91293 rev. Knowledge Brief Health, Nutrition and Population Global Practice HIV RESPONSE REDUCING THE HIV/AIDS EPIDEMIC: LESSONS FROM ARGENTINA Fernando Lavadenz and Lais Miachon September 2014 KEY MESSAGES: • Argentina reduced its HIV/AIDS burden by 21 percent from 2000 to 2010, saving an estimated 4,379 lives. This makes Argentina’s HIV/AIDS burden the second lowest in South America after Chile. • Argentina reduced the mother-to-child HIV/AIDS transmission rate by 62 percent from 2000 to 2011. • The National HIV/AIDS Program was created in 1995 and has since introduced key innovations that have contributed to the reduction of the HIV/AIDS burden in Argentina (Box 1). • As of 2010, the National HIV/AIDS Program is entirely domestically funded, and a World Bank study has found the Program to be cost-beneficial. Where does Argentina stand on Box 1. HIV/AIDS key programmatic HIV/AIDS? innovations Argentina is a country of 41.45 million people, (6 percent of the Latin American and Caribbean (LAC) population), I. Early introduction of free antiretroviral treatment with a GDP of US$14,760 per capita, surpassing the 2013 (ART) since 1997; regional GDP average of US$10,512. Argentina also fares II. Comprehensive legal framework for sexual and above regional averages in indicators such as mean reproductive rights; years of schooling (9.7 years, compared to the 7.9 LAC III. New sexual education program in schools; average) and life expectancy (76 years, compared to 74.6). IV. Strategic alliances between key health Programs for reducing mother-to-child transmission; Over the last 20 years, Argentina felt the impact of the V. Introduction of incentives and results-based HIV/AIDS epidemic, with HIV cases increasing from 1,000 financing in the HIV/AIDS program; in 1990 to 4,223 in 1997, and peaking at over 6,700 new VI. Strategic planning using results of national infections per year in 2004. Despite the exponential supply-side surveys in public health facilities; growth of new HIV cases, early financial coverage of ARTs beginning in 1997 has been essential in keeping VII. Electronic monitoring of supplies and medicines the number of AIDS cases under control (Figure 1). for increased accountability; Currently, there are an estimated 110,000 people living VIII. Implementation of an electronic clinical with HIV/AIDS (PLWHA) and approximately 5,500 new governance system for improving quality of care HIV cases per year. In 2010, the HIV/AIDS burden in and patient follow-up. Page 1 HNPGP Knowledge Brief Figure 1. New and projected HIV/AIDS cases in Argentina, 1990-2015 The cost of HIV/AIDS in Argentina 7000 In 2012, the Argentine government spent US$285.95 6000 million on the HIV/AIDS Program. The country currently spends US$3,178 per DALY of HIV/AIDS—almost three 5000 times the regional average of US$1,052. Argentina’s 4000 expenditure per DALY is the third highest in LAC after 3000 Cuba and Chile. The country also has the second highest spending per person living with HIV/AIDS in the region 2000 after Barbados. Argentina allocates 80 percent of total 1000 HIV/AIDS spending to care and treatment, compared to the LAC average of 75 percent. This is partially due to the 0 1990 1995 2000 2005 2010 2015 higher cost of ARTs in Argentina and lower allocation to prevention (Argentina allocates 1.2 percent of HIV/AIDS AIDS cases HIV cases spending to prevention activities, compared to 15 percent Argentina was 223 disability adjusted life years (DALYs) in LAC). per 100,000, less than half the regional average of 519 HIV/AIDS DALYs per 100,000. What can we learn from Argentina’s HIV/AIDS programmatic innovations? Argentina has 2.9 percent of the total regional HIV/AIDS DALYs. Colombia, a country with a similar GDP and I. UNIVERSAL ACCESS TO HIV/AIDS TREATMENT IS population size, has 15.7 percent of the region’s total A KEY PREVENTION INTERVENTION HIV/AIDS DALYs. Argentina has the second lowest Brazil and Argentina showed that universal access to HIV/AIDS burden in South America after Chile. However, HIV/AIDS treatment is key to reducing the HIV/AIDS while Chile showed an increase in the HIV/AIDS burden burden. Argentina achieved universal access to treatment from 2000 to 2010, Argentina further reduced its already in 2012, with 81 percent coverage (universal coverage is low burden by 21.2 percent–the seventh largest reduction defined by WHO as over 80 percent ART treatment). Both in LAC during that time (Figure 2). countries made HIV/AIDS treatment a public good, Brazil and Argentina were the first LAC countries to