Document of The World Bank Report No: 29146 IMPLEMENTATION COMPLETION REPORT (CPL-43920) ON A LOAN IN THE AMOUNT OF US$165.0 MILLION TO THE FEDERATIVE REPUBLIC OF BRAZIL FOR A SECOND AIDS AND STD CONTROL PROJECT May 30, 2004 Human Development Sector Management Unit Brazil Country Management Unit Latin America and the Caribbean Region CURRENCY EQUIVALENTS (Exchange Rate Effective as of September 2002) Currency Unit = Real R$ 1.00 = US$ 0.37 US$ 1.00 = R$ 2.7 Reais FISCAL YEAR January 1 December 31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ARV Anti Retroviral (drugs) ART Anti Retroviral Therapy AZT Azido-Deoxy Thymidine CAS Country Assistance Strategy CDC Centers for Disease Control, Atlanta, Georgia, USA CN DST/AIDS National Coordination of the STD and AIDS Programs CSO Civil Society Organization CSW Commercial Sex Worker DALY Disability-Adjusted Life Years HAART Highly Active Antiretroviral Therapy HIV Human Immuno-deficiency Virus ICR Implementation Completion Report IDU Injecting Drug User IEC Information Education and Communication MOH Ministry of Health MSM Men who Have Sex with Men NASCP National AIDS/STD Control Program NGO Non-governmental Organization PAM Action & Target Plans for States and Municipalities (Planos de Ações e Metas) OI Opportunistic Infection PLWHA People Living with HIV AIDS PMTCT Prevention of Mother to Child Transmission POA Annual Operating Plan QEA Quality at Entry Assessment SAE Specialized Ambulatory Care centers SIAIDS Information System of AIDS Project SINAN Sistema de Informações de Agravos de Notificação (National Notification System for Communicable Diseases) SOE Statement of Expenditures STD Sexually Transmitted Disease SUS Sistema Unico de Saúde TOR Terms of Reference UNAIDS United Nations AIDS Programme UNODC United Nations International Drug Control Program UNESCO United Nations Educational, Scientific, and Cultural Organization VCT Voluntary Counseling and Testing Vice President: David de Ferranti Country Director Vinod Thomas Sector Director Ana-María Arriagada Task Team Leader Sandra Rosenhouse BRAZIL AIDS & STD Control Project III CONTENTS Page No. 1. Project Data 1 2. Principal Performance Ratings 1 3. Assessment of Development Objective and Design, and of Quality at Entry 2 4. Achievement of Objective and Outputs 5 5. Major Factors Affecting Implementation and Outcome 21 6. Sustainability 25 7. Bank and Borrower Performance 26 8. Lessons Learned 27 9. Partner Comments 29 10. Additional Information 30 Annex 1. Key Performance Indicators/Log Frame Matrix 31 Annex 2. Project Costs and Financing 33 Annex 3. Economic Costs and Benefits 35 Annex 4. Bank Inputs 36 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 38 Annex 6. Ratings of Bank and Borrower Performance 39 Annex 7. List of Supporting Documents 40 Annex 8. Borrower's Contribution 42 Project ID: P054120 Project Name: BR: AIDS & STD Control II Team Leader: Sandra Rosenhouse TL Unit: LCSHH ICR Type: Core ICR Report Date: June 1, 2004 1. Project Data Name: BR: AIDS & STD Control II L/C/TF Number: CPL-43920 Country/Department: BRAZIL Region: Latin America and the Caribbean Region Sector/subsector: Health (100%) Theme: HIV/AIDS (P); Health system performance (P); Participation and civic engagement (S); Gender (S); Population and reproductive health (S) KEY DATES Original Revised/Actual PCD: 03/10/1998 Effective: 10/15/1998 02/09/1999 Appraisal: 03/20/1998 MTR: 05/07/2001 05/07/2001 Approval: 09/15/1998 Closing: 12/31/2002 06/30/2003 Borrower/Implementing Agency: FEDERATIVE REPUBLIC OF BRAZIL/MINISTRY OF HEALTH Other Partners: STAFF Current At Appraisal Vice President: David de Ferranti Shahid Javed Burki Country Director: Vinod Thomas Gobind T. Nankani Sector Director: Ana-Maria Arriagada Xavier E. Coll (Acting) Team Leader at ICR: Sandra Rosenhouse Theresa (Polly) Jones ICR Primary Author: Sandra Rosenhouse 2. Principal Performance Ratings (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible) Outcome: S Sustainability: HL Institutional Development Impact: SU Bank Performance: S Borrower Performance: S QAG (if available) ICR Quality at Entry: S S Project at Risk at Any Time: No 3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective: The project development objectives for the Second AIDS/STD Control Project (AIDS II) were to reduce the incidence of HIV and STD infection and to expand and improve diagnosis, treatment and care for people living with HIV, AIDS and STDs. The First AIDS/STD Control Project (AIDS I, Ln. 3659-BR) established the strategies and framework for the implementation of Brazil's National AIDS & STD Program (NASCP), a strong prevention program and a solid institutional base. The second project sought to consolidate and expand the gains achieved by the first project by broadening prevention activities to the general population (while maintaining the focus on high-risk groups), strengthening evaluation capacity, and working towards the sustainability of the program through (a) the devolution of some responsibilities to states and municipalities, and (b) the identification of the most cost-effective interventions. The project's objectives were consistent with the health goals contained in the Bank's Country Assistance Strategy for Brazil, discussed at the Board in June 1998, which included the control of traditional and emerging communicable diseases. The project objectives supported the Government of Brazil's overall health strategy to implement cost-effective approaches to health care, in this case through the prevention of a costly disease. The project's approach was also consistent with the Brazilian Unified Health System's (SUS) principles of decentralization of health services to states and municipalities, promotion of social participation through state and municipal health councils, and participation of the private sector in the provision of health services. 3.2 Revised Objective: The development objective was not revised during project implementation. 3.3 Original Components: Component 1: Prevention of AIDS and STDs (US$128.0 million, or 43 percent of total project costs). This component aimed to strengthen NASCP's prevention program by expanding the coverage and effectiveness of prevention activities targeting populations engaging in high-risk behavior, and beginning to address prevention needs of the general population. Although Brazil's AIDS epidemic was concentrated in population groups engaged in high-risk behavior, the program needed to begin focusing on the general population to improve the effectiveness of its prevention efforts. This component financed behavior change interventions targeting specific sub-groups at greater risk of contracting and/or spreading the HIV virus, including homosexual and bisexual men, intravenous drug-users, and sex workers; it also conducted some targeted interventions among more vulnerable populations including prisoners, truck drivers, adolescents, women and some low-income populations. Targeted interventions included peer group education and counseling to promote safe practices, needle exchange programs, and condom promotion. Targeted interventions were executed through NGO subprojects selected on a competitive basis. To reach the general population, the component financed mass media campaigns to raise - 2 - awareness and understanding of AIDS and STD transmission and to promote safer practices, HIV/AIDS education and condom promotion through schools and in the work place, and public events (such as World AIDS Day). It also included voluntary counseling and testing (VCT) services and a hotline providing AIDS information service (Pergunte AIDS). Given the need to reduce discrimination to remove some barriers to prevention, treatment and care, the component financed a National Human Rights Network promoting non-discrimination against persons with HIV/AIDS. Component 2: Diagnosis, Treatment and Care for persons with HIV, AIDS and STDs. (US$98.5 million or 34 percent of total project costs). This component sought to strengthen the delivery network (providers and approaches) to improve diagnosis, treatment and care of people with HIV/AIDS and STDs. To strengthen diagnosis of HIV/AIDS this component financed the operation, standardization and quality control of diagnostic laboratories, the implementation of 100 new VCT centers and maintenance for existing centers. To improve the follow-up of patients undergoing treatment, municipal public health laboratories would be strengthened through the purchase of equipment and provision of training to expand access to viral load and CD4 cell count testing. To strengthen and expand treatment and care of people infected with HIV/AIDS this component would support: 80 community support centers (casas de apoio) for care of AIDS patients, 40 centers for orphans of AIDS, 80 existing specialized care units, 30 existing day hospitals, 40 existing home care initiatives and in-patient care in 100 hospitals. STD diagnosis and treatment was to be strengthened through training in STD case management, licensing of about 10 National STD reference centers, which would review norms and procedures, and the provision of reagents, drugs, condoms, and educational materials. A centralized logistical control system for drugs, medical supplies and condoms, a cost-control system for HIV/AIDS care, and a reference system for gynecological care for HIV positive women were also envisioned. Investments in this component were to complement activities financed by the Health Sector Reform Project (REFORSUS, Loan 4047-BR) designed to improve quality control in public laboratories, and blood banks and transfusions. Component 3: Strengthening Executing Agencies Responsible for HIV/AIDS and STD Control. (US$70.0 million or 23 percent of total project costs). This component was to provide support to strengthen the capacity of institutions working on HIV/AIDS and STD control through (a) provision of technical training for health sector staff, laboratory technicians and NGO implementers; (b) strengthening the National Reference Laboratories for HIV, including quality control mechanisms for lab testing and the provision of training and equipment; (c) expansion of the national network to conduct drug resistance studies and the implementation of a network to monitor susceptibility to anti-retroviral therapy; (d) expansion of the knowledge base research on HIV/AIDS and STDs, including studies on survival, behavior of specific population groups, cost studies, and others; and (e) carrying out activities designed to monitor the epidemic and assess the impact of interventions, including: (i) the improvement of epidemiological surveillance systems (sentinel surveys for HIV, and expansion/upgrading of the HIV and STD case notification system, HIV prevalence studies among specific risk groups, HIV sub-type studies, and other epidemiological studies); and (ii) strengthening monitoring and evaluation of the program (including evaluation studies of program interventions, behavioral surveillance studies to assess program impact, operations research). - 3 - 3.4 Revised Components: There was no formal revision of project components. A reallocation of loan funds was approved in March 6, 2002, to reflect actual expenditure needs. The project closing date was extended once on December 3, 2002 from December 31, 2002 to June 30, 2003. The latter was necessary because of some counterpart funding delays and shortfalls, leading to slightly delayed implementation (see section 5.2). 3.5 Quality at Entry: ICR Rating: Satisfactory. The project's objectives and strategy were consistent with national objectives and priorities, and the Bank's overall social sector strategy for Brazil. Moreover, the project design included many of the suggestions made during the consultations held with key stakeholders during preparation. A quality at entry assessment (QEA) was conducted in early FY99. The QEA rated the overall quality of project design and key components as satisfactory, although some shortcomings were highlighted by the report. One of the main weaknesses cited in the QEA report was that, other than the mention of the failure of the first project to implement an adequate Monitoring and Evaluation (M&E) system and the lack of integration of prevention activities within the program and with other Ministry of Health (MOH) programs, the Project Appraisal Document (PAD) does not present an analysis of the first project's accomplishments and shortcomings. Thus, the design did not fully incorporate the lessons learned from the implementation of the first project, losing an opportunity to improve the second project's impact. The project design makes only minor adjustments on the design of the first project, and doesn't take opportunities to test new approaches. The QEA rates a number of aspects of project preparation as highly satisfactory, including the incorporation of key suggestions made by government-sponsored consultations with representatives from NGOs, CSOs, associations of people living with HIV/AIDS (PLWHA) and state and municipal AIDS programs in project design, the financial management arrangements, the overall efficiency of preparation resources, and the speed of preparation (nine months). The quality of the Bank's internal documents was also rated as highly satisfactory, yet the lack of specificity regarding some of the strategies to be implemented created a few problems during supervision, as it was difficult to assess whether or not the project was meeting some of these less explicit objectives. The case of decentralization is an example. The discussion of the project development objectives indicates that the project would "work towards the sustainability of the program through the devolution of some responsibilities to the states and municipalities", however, the only specific expected change noted was the gradual transfer of supervision responsibilities for subprojects to states and municipalities, that is, a very minimal level of decentralization. Similarly, there was no guidance as to how "maintaining the focus on high-risk groups vis-à-vis the general population" was to be measured. A clearer specification of these objectives and targets would have facilitated the assessment of progress on these dimensions. - 4 - The PAD addressed the need to strengthen the M&E component by: (a) defining, with the borrower, clear, measurable indicators to measure program impact; (b) identifying instruments to collect the information (including agreement on TOR for three impact evaluation studies); and (c) recommending the strengthening of the capacity of the evaluation unit. However, it did not identify the underlying reasons why the previous project did not carry out M&E. An analysis of the existing barriers in the implementation of the M&E component might have suggested some strategies to encourage the implementation of these activities. The project's capacity/willingness to conduct M&E was not identified as a risk. Finally, the PAD appropriately notes that the project unit is staffed primarily with consultants financed by the loan, posing a risk to its sustainability. However, the financing plan developed for the project does not introduce any incentives for changing the status quo since administrative costs, including consultants for the unit, are covered 100 percent by loan funds. A better approach would have been a declining percentage of loan financing in this category. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: ICR Rating: Satisfactory. Overall, achievement of development objectives and project outcomes is rated as satisfactory. While some evidence of changes in trends and specific impacts attributable to the overall project activities is available, study results are often not comparable because of the use of varying methodologies, and non-representative sampling. Moreover, they were not systematically applied to obtain trends over time, particularly in the case of prevention interventions. Annex 1 outlines the main objectives, proposed actions in the PAD and the key outcomes for each component. Reduce the Incidence of HIV and STD Infection. The assessment of the achievement of this first development objective employs prevalence data, since incidence data are difficult to obtain and generally employed primarily for research purposes. The project collected HIV prevalence data based on an annual sentinel surveillance system of women delivering in public maternities from 1997 to 2000 (because over time sentinel sites became reference centers for HIV/AIDS, data collected there lost its representativeness. Thus, data collection was modified after 2000 to include a random sample of hospitals with over 500 beds in each measurement. The first random sample measurement was conducted in 2002, but had to be redone in 2003 due to problems and the results were not available for this report). Prevalence of HIV has ranged from 0.5 to 0.8 percent since the end of 1997 showing a trend toward stabilization. Prevalence among women aged 20-24 delivering in public maternities (the closest estimate of incidence among young pregnant women) increased from 0.3 to 0.6 percent from 1998 to 2000. Prevalence of HIV was also collected on cohorts of army conscripts aged 17-19 in 1996 and 2002. Data were also collected in 1998, but the sample targeted high prevalence areas and thus is not comparable. However, data shows that the prevalence of HIV among army conscripts declined from 0.2 percent in 1996, to 0.09 percent in 2002. Overall prevalence of HIV for the general population has been estimated at 0.65 percent, with an estimate of 0.47 percent for women and 0.84 percent for men. - 5 - Regarding prevalence of STDs, the picture is mixed. Data from the National Notification System for Communicable Diseases (SINAN) continue to have significant under-reporting. However, there are some data available from annual conscript surveys and from periodic surveys of women delivering in public maternities. Data on prevalence of syphilis from public maternities showed a decline in prevalence of syphilis from 2.8 percent in 1998 to 1.7 percent in 2000. The measurement for 2003 is currently being processed. Prevalence of syphilis among army conscripts aged 17-19 increased from 0.5 percent to 1.8 percent from 1996 to 2002. However, the diagnostic procedures employed differed between these two measurements, limiting comparability. The same study noted that 16 percent of army conscripts had at least one symptom of STDs in 2002. Prevalence of symptoms was highest in the North, at 23.3 percent. There are some partially comparative conscript data for 1998, although the sampling focused on high prevalence areas. This would suggest that current measures should be somewhat lower as they are more representative of all of Brazil, even in the absence of program effects. Prevalence of symptoms decreased in the South from 11.2 to 9.5 percent but increased in the Southeast from 10.7 to 14.4 percent. Figures for the North are difficult to compare since the 1998 survey combined North with Central West. The figures suggest, however, that there was a decrease since the combined figure for 1998 is almost the same as that for the North alone in 2002, whereas the Central West figure is considerably lower (11.9 percent in 2002). With respect to changes in prevalence of HIV and STDs among high-risk groups, it is also difficult to make conclusive statements as either a second measurement was unavailable or the available measurement used a different methodology, making it difficult to compare results. Prevalence of HIV among injecting drug users (IDUs) decreased from 52 to 36.5 percent from 1998 to 2002. However, the second measurement included two additional municipalities with somewhat lower prevalence. Data on prevalence among commercial sex workers (CSWs) are only available for 2000 (a second survey is planned for 2004), and a prevalence of 6.5 percent was reported. Data on HIV prevalence among men-who-have-sex-with-men (MSMs) are only available from a cohort study conducted from 1994 to1999. The study had high levels of attrition and thus the data are probably biased. Although the available data on prevalence do not examine trends in the demographic profile and mode of transmission of HIV, analyses of reported AIDS cases over time, indicate that some important changes have taken place. While in 1985, 85 percent of all AIDS cases reported were among men who have sex with men, in 2000 they accounted for 17.6 percent of all cases, with heterosexual transmission increasing from 16 percent pre-1990 to 54 percent in 2000 (see Table 1). Women now account for 37 percent of all new cases compared with less than 15 percent pre-1990. The proportion of AIDS cases derived from blood transfusion has declined over time, as has the proportion transmitted through intravenous drug-use. The proportion infected through vertical transmission peaked in 1996-97, but has shown a decline since then. These data, however, do not provide information regarding any changes in rates of transmission by each mode, and give a clearer sense as to the evolution of the epidemic. - 6 - Table 1: Percent of Cases of AIDS reported by Mode of Transmission and Year of Diagnosis Cumulative Annual Cumulative Total 1980-90 1992 1994 1996 1998 2000 1980-2002 Sexual 61.9 54.8 56.9 59.0 67.4 71.9 63.5 MSM 45.5 29.1 23.8 19.4 19.5 17.6 23.2 Hetero 16.4 25.7 33.2 39.7 47.9 54.4 40.4 IDU 20.3 29.1 24.5 20.3 16.1 13.9 19.7 Transfusion 5.3 2.4 1.8 1.7 0.2 0.1 1.5 Perinatal 1.8 2.8 3.4 4.0 3.3 2.5 2.9 Unknown 10.7 10.8 13.3 15.0 13.0 11.6 12.3 Total 9.4 5.7 7.0 9.0 10.0 9.2 100% Source: Epidemiological Bulletin, March 2002 In addition to the feminization of the epidemic (which is occurring in many parts of the world), newly reported cases have less schooling and include a broader group of municipalities. More than 30 percent of male AIDS cases pre-1990 had completed primary school compared with 7 percent in 2001. Although AIDS is primarily an urban phenomenon, it has spread to 60 percent of all municipalities, many of which are less urban and therefore harder to reach. In sum, the data available indicate that HIV prevalence appears to be stabilizing, and possibly decreasing in some groups, and that the epidemic continues to be a concentrated one, albeit, beginning to include a greater proportion of women, heterosexual men, and less urban areas. Data on STDs are less conclusive but do show some promising downward trends. Two outcome measures of the prevention efforts financed by AIDS II, including adoption of safe practices and being tested for HIV, provide further evidence of achievement of project objectives. Although evidence of increased knowledge about AIDS transmission and how to prevent it might be used as outcome measures, they do not necessarily predict behavior change and thus are not included. Results from two population-based surveys in 1996 and 1999 suggest that condom use with a regular partner in the last 12 months increased among women (from 12 to 21 percent) and remained about the same among men (26 percent) (BEMFAM, 1996; CEBRAP, 1999). However, part of the difference can be attributed to the fact that the 1999 sample included only urban households. Highest use is reported among those less than 25 years of age (44 percent). A third population-based survey conducted in 2003 (IBOPE, 2003) indicated that 20 percent of the population used a condom in the last sexual relationship with a regular partner in the last six months, showing no change since 1999. However, use of a condom with non-regular partners increased from 64 to 76 percent from 1999 to 2003. Condom use with regular partners is as high - 7 - as 41 percent among 14-24 year olds, similar to the previous survey. The latter survey used "last relationship in the last 6 months" instead of the "last 12 months" as a reference period, and thus responses are not totally comparable. Some data are also available from a series of annual surveys conducted on male recruits entering the armed forces aged 17-19 from 1996 to the present. Results indicate that condom use increased from 38 to 50 percent (use condom in all sexual relationships in the last year) from 1997 to 2000. Figures for 2002 place condom use in all relationships at 48 percent. Use with a stable partner has hovered at about 44 percent, whereas use with paid sex increased from 69 percent in 1999 to 77 percent in 2002. Use with casual partners also increased slightly from 53 percent in 1999 to 57 percent in 2002. Data on high-risk groups are available from studies carried out to assess the effectiveness of interventions, including a study on CSWs and another on IDUs. The study on CSWs (2001) found higher use of condoms among program participants than non-participants, with both clients (74 versus 60 percent) and regular partners (24 compared with 16 percent). However, program participants were slightly older, more established CSWs working in less precarious circumstances, which may also have influenced results. Moreover, prevalence of HIV and syphilis were higher among program participants, and they could have been using condoms to protect their partners, a positive outcome of the project. A study on IDU behavior (2002) also compares program participants with non-participants, and found that participants were less likely to share needles (41 compared with 51 percent) than the control group, and more likely to use a condom (42 versus 31 percent). Data on MSMs are available for the last two years of AIDS II through two small urban surveys conducted in 2001 and 2002 (IBOPE 2001, 2002). Neither was representative of MSMs in Brazil, and the question on protected sex differed. However, results are consistent. In 2001 81 percent of MSMs with a fixed partner claimed use of condom in the last six months. Use was greater with non-regular partners, increasing to 95 percent. In 2002, 68 percent used condoms with all partners, and two-thirds of those that did not, did use a condom with irregular partners. Both show a high level of safe practices, which is mirrored in their reduced contribution to overall prevalence of HIV for the country as a whole. In sum, data on outcome measures, although not always comparative, do demonstrate consistent results in the right direction with respect to the achievement of the first development objective. Expand and Improve Diagnosis, Treatment and Care for People with HIV/AIDS and STDs. With regards to the second development objective, the evidence is clearer. Household survey data on HIV testing indicates that 22.8 percent of 16-65 year olds who had been sexually active during the last 12 months had been tested (26 percent of men and 15 percent of women) in 1998. Testing was highest among 26-40 year olds at 30 percent. Testing among the general population (aged 14 and over) who had been sexually active in the last 12 months increased to 30.8 percent in 2003, with 34 percent having been tested within the last 6 months. Testing is higher among women (34 versus 26 percent for men) because of their participation in the Prevention of Mother to Child Transmission (PMTCT) program. Testing was highest in the South (38 percent) and lowest in the Northeast (20 percent of the population). Testing by age also showed greater amount of testing among 20-29 year olds with testing as high as 38 percent. Close to 25 percent - 8 - of those tested did it through the PMTCT program, 21 percent by donating blood, 15 percent because of physician recommendation, and 8 percent because of employer requirements. Another 21 percent made an independent decision to be tested. With respect to testing among high-risk groups, surveys of MSM showed the proportion ever tested for HIV was 73 percent in 2001, and approximately 71 percent in 2002, both considerably higher than for the general population. Among surveyed CSWs that participated in program interventions, 49 percent had been tested for HIV compared with 36 percent in the control group. IDU surveys note an increase in the proportion tested from 44 to 48 percent from 1998 to 2000. With regards to the second development objective, the evidence is clearer. Household survey data on HIV testing indicates that 22.8 percent of 16-65 year olds who had been sexually active during the last 12 months had been tested (26 percent of men and 15 percent of women) in 1998. Testing was highest among 26-40 year olds at 30 percent. Testing among the general population (aged 14 and over) who had been sexually active in the last 12 months increased to 30.8 percent in 2003, with 34 percent having been tested within the last 6 months. Testing is higher among women (34 versus 26 percent for men) because of their participation in the Prevention of Mother to Child Transmission (PMTCT) program. Testing was highest in the South (38 percent) and lowest in the Northeast (20 percent of the population). Testing by age also showed greater amount of testing among 20-29 year olds with testing as high as 38 percent. Close to 25 percent of those tested did it through the PMTCT program, 21 percent by donating blood, 15 percent because of physician recommendation, and 8 percent because of employer requirements. Another 21 percent made an independent decision to be tested. With respect to testing among high-risk groups, surveys of MSM showed the proportion ever tested for HIV was 73 percent in 2001, and approximately 71 percent in 2002, both considerably higher than for the general population. Among surveyed CSWs that participated in program interventions, 49 percent had been tested for HIV compared with 36 percent in the control group. IDU surveys note an increase in the proportion tested from 44 to 48 percent from 1998 to 2000. With respect to treatment and care, the project invested in the provision of treatment of opportunistic infections (OIs), the infrastructure and training for the provision of anti-retroviral therapy (ART), treatment of STDs, home based care for PLWHA, and an expansion of the PMTCT program. While treatment of OIs continues to be provided, the use of ART has led to reductions in the incidence of OIs, and thus to reduced hospitalization, diagnostic procedures and overall care for patients. The number of hospitalizations per AIDS patient has declined from 1.6 in 1996, before ART was introduced, to 0.3 in 2001, for a total of 358,000 hospitalizations prevented during 1997-2001. This has represented a savings in terms of hospitalizations in 2001 to close to US$360 million. The use of alternative care options, such as day hospitals and specialized ambulatory facilities (SAEs), has also contributed to reduced hospitalization. In 1996, the government passed a law guaranteeing universal, free access to ART, to all who need it (as determined by government guidelines, that is anyone with AIDS-related symptoms or a CD4 cell count below 350 cells). The number of people on publicly-funded ART increased from about 48,000 in early 1998 to close to 130,000 by the end of AIDS II, a threefold increase. Brazil's decision to provide universal free access to ART introduced significant improvements in the survival and quality of life of PLWHA by shifting the morbidity and mortality profile of HIV - 9 - infection, with positive economic effects, both in terms of reduction of treatment for OIs and increased productivity (not measured). Average survival time for AIDS patients diagnosed in 1996 was extended by 58 months, compared with only five months for those diagnosed before 1990. As a result, mortality has gradually declined, slowly shifting AIDS from being a fatal disease to a chronic illness. Mortality from AIDS declined from 9.6 per 100,000 in 1996 to 6.3 per 100,000 in 2001. Declines in mortality, however, vary by region, with most of the decline occurring in the Southeast (17.1 to 8.9 deaths per 100,000 from 1995 to 2001), and Central West, a small decline in the Northeast and South, and an increase in the North (from 1.9 to 2.9 deaths per 100,000 during the same period). This suggests that the benefits of ART have yet to benefit the North, South, and to a lesser extent, the Northeastern regions of the country. The program reduced rates of vertical transmission of HIV through its expansion of the Prevention of Mother to Child Transmission (PMTCT) program. The rate of transmission declined from 8.6 to 3.7 percent of births during 2000- 02, respectively, a decrease of 57 percent. While the proportion receiving Azido-Deoxy Thymidine (AZT) quadrupled since 1998 (from 2,700 to close to 6,000), analyses conducted in 2001 noted that greater efforts need to be made in this respect as only 40 percent of women delivering that year had been tested for HIV, and only 32 percent of those infected received ART. Coverage of HIV positive pregnant women varies by region, and is as high as 49 percent in the Southeast, and as low as 7 percent in the Northeast. Regional disparities in coverage are evident in many of NASCP's interventions, since the program targeted areas with the greatest number of AIDS cases, particularly the Southeast and the South. While the strategy of targeting areas with the highest prevalence is a more effective response in the short run, there is a danger that the poorest regions of the country, where HIV infection is on the increase, and where implementation capacity is the weakest, can lead to widening disparities in the long run, because success will require considerably more effort. The program needs to focus on these areas to improve equity of access. 