Report No. 1 341 1-AFR Regional AIDS Strategy for the Sahel January 1995 Western Africa Department Population and Human Resources Division t4 B 5;4~~~~~. 21~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~* Th ~ V~ -A. -44 A,~~~~ ~~* -A -~~~~~ I~ This report was prepared by the AIDS core team in the Population and Human Resources Division of the World Bank's Western Africa Department (AF5PH) led by Edward Brown and comprising Roza Makonnen and Rejean Paradis. Bruce Benton (AF5PH) and Ernest Massiah of the Population, Health, and Nutrition Department (PHN) contributed to sections of the paper. Preparation of this paper was immensely aided by the contributions of participants in a number of consultations and review meetings. An inter-agency meeting bringing together about 10 multilateral and bilateral agencies, including NGOs, was organized in September 1993 to initiate the preparation process. Peer reviewers were Wendy Roseberry, Mead Over and Jean-Louis Lamboray. In addition, valuable contributions and advice were provided by the AF5PH Health and Population team and colleagues from other departments within the Bank. Many others outside the World Bank, including in particular the WHO/Global Program on AIDS, provided helpful comments and contributions. The paper was prepared under the general guidance of Ms. Katherine Marshall, the Western Africa Department Director, and Mr. Birger Fredriksen, the managing Division Chief, whose keen interest and support have helped shape the final product. Mr. Frangois Laporte is the Lead Economist and Mr. Emmerich Schebeck is the Projects Advisor. Ms. Ghislaine Baghdadi provided support services, Mr. Ross Pfile and Ms. Lauren Ptito provided editorial assistance for the report. LIST OF ACRONYMS AF5PH Western Afiica Department - Population and Human Resources Division AIDSCAP AIDS Control and Prevention Project AIDS Acquired Immune Deficiency Syndrome CAS Country Assistance Strategy CBOs Community-Based Systems CIDA Canadian International Development Agency ESS Epidemiological Surveillance Systems FAC Fonds d'Aide et de Cooperation FAO Food and Agricultural Organization (UN) GPA Global Program on AIDS GTUDs Genital Ulcer Diseases -IIV Human Immunodeficiency Virus IDA International Development Association EEC Information, Education and Communication KAP Knowledge, Attitude and Practice MCH Maternal and Child Health MTPs Medium-Term Plans NAPs National AIDS Program NGOs Non-Governmental Organizations PASE Projet d'Appui a la Surveillance Epidemiologique (Epidemiological Surveillance Support Project) PHN Population, Health and Nutrition SRI Sahelian Regional Initiative SSA Sub-Saharan Africa STDs Sexually Transmitted Diseases SWAA Society for Women against AIDS in Africa UNDP United Nations Development Programme UNESCO United Nations Educational, Scientific, and Cultural Organization UNICEF United Nations Children's Fund USAID United States Agency for International Development WNHO World Health Organization CONTENTS EXECUTIVE SUMMARY .......................................................... .i I. INTRODUCTION AND OVERVIEW 1 A. Introduction .....................................................1 B. Epidemiology of the Disease .....................................................1 General .....................................................1 Nature of the Data .....................................................2 Levels, Trends and Patterns .....................................................2 C C onsequences .....................................................7 11. MAIN ISSUES 8 A. Factors Affecting the Spread of the Disease ................................................8 B. Impediments to Effective Program Implementation ..................................... 11 Policy and institutional constraints .................................................... 11 Program-related issues .................................................... 12 m. CURRENT RESPONSES TO THE EPIDEMIC 17 A. Ongoing Government Interventions .................................................... 17 B. Donor and Bank Support ..................................................... 17 C. Support from the Non-Governmental Sector .............................................. 21 D. Lessons Learned .................................................... 21 IV. PROPOSED BANK STRATEGY AND INTERVENTIONS 24 A Country Level Activities Supported through Lending and Sector Work ...... 24 B Regional IEC and Capacity Building Program ............................................ 28 C. Collaboration and Coordination with Donors ............................................. 29 BIBLIOGRAPHY .......................................................... 3 1 ANNEX 1 Brief Country Profiles ANNEX 2 Projections of AIDS and HIV Infections 1986-97 ANNEX 3 STDAHIV Rapid Risk Assessment Surveys ANNEX 4 Outline for Proposed AIDS Prevention Interventions ANNEX 5 Estimated Costs for Regional IEC and Capacity-Building Program EXECUTIVE SUMMARY Introduction 1. The objective of this report is to define strategies for the World Bank ('the Bank') to effectively assist Sahelian countries in taking advantage of the window of opportunity that currently exists to carry the fight against the HIV/AIDS epidemic to a higher level. The report discusses the main issues and manifestations of the epidemic, identifies constraints to effective policy and program development and implementation, and proposes an agenda for action. It also spells out the key elements of donor collaboration and identifies areas and activities for Bank intervention. The report aims to enhance Bank staffs awareness and understanding of the dynamics of the epidemic in the Sahel and to help them engage in effective dialogue with government agencies, industry, NGOs, community organizations and donors. 2. The report argues that while the level of WIV seroprevalence and the number of AIDS cases in the Sahel are still relatively low in the general population compared to other regions of Sub-Saharan Africa (SSA), the rapidly rising trend and pattern of spread of the epidemic do not augur well for the future. The case is made that the late arrival of HIV/AIDS in Sahelian countries provides governments with a unique opportunity to draw upon the lessons learned about the disease and experience gained in combating it and to take action now and implement cost-effective AIDS prevention interventions before the epidemic takes hold in the general population. 3. Epidemiology of the disease. While available data are incomplete, current estimates suggest a rapidly increasing trend in the spread of the disease. Short-term projections indicate a tripling of the number of WlV-infected persons from about 782,000 in 1992 to approximately 2 million in 1997. The trend is even more alarming when the projected number of AIDS cases is considered. Based on estimated WHV seroprevalence, the cumulative number of AIDS cases is expected to rise from about 22,000 in 1992 to over 300,000 by 1997, a 15-fold increase in only 5 years. In addition, while WIV-2 infections are still predominant in countries such as Senegal, The Ganbia and Guinea Bissau, HIV-I infections are the most prevalent in the rest of the Sahel and are increasing at a much faster rate in all countries (the former is known to have a longer latency period and a lower pathogenicity than the latter). Thus, morbidity and consequent mortality rates are likely to rise rapidly over the next few years. Furthermore, there is evidence of a rapidly declining median age at infection, particularly among women, and there are as many women infected as men, suggesting higher proportions of heterosexual transmission. 4. Consequences. Although the demographic implications of the AIDS epidemic can be far- reaching, its effect on the rate of population growth in SSA and in the Sahel in particular is unlikely to be dramatic. It is estimated that even under the worst-case scenario, the Sahelian population will continue to grow at a rate higher than 2 percent per annum. However, the high morbidity and mortality impact of AIDS on the most economically active age group would have severe socio-economic consequences, leading to the disruption and disintegration of households and the creation of new poverty groups. 5. The rising trend in morbidity and mortality would also have a negative impact on all sectors, in particular on the provision and financing of health care. It is estimated that by 1997 deaths due to AIDS would account for no less than 30% of all adult mortality annually in the Sahel. In Burkina Faso, for example, about half of all beds in some wards at the National Hospital in Ouagadougou are already occupied by HIV/AIDS patients. Current direct lifetime costs of ii AIDS in Burkina Faso are estimated at about 4% of total health expenditures, and could easily exceed 20% by 1997. Indirect lifetime costs (the value of healthy life years lost from the disease) is estimated to be about 17 times higher than the direct cost. The HIV/AIDS situation in Burkina Faso is increasingly resembling the situation found in C6te d'Ivoire, and presents a likely scenario for other Sahelian countries, in particular Mali, Chad, Niger and The Gambia, where the number of AIDS cases is increasing rapidly. Main issues 6. Two broad categories of issues are discussed in the paper: (a) Factors affecting the spread of the disease, which include: (i) limited understanding of the determinants and consequences of the disease among all segments of society (policy makers, opinion leaders, service providers, and the general population); (ii) high population mobility, particularly inter-country migration to the high endemic coastal countries such as Cote d'Ivoire, Ghana, Togo and Benin; and (iii) relatively higher vulnerability of women to STD/HIV infection due mainly to socio-cultural factors (such as early marriages, low levels of education, adverse cultural and religious practices, including in particular female circumcision) and poverty; (b) Impediments to effective program implementation, which include: (i) limited political commitment, the absence of a multisectoral approach to program planning and implementation, limited involvement of NGOs and community organizations, and lack of funding; and (ii) program-related issues including the lack of effective information, education and communication (IEC) programs, limited initiatives on condom promotion, and weak epidemiological surveillance, laboratory capacity, STD clinical management and program management capacities. Responses to the epidemic 7. National programs to combat the AIDS epidemic in the Sahel were initiated in 1987 with the development of em. rgency action programs and the establishment of National AIDS Committees (NACs) with assistance from the WHO/Global Program on AIDS (GPA). These led to the development of the first medium-term plans (MTPs, 1988-91) which focused primarily on health sector interventions. These plans and activities brought AIDS to the national agenda, but very little was achieved, due to the constraints outlined above. All Sahelian countries are now in the process of either initiating or implementing their second MTPs (1994-98). These plans emphasize: (a) the integration of HIV prevention activities into STD interventions; (b) an intersectoral approach and decentralized management of AIDS programs, giving greater responsibility to community health; and (c) an intensification of IEC interventions, particularly peer education programs and community mobilization efforts. 8. Donors, particularly WHO and UNICEF, have actively supported these initiatives. WHO/GPA has been instrumental in developing the medium-term plans and in providing technical assistance for the implementation of national programs. Major bilateral donors active in this area include USAID, the Dutch, the Germans, the French, the Canadians and the European Union. iii 9. . The World Bank involvement. The Bank's support for HIV/AIDS initiatives in the Sahel has been, until recently, very limited. This was due, in part, to the reluctance of governments to use Bank funds to support activities to combat a problem which was not considered to be a major concern, and for which there was apparently adequate bilateral grant funding. However, during the last two years, there has been a several-fold increase in Bank funding (under the soft loan facility of the Bank, the International Development Association (IDA)), as other donor funding has decreased while funding needs have increased. 10. Over the last three years, the Bank has focused attention on the following areas: (a) Improving the knowledge base to enhance the Bank's dialogue with the countries concerned. This is being achieved by helping governments conduct Rapid Risk Assessment Surveys to build a strong data base for effective program planning and implementation. Within the Bank, AIDS-related issues are being given increased priority. Information meetings have led to greater staff awareness of the need for immediate action, task managers are placing more emphasis on such issues, and effective tools for dialogue and program development are being prepared. (b) Targeting key government officials to heighten their understanding of HIV/AIDS and of the urgency of concerted national action on all fronts to prevent the epidemic from becoming a serious public health problem. The Bank will contact Heads of Government to express its concem regarding the need for countries to act quickly and its willingness to assist them in their fight against the disease. In addition, in the course of Bank/Government policy dialogues a concerted effort will be made to include specific actions to be taken to address the AIDS issue. (c) Providing support in Bank-funded operations for under-funded priority activities under National AIDS Programs (NAPs), and integrating free-standing AIDS components into future IDA-financed projects in health (free-standing AIDS components -were added to two Population Projects in the 1994 fiscal year (FY94) and other sectors such as Education and Agriculture. Proposed and ongoing IDA-funded activities are defined in detail in Section HI of the report. 11. Local and international non-governmental organizations (NGOs) have become increasingly involved in activities dealing with women's reproductive health issues and AIDS. These organizations provide support for AIDS prevention and control activities, including the undertaking of research on cross-country issues such as migration and the spread of AIDS, the promotion of social marketing of condoms, and EEC programs. These include Care Intemational, SIDALERTE, Society for Women Against AIDS in Africa (SWAA), Save the Children Fund (US and UK), ENDA Tiers Monde, Family Health International under AIDSCAP, and a number of independent local organizations. 12. Lessons learned. The main findings over the last decade in developing and implementing AIDS interventions in Africa and elsewhere are that: (a) behavioral change is difficult and slow; (b) comprehensive programs are essential; (c) IEC programs should attempt to disseminate more positive messages; (d) understanding gender issues is important in determining the degree of behavioral responses; (e) targeting youth is cost-effective; (f) involving NGOs, communities, and the private sector is critical for the success of programs; (g) local institutional capacity building is essential; (h) regional/ provincial approaches are important in expediting the process of program iv impact; and (i) technical assistance is required to ensure effective program development and implementation. Proposed Bank strategy and interventions 13. The Bank's proposed HIV/AIDS Prevention and Control Strategy for the Sahelian countries is aimed at promoting a full-scale, broad-based attack on the problem with the objective of helping Sahelian countries avoid a generalized epidemic and a major developmental setback. This strategy will use a two-pronged approach consisting of country-level activities supported through the lending program and regional activities supported through grant funding. These two approaches are summarzed below and described in detail in Section IV of this report. 14. Country-level activities supported through lending program. Based on the perceived trend of the epidemic in the country, program quality and availability of funding, Sahelian countries have been ranked in order of priority for action. Burkina Faso, Mali, and Niger are ranked as high priority countries for Bank support, followed by Chad, The Gambia, and Mauritania, as medium priority, and Senegal and Cape Verde as low priority. Guinea Bissau and Sao Tome & Principe are not rated due to lack of relevant information. 15. For each of these countries the nature and level of Bank support would depend on the priorities already defined in the second MTPs and the extent of resources committed by the governments as well as other donors. However, the Bank's strategy for country assistance programs would cover activities in these key areas: (a) strengthening and expanding ongoing H1V/AIDS communication programs, targeting in particular decision-makers, opinion leaders, service providers, women and youth; (b) accelerating the establishment of social marketing programs to promote condom use, by strengthening and expanding existing public sector distribution networks and encouraging the development of private retail outlets; (c) expanding clinical management and care of STDs/HIV, and strengthening epidemiological surveillance and laboratory capacity, with particular emphasis on the integration of STD/HIV case detection and counseling into primary health care and family planning programs, and enhancing clinical capacity to enable screening and diagnosis of STDs/HIV, particularly among women; (d) increasing assistance to community, NGO and private sector initiatives; (e) encouraging multisectoral interventions; and (f) improving collaboration and coordination with other donors. 16. Regional program supported through grants. The focus of the Bank's work program for FY95-97 will be on developing integrated strategies and fostering cooperation at the regional level to increase the effectiveness of H1V/AIDS interventions. The thrust of the proposed regional program will be to: (a) establish a full-scale information, education and communication (IEC) program, using a variety of communication channels, to widely disseminate information on the disease and its prevention; and (b) foster regional cooperation and explore innovative approaches to controlling the spread of the epidemic. Such extensive, high impact programs are difficult to launch and implement through country lending programs, which lack the synergistic advantages and econormies of scale of a regional approach. A regional program could recruit the best program/technical specialists, often unavailable at the country level, to develop a wide-based carnpaign having the maximum regional impact in the shortest period of time. Specific attention would be given to the following activities: v (a) Mobilizing political and opinion leaders and organizations throughout the region to address HFV/AIDS issues at the highest level. Regional workshops, seminars, study tours and other kinds of group initiatives would be organized to exchange ideas and build a regional consensus at the highest level. Semiannual consultations would be conducted to evaluate progress and identify areas for further action; (b) Identifying and working with national figures/local heroes (political, religious and sports personalities) with regional appeal to develop strong advocacy roles and mount aggressive education and information campaigns; (c) Supporting pilot projects to test innovative ideas, particularly those relating to cross-border issues, such as migration (developing sub-projects around border towns and areas of affinity), condom promotion, etc.; (d) Promoting studies and research of regional significance by universities and research centers in the region, establishing collaborative arrangements with research centers, developing research networks, and providing opportunities for research results to be incorporated into programs at the national level; and (e) Providing technical support and training to NAPs to improve their capacity to manage multisectoral national programs and upgrading the quality of the response to the national HIV/AIDS issue. 17. Support will be provided for the development of effective mechanisms/structures to coordinate and facilitate the implementation of the regional activities. The nature and form of the mechanisms/structures were discussed during a regional technical planning workshop held in Ouagadougou, Burkina Faso from September 11-15, 1994. The workshop brought together 61 participants including NAP managers and observers from UNDP, UNICEF, AIDSCAP, CARE International, SIDALERTE, and Save the Children Fund (US and UK), as well as representatives of local NGOs. Participants identified priority problem areas at the regional level and selected specific interventions to address these priority areas. Constraints to program development and execution were identified and complementary interventions required to ensure effective implementation were discussed. 18. The total budget for this program is estimated at US$6.0 million, over a 3-year period -FY95- 97-(US$2.0 million per year), of which US$1.2 million is expected to be provided through the Special Grant Program (SGP) as the World Bank's contribution. The SGP has approved funding (US$300,000) for the first year (FY95) of this program. The remaining US$1.6 million for FY95 would be funded from external sources yet to be determined. It is anticipated, however, that the complementary donor financing would be readily forthcoming since such a program is widely seen as a high priority in the Sahel. I. INTRODUCTION AND OVERVIEW A. INTRODUCTION 1. The Sahel' is perhaps the last frontier in Sub-Saharan Africa (SSA) in the spread of the AIDS epidemic. Although available data are inadequate, they suggest that the overall prevalence of the hunan immunodeficiency virus (HIV, the causal agent of AIDS) is still very low in the Sahel. The devastating economic and social effects of this disease, which could negate achievements in all sectors, can still be averted if countries act vigorously to prevent H1V transmission. The relatively late arrival of HIV in the Sahel presents governments with an opportunity not enjoyed in other parts of Africa, where the caseload of HIV-induced illness and AIDS was already high by the time the presence of the virus was recognized. Governments in the region are in a position to draw from the body of knowledge and experience already accumulated about the epidemic both to prepare, at the earliest opportunity, to meet its consequences, and to take urgent action to control its spread. In the absence of a vaccine against HIV and affordable, widely applicable therapies for AIDS, at present the only means of preventing HIV transmission is to encourage people to adopt self- protective measures. Even if effective vaccines and treatment regimes become available in the foreseeable future, however, prevention would still be the first and foremost priority. 