64343 Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 for Botswana, Lesotho, Namibia, South Africa, and Swaziland ii | © March 2010 The International Bank for Reconstruction and Development World Bank, ACTafrica—AIDS Campaign Team for Africa The World Bank 1818 H Street, NW Washington, DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org E-mail: feedback@worldbank.org All rights reserved. The findings, interpretations, and conclusions expressed in this volume do not necessarily reflect the views of the Executive Directors of the World Bank or the governments that they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank con- cerning the legal status of any territory nor the endorsement or acceptance of such boundaries. | III Contents Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Subregional Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Status of the HIV/AIDS and TB Epidemic . . . . . . . . . . . . . . . . . . 4 Drivers of the Epidemic . . . . . . . . . . . . . . . . . . . . . . . . . 7 Impact of the Epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Demographic Impact . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Children Affected by AIDS: The Lost Generation . . . . . . . . . . . . . . . 11 Development and Economic Impact . . . . . . . . . . . . . . . . . . . . 12 Strategic Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Balancing Treatment and Prevention . . . . . . . . . . . . . . . . . . . 13 Global Financial Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Donor Coordination and National Planning. . . . . . . . . . . . . . . . . 15 Efficiency and Institutional Capacity . . . . . . . . . . . . . . . . . . . . 16 Financing HIV and TB Programs . . . . . . . . . . . . . . . . . . . . . . 17 Regional Cooperation and Coordination . . . . . . . . . . . . . . . . . . 18 World Bank Group Engagement to Date . . . . . . . . . . . . . . . . . . . . 19 Southern Africa HIV/AIDS and Tuberculosis Plan of Action 2010–2011 . . . . . . 22 Analytical Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Lending Operations and Mainstreaming . . . . . . . . . . . . . . . . . . 24 Technical Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Regional Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Working with Partners in the Subregion . . . . . . . . . . . . . . . . . 26 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Annex 1. Country Briefs . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Annex 2. Recommended Collaborative HIV-TB Activities and Targets . . . . . . . 36 iv | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Annex 3. Activities Completed and Ongoing . . . . . . . . . . . . . . . . . . 38 Annex 4. Bank Active and Pipeline Portfolios in the SACU Countries. . . . . . . . 41 Annex 5. Matrix for the Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 . . . . . . . . . . . . . . . . . . . . . . . . . . 43 References and Additional Sources . . . . . . . . . . . . . . . . . . . . . . 48 for Botswana, Lesotho, Namibia, South Africa, and Swaziland | V Abbreviations AAA Analytic and advisory activities AAP Africa Action Plan AFA Agenda for Action AFTHE Africa Health, Nutrition, and Population Unit AFTHV AIDS Campaign Team for Africa (ACTafrica) BAIS Botswana AIDS Impact Survey CPS Country Partnership Strategy DEC Development Economics Vice Presidency DfID Department for International Development, United Kingdom DHS Demographic and Health Surveys DOH Department of Health, South Africa DOTS Directly observed treatment, short course EC European Commission GAMET Global HIV/AIDS Monitoring and Evaluation Team GFATM Global Fund Against AIDS, Tuberculosis, and Malaria GHAP Global HIV/AIDS Program HCTA HIV/AIDS Capacity and Technical Assistance Project HIV/AIDS Human immunodeficiency virus/acquired immunodeficiency syndrome HSRC Human Science Research Council, South Africa IBRD International Bank for Reconstruction and Development IDA International Development Association IDF Institutional Development Fund IFC International Finance Corporation IMF International Monetary Fund IPT Isoniazid preventive therapy JSDF Japanese Social Development Fund JURTA Joint UN Regional Team for AIDS M&E Monitoring and evaluation MAP Multi-Country AIDS Program MCP Multiple concurrent partners vi | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 MDG Millennium Development Goal MDR Multi-drug-resistant MICs Middle-income countries MOH Ministry of Health MOHSS Ministry of Health and Social Services, Namibia MSM Men who have sex with men MTR Mid-term Review NABCOA Namibia Business Coalition against HIV/AIDS NAC National AIDS Council/ commission NASA National AIDS Spending Assessments NERCHA National Emergency Response Council on HIV/AIDS, Swaziland NGO Nongovernmental organization NPA National plan of action ODA Official development assistance OVC Orphans and vulnerable children PEPFAR President’s Emergency Plan for AIDS Relief (United States) PER Public expenditure review PLHIV People living with HIV PMTCT Prevention of mother-to-child transmission PPP Purchasing power parity QIMS Quality, Relevance, and Comprehensiveness of Impact Mitigation Services Survey RATESA UNAIDS Regional Support Team for Eastern and Southern Africa RBF Results-based financing RST Regional support team SACU Southern African Customs Union SADC Southern African Development Community SANAC South African National AIDS Council STIs Sexually transmitted infections TB Tuberculosis UNGASS United Nations General Assembly Special Session WDR World Development Report WFP World Food Programme XDR-TB Extensively drug-resistant tuberculosis for Botswana, Lesotho, Namibia, South Africa, and Swaziland | VII Acknowledgments This SACU Action Plan was developed by a team including: Eugenia Marinova (Task Team Leader), Markus Haacker, Michele Zini, Sheila Dutta, Joel Spicer, Marelize Gorgens, Joy de Beyer, Carolyn Shelton, Phindile Abigail Ngwenya, Richard Seifman, and Rachel Hoy under the overall guidance of Elizabeth Lule, AFTHV Manager, and Ruth Kagia, Country Director for the SACU countries. Inputs were provided by AFTHV, AFTHE, and GHAP. Technical support was provided by Cristina Romero and Faith Chirwa. | 1 as well as finance� and “playing a more active role in Executive Summary regional and global issues that cross national borders, including…infectious diseases.�2 The Bank has made specific attempts in recent years to adapt its approach to MICs, particularly the southern African MICs, in This paper for senior World Bank (Bank) manage- view of their economic impact on the continent, es- ment and staff describes the current status and im- pecially the impact of the South African economy on pact of the HIV (human immunodeficiency virus) the rest of Africa (World Bank 2008a). and tuberculosis (TB) epidemic in southern Africa, the strategic role the Bank has played to date, and The MICs in southern Africa (Botswana, Lesotho, puts forward an action plan for deeper Bank engage- Namibia, South Africa, and Swaziland), which have ment with the middle-income countries (MICs) in closely linked economies under the Southern Afri- this subregion, especially in light of the new political can Customs Union (SACU), have the highest HIV commitment by the government of South Africa. The prevalence in the world, as well as the highest HIV approach presented is consistent with the Bank’s Ex- incidence rates. The epidemic in these countries is ecutive Board-approved Africa Region HIV/AIDS described as hyperendemic—sustained high num- Agenda for Action 2007–2011 (World Bank 2008b) bers of people living with HIV (PLHIV) and high effort to “increase Bank engagement in the epicenter levels of new infections: an epidemic at very high of the epidemic—Southern Africa� and the Global equilibrium. At the end of 2007, HIV prevalence HIV/AIDS Program of Action (World Bank 2005), ranged from 15 to 26 percent of the population aged and is designed to support national efforts through 15–49 years, and 19 percent for the subregion over- evidence-based, prioritized strategies; scaling up tar- all. By 2007, these countries, with only 1 percent of geted multisectoral and civil society responses that the world’s population, carried a staggering 20 per- have demonstrated effectiveness; improving monitor- cent of the total number of PLHIV in the world (up ing and evaluation (M&E) capacity; and harmoniz- from 3 percent in 1990), and 32 percent of all new ing donor collaboration. This Southern Africa HIV/ infections. Women account for almost 60 percent of AIDS and Tuberculosis Action Plan 2010–2011, for HIV infections. South Africa has the highest num- Botswana, Lesotho, Namibia, South Africa, and Swa- ber of PLHIV (estimated at 5.7 million in 2007 by ziland (referred to henceforth as the “SACU Action the Joint United Nations Programme on HIV/AIDS Plan�) delineates an expanded operational response to [UNAIDS]). With only 0.7 percent of the world’s the unique constraints posed by this subregion, with a population, South Africa has 17 percent of the focus on assisting countries to better utilize available world’s HIV cases and the greatest HIV/AIDS bur- resources, and making the money work better. This ap- den closely linked to a TB epidemic that has more proach is aligned with the Africa Action Plan (AAP; than doubled since 2001 (an estimated 73 percent 2005),1 emphasizing new ways of doing business, of the PLHIV in South Africa also have TB). Glob- including enhanced leveraging of available financial ally, Swaziland’s 26 percent HIV prevalence among and technical resources. This strategy responds to the adults is the highest ever documented in a national World Bank President’s strategic themes of “build- population-based survey (UNAIDS 2008). The five ing a competitive menu of development solutions for SACU states are among the 15 countries with the middle-income countries, with customized services highest TB incidence in the world, ranging from 637 1 2 http://go.worldbank.org/E2QNH2SY91. http://go.worldbank.org/Z9C8QDP860. 2 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 new cases per 100,000 people annually in Lesotho, more PLHIV are added to the pool of those who to 1,198 cases per 100,000 in Swaziland; this com- need care and support. Increased access to antiret- pares with a continental average of 363 per 100,000 roviral therapy for over 700,000 PLHIV in the five (WHO 2009). national programs by end-2007 has saved their lives and restored the health of most; Botswana and Na- The impact of HIV/AIDS is evident in all sectors of mibia have reached over 80 percent of those who the economy and in households in every community. need treatment, and Swaziland has increased cover- In 2007, southern Africa bore almost one-third (32 age to 67 percent. All countries have made progress percent) of the world’s AIDS-related deaths (UN- in preventing infants from contracting HIV from AIDS 2007). In the five SACU countries, life expec- their mothers; Botswana has made the prevention tancy declined from an average of 60 years in 1990 to of mother-to-child transmission (PMTCT) a major 51 years in 2007 (World Bank 2009d). AIDS-related priority and has reduced the rate to only 4 percent illnesses kill predominantly adults in their most so- (UNAIDS 2008). cially and economically productive years, leaving be- hind orphaned children and the elderly, and thereby Despite the progress, challenges remain. HIV pre- increasing dependency ratios. The number of orphans vention progress lags, as is evident from the still high as a result of AIDS in South Africa alone was esti- incidence rates of 2.8 percent on average (almost 3 mated at 1.4 million in 2007 (UNAIDS 2008). The out of every 100 people become infected each year). epidemic has had significant developmental impact, More effective approaches and interventions as well representing a risk to living standards, especially for as behavior changes are needed. The sustainability of poor households, and for which additional expendi- existing antiretroviral therapy programs is contingent tures and income losses caused by illness and death on available funding and efficient systems to deliver result in more severe deprivation, in a subregion that the programs as well as to monitor and measure their already has high income inequality. HIV has an im- impact. This will require skilled staff, good coordina- mediate macroeconomic impact through productiv- tion to facilitate collaboration between communities ity losses and erosion of human capital (Haacker and the private sector, and the efficient allocation and 2004). The cost of responding to the epidemic has use of available resources. Countries are aware of the put a strain on the economy and diverted resources need to strengthen the institutions involved in pro- from other development needs. The high need for viding services in a multisectoral approach to mitigate HIV-related health care has strained health systems social and economic impacts, and are especially eager and affected the provision of other services, and for assistance in identifying which programs are most AIDS has increased the shortages of skilled medical effective, and how to make them more efficient. providers and other health support staff. Even with constrained resources and financing op- After 25 years of responding to the HIV epidemic tions, the Bank continues to play an important stra- through an unprecedented mobilization of resources tegic role in the subregion, especially in Swaziland and advances in knowledge and technology, the re- and Lesotho.3 Bank support4 to all SACU countries sponse is at a critical crossroads, both globally and has been met with appreciation by country officials in southern Africa. Population-based surveys and and key development partners and has been de- better surveillance have improved the reliability of 3 Lesotho is the only International Development Association HIV data. HIV prevalence in the five SACU coun- (IDA) country in SACU eligible for concessional funding under tries appears to have stabilized, but at extraordinarily the Multi-Country AIDS Program (MAP). 