4.2 Outputs by components: Component 1: Prevention of HIV/STDs ICR Rating: Satisfactory. The main objective of this component was to introduce a broader focus to the prevention activities of the NASCP while retaining the focus on population groups engaging in high-risk behavior. The project broadened the scope/population base of prevention activities and expanded prevention services significantly through increased participation of NGOs and partnerships with states and municipalities. The number of subprojects directed at populations engaging in high-risk behavior (financed by the project increased from 62 in 1999 to 628 in mid 2003, for a total of 1664 subprojects for the duration of AIDS II. Out of the total, 33 percent of subprojects were targeted to CSWs, 38 percent to IDUs and 29 percent to MSM. Coverage is difficult to estimate, particularly in the case of CSWs and MSMs, where the populations are more clandestine. Coverage of IDUs is estimated at 18 percent. It is estimated that approximately US$16 million was spent on NGO interventions targeting these population groups(estimated from average costs of CSW interventions). - 10 - The project also carried out specific interventions to reach other important groups through NGOs and governmental organizations, including prison populations, miners, youth, women, health workers, truckers, indigenous populations, and PLWHA (only three projects), for a total 991 projects, 81 percent of which were implemented by NGOs. These interventions included training, production of technical and educational materials, and financing for carrying out the interventions. Although generally NGOs worked with vulnerable populations and populations engaging in high-risk behavior, about one-third of the interventions were directed at the general population, including rural and poor populations, many of who are not necessarily vulnerable, suggesting improved targeting could have led to better use of funds. Instead, it may have been more cost effective to increase the number of interventions with PLWHA, who have a high potential of being a source of infection if they engage in risky behavior. Unfortunately, very few of these interventions were evaluated, making it difficult to ascertain if they were generally having a sufficient and correct effect. Some initial investments were made to strengthen the capacity monitoring and evaluation of these interventions. M&E of program interventions is an important focus of the follow-on Third AIDS and STD Control Project (AIDS III) (Ln.-4713-BR, effective in December 2003). In order to reach a broader sector of the population, the project carried out several large mass media campaigns to promote changes in sexual behavior and increase the population's knowledge of prevention of disease transmission. Thirteen large-scale multi-media campaigns were carried out, targeting primarily the general population (with the exception of one for truckers and another for MSM). In addition eight more focused special purpose campaigns were carried out targeting IDU, PMTCT, adherence to ART, truckers and STDs. Numerous educational and informational materials were prepared to complement the campaigns. A total of US$36 million was spent on mass media Information Education and Communication (IEC) programs. No empirical evidence is available to evaluate the full impact of this spending, although the NASCP has begun efforts to evaluate the impact of these programs. In an effort to mainstream HIV/AIDS and ensure a more multi-sectoral response, the project financed 76 projects for other governmental organizations, including the Ministry of Education, the Ministry of Justice, Ministry of Defense, Ministry of Labor, Ministry of Social Assistance, and different departments within the MOH to carry out preventive activities, and to provide treatment for STDs and AIDS, and OIs including TB. More work is necessary in this area since the goal is to encourage other key players to implement their own interventions to address their own needs, with their own financing. A variety of workplace interventions were also carried out. Although the program was very successful in broadening the response, it initially had difficulties in maintaining a focus on populations engaging in high-risk behavior. Several supervision missions in the beginning of the project indicated that the coverage of there populations was insufficient.The number of NGO subprojects and state/municipal projects addressing these groups increased significantly only in 2001, halfway through the project. Most of the increase was in subprojects targeting IDUs and CSWs. Coverage of MSM did not expand significantly until 2002. Nonetheless, a lot was accomplished. - 11 - Another important input to the success of the project's prevention efforts was ensuring access to low cost male condoms in the private and NGO sector and free access through public distribution. Female condoms were also made available although in smaller quantities given lower demand. From 2000 to 2003 the number of condoms purchased and distributed by the public sector increased nearly four fold, from 77 million in 2000 to 270 million in 2003. This was complemented by an increase in the private sector demand, from 350 million to 427 million in 2000 and 2003, respectively. The loan financed a total of US$20.3 million on male and female condoms alone. While the increase has been largely driven by the promotion of condom use, the NASCP also played an active role in lowering the barriers to access for the population such as lowering the price of condoms by 20 percent, reducing the taxes on condoms sold privately, and increasing the distribution network through active social marketing campaigns. The average cost per condom declined by more than 50 percent since its high of US$0.62 in 1996 to US$0.26 in 2001. One of the pillars of the Brazilian AIDS program has been the respect and protection of human rights. The protection of the rights of individuals with respect to access to health services, work, education and legal protection all contribute to improving access to prevention and treatment, and improving the quality of life of those affected by the epidemic. The Human Rights Network established by the AIDS I Project in 1997, has been providing active legal support of PLWHA, training the executive, judicial and legislative powers, and preparing supporting materials. Legal support was provided through 31 projects in partnership with NGOs. Twelve national events to train legal staff in partnership with the Ministries of Labor and Justice, and the National Women's Right's Council were held in 12 different cities. In sum, the project successfully broadened the scope/population base of prevention activities, although initially it was unable to sufficiently maintain a focus on high-risk behavior groups. Prevention activities executed by the project were comprehensive in their approach, and, according to supervision reports, were well executed, contributing to the outcomes mentioned in Section 4.1. The project would have benefited from improved targeting of interventions and a greater integration of prevention activities in treatment settings, since prevention is not sufficiently promoted at treatment facilities. Improved targeting by mapping the location of high-risk groups to ensure interventions were adequately located and prioritizing specific groups in requests for proposals in NGO subproject bidding processes would have increased the overall effectiveness of the program. As it was, NGOs could opt to target various types of populations, not just groups engaging in high-risk behavior in their state. Unfortunately, very few of the interventions were evaluated, limiting possibilities to select interventions on the basis of their cost-effectiveness. The project relied heavily on mass media campaigns, internationally known to be less effective than peer-executed behavior change interventions like those implemented by NGOs. An evaluation of the relative impact would have been useful. Component 2: Diagnosis, Treatment and Care for persons with HIV, AIDS and STDs ICR Rating: Satisfactory. This component was highly successful in reaching its objective of expanding and improving diagnosis, treatment and care for people with HIV/AIDS. The - 12 - knowledge and experience acquired by the NASCP staff has converted them into international experts on the management of structured treatment in relatively resource poor settings. The project was less successful in improving diagnosis and treatment of STDs. This component financed the expansion of the diagnostic, treatment and care services, and developed innovative approaches to reduce hospitalization costs, and costs of medications and medical supplies. The strengthening of diagnosis and treatment of HIV/AIDS has been a cornerstone of the NASCP. Early detection of HIV is important for both prevention and treatment. The number of Voluntary Counseling and Testing (VCT) sites doubled from 104 in 1998 to a total of 234 sites in 2003. The total number of HIV tests done annually in the public health system increased from 2.3 million in 1997 to 4.4 million for 2002, the last year for which there are complete data. As noted earlier, 30.8 percent of the population had been tested by early 2003, up from 20 percent in 1999. While this is considerably higher than what is reported in other Latin American countries, comparable figures for the U.S. placed the population ever tested at 42 percent in 1996 (CDC), suggesting some room for improvement. Another challenge facing the VCT program is reducing the time interval between testing and delivery of diagnoses. Access to timely test results is important to ensure individuals return for their results. Use of rapid tests is being considered in some cases to reduce delays. Prevention of Mother-to-Child Transmission (PMTCT) of HIV and syphilis expanded substantially. Treatment of infected mothers increased from 2,700 in 1998 to 6,000 in 2002. As noted in the previous section, despite advances, further efforts need to be made as only 40 percent of all women delivering in public maternities were covered by the program, and only one-third of those infected received treatment. STD prevention and control has been a weak part of the project since its inception. Although the project provided training in syndromic management of STDs, pharmaceuticals needed for STD treatment were often lacking. Part of the problem was that states and municipalities were responsible for the provision of pharmaceuticals for STDs, and given budget constraints, these needs were often secondary to HIV treatment (which is federally funded). A special effort was made to prioritize STD prevention in 2001, through the mounting of a national campaign targeting the general population, pharmacists, physicians and nurses, and community health workers. Educational materials and manuals were being reformulated. As part of AIDS III, STD treatment was included as one of the key areas in which states and municipalities will be held accountable for through a new results-based financing system. Alternative care options such as day hospitals and specialized ambulatory facilities were introduced early on to reduce hospitalization costs. Specialized ambulatory facilities (SAEs) increased five-fold since 1998, the number of day hospitals nearly doubled, the 50 additional conventional hospitals were accredited to provide treatment and care for a total of 383 (see Table 2). There are a total of 474 drug-dispensing units. - 13 - Table 2: Service Delivery for STDs and HIV/AIDS by Facility Type and Region February 2003 Day Region/Facility Accredited Specialized Ambulatory Hospital Home- Type VCT Hospital Services (SAE) based Care North 29 9 16 4 2 Northeast 43 37 44 13 9 Southeast 44 254 217 43 35 South 74 56 81 16 18 Center west 44 23 25 4 3 Brazil 234 375 383 80 67 In order to adequately monitor patients on ART, the NASCP established a laboratory network capable of performing lymphocyte subset counts (CD4 and CD8 cell count units) and plasma viral load testing throughout the country. It also established an independent quality control program with international participation. To date, a total of 79 laboratories with CD4/8 cell count testing capacity and 66 laboratories with viral load testing equipment were established, out of which 27 CD4/8 and 25 viral load testing laboratories were established in AIDS II. The NASCP provided 560,000 reagents for CD4/8 tests and about 690,000 for viral load testing. By 2002, more than 90 percent of all laboratories were participating in the quality control program and more than 80 percent of all laboratories successfully passed the quality control procedure. More recently a network to assess ART resistance genotyping was introduced, with 14 participating laboratories as of 2002. Due to the costs, the latter is limited only to patients reporting their first on-treatment viral failure (Levi & Vitoria, 2002). Laboratory facilities are also involved in serological testing for recent HIV seroconversion, studies in AIDS vaccine development, monitoring resistance to Anti Retroviral (ARV drugs), and development of improved combinations of ARVs. Provision of ART, including HAART, expanded from covering 48,000 persons in early 1998 to close to 130,000 in mid-2003. Providing structured ART implies close follow-up of patients to ensure adherence to treatment schedules to reduce the development of resistance to drugs. The program closely monitored HIV drug resistance and was successful in minimizing the development of resistance to available drugs. Results of a study of HIV drug resistance in drug-naive HIV infected individuals conducted in 2002 shows Brazil to have considerably lower rates of resistance than several European countries and the U.S. (2 percent versus 5-7 percent in the US, and more than 10 percent in Europe). While the project itself did not finance the antiretroviral drugs, it financed policy development, protocols, training, infrastructure and mobilization of political support to implement the government's policy of universal free access to ART. The implementation of the policy to provide universal treatment led to a doubling of federal expenditures for AIDS, from US$340 million to US$553 million from 1997 to 1999 (Piola, 2001). Spending on ARV increased from US$34 million in 1996 to US$336 in 1999 (NASCP/Ministry of Health, 2002). This led the government to search for cost-cutting measures, including the stimulation of national production of ARV drugs and generics. Important savings were achieved through the local production of seven of the 13 ARV drugs currently utilized, six - 14 - of which are available in generic form. Moreover, price negotiations with international manufacturers for the other six medications employed have also helped lower prices. Thus, from 1997 to 2001, the cost of ARV drugs was reduced by 54 percent, from an average per ART patient of US$4,860 per year to US$2,223 (Ministry of Health, 2002) As noted in Section 4.1, the use of ART has led to reductions in the incidence of OIs, leading to lower hospitalizations and need for drugs. With respect to co-infection of HIV-TB, training for health staff working in SAEs and HDs was provided on treatment of TB. Some training on early detection of HIV/TB and prevention was provided to community health workers in the Family Health Program. However, integration with the TB program needs to be strengthened. The project financed Care and Support subprojects implemented by CSOs, including home-based care, support groups, income generation, and psychosocial care through 369 subprojects. This is in addition to the legal counseling support provided as part of the protection of human rights of PLWHA. Provision of palliative care began in mid-2000. The NASCP developed guidelines, and established two training centers for palliative care. By project closing, 140 professionals were trained. Overall, this component had a highly satisfactory performance given that in addition to improving the quality of life of PLWHA by reducing morbidity and mortality, through the structured and monitored provision of ART, it also sought and introduced more cost-effective approaches to treatment and care, by using alternatives to hospitalization, and the use of generics. The program has attained international renown for the quality of its program, and is currently providing technical advice to numerous countries introducing treatment programs. However, because the NASCP continues to face challenges with regards to expansion of its PMTCT program and improving prevention and treatment of STDs, performance is rated as satisfactory. Component 3: Strengthening Executing Agencies Responsible for HIV/AIDS and STD Control ICR Rating: Satisfactory. Progress on this component was uneven, although on balance, it was satisfactory given its overall accomplishments. Significant improvement was evident with respect to epidemiological surveillance for HIV/AIDS, strengthening of national reference laboratories, and training of staff to improve provider competence. The project also managed to decentralize both management and finance of AIDS activities to states and municipalities, although this took place at the very end of the project. This process entailed considerable preparation and will have a significant impact on the implementation of the AIDS III Project. However, progress with respect to STD surveillance could have been greater, and an adequate M&E system was not established. Significant advances were made in strengthening the epidemiological surveillance systems for HIV/AIDS. Case notification for AIDS and congenital syphilis was further systematized and improved through revising case definitions and mode of transmission, conducting some quality control exercises, and training staff at central and state levels. Universal access to ART, and its impact on the reduction of AIDS mortality, made