53321 The Global HIV/AIDS Program and Latin America and the Caribbean Region THE WORLD BANK Planning for Results The Case of Honduras HONDURAS A T L A N T I C O C E A N P A C I F I C O C E A N November 2009 World Bank Global HIV/AIDS Program Reports This series, published by the Global HIV/AIDS Program of the World Bank's Human Development Network, makes interesting new work on HIV/AIDS widely available, quickly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account that it may be provisional. Papers are posted at www.worldbank.org/AIDS (go to "publications"). For free print copies of reports in this series please contact the corresponding author whose name appears the bottom of page iii of the paper. Enquiries about the series and submissions should be made directly to Joy de Beyer (jdebeyer@worldbank). Cover: Map No: IBRD 37274 November 2009 This map was produced by the MAP Design Unit of the World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of the World Bank Group any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. © 2009 World Bank © 2009 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. PLANNING FOR RESULTS THE CASE OF HONDURAS WORLD BANK GLOBAL HIV/AIDS PROGRAM AND LATIN AMERICA AND THE CARIBBEAN REGION World Bank Global HIV/AIDS Program Report www.worldbank.org/AIDS November 23, 2009 i ii Planning for Results: The Case of Honduras Rosalía Rodriguez-García,a René Bonnel,b and Marcelo Bortmana with Cesar Nuñezc, Jose Antonio Izazolad, and Eric Gaillardb a Senior Evaluation Specialist, Global HIV/AIDS Program, World Bank b Consultant c UNAIDS-Latin America Region c Director, National Aids Program of Mexico (formally, UNAIDS, Geneva) This paper is a joint product of the World Bank Global HIV/AIDS Program in the Human Development Network and the Latin American and Caribbean Region. The purpose was to learn from the process through which ASAP ­ the AIDS Strategy and Action Planning service hosted by the World Bank on behalf of UNAIDS ­ worked with Honduras, to support development of a new national AIDS strategic plan. The work was done as part of the UNAIDS Unified Budget and Workplan (UBW). Abstract: This paper assesses the process of developing the national AIDS strategy of Honduras during 2007. It does not analyze Honduras's new AIDS strategy--PENSIDA III. Rather, it derives lessons from the planning process that could be relevant to other countries involved in similar processes. Keywords: HIV/AIDS, World Bank, Honduras, results, strategy, strategic planning, AIDS Strategy and Action Plan (ASAP), Global HIV/AIDS Disclaimer: The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Rosalia Rodriguez-Garcia, World Bank, 1818 H Street, NW, Washington DC, 20433. tel: (202) 473-8846; fax: (202) 522-1252 email: rrodriguezgarcia@worldbank.org HDN Vice President: Joy Phumaphi GHAP Director: Debrework Zewdie Sector Manager: Antony Thompson Team Leader: Rosalia Rodriguez-Garcia iii iv Table of Contents Foreword ................................................................................................................................ vii Acknowledgments .................................................................................................................. ix Acronyms .................................................................................................................................x Executive Summary................................................................................................................. xi Introduction ............................................................................................................................. 1 I. Recent Developments and Macroeconomic Issues ................................................................3 II. Setting up the Preparatory Process ..................................................................................... 6 Management of the HIV Epidemic during PENSIDA I and II ................................................. 6 Setting up the Process ......................................................................................................... 8 III. Strategic Planning Process (PENSIDA III) ........................................................................... 13 Analysis of Epidemic and National Response (Phase I) ....................................................... 13 Identification of Results and Priority Programs (Phase II) ................................................... 21 Estimation of Spending and Financial Requirements (Phase III) .......................................... 23 Fiscal Space: the Challenge Ahead .................................................................................... 29 IV. Assessment of the Strategy Preparation ........................................................................... 33 Client Survey (2009) ........................................................................................................... 33 What Made the Difference? ................................................................................................39 Final Thoughts .................................................................................................................... 41 Annex 1: National AIDS Spending Assessment (NASA) ......................................................... 43 Annex 2: Assessment of the Planning Process of PENSIDA III ...............................................45 Bibliography ........................................................................................................................... 47 Tables Table 1. Honduras: Selected Economic and Social Indicators (2007) .............................. 3 Table 2: Road Map and Key Milestones ......................................................................... 9 Table 3: Subpopulations Prioritized in PENSIDA II and the Availability of Evidence for PENSIDA III ...................................................................................................................... 23 Table 4: Funding Sources and Implementation Agents, 2006 ....................................... 26 Table 5: Selected Macroeconomic Indicators, Honduras and Other Latin American Countries ......................................................................................................................... 30 v Figures Figure 1: Strategy Results Cycle ...................................................................................... 11 Figure 2: Cumulative AIDS Cases per 100,000 Inhabitants (1985­2005) ....................... 14 Figure 3: HIV Prevalence among ANC Attendees .......................................................... 16 Figure 4: HIV Prevalence Rate in Selected Populations ................................................. 16 Figure 5: Condom Use in Selected Populations ............................................................. 17 Figure 6: HIV Projection, % Adult Prevalence (1980­2010) .......................................... 18 Figure 7: Modes of Transmission ................................................................................... 19 Figure 8: HIV Resources (US$ Million) ........................................................................... 24 Figure 9: Allocation of Resources by Target Groups (2006) .......................................... 25 Figure 10: Costing National Aids Strategies ................................................................... 27 Figure 11: Allocation of Resources (PENSIDA II and III) (% of total) .............................. 28 Figure 12: Financial Requirements of PENSIDA III (US$ Million) ................................... 29 Figure 13: Honduras: Illustrative Fiscal Diamond .......................................................... 32 Figure 14: Rating of Situation Analysis (% of maximum score) ..................................... 34 Figure 15: Assessment of Results-Based Framework .................................................... 34 Figure 16: Ratings of Participatory Approach ................................................................ 35 Figure 17: Strategic Results (% of Maximum Score) ...................................................... 36 Figure 18: Assessment of Costing .................................................................................. 37 Figure 19: Comparison of Scores ................................................................................... 38 Box Box 1: What is the AIDS Strategy and Action Plan (ASAP)? ..................................................... 7 vi Foreword The critical importance of strategic planning for well-performing public institutions has come to the forefront in the past decade as we scale up efforts to achieve the Millennium Development Goals and Universal Access, and it is gaining renewed attention as health and other sectors face the challenges imposed by the economic crisis. I am therefore particularly pleased to endorse this publication about the HIV/AIDS strategy planning process in Honduras, brought to fruition through an effective and sustained partnership with AIDS Strategy and Action Plan (ASAP). Honduras was the first country in the Latin American Region and one of the first countries in the world to request and receive support from ASAP--a program of UNAIDS managed by the World Bank. I had the opportunity to oversee the ASAP support process, which was responsive to our needs, comprehensive, timely, reliable, and of high technical quality. At the same time, it was grounded and very much taking a learning-by-doing approach, especially at the beginning. One of the unique aspects of this experience, in my view, is the balance achieved between ASAP policy dialogue and technical guidance with stakeholder involvement and national ownership. The national HIV/AIDS Program was at all times in the driver's seat, leading the strategy preparation effort. As a result of this national leadership, the final product, the National HIV/AIDS Strategy (PENSIDA III), is informed by evidence and expenditure analysis, identifies priorities and targets and the cost of implementing the strategy. This is a "live" document, which is guiding the implementation of the national response. While this publication is intended primarily as a vehicle for sharing our joint experience (Honduras-ASAP), I hope that the lessons learned through experience and the approaches set forth here will serve readers in their own situations. Dr. Carlos Aguilar Secretario de Estado en el Despacho del Secretario de Salud June 2009 vii viii Acknowledgments This is a joint product of the World Bank Global HIV/AIDS Program in the Human Development Network and Latin American and Caribbean Region. Its purpose is to assess the process of developing the national AIDS strategy of Honduras during 2007. This case study is not aimed at analyzing Honduras's new AIDS strategy--PENSIDA III. Rather, it derives lessons from the planning process that could be relevant to other countries involved in similar processes. This case study is the result of a team effort under the direction and leadership of Dr. Rosalía Rodriguez-García, Global HIV/AIDS Program, World Bank; Dr. Marcelo Bortman, Latin America and Caribbean Region, World Bank; Dr. Mayté Paredes, Secretaría de Salud; Dr. Miguel Aragón, CDC-Honduras; Dr. Maria Tallarico, UNAIDS-Honduras; and Drs. Steven Forsythe and Eric Gaillard, ASAP consultants. This report incorporates the main conclusions of the document Building on Evidence: a Situational Analysis of the HIV Epidemic and Policy Response in Honduras, which was published in October 2008 (posted at www.worldbank.org/AIDS publications). The team is grateful for the comments provided by Janet Leno, Jonathan Brown and Joy de Beyer (GHAP), Shiyan Chao and Keith Hansen (Latin America and Caribbean Region). The assessment of the Honduras National Strategic Plan for HIV/AIDS 2003­2007 (PENSIDA II) was conducted under the institutional leadership of the National Secretariat of Health with CONASIDA (Comisión Nacional del Sida), represented by the Minister of Health. The PENSIDA III (Third National Strategic Plan for the HIV/AIDS Response in Honduras) team led by Dr. Mayté Paredes, head of the national HIV/AIDS Program, included Miguel Aragón (CDC-Secretaría de Salud), Jorge Fernández (Consejo Nacional de Sangre), Rudy Rosales de Molinero (CONASIDA), Maria Tallarico (UNAIDS), Xiomara Bú (FOROSIDA), Liliana Mejía (UNAIDS), Walter Tróchez (ASONAPVSIDAH), Bredy Lara (Secretaría Salud, CDC), Sundeep Gupta (CDC-Secretaría de Salud), and Irma Mendoza (CONASIDA). This team was supported by Daniel Aran, Marcelo Castrillo, Steven Forsythe and Eric Gaillard (ASAP consultants), and Miriam Montenegro (World Bank office in Honduras). The Comprehensive Assessment of PENSIDA II and the planning of PENSIDA III were conducted through a participatory process that included participants from various sectors, including civil society, government, the private sector, NGOs, and international partners. The significant effort and participation of these groups have been remarkable. The implementation of PENSIDA III is coordinated by the National HIV/AIDS Program, headed by Dr. Xioleth Rodriguez, and led by the Minister of Health. ix Acronyms AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care ART Antiretroviral therapy ARV Antiretroviral (drugs) ASAP AIDS Strategy and Action Plan BSS Behavioral Sentinel Surveillance CONASIDA Comisión Nacional de SIDA DFID Department for International Development (UK) GHAP Global HIV/AIDS Program (World Bank) GTT Global Task Team HAART Highly Active Antiretroviral Therapy HDN Human Development Network HIV Human Immunodeficiency Virus M&E Monitoring and Evaluation MEGAS Medición de Gasto en SIDA MSM Men who have sex with men NASA National AIDS Spending Assessment NGO Nongovernmental Organization ONUSIDA Programme Commun des Nations Unies sur le VIH/SIDA PAHO Pan American Health Organization PENSIDA Plan Estratégico Nacional de Lucha Contra el VIH/SIDA, 1999-2002 PENSIDA II Plan Estratégico Nacional de Lucha Contra el VIH/SIDA, 2003-2007 PENSIDA III Plan Estratégico Nacional de Lucha Contra el VIH/SIDA, 2008-2012 PEPFAR President's Emergency Plan for AIDS Relief PLHIV Person/s Living with HIV PMTCT Prevention of Mother-to-Child Transmission PRSP Poverty Reduction Strategy Paper SAT Self Assessment Tool STI Sexually Transmitted Infection/s SW Sex Worker/s UNAIDS The Joint United Nations Programme on HIV/AIDS UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children's Fund USAID United States Agency for International Development VCT Voluntary Counseling and HIV Testing WFP World Food Program x Executive Summary National AIDS Strategy Frameworks have become a mainstay of countries' AIDS responses. Faced with the challenge of responding to the epidemic in a context of growing needs and limited resources, governments have turned to AIDS strategies as a tool for designing and prioritizing their AIDS response. Honduras's government was forward thinking and recognized that technical support was needed to develop a more evidence-based, results-based strategy. At the request of the Ministers of Finance and of Health, technical assistance was mobilized in September 2006 through the Latin American Region of the World Bank. It was delivered by ASAP (AIDS Strategy and Action Plan), a team that had just been established by UNAIDS within the World Bank with the explicit mandate of helping countries develop truly strategic AIDS frameworks. Honduras was one of the first countries to receive ASAP's support. The technical assistance support was designed to be comprehensive, covering all the key aspects of strategic planning, and to be provided throughout the preparation of PENSIDA III over a 10-month period. This makes Honduras`s support stand out. Are the effort and cost involved in the process justified by the results that were achieved? This report attempts to provide an answer by documenting how technical assistance helped support the preparation of PENSIDA III and to derive some policy lessons that may be relevant for countries facing