Report No. PIC5042 Project Name Argentina-AIDS & Sexually Transmitted ... Diseases Control Project Region Latin America and Caribbean Sector Health Project ID ARPA43418 Borrower Argentine Republic Implementing Agency The Ministry of Health and Social Action (MSAS) 1925 Ave. 9 de Julio - Piso 7 Buenos Aires, ARGENTINA Phone: (54-1) 372-3733/3832 Fax: (54-1) 382-9366/6982 -NGOs involved in AIDS prevention programs nationwide Contact Point Dr. Roberto Pagano 9 de Julio 1925, Piso 4 Buenos Aires, ARGENTINA Tel. 541-372-3832 Fax: 541-382-9366 Date this PID Prepared April 24, 1997 Appraisal Date February 15, 1997 Projected Board Date May 22, 1997 1. Country and Sector Background: The HIV/AIDS epidemic in Argentina has increased significantly since 1992 and 1993 when for the first time more than 1,000 cases were reported each year, and in 1994 it doubled. By the end of the first trimester of 1996, 8,198 had been reported cumulatively (10,793 cases after correcting for delay in the reporting) or 312 AIDS cases per million inhabitants. According to the number of reported AIDS cases, Argentina ranks fifth in the continent, after the United States, Brazil, Mexico and Canada; according to the cases per population (rate), Argentina ranks third. It is noteworthy that the three countries with the highest AIDS rates in the Americas have significant HIV transmission associated with injective drug behaviors. The sexual transmission of HIV, excluding secondary cases of injective drug users (IDUs), has a pattern similar to neighboring countries (i.e., Chile). The rate for male cases (82w of the total cases) is 383 per million men, while there are 86 cases among females per million women. Of the total number of reported cases, 74t are men 15 to 49 years of age; 14t are among women of the same age group. Eighty-five percent of the total cases are located in three geographical areas. The most affected area (ranked by rate) is the Federal Capital (Buenos Aires City) with a rate of 1,036 cases per million inhabitants (3,096 cases); the second most affected area is Santa Fe jurisdiction with a rate of 237 cases per million (732 cases) and thirdly Buenos Aires provincial jurisdiction with a rate of 237 cases per million inhabitants or 3,120 cumulative cases (38w of the total). Of these three areas, the highest increase since 1990 was in the Buenos Aires jurisdiction with 106 cases reported by 1990 and 726 by 1995. The majority of cases in the beginning of the epidemic (1982-1987) were homosexual and bisexual men (76%), however by 1995 this category represented 26% of the total. Cases among hemophiliacs and blood transfusion recipients has decreased over time and in 1996 they represented 1% of the total. Forty-two percent of the cases are IDUs; AIDS cases among IDUs are typically young (63% of them are less than 30 years of age), and have low educational attainment (239 have junior high school or more). The number of cases among heterosexual individuals is steadily increasing, and in 1995 represented 20% of the total reported cases that year. A cumulative of 494 cases were newborns from HIV-infected women. Even when the exact figure is unknown, a significant number of cases in the heterosexual category are the female sexual partners of IDUs and their newborns. Because of the difficulties in determining the size of the population of men who engage in same-gender sexual behavior and of IDUs, the rate estimates (cases per population) are unknown. A larger concentration of cases among IDUs is in the Federal Capital City, and in Buenos Aires and Santa Fe jurisdictions (92% of cases); while in these three areas 83% of heterosexual cases and 78.5% of cases among homo-bisexual men are concentrated. Government Response Because of a mandate to provide the best quality of care possible, and the diminution of avoidable risks of death or disease for all, the federal government has included in its plans and policies the fight against HIV/AIDS, including the provision of the screening of donations in blood banks and the provision of antiretroviral and prophylactic drugs for HIV infected and AIDS patients. The budget of the National Program to Fight Human Retroviruses and AIDS has increased from US$8,058,000 in 1994 to US$19,332,000 in 1996. A recent modification of this program has added the control of sexually transmitted diseases (STDs) to the national program. Even when the budget has increased over the years, it is insufficient because it is mainly devoted to the provision of reagents for HIV testing and for prophylactic and antiretroviral drugs to AIDS patients (98% of the budget). Due to the relative scarcity of newer resources and the rapid increase of the AIDS epidemic, it is possible that the sources for the coming years is not sufficient for the provision of adequate levels of care for all AIDS patients. The National AIDS/STD program pays for the antirretroviral drugs from the federal budget without participation of the social security or private insurance systems. The predominant way of providing care is through in-hospital care. However, alternate and more efficient ways for the provision of care are being sought, such as the development of protocols for ambulatory care. Due to these budget constraints, the national AIDS Program has devoted only limited resources to the prevention of HIV- - 2 - transmission. Strict norms for bio-security in blood banks have been issued and have been enforced in major hospitals in urban areas. However, the screening of 100% of blood packages before transfusion and 100% compliance with universal precaution norms have not yet been reached in all facilities. The complex nature of HIV prevention mandates the involvement of the civil society. Many Civil Society Organizations (CSOs) are conducting activities on HIV/AIDS prevention and mitigation of its impact, and it has been shown that their embededness in affected communities allow them to provide an effective response in prevention of HIV infection and in the amelioration of its impact. Also, due to their community based nature, scarcity of resources, and recent creation, many of these institutions need to develop their institutional capacity in order to increase the efficiency of their interventions and to guarantee the sustainability of their operation. Unfortunately, AIDS patients in Argentina, as well as in other countries, suffer discrimination and stigmatization. Their discrimination relates not only to discrimination in the workplace, but also in the avoidance of preventive interventions, and the provision of inadequate health care services, resulting in delay or avoidance of early diagnosis and treatment. 