4 high levels (UNAIDS 2008), and every year, 100,000 Activities completed and ongoing are listed in annex 3. for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 3 scribed as catalytic. The high-quality analytical work co-epidemic in a coordinated fashion, to the extent and technical assistance were provided in record time possible. The team successfully provided an array of and served as an essential background for the prepa- analytical series and technical assistance under the ration of HIV projects in Botswana, Lesotho and 2006 operational plan (annex 3) on a purely demand- Swaziland, and responded to urgent demands from driven basis. The rationale for the new action plan Namibia and Swaziland. The Bank has used Institu- rests on three main factors: the extraordinarily high tional Development Fund (IDF) financing in Swazi- burden of HIV and HIV-related diseases, especially land to help build the M&E system and in Namibia TB; recognition by SACU countries that the Bank’s to enhance capacity for a coordinated public-private analytical, policy, and operational experience have response. The current Bank portfolio (active and been catalytic in securing support; and, triggered by pipeline projects) in the SACU countries provides the financial crisis, the growing need for complemen- good opportunities for mainstreaming HIV and tary funding in addition to funding provided by gov- TB (see annex 4). While some projects have specific ernments and others. At governments’ request, future HIV components, all operations seek appropriate Bank support will focus primarily on analytical work ways to integrate HIV and TB support—which will and technical support, but will also explore innova- also require a scale up of resources. The World Bank’s tive financing to fill financial gaps. The Bank will also Global HIV/AIDS Program (GHAP) has provided focus its support on systems strengthening, main- resources to help build the HIV M&E systems in streaming, regional integration, knowledge sharing, Namibia, Swaziland, and Lesotho at the specific re- capacity building, and partnerships. New lending quest of governments. GHAP has also conducted an for HIV support will depend on the gaps unfilled by analysis on the transmission modes and the epidemic other donors or governments, the receptivity of the in Lesotho and Swaziland. International Bank for Reconstruction and Develop- ment (IBRD) countries to available Bank financing, This SACU Action Plan is intended to deepen the and/or partner willingness to provide parallel financ- dialogue with the respective governments and jointly ing. Mainstreaming HIV and TB support into lend- identify areas where the World Bank can use its com- ing operations will depend on available opportunities parative strengths to help curb the spread of HIV and collaboration with various sectors. Analytical and TB in the subregion. The Bank’s presence in the work will focus on the efficiency, effectiveness, and subregion is seen as critical, especially due to the cur- fiscal sustainability of government programs; the im- rent global financial uncertainty. At this crucial time, pact of HIV and TB on development; cross-border the Bank has an important role to play in integrating transmission of HIV and TB; and helping countries HIV and TB into the development agenda by fill- use new evidence on the epidemic to make preven- ing financing gaps, and more importantly, by provid- tion more effective. Technical support will be provid- ing analytical and technical support based on global ed on M&E, governance, and neglected vulnerable knowledge and experience. The proposed action plan populations. builds on experience in the SACU countries and the HIV/AIDS operational approach developed in Depending on country context and regional op- 2006,5 and is the first attempt to address the HIV-TB portunities, various Bank instruments will be used: project-type lending or grant assistance, main- 5 The 2006 strategy, “Sub-Regional HIV/AIDS (and OVC) Oper- streaming in sectoral projects, technical analysis and ational Strategy, FY06–FY08, Southern African Customs Union, (Botswana, Lesotho, Namibia, South Africa & Swaziland),� was knowledge management, capacity building, partner- prepared as an internal Bank document. ship collaboration, or other means of support. Several 4 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 resource options will be explored to implement the action plan, including: exceptional rapid-response Subregional Diagnosis funding and/or accessing IBRD surpluses; innova- tive financing mechanisms, such as buy-downs for IBRD SACU countries; using results-based financ- ing (RBF); creating priority categories for HIV-TB The Southern African Customs Union—comprising SACU funding in special facilities such as the IDF, Botswana, Lesotho, Namibia, South Africa, and Swa- the Japanese Social Development Fund ( JSDF), or ziland—is an economically and culturally integrated other trust funds; and establishing a multidonor trust subregion. This is both the most economically devel- fund for SACU HIV-TB support. oped subregion in sub-Saharan Africa and the epicen- ter of the global HIV epidemic. The situation is exac- erbated by the extremely high TB burdens found in all five countries, including multi-drug-resistant (MDR) and extensively drug-resistant (XDR)-TB.6 The SACU countries and the international development commu- nity have recognized the extraordinary burden placed on the economies by the HIV-TB epidemic and are providing considerable domestic and development assistance to national HIV/AIDS and TB programs. However, the relative amount of official development assistance (ODA) supporting national HIV/AIDS programs in the middle-income SACU countries is much less than in the low-income countries in sub- Saharan Africa, including many countries with signifi- cantly lower HIV prevalence. The classification of the SACU MICs as IBRD countries makes them (except Lesotho) ineligible for World Bank–International De- velopment Association (IDA) zero-interest credits. Status of the HIV/AIDS and TB Epidemic The SACU subregion has the highest HIV preva- lence in the world, as highlighted in table 1, ranging from 15 to 26 percent of the population aged 15–49 years at end-2007, and an average of 19 percent, compared to 5 percent for sub-Saharan Africa and a worldwide average of 0.8 percent.7 With only 1 per- 6 Multi-drug-resistant TB is a form of TB that is difficult and expensive to treat and fails to respond to standard, first-line drugs. Extensively drug-resistant TB occurs when resistance to second- line drugs develops on top of multi-drug-resistant TB. 7 UNAIDS (2008). for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 5 Table 1 Country-Specific HIV Estimates (2007) Country Adulta Adulta Number of adults and children Proportion of HIV prevalence HIV prevalence living with HIV women over age rate (%) range (%) (estimate range) 15 living with HIV among PLHIV (%) Botswana 24 22–25 300,000 (280,000–310,000) 61 Lesotho 23 22–25 270,000 (260,000–290,000) 58 Namibia 15 12–18 200,000 (160,000–230,000) 61 South Africa 18 15–21 5,700,000 (4,900,000–6,600,000) 59 Swaziland 26 25–27 190,000 (180,000–200,000) 59 Source: UNAIDS (2008). a. Adult = ages 15–49 years. cent of the world’s population, the five SACU coun- cent, with women at 20.4 percent prevalence, com- tries have seen a staggering increase in total num- pared to 14.2 percent in men. Average national inci- bers of PLHIV from, 3 percent (1990) to 20 percent dence is 2.9 percent, but 8.7 percent among women (2007) of the world’s HIV-positive population (UN- aged 25–30 years (figure 2); nearly 9 percent of the AIDS 2008; World Bank 2009b). women from this population group become infected each year. Gender differences are most pronounced There are nearly 7 million HIV-positive people in the for those in the 15–24 years population group, and five SACU countries, similar to the combined total in Swaziland, the estimated prevalence among young population of the four small SACU countries.8 For women (aged 15–24 years) is 22.6 percent, compared example, in Lesotho, with a population of 2 million, to 5.8 percent for men in the same age group (Ofosu- there are nearly 60 new infections daily and preva- Amaah, Egamberdi, and Dhar 2009). More details lence is more than 23 percent, with both men and on the country-specific situation can be found in the women having sexual debut at an early age (UNAIDS country briefs (annex 1). 2009). A disproportionate share of HIV-positive people in the subregion are women (59 percent com- Worldwide, TB is the leading cause of death among pared to their 52 percent population share; figure 1). HIV-positive people, and HIV is the strongest pre- In South Africa, for instance, HIV incidence among dictor of progression from latent TB infection to ac- women aged 20–29 years in 2005 was more than six tive disease. Eighty percent of HIV-related TB is in times higher than for men of the same ages (Rehle sub-Saharan Africa, with South Africa carrying 24 et al. 2007). The latest results from Botswana’s AIDS percent of the burden. All five SACU countries are impact survey (Botswana CSO, NHL, and NACA in the top seven countries in the world for highest 2009) show a national HIV prevalence of 17.4 per- TB incidence, highest rates of TB-HIV co-infection 8 The combined population of Botswana, Lesotho, Namibia, and (figure 3), and all have confirmed cases of XDR-TB. Swaziland is about 7 million. The unchecked spread of drug-resistant TB is a re- 6 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Figure 1 HIV Prevalence among Young Women Sources: Shisana et al. ( 2009). Figure 2 Estimated HIV Incidence in Botswana, 2008 Source: Botswana CSO, and NHL, and NACA (2008), www.cso.gov.bw. for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 7 Figure 3 TB Incidence and Corre- gional public health issue that threatens HIV investments, the lives of co-infected people, and sponding Incidence Rates of the most vulnerable group of all—those with HIV-Positive TB Cases HIV who do not yet have TB, especially infants (Hesseling et al. 2009). The HIV/AIDS and TB co-infection is a deadly mix and the need to address both requires global attention. Although the SACU countries have been significantly affected by the HIV-TB co- epidemic, the response to integrate HIV and TB programs has been delayed. This co-epi- demic has placed extraordinary demand on the health care systems in all five countries (table 2), which are struggling to cope in the face of insufficient human resources and already over- stretched public health services, particularly in rural areas. Thus, there is a clear need to utilize HIV/AIDS entry points to encourage HIV-TB collaboration, and vice versa. This approach is, in theory, supported by all leading multilateral agencies, donors and implementers at all levels, and yet the scale up of integrated responses has not happened to the extent needed.9 Drivers of the Epidemic High HIV prevalence in the SACU countries has been the subject of numerous studies. The causes appear to be a combination of behav- ioral and sociocultural factors (Shisana et al. 2009; Namibia MoHSS 2008a; and UNAIDS 2008). The Expert Think-Tank Meeting on HIV Prevention in High-Prevalence Coun- tries in Southern Africa (SADC 2006) identi- fied the drivers of the epidemic in the SADC region as high population mobility; inequalities of wealth; cultural factors and gender inequality; male attitudes and behaviors; intergenerational sex; gender and sexual violence; stigma; lack of Source: WHO (2009), and www. who.int/tb/country/global_tb_database/ 9 For example, data from WHO (2008) notes that presently only 2 en/index.html. percent of the PLHIV are screened for TB. 8 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Table 2 TB in SACU Countries, 2009 Incidence Mortality Co-infection Detection Treatment Country New cases TB deaths TB deaths TB deaths TB deaths Of TB patients DOTS, new DOTS new per year per year per year (all per year (all per year tested for smear-positive smear- (all forms) (all cases, forms) per forms) per among HIV, percent case detection positive including 100,000 of 100,000 of PLHIV that are HIV rate (%) treatment PLHIV) population population positivea success (MDG indicator 24d) (%) Botswanab 13,761 731 3,649 194 2,945 67 57 72 Lesothob 12,782 637 5,282 263 4,542 76 16 66 Namibiab 15,905 767 2,124 102 1,518 59 84 76 South Africab,c 460,600 948 111,924 230 93,703 64 78 74 Swazilandd 13,674 1,198 3,619 317 3,160 74 55 43 Total Africa 2,879,434 363 734,891 93 377,535 51 47 76 Source: Data compiled for SACU countries from the WHO global TB report (2008). Note: DOTS= directly observed treatment, short course. a. Only 37 percent of all TB patients were tested for HIV. b. Confirmed XDR-TB. c. High TB burden country. d. Proportion of tuberculosis cases detected and cured under DOTS (internationally recommended TB control strategy). openness; untreated STIs; and multiple concurrent HIV, which is in turn exacerbated by gender-related partnerships (MCPs) by men and women with low sociocultural, legal, and physiological factors. While consistent condom use and in the context of low lev- data among men having sex with men (MSM) is els of male circumcision. Widespread mobility, the poorly documented, preliminary results from South migration of workers between workplaces and rural Africa’s largest cities show HIV prevalence ranging homes, and protracted periods working in mines, from 12.6 percent to 47.2 percent (Shishana et al. plantations, and border-trading zones put men 2009), albeit the studies involved only self-declaring with money next to women with limited access to MSM and the sample sizes were small (200 respon- the formal economy. Sexual coercion, gender-based dents or less). violence, gender inequality, and particularly wom- en’s lack of economic empowerment and inequal- ity in sexual relationships result in unprotected sex and multiple concurrent sexual partners, which fuels for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 9 Figure 4 Life Expectancy at Birth in Southern African Countries Source: United Nations Population Division (2009). Note: Broken lines represent counterfactual “no-AIDS� scenario. Swaziland, life expectancy fell from 60 years in 1990 Impact of the Epidemic to 46 years (UNDP 2009). It is estimated that in 2005, more infants died from AIDS-related illnesses than any other cause in Botswana and Namibia, with infant mortality in Botswana estimated at 55 infant deaths per 1,000 live births in 2005 (Epstein 2004). Demographic Impact Based on preliminary data, figure 5 shows estimates of the impact of increasing the availability of antiret- The HIV epidemic has led to high mortality rates roviral therapy. While antiretroviral therapy increases and declining life expectancy. AIDS-related illnesses life expectancy of PLHIV, AIDS continues to have a account for up to half of all deaths and are the ma- large impact on life expectancy even where treatment jor cause of death among young adults in this subre- coverage rates are now high. gion.10 As a consequence, life expectancy has dropped dramatically (figure 4). Three of the five SACU Figure 5 relates life expectancy and GDP per capita countries (Botswana, Lesotho, and Swaziland) have in low- and middle-income countries, showing that lost almost 20 years in life expectancy, reversing all SACU countries had life expectancy levels about 20 gains in life expectancy achieved since the 1950s. In years lower than countries with similar income levels that were not as affected by HIV/AIDS. Life expec- 10 For example, the United Nations Population Division (2007) tancy levels in middle-income SACU countries are estimates that crude mortality in Swaziland in 2000–2005 was 1.7 percent, compared to 0.7 percent for a “no-AIDS� scenario. For as low as normally seen in low-income countries.11 the population between ages 15 and 49, estimated mortality is 1.8 11 Few countries in figure 5 with life expectancy levels and income percent, a six-fold increase compared to a “no-AIDS� scenario. similar to SACU countries have recently experienced large gains in GDP associated with oil revenues (Angola, Gabon, and Equa- 10 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Figure 5 GDP per Capita and Life Expectancy, 134 Low- and Middle-Income Countries Source: IMF, World Economic Outlook Database (2008) for GDP per capita, and United Nations Population Division (2007) for life expectancy. Note: PPP = Purchasing power parity. Figure 6 Swaziland Population Pyramid, 2000–2025 Source: U.S. Census Bureau Web site, http://www.census.gov/ipc/www/idb/country.php. for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 11 The main costs of the pandemic arise from increased Figure 7 Number of Orphans in mortality and lower life expectancy. The impact of AIDS in the SACU countries can be compared to Sub-Saharan Africa, other catastrophic events, such as war. The only coun- 2001 and 2007 try where the increase in the death rate and reduction in life expectancy were more devastating than the ef- fect of AIDS on Swaziland is the case of Rwanda in the 1990–95 period, and the conflict-related drop in life expectancy there was far less persistent than the impact of AIDS. Increased mortality due to AIDS-related illnesses is distorting the population structure of SACU coun- tries, deforming their population pyramids. Figure 6 illustrates the situation in Swaziland. By remov- ing adults during their most socially and economi- cally productive years and leaving behind orphaned children and the elderly, the epidemic has greatly increased dependency ratios. Children Affected by AIDS: The Lost Generation One of the most dramatic consequences of the epi- demic is the number of orphans in SACU countries; more than 1.7 million children have been orphaned by AIDS (figure 7).12 AIDS has orphaned a percent- age of children in the SACU countries that is higher than even countries that have endured many years of civil war. Households headed by young children, who are trying to care for their siblings, are not uncom- Source: Compiled from UNICEF (2008). mon. Many orphans end up living as “street-kids� de- prived of an education and often turn to child labor or criminal activities to survive. Many children are also affected by HIV through their own infection or their parents’ HIV-related illness. These children Development and Economic Impact are particularly vulnerable to poverty, discrimination, child labor and social exclusion. Numerous studies have shown the significant im- pacts HIV has had on development gains; such as torial Guinea), whereas other development indicators have not life expectancy, maternal and infant mortality and improved in line with the fast gains in GDP per capita. 