51985 IDA At Work HIV/AIDS: Supporting Effective Prevention, Treatment, and Care A ddressing AIDS and other major diseases is one of the eight Millennium Development Goals that aim to halve poverty and improve welfare by 2015. Progress has been made in preventing new infections, increasing treat- ment access, and mitigating the effects of AIDS. But much more remains to be done, with more than 33 million people living with HIV in 2007--including more than 22 million people in Sub-Saharan Africa. UNAIDS estimates that in 2007, 2.5 million people became newly infected with HIV and 2.1 million people died of HIV-related illnesses, including 290,000 children. The International Development Association (IDA), the World Bank's fund for the world's poorest countries, was the first source of substantial funding for HIV/AIDS in Sub-Saharan Africa, the Caribbean, and India, and remains the most predictable, flexible, long-term financing source. Beginning in the late 1980s, IDA has committed more than $3 billion to support HIV/AIDS responses in 67 countries, and has helped developing countries broaden and intensify their efforts in HIV prevention, treatment, and care, benefiting millions of people, especially in Sub-Saharan Africa and South Asia. At a glance · AccordingtoUNAIDS,in2007HIVwasmostprevalentinSub-SaharanAfrica(5.0 percentofadultpopulation),followedbytheCaribbean(1.0percent),andEasternEurope andCentralAsia(0.9percent). · IDAhascommittedmorethan$3billiontosupportHIV/AIDSresponsesin67countries since1988. · TotalresourcesforHIVindevelopingcountriesincreasedfromaroundUS$300millionin 1996toUS$15billionin2008(includingdomesticpublicandprivatespending). · Thecreationof1,500counselingandtestingsiteshasenablednearlysevenmillionmore peopletobetestedforHIV,andIDAfundshavehelpedgetinformationaboutHIV/AIDSto morethan173millionpeople. · IDAsupportalsohashelpedmitigatetheimpactofAIDSformorethan1.8millionchildren andhalfamillionadultsthrougheducation,nutrition,andincome-generatingactivities deliveredby38,000grassrootsinitiatives. IDA's Multi-Country AIDS Program paved the way for other major AIDS support initiatives. This helped increase total resources for HIV in developing countries from $300 million in 1996 to $15 billion in 2008 (including domestic public and private spending). IDA-supported projects helped raise political awareness and mobilize societies early in the epidemic, build systems and institu- tions to channel resources to affected communities, and bring the public, private, and non-profit sectors together to deliver effective, evidence-based strategies and policies. Today, with the large grant resources of the Global Fund to Fight AIDS, TB and Malaria (the Global Fund) and the US President's Emergency Plan for AIDS Relief, IDA is no longer the major financier for AIDS, but remains a key source of support--continuing to strengthen national and sub-national capacity for planning, managing, and monitoring HIV responses and thus enabling countries to use other sources of global funding more effectively. IDA is also a valued source of funding because it can be used flexibly to complement other sources; deliver sustained support to strengthen health systems; support investments and outreach among marginalized groups which is key to preventing transmission in concentrated HIV epidemics; and sustain grassroots initiatives that reach poor, remote, and marginalized communities, empowering infected and affected people to cope better. IDA also plays a global leadership role. It is a founding co-sponsor of UNAIDS. It helped create the Global Fund and serves on its Board and as Trustee. IDA analytical work has contributed importantly to the development of evidence-based national strategies and global awareness. This analytical work supports better HIV/AIDS data collection and use, rigorous evaluation of epidemic patterns and potential and program impact, and studies of the macroeconomic and productivity impact of AIDS. Finally, IDA plays a strong role in promoting donor harmonization, coordination, and alignment. nnn RESULTS vention as well as some features unique to the AIDS epidemic, such as persistent stigma IDA has committed US$3.27 billion for HIV/ and denial; the difficulties of changing social AIDS in 67 countries since 1988. Since FY2001, norms and sexual behavior; and the challenges annual new commitments have averaged of working with many diverse stakeholders more than US$400 million. and groups, including sex workers, men who have sex with men, and injecting drug users. Of 25 IDA-financed HIV/AIDS projects com- pleted between 1998 and 2007, just over half However, the IDA portfolio for HIV/AIDS were rated marginally satisfactory or better shows clear evidence of "learning by doing." by the World Bank's Independent Evaluation Forthright action to correct earlier issues in Group. disbursement and procurement, coordina- tion capacity, health sector engagement, These ratings reflect the difficulty of design- and monitoring and evaluation is paying off. ing effective projects in new areas of inter- IDA-financed HIV/AIDS projects are achieving relevant and important results. 