70033 THE WORLD BANK Meeting the Challenge The World Bank and HIV/AIDS SYNOPSIS The World Bank was a leader in global HIV/AIDS financing in the early days of the emergency, and since 1989 has provided US$4.6 billion for HIV-AIDS-related activities. Bank activities – in particular through the International Development Association (IDA) – has financed 1,500 coun- seling and testing sites, ultimately testing nearly 7 million people for HIV. It has funded more than 65,000 civil society HIV initiatives in Sub-Saharan Africa, educated 173 million people about HIV/AIDS, and has mitigated the impact of AIDS for 1.8 million children and half a million adults through 38,000 grassroots initiatives. Challenge Approach Most of the world’s 34 million people living with The Bank’s approach has evolved with the changing HIV/AIDS are in developing countries. In 2010, HIV/AIDS landscape. When possible, the Bank 2.7 million people became newly-infected with HIV, participates in the pooling of funds, and works and 1.8 million died of HIV-related illnesses. Sub- closely with the joint United Nations Programme on Saharan Africa accounted for 68 percent of all new HIV/AIDS (UNAIDS) family and other partners to infections and nearly half of all deaths globally in ensure more effective and efficient responses in re- 2010 occurred in Southern Africa. Even where the gions and countries, consistent with the UNAIDS overall HIV prevalence is low, AIDS can be a severe vision of zero new infections, zero AIDS-related burden: It is the leading cause of premature death in deaths, and zero discrimination. The Bank responds Thailand and China. Although 6.6 million people to country needs within the context of Country As- are accessing treatment globally, 7.6 million who sistance Strategies, which take account of support need it do not have it. Moreover, for every one per- from other partners and the governments’ funding son on treatment, two are infected. Without effec- for effective prevention of new HIV infections, tive HIV prevention, the numbers requiring treat- care, and treatment. The Bank provides sustained ment will become unsustainable. funding for HIV/AIDS programs and supports countries to do “better for less” through improved Despite the global increase in funding during the efficiency, effectiveness, and sustainability of na- past decade—from US$1.6 billion in 2001 to tional AIDS responses. The Bank specifically sup- US$15.6 billion 2008—financing gaps persist, and ports analytical work in six related areas: (i) increas- available funds are mainly for treatment. As new ing the efficiency of aid allocations; (ii) program and infections rise, country and donor investments in technical efficiency; (iii) effectiveness studies; (iv) prevention are not being sustained. Nearly 90 per- financing and sustainability studies; (v) national stra- cent of AIDS spending is from international tegic planning; and (vi) financing through grants and sources, and the bulk of funding is jeopardized by loans. The Bank also engages in key sectors, such as tight donor and government budgets, household education, transport, energy, and infrastructure, to income losses, and worsened food security. bridge gaps in HIV prevention, care and treatment, April, 2012 2 THE WORLD BANK AND HIV/AIDS and mitigation. The Bank supports countries establishing 1,500 voluntary counseling and test- through its knowledge and financing for health sys- ing sites (where 7 million people were tested for tems strengthening; total Bank financing for health HIV); training to provide HIV services for more (including HIV, malaria, tuberculosis, and other dis- than half a million people; reaching more than eases) was US$3 billion in FY11 and totaled US$24 173 million people with information about billion since 2000. HIV/AIDS; workplace HIV information, test- ing, counseling, and treatment programs to Results serve 2.3 million employees; supporting about 40,100 organizations with advice and financing IDA- and IBRD-financed HIV/AIDS operations in 36 countries; and the impact of AIDS was are designed and implemented with a particular em- mitigated for more than half a million adults and phasis on helping countries achieve results and 1.8 million children through education, nutri- reach Millennium Development Goal Six. IDA has tion, and income-generating activities delivered financed 1,500 counseling and testing sites, ultimate- by 38,000 grassroots initiatives. ly HIV testing nearly 7 million people. It has funded more than 65,000 civil society HIV initiatives in  Abidjan-Lagos Corridor: The Bank-supported Ab- Sub-Saharan Africa and has helped reduce HIV risk idjan-Lagos Corridor HIV initiative, which cov- behavior among men and women aged 15-24. IDA ers the largest transport corridor in Africa, sup- has also educated 173 million people about ported a 30 percent increase in knowledge of HIV/AIDS and has mitigated the impact of AIDS how to prevent HIV, underpinned by a 20-fold for 1.8 million children and half a million adults increase in condom distribution, and major de- through 38,000 grassroots initiatives. IDA was the clines in risky behavior. first source of substantial funding for HIV/AIDS in Sub-Saharan Africa, the Caribbean, and India, and  Djibouti: The Bank has supported Djibouti’s na- remains the most predictable, flexible, long-term tional HIV/AIDS program, which has reduced financing source. IDA’s Multi-Country AIDS Pro- HIV seroprevalence among 15-to-24-year-old gram helped increase total resources for HIV in de- pregnant women from 2.9 percent in 2002 to 2 veloping countries from US$300 million in 1996 to percent in 2009. More than 2,000 persons living US$14 billion in 2008, which includes domestic with HIV/AIDS registered for HIV/AIDS case public and private spending. management, and of these, 1,541 received anti- retroviral treatment. IDA Results  India: The Bank has supported the foundation  Multi-Country AIDS Program: Since 2000, the of a national program that is averting 3 million Bank has committed US$2 billion to 33 coun- new infections—a 60 percent reduction in the tries and four regional, cross-border projects in HIV epidemic from around 5.5 million cases to Africa, to expand national HIV/AIDS efforts. 