12 The UNAIDS definition of orphan, a child who has lost either the immediate consequences, including orphans and one or both parents, is used here. 12 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 higher dependency ratios.13 The AIDS epidemic— HIV has implications for public policy in the SACU on the scale seen in the SACU subregion—also has subregion, such as eroding revenues and other re- macroeconomic implications for growth, poverty, sources, as well as the long-term costs of providing human capital investments and public services (es- antiretrovirals to all PLHIV. A slowdown in growth pecially the delivery of health services), and micro- also translates into a slowdown in fiscal revenues. economic level effects, both generally (increased risks More directly and immediately, high AIDS-related to living standards to the population overall) and for mortality erodes the human resource base of the pub- households affected by HIV, which are a significant lic and private sectors. Scarce evidence suggests that share of the population in SACU countries. this creates disruptions to public services, especially in rural areas, where replacements for public servants The premature mortality of adults increases poverty falling ill cannot be found as easily as in urban areas. and inequality and perpetuates a poverty trap for the next generations, who have little prospect of upward HIV also poses substantial challenges to the cost, al- mobility (Bell, Devarajan, and Gersbach 2004). Ac- location, and efficiency of government services, par- cording to Bell, Devarajan and Gersbach, early adult ticularly because of the increased demand for care and mortality reduces incentives and the ability to invest treatment and the need to address the social and eco- in education and training, and deprives orphaned chil- nomic consequences of HIV/AIDS on households, dren of the parental guidance and formal education including the massive increase in the number of or- that combine to produce a wellspring of long-term phans. Swaziland (where 31 percent of children are economic growth. Arbache (2009) further suggests classified as vulnerable), for example, reports that 30 that limited learning opportunities mean that orphans percent of all HIV-related spending in 2006 was for will likely earn less, and in turn invest less in their own the basic needs for orphans and vulnerable children children’s education, transmitting the deleterious im- (OVC; UNAIDS 2008). Responding to the double pact of AIDS over generations and affecting national challenge of eroding resources and increased demand long-term economic growth and capital formation. for services is particularly problematic in the health sector, where the additional demand for services is While there is consensus that HIV/AIDS, mainly due concentrated and the limited availability of skilled to reduced population growth, results in lower GDP personnel creates bottlenecks. growth rates, currently the evidence is much less clear regarding the impact on the growth of GDP per capita. While GDP growth in the region has declined since 1990, much of the slowdown took place before mortal- ity rates related to AIDS escalated, and other factors such as developments in the mining sector and the end of apartheid appear to have played a key role as well. Changes in GDP per capita patterns are less evident, because differences in the demographic transition across SACU countries mask the impacts of AIDS.14 13 The sector-specific development impacts of AIDS are detailed in numerous program documents, including the Multi-Country tion than other subregions of sub-Saharan Africa. In other sub- HIV/AIDS Program for Africa and the Africa Region HIV/ regions, population growth is declining because of reasons other AIDS Agenda for Action, 2007-2011. than AIDS. The decline in population growth in the SACU 14 SACU countries are more advanced in the demographic transi- countries, relative to sub-Saharan Africa overall, is therefore much smaller than the impact of AIDS on population growth. for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 13 Table 3 Access to Antiretroviral Therapy, End-2007 Country Number on antiretroviral PLHIV requiring Percentage of total therapy treatment (%) population Botswana 93,000 79 4.9 Lesotho 22,000 26 1.1 Namibia 52,000 88 2.5 South Africa 460,000 28 0.9 Swaziland 25,000 42 2.2 Sub-Saharan Africa 2,250,000 30 0.3 Sub-Saharan Africa, 1,600,000 29 0.2 excluding SACU Source: Authors’ estimates, based on data from WHO, UNAIDS, and UNICEF (2008) and the United Nations Population Division (2007). bia has a higher percentage of people on treatment Strategic Challenges (with a coverage rate of 46 percent). While this is im- pressive progress, insufficient M&E of antiretroviral therapy programs have failed to provide a complete and reliable snapshot of the coverage or compliance with treatment, complications, or development of Balancing Treatment and Prevention drug resistance. According to Serrao 2009, nearly 15 percent of HIV-positive patients in the Gauteng SACU countries have made progress in address- province (South Africa) have stopped using antiret- ing HIV impact, particularly in expanding access rovirals, and that nationally between 15 and 20 per- to treatment. Antiretroviral therapy coverage rates cent of these patients are dropping treatment. ranging from over 80 percent (Botswana and Na- mibia) to 26 percent (Lesotho) as of end-2007 are Looking ahead, SACU countries face considerable major achievements, and compare well to an average challenges in sustaining their responses to the HIV/ for sub-Saharan Africa of about 30 percent (table 3; TB co-epidemic. Compared to treatment, prevention WHO, UNAIDS, and UNICEF 2008). This is par- progress has not kept pace, with high numbers of new ticularly important given that SACU countries are infections throughout the subregion.15 Lesotho and facing great demand for treatment and stand out in 15 The “HIV Prevention Response and Modes of Transmission terms of the absolute number of people receiving Analyses� (March 2009) for Lesotho (Lesotho National AIDS treatment as a proportion of the population, ranging Commission, UNAIDS, and World Bank 2009) and Swaziland from 4.9 percent in Botswana to 0.9 percent in South (NERCHA, UNAIDS, and World Bank 2009) show that inci- Africa. Compared to the rest of Africa, only Zam- dence in Lesotho has stabilized at 1.7 percent, which still trans- lates to 21,000 new infections in adults in 2007, while in Swazi- 14 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Table 4 Distribution of HIV/AIDS-Related Expenditures by Category Country Year of Treatment and Prevention OVC Management reporting care (%) (%) (%) (%) Botswana 2007 61 7 22 9 Lesotho 2006 20 13 16 21 Namibia 2007 69 17 n/r 13 Swaziland 2006 19 16 30 14 Source: Compiled from UNAIDS country data sheets (http://www.unaids.org/en/CountryResponses/Countries/default.asp). Botswana report more spending on management than trends are to be sustained, all partners need to care- on prevention, while Swaziland allocates one-third of fully review and focus their resources on programs its resources to the basic needs of OVC (table 4). At that have demonstrated positive impact and can turn the same time, the effectiveness and efficiency of HIV the situation around. expenditures have not been carefully assessed. The prospects are daunting: rising numbers of orphans, increasing numbers of people needing treatment, and Global Financial Crisis possibly escalating costs of treatment as more people The global financial crisis and economic downturn need expensive second-line drugs. The need for ma- have not spared the SACU countries (table 5). The jor treatment, prevention, and mitigation support IMF expects the tighter global funding conditions in SACU countries will continue for years to come, to have noticeable effects on the MICs, particularly and one of the most critical analytical interventions South Africa (IMF 2009). The latest IMF estimates should be a careful assessment of the effectiveness of for 2009 show a 0.8 percent decline in global GDP, programs and the expenditures associated with them. as many countries were in recession (South Africa Prevention programs and efforts have yielded some 2010). South Africa’s economy saw its sharpest de- results. According to the UNAIDS 2010 Outlook cline in 17 years, shrinking by 1.8 percent in 2009 Report (UNAIDS 2009), the virtual elimination of compared to 3.7 percent growth in 2008. Given the mother-to-child transmission is achievable by 2015, close economic ties between South Africa and its and in Botswana, Namibia, and Swaziland it is re- neighbors, the downturn had negative effects on the ported that more than 90 percent of all HIV-positive smaller SACU countries. Output was significantly pregnant women receive antiretroviral prophylaxis to compromised by lack of demand for commodities prevent transmission to newborn babies. In addition, and other exports, which in turn, worsened an already UNAIDS (2009) reports that the integration of TB serious unemployment situation. South Africa’s un- and HIV services in South Africa has helped to save employment rate increased to 24.3 percent during lives and reduced the TB burden. If these positive 2009Q4 compared to 21.9 percent in 2008Q4. The mining and manufacturing sectors, which constitute land the annual adult HIV incidence is estimated at 3 percent. a significant proportion of the countries’ GDP, were Botswana reports 2.9 percent incidence in the latest impact survey particularly hard hit. Many companies in these sec- (Botswana CSO, NHL, and NACA 2009). for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 15 Table 5 Real GDP Growth—SACU Countries Country 2006 2007 2008 2009 estimated 2010 projected Botswana 5.1 4.4 2.9 0.0 5.0 Lesotho 8.1 5.1 4.4 1.4 3.0 Namibia 7.1 5.5 2.9 -0.7 1.8 South Africa 5.6 5.5 3.7 -1.8 2.3 Swaziland 2.9 3.5 2.4 0.4 2.7 Source: IMF (2009). tors retrenched workers and some increased their family structures and their consequences more visible; shut-down periods to contain their losses. Declines table 6 shows the dramatically low percentage of chil- in taxes on international trade, which generate more dren who grow up with both a mother and a father. than 50 percent of the SACU revenue pool, resulted South Africa in particular, but also Namibia and Bo- in 46 percent decline in SACU transfers. Falling rev- tswana, attracts people from across southern Africa enues undermine the fiscal space available to cushion and beyond. In South Africa, for example, the annual the adverse effects of the slowdown. Thus, countries number of visitors from other Southern African De- face difficult decisions regarding public spending. velopment Community (SADC) countries increased from around 1 million in the early 1990s to over Migration 5 million in 2004 (Crush, Williams, and Peberdy 2005). The SACU countries are home (permanent or Oscillatory worker migration, as well as the geo- temporary) for migrant workers and refugees from graphically disparate family structures caused by such neighboring countries, with unknown HIV-TB sta- frequent migrations, has been a factor in the spread tus, and who fall out of national health or social sys- of HIV. “High morbidity rates of preventable dis- tems. The South African mining industry, despite its eases, including STDs, have been the toll exacted good HIV and TB treatment programs, inadvertent- as a pre-capitalist, rural and agricultural society was ly contributes to the spread of HIV, TB, and drug- transformed into a capitalist, industrial economy de- resistant TB through its employment of migrant pendent largely on male, migrant labor� ( Jochelson workers (especially in Swaziland and Lesotho). 1999). These oscillatory migrations created a differ- ent social structure and “led to the development of an urban life which has profoundly disturbed the family Donor Coordination and National Planning stability and sexual mores of several million people� National AIDS coordinating bodies in all five SACU (Clark 2001). The consequences were devastating, countries are relatively well staffed and receive sup- and created geographically disparate families that rely port from development partners, including the Bank. heavily on remittances from migrant workers. No- However, particularly with ministries of health, co- where else but in southern Africa are these distorted 16 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Table 6 Family Structure: Percentage of Children Growing Up without Parents Living with Status of Living with Living with Living with neither Country Year parents both parents mother only father only mother nor unknown father Botswana 2005 26.5 35.8 2.6 28.1 7.1 Lesotho 2004 46.8 22.3 3.5 23.5 3.8 Namibia 2006–7 27.0 33.8 4.7 32.7 1.7 South Africa 2003 33.7 35.2 2.3 21.1 7.7 Swaziland 2006–7 22.5 39.5 5.4 30.8 1.8 Source: Data from Demographic Health Surveys from all countries, BAIS for Botswana, and HSRC surveys for South Africa. ordination and implementation capacity to scale up ♦ Poorly costed action plans services remain major challenges. Countries are im- ♦ Slow disbursement and procurement procedures proving their understanding of the drivers of trans- mission, which must be targeted to prevent HIV, and ♦ Weak supply chain management for HIV-related have a better appreciation of the additional human commodities and financial resources required. All national plans ♦ Limited implementation partnerships with civil are costed, estimate the resources needed, and iden- society and private sector agencies tify shortfalls that cannot be addressed by the coun- tries themselves, particularly in the current economic ♦ Weak M&E systems environment. However, it is clear that financing gaps ♦ Insufficient funder coordination to complement remain, yet they are not always articulated. Given the each others’ financing multisectoral aspect of the programs, there is insuf- ficient clarity on which institution is responsible for These issues pose a major challenge in reaching the the absorption and monitoring of financial flows. In Millennium Development Goal (MDG-6) of halt- terms of coordination, particularly with ministries of ing and beginning to reverse the spread of HIV by health, with which relationships are often complex, 2015. further improvements are needed. Major health systems issues negatively impacting the Efficiency and Institutional Capacity effectiveness of national AIDS programs include: Greater efficiency in use of resources, accountability, ♦ Limited and insufficiently trained human and other systemic aspects remain a challenge. An resources analysis of HIV program implementation in South ♦ Unpredictable or conditional funding Africa reported that the “increase in funding has not translated into positive results and this is due to for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 17 lack of or inadequate accountability mechanisms… bilateral donors; and major foundations, including the that may be impinging on delivery� (Reddy 2007). Gates Foundation, the Clinton Foundation, and the These inadequacies include the ineffective tracking Merck and Kaiser Foundations. Despite efforts for of donor funding, which results in the duplication better coordination among partners, at national and of resources and efforts. The consequences of these international level, and an agreed division of labor inadequacies were confirmed in a draft paper on among UN agencies, the global HIV “architecture� coordination of ODA prepared by the South Af- has become increasingly complex with overcrowding rican Department of Health (South Africa DOH in some areas. Further, international