2. The objective of this report is to define strategies and actions to assist Sahelian countries in taking advantage of this window of opportunity and carry the fight against the epidemic to a higher level. The report discusses the main issues and manifestations of the epidernic, identifies constraints and impediments to effective policy and program development and implementation, and proposes an agenda for action. It also spells out the key elements of donor collaboration and identifies areas for Bank intervention. The report draws on lessons learned in other regions, particularly the experience gained in those regions where the disease is now endemic. It is intended to enhance Bank staffs awareness and understanding of the dynamics of the epidernic in the Sahel and to assist them engage in effective dialogue with government agencies, industry, NGOs, and community organizations. B. EPIDEMIOLOGY OF THE DISEASE General 3. The epidemiology of HIV infections is becoming more and more complex as it spreads without recognizing any geographical, political, social, economic or religious boundaries. In SSA, the pandemic is characterized by its variability and unpredictability, with each population group having its own dynamics and patterns of transmission. As elsewhere, but even more predominant in SSA, heterosexual transmission is by far the most important mode of acquiring HIV, accounting for 80% to 90% of all infections. In addition, numerous studies indicate the predominant role of sexually transmitted diseases (STDs) as biological cofactors in the transmission and virulence of HIV. This association is strongest with genital ulcer diseases (GUDs) such as syphilis, chancroid, and genital herpes, the first two being highly prevalent in SSA. This relationship has been demonstrate in both directions; first GUDs foster HIV transmission (median risk estimate of approximately 10 times), and second, HIV causes more severe clinical manifestations of GUDs. The Sahel refers to Burkina Faso, Cape Verde, Chad, The Gambia, Guinea Bissau, Mali, Mauritania, Niger, Snegal, and Sao Tome & Principe. 2 Other studies have shown that gonococcal and chlamydial infections increase the risk of HIV transmission by 3-5 times. This is a major concern considering the very high prevalence of these infections among pregnant women in Africa, where gonococcal infections are 10-15 times higher, chlamydial infections 2-3 times higher, and syphilis more than 10 times higher, compared with similar groups in developed countries (Wasserheit and Holmes, 1992). 4. The progression of HIV infection to clinical onset of symptoms of AIDS appears to be different between African and industrialized countries, with African HIV-infected patients progressing more quickly to AIDS than patients in industrialized nations. Although more research is still needed to understand the specific reasons for this difference, it appears that differences in clinical management of opportunistic pathologies and individual health-seeking behavior may play a role in the spread of HIV infection. For example, over the last ten years, a dramatic increase of some pathologies such as tuberculosis has been noted in Africa, exacerbating the already high morbidity and mortality levels in the region. It has also been documented that poor nutritional status has an adverse effect on the clinical manifestation of HIV-related diseases. Nature of the data 5. Estimates of HIV-infected persons and AIDS cases in the Sahel rely almost entirely on two sources: (a) various small-scale H-IV prevalence surveys conducted beginning in 1985-86; and (b) data gathered from sentinel surveillance systems among specific population groups. With the exception of Senegal, and to a lesser extent The Gambia and Burkina Faso, most countries do not have reliable data on the levels and trends of HIV infection and even less so with regard to STDs. Moreover, AIDS case reporting is known to be highly incomplete, varying from 10% to 30% of the actual level in any country. This lack of reliable data on STDs, HIV, and AIDS is principally due to the weak and inadequate health information systems existing in these countries, and the absence of adequate epidemiological surveillance systems and poor laboratory capacity (paras 41, 43). In addition, there has been considerable reluctance to report AIDS cases, particularly in the early years of the epidemic (para. 19). Although data collection and analysis have improved markedly in recent years, many biases still remain and estimates should be interpreted cautiously, particularly for more "conventional" STDs. A proven rule of thumb, however, is that in areas where HIV infection rates are still low, the prevalence rates of other STDs, as well as the incidence of tuberculosis, are good indicators of the potential spread of HIV infection. Levels, trends, and patterns 6. The Sahel can generally be characterized as having relatively low levels of HIV seroprevalence when compared with other sub-regions in SSA. However, current estimates based on surveys and reported cases, suggest a rapidly increasing spread of the disease. And while HIV-2 infections are still predominant in countries such as Senegal, The Gambia and Guinea Bissau, HIV-I infections are the most prevalent in the rest of the Sahel and are increasing at a much faster rate in all countries (the former is known to have a longer latency period and a lower pathogenicity than the latter). Thus, morbidity and consequent mortality rates are likely to rise rapidly over the next few years. Furthermore, although the age pattern of the spread of the disease suggests higher levels of infection among populations over 30 years of age,2 there 2Evidence from a 1991 study of prostitutes in Ouagadougou indicated that by age, HIV-1 levels ranged from 1% to 4.3%, with those over 50 years of age most infected. HIV-2 levels range from 9.8% to 41.6% with a maximum at ages 40-49. 3 is evidence of a rapidly declining median age at infection, particularly among women. There is no conclusive evidence regarding the gender differentials in the rate of infection in the Sahel, however, estimates from elsewhere in SSA suggest a narrowing gender gap (almost a 1:1 ratio). 7. Levels. For the whole of the Sahel, as of December 1992, there were about three quarters of a million individuals (782,500) estimated to be already infected with HIV. Burkina Faso is estimated to have over 50% (425,000) of those infected, followed by Mali and Chad respectively (Figure 1).3 The cumulative number of declared AIDS cases for the region as of December 1992, was only 6,047.4 This figure, however, grossly underestimates the actual number of AIDS cases by a factor of about 3-5. Estimates based on the level of HIV seroprevalence suggest that there were about 4 times more AIDS cases (21,508) than were actually declared, of which 50% (11,682) was accounted for by Burkina Faso. Mali, Chad, Niger, and Senegal, all had over 1,000 cases of AIDS during this period (Figure 2). Figque 1: ESTIMATED NUMBER OF HIV POSITIVE (1992) Burkina Faso 425000 Chad 90000 Te Gamnbia 15000 Mai 150000 Maurtania 5000 Niger 52000 Snega 44000 Cpe Verde 1500 0 50 100 150 200 250 300 350 400 450 Niumber of HIV Poitive '000) 8. Compared with other sub-regions in SSA, however, levels of HIV seroprevalence are much lower in the Sahel. Current estimates of HIV seroprevalence for the general urban population in the Sahel are less than 5Olo, compared to over 10% in coastal West Africa, and between 15% and 20% in certain central and eastern African cities. Estimates of HIV infection among pregnant women attending maternal and child health (MCH) clinics (considered representative of the general population) are much lower, currently in the neighborhood of 1% to 30/O, although in some "pockets" in a few countries (e.g., Sikasso in Mali, Gaoua in Burkina Faso and Moundou in Chad) prevalence rates have already exceeded 5%. Much higher levels of HIV seroprevalence (over 20%) have been estimated among selected groups engaged in high-risk sexual behavior (such as commercial sex workers and STD patients); these levels are comparable to those in other parts of SSA (Table 1). 3Estimates are derived from surveys and sentinel data undertaken during the early 1990s. 4These are cases reported to WHO and they exclude Guinea Bissau and Sao Tome and Principe. 4 Figar 2: ESTIMATED CUMULATIVE NUMBZR OF AIDS CASES SAHZLIAN COUNTRIES (1092) 3SmoSel 11210 Nigr nmn 1429 M auritamis a 7 Mal 4123 Oambia m 412 Cad 2474 CApS V *r4. Burkima Faso 462 0 2000 4000 6000 3000 10000 12000 The highest estimad level of HIV seroprevalence is that found in Burkina Faso, where studies among commercial sex workers in Ouagadougou in 1989 and Bobo-Dioulasso in 1991 showed HIV-2 levels of 41.6% and 450/o, respectively. In addition, the level of other STDs is very high, about 20% (WHO, 1991). Annex I describes, in detail, the epidemiological situation in eight of the BANK countries. Table 1: H1V SEROPRIEVALENCE AMONG COMM CIAL SEX WORIES IN SELECTED AFRICAN COUNTRIES, 1992 LEVEL COUNTRY _URKINA _ASO . - - - - 0-CAR HIGH CONGO COTR &VOIRE (Abo 20%) E,IOPIA ..'..... - -. A j 3U- AU MALAWI MALE ~~~~~~RWANDA TANZANIA UWANDA ZIMBABWE ZAMBIA BENIN . . .. .. CAMEROON SUDAN (SOUTH) MEDIUM OHANA (Y-20%) NIGERIA TANZANIA (EXCEPT WEST) DJIBOUrI LOW LIBERIA (Below 5%) MADAGASCAR SOMALIA ANBOLA BOTSWANA BURUNDI lV...... .*.. 0-.. .....i ; 0 40.. COMOROS UNXNOWN EQUATORIAL URINEA GABON GUINEA LBSOTHO * )WRlAI ..... . . ..- .--....MAURZU)S MOZAI4BIQUE NAMBIA M g.-"~A)iTO.,a~ i,r,''t't-0't-0't't. SEYC S SIERRA LEONE SUDAN SWAZDAND TOO s.:a US BS_ oft C_n.(1992). 5 9. Trends. Since the first few hundred cases of AIDS were reported in the Sahel in the mnid- 1980s, the level of HIV infection and number of AIDS cases have been increasing and spreading rapidly among all groups. Short-term projections (1992-97)5 so far attempted for the Sahel indicate that by 1997 there will be almost 2 nillion individuals infected with HIV, almost tripling the estimated number of infections in 1992 (782,500). HIV seroprevalence among the general population, while still modest when compared to other subregions (para. 8), is expected to increase from about 2% to 4% during this period. Among the countries, the most striking case is Burkina Faso, where the estimated level of HIV seroprevalence is projected to increase from its current level of 7% to 10% by 1997, with over 1 million individuals infected with the virus (Annex 2). 10. The trend is even more alarming when the current estimates and projected number of AIDS cases are considered. Given the five- to seven-year lag between infection and manifestation of AIDS, there is tremendous momentum for the rapid increase in the number of AIDS cases in the Sahel over the next five years. Based on H[V seroprevalence data, in 1994 there are about 89,000 AIDS cases in the Sahel; a four-fold increase from 1992. This figure is expected to rise to over 300,000 by 1997 (Figure 3). Thus, in only five years (1992-97) the total cumulative number of AIDS cases is expected to increase more than 15-fold. The likely consequences of this rapidly increasing trend in HIV/AIDS are discussed in the next section. Figure 3: PROJECTED CUMULATIVE NUMBER OF AIDS CASES IN THE SAHEL (1992-97) Senegal Niger Mauritania Mali LI 1994 Gambia * 1992 Chad Cape V erde Burkina Faso 0 40000 80000 120000 160000 200000 11. Patterns. The pattem of the spread of HIV infection in the Sahel mirrors that in the rest of Africa, where predominately older cohorts of men and younger cohorts of women are infected, reflecting the early marital age for girls. While the evidence is not conclusive regarding gender differentials in the rate and level of infection,6 the importance of male seasonal out-migration to the highly endemic coastal countries of CMte d'lvoire, Ghana, Togo, and Benin suggests relatively higher levels of infection among men than women. There is, however, evidence of a rapidly s lZn projections are based on the WHOIGPA Epi Model. 6 Most surveys and studies have focused on women as the unit of analysis, and thus only limited estimates of seroprevalence among men are available, except for particular high risk groups, such as STD patients and to a lesser extent those in certain occupational groups, such as the military and truck drivers. 6 increasing rate of infection, particularly among younger women. There is also growing evidence of an increasing rate of mother-to-child transmission, particularly of HIV-1, with an estimated transmission rate of 35% to 40%. This rate is about twice that estimated for developed countries for the same strain of virus. Four hypotheses have been postulated to explain this marked variation: (a) more virulent strains in Africa; (b) increased viral load; (c) high prevalence of other STDs; and (d) breastfeeding (although it is still, and will remain, one of the major public health measures to encourage even in HIV hyper-endemic areas). C. CONSEQUENCES 12. The rapidly increasing trend in HIV infection and the number of AIDS cases do not augur well for the future in the Sahel. The limited analytical work undertaken so far in selected countries (Burkina Faso in particular) demonstrates that the socio-economic consequences of the epidemic would be devastating, exacerbating the already fragile economies in the sub-region.7 13. Direct demographic effects. Population projections incorporating the effects of AIDS prepared for selected Sub-Saharan African countries indicate that even in the worst case scenario, the long-term direct demographic effect of AIDS would be a reduction of about 1% or less per annum in the rate of population growth (Bulatao and Bos, 1992). In the Sahel, given the high rate of population growth (about 3% per annum), even without the slowing of HIV infections, the population will continue to grow rapidly - over 2 % annually - and will more than double in size during the next 25 years. 14. Mortality and morbidity effects. The most obvious and direct impact of the epidemic is on the health status of the population. Given the recent nature of the epidemic in the Sahel, the mortality effects of the epidemic are still very modest. About 10,000 deaths were attributable to AIDS in 1992, accounting for less than 2% of the total crude death rate. This figure is expected to more than triple this year to about 34,000 and would increase to 92,000 by 1997, by which time almost 10% of total deaths in the sub-region each year would be attributable to AIDS. When adult mortality is examined, it becomes even more evident that the mortality implications of the AIDS epidemic during the next 3 years would be far more devastating than that of any single illness, in particular due to the resurgence of pulmonary infections such as tuberculosis. By 1997, deaths due to AIDS would account annually for no less than 30% of all adult mortality in the Sahel. 15. The burden of the disease. The rapidly rising trend in long-term morbidity and mortality would have a serious negative impact on the provision and financing of health care, "crowding out" other health services. A recent rapid assessment of the economic impact of HIV conducted in Burkina Faso estimated that nearly half of the beds in some wards at the National Hospital in Ouagadougou are now occupied by HIV/AIDS patients. The situation in Burkina Faso is reaching alarming proportions, very much reflecting the situation in CMte d'Ivoire. Based on the estimated total lifetime average cost of AIDS care per patient of US$4168 (derived from the Burkina Faso 7The analysis below is based on short-term projections made using the Epi Model and recent work on rapid economic impact analysis done in Burkina Faso conducted by Ms. Logan Brenzel (January, 1994, see Biblio.). 'This figure compares favorably with those derived from other studies in Eastern Afiica, where more in-depth analytical work has been conducted. 7 study), the estimated total direct cost of HIV/AIDS was US$446,000 in 1992.9 While this amount may appear modest, it already represents approximately 4.1% of the total expenditures (recurrent and investment) of the Ministry of Health in 1992. But this is a very conservative cost estimate as it is based on the total number of reported AIDS cases in 1992, which clearly understates the actual number of AIDS cases by a factor of about five. Thus, the direct lifetimne cost of AIDS in Burkina Faso could already exceed 20% of the total health budget. This percentage is likely to increase rapidly during the next few years as the number of AIDS cases rises (Figure 3). In addition, estimates of the indirect cost of AIDS (the value of healthy life years lost from the disease) derived from the study (by calculating the discounted healthy years of life lost) is about US$8 million in 1993, based on 1,073 reported AIDS cases. A more plausible estimate of the indirect cost based on the estimated number of new AIDS cases would be about US$60 million. 16. These figures are substantial and predict the likely scenario in other Sahelian countries, particularly, Mali, Chad, Niger, and The Gambia, where the number of AIDS cases is rapidly increasing. However, this analysis represents only one aspect of the global burden of the disease, namely the impact on the health sector. The epidemic would have severe negative effects on household welfare and productivity, increase costs to firms, and affect major economic sectors, including education and agriculture. One major social consequence of the growing number of AIDS deaths is the rapid increase in the number of orphans. Estimates from the short-term projections cited above, indicate that by the end of 1994, for the Sahel as a whole, there would be almost 70,000 cumulative AIDS deaths. This figure would more than triple to over a quarter of a million (282,000) by 1997, resulting in over 1.7 million orphans.'" In addition, with a relatively higher percentage of mother-to-child transmission observed in Africa, the number of pediatric AIDS cases would increase significantly over the next three years, creating even greater pressure on already limited public health resources. At the household level there would be tremendous disruption of families as household resources are diverted to care for the growing pediatric AIDS cases, prolonged morbidity among the adult members, and the growing number of AIDS orphans. 17. Without effective intervention to mitigate the spread of HIV/AIDS, the epidemic, as currently observed in many Eastern African communities, would create new poverty groups, exacerbate the already difficult economic situation and pose a considerable challenge in coping with the situation. Moreover, it would alter the distribution of income, thwart efforts to develop sectors that rely on skilled or scarce manpower, and will likely reduce the growth rate of per capita income below levels that would have been feasible without AIDS. For the Sahel, further analytical work is urgently required to identify and measure quantitatively the distribution of the economic burden of the disease, particularly the potential impact on individuals, households, firms and sectors, in order to identify policies to mitigate the impact and implement cost-effective prevention programs in sectors most sensitive to HIV infection. 9 Ile cost is estimated by multiplying the 1,073 reported AIDS cases in 1992 by the average lifetime cost of AIDS care per patient of US$416. °Estimates of orphans are derived indirectly by multiplying the total cumulative deaths due to AIDS by the average number of children a Sahelian woman at age 35 would have had (5 children), 35 years being the average age at death of AIDS patients. 8 II. MAIN ISSUES A. FACTORS AFFECTING THE SPREAD OF THE DISEASE 18. Limited understanding of the determinants and consequences of the disease One of the most important problems confronting the National AIDS Programs (NAPs) in the Sahel is the continuing denial and, at best, latent acceptance of the existence and the potential gravity of the AIDS epidemic. This denial is pervasive at all levels of society. Among key policy and decision makers it has resulted in a reluctance to respond quickly and effectively to combat the disease. The almost casual reference to and dismissal of AIDS as a foreign problem, contracted only by selected groups such as commercial sex workers, underscores the levity with which the disease is treated in official circles. Few policy makers comprehend the socio-economic determinants of the disease. Fewer still appreciate the macro- and micro-level impact of the AIDS epidemic and the need for an expeditious and effective response to prevent a looming disaster. 19. The lack of awareness at the official level is compounded by the fact that the general population lacks an understanding of the nature of the disease and its modes of transmission." Among individuals and communities, the initial reaction of denial during the first stages of the disease has changed to a sense of fear and victimization as the fatality of the disease becomes known. While risk factors for HIV/AIDS depend on country-specific behavior patterns, the main risk factors are directly related to patterns and modes of sexual behavior. These include unprotected sexual intercourse, multiple sex partners, prior history of STDs, and infrequent use of contraceptives, particularly condoms. Limniting the spread of the epidemic, therefore, requires changes in sexual behavior. However, several obstacles exist, requiring concerted efforts at both the policy and program levels. Cultural and religious norns prevent an open discussion of HIV/AIDS and other issues such as sexuality, making efforts to increase awareness of high-risk behavior among the general population difficult. Misconceptions regarding the transmission of HIV persist and rumors and myths abound about traditional cures for AIDS, creating false hope and security among individuals and thwarting any efforts aimed at fostering behavioral changes that would enable the prevention of the transmission of IfV. 20. Low levels of knowledge are not observed exclusively among the 'general public'. Misinformation and myths about the disease are also prevalent among health and social workers. The main threat this poses is not to the workers' own health, but to client-provider interaction.'2 A survey of health personnel and social workers in Burkina Faso found that 60% had never attended a meeting in which AIDS was discussed, only 10% had received any fonnal training on AIDS, and 30% did not know the etiology of AIDS and its clinical characteristics. Adequate knowledge of HIV, STDs, AIDS and the contexts in which sexual activities occur are needed when interacting with STD patients, individuals who are HIV positive or have AIDS, and the families of those with the disease. Clinic-based service providers lack the interpersonal skills necessary to interact with "In the Sahel most people have heard of AIDS either through friends or the mass media. In the 1993 Burkina Faso Demographic and Health Survey, 84% of women and 94% of men had heard of AIDS, though strong regional differences were noted. Among secondazy school students a high level of klowledge was noted but precise questions were less familiar, only 33% knew what seroprevalence meant and 22% felt the information on AIDS was exaggerated (see Sicard et al., Biblio.). Among commercial sex workers in Mali 85% had heard of AIDS, but only 17% could name its symptoms. 