37219 HIV/AIDS M&E - Getting Results These reports describe activities, challenges and lessons learned during the World Bank Global Global AIDS Monitoring and Evaluation Team's (GAMET) work with countries and other partners. HIV/AIDS Program Understanding the HIV/AIDS Epidemic in South Asia David Wilson and Mariam Claeson A new synthesis, analysis and discussion of existing New data and a growing number of biological and data on HIV and AIDS from South Asian countries behavioral studies in South Asia offer a basis for provides insights into what is driving the epidemic, understanding South Asia's epidemic better. However, what future trends might be, and where programs these data and studies had not been synthesized, need stronger emphasis. analyzed and interpreted in an integrated way. The HIV/AIDS in South Asia: Understanding and World Bank South Asia AIDS team asked a group of Responding to a Heterogeneous Epidemic. World researchers to (i) look carefully at the available data, and Bank, 2006 provide a state-of-the-art assessment of South Asia's HIV epidemic, its major transmission dynamics and potential evolution; and (ii) to propose a rigorously evidence-based, practical and appropriate HIV/AIDS response strategy for the region, highlighting the How will the HIV/AIDS epidemic unfold in South priorities that need greater emphasis. A consultative Asia? review process was used to review the draft report, solicit feedback from national and global experts, and In thinking about how to support effective national discuss and validate the analysis. HIV/AIDS responses in the countries of South Asia, an important starting place is a clear sense of the epidemic's pattern and trends. Three diverging views anticipate very different future trends in the epidemic in South Asia. The "wildfire" view warns that unless a lot more is done, fast, a generalized epidemic will ignite throughout most of South Asia, dramatically increasing the number of people infected. It argues that the HIV/AIDS epidemic is comparable to Africa's in size and potential and requires an immediate, all embracing response. At the other extreme, a complacent view expects the epidemic to remain limited in size and importance with modest increases in infections. The middle view sees many "bush fires", with South Asia facing significant but distinctive concentrated epidemics, requiring urgent action to prevent a many-fold increase in the number of infected people. The different views have implications for national responses and for Bank support. But which view is right? And how different or similar is the HIV situation in Pakistan, India, Bangladesh, Sri Lanka, Nepal, Afghanistan, the Maldives and Bhutan? Although there are some commonalities culturally across the region, there are enormous differences in size, socio-economic situation, and in their HIV epidemics. There is also The resulting report is a landmark study that is diversity within countries, especially in India, which has generating much discussion and informed debate. It has multiple, varied local epidemics rather than a single already begun to influence program decisions in national epidemic. countries in the region, and has the potential to lead to better results in preventing new infections. The study team was drawn from the University of insights into the epidemic. The availability of so much Manitoba (UM), Pakistan's National AIDS Program, more research and data from India made it difficult to Princeton University, and the Bank's South Asia region keep an even balance of attention in the study across and Global HIV/AIDS Program. The UM group had a 1 the countries. However, about 97 percent of all long standing African AIDS research program, as well as estimated HIV cases in this group of countries are in five years of work and research with colleagues in India India, so greater attention to India is warranted. (in Karnataka and Rajasthan), and a huge data base of hundreds of studies on HIV and AIDS in India. Their The report focuses mainly on Bangladesh, India, Nepal, local presence in India and professional contacts in Pakistan and Sri Lanka, which had adequate data for several other countries was a great asset, added to their analysis. Some comments are also offered on the strong technical, research and analytic experience. intriguing strands of information from Afghanistan, Together, the full team brought together expertise in Bhutan and the Maldives, but there are too few data for public health, clinical medicine, epidemiology, social an in-depth analysis in these countries. science, and HIV/AIDS program management. Team members brought complimentary perspectives of global 2. Next, synthesize the data, and try to experience and local expertise, analytic rigor and understand the epidemic patterns and trends pragmatism. In retrospect, it might have been useful also to include skills in behavioral science. The HIV epidemic in South Asia is severe: there are already more than five million infected people. However, Approach: 1. First, gather all existing data 99.6% of South Asians are uninfected, and further spread could be prevented. The first step was to visit each country to interview key informants ­ especially people working on surveillance The epidemic is most severe in India, particularly in a or implementing programs, and to gather all the existing cluster of southern and western states, and some data and information. Countries had widely varying northeastern states, although there are not enough data amounts of surveillance data, behavioral survey results, to characterize the situation in many areas, especially in anthropological and ethnographic data, and research on northern India (Figure 1). HIV prevalence varies greatly HIV/AIDS. between and within districts, and even across villages in the same areas. Female sex work is central to Pakistan was just beginning a second generation transmission dynamics in most areas, and