2 · Workplace HIV information, testing, coun- Monitoring & Evaluation seling, and treatment programs to serve Results-basedmonitoringandevaluationiscritical 2.3 million employees. tomonitortheepidemicandimplementand · About 40,100 organizations supported with manageanappropriateresponse.Ittakestimeand technical advice and financing in 36 coun- resourcestobuildrobust,well-functioningnational tries. monitoringandevaluationsystems. · The impact of AIDS mitigated for more than half a million adults and 1.8 million In2003,UNAIDSestablishedtheGlobalHIV/ AIDSMonitoringandEvaluationSupportTeam, children, through education, nutrition, and whichislocatedattheWorldBank.Workingwith income-generating activities delivered by partners,theteam'sdedicatedexpertsinthe 38,000 grassroots initiatives. fieldprovideintensive,hands-onpracticalhelpto · 1.3 billion male condoms and 4 million countriestostrengthenmonitoringandevaluation female condoms delivered. capacity,systems,andpracticeatthecountry level.Thebroaderaimistobuildanewmodelof accountability,andacultureofachievingresults Individual project outcomes andusingdatatoimproveprograms. are also noteworthy. The Africa Multi-Country AIDS Program Because of the Multi-Country AIDS Program's Treatment Acceleration Project. This emphasis on monitoring and evaluation, demonstration project helped scale up key outputs have been carefully tracked. In treatment, care, and services to prevent HIV Sub-Saharan Africa, in the first 5 years of the transmission from mother-to-child, reaching Program ending 2006, these include: over 300,000 people in Burkina Faso, Ghana, and Mozambique, while maintaining good · Services to prevent mother-to-child HIV adherence rates by those on anti-retroviral transmission for more than 1.5 million treatment. It learned and shared crucial women. lessons about how to expand treatment · The establishment of 1,500 new voluntary successfully and responsibly, promote counseling and testing sites (about 20 per- treatment adherence and prevention, monitor cent of all sites in participating countries), and minimize drug resistance, and enhance which has enabled nearly 7 million more program effectiveness. people to be tested for HIV. · Anti-retroviral treatment (ARV) for 27,000 As of 2009, Rwanda's Multi-Country AIDS Pro- people and treatment for HIV-related gram highlights include: (i) funding voluntary infections for nearly 300,000 more funded counseling and testing for close to one million by the Multi-Country AIDS Program. people; (ii) distributing 18 million condoms; · Training to provide HIV services for over (iii) providing lifesaving antiretroviral therapy half a million people. to more than 9,000 patients (well above · More than 173 million people reached with the project target of 2,350); (iv) providing information about HIV/AIDS (about 60 financial assistance for school fees for about percent of the total population aged 15+ in 28,000 children; (v) subsidizing community MAP-supported countries). health insurance for over 52,000 households; and (vi) reaching 100,000 individuals with 3 lifesaving drugs for HIV-related infections, When Speed is Crucial and income-generating activities for people In2000,IDAmadeavailableaninitialamountof living with HIV and those at risk of infection US$500millioninflexibleandrapidMulti-Country due to poverty. AIDSProgramfundingtoAfricancountriesto assistinexpandingnationalHIV/AIDSefforts.IDA In Guyana, a project under the Multi-Country approvedanadditionalUS$500millionin2002 AIDS Project has enhanced civil society and tomeetunexpectedlyrapiduptake.TheProgram responses by government ministries across a hasnowcommittedUS$1.5billionto33countries andfiveregional,cross-borderprojectsinAfrica range of sectors. Before the Program, fewer andUS$118millionintheCaribbeanMulti-Country than 10 small, inexperienced civil society AIDSPrograminninecountriesandtheregional organizations (CSOs) were active in HIV/AIDS. Pan-CaribbeanPartnershipAgainstHIV/AIDS. The project set up a transparent system for CSOs to access funds, and quickly approved Theemphasisisonspeed,onexpandingexisting US$1.6 million for 65 CSOs through competi- programs,buildingcapacity,"learningbydoing," andreworkingprojectsasnewdatabecome tive proposals. IDA, the US President's Emer- available.Thisapproachreliesonmonitoring gency Plan for AIDS Relief, and the govern- andevaluationofprogramstodeterminewhich ment have done much to build CSO capacity. activitiesareefficientandeffectiveandshouldbe Eleven ministries and five national agencies expandedfurtherandwhicharenotandshould are implementing HIV/AIDS plans, with IDA bestoppedorbenefitfrommorecapacitybuilding. providing the only source of HIV funding for Funding"good"programsquicklyismoreimportant thanfunding"bestpractices"withdelay. non-health ministries. In Moldova, an IDA-financed project helped income-generating activities that are help- develop a national HIV/AIDS strategy that ing alleviate poverty. The project has also includes public campaigns and targeted CSO- supported government efforts to introduce run programs for injecting drug users, screen- performance-based financing for HIV services ing of pregnant women, prophylactic treat- with hopeful initial results. ment for