12 The occupational risks to health workers are low, the risk of health workers contracting HIV relates more to their sexual behavior patterns. 9 and counsel their clients. Frequently, service providers lack an understanding of their clients' cultural and social beliefs and their expectations of the provider-client interaction.'3 21. The lack of awareness concerning AIDS can also be found informal sector employment, where oftentimes employees who are known to have or believed to have HIV/AIDS face the risk of stigmatization or loss of employment. This is further complicated by the fact that regulations ensuring confidentiality do not exist and employees do not have legal recourse if they lose their jobs. Misconceptions and fears about the transmission modes of HIV make efforts to protect infected individuals against such problems difficult. Employers have not been capable or willing to implement cohesive policies and regulations concerning AIDS in the workplace. This is partly due to their limited understanding of the potential negative impact on profitability and productivity resulting from a loss of functional and productive employees from the workforce. It is therefore in the best interests of industry to protect all of its productive employees and promote the creation of working environments that foster the integration of functional individuals within a society that cares for members infected by HIV. 22. All of these factors create an environment in which few believe that the situation could reach an alarming level, worsening the already existing crisis in the countries. Consequently, there is clearly a lack of sense of urgency and, to date, no country has launched a vigorous program to combat the epidemic. Behavioral changes that would enable individuals to prevent the transmission of the virus have not been fostered. This situation is extremely worrisome and calls for massive campaigns to sensitize key officials, the general population, and health personnel to the need for immediate and vigorous action to limit the further spread of the epidemic and to minimize its impact. 23. High population mobility. Seasonal in-country and inter-country migration have been identified as potential factors in the spread of HIV/AIDS in the Sahel. This phenomenon is perhaps more critical in the Sahel than in any other SSA subregion. The migration factor is complex and multidimensional, incorporating economic, social, and behavioral dimensions. Economic activity within the region brings about the frequent and continual mobility not only of resources, but people as well, who bring their cultural habits and sexual norms and networks across borders. The movement of workers within countries from predominantly rural areas to economically active areas, such as mining and border towns, and the proliferation of commercial sex activity in these mobile communities, have dramatically increased the risk of the spread of H[V/AIDS. In addition, the potential spread of AIDS through inter-country mobility of workers and prostitutes has also increased, as the primary destination of most Sahelian migrants is one of the highly endemic coastal countries such as CMte d'Ivoire, Benin and Togo. In Niger, for example, 80% of AIDS cases are linked to migrants from CMte d'Ivoire. In The Gambia, the incidence of STDs and AIDS is higher in small towns along the Trans-Gambia highway than in rural areas, and in Burkina Faso, the incidence of STDs reflects the seasonal patterns of migratory movements, with peaks observed during the harvest time when young men retum. The risk of the spread of HIV/AIDS in home countries is also increased as migrants in the Sahel tend to return to rural 3 In Burkina Faso, an ethnographic study of health service utilization revealed that the low levels of clinic attendance were related to the widespread use of traditional medicine. The reasons for this high utilization of traditional medicine were: (i) traditional medicines were believed to be more efficacious for certain diseases; (ii) there was easy access to reputable traditional healers; (iii) traditional remedies were available at lower costs, and there was a 'sense of ease" when dealing with traditional healers; and (iv) clinic staff were perceived as "authoritarian, patronizing, and/or arrogant" and the overall quality of health care was rated as unsatisfactory. 10 areas, where health and other infrastructure (including communication services) are worse than those in urban areas. 24. The low levels of education, differing language skills, and status of migrants limit their access to information and services that may reduce their risk of contracting the HIV virus. A study in Abidjan revealed that 17% of all immnigrants and 38% of female immigrants did not understand French and were not receiving information on AIDS prevention (Yelibi, Valenti, Volpe, et al., 1992). Among Malian and Nigerien migrants to Cote d'Ivoire, it was observed that all had heard of AIDS, often via the radio, but that knowledge of its modes of transmission was limited and condom use infrequent. 25. Relatively higher vulnerability of women to STD/HIV infections. Evidence from various studies indicates that overall, more women than men are being infected with HIV at significantly younger ages (5-10 years younger than men).'4 Among females, those in their teens and early 20s are being infected more than those in any other age group. Biological, socio-cultural, and economic factors contribute to make women more vulnerable than men to HIV infection. Biologically, the transmission of HIV is more likely from an infected man to a woman than from an infected woman to a man. Sexually transmitted infections disproportionately affect the health of women. In the initial stages of STDs, less than 50% are symptomatic in women and therefore not immediately obvious or visible; as a consequence women are less likely to seek treatment when they contract STDs. Women are also less able to prevent exposure to STDs/IUV than men as they lack preventive methods which they control. Further, their subordinate decision-making role in sexual relationships limits their ability to negotiate, particularly as it relates to a partner's fidelity and condom use. Constantly traumatized genitals from infections, inadequate treatment, and poor hygiene are contributing factors which increase women's risk of contracting IHV/AIDS. 26. Among the socio-cultural factors, marriage at an early age and early initiation to sex increase young girls' risk of exposure to HIV. Due to the immature genitalia of younger women, non-STD related lesions and genital ulcers are common owing to the traumatic sexual experience and girls are thus exposed to a higher risk of HIV infection.'5 In addition to initiating sexual activity at an early age, the practice of polygamy, visiting relations, and high levels of partner exchange increase the transmission of STDs. In Niger, 30% of unmarried women were in sexual unions with two or more men and 36% of all women were in polygamous marriages. A condom acceptability study which followed 136 men in Mali over a period of one month, noted that each man had, on average, 9.4 sexual partners. 27. Moreover, other harmful cultural practices such as female infibulation and circumcision, which cause scarring and infections, as well as non-infectious genital inflammation caused by high fertility, contribute to increased risk of HIV infection among women. Female circumcision is still widely practiced in Chad, Mali, Niger, Senegal and The Gambia. Culturally, circumcision is associated with notions of female hygiene, modesty and social status and is seen by some women as a means of reducing promiscuity. The conditions under which circumcisions are performed increase the likelihood of female morbidity and mortality. They are generally performed by 14 Se UNDP - Young Women: Silence, Susceptibility and the HIV Epidemic. 15 In Niger 50% of women of reproductive age reported that their first sexual intercourse was at age 15 (Niger DHS 1993), and among students in Burkina Faso it was 15.6 years for males and 17.0 years for females (See Sicard etal. 1992). 1) traditional birth attendants, female elders, and in some cases by spouses, with the majority of these procedures being done at home. The sequelae of circumcisions include a higher frequency of major postpartum hemorrhage and urinary tract infections causing pain at micturition, dribbling urine incontinence and poor urinary flow. 28. Cultural and religious norms ensure that women's subordination is maintained in society and this is manifested by their subordinate role in decision-making, particularly as it relates to their sexuality and reproductive health. Further, cultural and societal norms discourage open discussions about sexuality, STDs, AIDS, and reproductive health issues. Women have little control over the behavior of their partners and little choice as to the circumstances under which they have sexual intercourse, thus placing them and their partners at risk. Low literacy rates and educational levels contribute to the fact that women in general do not have an adequate understanding of reproductive health issues and have limited access to information concerning STDs and AIDS. Further, women's reproductive responsibilities and their key role in maintaining household health, as well as their productive responsibilities, place severe constraints on their time and resources. As a consequence, women do not have the time, money, or means to seek medical treatment as often as they should. 29. Economic necessity and a lack of alternatives for financial independence force women to be highly dependent on spouses or male partners. This financial dependence places women in a weak position, restricting their decision-making role (particularly as it relates to their partner's sexual behavior) and limits their ability to request fidelity and/or use of condoms. For those women who do not have spouses or partners and who lack the skills to seek gainful employment elsewhere, prostitution often becomes an economic necessity. The sexual practices of commercial sex workers, such as frequent, unprotected sex with multiple partners, greatly increase their risk of HIV infection. B. IMPEDIMENTS TO EFFECTIVE PROGRAM IMPLEMENTATION Policy and institutional constraints 30. Absence of a multisectoral approach. The dynamic and complex nature of the AIDS epidemic underscores the importance of multi-sector/multi-level approaches for addressing the AIDS problem. However, this approach has yet to be effectively developed in the Sahel. National AIDS Programs (NAPs) have been managed almost exclusively by the Ministries of Health, with little or no inputs from the other sectoral ministries such as education, agriculture, and commerce. In addition, the central planning ministries are, for the most part, not involved in making decisions relating to funding and coordination. Thus, NAPs are very weak and lack the capacity and authority to enact broad-based social policies and to coordinate activities outside the health domain. Although the second generation Medium-Term Plans (MTPs), propose an intersectoral program approach, no clear strategies spell out how this will be implemented. This pattern cannot continue if AIDS programs are to achieve meaningful impact. 31. During an interagency meeting held at the Bank to discuss AIDS prevention and control in the Sahel,6 the difficulty of developing comprehensive, multisectoral STD/AIDS strategies was 16 The meeting, which was held on September 16, 1993, brought together about 20 individuals representing key multilateral and bilateral agencies and representatives of a few NGOs supporting AIDS initiatives in the Sahel and elsewhere. (See summary of meeting dated October 5, 1993). 12 recognized. The need to increase awareness, at the senior government level, that the AIDS issue is not specific to the domain of health and to make it relevant to other non-health sectors by clearly explaining the non-health impact of AIDS, i.e. relating it to Agriculture, Industry, Education, etc. was stressed. In Uganda, for examnple, an NGO presented this message to senior-level government officials, including the President, explaining the multidimensional impact of the AIDS epidemic and thus enabling the Govermnent to see AIDS as a multisectoral issue. A practical solution suggested was to adopt a "bottom up" approach, first identifying specific local initiatives (ongoing or proposed) and later developing institutional and sectoral linkages. 32. Limited NGO and community involvement. At present, the involvement of community- based organizations (CBOs) and NGOs in the design and implementation of HIV/AIDS interventions is limited. Very little has been done to harness the capacities of industry, NGOs, communities, and individuals in the prevention and control of the AIDS epidemic. CBOs and NGOs, in certain instances, interact with a segment of the general population that governments neither have the capacity nor the willingness to reach and therefore may serve as liaisons between governments and communities. In addition, their smaller size, moderate resource needs, and different orientation provide these organizations with a flexibility that the public sector nay not have and which is essential for implementing HIV/AIDS interventions. 33. Experience in eastern and southern Africa has shown that the most effective responses to the epidemic are those involving industry, NGOs, community groups and individuals who have been affected directly or indirectly by the disease. The challenge is to find the "right" type of institutional structure, i.e. community groups including NGOs and industry leaders, in an effort to build a network of front-line initiatives and to avoid creating new structures. 34. Inadequate funding. Funding has become a question of growing concern for AIDS programs in the Sahel. While the MTPs produced at the inception of the national programs were apparently fully funded by way of pledges, actual funds made available fell far short of required resources. Domestic resource mobilization has also been limited as governments have been constrained due to the multitude of demands/priorities placed on public resources. In addition, the expectation that donors would come through with their commitments delayed efforts to seek other sources of funds, including funding from IDA. For example, in Burkina Faso, The Gambia and Niger, only 20% of the funds required to implement FY91 and FY92 activities were made available. Private sector involvement, while increasing, has also been limited. Thus, while good progress has been achieved in many program areas, the lack of adequate resources has been a major constraint in the effort to accelerate implementation of AIDS prevention and control programs in most of these countries. Program-related issues 35. The failure to adopt safe behavior may be indicative not only of a lack of knowledge, but of the poor quality of and limited access to services that restrict the individual's ability to realize behavioral intentions. For exarnple, the lack of condoms or inappropriate clinic hours may explain the dichotomy between low levels of condom use and high levels of awareness of their importance in preventing the transmission of STDs and AIDS. The matrix below (Table 2) provides a qualitative assessment of the NAPs in eight Bank countries. A maximum country score of 20 13 points is given for an effective program, with each program component rated on a scale of 1 to 4.1' Five of the countries scored below average (10 points). Chad has the weakest program with a score of 5 points, followed by Mauritania and Niger with 7 points each. For the sub-region as a whole, the weakest program component is IEC, followed by clinical management and laboratory capacity. An important program element which is partially subsumed under the IEC component in the matrix is condom promotion, which is very weak in all countries except Burkina Faso. The issues relating to these program elements are discussed below. TABLE 2: QUALITATIVE ASSESSMENTS OF NATIONAL AIDS PROGRAMS Progra Copoent EPI. [EC CLIN. LAR SUPJ PROG. TOTAL SURV. STD BLOOD MGMT Country MNT SAFETY BURICINA FASO 3 2 3 3 2 7/20 CAPERVERDE 3 2 3 3 3 14J20 CHAD 2 1 I 1 1 5/20 GAMBIA 2 2 3 3 2 12/20 MALI 2 2 1 2__ 8/20 MAURITANIA 1 I 2 I 2 7/20 NIGER 2 I I I 2 7/20 SENEGAL ___ 3 12 12 13 13 13/20 I TOTAL | 16/32 1 13/32 _.I. 14/32 1 14/32 | 17/32 Sele: 4: Good- adequae program input (human, fiancial, and logistical support). Well-conmeived to adcieve defined objecives; 3: Fair- some limtaions in progrnm iput, but functioning adequate to achieve defined objectives; 2: Weak- major timitations; 1: Very weak- program practicaily non-exiseL 36. Weak Information, Education and Communication (IEC) programs. The IEC elements of the NAPs have been, to date, very limited in scope and intensity, and extremely timid in the nature of the messages conveyed. This has been due in part to the continuing problem of denial of the existence of the epidemic, the absence of strong political commitment, and the limited understanding of the deterninants and consequences of the disease (para. 18). In addition, there has been considerable reluctance on the part of governments to admit that they do not have the required capacity to develop effective IEC programs, which has led to limited use of well-qualified, non-government expertise. As a consequence, the first MTPs had very limited support for IEC activities, and most of the efforts were characterized by their: (a) emphasis on medical issues, particularly on cognitive information to raise knowledge levels, while failing to adequately examine the social and cultural contexts in which sexual behaviors occur; (b) ad hoc nature and limited duration; (c) materials, which were targeted at specific populations and not at specific behaviors; (d) messages, which were essentially negative and were designed to generate fear; (e) focus on increasing demand for services without attention to the adequacy and quality of supply, namely the limited technical/managerial skill mix needed to develop AIDS prevention activities; and (f) inadequate behavioral impact evaluations. 17 Tne above ratings are based on an evaluation undertaken by AF5PH of program quality and impact of the strngths and weaknesses of the National AIDS Pgram in eight Sahelian countries. 14 37. There has been a heavy reliance on a narrow range of communication mediums and strategies. A recent review of IEC in a number of Sahelian countries " noted the near-exclusive use of group talks as a communication strategy. These talks tended to be didactic and targeted at a small audience. While print materials were visible, they were more frequently found in administrative centers and not in the field. Materials, in particular pamphlets, were used more as decorations rather than as tools for facilitating dialogue with clients. The use of electronic media was almost entirely limnited to a few intermittent emissions of messages focusing on the health consequences of the disease. Messages were poorly designed and were primarily targeted at groups considered to be engaged in high-risk behavior (commercial sex workers, single women, truck drivers, STD patients, etc.). Program managers tended to regard these groups as pools of infection rather than as human beings with their own needs and rights. The emphasis has been on containing the spread of HIV infection into the community rather than on providing support services and information for the individuals concemed. This approach has tended to reinforce the impression that AIDS is a condition remote from the daily lives of the majority of the population. 38. Surprisingly, in a sub-region with low literacy levels, indigenous oral communication mediums such as music and drama have not been enthusiastically embraced. Little attention has been paid to interpersonal communication as a way of improving communication between clients and providers. The token attempts at community participation have been non-participatory and have reflected a limited knowledge of community structure and dynamics. Hamessing the potential of existing NGOs (paras 32-33) to mobilize conmmunity action, use of religious networks and peer education is only beginning to occur and should be encouraged. 39. Another weak element of the IEC program is the limited attention to female reproductive health issues (paras 25-29) and their linkage to family planning. The limited understanding of the determinants of the disease and its implication for family welfare and economic well-being has led to strong resistance, even among service providers, to addressing these multidimensional elements of the program, and has, in turn, reinforced stereotypes and misinformation. The role of IEC programs in fostering the natural linkages between activities to prevent and control lIV/AIDS and all other sectoral interventions cannot be overemphasized. 40. Limited condom promotion initiatives. Availability of and access to condoms is very limited in most Sahelian countries. The distribution and sale of condoms are carried out mainly in public health facilities and a few pharmaceutical depots, covering less than 40% of the population in most countries. Because of their "formal" nature, these distribution networks do not offer access to the majority of the population, particularly the youth, men, and single women. The sale and advertising of condoms through informal networks of retailers (social marketing) has proven effective in educating the general population about STD/HIV infections and in promoting condom use. In the Sahel, Burkina Faso is the only country with a well-established social marketing program for the sale of condoms, and has, to date, achieved higher levels of condom sales than the combined distribution and sales of the other countries in the sub-region. In Senegal, Mali, and Niger, while efforts to initiate social marketing of condoms have been under discussion for many years, only limited progress has been made so far, due in part to objections from certain segments t A review of the use of educational materials by health agents was undertaken in Mali, Senegal, Niger, and Mauritania by Management Sciences for Health in 1990. 15 of the society and reticence on the part of decision makers to permit mass media advertising of condom use for AIDS prevention. 41. Weak Epidemiological Surveillance Systems (ESS). Despite its demonstrated importance, in general, epidemiological surveillance is very poorly developed in SSA, and in Sahelian countries in particular. In these countries, ESS is characterized by: (a) a lack of reliable data on levels, trends, and patterns of STDslHIV to monitor and forecast the epidemic; (b) the limited use of existing data for decision making; (c) an inadequate number of personnel trained in data collection, analysis and dissemination of needed information for prevention and control activities; and (d) a lack of regional cooperation between countries to address common problems. The central role of data and information for effective planning and implementation of NAPs underscores the need to quickly address these impediments and constraints. Efforts will have to be geared towards building a strong human resource base to strengthen the existing systems. 