it imperative that the program move to incorporate HIV-based information systems to track the epidemic. Several important steps were - 15 - made in this direction: (a) the sentinel surveillance of pregnant women was strengthened by introducing a new methodology; (b) a new HIV case notification system of HIV positive pregnant women and their newborns linked to the AIDS notification system (SINAN) was introduced in 2001 (subject to some software problems); (c) a VCT-based sentinel surveillance was introduced in early 2002 to monitor risk behavior and the demographic profile of those tested; (d) three prevalence studies were carried out on army conscripts (1996, 2000 and 2003); and (e) surveillance training for state-level staff was provided. Changes were introduced into the surveillance system in 2000 because it became evident that all hospitals selected as sentinel surveillance sites were slowly becoming reference centers for HIV/AIDS, thus providing biased estimates. Currently, a random sample of 150 maternities having over 500 deliveries per year was selected to test women delivering in those facilities to obtain a more representative measurement of HIV prevalence. A different sample is selected for each measurement. The first measurement was obtained in 2000 and another in 2003 (currently under analysis). Prevalence of Hepatitis B and C, and syphilis were also tested. Emergency room and STD clinic sentinel surveillance were recently discontinued, in the latter case due to the poor quality of the data. The project also conducted some behavioral surveillance surveys. Annual surveys were conducted on army conscripts aged 17-19, a national level survey with regional urban representativeness was conducted in 1998 by AIDS I, and in January 2003 an opinion/behavioral survey was conducted on an national urban sample. In addition a five-city survey of CSWs was conducted in 2001, two surveys of IDUs (1998, 2000), and two surveys of MSM (2001, 2002). However, the use of varying methodologies and lack of regularity of the surveys resulted in some important gaps in information with respect to behavior. Although advances with respect to STD surveillance were limited, the program successfully adopted a syndromic management approach to expand coverage of treatment increases under reporting of STD since treatment is given without a lab-based diagnosis. The program purchased equipment and materials to improve surveillance. Training is still pending. The project was successful in strengthening of national reference laboratories for quality control of lab testing for HIV, and the expansion of the national network to monitor resistance to ARV drugs and to conduct genotyping and characterization of HIV. Training was provided to states and municipalities on Bank procurement methods, use of the project's excellent computerized information system to track financial and physical progress (SIAIDS), and on various issues regarding project implementation. Training was also provided to NGOs to foster sustainability and improve their technical competence. The effectiveness of the training, however, was not assessed. While considerable research took place (more than 160 studies in addition to large evaluation studies already mentioned), leading to significant knowledge generation in some particular areas, an analysis of the usefulness of the studies conducted and identification of knowledge gaps remaining would have permitted the NASCP to focus requests for research proposals on identified gaps, resulting in a more solid body of knowledge. - 16 - An important weakness of the project was that it failed to set up an adequate monitoring and evaluation system to assess the impact of interventions and derive lessons to improve overall program effectiveness. This was true particularly of prevention interventions. Although numerous studies were conducted, the use of differing methodologies limited the comparability of results across regions and over time. The absence of regular data on program progress and effectiveness of interventions limited possibilities of selecting interventions on the basis of their cost-effectiveness, and steering the program toward higher impact and more sustainable interventions, another specific objective of the project. The program lacked a systematic approach to M&E and a dedicated in-house team (M&E unit) to implement it. The coordination unit adhered to a matrix management model where each unit functioned with great autonomy, commissioning studies as each saw fit. Moreover, the staff commissioning/conducting these studies sometimes lacked the necessary background on quantitative and qualitative evaluation methods, as they were specialists in the field managed by their specific department. This led to an uncoordinated "dispersion" of M&E efforts across units resulting in evaluation studies that failed to provide comparative data to build on a body of evidence of the impact of the program. A culture of using data for decision-making needs to be fostered, particularly in view of decentralization of program financing and activities to states and municipalities and the stewardship role that the national level has to assume. Given that the preparation of AIDS III was made contingent on the establishment of an adequate M&E unit and agreement on an effective M&E strategy, the program now has a well-functioning M&E unit and there is a greater interest in measuring results. Program monitoring should include desk reviews of program data as well as supervision visits, enabling managers to detect problems early on and provide corrective actions on the spot. While the program developed a good physical and financial information system to follow-up on contracts, it did not focus on technical issues and therefore it would have been key to complement this with periodic visits to the field. However, supervision of field activities could have been greater. Throughout the 4.5 years of project implementation, only 46 visits were conducted, or about 10 per year. The project was to "work towards the sustainability of the program through (a) the devolution of some responsibilities to states and municipalities; and (b) the identification of the most cost-effective interventions." The degree to which the latter issue was addressed is noted in the previous paragraphs. With respect to decentralization, progress was slow although in the end a lot was accomplished. While the program during AIDS I was initially structured to have strong participation by the federal level in order to define strategies, pilot test interventions and strengthen state and municipal level capacity to implement the program, AIDS II was to decentralize some functions to states and municipalities. Up until the final year of project implementation, AIDS II financed states and municipalities as it did during AIDS I, with financing agreements (convenios) negotiated at the beginning of each year. Approximately 45 percent of funds in AIDS II were executed by states and municipalities through convenios with the National Coordination of the STD & AIDS Program (CN). However, this amounted to a de-concentration rather than a decentralization of the program, since although financing was decentralized, the definition of work plans was a top-down process, reflecting national priorities. The project did - 17 - transfer the responsibility for the supervision of NGO subprojects to states early on, and in eight states it decentralized the bidding of NGO subprojects to the state level. True decentralization of financing and management of the program occurred in the final year of the project. That said, preparation for this crucial step took more than a year given legal, technical and political issues that needed to be addressed. In 2001, the NASCP began to define a legal framework to introduce a matching grant funding system to finance HIV/AIDS and STD activities in qualifying (affected) states and municipalities. The law establishing the fund-transfer system, ("incentivo"), was signed by the Minister of Health in December 2002. A total of 411 municipal (compared with only 150 during AIDS II) and 27 state health programs are currently eligible to receive funds on the basis of their epidemiological profile. Fund transfers earmark 10 percent of funds for NGO-executed subprojects, providing some sustainability to the participation of NGOs. The formulation of the draft law was accompanied by the preparation of instruments and manuals to accompany the implementation of the fund transfer program. Much of the training for relevant state and municipal level staff was also carried out in 2002. Under the "incentivo" fund transfer program, qualifying states and municipalities prepare annual action and target plans (PAMs) describing the extent of the epidemic in their area of influence, their program's priorities, the activities they plan in response to it, the targets which they agree to meet and the resources they will spend, including federal transfers and counterpart funds. This in essence transformed the traditional annual operational plans, almost entirely focused on input and process-related indicators and national priorities, to one where municipal and state program goals have greater weight and where the focus is on outputs and outcomes, introducing greater accountability into the system. The new system began implementation during the six-month extension granted to the project, and thus the early implementation of the policies cannot be evaluated. However, this is an important advance with respect to decentralization and coherence with the current health policy, and ensures funding for AIDS activities as part of the regular program of states and municipalities. Two final issues must be mentioned regarding strengthening the sustainability of the project. The first relates to program management, and the second with the role of NGOs. On program management, the NASCP continues to rely on a large number of external consultants (now partially financed by the third loan to the program on a declining basis). Given steps taken to decentralize an important share of program activities, and the need to strengthen MOH capacity to manage the program once external financing is unavailable, it is important that the program continually assess its human resource needs in light of current reality. Although 10 percent of funds transferred from the federal level are earmarked for NGOs, funds are insufficient for an adequate response by this sector. The NASCP took specific steps to promote greater sustainability of the NGOs working with the program. A total of 180 NGOs received training designed to improve their professional and management capacity, and to strengthen their proposal writing and fund-raising skills. Despite these actions, the issue of sustainability for the NGOs needs to be addressed more aggressively. On the financial side, most of the NGOs are nearly entirely dependent on project financing for their revenues and - 18 - sustainability. On the management side, many of the NGOs appear to dedicate a significant percentage of their expenditures to administrative, or overhead expenses, and are dangerously close to financial collapse. Many of the smaller NGOs are unable to finance an administrative structure that is sufficient to respond to the project's needs and to deliver the services. Different alternatives for public-private partnerships need to be explored to give NGOs greater sustainability, including the possibility of allowing some NGOs to use existing public infrastructure to deliver services. In sum, although an adequate M&E function was not established, achievements with respect to other activities in this component were significant and thus the performance of activities in this component is rated as satisfactory. 4.3 Net Present Value/Economic rate of return: Available data were insufficient to carry out a detailed economic analysis of the project at closing. The results presented here are based on the economic analysis prepared for the AIDS III Project. In particular, as discussed earlier, it is not feasible with available data to arrive at a reasonable and reliable estimate of preventive effectiveness for AIDS II. It is possible, though, to illustrate the effects of different assumptions for preventive effectiveness, and to consequently calculate cost-utility of the project. The total budget of the AIDS II Project was US$300 million. The savings in reduced hospitalization alone (US$360 million in 2001) more than offset the total investment cost of the project, demonstrating a high level of cost-benefit to the system. Based on the average age of death from AIDS in Brazil, period of incubation, typical length of illness, and disability weights from the Global Burden of Disease Study (Murray & Lopez 1996), it is estimated that each HIV infection prevented averts an average of 19.2 Disability-Adjusted Life Years (DALYs) (for simplification, this does not include the effect of preventing STDs). Using these results, and the model output of an estimated 52,000 new cases of HIV in the 2003 to 2005 period, the number of prevented infections, averted DALYs, and the marginal cost-utility of the project was calculated. It is necessary to emphasize that the marginal or incremental cost-utility of the AIDS-II Project refers to the increase in prevention attributed to the project's actions and not the sum of preventive effects of all control activities. The results indicate that for each percentage point of preventive effectiveness (that is, for each additional 1 percent of infections prevented), an additional 9,700 DALYs would be averted. Within the range of preventive effectiveness examined, the incremental cost-utility ranges from about US$ 400 to 2,000 per DALY, with the lower limit reflecting the higher cost-effectiveness of preventive activities and the higher limit the effectiveness of treatment. 4.4 Financial rate of return: N/A. 4.5 Institutional development impact: ICR Rating: Substantial. Project investments resulted in a substantial institutional development impact at municipal, state and federal levels, both directly by strengthening local institutions, and - 19 - indirectly, with project investments playing an important role as a catalyst for change. While overall project financing accounted for roughly 10 percent of the total annual public allocations to the NASCP, the net impact was significantly greater. The strategic focus of the activities included in the project served as a catalyst for change in other parts of the NASCP, to attract additional investment and, more important, to promote change. The importance of the project is even clearer at the municipal level, where several municipal authorities highlighted the importance of project funds in prioritizing and protecting core interventions from local political decision-making process, and in ensuring necessary counterpart funds. Without the project, it is highly likely that the implementation of the National Program would have moved more slowly and would have been more subject to political influence. The project was successful in strengthening state and local capacity to manage programs, and improve their technical competence. The preparation and initial implementation of the federal matching grant fund transfer mechanism to finance HIV/AIDS and STD activities in states and municipalities during the final year of the project also served to further strengthen their management skills. The first round of negotiations of annual targets to be met already demonstrated a change in attitude on the part of executers (states and municipalities), with some states moving more rapidly into their new role. At the federal level, the project contributed to strengthening the NASCP's coordination and leadership role, including the formulation of national policy, advocacy both nationally and internationally, and program planning and implementation. The financial management system developed for the project (SIADS) has served as an example for other Bank-financed projects in Brazil and, together with the CN's organizational and operational skills, contributed to a rapid response to operational problems at all levels. Its ability to integrate an additional 350 municipalities into the program during the last eight months of implementation clearly demonstrates its strengthened capacity. The Brazilian NASCP has attained international visibility and respect through the excellence of its program, its role in the promotion of human rights of PLWHA and improving access to ART worldwide. Its international recognition is evident by its selection by Latin American and Caribbean states as their representative on the Board of the Global Fund to Fight AIDS, TB and Malaria from 2002 to 2003, its role in implementing some UNAIDS activities including the provision of technical assistance to lusophone African countries to strengthen their response to the epidemic, and its technical cooperation agreements with the International AIDS Vaccine Initiative (IAVI), the Centers for Disease Control of the United States (CDC), Ford Foundation and others, to strengthen AIDS