,000] 18,000 [12,000 - 25,000] Malawi * 84,000 [58,000 - 120,000] 75,000 [52,000 - 110,000] 500,000 [330,000 - 710,000] 390,000 [260,000 - 560,000] Mali 12,000 [5,100 - 29,000] 11,000 [4,500 - 26,000] 75,000 [50,000 - 110,000] 59,000 [40,000 - 85,000] Mauritania <500 [<1,000] <500 [<1,000] 2,000 [1,100 - 2,300] 1,000 [700 - 1,400] Mauritius ... ... ... ... ... ... ... ... Mozambique 110,000 [74,000 - 160,000] 89,000 [60,000 - 130,000] 470,000 [310,000 - 670,000] 330,000 [220,000 - 470,000] Namibia 16,000 [11,000 - 22,000] 11,000 [7,900 - 16,000] 57,000 [38,000 - 81,000] 33,000 [22,000 - 48,000] Niger 4,800 [2,300 - 9,800] 3,600 [1,700 - 7,600] 24,000 [16,000 - 35,000] 16,000 [11,000 - 23,000] Nigeria 310,000 [200,000 - 490,000] 260,000 [160,000 - 410,000] 1,800,000 [1,200,000 - 2,600,000] 1,300,000 [890,000 - 1,900,000] Rwanda * 22,000 [14,000 - 36,000] 21,000 [14,000 - 34,000] 160,000 [110,000 - 240,000] 160,000 [110,000 - 230,000] Senegal * 3,500 [1,900 - 6,500] 2,800 [1,500 - 5,300] 17,000 [12,000 - 25,000] 12,000 [8,200 - 18,000] Sierra Leone ... ... ... ... ... ... ... ... Somalia ... ... ... ... ... ... ... ... South Africa * 370,000 [270,000 - 520,000] 270,000 [190,000 - 390,000] 1,100,000 [710,000 - 1,500,000] 660,000 [440,000 - 940,000] Swaziland ** 17,000 [13,000 - 23,000] 13,000 [9,900 - 18,000] 65,000 [43,000 - 93,000] 44,000 [30,000 - 63,000] Togo 10,000 [6,400 - 16,000] 8,900 [5,600 - 14,000] 54,000 [36,000 - 77,000] 37,000 [25,000 - 53,000] Uganda * 78,000 [54,000 - 120,000] 94,000 [66,000 - 140,000] 940,000 [630,000 - 1,400,000] 910,000 [610,000 - 1,300,000] United Rep. of Tanzania * 160,000 [110,000 - 230,000] 150,000 [98,000 - 220,000] 980,000 [660,000 - 1,400,000] 790,000 [530,000 - 1,100,000] Zambia 89,000 [63,000 - 130,000] 88,000 [62,000 - 120,000] 630,000 [420,000 - 910,000] 570,000 [380,000 - 810,000] Zimbabwe 170,000 [130,000 - 230,000] 160,000 [120,000 - 220,000] 980,000 [660,000 - 1,400,000] 830,000 [560,000 - 1,200,000] East Asia 44,000 [22,000 - 75,000] 31,000 [15,000 - 52,000] China 44,000 [21,000 - 75,000] 30,000 [15,000 - 51,000] ... ... ... ... Hong Kong SAR <200 [<400] <200 [<400] ... ... ... ... Dem. Peo. Rep. of Korea ... ... ... ... ... ... ... ... Japan <500 [<1,000] <500 [<1,000] ... ... ... ... Mongolia <200 [<400] <200 [<400] ... ... ... ... Republic of Korea <200 [<400] <200 [<400] ... ... ... ... Oceania 700 [<1,300] 400 [<800] Australia <200 [<400] <200 [<400] ... ... ... ... Fiji <200 [<400] <200 [<400] ... ... ... ... New Zealand <200 [<400] <200 [<400] ... ... ... ... Papua New Guinea 600 [200 - 1,200] <500 [<1,000] ... ... ... ... 70 The World Bank's Global HIV/AIDS Program of Action 2. AIDS Deaths 3. Orphans due to AIDS Deaths in adults Deaths in adults Orphans (0-17), Orphans (0-17), and children end 2003 and children end 2001 currently living 2003 living in 2001 [low estimate - [low estimate - [low estimate - [low estimate - Country Estimate high estimate] Estimate high estimate] Estimate high estimate] Estimate high estimate] South & South-East Asia 460,000 [290,000 - 700,000] 390,000 [240,000 - 590,000] Afghanistan ... ... ... ... ... ... ... ... Bangladesh ** ... [<400] ... [<400] ... ... ... ... Bhutan ... ... ... ... ... ... ... ... Brunei Darussalam <200 [<400] <200 [<400] ... ... ... ... Cambodia 15,000 [9,100 - 25,000] 13,000 [7,800 - 21,000] ... ... ... ... India ... ... ... ... ... ... ... ... Indonesia 2,400 [1,100 - 4,100] 600 [300 - 1,000] ... ... ... ... Iran (Islamic Republic of) 800 [300 - 1,600] <500 [<1,000] ... ... ... ... Lao People's Dem. Rep. <200 [<400] <200 [<400] ... ... ... ... Malaysia 2,000 [1,000 - 3,600] 1,500 [700 - 2,900] ... ... ... ... Maldives ... ... ... ... ... ... ... ... Myanmar ** 20,000 [11,000 - 35,000] 14,000 [7,800 - 26,000] ... ... ... ... Nepal 3,100 [1,000 - 6,400] 2,000 [900 - 