42. Weak clinical management. Clinical management has to be considered at two levels; first, the provision of appropriate diagnosis, treatment, and counseling for STDs; and second, the provision of effective medical treatment and counseling to HIV-infected people with or without AIDS. Unfortunately, in the Sahel, not only are STDs believed to be very prevalent, as in other SSA countries, but there is also a very limited capacity for STD clinical management demonstrated by: (a) the non-existence of STD clinics in most Sahelian countries; (b) the lack of medical supplies and antibiotics for diagnosis and treatment; and (c) the lack of adequately trained health personnel for STD management. Actions needed to address these limitations must focus primarily on the provision of adequate training for health personnel in STD management, adequate supply of STD drugs and medical supplies, minimal laboratory capacities at the central and regional levels, and support for better diagnosis and treatment. Providing adequate medical treatment and counseling to STDlHIV-infected people helps to alleviate physical and psychological suffering from diseases associated with HIV infection, and prevent transmission to non-infected people. 43. Limited laboratory capacity. Limited laboratory capacity has two major implications, namely the effects on: (a) the safety of blood transfusion; and (b) clinical management of STDs. Although the transmission of HIV and other blood-borne diseases such as hepatitis B by way of blood transfusion is currently practically fully prevented in industrialized countries, in SSA and in the Sahel in particular, transfusion is still responsible for significant numbers of these infections (at least 10% of cases of HIV infection are still transmitted through blood). This sad reality is indicative of the weakness of the laboratory systems in the sub-region. The situation in the Sahel is characterized by a severe lack of human resources, laboratory equipment, materials and supplies. Even where minimal equipment is available, frequent ruptures in stocks of test kits, reagents, etc. make them as inoperative as those without equipment. All these factors have a severe negative impact on the capacities of the laboratories to support curative and preventive activities. The lack of adequate laboratory support is hampering effective clinical management of infectious and communicable diseases in the Sahel, particularly opportunistic infections and traditional STDs. Lack of appropriate facilities for precise and accurate diagnosis leading to improper management of STDs has resulted, in many areas, in a resistance to antibiotics and an increasing practice of auto-medication. This phenomenon has become a major public health problem in the region, with increasing evidence of more severe morbidity and complications from STDs, thus facilitating the spread of STD/HIV infections. 44. Weak managerial capacity. The management of NAPs in the Sahel is characterized by inadequate and poorly trained personnel, and in most countries by an institutional dichotomy in the 16 management of STD and HIV/AIDS, usually represented by a coordinator for each program. In addition, the location of the NAPs in the Ministries of Health exposes them to all the weaknesses of the public health systems in these countries. National AIDS coordinators are often clinicians with limited or no public health and management experience and thus lack the capacity to facilitate broad-based intersectoral programs. The tendency has been to create highly centralized management structures with limited integration of AIDS activities into existing health delivery systems, thus narrowing the scope of interventions even in the health sector. To improve capacity for program implementation, NAPs must be managed as multi-sectoral programs (para. 30) by adequately trained program managers at all levels (central, regional, and local) and in the various sectors (health, education, agriculture, and industry). 17 III. CURRENT RESPONSES TO THE EPIDEMIC A. ONGOING GOVERNMENT INTERVENTIONS 45. The first cases of AIDS in the Sahel were reported as early as 1985-86. However, it was not until late 1987 that national programs to combat the disease were officially initiated. National AIDS Committees (NACs) were established to help prepare emergency action programs. These programs led to the development of the first three-year MTPs (1988-91) which focused primarily on health sector interventions: training of health personnel, enhancing diagnostic techniques, disseminating information (public awareness), conducting small-scale epidemiological surveys (usually in major cities), and providing a limited supply of STD medication and equipment. In Burkina Faso condoms were also promoted and distributed. 46. Although these plans and activities brought AIDS issues on to the national agenda, very little was achieved during the first phase because of the constraints described in Section II. There has evolved, however, a greater recognition of the need to develop a more aggressive information, education, and communication (IEC) strategy and to broaden the scope of interventions to deal with multi-sectoral/multi-level dimensions of the problem. The second-generation MTPs (1994- 98) were designed to respond to these concerns. The plans emphasize: (a) integration of HIV with STD interventions; (b) an intersectoral approach and decentralized management of AIDS programs, giving greater emphasis to community health; and (c) intensification of IEC interventions, particularly peer education programs and community mobilization efforts. B. DONOR AND BANK SUPPORT 47. Donors, particularly WHO and UNICEF, have actively supported these initiatives. The WHO/ Global Program on AIDS (GPA) has been instrumental in the development of the MTPs, and in the provision of technical assistance to implement national programs. As mentioned earlier, NAPs are facing increasing funding gaps, particularly since the early 1990s. IEC activities, and to a lesser extent epidemiological surveillance, have been more attractive to multilateral and bilateral agencies such as the Dutch and German governments for interventions mostly in rural areas, USAID with condom promotion and distribution, and CIDA for epidemiological surveillance in selected countries. Other donors, namely the French and the European Union, have provided support mainly for STD clinical management and laboratory equipment and supplies in major cities. Recently, however, some principal donors, in particular USAID, are beginning to concentrate their efforts at the regional level, and to disengage from "lower priority" countries. 48. The World Bank Involvement. The Bank's support for AIDS initiatives in the Sahel has been, until recently, very limited. This was due, in part, to the reluctance on the part of officials to use Bank funds to support activities to combat a problem which was not considered to be a major concer, and for which there was apparently adequate bilateral grant funding. This orientation has, however, changed over the last two years as other donor funding has decreased while funding needs have increased. There has, in fact, been a several-fold increase in IDA support during the last two years for AIDS initiatives in the Sahel. The Bank's interventions to date have been at two levels: within the Bank, to promote the inclusion of AIDS issues in sector activities in all countries and to develop a comprehensive AIDS strategy for the Sahel; and at the country level, to assist Sahelian countries launch vigorous action programs to prevent AIDS from becoming a major health problem. 18 49. Over the last three years, the Bank has focused attention on the following areas: (a) Improving the knowledge base to enhance the Bank's dialogue with the countries concerned. This is being achieved by helping governments conduct Rapid Risk Assessment Surveys to build a strong data base for effective program planning and implementation (see Annex 3). This effort is aimed at better understanding the AIDS situation within countries and increasing awareness of the disease among policy makers and the population as a whole'9. Within the Bank, AIDS-related issues are being given increased priority. Information meetings have led to greater staff awareness of the need for immediate action, task managers are placing more emphasis on such issues, and effective tools for dialogue and program development are being prepared. (b) Targeting key government officials to heighten their understanding of HIV/AIDS and of the urgency of concerted national action on all fronts to prevent the epidemic from becoming a serious public health problem. At the 1993 Annual Meetings, the need for urgent attention to AIDS prevention figured prominently among the issues discussed with national delegations. The Bank will also contact Heads of Government to express its concem regarding the need for countries to act quickly and its willingness to assist them in their fight against the disease. In the course of Bank/Govemment policy dialogues a concerted effort will be made to include specific actions to be taken to address the AIDS issue. (c) Providing support in Bank-funded operations for under-funded priority activities under NAPs. During the last two years, upon request from national authorities and in response to further analysis of national programs, the Bank has substantially increased its support for AIDS initiatives in all countries (except Sao Tome & Principe and Cape Verde). This support has primarily been in the form of health sector interventions, particularly through ongoing and newly-approved IDA-funded Health and Population projects. The following provides a brief description of the ongoing and proposed country-level activities. (i) Burkina Faso. The Bank recognizes the critical nature of the AIDS situation in this country and has, over the last two years, undertaken vigorous action at both the policy and program levels in support of the National AIDS Program. Under the ongoing Health Project, a total of US$750,000 was allocated to finance priority activities planned during the first two years of the Second MTP (1993-1997). These include support for epidemiological surveillance (in particular conducting STD/I-V Rapid Risk Assessment Survey), laboratory equipment and training. In addition, when the Population and AIDS Project becomes effective in the next few months, the IDA credit will constitute the largest single source of external funds (US$10.6 mnillion) for AIDS prevention activities in the country (see Box I below). 9 The data will also assist in improving dialogue with governments and better targetting of AIDS interventions. For example the Niger survey, which was completed in June 1993, provided the needed data for the in-country workshop to develop the second MTP organized in October 1993. By the end of 1994, surveys were completed in 5 countries where they have been identified as a priority (see Annex 2) 19 Box 1: BURKINA FASO: Population and AIDS Control Project This project will be the first IDA-funded project in the Sahel to include a fil-fledged AIDS oomponent. The AIDS control ccmponent aims at slowing down the spread OUWVAIDS by promoting behavioral change, through increasing public awarenes otHIAIADS Particular emphasis wod be placd on streigteing management capacity at the national and community levels, and on increasing the involvement of the private sect and NOOs in project activities. $pecific tvites istlude. (a) Social marketing and public seaor distbution of condoms; (b) Establishment of a Fund to provide grant financing for projects in the areas of population,:, famnily planning, and AIDS prevention and control activities nndertaea lgely by -Go, (c) IEC campaigns uing vaious ma channels SUCh s radio St, eil ramas, dance, ad singing groups, folk thater, etc. to raise awareness of lIlAIDS and other STDs and to promote behavioral changes, and (d) Institutional strengthening of cliical managonent and community er evacities within the counry. (ii) Cape Verde. So far there has been no direct Bank support for the AIDS Program, which is fairly well advanced and apparently well-funded. However, some support is being considered for preventive activities, particularly for IEC under the proposed Education Project (FY96). In addition the Government has expressed interest in being actively involved in the proposed Sahelian Regional Initiative (see Section IV). (iii) Chad. Although to date only limited Bank support has been provided to the National AIDS Program, preparation is underway for major support under the proposed Population and AIDS project planned for FY95. Meanwhile, support is being provided under the Project Preparation Facility I(PPF) for the proposed project to undertake a STD/-HIV Rapid Risk Assessment Survey to be followed by a KAP survey in early 1995. In addition, support was provided by the Bank for the preparation of the Second Multisectoral MTP in May 1994. The Chad National AIDS Program has encountered some funding difficulties in the past, and it is hoped that the support to be provided by the Bank under the proposed Population and Health Project will fill a major gap in funding needs and help achieve the objectives of the National AIDS Program. (iv) The Gambia. Funding is being provided under the ongoing National Health Development Project for IEC activities, epidemiological surveillance, STD materials and supplies, and technical assistance for strengthening laboratory capacity. Approximately US$200,000 has been provided to date, including funding costs for conducting the STD/HIV Prevalence Survey beginning in mid- May 1994. Although The Gambia is one country in the Sahel where valid information on epidemiology of STD/HIV infections has been available since the 20 Although project preparation is the Governmnent's responsibility, advances to finance project preparation activities are made by the Bark when there is a strong probability that a Bank loan will be made for the project. 20 mid- and late-1980s, the planned 1994 survey is likely to provide more recent and updated data for most of the country. Additional funding for AIDS activities will be considered under the proposed Health and Population Project (FY96). (v) Guinea-Bissau. Support for the National Blood Donor Bank, provision of drugs for AIDS-related diseases, and AIDS prevention activities is being provided under the health component of the ongoing Social Sector Project. In addition, preparation efforts have been initiated for a Population and AIDS Project planned for FY96. This project will provide substantial funding for activities planned under the Second MTP (1994-1998). (vi) Mali. Priority activities are being supported under the ongoing Health, Population and Rural Water Supply Project. A total of US$1.4 million has been allocated under the project in support of the last two years of the first MTP. This includes support for IEC, epidemiological surveillance (including STD/HIV Rapid Risk Assessment Survey), STD clinic management and laboratory facilities to strengthen sentinel surveillance in six selected sites, training of health personnel in clinical and laboratory procedures at district hospitals, program management and monitoring, and technical assistance for the development of the Second MTP (1994-98). Given the rapidly rising HIV/AIDS trend in Mali, further Bank support would be required to meet the program needs under the Second MTP currently under preparation. (vii) Mauritania. Under the ongoing Second MTP (1994-1998), financial support for high priority activities is being provided through the ongoing Health and Population Project. A total of US$0.9 million has been allocated under the IDA credit to support the program during the next 3 years (1994-97). The funds include substantial support for IEC, training, and epidemiological surveillance (including a small-scale STD/HIV prevalence survey among pregnant women in Nouadhibou). (viii) Niger. The first Bank support for AIDS in the Sahel was provided in 1987 under the ongoing Health Project for the procurement of laboratory equipment to ensure blood safety. Since then, considerable support has been provided through both the Health Project and the new Population Project. Funding has focused primarily on IEC initiatives, epidemiological surveillance, procurement of STD and anti-tuberculosis drugs, and strengthening laboratory capabilities at the national and selected regional hospitals, particularly to ensure safe blood transfusions. Total Bank support under the two credits is USS1.3 million. Following Senegal, Niger is the second country in the Sahel to benefit from Bank support in conducting a STD/HIV Rapid Risk Assessment Survey, which was completed in June 1993. The survey has significantly improved the knowledge about the prevalence of major STDs in the agglomeration of Niamey, and therefore provides valid data for strengthening the National STD and AIDS Program (see Annex 1, item 6, for further details). It is also envisaged that the new Health Project (FY96), currently under preparation, will provide substantial support for AIDS prevention activities. 21 (ix) Senegal. Direct financial support to the National AIDS Program has not yet been provided, although an official request is expected for support of planned activities during the 1994-1998 five-year Strategic Plan. However, support is being provided for IEC activities for youth through the Family Life Education prograrn financed under the ongoing Human Resource Development Project. Total Bank support for AIDS prevention activities is estimated at US$600,000. C. SUPPORT FROM THE NON-GOVERNMENTAL SECTOR 50. Over the past few years the changing political situation has given rise to the creation of a number of local NGOs either as local affiliates of international NGOs, such as SIDALERTE, Society for Women Against AIDS in Africa (SWAA), Save the Children Fund (US and UK), and ENDA Tiers Monde, or as independent local organizations venturing into community activities dealing with women's reproductive health issues and AIDS. There is also a numnber of well- established international NGOs doing interesting work on AIDS prevention. Notable amnong these are Care International, focusing primarily on migration issues, and Population Services International and the Futures Group, both promoting social marketing of condoms. Family Health International, through its AIDSCAP programs, is also targeting specific groups for AIDS prevention activities. These international NGOs are primarily funded through USAID. In addition, considerable support for epidemiological surveillance is being provided in four countries through CIDA under the PASE project (Projet d'Appui a la Surveillance Epidemiologique). D. LESSONS LEARNED 51. Over the last 10 years a series of programs in communicable disease prevention, family planning, and, more recently, AIDS has been developed in the Sahelian region. The success of these interventions has varied. While some small-scale interventions have been notably successful, few state-organized national level interventions have demonstrated similar results. The varying impacts are illustrative of the difficulty faced in changing one of the most complex social behaviors - sex - and accepted norms of sexuality, are intimately linked to gender relations and religious norms, and are shrouded by social taboos that limit public discussion. AIDS forces discussion of sex and its relationship to disease, death, and life. Some of the main lessons learned over the last decade in developing AIDS interventions in Africa and elsewhere are: (a) Behavioral change is difficult and slow. There is a need to address the non- cognitive determinants of behavior. In the earlier stages of the global response to AIDS, the exhortation to provide information in an attempt to halt its spread led to a profusion of biomedical jargon directed at the public. This strategy increased recall of the name of the disease but it did not increase knowledge of the causes, symptoms, and treatment options available for the opportunistic infections associated with AIDS. More importantly, recall of the disease did not produce the desired behavioral responses. Changing sexual behaviors requires research on the non-cognitive aspects of these behaviors, and the belief systems that exist about death, sickness, disease, and sexual practices. Effective AIDS education initiatives must be based on an understanding of the socio-cultural dynamics and the nexus between treatment options, service delivery modes, gender relations, and the belief systems mentioned above. It is necessary to convince policy makers to have more realistic expectations for behavioral change. 