providing free access to all those in need. guarantee free universal access to HIV/AIDS treatment in 1996 and 1997, respectively. Despite the high cost of II. A COMPREHENSIVE LEGAL FRAMEWORK FOR ART, a WB study shows that the Argentine National SEXUAL AND REPRODUCTIVE RIGHTS MATTERS HIV/AIDS Program is cost-beneficial, with an estimated 1.03 benefit to cost ratio. From 2001 to 2010, Argentina In 1995, Argentina’s Law 24,455 guaranteed universal saved 4,379 potential lives, corresponding to an average access to HIV/AIDS care and treatment, including clinical, of 23,600 DALYs per year. pharmaceutical and psychological assistance for PLWHA. In 1997, the country introduced the free provision of ART, regardless of income or health insurance status, Figure 2. Percentage change in HIV/AIDS DALYs in guaranteeing the financial protection of HIV/AIDS Latin America, 2000-2010 treatment for all. This legal framework became vital for reducing both new HIV infections and AIDS deaths. Mexico -57 Guyana -50 Panama -49 In 2002, Law 25,543 mandated all health providers and Peru -43 facilities to offer HIV testing to pregnant women. The law El Salvador -24 Honduras -23 also mandated financial coverage of testing, becoming Argentina -21 key for the prevention of vertical transmission. Also in Nicaragua -13 2002, the law on Sexual Health and Responsible Costa Rica -11 Brazil Parenthood (Law 25,673) mandated the provision of -5 Uruguay -1 contraceptive methods and free family planning Paraguay 0 counseling in primary health care centers and public Colombia 1 hospitals. Bolivia 20 Chile 28 Ecuador 32 In 2006, another law (26,150) established the creation of Guatemala 77 the National Comprehensive Sexual Education Program, Venezuela 88 which is part of federal and state school curricula across Page 2 HNPGP Knowledge Brief  the country and seeks to expand knowledge on safe tuberculosis, non-communicable diseases, blood sexual practices. services, and HIV/AIDS. In each of the programs, intermediate results were identified as outputs. In the In 2010, the Marriage Equality Law (26,618) recognized case of the National HIV/AIDS Program, a third party unions between persons of the same sex. Most recently, external auditor verifies the completion of six outputs prior in 2012, the Gender Identity Law (26,743) allowed to authorizing payments to provinces. The use of RBF transgender and transsexual persons, who carry a has since been expanded, and the use of outputs has disproportionate burden of HIV/AIDS in the country (34 been consolidated throughout the country. percent HIV prevalence), to change their gender. These laws create a legal framework to reduce stigma that VI. NATIONAL SUPPLY-SIDE SURVEYS CAN HELP TO prevents diverse populations from accessing health IMPROVE STRATEGIC PLANNING services. Argentina conducted two national supply side surveys III. SEXUAL EDUCATION IN SCHOOLS IMPROVES (2007 and 2011) in health facilities throughout the PREVENTION KNOWLEDGE AMONG YOUTH country. Subnational HIV/AIDS program officers also participated in the survey. Responses, trends, practices Since the 2006 passage of Law 26,150, Argentina and results were used to inform national HIV/AIDS implemented a new sexual health education program in strategic planning process. Results show that 90 percent all public schools. Argentine youth have the highest of provinces reported an improvement in the supply of knowledge of HIV transmission and prevention in the and access to preventive, diagnostic, and health care region, with 84 percent of young men and 89 percent of services for PLWHA from 2007 to 2011. young women (ages 15-24) accurately identifying prevention methods and major misconceptions about HIV VII. ONLINE MONITORING SYSTEMS CAN PLUG transmission, followed by Chile with 78 percent and 85 DUPLICATION AND BOOST EFFICIENCY percent of young men and women, respectively. In 2009, the MoH introduced an online monitoring system IV. STRATEGIC ALLIANCES IN SERVICE DELIVERY that tracks the use and distribution of HIV/AIDS supplies. CAN HELP TO REDUCE MOTHER-TO-CHILD The system was designed with support from the EPHFP TRANSMISSION (MTCT) to avoid loss and duplication of HIV/AIDS medication and supplies and to improve efficiency in procurement, Argentina has reduced its MTCT rate by 62 percent, from shipment, and accountability. Implementation of the online 13.7 per 100,000 live births in 2000 to 5.2 in 2011 (Figure monitoring system has been extended to half of the 3). This success was possible thanks to: (i) A strategic country’s Provinces. alliance