programs nationally and internationally. Overall, through various programs, technical assistance has been provided to more than 40 countries in Latin America, the Caribbean and Africa. The project also strengthened numerous NGOs and CSOs both technically and administratively to provide prevention and care services, and to promote human rights. Moreover, partnerships with various other government entities and private enterprises further mainstreamed AIDS activities to other players. Joint programs were implemented with the Ministries of Education, Justice, Labor, Social Assistance, Agriculture and Defense. - 20 - The project's institutional development impact could have been even greater had there been: (a) lower turnover of staff in states and municipalities, thus reducing the loss of trained professionals and making it easier to establish a more solid response at the state and municipal levels; and (b) a lower proportion of externally funded consultants in the CN, making it more likely that many staff whose capacity was strengthened will remain in the CN once external financing ends. 5. Major Factors Affecting Implementation and Outcome 5.1 Factors outside the control of government or implementing agency: Project implementation was affected by the following six underlying factors: (a) the status of the process of decentralization of the health system; (b) low implementation capacity of implementing entities, including some states, municipalities and CSOs; (c) existing unequal distribution of health service delivery infrastructure; (d) the evolution of the epidemic in Brazil; (e) existing prejudice and discrimination toward PLWHA and some groups engaging in high risk behavior; and (f) changes in government authorities. The Brazilian health system has been decentralizing through a series of reforms introduced gradually since the late 1980s. Reforms in the early 1990s transferred most of the responsibility for health care delivery to municipalities, and with it, mechanisms for the financial allocation of federal funds to states and municipalities. More recent reforms (1996-2001) have introduced legislation and regulations to clarify the roles of the different levels of government. Despite these reforms, the role of State Health Secretariats vis-à-vis the Ministry of Health and municipalities within the Unified Health System (SUS) continues to be ambiguous as they are no longer responsible for the provision of care, yet have had an unclear role regarding monitoring and control of federal financial transfers. This lack of clarity affected the implementation of the project, since the states did not always assume their role in the adequate supervision of the project, and the federal level at times felt it could insist only so far, as it did not consider it its mandate. A closely related issue is the fact that many states have not developed the technical and managerial capacity to fulfill their new functions within SUS, including: planning, coordinating, monitoring and evaluating the implementation of national policies and delivery of municipal-managed services. Thus, implementation of the project was uneven, with weaker states and municipalities requiring considerably more assistance. Weaker states also tended to have less developed NGOs and CSOs, limiting their capacity to develop and implement prevention and care interventions, and reducing the overall quality of the response. Moreover, the majority of states and municipalities lacked the necessary human resources to carry out their responsibilities. The project/program also inherited Brazil's unequal distribution of health resources and infrastructure. Although health sector reforms have improved the equity of resource allocation, inequalities in health status, finance and service utilization persist. Urban areas in the southeast possess a higher concentration and better quality resources than other regions of the country, and, within all regions, urban areas are always favored. Access to health services continues to be a serious problem in indigenous areas. The fact that the epidemic is now spreading to poorer, less urban - 21 - areas, where the population is less concentrated, and to regions with lower capacity to implement high quality interventions, has made HIV/AIDS and STD control a much greater challenge. Complicating matters with respect to implementation capacity, existing prejudice and discrimination toward PLWHA and some groups engaging in high-risk behavior, created important obstacles to improve access to care, despite the program's proactive approach to address these factors. Changing health sector staff attitudes to improve their reception of CSWs and transvestites continues to be an important challenge. The incorporation of prevention and treatment programs among the military and the operationalization of national policies on harm reduction have also met some political resistance. A final factor affecting the project's implementation was changes in government administration. However, the effects were mainly at the state and municipal levels where incoming administrators were not always in tune with program priorities, and had to be "convinced." This led to complications regarding the planning and provision of supplies and drugs that often led to shortages and delays in the delivery of service. While the project was implemented through parts of three administrations, only the last change caused some temporary delays as the new administration established priorities and made the necessary administrative changes. Project implementation resumed its smooth execution shortly. 5.2 Factors generally subject to government control: The NASCP is a central part of the government's overall health strategy, and the program always received the necessary support. There were two factors that were within the control of the government that slowed down project implementation: (a) the government's budgeting processes; and (b) a shortfall of counterpart funds in 2001 and 2002. Initial annual budgets received by the project from the Ministry of Finance were always lower than what had been requested, leading the CN to have to request annual supplementary budgets. Although by the end of the year, the project received what it originally requested (with the exception of 2001 and 2002), supplementary budgets were only approved in December of each year, leaving little time to execute the funds. Late supplementary budget approvals resulted in a budget execution of only 92 percent in 2000 and 2001. Moreover the funds released did not always contain the correct proportion of funds in local currency and US dollars, making it difficult to pay some large contracts in a timely manner. Budgeting processes affected the Brazil portfolio as a whole. The last two years, there was also a shortfall in the funds budgeted overall. In 2001 the project was allocated only 87 percent of what it requested. In 2002 this figure was 90 percent. An unstable economy, primarily caused by insufficient investor confidence prior to elections, led to a shortfall in counterpart funds in 2002. Although there was one change in project coordinator during implementation, the transition was very smooth and had no negative effects on project execution. 5.3 Factors generally subject to implementing agency control: The project was generally well managed and efforts were made to ensure a timely execution. Technical knowledge required for the planning and execution of the project was ensured through the contracting of capable staff at the central level and was enhanced through the provision of - 22 - technical assistance and training to state and local coordination units. At the same time, the project's management team established an excellent working relationship with the MOH and other stakeholders to ensure the continued institutionalization of the project's activities. Moreover, ample participation of civil society was encouraged and taken into account in policy formulation and overall project implementation. Although the capacity of the implementation team at the federal level was good, support and supervision to states and municipalities could have been more frequent. This was particularly serious with respect to procurement as two post reviews of procurement processes at the state level noted. Procurement reviews revealed weaknesses in procurement capability in several states, and that the central level had provided insufficient follow-up to detect problems in a timely fashion. More frequent follow-up of technical issues would have in part addressed the absence of an adequate monitoring system of project results since it would have facilitated the identification of implementation problems in a more timely fashion. 5.4 Costs and financing: Total expenditures incurred for the project were US$296.5 million, or 98.8 percent of the total US$300.0 million estimated at appraisal. The US$3.5 million difference was cancelled from the loan in September 2000, the result of a declaration of misprocurement in AIDS I which was identified after AIDS I had closed. Instead of reimbursing the Bank in that amount, it was agreed that an equivalent amount would be discounted from the AIDS II Project. The reduction in the amount affected directly the allocation for ICB in AIDS II. While the project experienced a slow start, executing only 50 percent of the expected disbursement in the first two years, by year three the project recovered the disbursement plan and reached nearly 80 percent of expected cumulative disbursements. The project closing date was extended for six months, with a total of 4.5 years of implementation. The explanation for the delays is provided in section 5.2. Project financing was to be shared by the Government of Brazil and the Bank at 45 percent to 55 percent ratio, respectively. In accordance with these estimates, total project financing of $296.5 million was financed 45 percent by the government and 55 percent by the Bank. Overall, the project spent almost 10 percent more on institutional strengthening than originally planned and about 4 percent more on prevention. Almost 15 percent less was spent on diagnosis, treatment and care. Loan financing was greater than planned on prevention and less on the other two components (see Annex 2 Table 2a). More was spent on project administration than originally expected, which included categories of administrative expenses, maintenance and supervision. Overall project administration was expected to be about US$20 million, but it was actually about US$34.6 million, or 73 percent more (11 percent of total project costs). Given that some of the consultants included in "consultant services" were project implementation staff, it seems overall administrative costs were even higher. The United Nations Educational, Scientific and Cultural Organization (UNESCO), and the United Nations International Drug Control Programme (UNODC) administered 44 percent of project funds, including consultant contracts and the purchase of goods and equipment. - 23 - Procurement. The largest discrepancy in the procurement arrangements was with respect to the NCB procurement. In the original planning it was assumed that the MOH would purchase, printing materials, computers and information systems for the participant state and municipal entities. This approach proved to be impractical because the agreements (convenios) between the federal government and sub-national entities did not entail the transfer of goods, permitting only financial transfer. Furthermore, the project did not include arrangements for the distribution of such items throughout the country. Consequently, it was not possible to combine the larger packages for competition through national bidding as envisioned in the initial procurement arrangements. As result, those same items were purchased by implementing entities at the state and municipal level in smaller packages through shopping procedures. During project supervision, it was determined that the beneficiary entities at the state and municipal level periodically procured items of the same nature. When the issue was raised to seek larger packages at the decentralized level, it was explained that the flow of funds through the agreements was subject to budget cuts or required extensive bureaucratic work to implement changes in the quantities or specifications of the goods, and therefore, the uncertainties on the budget availability forced the purchasing entities to fragment the procurement. Additionally, there was an inconsistency between the actual project implementation and the initial procurement arrangements. During implementation, it became clear that many of the actions in AIDS II were being implemented by NGOs and community organizations through subprojects. The categories of investments did not foresee subprojects, and consequently, resources allocated to more competitive procurement resources were transferred to shopping, as this was the method suitable for the implementation of sub-projects by NGOs. The only ICB procurement for the project was for male condoms and few items procured by the CN. The category of consultant services increased substantially compared to the original arrangements because staff at the CN were hired as individual consultants. In general, the procurement performance by the Borrower was average to low. The project was seriously affected by the difficulties at the state and municipal level to implement shopping procedures instead of the national procurement law. Through training, workshops, conferences, ample dissemination of the Operational Manual and supervision by the CN, the last two years of procurement implementation improved substantially as shopping became the preferred method for procurement of small value goods and technical services. The lessons gained in the implementation of the AIDS I and II led to the redesign of the flow of funds of the AIDS III in which the sundry and operational items and salaries of the staff at the state and municipal level are paid out of the federal to state and municipal funds. - 24 - 6. Sustainability 6.1 Rationale for sustainability rating: ICR Rating: Highly Likely. Government commitment to the program remains extremely high and commitment by states and municipalities has increased significantly, although commitment in the states most affected by the epidemic has been high for a long time. The role of NGOs and CSO in program implementation, policy formulation and social accountability, have ensured broad national support for the program. The program has a very high profile nationally and internationally, and is active in promoting access to treatment and care worldwide. The NASCP has also provided technical assistance to numerous governments on all aspects of program implementation. Despite rising costs of treatment, the government is very active in seeking lower cost options, while at the same time ensuring adequate funding for the program. Partnerships with other government sectors and the private sector have also given the program broader support. The fact that a large share of the program was decentralized to states and municipalities ensures greater sustainability as it inserts the program in the regular financing of SUS, and includes it among the priority actions implemented by the health secretariats. Decentralization helps eliminate the barriers between AIDS and other health programs and promote integration, encourage greater participation of NGOs at the state and municipal levels, increase program accountability as users are closer to the services and allow for a more locally sensitive response, and help integrate AIDS programs with other social policies. While not yet evident, it is highly likely that decentralization will lead to an increased contribution in financing for AIDS activities by municipalities, as has occurred with respect to overall health financing by municipalities in response to other federal transfers, which have increased municipal financing from 7 percent of public spending in 1980 to more than 15 percent in 2000. The program does, however, face some important challenges in the near future that the follow-on AIDS III Project is helping to address, namely: reaching less accessible populations (the poor, less educated and less rural populations) now being affected by the epidemic; the development of new and less expensive technologies for treatment and prevention; and the transition to an implementation team consisting of mostly MOH staff, as the new loan finances unit staff only on a declining basis. 