a similar task. The main conclusion of the report is that the preparation of PENSIDA III achieved its objectives. A revised AIDS response was developed by carrying out an extensive analysis of the previous strategy (PENSIDA II), developing an evidence base, and using the evidence to prioritize interventions while relying on broad participation of stakeholders to ensure country ownership. Those are characteristics that many countries want to achieve but find extremely difficult to manage. Several elements were found to contribute to this result. These include: Macroeconomic analysis of the use of resources Leadership by the national authorities Development of a framework guiding the preparation of PENSIDA III At the national level, macroeconomic analysis underlined the importance of improving the use of resources. In recent years, much of the increase in social sector expenditures has been used to raise wages -- without corresponding increases in productivity. This shortcoming provided an important motivation for improving strategic planning, a conclusion that was underscored by the strong support provided by the Minister of Finance during the preparation of PENSIDA III. xi Leadership by the national authorities was essential to launch and maintain support throughout the preparation process. From the beginning, the Minister of Health--also chair of the National AIDS Commission (CONASIDA)--followed the process closely and provided overall guidance to the technical team. His support made it possible for the technical team to reach out to a broad array of stakeholders, including civil society and people living with HIV. The strategic planning exercise was made possible by applying a clear and structured framework with four key components: The development of a road map with key milestones: this was supported by ongoing communications between national stakeholders and ASAP and allowed all involved to monitor progress and understand the full process. By designing a process under the umbrella of CONASIDA, it was possible to ensure high levels of participation and ownership in the planning process; The development of a strong evidence base informed by analysis of the epidemic and the review of the achievements of the national response; A clear results-oriented framework for formulating the strategy accompanied by the identification of key programs and estimation of their financial costs; and A results-focused monitoring and evaluation approach that provides information on the progress of the response and can serve to inform the revision of programs. The development of evidence for decision making was time consuming, but it was essential for ensuring an effective participatory process and for building consensus. The evidence base revealed that, contrary to earlier projections, the HIV prevalence rate was declining and had fallen from 1.3 percent in 1995 to 0.7 percent in 2007. It also documented the complex nature of the epidemic. Some 48 percent of HIV infections were found to occur in men who have sex with men (MSM), sex workers (SW), their clients and clients' wives. Although SW make up only about 1 percent of new cases, 15 percent of new infections were estimated to occur among their clients and 12.4 percent among clients' wives or other sex partners. This showed clearly that it was not enough to target only sex workers, but that efforts should be directed at their sexual networks. The analysis showed that 48 percent of infections take place among vulnerable populations, which include adolescents, women, men, prisoners, and uniformed officials. The broad nature of this category indicates the need to better determine the groups that account for nearly half the infections, to enable more effective targeting. The analysis of the epidemic served to revise the understanding of the epidemic, and also provided a new way to look at the programs that were put in place during PENSIDA II. This enabled stakeholders to assess the shortcomings of PENSIDA II in xii terms of the efficacy of programs in turning around the epidemic, after taking into account the factors that have contributed to the decline in prevalence, such as shifts in preventive behavior. Prioritization of interventions The lessons derived from the review of PENSIDA II pointed in one central direction: strengthen the prioritization process, and in particular prevention efforts. However, a key obstacle was the limited data available and the position of some stakeholders who were opposed to a focused approach to priority populations. To overcome this challenge, a compromise was reached. Target groups were classified into three categories: (i) highest priority groups, which could be prioritized based on the available evidence; (ii) second priority groups, which included populations considered to be vulnerable but with low HIV prevalence; and (iii) vulnerable groups about whom more research is needed before they can be prioritized. The classification of groups was meant to ensure that the groups known to be driving the epidemic would receive the highest priority, but it did not imply that the other groups would be ignored. It was hoped that this classification would help drive the research agenda so that data could be obtained about subpopulations that may be at high risk but for which little accurate data exist. Through this new system of categorizing at-risk and potentially vulnerable groups, the prioritization process was able to walk a fine line between excessive focus on high risk-groups and excessive generality. In the end, this ensured that the participatory process that guided the preparation of PENSIDA III was maintained. Financial Requirements of PENSIDA III The agreement reached on the priorities of PENSIDA III made it possible to propose a more appropriate resource allocation. The estimation of spending that had been carried out prior to the preparation of PENSIDA, following the NASA (National AIDS Spending Assessment) methodology, proved useful. It helped correct the perception coming from the 2000 and 2001 National AIDS Accounts that the national response was quite costly: the actual amount was found to be only one-third of the initial estimate. Another important finding was that the share of national resources had risen from only 3 percent of all HIV resources in 2003 to 40 percent in 2007. The combination of NASA data and the new epidemiological results proved valuable. It forced the stakeholders to assess whether the current allocation of funds was justified in view of Honduras's epidemic. Given the complex and evolving nature of the epidemic, a consensus was reached that interventions for the general population should be maintained, but that interventions for MSM should be reinforced while attempting to identify the risk and vulnerability of other subpopulations that have not yet been reached. This might include ethnic groups (e.g., Tolupan and Misquito) and people with disabilities. xiii Funding PENSIDA III. In total, the financial requirements of PENSIDA III were projected to increase from US$30 million in 2008 to US$50 million in 2012. This would increase AIDS expenditures from 8 percent of health expenditures in 2008 to 11 percent in 2012. Given the current scarcity of resources, Honduras would have to create some budgetary "room" for funding these expenditures. One option would be to mobilize additional funding from Honduras's development partners, especially from the Global Fund. In the short run this may prove difficult because the global economic crisis is likely to affect donors' contributions to the Global Fund. An alternative would be to raise more resources domestically and/or improve the efficient use and allocation of public resources. Assessments of Results There are encouraging indications that the efforts involved in the preparation process of PENSIDA III were worthwhile. These are revealed by a survey of stakeholders carried out nearly one year after the completion of the preparation process of PENSIDA III. While some participants felt that more should have been done in some areas, a high percentage of the surveyed respondents indicated that the preparation process had led to the setting of new priorities, contributed to the identification of new programs, and influenced resource allocation. Participants also rated highly the participatory approach and the capacity building that was achieved. These results highlight the importance of providing a comprehensive package of technical assistance covering all the key aspects of a strategy. This approach generated strong synergies. It allowed constant iteration and integrated thinking about the focus of interventions, the results to be achieved, and the allocation of resources. In the end, the overall result was rated much more highly than the individual components of the process. Next Steps The revision of Honduras's strategy raised new expectations that will have to be addressed during the implementation of PENSIDA III. These include the following: Research agenda: An agenda would have to be implemented to address the knowledge gaps identified during the revision process; Mid-term evaluation of PENSIDA III: The implementation of PENSIDA III should be regularly evaluated and the results shared widely among stakeholders; Role of CONASIDA: An important step for improving coordination among actors would be to strengthen CONASIDA; and Participation of civil society: Shortcomings expressed by some participants perhaps point to the need to create a more structured institutional setting. Overall, despite remaining challenges, the preparation process of PENSIDA III represents a major step forward in Honduras's effort to respond to the epidemic, based both on evidence and stakeholder participation. xiv Introduction Since HIV emerged on the international scene as a major epidemiological disaster in the 1980s, much has been learned about how to reverse the course of the epidemic. Experience in the most affected countries has demonstrated the need for strong leadership to ensure that sufficient human and financial resources are mobilized and used efficiently. Key milestones include the World Bank commitment to provide US$1 billion to fund HIV/AIDS projects aimed at scaling up the HIV/AIDS response (2000), the 2001 UN General Assembly Special Session followed by the creation of the Global Fund (2002), and the decision of the US Government to establish the President's Emergency Plan for AIDS Relief (2003). With the generation of significant additional resources at the global and country levels, there has been an acknowledgment that countries have a responsibility to achieve and demonstrate results. This necessitates realistic strategic plans that are informed by evidence, followed by detailed implementation action plans and monitoring and evaluation plans that lay out how the expected outcomes would be measured and analyzed and the resulting information used for decision-making. The government of Honduras recognized that the revision of its ongoing AIDS strategy (PENSIDA II) needed to result in a new strategy that would be more evidence- informed, results-oriented, and costed, with a stronger monitoring and evaluation approach. The Honduran Government was forward thinking and realized that it needed technical support to facilitate the process of formulating a new strategic framework for HIV/AIDS covering the years 2008 to 2012. The Health Sector Unit of the Latin American and Caribbean Region in the World Bank responded positively and took advantage of the policy it had initiated to use regular supervision meetings to discuss the mobilization of technical assistance. This approach facilitated the provision of support through a then new interagency initiative hosted by the World Bank--ASAP (AIDS Strategy and Action Plan), while at the country level the partners' thematic group on HIV/AIDS led by UNAIDS supported and contributed to the effort, and CONASIDA provided overall coordination. The main rationale of this case study is to explain how Honduras proceeded to prepare (PENSIDA III), and to derive policy lessons from this experience. Its focus is therefore on the process that took place during the preparation of PENSIDA III, as it is during that time that technical assistance was provided to Honduras. Honduras was one of the first two countries (the other was Madagascar) to receive support from ASAP. ASAP was established by UNAIDS within the World Bank to assist countries in their evidence-informed and results-based strategic planning. This case study of Honduras is part of ASAP'S process of self-assessment and learning about good practices and processes for developing effective strategic AIDS responses. To assess results, a survey of stakeholders was conducted one year after the draft strategy was finalized. 1 It is hoped that these lessons could be useful to countries that are in the process of revising their National AIDS Strategies. Key questions analyzed in the report include: Evidence base: o How was the evidence base developed? o How did it influence the design of the strategy? Prioritization of programs: o How was prioritization achieved? o What were the shortcomings and trade-offs? Participatory approach: o Was the participatory approach broad enough? o How were the different priorities of groups reconciled? o Did stakeholders find the participatory process useful? Methodology o What was innovative? o What were the areas of weakness? o Was the technical assistance useful? Results o Did the stakeholders gain a clear vision of priorities? o Did the revision process lead to new interventions in the strategy? o Did the new evidence lead to a new allocation of resources? Outline of report. Chapter I outlines the main economic and financial challenges faced by Honduras. Chapter II describes the management of the AIDS response during PENSIDA I and II and the initial preparatory phase of PENSIDA III, including the methodology that was followed, with its strong focus on a results-based framework and facilitated by the strong commitment of political leaders and the involvement of Honduras's development partners and civil society. Chapter III discusses the planning process for PENSIDA III, especially the identification of target groups and the prioritization of programs. It also presents estimates of the resources spent by Honduras in 2002­2006 and the projection of the financial requirements for PENSIDA III. Finally, Chapter IV presents an assessment of the process of revising the strategy based on a survey of stakeholders carried out in January 2009, a little more than one year after the completion of the work. It draws out some lessons by highlighting the success factors and the areas of weakness. While this survey is not a formal evaluation of the process that was followed, it provides some indication of whether the time and effort invested in it were worthwhile. 2 I. Recent Developments and Macroeconomic Issues Country Context Honduras is a lower-middle-income country, with a per capita income of US$2,100 (2006) and a population of 7.5 million inhabitants. Relative to other Central American countries, Honduras's social indicators are among the weakest, lagging behind in the areas of child malnutrition and education quality (Table 1). Table 1. Honduras: Selected Economic and Social Indicators (2007) Honduras Latin America & Caribbean) Population (millions) 7.5 556 Per capita income in U.S. dollars (2006) (Atlas method) 1,270 4,785 Rank in UNDP Development Index (2007/08) 115 of 177 n.a. Life expectancy at birth (2006) 70 73 Adult literacy rate (age 15 and above) 80% 91% Infant mortality (per 1,000 live births) 23 22 Child malnutrition (% of children under 5 underweight) 8.6 5.1 Poverty headcounts ratio at $1 per day 21% 9% Adult HIV prevalence rate (%) 0.7 0.5(a) 1.1(b) Source: World Bank Indicators 2008, UNAIDS 2008 Note: (a) Latin America, (b) Caribbean HIV Epidemic Honduras' estimated HIV prevalence rate of 0.7 percent in 2007 is among the highest in Latin America.1 Honduras's HIV epidemic is both unusually severe for the region and sexually driven, dictating both the urgency and strategic orientation of the needed response. The epidemic has a complex profile: it is both concentrated among some population groups and generalized (more than 1% of the general population) in some regions of the country, especially in the north. The HIV epidemic is particularly severe among ethnic minorities such as the Garifunas, men who have sex with men, female sex workers, and prisoners. 