Document of The World Bank FOR OFFICIAL USE ONLY CR 15 _ sA Report No. 7260-ZR STAFF APPRAISAL REPORT ZAIRE NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT August 11, 1988 South Central and Indian Ocean Department, Africa Region Population and Human Resources Operations Division This document has a restricted distribution and may be used by recipients only in the performance of ZAIRE: NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT CURRENCY EQUIVALENTS Currency unit = Zaire (Z.) US $1.00 Z. 138 (February 88) Z. 1.00 US $0.007 (February 88) MEASUREMENTS EQUIVALENTS 1 meter 3.28 feet 1 kilometer 0.62 mile 1 square kilometer = 0.39 square mile GOVERNMENT OF ZAIRE - FISCAL YEAR January 1st December 31st This report is based on the findings of an appraisal mission which visited Zaire in February 1988 and consisted of Dr. Jacques Baudouy (mission leader) and Dr. Lamboray (public health specialist). The report was prepared by Dr. Jacques Baudouy with contributions from J-L. Lamboray, M. Over (health econunist) and R. Bulatao (demographer). Wi - I -I I .a.d .A5 ZAIRE: NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT ABBREVIATIONS AIDS Acquired Immunodeficiency Syndrom BCC Bureau Central de Coordination (Central Coordinating Office for AIDS Control Program) CDC US Centers for Disease Control CIDA Canadian International Development Agency DOH Department of Health DOP Department of Planning EEC European Economic Community EPI Expanded Program on ImmunizatJon FONAMES Fonds National de MAdecine Socisle (National Fund for Social Medicine) GPA Global Program on AIDS (WHC) FP Family Planning FRG Federal Republic of Germany HC Health Center HZ Health Zone IEC Information, Education and Communication IMR Infant Mortality Rate IN'.'. Ir.stitut National de Recherche BiologiQue (National Institute of Biological Research) KAP Knowledge, Attitude and Practice MCH Maternal and Child Health MPR Mouvement Populaire de la Revolution (the only Political Party' NACP National AIDS Control Program MYH Mama-Yemo Hospital (the largest - 2000 beds - hospital in Kinshasa) NGO Non-Governmental Organization ODA Official Development Assistance PEP Public Expenditure Program PHC Primary Health Care PIP Public Investment Program PSI Population Services International PSND Projet de Services de Naissances Desirables (FP project). STD Sexually Transmitted Disease UNDP United Nations Development Program UNICEF United Nations Children's Fund USAID United States Agency for International Development WHO World Health Organization WHO/GPA WHO/Global Program on AIDS This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. ZAIRE: NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT DEFINITIONS Case Fatality Rate: Percentage of deaths due to a disease among the total number of people who have contracted the disease. Incidence Rate: The number of new cases of a disease which occur in a population during a specified period of time usually expressed as the number of cases per 1,000 persons. Infant Mortality Rate: The number of deaths of infants under one year of age in a given year per 1,000 births in that year. Life Expectancy at Birth: The average number of years a newborn would live if age/sex - specific mortality rates prevailing at the time of birth were maintained. Pandemic: An epidemic occuring over an exceptionally wide geographic area. Prevalence Rate: The total number of people affected by a dIsease estimated either at a specific tinie (point prevalence) or over a stated period (period prevalence) expressed per 1,000 porulation (in case of low figures, prevalence is expressed per 100,000 population). Rate of Natural Increase: The rate at which a population is increasing in a given year due to a surplus of births over deaths, expressed as a percentage of the total population. Rate of Population Growth: The rate of natural increase adjusted .-)r net migration, and exprebsed as a percentage of the total population of a given year. Total Fertility Rate: The average number of children that would be born alive to a woman during her lifetime if she passed through her childbearing years conforming to the age- specific fertility rates of a given year. ZAIRE: NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT BASIC DATA (all figures apply to 1987 estimates unless otherwise indicated) General Total area 2,345,400 Km2 Total Population 31 million (1985) Urban Population (Z of total) 39 (1985) Population Growth Rate 3.0 Urban Population Growth Rate 7.9 Population Density per Km2 13 Density per Km2 of Agricultural Land 189 Population Age Structure (Z) 0 - 14 years 46 15 - 64 years 51 65 and above 3 Crude Birth Rate 45 Crude Death Rate 15 Total Fertility Rate 6.1 Infant Mortality Rate 114 Life Expectancy at Birth 49 Adult Literacy Rate (Z) 60 Primary School Enrollment (Z) 89 Secondary School Enrollment (Z) 21 GNP per Capita US$170 (1986) Health Population per Physician 15,000 Population per Paramedical Staff 1,700 Population per Hospital Bed 560 Population Within Reach of PHC Services (S) 50 DOH Share of Government Recurrent Expenditure 3.5? (average 1980-87) Daily per Capita Calorie Supply (as X of requirement) 90? (UNICEF Standards) ZAIREs NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT STAFF APPRAISAL REPORT TABLE OF CONTENTS Page No. CREDIT AND PROJECT SUMARY . . . . . . . . . . .(i-i..) I. BACKG'nOUND A. Sectoral Background . . . . . . . . . . 1 B. The AIDS Pand6mic . . . . . . . . . . . 2 C. AIDS Epidemic in Zaire. . . . . . . . . 4 D. Current and Potential Impact of AIDS . 8 E. Sectoral Strategy and Bank Involvement. 14 II. THE PROJECT A. Project Objectives and Design . . . . . 16 B. Summary Description . . . . . . . . . . 17 C. Project Components . . . . . . . . . . 18 III. PROJECT COSTS AND FINANCING A. Costs .... . . . ...... . . . . 27 B. Project Affordability . . . . . . . . . 29 C. Project Financing . . . . . . . . . . . 31 D. Procurement . . . . . . . . . . . . . . 32 E. Disbursement . . . . . . . . . . . . . 33 IV. PROJECT IMPLEMENTATION A. Project Preparation . . . . . . . . . . 34 B. Organization and Management . . . . . . 34 C. Monitoring and Evaluation . . . . . . . 36 V. PROJECT BENEFITS, JUSTIFICATION AND RISKS A. Benefits . . . . . . . . . . . . . . . 37 B. Risks .... . . . . . . . . . . . . . 39 VI. ASSURANCES AND RECOMMENDATIONS . . . . . . . 39 ZAIRE: NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT List Of Tables Page no. 1.1 Percentage of Seropositives in Kinshasa . . . . . 6 1.2 Projected AIDS Impact on Population . . . . . . . 9 1.3 Projected AIDS Impact on Health Expenditure . . 12 1.4 Total Cost of AID . . . . . . . . . . . . . . . 14 3.1 Project Cests by Expenditure Category . . . . . . 28 3.2 Price Contingencies . . . . . . . . . . . . . . . 29 3.3 Financing the Recurrent Costs of the AIDS Control Program .... . . . . . . . . . . . . . 30 3.4 Procurement Arrangements . . . . . . . . . . . . 3. Annexes 1. Prevalence of HIV for Zaire. 2. Implicatlons of Control Measures for the Spread of HIV Infection. 3. Research Strategy For the Analysis of the Economic Impact of AIDS. 4. Project Implementation Schedule. 5. Detailed Cost Tables by Component 6. Project Costs by Financing Sources. 7. Estimated Schedule of Disbursement. 8. Selected Documents in Project File. 9. NACP Organizational Chart. llat 1. ~IBRD 20674 (i) ZAIRE: NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT CREDIT AND PROJECT SUMMaRY Borrower: Republic of Zaire Beneficiary: Department of Health (DOH) Credit Amount: SDR 6.2 million (US$8.1 million equivalent) Terms: Standard IDA Terms Proiect Description (a) Objectives. To: (i) prevent through sexual behavior changes, donated-blood screening and sterilization of skin-piercing instruments Human Immunodeficiency Virus (HIV) transmission; (ii) irprove the data base on AIDS in Zaire through epidemiological, sociological and economic research; and (iii) reduce the impact of AIDS on individuals, families and communities, through the integration of specific AIDS activities into health and social programs. The project represents donors' contributions (including IDA) to the first three years of NACP's implementation under the overall direction of WHO/GPA. (b) Components. The project would provide for: (i) the development of a national Information, Education and Communication (IEC) program, in parallel with condom supply (audio-visual equipment, IEC material development, health staff and social workers training and condom distribution); (ii) integrating AIDS control activities in Health and Social Programs (blood screening, sterilization of skin-piercing instruments, in-service traininig and superviaion program, strengthening social activities); (iii) operational research and studies (HIV transmission, sociocultural aspects of AIDS, cost-effectiveness of Control Measures, constraints on condom use, case management strategies, economic impact of the disease, strengthening the surveillance system); and (iv) institutional strengthening (central coordinating office, regional, sub- regional and Health Zone levels and non-governmental organizations). (c) Benefits and risks. The project would provide immediate attention to a pablic health crisis which has already a negative impact on health status and health system in urban areas, and has the potential cko cause severe human and economic losses in an already poverty-stricken country. The proposed project would provide the resources required to: (i; make the national AIDS control program fully operational; (ii) assist the Government in reallocating resources intra-and int-ersectorally in favor of a balance between priority public health programs, including AIDS control; and (iii) coordinate donor support both financially and technically. The project's main risks are: (i) the weak managerial capability of DOH, particularly in regard to the complexity of the control program; (ii) the experimental nature of the control measures; and (iii) the uncertainty regarding the long term commitment from the donor community. (ii) ZAIREs NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT Prolect Cost Summary Estimated Costs Local Foreign Total - - - - US$ million - - - - IEC/Condom Distribution 1.10 4.70 5.80 - Integrating AIDS Control 0.62 8.08 8.70 - Research and Studies 0.60 0.40 1.00 - Institutional Strengthening 1.42 1.78 3.20 - PPF 0.06 0.24 0.30 Total Baseline Costs 3.80 15.20 19.00 Physical Contingencies 0.03 1.27 1.30 Price Contingencies 0.30 1.30 1.60 TOTAL PROJECT COST 1/ 4.13 17.77 21.90 FinancinR Plan - Government of Zaire 1.67 - 1.67 - IDA 0.50 7.60 8.10 - Other Donors 2/ 0.30 10.17 10.47 Beneficiaries 1.66 - 1.66 TOTAL 4.13 17.77 21.90 1/ Inclusive of taxes and duties, whvich are negligible 2/ Other donors include: Belgium (US$1.5 million), Italy (US$1.2 million), Federal Republic of Germany (US$0.6 million), USAID (US$1.7 million), EEC (US$2.0 million), UNDP (US$1.0 million), TUNICEF (US$1.5 million), and WHO (US$1.0 million). WHO and UNDP are responsible for coordinating donor support, including IDA's contribution. Estimated Disbursements US$ million FY89 FY90 FY91 FY92 Annual 1.0 2.5 3.0 1.6 Cumulative 1.0 3.5 6.5 8.1 Proiect ComPletion Date: June 30, 1992 ZAIREs NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT STAFF APPRAISAL REPORT I. BACKGROUND A. Sectoral Background 1.01 The Population, Health and Nutrition Sector Review, which gives the basis for overall sectoral analysis, is expected to be distributed to the Board at the end of calendar year 1988. As in most Sub-Saharan African countries, health conditions in Zaire are bleak. In 1986 life expectancy at birth was estimated at 49 years, the infant mortality rate (IMR) at 114 per 1000 and maternal mortality at 7 per 1,000 live births. Infections and parasitic diseases cause at least 50Z of all deaths in Zaire (as compared, for example to 1.5Z in the USA). 1.02 The Za'rian health sector is characterized by a complex organizational structure where a large share of health care services are provided by NGOs, enterprise medical departments and private providers. Overall, close to 502 of the population has access to a health facility delivering primary health care (PHC). Among major public health programs, the expanded program on immunization (EPI) is probably the most successful: at the end of 1987 the national measles vaccination coverage for under-one children reached 45?, a significant achievement in such a large country. Total health care spending (ircluding public, para public and private spending) is about US$6 per capita (1986), an average figure in Sub-Saharan Africa. On the other hand Government healtk expenditure has been steadily declining since 1980: in 1986, the health share of the Government expenditure was less than 3Z and represented only US$0.33 per capita. Both figures are extremely low, even for a low income country. 1.03 The major constraints for further health sector development include: (a) a deteriorating economic situation which makes health care and basic drugs scarcely affordable by the poorest segments of the populationt (b) the Government's declining Mole in health administration and health planning, due to major financial and managerial constraints; and (c) increasing health hazards such as maln"trition, malaria resistance to chloroquine, emerging 'modern" health problems (traffic accidents, cardiovascular diseases, etc.) and most recently the AIDS epidemic. -2- B. The AIDS Pandemic 1.04 The Acquired Immunodeficiency Syndrome (AIDS), first recognized in the USA in 1981, is a deadly disease caused by the Human lImunodeficiency Virus (HIV)1 which has the ability of depressing the human immune system and making the infected person extremely vulnerable to opportunistic infections. In addition, the virus itself can cause lesions in various organs, including the brain (where it can cause dementia), the bowels, the heart, and other organs currently being explored in search of AIDS-related manifestations. AIDS is a global epidemic (a pandemic) affecting more than 130 countries in all continents. The disease is transmitted through sexual intercourse, the transfusion of contaminated blood, infected skin-piercing instruments (medical or not) and from infected mothers to their offspring. AIDS is mainly a sexually transmitted disease (STD). AIDS transmission appears to be linked with the number of sexual partners (which increases the risk of infection) and with factors causing a direct contact between infected body fluids (such a sperm or vaginal secretions) and the bloodstream. In some male homosexual communities both conditions were met: high promiscuity as part of the lifestyle; high prevalence of other STDs which, through mucosa ulcerations, facilitate the penetration of the HIV; and in some cases traumatic intercourse bringing the sperm in direct contact with the bloodstream. It explains why the disease spread so quickly among some m,ale homosexual groups and has gained high visibility worldwide. 1.05 In industrialized countries, male homosexual transmission is currently the most common way of tr4nsmission but transmission patterns are changing due to information campaigns promoting "safe sex"; the role of contaminated needles and syringes among intravenons (IV) drug users becomes increasingly important as a way of transmission. Transmission through blood transfusion has been almost eliminated with the systematic screening of all blood supplies. Heterosexual transmission is now well-documented (both male-to-female and female-to-male) but its potential to rapidly spread the disease is still unknown; a recent study2 shows that the risk of heterosexual HIV transmission is highly variable and the factors responsible for this variability have to be determined. In developing countries, AIDS is 11 There are several types of HIV including LAV-2, HTLV-4 and other HIV-related retroviruses. In this report, HIV stands for all these viruses. 21 The authors (Dr. T. Peterman et al, Journal of the American Medical Association, January 1, 1988) studied 80 families where spouses repeatedly had sexual contact with the infected family member. Eight percent of the husbands and eighteen percent of the wives of the HIV patients tested pocitive for the virus. Eleven wives remained uninfected after more that 200 sexual contacts with their infected partners while one of the seropositive women had had only a single sexual contact with the infected husband. -3- also mainly a sexually transmitted disease (STD) juut, in contrast to '-.ustrialized countries, transmission is essentially heterosexual. The reasons for tl.is difference are not really known. Several hypotheses have been proposed, including: (a) the high incidence of other STDs; (b) the multiplicity of sexual partners and widespread prostitution which increase the risk of contamination in some countries; (c) the prevalence of diseases and conditions (tuberculosis, malaria, malnutrition, etc.) which already deplete the immune system and can facilitate HIV penetration and activation; (d) the existence of sexual practices whirh may facilitate the contact of infected body fluids with the bloodstream; and (e) in the case of Central/Eastern Africa, the possibility of an earlier start of the epidemic leading to higher infections rates than in the US or Europe. Further research is urgently needed to investigate these various hypotheses. 1.06 Unprecedented international efforts to understand and control this disease have led in a short time to HIV identification and to some understanding of AIDS pathogenesis. However, it is unlikely that a vaccine and a cure can be developed in the near future, mostly because the HIV ernvelope (key target for vaccines and drugs) has changing genetic patterns. The World Health Organization (WHO) is playing a leading role in AIDS control. In February 1987 WHO created the Special Program on AIDS (SPA), since renamed the Global Program on AIDS (WHO/GPA). The Fortieth World Health Assembly (May 1987, WHO 40.26), the Economic and Social Council (July 1987, Resolution E/1987 75) and the United Nations General Assembly (October 1987, kesolution A/42/8) successively recognized the need for a globally coordinated approach to AIDS control. WHO/GPA's objectives are to: (a) provide technical and financial assistance to governments in planning, implementing and monitoring AIDS programs, including AIDS education activities; (b) coordinate, promote and finance biomedical, social, behavioral, epidemiological and operational research; (c) coordinate, promote and finance data collection and analysis to describe current and predict future HIV infection trends along with associated social, economic and demographic impacts.3 WHO/GPA activities are financed through donor grants, such as the recent World Bank's contribution of US$l million through the PPR-administered Special Grant Programs (July 1988). In order .o ensure a well-coordinated approach in AIDS control activities at the country level WHO/GPA and UNDP have forged an alliance to combat AIDS and to coordinate the support of all external partners. 1.07 In industrialized countries, control measures are based on Information, Education and Communication (IEC) programs, promotion of the use of condoms, donated blood screening, and strict sterilization measures for medical equipment. The treatment of AIDS patients (which includes some experimental drugs like azidothymidine (AZT) that seem to slow down the progress of the disease) is extremely expensive and 3/ Since February 1987 WHO/GPA has made significant progress in Africa: as of July 31, 1988 thirty countries including Zaire have completed medium-term plans (MTPs) with WHO guidance and support. -4- is now a serious concern for medical insurance groups in industrialized countries. Legal and Civil Rights issues (including employment or schooling of HIV-infected individuals) are becoming an important dimension of the AIDS epidemic. The response of political leaders to the AIDS threat has been a key factor in the early start of control programs. In some countries, the fact that some members of the government had initially refused to consider the disease as a potential threat for the non-homosexual population (in spite of the US Centers for .Asease Control - CDC's warning) has certainly made the epidemic more difficult and more expensive to control. 1.08 In developing countries control programs face major constraints, including: (a) the reluctance of some leaders to recognize that AIDS is a public health threat calling for major control measures; (b) the lack of financial resources which is aggravated by the current economic crisis; (c) the lack of the required public health expertise, particularly in IEC; (d) the "competition" with numerous other health priorities (malaria, malnutrition, measles, etc); (e) the lack of implementation capacity to carry out a major control program; and (f) the low level of the population's education which makes information and communications particularly difficult. Among the developing world, urban populations of Central and Eastern African countries are the most heavily stricken by the disease. Among these countries Zaire was the first to recognize the gravity of the disease and to start epidemiological research. C. AIDS Epidemic in Zaire 1.09 Epidemiological Data. In 1983, the first cases of AIDS in Zaire were recognized. In 1984, the Government supported the establishment of Projet SIDA, which is jointly supported by the Belgian Institute of Tropical Medicine in Antwerp, the US Centers for Disease Control (CDC) and the US National Institute of Infectious Diseases, to start a systematic long-term study of the disease. Estimated HIV seropositivity4 prevalence (or seroprevalence) rates in Kinshasa (total population of about 3 million) are as follows: 4Z-8Z in the general population; 6Z-102 in pregnant women; 62-10 in blood donors; 30Z in prostitutes and 17Z in Tuberculosis (TB) patients. All 41 Seropositivity means that a test for determining antibodies to the HIV in a person's blood is positive. The presence of these antibodies means that a persor. has been infected with HIV and is assumed to indicate continuing infection. The Seroprevalence rate represents the number of seropositive people at a specific time (point prevalence) expressed as a percentage of the population per 1,000. The sero-incidence rate represents the number of new seropositive cases in a population during a specified period of time expressed as a percentage of the total population or per 1,000. -5- these data come from reliable sources (including Projet SIDA). Data from other cities, though scanty and based on small samples, indicate that the disease already has a large geographical expansion.5 In rural areas the few studies available give seroprevalences between 0 and 1S, but the samples are too small to be significant and further research is needed. What is already clear is that the major risk factor in a rural area is the mobility of the population, i.e. frequent contacts with cities. A comprehensive AIDS/HIV statistics database, prepared and regularly updated by the US Bureau of the Census on the basis of published materials, is given in Annex 1. 