assistance is un- 2009), which notes an overcrowded HIV field while evenly distributed in the SACU subregion and largely the rest of the health sector is left unattended. De- concentrated in the highest income countries. For ex- spite efforts to build effective M&E systems, there ample, financial arrangements and fiscal years do not is little information on the impact of interventions always coincide with the country’s own medium- and and far too little monitoring of compliance and drug long-term commitments, and reporting on financial resistance. flows from donors are often ad hoc and incomplete, making forecasts and long-term projections difficult. Limited focus on building institutional capac- Countries, and some development partners, do not ity, particularly on leadership, and coordination of always report a detailed breakdown on funding and the national HIV response are additional national spending, and some lack the capacity to capture and challenges. SACU countries have pursued differ- analyze such information for use in planning. ent institutional arrangements in their HIV/AIDS efforts. South Africa and Namibia’s responses are The financial crisis is threatening the sustainability coordinated and led primarily through their health of HIV/AIDS and TB programs, especially those department/ministry, while Botswana, Lesotho, and for treatment. ODA and private assistance funding Swaziland have created separate national AIDS commitments have remained in place for the mo- commissions. The different models have strengths ment, but the global economic downturn is likely and weaknesses, with some more attuned to a mul- to affect future external resource flows. Projections tisectoral, prevention-oriented approach. No matter of declining SACU revenues as a result of reduced the model chosen, capacity and human resource con- exports, particularly in commodities, and lower re- straints exist and need to be overcome, generally, and mittance flows put SACU governments under pres- in the health sector in particular. sure regarding spending priorities. Unemployment, already high in all five countries, particularly among youth,16 will remain a pressure point (at least in the Financing HIV and TB Programs short term). Higher unemployment may trigger While it is difficult to obtain precise estimates, more risky behavior. Further, the influx of “econom- funding gaps remain despite significant country ic� refugees, mostly from neighboring Zimbabwe to and international resource commitments (table 7). South Africa, but also to Botswana and Namibia, Major financiers in the region include the United increases the number of people in need of HIV and States President’s Emergency Plan for AIDS Re- TB services. lief (PEPFAR); the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM); the United 16 Youth unemployment in 2000–2006 was 39.6 percent in Kingdom’s Department for International Develop- Botswana, 44.8 percent in Namibia, and 60.1 percent in South ment (DfID); the European Union; several European Africa (World Bank 2009a). 18 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Table 7 Country Reports on Domestic and International Spending and Funding Sources Share by financing source (%) International Total UN and All other reported other international expenditures Domestic Bilateral GFATM multilateral sources (%) Country Year (US$ millions) (%) (%) (%) sources (%) Botswana 2007 229 88.8 10.5 0.2 n/a 0.4 Lesotho 2006 24 18.7 28.5 14.5 30.3 7.9 Namibia 2007 130 50.8 n/a n/a n/a 49.2 South Africa 2007 621 77.3 4.0 13.0 3.2 2.6 Swaziland 2006 49 39.8 5.8 31.0 9.7 13.6 Source: UNAIDS (2008). Note: n/a = data unavailable. Regional Cooperation and Coordination The SADC Secretariat is the key policy coordinating body in the region, and there has been progress since Coordination among the five countries is limited and the SADC HIV/AIDS summit in 2003.18 SADC is a concern in this interdependent subregion. Some extends well beyond the SACU region and has broad progress has been made in moving the dialogue policy and programmatic functions. The SACU forward; for instance, the SACU national AIDS countries are a subset of SADC and subscribe to all authorities meeting,17 held in 2005, was critical in SADC protocols, including the SADC HIV and confirming the Bank’s commitment to the subregion. AIDS Strategic Framework (2009–2015) and the Participants expressed the need for a subregional fo- accompanying documentation, the five-year busi- rum for institutional, professional and technical ca- ness plan 2010–15, M&E plan, and others. Hence, pacity building and endorsed a possible mechanism a separate SACU-specific subregional strategy is not for such a network, which would also permit SACU envisaged by the five countries at this point. Donor countries facing similar challenges to learn from each support to strengthen the SADC Secretariat has re- other and to commission relevant analytical work to sulted in improved performance, including a stronger inform policy and program decisions. SADC HIV/AIDS unit, but which has not integrat- 17 A successful and promising first meeting of national AIDS ed TB. However, given its broad mandate and diverse councils’ heads or representatives and donors was held in Octo- membership, SADC has not yet been able to provide ber 2005, for which the Bank secured funding and high-level Bank participation. South Africa was not represented. The first sustained regional facilitation and integration, attract SACU operational strategy (2006) was one result of that meeting. 18 The Bank supported the summit, held in Maseru, Lesotho, A follow-up on the macroeconomics of AIDS to be hosted by which was attended by all 14 member states. Botswana (at their request) was planned, but has not taken place. for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 19 financing, or implement significant regional proj- ects. More recently, a SADC-wide HIV prevention World Bank Group strategy, HIV M&E framework, and HIV capacity- building strategy were developed, which all member Engagement to Date states have agreed to implement. At the Seventh An- nual Forum of SADC National AIDS Authorities held in Kinshasa, Democratic Republic of Congo, The Bank’s dialogue with SACU countries and October 12–14, 2009, the Bank was specifically re- jointly elaborated partnership strategies have high- quested to present the impact of the global finan- lighted the development challenges posed by HIV cial crisis on HIV program financing, and the Bank’s for each country, and for the subregion. For example, engagement. One of the meeting recommendations the current Lesotho Country Assistance Strategy19 was to urgently call a high-level meeting of financial (2006) and the new one under preparation empha- and HIV representatives of the SADC countries to size support to HIV and TB through new health discuss financing options that would ensure the sus- and HIV projects. The Swaziland Interim Strategy tainability of the programs underway. (2008) is built around the “chronic disaster� of HIV, which makes Swaziland a special MIC/IBRD case. The Botswana Country Partnership Strategy (2009) stresses that “if not for the devastating HIV/AIDS situation, Botswana would be well on its way to achieve remarkable development success of meeting the MDGs.� Namibia’s Interim Strategy (2007) also has HIV as one of the three key Bank areas of sup- port, greatly appreciated by government and nongov- ernment actors that have benefited from the targeted assistance. The South Africa Country Partnership Strategy (2007) specifically notes the impact of HIV on the biggest economy on the African continent. Dialogue with the South African government, which has significantly expanded on HIV-TB and health- related issues recently, offers good opportunities for more Bank involvement. The Bank is exploring how it can play a constructive role in responding to HIV/ AIDS, TB and health sector needs, whether directly or through mainstreaming in Bank-supported prod- ucts, analytical work, and subregional efforts. In ad- dition to HIV- and TB-specific lending, all health and other relevant Bank-funded projects in the SACU countries will seek to integrate HIV and TB (see annex 4). 19 This strategies mentioned in this paragraph can be found at http://go.worldbank.org/CIUL1PYIB0. 20 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Despite the Bank’s constraints in supporting the ♦ Assistance in developing and costing national IBRD SACU countries, much has been achieved AIDS strategies and action plans through innovative approaches. Stand-alone lend- ♦ Communication strategies ing has been provided to Lesotho through a $5 mil- ♦ Review of antenatal clinic surveillance method- lion20 IDA grant for HIV/AIDS capacity building and technical assistance. A $50 million IBRD HIV/ ology AIDS–TB operation in Botswana, with buy-down ♦ Impact of HIV on people with disabilities parallel financing from the European Commission ♦ Understanding how and through whom HIV is (EC), is the first such operation in an IBRD coun- being transmitted (the main groups and behav- try. A similar approach has been adopted for Swazi- iors driving the epidemic). land, where a project on health, HIV, and TB is un- An analysis of the HIV impact on the banking and der preparation. Projects in key sectors—transport, nonbanking sectors in Namibia (for example, insur- energy, water, and education—have included HIV/ ance schemes, health insurance and pensions) sup- AIDS in the workplace, and surrounding community ported by the Bank is the first such study in southern subcomponents have mainstreamed HIV into their Africa and was conducted at the request of the Bank operations, either as specific components or interwo- of Namibia. While these important pieces of analyti- ven in activities. cal work contributed to the overall research agenda, A stand-alone rapid response facility (fiscal years were of the highest quality, and were appreciated by 2004–2006) was extended to support Swaziland. This both governments and partners, the fact that they was the first such experimental approach within the were completed without a concrete, focused, jointly Bank and proved to be an effective way to urgently developed framework makes the whole of Bank ana- respond to country demand and engage with devel- lytical work in the field appear a lot less than the sum opment partners, who have greatly appreciated the of its parts. timely assistance. This flexible approach allowed the In addition, grant funding was mobilized through Bank to demonstrate its commitment to the most the Institutional Development Fund (IDF) to pro- affected region in the world and provide technical vide assistance to Swaziland and Namibia. In Swa- support, mostly for analytical work, not only to Swa- ziland, the project helped develop the HIV M&E ziland, but also to other SACU countries. system, a critical factor in Swaziland obtaining Analytical support, usually in response to specific GFATM financing. The IDF project was the be- requests from governments and the nongovernment ginning of a valuable partnership not only with the sector, has been provided to all SACU countries in a national AIDS coordinating agency (NERCHA), range of areas including, but not limited to: but across the human development and social sec- tors, with M&E as one of the Bank’s main areas of ♦ Macroeconomic and fiscal sustainability support to Swaziland. A JSDF grant has also been ♦ Socioeconomic impacts approved for Swaziland to build capacity for deliver- ♦ Health information management systems ing maternal-child health care to vulnerable popu- ♦ The private sector response to the HIV epidemic lations. Namibia’s IDF grant piloted an HIV/AIDS public-private partnership approach, which was a ♦ Financing modes, such as conditional cash trans- cornerstone in bringing together various stakehold- fers for OVC ers involved in providing services and advocacy. The 20 All dollars are U.S. dollars unless otherwise noted. project was hailed by government as the “pioneering� for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 21 of the concept that has demonstrated the benefits Against AIDS Initiative has been to advise IFC of public-private partnership well beyond the HIV- clients and their implementation partners on effec- specific agenda and programs. tively developing and implementing HIV/AIDS, TB, malaria and community health programs and A Development Marketplace competition21 for small on mobilizing resources to improve people’s health HIV grants in the SACU countries provided seed and protect profitability. One objective is to accel- money to implement innovative ideas and also fos- erate private sector involvement in national efforts tered regional exchange and support through follow- and mitigate the effects of communicable diseases up meetings. The competition developed a network on the sustainability of communities and companies. of nongovernmental organizations (NGOs) that has IFC has been involved in the mining and agricul- been maintained through Bank follow-up facilita- tural sectors in South Africa, helping with workplace tion and events. In addition, the Bank has initiated programs for employees and disadvantaged commu- an HIV development-dialogue series sponsored by nities directly linked to the IFC clients. Hernic Fer- learning institutions at the Bank’s Development In- rochrome (Pty) Limited, the world’s fourth largest formation Centers, which are now open in all SACU producer of ferrochrome, is based in South Africa countries. The first event in the series, jointly orga- and worked with the IFC Against AIDS Initiative nized in Lesotho by the Bank and the University of to develop an HIV/AIDS policy and action plan in Lesotho, attracted a large and diverse audience, in- 2005 after collaboration was initiated in 2004. IFC cluding the First Lady of Lesotho. A list of com- joint work with IDA in Lesotho on public-private pleted and ongoing activities is found in annex 3. partnerships in health has been positive and has trig- Capacity building has included hands-on training to gered interest in other countries.22 design impact evaluations and a workshop in which Overall, with the limited resources available for marginalized high-risk groups and program manag- IBRD countries, the World Bank Group has provid- ers worked together to identify ways to improve pro- ed substantial assistance through innovative meth- grams and grant assistance to civil society organiza- ods, working closely with development partners in tions for service delivery improvements. the subregion, using every opportunity to build rela- Collaboration with key partners through joint plan- tionships and extend services to the SACU countries ning and implementation has included working with to the extent possible based on demand from govern- partners and governments to harmonize fiduciary ments and the nongovernment sectors. and M&E systems, and advocacy for critical priori- ties, such as prevention for key populations at higher risk. HIV M&E systems building, with hands-on support to Lesotho, Namibia, South Africa, and Swaziland, has been provided by GHAP, with fund- ing from UNAIDS. The International Finance Corporation (IFC) has played a strong role in catalyzing private sector HIV/ AIDS efforts. The strategic purpose of the IFC 21 The competition awarded 24 grants in the five SACU coun- tries; the funding of over $400,000 was from IBRD, IFC, and the 22 United States Agency for International Development. Lesotho New National Referral Hospital PPP project. 