2. Project Objectives. The Project will work to reduce the rate of growth of the incidence of HIV infection by 15 percent. To achieve this objective the following strategies would be adopted: (a) reduce misconceptions about the transmission and prevention of HIV/AIDS and STDs by 25 percent; (b) increase the proportion of the population at high risk of HIV infection that adopts preventive measures to reduce the spread of HIV and STDs by 15 percent; (c) reduce transmission of HIV through blood transfusions and other biological products by 50 percent; (d) reduce mother-child transmission by 30 percent. The Project will also work to improve the quality and efficiency of care provided to AIDS patients, indicated by decreased hospital admissions and decreased length of stay in hospitals. 3. Project Description: The project, whose total cost is estimated at US$30 million, would be implemented over a four-year period starting in 1997 and would have five components. These components include: (a) Health Promotion. This component would cover (i) mass and targeted communication campaigns; and (ii) primary and secondary education on HIV/AIDS and STDs, including educational materials, teacher training and school-based participatory projects. (b) Prevention of HIV and STD transmission. This will consist of (i) prevention fund for high risk groups, vulnerable groups and the general population; (ii) blood bank quality control; and (iii) mother-child transmission control. (c) Diagnosis, treatment and care of HIV infection and STDs. This component would help finance the (i) establishment of anonymous diagnostic and counseling centers; (ii) strengthening or developing of laboratories, day care centers, home care services and STD diagnosis and treatment services; and (iii) institutional -3 - development, including the training of physicians and other health care personnel in the diagnosis, treatment, counseling and care of HIV/AIDS and STD patients. (d) Monitoring, Evaluation and Research. This component will work to (i) strengthen the HIV/AIDS management information system, including the establishment of an HIV and STD surveillance system with about 20 sentinel centers; (ii) train physicians and other health care personnel in completing death certificates and hospital discharge summaries and statistics, using STDs and AIDS related diseases as tracer conditions; (iii) train Municipal/Provincial programs and heads of sentinel centers in epidemiology and planning; (iv) periodic survey using HIV/STD- related Knowledge, Attitude and Practice survey (KAP); (v) review financial and management arrangements, and evaluate ex-post a sample of subprojects; and (vi) support research and development studies on AIDS/STDs. (e) Project Administration. This component would help strengthen the capacity of the Project Coordination Unit through the provision of specialized technical assistance and staff, and the acquisition and use of appropriate office space, equipment and communications services. 4. Project Financing. Project costs are estimated at US$30 million. Bank financing would be for US$15 million, and the federal government would finance the remaining US$15 million. 5. Project Implementation. The executing agency will be the Ministry of Health. 6. Project Sustainability. The project would be sustainable because (i) the Government is committed to the project; (ii) the fiscal impact of the project is very modest; (iii) the PCU is strong and will merge progressively into the National Program for AIDS and STD control; and (iv) major stakeholders in civil society will be involved in project oversight. 7. Lessons Learned from Past Operations in the Country/Sector. (a) Importance of agreeing on performance indicators at the outset of the project, and on an adequate monitoring system. The project will strengthen the MoH management information system. A set of 14 agreed Monitoring Indicators are part of the Loan Agreement's Supplemental Letter. (b) CSO capacity is limited for presenting subprojects, for ensuring the administrative requirements of a typical Bank project and for maintaining good accounts. When working through CSOs, the need for TA (Technical Assistance) should be anticipated for project preparation and presentation. The proposed project would retroactively finance TA for subproject preparation, and the PCU (Project Coordinating Unit) will organize or contract launching workshops and offer technical assistance to CSOs which do not have sufficient technical capacity for preparation and presentation of the subprojects. Likewise, the PCU will provide and maintain a standard software for accounting and stating expenditures. (c) Single disease projects tend to become isolated in the respective provincial MoH leading to progressive alienation. Within projects it is easy for different components to overlap and -4 - duplicate efforts. The project would be guided by a steering committee which would ensure integration with the MoH and the AIDS/STD program. In the third and fourth year of project implementation, the project would progressively merge with the AIDS/STD program. (d) Bank procurement procedures are often ill-suited for the procurement of condoms, diagnostic supplies, and pharmaceuticals, leading to shortages and delays. The Project would be assisted by UN agencies (i.e. UNDP, UNAIDS) in the procurement of such goods, and in contracting consultants. 8. Poverty Category. N/A 9. Environmental Aspects. The project consists mostly of mass and focused communication campaigns, training, and community-based subprojects with no environmental impact. Refurbishment and equipment of existing laboratories and day care centers will not add significant hazardous medical wastes. Issues related to hospital hazardous waste treatment and disposal, including those derived from AIDS and STD patients, are being addressed by the Provincial Health Sector Development Project (Ln 3931). 10. Program Objective Categories. The primary categories are Institution-Building and Policy. Contact Point: Alexandre V. Abrantes, Task Manager The World Bank 1818 H Street N.W. Washington, D.C. 20433 Telephone No.: (202) 458-5454 Fax No.: (202) 522-1500 Note: This is information on an evolving project. Certain components may not necessarily be included in the final project. Processed by the Public Information Center week ending May 2, 1997. - 5 -