1.10 Sero-incidence and case6 incidence rates are not really known. In Kinshasa the sero-incidence rate has been estimated at 0.2Z (2 new seropositive per 1,000 population) per year but a longer follow-up is necessary to obtain more reliable data. Case incidence in the general population of Kinshasa is estimated at 0.5 to 1 case per 1,000 population per year. Among health workers of the Mama Yemo Hospital (MYH) the sero-incidence rate is 2.0, revealing a high risk population.7 Among hospital infected workers, 5? to 8Z of the HIV seropositives develop the disease each year. Although sketchy these data show that Kinshasa (and most likely the other major cities) is facing a severe public he 1th problem, which could easily become a disaster if the disease spreads rapidly to the entire country. The key element which will determine the future importance of AIDS is the speed of its transmission throughout the country. 1.11 AIDS Transmission in Zaire. Based on available data, AIDS transmission in Zaire occurs mainly through sexual intercourse (80Z), infected blood transfusions and contaminated skin-piercing instruments (15X), and from infected mothers to their offspring (5Z). Patterns of sexual transmission are different from industrialized countries as shown by the Male/Female sex ratio of 1 s 1.4, (in USA 13 : 1). The reasons for this effective heterosexual transmission are not known. Some hypotheses include: (a) the high rate of STDs as mentioned in para. 3, in both men and women; (b) the number of sexual partners which may be particularly high in some socioeconomic groups; (c) the 5/ For example in Dungu (Haut-Zaire), a city of 100,000 people, prevalence rates are as follows: 5.8? in the general sedentary population, 24.2? in the general mobile population and 32.3? in prostitutes. 6/ A seropositive patient (HIV carrier) can remain asymptomatic for some time (the time span can vary greatly from one individual to another), before developing AIDS symptoms (weight loss, fever, diarrhea, etc.) and becoming an "AIDS case". 7/ The risk factors of these health workers do not appear occupational (high exposure to HIV-infected patients) but linked to their age group and their sexual behaviors (multiple sexual partners). -6- importance of prostitution, including occasional prostitution; and (d) some sexual practices common in Central and Eastern Africa.8 High risk groups include prostitutes, individuals with numerous sexual partners, patients with STDs and people receiving blood transfusions. In Kinshasa, a group at particularly high risk is females aged 15 to 29 as shown in Table 1 below. TALE 1.1 Percentane ot Seroeoutive In Kinshasa. By Am GroUD Age Oroue Male Female Flrot year of lIt- 8.1 8.1 1-14 1.0 1.6 16-19 8.7 9.8 20-29 4.4 10.8 8e-89 6.8 6.1 40-49 6.0 6.8 >60 6.0 1.6 Source: Kinshasa Survoy on 6,899 healthy people (Quinn et e., 1986) 1.12 Infection prevalence rates among school-aged girls (15-19) is almost three times higher than the rates for boys. This may be due to their young age at first intercourse and to the multiplicity of much older sexual partners. If these assumptions are true, they would represent important factors to consider during the design of an IEC program. 1.13 Regarding transmission through blood transfusion, high risk groups include: children with malaria and sickle-cell anemia and pregnant women, because these people often require blood transfusions. In addition, medical injections is a common practice in Africa: in Kinshasa a child can receive as many as 20 intramuscular injections during his first two years of life. This is due to the common belief that injections are more effective than oral drugs. Given the poor standards of sterilization in most heelth facilities the high number of injections increase the risk of transmission through contaminated 8/ In some Central African cultures, after a delivery, women often use a variety of astringent leaves and herbal preparations to restore the vagina's elasticity. These practices (among others) may reduce the vagina's moisture and lead to a rupture of the genital mucosa during intercourse. syringes and needles. However, the importance of this way of transmission in the overall picture is likely to be small (by contrast with intravenous drug users who directly flush contaminated blood in their vein when they share syringes and needles). 1.14 Social Aspects of AIDS. Among major public health problems AIDS is a special case because of its deep social implications. As in other affected Sub-Saharan African countries, it appears that a combination of socioeconomic factors has favored the spread of AIDS in urban areas of Zaire. First, the prolonged economic crisis which started in the early 70's and which seems to have worsened in the past few years has led to a major impoverishment of the population. Women, who are the key providers of food and additional income (through either menial jobs or established businesses) to the family, have particularly suffered from the dramatic loss of purchasing power. Some women have no other choices than to provide sexual services in order to support their families.9 This occasional prostitution, in addition to the 'professional" prostitution which also has developed in urban areas of Zaire, can be extremely damaging in terms of spreading STDs, including AIDS. Second, the "Deuxibme Bureau", the vernacular expression for a second semi-official wife (polygamy is illegal in Zaire), is the usual way of l'fe for many well-off men in urban areas. In addition, the lifestyle among some members of the upper middle class, at least in Kinshasa, promotes the frequent changes of sexual partners and the contact with prostitutes (who are readily available in numerous bars, night-clubs and hotels). Third, unemployment, rural-urban migration and the need for people to be mobile in their quest for jobs constitute a fertile ground for the spread of STDs including AIDS. Finally, the bleak future that some young Zalrians face in urban areas seems to accelerate the disappearance of traditional cultural, ethical and religious values. This makes them particularly vulnerable to an early and widespread sexual promiscuity. (See HIV seroprevalence among females ages 15-29). 1.15 This description of the social aspects of AIDS should not be seen as a derogatory assessment of the Zairian society. The Zairian people are not the cause of the disease but its victims. In industrialized countries also, many young adults have multiple sexual partners and have a high risk of contracting STDs, including AIDS. Central African cities may be ten to twenty years ahead of Western cities due to an earlier start of the epidemic. Social aspects of the disease, as brutal as they can be, have to be understood in order to develop targeted and effective control programs. 91 B. Gundfest Schoepf; Women, AIDS and Economic Crisis in Central Africa; paper ac4epted for publication in the Canadian Journal of African Studies, October 1987. - 8 - D. Current and Potential Impact of AIDS Demographic Impact 1.16 The World Bank has developed a model to assess the potential demographic effect of the disease.10 Four population projections are proposed: (a) a standard projection with no effect of AIDS; (b) a high threat run (no decline in transmission rates); (c) a medium-threat run (slow decline in transmission rates); and (d) a declining-threat run (faster decline in transmission rates). The basis for modeling is a seroprevalence survey conducted in 1985 in Kinshasa, already quoted in para. 1.10. The potential impact of AIDS on the size of the population and on demographic variables is summarized in Table 1.2. Projections are not predictiona. and their validity is evidently limited by uncertainties about the value of current and future parameters, inherent problems with the complexity of social behavior and limitations of the mathematical model itself. However, they are useful to quantify the potential magnitude of the problem: for example, under the high threat assumption, the infant mortality rate is likely to rise from 102 (projection 1985-1990) to 130 per 1,000 instead of being reduced to 70 per 1,000 by year 2005. This kind of impact would more than annihilate any progress made through immunization and primary health care (PHC). 10/ R.A. Bulatao. Initial investigation of the demographic impact of AIDS in one African country. Working papers, 1987. The World Bank. 9 - TABLE 1.2 Prolectod AIDS Impact on population Asetmatione Yoar No Aide High threat Medium threat Declining Threat Popu l ati on (thousand) 1985 8667 36667 3O657 36557 1990 56seo 85616 85625 85627 1995 41001 40886 46878 40916 2000 46957 46837 46646 46712 2£06 63298 51642 52888 62851 Lif. expectancy at birth 1985-96 51.5 61.1 51.2 51.2 1990=95 63.6 52.6 62.6 53.0 1996-U 56.1 62.8 65.6 64.9 260-06 68.7 62.4 54.7 67.2 Infant mortality rate 1985-90 102 106 106 16 1990-96 92 106 162 98 1996-00 81 115 104 91 2060-05 76 186 167 81 Source: R. Bulstao, working paper, The World Bank, 1987. Tmpact on Health and Social Services 1.17 Health Services. At the moment, the most visible impact of AIDS in Zaire is the high number of AIDS patients in urban health facilities. For example, at Mama Yemo Hospital (MYh), AIDS patients' bed occupancy rates eccount for: 252 in the internal medicine ward, 33? in the tuberculosis (TB) ward and 10? in the pediatric ward. Since the occupancy rates of these wards are close to 100?, one can assume that a significant percentage of patients who otherwise would have access to hospital care are kept out. At the Cliniaue Ngalidma,11 11/ Clinique Nqali6ma is a Belgian-run hospital with good quality health care. Since user charges are relatively high, most of the clients are either insured people (employees) or better-off citizens. Overall the clients are representative of the middle/upper middle class of Kinshasa. - 10 - 50Z of the deaths are AIDS-related and 1OZ of the children's deaths (under five years of age) are AIDS-related. At the Cliniques Universitaires (600-bed teaching hospital) the picture is similar. In other large cities data are not readily available but anecdotal evidence suggests that the disease is spreading to communities through the main lines of transport (particularly roads widely used by truck drivers, but also probably along the Zaire River). In all cities and small towns visited by the Appraisal mission, local health staff acknowledged that the number of clinical AIDS cases was increasing steadily. On the other hand, in rural health facilities clinical AIDS cases were sparse but affecting better-off people.12 1.18 AIDS patients are hospitalized for severe opportunistic infections, including pneumonia, acute diarrhea, severe oral/oesophagal candidiasis (fungal infection) and various other AIDS- related problems including Kaposi Sarcoma (skin cancer), major weight loss and central nervous system disorders (dementia). Concurrently with the rise in AIDS incidence, there is an increase in the number of TB cases (due to the depression of the immune system) and syphilis cases (for unclear reasons). All these diseases require difficult and expensive treatments: multiple antibiotherapy, intravenous (IV) fluids, forced feeding for renutrition, etc. Since the disease and its manifestations are new and poorly understood, physicians "experiment' with various therapeutic schemes, which is both time consuming and expensive. In addition the X rays, laboratory tests and other diagnosis activities are often numerous and resource consuming. This can create a heavy burden for some urban hospital facilities. For example, at MYH, where the situation has been steadily deteriorating for the past ten years due to a lack of operating funds, the AIDS epidemic might represent a final blow. The situation is somewhat better in Kinshasa's other hospital facilities since their lower occupancy rates have allowed them to absorb AIDS patients more easily than MYH. In other urban areas data are too scanty to assess the impact of AIDS on the functioning of health services. In rural areas, the number of AIDS cases is still low and does not represent so far a major burden for health facilities. 1.19 Social Services. The diagnosis of AIDS with its fatal prognosis and association with sexual promiscuity puts an extreme psychological strain on the patient and its family. The cost of treating the frequent opportunistic infections and taking care of the patient either at the hospital or at home creates financial problems that most families cannot address without borrowing from relatives and sometimes from friends. However, given the pool economic situation of Zaire this solidarity has obvious limits. Beyond this immediate liquidity problem, there is the longer term problem of families where one, and eventually two of the household income earners die from AIDS. 12/ According to managers of rural development projects in North Equateur, there is an important seasonal migration of prostitutes from urban to rural areas at the time when farmers sell their cash crops. After a few weeks, prostitutes are back in town. - 11 - The number of AIDS-stricken families which will fall under the poverty line and the number of orphans is likely to substantially in.crease in urban areas within the next few years. In view of this worrisome situation, the extreme weakness of public social programs is even more blatant. The Department of Social Affairs, which, in theory, should be the leading agency for welfeare programs, has such a minuscule budget that in 1987 only sixty social cases were taken care of for the entire country. In fact, social assistance is mostly provided by NGOs (particularly the religious ones) at the community level. The NGOs' ability to cope with the new needs created by the AIDS epidemic it} difficult to assess given the lack of quantitative data on their activities. However, it is clear that some guidance and operational support would help these organizations in identifying and assisting AIDS-stricken families. Economic Impact 1.20 Health Expenditures. The cost of treating an AIDS patient from onset of the clinical manifestations until death has been estimated by a joint WHO/World Bank mission in December 1987.13 These preliminary calculations are based upon (a) the estimated costs of specific clinical manifestations associated with AIDS and (b) the estimated proportions of AIDS patients with each manifestation. Given the multiplicity of health care delivery systems in Zaire, the costs of treatment dramatically vary from one system to another: US$132 in PHC facilities (Health Zone Systems); US$228 for employees (enterprise medical insurance system); and US$1,585 in the private sector (private physicians and clinics). A weighted average (702 of the patients attend PHC facilities, 25Z are insured and 5Z use private facilities) give an average cost of US$229 for each AIDS patient in Zaire (in constant 1986 dollar). This cost can be considered as an annual cost since it is estimated that on average in Zaire AIDS patients die within a year after starting clinical manifestations. US$229 is a high figure compared to the annual average incomes of US$890 in Kinshasa and US$144 in rural areas. AIDS-stricken "amilies will face, if they seek care for the AIDS patients, a serious financial problem and might fall below the poverty line. This problem will be compounded if the AIDS patient is the key income-earner in the family. The number of families which will be affected in the future is an important factor to be considered when planning health resource allocation. 1.21 In order to assess the potential impacts of AIDS on health expenditures at a macro level, an epidemiological model14 has been used to project annually the expected number of AIDS cases, based on the current level of infection (6Z in urban areas and 1? in rural 13/ Members of the mission were Mead Over (PHRHN) and Stefano Bertozzi (consultant). Their full report and further work are available in project files. 14/ This model has been prepared by Dr. J. Chin from WHO/GPA. - 12 - areas), the conversion rate of infected person to AIDS case (42 per year) and the conservative assumption that the infection incidence rate which led to the current seroprevalence would stay the same (2 per 1,000 per year). Since it is unlikely that all AIDS cases will have access to health care systems (for geographic or economic reasons), estimates of the number of treated cases have been made based on the current and projected health coverage levels. The direct cost of AIDS has then been estimated by multiplying the number of treated cases by the average treatment cost. These direct costs of AIDS are compared to the projected National Health expenditures in Table 1.3 below. TABLE 1.8 Prolected AIDS Zesact on H.alth ExDmndtture Year Cases t Cause Direct Costs Health Expendit. (oco) treated (x)I/ US millon USS ml1lion (ooo) Total (X)V/ Gov(X)!/ ConsumersQlMg (1) (2) (3) (4) (5) (8) (7) 89 24 12 (60) 2.7 210 (1.2) 11.6 (23) 70 (3.8) 90 28 16 (62) 3.3 218 (1.6) 12.0 (27) 71 (4.6) 91 37 20 (54) 4.6 223 (2.0) 12.4 (87) 74 (6.2) 92 47 27 (56) 6.0 230 (2.6) 12.8 (47) 77 (7.7) 98 68 84 (56) 7.7 236 (8.2) 18.1 (5e, 79 (9.7) 2 0GM 160 106 (79) 24.0 286 (8.8) 16.0 (160) 96 (26.0) 2 d10 286 214 (76) 48.9 860 (18.6) 20.0 (244) 120 (40.7) Note: all cost. In constant 166 US$. P-rcentages: / (8) over (2); V (4) over (6); V1 (4) over (6); I/ (4) over (7). 1.22 Financing the direct cost of AIDS would increase national health expenditure by 1.22 in 1989 up to 13.52 in 2010. The share of health expenditure in the GNP would have to increase form 3.5Z to 4.02. Given the absence of national risk-sharing/cost-sharing mechanisms in Zaire the key issue is the equity of di,tribution of this financial burden among health providers and health consumers. As shown in Table 1.3 it is obvious that the State cannot afford to finance these direct costs: its health budget would have to increase by 232 in 1989 and by 58Z in 1993 (not to speak of 244Z in 2010). Consumers could initially absorb these costs if cost-sharing mechanisms were put in place (increase of 102 within 5 years); however, starting around year 2030 the increase due to AIDS costs (25Z) would be too high to te absorbed without subsidies. This model shows that AIDS will have a significant impact on health expenditure -13 - and that this impact will grow steadily unless cuntrol measures are effective. Thus, decision makers and health planners should start developing resource allocation strategies in order to protect some segments of the population from the AIDS-related financial burden. 1.23 Mlacroeconomic Impact. The macroeconomic impact of AIDS (productivity losses associated with AIDS-related disability and death and direct cost of taking care of AIDS patients) iJ difficult to quantify given: (a) the lack of knowledge of the extent of the epidemic and its effects; (b) the lack of accurate data on incomes by socio-professional categories; (c) the importance of the informal sector in the nation's economy; (d) the absence of data regarding unemployment rates; and (e) the inherent difficulties of measuring the productive value of human resources. However, such an analysis is necessary since some characteristics of the AIDS epidemic are likely to have a negative economic impact: (a) disability and deaths mostly occur in the most productive age group (15-45); (b) the epidemic is spreading in urban areas whe-e educationi levels are higher; and (c) there is no indication that a cure or a vaccine will be available soon. 1.24 Preliminary estimates of the productivity losses have been made by the December 1987 WHO/World Bank mission (already mentioned in para. 1.19). These estimates are based on the calculation of healthy life years (HLYs) saved per case of HIV prevented. This methodology takes into account estimates of HIV incidence, and days of healthy life lost from (a) acute illness; (b) disability before premature death; and (c) prerlture death. These healthy days of life lost are then discounted to their present value and weighted for productivity by estimating the age earning profile.15 In Zaire, the HLYs (productivity weighted and discounted) saved per case of infection prevented would be on average 6.2. Based on average annual incomes (respectively US$890 in urban areas and US$144 in rural areas) the monetary value of these 6.2 HLYs would be US$5,512 in urban areas and US$893 in rural areas. Since currently 802 of AIDS cases occur in urban areas, the weighted indirect cost of each case of infection is approximately US$4,600; which is more than twenty times higher than the direct cost of each AIDS case. 1.25 Using the epidemiological model to project the number of expected cases, the Appraisal mission made estimates of the annual total (direct plus indirect) cost of AIDS, taking into consideration the balance between the increasing number of AIDS cases in rural areas and the urbanization process, and assuming that adults (income earners) would represent 752 of the cases. Findings are summarized in Table 1.4 below. 