22 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 ♦ Delivering effective results through better M&E Southern Africa HIV/AIDS and ♦ Improving donor harmonization. Tuberculosis Plan of Action, While there is a large menu of options, the Bank’s 2010–2011 future support will be focused primarily on demand- driven analytical work, technical support, and knowl- edge-sharing, including capacity building, consistent with its role as a “knowledge bank,� and capitalizing While Bank engagement has been relatively limited, on its experience across the region and globally. The SACU countries have recently expressed a clear de- Bank’s provision of high quality analytical work, in- mand for the Bank’s global knowledge, experience, cluding economic analysis, impact evaluation, and and policy advice on the overall development agenda, systems strengthening, is highly regarded by its part- which integrates HIV and TB. The Bank has ad- ners and client countries. While the Bank’s financial opted a multisectoral approach to dealing with HIV contribution is minimal, it is seen as an important and HIV-related diseases, which includes main- and valued partner, leveraging resources and pro- streaming HIV support into Bank operations. The viding analytical and technical support that have analytical work carried out in the SACU countries contributed to the development agenda, supported has been greatly appreciated by country counterparts national programs, and brought the HIV and TB and development partners and has provided solid epidemics to the attention of high-level government foundations for preparing HIV projects in Lesotho, officials. With respect to stand-alone lending, much Botswana, and Swaziland. Analytical support and will depend on the gaps not filled by other donors technical assistance are seen as the most important or governments, the receptivity of the IBRD coun- Bank contributions to the national and regional HIV tries to available Bank financing, and/or partner and TB programs. willingness to provide parallel or buy-down financ- ing. Mainstreaming HIV and TB into other lending The strategic objective of this action plan is to sup- operations will depend on the sector units preparing port the southern African MICs in reaching MDG- such products and incorporating suitable activities. 6 (reversing HIV and TB by 2015). In line with The Bank will seek to focus on providing strategic the Bank’s Africa Region HIV/AIDS Agenda for advice to assist countries make their programs more Action (AFA), this SACU action plan will seek to efficient and effective by applying a combination of strengthen the long-term, prioritized, sustainable products and further seeking innovative financing response; build stronger national systems to manage (figure 8). More details on the specific proposed ac- the response effectively and efficiently; and strength- tivities are contained in annex 5. en coordination. This will be achieved through the strategic AFA pillars: Analytical Support ♦ Focusing the response through evidence- informed and prioritized HIV and TB strategies In line with the Bank’s knowledge agenda and ca- ♦ Scaling up effective multisectoral and civil pabilities, analytical work requested from SACU responses countries will be the mainstay of the Bank’s efforts. Two to three major analytical pieces will be deliv- ered per year, designed to contribute to policy mak- for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 23 ing, including political economy aspects.23 Countries for risk reduction. As part of this study, a technical have expressed specific interest in analyses of the fis- group will consider good practices in HIV/TB inter- cal implications of scaling up HIV and TB efforts. ventions in worker-based populations, with special Substantial resources have been allocated to provide reference to the mining sector. The Bank has estab- treatment, and in Botswana and Namibia, national lished a positive relationship with the South Afri- targets have been met. Discussions reveal significant can National Institute for Occupational Health and concerns about the financial sustainability of treat- will explore opportunities to jointly work on issues ment, reduced donor contributions to fund treatment related to services, challenges, and opportunities for costs, and the impact on health sector budgets into ex-miners (HIV positive or affected by HIV) and the future. The need to analyze the sustainability of their families after they leave the sector and return to antiretroviral therapy programs in light of the poten- inadequate health systems. tial for greater demand is a priority for all countries The Bank, along with other partners and client in this subregion. Analysis has already started for countries, has conducted studies on the prevention Botswana and South Africa, and Swaziland, which response and transmission modes in Lesotho and will provide governments with a clearer picture of Swaziland and is analyzing how prevention could how HIV/AIDS is impinging on the governments’ be better targeted and more effective in changing or fiscal space and capacity to achieve broader devel- mitigating the risk behaviors that cause most new opment and program objectives and inform deci- infections. A similar study is being carried out in sion makers on the implications of policy choices. In South Africa as part of the mid-term review of the South Africa, the fiscal space work will link with the national strategic plan for HIV and STIs. The goal is AIDS 2031 costing component already underway.24 to improve prevention, which is critically important Data from the national AIDS spending assessments in all SACU countries, particularly in South Africa, (NASA) being conducted in all SACU countries and because of its large antiretroviral therapy program. information from the epidemiology and response The Bank will continue working with UNAIDS and synthesis reports will provide the basis for looking at strive to deliver the synthesis work in South Africa allocation efficiencies and effectiveness of HIV and during 2010, as well as a regional synthesis report to TB programs. distill key messages across the subregion. A clear understanding of the HIV epidemic and A study on HIV and disabilities was conducted for response is even more critical in the context of un- South Africa as part of a three-country comparison, certain long-term funding. A proposed study on the and will be disseminated in 2010. Swaziland has re- cross-border spread of HIV and TB via the mining quested a similar study to provide increased under- and transport sectors and associated costs will review standing of the challenges facing people with dis- and distill evidence on the impact of the co-epidemic abilities and to assist in the national policy dialogue. and stimulate a dialogue on coordinated approaches In addition, the Bank is also looking into the impact 23 The Independent Evaluation Group report, Improving Effec- of HIV/TB on the social safety nets in the SACU tiveness and Outcomes for the Poor in Health, Nutrition, and Population (World Bank 2009c), provides useful lessons for countries and will undertake a rapid assessment, spe- assessing the political economy, particularly in IBRD countries. cifically in Botswana and Swaziland, as part of the 24 This work on future HIV/AIDS financing and program costs ongoing project supervision and project preparation covers many countries and is being conducted by expert teams work respectively, but also in Namibia and South Af- coordinated by the Results for Development Institute (http:// www.resultsfordevelopment.org/projects/aids2031-costs-and- rica, should there be interest. Working with partners, financing-working-group). the Bank can contribute to the analysis of a range 24 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Figure 8 Bank Strategic Approach to Providing Support Source: Authors. of issues to help countries consider the immediate interventions through strengthening institutional and longer-term implications of their national HIV management and coordination capacity, financing responses and options. Possible areas of analysis in- strategic and innovative prevention and mitigation clude: labor mobility and policy, social mapping, activities, and integrating HIV/TB services to con- gender assessments, sustainability of drug financing, tain proliferation of the dual epidemic. The Swazi- fiduciary management, medical supply chains, assess- land operation is following the same approach of ing the potential and implications of pooled procure- parallel donor financing to strengthen the capacity of ment, and addressing vulnerable groups, including the health and social sector to mitigate the impact of people with disabilities. the HIV epidemic. In addition, the Bank has devel- oped a grant-financed ( JSDF) project for providing integrated sexual and reproductive health and HIV Lending Operations and Mainstreaming services to young women through a mobile clinic, Currently, the Bank has HIV- and TB-specific along with health education, life skills, and leader- projects under implementation and preparation in ship training. In Lesotho, the Bank has prepared a three SACU countries: Botswana, Swaziland and new HIV/AIDS technical assistance project to build Lesotho. In Botswana, the Bank approved its first the capacity of government agencies and civil society IBRD HIV/AIDS operation in Africa in 2008. The organizations at the national and local level to sup- project aims to assist the government of Botswana port the implementation of the national HIV and to increase the coverage, efficiency, and sustainabil- AIDS strategic plan and expand coverage of effective ity of targeted and evidence-informed HIV/AIDS interventions in an effort to contain and reverse the for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 25 epidemic. The projects in all three countries address the work already underway in several countries by the critical issues of health system strengthening and the World Bank Global HIV/AIDS Monitoring the integration of the HIV and TB responses. In and Evaluation Team (GAMET), Development addition, all Bank projects in the transport, energy, Economics Vice Presidency (DEC), and the Impact water, and education sectors have incorporated HIV Evaluation Initiative. Working closely with partners, components or activities. regional training on building decentralized M&E systems will be carried out in the next two years. An Additional funding will be provided through IDF institutional assessment of the HIV structures will be funds. A regional project has already been approved completed in Lesotho at the request of the govern- to strengthen health systems and will focus on build- ment, which will complement the recently finalized ing capacity in TB epidemiology in Botswana, Le- mid-term review of the national strategic plan and sotho, Namibia, and Swaziland by working with the provide a clearer picture of coordination and man- South African Medical Research Council, which has agement mechanisms currently in place, and how the only supranational TB reference laboratory in they could be streamlined and improved. Africa. IDF proposals on further M&E strengthen- ing will be considered depending on demand from the countries. Regional Activities Regional activities will promote cross-country learn- Technical Assistance ing and capacity building within the SACU coun- tries, and beyond, with a major focus on the trans- The primary focus of technical assistance is on im- fer of experience and knowledge among the smaller proving HIV prevention. Following the multicoun- SACU countries, which face many similar challenges try workshop on vulnerable and most-at-risk popu- and have opportunities for productive cross-fertiliza- lations, which all SACU countries (except Namibia) tion. The Bank is also supporting the newly formed participated in, the Bank will support countries in Champions for an HIV-Free Generation Initiative, a developing national action plans for evidence-based proposal of the former president of Botswana, which responses targeting neglected populations, and will is an emerging instrument for mobilizing regional continue to support HIV stigma reduction activi- leadership to address common issues and for pro- ties. Building on the impact assessment training that viding support to strengthen political commitment provided countries with a set of tools and practical across the region. The initiative is supported by the exercises on how to better assess the results of various Gates Foundation, UNAIDS, PEPFAR, the United interventions, evaluation of results will continue to Nations Childrens Fund (UNICEF), GFATM, and be emphasized in Bank support. the Bank. The Champions visited Namibia in June A critically important factor for improving preven- 2009, and South Africa in early 2010. This interac- tion is the reduction of multiple concurrent partners tion at the highest political level could help the new (MCP). Work is underway to develop more accurate players in South Africa who are responsible for the ways of measuring MCP behaviors, and technical response to HIV and TB to gain momentum and support for the evaluations of MCP programs will support. be carried out in three SACU countries. All coun- The Bank is also seeking to expand its collaboration tries have indicated the need for improved M&E and with the SADC Secretariat with respect to financial impact assessments, which will be addressed through sustainability in light of the global economic crisis. 26 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 SACU countries will continue to benefit from all and activities; and contributing to efforts support- regional knowledge-sharing activities, including the ing national and regional strategies. In addition, the development-dialogue series and training activities Bank will continue to work with national and inter- provided for IDA countries in the SADC, the Africa national organizations involved in research such as region, and globally. the South African Human Science Research Council (HSRC), the Desmond Tutu HIV Foundation, and universities. Working with Partners in the Subregion This SACU action plan is aligned with the new While other development partners provide greater UNAIDS “Joint Action for Results 2009–2011�27 funding, the Bank is recognized as being well po- approach and the Paris Declaration on Aid Effec- sitioned to assist in making the money work. The tiveness.28 Following the historic commitment of the Bank has made considerable efforts throughout the United Nations in 2006 to achieving universal access years to engage with partners, and has strengthened for HIV prevention, treatment, and support for those its dialogue with governments and major players and in need, the new UNAIDS Outcomes Framework funders in this subregion. Stronger linkages with (UNAIDS 2009) outlines nine priority areas, includ- key partners,25 within and between SACU countries, ing the need for an integrated approach to HIV and should focus on pooling technical and financial re- TB. The Outcomes Framework also calls for main- sources and working within each agency’s compara- streaming HIV and working jointly under the UN- tive advantage(s). Working closely with other devel- AIDS Unified Budget and Workplan. Specific joint opment partners is essential, especially in countries activities will be coordinated and carried out with the where the Bank has yet to have a physical presence. UNAIDS Regional Team for Eastern and Southern The World Bank Group, including the IFC, has pos- Africa and all country teams. The SACU action plan itive relationships with major partners working on 2010–2011 is consistent with the Paris Declaration HIV, namely the UN family, the European Commis- on Aid Effectiveness, and in implementing the ac- sion, the United Kingdom (DfID), the United States tion plan, the Bank has specifically focused on areas (PEPFAR, USAID, and the Centers for Disease that will complement and build on work already un- Control and Prevention), and the Gates and Clinton derway. Foundations, and will continue to develop concrete partnerships to avoid duplication, coordinate efforts, The Bank will continue to explore options for work- and leverage resources. Through the preparation of ing with the nongovernment sector (both for-profit this action plan, the Bank has informally consulted and not-for-profit groups), including public-private the countries and development partners; is regularly partnerships. The highly successful regional Devel- informing them of the proposed and ongoing Bank work and providing inputs to strategic documents as in Johannesburg); the 2031 financing pilot in South Africa; and more. requested; participating in various partnership fora26 27 http://data.unaids.org/pub/Report/2009/jc1713_joint_ 25 action_en.pdf. The Bank is a member of the UN Thematic Group on HIV/ 28 The Paris Declaration is an international agreement to which AIDS in South Africa and Lesotho. 