mobility of surveillance program when the study began, and the sex workers and their clients helps spread the epidemic. team was able to use the results of the first of two Sex between men is probably a more important planned waves of integrated bio-behavioral surveillance, transmission factor than previously assessed. as well as results from mapping and estimating the size of the sex worker population in five Pakistani cities. Figure 1: HIV Prevalence at antenatal care sites, by district, India, 2005 Nepal began surveillance in 1991, but data collection has been badly disrupted. Current knowledge of Nepal's HIV situation comes mainly from a series of cross- sectional studies commissioned by donors. India, Bangladesh and Sri Lanka all have fairly well established surveillance systems. However, far more has been written about HIV in India than in any of the other countries, including a great deal of detailed research by the UM group in rural Karnataka. The UM group's mapping and statistical analysis of the data from Karnataka were carefully incorporated and gave good < 1.0% 1 The study team members were: Han Kang (Princeton 1.0%­1.5% University, USA); James F. Blanchard, Stephen Moses, 1.5%-2.0% Sushena Reza Paul, and Marissa Becker (University of Manitoba, Canada); Faran Emmanuel (National AIDS Control 2.0%-2.5% Program, Pakistan); David Wilson (Global HIV/AIDS Program, 2.5%-3.0% World Bank) and Mariam Claeson (South Asia Region, World >3.0% Bank). The study was initiated by Hnin Hnin Pye and Sandra Rosenhouse (World Bank). Helpful review comments were provided by Susan Stout, Joe Valadez, Olusoji Adeyi (World Source: NACO (India) 2005 Bank), Neff Walker (UNAIDS/UNICEF), Tim Brown (East West Center), Ruben del Prado, (UNAIDS), Shanti Conoly (USAID) and Ted Karpf (WHO). 2 The HIV epidemic may be as severe as in India in parts Figure 2: Coverage of interventions for high risk of Nepal, where transmission occurs largely through sex groups is very low in South East Asia work and injection drug use, and among the sexual partners of injecting drug users. Significant numbers of 100 both men and women have HIV, but the insurgency makes surveillance and response very difficult. 80 Pakistan and Bangladesh's epidemics are centered 60 among injecting drug users, and are expanding among men who have sex with men (MSM) and hijra2 40 communities. HIV infection among sex workers in 20 Pakistan and Bangladesh is still generally low, but there is substantial potential for the epidemic to grow among 0 sex workers and clients, especially among sex workers MSM IDU SW who inject drugs or whose sexual partners inject drugs. The high levels of male circumcision in both countries Source: USAID, UNAIDS, WHO, UNICEF and the Policy may curtail substantial heterosexual epidemics. Project, 2004. Coverage of selected services for HIV/AIDS prevention, care and support in low and middle income The data from Afghanistan indicate rapidly growing HIV countries in 2003. Available at www.FuturesGroup.com infection in the large population of injecting drug users, and especially where injection drug use and the sex Some of the other recommendations and specific trade intersect. Bhutan and the Maldives' epidemics are implications for programs: in an early phase, with relatively low potential. In Sri Lanka, HIV remains low even among high risk groups. Surveys document high levels of unsafe behavior such as sharing contaminated needles among IDUs, 3. Draw out the implications for programs and and instances of rapid, explosive spreading of HIV practical recommendations through injection drug use from negligible levels to 50% or higher prevalence in just a few years (Figure The analysis points to the need for a two pronged 3). Prevention programs among IDUs need to give approach to HIV prevention: (a) most important are more attention and resources to comprehensive effective large-scale programs for sex workers and harm reduction approaches, including needle clients, injecting drug users and their sexual partners, exchange and drug substitution. There is a short and men who have sex with men and their other sexual window of opportunity and a critical need for partners. (b) To support these programs, there need to concentrated prevention and treatment programs be widespread HIV prevention and stigma reduction among IDUs. The epidemic potential in Pakistan, campaigns for the general population and for individuals Bangladesh, Afghanistan, Nepal and north-eastern and groups who can facilitate or impede program India depends greatly on implementing effective implementation. harm reduction programs now. Programs could be more effective if they combine a Figure 3: HIV prevalence among injecting drug users laser focus on the highest prevalence areas and can rise sharply, very quickly communities, with expanded coverage nationwide. Wider coverage of adequate interventions would have 80 more impact than low coverage of perfect interventions ­ 70 small behavior change on a large scale has more effect 60 than large behavior change on a small scale. Figure 2 50 shows how low program coverage is among key groups. % 40 It is critical to scale up prevention programs among key 30 populations to "saturation" level, to reach as close to full coverage as possible. 