15/ See Over, Bertozzi, Chin, N'Galy and Nyamuryekurg's "The Direct and Indirect Cost of HIV infection in Developing Countries: The Cases of Zaire and Tanzania" in the project file. - 14 - TABLE 1.4 Total Cost of AIDS Year Pop. Cases Adult Direct Costs Indirect Costs Total Costs Projected GDP3/ Total million (000) Cases USS million USS million USS million USS million as X (000) CDP N9 3S 24 18.0 2.7 15.5 18.2 5,880 0.V 90 86.6 29 21.0 8.8 83.5 86.9 6,980 0.6 91 87.2 87 27.8 4.8 67.4 62.0 6,260 1.0 92 38.4 47 85.8 6.0 87.7 93.8 6,461 1.6 93 89.3 s8 48.6 7.7 125.1 132.9 6,602 2.0 20e0 48.0 160 112.6 24.0 221.9 246.0 8,064 3.1 2010 60.0 286 2138. 48.9 406.8 464.7 10,080 4.6 Note: all costs are In constant 1988 US$ 1/ GDP Is assumed to grow at ax per yebr from 1989-93, 4X thereafter. Table 1.4 shows that, if transmission rates are not cut, AIDS-related costs will become quite significant within 5 years. The comparison with the GDP gives the order of magnitude of the annual productivity loss and this loss would be extremely high by 2010 if the epidemic is not by then under control. E. Sectoral Strategy and Bank Involvement 1.26 The Government has shown its commitment to addressing this public health issue by supporting the creation of the Projet SIDA in 1984, establishing a National AIDS Committee in 1985 and producing, with WHO support, 6 the National AIDS Control Program (NACP) in 1987. In June 1987, the State Commissioner (Minister) of Health and Social Affairs officially launched a national information campaign, the scale of which is still extremely limited due to the lack of financial resources and domestic technical expertise in IEC. WHO, through its GPA, has provided start-up funds for the national control program (about half a million US dollars) and a technical assistant for management. Other international agencies have provided some support to AIDS control through their ongoing activities. Among donors, USAID has been the most active, so far, through several existing projects, including rural primary health care (SANRU), tne School of Public Health, and the Family Planning projects (PSND and TIPPS). USAID funding levels have been US$0.7 million in FY87 and it will be about 161 As mentioned in para. 1.06, WHO, through its Global Program on AIDS (GPA), is the leading agency in developing general AIDS control strategies and providing technical assistance and short- term financial support to national AIDS control programs. - 15 - US$l million in FY88. Other donor-supported activities include the vaccination research program of the French-supported National Institute for Biomedical Research (INRB) and the Belgian/NIH- cofinanced Proiet SIDA and blood screening at Clinique NgaliXma. FGR, Italy and EEC are financing blood banks in Kinshasa, Goma and Lubumbashi respectively. More recently (April 1988) the AfDB has accepted to finance a US$1 million research project. 1.27 All these efforts had to be strengthened and organized given the magnitude of the problem and the high cost and complexity of control measures. Most activities so far have been research-oriented and not con-rol-oriented. This is understandable given the background of the professionals who started working on AIDS -- scientists, epidemiologists and laboratory technicians who are primarily interested in understanding the disease and evaluating its prevalence and incidence. Other skills are required to develop a control program (health planning, team management, IEC experts, sociologists, lawyers, field epidemiologists, etc.), but they are either not available in Zaire or not involved in the control program. This situation mr.y lead to a piecemeal approach (each specialized team dealing with its own interests) which would be most detrimental in terms of effectiveness and efficiency. 1.28 As a first step to address these issues, the Government and WHO/GPA organized in February 1988 a donor meeting to discuss the mediurn-term plan of the NACP and prepare a preliminary financing strategy. During the meeting, the participants agreed that major and urgent efforts were required to: (a) make the NACP priority-oriented and fully operational as soon as possible; (b) assist the Government ; in reallocating resources between ongoing health activities and AIDS control activities; and (c) coordinate donor support both financially and technically. In all these areas the World Bank could make a significant contribution, given (a) its expertise in planning/programming/budgeting large national programs, financial management, broad-based economic analysis; and (b) its leading role in aid coordination as chairman of the Consultative Group. Ultimately, most donor3 pledged additional funding to the NACP as detailed in para. 3.08. 1.29 The proposed general strategy conforms to the Global Strategy on AIDS as stated in WHO's Guiding Objectives and Principles (Fifth Meeting of Participating Parties). The specific strategy is two- pronged: first, the rapid implementation of a self-standing AIDS project aimed at contributing within three years to the effective and timely launching of the National AIDS Control Program (NACP) as part of the WHO-supported MTP and second, the development of a long-term AIDS control component as part of the proposed FY91 Social Sector project. This approach would allow to: (a) help to establish an overall control strategy, including the institutional framework in which the NACP would operate; (b) support urgent control activities - 16 - (IEC, blood screening, control of other STDs) described in the MTP document which may diminish the future magnitude of the epidemic; and (c) prepare effectively, in conjunction with WHO/GPA, the AIDS component of the future Social Sector project (FY91) through an early involvement in field operations. 1.30 Any delay in the Bank's assistance to the Government and WHO/GPA would make the disease more difficult and more expensive to control in the future since: (a) certaLn programmatic improvements in the NACP are unlikely to be implemented promptly; (b) the required amount of financial resources would not be attained, and (c) without the Bank's coordinating role it would be more difficult for Zaire to mobilize and organize cofinancJrig. II. THE PROJECT A. Proiect Obiectives and Design 2.01 The proposed project represents donors' contributions (including IDA's)17 to the first three years18 of NACP's implementation under the overall direction of WHO/GPA. Thus, the project objectives are fully congruent with NACP's general objectives which are: (a) to Prevent HIV transmission, through: (i) sexual behavior changes induced by an IEC program; (ii) wide availability and use of condoms; (iii) adequate treatment of other STDs; (iv) donated blood screening; (v) sterilization of skin-piercing instruments; and (vi) control of perinatal HIV transmission; (b) to improve the database on AIDS in Zaire, through: (i) strengthening and developing the laboratory infrastructure; (ii) developing the AIDS surveillance system; (iii) improving the knowledge of AIDS-related behaviors in tne general populati.n; (iv) developing socio-economic surveys in relation to AIDS; and (v) developing operational research; and (c) to reduce the impact of AIDS on individuals, families and communities, through: (i) special assistance to AIDS cases and seropositive patients; and (ii) information and education of people in contact with infected persons. These objectives are relevant to the country's needs, but 17/ Donors' contributions have been assessed as of February 11-12, 1988, date of the latest Donor Meeting. Further contributions (from Canada for example) are expected, and are likely to increase the scope of the project. 18/ The three-year period is consistent with the three-year rolling PEP process currently being established by the Government with Bank's support. - 17 - they have to be prioritized and linked with phased operational objectives. The proposed project would support this effort and has been designed as an urgent assistance operation to the NACP. It constitutes the first phase of a long-term support aiming at helping the country to deal with this major epidemic. During its three and one-half years of implementation, control measures would be developed, tested and integrated into health and social systems and long-term strategies would be developed. B. Summary Description 2.02 The proposed project consists of four components: (a) IEC program developmtnt and condom distribution; (b) integration of AIDS control activities in existing health and social programs; (c) operational research, including the development of a surveillance system; and (d) institutional strengthening of the NACP. All components are closely inter-related and mutually reinforcing: they aim at making the NACP fully operational and effective as soon as possible . The base costs are US$19.0 million. 2.03 IEC Program Development and Condom Distribution (US$5.8 million). The IEC component would: (a) attempt to induce behavioral changes in both the general population and target groups (prostitutes, students, teachers, soldiers, truck drivers, migrant workers, etc.); (b) inform and educate 10-14 year olds before they enter a high risk age group; (c) inform AIDS patients, HIV seropositives and families on ways of coping with the disease. This would require a combination of mass media programs and person-to-person communication. In addition, condoms would be made widely available to respond to the expected increase in demand. 2.04 Integrating AIDS Control Activities (USS8.7 million). AIDS control activities have to be integrated nationwide in health and social programs, in order to reach a large segment of the population efficiently and assist health facilities in dealing with an increasing number of AIDS patients and HIV infected individuals. This would require specific support for: (a) blood screening on a large scale; (b) sterilization of skin-piercing instruments; (c) in-service training, operational support and supervision for case management, STDs detection and treatment and communication activities; and (d) social programs at the community level through both public sector programs and NGOs. 2.05 Operational Research and Studies (US$1 million). Operational research and studies are essential since, AIDS being a new disease, the effectiveness of control measures has to be tested. In addition to on-going research activities, the proposed component would support research on: (a) HIV transmission; (b) sociocultural dimensions of AIDS; (c) cost-effectiveness of control measures; (d) constraints to - 18 - condom use; (e) case management strategies; (f) developing diagnosis tools; (g) economic impact of the disease; and (h) the development of a national surveillance system. These studies would enable the NACP to be more effective and efficient. 2.06 Institutional Strengthening (US$3.2 million). Institutional aspects of the NACP are particularly important given: (a) the complexity of the control program; (b) the intersectoral natisre of many control activities; (c) the need for developing cofinar.cing strategies; and (d) the necessity of monitoring several implementir.g agencies. The project would support institutional strengthening at the central, regional, sub-regional and Health Z0ne (iiZ) levels. C. Proiect Components Development of an IEC Program 2.07 This componer:t has the broad objective of disseminating information which would lead to a reduction in HIV sexual transmission through development of a "sexual responsibility" concept, limitation of the number of sexual partners, promotion of condom use, promotion of early STD treatment, and education of seropositive patients. Several knowledge, attitude and practice (RAP) surveys and specific studies on sexual behavior are part of the component preparation. The implementation of this component will be facing some major challenges including: (a) the sensitivity of some messages (use of condom, limitation of the number of sexual partners); (b) the necessity of condom availability to respond to the expected increase in demand; (c) the lack of national expertise in implementing large IEC programs; and (d) the necessity of combining and balancing mass media approaches and targeted interpersonal communication techniques. Several specialized internati'nal agencies have expressed interest in supporting the development of this IEC program. From the USA, Population Services International (see following paragraph) is already involved; t.he Academy for Educational Development(AED), through its USAID-supported international communication project (AIDSCOM) might also contribute to the IEC program, at a more peripheral level. Additional support would also be available from Canada (CIDA/Laval University) and Belgium (NGOs specialized in school health education). Coordination of these efforts would be essential to ensure the prompt and effective deployment of a comprehensive IEC program (see project implementation, para. 4.06). 2.08 Mass Media. This sub-component aims at developing a broad awareness of the seriousness of the AIDS epidemic and means of avoiding the infection. Radio, television and written materials (press, leaflets, brochures) will be used to convey general information on: (a) the lethal nature of AIDS; (b) transmission modes; and (c) means of preventing transmission (including use of condoms and reduction of number of sexual partners). This approach is somewhat - 19 - targeted at the most educated segments of the the population (people who can read) and to urban populations (reached by TV and radio networks) where the epidemic is, at the moment, most prevalent. The design of messages and their presentation will be done by the IEC statf cf the NACP's Bureau Central de Coordination (BCC), which will also be in charge of identifying target groups and specific communication strategies. The BCC w.fi be assisted by Population Services International (PSI), a U.S. private voluntary organization, being funded by USAID to undertake this activity. The project would provide equipment and operating funds for IEC material development, production and broadcasting. This mass-media approach is expected to raise the general awareness of the population, but, in order to obtain significant behavioral changes, it has to be complemented by targeted face-to-face communication strategiec. 2.09 Person-to-Person Communication. This strategy will focus on three major target groups: children in the 10-14 age group, the population covered by health facilities and the citizens participating in the political party (Mouvement Populaire de la Revolution - MPR) activities. The 10-14 age group, in which the seropositivity rate is extremely low, represents the highest priority in terms of prevention since they are about to enter into the most infected age group (15- 29), particularly for women. If this segment of the population could be protected nationwide, it is likely that transmission rates would diminish or at least reach a plateau. As a first step the proposed program would aim at reaching the 10-14 year olds of Kinsha: (about 400,000 children) through the schooling system. The 10-11 year olds are in primary schools where the enrollment rate is close to 90X. The 12-14 year olds are in secondary schools where the enrollment rate is close to 50Z. Approximately 300,000 children would be reached this way, and might be able, through contacts with friends in the community, to disseminate information to the majority of the target population. About 10,000 teachers would have to receive special training, as part of the proposed program. If this approach is successful, it would be progressively replicated nationwide, starting with major cities. 2.10 Patients attending health facilities and the population covered by outreach health programs (such as immunization) are also an important target group which can receive specific information and recommendations through direct contact with health workers and social workers. Of particular importance are the patients receiving care for STDs (an important cofactor for HIV infection). In order to carry out these tasks, the health staff would receive an IEC in-service training as part of the global in-service training described in para. 2.17. 2.11 Finally, citizens participating in MPR activities may expand information to their communities with more persuasion than "ordinary" citizens. The MPR network is relatively well organized and benefits from presidential support. As part of the program MPR leaders would be trained in basic IEC techniques in order to insure consistency in the messages delivered to the public. Some other target groups are - 20 - important, including the army, truck drivers and 'professional" prostitutes. The army can be reached through their public relation office which is in charge of conveying educational (most!, political) messages to the soldiers. The truck drivers can, to some extent, be reached through the truck driver association. The prostitutes, as an organized group, are more difficult to reach, except at the community level where small scale experience have already been attempted with some success in poor peri-urban areas of Kinshasa. 2.12 Targeted Condom Distribution. In order to respond to and stimulate an increase in demand for condoms, the proposed project would follow a two-pronged strategy: to make condoms widely available in strategic places such as bars, night clubs, hotels, health facilities, enterprises, pharmacies, shops, markets and others to be identified; and to promote their use among target groups including prostitutes, students, employees, civil servants, etc. Several channels of distribution would be used: private pharmaceutical networks, NGOs' distribution systems, the Family Planning Project (PSND), EPI, the Tuberculosis Control Program and others to be identified. Efforts have to be coordinated in order to ensure a wide distribution in a short time. Condom availability and use are key elements of the control strategy since, according to epidemiological modelling, only the wide use of condoms can have a significant impact in reducing HIV transmission in a population where HIV seroprevalence is already high (see Annex II). Given the importance of increasing condom use, their selling price would be subsidized by 502 (see para. 3.06). In some cases, in order to launch a promotion program, condoms would initially be distributed free to some high-ri3k groups (such as prostitutes, soldiers and truck drivers). 2.13 Program Management. The DOH at the central, regional, sub- regional and Health Zone (HZ) levels will be institutionally strengthened to plan, monitor and evaluate IEC activities. At the service delivery level the PHC network, including NGOs and enterprise medical departments will be the key implementing vehicle: FONAMES (the para-statal agency in charge of monitoring nationwide PHC implementation) will play a leading role in retraining the health staff. The proposed project would provide IEC material and equipment, vehicles, training, technical assistance, condoms and operating funds. Integration of AIDS Control Activities in Health and Social Programs 2.14 Several AIDS control activities, including blood screening, sterilization of skin-piercing instruments, case management, STDs treatment, counseling of AIDS patients and seropositive individuals and social support to families should become part of the routine activities of the health and social systems. The project would support the integration of these activities through the provision of in-service staff training, equipment, medical supplies, supervision and operating funds. - 21 - 2.15 Blood Screening. Currently, only two health facilities in Kinshasa routinely screen donated blood (MYH and Clinique Ngaliema) and the only blood bank is the one at Clinique Ngaliema for its patients exclusively. This represents an extremely small supply of safe blood for a city like Kinshasa where 60 to 120 blood transfusions occur every day. Additional blood banks are being established at MYH and the teaching hospital with FRG financing. The NACP aims at creating eight regional blood banks in the major cities (financing has already been secured for Goma through Italian cooperation). This program is indeed useful but addresses only part of the problem since at least 50? of blood transfusions occur in small hospitals or health centers in an emergency context: the donated blood comes from relatives of the patient or from "professional" donors who sell their blood on the spot. Thus, in addition to the blood bank development strategy, rapid screening tests should be distributed19 to primary health care facilities where blood transfusion is often used. In addition, the project would support the establishment of standards and protocols for adequate use of transfusions as an emergency therapeutic tool. 2.16 Sterilization of Skin-piercing Instruments. As mentioned in para. 1.12 the effectiveness of HIV transmission through contaminated needles and syringes is probably extremely low. However, it does not mean that health staff should be complacent about it and the AIDS epidemic should be a good opportunity for enforcing all the standard sterilization techniques which should be applied by health staff. These standard procedures should be sufficient to virtually eliminate this means of transmission. The proposed project would support these activities though the provision of sterilization equipment and staff training as part of the larger AIDS-related in-service training program. 