6.2 Transition arrangement to regular operations: The Bank approved a third loan to finance Brazil's HIV/AIDS and STD Control Program in June 2003. The loan became effective in December 2003. The third loan is directly assisting the NASCP's efforts to increase sustainability of its actions by: (a) supporting the decentralization of the program through the implementation of annual federal matching grants for states and municipalities to conduct HIV/AIDS and STD activities as part of their regular activities; (b) financing technological research and development to identify more cost-effective medical supplies including reagents for HIV testing and treatment follow-up, and new forms of treatment; and, (c) strengthening the program's response regarding emerging populations affected by HIV/AIDS. - 25 - Project preparation was conditioned on establishing adequate structures (a well-staffed unit) to conduct M&E and a solid M&E plan, both of which were concluded before effectiveness. Several of the agreed M&E activities are already under way. With respect to CN staff, a small part of the implementation team was incorporated into the MOH, and there are plans to increase that number. As noted above, CN staff is financed only on a declining basis. 7. Bank and Borrower Performance Bank 7.1 Lending: ICR Rating: Satisfactory. Project preparation was swift, very responsive to the Borrower's needs and was consistent with the CAS. The technical design incorporated suggestions from government-sponsored consultations with a wide variety of stakeholders in the overall design, and adequately addressed financial management issues. As detailed in Section 3.5, there were some weaknesses in terms of incorporating lessons learned from the AIDS I Project, including issues regarding M&E (which did prove to be problematic in AIDS II) and there could have been more specificity regarding the decentralization strategy and the targeting of high-risk groups. 7.2 Supervision: ICR Rating: Satisfactory. Most of project supervision remained in the hands of a single Task Team Leader, giving stability to project management. Although supervision visits were less than the standard two visits per year (only one visit was made in 1999 and 2001), the support provided by the teams from headquarters and the resident mission was valuable and greatly appreciated by the Borrower in terms of skill and timeliness. The expertise of the professionals in the teams was of high quality. However, most of the focus was on surveillance and prevention, and thus, treatment, an important component in the project, received less attention by the team. Supervision reports focus on the achievement of objectives, are informative and identify key issues that need to be addressed by the Bank and the Borrower. The ratings are realistic. The areas where the project could have had better performance, including the need to increase coverage of high-risk groups, increase decentralization of project activities, provide technical assistance to states, establish an M&E system, and move from surveillance of AIDS to surveillance of HIV appear repeatedly in Aide Memoires and supervision reports. Many of these issues were addressed by the project even if with some delays, except for M&E. 7.3 Overall Bank performance: ICR Rating: Satisfactory. For the reasons outlined in Sections 7.1 and 7.2, overall Bank performance is rated as satisfactory. Borrower 7.4 Preparation: ICR Rating: Satisfactory. The Borrower was very proactive in the preparation of the project since it was as keen as the Bank to have fast preparation. The Borrower prepared a comprehensive proposal and sponsored a stakeholder consultation during preparation that provided useful feedback and allowed the team to socialize the proposal and obtain stakeholder - 26 - support. The preparation of the necessary materials was timely, and the collaboration of the team excellent. Given that a critical analysis of past achievements and obstacles faced was not made, particularly on M&E, the project design did not incorporate elements to improve potential project impact. 7.5 Government implementation performance: ICR Rating: Satisfactory. Overall, the government's implementation performance was satisfactory, since it has been fully committed to combating HIV/AIDS at the highest levels since the beginning of the epidemic. The government appointed highly qualified project coordinators to lead the program, and has strongly supported policy decisions encouraged by the project. Moreover, it has generally allocated the necessary funds, although, as noted in Section 5.2, existing budgetary processes resulted in delayed execution at times. Also, some budget shortfalls were experienced in the final two years of implementation. 7.6 Implementing Agency: ICR Rating: Satisfactory. The project maintained satisfactory ratings throughout the implementation process. Project execution was generally timely. Implementation was smooth despite the change in project coordinator. Financial and technical management of the project was consistently carried out with high standards. An excellent financial management system was developed that fully satisfied Bank requirements. Issues identified in audits were adequately addressed. The national coordinating unit was staffed with very good professionals who had developed a strong capacity to manage the project. Progress reports prepared were of good quality and timely. Nonetheless, state and municipal capacity was variable, with some states having significant problems with Bank procurement procedures. This was an area that required greater support. Moreover, M&E of the project was not adequately addressed, and there should have been more technical assistance to states. 7.7 Overall Borrower performance: ICR Rating: Satisfactory. On the basis of the ratings above, overall Borrower performance is rated as satisfactory. 8. Lessons Learned Project Design Issues Even when Bank funding comprises a small proportion of overall program financing needs, this financing can be a catalyst for change.The strategic focus of the activities in the project served as a catalyst for change, including attracting additional investment, promoting change, and protecting program investments from political influence, particularly at the municipal level. - 27 - Lack of adequate M&E of project investments makes it difficult to assess program progress and effectiveness of interventions. Even though the project collected significant amounts of data on HIV/AIDS and STDs, it was not possible to assess trends over time since the use of differing methodologies resulted in inconsistencies that could not be interpreted. Thus, the project was unable to demonstrate many of its achievements. If program managers do not value the use of data for management, an adequate M&E program will not be implemented. Although the preparation team agreed on indicators and TORs for evaluation studies to assess project progress and effectiveness, and the supervision team provided support to get the subcomponent off to a good start, an adequate M&E system was not established. If management had relied on the data to allocate resources and define strategies, they would have had more incentives to take the necessary actions to address this. Project administrative costs should be partially financed with counterpart funds to discourage the contracting of large numbers of externally funded consultants and ensure project funds build internal capacity. If AIDS II had financed administrative costs on a declining basis, the MOH would have had fewer incentives to rely on external consultants. While partnering with NGOs to reach many population groups not normally reached by the health system, and to give the program greater accountability, have proven to be a very effective approach, working with NGOs constitutes a significant management challenge both to ensure technical quality of projects and to develop mechanisms to ensure their sustainability. The project significantly underestimated the administrative demands incurred by the evaluation of more than 2,000 projects executed by civil society. At one point, the CN employed more than 50 people to evaluate and approve NGO subproject proposals. The number of projects and the lack of a clear framework for monitoring NGO-executed activities made it difficult to ensure quality of interventions. While many efforts were made to provide NGOs with greater skills to become more sustainable, it is clear that this issue needs to be properly assessed, since the provision of training seems to be insufficient. HIV/AIDS and STD Prevention and Treatment Issues Transferring management and financing for HIV/AIDS activities to states and municipalities and focusing on outputs and outcomes rather than inputs clearly places implementers in the driver's seat and ensures accountability for their actions. Decentralization of management responsibilities to states and municipalities implies a change in roles for all players. The national coordination unit is no longer implementing directly, but needs to steer the program and define policy, must also hold local administrators accountable for results. Thus, a change in focus from inputs to outputs and outcomes is indispensable. The introduction of a performance-based financing system would facilitate the introduction of a system of accountability. Program financing should be integrated as early as possible into the general health financing mechanisms. Financing program activities in states and municipalities separately from the MOH budget threatens to create a parallel and vertical program, and may make it more - 28 - difficult to integrate the MOH activities at the local level. The current system allows states and municipalities to make better use of resources at the local level, by increasing synergy with other programs and reducing duplication of efforts. Targeting resources on a priority basis to the highest-incidence areas is a successful strategy to combat the epidemic in the short-run. However, programs should combine this approach with broader, equity-based formulas to ensure that resources reach more difficult to reach low-income and less urban groups. The use of explicit criteria to allocate resources and preventive activities to those areas with the highest reported incidence was successful in improving national outcomes. However, because in Brazil the epidemic began in higher income and higher implementation capacity areas, the poorest regions in the North and Northeast, where HIV is on the increase, currently have considerably lower access to prevention and care services. Given the lower capacity in these areas, and lower educational attainment of the population, reaching these groups will entail a greater amount of effort and resources and thus, risk always being underserved. The provision of ART significantly reduces hospitalization and treatment costs for OIs, resulting in savings that offset part of the increase in costs of providing ART. The number of hospitalizations per AIDS patient declined from 1.6 in 1996, before ART was introduced, to 0.3 in 2001, for an estimated 358,000 hospitalizations prevented during 1997-2001. Unfortunately, a quantitative assessment of reductions in loss of productivity due to HIV/AIDS, or of the full costs of providing ART was not carried out to see what the true cost of provision of ART is, independent of humanitarian reasons for doing so. Providing ART free of charge is not enough to make everyone come forward for treatment. Limited physical and social access to treatment is also important impediments. While the program provided ART to 135,000 PLWHA to date, SINAN data, which are subject to reporting delays of between 3 and 5 years, and an important degree of under reporting, indicate that there were as many as 159,000 AIDS cases reported since 1996, the year when ART was made widely available. Although this figure includes several cases that have died, the fact that treatment was already available would suggest a majority should be alive. This suggests, then, that coverage of ART is less than 80 percent and probably lower. Those not covered are likely living in resource poor and less urban areas. Lack of knowledge about HIV/AIDS and stigma are also important barriers to treatment. The fact that people with lower educational attainment are less likely to seek health care, means they are less likely to be "reported," and also less likely to have adequate knowledge about HIV/AIDS, suggests that new strategies need to be devised to reach less accessible populations. 9. Partner Comments (a) Borrower/implementing agency: The Borrower's comments on the draft ICR were incorporated into the text. The Borrower's own contribution to the ICR is generally in agreement with the Bank's overall assessment of project performance, and is included in Annex 8. The indicators the Borrower provided are included in Annex 1. - 29 - (b) Cofinanciers: N/A. (c) Other partners (NGOs/private sector): N/A. 10. Additional Information ICR Team Sandra Rosenhouse (Senior Health Specialist, ICR Task Leader, main author) James Cercone (Health Economist, Consultant) Lerick Kebeck (Team Assistant) Comments provided from: Bank: Suzana Abbott (Lead Operations Officer, LCSHD) Theresa Jones (Lead Operations Officer, LCSHD, TM for project preparation) Anabela Abreu (Sector Manager, SASHD, TM for supervision) Isabel Noguer (Epidemiologist, Consultant project supervision) Efraim Jimenez (Lead Procurement Specialist, LCOPR) Borrower: Alexandre Grangeiro (Director NASCP) Joel Sadi Nunes (Planning, NASCP) Aristides Barbosa (M&E, NASCP) Ana Roberta Pascom (M&E, NASCP) Sérgio D'Avila (Prevention, NASCP) - 30 - Annex 1. Key Performance Indicators/Log Frame Matrix Because of difficulties in gathering some of the required data for some of the initial indicators, several were replaced by similar indicators utilizing more easily available information during project supervision. This annex contains the both the original variables and the additional ones. Outcome / Impact Indicators: PAD Baseline End of Project PAD Actual/Latest Estimate Target Indicator/Matrix Biannual or annual measurements of point prevalence of HIV positives in the general population: Army Conscripts 0.2% (1996) 0.15% (2002) .09% (2002) Pregnant Women (aged 20-24) 0.3% (1997) 0.6% (2002) 0.6% (2000) Emergency Room Patients 4.1% (1997) 3.0% (2002) Not measured Biannual measurements of point prevalence of HIV positives in high risk groups: STD patients (men aged 20-24) 5.4% (1997) 4,5% (2002) Not measured CSW (not included originally) 6.5% (2001) 1/ IDU (not included originally) 52% (1998) 36% (2000) Estimates of point prevalence of syphilis in general population 2/ Army Conscripts 0.53% (1996) 0.3% (2002) 1.8% (2002) 3/ Pregnant Women 2.8% (1998) 2.0% (2002) 1.7% (2000) Output Indicators: PAD Baseline End of Project PAD Target Actual/Latest Estimate Indicator/Matrix Increased knowledge regarding high-risk behavior 0.98 (1999) Not defined. 0.88 (2002) (changed to "risky sexual behavior index") Army conscripts. Reduction in number of partners (% army 20.2% (1999) Not defined. 19.1% (2002) conscripts that have had more than 10 sexual partners) Increased condom use (army conscripts) Use in all relationships last 12 m 37.6% (1997) 50% 48.3% (2002) Use in last sexual relationship 61.5% (1999) Not defined. 69.3% (2002) Use in paid sex 69% (1999) Not defined. 77.3% (2002) No. of condoms sold 228 million 350 million 395 million Average retail price of condoms $0.62 (1996) Not defined $0.26 (2001) No. of NGO projects promoting safe practices w/ IDU 19 30 137 CSW 14 36 127 MSM 11 40 83 No. of areas covered by harm reduction projects 55 160 837 No. of state/municipal projects promoting safe Not measured practices with CSWs and MSM No. of schools receiving AIDS/STD training Not measured % of public schools receiving AIDS/STD training Not measured No. of teachers who received AIDS/STD training Not measured % schools carrying out HIV/STD interventions 70% (1999) 77% (2002) 4/ Not measured No. of persons counseled in VCTs Not measured No. of tests performed in VCTs 5/ 120,468 (1997) 311,000 (2002) 271,056 (2001) No. of VCT centers 127 191 246 % of persons tested for HIV in VCTs who returned Not measured. for results & counseling - 31 - % of the sexually active population ever tested for 22.8% Not defined. 30.8% HIV (aged 16-65) (not included originally) Rate of mother to child transmission of HIV 8.6% (2000) Not defined. 3.7% (2002) No. of PLWHA on ART 33,830 (1997) Not defined. 129,276 (2002) % of sentinel sites collecting samples using the 75% (1998) 100% (2002) Not measured. established norms Average time needed to receive the results per Not measured. sample and per cohort (all samples) No. of PLWHA hospitalized in SUS 34,940 (1998) Not defined. 38.558 (2002) Average time needed for test results to reach VCTs 12 mos. 1 mo. Not measured % labs receiving samples for quality control for HIV 20% (1997) 98% (2002) Not measured with 100% accuracy % labs receiving samples for quality control for viral 43% (1997) Not defined. Not measured load with 100 percent accuracy No. of Labs participating in external quality control 45 (1998) 120 123 (2002) of diagnostic procedures for HIV/STD (not included originally) 1/ Figures are difficult to compare as testing was voluntary and less than half agreed to be tested at each measurement (44% in 1998, 48% in 2000) and it is unknown if the bias. Also, the sample size utilized in the second measurement includes 2 additional municipalities. 2/ Figures aren't comparable as different lab tests were used, 1996 used VDRL and 2002 used ELISA. 3/ Data for 2002 were damaged. A re-survey conducted early 2003 is being analyzed. 