4,200] ... ... ... ... Pakistan 4,900 [1,600 - 11,000] 3,900 [1,300 - 8,500] ... ... ... ... Philippines <500 [<1,000] <200 [<400] ... ... ... ... Singapore <200 [<400] <200 [<400] ... ... ... ... Sri Lanka <200 [<400] <200 [<400] ... ... ... ... Thailand 58,000 [34,000 - 97,000] 58,000 [34,000 - 96,000] ... ... ... ... Vietnam 9,000 [4,500 - 16,000] 5,000 [3,000 - 9,100] ... ... ... ... Eastern Europe & Central Asia 49,000 [32,000 - 71,000] 31,000 [21,000 - 45,000] Armenia <200 [<400] <200 [<400] ... ... ... ... Azerbaijan ... ... ... ... ... ... ... ... Belarus ... [900 - 3,300] ... [800 - 3,000] ... ... ... ... Bosnia and Herzegovina ... ... ... ... ... ... ... ... Bulgaria ... ... ... ... ... ... ... ... Croatia ... ... ... ... ... ... ... ... Czech Republic ... ... ... ... ... ... ... ... Estonia <200 [<400] <200 [<400] ... ... ... ... Georgia <200 [<400] <200 [<400] ... ... ... ... Hungary ... ... ... ... ... ... ... ... Kazakhstan <200 [<400] <200 [<400] ... ... ... ... Kyrgyz Republic <200 [<400] <200 [<400] ... ... ... ... Latvia <500 [<1,000] <200 [<400] ... ... ... ... Lithuania <200 [<400] <200 [<400] ... ... ... ... Poland ... ... ... ... ... ... ... ... Republic of Moldova ... ... ... ... ... ... ... ... Romania ... ... ... ... ... ... ... ... Russian Federation ... ... ... ... ... ... ... ... Slovak Republic ... ... ... ... ... ... ... ... Tajikistan ... ... ... ... ... ... ... ... Turkmenistan ... ... ... ... ... ... ... ... Ukraine 20,000 [9,600 - 33,000] 14,000 [7,000 - 24,000] ... ... ... ... Uzbekistan <500 [<1,000] <200 [<400] ... ... ... ... Western Europe 6,000 [<8000] 6,000 [<8000] Albania ... ... ... ... ... ... ... ... Austria <100 [<200] <100 [<200] ... ... ... ... Belgium <100 [<200] <100 [<200] ... ... ... ... Denmark <100 [<200] <100 [<200] ... ... ... ... Finland <100 [<200] <100 [<200] ... ... ... ... France <1,000 [<2,000] <1,000 [<2,000] ... ... ... ... Germany <1,000 [<2,000] <1,000 [<2,000] ... ... ... ... Greece <100 [<200] <100 [<200] ... ... ... ... Iceland <100 [<200] <100 [<200] ... ... ... ... Ireland <100 [<200] <100 [<200] ... ... ... ... Italy <1000 [<2,000] <1000 [<2,000] ... ... ... ... Luxembourg <100 [<200] <100 [<200] ... ... ... ... Malta <100 [<200] <100 [<200] ... ... ... ... Netherlands <100 [<200] <100 [<200] ... ... ... ... Norway <100 [<200] <100 [<200] ... ... ... ... Portugal <1000 [<2,000] <1000 [<2,000] ... ... ... ... Serbia and Montenegro <100 [<200] <100 [<200] ... ... ... ... Slovenia <100 [<200] <100 [<200] ... ... ... ... Spain <1000 [<2,000] <1000 [<2,000] ... ... ... ... Sweden <100 [<200] <100 [<200] ... ... ... ... Switzerland <200 [<400] <200 [<400] ... ... ... ... Macedonia, FYR <100 [<200] <100 [<200] ... ... ... ... United Kingdom <500 [<1,000] <500 [<1,000] ... ... ... ... 4. HIV prevalence rate 5. HIV prevalence rate (%) in groups 6. Knowledge and 71 Appendix 2: Country-Level HIV/AIDS Data 2. AIDS Deaths 3. Orphans due to AIDS Deaths in adults and Deaths in adults and Orphans (0-17), Orphans (0-17), children end 2003 children end 2001 currently living 2003 living in 2001 [low estimate - [low estimate - [low estimate - [low estimate - Country Estimate high estimate] Estimate high estimate] Estimate high estimate] Estimate high estimate] North Africa & Middle East 24,000 [9,900 - 62,000] 17,000 [7,500 - 40,000] Algeria <500 [<1,000] <500 [<1,000] ... ... ... ... Bahrain <200 [<400] <200 [<400] ... ... ... ... Cyprus ... ... ... ... ... ... ... ... Egypt, Arab Republic of 700 [200 - 1,600] <500 [<1,000] ... ... ... ... Iraq ... ... ... ... ... ... ... ... Israel ... ... ... ... ... ... ... ... Jordan <200 [<400] <200 [<400] ... ... ... ... Kuwait ... ... ... ... ... ... ... ... Lebanon <200 [<400] <200 [<400] ... ... ... ... Libyan Arab Jamahiriya ... ... ... ... ... ... ... ... Morocco ... ... ... ... ... ... ... ... Oman <200 [<400] <200 [<400] ... ... ... ... Qatar ... ... ... ... ... ... ... ... Saudi Arabia ... ... ... ... ... ... ... ... Sudan 23,000 [8,700 - 61,000] 16,000 [6,800 - 39,000] ... ... ... ... Syrian Arab Republic <200 [<400] ... ... ... ... ... ... Tunisia <200 [<400] <200 [<400] ... ... ... ... Turkey ... ... ... ... ... ... ... ... United Arab Emirates ... ... ... ... ... ... ... ... Yemen, the Republic of ... ... ... ... ... ... ... ... North America 16,000 [8,300 - 25,000] 16,000 [8,300 - 25,000] Canada 1,500 [740 - 2,500] 1,500 [740 - 2,500] ... ... ... ... United States of America 14,000 [6,900 - 23,000] 14,000 [6,900 - 23,000] ... ... ... ... Caribbean 35,000 [23,000 - 59,000] 32,000 [22,000 - 50,000] Bahamas <200 [<400] <200 [<400] ... ... ... ... Barbados <200 [<400] <200 [<400] ... ... ... ... Cuba <200 [<400] <200 [<400] ... ... ... ... Dominican Republic 7,900 [4,700 - 13,000] 7,000 [4,200 - 12,000] ... ... ... ... Haiti 24,000 [12,000 - 47,000] 22,000 [13,000 - 40,000] ... ... ... ... Jamaica 900 [500 - 1,600] <500 [<1,000] ... ... ... ... Trinidad and Tobago 1,900 [900 - 4,100] 1,500 [800 - 2,900] ... ... ... ... Latin America 84,000 [65,000 - 110,000] 63,000 [50,000 - 81,000] Argentina 1,500 *** [1,400 - 3,000] *** 1,500 *** [1,400 - 3,000] *** ... ... ... ... Belize <200 [<400] <200 [<400] ... ... ... ... Bolivia <500 [<1,000] <500 [<1,000] ... ... ... ... Brazil 15,000 *** [14,000 - 22,000] *** 14,600 *** [13,000 - 20,000] *** ... ... ... ... Chile 1,400 [700 - 2,500] 800 [400 - 1,500] ... ... ... ... Colombia 3,600 *** [2,200 - 6,000] *** 3,300 *** [2,000 - 5,800] *** ... ... ... ... Costa Rica 900 [400 - 1,600] 800 [400 - 1,400] ... ... ... ... Ecuador 1,700 [800 - 3,600] 1,600 [700 - 3,200] ... ... ... ... El Salvador 2,200 [1,000 - 4,100] 2,000 [1,000 - 3,800] ... ... ... ... Guatemala 5,800 [2,900 - 10,000] 4,900 [2,400 - 8,400] ... ... ... ... Guyana * 1,100 [500 - 2,600] 1,300 [600 - 2,700] ... ... ... ... Honduras 4,100 [2,300 - 7,200] 3,100 [1,700 - 5,500] ... ... ... ... Mexico 5,000 *** [4,500 - 10,000] *** 4,200 *** [4,000 - 9,000] *** ... ... ... ... Nicaragua <500 [<1,000] <500 [<1,000] ... ... ... ... Panama <500 [<1,000] <200 [<400] ... ... ... ... Paraguay 600 [300 - 1,000] <500 [<1,000] ... ... ... ... Peru 4,200 [2,100 - 7,300] 3,700 [1,800 - 6,400] ... ... ... ... Suriname <500 [<1,000] <500 [<1,000] ... ... ... ... Uruguay <500 [<1,000] <500 [<1,000] ... ... ... ... Venezuela, R.B. de 4,100 [1,900 - 8,000] 2,600 [1,200 - 5,300] ... ... ... ... Global Total 2,900,000 [2,600,000 - 3,300,000] 2,500,000 [2,300,000 - 2,800,000] 72 The World Bank's Global HIV/AIDS Program of Action 4. HIV prevalence rate (%) in young (15-24 yrs) pregnant 5. HIV prevalence rate (%) in groups 6. Knowledge and women in capital city with high-risk behaviour in capital city behaviour indicators Know that a healthy-looking Men who have person can have the Injecting Drug Users Sex Workers sex with men AIDS virus (%) (15-24) Country Year Median Year Median Year Median Year Median Female Male Global Total Sub-Saharan Africa Angola ... ... ... ... 2002 33.3 ... ... ... ... Benin 2002 2.3 ... ... 2001 60.5 ... ... 56 69 Botswana * 2003 32.9 ... ... ... ... ... ... 81 76 Burkina Faso * 2002 2.3 ... ... ... ... ... ... 42 v 64 v Burundi 2002 13.6 ... ... ... ... ... ... 66 ... Cameroon * 2002 7.0 ... ... ... ... ... ... 57 63 Central African Republic 2002 14.0 ... ... ... ... ... ... 46 ... Chad 2003 4.8 ... ... ... ... ... ... 28 ... Comoros ... ... ... ... ... ... ... ... 55 ... Congo, Republic of ... ... ... ... ... ... ... ... ... ... Côte d'Ivoire 2002 5.2 ... ... ... ... ... ... 64 67 Dem. Republic of Congo ** ... ... ... ... ... ... ... ... ... ... Djibouti ... ... ... ... ... ... ... ... ... ... Equatorial Guinea ... ... ... ... ... ... ... ... 46 ... Eritrea ... ... ... ... ... ... ... ... 