2.17 In-Service Training and Supervision Program. The training and supervision program would focus on case management, detection and treatment of STDs and IEC techniques. Case Management would include the implementation of: (a) standard treatments for each type of AIDS- related opportunistic infection and disease symptoms; (b) an adequate balance between hospital care and home care according to the stage of the disease; (c) counselling for affected individuals, the family and the community (including the work place and the schools); and (d) adequate case reporting. STDs detection and treatment could contribute significantly to the reduction of AIDS transmission. As mentioned in para. 1.04 ulcers due to STDs increase the risk of HIV transmission, particularly from male to female. The health staff will have to move from passive detection of STDs to active screening and treatment in accordance with adequate therapeutic protocols. In addition, STDs prevention measures (to be promoted by the health 19/ Five rapid screening tests are being currently experimented with in Kinshasa (Projet SIDA). These tests are fast (a few minutes) but give a certain amount of false seropositives. They can be used as a fast screening technique when an urgent blood transfusion is needed. They cannot be used as a diagnostic test since they have to be confirmed by the more reliable tests (ELISA and Western Blot). - 22 - staff) are similar to those used for AIDS transmission and could have an important synergistic effect. Communication activities would aim at: (a) promoting AIDS prevention among the population covered by health facilities (see para. 2.10); (b) advising local authorities (including the teachers) on the content of messages that they should convey to specific target groups; and (c) advise asymptomatic HIV seropositive patients on the necessary behavioral changes. Regarding the latter point, mother-neonate transmission is a specific and sensitive topic, given the extreme importance of motherhood in Africa. About 50Z of the HIV-infected mothers will transmit the disease to their offspring. In children the disease is lethal within 2-3 years. The only means to prevent this transmission are contraception and sterilization. Given the sensitivity of these issues, health staff should be given instructions by the Government to have these decisions made at the individual level after adequate information. 2.18 The in-service training program will be carried out by the DOH through FONAMES which is already largely experienced with this type of activity. Since the number of health staff to be trained is close to 10,000 , the training program would have to be phased, starting with areas where seroprevalence is highest, i.e. urban areas. 2.19 Social Programs. AIDS-related socio-economic problems will increase the strain on social services (mostly private, as mentioned in para. 1.18), particularly in urban areas. The project would support social interventions to help households and enterprises cope with the impact of AIDS. These would be designed using information from the economic impact studies (see para. 2.27) and carried out by both the public and private sectors. At the public sector level the project would provide operational support to selected Centres de Promotion Sociale in areas where HIV infection is highly prevalent - and to social services located in hospitals. At the private sector level the project would support NGOs working on AIDS-related social problems through the provision of technical assistance, in-service training, and operating funds. Operational Research and Studies 2.20 In addition to on-going research activities (see para. 1.21) the proposed project would support a program of operational research and studies aiming at: (a) analyzing HIV-transmission parameters; (b) assessing the social and behavioral dimensions of AIDS; (c) comparing the cost-effectiveness of various control measures; (d) identifying the specific constraints on condom use and ways of overcoming them; (e) developing case management strategies; (f) developing diagnosis tools for HIV infection; (g) assessing the financial and economic impact of the disease; and (h) developing the AIDS surveillance system. Several institutions in Kinshasa have the capability of - 23 - carrying out zesearch and studies: University of Kinshasa (School of Public Health, School of Medicine), Institut de Recherches Economiaues et Sociales, Departement de Demographie, Institut National de Recherche Biologique (INRB); Prolet SIDA; among others which would be identified during project implementation. In addition, several international organizations (for example the USAID-supported AIDSTECH project) have already expressed interest in supporting these research efforts. Given the technical specificity of the research and study programs, it was agreed during negotiations, that the DOH shall not carry out any operational research program or conduct any study as part of the Project, except on the basis of a detailed description of objectives, methodology and costs previously approved by IDA (para. 6.02 (a) ). 2.21 HIV transmission. There are still uncertainties regarding the effectiveness of various ways of HIV transmission and the factors which facilitate or prevent this transmission. This information will be important in improving the design of preventive programs and assessing the potential for further spread of the epidemic. 2.22 Sociocultural and Behavioral Dimensions of AIDS. To understand how AIDS spread so rapidly in some population groups requires a knowledge of social, cultural and behavioral aspects of the society which are not often scrutinized, including: sexual behavior among various socioeconomic groups, importance of occasional and professional prostitution, stability of relationships between spouses, attitude towards women, prevalence of homosexuality, etc. The KAP surveys used for developing the IEC program (see para. 2.07) would certainly help to grasp some of these elements but they are too superficial to have enough analytical depth. A more "ethnological approach" based on the analysis of the social, economic and cultural characteristics of AIDS patients and their implications in terms of mechanisms leading to high risk sexual behaviors would lead to a better assessment of the potential risk of transmission among various socioeconomic groups, and to an identification of potential ways of diminishing these risks. 2.23 Cost-effectiveness of Control Measures. Given the limited resources available to the health sector, it is important to carry out a cost-effectiveness analysis of the various proposed control measures, in order to assist health planners in designing the control program and reallocating resources within the health sector. In particular, a study is needed of the relative cost-effectiveness of alternative approaches to reducing transmission through blood transfusion: screening for low-risk donor recruitment versus better criteria for transfusion. In addition, a cost/benefit analysis of AIDS prevention programs would give government decision makers a basis for intersectoral reallocation of resources. In order to carry out these studies, an in-depth analysis of AIDS costs is required, as proposed in para. 2.27. - 24 - 2.24 Constraints on Condom Use. According to preliminary analysis of the effectiveness of various control measures, the wide use of condoms would be the measure with the highest potential to effectively curtail HIV transmission rate (see Annex 2). Unfortunately, condom use implies a major behavioral change, one extremely difficult to accomplish in both developed and developing countrien.20 An in-depth analysis of the constraints specific to the Zairian society would he most useful for improving the condom promotion program. 2.25 Case Management Strategies. In industrialized countries, the high cost of hospitalization of AIDS patients has led to the development of case management strategies balancing hospital care and home care with the assistance of social community programs. These strategies have allowed a dramatic reduction in the cost of treating AIDS patients without reducing the quality of care. This approach should be applied to Zaire and include the development of standard therapeutic schemes (see para. 2.17). The implementation of such a strategy would reduce both the direct cost of AIDS and the workload of health facilities. 2.26 Developing Diagnosis Tools. The laboratory tests for HIV infection should be improved in two areass rapidity and facility in the case of rapid screening tests (used for donated blood), and specificity in the case of tests confirming the diagnosis (such as Western Blot). The latter point is particularly important since some physicians are reluctant to inform the seropositive individuals on their status, given the percentage of false (or ambiguous) positive results with the currently available tests. Proiet SIDA, which has the capability of conducting such studies, would receive the necessary financial support from the proposed project. 2.27 Economic impact of AIDS. As mentioned in para. 1.23 a joint WHO/World Bank mission has prepared a research strategy for the analysis of the economic impact of AIDS in Zaire. The detailed proposal (which has been - in principle - accepted by the Government) is in Annex 3. The overall objective of the study is to estimate, as accurately as possible, the direct and indirect (loss of productivity) cost of AIDS to the Zalrian economy for each of a number of distinct population groups (in both urban and rural areas) and treatment options. The research methodology would include prospective and retrospective studies on both population-based random samples and convenience samples of particularly important target groups. The studies would be carried out by local groups or researchers with the internal support of two short-term technical assistants in economic analysis. 20/ Dr. N. Adler, Dr. C. Irwin, American Journal of Public Health, April 1988. This University of California-San Francisco study has found that even in a city where there is a high awareness of AIDS and during a period when AIDS prevention education intensified, most sexually active adolescents do not use condoms (2Z of girls and 82 of boys surveyed said they used condoms every time they had intercourse). - 25 - 2.28 StrenRthening the Surveillance System. The NACP includes a proposal for establishing a comprehensive HIV infection Surveillance System including: (a) a study of HIV seroprevalence in the general population, (b) a monitoring of the geographical expansion of HIV infection in "sentinel" groups; (c) a study of HIV infection's incider.ce; and (d) the reporting of AIDS cases. Some of these activities are already funded by WHO and Prolet SIDA; the proposed project would complement these efforts in order to fully develop the Surveillance System. 2.29 The study of HIV seroprevalence will be carried out in several major cities (starting with Kinshasa) and in a sample of rural areas. This study would give the extent of HIV infection in the general )opulation (by age groups and by sex) at a given point in time ("point prevalence"). Repeated a few years later, this study would inform on the overall trends of the epidemic. The study will be implemented with WHO technical and financial support. 2.30 In order to assess the magnitude of HIV infection's geographical expansion, some "sentinel" groups, particularly susceptible to HIV infection, would be regularly tested. These groups include prostitutes, TB patients, students, patients with STDs, soldiers, truck drivers, etc. 2.31 The speed at which HIV infection is transmitted in a population is a key factor to assess the potential magnitude of the epidemic and to measure the impact of control measures. The only way to evaluate precisely this speed of transmission is to measure the sero incidence of HIV infection in a specific and stable population (a "cohort"). A follow-up study of this cohort over several years permits the assessment of the annual incidence rate of HIV infection. This type of study is difficult to implement (the cohort has to be stable and confounding factors and bias have to be eliminated) and is time-consuming. The Proiet SIDA has started such a study on employees of a large private enterprise in Kinshasa. The proposed project could support the execution of similar studies in a few other cohorts. 2.32 Finally, as mentioned in para. 2.17, health staff will Le trained in AIDS case reporting, based on clinical criteria, since confirmatory tests are expensive. This reporting system would allow the AIDS control program managers to assess the impact of the epidemic on the health systems. Institutional Strengthening 2.33 Institutional aspects of the NACP are particularly important since: (a) the control program is complex, with many medical, social, economic, legal and political implications; (b) the control activities are intersectoral and have to be coordinated by several institutions (DOH, Department of Education, Department of Planning, etc.); (c) financing comes from several sources with their specific accounting - 26 - procedures; and (d) implementing agenci.es are numerous and scattered all over the country. The project would support institutional strengthen.ing at the central, regional, sub-regional and HZ levels. 2.34 Central Level. At the central level, the BCC has a key role to play in project management (see para. 4.04). WHO is already providing technical assistance to the bCC with an administrative officer and is planning to provide an epidemiologist and an IEC specialist. The BCC will require further strengthening with a program manager (deputy BCC director), an accountant, and a team of local consultants to be contracted as needed. -he project would also provide the necessary equipment and logistical support. In addition, the project would provide fellowships, seminars and study tours to train program managers of various levels. Given the importance and complexity of project management, it was agreed during negotiations that the following would be conditions of credit effectiveness: (a) that a specialist in health program management with satisfactory qualifications and experience be appointed by DOH as BCC deputy director during the three years of project implementation;21 and (b) that an accountant with qualifications and experience satisfactory to IDA be appointed by DOH as BCC chief accountant during the three years of project implementation (para. 6.01 (d)). 2.35 Regional Level and Sub-Regional Level. The monitoring of NACP's implementation will be decentralized at the regional and sub- regional levels through the Public Health inspectorates. The project would support seminars to inform and train these individuals. The project would also provide some operational support to assist regional and sub-regional inspectorates to carry out supervision activities. 2.36 HZ Level. The HZ chief medical officer and his/her staff would receive the following operational support from NACP: (a) detailed guidelines for developing AIDS control activities in HZs; (b) resources (rapid HIV screening tests, condoms, drugs, IEC material, operating funds) to initiate AIDS control activities through the health facilities network; (c) feedback information to keep the HZ staff abreast of AIDS control strategies; and (d) means to report and notify the central level about the progress of AIDS epidemic in the HZ. HZ committees (which include the key community leaders) would assist in developing intersectoral collaboratWon (Education, Administration, Social Services, NGOs, etc.). Institutional strengthening at the HZ level would be progressive, starting with the most operational HZs in both urban and periurban areas, to reach about 100 HZs within three years (one third of the total). 21/ This specialist would be recruited after a joint review of the proposed candidacies by the Government, UNDP (which finances this position), WHO/GPA (which is the implementing agency for UNDP and the lead advisor for the program) and IDA (since the specialist would have an important role in managing the IDA's credit). -27 - 2.37 Non-Governmental Health Sector. Several non-governmental networks will actively participate in AIDS control activities, including NGO-run health facilities, enterprise medical departments, and private health facilities. These institutions may eventually require some institutional strengthening in order to improve their implementation capability. Thus the project would provide support to these institutions, including training and some operational assistance as needed. III. PROJECT COSTS AND FINANCING A. Costs 3.01 On the basis of a three year implementation period, total costs of the project amount to Z. 3.0 billion, or US$21.9 million equivalent. Base costs as of February 1988 are calculated at US$19.0 million equivalent (86Z) and contingencies at US$2.9 million equivalent (14Z). Since goods and equipment for project purposes would be imported free of custom duties and internal taxes, base costs are net of tax liabilities. The estimated cost, expenditure categories and foreign exchange component are summarized in Table 3.1 below. - 28 - TABLE 81 Prorect Cost by Exsdiltur. Coteaory ACcount. Cost Sua rY US. I low Local Foreign Total Invostment Costs - Material Dovpt 246 341 S7 - Training 722 496 1,217 - Equipmnt - 808 908 - Furniture 42 63 106 - Tech. Assistanco 252 1,128 1,380 - V-hicls 499 499 - Research 699 870 969 - PPF e6 240 800 Total Invostment Costs 1,921 8,939 6,880 Recurrent Costs - Salaries 881 881 - Stipends & Tr. Allowances 677 - 677 - Equip. Maintenance 22 87 109 - Vehic. op. A Maintenance 68 252 815 - Condoms - 8,861 8,861 - Medical Supplies - 7,010 7,010 - Office Supplies 47 47 94 - Utilities 150 - 150 - Audit 4 41 46 Total Recurrent Costs 1,844 11,848 18,192 Total Baseline Costs 8,765 16,287 19,062 Physical Contingencios 80 1,230 1,28O Price Contingencio- 292 1,299 1,691 Total Costs 4,087 17,816 21,903 195 81x 100 3.02 Basis of Cost Estimates. Project costs are estimated in Februacy 1988 prices. Costs of equipment, vehicles, furniture and supplies are based on CIF unit prices on local market prices, adjusted to include installation. Cost of training, operational research, local and international consultants, fellowships and other services reflect local or international rates as applicable. 3.03 Contingency Allowance. Physical contingencies are estimated at 10? for equipment, furniture and medical supplies. No physical contingencies are allowed for technical assistance, studies and operational research. Assuming that the high local inflation rate (more than 100Z in 1987) would be counterbalanced by the local currency's devaluation, all unit costs are calculated in US dollar - 29 - (exchange rate of February 1988) and estimated price increases (Table 3.2 below) are based on the annual rates of price escalation from the base costs in accordance with the implementation schedule (see Annex IV). TABLE 8.2 Price Continsue. ion 199 1991 For-T gn as 4X 4X 3.04 Foreign Exchange Component. The estimated foreign exchange component is US$17.1 million or 80? of project costs. It is based on the expectation that: (a) about 402 of the furniture will be locally manufactured with an indirect foreign exchange of 65Z; (b) 1002 of equipment, vehicles and supplies would be imported; (c) about 902 of technical assistance would be provided by foreign consultants; and (d) training would have a foreign exchange component of 50?. B. Proiect Affordability 3.05 The recurrent cost implication of the proposed project were calculated assuming the following for the 1989-91 period: (a) GNP growth rate of 3? per year; (b) a constant share of Government recurrent expenditure of 28? of GNP; and (c) a constant share of 3.5? for DOH in the government budget. 3.06 In 1992 the project would have a recurrent cost implication of about US $6 million. The cost structure would be as follows: (a) salaries, maintenance and vehicle operation, US$l million; (b) medical supplies US$3.2 million; and (c) condoms US$2.2 million. In comparison to these recurrent costs the projected 1992 Government health operating budget - US$12.4 million - appears highly insufficient to finance the program. Table 3.3 below shows the proposed financing plan. - 30 - TABLE 8.8 Financina Recurrent Cost of the AIDS Control Prosra. 1092 (millions of USt 1981 ) Recurront Costs Govt. Consumers Foreign Aid Total - Salaries, rate A 0.6 0 0.6 1.0 v-hiclo operation - Condoms 0 1.1 1.1 2.2 - Medical supplies 0 1.8 1.8 8.2 Total 0.6 2.7 8.2 6.4 Projected Expenditure 12.9 77 0 X increase 4 8.6 Sourc*- pprsisl mission, February 1988. 