26 over 100 ministers, heads of agencies and other senior offi- The Bank is a member of several country-specific and regional cials adhere to and committed their countries and organizations consultative groups, such as the EU+ Health and HIV/TB Devel- to continue  to increase efforts in harmonization, alignment and opment Partners Consultative Group; the Department of Health managing aid for results with a set of monitorable actions and Partners Forum in South Africa; the joint UN teams on HIV; indicators (http://www.adb.org/media/articles/2005/7033_inter- the Eastern and Southern Africa Regional UNAIDS Team (based national_community_aid/paris_declaration.pdf ). for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 27 opment Marketplace29 could be repeated and the impact further reinforced by expanding the network Conclusion group that emerged from the first competition. Civil society practitioners in the SACU countries are a major driving force in providing services and pro- moting behavior change at the grassroots level, and Bank intervention in the SACU countries is contin- work can be channeled through NGOs, particularly gent on the commitment of the respective govern- for addressing the problems of marginalized popula- ments to interact and work collaboratively with the tions and scaling up prevention efforts.30 Positive re- Bank. The Independent Evaluation Group (IEG; lationships already established with corporations (for World Bank 2009c) reviewed the objectives of the example, Anglo American) and business coalitions Africa Multi-Country AIDS Program (MAP), the (including the Pan-Africa HIV/AIDS Business Co- assumptions underlying the rationale, the validity of alition) should be sustained and expanded. the assumptions, followed by an assessment of the program’s design and risks. One of the main conclu- sions was that lack of political commitment was the most important constraint to action—not only in Africa, but in all developing regions. While the SACU countries (except for Lesotho) have not benefited from MAP, the lessons identified by the IEG report are important in terms of the risks associated with Bank engagement in the subregion with the highest co-epidemic. Given the chang- ing conditions, including the landmark speech31 of South Africa’s President Jacob Zuma calling for an end to denialism, there is a clear, growing demand from the SACU countries for Bank engagement to help address HIV/AIDS, TB and health systems is- sues. Also, there is an opportunity for the Bank to have significant subregional impact in the part of the world most affected by the HIV-TB co-epidemic. Beyond the buy-down operation in Botswana, the Bank runs the risk of not having the appropriate financing instruments to assist MICs in southern 29 A network of SACU countries’ NGOs was informally estab- Africa, and funding the proposed programs will de- lished during the Development Marketplace competition event in pend on sufficient allocation of internal resources for 2004 and has been maintained through Bank facilitation (follow analytical and technical support and on grant donors’ up in Namibia in 2005; Africa-wide youth consultations on the willingness to make financing packages attractive to Africa action plan, Johannesburg, 2006; and youth HIV preven- tion event, Johannesburg 2008). the IBRD countries, especially for HIV and TB sup- 30 Examples where working with NGOs is especially valuable port. The Bank is exploring options for mobilizing include the consultation on vulnerable and neglected groups; 31 work involving people with disabilities; protection of orphans; and South African President Zuma’s speech, October 2009, http:// M&E and impact assessments. www.thepresidency.gov.za. 28 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 trust funds and parallel financing. Implementation of the proposed programs hinges on making fund- ing available, ensuring the capacity to deliver, and focused, intensive dialogue and good project supervi- sion on the Bank side. On the government side, own- ership and a clear indication of where they want the Bank’s inputs will be critical in focusing the limited resources. Working with other development partners will be essential to making the money work. To en- sure a clear understanding of its role and engagement in the subregion, the Bank will develop a communi- cations and dissemination strategy to inform Bank in- ternal audiences and partners in the government and nongovernment sectors as well as the development partners of the proposed approach and activities. for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 29 Annexes 30 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Unlike HIV, TB is a notifiable disease. TB incidence Annex 1. Country Briefs has increased rapidly from 110,000 new cases per year in 1990 to 460,000 new cases per year in 2007, and South Africa ranks fourth in the world in terms of number of cases. It also has the greatest share of HIV-positive TB cases, accounting for 24 percent of South Africa the global total. TB has become the most common notified natural cause of death in South Africa, and South Africa faces a huge health sector challenge the yearly TB mortality rate increased almost three- due to explosive HIV and TB epidemics, a high fold from 1990 to 2006 (Lancet 2009). burden of chronic diseases, and a “silent epidemic� of maternal, neonatal, and child mortality. Accord- Outbreaks of drug-resistant (MDR and XDR) TB ing to a recently published study (Lancet 2009), complete the scenario of a perfect storm. For ev- South Africa’s per capita health burden is the high- ery 100 infectious TB patients in South Africa, est of any MIC in the world, with the brunt borne only 58 are currently being found and cured by the by the poorest families. With only 0.7 percent of health system. Collaborative activities to address the world’s population, South Africa has 17 percent co-epidemic have far to go; for example, in 2006, of the world’s HIV cases and a closely linked TB only one-third of TB patients were tested for HIV epidemic that has more than doubled since 2001. (WHO 2008). Up-to-date incidence and prevalence An estimated 5.7 million South Africans currently estimates of drug-resistant TB are lacking, although live with HIV (figure A1.1)—more than any other surrounding countries have confirmed MDR- and country in the world. South Africa is currently im- XDR-TB in their citizens, infections that were ac- plementing the largest antiretroviral therapy treat- quired while working in the mining industry in ment program in the world (Shisana et al. 2009; South Africa. TB drug resistance is a deadly com- South Africa DOH 2008; USAID 2008). HIV modity imported and exported through migrant la- incidence data from 2008 among the 15–20 years bor in the subregion. age group shows a promising decline of nearly 50 The poor are particularly vulnerable to the co-epi- percent compared to 2002 and 2005, however, age demic, which has considerably strained the health at first sex has not changed for those aged 15–24 system and caused a range of health indicators to years (Shisana et al. 2009). HIV prevalence among decline: South Africa is 1 of only 12 countries in young women is four times higher than in men aged which mortality rates for children have increased 15–24 years, estimated at 16.9 percent and 4.4 per- since the baseline for the MDGs in 1990 (Lancet cent respectively (WHO, UNAIDS, and UNICEF 2009). South Africa has made significant strides in 2008). HIV prevalence in older age groups has sig- focusing on the epidemic and addressing the crisis, nificantly increased. Since the antiretroviral treat- including numerous policies and legislative changes ment program launch in 2004, more than 700,000 and increases in social grants and primary health adults and children have been enrolled in public care services, but much remains to be done in ad- sector programs alone. The success of the massive dressing the co-epidemic. The HIV/AIDS and STI roll-out is contingent on uninterrupted drug sup- National Strategic Plan (2007–2011) spells out the plies and careful monitoring of patients, which are multisectoral response to HIV that is managed at currently major challenges. different levels in government and nongovernment for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 31 Figure A1.1 South Africa: HIV Prevalence and Number of PLHIV, 1990–2007 Source: South Africa Epidemiological Fact Sheet, WHO, UNAIDS, and UNICEF (2008), http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/ EFS2008_ZA.pdf.. sectors. The Tuberculosis Strategic Plan for South to ensure the care, socialization, and protection of Africa (2007–2011) similarly identifies deficiencies these OVC. Thus the sustainability of the antiret- and the approach to dealing with the disease. How- roviral therapy program is of critical importance to ever, implementation lags, investments have not the country for protecting human capital and eco- shown strong enough results, and the pressure on nomic growth and mitigating the HIV impact on the health system is enormous, especially at district development. The 2010 budget recently presented level. to Parliament allocated more than ZAR 8 billion (over US$1 billion) for HIV programs. The budget The biggest challenges are human resources, alloca- provides for the number of people on antiretroviral tion and efficiency of services, and the need for an therapy to rise to 2.1 million in 2012/2013.32 aggressive campaign for HIV prevention and TB detection and treatment. HIV poses a great threat With the revived South African National AIDS to the economy; analysis (BER 2006) suggests that Council (SANAC), the country is well positioned GDP growth could be 0.5 percentage points lower to reverse the national and regional trend and con- on average per year over the period 2000–2020 tinue its role as a leader and center for research and compared to a no-AIDS scenario, and that anti- capacity building for the continent. In his speech to retroviral therapy coverage of 50 percent could re- Parliament,33 South Africa’s President Zuma empha- duce this impact by 17 percent to 0.4 percentage sized the significance of urgently addressing the HIV points. The same study projects the number of or- and TB epidemics: phans to increase to 2.3 million in 2010, which will put further pressure on the public system to pro- 32 As quoted in the Financial Mail, February 19, 2010. vide foster care grants and on community systems 33 President Zuma’s speech to South African Parliament, October 29, 2009. 32 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 We must not lose sight of the key targets that (15–24 years old) in 2004 was 5.8 percent for men we set ourselves in our national strategic plan. and 18.2 percent for women (WHO, UNAIDS, These include the reduction of the rate of new and UNICEF 2008). Government finances approxi- infections by 50 percent, and the extension of mately 90 percent of the national response to HIV/ the antiretroviral program to 80 percent of AIDS in Botswana, including treatment with over those who need it, both by 2011. Prevention 80 percent coverage, achieving a five-year survival remains a critical part of our strategy. We need rate of 88.6 percent for people receiving antiretrovi- a massive change in behavior and attitude es- ral therapy (Botswana MOH 2007). pecially amongst the youth. We must all work In terms of TB, for every 100 infectious TB cases in together to achieve this goal. Botswana, only 41 are being found and cured by the health system. Case detection is 57 percent (WHO Botswana 2009), which lags behind the global target of 70 per- cent. An estimated 67 percent of new TB patients are The latest results from Botswana’s AIDS Impact HIV positive and 38 percent of AIDS-related deaths Survey (Botswana CSO, NHL, NACA 2009) show a are due to TB. TB incidence has more than doubled national HIV prevalence of 17.4 percent, with wom- since 1990, from 307 to 731 per 100,000 people. en carrying the brunt with 20.4 percent prevalence MDR and XDR-TB continue to spread. compared to 14.2 percent in men. Average incidence is 2.9 percent for the country as a whole, but 8.73 Botswana’s HIV/AIDS program has been supported percent among women aged 25–30 years (nearly 9 by GFATM, PEPFAR, other bilaterals, the Gates percent of these women become infected each year, Foundation, and Merck, an international pharma- figure A1.2). HIV prevalence among young people ceutical company. However, even the combined lev- els of donor and government spending have not kept Figure A1.2 Botswana: HIV Prevalence and Number of PLHIV, 1990–2007 Source: Botswana, Epidemiological Fact Sheet, WHO, UNAIDS, and UNICEF (2008), http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/ EFS2008_BW.pdf.. for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 33 pace with the rising cost of the response to the epi- mother-to-child transmission coverage increased rap- demic. Given the magnitude and long-term impact idly to 31 percent in 2007 (Lesotho National AIDS of the epidemic, the government is moving from an Commission, UNAIDS, and World Bank 2009). TB “emergency� response to a broader, more strategic, incidence has increased fourfold since 1990, when and more sustainable approach. A critical element for there were 2,945 new cases per year, to 12,782 cases success will be a massive prevention effort to bring in 2007. Of TB patients tested for HIV, 76 percent down the number of new infections. tested positive—the highest rate in the world (WHO 2009). The case detection rate (16 percent; WHO 2009) is appallingly low and lags significantly below Lesotho other countries in SACU, and indeed the world. For Adult prevalence in Lesotho in 2007 was estimated at every 100 infectious TB cases in Lesotho, only 11 are 23 percent, with nearly 300,000 HIV-positive people, being found and cured by the health system. and a prevalence of 6 percent for young men and 15.4 The country has placed a lot of emphasis on address- percent for young women in 2004 (WHO, UNAIDS, ing the HIV/AIDS epidemic through strong com- and UNICEF 2008). HIV prevalence in women aged munity involvement. HIV and TB programs are fi- 15–24 years appears to be falling, but was still increas- nanced primarily by grants from GFATM. The Bank ing between 2005 and 2007 in antenatal clinic cli- provided $5 million to support implementation of ents aged 30–40 years. In September 2008, coverage GFATM activities through the HIV/AIDS Capacity of antiretroviral therapy among those in need was at and Technical Assistance Project (HCTA), support- 45 percent (38,600 treated, 85,000 in need). The esti- ing capacity building for key functions of the national mated number of AIDS-related deaths has dropped AIDS council (NAC) and the Ministry of Health and sharply since its peak in 2005. Services to prevent Social Welfare, as well as civil society organizations. Figure A1.3 Lesotho: HIV Prevalence and Number of PLHIV, 1990–2007 Source: Lesotho Epidemiological Fact Sheet, WHO, UNAIDS, and UNICEF (2008), http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/ EFS2008_LS.pdf. 34 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Namibia tients are HIV positive (national average 59 percent, but as high as 72 percent in some districts), with The most recent sentinel survey conducted in 2008 most accessing appropriate HIV care and treatment, shows an overall prevalence of 17.8 percent among but not HIV prevention services.34 All government pregnant women, with some regions as high as 31.7 departments have developed strategies and allocated percent (Namibia MOHSS 2008c). Namibia is rec- resources for workplace programs, as is clearly speci- ognized for doing exceptionally well in rapidly ex- fied in the medium-term expenditure framework.35 panding its antiretroviral therapy program to 64,000 The private sector is also playing a vital role in the people—about 90 percent of those who needed AIDS response, and the Namibian Business Coali- treatment in 2009, and more than double the nation- tion against HIV/AIDS (NABCOA) is among the al plan target. Namibia recently conducted a study on most active in Africa. While fully committed to ad- the impact of AIDS, which projects that the number dressing the HIV epidemic, the country is still very of people needing antiretroviral therapy will increase dependent on external funding, which accounts for from 69,500 in 2008 to 114,500 in 2013 (Namibia half of the total according to the latest United Na- MOHSS 2008b). Namibia has the fourth highest tions General Assembly Special Session (UNGASS) TB incidence in the world after Swaziland, South report. PEPFAR is the largest donor and has in- Africa, and Djibouti. Since 1990, the incidence of creased funding tenfold in the past five years, to $109 TB has more than tripled, from 4,566 to 15,905 new million per year. cases per year in 2007. A high proportion of TB pa- Figure A1.4 Namibia: HIV Prevalence and Number of PLHIV, 1990–2007 Source: Namibia Epidemiological Fact Sheet, WHO, UNAIDS, and UNICEF (2008), http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/ 34 EFS2008_NA.pdf. Namibia External National TB Control Program Review, Exec- utive Summary, February 28, 2009. 