1 In 2005, the HIV prevalence rate in Honduras was estimated to be 1.5 percent. This was subsequently revised downward during the preparation of PENSIDA III (see figure 3.5 in chapter III). Countries in Latin America with higher estimated prevalence in 2007 are: Guyana (2.5%), Suriname (2.4%), Belize (2.1%), Panama (1.0%), El Salvador and Guatemala (0.8%). All countries in the Caribbean except Cuba have estimated HIV prevalence rates higher than Honduras. Data source is UNAIDS, 2008. 3 Government's Commitment to Reform Passage of the budget in March 2008 signaled the Honduran congress' endorsement of an economic program that includes a comprehensive set of fiscal, monetary and external policy measures to address macroeconomic imbalances. At the same time, the Government indicated that it intended to finalize its Poverty Reduction Strategy Paper. Initial drafts had been prepared shortly after the change in administration in early 2006, and the proposed revisions were outlined in the Progress Report published in June 2007. The decision to revise Honduras's Poverty Reduction Strategy (PRS) offered three crucial opportunities. First, it gave greater urgency to the revision of the National AIDS Strategy (PENSIDA II), which was coming to end in 2007. In order for PENSIDA III to be reflected in the new PRS, the National AIDS Strategy had to be revised during the first nine months of 2007. In doing so, the Government was forward looking and recognized that a more results-focused framework was needed. How this was done is discussed in the following chapters. The second opportunity was the generation of sufficient fiscal space for the Government to fund its priority programs. Fiscal space refers to a budgetary situation that allows a government to provide resources for a desired purpose in a manner that does not compromise the sustainability of a government's financial position. Central to the definition of fiscal space is the notion that expenditures have to be financed in a manner that is financially sustainable (see Chapter IV). This is especially important for long-term epidemics such as HIV/AIDS. The third opportunity came from the realization that there was significant inefficiency in public expenditures that needed to be addressed. Research at the World Bank (based on cross-country data from 1996­2002) suggested that the efficiency of public social spending generally is lower in Honduras than elsewhere in the region: out of 23 countries, Honduras ranks close to the bottom in education spending efficiency, and near the median in health spending efficiency. Other research at the Inter-American Development Bank that extended this analysis to measure the efficiency of public spending in terms of overall development performance indicators, also found that Honduras ranks significantly below the regional average and median efficiency scores. These conclusions were further reinforced by recent analysis of macro-economic trade-offs which compared how Honduras and Ghana were progressing toward the Millennium Development Goals.2 The main conclusion was that Honduras has made great progress in improving its social indicators since 1990, but the current pace of advance would not be financially sustainable without improving the efficiency of MDG- related spending. This conclusion is important because it suggested that the 2 Buzzo M. and Denis Medvev. Challenges to MDG Achievement in Low Income Countries: Lessons from Ghana and Honduras. Policy Research Working Paper No. 4383. World Bank. November 2007. 4 successful implementation of PENSIDA III will largely depend on the design of a sound strategy aimed at ensuring that resources are allocated in a manner that has the greatest likelihood of turning around the epidemic. Overall, this analysis highlighted the importance for Honduras of improving strategic planning. In recent years, much of the scaling up of the HIV/AIDS response was facilitated mobilizing more external financial assistance and increased budgetary revenues. But both are under threat. The global financial crisis has reduced the ability of developed countries to increase their financial assistance for HIV/AIDS at the same rate as in recent years. The global crisis also is affecting the economies of countries such as Honduras, and in particular budgetary revenues. Both factors raise concerns about the financial sustainability of Honduras's HIV/AIDS response, and in particular the continued ability to finance antiretroviral treatment throughout 2009 and beyond. In a context of considerable uncertainty concerning the severity and length of the economic downturn, policy makers face a difficult choice. A short-lived economic contraction would call for short-term measures that are easily reversible. A longer- term recession argues for lengthening the horizon over which it is desirable to implement measures that would offset the effect of the crisis. There still is no clear consensus on the length and severity of the crisis. This makes contingency planning, and in particular the development of alternative scenarios, critical. The good news is that Honduras should be well placed to address this challenge thanks to the efforts it deployed during the revision of its National AIDS Strategies. These are discussed in the following chapters. 5 II. Setting up the Preparatory Process Management of the HIV Epidemic during PENSIDA I and II National AIDS Control Program Honduras was one of the first countries on the continent to organize a national response system to the epidemic, including an Epidemiological Control System, which provided national coverage and a network of laboratories that guaranteed free HIV tests for the entire population. Eventually, the National HIV/AIDS Program was created and in 1994 it merged with the STD Program. In 1998 Honduras launched its first National AIDS Plan (PENSIDA I), which covered the period 1998­2002. PENSIDA I was followed by PENSIDA II (2003­2007), which was developed through a consultative process around two main strategic components: preventive interventions targeted to high-risk populations to reduce vulnerability, and prevention and treatment of and STDs and HIV/AIDS and care for those affected. Coordination. The National AIDS Commission (CONASIDA) was initially created in order to document the HIV epidemic and make recommendations to the authorities of the Health Secretariat. It includes representatives from the public and private sectors and civil society and is chaired by the Minister of Health. In recent years, coordination with other sectors has remained weak, due to limited resources within the Ministry of Health for this task. This has been compounded by the lack of an institutional framework that would require CONASIDA to coordinate the response among sectors and require the sectors to implement the national response and provide resources for it. The result has been a commission that has not been functioning to its full potential. M&E system and evidence-building research. The Ministry of Health has an M&E (monitoring and evaluation) system, but its task under PENSIDA II (2003­2007) was focused on collecting data within the health sector. This system faced many challenges, which are also observed in other Central American countries, such as underreporting of AIDS cases, lack of support from the network laboratories, an inadequate Guidelines and Control Manual, and the need to develop an integrated STD/HIV/AIDS information system with a focus on sexual and reproductive health. The Ministry was fully aware that a broader M&E system was needed, but it faced major institutional and human capacity challenges in implementing such a system. In the second AIDS strategy (PENSIDSA II), M&E was addressed superficially and there were no baselines for most indicators. A number of studies had helped monitor the epidemic, but these studies, many supported by donors, were not conceived as part of a broader and cohesive national M&E plan. 6 Strong National Leadership As the national response was being scaled up,3 questions regarding the allocation of funds and their impact on the course of the epidemic were frequently raised. The challenges facing Honduras were analyzed in a 2006 regional study covering Central American countries, including Honduras.4 This report stressed the need to (i) improve the analysis of data to identify national strategic priorities; (ii) increase funding of the AIDS response; and (iii) allocate resources in a manner that reflects the realities of the epidemic, especially among high risk groups and highly vulnerable groups. The timing of this report was important: as PENSIDA II was scheduled to end in 2007, it helped make the case that the revision of PENSIDA II would need to address these shortcomings. What made this possible was the importance given by the Government of Honduras to improving its planning process. In the summer of 2006, the Honduran Minister of Finance and the Minister of Health requested the assistance of the Global HIV/AIDS Program (GHAP) of the World Bank to support the process of formulating a new HIV/AIDS strategy (PENSIDA III). GHAP responded positively through ASAP -- an initiative that had recently been established by UNAIDS to provide technical support to countries that wished to strengthen their national plans (See Box 1). Honduras was the first country in Latin America to request assistance and one of the first two to receive support (the other country was Madagascar). Box 1: What is the AIDS Strategy and Action Plan (ASAP)? ASAP, hosted by the World Bank on behalf of UNAIDS, provides support for HIV strategic planning (primarily to governments) in response to requests from countries, and in consultation with the UNAIDS Secretariat and Regional Technical Support Facilities, and other key partners. Since beginning operations in July 2006, ASAP has been active in over 60 countries and has supported two regional initiatives and three civil society networks. ASAP services include the following: External reviews of draft national strategies Technical and financial support to assist countries and regions to strengthen their strategic response to HIV/AIDS Development of tools to assist countries in their strategy and action-planning work Capacity building for policy makers, practitioners, and UNAIDS colleagues in strategic and action planning to strengthen the response to HIV/AIDS 3 In total, AIDS financial resources from government and donors rose from US$6 million in 2000 to US$23 million in 2007. 4 Reducing Vulnerability in Central America: Honduras: HIV/AIDS Situation and Response to the Epidemic. Latin America and the Caribbean and the Global HIV/AIDS Program. World Bank. 2006. 7 The timing of this work was critical. The request came at a moment when Honduras was planning a second generation Poverty Reduction Strategy Paper (PRSP). It was deemed essential that a revised AIDS strategy be available early on to be fully consistent with the national development objectives of the country. There was therefore a strong motivation to develop a new strategic plan to guide the effective response. Setting up the Process The decision to bring a new prism to the revision of the AIDS strategy came from within the country itself. It began with a committed leadership that guided the process and endorsed the new approach that was applied. Key elements included: Leadership by national authorities and broad social participation; A road map with key milestones supported by periodic and sustained communications between national stakeholders and ASAP; Participatory approach; and Strategic planning informed by evidence. Leadership The Ministry of Health played a crucial role during the process. It established a technical working group consisting of stakeholders from many sectors, government officials, academics, and representatives of civil society, PLHIV, and MSM/gay/lesbian associations. The technical working group was led by the National HIV/AIDS Program of the Health Secretariat and assisted by ASAP consultants and other bilateral and multi-lateral agencies. Its function was to assist the Ministry of Health in guiding the overall process. Its first task was to set up a road map. Road Map with Key Milestones The work was to be carried out in two phases (Table 2). The first phase of the work lasted from June 2006 to April 2007. It was aimed at providing the Government of Honduras with robust data and information on the situation of the epidemic and the response that could be utilized in formulating the next strategy. During that period, analyses were carried out to understand the HIV epidemic, assess the results achieved by the National AIDS Strategy (PENSIDA II), and identify the key issues that the new country strategy (PENSIDA III) should address. The second phase of the work occurred in May­November 2007. It was aimed at supporting the planning process of PENSIDA III, including the formulation of a results-based framework, the revision of the Monitoring and Evaluation Plan, and the estimation of the financial cost of PENSIDA III. 8 Table 2: Road Map and Key Milestones PHASE 1: DATA COLLECTION AND ANALYSIS Key milestones Due date Video conference to prepare initial visit of technical assistance mission June 29, 2006 Meeting between CONASIDA, World Bank, and consultants to define objectives of Sept. 17-22, 2006 work and critical steps Analysis of data, lessons to be derived, and elaboration of draft outline of Synthesis Nov. 27-30, 2006 Study report. Workshop to launch the process and define responsibilities with stakeholders Data collection by participants and preparation of Synthesis Study report Dec. 1-Jan 19, 2007 Consolidation of contributions in one report; first draft of Synthesis Study report; Jan. 22-Feb. 2, 2007 evaluation of PENSIDA II (self-evaluation tool) with some 60 participants Preparation of second draft of Synthesis Study report; elaboration of conclusions Feb. 5-March 9, 2007 Meeting with representatives of the First Lady's office, President, Ministry of Health March 19-22, 2007 officials, CONASIDA, and World Bank to define cooperation during second phase Revision of the situation analysis report, elaboration of recommendations, April 9-13, 2007 organization of working groups with national technical team and CONASIDA Preliminary Synthesis Study report is ready April 26, 2007 PHASE 2: DATA UTILIZATION AND PLANNING Key milestones Due date Three workshops (San Pedro Sula; Tegulcigalpa; Choluteca); sharing of synthesis May 15-16, 2007 report to prepare PENSIDA III Seminar with 60 participants to prepare PENSIDA III focused on (a) results-based June 12-14, 2007 planning and (b) monitoring and evaluation; agreement on work agenda for May- September period First workshop to elaborate PENSIDA III with the working groups selected by June 6-8, 2007 CONASIDA Second workshop with working groups July 11-13, 2007 Third workshop with working groups Aug. 8-10, 2007 Workshop to estimate and project the HIV epidemic Aug. 16-17, 2007 Workshop to estimate the cost of PENSIDA III Aug. 21-24, 2007 National Workshop to validate PENSIDA III Nov. 2007 Meetings with various national institutions to present PENSIDA III Nov. 2007 PENSIDA III launched Dec. 2007 9 Participatory Process From the beginning, broad consultation was deemed essential to ensure relevance and ownership of the national strategy. However, it necessitated clarifying the purpose of the consultations. Consultations can be for (1) information-gathering, (2) awareness- raising, (3) buy-in, or (4) a combination of these. Unless the purpose is clear, misunderstanding and frustration