2.5 million cases—during the period 1995-2015. IDA has funded more than 65,000 civil society More than US$640 million in IDA financing has projects; purchased and/or distributed 1.3 bil- helped to create the institutional framework of lion male condoms and delivered 4 million fe- India’s HIV response at national and state le- male condoms for the prevention of HIV, sex- vels, including a strong surveillance system. The ually transmitted diseases, and unwanted preg- Bank has also financed, through pooled funding nancies; allowed 3 million pregnant women to with the Indian government and other partners, receive antenatal care; and delivered antiretro- more than 1,300 targeted interventions for viral therapies to almost 2 million adults and those most at risk, reaching more than 70 per- children with HIV, and treatment for HIV- cent of female sex workers and increasing the related infections for nearly 300,000 more. Oth- use of condoms. This intervention has helped er results in Sub-Saharan Africa included offer- contain HIV prevalence in the general popula- ing services to prevent mother-to-child HIV tion. “There has been a tremendous scale-up of preven- transmission for more than 1.5 million women; tion interventions under this program, which has led to an overall reduction in new infections and AIDS-related WORLD BANK RESULTS 3 deaths in India,” said Sayan Chatterjee, Secre- estimated at R$1.1 billion in a decade (1997– tary and Director General of India’s Nation- 2007). al AIDS Control Organisation. “With expand- ing coverage of treatment, the program has to ensure that  Thailand: Through a mass media campaign to the treatment requirements are fully met without sacrific- promote universal and consistent condom use ing the needs of prevention.” in commercial sex, visits to sex workers and in- fection rates among army conscripts fall by half  Vietnam: Since 2006, IDA and the United King- in a few years. Nationwide, new infections have dom’s Department for International Develop- declined by more than 80 percent since their ment (DFID) have promoted safe injecting and peak in the early 1990s. sexual behaviors to reduce HIV transmission among vulnerable populations in 32 provinces IDA-IBRD Combined Results in Vietnam. In 2010 alone, provincial services reached 56,459 injecting drug users (70 percent  Caribbean Region: The region has made signifi- of total injecting drug users in the 32 provinces) cant strides in increasing access to HIV treat- with harm reduction interventions, and 44,386 ment. Caribbean residents in need of treat- female sex workers (representing 75 percent of ment—and receiving antiretroviral drugs— this population in the 32 provinces) with inter- increased from 10 percent in 2004 to 51 percent ventions to promote the use of condoms. by December 2008, surpassing the global aver- age of 41 percent for low- and middle-income IBRD Results countries. Approximately 21,276 people living with HIV are receiving antiretroviral treatment  Botswana: In Botswana, IBRD has increased the in Barbados, Dominican Republic, Grenada, coverage, efficiency, and sustainability of tar- Guyana, Jamaica, St. Kitts and Nevis, St. Lucia, geted HIV/AIDS interventions. The country St. Vincent and the Grenadines, and Trinidad scaled up access to treatment from less than 5 and Tobago. Expansion of services to prevent percent in 2000 to more than 80 percent (in- mother-to-child-transmission of HIV has re- cluding 95 percent coverage for pregnant wom- duced mother-to child transmission of HIV en living with HIV), which it has maintained from 10 percent in 2006 to less than 5 percent since 2009. The annual number of new infec- in 2010 in Jamaica, and no baby was born HIV- tions has declined by more than two-thirds since positive from HIV-positive mothers in the past the late nineties and data suggests that the num- four years in Barbados. ber of new HIV infections in Botswana is 30-50 percent lower today than it would have been in Other Results the absence of antiretroviral therapy. Estimated annual AIDS-related deaths fell by more than  Partnership with UNAIDS, the United Nations De- half—from 15,500 in 2003 to 7,400 in 2007— velopment Programme (UNDP), and the World Health while the annual number of new HIV infections Organization (WHO): A study by the Bank and among children declined five-fold from 4,600 in these partners, entitled “The Global HIV Epidem- 1999 to 890 in 2007. ics Among Men Who Have Sex with Men (MSM): Epidemiology, Prevention, Access to Care, and Human  Brazil: With Bank support (US$492 million since Rights,” evaluates global costs of inaction in ad- 1994), Brazil’s provision of free, universal access dressing HIV within this population, critically to antiretroviral drugs led to a decline in moth- reviews epidemiological evidence of HIV er-to-child HIV transmission from 16 percent in transmission, rigorously reviews the evidence of 1998 to around 3 percent in 2011, reaching efficacy and intervention costs, and models the more than 80 percent of the country’s HIV- costs and impact of addressing the needs of this positive pregnant women. This initiative population in various epidemic contexts. The doubled the survival of people living with HIV report has found that addressing this aspect sig- from 58 months to 108 months (1996-2007), nificantly affects a country’s HIV epidemic— and savings due to antiretroviral treatment are 4 THE WORLD BANK AND HIV/AIDS even in generalized epidemic scenarios such as AIDS investment framework, unveiled in July those in Sub- Saharan Africa. 