79 ... Ethiopia 2003 11.7 ... ... ... ... ... ... 39 54 Gabon ... ... ... ... ... ... ... ... 72 81 Gambia ... ... ... ... ... ... ... ... 53 ... Ghana * 2003 3.9 ... ... ... ... ... ... 71 77 Guinea * ... ... ... ... 2001 39.7 ... ... 60 56 Guinea-Bissau ... ... ... ... ... ... ... ... 31 ... Kenya ... ... ... ... 2000 25.5 ... ... 74 80 Lesotho * 2003 27.8 ... ... ... ... ... ... 46 ... Liberia ... ... ... ... ... ... ... ... ... ... Madagascar ... ... ... ... 2001 0.2 ... ... 27 ... Malawi * 2003 18.0 ... ... ... ... ... ... 84 89 Mali 2003 2.2 ... ... 2000 21.0 ... ... 46 59 Mauritania ... ... ... ... ... ... ... ... 30 39 Mauritius ... ... ... ... ... ... ... ... ... ... Mozambique 2002 14.7 ... ... ... ... ... ... 62 71 Namibia ... ... ... ... ... ... ... ... 82 87 Niger ... ... ... ... ... ... ... ... 37 41 Nigeria 2003 4.2 ... ... ... ... ... ... 45 51 Rwanda * 2002 11.6 ... ... ... ... ... ... 64 69 Senegal * 2002 1.1 ... ... 2002 14.2 ... ... 46 ... Sierra Leone ... ... ... ... ... ... ... ... 35 ... Somalia ... ... ... ... ... ... ... ... 13 ... South Africa * 2002 24.0 ... ... ... ... ... ... 54 ... Swaziland ** 2002 39.0 ... ... ... ... ... ... 81 ... Togo 2003 9.1 ... ... ... ... ... ... 66 73 Uganda * 2001 10.0 ... ... ... ... ... ... 76 83 United Rep. of Tanzania * 2002 7.0 ... ... ... ... ... ... 65 68 Zambia 2002 22.1 ... ... ... ... ... ... 74 73 Zimbabwe ... ... ... ... ... ... ... ... 74 83 East Asia China ... ... 2000 0.0 2000 0.2 ... ... ... ... Hong Kong SAR ... ... ... ... ... ... ... ... ... ... Dem. Peo. Rep. of Korea ... ... ... ... ... ... ... ... ... ... Japan ... ... ... ... ... ... 2000 2.9 ... ... Mongolia ... ... ... ... ... ... ... ... 57 ... Republic of Korea ... ... ... ... ... ... ... ... ... ... Oceania Australia ... ... ... ... ... ... ... ... ... ... Fiji ... ... ... ... ... ... ... ... ... ... New Zealand ... ... ... ... ... ... ... ... ... ... Papua New Guinea ... ... ... ... 2000 16.0 ... ... ... ... 73 Appendix 2: Country-Level HIV/AIDS Data (%) in young with high-risk behaviour in capital city behaviour indicators (15-24 yrs) pregnant Know that a women in capital city healthy-looking Men who have person can have the Injecting Drug Users Sex Workers sex with men AIDS virus (%) (15-24) Country Year Median Year Median Year Median Year Median Female Male South & South-East Asia Afghanistan ... ... ... ... ... ... ... ... ... ... Bangladesh ** ... ... 1999 2.5 2000 20.0 1999 0.3 ... ... Bhutan ... ... ... ... ... ... ... ... ... ... Brunei Darussalam ... ... ... ... ... ... ... ... ... ... Cambodia ... ... ... ... 2002 18.5 ... ... 62 ... India ... ... 2002 7.2 ... ... ... ... ... ... Indonesia ... ... ... ... 2001 0.0 ... ... 32 ... Iran (Islamic Republic of) ... ... ... ... ... ... ... ... ... ... Lao People's Dem. Rep. ... ... ... ... 2001 1.1 ... ... ... ... Malaysia ... ... ... ... ... ... ... ... ... ... Maldives ... ... ... ... ... ... ... ... ... ... Myanmar ** ... ... 2000 37.1 2000 26.0 ... ... ... ... Nepal ... ... 2000 50.0 2002 17.0 ... ... ... ... Pakistan ... ... ... ... ... ... ... ... ... ... Philippines ... ... ... ... ... ... ... ... 67 ... Singapore ... ... ... ... ... ... ... ... ... ... Sri Lanka ... ... ... ... ... ... ... ... ... ... Thailand ... ... 2002 53.7 2002 2.6 ... ... ... ... Vietnam ... ... 2001 22.3 2001 11.5 ... ... 63 ... Eastern Europe & Central Asia Armenia ... ... ... ... 1999 7.5 ... ... 53 48 Azerbaijan ... ... ... ... ... ... ... ... 35 ... Belarus ... ... ... ... ... ... ... ... ... ... Bosnia and Herzegovina ... ... ... ... ... ... ... ... 74 ... Bulgaria ... ... ... ... ... ... ... ... ... ... Croatia ... ... ... ... ... ... ... ... ... ... Czech Republic ... ... ... ... ... ... ... ... ... ... Estonia ... ... ... ... ... ... ... ... ... ... Georgia ... ... ... ... ... ... ... ... ... ... Hungary ... ... 