22 (b) Comprehensive programs are essential. While the demand for condoms should be addressed at the early stage of programs, supply side issues must also be addressed very early in program development. Communication is frequently associated with the production of materials and diffusion of information that stimulates the demand for services. Demand-side approaches to communication fail to address service delivery concerns. Stimulating demand for services that do not exist, or that cannot adequately serve the population, reduces the credibility of the source of information and prejudices the target audience's attentiveness to future messages. Attention must also be paid to the quality of the services provided. One of the main reasons for low levels of service utilization in the Sahel is that the client's negative perceptions or experiences are communicated within the social networks. To improve the utilization of services, clients must be provided with quality services; quality being defined from both cultural and technological perspectives. Strategies for stimulating demand and providing quantitative and qualitative inputs into the supply for services must be incorporated within a comprehensive AIDS communication plan. Attempts at coordination between supply- and demand-side approaches are difficult when communication strategies have been developed independently, or in an ad hoc manner. (c) Local institutional capacity building is essential. Response to the AIDS epidemic comes spontaneously from within. It is necessary to relate to what is happening at the country level and build upon these efforts. Decentralization of decision-making should be encouraged. Multiple actions with significant amounts of funding (i.e. dosage effect) can be effective. However, donor agencies need to be careful not to thwart community-level institutional infrastructure through the creation of new organizational structures and/or through overfunding. In some instances, the best strategy might be to leave communities alone. (d) The importance of targeting youth. Interventions targeting youth constitute an important cost-effective means of preventing and mitigating the spread of STD/HIV. However, perceptions that sex education and teaching about reproductive health may encourage early sexual activity among youth represent highly negative barriers to the implementation of effective prevention programs for young people. Various studies, however, have shown no evidence of increased sexual promiscuity and precocious sexual activity among youth receiving sex education.2" In addition, some of these studies (6 out of 19) concluded that "sex education either delays the onset of sexual activity or decreases the level of sexual activity." In many of the studies (10 out of 19), it was found that sex education has increased adoption of safer practices by sexually active youth. Therefore, there is strong evidence that effective school-based sex education programs may serve as effective mechanisms for promoting changes in sexual behavior. (e) The importance of provincial/regional approaches. The ethnic and social variations in the sub-region necessitate a mosaic of communication approaches within a country. These approaches have a greater appeal to the intended audience and are cost- effective. National boundaries are not indicative of cultural differences and strategies can be tailored to the linguistic and cultural diversity of the region. Programs developed in one 21 This follows a detailed review of 19 studies that evaluated the sexual behavior of students receiving sex education. The reviews were undertaken by WHO/GPA in collaboration with research groups at Macquarie University in Sydney, Australia; the University of Exeter, U.K., and The Bowling Green State University in Ohio, U.S.A. 23 country may be relevant to populations residing in another country when the socio- economic as well as infrastructure realities within countries are taken into account. Innovation is key; it is therefore important to learn from others. (f) The important role of technical assistance. Specialists' assistance is often required in project development, implementation, and evaluation given the relative inexperience and limited manpower capabilities of local implementing agencies. Technical assistance must be planned to build institutional capacity and reduce the reliance on external assistance. 24 [V. PROPOSED BANK STRATEGY AND INTERVENTIONS 52. The issues discussed above and the lessons learned underscore the need for broad-based intersectoral, multilevel strategies, focusing principally on preventive measures to mitigate the spread of the epidemic as well as to cope with the burden of the disease. In a sub-region where the disease is principally transmitted through heterosexual intercourse, the challenge of changing sexual behavior is daunting. Low literacy levels, low status of women, religious and social taboos, and a limited human resource base constitute major irnpediments to efforts to combat the epidemic. The Bank is well-placed to help these countries take advantage of the window of opportunity that still exists to mitigate the rapid spread of the epidemic in the region. Its comparative advantage in policy dialogue at the highest level can ensure greater visibility and effective integration of HIV/AIDS issues into macroeconomic dialogue and country assistance strategies. Its interventions in almost all sectors of the economy can facilitate effective interaction among the various actors in the field; and its funding capacity can help meet major gaps in the resource needs as other funding sources dwindle. 53. Only an immnediate full-scale, broad-based attack on the problem can prevent a generalized epidemic and major developmental set-back for the Sahelian countries. To this end, the Bank would support a two-pronged strategy. First will be country-level activities supported through lending operations and sector work. This support will focus on medium- to long-term strategies to develop sustainable policies, programs and institutions to deal with the epidemic. Second will be support for a short-term (3 years, FY 95-97) high-impact interventions at the regional level. This program will complement national programs by helping to build a regional coalition, increase the level of political commitment at the national level, and achieve maximum impact in the shortest time possible. These two strategies are summarized below and described in more detail in Section IV of this report. A. COUNTRY-LEVEL ACTIVITIES SUPPORTED THROUGH LENDING AND SECTOR WORK 54. While efforts will be made to support AIDS initiatives in all countries in the sub-region, there is a need to focus on countries with the greatest needs in order to achieve maximum impact. An attempt has therefore been made to rank the countries in order of priority for IDA support. This ranking is based on the current assessment of: (a) the perceived trend in the spread of the epidemic (scope and earlier occurrence of the epidemic, population size, migration patterns and geographic proximity to hyper-endemic countries); (b) program quality (section II, para. 35-44); and (c) the adequacy of funding. Burkina Faso, Mali, and Niger are ranked as high-priority countries, followed by Chad, The Gambia, and Mauritania as medium-priority countries, and Senegal and Cape Verde as low-priority countries. Guinea Bissau and Sao Tome & Principe are not rated due to lack of relevant information. 55. For each of these countries the nature and level of Bank support would depend on the priorities already defined in the second MTPs and the extent of resources committed by the governments as well as other donors. However, the Bank's strategy for country assistance programs would cover activities in these key areas: (a) strengthening and expanding ongoing HIV/AIDS communication programs at the country level; (b) accelerating the establishment of social marketing programs to promote condom use; (c) expanding clinical management and care of 25 STD/HIV-infected persons, epidemiological surveillance, and laboratory capacity; (d) increasing assistance for community/NGO and private sector initiatives, particularly in support of programs in the work place and home care of HlV-infected persons and those with AIDS; (e) promoting of broad-based policy analysis, program coordination, research, monitoring and evaluation; and (f) improving collaboration and coordination with key donors in the region. Attention would be given to inter-country and inter-regional dimensions of the problem while taking into consideration specific national concerns. 56. Strengthen and expand ongoing HIV/AIDS communication programs. While the approach to communication program development does not represent a break with previous approaches to health communication in the sub-region, its inadequacy is magnified in the case of STD/AIDS prevention (paras 36-39). Changing sexual behavior requires an in-depth understanding of socio-cultural norms and behaviors regarding sex, sexuality, gender relations, and the public discussion of these subjects. In this regard, the Bank's AIDS communication strategy would focus primarily on assisting the NAPs in broadening the range of channels currently being used and will: (a) involve beneficiary participation in all stages of program design and implementation; (b) be research-driven and adhere to a systematic approach to communication program development; and (c) pay particular attention to the evaluation of the cognitive, attitudinal, and behavioral impact of communication interventions. 57. The objectives of the Bank's AIDS communication strategy will be to: (a) increase knowledge about STDs/AIDS as well as the perceived sense of the risk of contraction among specific target populations (decision makers, opinion leaders, service providers, women, and youth) as well as the general population; (b) promote safe health and sexual practices; (c) promote the utilization of health services for treatment of STDs and care of HIV/AIDS cases; and (d) contribute towards the development of local manpower with expertise in communication, particularly to strengthen the capacity of health communication personnel to design, manage, implement, and evaluate multi-channel behavior change interventions; and support the integration of communication skills in the curricula of tertiary-level institutions that train public health personnel. Support would be provided in the following five critical areas: (i) mass media production and dissemination of information; (ii) interpersonal communication and peer education, particularly for youth both in and out of school; (iii) consultative meetings and seminars to build a strong political commitment at the highest level to address the problem; (iv) training; and (v) research and evaluation to improve the quality of data on the social, cultural and economic determinants of sexual behavior patterns, the utilization of treatment facilities, and the impact of communication interventions. 58. Condom promotion. With the exception of Burkina Faso, no country has yet launched a nationwide condom promotion program for STD/HIV prevention, using all possible channels of delivery. Critical elements of the Bank's strategy will be to: (a) assist the countries in the region to develop nationwide condom social marketing programs; and (b) strengthen and expand the existing public sector distribution network, through procurement of condoms, training, and logistic support. With regard to condom social marketing, efforts are underway in Niger under a USAID-funded initiative and, in The Gambia, the Government has requested IDA-funding for a similar program. Senegal, Mali, Mauritania, Chad, Guinea Bissau, and Sao Tome & Principe, are yet to come on stream and efforts will be made to assist these countries to initiate similar programs. To accelerate the process of implementing such a program, preparatory work would be supported under the proposed centrally-funded regional program (para. 65). 26 59. Expanding clinical management of STD/IIV, epidemiological surveillance and laboratory capacity. The Bank's strategy will be to support the integration of STD/HIV services, namely case management, care and counseling at all levels of the public health system, and to build capacity for referral at the secondary and tertiary levels. In particular, emphasis will be placed on: (a) integrating STD/HIV case detection and counseling in the primary health care and family planning programs; (b) enhancing clinical capacity to enable screening and diagnosis of STDIHIV, particularly among women, and providing opportunities for youth to seek help through non-formal networking; (c) developing a robust epidemiological data base through improved data collection at the peripheral level, and laboratory confirmation of most frequent syndromes at the regional and central levels; (d) training of the various levels of health personnel, social workers, laboratory technicians, data analysts in appropriate cognitive skills (counseling, referrals, testing, and data recording and management); (e) developing protocol/clinical algorithms to improve diagnosis, treatment and follow-up of STD patients and treatment for tuberculosis; (f) developing the capacity for blood screening and precise guidelines for blood transfusion to avoid unnecessary transfusions; and (g) providing essential drugs and laboratory supplies. 60. Support for NGO/community/private sector initiatives. To ensure effectiveness of AIDS initiatives, it is essential to foster ownership of activities by involving, from the outset, individuals and communities who are directly or indirectly affected by HIV/AIDS. In addition, involvement of CBOs, including various youth and women's associations, NGOs and industry (including various workers' associations) in activities in which they are more efficient, such as targeted information dissemination, counseling, and peer education programs, would be supported under the Bank's strategy. Moreover, during the next three to five years, the growing number of AIDS patients and orphans of AIDS (paras 14-16) would necessitate support for community and home care of AIDS patients and their families. As experience for Eastern Africa demonstrates, NGOs would be actively encouraged, under the Bank's strategy, to support home and community care initiatives. Where needed, technical and financial assistance would be given to CBOs, NGOs and the private sector to enhance their institutional capacities. Also, recognizing the important role of traditional healers as a source of care, the Bank's strategy would be to encourage the exploration of mechanisms to integrate them into the system of care. In addition, effective coordination and communication would be encouraged among all actors to avoid duplication of efforts and misuse of resources. 61. Support for multisectoral interventions. In addition to support for NGO/community initiatives and health sector interventions, the Bank, through its lending program, would encourage the inclusion of AIDS prevention activities in other sector-specific investment lending, especially in education, agriculture, industry, and urban development. Programs in these sectors affect the masses of the population and are thus effective vehicles for reaching the most vulnerable groups. In addition, efforts will continue to strengthen the poverty and gender focus of Bank interventions to provide the enabling environment for effective actions in all sectors. In the education sector, beyond the conventional in-school health education programs through which AIDS education activities are being promoted, a more comprehensive program to address AIDS within the sector needs to be developed. Already, the Bank has initiated a major step to increase enrollment of girls in primary and secondary schools, a critical factor in reducing the social and economic vulnerability of women (paras 25-29). Task managers would be encouraged to collaborate with UNESCO, which is in the process of developing a program on AIDS, to address policy and institutional concerns in the education sector. Similarly, the Agriculture and Environment Division would be encouraged to link up with FAO, which is currently assessing the implications of the AIDS epidemic in the agricultural sector. Task Managers in all sectors would be sensitized to the 27 issues, and encouraged to take the lead in policy dialogue relating to appropriate actions in their sectors. At the country operations level, country officers and economists would be encouraged to discuss AIDS issues at the highest level of government in their macroeconomic dialogue, and to include these issues in documents such as Country Assistance Strategies (CASs) and Policy Framework Papers (PFPs), etc. To enhance their capacities to deal with these issues at the macro level, they would be encouraged to undertake country-specific analyses of the economic impact of AIDS, drawing on the various sectoral analyses to be undertaken by the various sector operation divisions (para. 63). 62. Program management and coordination. The multisectoral nature of interventions necessitates a strong and effective coordination mechanism in order to avoid duplication of efforts and conflicting objectives. The Bank's strategy would be to provide support to strengthen coordination of activities at all levels, encourage decentralization of program management to the local level, and support management training. National AIDS Committees would be given support to: (a) increase their capacities to collect and make available relevant baseline data for decision making by those participating in the planning and implementation process; (b) facilitate the identification of the unique roles of the various sectors, NGOs and other actors; (c) ensure the political commitment at the highest level, including, in particular, the active participation and leadership by the Ministry of Finance and Plan; (d) take active leadership in the planning process to ensure maximum ownership of the plans; and (e) ensure that AIDS planning is synchronized with overall health and development planning. 63. Policy analysis, research, monitoring and evaluation. As the epidemic advances in the Sahel, there is an ever-increasing need to understand its determinants and consequences in order to adopt appropriate policy changes, and continuously refine program planning and implementation strategies. Building strong political commitment for effective action will depend primarily on understanding the burden of the disease on society as a whole. To this end, in-depth analytical research is required. A specific research agenda will be collaboratively developed at both national and regional levels. The ongoing Bank support for the collection of epidemiological data in all AF5 countries (Annex 2) will be complemented by a more comprehensive research agenda directed at the following areas: (a) Socio-cultural and behavioral dimensions of AIDS. Considerable analytical work has already been conducted in most of the countries regarding gender issues and development.' These studies would be complemented by formative research focusing primarily on: (i) analysis of the social and cultural determinants of sexual behavior, sexual preferences, and cultural practices such as circumcision, bloodletting, etc., and their link to HIV transmission and assessment of the appropriate channels and mediums for the diffusion of AIDS education and information messages; (ii) evaluation of the behavioral and attitudinal impact of communication programs, a very much neglected area; and (iii) evaluation of the cost-effectiveness of interventions; and (b) Economic analysis. Although the channels through which AIDS will have an economic impact is clear (paras 13-17), the magnitude of the impact is still not well documented both due to a dearth of studies measuring current impacts and in the case of the Sahel, because of the uncertainties concerning the future spread of the disease. The 22 WID and poverty assessments have been undertaken in all Sahelian countries. 28 proposed research agenda would include: (i) analysis of the economic and demographic burden of the disease; (ii) its public expenditure implications; (iii) current and future costs to households; and (iv) implications for employment and productivity, GDP growth and GDP per capita. 64. The Bank's role, through investment lending, sector work, and dialogue with govemmet, would be to assist policy makers in defining policies, undertaking legislative reforns, and providing guidelines regarding such issues as AIDS in the workplace, confidentiality, empowerment of women (reproductive health issues, economic and social status), and youth and AIDS. B. REGIONAL ADVOCACY AND CAPACITY-BUILDING PROGRAM 65. Rationale. A key element of the Bank work program on AIDS for FY95-97 will be the development of a regional advocacy and capacity-building program to complement the ongoing and proposed national programs. The economic and social linkages and the scarcity of technical and financial resources caDl for the development of integrated regional strategies and collaboration to increase the effectiveness of HIV/AIDS interventions at the country level. A regional program with high visibility and substantial grant financing from the donor community can bring the necessary urgency to bear on the problem. There are also important regional factors, notably inter- country migration, which are accelerating transmission and which cannot be adequately addresed through a country-by-country approach. There is also much to be gained through cross- ferdlization of ideas, "peer pressure" among decision-makers, and program planning in a sub- region where social/sexual behavior and political sensitivities to the problem are relatively uniform. Moreover a broad regional coalition backed by sizable funding from the donor community would be more effective in taking the bold actions required in overcoming denial and inertia at the national level. Such a regional program would also have the advantage of ensuring collaboration among the major international agencies concerned (UNDP, WHO, UNICEF, and the Bank) and drawing upon their comparative advantages. 66. Proposed activities. The thrust of the proposed regional program wil be to: (a) establish a full-scale Information, Education and Communication (IEC) program to widely disseminate information on the disease and its prevention; and (b) foster regional cooperation and explore innovative approaches to controlling the spread of the epidemic. Such extensive, high-impact programs are difficult to launch and implement through country lending programs, which lack the synergistic advantages and economies of scale of a regional approach. A regional program could recruit the best program specialists, often unavailable at the country level, and develop a broad- based campaign aimed at having the maximum regional impact in the shortest period of time. Thae efforts would entail: (a) Mobilizing political and opinion leaders and organizations throughout the region to address HIV/AIDS issues at the highest level. Regional workshops, seminars, study tours and other kinds of group initiatives would be organized to exchange ideas and build a regional consensus at the highest level. Quarterly consultations would be conducted to evaluate progress and identify areas for further action; (b) Identifying and working with national figures/local heroes (political, religious and sports personalities) with regional appeal to develop strong advocacy roles and mount aggressive education and information campaigns; 29 (c) Supporting pilot projects to test innovative ideas, particularly those relating to cross-border issues, such as migration (developing sub-projects around border towns and areas of affinity), condom promotion, etc.; (d) Promoting studies and research of regional significance by universities and research centers in the region, establishing collaborative arrangements with research centers, developing research networks, and providing opportunities for research results to be incorporated into programs at the national level; and (e) Providing technical support and training to NAPs to improve their capacity to manage multisectoral national programs and upgrading the quality of the response to the national HIV/AIDS issue. 67. A variety of communication channels would be utilized to reach certain audiences with specially designed messages regarding information on HIV/AIDS, prevention interventions and appropriate health seeking behavior. Cultural and language differences as well as points of optimal access to target groups would be given extensive consideration and attention. These activities would be coordinated with bilateral donor financing and in-country Bank projects that strengthen health services, in particular STD clinical management and counseling, family planning, and condom distribution. Support will be given for the development of effective mechanisms/ structures to coordinate and facilitate the implementation of the regional activities. The nature and form of the mechanisms/structures were discussed during a regional technical planning workshop held in Ouagadougou, Burkina Faso from September 11-15, 1994. The workshop brought together 61 participants including NAP managers and observers from UNDP, UNICEF, AIDSCAP, CARE International, SIDALERTE, and Save the Children Fund (US and UK), as well as representatives of local NGOs. Participants identified priority problem areas at the regional level and selected specific interventions to address these priority areas. Constraints to program development and execution were identified and complementary interventions required to ensure effective implementation were discussed. 