3.07 The DOH operating budget would have to increase by 4Z in 1992. Its share of the total gov2rnment recurrent expenditure would have to increase from 3.5% to 3.6X. Such an increase should be easily acceptable by the Government given the importance of reducing the spread of the epidemic. The increase in health service consumer expenditure should also, in theory, be affordable (3.6? of projected expenditure) since user charge and full cost recovery are usual features of the health system in Zaire. However, as mentioned in para. 1.21, the key issue will be the inequitable distribution of AIDS-related expenses, given the absence of risk sharing/cost sharing mechanism among the population not covered by medical insurance. Such mechanisms could be experimented as part of the proposed FY91 sectoral adjustment lending. Meanwhile, foreign aid will have to support both DOH and consumers by financing 502 of operating expenses, as shown in Table 3.3. In addition, project affordability will have to be considered in relation to financial implications of other health sector investments. As part of the IDA-supported Structural Adjustment Credit the PEP, which includes the NACP since March 1988, is being reviewed in order to avoid low-priority investments which would divert essential resources from priority programs such as the AIDS control program. It was agreed during negotiations that, by September 30 of each year of project implementation, the three year rolling PEP of the Borrower for the health sector would be presented to IDA for review and comment, starting September 30, 1988 (nara. 6.02 (b)). _ 31 - C. Proiect Financing 3.08 An IDA credit of US$8.1 million equivalent would finance 37Z of total project costs, including 422 of foreign exchange costs and 12S of local costs. Coordinated cofinancing would be provided by several donors, including Belgium (US$1.5 million), Italy (US$1.2 million), FRG (US$0.6 million), USAID (US$1.7 million), EEC (US$2.0 million), UNDP (US$1.0 million), UNICEF (US$1.4 million), WHO (US$1.0 million); for a total of US$10. million.22 WHO and UNDP will be responsible for coordinating and monitoring cofinancing mechanisms. Since most financial pledges are additional contributions to on-going donor-supported activities, it did not appear necessary to include cofinancing conditions for project effectiveness. Furthermore, even if other donors financing did not materialize (aa unlikely hypothesis given the importance of controlling the AIDS epidemic), IDA's contribution would still be essential to support core NACP activities. The Government would allocate US$1.5 million to the project (72 of total cost) and beneficiaries' contributions would amount to US$1.5 million (72 of total cost). Canada and France have also expressed interest in participating in the project, but have not yet committed any specific funding. If these resources become available during project implementation for financing specific project components, the Government would be able to carry out additional activities broadening the scope of the project. 22/ These cofinancing amounts are preliminary estimates based on on- going financing anxd p.edges made during the February 1988 Donor Meeting in Kinshasa. Detailed cofinancing strategies would be prepared during the first meeting of the Joint Coordinating and Monitoring Committee (see para. 4.05). - 32 - D. Procurement 3.09 Procurement arrangements are summarized in Table 3.4 below. TABLE 3.4 Pro.-ct El-nnt ICB LCD Other NA Total Cost - Equipment 0.94 ( .27) 0.94 ( .2;) - Furniture 0.14 ( .06) 0.14 ( 08) - Vehicles 0.51 ( .82) S.61 ( .82) - Material Dvpt. 0.69 ( .22) 0.69 ( .22) - Training/TA 2.98 (1.49) 2.98 (1.49) - Research 1.11 (.566) 1.11 ( .56) - PPF 0.6 (0.6 ) 0.5 (0.6 ) - Condoms 4.84 (1.44) 4.84 (1.44) - Md. Supplies 8.07 (2.70) 8.67 (2.70) - Other Op. Coat 2.72 ( .62) 2.72 ( .52) 18.80 (4.78) 0.14 ( .68) 4.68 (2.26) 3.22 (1.62) 21.9 (8.07) Note: Amounts In parentheses reprosent IDA financing. 3.10 Goods. Given DOH's lack of experience in procuring medical and educational equipment and supplies, UNICEF would be appointed as procurement agent for MOH and would carry out the procurement following ICB procedures in accordance with IDA guidelines. In view of the relatively small number of vehicle (30) and their variety (pick-ups, 4-wheel drive, passenger cars), limited tender inquiry or international shopping (minimum 3 bids) would be used. Procurement of vehicles would be limited to contractors who have or are prepared to establish after-sale services and spare part facilities. Procurement of furniture amounting to US$60,000 equivalent in total, would be done following LCB procedures acceptable to IDA. Contracts for miscellaneous goods amounting to US$100,000 equivalent in total, would be procured through prudent shopping (at least three price quotations). 3.11 Services. The appointment of consultants would be done following procedures that are satisfactory to IDA and in accordance with IDA guidelines. Terms of reference and conditions of employment of consultants as well as their qualifications would have to be satisfactory to IDA. The selection of consultants and candidates for the fellowship program would be submitted to IDA for review. - 33 - 3.12 Bank Review Requirements. Drafts tender documents and master lists of furniture, equipment, supplies, and vehicles with related cost estimates anA prequalification of contractors will be reviewed by IDA. IDA review of tender documents prior to award would be required only for contracts above US$50,000 equivalent. All other contracts would be subject to review by IDA after the contract award. E. Disbursement 3.13 Disbursement of the IDA credit would be as follows: 100Z of foreign expenditures and 90Z of local expenditures for furniture, equipment, materials, vehicles, medical supplies, training, consultants and expert services, studies and operational research; and 507 of non-salary operating costs. Withdrawal applications for expenditures of less than US$10,000 will be submitted against statements of expenditure (SOEs). All other disbursements will be fully documented. The SOEs would be retained by the Borrower for inspection by supervision missions and review by the annual audit. The Borrower would not submit application for reimbursement valued below US$20,000 equivalent. 3.14 The project would be completed in three and one-half years, including six months to finalize accounts and submit final withdrawal applications. It is expected that the loan would be fully disbursed by June 30, 1992. 3.15 Special Accounts. In order to ensure that funds for project implementation would be available when required, a special account would be established with a Bank acceptable to the Association. This special account would be managed by DOH's BCC to carry out the project-related activities. The initial deposit by IDA would cover about three months' anticipated expenditure, estimated at US$0.75 million. This amount would be available from the IDA credit amount afi-r credit effectiveness. The special account would be replenished by jDA on the basis of documentary evidence of payments for goods and services made by BCC. In addition, the Borrower would also open in BCZ a project advance account to cover three months of Government contribution to operating costs and to be replenished quarterly. It was agreed during negotiations that establishment of these accounts and an initial deposit equivalent to US$125,000 in the project advance account would be conditions of credit effectiveness (para. 6.01(a)). 3.16 Accounting and Auditing. The project would be subject to normal governmental accounting procedures, which are satisfactory to IDA. The DOH's BCC would be strengthened with a certified public accountant to work specifically on the proposed project accounting (see para. 2.34). Annual auditing would be required for all expenditures financed under the project, with particular attention to - 34 - those expenditures reimbursed under SOEs. Auditing would be performed by independent auditors acceptable to IDA. It was agreed during negotiations that audit reports would be submitted yearly to IDA, within the six months following the end of the Borrower's fiscal year (para. 6.02(c)). IV. PROJECT IMPLEMENTATION A. Proiect Preparation 4.01 In September 1987, the Department of Health ar4 Social Affairs (DOH), with the tcchnical and financial suppor- WHO/GPA, had prepared a medium-term plan (1988-92) for the implb. ation of the National AIDS Control Program (NACP). In October 198/, the Medium Term Plan (MTP) which was intended to provide a framework for all AIDS control activities in Zaire, was endorsed by WHO/GPA and shared with the donor community, including the World Bank, for an eventual support. In December 1987 a Bank mission, on the basis of the MTP, pre-appraised the proposed project and specifically identified with key members of the National AIDS Committee what could be the Bank's contribution to the NACP in the context of the WHO/GPA supported Global AIDS Control Strategy. In addition, a set of specific recommendations were made to improve the design of the MTP, and consequently additional documents (integrating AIDS control activities in the PHC system and management of AIDS cases and HIV seropositives) were prepared by the DOH and shared with WHO/GPA. On February 11-12, 1988, a donor meeting was organized by the Government and WHO/GPA, to solicit pledges from bilateral and multilateral organizations, including the Bank. Following the donor meeting, a Bank mission appraised the AIDS control project. In June 1988, the Government received a US$300,000 PPF to complement the funding that WHO provides for the preparation of AIDS control activities. B. Oritanization and Manaaement 4.02 The project will be implemented through the existing management structure, which has been strengthened by the creation of a National AIDS Committee, a Central Coordinating Office (BCC) and two executive committees, as described in the following paragraphs. WHO/GPA and UNDP will have a key role to play in project implementation, particularly in regard to: (a) policy and strategy development; (b) donor coordination, including the development of consistent financing plans; (c) technical assistance to AIDS control activities; and (d) the review of detailed plans of operation. - 35 - 4.03 National AIDS Committee. The national AIDS committee is composed of representatives from various institutions, including the Department of Planning, DOH, the Department of Education, the Department of Women's Condition, Department of Information, MPR and the Presidency. The chairm&n is the State Health Commissioner. This committee is responsible for defining the policies and strategies of the NACP and for regularly monitoring the progress of the program. The committee can also be called upon if some major issues arise durin3 program implementation. The National AIDS Committee has an executive secretariat, the Bureau Central de Coordination (BCC). 4.04 Bureau Central de Coordination (BCC). The BCC is under the direct supervision of the State Health Commissioner. It is composed of a Director, two epidemiologists, an administrative officer (WHO consultant), a laboratory specialist, two IEC specialists, (including a consultant from Population Servic^s International, as mentioned in para. 2.08) a public relations person, a deputy administrative officer (WHO consultant), two secretaries, five drivers and three workers. As mentioned in para. 2.34, the BCC will be strengthened under the proposed project by a program manager (Deputy Director) experienced in the planning and management of large public health programs, an accountant and additional support staff as needed. The BCC is in charge of coordinating, maintaining and evaluating all control activities. More specifically, the BCC will have to: (a) prepare the annual plans of operations; (b) coordinate and control activities to be implemented by various agencies (such as FONAMES, PSND or Projet SIDA); (c) directly carry out some activities (such as the aggregation of epidemiological data, the execution of some studies or the development of IEC messages); (d) provide funding to implementing agencies and control their expenses; and (e) contribute to the coordination among the various funding agencies. The latter task would be carried out in collaboration with WHO, which is providing overall guidance and support to program implementation and with UNDP, which will help coordinate the participating bilateral and multilateral agencies. In order to ensure an effective and consistent implementation process, it was agreed during negotiations that by October 31 of each year the DOH would submit to IDA for review and comment the annual project operation plans starting December 31, 1988 (para. 6.02 (d)). 4.05 Joint Coordinating and Monitoring Committee. In order to avoid duplication and overlapping among contributing agencies, the Government created in July 1988 a joint coordinating and monitoring committee (Commission mixte de suivi des ressources exterieures dans le cadre du programme national de lutte contre le SIDA), as described below. This committee would include representatives from the DOH, DOP, BCC, UNDP, WHO and each donor agency supporting the program. It was agreed during the February 1988 AIDS Donor meeting that UNDP would play a leading role in providing technical assistance to this committee, in accordance with the WHO/UNDP Alliance to combat AIDS. The committee is in charge of: (a) preparing the overall financing - 36 - plan; (b) monitoring the implementation of this plan, and, if necessary, looking for additional funding; and (c) assessing the overall program implementation performance. 4.06 Implementation Committee. The BCC will have to "contract" both intra and intersectorally several implementing bodies in order to carry out most of the cortrol activities. In order to ensure a strong coordination and collaboration between the various implementing agencies, an implementation committee (commission d'4x4cution du programme SIDA) was established in July 1988 in order to have the key managers for each project component meet on a regular basis. Objectives, strategies, programs and budget will be revised by this committee under the overall guidance of the BCC. C. Monitoring and evaluation 4.07 The BCC would monitor the progress of project implementation through process indicators to be developed as part of the annual operations plans. In addition, standard outcome indicators would be developed in collaboration with WHO/GPA in the near future. Each project component would have its specific set of process indicators, to be monitored by the managers of each implementing agency. The BCC would be responsible for overall projecL implementation monitoring and for initiating corrective actions as necessary. Meanwhile, the proposed set of process indicators include: (a) for the IEC component: ti) the posting of IEC staff at the regional and sub-regional levels; (ii) the number of general and targeted IEC campaigns; (iii) the number of condoms distributed; and (iv) the number of school-aged children reached by the education program. (b) for the integration of AIDS control activities: (i) the number of health facilities with blood screening capabilities, (ii) the number of health staff having received in-service training, and (iii) the number of AIDS-related social programs. (c) for operational research and studies: the number of studies and operational research programs being implemented. (d) for the surveillance system: (i) the number of seroprevalence and seroincidence surveys being carried out; and (ii) the number of reported AIDS cases. (e) for institutional strengthening: (i) the recruitment of additional staff and technical assistance at the central level; (ii) the number of retraining seminars for regional and sub-regional personnel; and (iii) the level of operational support for non-governmental programs. - 37 - 4.08 All these indicators are quantitative and would not give much information on the quality and impact of the various operations. In order to assess the qualitative aspect of ongoing control activities the BCC would have to carry out some specific sample surveys. In addition, the operational research program would give some indepth information on the performance of che various control activities and their potential impact on HIV transmission. It was agreed during negotiations that a project performance review, including project management, would be carried out annually under terms of reference acceptable to IDA and that the review findings and recommendations would be transmitted to IDA not later than October 31 of each year of project implementation (para. 6.02(e)). V. PROJECT BENEFITS. JUSTIFICATION AND RISKS A. Benefits Short-term Benefits 5.01 The proposed project would provide immediate attention to a public health crisis which has already had a negative impact on health status, health systems, health financing and the workforce and has the potential for causing severe human and economic losses in an already poverty-stricken country. Within three years, the project would help to: (a) establish key preventive measures aimed at protecting the most vulnerable segments of the population (10-14 year olds and women in reproductive age); (b) rationalize the packaging of AIDS control measures; (c) make the N{ACP fully operational and institutionally sound; and (d) understand the AIDS epidemic patterns. During this launching phase, a major drop in HIV transmission cannot be expected nation-wide; however as shown in specific and highly motivated population groups in the US,25 control measures aiming at inducing safer sexual behaviors can be effective in a short time. 5.02 Protecting Vulnerable Groups. Children in the 10-14 age group, and particularly the females who will enter the most HIV-infected age group (15-29) will be a target group of the Project's IEC component. Protecting this segment of the population, which is still largely uninfected, is a priority. Intersectoral collaboration between the DOH and the Department of Education would ensure, through the proposed project, an early start of targeted IEC activities. In addition, the project would provide the level 231 In 1982 in San Francisco the HIV infection prevalence rate was 232 among homosexual men (sample of 1,000 individuals, non-drug addicts). The incidence rate was about 122 per year, and in 1984 the prevalence rate was close to 502. In 1983 a massive targeted IEC campaign promoting "safe sex' was launched (limitation of the number of sexual partners, use of condoms, treatment of STDs, etc.). Since 1984 the incidence rate has dropped dramatically to the current level of 2S per year and the prevalence rate remains at around 50Z. Concurrently, the incidence rate of other STDs dropped by 922 between 1980 and 1986. - 38 - of resources needed to reach, through IEC techniques and condom promotion, other target groups, including prostitutes, soldiers, migrant workers and other high risk groups which are at the same time vulnerable groups and vehicles for transmitting HIV infection. 5.03 Rationalizing Control Measures. Through the early start of major control measures (IEC, condom promotion and distribution, blood screening, assistance to AIDS patients, etc.) and specific operational research aiming at assessing the effectiveness and efficiency of these measures, the project would: (a) assist in developing the most cost-effective packaging of AIDS control measures; (b) initiate the integration of AIDS control activities into health and social programs; and (c) monitor the impact of control measures on selected target groups. 5.04 Develop. g NACP's Institutional Framework. The project, through its institutional strengthening component, would make the NACP's organizational structure fully operational by: (a) developing the managerial structure at the central (BCC), regional, sub-regional and HZ levels; (b) establishing intra-and intersectoral coordination and implemen,ation mechanisms; and (c) balancing the governmental and non- governmental sectors' roles in the AIDS control program. 5.05 Establishing Financing Mechanisms. The project would establish financing mechanisms aiming at: (a) ensuring long-term and coordinated external financing; (b) integrating the AIDS control program in the three- year rolling PEP; (c) developing cost-recovery mechanisms for essential commodities (condoms, medical supplies); and (d) establishing risk- sharing/cost-sharing mechanisms at the community level. 5.06 Understanding the Epidemic. Through various studies, the project would contribute to a better understanding of the epidemic, including an analysis of: (a) the physiological factors contributing to HIV transmission; (b) the sociological and behavioral parameters contributing to AIDS spread; and (c) the epidemiological trends, including prevalence and incidence of the infection in various geographical areas and socioeconomic population groups. These baseline data would allow decision makers to improve the design of the various control strategies. Long-Term Benefits 5.07 As described in para. 2.01, the proposed project would represent the first phase of a longer term program aiming at: (a) protecting the majority of the population from HIV infection; (b) assisting the country in coping with the burden of illnesses and deaths among people who are already infected and will develop the disease; and (c) alleviating the AIDS-related negative impact on the nation's economy. 5.08 Health Benefits. The program would: (a) reduce the impact of AIDS on morbidity and mortality in both adults and children; (b) contribute to the control of STDs; (c) assist the health system in coping with AIDS patients; and (d) avoid major imbalance in resource allocation between priority public health programs. - 39 - 5.09 Social Benefits. The program would set up social structures and mechanisms to assist AIDS-stricken individuals, families and communities. This aspect of the program would particularly benefit the poorest families, which would not have otherwise the means of either taking care of AIDS patients or losing family income earners. 