35 Namibia Medium-Term Expenditure Framework for 2008/9– 2010/11, http://www.mof.gov.na. for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 35 Swaziland response is financed mainly through grants from GFATM, which has approved expenditures of nearly This small country of one million has among the $150 million for HIV, TB, and malaria programs. highest rates of HIV and TB in the world and is As a result of the socioeconomic situation and the struggling to address one of the worst co-epidemics HIV/AIDS epidemic, all children in Swaziland are in Africa. HIV prevalence is 26 percent among the potentially vulnerable, hence the National Plan of population aged 15–49 years, with infection rates Action (NPA) 2011–2015 for All Children (Swazi- higher among women (31 percent) than men (19 per- land 2009). While there are many ways of defining cent; Swaziland CSO 2007). HIV prevalence peaks and evaluating vulnerability, the NPA acknowledges at 49 percent for women aged 25–29 years, almost that communities themselves best define vulner- five times the rate among women aged 15–19 years ability. They know which children are vulnerable and more than double the rate among women aged and prioritize accordingly. In addition, the National 45–49 years. About 33,000 of the estimated 58,250 Children’s Policy (2008), recognizes that children or- people who needed treatment were on antiretroviral phaned and made vulnerable because of HIV/AIDS therapy by the end of 2008. are the most vulnerable population in Swaziland. The HIV epidemic has also given rise to a TB epi- The policy notes that these children are subjected demic in the country, with recorded new cases ris- to a wide range of social and economic difficulties: ing sixfold from 2,310 in 1990 to 13,674 in 2007. psychosocial distress, grief, stigma, discrimination, TB has become a major public health problem. It isolation, economic deprivation, loss of educational is estimated that over 80 percent of all people with opportunity, burdensome domestic responsibilities, TB also have HIV (WHO 2008). The case detec- and fear for their own future. The NPA 2011–2015 tion rate (55 percent) and cure rate (43 percent) are places these issues at the heart of its strategic agenda. below the international targets of 70 percent (detec- Currently, the trend shows that poverty and hun- tion) and 85 percent (treatment success rate); only ger are on the increase in Swaziland, in both rural 24 out of every 100 infectious TB cases in Swaziland and urban areas, with the number of people living are being detected and treated.36 Increasing rates of on food aid increasing from 210,000 in 2005–6 to drug resistance combined with inadequate labora- more than 400,000 in 2006–7. The World Food tory infrastructure remain major obstacles to tack- Programme (WFP) Crop and Food Supply Assess- ling the co-epidemic. This results in higher mortality ment Mission to Swaziland in 2007 observed that 21 and, combined with labor migration, will produce percent of the nation’s households are food insecure, negative population growth in the foreseeable fu- while 69 percent are living below the poverty line. ture. With staggering orphan numbers, the situation According to the Swazi Vulnerability Assessment in Swaziland is seen as a major demographic crisis Committee (2006), approximately 40 percent of the by the National Emergency Response Council on poor were not accessing sufficient food, with a fur- HIV/AIDS (NERCHA). Since inception in 2001, ther 40 percent receiving food aid. NERCHA has played a key role in the fight against HIV, against all odds, and with very limited capaci- “Child Poverty and Disparities in Swaziland� (UNI- ties in other government agencies and in the face of CEF 2009b) examines the demographic and socio- the most severe epidemic worldwide. Swaziland’s economic characteristic of Swazi children based on the Demographic and Health Survey, and for the 36 Based on the calculation: 100 cases V 57 percent (case detection) first time looks at the extent and distribution of se- V 42 percent (of those detected that are cured) = 24. 36 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 vere deprivations among this population group. The results show that 28 percent of children have two Annex 2. Recommended or more deprivations (education, health, nutrition, water and sanitation, shelter, and information), with Collaborative HIV-TB education strongly influencing severe deprivation, including household income and wealth. There are Activities and Targets wide disparities within and among the four regions, (WHO Interim Policy) and rural children are more likely to suffer two or more severe deprivations than urban children. The “Situation and Needs Assessment of Child-Headed Households in Drought Prone Areas of Swaziland� (UNICEF 2009a) provides for the first time system- A. Establish the mechanisms for collaboration atic findings on the needs and the plight of child- 1. Set up a coordinating body for HIV-TB ac- headed households, and confirms that these house- tivities effective at all levels holds are particularly vulnerable. Results show that most child-headed households do not fulfill the basic 2. Conduct surveillance of HIV prevalence needs such as food, shelter, water and sanitation, and among TB patients lack basic necessities, such as blankets, clothes, and 3. Carry out joint HIV-TB planning shoes. In addition, children from such households show emotional and behavioral problems. 4. Conduct M&E B. Decrease the burden of TB in PLHIV 1. Establish intensified TB case finding 2. Introduce isoniazid preventive therapy 3. Ensure TB infection control in health care and congregate settings C. Decrease the burden of HIV in TB patients 1. Provide HIV testing and counseling 2. Introduce HIV prevention methods 3. Introduce co-trimoxazole preventive therapy 4. Ensure HIV/AIDS care and support 5. Introduce antiretroviral therapy 2008 for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 37 Table A2.1 TB/HIV Targets Country Global plan Activity reports for target 2007 Number of PLHIV 630,000 actively screened 14,000,000 (4.5% of for TB target) Number of eligible 29,000 1,500,000 (1.9% of PLHIV offered IPT target) Number of TB 1,000,000 patients tested for 2,000,000 (50% of HIV target) Number of HIV-positive TB 90,000 patients started 300,000 (30% of on antiretroviral target) therapy Source: World Health Organization, Stop TB Department. 38 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Annex 3. Activities Completed and Ongoing Completed fiscal year (FY) 2005–10 Ongoing SACU subregion Development Marketplace (FY2005) SACU NACs consultation meeting (FY2005) Dissemination and presentation of key Bank HIV/AIDS–related documents Dissemination and presentation of key Bank HIV/AIDS–related documents (for example, MAP interim review, school health report, IEG report, and board response) HIV and disabilities study of three countries (South Africa, Uganda, and HIV and disability study of three countries (South Africa, Uganda, and Zambia), findings presentation workshop (FY2008) Zambia), publication, and dissemination WDR youth report (HIV-focused sections) consultations (FY07) Youth HIV prevention event organized by LoveLife (SACU countries + Kenya, FY2009) Africa region impact evaluation workshop (Botswana, Lesotho, South Africa, and Swaziland participation, FY2009) Vulnerable groups consultation (sexual minorities, such as MSM, com- mercial sex workers, and prisoners); Botswana, Lesotho, South Africa, and Swaziland participation (FY2009) Champions for an HIV-Free Generation Initiative, advocacy IDF project on TB laboratories: Botswana, Lesotho, Namibia, and South Africa Botswana Consultancy and technical assistance support for medium-term review of Fiscal implications of scaling up the HIV response (AAA) the national HIV strategy (FY2006–7) Multicountry voluntary counseling and testing study (DEC; FY2006–7) Multiple Concurrent Partnerships program evaluation—technical as- sistance Economic analysis of HIV/AIDS funding and resource flows (FY2008) HIV/AIDS IBRD buy-down, project preparation (FY2008) HIV/AIDS IBRD buy-down, supervision for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 39 Completed fiscal year (FY) 2005–10 Ongoing Lesotho Assessment of dual HIV and TB infection linkages within the national program (FY2006) Assessment of impact/coverage of young people (FY2007–8) Supervision of AIDS Implementation Support Grant HIV/AIDS Capacity and Technical Assistance Project (HCTA), closed HCTA-2 Project, preparation December 2008 Development dialogue on HIV/AIDS (FY2009), in cooperation with the University of Lesotho “HIV Prevention Response and Modes of Transmission Analysis,� joint World Evaluating the impact of community-based support interventions in Bank, UNAIDS, government study, March 2009 improving the sustainability of antiretrovirals Namibia Public-private partnership against AIDS, IDF project (FY2005–8) Study on the impact of HIV on banking sector (FY2007) Study on the impact of HIV on the nonbanking sector (FY2009–10) Assessment of the health sector in Namibia (FY2010–11) Technical assistance on the national review of the health sector in Namibia (FY2009) South Africa Conditional cash transfers for OVC pilot (FY2006–7) ARV Assessment in Free State University (DEC) FY2006–10 Fiscal implications of scaling up the HIV response (Analytic and Advisory Activities, AAA) Know-your-epidemic analysis—support for the Mid-Term Review of the National Strategic Plan for HIV and STIs Swaziland Conditional cash transfers, bringing back into the school system the Health and HIV project, preparation children orphaned by HIV/AIDS, technical assistance (FY2004–5) Private sector response to HIV, Royal Swazi Sugar Corporation and pulp JSDF—Delivering Maternal Child Health Care to Vulnerable Populations, factory case studies, economic sector work (FY2004–5) proposal preparation Communications strategy review, technical assistance (FY2005) Fiscal implications of scaling up the HIV response (AAA) Costing the HIV/AIDS national strategy—technical assistance (FY2006) Quality, Relevance, and Comprehensiveness of Impact Mitigation Services Survey (QIMS; AAA) 40 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Completed fiscal year (FY) 2005–10 Ongoing Health management information systems review (FY2006) AIDS and education assessment and dissemination (FY2007) Socioeconomic impact of HIV assessment (FY2007) Hospital assessment (FY2006–7) IDF, building M&E system and capacity supervision (FY2004–7) Assessment of medical referral schemes (Phalala and Civil Service; FY2008) Small grants HIV competition (FY2008) “HIV Prevention Response and Modes of Transmission Analysis,� joint World Bank, UNAIDS, and government study, March 2009 Source: Compiled by author. for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 41 Annex 4. World Bank Active and Pipeline Portfolios in the SACU Countries Active Portfolio as of March 2010 Fiscal Commitment Project year of amount Country ID Project title approval (US$ millions) Botswana P095617 Northern Botswana Human Wildlife Coexistence Project 2010 5.5 Botswana P102299 Botswana National HIV/AIDS Prevention Support Project 2009 50.0 Botswana P102368 Integrated Transport Project 2009 186.0 Botswana P112516 Botswana - Morupule B Generation and Transmission Project 2010 136.4 Lesotho P056418 Lesotho Water Sector Improvement Project 2005 14.1 Lesotho P075566 Lesotho Integrated Transport Project 2007 23.5 Lesotho P088544 Private Sector Competitiveness and Economic Diversification 2007 8.1 Lesotho P104403 Lesotho New Hospital PPP 2008 6.3 Lesotho P107375 Lesotho HIV and AIDS Technical Assistance Project 2010 5.0 Lesotho P108143 Water Sector Improvement APL Phase II: Metolong Dam and Water 2009 25.0 Supply Namibia P070885 Namibian Coast Conservation and Management Project 2006 4.9 Namibia P073135 Integrated Community-Based Ecosystem Management  2004 7.1 South Africa P064438 Greater Addo Elelephant National Park Project 2004 5.5 South Africa P073322 Renewable Energy Market Transformation  2007 6.0 South Africa P075997 C.A.P.E.: Biodiversity Conservation and Sustainable Development 2004 9.0 Project South Africa P086528 Development, Empowerment and Conservation in the Isimangaliso 2010 9.0 Wetland Park and Surrounding Region Project Source: World Bank Business Warehouse. Data also available on World Bank website: www.worldbank.org. 42 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Pipeline Portfolio in the SACU Countries as of March 2010 Total commitment Fiscal Bank amount year Country Project ID Project title approval date (US$ millions) 2010 Lesotho P112817 2nd Poverty Reduction Support Credit 3/30/2010 25.0 2010 Lesotho P119443 Lesotho Integrated Transport Project— 5/20/2010 15.0 Additional Financing  2010 Swaziland P095232 Local Government Project (SLGP) 5/28/2010 16.1 2010 Swaziland P110156 Swaziland Health, HIV/AIDS, and TB Project 5/27/2010 20.0 2010 South Africa P116410 Eskom Investment Support Project  4/8/2010 3,750.0 2011 Lesotho P114859 Lesotho Health Sector PPP Technical Support 7/13/2010 5.0 Project  2011 Lesotho P119432 Lesotho Smallholder Agriculture Development 6/15/2011 10.0 Program Source: World Bank Business Warehouse; data also available on World Bank Web site: www.worldbank.org. for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 43 Annex 5. Matrix for the Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Anticipated Strategic Objectives Specific actions Indicators Critical risks results partners AFA Pillar I Support for evidence-informed and prioritized HIV and TB strategies Analytical work Studies on drivers of the Two studies conducted in Improved evidence base Availability of Bank HNP and knowledge epidemic and transmission response to requests for response interven- technical and budget GHAP management modes tions support (Lesotho and Swaziland PREM completed), South Africa underway DEC Partners’ commit- ment WHO South Africa, Swaziland, and Stop TB Fiscal implications of scaling Botswana underway; and UNAIDS up antiretroviral therapy Namibia proposed Regional analysis of epi SACU countries Improved efficiency synthesis data, NASA, and and effectiveness of fiscal data analysis programs Effectiveness and efficiency SACU countries of HIV programs Study on cross-border One study on cross-border spread of HIV and TB (via spread of HIV and TB mining and transport sector) SACU countries consider and associated health coordinated approach to system costs HIV-TB response Continued on next page. 44 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Anticipated Strategic Objectives Specific actions Indicators Critical risks results partners Vulnerable group Support development of At least one country Evidence-informed Weak country UNAIDS studies national actions plans develops national plan responses developed commitment to Norwegian Agency (most-at-risk- as a follow-up to the for integrating vulnerable for most-at-risk work with vulner- for