2000 2.2 ... ... ... ... ... ... Kazakhstan ... ... 2002 0.0 ... ... ... ... 63 x 73 x Kyrgyz Republic ... ... ... ... ... ... ... ... ... ... Latvia ... ... 2002 17.3 ... ... ... ... ... ... Lithuania ... ... ... ... 2001 0.5 ... ... ... ... Poland ... ... ... ... ... ... ... ... ... ... Republic of Moldova ... ... ... ... ... ... ... ... 79 ... Romania ... ... ... ... ... ... ... ... 70 77 Russian Federation ... ... ... ... 2002 3.0 ... ... ... ... Slovak Republic ... ... ... ... ... ... ... ... ... ... Tajikistan ... ... ... ... ... ... ... ... 8 ... Turkmenistan ... ... ... ... ... ... ... ... 42 ... Ukraine ... ... ... ... ... ... ... ... 78 ... Uzbekistan ... ... ... ... ... ... ... ... 41 ... Western Europe Albania ... ... ... ... ... ... ... ... 40 ... Austria ... ... ... ... ... ... ... ... ... ... Belgium ... ... ... ... ... ... ... ... ... ... Denmark ... ... ... ... ... ... ... ... ... ... Finland ... ... ... ... ... ... ... ... ... ... France ... ... ... ... ... ... ... ... ... ... Germany ... ... ... ... ... ... ... ... ... ... Greece ... ... ... ... ... ... ... ... ... ... Iceland ... ... ... ... ... ... ... ... ... ... Ireland ... ... ... ... ... ... ... ... ... ... Italy ... ... ... ... ... ... ... ... ... ... Luxembourg ... ... ... ... ... ... ... ... ... ... Malta ... ... ... ... ... ... ... ... ... ... Netherlands ... ... ... ... ... ... ... ... ... ... Norway ... ... ... ... ... ... ... ... ... ... Portugal ... ... ... ... ... ... ... ... ... ... Serbia and Montenegro ... ... ... ... ... ... ... ... ... ... Slovenia ... ... ... ... ... ... 1999 1.7 ... ... Spain ... ... ... ... ... ... ... ... ... ... Sweden ... ... ... ... ... ... ... ... ... ... Switzerland ... ... ... ... ... ... ... ... ... ... Macedonia, FYR ... ... ... ... ... ... ... ... ... ... United Kingdom ... ... ... ... ... ... ... ... ... ... 6. Knowledge and behaviour indicators 74 The World Bank's Global HIV/AIDS Program of Action 4. HIV prevalence rate (%) in young (15-24 yrs) pregnant 5. HIV prevalence rate (%) in groups 6. Knowledge and women in capital city with high-risk behaviour in capital city behaviour indicators Know that a healthy-looking Men who have person can have the Injecting Drug Users Sex Workers sex with men AIDS virus (%) (15-24) Country Year Median Year Median Year Median Year Median Female Male North Africa & Middle East Algeria ... ... ... ... ... ... ... ... ... ... Bahrain ... ... ... ... ... ... ... ... ... ... Cyprus ... ... ... ... ... ... ... ... ... ... Egypt, Arab Republic of ... ... ... ... ... ... ... ... ... ... Iraq ... ... ... ... ... ... ... ... ... ... Israel ... ... ... ... ... ... ... ... ... ... Jordan ... ... ... ... ... ... ... ... ... ... Kuwait ... ... ... ... ... ... ... ... ... ... Lebanon ... ... ... ... ... ... ... ... ... ... Libyan Arab Jamahiriya ... ... ... ... ... ... ... ... ... ... Morocco ... ... ... ... ... ... ... ... ... ... Oman ... ... ... ... ... ... ... ... ... ... Qatar ... ... ... ... ... ... ... ... ... ... Saudi Arabia ... ... ... ... ... ... ... ... ... ... Sudan ... ... ... ... ... ... ... ... ... ... Syrian Arab Republic ... ... ... ... ... ... ... ... ... ... Tunisia ... ... ... ... ... ... ... ... ... ... Turkey ... ... ... ... ... ... ... ... ... ... United Arab Emirates ... ... ... ... ... ... ... ... ... ... Yemen, the Republic of ... ... ... ... ... ... ... ... ... ... North America Canada ... ... ... ... ... ... ... ... ... ... United States of America ... ... ... ... ... ... ... ... ... ... Caribbean Bahamas ... ... ... ... ... ... ... ... ... ... Barbados ... ... ... ... ... ... ... ... ... ... Cuba ... ... ... ... ... ... ... ... 91 ... Dominican Republic ... ... ... ... 1999 3.5 ... ... 92 91 Haiti ... ... ... ... ... ... ... ... 68 78 Jamaica ... ... ... ... ... ... ... ... ... ... Trinidad and Tobago ... ... ... ... ... ... ... ... 