5.10 Economic Benefits. By diminishing HIV transmission, the program would reduce the magnitude of AIDS-related morbidity and mortality and thus diminish the productivity losses induced by the epidemic. The preliminary results of a cost/benefit analysis, comparing the costs of control measures to the economic value of AIDS cases averted, already indicate that the NACP would have a net economic benefit.24 B. Risks 5.11 The project's main risk concerns the weak managerial capability of DOH, particularly in regard to the complexity of the control program. The project is designed to address this risk by distributing managerial responsibilities among various implementing entities and several coordinating/monitoring committees. In addition, the project's institutional strengthening component would provide training, technical assistance and operational support aiming at developing planning and managerial capabilities at both the central and peripheral levels. The second risk is related to the experimental nature of the control measures: some of the proposed control activities may not have the expected impact on HIV transmission. The various project-supported operational research programs are designed to respond to this uncertainty and to adjust as necessary the NACP. The third risk concerns the potential for financing shortcomings on the long term. It is likely that the AIDS epidemic will be a long term problem in Zaire and there is a risk of donor fatigue in financing the NACP. The joint coordinating and monitoring committee (Government, WHO, UNDP, Donors) would be created to address this risk. VI. ASSURANCES AND RECOMMENDATIONS 6.01 The following would be conditions of credit effectiveness: (a) that the Special Accounts (IDA revolving funds and project advance account with initial deposit equivalent to US$125,000) be established by the Government (para. 3.14); 24/ In the US a cost-benefit analysis of screening blood donors for HIV has shown a benefit:cost ratio of 1.2 : 1. (R.S. Eisenstaedt, T.E. Getzen, American Journal of Public Health, April 1988). - 40 - (b) that a specialist in health program management with satisfactory qualifications and experience be appointed by DOH as BCC deputy director during the three years of project implementation; and that an accountant with qualifications and experience satisfactory to IDA be appointed by DOH as BCC chief accountant during the three years of project implementation (para. 2.34). 6.02 It was agreed during negotiations that: (a) the DOH shall not carry out any operational research program or conduct any study as part of the Project, except on the basis of a detailed description and terms of reference previously approved by IDA (para. 2.20). (b) by September 30 of each year of project implementation, the three year rolling PEP of the Borrower for the health sector would be presented to IDA for review and comment, starting September 30, 1988 (para. 3.07); (c) audit reports would be submitted yearly to IDA, within the six months following the end of the borrower's fiscal year (para. 3.15); (d) starting December 31, 1988, the DOH would submit the annual project operation plans to IDA for review and comment by October 31 of each year (para. 4.04); (e) a project performance review, including przject management, would be carried out annually under terms of reference acceptable to IDA, and the Review findings and recommendations would be discussed with IDA not later than October 31 of each year of project implementation (para. 4.08). 6.03 Subject to the above e nditions and assurance, this project constitutes a suitable basis for an IDA credit of SDR 6.2 million (US$8.1 million equivalent) to the Republic of Zaire. - 41 - Paget* PREVAU31ARE Di aI. Oaograph.c Reference Population Se- Age Prov. Size o Viru- Typ of Soure Area D te Subgroup Group Rate Sampl Tested Tyet ID Nbo C_nt ARU 1987 TOTAL AREA 8I/ 17-76 5.3 S19 HIV ELISA, va AOOO North-erast Zaire, Mean age - 82.7: Sea ratio - 1.7 ARU 1987 MARKET B 17-75 10.6 16o HIV ELISA. WV AOO0 North-east Zaire: mean age - DISTRICT 32.7: Sex ratio - 1.7 DUNCU 1986-87 MOBILE B ALL 24.2 33 HIVI LUN SOO5 I Norte-eaetern Zaire POPULATION DUNOW 1986-87 SEDENTARY a ALL 5.6 311 HIVI Uw SOOIl North-eaetern Zaire POPULATION OUNL 1986-87 MOBILE F2V ALL 11.1 9 HNVi UW 50011 North-eastern Zai r POPULATION DUNOU 1986-87 SEDENTARY F ALL 10.0 160 HIV1 Uw S0011 North-eastern Zaire POPULATION DtOJ1 1986-87 MOBILE M§J ALL 29.2 24 HIVI LUN SOOlI North-eastern Zaire POPULATION DUNGU 1986-87 SEDEBTARY H ALL 1.3 161 HIVI kNW SOOlI North-eastern Zaire POPULATION OU4QJ 1988 NOT F ALL 4.0 126 HMlV Uw SOOII North-eastern Zaire PROSTXTUrES DU4aLC 198t PROSTITUTES F ALL 32.4 84 HIVI Uw 50011 North-eastern Zaire ED.ATBPR 1976 PERSONS TESTED 8 ALL 0.8 689 HIV BLISA, VS FOOOI Sare collected during an RESION FOR EBOLA VIMUS investigation of Ebol virue. 8 110.diedu2 hea11t8hy: KINSiASA 1987 PREQA?T F ALL 6.0 2574 HXVI Uw 80010 KINSHASA 1987 PRE4ANT F 15-44 5.7 6000 HIVI UW NOOOB KXNHASA 1986 ASYMPTOMATIC B ALL 6.7 264 HIV ELISA K0001 AsyAptomtic for AIDS/ARC HOSPITAL Mean age was 23.2 PATIENTS KINSHASA 1986 MOTtF F ALL 6.0 529 HIV ELISA.IFA JOOO1 Number of cases based prevalence rate and sample KINSHASA 1985 HOSPXTALIZED 8 00-02 1.5 180 "IV UW DOOO1 Children 9 to 24 CHILDREN KINSHASA 1988 WELL-CHILD 8 00-02 8.6 S6 HXv LW D0001 Children 9 to 24 mo,ths CLINIC LAV/HTLB-II. KINS4ASA 1988 ADMISSIONS AT B 02-14 10.6 368 HXV ELISA, VSb DO01 40 of the 868 were HIV MAMA YE40 HOSP. positive using ELISA test. 24/40 aeropositives and 107/328 seronegatives had previously received blood transfusions. LAV/HTLVIII. KINSHASA 1986 MOTHI4tS P ALL 8.0 191 IV ELISA, WB JOO01 Mothers of children attending well-baby cl nice, Mama Yo= hospital: number of case based on prevalence rate and * mple sie. 1/Bboth j9F: fetale orc: U.S. Bureau of The Census. Center for International Resarch. AIOS/HIV Statistics Databas. - 42 - Ceogrephic Referenc Populution Sex Ago Pr*v. Size of Virus Type of Source Area D te Subgroup Croup Rate Semple Tested Teot ID No. Coments KINSHASA :aS6 IWATIENTS IN B ALL 27.0 169 HIV ELISA, VS JOOOt Inpatient in tubarculceis SANITDRIU1 saniteriu tori k h cnf`irad pulmonary tubercu losis, median age: 29. 60S men 43 of 53 BITSA-positive a;mples ware teoted by VS: number of coesa bae,:d,on sample size and prevalnce rate. KINSHASA 1985 PROSTITUtES F ALL 27.0 376 HIV ELISA, VS J0001 Cases baeed on preovlence rate and smaptie size. KINSHASA 1985 INPATIENTS B 09-67 84.3 274 HIV ELISA, WB MOO08 Tuberculosis Sanitorium. 691 of HIV positiv* were tubercular: 601 Sale and 401 fefma Is. KINSHASA 1lo" HOSPITAL 8 00-00 11.8 102 HIV ELISA-, VB 0009 Mam Yeso Hbpital. Age: 1-8 PATIENTS mnths. KINSHASA 1985 HOSPITAL B 00-02 12.4 258 HIV EUISA, WO M0009 Mass Ysmo Hospital. PATIENTS Age; 2 to 24 months. Snmple 851 saIe, 451 female. Risk factors: 16/32 mother HIV positive. Major risk factors: injections and blood transfusions. KINSHASA 1985 HOTHUSE OP P 1-9 7.8 250 HIV ELISA, WS H#0002 Moan Yso HoASpital HOSPITAL 16/20 seor-positive children. PATIENrS KINSHASA 1485 HOSPITAL a ALL 12.8 156 HIV ELISA, Va i10009 Mma Yomei Hospital PATIBITS Aos: children 9 sonths and KDISHASA 1985 SLOW DOCNOL ALL 12.0 25 HIV kw ZOOCS KINSHASA 1984-85 HOUSB4OLD 8 ALL 9.8 204 HIV EUISA, VS M0002 Contacts of AIDS and HIV CONTACTS OF patients. AIDS KINSHA'SA 1984-85 NTON-SPOUSE b ALL 4.8 18s HIV ELISA, VS W 0002 Household contact of patients HOLUS40LD vith AIS or HIV positive. CONrACT KINSHASA 1984-85 HOSONSLD a ALL 1.9 165 HIV ELISA, VS M0002 Contacts of HdV negative CONTACTS OF patients. HIV NM. KINI0ASA 1984-8 PATITAS B 02-14 10.9 2 68 HIV ELISA, WV MO001 Mam Yemo Hospite. Moan ag-1.1 yearsr. Risk factors: 61blood transfusions. 94.91 medical in actions, 251 acarifica Ion. 10 iseronegative children died (10/328) = 3.0511. KIPISHASA 1984-85 HEALTHY F ALL 6.9 2117 HIv ELISA, VS 0.0002 Coase estimated based on PERSONS a~~~~~~~~~~~~~~sample size and prevalence KIPSISA 1984 HOSPITAL 8 20-29 9.2 468 #4IV ELLSA, VS #40007 Mams Yomo Hospital. PFJtSONNEL KINSASA 1984 HOSPITAL B S0-S9 6.o 1211 HIV ELI5A, VS H0007 Mama YVeo Hospital. KINSHASA 1983 OUTPATIENTS B 13-6e 6.0 100 HIV ELISA, WB W I001 Mam Yxo Hospital, 53 male, PFSI>NEL 47 femle. KINSHASA 1980 MOTHES AT F ALL S.C 498 HIV EISA, J0001 Use of frosen stored zera WELL-BABY IFA, RIPA indicated: number of cases CLINICS based on prevalence rate and "aMple size. NODEW 1986-87 RANOMN a 00-14 0.0 170 HIVI Uw SOO5I North-eastern Zaire. Village SAMPLE near Dungu. NDEDU 1984-87 RAP'O B ALL 0.5 222 HIVI UW S0011 North-eastern Zaire. Village SAMPLE near Oungu. NDEDU 1988-87 RANDOM P ALL 1.0 108 HIVi UW S0011 North-eastern Zaire. Village SAMPLE near Dungu. NDEWU 1986-87 RANDOM n ALL 0.0 110 HIV1 UW 50011 North-eastern Zaire. Village SAWLE noar Dungu. AOOOG Akter, I., B. Lrouze, S Mabika We Bantu, at al., 1987, Distribution of Antibodies to HIV1 in an Urban Co_un"ty (Aru, Upper Zaire), Second International Symposium on AIDS and Associated Cancers in Africe, Naples, Italy, 10/7-9, Abstract, TH-34. 80010 Bmerde, E., R. Ryder, F Bhetie et *l, 1987, Congenital HIV Transmission at an Upper Middle Class Hospital in Kirshaos, Second International Syeposium on AIDS in Associated Cancers in Africa, Naples, Italy, October 7-9, Abstract, F-2. F0001 Forthal, 0. N, J.P. Setchell, J. Mann, t al., 1986, HTLB-III/LAV in Sera Collected in 1976 Equateur Region, Zaire, International Conference on AIDS, Paris, 6/23-25, Absteact. 0OOO0 John Hopkins University, 1986, Issues in World Health, Population Reports, 7, Series L, No.6. K0001 Kalambay, Kaysbe, .J. M. Mann, H. Harris, et al., 1986, LAV/HTLV-III Seroprevalence among patients without AIDS or ARC hospitalized at University Hospital, International Conference on AIDS, Paris, 6/25-25, Abstract. - 43 - HO0D7 Mann, Jonathan. Henry Francis. Thomms C. Quinn, at *i.. 1986, H1V Seroprvevlence Among Hospital Workers in Kinshasa, Zairs, J, December 12, Vol. 286, No. 22, pp. 3099-3102. H0oo0 Mann. Jonathan, Fergin Davechi, Thoase Quinn, of., 1986, Ri;k Factoro for Human Iiunodeflency Virus S.ropositivity Aong Children 1-24 Months Old in Kinshasa, Zaire, Lancet, Septeber 20, Vol. 2. No. S60, p. 654- 686. MOOll Mann, Jonathan, Henry Francis, Poole Baudoux, et al., 1986, Human Iunodeficiency Viru- Seraprveylence in Pediatric Pationto 2 to 14 Years of Age at Mama Yamo HoopItol. Kinshasa. Zairc, ued iatrico, OctAer 4, Vol. 78, pp. 673-677. NOOOS NHa. VW. R. Ryder, *nd H. Francis, 1987. Congenital HIV Trans.ieaion in a Lsrce Urban Hospital in Kinahasa Second Intarnational Sypoeius on AIDS and Asocisted Cancers in Africa. Naples , Italy, October 7-9, Abstract, F-i Q000 Quinn. Thoiaa, Peter Piot, Josph McCornlck, at al., 1987 Serologic and Immunologic Studies in Pmtienta with AIDS in North Americo and Africa, J, May o, Vol. 2S7, No. 14, pp. 2617-2621. Q2002 Quinn, Thomas C J M Mann. J.W. Curran *t al., 1986, AIDS In Africa: An Epideelologic Paradigs, Science Nov. 21. Vol. 234, pp. 95i-962 SOGil Surmont, I., *nd J. Deseyter, 1987, Urban to Rural Spread of HIV Infection In '.unau. Zsire, Second International Symposium on AIDS and Asociated Cancers in Africa, NMples. Italy, 10/7-9, Abstract. TH133. ZOOO1 Zmgury D, KD Lurhu, R.C. Cll., at al., 198S, HTLV-III/LAV Infection In Central Africa. International Symposium on African AIDS, Brueel-, November 22-23, Abstract. ZOOOS Zagury, D., K. Lurhu-, R.C. C(llo, et al., 1987. HfLV-III/LAV Infection in Central Africa Second Intrnational Symposum on A'DS and Associated Cancers in Africa, NMples, Italy, October 7-9. Abstract. S.8.1. - 44 - ANNEX II Page 1 of 14 IMPLICATIONS OF CONTROL MEASURES FOR THE SPREAD OF HIV INFECTION1 A. Framevork 1. Figure 1 includes five possible control measures, from vacci4ie development to information, education, and communication (IEC) programs. Each measure gives rise to particular behaviors in the population. these behaviors being the proximate determinants that lead to modificitions in HIV transmission. Figure 1 suggests that targeting control measures at different groups may lead to important differences in the distribution of the proximate determirant behaviors across the population. 2. How the control measures affect the proximate determinants is poorly understood. For instance, IEC is known to increase condom use, but what types of IEC programs, how much of them, and how much must be invested in them are all questions without reliable answers. Empirical research is seriously lacking on these issues. Therefore, we focus here only on the proximate determinants and their impact on the HIV epidemic. 3. The effects of a vaccine is excluded since development may be a decade or more away, and distribution would impose further delays. When realistic prospects for a vaccine develop, this exclusion can be reconsidered. B. Method 4. The simulation model is a standard epidemiologic-demographic model that allow HIV to be transmitted sexually, perinatally, through needles, or through blood, represents the progression from infection to frank AIDS mainly from data on transfusion cases, and projects the population to provide estimates of susceptibles. Parameters were obtained for the model from the literature and, where this did not suffice, were estimated iteratively by running the model and attempting to fit reported rates for a Central African country with relatively high HIV seroprevalence. 5. Among the key parameters for transmission are the number of new sexual partners and numbers of injections and transfusions. These were defined by dividing the population into subgroups and assigning an appropriate rate to each subgroup. Across subgroups, number of sexual partners was assumed to average between 3 and 4, but the distribution was skewed so that 60 to 80 percent of the new pairings were accounted for by the most sexually active subgroup. Injections were assumed to average 4 per person per year, again highly skewed, and transfusions 4 per thousand persons per year. These means were the initial values provided to the program, which alters them in two ways. First, population in each subgroup changes over time, so that the means strictly apply only in the first year. Second, in the case of sexual partners, the program adjusts the rates to ensure agreement between the number for males and females. 1/ This annex is a summary of R.A. Bulatao and E.R. Bos' working papers, The World Bank, 1988. - 45 - ANNEX II Page 2 of 14 6. A base scenario was constructed, in which all the proximate determinants were assumed to stay constant from the present to 2010. Alternative scenarios were then constructed as variations oni the base scenario, allowing the proximate determinants to vary individually, increasing or decreasing by some constant percentage beginning in the year 1990. 7. To reduce the complications of these simulations, a number of simplifications were introduced. First, the results to be reported will focus mainly on adults. The simulations do generate figures for children, but they are assumed to be infected only perinatally, and not through injections or transfusions. Second, adults are assumed to stay in a particular sexual-frequency subgroup throughout their lives. Some random movement between subgroups can be introduced; initial tests showed that it made little difference, and this is therefore not explored here. Third, proportionate mixing is assumed: the likelihood of a sexual pairing is proportionate to the frequency with which the prospective partners take new sexual partners relative to the frequencies for all competing individuals. Fourth, separate urban and rural sectors are not distinguished. Consideration will be given to relaxing each of these limitations in later work. C. Results Effects of changes in sexual behavior 8. Figures 2 & 3 illustrate the effects of changes in sexual behavior. Condom use (assumed to be 90 percent effective in preventing infection) is represented *v alternative scenarios in which the percentage not using condoms declineb annually by either 2 or 10 percent. (The rate of change is applied to non-users rather than users in order to allow slower growth in condom usage as the proportion using approaches high levels and to prevent this proportion from exceeding 100 percent). These rates o. change resemble rates of change for non-use of all contraception: Kenya, for instance, achieved a 2 percent annual reduction in contraceptive non-use between 1977 and 1984, Mauritius a 4 percent annual reduction between 1971 and 1984, and Zimbabwe a 6.9 percent annual reduction between 1979 and 1984. For higher rates, one has to look to Asia, where Singapore, for instance, achieved a 9.1 percent annual reduction in contraceptive non-use between 1970 and 1977 (Mauldin and Segal 1986). - 46 - ANNEX II Page 3 of 14 9. In the low-condom-use scenario, usage goes from 0 percent of all sexually active pairings in 1990 to 33 percent in 2010. In the high-condom-use scenario, usage reaches 88 percent in 2010. Figure 1 also shows an alternative scenario where number of sexual partners changes, with the average sexually active individual having only two- thirds the number of partners in 2010 as in 1990. Such a decline appears quite plausible in view of rapid changes in sexual behavior found among high-risk groups in various countries (Carne et al., 1987; icCusick et al., 1985). 10. Figures 2 and 3 focus on the percent of adult females who are HIV-seropositive. Among adult males, the percer.tages Are similar but not exactly identical. These HIV seroprevalence c.'rves lag slightly behind curves for proportions of seroconverting, which are roughly one tenth as high. 11. Figure 2 indicates that high condor use could have a substantial effect, reducing peak seropreval?nce from 13 to 8 percent and hastening the inevitable decline from peak seroprevalence by about five years. Low condom use has a smaller effect. The figures also illustrate the effects of targeting. In the "balanced' condon use scenario. the high-sexually-active group is assumed to adopt high condom use and the low-sexually-active group low condom use, whereas in the "skewed" condom use scenario, the two groups' situations are reversed. The balanced scenario involves only 50 to 65 percent as much condom use as the skewed scenario, because the low-sexually- active group is much bigger than the high-sexually-active group. However, the balanced scenario produces much greater reduction in HIV spread. 12. The more modest declines assumed in numbers of sexual partners also appear to have some effect (Figure 3). Again, targeting makes a big difference. If the 2 percent annual declines take place mainly among the more sexually active, the outcome is almost as good as if the declines come across the board. Effects of medical interventions 13. Figure 4 illustrates the effects of medical interventions. The proportion with genital ulcers, assumed to be 5 percent among the most sexually active women (and much lower in all other groups), is assumed to decline to half of a percent in 1993. The proportion of injections that use sterilized needles is assumed to start at 20 percent in 1990 and to reach 60 percent in 1991 and 95 percent in - 47 - ANNEX II Page 4 of 14 1994. And the proportion of transfusions involving screened blood is assumed to start at 10 percent in 1990 and to reach 55 percent in 1991 and 94 percent in 1994. 14. These changes are more extreme, in percentage terms, than the assumed changes in sexual behavior, but, as Figure 4 shows, the results on HIV transmission are negligible. None of these changes in proximate behavior appears to produce a substantial effect. Each change will be considered further. i5. Even assuming four injections annually per capita, as the base simulation does, this source accounts for only 1 to 3 percent of all infections (Figure 5). Sterilizing needles cannot, therefore, have a large effect. The probability of transmission through an infected needle was assumed to be about half the probability of transmission to a woman through intercourse with an infected man. If the former probability were raised to the level of the latter, infection through injections could eventually account for about 6 percent of all infections, and sterilizing needles would therefore be more important. If, in addition, injections were assumed to be twice as frequent in the population, injections could eventually account for 12 percent of infections. These alternatives may be somewhat less realistic, but reliable evidence on this matter has not been found. 16. Like injections, transfusions account for 2 percent or fewer seroconversions. The probability of infection if the donor is seropositive is already set at 95 percent, and cannot go much higher. Transfusions could conceivably be more frequent than 4 per thousand. If they were much more frequent, blood screening could then have a larger effect. 17. The simulation assumed that the proportions of women with genital ulcers were 5 percent, 1 percent, and 0.1 percent in the high- sexually-active, medium-sexually-active, and low-sexually-active groups, and 0.1 percent among men in all sexual activity groups. It also assumed that the risk of transmission, given genital ulcers, was five times as great as the risk without ulcers. No basis exists for substantially raising the proportions with genital ulcers. The effect of ulcers on transmission is essentially unknown and might conceivably be much greater. If instead ulcers multiplied the risk fifty-fold rather than five-fold, they would contribute to a much more rapid spread of infection (Figure 6). - 48 - ANNEX II Page 5 of 14 Effects of timing and targeting 18. In the base scenario, 1985 HIV seroprevalence, across the entire society, is about 1.25 percent. What if control measures are being considered in a country with lower seroprevalence? One way to look at this is to assume that such a country is at an earlier stage of the epidemic, but is following the same basic path. Then the same base scenario can be used, but with control measures being introduced several years earlier. Figure 7 illustrates the situation where a 2 percent decrease in proportion not using condoms starts in 1990, in 1985, or in 1980 (also see Table 1). An earlier start clearly allow the epidemic to be contained at a lower level. 