68. The total budget for this program is estimated at US$6.0 million over a 3-year (FY95-97) period, or US$2.0 million per year, of which US$1.2 million is expected to be provided through the Special Grant Program (SGP) as the Bank's contribution. The SGP has approved funding (US$300,000) for the first year (FY95) of this program. In addition, the Bank will allocate the equivalent of one staff position to manage the program. The remaining US$1.6 million for FY95 would be funded from external sources yet to be determined. It is anticipated, however, that the complementary donor financing would be readily forthcoming since such a program is widely seen as a high priority in the Sahel. The estimated cost breakdown by activity is shown in Annex 5. C. IMPROVING COLLABORATION AND COORDINATION WITH DONORS. 69. The activities defined above can only achieve effective results if there is true partnership and collaboration among the key donors actively seeking to assist national and local authorities in the Sahel in combating the epidemic. The importance of this issue was clearly recognized by donors who attended the Inter-Agency Meeting on AIDS held by the Sahel Department in September 1993. Although the partnership issue is complex and often difficult to resolve, the will is there and resloution is possible. Bank management recently made a commitment to support and actively participate in the UN co-sponsored program. The Bank will work within the broad 30 framework of this program and actively collaborate with key agencies (WHO/GPA, UNICEF, UNDP, and UNFPA). Contructive dialogue and partnership will be developed with the mujor bilateaml agencies (such as USAID, FAC, the Nordic govermnents, Germany, and Canada) as well as with NGOs, afl of which are actively supporting initiatives in AIDS prevention in the Sahel. 31 BIBLIOGRAPHY Ainsworth, M. and Over, M., The Economic Impact of AIDS: Shocks, Responses, and Outcomes. World Bank Technical Working Paper, no. 1. Washington, D.C.: World Bank, 1992. Amat-Rose, J. et al., (1990) 'La geographie de l'infection par les virus de l'imun cience humaine en Afrique noire: Mise en evidence de facteurs d'epidemisation et de r6gionalisation," Bulletin de la Societe de Pathologie Exotique et de ses Filiales 83(2): 137-148. Benor, D. et al., Agricultural Extension: The Training and Yisitation System, Washington, D.C.: World Bank, 1984. Brenzel, Logan,(1994) "The Economic Impact of AIDS in Burkina Faso". Report submitted to the AF5PH division, World Bank, under the preparation of the Population and AIDS Project (FY94). Bulatao, R. and Bos, E., Projecting the Demographic Impact of AIDS. World Bank Staff Working Paper, no. 941. Washington, D.C.: World Bank, 1992. Caldwell, J., Caldwell, P., and Quiggin, P., (1989) "The Social Context of AIDS in Sub-Saharan Africa," Population and Development Review 15(2): 185-234. Daniiba, A., Vermund, S., Kelley, K., (1990) "Rising Trend of Gonorrhea and Urethritis Incidence in Burkina Faso from 1978 to 1983", Transactions of the Royal Society for Tropical Medfcine and Hygiene 84(1): 132-135. Dayal, R., "Social and Gender Dimensions of the AIDS Epidemic in AsiaW (draft). World Bank, Asia Technical Department, April 23, 1993. de Bruyn, M., 'Women and AIDS in Developing Countries," Social Science and Medicine 34(3): 249- 262. Demographic and Health Surveys: Burkina Faso - Preliminary Report (1993). Demographic and Health Surveys: Niger (1992). Demographic and Health Surveys: Senegal (1987). Foster, S., Lucas, S., (1991) "Socioeconomic Aspects of HIV and AIDS in Developing Countries: A Review and Annotated Bibliography," Department of Public Health and Policy, Lodon School of Hygiene and Tropical Medicine. Harrison, L.H. et al., (1991) "Risk Factors for HIV-2 Infection in Guinea-Bissau," Journal of Acquired Immune Deficiency Syndromes 4(11): 1155-60. Hunt, C., (1989) "Migrant Labour and Sexualy Transmitted Diseases: AIDS in Africa," Joumal of Health and Social Behavior 30(4): 353-373. 32 Jancloes, M., "Balancing Community and Government Financial Responsibilities for Urban Primary Health Care: Pikine-Senegal, 1975-1981." In Primary Health Care: The Africa Experience, edited by R. Carlow, R., and W. Ward. Oakland, CA: Third Party, 1988. Kennedy, E., Successful Nutrition Programs in Africa: What Makes them Work? World Bank Population and Humnan Resources Department Working Paper, no. 706. Washington, D.C.: World Bank, 1991. Koumare, B., Ba, M., Jesencky, K., and Nichols, D., (1990) "A Pilot Intervention to Slow the Spread of AIDS in a High-risk Group in Bamako, Mali", unpublished. Lamnboray, J. and Elnendorf, E., Combating AIDS and Other Sexually Transmitted Diseases in Africa: A Review of the World Bank Agenda for Action, World Bank Discussion Paper, no. 181, Africa Technical Department Series. Washington, D.C.: World Bank, 1992. Kim, Young-Mi, et al., (1992) "Improving the Quality of Services Delivery in Nigeria," Studies in Family Planning 23(2): 118-127. Lindan, C., Allen S., et. al., Knowledge, Attitudes, and Perceived Risk of AIDS Among Urban Rwandan Women: Relationship to HIV Infection and Behavior Change. Current Science Ltd, December 1990. Over, M., The Macroeconomic Impact of AIDS in Sub-Saharan Africa. World Bank Technical Working Paper, no. 3. Washington, D.C.: World Bank, 1992. Reid, E., (1992) The Challenge of the HIV Epidemic. Paper presented to the Royal Australian Colege of Medical Administrators, Brisbane, Australia, April 22, 1992. Reid, E., (1992) "Why Women and HIV? It Takes Two to Tango, Safely," AIDS Health Promotion Exchange no. 3, Royal Tropical Institute (Netherlands). Sicard, J., Kanon, S., Quedraogo, L. and Chiron, J.P., (1992) "Evaluation du comportement sexuel et des connaissances sur le SIDA en milieu scolaire au Burkina Faso: Enqu&e connaissances, attitudes, crayons et de pratiques (CACP) a Banfora sur 474 adolescents de 14 a 25 ans." Annales de la Societe Belge de Medecine Tropicale 72(1): 63-72. Summary of the Meeting on AIDS Prevention and Control in the Sahel, Washington, D.C. October 5, 1993. U.S. Agency for International Development, "HIV/AIDS Strategic Action Plan for Asia" (Draft). Washington, D.C., 1993. U.S. Bureau of the Census, AIDS/HIV Surveillance Database, Center for International Research, Washington, D.C., 1992. United Nations Development Programme, Young Women: Silence and Susceptibility and the HIV Epidemic, n.d. 33 Wasserhelt, J.N., and Holmes, K.K., (1992), "RTIs: Challenges for Intemational Health Policy, Programs and Research." In Reproductive Tract Infections: Global Impact and Priorities for Women's Health, edited by Gernain, A., Holmes K.K. Piot, P., Wasserheit, J.N. New York: Plenum Press, 1992. World Bank, (1992) "Tanzania: AIDS Assessment and Planning Study." Population and Human Resources Division, Southem Africa Departnent, Report No. 9825-TA. Washington, D.C., June 1992. World Bank, (1992) "Women and AIDS in Sub-Saharan Africa." Women in Development Unit, Poverty and Social Policy Division, Technical Department Information Note, September 1992. World Bank, (1993) Brazil, AIDS and STD Control Project Staff Appraisal Report, Human Resources Division, Country Department I, Report No. 11734-BR. Washington, D.C., October 8, 1993. World Bank, (1993) Burkina Faso: Proposed Population and AIDS Control Project, Staff Appraisal Report (Draft). Washington, D.C., November 1993. World Bank, (1993) Zimbabwe: Sexually Transmitted Infections Prevention and Care Project, Staff Appraisal Report, Southem Africa Department, Population and Human Resources Operations Division, Report No. 11730-ZIM. Washington, D.C., May 28, 1993. Yelbi, S., Valenti, P., Volpe, C., et al. (1992) Assessing Health Education Needs for AIDS among immigrants in an Urban Context: Cote d'Ivoire. Paper presented at the International Conference on AIDS, 1992. CFd 3,-1995 4:50DOC Februsay 3. 1995 4:50 PM r1 Annex 1 Page 1 of 8 Brief Country Profiles I BURKINA FASO As of December 31, 1992, 2,886 cumulative AIDS cases have been reported in Burkina Faso, with 1,073 cases reported for 1992 Figure 1: HEIV S&roprvslace for Pro_Utute alone (although the actual Ougadougou, Buridn Fawo 199 number of cases is most likely much higher).' A 45 Sour: US. Bumu ofCenaL, 1989 study among 40 - Novarmbx1992 *IDH-1 prostitutes in Ouagadougou 35i *HI-2 showed HIV-1 levels 30 ranging from 0 to 14.3% 25 and HIV-2 from 9.8% to as 15 - high as 41.6%, with a peak 10 - in the 40-49 age group (see 5 Figure 1). A more recent 0 study conducted in 10-19 20-29 30-39 40-49 50+ December 1991 among 182 Age Groups prostitutes in Bobo-Dioulasso as part of a joint project of Family Health International (AIDSCAP) and the Centre Muraz, showed that 45% of women screened were HIV positive. Prevalence rates among STD patients were estimated at 15.6% and 19.2% in two studies conducted in Ouagadougou (1985-86) and Bobo-Dioulasso (1990-91) respectively, with approximately one out of four TB patients found HIV positive. Infection rates among pregnant women increased significantly from 1.7% in 1985-87 to 4.9% in 1990 and 7.2% in 1991 (HIV-1). A recent survey supported by GTZ in Gaoua, Province of Poni (near Cote d'Ivoire) in 1992, showed a staggering HIV prevalence rate of 14.5% among a similar group, approaching prevalence rates encountered in urban areas of neighboring hyperendemic countries (Cote d'Ivoire, Ghana). These last figures are of particular concern for a population of supposedly low risk, and therefore call for vigorous intervention programs. A seroprevalence survey among 197 truck drivers in Ouagadougou in April-May 1993 showed, on the other hand, prevalence levels of over 13%, which again confirms the steady increase of HIV infections (mostly HIV-1 and dual HIV-1/2) in various population groups in recent years. Concerns about increased risk of STD/HIV transmission among occupational groups such as truck drivers and particularly among miners (reflecting the importance of the gold mining industry in the country) underscore the importance of further investigating the social-behavioral aspects of transmission of the disease to assist in the design of appropriate interventions. Although data are routinely collected in all health centers with regard to more "traditional" STDs such as syphilis and gonococcal infections, prevalence of these infections has been estimated at approximately 2-3 and 7-9 cases per 1,000 STD consultations in 1987- 1988. This information should be interpreted very cautiously given the unavailability of efficient laboratory facilities for diagnostic confirmation, except for the Centre Muraz in Bobo- Dioulasso. Results obtained from the STD/HIV prevalence survey conducted in 1991 among prostitutes in Bobo-Dioulasso are the only reliable information on prevalence of few STDs 1 Source: Lankoande, S., Protocole d'tude de prevalence des maladies jexuellement transmissibles et des ihfections VIH au Burkina Faso. CoU National de Lutte contre le SIDA, Jume 1993. Annex 1 Page 2 of 8 such as syphilis and chlamydial infections (approximately 10%) and gonococcal infections (5.5%). These fragmentary data make it difficult to provide reliable estimates of HIV prevalence at the country level, although it could be estimated that between 300,000 and 425.00 inhabitants are actually HIV positive, assuming a prevalence of between 7-8% in the adult population (15-49 years of age). These figures are estimated from information derived from surveys and sentinel surveillance programs addressing pregnant women seen on consultation in selected antenatal clinics, and occupational groups such as truck drivers. These estimates should again be interpreted with great caution based on important variations in prevalence rates between higher endemic regions (Southern and Western Provinces closest to Cote d'Ivoire, Ghana and Togo) and regions with relatively low endemicity (Eastern and Northern Provinces), and urban (prevalence rates among adult population estimated between 7 to 9% in Ouagadougou and Bobo-Dioulasso) vs. rural areas. However, the epidemiological situation in Burkina Faso seems to have reached a dramatic and rapidly worsening proportion. 2. CHAD In Chad, only 59 cases of AIDS were reported in 1990. However, by December 31, 1992, the cumulative total of AIDS cases reported had increased to 899, and as of June 30, 1993, to a total of 1,131. Although these numbers indicate a rapid increase in the number of AIDS cases, the lack of adequate and reliable seroprevalence data makes it difficult to assess the extent of HIV infection in the country. A survey conducted in 1989 among the adult population in four sentinel surveillance sites showed levels varying from 0 to 1.6% for HIV-1 infections, with an estimated rate of 1. I % for the city of N'Djamena. In 1992, data from a small-scale study indicated much higher levels of HIV infection among pregnant women (3.1 %), blood donors (4.3%), and tuberculosis patients (8.8%). Most recent data obtained from five selected sentinel surveillance sites (January-October 1993) showed a significant increase among pregnant women in N'Djamdna (3.8%) and Moundou (7.6%), while in other cities the rates varied between 2% and 3.1%. Information on prevalence of STDs is very limited. 3. THE GAMBIA In The Gambia, where more relevant and updated data on various STDs are available, a cumulative total of 240 AIDS cases was reported as of mid-June 1993, with HIV-2 infections representing about 55% of all cases. National seroprevalence surveys conducted in 1988 and 1991 respectively revealed an increase in HIV from 1.7% to 2.2% among the general population, with a predominance of HIV-2 (over 75% of all positive cases). A study among commercial sex workers (CSWs) showed an overall prevalence of 30% in selected urban areas. Two studies conducted among STD patients in 1989 and 1990 estimated prevalence rates varying from 4.9% to 6.7%, while data from sentinel surveillance systems found infection levels for pregnant women to be 1.4% in 1990. However, a study conducted in 1985 among Annex 1 Page 3 of 8 attendants of antenatal clinics showed that between 22% and 27% were positive for N.gonorrhoeae and 35% for C.trachomatis infections, which is of particular concern for the further spread of HIV. Preliminary results from the recently launched MRCIGOG longitudinal study on the perinatal transmission of HIV infection2 among all women attending eight (8) antenatal clinics throughout the country showed a relative stability of HIV-2 (about 1.0%) but a significant rise in HIV-1 prevalence (at 0.6%) compared to previous surveys. According to the same study, an estimated 4.2% of women had serological confirmation of active syphilis. This high prevalence of syphilis, combined with the observed upward trend of HIV-1 intection. constitute a major cause for concern. There is also evidence of particular patterns of STD/HIV transmission among specific ethnic groups, such as a high prevalence of syphilis among the Jola women in younger age groups and presence of HIV- 1 infection among the Serahuli group in the Upper River Division. These preliminary results show the need for specific control program interventions in the very near future. 4. MALI A total of 460 AIDS cases were reported in Mall during 1992, compared with 377 and 242 cases in 1991 and 1990, respectively. This represents an almost twofold increase during this 3-year interval, with a cumulative total of 1,479 cases reported as of March 1993. However, these reported cases were derived exclusively from the two main hospitals in Bamako, and this clearly underestimates the actual number of AIDS cases in the country. Results from a study of prostitutes in Bamako in 1987 showed that nearly one-quarter (23%) were infected by HIV-1, while an even larger proportion (27.4%) was HIV-2 seropositive. A study among pregnant women in Bamako also showed the presence of both infections in 1987, with rates of 0.4% for HIV-1 and 1.4% for HIV-2. Seroprevalence among blood donors in 1987 and 1988 has more than doubled, increasing from 1.7% to 4.1%. Preliminary results from a national prevalence survey conducted among the general population trom the eight regions (sample size of 4,892 participants) during 1992 and early 1993 indicate a significant increase in HIV infections, varying from 2% in Gao and Tombouctou to levels of 4% to 6% in Kayes, Segou, Bamako, and even higher (over 6%) in Sikasso, which is closer to C6te d'Ivoire. The overall national prevalence was estimated at 5.3%, with 3.4% prevalence for HIV-1, 0.9% for HIV-2 and 1.0% for dual HIV-1/2 infections. While these results should be interpreted with caution due to biases in the selection criteria of studied population groups, they seem to indicate a rapid increase in HIV infections, particularly HIV-1. No reliable data are available on other STDs. 2 PreliminuyProgress Note, July 1993. Ann=x 1 Pae 4 of 8 5. MAURITANIA In Mauritnia,' a cumulative total of 40 AIDS cases have been reported as of December 31, 1992. However national authorities acknowledge that this represents an under- estimation of the real number of cases in the country, mainly due to a lack of awareness and training of health professionals, as well as weaknesses in laboratory support for case confirmation. Studies conducted in 1986 among pregnant women, STD patients, and prostitutes showed HIV prevalence varying from 0% to 0.6%. The prevalence still remains at 0% among a representative sample of 200 pregnant women according to a survey conducted in Nouakchott in 1992. Data collected from blood donors during 1987-1989 gave an estimated HIV prevalence between 0.3% to 0.5%, while the prevalence among similar groups in 1992 had reached 0.71 %. Results from a survey conducted in 1989-90 suggest that HIV seroprevalence still remains low among STD patients (1.41 % in Nouakchott and 1.73 % in Nouadhibou), while prevalence has reached 14.29% among hospitalized TB patients in 1991 compared to 5.71% the previous year. It appears that the AIDS epidemic in Mauritania is lagging a few years behind neighboring countries, with an estimated HIV prevalence of 0.5% among the general adult population in the main cities, and a two- to three-fold increase among STD patients. Data obtained from 1,689 blood donors during the first trimester of 1993 show that 11.7% of them were positive for syphilis; however prevalence of gonococcal and chlamydial infections for the country is unknown. 6. NIGER Figure 2: Cumulative Number of AIDS Cases by Sex In in Mger, 809 Niger. 1987-1992 (Total: 809) cumulative AIDS cases had been reported as of December 31, 1992 (see 19% Figure 2). A study U FenDles conducted during 1987- 4% O Unknown 1989 among prostitutes E Males in Niamey showed moderately high levels of HIV-1 (4.9%) and HIV-2 (7.6%) 77% infections, with an Source: Programme Nstional de Lufte contre le SIDA, Niger overall increase of 50% I in 1989 (11.2%) compared to the first two years. In the same study, HIV seroprevalence among pregnant women varied from 0.1% (HIV-1 and HIV-2) and 0.3% for dual infection. On the other hand, a 1988 study in the northern mining town of Arlit showed a prevalence of 3 Prmm Natomal de Lutte contre l SIDA et le MST - Reve extame du premier Plan A Moyen Tame 1991/1993. Nouakchoft: Mi4y of fgslth and Social Affairs/WHO, August 1993. Annx1 Page 5 of 8 4.3% amng prostitutes. More recent sentinel surveys among pregnant women in Zinder, Tahoua, Maradi, and Niamey (1991-1992) showed a slight increase of HIV prevalence, ranging from 0.3% to 1.3%, while prevalence among prostitutes was estimated at between 5% and 7%. Figure 3: Prevaln of Moad Com"mo STD Among Differet opulatio Groups Niger Survey: May-Jue 1993 Tnchonowaiai Tr.chonwmasis 1 Pregnant Women ChNDydia U Protitutes Go_arrhos 'l out of 5 preant women ha Sy l2hili at least one STD, wiile mare than half of prostitutes had at least one. TarAL__ 0% 10% 20% 30% 40% 50% 60% Soucce: Rapid Risk Aa.imat Survey Niamey. June 1993 Preliminary analysis of data from the recent rapid risk assessment survey carried out from May 24 to June 28, 1993 among specific population groups in the urban agglomeration of Niamey (including Dosso for truck drivers) shows overall HIV prevalence of 1.3% among pregnant women (5/400), 15.4% among prostitutes (39/254) and 3% among truck drivers (8/263), which seems to indicate a significant rise in recent years. Among various other STDs studied, the prevalence of syphilis was relatively high in pregnant women (4%), and N. gonorrhoeae infections relatively low (1.5%) (Figure 3). As expected, syphilis (26.8%) and gonorrhoea (28.7%) rates were much higher among prostitutes. These data provide the first valid estimates on the most prevalent STDs for the country as well as related social and behavioral factors, although analysis has been undertaken for Niamey only. The results of the survey were presented and discussed at a National Consensus Seminar in October 1993 as part of the preparation of the Second Medium-Term Plan (1994-1998), and should be used for planning and evaluation of future interventions. The following figures present the cumulative AIDS cases by age groups for the period 1987-92 (Figure 4), the proportion of HIV-1 (88%) and HIV-2 (12%) strains among confirmed AIDS cases (Figure 5), and the projection of AIDS cases for the 5-year period 1993-1998, using the WHO/GPA Epimodel (Figure 6). Annxl Pagp 6 of 8 Flgure 4: Cumulative AIDS Cases by Age Group Niger (1937-1992) 233 203 174 Ni9 e (18-92 127 0 z 0-4 5-14 15-19 20-29 30-39 40.48 50-59 80+ NS SDxce: PNLS, Niger Age Group FIgure 5: IV Strains Among Coufirmed AIDS Cuses Niger (1967-1992) 12% U mv-i 88% Source: Programme National de Lutte contre le SIDA, Niger Figure 6: AID8 Cases Estistes In Niger 1993/1M WHO/CPA Epimodl 3,708 9000 m 3000 7000-- 6000 Almost 2.5 timwa more AIDS (e) cm in 1998 v 1993 5000 _3^::4j 4000-- 3000 - 2000 ek) _ t000000000(FemIle) 1000 04 5-14 20-49 2049 50+ TOTAL AimexI Page 7 of 8 7. SENEGAL As a result of successive surveys conducted among different population groups since 1985, Senegal is the only country in the Sahel where valid and detailed data on most common STDs and HIV/AIDS exist. Follow-up studies on registered prostitutes in Dakar during the 1985-1992 period have shown an increase in HIV-1 infections from 0% to 3.9%, with HIV-2 infections increasing from 7 % to 9 % over the same period (Figure 7). A similar pattern of infection rates has also been noted among the same population group in other cities. HIV prevalence for STD patients has remained more or less constant over the years, varying between 0.5% and 1.5% for HIV-1, HIV-2 and mixed infections, with a gradual spread of HIV-1 to different regions. Figure 7: HIV Seroprevalence for Registered Prostitutes Dakar - Senegal (1985-1991) * HIV-1 Se: US. Buieu of CAuu,I 12 Novnmbur 1992 0 aIV-2 10 1985 1986 1987 1988 1989 1990 1991 Year Studies among pregnant women showed variations in infection rates between regions, with HIV-2 being more predominant in all regions except Saint-Louis, with levels varying between 0.2%-0.4% and 0.9%-1.6%. HIV seroprevalence among blood donors was measured at 0.8% and 0.5% for HIV-1 and HIV-2 respectively, with a steady decline of HIV-2 during 1987-1990. With regard to other STDs, a 1991 study determined the prevalence of the following diseases among antenatal and Ob/Gyn clinic attenders, respectively, as follows: a prevalence of N. gonorrhoeae of 1.1% and 1.6%, a prevalence of C. trachomatis of 11.3% and 13.3%; and of syphilis of 5.4% and 15.9%. In a third group (male STD patients), a prevalence of as high as 47% was detected for gonococcal infections. Another study, conducted in 1991 among commercial sex workers (CSWs), found the prevalences of these three infections to be: N. gonorrhoeae- 15.3%; C. trachomatis- 19.9%; and syphilis- 26.8%. This pattern clearly demonstrates the risk of the potential further spread of HIV infections in Senegal with significant increase in major STDs, even if actual figures seem to present only a relatively slight increase of HIV during a 7-year interval.4 4 Source: iden. Infomrauon avalAble on five couu*ax Burkina Faso, Chad, Mali, Niger and Senegal. Annex 1 Page 8 of 8 8. CAPE VERDE In Cape Verde, various HIV seroprevalence surveys were conducted, including one in April 1986 (Praia and Sal), one in February 1987 (Praia, Fogo and Sao Vicente), and a national survey among the general population (over 5,000 subjects in the 9 inhabited islands) in 1988-1989. This last survey showed an overall 0.47% HIV prevalence, with a clear predominance of HIV-2 infection. Data routinely collected through a sentinel surveillance system among attendants at prenatal clinics indicate a relatively low level of infection, varying between 1.0% and 2.5 % in Praia in 1992, and less than 1.0% in Mindelo; in the capital, the prevalence among 146 STD patients varied between 2.0% and 7.5% for the same year. Since 1989, an average of 10 to 15 AIDS cases are registered every year, with a total number of 65 cases reported as of December 1992. Although published data are not available on most common STDs, according to health authorities prevalence is estimated to be relatively low. It is believed that the control of STD/HIV transmission in recent years has been relatively successful, with particular emphasis on the IEC component of the NAP, and that both STDs/AIDS programs are well integrated. An AF5PH mission appraised the respective strengths of the epidemiological surveillance component, as well as the laboratory capabilities and clinical management in July 1993. Annex 2 PROJECTJONS OF A3 AOSD HIV INPECTIONS Page 1 of 2 SLPKNA FASO 166S 1U67 19S lse 1000 1901 1902 1903 104 1095 190 19097 MIV Now 0 60 22762 5380 803s41 122225 147308 164550 17204s 171580 1 6480 153707 HIV Cutt 0 607 25389 77178 166519 28744 436682 601232 773281 34470 110W739 126344 XIV Cun. 0 _607 2336 77048 1e651? 