can easily arise among the participants and the organizers. The pure information-gathering approach encourages the greatest involvement and input from members, but can be counter-productive if it raises expectations that all the statements of the participants will be reflected in the final document. It can also lead to polarization of debate, particularly if participants hold views that reflect their own understanding of the epidemic or on their institutional mandates but are not well based on evidence of the epidemic. Consultation for awareness-raising avoids some of these issues. It provides an opportunity for community education, but participation may then have to be selective and more limited. This approach is often used when the National Strategy is nearly finished, and it is felt that the strategy needs to be widely disseminated. Consultations for buy-in encourage dialogue with policy makers, social leaders, and "public opinion," whose views of the strategy may affect its progress and reception. In Honduras, the approach that was chosen was to start with wide participation to inform all stakeholders of the planned revision of the strategy. The initial awareness- raising consultation was quite broad. Two-hundred and thirty-nine participants attended the initial launch of the process and at least fifty-five participants from forty- seven institutions remained actively engaged throughout the process. The detailed work took place through technical working groups, which were assigned different topics. An important aspect of this approach is that it made it possible for stakeholders from various backgrounds to participate in the review of the evidence that was generated as well as in the process of prioritizing interventions (Chapter III). As a result, stakeholders appreciated the participatory approach and viewed it as quite successful (Chapter IV). Strategic Planning Like the leaders of private companies, managers of AIDS programs want to know whether their programs are likely to provide satisfactory results. This is best achieved by using a results-framework for developing a strategy. With such a framework, managers are in a much stronger position for allocating resources to the programs most likely to halt and reverse the course of the epidemic. The application of a 10 results-based process to the preparation of the NSP started with a workshop to introduce the concept of the Strategy Results Cycle.5 The Strategy Results Cycle is a logical approach that starts the planning process with an analysis of the situation in the country, followed by the identification of expected results and priority programs for most-at-risk and other vulnerable populations (steps 1 to 4). It continues with the estimation of financial requirements and available resources (step 5) and the development of an M&E plan (steps 6 to 7) and ends with the preparation of the next strategic plan (step 8) (figure 1). This iterative framework is shown as a circle to emphasize that the preparation of a strategy does not stop once the draft strategy is ready, but needs to continue with the costing of critical interventions, the revision of the M&E plan, and the identification of a research plan to evaluate the results of the strategy. Once this is done, the process continues with the preparation for the next strategy. Figure 1: Strategy Results Cycle Set up the Step 8 overall Step 1 Use process Analyze evidence epidemic for next and assess strategy national response Step 7 Plan for Step 2 evaluating Identity NSF results NSF results Step 6 Specify Step 3 monitoring of NSF Select results Step 5 strategic programs Estimate cost Step 4 of Identify interventions critical and available interventions resources Source: Planning and Managing For HIV/AIDS Results: A Handbook. Global HIV/AIDS Program. World Bank. 2007 Note: NSF stands for National Strategic Framework for the AIDS response. 5 Rodriguez-Garcia, R., and J. Kusek. Planning for HIV/AIDS Results. World Bank, Global HIV/AIDS Program. 2007. 11 The use of the Strategy Results Cycle offered several advantages. First, it helped focus the work of the technical groups in answering the following questions: What are the lessons learned from the epidemic and the national response? What results needs to be achieved taking into account the available evidence? Which indicators need to be monitored to evaluate the expected results? Which strategic interventions need to be implemented to achieve the results? Which entity is responsible for implementing the intervention? Second, it provided a guide for preparing the new strategy by following the eight steps outlined in figure 1. They are described in the following chapter. 12 III. Strategic Planning Process (PENSIDA III) Improvements in policies and programs occur through constant reassessment in the light of relevant and up-to-date evidence. In Honduras, the process began with the analysis of the HIV epidemic and the national response during the previous plan (phase 1) and continued with the identification of priority programs. Analysis of Epidemic and National Response (Phase I) Analysis of the HIV Epidemic6 The epidemic has a complex profile: it is both concentrated among some population groups and generalized in some regions of the country. The HIV epidemic is particularly severe among ethnic minorities such as the Garifunas, which have a prevalence rate of 5 percent (2006 study), among men who have sex with men (MSM) (13 percent tested positive in a 2005 survey7), female sex workers (prevalence rate as high as 11 percent), and prisoners (HIV prevalence of 8 percent). Honduras's epidemic is also generalized in some regions such as the north -- it has established itself in the general population with HIV prevalence rates exceeding 1 percent among pregnant women. What explains these particularities of the Honduran epidemic? Why has it apparently spread primarily through sexual infection? Three key socio-historic factors8 inform the epidemic's geographical distribution and the population groups specifically at-risk: The development of a relatively large sex industry, coinciding with the presence of national and foreign armed forces in Honduras during the early 1980s; The high levels of mobility among the ethnic Garífuna population and other population groups, especially among the merchant marine and through their contacts with the northeastern United States; and, The initial rapid increase in the epidemic's prevalence among at-risk groups, particularly MSM. In what follows, we discuss the various ways in which this epidemic is reflected in geographical distribution, age, gender, and overall prevalence among at-risk populations.9 6 Much of the data in what follows is derived from "III Plan Estratégico de Respuesta al VIH en Honduras: PENSIDA III (2008-2012)." Tegucigalpa, Honduras. December 2007. 7 In the available data, the category MSM is exceptionally broad, comprising male homosexuals, transvestites, transsexuals, and bisexuals. 8 Cohen J. Honduras, Why So High? A Knotty Science Story. Science, no. 313 (July 28, 2006): 481:3 9 The following description is based on: Building on Evidence: A Situational Analysis of the HIV Epidemic and Policy Response in Honduras. Global HIV/AIDS Program. World Bank. 2008. 13 Geographical Distribution. As shown in figure 2, all 18 departments of Honduras have reported some AIDS cases. However, as previously mentioned, the HIV epidemic in Honduras is a relatively concentrated phenomenon, with a strong geographical concentration of AIDS cases. Figure 2: Cumulative AIDS Cases per 100,000 Inhabitants (1985­2005) Islas de la Bahia 297.5 Atlántida Colón Gracias a Dios Cortès 368.6 Santa 226.4 Bárbara 521.1 213.7 Copán 74.7 115. Yoro 122.6 7 Comayagua 48.2 62.4 144.6 34.5 Fco Morazán Ocotepeque 28.2 298.2 Lempira 52.4 Olancho 76.9 Intibuca La Paz El Paraíso Legend 202.1 184. 28 - 151 (10) Valle 4 151 - 275 (4) Choluteca 275 - 398 (3) 398 - 521 (1) Source: Department of STIs/HIV/AIDS, Health Secretariat, Honduras Reported cases of HIV are heavily concentrated by geographic area, reaching the status of a generalized epidemic along two axes, which together form a "T": east-to- west along the northern Atlantic coast (Cortés, Atlántida) and the islands (Islas de Bahia) and north-to-south from Cortés to the capital Tegucigalpa (in Francisco Morazán) and continuing southward to Valle on the Pacific coast. Together, these regions constitute the vast majority (71 percent) of all reported AIDS cases since 1985. In contrast, relatively few AIDS cases have been reported in the eastern and the western part of the country. A key factor in the geographical distribution of the epidemic has been its concentration in two urban areas--San Pedro Sula in Cortés and Tegucigalpa in Francisco Morazán. A key challenge is to determine whether the heavily urban character of AIDS in Honduras has to do primarily with the concentration of SWs or if other factors come into play. Other key concentrations are more easily explained by the prevalence of the Garífuna population in the islands and La Ceiba, in Atlántida, a major port and landing-point from the islands. But some developing trends require further explanation. For example, recent data show that some cities in the southern 14 department of Valle report a growing number of AIDS cases, suggesting a potentially worrying geographical shift whose causes must be determined and confronted. Age and Sex Distribution. As in other countries, HIV in Honduras primarily affects younger, economically and reproductively active people, and since the onset of the epidemic in Honduras, those between 15 and 39 have constituted between 65 and 70 percent of all reported cases. While the analysis of the epidemic's age distribution is fundamental for policy-making purposes, even more suggestive of the epidemic trends is the significant shift seen in the infection ratio between men and women. In 1994, this ratio was 1.7:1.0, suggesting an early prevalence among MSM and the exceedingly mobile male Garífuna population. But as the epidemic gained ground among sex workers and women in the Garífuna community, the ratio fell to 1.1:1.0 in 2005, and among the newly infected cases, the vast majority are women, with a ratio of 0.6:1.0. However, current projections suggest that this new imbalance may have peaked and may begin to recede as the brunt of new infections is estimated to fall on the MSM populations and (largely male) clients of sex workers. Prevalence in Specific Populations Pregnant women. Early surveillance data showed an infection rate among pregnant women attending an antenatal clinic (ANC) in San Pedro Sula of 3.4 percent in 1990 and 4.1 percent in 1995, and in Tegucigalpa of 0.2 percent in 1991 and 1.0 percent in 1996. These data gave rise to projections that the HIV prevalence rate would reach double digit figures within the decade, suggesting the possibility of a spread of the epidemic throughout the population. However, newer data from the PMTCT program (prevention of mother-to-child transmission)--which came into force in 2001--has painted a more optimistic picture. As shown in figure 3, HIV prevalence in PMTCT clinics--rather than continuing to rise--appears to have declined in both major cities, and a broad, eight-city study carried out in 2004 showed a prevalence of just 0.46 percent. While the geographical expansion of the PMTCT program makes it difficult to identify clear causes for the statistical decline, prevention efforts and the PMTCT program may have played a significant role in reducing HIV prevalence among the general population. 15 Figure 3: HIV Prevalence among ANC Attendees 6 5 HIV Prevalence (%) 4 3 2 1 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 San Pedro Sula Tegucigalpa Source: Secretaría de Salud de Honduras, Various surveys conducted at ANC clinics. Sex workers, men who have sex with men, and Garífunas. As with pregnant women, the data suggest that HIV prevalence has decreased among these three most at-risk populations (figure 4). The MSM population experienced a sharp increase--from 8 percent prevalence in 1998 to 13 percent in 2001--before dropping to 10 percent in 2006. The SW population also saw an increase--from 9.9 to 10.1 percent during the same years--but then declined sharply to 4.1 percent in 2006. The Garífuna population saw a steadier decline in HIV prevalence from 8.4 percent in 1998 to 4.5 percent in 2006. Several qualifications are required, however. First, the decline is statistically significant only for sex workers. And second, as these data come from different studies with different methodologies, it is important to note that they are not necessarily comparable across time. Figure 4: HIV Prevalence Rate in Selected Populations 15% HIV Prevalenced Rate Sex 10% Workers (%) MSM 5% Pregnant Women 0% 1998 2001 2006 Source: Studies of HIV Prevalence and Other STIs and Behavior. 1998 and 1999 Multicenter Study, Health Secretary/PASCA 2001. EVCV Health Secretary/CDC/GAP/CAP/ USAID, 2007. The persistence of HIV prevalence in the MSM population is of considerable concern, especially given increased condom use (see the next paragraph). It could suggest a contribution of further risk factors, most obviously sexually transmitted infections 16 (STIs) like syphilis, to the epidemic's intractability in that group. Furthermore, this persistence alongside the sharp decline in HIV among SW may suggest that current trends toward the feminization of the epidemic are occurring through other populations, such as the clients of SW transmitting HIV to their wives or other partners, and perhaps female sex partners of MSM who also have sex with women. Knowledge and Behavior Awareness of HIV in Honduras is nearly universal -- 98 percent of women have heard of AIDS. Among women who have heard of AIDS, 89 percent know that AIDS can be avoided by having sex with only one uninfected partner and 70 percent know that infections can be avoided by the use of condoms. The level of knowledge about HIV is higher among subpopulations at highest risk of infection (with the exception of PLHIV surveyed in 2006). For example, in 1998, 76 percent of MSM knew that condoms reduce the risk of HIV infection, and by 2001 the percentage had risen to 97 percent. Almost all SW (99 percent) knew that condom use reduces the probability of transmission of HIV. Better yet, condom use among at-risk population groups has increased in recent years (figure 5), although remains low (below 40%) among SW with regular partners. Figure 5: Condom Use in Selected Populations 100% HIV Prevalence Rate (%) 80% 60% 40% 20% 0% 1998 2001 2006 Sex Workers (n) MSM Garifuna Sex Workers (s) Source: Sierra M.A., Paredes C., Pinel R., Fernández J., Mendoza S., Branson B., Soto RJ. "Estudio Seroepidemiológico de VIH, Sífilis y Hepatitis B en hombres que tienen sexo con hombres de Tegucigalpa y San Pedro Sula, Honduras," 1998. Secretaria de Salud de Honduras. "Estudio Multicéntrico Centroamericano de Prevalencia de VIH/ITS y Comportamientos en Poblaciones específicas en Honduras," 2003. CDC. "Versión preliminar de los informes de la Encuesta Centroamericana de Vigilancia de Comportamiento en Hombres que tienen sexo con Hombres y de Trabajadoras Sexuales", 2007. Note: Sex workers (n) refers to condom use with new partners, sex workers (s) refers to stable partners. 