19. The demographic effects of the various interventions have not been detailed up until now because they do not vary much from previously reported results. In all the simulations, total population is barely affected, but mortality, and especially infant mortality, is increased. Compared to an equivalent society with no HIV infection, by 2010, the crude death rate could be as much as 20 percent higher due to AIDS. Condom use reduces the impact on mortality, but this effect is not noticeable for a decade after the condom program begins, auId .s t .Lally OUSll. D. Conclusion 20. Table 1 summarizes the effects of behavioral changes and medical interventions of the HIV epidemic. In a situation where HIV is relatively widespread, changes in sexual behavior are essential to reduce the scale of the epidemic. Earlier changes lead to better containment of the epidemic than later changes. The other proximate determinants do not appear as important for overall control of HIV transmission. Nevertheless, they may be important for other reasons: to guarantee the integrity of the health delivery system, for instance, or as part of a broad-scale attack on the disease in which synergisms among control measures may be critical. As Figure 1 illustrates, a program to control sexually transmitted diseases may have not only direct effects on genital ulcers but also effects in promoting condoms and reducing number of sexual partners. Given the vast uncertainties about how to change sexual behavior, such linkages should not be ignored. - 49 - ANNEX II Page 6 of 14 21. These results obtain under the specific parameters used in these simulations. Parameters were chosen to reflect an African situation, with high but declining fertility and mortality, relatively high HIV seroprevalence, rough parity between males and females infected, a blood supply not fully monitored, and a minimal contribution to transmission of homosexual behavior and intravenous drug use. Where these conditions do not hold - in the US, for instance - different priorities for control measures might apply. Whereas some parameters were based on clinical and epidemiological studies, others have little basis other than their contributing to scenarios roughly consistent with the reported HIV situation. Clearly, given the likely impact of the virus, much more and much better data on the relevant behaviors are needed. -50 - ANNEX II Page 7 of 14 Figure 1 Effects of control measures on the HIV epidemic. COYTROL MEASURE PROXIMATE DETERMINANT Vaccine development, > Vaccination distribution T of susceptibles A Blood donor > Use of screening R screened blood - Lower HIV > seroin- G cidence Provision of Use of sterilized E > sterilized | needles needles ' T14 I > Fewer genital Lower HIV STD control ulcers seroprev- N alence, I fewer AIDS Information G > Greater cases, education, _ condom use I fever AIDS communication deaths > Fewer sexual | partners ftpri 2 ANNEX II Effecis of Condom Use: Page 8 of 14 PUCUE Sy sgPOMVC AMONG ?gMAL 13 12 I * 2 * 3 a x a CM1 USZ SCEZNARIOS 1 Base No condom use 2 Low condom use Proportion not using condoms decreases annually, from 100% in 1990, by 2% 3 Skewed condom use Proportion not using condoms decreases annually, from 100% in 1990, by 10% among the low sexually active 5% among the medium sexually activ-- 2% amonq the high sexually active 4 Balanced condom use Proportion not using condoms decreases annually, from 100% in 1990, by * ~~~~2% amonq the low sexually active 5% among the medium sexually active 10% among the high sexually active 5 High condom use Proportion not using condoms decreases annually, from 100% in 1990, by 10% -52 - 11az 3 ANNEX II Effects of Fewer Sexual Partners: Page 9 of 14 pUcUiV iv ilElPdIve AMNG VCMALUO 13- 12- 10 *ww * IL 1ts 1tO I I00 25X 2010 a I + 2 93 A 4 S UAL PATNZS SC :NOS 1 Base No change in numbers of new sexual partners 2 Skewed reduction Number of new sexual partners decrease annually from 1990 by 2% among the low sexually active 1% among the medium sexually active 0% among the high sexually active 3 Balanced reduction Number of new sexual partners decreases annually from 1990 by 0% among the low sexually active 1% among the medium sexually active 2% among the high sexually active 4 High reduction Number of new sexual partners decreases annually from 1990 by 2% - 53 figur 4 ANNEX II Effects of Medical Inierventions: Page 10 of 14 fVQi IV sItlOSrVC AMON0 rEMAL5 13 12 I tr 10 z a 0 7- 4- 3 2 IO190 199 2Wf 2W 2010 0 1 + 2 0 3 A 4 x a v 4 IEDTCAL flITERVENTON SCENARIOS 1 Base No interventions 2 Injections Unsafe injections reduced beginning 1990 by 50% annually 3 Transfusions Unsafe blood supplies reduced beginni 1990 by 50% annually 4 Low STD control Genital ulcers reduced beginning 1990 by 20% annually 5 High STD control Genital ulcers reduced beginning 1990 by 50% annually 6 All interventions Unsafe injections, unsafe blood supplies, and genital ulcers all reduced beginning 1990 by 50% annuall, ~ 54 - FigureS ANNEX II Aliernative Effects of Safer Injections Page 11 of 14 I MV 5mC Om#Ud mu *C1iONS 2 - o -, -, - - - - -.. " tf0 1f70 tZ0 "* 190 t 201 200S Y 11A 1 a X + 2 <> A 4 * a f e .xTZRNTrVEINJECT5QN COCTROL SCENAROS -- BaLse No reduction in unsafe injections 2 Reduction- Unsafe injections reduced beginning 1990 by 50% annually 3 Serious Unsaf e in jections, which are about twice as likely to transmit HIV, are not reduced 4 Serious-reduction Unsafe injections, which are about twice as likely to transmit HIv, are reduced beginning 1990 by 50% annually 5 Severe Unsafe injections, which are about twice as likely to transmit HIV and twice more frequent in the Population, are not reduced 6 Severe-reduction Unsafe injections, which are about twice as likely to transmit HIV and twice more frequeat in the population, are reduced beginning 1990 by ;0% annually -55 - Figure 6 ANNEX II Alternative Effects of STD Control: Page 12 of 14 PUCVdT WV sMPosMnvt AMONG WMLO I- 12 2 12 ALTERNATIVE STD CONT!ROL SCENARIOS z~_ a I Base Genital ulcers raise susceptibilityt HIV infection 5-fold, and do not decrease in prevalence 2 High STD control Genital ulcers raise susceptibility tc HIV infection 5-fold, and are reduced in prevalence beginning 1990 by 50% annually 3 Severe Genit'al ulcers raise susceptibility tc HIV infection 50-fold, and do not decrease in prevalence 4 Severe-high control Genital ulcers raise susceptibility to HIV infection 50-fold, and are reduced in prevalence beginning 1990 by ;oZ annually - 56 - Figure 7 ANNEX II Effecis of Timing of Condom Program: Page 13 of 14 POCR5 WiV SM053MVC AMONG VCMALI 12 1, 3~~~~~~~~~~C ta M Id I 4 2 ISSS 1q90 1991 2000~~~~~ MA A 2010 0 1 0 2 3 A 4 TIZaNNG OF CONDOM INCREASE SCM(ARMOS 1 Base No condom use 2 1990 2% annual increase in condom use start- in 1990 3 1985 2% annual increase in condom use starts in 1985 4 1980 2% annual increase in condom use starts in 1980 - 57 - lUiv~i. ILI Page 14 of 14 Table 1 Effects of behavior change and medical interventions on the XIV epidemic: Percentage reductions in various parameters from the base scenario as of 2010 Percentage HIV serocon- of adults HIV versions per Cumulative seropositive 1000 adults ------------- Behavior change or ------------- ------------ AIDS AIDS medical intervention Female Male Female aHle cases deaths Condom use (annual reduction in nonuse, from 1990) Low (22) 23 25 31 34 7 7 Skewed (10 to 2%) 35 38 46 49 11 10 Balanced (2 to 10%) 61 64 75 78 23 22 High (10%) 68 72 82 85 27 26 Reduction in sexual partners (annuallvy from 1990) Skewed (2 to O%) 5 6 8 8 1 1 Balanced (0 to 2%) 23 26 28 31 It 10 UiRh (2Z) 26 29 32 35 12 11 Hedical interventions (annual reduction, from 1990) Unsafe injections (502) 2 2 3 3 1 1 Unsafe blood supplies (502) 2 2 2 2 1 1 Genital ulcersiT202) 1 1 1 1 1 1 Genital ulcers (50%) 1 1 1 0 2 2 All interventions (50%) 5 5 5 5 4 4 Condom use (year when 2% annual reduction begins) 1990 23 25 31 34 7 7 1985 31 35 38 42 16 15 1980 40 45 45 49 28 27 - 58 - ANNLA I Page 1 of 9 A RESEARCH STRATEGY FOR THE ANALYSIS OF THE ECONOMIC IMPACT OF AIDS ON ZAIRE* r. OBJECTIVES AND POLICY RELEVANCE 1. Like other diseases, the Acquired Immune Deficiency Syndrome (AIDS) depletes the limited resources otherwise available either for raising society's per capita income or for enjoying the.income level already attained. The annual losses to society can be defined as the annual cost of the disease per HIV-infected individual multiplied by the number of HIV- infected individuals. This research strategy proposes a group of research protocols to estimate the cost per infected individual, leaving as a separate exercise the estimation of the current and future prevalence of HIV-infection.1 2. It is conventional to divide the resources lost to society as a result of a disease into two categories, called the "direct" and the "indirect" cost of the disease.2 The direct cost is defined here as .he entire social cost of the resources used to treat patients with the disease.3 The indirect cost is defined as the lost output due to the * ;r -U _ a; a draft which the consultants have advised the Government of Zaire to adopt as an annex to the Plan a Moyen Terme (Mid Term Plan). 1 Strategy 1.2 of the provisional Plan a Moyen Terme, September, 1987, proposes a budget of $376,700 over a period of three years to estimate the prevalence of EIV infection in the general population and in several "sentinel" groups. The development of appropriate mathematical models for projecting current seroprevalence rates to future rates of incidence and prevalence of AIDS is proceeding in research institutes around the world. 2 This distinction has been applied to estimating the cost of AIDS by A.A. Scitovsky and D.P. Rice, "Estimates of the Direct and I:,direct Costs of Acquired Immunodeficiency Syndrome in the United States, 1985, 1986 and 1991," Public Health Reports, Vol. 102, No. 1, pp. 5-17. They estimated the treatment cost per AIDS case in the United States in 1985 to be between $20,353 and $54,273, while the estimated indirect cost was between $160,470 and $200,053 (all in 1984 dollars). Resources consumed must be evaluated at their "opportunity cost," that is, at the value they would have had in their next most productive alternative use. This research strategy ignores costs of research and prevention, which are sometimes included in the definition of direct zasts. ~ 59 - ANNEX III Page 2 of 9 morbidity and mortality of otherwise productive HIV-infected individuals. Since every disease imposes direct and indirect costs on society, the cost of AIDS must be measured relative to the cost of other diseases. 3. Importance of Direct Cost Estimates. Estimates of the direct cost of treating individual HIV-infected patients in Zaire will help decision makers to: (l) weigh the extra treatment costs of these individuals against the treatment needs of other patients; (2) develop low-cost treatment protocols; and (3) anticipate and prepare for the impact of the projected growth of the AIDS epidemic. Furthermore, since preventive programs would avert some of the costs, estimates of their magnitudes will help decision- niakers determine the priorities of these programs. To serve.these purposes, estimates of direct costs must include information on the matnitude of treatment cost in a broad range of settings, on the deRree of variation in cost from one setting to another and on the reasons for the variation of these costs. 4. ImDortance of Indirect Cost lst:Lmat2s. Sinca estimates of the indirect cost of a single XIV infection in Zaire measure the harm done to national economic output by the disease, these estimates will help decision- makers to determine the importance of AIDS prevention relative to prevention of other diseases and relative to expenditures on other productive sectors.4 5. Calculating the Total Cost of AIDS in Zaire. The research strategy will be to estimate the direct and indirect cost of AIDS to the Zairian economy for each of a number of distinct population groups and treatment options. One way to define these population groups is to categorize each individual according to the occupation of the head of the household as in the left margin of Table 11.1. The next step is to estimate the direct and indirect cost per infected person in each of these groups. Once these cost estimates are available, they can be combined with estimates of the size of each of these groups and the prevalence of HIV infection in 4 In a perfect market for cures of non-contagious diseases, the amount paid for a cure would include the value to the individual and his or her family of the averted consequences of the disease and there would be no need to compute the additional so-called "indirect" cost of the illness. The two major reasons to add the indirect cost to the direct cost in the present analysis are: (1) it is impossible to purchase a cure for AIDS, so that willin*ness-to-pay for treatment necessarily understates willingness to avert the individual consequences o£ the disease; (2) capital market imperfections prevent disease victims from revealing their valuation of any disease, by preventing them from borrowing the full present vaiue of their future stream of savings to treat it. ANNEX III 60- Page 3 of 9 each to gomputs an estimate of the aggregate cost of the disease to the economy. Table I1.1. Framework for Assessing Impact of HIV Infection on the Zairian Economy ANNUAL COST PER PREVALENCE LABOR FORCE HIV-INFECTED PERSON: GROUP HIV GROUP GROUP DIRECT INDTRECT SIZE INFECTION COST (a) (b) (c) (d) (a) Urban (M & F) Unemployed Homemaker Unskilled Skilled Managers Civil Servants Rural (H & F) Unemployed Homemaker Agricultural Worker Subsistence Farmer Commercial Farmer Merchant II. STUDY METHODOLOGY 6. Multiple Studies. Despite the AIDS epidemic, HIV-infection and its associated costs are manifest in only a small proportion of the general population. This proportion must be further subdivided to discover the impact of AIDS on individual industries or segments of the economy. To obtain information on the effect of AIDS on all these subsets of the economy through a random sample alone would be prohibitively expensive because of 5 The cost per HIV-infected person is computed as a weighted average of the costs,of individuals at different stages of their dtsease. The alternative of using lifetime cost per HIV-infected person instead of annual cost would require using the incidence rate in place of the prevalence rate of the disease. ANNEX III -61 - Page 4 of 9 the size of the required sample. A more cost-effective research strategy is to supplement or "enrich" the data from a small random sample of the general population with data from a series of targetted samples. This approach has the additional advantage of being consistent with the geographic and institutional heterogeneity of Zaire's health care "system" and with the diversity of its health care research establishment. The following paragraphs define the various desired studies, first by methodology and then by labor force category. 7. Methodological Distinctions. The major methodological distinctions applied below are: (1) the distinction between prospective (P) and retrospective (R) studies; and (2) the distinction betweemnpopulation- based random samples (PBRS) and samples of convenience (CS). Of the four possible combinations of these two distinctions, the most rigorous is a prospective study of a population-based random sample (P-PBRS), but this is also the most expensive and time-consuming to perform. Conversely retrospective studies of a sample of convenience (R-CS), though more likely to be biased, are relatively quick and inexpensive. The R-CS class of studies will provide quick answers which will guide the start-up phase of Zaire's AIDS control program. As the more time-consuming P-PBRS studies ar. cowjleted, it will be possible to piece together a more complete picture of the effect of AIDS on the economy using an analytical framework like that of Table II.1. 8. Prospective, Poculation-Based Studies. The aim of a prospective, population based study (P-PUS) would be to collect longitudinal data on a panel of individuals who hive been randomly selected from a well-defined population. Because of seasonal fluctuations in health care utilization and the slow progressior. of HIV infection, subjects in these studies should be followed for at least a year. The population studied should have a presumed prevalence rate of HIV-infection of at least one percent. Examples of possible populations include (a) the urban and peri-urban population of Kinshasa or Lubumbashi; (b) the population of a Health Zone with high prevalence, such as one near Lake Kivu; (c) any of the several high-density "urbano-rural" districts in Zaire. 9. Substantial cost savings can be achieved if the population-based seroprevalence surveys to be implemented under Strategy 1.2 of the Plan a Moyen Term are used to identify the individuals to be followed in the prospective study. If researchers propose to study a different population or draw a different sample, they must explain why the results of the study would justify the additional expense and they must describe their proposed sampling methodology in detail. On the basis of an initial serological examination, the sampled individuals are divided into two groups of individuals as follows: a. Sero-positives: Re-interviewed periodically for duration of study. Minimum size of this sub-sample should be about _0. :. the expected seroprevalence rate is 1.0%, then 5,000 people will have to be tested to identify 50 seropositives, of which ANNEX III - 62 - Page 5 of 9 about 5 to 10 may be expected to have clinical AIDS. In order to enrich the sample with additional AIDS patients. the 50 randomly chosen subjects should be supplemented with an additional ten AIDS patients to bring the total sample of seropositives to 60 subjects. b. Sero-negative controls: Same questionnaire and interview schedule as sero-positives. This sub-sample should be approximately half the size of the sub-sample of sero-positives. (See the discussion below of sample size.) 10. Two prospective studies on population-based samples should be performed, one on an urban sample and one on a rural sample. Collected data would include serological status, labor force participation by industry and wage rate (for indirect cost') and health care utilization and expenditure (for direct costt). 11. ?,-osgecrtve, Studies of Convenience SamDles. A prospective study of a sample of convenience (P-CS) is appropriate when the available s;mple is particularly important for policy or epidemiological reasons. For example, to understand the effect on utilization of a major urban hospital or of the facilities of a health zone, a random sample of patients can be sero-tested and followed over time. To understand the interaction of AIDS and other health problems, a random sample of all patients presenting with a specific disease or of members of a specific risk-group can be studied prospectively. Examples include mothers and children, tuberculosis patients, students, or prostitutes. Alternatively, to understand the effect of AIDS on worker productivity and health care utilization, a random sample of employees who benefit from the same employer-sponsored health care system can be followed.6 In these studies, as in the P-PBRS studies described above, a control group of seronegatives must also be followed. 12. Five small prospective studies of convenience samples (P-CS) should be performed, three in representative enterprises from the primary, secondary and tertiary sectors of the economy, one on a rural health zone and one on an urban public hospital such as Hopital Mama Yemo. These studies will enrich the data available from the P-PBRS studies . Data collection instruments can closely parallel those developed for the P-PBRS studies described above. 13. Retrospective Studies of Convenience Samples. When adequate medical records are available, it may be desirable to analyze these records retrospectively in order to estimate the relative expenditures of - positive and other individuals. Such records may be availaDle .or patients who are treated in a particular health facility, or for emplovees who are 6 6 The Comite National de Lutte Contre le SIDA may wish to seek guarantees of confidentiality from employers before assisting them with serologic surveys of their employees. - 63 - ANNEX Ii Page 6 of 9 served by a single health care system. A retrospective study of a sample of convenienea (R-CS) has the advantage of quickly producing individual expnditure histories, which would take much longer to accumulate in a prospective study. Sias may be introduced because the sample of patients is not representative of the population and because medical records may be Incomplete and will not contain information about expenditures in other facilities or systems (e.g. traditional providers). However, such studies are fast and inexpensive compared to prospective studies and can enrich the prospective data by providing baseline data. Table 11.2. Segments of the Labor Market Analyzea'by Each Class of Study Class of Study P-PBRS P-CS R-CS LABOR FORCE |Urban Rural Entrps Rur Urb Entrps Hth Zn GROUP 1 2 3 4 5 6 7 Urban (M & F) Unemployed a m m Homemaker t&m t&m t&m Unskilled m 2&3 m 2&3 m Skilled a 2&3 m 2&3 Managers m 2&3 m 2&3 Civil Servants m m m Rural (H & F) Unemployed t t t Homemaker t t t Agricultural t&m 1 tEm 1 t Worker Subsistence t 1 t t Fanrme Commercial t&m 1 t&m 1 Farmer I Merchant tEm 3 tEm Miner I m 1 I II 1 Notes: m - modern sector; t - traditional economy; 1 - primary sector (agriculture and mining); 2 a manufacturing sector; 3 * tertiary sector (banking, retailing and other services). 14. Assemblint the Pieces. Table II.2 above illustrates how each of the seven classes of study contributes to the overall picture of the cost zf AIDS. Information on modern sector workers residing in urban areas is obtained from the urban P-PBRS study (Class 1) and enriched by the --CS - 64 - ANNEX III 64 ~~~~~~~~Page 7 of 9 studies of secondary and tertiary sector enterprises (Class 3) and of an urban hospital (Class 5) and by the R-CS studies in these enterprises and in a Peri-urban Health Zone Study (Class 7). Information on rural residents in various segments of the labor market is similarly pieced together. 