20 10 0 Pakistan Katmandu, Nepal 2 Hijra see themselves as neither male nor female, most are Katmandu valley Pokhara, Nepal "born with a male body but with a feminine gender identity", Tamil Nadu, India and they dress and behave in feminine ways. (http://www.geocities.com/leylasuhagi/hijradef.html) Sources: National data 3 from Bangladesh, India, Nepal, Pakistan, Sri Lanka, and Surveillance needs to be expanded and further from many stakeholder organizations: National AIDS supported in all countries, especially to monitor managers, people living with AIDS, other government behaviors and HIV among high-risk groups, such as and NGO partners, researchers, UNAIDS, UNICEF, sex workers, IDUs and MSM. Expanded and more USAID, WHO and the World Bank. Given India's size comprehensive mapping at district level and below and complexity, one videoconference focused for the main risk groups would indicate the reach specifically on India, where the Global Development needed from prevention programs. Learning Network and the India National Informatics Center3 worked together to connect 70 people in five In India, female sex workers are much less likely to cities for a rich exchange. In addition to national experts use condoms with non-paying sexual partners than and development partners, the participants in India with paying clients. This suggests that they included representatives of associations of women living misperceive non-paying partners as less likely to with HIV/AIDS, and university students. In each session, transmit HIV. Prevention programs among sex a presentation of the study results and comments by workers should emphasize correct and consistent panelists were followed by general discussion. condom use with both paying clients and non-paying partners. "This was my first VC and it was wonderful. It The role of MSM/MSWs in the HIV epidemic needs was so good to be able to discuss like this ..." to be better delineated through focused research in (Anandi Yuvaraj, International HIV/AIDS Alliance, the region, and programs developed accordingly. India). The course of the HIV epidemic and HIV transmission dynamics in rural areas need to be The opportunity to provide feedback and debate points researched, particularly in India. Questions remain made in the draft report was greatly appreciated. about whether and under what circumstances Participants at each consultation provided additional substantial rural epidemics can be maintained on data and insights, enriching the final report. The study their own, or the extent to which they reflect urban conclusions were validated, and those that were epidemics; as well as the role of local sex workers challenged stimulated constructive discussion, and and other risk networks in maintaining rural helpful guidance for refining and finalizing the report. epidemics. The importance of rural-based interventions and community driven programs needs There was robust discussion on areas where received to be better understood, as well as practical wisdom, assumptions and beliefs were not fully approaches developed to reduce risk and consistent with the data analyzed in the report. For vulnerability among rural populations. example, the report noted that HIV transmission among female sex workers in Pakistan was close to zero, but Some of the major challenges in South Asia require many people believed that sex worker prevalence was regional and cross-border collaboration, 7%. The discussion clarified that the 7% rate referred to transcending national boundaries and bureaucratic male sex workers, not women, a very important regions. For example, harm reduction in Afghanistan distinction for prevention programs. and Pakistan would benefit from coordination with similar initiatives in Iran and Central Asia. HIV The report also generated debate on the role of prevention among sex workers in Nepal could be treatment of other sexually transmitted infections (STIs) enhanced by coordinated efforts with India, with a in preventing HIV. This has long been believed to be an focus on migration and trafficking, especially to important part of prevention programs, but experience Mumbai. Drugs and sex are extensively traded from Africa challenges the orthodoxy. In four out of five across the borders between the highest prevalence carefully evaluated programs, STI treatment had a clear districts in northeastern India, parts of Bangladesh impact on STIs ­ but not on HIV transmission. In a fifth and bordering Myanmar, calling for collaboration study, STI treatment reduced HIV transmission, but not across borders, regions and sectors. the incidence of STIs. These findings are not well known in Asia, suggesting scope for much more sharing of data and results across the globe, with appropriate caution 4. Discuss the draft report extensively before about generalizing results from one place to another. finalizing it The implication of the Africa STI studies is that treating STIs appears not be an effective intervention against Discussing and finalizing the report was a valuable and HIV transmission, although it remains an important part integral part of the work. Once an initial draft was completed, in addition to the usual peer review to solicit and incorporate views from colleagues within the World 3 Bank and an external reviewer, three consultations were NIC, the information technology agency for the Government held with country experts and donors, to discuss the of India, provides a wide range of e-government services to preliminary findings. Videoconferences linked people central, state and district government departments, including the Indian Government Portal (http://india.gov.in/). 4 of the broader reproductive health agenda. When educators, manage and solicit financing, and monitor considering investing in STI treatment programs, the first impact among vulnerable groups at high risk is a key step would be to check the prevalence and profile of recommendation of the report, guiding programming and STIs, before deciding how to proceed. planning in World Bank supported operations in South Asia. The foundation has been laid for achieving results Another important point, based on data, is the ­ impacting the AIDS epidemic in South Asia ­ based on recommendation that much more attention needs to be more solid evidence. given to injecting drug use. HIV infection among injecting drug users is clearly a problem in several of the The report's assessment of the trend that the epidemic countries, and quite likely in others as well although data appears to be following in South Asia is consistent with are too patchy to