4/ The school census that was to include questions to obtain these data which was under negotiation with the Ministry of Education was not carried out as negotiations were interrupted with the change of administration in January 2003. 5/ 1997 data based on 94% of VCTs, and data for 2001 based on 66% of VCTs. - 32 - Annex 2. Project Costs and Financing Table 2a. Project Cost and Financing by Component (in US$ million equivalent) Planned (PAD) Actual % of Appraisal Components IBRD Govt. Total IBRD Govt. Total IBRD Govt. Total Prevention of HIV, 63.0 65.0 128.0 72.4 60.5 132.9 115 93 104 AIDS and STD Diagnosis, Treatment, 52.0 50.0 102.0 47.5 39.7 87.2 91 79 86 and Care Institutional 50.0 20.0 70.0 41.6 34.8 76.4 83 74 109 Strengthening of Executing Agencies Total 165.0 135.0 300.0 161.5* 135.0 296.5 98.8 100.0 98.8 * On September 5, 2000, a cancellation in the amount of US$3.5 million was made from the "Goods" disbursement category as a result of the declaration of misprocurement of a contract processed in AIDS I. Table 2b. Project Financing by Disbursement Categories (in US$ million equivalent) Planned (PAD) Actual % of Appraisal Disbursement IBRD Govt. Total IBRD Govt. Total IBRD Govt. Total Categories Goods 68.0* 11.0 79.0 63.5 11.2 74.7 93 102 94 Instructional 20.0 6.0 26.0 15.0 2.6 17.6 Materials 75 43 68 Training 40.0 9.0 49.0 39.4 9.0 48.4 98 100 99 Consultant 27.0 - 27.0 32.9 - 32.9 - Services 122 122 Administration 10.0 - 10.0 10.7 - 10.7 107 - 107 IEC - 80.0 80.0 - 65.5 65.5 - 82 82 Drugs - 19.0 19.0 - 22.8 22.8 - 120 120 Maintenance - 4.0 4.0 - 15.4 15.4 - 385 385 Supervision - 6.0 6.0 - 8.5 8.5 - 142 142 Total 165.0 135.0 300.0 161.5* 135.0 296.5 98 100 99 * On September 5, 2000, a cancellation in the amount of US$3.5 million was made from the "Goods" disbursement category as a result of declaration of misprocurement of a contract processed under AIDS I. - 33 - Table 2c. Project Costs by Executing Arrangements (US$ million equivalent) Executing Agency Executed Bank Executed Government Total UNESCO 54,90 37,79 92,69 UNODC 22.86 15.74 38.60 States 25.83 34.35 60.18 Municipalities 38.76 15.83 54.59 Ministry of Health 19.15 31.29 50.44 TOTAL 161.50 135.00 296.5 Project Costs by Procurement Arrangements (Appraisal Estimate) (US$ million equivalent) Annex 2d. Project Costs by Procurement Arrangements (in US$ million equivalent) . Planned (PAD) Actual Expenditure ICB NCB. Other N.B.F. Total ICBa NCB Otherb. N.B.Fc Total Category Goods 31.0 26.0 22.0 - 79.0 17.6 1.5 44.1 11.5 74.7 Instructional - 14.0 12.01 - 26.0 - - 15.1 2.5 17.6 Materials Training - - 49.0 - 49.0 - - 39.5 8.9 48.4 Consultant - - 27.0 - 27.0 - - 32.9 - 32.9 Services Administration - - 10.03 - 10.0 - - 10.8 - 10.8 IEC - - - 80.02 80.0 - - - 65.5 65.5 Drugs - - - 19.0 19.0 - - - 22.8 22.8 Maintenance - - - 4.0 4.0 - - - 15.3 15.3 Supervision - - - 6.03 6.0 - - - 8.5 8.5 Total 31.0 40.0 120.0 109.0 300.0 17.6 1.5 142.0 135.0 296.5* Note: N.B.F. =Not Bank-financed (includes elements procured under parallel cofinancing procedures, consultancies under trust funds, any reserved procurement, and any other miscellaneous items). * On September 5, 2000, a cancellation in the amount of US$3.5 million was made from the "Goods" disbursement category due to the declaration of misprocurement of a contract processed under AIDS I. 1 National shopping 2 About half would be service contracts for mass media campaigns 3 Consultant services a Includes Direct Bidding b Includes shopping c Non Bank Financed - 34 - Annex 3. Economic Costs and Benefits See Section 4.3. - 35 - Annex 4. Bank Inputs (a) Missions: Stage of Project Cycle No. of Persons and Specialty Performance Rating (e.g. 2 Economists, 1 FMS, etc.) Implementation Development Month/Year Count Specialty Progress Objective Identification/Preparation 12/09/1997 4 TASK TEAM LEADER (ECONOMIST); HEALTH SPECIALIST (1); CONS. AIDS SPEC (1); CIVIL SOC SPEC (1) Appraisal/Negotiation 03/16/1998 4 TASK TEAM LEADER (ECONOMIST); HEALTH SPECIALIST (1); CONS. AIDS SPEC (1); CONS. EPIDEMIOLOGIST- HEALTH EDUCATOR (1) 07/15/98 Supervision 06/26/1999 5 TASK TEAM LEADER (1); S S CONS. DIAGNOSTIC TREATMENT (1); CONS. HEALTH SPEC (1); PROCUREMENT SPEC (1); FINANCIAL SPECIALIST (1) 02/09/2000 7 HEALTH SPEC (1); S S HIV AIDS EPIDEMIOLOGIST(1); HIV AIDS SPEC (1); PROCUREMENT SPEC (1); NGO SPEC (1); FINANCIAL SPEC (1); EPIDEMIOLOGIST-SIDALAC (1) 09/24/2000 3 PUBLIC HEALTH SPEC (1); S S HIV AIDS EPIDEMIOLOGIST (1); HIV AIDS SPEC (1) 05/09/2001 4 PUB. HEALTH SPEC (1); S S EPIDEMIOLOGIST (1); PROJ. IMPL. SPEC (1); PROC. SPEC (1) 01/22/2002 2 PUBLIC HEALTH SPEC (1); S S EPIDEMIOLOGIST (1) - 36 - 09/13/2002 9 TASK MANAGER (1); S S OPERATIONS ANALYST (1); CONS. DIAGNOSIS, TREATMENT (1); PROCUREMENT SPEC (1); FINANCIAL MGMT SPEC (1); CIVIL SOCIETY SPEC (1); OPS/UNAIDS (1); CDC-MONITORING/EVAL. (1); CDC- EPIDEMIOLOGIST SURVEY SPEC (1) ICR 09/08/2003 2 TASK MANAGER (HEALTH SPECIALIST); CONS HEALTH ECONOMIST (1) (b) Staff: Stage of Project Cycle Actual/Latest Estimate No. Staff weeks US$ ('000) Identification/Preparation Appraisal/Negotiation 135,266 Supervision 73 332,454 ICR 5 34,980 Total 78 502,700 - 37 - Annex 5. Ratings for Achievement of Objectives/Outputs of Components (H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable) Rating Macro policies H SU M N NA Sector Policies H SU M N NA Physical H SU M N NA Financial H SU M N NA Institutional Development H SU M N NA Environmental H SU M N NA Social Poverty Reduction H SU M N NA Gender H SU M N NA Other (Please specify) H SU M N NA NGO Participation Private sector development H SU M N NA Public sector management H SU M N NA Other (Please specify) H SU M N NA - 38 - Annex 6. Ratings of Bank and Borrower Performance (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory) 6.1 Bank performance Rating Lending HS S U HU Supervision HS S U HU Overall HS S U HU 6.2 Borrower performance Rating Preparation HS S U HU Government implementation performance HS S U HU Implementation agency performance HS S U HU Overall HS S U HU - 39 - Annex 7. List of Supporting Documents BEMFAM, Macro Systems International, 1997. DST/AIDS e a Pesquisa Nacional sobre Demografia e Saúde: uma análise do nível de conhecimento e comportamentos de vulnerabilização. CEBRAP, 1999. Pesquisa Nacional de Reprodução Humana. São Paulo, Brasil. IBOPE, 2003. Pesquisa de Opinião Pública sobre , São Paulo, Brazil. IBOPE, 2002. Pesquisa de Opinião Pública sobre Homossexuais Masculinos, São Paulo, Brazil. IBOPE, 2001. Pesquisa de Opinião Pública sobre Homossexuais, São Paulo, Brazil. Levi, Guido Carlos, and Vitoria, Marco Antonio. 2002 . "Fighting against AIDS: the Brazilian Experience". 2002. Editorial Review. AIDS 2002, 16: 2373-2383. Ministry of Health, 2002. Boletim Epidemiológico-AIDS. July-Sept 2001, XV no. 1. Ministry of Health, 2002. Boletim Epidemiológico-AIDS. October 2001-March 2002, XV no. 2. Ministry of Health, 2002. Boletim Epidemiológico-AIDS. April -December 2002, XV1 no. 1. Ministry of Health, 2002. Pesquisa entre conscritos do exército brasileiro, 1996-2000: retratos do comportamento do risco do jovem brasileiro à infecção pelo HIV. Ministry of Health. 2002. Relatório de Implementação e Avaliação-1998-2002. Acordo de Empréstimo BIRD 4392/BR Projeto AIDS II. Brasília, August 2002. Ministry of Health, 2002. Relatório de mplementação e Avaliação-1998-2003. Acordo de Empréstimo BIRD 4392/BR Projeto AIDS II. Brasília, August 2003. Piola, Sérgio, Teixeira, Luciana, Sadi Dutra, Joel, 2001 Cuentas Nacionales en VIH/SIDA: Estimación de flujos de financiamiento y gasto en VIH/SIDA: Brasil 1999/2000. SIDALAC, ONUSIDA, Fundación Mexicana para la Salud. Universidade Federal de Minas Gerais, 2002. Pesquisa de usuarios de drogas injetáveis. 2002. Universidade Federal de Minas Gerais, 200. Pesquisa de usuarios de drogas injetáveis. 1999 Universidade Nacional de Brasília, 2002. Avaliação da efetividade das ações de prevenção dirigida as profissionais do sexo em tres regiões brasileiras. 2001. World Bank. 2002. Brazil Health Policy Transition Notes: Summary Of Major Messages, Issues - 40 - and Policy Choices. Internal Bank Document. September 2002. World Bank. 2002. Country Assistance Strategy Progress Report for the Federative Republic of Brazil. May, 2002. Report 24182-BR. World Bank. 2000. Country Assistance Strategy for the Federative Republic of Brazil. Report 20160-BR. World Bank, 1999. Quality at Entry Assessment. Brazil AIDS & STD Control Project II. World Bank, 1998. Loan Agreement for the Brazil AIDS & STD Control Project II. December 11, 1998. World Bank. 1998. Project Appraisal Document: Brazil Second AIDS & STD Control Project II. Report No. 18338-BR. World Bank. 1993. Staff Appraisal Report: Brazil AIDS & STD Control Project II. Report No. 11734-BR. World Bank. Project Status Reports (PSRs), 1999 to 2003. World Bank, 1999-2003. Aide-Memoires and Back-to-Office Reports. 1999-2003. - 41 - Additional Annex 8. Borrower's Contribution: Ministério da Saúde Secretaria de Vigilância em Saúde Programa Nacional de HIV/Aids e Outras DST PROJETO AIDS II (Acordo de Empréstimo BIRD 4392/BR) Relatório de Avaliação Final 1998 a 2003 Brasília-DF, outubro/2003 INTRODUÇÃO Panorama epidemiológico do HIV/aids no Brasil O Brasil tem hoje 257.780 casos de aids notificados de 1980 até dezembro de 2002, tendo atingido quase 26 mil em 1998, com taxa de incidência estimada de 15 casos por 100 mil habitantes no ano 2000. Estima-se que a prevalência do HIV seja de 600 mil indivíduos de 15 a 49 anos, para o ano de 2000. O Projeto AIDS II O segundo acordo de empréstimo BIRD 4392/BR ­ Projeto Aids II, foi assinado em 11.12.1998 e teve sua efetividade declarada em 09.02.1999. O Projeto foi de US$ 300,0 milhões de dólares, sendo US$ 165,0 milhões de financiados pelo BIRD e US$ 135,0 milhões de dólares de contrapartida nacional. OBJETIVOS GERAIS Os objetivos gerais do Projeto foram: § Reduzir a incidência da infecção pelo HIV/aids e outras DST; e § Ampliar o diagnóstico e melhorar a qualidade do tratamento e da assistência aos portadores de HIV/Aids e outras DST; - 42 - PRINCIPAIS ENTIDADES EXECUTORAS DO PROJETO § Ministério da Saúde e Secretaria de Políticas de Saúde, e a partir de 2003 passou a ser a Secretaria de Vigilância em Saúde; § Coordenação Nacional de DST e Aids - CN, a partir de 2003 passou a ser a Diretoria do Programa Nacional ( PN ) § 26 Estados , DF e 150 Municípios § Agências de Cooperação Técnica Internacional: as agências das Nações Unidas - UNESCO e a UNODC foram as parceiras do Projeto Aids II; § Organizações da Sociedade Civil (OSC) - As OSC representam uma ampla gama de executores fora dos setores governamental e produtivo, incluindo organizações não-governamentais (ONGs), associações profissionais, organizações de PVHA, organizações ligadas a igrejas e organizações comunitárias (OC). § Outros Atores do Projeto: Instituições Públicas externas à área da Saúde ( Justiça, Educação, Assistência Social, entre outras ); Outras Instituições do setor público: Universidades, Fundações, Institutos de Fomento e Pesquisa, Centros de Excelência, dos três níveis de governo; Órgãos colegiados em saúde das três instâncias de governo: O Conselho Nacional de Saúde - CNS, o Conselho Nacional de Secretários Estaduais de Saúde - CONASS, o Conselho Nacional de Secretários Municipais de Saúde - CONASEMS, assim como as Comissões Intergestores do SUS, a Tripartite e a Bipartite; As comissões e comitês interinstitucionais estaduais e municipais de DST e Aids; Setor Privado; Rede de Direitos Humanos em HIV/Aids. PRINCIPAIS IMPACTOS E RESULTADOS Os impactos e resultados alcançados pelo Programa Nacional representam ganhos significativos na luta contra o HIV/aids e outras DST, nos quais seria difícil separar àqueles exclusivos do Programa, do Projeto Aids II e do Acordo de Empréstimo BIRD 4392/BR, uma vez que as ações implementadas que indicam os impactos e os resultados, são integradas entre si, sejam do Programa ou sejam do Acordo. · Governo garante tratamento a 100% das pessoas com aids. Total de 135 mil pacientes com acesso tratamento com anti-retrovirais em 2003; · A sobrevida das pessoas com aids cresce 12 vezes: de 5 para 58 meses; · Cai em 50% a mortalidade das pessoas com aids no País. Ao todo, 90 mil mortes são evitadas; · País evita 358 mil internações em 5 anos; · Cai custo de tratamento do paciente com aids. Redução é de 54% entre 1997 a 2001; · País economiza US$ 2,2 bilhões com a assistência a pessoas com aids entre 1996 a 2002; · US$ 1,23 bilhão ­ economia com internação e tratamento de doenças oportunistas; · US$ 960 milhões ­ economia com redução de preços de medicamentos. · Brasil fabrica 8 dos 15 medicamentos usados no tratamento. Os genéricos para aids são até 80% mais baratos que os medicamentos de marca;o · Brasil evita 600 mil novas infecções pelo HIV: em 1992, o Banco Mundial estima que na virada do século haveria 1,2 milhão de pessoas infectadas pelo HIV no Brasil. Chegamos ao ano 2000 com menos da metade estimada; · A cada ano, menos brasileiros são diagnosticados com aids. País evitou 58 mil casos entre 1994 e 2002; · Uso consistente do preservativo é de 58% entre pessoas com parceiros eventuais e 11% entre pessoas com parceria fixa; - 43 - · Compra e distribuição de preservativos crescem mais de 15 vezes nos últimos 10 anos; · Redução da infecção pelo HIV em grupos vulneráveis: · Profissionais do sexo: cai de 18%para 6,1%em 2000. (Índice menor que o Canadá, 15% e Tailândia,19%) · Homossexuais: cai de 10,8%, em 1999,para 4,7%, em 2001. · Usuários de Drogas Injetáveis: representavam 21,4% dos casos de aids, em 1994, e, em 2000, passam a representar 11,4%.manos · O governo, em parceria com a sociedade civil, incluiu nas políticas públicas voltadas às pessoas vivendo com HIV/AIDS e grupos mais vulneráveis à epidemia, o acesso à justiça, à saúde e ao trabalho digno e benefícios sociais, em ações voltadas à redução do estigma e discriminação, promovendo a inclusão social e a garantia dos direitos humanos; · Governo desenvolve 1.780 projetos em parceria com a Sociedade Civil entre 1999 e 2002. Investimento de U$S 31 milhões. INDICADORES DE AVALIAÇÃO--ver texto do relatório, Anexo 1. PRINCIPAIS RESULTADOS POR COMPONENTES Componente 1: Promoção à saúde, proteção dos direitos fundamentais das pessoas vivendo com HIV/aids, prevenção da transmissão das DST, do HIV/aids e do uso indevido de drogas. Foram alcançados diversos resultados, nas populações mais vulneráveis e nas demais populações atendidas pelo Programa Nacional, com aumento de cobertura, acesso a serviços, distribuição de preservativos e outros insumos de prevenção. UDI - O crescimento significativo do número de projetos e de usuários de drogas injetáveis, sendo a cobertura atual estimada em 18,2 % , considerando-se a população de base de 800.000 usuários de drogas injetáveis no país. Oficialmente no Brasil foi somente em 2.001 que a Secretaria Nacional Antidrogas da Presidência da República incluiu as estratégias de redução de danos na Política Nacional Antidrogas, delegando ao Ministério da Saúde sua normatização. Homossexuais e Outros Homens Que Fazem Sexo Com Homens - O Programa Nacional de DST/Aids conduziu estudo para estimação dos homens que fazem sexo com homens (HSH) no âmbito da população brasileira. Foi possível estimar que 5,9% da população masculina com 15 anos ou mais é constituída de HSH, correspondendo a cerca de 3.200.000 indivíduos. Estimamos hoje a cobertura em torno de 96% dos homossexuais estimados no país, acessados por meio dos projetos e das mobilizações nas paradas gays realizadas anualmente. A probabilidade de um homossexual estar infectado pelo HIV é cerca de 11 vezes maior do que a de um homem heterossexual. Profissionais Do Sexo - No período de 1999 a 2002, o total de financiamento em projetos de prevenção direcionados à profissionais do sexo, foi da ordem de US$ 4,011,784.14. Considerando um incremento de 178% em relação ao financiamento realizado no período do AIDS I. O número de projetos atingiu a marca de 420. Sistema Prisional / População Confinada Adulta - A estimativa populacional é de 284.989 pessoas confinadas no sistema penitenciário brasileiro. Foram desenvolvidos no período de 1998 a 2003 um total de 59 projetos sendo que 17 em parceria com órgãos governamentais e 42 com parcerias junto a sociedade civil organizada. A cobertura populacional atingida pelas ações de forma direta foi de 70%. O total de preservativos distribuídos no período foi de 951.900 masculinos e de 59.000 femininos; ainda foi feita disponibilização de 17.200 seringas para ações de redução de danos junto a população de internos. - 44 - Outras populações alvo: Trabalhadores; As Forças Armadas; Povos Indígenas; Populações em situação de pobreza; População Rural - Assentamento, Garimpo, Quilombos e Extrativista; Mulheres; Crianças e Adolescentes. Diagnóstico do HIV, Aconselhamento e os Centros de Testagem e Aconselhamento ­ CTA O período de 1998 a 2003 é marcado pela forte necessidade de promover possibilidades de diagnóstico precoce, com o objetivo de ampliar a cobertura da testagem por parte da população brasileira. As regiões sul e sudeste ainda concentram a maioria das