17 Evolution of the HIV Epidemic One of the most important tasks of the planning team was to review the available evidence, revise the estimate of HIV prevalence, and predict future trends in Honduras. The analysis had an important conclusion: it showed that earlier predictions of rapid growth of the epidemic--possibly due to poor data--were not accurate. Instead of increasing, the analysis of the data showed that the national HIV prevalence rate has steadily declined in recent years and reached 0.7 percent in 2007 (figure 6). While it is too early to say for sure, several possible causes for the past and predicted decline in HIV prevalence stand out. The natural course of the epidemic (and the death of people infected early in the epidemic) could have contributed to this trend. The picture is certainly complex, but it does suggest that improved knowledge and behavioral changes, and especially the significant shift in condom use in affected populations, could have helped to bring about the decline. Figure 6: HIV Projection, % Adult Prevalence (1980­2010) 1.6 1.4 1.2 Adult prevalence (%) 1.0 0.8 0.6 0.4 0.2 0.0 1980 1985 1990 1995 2000 2005 2010 Another tool used by the team was the Modes of Transmission Model, which shed some light on the source of new infections (figure 7). It was estimated that 1,500 new infections occurred in 2007. The Garifuna population contributed 5 percent, given their relatively small numbers, high use of condoms, and decline in HIV prevalence in recent years. MSM, SW, clients of SW and the wives of clients together accounted for 48 percent of new infections. The most striking result was that only 1 percent of new cases are expected to be among sex workers, but 15.3 percent of new cases would occur among their clients and 12.4 percent among the partners of those clients. This showed clearly that it is not enough to target sex workers, efforts have to be directed at their sexual networks as well. Another 43.8 percent of infections were estimated to 18 occur among vulnerable populations, which include prisoners, adolescents, women, uniformed officials, and men. The broad nature of this category indicates the need to better specify and determine the groups that are expected to contribute to nearly half of new HIV cases, to enable more effective targeting. Figure 7: Modes of Transmission Garifunas 5% IDU 3% Clients of SW 15% Other Vulnerable Other Populations 29% 44% Client Partners 13% SW MSM 1% 19% Source: UNAIDS Modes of Transmission Model. SSH, Honduras. 2007 While the spread of HIV into the general population is important to recognize and address, it nonetheless remains critical to maintain a strong focus on those groups that continue to have the highest risk of infection. MSM and SW have HIV prevalence rates nearly 10 times higher than that of pregnant women. Their sexual partners may create a bridge for HIV to spread to the general population. The analysis of the HIV epidemic revised the understanding of the epidemic in Honduras, and provided a new way to look at the programs and policies that were put in place during the previous AIDS Plan (PENSIDA II). It made it possible to assess the shortcomings and failures of PENSIDA II from the point of view of their efficacy in turning around the epidemic, after taking into account the factors that have contributed to the decline in HIV prevalence, such as increases in knowledge and shifts in preventive behavior. Assessment of PENSIDA II There are a number of ways to evaluate the successes and failures of a strategic plan. In Honduras it was determined that the best approach would be to ask those who would be involved in the development of the strategic plan to assess the shortcomings 19 and the achievements of PENSIDA, thereby shifting the assessment from an abstract evaluation to a practical assessment. The Comprehensive Assessment of PENSIDA II was conducted through a participatory process involving over 100 participants from government, universities, NGOs, civil society, the private sector, donor agencies, and people living with HIV. Participants were divided into six groups. Each group was asked to complete the Self Assessment Tool (SAT), which had recently been developed for evaluating the strengths and weaknesses of a national strategic plan.10 The tool includes an Excel spreadsheet with a set of 55 questions covering 12 programmatic areas. For each question in the SAT, guidelines provide examples and benchmarks to help rate how well the strategy meets the criteria for each question. When groups lacked consensus about a particular question, they were asked to discuss the responses until a consensus was reached. Following the SAT assessment, the Technical Working Group was asked to identify what specific successes and failures had been most significant during PENSIDA II. Shortcomings of PENSIDA II PENSIDA II was generally unfavorably rated, with none of the programmatic areas scoring above 50 percent. PENSIDA II was deemed to have lacked the necessary resources and organization to implement a coherent response to the epidemic. Areas of particular weaknesses included (1) insufficient capacity to scale up the national response, (2) limited political commitment to address HIV, (3) limited prioritization, (4) inadequate monitoring and evaluation, and (5) limited financial resources. Limited capacity. PENSIDA II was unable to address the high turnover of personnel in all sectors of the public sector and civil society, both at the central and local level. High turnover made capacity building particularly difficult. This was compounded by a lack of human and financial resources and the limited involvement of education institutions in training medical staff on HIV/AIDS. Insufficient political commitment. PENSIDA II was not able to mobilize sufficient political support for mounting an adequate HIV/AIDS response. It did not adequately engage key groups such as religious groups and trade unions in participating in the national response. As a result, support for promoting sexual and reproductive health among adolescents and young people and mounting strong prevention programs among at-risk population groups remained limited. Weak prioritization. Unlike other strategies that focused on a limited number of priority populations, PENSIDA II identified 11 priority populations, ranging from those at high risk of infection to some in which the risk was negligible. The classification of such a large list of poorly defined subpopulations as priority target groups suggests that the strategic planning process was not sufficiently focused on the subpopulations 10 This tool can be found on the following World Bank website: http://worldbank.org/asap in English, Spanish and French. 20 that are driving the epidemic. In a context in which infection rates among the general population are low and declining, but in which some at-risk groups are experiencing high infections rates, a better focus on the sources of infection is needed. Shortcomings in monitoring and evaluation. Most National AIDS Strategies include a long list of indicators to measure results, but few have all the baseline indicator values, and seriously assess whether the needed data are available or indicate how missing data will be collected. A similar situation applied to Honduras. PENSIDA II included 35 indicators (10 measuring impact and 25 assessing results). However, only 18 were measurable. And only nine were successfully achieved. The failure of PENSIDA II to measure its indicators revealed significant shortcomings in its monitoring and evaluation. This was shown by the analysis of epidemiological data, which indicated that epidemiological evidence was available for only five (pregnant women, MSM, PLHIV, SW and Garifuna) of the eleven groups identified as being priority groups most at risk. Successes of PENSIDA II Putting concerns aside, it must be noted that PENSIDA II made considerable progress in addressing the HIV/AIDS epidemic in Honduras. In particular: Prevention activities increased quite substantially, as shown by: o Condom distribution reached 3 million per year and 1 million among the armed forces. o Some 100,000 people received HIV counseling between 2003 and 2006 at clinics and health centers. Treatment programs were scaled up: o Twenty-two care centers were created for people living with HIV and the number of facilities that can diagnose HIV increased from 48 in 2003 to 97 in 2006. o Access to antiretroviral therapy increased from very low levels prior to PENSIDA II to over 6,200 persons in 2006, a tremendous accomplishment. o The number of health facilities providing PMTCT rose from 15 in 2001 to 402 in 2006, covering the 20 health regions of the country. The strategy's overall success, as seen by falling prevalence rates among some at-risk population groups, is an important achievement. Identification of Results and Priority Programs (Phase II) Given the acknowledged need for a more strategic response, the preparation of PENSIDA III would have been incomplete had it failed to make the transition from 21 defining only the goals of the strategy without specifying how the goals would be achieved. First, this required a greater focus on monitorable programs with clear indicators and expected results.11 And second, it implied that the strategy would have to strengthen its focus on high priority groups, based on the new evidence on the sources of infections. Prioritization of Programs The lessons derived from the experience of PENSIDA II pointed in one central direction: strengthen the prioritization process and, in particular, prevention efforts benefiting the most at-risk groups. However, the prioritization process faced a key obstacle due to the limited data that was available. This was revealed by an analysis of HIV and STI prevalence studies as well as behavioral studies, which showed that there was sufficient information to warrant prioritization for a few groups only, notably MSM, PLHIV, SW and Garifunas. There was information for some other groups, such as pregnant women, but it was insufficient to provide a basis for prioritization. Finally, there are subpopulations such as drug users about which there is little or no information about HIV or STI prevalence or risk-taking behaviors (Table 3). In addition to shortcomings in the data available, the process of prioritization encountered another obstacle. Some representatives of civil society, who were members of technical working groups, overruled the voices of those who called for a focused approach to priority populations. As a result, the total number of target groups reached 20, a number that is twice as high as any other country in the region. Faced with this situation, a compromise was reached. The target groups were classified into three categories: (1) highest priority groups, which could be prioritized based on the available evidence; (2) groups known to be vulnerable but with low HIV prevalence; and (3) vulnerable groups for which more research is needed before they could be prioritized. Criteria for inclusion in these categories included evidence about their size, level of HIV and STI prevalence, estimated cost to reach them, access to services, and regional or global knowledge about the relevant risk factor/s. The prioritization process followed did not mean that the highest priority groups would receive all the resources while the population groups in the third category would be completely ignored. Instead, the classification of groups was meant to ensure that the groups known to be driving the epidemic receive the highest priority in PENSIDA III. It was also hoped that this prioritization would serve to drive the Honduran research agenda, to obtain better information for subpopulations that may be at high risk but for which little accurate data exist. Through this new system of categorizing at-risk and potentially vulnerable populations, the prioritization process was able to walk a fine line between excessive focus and excessive generality and at the same time ensure that the participatory process, which guided the preparation of PENSIDA III, could be maintained. 11 For more details, see III Plan Estratégico Nacional De Respuesta AL VIH Y SIDA en Honduras : PENSIDA III 2008 ­ 2012. República de Honduras, Comisión Nacional de SIDA (CONASIDA). December, 2007. 22 Table 3: Subpopulations Prioritized in PENSIDA II and the Availability of Evidence for PENSIDA III Subpopulations PENSIDA HIV STI Behavioral II Prevalence Prevalence Studies Disabled persons Ethnic groups o Garifuna o Tolupan o Misquito Orphans MSM and Lesbians o Gay men and other MSM o Lesbians Youth o Adolescents (10-19 years old) o Young adults (20-24 years old) o Street children Women in the general population o Housewives o Pregnant women o Victims of gender-based violence o Domestics PLHIV Mobile population o Truck drivers o Migrants o Taxi drivers Uniformed services o Police o Military o Security guards Prisoners Factory workers Sex workers Drug users Little or no information Insufficient information Reasonable information Estimation of Spending and Financial Requirements (Phase III) In order for PENSIDA III to respond effectively to the country's evolving epidemic, resources have to be spent in such a way that the country's priorities are fully funded. This required that Honduran policy makers (1) have accurate information about how resources are currently being spent and (2) assess the resources required to achieve the goals of PENSIDA III. Both goals were achieved by applying two tools, NASA 23 (National AIDS Spending Assessment12) and RNM (Resource Needs Model). The ASAP and NASA teams collaborated to provide harmonized support to Honduras in resources analysis. Spending Assessment A new picture of spending. The analysis from the National AIDS Spending assessment that had been carried out prior to the preparation of PENSIDA III revealed that HIV spending in Honduras increased almost 2.5 fold during PENSIDA II. After increasing steadily in 2003­2005, expenditures fell in 2006 but rose in 2007, reaching US$22 million that year (figure 8). This finding differed substantially from previous estimations. In particular, it corrected the perception coming from the 2000 and 2001 National AIDS Accounts that the national response was quite costly. At that time, national spending had been estimated at US$26 million with household spending accounting for half. The actual amount was only one-third of this amount. Another important trend revealed by the analysis was the growing share of national resources. They accounted for only 3 percent of all HIV resources in 2003, but their share has been steadily increasing in recent years and reached an estimated 40 percent in 2007 reflecting the growing role of government resources. Figure 8: HIV Resources (US$ Million) $25 $20 US$ Million $15 $10 $5 $0 2003 2004 2005 2006 2007 National Resources Development partners Allocation by interventions. About half was spent on prevention (51 percent), 31 percent on treatment and mitigation, and the rest on management (13 percent), human resources (2 percent) and research (3 percent). Within prevention, condom distribution (public and commercial sector) accounted for 28 percent of expenditures. The share of other prevention activities was as follows: STI treatment among women (14 percent), voluntary counseling and testing (VCT, 11 percent), out of school youth (11 percent), PLHIV (2.2 percent), MSM (2 percent), sex workers (male and female: 4.1 percent), and clients and partners of SW (2.2 percent). 