HIV-positive mothers and free milk formula for replacement feeding. Together, Ethiopia's component of Multi-Country AIDS these actions helped decrease mother-to- Program provided the country with the only child transmission by 76 percent, stabilize systematic support for civil society organiza- HIV incidence (new cases) among 15-24 year tions working on AIDS and community action. olds, and reduce overall AIDS mortality by 70 These activities have changed attitudes percent between 2002 and 2005. towards people living with HIV, encouraged testing, and led to a remarkable growth in India illustrates the benefits of sustained and associations of people living with HIV. They predictable long-term support. Through con- have mobilized groups of women, youth, tinuous support since 1992, IDA helped spur religious leaders, and iddirs (neighborhood early action on HIV. IDA helped create the leaders) to discuss the risks and responsibili- institutional framework of India's entire HIV ties of their communities, and to take direct response at the national level and in 28 states action such as caring for orphans and bedrid- and territories. It helped finance over 1,000 den people with AIDS. The project financed activities targeting those most at risk, reach- 4 ing 35-45 percent of female sex workers and Economic Impacts of AIDS 46 percent of injecting drug users. This has helped contain HIV prevalence in the general · Analysisoftheeconomicimpactincludeswork population below 0.3 percent, with notable thatshowstheintergenerationaleffectsofAIDS declines among highly affected groups in the inunderminingeducationalattainmentand most affected southern and western states in futureproductivityandeconomicgrowth,by India. reducingincentivesandresourcesforinvesting ineducationandleavingchildrenwithout parentalguidanceandsupport(Bell,Devarajan Building the evidence base &Gersbach,2003). for policy on HIV/AIDS. · AnanalysisoftheimpactofHIV-related Successful national and local responses-- illnessanddeathsonthreelargeAfricancities especially for prevention--are grounded demonstratesthestrongfinancialimperativefor workplacepreventionandtreatmentprograms. in understanding the epidemic and the Aconservativeestimateofthecosttothecity behaviors and groups driving most new infec- ofeachHIVinfectionisapproximatelytwice tions. Better evidence on HIV epidemiology theannualsalaryofanemployee,andtotal and risky behaviors requires investments in annualcostsat1-2percentofthemunicipal surveillance, data collection, and analysis. wagebill.AIDSunderminesmunicipalservices IDA is co-financing nationally representative efficiencyandquality,andreducesthereturns toinvestmentsinmunicipalcapacitybuilding household surveys in many countries, provid- (Sarzin2006). ing a better basis for HIV program decisions. To ensure that data are actually used, IDA is · IDAanalysisoftheepidemiologyofHIValso also systematically compiling and analyzing offersvitalevidencetoinformsoundpolicies,for all available data and information on the epi- exampledemonstratingthatepidemicsdriven demic in each country, and drawing out the byinjectingdrugusersandsexworkersdemand effectiveinterventionswithhighcoverageof implications for where effective programs thesehighriskpopulations(Wilson;Kangetal must focus. 2006). IDA is also working with countries to rigorously evaluate the impact of different AIDS preven- tion and treatment programs. In Rwanda, Providing predictable, long- Burkina Faso, the Dominican Republic, Haiti, term and flexible funding. and elsewhere, IDA technical support for carefully designed evaluations is expanding IDA remains the most predictable long-term the knowledge base on "what works" to source of funding for AIDS. Ministries of combat HIV. Finance and AIDS Program Managers empha- size the importance of being able to rely on Finally, IDA has produced pioneering work IDA funding when they need it. This is most to assess the economic impact of AIDS and obviously necessary for the sustainability of the productivity and family-welfare impacts lifesaving treatment programs, but equally of access to treatment and prevention pro- important for sustained prevention and care grams. efforts. 5 Countries also value the flexibility of IDA Pan-Caribbean HIV/AIDS Partnership through funding and processes, enabling them to the Caribbean Community. respond to rapidly changing circumstances, fill unanticipated gaps and fund important Whereas a large proportion of other global interventions that others do not fund. funding for HIV/AIDS focuses on treatment, one-third of IDA funds have been allocated to Working across sectors. prevention. IDA is able to work across all the sectors that IDA is able to support controversial but crucial, need to be engaged for effective HIV/AIDS evidence-based, effective interventions with responses, and embed funding and technical marginalized groups where the epidemic often support in IDA-financed operations and work ignites, such as interventions for sex workers, in other sectors. For example, as part of its men who have sex with men, and injecting procurement system, the Standard Bidding drug users (who account for 60­80 percent of Documents include a clause