284543 425000 575530 7240: 683710 964459 1o0230e AIDS N0 ° 3 129 875 3104 7481 14020 22616 32640 44121 55860 AIDS Cum 0 a 3 132 1007 4201 11U82 25702 48320 81160 125260 1a114o AIDS Cutr 0 0 2 64 437 1597 3741 7010 11301 16420 2206o 27030 DEATH Now 0 0 2 6e 502 2034 5338 10751 18319 2772s 36440 49000 DEA lH Cun 0 0 2 68 see 2604 7941 16192 37011 64740 103220 153210 DEATH C4u a 0 2 Sa 5e 2604 7941 1882 37011 64740 103220 153210 CAPE VERDE 1104 1047 13"8 1383 10 1001 1902 1903 1994 1905 1ne9 197 HIV N 0 2 so 10o 315 432 522 5S1 608 606 582 543 HIV CUM a 2 62 272 587 1019 1541 2122 2730 3338 3918 4461 HIV cur? a 2 U2 272 565 1004 1500 2031 2560 3050 3478 3622 AiOS Now 0 0 0 0 3 11 25 49 80 1l5 158 107 AIOS CUn 0 0 0 0 4 15 41 9l 170 266 442 639 AIDS cQW 0 0 0 0 2 6 13 25 40 5s 78 00 OEATH Now 0 0 0 0 2 7 1S 38 65 90 136 176 DPATM C4u 0 0 0 0 2 9 26 as 131 228 364 541 DEATH Cur 0 a 0 2 s 28 as 131 226 364 541 CtAD 10" 1947 1114 10ow 10o 19191 1302 1903 1004 1fes 1906 1907 HIV Now 0 12 4120 11365 181 25813 31326 346 31434 38337 34814 32550 HIV Cu. 0 12S 48 la4m 362U #1145 32473 127319 183753 200090 235004 267154 XIV Cuwr 0 126 4847 16315 35040 flam 833 121676 15321 132904 206474 221915 AIDS Nw 0 0 1 27 116 676 151 2 4700 6964 S343 11829 AIDS CLan 0 a 1 26 213 6 2474 543 10232 1718 26530 38350 AIDS CQ.u 0 0 a 14 63 338 792 14.4 2365 3477 4672 515 DEATH Now 0 a 0 14 110 431 1130 2277 369 572 6140" 105 OEATH Cw,n 0 0 0 14 121 sol 1612 305 7237 11370 21858 32444 DEATH Cur? 0 0 0 14 121 551 1612 3658 737 13701 21658 3244 GAM3M 196 1667 108 Ism 100 19101 102 1903 1904 1995 190 1007 HtV Now 0 21 S0o It 3153 4314 s5 s580 67 e0s 5616. 5425 XlvY Cum 0 21 624 273 5476 10190 15412 21220 27293 334 3816S 44503 HIv Cuff 0 21 624 27 5441 10042 15000 20313 2558 30465 34747 38200 AIOS Now 0 0 a a 31 t13 204 495 706 11S 1557 1972 AIDS Cu. 0 0 a 5 35 14 412 207 1706 24 4421 6393 AIoS Cu? a 0 a 2 Is 58 132 247 3" 580 771 986 DEATH Now a 0 0 2 19 72 1" 379 646 979 1358 1764 DEATH Cu. 0 0 0 2 20 *2 260 60 1306 2263 3643 5407 DEATH C4S? 0 0 0 2 20 *2 260 6m 1300 2265 36&3 5407 Annex 2 Page 2 of 2 MAu it 1T it ig i iwi tl Iom tIsm i_ * l? 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MW _ 6 iti? u11 6667 ie m? 7ai 206667 3161 311166 am SoOW "eV amm6 III? 40041 ido7 30~ 11166 403 110567 I&=4o I r 136 300M 13 _v @, * III? 4315 14150 _ I673 m ls730 153 1i7 sad"4 1s116 low? os~~ 6 6 11 161 ml 137 Pmi *a mg naiai 1017 _*tm Ace6 Cdull 6 a 0 D I53 7136 21160 447t lsas 3206 3=10 A&S 6a a a lie am3 MT6 13607 WIM 232M 4a617 1434 DEAThw c 6 3 In 694 V7AG 1mm 16734 373ts 6 s51a 73560 Sv4 DorAr Cum a * a 124 1060 4764 1d6l 341 66143 116187 It6 = T7 D6A1W Qav 6 6 3 li Si 73 14631 34415 1143 110167 160060 3au06 Annex 3 Page I of 3 RAPID RISK ASSESSMENT SURVEYS litroduci 1. Despite its demonstrated importance, epidemiological surveillance is generally very poorly developed in Sub-Saharan Africa, particularly in Sahelian countries. Most Sahelian countnes have weak Epidemiological Surveillance Systems (ESSs) characterized by: (a) a lack of reliable data on levels, trends, and patterns of HlV/STDs to monitor and forecast the epidenic; (b) a limited use of existing data for decision maldng; (c) an inadequate number of personnel trained in data collection, analysis and dissemination of neded information for prevention and control activities; and (d) a lack of regional cooperation between countries to address common problems. 2. The central role of data and infornation for the effective planning and implementation of National AIDS Programs (NAPs) underscores the need to quicldy address these inpedimets and constraints. Design and carrying out of STD/HIV prevalence survevs 3. In order to alleviate these problems, the Population and Human Resources Division of the Sahel Department (AFSPH) undertook Rapid Risk Assessment Surveys in most AF5 countries in order to improve country-specific data on HIV/STD prevalence. This effort is aimed at better understanding the AIDS situation within countries and increasing awareness of the disease among policy-makers and the population as a whole. The data will also assist in improving dialogue with governmens and in the better tuating of AIDS interventions. 4. Altugh most of the costs of these surveys will be supported under existing Bank- financed health and population projects, except for Chad where an external grant is expected, additional costs such as consuaancy fees (field epidemiologist and microbiologist) as well as travel-related costs (airfare, per diems) for all surveys must be borne by external trust funds. These costs are estimated at approximately 26% of the total survey costs for Mali, Burkina Faso and The Gambia. Annex 3 Page 2 of 3 5. Although the implementation of the surveys has fillen slightly behind the original timetable in the case of Mali and Burkina Faso, it is expected that by the end of FY95 they will all have boen comaplted, exoept for counties where such an approach is not essential, namely Senegal, Cape Veade, Msauriaia, Guinea-Bissau and Sao Tome & Principe. For some countries (Senegal, Cape Verde) this information is already available, while for otis (Mauriania, Guinea-Bissau), results from rooendy conducted STD surveys are available. Therefore, most countries in the Sahel will benefit from an updated and reliable database, particularly for the most prevalent STDs. This infrmation will be essential for the planning and evaluation of appropriate interventions for STD nd AIDS control activities. 6. As a complement to these epidemiological surveys, a more detailed protocol will be developed in FY95 in order to assess the various social and behavioral aspects of STDs and HIVIAIDS transmission, particularly regional and inter-country issues such as migration and AIDS. Such a multi-country survey is planned for Niger, Mali, Burkina Faso and Chad, and a seond survey is envisioned for late FY95 for Mauritania, Senegal, The Gambia and Guinea- Bissau. A budget of approximately US$120,000 each will be necessary for the planning and conduct of these socio-behavioral surveys. 7. National seminars are planned in each country as part of reults diffusion and launching of appropriate intventions for pmvention and control of STDs/HIV infections in the Sahel, both at he county and regional levels. Annex 3 Page 3 of 3 DEVELOPMENT OF RESEARCH PROTOCOLS 1. Objectives 1.1 To assess, by conducting rapid prevalence surveys, the existing situation in Sahelian countries with regard to HWV prevalence and the more important STD infections, such as: syphilis, gonococcal and chlamydial infections, genital ulcers (chancroid), trichomoniasis and candidosis (in women), among different population groups (e.g. pregnant women, prostitutes, truck drivers, military); and 1.2 To study risk factors related to STDs, including behavioral and socio-deographic characteristics. 2. Methodological Aspects: 2.1 Standardized questionnaires were developed and criteria were used to select representative samples from the general population (e.g. pregnant women) and specific high-risk groups (e.g. prostitutes, STD clients, migrant workers); 2.2 Development of indicators and laboratory procedures (training of laboratory technicians, procurement of materials and supplies), follow-up of positive cases and contact tracing, ethical considerations; 2.3 Procedures were developed for data collection, analysis, and dissemination of results (national and/or regional seminars, etc.). 3. Expected Outcomes 3.1 Increased knowledge of prevalence of STD/HIV infections. 3.2 Increased capacities to develop immediate and long-term interventions. Amnx 4 Pap 1 of2l Outline for Proposed AIDS Prevention Interventions ISSUF SYMPTOMS CHANGE ACTIONS CONSTRAES1 ACTIVITIES CONDmONS FOR _________________ _______________4_ IMPEDIMENTS SUCCESS Limited awareness of A) Policv-makina level gravity of AIDS situation Denial and/or latent Sensitize key officials to the Limited knowledge of macro- Undatake research on Political commitment to acceptance of the existence gravity of the AIDS and micro-level impact of macro- and micro-level combat the AIDS epidemic and potential gravity of epidemic. AIDS. impat of AIDS and manifested by GovmnentVs epidemic at enior disseminate results. oepressed declaration of its govemment level, ncem and commitment particlarly ouside of the through allocation of health sector. resoures to AIDS interventions. Political resistance to change Hold national and regional Efrecfive markeing by Attitudes persist whereby as policy-makers are not level workshops/seminars and oiin lea er to AIDS is seen primarily as a Increase awareness/ convinced of gravity of targeted towards senior level . a 'foreip problem' contracted understanding of socio- situation and therefore may govcrnment officials to encourag prtcipabon of by marginal groups such as econonuc determinants and not respond quickly. sensitize them about target audience. prostitutes. consequence of the disease. H1V/AIDS and its macro- econnic impacts, through various tools such as the AIDS Impact Model (AIMS). Hold watshopstaminars to Lack of infornation on increase policy-makes Policy-makers are not fully effective interventions being knowledge of possible aware of interventions to be Increase policy-makaV being desiged/implemend H[V/AIDS interventions. undetaken to preven and/or awarmess of effective AIDS in other regions and control the sead of AIDS. interventions. countries. Plan policy and study tours to Tour participants must be highly endemnic counties thr such as Uganda, C6te iniiulswti llvir Indonesia etc., lad lo la tgargtd at senior govnment opno ads,A o n officials wnefeieywnlz ang md attempt to birin about -mg Fagp 2 a121 ISSUg SYMPTOMS CHANGR ACTIONS CONSTRAINlS/ ACTIVITIRS CONDmONS FOR IPEDIPMENTS SUCCESS limited awarenes of B) Geal gravity of AIDS situtlil General population has Imove knowledge of sXUal Cultural, rligious norms Undetake qualitative Availability of research (ast) limited knowledge and behavior/paens of various prevent open disaion of resarch to better understand capacity and resoures for understanding of the nature groups to assist in the sexuality, ADS. soiobehavioal aspocts of IEC campaigns with of the disease and modes of development of IEC and .a gender d HIV/AIDS including factors culturally sensitive and tra_ssio education progrmms. Cbssmake geizationdr of that influence sxual hnguistically differentiated transmission, edcation pro rums.make geerlzain of . _. Behavioral changes that Increase geneal population's messges difficult derciionsa would enable individuals to awareness of disease and its prevent transmission of transmission modes by Use of media channels that infection have not been disseminating information on Population's limited acess Strengthen EEC campais have outreac capacty to fostered. STDs and HIV/AIDS though information. th,ugh vaious mndia foms genral populatio different comnuunication .ludi radio, TV, channels. nesocsadohrUse of appropriate media Misinformation and myths c ind channels that take into abound about the disease and ehmns mcludmg accotnt educational levels of . . s , x sminars,... possible preventive p p d target grmups, acessibility to measures. eommnt medetersi yth na etc. clubs, women's associations, Use of appropriate language Socidal norms and savings clubs, relio that is readily undastood by behavioed habits that networks as well as schools target goups. eheourage multple partners and at workplaces. Frequency, intemsity and are difficult to change. timing of message Prmote intaperonal sh bould take communication such as int _a_d c counseling, information aabag and pe education in speific sites for tard Identify and me individuals wHeruess t wbip will that are paunved a local need to have credibility and 'heoes' or "baoine' to trust of community. sere as advocates for HIV/AI)S peventioL Annex 4 Pape 3 of2l ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINTS/ ACTIVITIES CONDMONS FOR IMPEDIMENTS SUCCESS Limited awareness of C) Health Personnel, Social gravity of AIDS situation Service and Providers (cont.) Health personnel have Increase traiiing for health Messages must be limited capacity for case and social service providers Provde trameng n case internalized by health management, counseling and to improve clinical capacity management, and AIDS personnel and social workers educating public about and counseling services as AIDSeluig and farnilyr for them as advocates for HVtAIDS. well as their overall concept AIDS patients and family change. of quality of care. Hiold training workshops/ Messages and approaches Limited awareness and Sensitize health personnel Hold aining sensihopst must be differentiated by age, Llmlted awareness and . ~~~~~~~~~~~~~semrunars aimed at sensitizing undertanding of perceptions and social workers to pernnel who are involved gender, socio-economic status and behavior of general perceptions, behefs, myths, in HIWAIDS activities, and status within families. population by health practices of general personnel and social service population to FUV/AIDS. providers. Limited understanding of the Better understand traditional Limited knowledge of Undertake qualitative Make effort to create role that traditional medicine medical care and integrate it traditional medicine practice research to better understand partnerships with traditional and its practitioners play in into HIV/AIDS intervention and its practitioners. the activities undertaken by practitioners rather than the fight against the AIDS to foster behavior changes. traditional practitioners and 'educating" them. epidemic. their role in the fight against AIDS. Ax 4 Pap 4 o21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINTS/ ACTIVITIES CONDITIONS FOR IMPEDIMENTS SUCCESS Increased risk of the spread Lack of awarness among Sensitize policymakas to Policy-makers do not fully Use country-specific data to Recognition of the urgeny of of HIV/AEDS due to policy-makers of the the socio- economic comprehend the relationship demostrate the impact of the issuw and pohtical migration of worksen to migration factor in the spread imphcations of migration in bdween migration and the migration on the spread of commitment to address it endemic countries of HIV/AIDS. the Sahel and behavior of spread of HIV/AIDS in the HIV/AIDS. migrants and CSW at Sahel. Conduct national and Commitment by govemuents Sex trade and prostitution at dination. regional wrkshops/seminars to seek and enforce national migrant destination sites is Complexity and targted towards senior-level and regional solutions to the seen primarily as 'foreign multidimensional aspect of policy-makers to increase issue. problem". the migration issue. awareness of behavior patterns of migrants and to educa them of impact of migration on the spread of HIVAIDS both in country of origin and country of immigraticon Seasonal internal and Educate migrants and CSW Lack of understanding of Undertake qualitative Accessibility and extanal mobility of workers about risks of HIV infection behavior patterns of migrant resrh to better undestand approprate of channels (mainly male) to hyper - and foster behavioral change warkers, CSW, truck drivers behavior patterns of migrant used for dissemination of endemic countries, e.g. Cote in sxual activities. at destination sites. wvrkers, CSW, truckers etc. information on HIVIAIDS. dlvoire, Benin, Togo. Diffieuty in identfying to assist in development of target population, i.e. migrant strategLes that are cogmiant Movement of CSWs to waker, CSW, truck drivas, of diffet behavior pterns. Appropiatenes of languages economically active araknteyrse CxW,trck drbive.s used in education and both within cories and as they are extrly mobile. Identify appropriate chamels infa mation dissemination aaoss borders such as Difficulty in identifying for infannation interventions and media mining aras, border towns, appropiate mechanis for dissemination, ie. extaisicm choice. fisbing villages etc. intervention due to mobility workers for migrant farm of taet groups. workers, etc. Language barriers that arise due to influx of migrants Launch IEC, counseling, and firom different countries. peer education programs and social marketing of cwamms at national borders targeed at migrants, truckers and CSWs to foster behavioral _ _ _ __ _ _ _ _ change. A 4 Pr 5 o(21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINIV ACTIVITIES CONDMONS FOR IMPEDIMENTS SUCCESS Increased risk of the spread Individual countries do not Develop a regional strategy Difficulty in mobilizng Hold regional-level seninars/ Cooperation ang countries of HIV/AIDS due to sec migration issue as their to address inter-country resources for regional -rkshops addressing the to address this as a regional migration of worken to specific concern. migration and AIDS in the strategies and activities. migration factor in the spread issue and develop and endemic countrks (cont.) Sahel. of HIV/AIDS in the Sahel. enforce regional stategies. Poor regional institutional Develop inter-country capacity. pmgrams by aumarking resources for specific interventions. A 4 Pa 6 a421 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINIS/ ACTIVITIES CONDITIONS FOR IMPEDIMENTS SUCCESS Relatively higher Lack of political commitment Increase awareness of low Difficulty in mobilizing Utilize communitn s networks Constituency lobbying within vulnerability of women to to address women's issues. status ol women in society at political leadership on this to inctrease awareness of the countries. HIV/AIDS infection the polic level issue. social/religious constramts on women and mobilize support. Cultural, religious and legal Foster culuraI reforms and Strong and entrenched Promote legislative reforms Political comtitment to costraints exist which enact legislative changes that cultural norms that place that address constraints reform and change. ensure the subordination of would promote the wouen in subordinate placed an women, such as Constitutncy lobbying women in society. empowerTeni of women. position- legislation to increase age at within co btit. marriTge. Biological factors lead to Enhance clinical capacity to Women have limited access Include STD detection and Health care providers women having greater risk of enable screening and to OB/GYN and STD diagnosis as integral part of increase their awareness of infection for STDI1IV and diagnosing of and affordable savices. MCH/FP service provision. the costs of care and these factors are exacerbated treatment for STD/IHIV for treatment to womcn and by social factors such as early womnen STD detection and diagnosis U s to refer patientsctoe concept of 'invisibility" of age at maffiage and initibaton are not routine elements of STD related care. STDs. to sex. MCH/FP services provided. Target audience must have STD/HIV transmission rates Medications are difficult to ability to fit new concepts of are higher for women than find and return treatments sexuality, reproductive health for men n required, pling issues etc. into existing STDs are often asymptomtic further constraints on concexual fiamcwyk about and therefore not always wunen's ime and resources. selty, ines and immediately visible or obvious in wmen, leading to delays in seeking medical assistance. Anne 4 Pap 7 o21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINTSI ACTIVITIES CONDMONS FOR IMPEDIMENTS SUCCESS Relatively higher Women have limited Increase wxnen's awareness Women have limited access Promote family life Effective integration of issues vulnerability of women to undertanding of of their rights in their sexual to informnation on HIV/AIDS education, i.e. human into curriculum. HIW/AIDS Infection (cont.) reproductive health issues life and their understanding and therefore are not fully reproduction, STDs, etc. in Selecti of appropriate and control over their sexual of reproductive health aware of risks. fonnal and non-formal school channels and fonms for life. concerns. settings, community centers, channicang mmsf Low socio-economic status of savings groups etc. ating messaes Increase womees awareness woen manufested by low IEC campaigns usg Media channels used need to of I U/AH)S litmiy andtheirsubordinate media (radio and TV) and tedake ml se edt of HIVIAfl)S. role in decision-making, . aret