2011, places community mobilization at the cen- ter of AIDS programming, and the evaluation is  Argentina, Ecuador, El Salvador, Guatemala, Pana- contributing valuable data to this global effort. ma, Paraguay: In 2010, following a Bank study, Finally, the active involvement of civil society in several governments reallocated their budgets to all eight countries and globally through the more effectively target prevention, a critical step United Kingdom NGO Consortium for AIDS in the process of scaling up programs and en- and International Development has demon- suring that they are sustainable. Resource alloca- strated the strong engagement of civil society in tion to most at-risk populations increased nine- the evaluation and the Bank’s commitment to fold, compared with 2008. A total of US$27 work effectively with them. million was allocated to men who have sex with men in 2010, up from US$1.1 million in 2008.  East Asia and the Pacific: The Bank has provided Projects focused on sex workers saw similar technical assistance to countries to ensure that gains, with US$10 million allocated in 2010 in- available resources for HIV/AIDS are priori- stead of the US$1.8 million spent in 2008. There tized and targeted to effective interventions. were also significant increases in money allo- Since 2010, the Bank has provided cost- cated to campaigns aimed at prisoners and in- effectiveness analysis trainings and results- jecting drug users. management workshops in Indonesia, Thailand, and China, which have trained more than 70  Burkina Faso, Kenya, Lesotho, India, Nigeria, Senegal, public officials in the use of economic tools to South Africa, Zimbabwe: In partnership with DF- improve national and sub-national strategic ID, the United Kingdom NGO Consortium for planning for HIV/AIDS. AIDS and International Development, and oth- er partners, the Bank is wrapping up a three year  Kenya, Lesotho, Mozambique, South Africa, Swazil- evaluation of community responses to HIV and and, Uganda, and Zambia: The Bank’s analytical AIDS in eight countries to determine the extent work on HIV transmission dynamics and im- to which a strong community response helps in- pact evaluations to generate evidence on what crease the effects of the national AIDS efforts. works in prevention in various epidemic con- Ten evaluation studies provide strong evidence texts has resulted in major policy and program that specific community interventions can affect shifts. In Uganda, Kenya, Lesotho, Swaziland, the course of the epidemic by increasing HIV Zambia, Mozambique, and South Africa, the knowledge, reducing stigma, and increasing Bank’s support to HIV epidemiological, policy, condom use, HIV testing uptake, treatment ad- and response syntheses has resulted in the de- herence, and use of services. The studies also velopment and/or revision of national HIV show that community-based actions play a pi- programs. Uganda doubled its prevention fund- votal complementary role to national programs ing and agreed to focus on couples in HIV pre- by providing services to rural communities and vention. The synthesis report helped Kenya high-risk groups, which would otherwise have shape its national strategy and operational plans; none. Further, the studies reveal that communi- in Lesotho and Mozambique, the findings ty-based organizations—many of which operate helped inform strategic planning; and Zambia on small annual budgets between US$15,000 held its first HIV prevention summit. In South and $25,000—are doing much with little. The Africa, the new national HIV strategic plan re- Bank leveraged DFID financing for the evalua- flects the Bank’s policy advice to characterize tion by mobilizing additional funding by 30 per- the epidemic and improve prevention pro- cent and increasing intra-Bank collaboration. gramming. The evaluation has attracted support from other global partners including the Bill & Melinda  Malawi, Tanzania: A study by the Bank showed Gates Foundation, USAID, the U.S. President's that conditional cash payments to men and Emergency Plan for AIDS Relief (PEPFAR), young women in Malawi and Tanzania were the Global Fund and UNAIDS. The new UN- linked to significantly lower HIV and other sex- WORLD BANK RESULTS 5 ually transmitted infection rates than in other own funds – are reaching the intended benefi- groups in the same communities. Eighteen ciaries, and are targeting the right prevention months after the program began, new HIV in- priorities. Data will enable the provincial gov- fections among girls in the program were 60 ernment to assess the effectiveness and efficien- percent lower than among those who were part cy of public spending on HIV/AIDS programs, of a control group and did not receive pay- and ultimately make appropriate changes to im- ments. prove HIV responses across Kwa-Zulu Natal.  