give a clear sense of its magnitude or important new analysis of data from India (Kumar et al., potential. Data from some areas ­ north east India, Lancet 3/30/06). Contrary to some earlier predictions of Pakistan and Afghanistan ­ show HIV prevalence rates major increases in HIV in India, data from women rising very rapidly among communities of IDUs. Although attending antenatal clinics and men attending sexually- IDUs are difficult to reach, effective harm reduction transmitted infection clinics indicate declining HIV programs involving peer educators are showing results. prevalence between 2000 and 2004 among young This calls for multi sector approaches, including working women and men in South India, and stable prevalence in on the legal framework and seeking agreements with North India, although at lower levels. The researchers local police to effectively reach vulnerable groups at high suggest that the decline may be due primarily to high risk. Good practices are emerging from Bangladesh and levels of condom use during commercial sex, and India. Likewise intensified efforts across sectors are conclude that expanding peer-based condom programs needed to reduce stigma associated with HIV and AIDS for sex workers remains a top priority to control HIV-1 among IDUs, MSM and sex workers throughout the growth in India. region. Sharing the experience The discussion also focused on migration, which the report touches on, but does not deal with in detail. The Is the study replicable elsewhere? data suggest that migration is often associated with other risky behaviors: many IDUs in Afghanistan began The South Asia region has some unusual characteristics injecting while living in other countries; Nepalese sex that facilitated the study. Because the region comprises workers who have worked in Mumbai have much higher only a few countries, detailed analysis for the different HIV rates than sex workers who have worked in other countries and cross-country comparisons were possible; parts of India, and both groups are much more likely to many more countries would have made the task be infected than Nepali sex workers who have not daunting. The country analysis that had already been worked outside the country. Migration warrants more done was also very helpful. If a similar study were being careful thought and discussion, including differentiating considered in countries with less existing data and among migrants (e.g. people who have been trafficked, research, it would probably make sense to trade off transport workers, seasonal migrants) to understand geographic reach for intensive investigation, and do better which groups might be at risk and how to reduce detailed analysis on selected areas of the countries. the risk. Criteria for inclusion and for grouping countries should also be carefully considered, since countries of very The videoconferences touched on just some of the different size, availability of data, and epidemics will important issues raised in the report. No other disease inevitably get uneven attention. But even if the study has generated so many certainties and orthodoxies, but cannot be precisely replicated in other regions or less progress. This suggests a huge need for continued subregions, the analytic approach certainly can be well informed debate and discussion ­ one of the main adopted within or across other countries. objectives of this report ­ to try and ensure that global, national and local responses achieve stronger results. Sharing experiences, building skills Impact To build on the work done and having seen how useful the analysis is proving to countries, the Bank's Global Long before the study's formal launch in August 2006 at AIDS Program is developing a skill-building clinic on how the XVI International AIDS Conference in Toronto, its to do this kind of analysis. The 3-5 day clinic will be impact had begun to be felt, for example, in the aimed at people who need to understand the epidemic in preparation for the third national AIDS program of work their country, as a basis for making program decisions. in India. One outcome of the work has been to provide This would include, for example, Ministry of Health solid evidence to justify support to local groups in epidemiologists, staff in national AIDS programs, as well implementing outreach programs for high risk groups, as researchers and analysts, although the orientation will including men who have sex with men (MSM) where the be practical rather than academic. coverage of effective preventive interventions is the lowest in the region. Building local capacity to train peer 5 Preparatory work will be important, and participants will be asked to bring their national HIV/AIDS data with them, so that the clinic can be hands-on and "real world", not theoretical. Having seen the kinds of data sources that countries can draw on, and brought them to the clinic, participants will then work on using the various types and sources of data to build a composite picture of the epidemic. The final topic will be to talk about the implications for HIV/AIDS programs. A better understanding of the patterns and trends in transmission, risk and infection could inform more strategic programs, that are more likely to achieve results in preventing infections and providing care and treatment to those who need it most. For more information: "HIV/AIDS in South Asia: Understanding and Responding to a Heterogeneous Epidemic", available on line (from 08/15/06) at www.worldbank.org/saraids and www.worldbank.org/aids > publications For more information on the report, or World Bank support for the response to HIV in the South Asia region, please contact: Mariam Claeson, AIDS Coordinator for the South Asia Region mclaeson@worldbank.org For more information or feed-back on this series, or to request additional copies of this note, please contact: Joy de Beyer, Global HIV/AIDS Program, jdebeyer@worldbank.org June 2006 6