95 ... Latin America Argentina ... ... 2001 44.3 ... ... 2001 24.3 ... ... Belize ... ... ... ... ... ... ... ... ... ... Bolivia ... ... ... ... ... ... ... ... 64 74 Brazil ... ... ... ... ... ... ... ... ... ... Chile ... ... ... ... ... ... ... ... ... ... Colombia ... ... ... ... ... ... ... ... 82 ... Costa Rica ... ... ... ... ... ... ... ... ... ... Ecuador ... ... ... ... 2002 14.0 ... ... 58 w ... El Salvador ... ... ... ... 2002 4.0 2002 17.7 68 ... Guatemala ... ... ... ... 2002 3.3 2002 11.5 ... ... Guyana * ... ... ... ... ... ... ... ... 84 ... Honduras ... ... ... ... 2002 8.1 2002 8.2 81 90 Mexico ... ... ... ... 1999 0.3 ... ... ... ... Nicaragua ... ... ... ... 2002 0.0 2002 9.3 73 z ... Panama ... ... ... ... 2002 1.8 2002 10.6 ... ... Paraguay ... ... ... ... ... ... ... ... ... ... Peru ... ... ... ... ... ... 2002 22.0 72 ... Suriname ... ... ... ... ... ... ... ... 70 ... Uruguay ... ... ... ... ... ... ... ... ... ... Venezuela, R.B. de ... ... ... ... ... ... ... ... 78 ... Global Total 75 Appendix 2: Country-Level HIV/AIDS Data 6. Knowledge and behaviour indicators Can identify two Used a condom the last prevention methods and time they had higher risk reject three Reported higher risk sex sex, of those who had misconceptions Had sex before in the last year high risk sex in the last (%) (15-24) age 15 (%) (15-19) (%) (15-24) year (%) (15-24) Country Female Male Female Male Female Male Female Male Year Global Total Sub-Saharan Africa Angola ... ... ... ... ... ... ... ... ... Benin 8 14 16 24 36 90 19 34 2001 d Botswana * 40 33 ... ... ... ... 75 x 88 x 2001 b Burkina Faso * ... ... 12 8 19 82 41 55 1999 d Burundi 24 ... ... ... ... ... ... ... 2000 c Cameroon * 16 c,x ... 26 18 41 86 16 31 1998 d Central African Republic 5 ... ... ... ... ... ... ... 2000 c Chad 5 ... ... ... ... ... ... ... 2000 c Comoros 10 ... ... ... ... ... ... ... 2000 c Congo, Republic of ... ... ... ... ... ... ... ... ... Côte d'Ivoire 16 c,x ... 22 14 51 91 25 56 1998 d Dem. Republic of Congo ** ... ... ... ... ... ... ... ... ... Djibouti ... ... ... ... ... ... ... ... ... Equatorial Guinea 4 ... ... ... ... ... ... ... 2000 c Eritrea ... ... 9 ... ... ... ... ... 2002 d Ethiopia ... ... 14 5 7 64 17 30 2000 d Gabon 24 22 24 48 53 75 33 48 2000 d Gambia 15 ... ... ... ... ... ... ... 2000 c Ghana * ... ... 7 4 ... ... ... ... 1998 d Guinea * ... ... 27 20 23 92 17 32 1999 d Guinea-Bissau 8 ... ... ... ... ... ... ... 2000 c Kenya 26 c,x ... 15 32 39 92 14 43 1998 d Lesotho * 18 ... ... ... ... ... ... ... 2000 c Liberia ... ... 32 12 ... ... ... ... 1999 d Madagascar ... ... ... ... ... ... ... ... 2000 c Malawi * 34 41 17 29 17 71 32 38 2000 d Mali 9 15 26 11 18 85 14 30 2001 d Mauritania ... ... 13 2 ... ... ... ... 2000 d Mauritius ... ... ... ... ... ... ... ... ... Mozambique ... ... ... ... ... ... ... ... 2001 e Namibia 31 41 10 31 80 85 48 69 2000 d Niger 5 c,x ... 28 10 4 56 7 30 1998 d Nigeria ... ... 16 8 ... ... ... ... 1999 d Rwanda * 23 20 3 ... 10 42 23 55 2000 d Senegal * ... ... ... ... ... ... ... ... 2000 c Sierra Leone 16 ... ... ... ... ... ... ... 2000 c Somalia 0 ... ... ... ... ... ... ... 2000 c South Africa * 20 ... 9 ... ... ... 20 ... 1998 d Swaziland ** 27 ... ... ... ... ... ... ... 2000 c Togo 20 c,x ... 20 ... 51 89 22 41 1998 d Uganda * 28 40 14 16 22 59 44 62 2000 d United Rep. of Tanzania * 26 29 15 24 40 87 21 31 1999 d Zambia 31 33 18 27 19 50 33 42 2001 d Zimbabwe ... ... 3 6 20 82 42 69 1999 d East Asia China ... ... ... ... ... ... ... ... ... Hong Kong SAR ... ... ... ... ... ... ... ... ... Dem. Peo. Rep. of Korea ... ... ... ... ... ... ... ... ... Japan ... ... ... ... ... ... ... ... ... Mongolia 32 ... ... ... ... ... ... ... 