with the safe blood program, creating a comprehensive system for integrated prenatal testing of HIV/AIDS, STIs and other diseases; and (ii) A strategic Figure 3. New HIV cases in Argentina by alliance with the public health surveillance system for the transmission route, 2001-2002 epidemiological monitoring of health events of seropositive pregnant women and analysis of related 6000 data. 5000 From 2009 to 2010, 47 percent of newly diagnosed HIV positive women were diagnosed in the context of 4000 pregnancy, underlining the need for early HIV testing among women of all ages. 3000 V. INCENTIVES AND RESULTS-BASED FINANCING 2000 (RBF) CAN BOOST THE EFFECTIVENESS OF HIV/AIDS PROGRAMS 1000 The use of RBF by the HIV/AIDS Program increased 0 overall systemic accountability and improved Program 2001-2003 2004-2006 2007-2009 2010-2012 performance. Under the Essential Public Health Functions Heterosexual intercourse (males) Project (EPHFP), a package of guaranteed public health Heterosexualintercourse (females) services was created with the use of RBF in six public Homosexual intercourse (male only) health programs for the following conditions: vaccine Mother-to-child transmission preventable diseases, vector-borne diseases, Injection drug use Page 3 HNPGP Knowledge Brief VIII. CLINICAL GOVERNANCE SYSTEMS IMPROVE References THE QUALITY OF HEALTH SERVICE PROVISION Aran-Matero, D. et al. 2011. Levels of Spending and Resource The EPHFP also supported the National HIV/AIDS Allocation to HIV Programs and Services in Latin America and the Program in the development and implementation of a Caribbean. patient case-management system. The system allows for IHME, Global Burden of Disease (database). the online registration of patients, online request for http://www.healthdata.org/gbd authorizations, monitoring of patient’s viral load and other tests, as well as monitoring of drug regimen and treatment Lavadenz, F., Pantanali, C., Zeballos, E. Thirty Years of the HIV/AIDS protocols. The case-management software introduced in Epidemic in Argentina: An Assessment of the National Health Response 2011 allows for assessment of treatment quality, (Unpublished). adherence, and resistance to treatment. All provinces are linked into the system, which, by the end of 2012, Ministry of Health of Argentina. 2013. Boletin N0 30 sobre el VIH-SIDA y included over 30,000 patients. The HIV monitoring system ETS en Argentina. for patients increased the efficiency of prescription and delivery of ART, as well as patient follow-up. Pan American Health Organization. 2013. Antiretroviral Treatment in the Spotlight: A Public Health Analysis in Latin America and the Caribbean. Challenges Washington DC. Despite these achievements, Argentina still faces a _____. 2010. Situation Analysis: Elimination Mother-to-child number of challenges in halting the spread of HIV, which Transmission of HIV and Congenital Syphilis in the Americas. include the following: Washington DC.  Long-term financial sustainability of the AIDS Program, considering the increasing number of patients in UNAIDS. 2012. Global Report: UNAIDS Report on the Global AIDS treatment; Epidemic. Geneva.  High comparative cost of antiretroviral medicines; UNDP, 2014. Human Development Report. http://hdr.undp.org/en/countries.  Stubbornly high number of new infections among young MSM, while most other groups show marked reductions (Figure 3); World Bank. 2013. Argentina - Essential Public Health Functions and Programs Project. Washington, DC, World Bank.  Geographical inequalities in HIV/AIDS rates between provinces; http://documents.worldbank.org/curated/en/2013/06/17996750/argentina -essential-public-health-functions-programs-project-argentina-essential-  Insufficient coverage of HIV diagnostic testing; public-health-functions-programs-project  Governance issues in health service delivery (service networks, human resources, training, budget); and  Low expenditure on HIV prevention. Keep in mind  Argentina’s case shows that provision of free HIV This HNP Knowledge Brief highlights the key findings from a study treatment can help to reduce the number of new by the World Bank on the “Thirty Years of the HIV/AIDS Epidemic infections; in Argentina: An Assessment of the National Health Response” by Fernando Lavadenz, Carla Pantanali, and Eliana Zeballos  Continued innovations make it possible to reduce an (forthcoming). already low-level HIV/AIDS epidemic; and  Recent HIV control efforts in Argentina have not yet been fully evaluated. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4