12 See Annex II for a description of NASA. 24 Allocation by target groups. The largest proportion of funds was allocated to the general adult population (41 percent), followed by MSM and SW (33 percent), PLHIV (10 percent), health workers (6 percent), and others, which included prisoners, youth, students, migrant workers, etc. (figure 9). Figure 9: Allocation of Resources by Target Groups (2006) Health Other workers 10% 6% General Adult Population 41% MSM and SW PLHIV 33% 10% Source: PENSIDA III Note: the group "others" includes youth, students, prisoners, migrant populations, etc. Was this allocation justified in view of Honduras's epidemic? Should resources be more focused on (1) the general population, (2) subpopulations with the highest prevalence of HIV (such as MSM and SW), or (3) new subpopulations for which less data are available? On the one hand, the HIV epidemic remains generalized in some areas of the country, which suggests that current interventions should be maintained. On the other hand, the prevalence rate seems to be falling among the general population, which argues in favor of a shift toward other groups that may be at greater risk. However, the prevalence rate also seems to be declining, at least among SW and Garifunas, but not much among MSM. These trends suggest that it may be best to maintain interventions for the general population while reinforcing interventions for MSM and perhaps identifying other subpopulations that have not already been reached. This might include ethnic groups (e.g., Tolupan and Misquito) and people with disabilities. Funding of the AIDS Response. Implementation of the National Response is carried out through national agents (public and civil society), but it is funded in large part through external resources. In Honduras, 58 percent of HIV funding comes from foreign sources (multilateral and bilateral), 24 percent from public sources, and 18 percent from private sources (households). However, the implementation of the response shows a different pattern. The public sector (National AIDS Program and 25 health care units) accounts for 50 percent of expenditure, the private sector (pharmacies and NGOs) for 46 percent, and the external sector 4 percent (table 4). The result is that some sectors have relatively too much funding and others not enough. How to manage the differences between funding and implementation is an issue that is not specific to PENSIDA III. Other countries have tried to address it by strengthening the coordination function of a national AIDS commission. Perhaps it would also be beneficial to enhance the role of CONASIDA. Table 4: Funding Sources and Implementation Agents, 2006 Funding Implementation (% of Total) (% of National Response) Multilateral and Bilateral Donors 58% 4% Public Sector 24% 50% Private sector 18% 46% Source: NASA 2006. Honduras. Financial Requirements of PENSIDA III Methodology. When national strategies are being prepared, the need is to obtain an estimate of financial requirements that can inform the design and implementation of the strategy. Having such estimates early on during the preparation of the strategy enables planners to check whether the strategy can be financed with the available and expected resources. If not, the strategy can then be revisited and some parameters adjusted, such as the speed at which activities are scaled up or the degree to which the coverage of target groups is increased. In Honduras, there was limited information on the flows of funds through the national response, which made it difficult to estimate the unit cost of interventions. A model that did not require too much new data to be collected had to be used. Following the examples of other countries, the Resource Needs Model (RNM) was chosen for estimating the financial cost of Honduras' strategy. The underlying methodology of the model is quite simple: for most programs the cost is calculated by multiplying unit costs by the expected coverage of the interventions (figure 10). This requires knowing the following: The estimated unit cost of reaching each target population; The size of each target population; The current size of population groups receiving services; and The projected size of the target groups during PENSIDA III. 26 Figure 10: Costing National Aids Strategies STEP 1: IDENTIFY PRIORITY PROGRAMS STEP 8: REASSESS SCALE STEP 2: DEFINE TARGET AND COVERAGE OF POPULATION GROUPS INTERVENTIONS STEP 3: IDENTIFY STEP 7: ESTIMATE PRIORITY INTERVENTIONS FUNDING GAP STEP 4: SET COVERAGE STEP 6: ESTIMATE COST OF TARGETS PROGRAM STEP 5: ESTIMATE UNIT COST OF INTERVENTIONS As the RNM is described in great detail on the Web site of the Futures Institute,13 the focus here is only on its broad characteristics and the main results. Assessment of the Projected Financial Requirements Are needs overestimated? The RNM methodology suffers from well-known shortcomings stemming from the difficulties involved in correctly estimating how unit costs would evolve over time. Like many other countries, Honduras did not have data on unit costs and it was not feasible to collect specific data to determine the unit cost of each intervention. Instead, unit costs were derived from the ABC model, which had been estimated earlier on for Honduras,14 or from the default values of the RNM. As these values might not accurately reflect Honduras's unit costs, the cost of the national strategy could be either underestimated or overestimated. How likely is this? One indication is provided by comparing actual expenditures from NASA with the projected amounts. Figure 8 shows steadily increasing expenditures that, if extrapolated to 2008, are consistent with projected financial requirements of about US$30 million in 2008. This suggests that there is no obvious bias in the projected aggregate cost. However, this may not be the case for each program. Improving the accuracy of the estimation is one of the challenges facing PENSIDA III that has to be addressed when the annual operational plans are prepared. 13 A more detailed explanation of the Resource Needs Model (as well as the actual software) can be found at www.futuresinstitute.org/pages/resources.aspx. 14 This model is described in Optimizing the Allocation of Resources among HIV Prevention Interventions in Honduras, The World Bank, HNP. 2002. 27 How different is PENSIDA III? The PENSIDA III priorities are reflected in the projected coverage of interventions and the allocation of resources, which demonstrate the program's commitment to target at-risk populations. For instance, one aim is to increase the percent of SW with sound knowledge about HIV transmission from 54 percent (2006) to 93 percent by 2012, and increase condom use from 86 percent to 95 percent during the same period. The goals for the MSM population are to increase knowledge from 28 percent (2006) to 75 percent (2012) and increase condom use from 67 percent (2006) to 90 percent (2012). For the Garífuna population, the focus is above all on education, with the aspiration to increase knowledge about the epidemic from 20 percent (2006) to 80 percent (2012). As a result of the increased focus of interventions on at-risk groups, there will be a progressive doubling of the funds allocated to these target populations: from $100,000 to $200,000 annually for Garífunas; from $300,000 to $600,000 annually for SWs; and from $800,000 to $1.6 million for MSM. Differences in the allocations do not reflect the relative priority of each target group; instead, they are driven by the size of each target population and the estimated unit costs of reaching an individual in that population (the estimated unit costs for reaching SW, for example, are four times that of providing prevention services to Garífunas). Figure 11: Allocation of Resources (PENSIDA II and III) (% of total) 60 50 Percent of total 40 30 20 10 0 Prevention Treatment and Administration, Mitigation Care Policies and Research PENSIDA II (2003) PENSIDA II (2004) PENSIDA III Note: PENSIDA II (2003): budget allocation estimated in 2003, PENSIDA III (2004): budget allocation estimated in 2004 with Global Fund Proposal How different is the overall allocation of funds among program categories? As summarized by figure 11, the main increases are in prevention; administration, policies and research; and mitigation, which reflect the PENSIDA III focus on strengthening prevention activities for populations at-risk and developing a strong evidence base. The sharp fall in the share of treatment and care is due to the lower 28 cost of treatment (as a result of the decline in drug prices). Within prevention, 32 percent is allocated to the high priority groups, 52 percent to service delivery (condom distribution, STI treatment, VCT, PMTCT, and IEC) and 16 percent to health care (blood safety and Universal Precautions). Funding gap. PENSIDA III foresees a marked increase in overall program funding. For PENSIDA II, the initial budget was estimated at US$5 million in 2003, and increased to US$25 million in 2004. In comparison, PENSIDA III looks ambitiously toward a gradual increase from $30 million in 2008 to $50 million in 2012 (figure 12). There was no national spending assessment (NASA) for 2008, but based on the 2006 estimates of US$20 million, the financial gap could be between US$10 million and US$30 million per year. To fund it, Honduras will have to generate some fiscal space. Figure 12: Financial Requirements of PENSIDA III (US$ Million) 60 50 40 US$ Million 30 20 10 0 2008 2009 2010 2011 2012 Administration Orphans Treatment Prevention Fiscal Space: the Challenge Ahead Fiscal space can be generated through the following options: (a) increasing taxes and strengthening tax collection, (b) mobilizing additional aid (grants) and borrowing domestically or externally, and (c) reducing lower priority expenditures and improving technical efficiency. Typically, fiscal space is generated through a combination of these three options, but with a different emphasis that depends on the country's characteristics. The generation of additional fiscal space is important for Honduras. The country is facing mounting fiscal pressures that have to be brought under control. Signs include the acceleration of inflation, which reached 9.6 percent at the end of 2007; the doubling of the current account deficit to 10 percent of GDP; and the decline in international reserves. It is difficult to increase public expenditures in this environment, as this would worsen economic imbalances. 29 This situation creates a dilemma for the national AIDS response. The absolute amounts required for financing the country's National HIV/AIDS Plan (PENSIDA III) would rise from US$30 million in 2008 to US$50 million in 2012. This means that HIV/AIDS expenditures as a share of total health spending would rise from 8 percent in 2008 to 11 percent in 2012. Over the longer term, costs may rise much more, mainly due to treatment of an increased number of patients and especially as the numbers on second line regimens increases. How could this cost be financed? The first option for mobilizing additional resources is external borrowing. In that respect, Table 5 seems to offer an optimistic outlook. It shows that Honduras's debt service is relatively low. However, this is mainly because the country received substantial debt relief under the Highly Indebted Poor Countries initiative (over US$3 billion). Over the medium term, it is expected that external financing will be mainly on concessional terms, which should allow for some additional space. But the actual amount is likely to be constrained by the limited availability of concessional lending from international financing institutions. Table 5: Selected Macroeconomic Indicators, Honduras and Other Latin American Countries Gross National Revenues Expenditures Aid Debt Service Income per (% of (% of GDP)2 (% of GDP) Ratio capita GDP)1 (% of exports) Bolivia 1,010 23.5 26.6 6.5 14.8 Columbia 2,290 27.6 31.4 0.4 35.3 Dominican 2,460 16.7 16.2 0.3 6.9 Republic El Salvador 2,450 16.0 17.7 1.2 8.6 Guatemala 2,400 10.1 11.0 0.8 5.8 Honduras 1,270 16.4 19.9 8.6 3.7 Nicaragua 950 22.4 21.0 15.4 6.9 Paraguay 1,040 21.2 16.7 0.7 11.4 Peru 2,650 17.6 17.3 0.5 26.0 Notes: 1 Revenues including grants of the central government budget 2 Total expenditures of the central government budget Source: World Development Indicators, 2008. World Bank The second possibility for increasing revenues would be to mobilize additional grants. Recently, Honduras was able to obtain grant funding from the Global Fund. It was also quite successful in mobilizing other external donor assistance. Compared to other countries (table 5), Honduras's aid inflows rank second highest (after Nicaragua). Given that the current financial crisis is affecting nearly all donor countries and may 30 affect their contributions to the Global Fund,15 Honduras may not be able to increase external funding for AIDS in the near future. The third option would be to increase tax revenues. The comparison in Table 5 shows that Honduras raises much less revenue (as a percentage of GDP) than other Latin American countries with similar income per capita (Bolivia, Nicaragua, and Paraguay). If the comparison is extended to include all countries in the region, its tax ratio is the lowest with the exception of Guatemala. This suggests that over the longer term Honduras could finance its increased AIDS expenditures by generating additional fiscal revenues. As the projected AIDS expenditures would increase from 0.2 percent of GDP in 2008 to 0.3 percent of GDP in 2012,16 the required raise in taxes would be sufficiently small to seem feasible. The fourth option for financing additional expenditures consists in reducing lower priority expenditures and improving efficiency. Compared to the Latin American countries listed in table 5, Honduras's budgetary expenditures do not appear particularly low. Only Bolivia, Columbia, and Paraguay have markedly higher expenditures. But in all these three cases, the higher level of expenditures was financed through higher tax ratios. This suggests that Honduras' room for further increases in expenditures would depend on its ability to raise more taxes. Given the difficulties involved in raising taxes, it may be necessary to increase the efficiency of existing expenditures. To the extent that expenditures can be reallocated from low to high priority areas, there would be room for accommodating new expenditures within the existing envelope. This could help finance the projected increase in AIDS expenditures if AIDS is considered a high priority. The various options opened to Honduras are shown as a "fiscal diamond" (figure 13). This diamond is purely illustrative. It is meant to summarize the previous discussion rather than present the actual fiscal space gains; that would need more detailed analysis than is feasible here. The illustrative diamond suggests that additional fiscal space could be generated through additional revenues, borrowing on concessional terms and increasing the efficiency of public expenditures. The vertical axis reflects the assumption that Honduras could raise additional tax revenues, but that it may not be in a position to mobilize more external aid (grants). The right hand horizontal axis reflects the hypothesis that increases in allocative and technical efficiency could provide an important source of fiscal aid accompanied by increases in external borrowing on concessional terms (bottom vertical axis). 15 For more details, see: Global Economic Crisis and HIV Prevention and Treatment Programmes: Vulnerability and Impact. Joint World Bank/UNAIDS Report. June 2009. 16 These estimates are obtained by assuming that (i) GDP would increase by 24.6 percent in constant prices from 2007 to 2012 (IMF staff report, February 2008) and (ii) health expenditures would increase at the same rate as GDP. In 2007 total health expenditures amounted to 6.4 percent of GDP and public expenditures were 47.8 percent of the total. 