take into account particularly regarding issues community centers, savings appropriatenss of language. Design interventions and of sexuality. groups etc. Timing of education and reorient outreach toward information dissemination women. Women face severe efforts will need to be constaints on their time and Establish information and/or scheduled taking into account lack resources to seek counseling centers in womnens time constraints. medical treatment as often as conjunction with the they should. provision of FP services or as separate units. Annex 4 PageS of 21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINT ACTIVITIES CONDMONS FOR _IMPEDIMENTS SUCCESS Relatively higher Women work in the infornal Provide mobile IUV/AIDS Identification of key vulnerability of women to sector, either in markets, on counseling services, special gathering places/occassions HIV/AIDS Infection (cont) the street or at home and media campaigns. for women. therefore access to various types of media may not be Develop aggressive condomn readily available to them. cai marketing strategies targeted at general population and high risk groups, i.e. CSWs. Use family planning centers Availability of family to provide counseling, drugs, planning centers and MCH condoms etc. targeted clinics with outreach towards women. capacity. Launch education carnpaigns targeted towards young girls which use peer group discussions, schools, religious and conmunity networks. Develop peer education pprorms and counseling servces targeted towards CSWs. Identify and use female 'role Credibility of role model and models to serve as advocates aceptance by target group. for safe sex. Women lack alternative Provide alternative Women usually have limited Launch employment Availability of alternative ernployment generation employment opportunities for skills and may find it difficult counseling and vocational income generation activities and are forced to be CSWs. to seek alternative means of raining senrices to enhance oppobtumties involved in the sex trade. income. mobility of CSWs into other employment opportunities. Aaxex 4 Page 9 of 21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAITS ACTIVITIES CONDMONS FOR IMPEDIMENTS SUCCESS Inadequate attention to the Dominance of health issues Increase awareness at policy Policy-makers do not fully Undertake analytical wrk on Willingness of various actoms multisectoral dimension of and health personnel in level of non-health impacts understand non-health non-health impact of AIDS to view this issue as the AIDS epidemic HIVIAIDS activities. of AIDS epidemic - dimensions of AIDS and disseminate results. multisectoral. Agriculture, Industry, epidemic. Education, etc. Messages relayed to policy- Seminars/workshops targeted makers must be simple and toward government officials, effective. private industry, NGOs and community aimed at increasing awareness of multisectorality/ multidimensional of AIDS. Limited involvement of non- Develop multisectoral Sectoral imperatives make it Identify and develop specific Sectoral analyses and health sectors such as strategies to deal with ASDS. difficult to perceive AIDS as sector initiatives, in mnitiatives need to be clearly Agriculture, Education, a non-health issue. Agriculture, Education, defined and clarified. Industry, Planning etc. in Industry etc. and then IV/AIDS activities. establish institutional and Amoness persel . . ~~~~among field-level personnel Foster coordination for the Lack of well-defined sectoral sectoral linkages using setor in non-health ministries. development of integrated strategies for dealing with personnel, i.e. agricultus l multisectoral and multilevel AIDS. extension workers. activities. Lack of coordination between Foster commitment at the Financial and political Broaden network of Political leadership must be Government, NGO and highest level to develop constraints coordinating cooperative agencies to committed. community level multisectoral initiatives. multisectoral interventions. involve non-health personnel Due m be eblshed rAnizations implementing i-IV/AlDS wctivities. between various actors AIDS activities. including Government, private sector & communities. Annexc 4 Pap 10 of2l ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINTS/ ACTIVITES CONDMONS FOR EIMPEDIMENTS SUCCESS Limited NGO and Community involvement in Foster ownership and CBO/NGO programs might Identify CBOs & NGOs who Effective institutional community involvement in the design and sustainability by involving be 'captured' by are conunitted to involvement arrangements with clear HIV/AIDS interventions implementation of communities from the outset. entrepreneurs. in AIDS activities and get delineation of tasks and interventions is limited. them involved in design and responsibilities among implementation of various agencies involved. interventions. "Grassroots" organizations should be kept relatively CBOs and NGOs may lack Provide technical and small, responsive and human and financial capacity fmancial assistance to CBOs flexible. to effectively implement and NGOs to be involved in interventions. activities. The potential of NGOs to Encourage more active Management capacity of Assess capacity of Adequate resources to serve as liaisons to involvement of NGOs in NGOs/CBOs may often be NGOs/CBOs to finance finance activities. Government and program implementation. limited. and/or implement IWV/AIDS communities has not been interventions. Awareness of constuctive There could be a tendency to versus destructive overlaps adequately organized and overfund NGOs/CBOs with and redundancies. utilized. Promote the involvement of mr iacn hnte CBOsandNGO inactivities more financing than they in which they are more Etbsmcaith efficient such as education Lack of clear communication Establish mechanismn that programs, information of activities may lead to enables clear communication dissemination, counseling duplication of efforts and between agencties on etc. misuse of resources. Annex 4 Pap II o(21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAIITS ACTIVITIES CONDMONS FOR IMPEDIMENTS SUCCESS Constraints due to Current bilateral donor Promote more flexible Difficulty in revising donor Dialogue between donors to Willingness of bilateral and restrictions on procurement regulations and restrictions procurement procedures for agencies' regulations on foster establishment of less multilateral agencies to relax of STD drugs, kits and on STD drugs and other STDs drugs and other procurement. rigid procurement procedures procurement procedures. other essential commodities essential commodities such commodities. for commodities ie. to enable as condoms make it difficult purchase of commodities in and more expensive to least exp nsive way. Availability of accessible provide them at the country markets for STD drugs, level. condoms etc. Multilateral agencies have Multilateral agencies could Possible encouragement of Encourage increased Collaboration between relatively fewer restrictions play a more significant role monopoly distribution involvement of multilateral and bilaterals in on country of origin of in the procurement of these conditions for drug multinationals in the purchase and/or provision of commodities. goods. companies. provision of goods. essential drugs and commodities to ensure efficient allocation and distribution. Limited resources are Encourage multilateral and Encourage donor agencies to Availability of financial available to purchase bilateral donor agencies to provide more financing for resources for purchase of commodities. provide financing of goods. goods. SWT drugs, condoms etc. Annex 4 Pa. 12 of21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINTSI ACTIVITIES CONDMONS FOR IMPEDIMENTS SUCCESS Inadequate funding for Funding for national-level Increase funding to national Multitude of Mobilize domestic resources AIDS interventions places AIDS interventions is AIDS program from domestic demands/priorities on pubhc for the funancig of AIDS constraints on program inadequate. sources. resources which limits activities though more implementation capacity of Sahelian efficient reallocation of govemments to generate available public resoumns. necessary funding for AIDS programs from public sources. Promote and encouage the participation of the private sector in financing and implementing HV/AIAfS activities, such as companies fmaning mass media progrm, counseling at wvk sites etc. Limited extnal resources Increase extenal assistance Limited extreal (donor) Mobilize extenal donor have been major constraints to AIDS activities. resources to fuid activities. community to increase its in rapid implementation of reoce cotmmitment to AIDS prevention progams. AIDS intventims. Prnmote the inclusion of AIDS rlat activities in Bank-fmded projects. Anx 4 Pap 13 of21 ISSUE SYMPTOMS CHANGE A( TIONS CONSTRAINTSJ ACTIVITlES CONDMONS FOR IMPEDIMENTS SUCCESS Lack of policy position on Stigmatization of individuals Create working en Vmronment Confidentiality of individuals Educate enployers of the Employers must understand AIDS in the workplace who are known to have or are that enables those who are is not respected. impact of AIDS on the consequences of believed to have HIV/AIDS. capable of working to work profitability and productivits inactivity. of eaterprise. Companies need to erdoise Sensitize emplovers and Insufficient knowledge and Companies to enact HIV/AIDS initiatives. employees to modes ot misconceptions concening regulations that protect the transmission ol I 1W/AIDS. the transmission of confidentiality of HIV HIV/AIDS. infected persons. Employers, including Goverment, to put in place regulations that ensure "fitness to work' as the only criteria for vrk. IEC, peer education campaigns at place of work to sensitize wrkers and employers to HIV/ADS. Activities may include trining, discussion groups, film viewing, condom distribution. Encourge companies to become involved in IEC initiatives & other HV/AIDS prevention activities. Lack of legal recourse for Enact legislation to ensure Legal and political Mobilize trade and vwrkers Strong lobbying to pressure employees who lose the rights of employees who impediments to enacting unions & other professsional Govemment to enact employment due to have HIV/AIDS legislation aimned at associations to obtain support legislation that protect rights stigmatization. addressing needs of people for legislative refonms/ of people with lIV/AIDS. with HIV/AIDS. changes. Enact legislation that protects the privacy and rights of employees with HIV/AIDS and guarantees employment. Anex 4 Pape 14 of 21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINTSI ACTIVITIES CONDITIONS FOR IMPEDIMENTS SUCCESS Lack of policy position on Employees in informal sector Develop legislation that Workers in the informal Sensitize policy-makers of AIDS in the workplace have relatively fewer would protect informal sector sector usuly do not have the need to enact legislation (cont.) opportunities and/or avenues workers from stigmatization lobbying capacity and a for informal sector workers. for recourse when they lose and loss of employment. forum to express their needs. their jobs due to stigmatization Limited avenues for Develop outreach strategies The diversity of work IEC campaigns using radio dissemination of information for workers in the informal activities and workplaces in and posters and pamphlets in on HIV/AIDS to informal sector to educate them on the informal sector prohibits market places, construction sector workers, particularly HIV/AIDS in the workplace. the development of one sites etc.. those working at home or cohesive strategy to address Provision of mobile selling on the street etc. this issue. HIV/AIDS counseling services targeted towards people who work at home or sell goods on the street. Condom distiibution in specific work areas or through mobile facilities. ArAu 4 Pap 15 oI21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTAINRTS ACTIVITES CONDMONS FOR __EDMENTS SUCCESS Weak epidemiological LAc of reliable information Develop effectivyesimple Unreliable information On Adequate staffig at central Priority given by national surveillance to assess levels, trends and epideniological surveillance epidemiology of most peripheral levels. authorities to adequate patems. system at peripheral <-> frequent STDs and epidemiological suveillance regional <-> central levels. HIV/A]DS for plaing and system on STD and evaluation of IVAIDS. opsices. Difficulties in Begin systematic collection Severe under-reporting of Conduct of rapid risk Beter integration of epi. monitoringtforecasting of simpletrapid indicators on STDs. assesemant sueys when surveillance systems with epidemics. morbidity/mortality related to necessary. other STD/Ht progam STDs and HIV/AIDS. components, i.e. cinical management, laboratory capacities, etc. and with monitoring of other infecions (TB cases) and noD- infections diseases, i.e. comprehensive/ntegrated health information system (HIS). Collection/analysistdiffusion Analyze/diffuse information Weakness of laboratory Procurement of material Availability of information to of data weak. on a routinetsystematic basis. support for diagnostic of STD supplies to impmve data monitor trends/levels on and HIV/AIDS. collection/analysis i.e. laptop STDs/HIV and AIDS. computes; EPIINFO softwre, etc. Lwck of adequately trained Lack of equipment/ material Str_ngthing of health health personnel (field i.e. standard form for data information systems at epidemiologist) at central/ collection distinct leveL peripheal (data collection) peripheral levels. regional and central levels; and regional/central levels computer facilities for data (data analysis/dissemination analysis.. of results) Aanne 4 Pagc 16 of2l ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINTS/ ACTIVITES CONDITIONS FOR IMPEDIMENTS SUCCESS Weak laboratory support Lack of minimal laboratoiy Recognize the importance of Constraints in infrastructure, Furnish/strergthen laboratory Improvement in lab. and Inadequate blood safety facilities in all countries laboratory support in lack of adequate laboratory facilities, diagnostic facilities at procedure (human, material, financial management of STDs and facilities/lack of competent . . central/regional levels, a) I-boratry suportresources), at both the central strengthening of trained laboratory Ifmabraove technmWsericions (minimal microbiology) and a) Laboratory support (eeeclbrtr)n stntunotaida tryof laboratory technucians penphera (simnplediagostic (reference laboratory) and epideniological surveillance. technicians/ frequent rupture prpea srpedansi regional/district levels. of stock of laboratory kits). supplies/ equipmTienlt. Improvement in clinical management and follow-up of STDs patients and in counseling . Lack of laboratory support for Establish mechanism for Support the development of Planning of adequate services clinical management of laboratory confirmation of essential laboratory facilities. based on prevalence of STDs/AIDS. clinical diagnoses. STD&s/HIV. Inadequate training capacities and personnel. No linkage between laboratory and epidemiological surveillance units. Deficiency in the reporting Develop an effective Problems with referral Elaborate simple Improvement in case system.(lab. <-> epide- mechanism for reporting of system mechanism; diagnostic/treatment reporting case management. miology units). laboratory results. Manageent problems algorithms at PHC facilities Lack of maintenance of and refer ceters. lboratory equipment and material. Ancwx 4 Page 17 of 21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINTSI ACTIVITIES CONDMONS FOR _IMPEDIMENTS SUCCESS Weak laboratory support and inadequate blood safety procedures (cont.) b) Blood safety Limited capacities of blood Establish minimal safety Risk of transmission of Provide adequately-trained Improvernent in blood safety banks. guidelines for blood HIV/AIDS through personnel, material and to at least 900/c of the blood Increased risk of transmission transfusion in all hospitals contaminated needles, supplies supply in the next 5 years. of HIV/ArDS through: and major health centers. syringes, surgical procedures, Provide screening/ diagnostic Train all health piercing instruments. tests whiere blood Contaminated blood T ra ditional tests ood Enhancement in the national personnel/traditional transfusions occur. Supplies, contaminated practitioners on risk of lIlV user of blood transfusion. instruments/infections from transmission through indigenous practitioners medical/surgical procedures. Ritual matters Educate traditional leaders, general population. Annex 4 Page 1 of 21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINTS ACTIITIES CONDIONS FOR IMPEDIMENTS SUCCESS UJmited capacity for Poor coverage by health Integrate STD management Lack of medical supplies, Develop traiinig programs Better clinical management clinical management of sector in clinical management into HCH/FP programs and drugs, clinical facilities. for health personnel in STD of STDs at hospitals and STDs of STDs, both at central and hospital outpatient facilities. case management and peripheral health centers. peripheral levels. Provide minimal laboratory counseling develop and clinical facilities in main guidelines on IV/ STDs cities and regional hospitals. prevention and control and cities and regional hospitals. health centers and regional/distinct hospitals.. Inadequate and/or inexistent Develop training Lack of adequately trained Improved referral appropriately staffed and materials/supervision clinical personnel. mechanisms from peripheral equipped STD clinics in most mechanism for staff at PHC . . to regional and central levels. conre,lvl Weakness in counseling/torinaadcerllvls countnles. level. follow-up of STDs patients. Inadequacies in training/ supervision of clinical staff. Lack of drugs/antibiotics, Inadequacies in drug Develop protocol/clinical Reductions in STD medical supplies, etc. procurement/distribution algorithms to improve prevalence and HIV mechanism in the public diagnosis, treatment and transmission in high-care sector. Absence of follow-up of STDs patients. groups and general coordination of policies population. between public/private sector (pharmacies). Am3x 4 Pap 19 A21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINIS/ ACTWVITES CONDIONS FOR _IMPED IMENTS Weak management Poor absorption capacity of Improve managerial Lack of adequately trained Develop management skills Increase in efficiencyt capacity donors' support. capacities at the Ministzy program managers. at central/regional levels. effectiveness of program level, and at hospitalsthealth Deficiencies in most Develop apprpriate on-site managemeL centers. admimstrative components of tvainel materials n Often highly centralized health programs (STDs and management. others). Lack of integration of Improve coordination Problems in planning! Facilitate involvemnent of Achievement of targettgoals! HIV/AIDS with STD activities between various programming of intersectoral non-health personnel in activities as identified in program activities, and with donors. activities. management procedures. Medium Term Plans. other comununicable diseases programs (cx TB program). Lack of coordination between Plan activities according to Deficiencies in functioning of Improve representativity of Improvement in cohesion donors, between central and real needs at country level NAC (i.e. representativity of the National AIDS between different.sectors' peripheral levels, between (instead of donors specific other sectors) and problems Comnittee, and reporting at activities. various sectors. agenda). of coordination between sub- the highest political level.. committees. Lack of commitmnent from Create greater awareness other sectors. among different sectors! Identify key persons (role Increased awareness of commumty leaders. models) among different HIV/AIDS and STDs among population groups. political/religious/community Ileaders. Aam= 4 Page 20 of21 ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAIT/ ACTIVITIES CONDMONS FOR _________________ _________________ IMPEDIMENTS SUCCESS EEC Lack of knowledge among Improve level of knowledge Inadequate programs/audio- Conduct well-designed KAP Increased awareness among general population/specific about STD/HIV transmission visual materials to be used in surveys. Investigate complex community leaders, health pop.groups about modes of and prevention, as well as mass media campaign. social/political/cultural issues personnel. transmission of STDsaHIV. attitudes and practices pertaining to the Sahel. Lack of availability of Improve condom distribution Inadequate training of health Develop social marketing Increased condom condoms. within/outside health sector, personnel on strategies on programs for condom distribution/ condom use and at regional /district social/behavioral aspects procurement/ distribution. among targeted population levels. related to STDs and groups. Develop social marketing HIV/AIDS. programs in each country. Lack of coordination among Strengthen coordination Coordination problems Ensure sustainability of EC Development of appropriate different sectors, donors, mechanism between various between different agencies. programs. intervention programs, with agencies and NGOs in IEC donors. Develop programs aimed at improved coordinabon. interventions. specific population groups, particularly youth. Annx 4 Par 21 of2I ISSUE SYMPTOMS CHANGE ACTIONS CONSTRAINTS ACTIVITIES CONDMONS FOR SUCCESS __________________ IMP~~~~U EDIMENTS _ _ _ _ _ _ _ _ _ EEC Lack of appropriate Develop appropriate Promote research activities Increased knowledge, and message/education materials material. on serial/ behavioral aspects safe behavior among general to meet needs of population related to STDs and population and specific (particularly in rural areas). HIVIADXS. higher risk groups. Problems in coordination of Orient training sessions. Train social workers and various categories of health Encourage team approach. medical personnel personnel (i.e. medical personnel vs social workers). Annex 5 Page 1 of I PROPOSED REGIONAL [EC AND CAPACITY BUILDING PROGRAM EST1MATED COSTS BREAKDOWN BY ACTMITTY Teti Activhy FY96 FY96 FY97 US$ 1 Supo for 2 Progrn CoerdiataO t regonai lvel 1.1 Fe_ 172 pwra nmmtd S US$ 700hnionti 170,000 170,000 170,000 510.000 1.2 Adnin. & Travl budget S0.000 80.000 90.000 240.000 1.3 Canyriiciondseeenwtioa 150.000 150.000 150.000 450.000 2 Mobazg Pofitical Wd qogun leoder 2.1 Pegiond m1rnar Itwo p. yvo for five coun_m" secN 200.000 200.000 200.000 600.000 2.2. TechniW warkuIep. tr ard _nn1d mvlew 200.000 200.000 200.000 300,000 2.3. SBdy tos 100.000 100.000 100.000 300.000 3 ScrV nadwn wd load herom ttruii. _ evtraL dieeimon budget. te..) 200.000 150.000 150.000 500,000 4 Furid for plot irftitivs(socia -mrkmaM -wnmunity ps-,. IEC caog. etc..) 700.000 750.000 750.000 2.200,000 5 6 miti.oauitry autum an beheviard and e_anwiug oorweqe_ncm of thde epidwi 200.000 200.000 200.000 600.000 TOTAL 2.000.000 2.000.000 2.000.000 0.000.000 SUMMARY OF rELlUfD CONT1MUTON FROM THE DANK Gram 300.000 300.000 300.000 30,000 Adrrnovueive supot 100,000 100,000 100.000 300.000