pessoas testadas: BRASIL = 25,2 milhões de pessoas testadas. . A implantação de projetos de CTA - Centro de Testagem de Aconselhamento em todo o Brasil teve um crescimento de 127% do ano de 1998 a 2003, superando as metas estabelecidas, totalizando 237 CTA apoiados. Política De Acesso A Insumos De Prevenção Preservativos. O Brasil tem ampliado significativamente sua distribuição do preservativo masculino neste período foi ampliada de 12 milhões de unidades para 22 milhões de unidades mensais. Quantitativo de Preservativos distribuídos/Ano Ano Nº de Preservativos Nº de Preservativos Nº de Preservativos Femininos Masculinos 49mm Masculinos 52 mm 1999 0 0 39.456.646 2000 1.407.500 4.798.944 73.628.511 2001 517.000 9.114.776 116.549.418 2002 1.967.000 6.220.656 139.845.680 2003* 1.737.300 10.128.528 149.286.982 TOTAL 5.628.800 30.262.904 518.767.237 SETEMBRO/2003 Parceria e Articulação com a Sociedade Civil para o Controle Social - A participação e a articulação com as organizações da sociedade civil e seus representantes têm sido imprescindível, na construção de respostas integradas à epidemia. Neste sentido foram estimuladas e apoiadas parcerias em programas que apontassem para o fortalecimento da organização da sociedade civil, ampliação das instâncias de representação no âmbito do Estado e a participação da sociedade civil na formulação de políticas públicas em HIV/aids e outras DST. - 45 - Política De Comunicação Em Saúde - As campanhas nacionais em HIV/aids carregam mensagens que se disseminam por todo o País de forma homogênea. Com base nos princípios do Projeto, são mensagens prioritárias: (i) Transmissão do HIV/aids pela via sexual: O uso consistente do preservativo é o meio mais seguro de se prevenir do HIV/aids e outras doenças sexualmente transmissíveis; (ii) Transmissão do HIV/aids pelo uso de drogas injetáveis: Seringas e agulhas não devem ser compartilhadas; (iii) Transmissão vertical do HIV/aids: Toda gestante deve ser informada de que deve fazer o teste de aids e, em caso de resultado positivo, tem direito aos tratamentos recomendados que previnam a transmissão do HIV para o seu filho antes, durante e após o parto; (iv) Tratamento dos portadores e pacientes HIV/aids: Todo cidadão tem direito ao acesso gratuito aos anti-retrovirais, e a boa adesão ao tratamento é condição para a prevenção e controle da doença, com efeitos positivos diretos na vida da pessoa com HIV/Aids. Componente 2 - Diagnóstico, Tratamento e Assistência às Pessoas Portadoras de DST/HIV e Aids · Serviços de Referência para Assistência em HIV/AIDS: Assistência Hospitalar; Hospitais Gerais de Referência; Hospital-Dia; Serviço de Assistência Especializada ­ SAE ; Assistência Domiciliar Terapêutica (ADT) · Acesso aos medicamentos para tratamento da infecção pelo HIV e infecções oportunistas e para o tratamento das DST · Ações voltadas para abordagem da síndrome lipodistrófica associada ao HIV; · Adesão ao tratamento anti-retroviral na rede pública de saúde · Avaliação da Qualidade da Assistência em Serviços de HIV/AIDS na Rede Pública de Saúde · Prevenção da Transmissão Vertical do HIV e Sífilis ( Projeto Nascer) Controle das Doenças Sexualmente Transmissíveis Ações voltadas à atenção das pessoas com infecção pelo HTLV · Diagnóstico e Acompanhamento Laboratorial e Fortalecimento da Rede de Laboratórios para Controle da Qualidade e Pesquisa; · Estruturação da rede de laboratórios que realizam testes anti-HIV; · Monitoramento Laboratorial dos Pacientes Vivendo com HiIV/Aids; · Rede Nacional de Laboratórios para Contagem de Linfócitos T (CD4+/CD8+) e para Carga Viral do HIV; Descentralização das redes nacionais de CD4 e carga viral; · Rede Laboratorial para Realização dos Testes de Genotipagem ­ RENAGENO; Sistema de Informação da Rede Nacional de Genotipagem ­ SISGENO; · Rede Nacional de Isolamento e Caracterização do HIV (RENIC); Diagnóstico Laboratorial das DST; · Rede Nacional de Susceptibilidade Antimicrobiana do Gonococo (RENAGONO); · Treinamento à Distância de Profissionais de Saúde; · Sistema de Educação à Distância para Profissionais de Unidades Hemoterápicas e Laboratórios de Saúde Pública (TELELAB); · Sistema de Garantia da Qualidade; · Sistema Nacional de Garantia da Qualidade dos Testes Laboratoriais para DST e AIDS. - 46 - Quadro Demonstrativo de Resultados do Componente 2: Projeto AIDS II Descrição do produto QUANTITATIVOS 1999/ 2001 Até Junho N.º AIDS II TOTAL 2000 de 2003 AIDS I + II Projetos de HD 15 05 15 35 84 financiados (implantação/ implementação) Projetos de ADT 14 01 05 20 53 financiados (Implantação/ implementação) Projetos de SAE 30 20 53 103 179 financiados (implantação/ implementação) Hospital 24 05 18 47 385 Convencional credenciado Hospital Dia 09 02 17 28 77 credenciado ADT cadastrado 19 02 04 25 58 SAE Pediátrico 01 02 03 21 Descrição do produto QUANTITATIVOS 1999/2000 2001 2002 SAE Materno-Infantil 02 05 SAE ­ Adulto 50 / 23 19 34 SAE ­ CTA 04 SAE ­ HD 05 SAE ­ HD ­ ADT 01 01 SAE ­ LAB 05 Equipes multiprofissionais de 329 profissionais ( 80 profissionais). 04 cursos de SAE e SAE, HD e ADT treinadas capacitados (400 participantes no ADT (85 profissionais) total). Unidades de Saúde para 1.000 1.126 1.142 assistência às DST, cadastradas. Centros de Treinamento em DST, Recadastramento 18 26 conveniados Descrição do produto QUANTITATIVOS 1999/2000 2001 2002/2003 Treinamento de instrutores i. 1.3ii. 957 Levantamento das / supervisores 52 instrutores/ instrutores/ supervisores informações em (enfermeiros/as) e Agentes supervisores capacitados; andamento. Comunitários de Saúde 277.040 ACS 16.461 ACS capacitados (ACS) do PACS/PSF. capacitados. - 47 - Descrição do QUANTITATIVOS produto 1999/2000 2001 2002/2003 Manual do Agente 160.000 impressos; 40.000 exemplares impressos, 1.798 14.368 exemplares Comunitário de 155.233 exemplares distribuídos distribuídos Saúde distribuídos Livro da Família 750.000 impressos; 400.000 exemplares impressos para as 1.499.000 exemplares 706.650 Equipes de Saúde da Família; distribuídos às distribuídos 500.000 exemplares de bolso Equipes de Saúde da Família Descrição do produto QUANTITATIVOS 1999/2000 2001 2002/2003 Elaboração do Consenso - 100.000 exemplares 100.000 exemplares de Terapia ARV-Gestantes impressos distribuídos Atualização do Consenso - 40.000 exemplares 40.000exemplares de Terapia ARV-Adultos impressos distribuídos Atualização do Consenso - 40.000 exemplares 40.000 exemplares de Terapia ARV-Crianças impressos distribuídos Unidades dispensadoras de medicamentos de aids com 113 145 252 SICLOM implantado COMPONENTE 3 - Desenvolvimento Institucional e Gestão do Projeto AIDS II Implementação da vigilância de casos de AIDS, sífilis congênita e DST Pesquisa e Vacina · Treinamentos e Capacitações · Cooperação Técnica Internacional Gestão do Projeto Durante a gestão do AIDS II, todas as principais ações previstas no PAD foram implementadas. Ação descentralizada - financiou, por meio de convênios e projetos estratégicos, no período de 1999 a 2002, com os 26 Estados, com o Distrito Federal e com 150 Municípios e aproximadamente 3.400 projetos estratégicos com organizações governamentais e não-governamentais. Nos Convênios foram investidos aproximadamente 167 milhões de reais em ações realizadas pelos Estados e Municípios nas áreas de: Promoção, Prevenção e Proteção; Assistência, Diagnóstico e Tratamento; e Desenvolvimento Institucional. A partir de dezembro de 2002 foi instituído pela Portaria 2313/GM, de 19.12.2002, a Política de Incentivo em HIV/aids e outras DST, destinando R$ 100 milhões ao ano para os 26 Estados, Distrito Federal e 411 municípios. Essa Política caracteriza-se como uma estratégia de descentralização, busca de sustentabilidade para a Política Nacional de DST e Aids e de sua integração aos atuais mecanismos gerencias do SUS, respeitando os diferentes graus de autonomia desses níveis governamentais e inserindo a participação da sociedade civil. Outras Ações de Gestão: Finalização do Projeto AIDS II com 100% dos recursos aplicados; Capacitação dos Orgãos Gestores do Projeto ­ OGP; Supervisão pedagógica; Estudo de Contas Nacionais em Aids; Comissão de Gestão das Ações de DST/HIV/aids (COGE); SIAIDS (Sistema de Informação de Gestão Física e Financeira do Projeto); Implantação da Política de Incentivo no âmbito do Programa Nacional de HIV/aids e outras DST. - 48 - DESEMPENHO FINANCEIRO DO PROJETO AIDS II O Segundo Projeto de Controle das DST e da Aids ­ Aids II, resultante do Acordo de Empréstimo BIRD 4392/BR, celebrado entre a República Federativa do Brasil e o Banco Mundial(BIRD), foi assinado em 11 de dezembro de 1998 e teve sua efetividade declarada em 9 de fevereiro de 1999. O Acordo previa, para o período de 1998 a 2003, a execução de US$296,50 milhões, sendo US$161.50 milhões provenientes do Banco Mundial e US$135.00 milhões da contrapartida nacional (Federal, Estados e Municípios conveniados), que foram integralmente executados durante seu período de implementação finalizado em 30.06.2003. Execução Financeira por Categorias de Despesas Em US$ Milhões CATEGORIAS de DESPESAS PROJETO PAD EXECUTADO 1999 a 2003 1. Bens 74.69 76.50 2. Mat. Instrucional 17.65 19.00 3. Treinamento 48.36 49.00 4. Serviços de Consultoria 32.90 30.00 5. Administração do Projeto 10.75 12.00 6. IEC 65.50 80.00 7. Medicamentos para DST 22.76 20.00 8. Serviços 15.35 4.00 9. Supervisão 8.54 6.00 TOTAL 296.50 296.50 Principais Dificuldades encontradas na implementação do Projeto Aids II: - Carência de dados científicos sobre perfis populacionais das diversas populações alvo do Programa Nacional; - Pouca participação de estados e municípios no desenvolvendo de projetos de intervenção comportamental, com aumento de cobertura com Profissionais do Sexo; - Preparar os serviços do SUS para ampliar e melhorar o acolhimento das OS e Travestis; - Resistências políticas para a implantação de políticas de Redução de Danos; - Dificuldades de inclusão dos parceiros (das mulheres atendidas) nos serviços de saúde reprodutiva e DST/HIV/aids; - Aumentar o acesso aos insumos de prevenção na atenção básica; - Inserção da política de prevenção e assistência nos procedimentos regulares das corporações militares; - Principais dificuldades da população indígena estão relacionadas ao acesso a serviços de saúde; gerenciamento/articulação dos DSEI e dos Programas Estaduais e Municipais; e capacitação dos agentes e profissionais da saúde; - Escassez de recursos humanos, apresentada pela grande maioria dos gestores municipais e estaduais; - Falta de priorização das ações de controle das DST por parte de muitas Coordenações Estaduais e Municipais; - 49 - - Grande rotatividade dos profissionais treinados, o que praticamente impossibilita a manutenção e consolidação de uma Rede de Referência e Contra-Referência regionalizada para assistência às DST/HIV/Aids; - Baixa qualidade do pré-natal e assistência ao parto; falta de profissionais de saúde para oferecer e realizar o aconselhamento pré e pós-teste anti-HIV nos serviços de pré-natal e parto; - Problemas sociais, como pobreza e baixa instrução, são fatores importantes de não adesão dos pacientes à terapia anti-retroviral; - Reforço da infra-estrutura existente em instituições de estudos e pesquisas; - Priorização de atividades que envolvam transferência de tecnologia. Principais Lições Aprendidas - A epidemia do HIV/aids assume diferentes situações para cada região do país, havendo necessidade de intervenções diferenciadas; · As parcerias com OSC, OG e iniciativa privada são fundamentais para a resposta nacional efetiva; · As ações de prevenção, tratamento e assistência devem estar integradas e articuladas; · A implementação do projeto, deve ser feita buscando sua permanente ampliação e descentralização, pois são fundamentais para o combate à epidemia; · A sustentabilidade das ações em HIV/Aids e outras DST foi conseguida pela implementação da Política do Incentivo; · Os recursos financeiros destinados às OSC/ONG na política do incentivo deve ser ampliada; · A prevenção à infecção pelo HIV nas diferentes populações é a atividade principal e fundamental ao combate à epidemia, principalmente nas populações de maior risco; · A melhoria da atenção as PVHA deve ser implementada pelas Casas de Apoio; · As OSC/ONG prestam bons serviços de prevenção e de assistência, sendo essenciais no combate ao HIV/Aids e outras DST; · A Política do Incentivo às Ações de HIV/Aids e outras DST é uma iniciativa de sucesso, devendo ser ampliada nas suas ações, nos seus recursos e no número de municípios participantes; · O apoio aos movimentos sociais de OSC/ONG deve ser aprimorado, para garantir sua maior participação nos conselhos de controle social do SUS; · A transmissão vertical do HIV pode ser reduzida em curto prazo, com diagnóstico e tratamento efetivos junto aos serviços de pré-natal, na atenção a gestante e às crianças expostas; · As populações de menor renda e escolaridade, assim como os grupos de difícil acesso e excluídos ( presos, profissionais do sexo, UDI e HSH ) são mais expostos e vulneráveis à epidemia; · A prevenção, o tratamento e a assistência as mulherese aos jovens deve ser aprimorada; · Os insumos de prevenção (preservativos masculinos e femininos, gel, seringas, etc ) adquiridos e distribuídos pelo programa nacional, são uma estratégia comprovada no combate a epidemia; · A garantia dos direitos humanos é fundamental como estratégia na implementação do Projeto; · O diagnóstico do HIV deve ser ampliado e disponibilizado para a população; · O tratamento dos pacientes HIV/Aids com a TARV traz inúmeros benefícios sociais às pessoas em tratamento e benefícios econômicos para o país; · O apoio na gestão dos executores descentralizados deve ser constante e efetivo de maneira a garantir a melhoria da implementação das ações descentralizadas; · A ampliação e consolidação do monitoramento e avaliação do programa nacional são fundamentais para a gestão e efetividade das ações; - 50 - PRINCIPAIS DESAFIOS FUTUROS · Reduzir o crescimento da epidemia em todo o país, priorizando as ações nas regiões mais afetadas e reduzindo as diferenças regionais. Priorizar Norte, Nordeste e Sul e diminuir diferenças regionais. · Aprimorar a abordagem para a prevenção e tratamento entre as mulheres e jovens. · Promover a inclusão de populações de baixa renda nas ações de controle da epidemia. · Promover a inclusão de populações vulneráveis nas ações e serviços do SUS. · Fortalecer a rede social de apoio para ampliar a inclusão das pessoas com HIV e aids. Diminuir o estigma e a discriminação. · Elevar o volume de preservativos disponibilizados em todo o país, de 700 milhões/ano para 1,2 bilhão/ano. · Aumentar em 1,5 vezes ( de 1,8 milhão de testes/ano para 4,5 milhões de testes/ano) o diagnóstico do HIV. · Garantir o acesso universal aos medicamentos ARV e de infecções oportunistas; Desempenho do Programa Nacional - O desempenho do Programa Nacional, assim como do Projeto Aids II e do Acordo de Empréstimo foi mais que satisfatório, como demonstram os impactos, os resultados e os indicadores alcançados durante o seu período de implementação. Somam-se ainda que não houve pendências de auditoria, que foram executados integralmente os recursos previstos no empréstimo e na contrapartida nacional, e que o programa se tornou um exemplo internacional. Desempenho do BIRD - O desempenho do BIRD foi mais que satisfatório, devido ao apoio fornecido pelas suas equipes, de Brasília e de Washington, no encaminhamento e orientações para solução dos problemas encontrados na implementação do Projeto. Destacam-se: (i) equipes de Missões de Supervisão formadas por profissionais conhecedores do universo HIV/Aids e outras DST; (ii) equipes Missões BIRD que discutiam os assuntos com propriedade e entendimento, sem necessidade de intérpretes; (iii) ajudas-memória de cada Missão discutidas e finalizadas; (iv) muitos assuntos e trocas de informações sobre desembolsos, não objeção prévia, andamento do projeto, orçamento, e outros procedimentos foram desburocratizados via e-mail, fax e telefone; (v) apoio, orientações e decisões fornecidas de maneira ágil pela Task Manager e suas equipes; (vi) aceitação pela Task Manager de declaração de despesas SOE quando da transferência dos recursos do Ministério da Saúde/Fundo Nacional de Saúde para os executores descentralizados, o que muito contribuiu para o desempenho do projeto; (vii) aceitação da proposta de remanejamento de recursos entre as categorias de despesas, visando atender demanda do projeto; (viii) apoio na preparação e negociação do Projeto Aids III. Dificuldades com o BIRD - (i) exigência de utilização das normas de aquisições do BIRD (shopping) para pequenas compras, até US$ 1,000.00 pelos executores descentralizados, em detrimento das normas nacionais que possuem dispensa de licitação até US$ 4,624.28 ( dólar da época da proposta - 1999 ); (ii) pouco apoio na capacitação dos executores descentralizados nas normas de aquisições do BIRD de 1999 a 2001; (iii) indefinição da utilização do LACI (relatórios PMR ); (iv) respostas com demora ou não respondidas, relativas à solicitações de não objeção para compras diretas de pequenos valores pelos executores descentralizados. - 51 - - 52 -