31 Figure 13: Honduras: Illustrative Fiscal Diamond Increase in Revenues Improvements in Increase in Aid Expenditure Efficiency Increase in Concessional External Debt This conclusion, based on aggregate data, is consistent with the analysis of the AIDS response during PENSIDA II, which indicated that the AIDS response needed to be better focused on attacking the sources of the epidemic and supported by a corresponding realignment of financial resources. Have these changes been achieved? While it is certainly too early to tell, there are some encouraging indications that the preparation of the PENSIDA III led to improvements in the setting of priorities and the allocation of resources. These are discussed in the following chapter, which assesses the results attained through the preparation of PENSIDA III. 32 IV. Assessment of the Strategy Preparation The previous chapters described how the process of revising Honduras's strategy was carried out, highlighting four central characteristics: The presence of country-owned strategy made possible by a committed leadership and sustained by a focused participatory approach; The development of a strong evidence base informed by the analysis of the epidemic and the review of the achievements of the national response; A clear results-oriented framework for formulating the strategy, accompanied by the identification of key programs and the estimation of their financial costs; and, A results-focused monitoring and evaluation approach that provides information on the progress of the response and can serve to inform the revision of programs. However, one question was left unanswered: has the preparation of PENSIDA III had lasting effects? Too often strategies remain documents that are quickly forgotten once they are published, with little effect on implementation. Was this the case in Honduras? To find out, a survey of government officials, civil society representatives, and development partners was carried out a little more than one year after the completion of PENSIDA in 2007 to determine whether the revision process was deemed to have made a difference. Client Survey (2009) The survey covered people who had participated in the revision of the strategy. Seventeen people attended the meeting during which the survey was conducted. While relatively small, the group included a broad range of participants from donor agencies (7 percent), government ministries (20 percent), National AIDS Commission (13 percent), civil society (47 percent), and United Nations agencies (13 percent). The survey included 29 questions in five broad categories: analysis of the national response, results framework, participatory process, and financial costing of the strategy and impact of the work. The questionnaire is provided in Annex 3. Overall, the survey points to the following achievements and challenges: Achievements Participants were satisfied with the analysis of the epidemic and the national response, the results-based framework, capacity building, and the participatory approach. Most important, high ratings are given several of the characteristics of strategic planning (namely, setting of priorities, identification of key programs, and allocation of resources). Questions were rated on a score of 1 to 5 and converted in percentage terms from 0 percent to 100 percent of maximum score. 33 The analysis of the epidemic and national response was rated at 85 percent of the maximum score. The work was deemed to have been extremely relevant, easy to understand, objective, and detailed. Ratings for these categories were close to 90 percent of the maximum score. The timing of the work, the use of all available information, and the links between the evidence and the conclusions received ratings close to or above 80 percent of the maximum (figure 14). Figure 14: Rating of Situation Analysis (% of maximum score) 100 Percentage of Maximum Score 90 80 70 60 50 Good timing Strong links Objective Easy to Clear Detailed Relevance between analysis understand methodology analysis evidence and conclusions The results based-framework received an average score equal to 84 percent of the maximum possible score. The framework was rated as easy to understand and useful with a clear methodology, and the working groups were able to develop their own results-based framework (figure 15). Figure 15: Assessment of Results-Based Framework 100 90 Percent of maximim score 80 70 60 50 Easy to Useful Clear Able to understand Methodology develop framework 34 Capacity building was achieved. Participants felt that they had gained a better understanding of the HIV epidemic (94 percent of maximum score) and received practical information that helped them take decisions on HIV programs (92 of maximum score). Given these results, it is not surprising that the technical assistance that was provided got excellent ratings (89 percent of maximum score). The participatory approach was deemed to have been useful (figure 16). Participation was judged to have been useful--this category received one of the highest ratings (95 percent of maximum score). The area rated lowest was the involvement of civil society, but this reflected the desire of some participants to participate in decision making--a task which may conflict with the government functions. Figure 16: Ratings of Participatory Approach 100 Percent of maximum score 90 80 70 60 50 Involvement of Participation Communication Was the Technical civil society was broad among participatory assistance enough participants process useful Strategic results were achieved (figure 17). In particular, survey participants mentioned that the revision process: Influenced the setting of priorities (90 percent of maximum score); Provided practical information that led to the identification of specific interventions (92 percent of maximum score); and Resulted in a new allocation of resources (95 percent of maximum score). Importantly, participants said that the new strategy is being used (88 percent of maximum score) and that the approach used for preparing PENSIDA III should be used for the next strategy (89 percent of maximum score). 35 Figure 17: Strategic Results (% of Maximum Score) 100 Percentage of maximum score 90 80 70 60 50 Strategy is Gained clear Influenced Contribued to New resource used vision of setting of new allocation priorities priorities interventions Shortcomings Revision process. There are always trade-offs involved when asking a large and diverse group of representatives from different sectors of society to work in technical groups. This becomes even more complicated when this work is constrained by the time schedule of staff, consultants, and actors. Some participants expressed frustration with the process, particularly with the lack of clear assignment of responsibilities to the technical working groups and the lack of continuity among the participants. They viewed the process as not being sufficiently well articulated between groups. Participatory approach. How to ensure "effective" participation in the preparation of a strategy is a long-standing issue. This is even more the case when dealing with the HIV epidemic, which may require technical knowledge that some participants may not have. This was well reflected by some participants, who complained that the analysis was sometimes difficult to understand. Another issue is how broad the participation of civil society should be. It would seem that a good compromise was achieved. However, some disappointment was expressed, perhaps because some members had expected to be actually involved in decision making. Dissemination and sharing of analysis. Related to some of the criticisms of the participatory approach followed, some participants thought that the results of the work should have been shared more widely, and especially among government ministries. This criticism is certainly valid, but it is also important to note that not all government ministries need to be involved. Only those that have a clear role in implementing the AIDS response need to be involved. Costing. The question as to whether the methodology used for estimating the financial resource requirements met participants' expectations received a 68% 36 score. The extent to which it was useful for the strategy preparation was scored only 78 percent, among the lowest scores. Offsetting this assessment, survey participants gave a very high score of 95 percent when asked if the financial estimation of resources led them to propose a new allocation of resources (figure 18). Figure 18: Assessment of Costing 100 Percent of maximum score 90 80 70 60 50 Meet Useful for Influenced the expectations strategy allocation of preparation resources Overall Assessment Synergy effect. All variables were rated very high. While the variation in the scores given to individual questions reveals the shortcomings and weaknesses of the revision process, the average rating17 given to the five broad categories used in the survey shows the synergy that was achieved (figure 19). Four categories (situation analysis, results-based framework, costing, and participatory process) represent the various "tools" that were used to revise the strategy. The overall average is captured in the first column, "overall result." Interestingly, each of the four tools was rated lower than the result of the process, and it is within the category "impact" that some of the highest scores were registered. This suggests that while each tool was imperfect in some aspects, the shortcomings were muted by the interactions among them. This result is important: it suggests that providing a comprehensive process of technical assistance covering several aspects of a strategy is highly beneficial. In the end, it achieves results which go beyond those derived from technical assistance that is limited to one area. Technical assistance. The high rating given to technical assistance (89 percent of maximum score, figure 19) highlights the benefits of sustained assistance through several visits to Honduras over a 10-month period. This was costlier than the more usual short-term assistance, but generated worthwhile benefits that were highly rated by the survey participants. In particular, it helped sustain the policy dialogue 17 The average rating for a category was calculated as the average of ratings for individual questions. 37 throughout the preparation of PENSIDA III as reflected in the high rating given to the overall impact (figure 19). Figure 19: Comparison of Scores 100 90 Percent of maximum score 80 70 60 50 Challenges ahead The revision of Honduras's strategy clearly raised new expectations to be addressed during the implementation of PENSIDA III. These concern the following: Research agenda. An agenda would have to be implemented to address the knowledge gaps identified during the revision process. This would help prioritize areas where the lack of evidence prevented prioritization during the preparation of PENSIDA III. M&E system. It needs to be strengthened so that it can generate the data needed for monitoring progress, making improvements, and evaluating results. Evaluation of PENSIDA III. The implementation of PENSIDA should be regularly evaluated, and the results shared widely among stakeholders. This process will also facilitate the elaboration of PENSIDA IV. Role of CONASIDA. An important step for improving the coordination and involvement of actors in the implementation of the strategy would be to strengthen CONASIDA. Participation of civil society. The involvement of civil society was deemed good, but the shortcomings expressed by some participants perhaps point to the need for creating a more structured institutional setting and more selective participatory process. Methodology. While participants expressed satisfaction with the tools that were used, further refinement and improvement seem necessary, especially in the estimation of financial requirements. 38 What Made the Difference? Four factors stand out: Decisive national leadership and support by international development partners; Sustained technical assistance combined with a strong planning team; Sustained participatory approach; and Focus on capacity enhancement through knowledge transfer. Decisive Leadership In Honduras there was decisive national leadership. Since September 2006, when support started, the Minister of Health--also chair of the National AIDS Commission (CONASIDA)--followed the process closely. The Minister provided effective support as champion of the process and met regularly with staff and consultants for briefings. His support added strong legitimacy to the process and made it possible for the national technical team to reach out to a broad array of interested stakeholders (including people living with HIV, civil society, etc.). Support of Key International Partners. The national HIV/AIDS program obtained substantial ongoing support from the UNAIDS office. UNAIDS in country was critical in brokering support for the national program from all other partners and ensuring that partners' ideas were taken into account in the provision of technical support for the formulation of PENSIDA III. The UNAIDS regional support team, as well as USAID, CDC, PAHO, The Global Fund, and other donors, also provided essential contributions at critical times in the situation analysis and strategy formulation process. Collaboration with the UNAIDS Secretariat in Geneva was instrumental in providing specialized support to the analysis of HIV/AIDS spending in Honduras, which--together with costing--allowed for a more robust resource analysis. Building on World Bank supervision missions. The World Bank provided support that involved close cooperation among the LAC Region Central America Health/AIDS Project, the Global HIV/AIDS Program (ASAP), and the World Bank's country office. The LAC Region implemented a different approach to the traditional supervision of Bank-funded projects. In parallel to supervision missions, it organized workshops on specific technical issues to which key actors, including donors and international agencies working on HIV/AIDS, were invited. This framework provided a space where planning teams and development partners could discuss the HIV/AIDS response. When the Ministry of Health identified the need for technical assistance, the LAC region was therefore able to respond by mobilizing support from ASAP. 39 Sustained Technical Support The support team (GHAP and LAC-CA) provided overall guidance during a ten-month period.18 Country visits were combined with virtual communication for support management, team building, and open communication. These ensured dialogue with national counterparts, UNAIDS-Honduras and UNAIDS-Geneva, other partners, and consultants, to monitor progress, and most importantly, to keep everyone involved and engaged. The support team worked closely with national counterparts led by the HIV/AIDS Program of the Health Secretariat. From the outset it was agreed that the planning process needed to be participatory and the products shared widely with stakeholders--policy makers, civil society, and partners. Synergy effects. Honduras benefited from the presence of strong national technical experts. This allowed the planning team to take advantage of the tools provided by the international technical assistance and apply them. With the Minister of Health-- also chair of the National AIDS Commission (CONASIDA)--playing the role of a champion, the technical experts made a commitment to conduct a comprehensive analysis of the situation in Honduras in preparation of the next strategic plan. This 360-degree analysis engaged stakeholders and enhanced the team's ability to generate information that was fed into the formulation of the new strategic plan. As mentioned, the combined use of several tools generated some strong synergy effects. Continuity in support. The technical support team remained the same throughout the 10-month process. This included two World Bank headquarters staff and one country office staff, two main consultants, the UNAIDS office staff, and the core planning team. Two other consultants were added later in the process to facilitate spending analysis and the completion of the results, indicators and targets table for the strategy. Participatory Approach The new HIV/AIDS strategy and an analysis of the epidemic are byproducts of an effective participatory process involving the efforts of people who guide, facilitate, and participate in this process with open minds. Of the assessment survey participants, 73 percent said they had participated in all the meetings throughout the process. While it is difficult to know how representative this is, the revision of the strategy was carried out with a large number of stakeholders attending meetings. In total, the national HIV/AIDS strategy planning process involved well over 100 Honduran stakeholders and more than 300 people who participated in central and regional workshops. This approach was followed in order to establish a national consensus about the priorities in PENSIDA III as well as to gain support for new priorities. Listening to counterparts and stakeholders made a difference in everybody's understanding of the national situation and opened minds as to possible actions. This 18 The support team consisted of World Bank staff and ASAP consultants, who were joined in country by the UNAIDS office staff. The World Bank country office staff facilitated key in-country logistics. 