2000 c Republic of Korea ... ... ... ... ... ... ... ... ... Oceania Australia ... ... ... ... ... ... ... ... ... Fiji ... ... ... ... ... ... ... ... ... New Zealand ... ... ... ... ... ... ... ... ... Papua New Guinea ... ... ... ... ... ... ... ... ... 76 The World Bank's Global HIV/AIDS Program of Action Can identify two Used a condom the last prevention methods and time they had higher risk reject three Reported higher risk sex sex, of those who had misconceptions Had sex before in the last year high risk sex in the last (%) (15-24) age 15 (%) (15-19) (%) (15-24) year (%) (15-24) Country Female Male Female Male Female Male Female Male Year South & South-East Asia Afghanistan ... ... ... ... ... ... ... ... ... Bangladesh ** ... ... ... ... ... ... ... ... ... Bhutan ... ... ... ... ... ... ... ... ... Brunei Darussalam ... ... ... ... ... ... ... ... ... Cambodia 37 ... 1 ... 1 ... ... ... 2000 d India 21 x 17 x ... ... 2 12 51 59 2001 a Indonesia 7 ... ... ... ... ... ... ... 2000 c Iran (Islamic Republic of) ... ... ... ... ... ... ... ... ... Lao People's Dem. Rep. ... ... ... ... ... ... ... ... ... Malaysia ... ... ... ... ... ... ... ... ... Maldives ... ... ... ... ... ... ... ... ... Myanmar ** ... ... ... ... ... ... ... ... ... Nepal ... ... 9 20 ... ... ... ... 2001 d Pakistan ... ... ... ... ... ... ... ... ... Philippines ... ... 1 d,v ... ... ... ... ... 2000 c Singapore ... ... ... ... ... ... ... ... ... Sri Lanka ... ... ... ... ... ... ... ... ... Thailand ... ... ... ... ... ... ... ... ... Vietnam 25 ... ... ... ... ... ... ... 2000 c Eastern Europe & Central Asia Armenia 7 8 1 1 0 69 0 44 2000 d Azerbaijan 2 ... 1 f,y ... ... ... ... ... 2000 c Belarus ... ... ... ... ... ... ... ... ... Bosnia and Herzegovina ... ... ... ... ... ... ... ... 2000 c Bulgaria ... ... ... ... ... ... ... ... ... Croatia ... ... ... ... ... ... ... ... ... Czech Republic ... ... ... ... ... ... ... ... ... Estonia ... ... ... ... ... ... ... ... ... Georgia ... ... 3 ... ... ... ... ... 1999 f Hungary ... ... ... ... ... ... ... ... ... Kazakhstan ... ... 1 6 27 78 32 65 1999 d Kyrgyz Republic ... ... ... ... ... ... ... ... ... Latvia ... ... ... ... ... ... ... ... ... Lithuania ... ... ... ... ... ... ... ... ... Poland ... ... ... ... ... ... ... ... ... Republic of Moldova 19 ... ... ... ... ... ... ... 2000 c Romania ... ... 3 12 ... ... ... ... 1999 f Russian Federation ... ... ... ... ... ... ... ... ... Slovak Republic ... ... ... ... ... ... ... ... ... Tajikistan ... ... ... ... ... ... ... ... 2000 c Turkmenistan ... ... 0 ... ... ... ... ... 2000 d Ukraine ... ... ... ... ... ... ... ... 2000 c Uzbekistan 3 ... ... ... ... ... ... ... 2000 c Western Europe Albania 0 ... ... ... ... ... ... ... 2000 c Austria ... ... ... ... ... ... ... ... ... Belgium ... ... ... ... ... ... ... ... ... Denmark ... ... ... ... ... ... ... ... ... Finland ... ... ... ... ... ... ... ... ... France ... ... ... ... ... ... ... ... ... Germany ... ... ... ... ... ... ... ... ... Greece ... ... ... ... ... ... ... ... ... Iceland ... ... ... ... ... ... ... ... ... Ireland ... ... ... ... ... ... ... ... ... Italy ... ... ... ... ... ... ... ... ... Luxembourg ... ... ... ... ... ... ... ... ... Malta ... ... ... ... ... ... ... ... ... Netherlands ... ... ... ... ... ... ... ... ... Norway ... ... ... ... ... ... ... ... ... Portugal ... ... ... ... ... ... ... ... ... Serbia and Montenegro ... ... ... ... ... ... ... ... ... Slovenia ... ... ... ... ... ... ... ... ... Spain ... ... ... ... ... ... ... ... ... Sweden ... ... ... ... ... ... ... ... ... Switzerland ... ... ... ... ... ... ... ... ... Macedonia, FYR ... ... ... ... ... ... ... ... ... United Kingdom ... ... ... ... ... ... ... ... ... 