Development Co- populations) March 2009 Cape Town groups groups able groups and operation (NORAD) workshop deal with stigma UN Population Fund SWEAT (South Increase understanding, Assessment of HIV and African NGO) constraints, and possible disability conducted in national policy dialogue Better understanding UN one country—Swaziland of HIV and disabilities Development Pro- expressed interest gramme (UNDP) Study already completed Bonela (Botswana for South Africa NGO) D. Tutu Foundation AFA Pillar II Scale up targeted, multisectoral response (mainstreaming and lending operations) HIV/AIDS integra- Technical assistance to At least one key sector Increased commit- Insufficient sec- UNAIDS tion into priority support sectoral institu- effort supported with ment in key sectors toral commitment, DfID sectors tional capacity for HIV/ good practice or technical to include HIV/AIDS lack of clarity and (mainstreaming) AIDS in critical sectors, support in four countries and TB guidance from EC particularly education, government, and transport, energy, and insufficient budget urban development Botswana—Morupule B energy project; inte- grated transport project Lesotho—water project; transportation project Namibia—education sector project Swaziland—local government project for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 45 Anticipated Strategic Objectives Specific actions Indicators Critical risks results partners Lending operations Botswana—HIV project Project performance Improved prevention Slow disburse- EC indicators ment rates Lesotho—second capac- Improved financial UNAIDS ity building and technical Project performance and procurement Institutional UNAIDS assistance project indicators management arrangements and coordination GFATM Swaziland—health and Project performance Improved health HIV project indicators management sys- Capacity tems, including HIV constraints and EC institutional ar- rangements GFATM AFA Pillar III Systems strengthening: financial, supply chain, health, and M&E M&E capacity Training and capacity Lesotho, Namibia, Improved manage- GHAP building building for decentralized ment and decision- SADC M&E systems making capacity UNAIDS RST South Africa and GFATM IDF grant proposals Swaziland Impact assessment Integrate impact assess- Botswana—HIV project Better evidence- Impact evaluation, AFTRL ments in Bank projects informed approach staff working with Lesotho—HIV project, AFR Impact Evalua- impact assessment to HIV teams on develop- tion initiative ing appropriate Swaziland—impact system DEC evaluation and cost effectiveness Free State University South Africa—impact assessment of antiretro- Follow-up of Cape Town viral therapy program in workshop Free State University Design program/studies for Lesotho and South Africa Prevention policy MCP program evaluation Botswana, Namibia, and Improved knowledge Delicate nature of strengthening Swaziland on reducing risky dialogue behavior Continued on next page. 46 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Anticipated Strategic Objectives Specific actions Indicators Critical risks results partners Governance Assist in improving Botswana—HIV project Improved governance Delicate nature PREM (including. HIV) existing governance structures, demand of governance Botswana—Public Ex- HD and public sector structures, public sector for accountability, dialogue penditure Review (PER) management management, and trans- and performance AFTHV support parency mechanisms Lesotho—health PER UNAIDS through PER and institu- Lack of coordina- Swaziland—fiduciary Regional Support tional assessment as part tion among assessment Team (RST) of project preparation national AIDS Swaziland—finance authorities UNDP management, IDF Economies of scale DfID Examine options for Swaziland—local pooled procurement PEPFAR government project GFATM Concept for pooled procurement of HIV-TB Gates Foundation medication developed AFA Pillar IV Strengthen donor coordination and support to subregional and cross-border initiatives Collaboration and Collaboration with key At least one regional Better implementa- Willingness of GHAP harmonization partners to harmonize meeting annually with tion and division of partners to take UNAIDS and all with key partners financing, fiduciary, key partners labor common action other UN agencies M&E systems (including impact evaluation), and GFATM supply chains PEPFAR Gates Foundation Cooperation with SADC Meeting with SADC NAC DfID heads Review of the EC collaboration and funding from World SADC Secretariat Bank to SADC states and member states NACs Joint planning Conduct joint planning At least two joint UN- More effective and Difficulty in UNAIDS Regional and reviews with and operational and AIDS/GFATM/World Bank efficient allocation coordinating with AIDS Team for East- partners capacity building missions and partnership and utilization of other partners in ern and Southern fora resources countries where Africa Bank inputs in UN joint the Bank has no Joint UN Regional team work plans in all country offices or Team on AIDS countries a dedicated HIV-TB coordinator GFATM PEPFAR for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 47 Anticipated Strategic Objectives Specific actions Indicators Critical risks results partners Support for cross- Support in the design One cross-border project Improved recognition Lack of conces- Human Develop- border projects and financing of cross- that addresses critical and dealing with sional funding ment network border efforts gaps in national efforts HIV/AIDS and TB as a mechanisms for Transport sector multicountry public IBRD countries At least one regional TB health issue UNAIDS consultation cofinanced by World Bank DfID Shared TB good practice International documentation Organization for Migration SACU Policy dialogue on Analysis of cross-border Assessment of effective- Harmonized protocols No harmonized UNAIDS cross-border labor labor mobility ness of cross-border and procedures on approach to cross- DfID mobility health/HIV points treatment, care, and border issues support for HIV and TB mobile popula- tions Advocacy Support to the Cham- Visits to all SACU coun- Commitment of Complicated GHAP pions for an HIV-Free tries, planned visits: highest level of gov- coordination HD Vice President’s Generation Initiative Namibia—June 2009 ernment to scaling up Office Lesotho and Swazi- the response to HIV land—2010 Development dialogues UNAIDS via the Development Information Centers HIV development GFATM dialogue: Gates Foundation Lesotho—March 2009 PEPFAR Namibia—planned for 2009 48 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 Crush, J., V. Williams, and S. Peberdy. 2005. “Migra- References and Additional tion in Southern Africa.� Paper prepared for Sources the Policy Analysis and Research Programme of the Global Commission on International Migration, Geneva. http://www.gcim.org/ attachments/RS7.pdf Arbache, J. S. 2009. “Links between HIV/AIDS and Epstein, B. 2004. “The Demographic Impact of HIV/ Development.� In The Changing HIV/AIDS AIDS.� In The Macroeconomics of HIV/AIDS, Landscape, ed. E. Lule, R. Seifman, and A. ed. M. Haacker. Washington, DC: IMF. David. Washington, DC: World Bank. GFATM (Global Fund to Fight AIDS, Tubercu- Bell, C., S. Devarajan, and H. Gersbach. 2004. losis, and Malaria). 2005a. “Fifth Call for “Thinking about the Long-Run Economic Proposals.� Proposal request document, Costs of HIV/AIDS.� In The Macroeconomics Botswana. http://www.theglobalfund.org/ of HIV/AIDS, ed. Markus Haacker. Wash- grantdocuments/5BOTT_963_0_full.pdf ington, DC: IMF. ———. 2005b. “Lesotho’s Coordinated Proposal BER (Bureau for Economic Research). 2006. “The for Preventing the Spread and Mitigat- Macroeconomic Impact of HIV/AIDS ing the Impact of HIV/AIDS on Orphans under Alternative Intervention Scenarios and Vulnerable Children and Enhancing (with Specific Reference to ART) on the Community Involvement in TB Control.� South African Economy.� Bureau for Eco- Lesotho. http://www.theglobalfund.org/ nomic Research, University of Stellenbosch. grantdocuments/6LSOT_1359_0_full.pdf http://www.research4development.info/ Haacker, M. 2004. “HIV/AIDS: The Impact on the PDF/Articles/00010925.pdf Social Fabric and the Economy.� In The Mac- Booth, P. 2008. “Making Progress against AIDS: The roeconomics of HIV/AIDS, ed. M. Haacker. State of South Africa’s Response to HIV/ Washington, DC: IMF. AIDS and TB Epidemics.� Briefing pre- Hesseling, A. C., M. F. Cotton, T. Jennings, A. pared for SANAC. Whitelaw, L. F. Johnson, B. Eley, P. Roux, P. Botswana CSO, NHL, and NACA. 2009. “Botswana Godfrey-Faussett, and H. S. Schaaf. 2009. AIDS Impact Survey III� (BAIS III). Pre- “High Incidence of Tuberculosis among liminary results, Gaberone. www.cso.gov.bw HIV-Infected Infants: Evidence from a South African Population-Based Study Botswana MOH (Ministry of Health). 2007. 2007 Highlights the Need for Improved Tuber- Botswana ANC Second Generation HIV/AIDS culosis Control Strategies.� Clinical Infectious Sentinel Surveillance Technical Report. Diseases 48:108–14. http://www.journals. Clark, Samuel J., Mark Collinson, Kathleen Kahn, uchicago.edu/doi/full/10.1086/595012 et al. 2007. “Returning Home to Die: Cir- IMF (International Monetary Fund). 2009. Regional cular Labour Migration and Mortality in Economic Outlook, Sub-Saharan Africa: South Africa.� Scandinavian Journal of Public Weathering the Storm. Washington, DC: IMF. Health. http://sjp.sagepub.com/cgi/content/ refs/35/69_suppl/35 for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 49 Jochelson, K. 1999. “Sexually Transmitted Diseases in Swaziland. http://www.unaidsrstesa.org/ Nineteenth-and Twentieth-Century South files/u1/aziland_MoT_Country_Synthesis_ Africa.� In Histories of Sexually Transmit- Report_22Mar09.pdf ted Diseases and HIV/AIDS in Sub-Saharan Ofosu-Amaah, A. W., N. Egamberdi, and A. Dhar. Africa, by Philip Setel, Milton James Lewis, 2009. “Gender and HIV/AIDS.� In The Maryinez Lyons, chapter 10. Westport, CT: Changing HIV/AIDS Landscape, ed. E. Lule, Greenwood Press. R. Seifman, and A. David. Washington, DC: Lancet. 2009. “Health in South Africa.� August 25. World Bank. http://www.thelancet.com/series/health-in- Reddy, T., ed. 2007. A Lethal Cocktail: Exploring the south-africa Impact of Corruption on HIV/AIDS Preven- Laxminarayan, R., E. Klein, C. Dye, K. Floyd, S. tion and Treatment Efforts in South Africa. Darley, and O. Adeyi. 2007. “Economic Ben- Institute for Security Studies, Transparency efit of Tuberculosis Control.� World Bank International (Zimbabwe), Cape Town. Policy Research Working Paper 4295, World Rehle, T., O. Shisana, V. Pillay, K. Zuma, A. Puren, Bank, Washington, DC. and W. Parker. 2007. “National HIV Inci- Lesotho National AIDS Commission, UNAIDS dence Measures—New Insights into the ( Joint United Nations Programme on HIV/ South African Epidemic.� South African AIDS), and World Bank. 2009. “HIV Pre- Medical Journal 97: 194–99. http://www2. vention Response and Modes of HIV Trans- samj.org.za/index.php/samj/article/view- mission Analysis.� Lesotho National AIDS File/777/247 Commission, Maseru. http://www.unaid- SADC (Southern African Development Commu- srstesa.org/files/u1/Lesotho_MOTCoun- nity). 2006. Expert Think-Tank Meeting on try_Synthesis_Report_13April.pdf HIV Prevention in HIGH-Prevalence Coun- Namibia MOHSS (Ministry of Health and Social tries in Southern Africa, Maseru, Lesotho (May Services). 2008a. “Demographic and Health 10–12, 2006). Report, SADC publication, Survey, 2006–7.� Ministry of Health and SADC Secretariat, Gaberone, Botswana. Social Services, Macro International Inc, Serrao, Angelique. 2009. “’Worryingly’ High Rate of Windhoek and Calverton. Dropping of ARVs.� The Star November 30, ———. 2008b. Estimates and Projection of the Impact Pretoria. of HIV/AIDS in Namibia. June. Shisana, O., T. Rehle, L. C. Simbayi, et al. 2009. ———. 2008c. Report on the 2008 National HIV Sen- South African National HIV Prevalence, Inci- tinel Survey. MOHSS, Directorate of Special dence, Behavior and Communication Survey, Programs, Windhoek, Namibia. 2008: A Turning Tide Among Teenagers? NERCHA (National Emergency Response Coun- Cape Town: HSRC Press, MRC, CADRE, cil on HIV and AIDS), UNAIDS ( Joint NICD. http://www.hsrcpress.ac.za/product. United Nations Programme on HIV/ php?productid=2264&freedownload=1 AIDS), and World Bank. 2009. “HIV Pre- South Africa, Republic of. 2010. “Budget Review vention Response and Modes of HIV Trans- 2010.� National Treasury, February 17. mission Analysis.� NERCHA, Mbabane, http://www.treasury.gov.za 50 | Southern Africa HIV/AIDS and Tuberculosis Plan of Action, 2010–2011 South Africa DOH (Department of Health). 2007. Development. http://hdr.undp.org/en/media/ “HIV and AIDS and STI National Strategic HDR_2009_EN_Complete.pdf Plan for South Africa 2007–2011.� http:// UNICEF (United Nations Children’s Fund). 2008. www.doh.gov.za/docs/misc/stratplan-f.html State of the World’s Children 2009: Maternal ———. 2008. “The National HIV and Syphilis and Newborn Health. New York: UNICEF. Prevalence Survey 2007.� http://www.doh. ———. 2009a. “A Situation and Needs Assessment gov.za/docs/hivaids-progressrep.html of Child-Headed Households in Drought _____.2009. “Proposals for Improving ODA Coor- Prone Areas of Swaziland, Key Findings.� dination, Management and Resource Mobi- Save the Children, UNICEF, Swaziland. lization in Health in South Africa.� Final ———. 2009b. “Child Poverty and Disparities in draft, January. Swaziland, Key Findings.� UNICEF, Swa- Subbarao, K., and D. Coury. 2004. “Reaching Out ziland. to Africa’s Orphans: A Framework for Public World Bank. 2008a. The World Bank Group’s Role Action.� World Bank, Washington, DC. in Africa’s Middle-Income Countries: A Swaziland. 2009. “Revised National Plan of Action Plan of Action. (NPA) for Children—2011–2015.� First ———. 2008. The World Bank’s Commitment to HIV/ draft, National Children Coordination Unit, AIDS in Africa: Our Agenda for Action, 2007– Deputy Prime Minister’s Office, Swaziland, 2011. Washington, DC: World Bank. November, not published. ———. 2009a. Africa Development Indicators Swaziland CSO (Central Statistical Office). 2007. 2008/09: Youth and Employment in Africa; The “Demographic and Health Survey 2006–07.� Potential, the Problem, the Promise. Washing- Measure DHS, Macro International, Mba- ton DC: World Bank. bane and Calverton. http://www.safaids.net/ files/Swaziland percent20Demographic per- ———. 2009b. Averting a Human Crisis During the cent20and percent20Health percent20Sur- Global Downturn: Policy Options from the vey percent202006-2007.pdf World Bank’s Human Development Network. Washington, DC. UNAIDS ( Joint United Nations Programme on HIV/AIDS). 2007. “Sub-Saharan Africa ———. 2009c. Improving Effectiveness and Outcomes Factsheet.� Regional summary, WHO. http:// for the Poor in Health, Nutrition, and Popu- data.unaids.org/pub/FactSheet/2008/epi07_ lation: An Evaluation of World Bank Group fs_regionalsummary_subsafrica_en.pdf Support Since 1997. Washington, DC: World Bank, IEG. ———. 2008. Report on the Global AIDS Epidemic. Geneva. ———. 2009d. World Development Indicators, 2009. http://go.worldbank.org/6HAYAHG8H0 ———. 2009. UNAIDS Outlook Report 2010. Geneva. http://data.unaids.org/pub/Report/ WHO (World Health Organization). 2008. Global 2009/jc1796_outlook_en.pdf Tuberculosis Control—Surveillance, Plan- ning, Financing: WHO Report 2008. Geneva. UNDP (United Nations Development Programme). http://www.who.int/tb/publications/global_ 2009. Human Development Report 2009: report/2008/en/index.html Overcoming Barriers: Human Mobility and for Botswana, Lesotho, Namibia, South Africa, and Swaziland | 51 ———. 2009. Global Tuberculosis Control—Epide- miology, Strategy, Financing: WHO Report 2009. http://www.who.int/tb/publications/ global_report/2009/en/index.html WHO, UNAIDS ( Joint United Nations Pro- gramme on HIV/AIDS), and UNICEF (United Nations Childrens Fund). 2008. Towards Universal Access—Scaling up Priority HIV/AIDS Interventions in the Health Sector. Geneva. The World Bank AIDS Campaign Team for Africa - ACTafrica 1818 H St NW Washington, DC 20433 1 202 458 0606 actafrica@worldbank.org www.worldbank.org/afr/aids