40 approach helped increase the focus of PENSIDA III on addressing the needs of those most affected. For instance, an analysis of Latin American HIV/AIDS Strategic Plans reveals that a disproportionately small level of resources is allocated to groups such as men who have sex with men that are critical to responding to the region's HIV/AIDS epidemic. Involving MSM in the actual strategic planning process in Honduras helped increase commitment to providing more resources for delivering prevention, treatment, and care services to MSM. Focus on Capacity Enhancement This approach to assisting countries in their strategic and action planning process emphasizes the need to transfer knowledge and build the capacity of local teams. Rather than developing a "ready-made" guide around which Honduras could design its strategic plan, the support team worked directly with Honduran stakeholders and decision makers to meet their needs and build their capacity in various aspects of strategic planning. This approach was designed to emphasize the transfer of skills and knowledge and to meet the needs of counterparts. The strategic planning process in Honduras also revealed the importance of strengthening the capacity of stakeholders to use data. For example, the support team worked with Honduran counterparts to develop an "analysis and synthesis report," which summarizes all available epidemiologic and economic data regarding the epidemic in Honduras. By providing stakeholders with skills in areas such as epidemiologic projections, costing, general strategic planning, and monitoring and evaluation, national authorities and the support team hoped also to improve the use of data in the overall decision-making process. In discussions about which populations should be prioritized in Honduras, for example, stakeholders challenged each other to provide evidence that illustrates how the next strategic plan should be focused. Final Thoughts Country ownership is crucial. Technical support must encourage and respect national decision making. When national planning teams are small and are given additional responsibilities such as the preparation of a national strategy, government staff has to carry the burden of their daily responsibilities plus those added by the new project deadlines. In situations such as these, consultants cannot play the role of managers if the objective is to have national ownership of the strategy. The preparation of a new strategy must be embedded within national processes with technical assistance playing a role of catalyst and coach. At the end of the day the final product--in this case the national HIV/AIDS strategy--is a national document, and the political and social reality of the country is the context within which advice from international assistance is considered. There is a need for technical assistance to middle-income countries. As shown by the results that were achieved, there are valid reasons for providing technical assistance 41 to middle-income countries, which tend to have less access to grant financing for developing national AIDS strategies than lower income countries. Participatory approaches are hard but beneficial. It takes time--a challenge when working to deadlines--patience, and effort, and therefore money. There are times when it would have been easier for the consultants to just do their jobs without trying to fit within national processes. Proceeding in this manner, however, would not have allowed for leveraging the local talent, the added value of learning from dedicated local teams, and the lessons learned elsewhere and in the country. The process is probably as important as the product. The technical assistance provided to Honduras was not aimed at producing the "perfect" National AIDS Strategy. Rather it was aimed at ensuring that the preparation process would lead to an improved National AIDS Strategy. Key elements included the following: o Development of a road map with key milestones supported by constant communications between national stakeholders and ASAP technical assistance. This allowed the national leadership to monitor progress and understand the full process. o Agreement on a participatory approach that brought in a wide spectrum of views and led to country ownership of the final product. o Development of evidence for decision making. The review and analysis of PENSIDA II was time consuming but effective. It allowed stakeholders to assess the shortcomings of PENSIDA II and to revise their understanding of the epidemic. o Prioritization of interventions. The formulation of a new system to identify both potentially vulnerable and at-risk populations allowed the stakeholders to prioritize results and interventions for PENSIDA III. o Importance of monitoring and evaluation. The importance attached to measuring results gave strong impetus to efforts aimed at closing the knowledge gaps identified during the preparation process of PENSIDA III. o New resource allocation. The identification of relatively clear priorities and agreement to target at-risk groups made possible a new resource allocation. Despite remaining challenges, PENSIDA III represents a major step forward in Honduras's effort to respond to the epidemic based on both evidence about the epidemic and stakeholder participation. 42 Annex 1: National AIDS Spending Assessment (NASA) NASA is the third-generation tool developed by UNAIDS for assessing national spending on AIDS.19 The first-generation tool was a sub-analysis of National Health Accounts, which provided a breakdown of HIV/AIDS expenditures. The second generation tool--National AIDS Accounts--was developed to include expenditures on activities outside the health sector. NASA represents the first effort to harmonize the various classifications of HIV/AIDS activities. It is expected that this harmonization process will facilitate comparison of estimates of actual expenditures with the projected future needs estimated using the Resource Needs Model, and thus help identify the funding gaps likely to emerge. Methodology When the work plan was being designed for applying the NASA methodology to Honduras, great skepticism was encountered. It was felt that the team would not be able to overcome information gaps and the likely unwillingness of various stakeholders to provide the needed data. Contrary to these expectations, data collection proceeded quite well. What made this possible? Certainly, UNAIDS was instrumental in calling various NGOs and convincing them to participate in the exercise. But there are other factors. Participants were made part of the data collection and analysis. They were informed that they would be contacted later on to discuss the overall results of the exercise and validate the data. This approach helped participants feel that even though they would have to spend time collecting data, in the end they would derive benefits. Data collection. The main challenge facing the team was the lack of a centralized information system, which would have enabled transactions related to HIV to be tracked. Records had to be reconstructed following top-down and bottom-up approaches, which allowed for an important consistency check, namely, that the two sources agree on the amount of money spent (Box 1). Participatory approach. Once the initial data collection had been carried out, confirmation needed to be obtained that the data were correct. This was done by first holding a meeting with the technical experts involved in the management of the national response. This meeting served to identify missing information or correct erroneous interpretation of connections among funders and implementers. Another meeting was then held with those who had provided information (and had been told that a feedback session would take place). During this feedback session, participants were shown how spending flows through the national response, based on the information they provided. As the 25 specialists who attended were responsible for 78 percent of the resources of the national response, the meeting reinforced the 19 NASA, including the Excel file and the RTS software to create matrices, can be downloaded from the following site: http://www.unaids.org/en/Coordination/FocusAreas/track-monitor-evaluate.asp. 43 conclusion that expenditures were correctly measured. All the changes recommended by the participants were then made, ensuring that the information generated by NASA was assimilated by all actors, who made a commitment to improve their internal information systems so that future collaborative studies could take place using more detailed information. 44 Annex 2: Assessment of the Planning Process of PENSIDA III The purpose of the survey was to assess the results achieved by the process of knowledge transfer, technical support, and consultation that was implemented for the preparation of PENSIDA III. The survey assesses the extent to which the knowledge transfer provided was relevant and had an impact, and it reviews the effectiveness of the preparation process. Ratings ranged from 1 (lowest) to 5 (highest). Institutional background Yes No National AIDS Program Other government agencies UN Agencies Other donor agencies Participation in preparation of PENSIDA III Were you aware of the process? If yes, Did you participate throughout the process? Did you participate only through part of the process? Ratings Analysis of HIV Situation 1 2 3 4 5 1. How was the analysis relevant to your own work 2. Was the purpose of the analysis easy to understand? 3. Was the analysis timely? 4. Was the analysis unbiased and objective? 5. Was the analysis insightful and strong? 6. Did the analysis incorporate all available information? 7. Was the methodology transparent and clear? 8. Was the link between the conclusions and the evidence strong? Application of Results Framework 1 2 3 4 5 9. Was the framework easy to understand? 10. Was the framework useful? 11. Was the methodology transparent and clear? 12. Was the planning team able to develop a results framework? Estimation of Financial Cost of Strategy 1 2 3 4 5 13. Did the estimation meet your expectations? 14. Was the estimation useful for the formulation of the strategy? 15. Did it stimulate you to propose new allocation of funds? 45 Ownership and Participatory Process 1 2 3 4 5 16. Was the participation process sufficiently broad? 17. Did the consultants assist in an effective manner the planning team? 18. Was the civil society sufficiently involved? 19. Was there sufficient communication among participants? 20. Do you feel that the participatory process was useful? Impact of Work 1 2 3 4 5 21. Did it influence your understanding of the HIV/AIDS epidemic? 22. Did it help you gain a clear view of essential lessons? 23. Did it influence the prioritization of the HIV strategy? 24. Did it provide you with practical information to help you make decisions on HIV strategies and programs? 25. Did it help you make the case for a particular HIV intervention? 26. Did it help you identify knowledge gaps and proposing new analysis and research? 27. Did it help improve programming of PENSIDA III (better links between results and output) 28. 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Soto RJ, Alvarenga M, Walker N, Garcia-Calleja J, Zacarias F. (2002). Estimating HIV/AIDS Prevalence in countries with low-level and concentrated epidemics: the example of Honduras. AIDS, 16 (Supplement 3), S18-S22. Stover J, Bollinger, L, and Cooper-Arnold, K. Goals Model for Estimating the Effects of Resource Allocation Decisions on the Achievement of the Goals of the HIV/AIDS Strategic Plan. Washington DC: The Futures Group, 2003. Trujillo OG, Paredes M, Sierra M. VIH/SIDA: Análisis de la Evolución de la Epidemia en Honduras. 1998. 49 UNAIDS. 2006 Report on the Global AIDS epidemic. UNAIDS, 2006 UNAIDS. AIDS epidemic update: December 2005. UNAIDS, 2005 UNAIDS, UNICEF, PAHO, & WHO. Honduras Epidemiological Facts Sheets on HIV/AIDS and Sexually Transmitted Infections - 2002 update. UNAIDS, 2002. UNAIDS. Guide to the Strategic Planning Process for a National Response to HIV/AIDS. Geneva, Switzerland: UNAIDS, 1998. USAID. Honduras HIV/AIDS Strategic Plan, 2004-2008. Honduras, 2003. World Bank. HIV/AIDS in Central America: An Overview of the Epidemic and Priorities for Prevention. 2003. World Bank. Optimizing the Allocation of Resources for HIV Prevention: The Allocation by Cost-Effectiveness (ABC) Model: Guidelines. Washington DC: The World Bank, 2002. World Bank. Global Economic Crisis and HIV Prevention and Treatment Programmes: Vulnerabilities and Impact. June 2009. World Bank/UNAIDS report. UNAIDS. 2006 Report on the global AIDS epidemic. Geneva, Switzerland: UNAIDS, 2006. UNAIDS. 2004 Report on the Global AIDS Epidemic. Geneva, Switzerland: UNAIDS, 2004. 50 Titles in this publication series available at: www.worldbank/aids > publications 1. Lessons from World Bank-Supported Initiatives to Fight HIV/AIDS in Countries with IBRD Loans and IDA Credits in Nonaccrual. May 2005. 2. Lessons Learned to date from HIV/AIDS Transport Corridor Projects. August 2005. 3. Accelerating the Education Sector Response to HIV/AIDS in Africa: A Review of World Bank Assistance. August 2005 4. Australia's Successful Response to AIDS and the Role of Law Reform. June 2006. 5. Reducing HIV/AIDS Vulnerability in Central America. December 2006. (English, Spanish) 6. Reducing HIV/AIDS Vulnerability in Central America: Costa Rica: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 7. Reducing HIV/AIDS Vulnerability in Central America: El Salvador: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 8. Reducing HIV/AIDS Vulnerability in Central America: Guatemala: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 9. Reducing HIV/AIDS Vulnerability in Central America: Honduras: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 10. Reducing HIV/AIDS Vulnerability in Central America: Nicaragua: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 11. Reducing HIV/AIDS Vulnerability in Central America: Panama: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 12. Planning and Managing for HIV/AIDS Results ­ A Handbook September 2007 (English, Spanish, French, Russian) 13. Rapid analysis of HIV epidemiological and HIV response data about vulnerable populations in the Great Lakes Region of Africa. January 2008. (English, French) Published with the Great Lakes Initiative on AIDS. 14. HIV/AIDS in Ethiopia - an Epidemiological Synthesis. April 2008. Published with the Ethiopia HIV/AIDS Prevention and Control Office (HAPCO). 15. Blood Services in Central Asian Health Systems: A Clear and Present Danger of Spreading HIV/AIDS and Other Infectious Diseases. May 2008. (English, Russian) Published with World Bank Europe and Central Asia Region. 16. Knowledge, Attitudes and Behavior Related to HIV/AIDS among Transport Sector Workers - A Case Study of Georgia. June 2008. Published with World Bank Europe and Central Asia Region. 17. Building on Evidence: A Situational Analysis of the HIV Epidemic and Policy Response in Honduras. October 2008. 18. West Africa HIV/AIDS Epidemiology and Response Synthesis. Characterisation of the HIV epidemic and response in West Africa: Implications for prevention. October 2008. (full report in English and French; report summary available in Portuguese) 19. Swaziland HIV Modes of Transmission and Prevention Response Analysis. March 2009 20. Lesotho HIV Modes of Transmission and Prevention Response Analysis. March 2009 21. Kenya HIV Modes of Transmission and Prevention Response Analysis. March 2009 22. Uganda HIV Modes of Transmission and Prevention Response Analysis. March 2009 23. Zambia HIV Modes of Transmission and Prevention Response Analysis. June 2009 WW W. WO RL D B A N K . O R G / A I DS For more information, please contact: The Global HIV/AIDS Program World Bank Group 1818 H St. NW Washington, DC 20433 Tel: +1 202 458 4946 Fax: +1 202 522 1252 wbglobalHIVAIDS@worldbank.org