1. Estimated number of people living with HIV 77 Appendix 2: Country-Level HIV/AIDS Data 6. Knowledge and behaviour indicators Can identify two Used a condom the last prevention methods and time they had higher risk reject three Reported higher risk sex sex, of those who had misconceptions Had sex before in the last year high risk sex in the last (%) (15-24) age 15 (%) (15-19) (%) (15-24) year (%) (15-24) Country Female Male Female Male Female Male Female Male Year North Africa & Middle East Algeria ... ... ... ... ... ... ... ... ... Bahrain ... ... ... ... ... ... ... ... ... Cyprus ... ... ... ... ... ... ... ... ... Egypt, Arab Republic of ... ... ... ... ... ... ... ... ... Iraq ... ... ... ... ... ... ... ... ... Israel ... ... ... ... ... ... ... ... ... Jordan ... ... ... ... ... ... ... ... ... Kuwait ... ... ... ... ... ... ... ... ... Lebanon ... ... ... ... ... ... ... ... ... Libyan Arab Jamahiriya ... ... ... ... ... ... ... ... ... Morocco ... ... ... ... ... ... ... ... ... Oman ... ... ... ... ... ... ... ... ... Qatar ... ... ... ... ... ... ... ... ... Saudi Arabia ... ... ... ... ... ... ... ... ... Sudan ... ... ... ... ... ... ... ... ... Syrian Arab Republic ... ... ... ... ... ... ... ... ... Tunisia ... ... ... ... ... ... ... ... ... Turkey ... ... ... 0 ... ... ... ... 1998 d United Arab Emirates ... ... ... ... ... ... ... ... ... Yemen, the Republic of ... ... ... ... ... ... ... ... ... North America Canada ... ... ... ... ... ... ... ... ... United States of America ... ... ... ... ... ... ... ... ... Caribbean Bahamas ... ... ... ... ... ... ... ... ... Barbados ... ... ... ... ... ... ... ... ... Cuba 52 ... ... ... ... ... ... ... 2000 c Dominican Republic ... ... 13 18 16 49 ... ... 2002 d Haiti 14 24 12 28 59 93 19 30 2000 d Jamaica ... ... ... ... ... ... ... ... ... Trinidad and Tobago 33 ... ... ... ... ... ... ... 2000 c Latin America Argentina ... ... ... ... ... ... ... ... ... Belize ... ... ... ... ... ... ... ... ... Bolivia 22 c,x ... 5 15 ... ... ... ... 1998 d Brazil ... ... ... ... ... ... ... ... ... Chile ... ... ... ... ... ... ... ... ... Colombia ... ... 10 ... 49 ... 29 ... 2000 d Costa Rica ... ... ... ... ... ... ... ... ... Ecuador ... ... 7 ... ... ... ... ... 2001 f El Salvador ... ... ... ... ... ... ... ... 1998 f Guatemala ... ... 7 15 ... ... ... ... 2002 f Guyana * 36 ... ... ... ... ... ... ... 2000 c Honduras ... ... 13 19 ... ... ... ... 2001 f Mexico ... ... ... ... ... ... ... ... ... Nicaragua ... ... 11 ... 10 ... 17 ... 2001 d Panama ... ... ... ... ... ... ... ... ... Paraguay ... ... ... ... ... ... ... ... ... Peru ... ... 5 ... 29 ... 19 ... 2000 d Suriname 27 ... ... ... ... ... ... ... 2000 c Uruguay ... ... ... ... ... ... ... ... ... Venezuela, R.B. de ... ... ... ... ... ... ... ... 2000 c Global Total ... Where sufficient data from the last six years were not available, no estimates have been made. * A population-based survey with HIV prevalence measurement will be conducted in the near future. ** New surveillance has been conducted recently but the results were not available for inclusion in the estimation process. *** Estimates and ranges have been informed by data from vital registration systems. a. Behavioural Surveillance Surveys (FHI[U31]). b. Botswana AIDS Impact Survey ([U32]2001). c. Multi-Indicator Cluster Survey (UNICEF[U33]). d. Demographic and Health Survey. e. Survey of Youth and Adolescent Reproductive Health and Sexual Behaviours in Mozambique (INJAD, 2001[U34]). f. Reproductive Health Survey (CDC[U35]). v. Survey year is 1998. w. Survey year is 1999. x. Survey year is 2000. y. Survey year is 2001. z. Survey year is 2002. Source: UNAIDS, 2004 Report on the Global AIDS Epidemic, UNAIDS, Geneva. 78 The World Bank's Global HIV/AIDS Program of Action WWW.WORLDBANK.ORG/AIDS For more information, please contact: The Global HIV/AIDS Program The World Bank Group 1818 H Street, NW Washington DC 20433 USA Tel: 202 458 4946 Fax: 202 522 1252 wbglobalHIVAIDS@worldbank.org