Niger: In Niger the Bank supported the epide-  Ukraine: Through its strategic planning role, the miological analysis of HIV transmission dynam- Bank is focusing on the most-at-risk groups ics and the adequacy of the government re- such as injecting drug users and sex workers. sponse. This support helped to identify new Ukraine is the country most affected by the priorities and to inform the design of the Bank- HIV epidemic in the Europe and Central Asia funded US$20-million AIDS project, which fo- region. cuses resources on most at-risk populations, in- creasing the efficiency of the health system. Bank Contribution Similar epidemiological analysis in Benin and Ghana informed the priority setting and alloca- IDA has committed more than US$3.6 billion since tion of resources for key populations at risk in 1988 to support HIV/AIDS responses in 67 coun- the two countries. tries, while IBRD has provided US$969 million in 18 middle-income countries since 1993. Bank-  Middle East and North Africa: The Bank devel- supported projects have helped raise political oped a groundbreaking HIV report that has led awareness and mobilize societies, build systems and to program shifts. “Characterizing the HIV/AIDS institutions to channel resources to affected com- Epidemic in MENA” shows how focusing in- munities, and bring the public, private, and non- vestments on prevention efforts for priority profit sectors together to deliver effective, evidence- populations at increased risk of HIV infection based strategies and policies. Bank financing is used can yield long-term health and social benefits. flexibly to complement other sources, deliver sus- As a result, the governments of Egypt, Moroc- tained support to strengthen health systems, support co, Jordan, Sudan, and Syria have increased their investments and outreach among marginalized resource allocation to most at-risk populations, groups, (key to preventing transmission in concen- placing them at the center of their response. trated HIV epidemics), and sustain grassroots initia- tives that reach poor, remote, and marginalized  Colombia: In Colombia, the Bank worked closely communities, empowering infected and affected with the ministry of health to conduct a study of people to cope better. the implementation efficiency of the national HIV/AIDS program. The study addressed three Partners main domains: efficiency of resource alloca- tions, programmatic efficiency, and services de- Today, with the large grant resources of the Global livery efficiency. The study shows that while the Fund to Fight HIV/AIDS, Tuberculosis, and Mala- AIDS program is fully embedded in the national ria and PEPFAR, the Bank is no longer the major social security system, the complexity of the financier for AIDS, but remains a key source of services delivery system poses challenges for support—continuing to strengthen national and coordination of services. sub-national capacity for planning, managing, and monitoring HIV responses and thus enabling coun-  South Africa: In Kwa-Zulu Natal, the province in tries to use other sources of global funding more South Africa with the highest HIV prevalence, effectively. The Bank continues to finance specific the Bank has initiated a fund-tracking study to country projects as well as use policy lending to look at whether the significant HIV funds Kwa- strengthen these national HIV/AIDS responses. Zulu Natal attracts from the national govern- ment and donors – as well as the province’s 6 THE WORLD BANK AND HIV/AIDS The Bank plays a global leadership role and is a Moving Forward founding cosponsor of UNAIDS, and works closely with global partners in the UNAIDS family to de- The Bank continues to view HIV/AIDS as a fun- liver results. The Bank also helped create the Global damental development problem, focusing especially Fund and serves on its board and as trustee. The on HIV strategic planning, prevention, care, and Bank plays a strong role in promoting donor har- treatment services, along with social protection for monization, coordination, and alignment. people affected by HIV. The Bank will continue to support countries to achieve the greatest impact, In partnership with DFID, the Bank is in the final utilize the most cost-effective prevention activities, phase of evaluating community responses to utilizing our analytical and advisory work and fund- HIV/AIDS to build evidence on the impact of spe- ing. Additionally, the Bank will make a targeted ef- cific activities and programs. The Bank is also work- fort utilizing results-based financing to scale up pre- ing with the International AIDS Vaccine Initiative vention of mother-to-child transmission of HIV, in to support research on a vaccine to bring an end to support of our pledge to help countries accelerate the AIDS pandemic. progress on maternal and child health, in line with the Millennium Development Goals. The Bank will continue to broaden its analytic support to countries to bolster the efficiency and effectiveness of their disease programs, and work with them to assess their fiscal capacities to make the best-informed de- cisions about financing priorities. LEARN MORE Web Sites – HIV/AIDS and the World Bank – Health, Nutrition, and Population and the World Bank – 2007 Health, Nutrition, and Population Strategy and the 2009 Progress Report – Blog: Investing in Health Multimedia – Maya: why health systems matter – Djibouti: health programs reduce HIV/AIDS prevalence among young pregnant women