15. Once the elements of Table II2 are available. they can be used to calculate the average direct and indirect costs for each labor force category for columns (a) and (b) of Table 11.1. Meanwhile the seroprovalence studies will have been completed, providing the data for column (d) of that table. At this point the calculation can be completed. 16. Sample Size. The study design to be employed for most of the studies proposed here will be (1) to draw two random samples, of which one consists of M,x seropositives and the other of N seronegatives; (2) to gather longitudinal data on both samples, either retrospectively or prospectively; and then (3) to calculate the averages of each of several variables in each sample. The statistical problem is to choose the two samole sizes, N. and NY, so that a difference between the two means will be confirmed at an acceptable level of statistical significicance if it exists. As an example from actual data, the average cash reimbursements by an employer over nine months for outside medical services to a group of seropositive employees was 7,517 Zaires with a standard deviation of 11,436 Zaires. Over the same period the xnverage raimbursements for a randomly chosen group of seronegativts employees was 3,314 Zaires with a standard deviation of 9,559 Zaires. Assuming the relative values of these figures are typical of the order of magnitude to be found in other study settings, one can calculate the alternative values of N. and Nv corresponding to a given significance level for the difference between the two means. In Figure II.1, the various combinations of N. and N are displayed graphically for each of three specific levels of signiicance. 40 * 30 00 10 'Wumbeer of 2Wfl6gOIw0 Figu~ 1.1 ~ 8SP~e iSS NeeSsaryto Con lflX, a Differaevein the 14ea1Ze f Tw Uypte i s at ? frobabilit; Levels Re.aTh of veil Rypothsticcptablbt of..f~1So .05 could be i'mmee cfanl bize.boSfl bh*- 5 1 4- o6 fo i a total Ip u m f 7~ ~~~lyacp Ya1 fori if ca,nW cm ini t obtained 6 6 . Tsu eC t h s lte i U G S ' th sam e le v e l o f s isnsft c P °A st obta'insd'w tively- th" opl Size Of the least .3Pensive vih "27anstd deNdY on the, total numbe'r Of " subebtS. i coiubi study o*tfll dpends i jndiCated in the fiU byterOWa - 40 ad 1y-17tor atti tota0 if 57 subjeCts' 18. The 1enra frule forthe Of iSo ml iei to put more subjecets in te grUP ipeced o hae alarg? vrifllc n th prsent case, it appears tat a rato of 5 boicael tOf to one be*T.thee srPOsitisS and in theil be i hetfac that the . se toe apparstha~t Tgrati of1. mayntl be tyical oothefatr studY situations5 thea samplnegszs shouldI be inrasd prhalps to N 966 and y4.4 orattl sapl s7ie of 100. Ti zlPe aclto hee1i e s ple sizes neededrto demoultrae ainfereasec e letieen hie means o tw 4'if ferent sampllsieS s TodmnTratextatpl that difeehe ieas of tvcti magnitude. at a siml" leel of5~~fficne wul retqui? o larS certain. Inra Sapl Sz Ofsa id th e nu diber bf efoOStiVS nrp a pcfC su: i ruraltd b nhead tota dmn st strloated ina the t dreil na l asro 're ,aSflmSsure. T iUr taMI.. sh os that sipnto iaponte, aol sh r euta e o eooiie a ~0~pnsaeve bamoretafqa ub?o eongtvsi re ~oti 7The naedgreo stithca Porer.. .itv,c ooti - 66 - ANNEX III Page 9 of 9 areas and in other settings where the variances can be expected co be smaller relative to the means, sample sizes could be reduced. III. RESOURCES 19. Serotestinf Capacity. Each of the studies described above, whatever its methodology, will require serotests of the studied individuals to distinguish the costs incurred by a seropositive individual from those of a seronegative one. However, the serotestin1n capacity of Kinshasa laboratories is limited. Thus, each seroprevalence studv on any population should be considered as a possible site for an economic imoact studv. Furthermore, if a choice between two sercprevalence studies presents itself, the usefulness of each for a subsequent economic impact study should be one of the criteria used to choose between them. 20. Economic Advise. Of the several governmental and non-governmental organizations wnicn may contribute to economic impact studies, some have available economic advise and others do not. The Bureau Central de Coordination undertakes to make general economic advise available to all impact studies and to provide more extensive support to a few of them by requesting consultant health economists from the World Health Organization. 21. Financial Resources. The Bureau Central de Coordination will have limited funds available to finance the incidental expenses (fuel, photocopying, etc.) for one.or two small studies which are approved by the Comite Central pour la Lutte Contre le SIDA. In addition, the Bureau and the Comit4 welcome proposals for studies to be cofinanced by the Bureau and other organizations. IV. OPTIMAL TIMING OF STUDIES 22. Among the seven types of studies defined above, certain deserve a higher priority because they are relatively simple to execute and relatively important for the choice of preventive strategies. Retrospective studies on convenience samples (Type R-CS) in urban enterprises and universities have the highest priority, because of the serious implications of the epidemic in these milieus for the future productivity of the country. In second place would be prospective studies on these same populations (Type P-CS), which will be necessary to determine the bias introduced by convenience samples. In third place, but still important, are prospective studies on population- based random samples (Type P-PBRS), which are the only way to learn tne economic impact of the disease on the general population. - 67 - ANNEX IV Page 1 of 3 IMPLEMENTATION SCHEDULE 1989 1990 1991 IEC PROGRAM DEVELOPMENTICONDOM DISTRIBUTION Material Dvpt Video Programs 4 4 4 Audio Programs 8 8 8 Manuals prod.-Distribution- Written Materials prod.-Distribution- Training Seminars 4 3 3 Conferences 10 10 10 Study tours 5 5 5 Technical Assistance International 1 1 1 Local 10 10 10 Staffint Central level 5 5 5 Regional staff 3 6 9 Condom Distribution General (thousands) 70 140 280 Targeted (thousands) 10 20 40 Vehicles 4wd 10 - - Pass cars 5 _ - INTEGRATING AIDS ACTIVITIES Trainint Physicians 30 80 280 Lab. technicians 30 80 280 Public Health Nurses 100 200 300 Social Workers 100 200 300 Ecuiment Blood Banks 1 1 1 Laboratories 3 3 3 Med. Equipment 50 100 150 - 68 - ANNEX IV Page 2 of 3 IMPLEMENTATION SCHEDULE (continued) 1989 1990 1991 SuDervision Central Level 3 6 9 Regional Level 9 9 9 Sub-Regional Level 27 27 27 Medical Supplies Blood Tests 60,000 90,000 120,000 Case Management Packages 10,000 15,000 20,000 RESEARCH AND STUDIES HIV Transmission xxX xxx xxx Sociocultural Dimensions xxx xxx xss Cost Effectiveness Control Measures xxx xxx Constraints on condom use x Case Management Strategies xss Developing Diagnosis Tools xI= xxx xxx Economic Impact xxx xxx xxx Surveillance System xx xxx xxx INSTITUTIONAL STRENGTHENING Trainina Fellowships 5 5 5 Seminars 1 1 1 Study Tours 5 5 5 Technical Assistance Epid (WHO) 1 1 1 IEC (WHO) 1 1 1 IEC (PSI, 1 1 1 Admin. (WHO) 1 1 1 Program Mgt. 1 1 1 Accounting 1 1 1 Others (Local Consultants) x x x - 69 - ANNEX IV Page 3 of 3 | Z~~~~~~TPL14NATION SCHDL (continued) Staffing Central Level 10 Regional Level 9 9 9 Sub-Regional Level 27 27 2t Vehicles 4wd 10 Pick-ups 5 -70 ANNEX V UTIONk A101~~~~16i ~Page 1 of 4 Til 0S1111IN922 'Is" SJOOb2T, ~ ~ ~~~~~~~WECOTS 0000420 CORP C03b LKk 930000 000. Coot a' to 0~ ~ ~~~~1 0; o 1. 20015W"Ek M0I1 0. £0TE01. CEVEOUPN1OI I0ll pro# ,sOoo 2.300 4 4 0 to.000 00,00 No00 rA 501 0,00 25,00 25,000 40I 04.2 & Cr00 auii~ 0u~ 0 0 1,20, 13,20 1.200 FAT? 54 ,000 0,000 4,60 et 0000 apchr 1,000 I I 0 0,04 I.0m l,0;0 PAT 54 ,0 ,0 ,500 el 9702 01 00 20 3000 3000 1004i 600, 40,00 40,040 MbT 50 I ,00 0,00 0,00 0 00ogn 0.00.0 5,040 0~~~~~~ 5,0406 0 0 PAT 50 5,000 2,5o 2,500 0I 2,00020 WhOA! 20 5000 ~~~~ ~~500 S00 50,000 50,04 000 0401 0 1 20, 1,0 15000 00 oieduo b&at ~ 2,0 50 I20 2.000M 01 5,00 2,000 250 0 310( rkIcuro I020 20230 000 2004 3,042 50 000 3,0 2000 Molgopuotif ~ ~ ~~2'00 2 0-Jo 2 BOb 501 240 500 so 00 r0t000 0 20 05 0 t000 5,0 2,040 51 5,000 25000 2,00 oreduct I Kkure 2~~~~~~~~3,0 0 4000 40,50040 ml 0 10,40 n500 15,400 0 kb-T Pott ota 0141 C0UOET2 0.71 20o200 24071 42140 c2o3 321,a 8. 1101106 2 00 s00 300 A 5 00 tN 25n tt- ~ 2,00 0 0.00 3.0 3,414 t0o0,0 150040 753 00a Co0roucuoel t 2,0c 200 200 20 2,00 20,00 0 2w 0,040 MT 50 I00,40 3,0 3,000 010,Tta NABun 5,000 T 511.000 219,2000 25100133 500 42,70 371,511 321,500 Onitao 50,000 2 40,00 30 00 30 0? T 240 50,000 0o" SO,3 000 hon.ret 20,000 I 1 2 00,000 20 0L000 20,00RII 50 0 " 000 0400 000 OtdyfOa s 2,040 20 5 0000 2500 0 OP 0012,000 To00 50 7-O 20,040 a kb-total 11021911161 10,000 700 750t 10,00 11,0 80.00 C. 1103U 40 ISIOOE Local C5ll200 20 2000 20,04 2000 2000 10 001 3000 N 0,00 0olo 01 Su0tottiEUIC1. SSITIOO 2)0,3 2000 2000EP to 0,000 5000 30,000 I 0Offi20,000 00 200,000 0 0 0E0 000 20.0,00 0 240,000 00 Pcououae cDI,KN 22.000 S 000 0 001 200 0.000 0 100,000 0 Sub-entota 00201 240,000 000 I I 0 00 10 20,o 000 0 240,0400 TtL 06101111t0t1100 t t COSTS 4240,70 204,200 334,730 la o,2fl,70 40, 000 008,3 E. 544.4001 40 ad rio.o 2000 102 2 2 20,040 200 2,00 I oo0 1200 2,00 0 20,0 00 24 r~~ama0 itoH 2~00 00 0 0 20 2,000 2400 24000 OIL 00 1,00 1,00 0 0 0.0-0,0. 00.0013,00 2,00 3,4 I 00,000 00,000 Centrala 01002,00 20 20 0 20,0,000 ,00 2000 STP 0 0,000 4000 0 01O toa iftupm osts 21000 7 5 22,1,00 314,20 36710,0. 9 01.027,400 252,040 10101 C. 011021 401101 OUa o detr2,00 12 12 2 2,5400 2,400 2,500 0190 100 7,50 2 200 400 00t hOac 500 I~~~~~~IS a 02 0 20 03 5400091 010 21,500 at00 120 001 0 regioa 2tf 00 20 20 20 24000 24040 240000090 01 32.00 7200 20 100 kb-total 0109A0LAR 60380 320 3,140 3,000 4,300o 2,040. 1,0 0. 01020. 1920 I 4000o1.2 o 2 o 0 0PP t 6,00 6 00 a o looll 1.54000 20 3:00 00 00 000 40,00 5000 01TI2 40120,000 24,000 0400 01 Paooo.9.rcar 3,000 25 154 1 27,000 15,000 25.000 I 010 01052,000 0,000 300 00 Isob-total 0102I0. C41* TRVE 121141. ss,ooo ss.ooo0 1ss,oo oos,ooo 32,ooo 0 VI arto tltI02 2 0000I 2 I0 000 02,000 20,0 2,.400 COO 2000 600,000 0 640000 201 Si1-total 13338TRANTO 54,000 2,00,00 2,04,00 93,1400 0 3,730,000 4 tad 11100 to COlto 4020 ,2,00 0 2,0324 1,34.240 242,444 6,20,040 Tobtatl 2,3206NAby 5,000 0504,00 2 5,70000 5,0a,.00 097.000 4120,020 - 71- ANNEX V Page 2 of 4 .sisi 00112 Tible02. MIh I 1 WIIWIIID htatli Cast TIbI IIIt Vn a a UL FEI T 3IU1 FE TOTIL.WIl Uwit - - - - _ -A Cont n 91 3 0 97 A. TAlOItS s No so500 2 15,000 40,000 140,000 115 501 I",000 7,10 7,50 Ot 250 30 00 210 7,500 20,000 7e,0e00o13s 50 9,5e00 4,750 48,50 O0 ullicialth hIs 250 t00 200 300 25,000 50,000 5,e0001Ti 5021 000 15,000 1,000 0n I8 NwSiMs 250 to0 200 30 25,000 50,000 75,000 TNE 5 ,50,000 75,0 15,0010 0 So-total MUIU11 12,500 1u0,000 30,000 m,500 296,2O 26,25 e. EouIpEII Laratorin 25,000 3 3 31 75, 0 1,000 n NoEW 1001 225,00 * 225,00 In slw1m % a6 20,000 1 I 20,000 20,000 20,000 Er9 1001 60,000 0 6,00 i0n h6 sqpat 1,000 50 100 Is, 50,000 100,000 150,000 3 IOU 300,000 300,000 10 Sik-total EKIPIEnT t4,000 If,O000 241,000 ,000 0 5,000 tal IUVESIiN t CTS 217,50 35,000 05,000 1o,7,50o 296,250 *1,250 -~~ ~ ~ - - rnS A. STIPES & TAVEL OICES Costral ltl 2,000 3 6 I 6,000 12,000 1t,000 o IP o0 36,000 36,000 0 02 oi l Inh l 1,500 9 le 27 13,500 21,000 40,500 s1TP o0 11,000 81,000 0 02 W Ag Ialevel 1,000 27 54 It 27,000 54,000 e 1,000 5119 02 162,000 162,000 0 0 3b-total IIPIEI 1 RAMl AR DWE S 46,500 9000 £39,500 279, 219,000 0 3. IUtAL OInIftoES Sto tstdtt 3 2000o 30000 40000 60,000 9,3000 120,0on00 UN 002 270,000 0 270,000 lot Orqs ~~~~~150 10000 Ism0 2000 1,500,000 2,250,000 3,000,000 NM I 1002,1,000 0 6,10000 102 Sib-total IIlEICAL SWPI.IES 1,560,000 2,340,000 3,120,000 7,020,000 0 7,020,000 C. EDUIPIEI MIMITEITAEE Laorater" 2,500 3 & 9 7,500 5,000 22,500 E133 602 45,000 9,000 36,000 102 B1oo lakts 2,000 I 2 3 2,000 ,000 6 ,000 EMS SO? 12,000 2,400 9,600 lo bE .qupmt 50 50 £50 300 2,500 % 7,500 15,00 EOPII 002 25,090 5,000 20,000 501 3mb-total EWIPUNT KAINTENMIIE 12,000 26,500 43,500 82,000 £6,400 s,600 jtal RECET COSTS 1,610,50 2,459,500 3,303,000 7,31,000 25,400 7,065,600 ta 1,36,000 2,814,500 3,901,000 3,55,500 591,40 7,966,050 .__--a_. _- - 03-ba-fl -72- ANNEX V Page 3 of 4 HAllOW. AINS CUME NOES ASSISaICE noJEct Tible 03. RESEARCH ND STULIES Detalled Cost Table SIuIAN! FE TOTAL PHYSICAL UANTITY BSE COSTS ACCoUmT CON COSTS LOCAL FOMIGH COT. Unit ---- Cost 99 90 93 n 0 91 INVESTMENT COSTS A. RESEARCH NHI Trannusison 10,000 I I I 30,000 30,000 1 0,000 RES 501 S3,00o 35,000 15,000 01 Vaccine dewe ent 10,00 t t t t80,8 t8,88000 0 0,000 RES 50so 30o,00 158000 15 ,000 0 Drug Aeeoao 0,000 I 30,000 30,000 30,000 RES 501 3000 3500 3500 0 blood tet dnevopemt t 10,0 O 110,00 30,000 10,000 RES 501 30,000 35,000 35,000 0l Sib-total RESEARCH 40,000 40,000 40,000 320,000 Ao,000 60,000 B. SCCIOCIURAL SuRVEYS Urban areas 10,000 1 3 3 10,000 30,000 30,000 RES 50! 10,000 35,000 35,000 01 Rral areas 10,000 3 3 3 10,000 30,000 30,000 RES 501 70,000 35,000 35,000 02 Sbi-total SOIOCILIUML SURVEYS 20,000 60,000 60,000 340,000 70,000 10,00 C. ECDONIC STUDIES Direct costs 30,000 1 I 3 30,000 30,000 S3,0o 00 S 501 O,000 45,000 4,000 0 Indirect costs 30,000 1 t I 30,000 30,000 30,000 RS 501 90,000 t5,000 45,000 0N SuLb-total ECOMIC STUDIES 60,000 0o,ooo 60,000 160,0000 1OO 0 0,t000 B. WERAE AL RESEAI Ca uinatat 25,000 1 1 1 25,000 25,000 25,000 ES 501 75,000 37,500 37,500 01 Cost recovery 25,000 1 1 1 25,000 25,000 25,000 RES 501 75,000 37,500 37,500 01 Social progras 25,000 1 1 1 25,000 25,000 25,000 RES 501 75,000 37,500 37,500 OS Laden ose 25,000 1 1 1 25,00u 25,000 25,000 RES 502 75,000 37,500 37,500 01 Sub-total OPERATItS RESEARCH 000,000 100,000 300,000 300,000 150,000 150,000 E. DIVELOPINS THE SURVEILLANCE SYETER Setrprevalence surveys 50,000 I 1 50,000 0 50,000 RES 501 1o,o000 50,000 50,000 Ot Setsenl cesups 15 o000 I I 35,s000 38000 15,000 RES 50? 45,000 22,500 22,500 O0 Reporting AIDS cases 3,000 1 3 9 3, 000 9,000 27,000 RES 501 39,000 39,500 39,500 01 Sub-total DEVELW'IBS TIE SURVEILLANCE SYSTEM 93,000 39,000 307,000 229,000 114,500 314,500 oVtl IRVESTRENT COSTS 303,000 290,000 367,000 969,000 484,500 484,500 03: 7±10 - 73 - ANNEX V Page 4 of 4 ZAIRE AIlAtlO AIDS 0O8ROL P31060. ASSISIOE'E PROJEC tiDllt IC . 11;TITUTI IHAL STRENGTHEN1IN OWta,ld Cott fable 411,311 ~~~~~~~~~~SUI8AOI FE TOTAL. PITSIC&i. tliOOTITo BASE COSTS ACCOULT COP COSTS 1Lm FM00061 COAT, Unit ------ Cosot E; f 91 89 90 91 ......... -- ..... --- ..... ----- I. IlNVES9IMEhl COSTi A. ,.F.IbhW FelIon0sho 20,00 S 5 100.0Ot 100,OG5 100,000 1I00 50 300,006 150,000 150,000 01 Sesinors 5,0S 1 I 1 5. 00v 5,00, 5,000 TANG6 S; 3S,000 7,500 7.50N O Sto. IoU'so 50i*W 5 5 : 25,000 .5,9. 2,75000 * 7,500 37,500 0t Sub-total IRAINIII 1;0.009 130,000 IS0,000 390,000 105,000 195,000 0. TECNtICAl ASSISTANCE Pfo3ras tnaoaq.aent sO,000 I I I 80,000 10,000 80,000 tA 0Oot 240,000 0 240,000 °O EpiA (8HOJ 0,000 I I I 80,000 80,000 80,000 1A 1lOO 240,000 0 240,000 O0 IEC (800 80,000 1 1 I 80,000 80,000 80,000 TA 1001 240,000 0 240,000 01 Adamn 4800) 00,000 I I I 00,000 60,000 A0,000 1A Icot 080,000 0 180,000 03 kt iotnq 50,000 1 1 I 30,00 50,0 90,000 TA 1001 150,000 0 t50,000 Ot Ecoenos,t 10,000 3 3 3 30,000 30,000 30,040 TA tOO1 90,000 0 90,000 0o Local co eltant 10,0C0 n t t0,000 60,000 40,000 TA 0 t8O,OO0 180t,00 0 Ot Sub-total TCINIlCAL ASSISlA8CE 440,000 440,000 44O,OO 1,320,000 ItO,000 1,140,000 C. VEHICLES 4d 20,000 10 200,000 0 0 VEH OOt 200,000 0 200,000 lO3 pa'aieoqf Car 12,000 5 60,000 0 0 VEN tOOt 40,000 0 60,000 10l Sob-total VHtICLES 260,000 0 0 2tO,000 0 260,00 O. FURITlURE Central level 10.000 1 10,000 0 0 FURl 601 0,N00 4,000 *,000 lOt regional level 5,000 9 45,000 0 0 F0r3l 01 45,000 38,000 27,000 lOt Sub-Oegiooal level 2,500 20 500 0 FURN 601 50,000 20,000 30,000 3Ot Sob-total FUlIItTURE 3000 0 0 105,000 42,000 63,000 total IVESTET COSTS 935,000 570,000 570,000 2,075,000 437,000 1,659,000 ;1. OCCURENT COSTS A. SALARIES Central level 4,200 10 10 10 42,000 42 000 42,000 SAL Ot 126,000 126,000 0 Ot reoMonal level 3,i00 9 1i 2; 32,400 04,000 97,200 SAL 02 194,400 194,400 0 01 Sob4elonal level 3,000 27 54 71 01,000 362,00.3 20,N000 S0L Ot 4t6.000 45t,000 0 Ot Sub-total SAIARIEi 155,400 263,000 352,200 776,400 776,400 0 i. STIPENOS & TRAVEL ALLOAOKSM Central lInel 2.000 10 10 10 20,000 20,000 20,000 STIP Ot 60,000 60,000 0 O0 regional level 1.50ti 5 le 27 13,500 27,000 40,500 STIP O 8t,000 80, 0O 0 0O Sub-Reional level 13000 27 54 71 27,000 54,000 71,000 St1P 01 152,000 152,000 0 O0 Sub-total STIPEDS5 & TRAVEL ALLOWANCES 60.500 101,000 131,500 293,000 293,000 0 C. VEHICLE OPER. & 0UlrtT. 4 mu 4.000 10 10 10 40,000 40,000 40,000 V1EK 003 120,000 24,000 96,000 302 PasOner car ; O; 5 5 5 15 00 _15,000 15,000 VfHII 80 45,000 9 000 35,000 lOt iSb-total VEHICLE OFEk. M itAlhi 55,000 55,000 55,000 105,000 33,000 132,000 2. OFFICE SUFFLIES Central letel 3,200 I I 3 ,000 3,000 3,000 OFFS 503 9,000 4 500 4,500 lOt renioval level 1,50tt V 9 9 3,500 33,50 13U 500 OFFS 501 40,900 20,250 20,250 103 Sub-Oeoionaa levve 750 20 20 20 15,000 15.000 15,000 OFFS 501 45,000 22,500 22,500 lOt Sub-total OFFICE SOFPLIES 31 ,5 3,500 33i5,500 i4,500 47,250 47,25 E. UTILITIES Fb.roF 10.000 1 1 I 10.000 10 000 10,000 U01L 03 30,000 30 000 0 I0; iomajnications 10,000 I I I 10,000 00000 10,000 UTIL 1 30,0000 50,000 0 10; Insurance 30,000 1 1 1 30,000 30,000 30,000 UTIL O0 90,000 90,000 0 3t0 Sub-totil UTILITIE 50,000 50,000 50,000 190,000 150,000 0 F. AU0IT local 5.000 1 1 5,000 5,000 5,000 AUD 03 15,000 15,000 0 03 Inte'nation.1 3o.00t; 1 I I 10,000 10,000 10,000 AU0 1001 30,000 a 30.000 0; Sub-totil AUDI, 15,00 15,000 15,000 45,000 15,000 30.000 Totil F.ECUAPEhT COSTS 367,400 521,300 635,200 152.,900 1,314,650 209,:50 Total INOESTIicOT COSTS 3 ,32,400 1,091,300 1,205,.90 3,598,900 1,7310,50 1O 67,.25v 03-Auq -0 03:5;:50 Fh - 74 - ANNEX VI Page 1 of 1 PROJECT COSTS BY FINANCING SOURCE (US$ .000) Government IDA Other Beneficiaries TOTAL Donors Investment Costs Material Dvpt. - 220 449 - 669 Training - 714 803 - 1517 Equipment - 270 541 - 811 Furniture - 160 79 - 139 Tech. Assist. - 785 868 - 1653 Vehicles - 320 90 - 410 Research - 550 555 - 1105 PPF - 500 - - 500 Total Invest. Costs - 3419 3385 - 6804 Recurrent Costs Salaries 1039 - - - 1039 Stripends & Travel Allow. 356 265 174 - 795 Equip. Mtce. - 84 52 - 136 Veh. op. & Mtce. - 318 41 - 359 Condoms - 1796 1815 730 4341 Med. Supplies - 2108 5037 930 8074 Office Supplies 39 80 - - 119 Utilities 178 - - - 178 Audit 58 - - - 58 Total Recurrent Costs 1670 4650 7119 1660 15099 TOTAL 1670 8069 10S04 1660 21903 - 75 - ANNEX VII Page 1 of 1 ESTIMATED SCHEDULE OF DISEUSNIENTS (USO illion) IDA FISCAL YEARIOQARTER END Disburs_mat Accmumlated Cumulative durint muarter disbursement disbursement (1) FY89 March 31, 1989 .46 .46 5 June 30, 1989 .54 1.00 12 MF90 September 30, 1989 .57 1.57 19 December 31, 1989 .60 2.17 26 March 31, 1990 .64 2.81 34 June 30, 1990 .68 3.49 43 FY91 September 30, 1990 .73 4.22 52 December 31, 1990 .77 4.99 61 March 31, 1991 .81 5.80 71 June 31, 1991 .71 6.51 80 FY92 September 30, 1991 .69 7.20 88 December 31, 1991 .53 7.73 95 March 31, 1992 .27 8.00 98 June 31, 1992 .10 8.10 100 - 76 - ANNEX VIII Page 1 of 1 SELECTED DOCUMENTS IN PROJECT FILE 1. ProRramme National de Lutte Contre le SIDA, Plan a Moven Terme 1988-1992, Republic of Zaire, September 1987. 2. Prise en Charge des Malades Atteints de SIDA et Individus HIV positifs, Republic of Zaire, DOH, October 1987. 3. Int6gration de La Lutte contre le SIDA dans le Programme National de SSP, D4partement de la Sante Publique et Affaires Sociales, February 1988. 4. Zaire Population, Health, and Nutrition Sector Review, November 17, 1987, The World Bank. 5. Initial Investigation of the DemoRraphic Impact of AIDS in One African Country, R.A. Bulatao, June 1987, The World Bank. 6. Assessment of the Economic Impact of AIDS in Zaire: Back-to-Office Report and Annexes, M. Over, January 1988, The World Bank. 7. Implications of Control Measures For the Spread of HIV Infection: Working Paper, R.A. Bulatao, E.R. Bos, April 1988. The World Bank. - 77 - ANNEX IX Page 1 of 1 C*ART T Organizational Structure of the NACP NATIONAL AIDS IC1MCTEEI Strategies Polcies Financing IMPNT-HATION 0|JITCODNTN dMITEE BCC ANllD MONITORIYt; Integrated supervision mnltisectorial monitoring control evaluation activitles SOCIAL SYSTEMS nMPLEMIENTIIG ______________ AGENCIES PRODUCTIVE SYSTEMS CONMNUNITIESIFAMILIES L INDIVIDUAL IBRD 21081 J ~~~~~~~~~~~~~~~~~~~2'0' 24' 2I5'3 MALI / NIGER - 232 - - / L7 HAD i/. 'AIJ ~ 4 SUDAN CENTRAL AFRICAN REPUBLIC CE j t .> / .tX / _. ~~~~~~~~~~~~~~~ N ~SUDAN NIGERIA / A SUDAN ETHIOPIA aANGUI,9 Ed, J CAMEROON, ENTRAL FA"iCAN REP \ A e_, A-., 4 EQ GUINEA V-_T tc / A RENVA CiABIN /Orm..fle tI rJ2~~Q SRANIA ~'i N N vKIns%oso; A I H F O PRRUNDI 4t'K,n~ha~a HAU -ZAIRETANZANIA ANGOLA r- Z .~AMIIQUE. SEI EOU AtEUR ZAMBIA z °_____________________________________BAK UGANDA GA B ON ( ~~PEOPLE'S REPUJBLIC I' OF THE CONGOD /-NS 5 <' !: - 4gD - 'IA -'2~_r @,T ) ,, gM., NdaenI N . § + ~ @486~-e _( / > / K I N O U <>N BRAZZ VILLE . C'b- ' I J / lEAS id 0 C I L - mAe ,ETANZANIA (1 --.hW 1< X 5Rp IA A l 7 K..Tqro KIlometers () \ - 9andapll.l.r 0 100 200 300 * \-- y O 50 100 150 200 I -, K a' 12' 16° ZAIRE ' NATIONAL AIDS CONTROL PROGRAM V'. '8 ASSISTANCE PROJECT POPULATION DENSITY - Paved Roads above 40 km Ma, Earth Gravel Roads 15-40 K- m Railroads bIA . o Is *t- pOLWEr It - S P) rh5 mm h P S by Th. s-ad OaSA Ifff Mk5,5nn, 5-15k,, t Akrelnds ANGOLA * s''m ' 1 a6 ' orantssonoosnep belowS: 5 k,,e NatIonal Capitals i |P i 'IUSH I-a a Tlma Worltd6nAr * Reg,on Captals ! _ BuMMlid F-e he R,ves -12- , u 7U6 nlfmPo2"l ne 2 Zone Boundaries '0. pod or ,the hm PanS arid b Sub-region Boundaries AdA-1 a AdSenn n -h lp 18 - - Region Boundaries _ _Sense\j.ni Or eM. a, --- Internatonal Boundaries 201'24 208 32 SEPTEMBER 1988