that requires all new infections in some countries). IDA-funded construction contracts to include prevention and treatment for the workforce. IDA has also been the only significant source The Multi-Country AIDS Program (MAP), IDA's of support for many thousands of grassroots major HIV funding mechanism, has a strong initiatives that reach poor and remote com- focus of actions across relevant economic and munities. This funding has empowered com- social sectors. munities and people with HIV to take the ini- tiative, define their needs and work together Filling important funding gaps. to fill them. The funding has been used to care for orphans, offer home-based care for poor IDA has funded some important interventions people ill with AIDS, counseling and psycho- that others did not fund and some countries social support, information, to encourage where others cannot work--especially those HIV testing, and support income-generating affected by conflict. Funding from the US activities. These actions are crucial to reduc- President's Emergency Plan for AIDS Relief, ing stigma and changing behaviors to prevent for example, is heavily concentrated in 15 infections, and caring for people infected and countries, while IDA has funded efforts in 67 affected by HIV. countries and across borders. CHALLENGES AHEAD In the Caribbean, IDA resources have soft- ened the borrowing terms for HIV, providing The AIDS virus mutates faster than any known additional external resources to countries virus and radiates along myriad, complex whose borrowing capacity is constrained by transmission lines in societies and across high levels of external debt and the need to borders. Since it emerged in the early 1980s, cope with effects of devastating hurricanes AIDS has presented a formidable development (Grenada, St. Lucia, St. Vincent and the challenge. Although global action to fight Grenadines). In a region that is second only AIDS today is larger-scale and more concerted to Sub-Saharan Africa in HIV prevalence, IDA than ever before, it is clear that unrelenting resources have provided direct funding to the effort will be needed to reverse and end the 6 epidemic, and to invest in health systems ity action areas in The World Bank's Global that can also meet all the other urgent needs HIV/AIDS Program of Action (December 2005), for care. and the new strategy for Africa, "HIV/AIDS Agenda for Action 2007­2011," that positions Uganda, long a beacon of hope against HIV, the Bank for the next phase of the African now offers a warning against complacency. response. To play these roles effectively, IDA Uganda was the first country in Africa to needs to remain fully engaged in supporting make significant gains against the epidemic, national HIV responses. reducing prevalence among antenatal clients in Kampala from 30 percent in 1992 to 7 After reaching a peak in the 2007 fiscal year, percent by 2001. Now there are worrying new IDA commitments were only $65 million signs of risky behaviors and HIV prevalence the next fiscal year and most of the $232 mil- rising again in some rural areas (prevalence lion committed in fiscal year 2009 comprised doubled in Masaka from 4­5 percent in 2001 a large credit for Nigeria. New commitments to 8­10 percent in 2005). may remain modest in future years, perhaps because of a perception that AIDS is "over- For IDA specifically, the challenge is to main- funded" relative to other needs. This is tain strong engagement and achieve results despite the fact that funding is concentrated in the priority areas where IDA has been in a relatively small number of countries and asked by partners and countries to focus, to remains well below the amount needed to support effective countries' HIV responses, deliver services to all who need them. The and to help countries use scarce resources end of the special IDA13 grant allocation for more effectively and efficiently for stronger AIDS (covering FY 2001­04) and the availabil- results. ity of large amounts of grant funding through other sources are also factors. Global partners have requested that IDA play a leadership role in key areas: (i) pro- Within the shifting global aid architecture, viding analysis to "know your epidemic" so IDA's role is as the "funder of first resort" for that national responses can be tailored and some low-income countries and key activities, well-focused; (ii) helping countries develop and as the "funder of last resort" to enable stronger results-focused and evidence-based countries to sustain prevention and treatment national HIV and AIDS strategies; (iii) building programs. IDA is also a valued partner for the national M&E systems to provide data that technical, logistical, analytical, fiduciary, and is used to measure and manage programs to policy support to national programs, and for achieve results; and (iv) helping integrate working to better harmonize and align donor HIV into the broader development agenda, support with country needs. including into Poverty Reduction Strategies. The Bank is also a key partner in improving July 2009 implementation and helping countries resolve http://www.worldbank.org/ida bottlenecks. These are reflected in the prior- 7