AFRICA REGION HUMAN DEVELOPMENT U WO R KI N G PAPE R SE R I ES THE WORLD BANK AIDS, Poverty Reduction dnd Debt Relief A Toolkit for Mdinstredming HIV/AIDS Progrcris into Development Instruments 22800 AuAgust 2001 2 *wie- s .s Wow S5 t~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. ..... Other Titles in This Series Dynamic Risk Management and the Poor-Developing a Social Protection Strategy for Africa Engaging with Adults-The Case for Increased Support to Adult Basic Education in Sub-Saharan Africa Inclure les adultes - Pour un appui a I'education de base des adultes en Afrique subsaharienne Enhancing Human Development in the HIPC/PRSP Context-Progress in the Africa Region during 2000 Early Childhood Development in Africa-Can We Do More for Less? A Look at the Impact and Implications of Preschools in Cape Verde and Guinea Africa Region Human Development Working Paper Series AIDS, Poverty Reduction and Debt Relief A Toolkit for Mainstreaming HIV/AIDS Programs into Development Instruments Olusoji Adeyi Robert Hecht Elesani Njobvu Agnes Soucat THE WORLD BANK / UNAIDS Acronyms and Abbreviations AIDS Acquired Immunodeficiency Syndrome CSW Commercial Sex Worker DflD Department for International Development (United Kingdom) HAART Highly Active Antiretroviral Therapy HIPC Heavily Indebted Poor Country HIV Human Immunodeficiency Virus IDU Injecting Drug User IEC Information, Education and Communication I-PRSP Interim Poverty Reduction Strategy Paper NGO Nongovernmental Organization PLWHA Person Living With HIV/AIDS PRSP Poverty Reduction Strategy Paper STI Sexually Transmitted Infection UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme USAID United States Agency for International Development VCT Voluntary Counselling and Testing WHO World Health Organization c August 2001 Human Development Sector Africa Region The World Bank The views expressed herein are those of the author and do not necessarily reflect the opinions or policies of the World Bank or any of its affiliated organizations. Cover photo by Curt Carmenark, courtesy of World Bank Photo Library Cover design by Tomoko Hirata Inside layout by Services Concept, Geneva, Switzerland CONTENTS Acronyms and abbreviations ...................2 Acknowledgements ...................4 Foreword ...................5 Summary ...................6 1. Introduction .7 1.1. What is this Toolkit for? .7 1.2. To whom is it addressed? 8 1.3. Links between HIV/AIDS and poverty .8 2. The National AIDS Programme as a contribution to poverty reduction 11 2.1. Rationale .11 2.2. What works against HIV/AIDS? .11 2.2.1. An enabling environment across multiple sectors ...................................... 12 2.2.2. Preventing HIV infection ....................................................... 13 2.2.3. Care, support and impact mitigation ....................................................... 15 2.2.4. Mobilization of resources ....................................................... 16 3. The Essential HIWAIDS content in the PRSP and HIPC documents ....17 3.1. What are PRSPs? ....................................................... 17 3.2. An introduction to debt relief ....................................................... 18 3.3. Making the case for HIWAIDS control in the PRSP and HIPC documents 19 3.3.1. AIDS as cause of poverty and poverty as a contributor to AIDS ............... 20 3.3.2. Strategies derived from the national AIDS plan ......................................... 21 3.3.3. Medium-term goals and poverty monitoring indicators ............................ 21 3.3.4. Short-run actions that could be part of agreements for debt relief .......... 22 3.3.5. How has HIWAIDS been included in PRSPs? ............................................. 22 3.3.6. HIWAIDS conditionalities used in HIPC in 2000 .23 4. Uses of funds released through HIPC - earmarking, channelling and accountability .29 4.1. Earmarking .29 4.2. Channelling funds to local initiatives .30 4.3. Accountability .30 5. Influencing policies .33 5.1. Building coalitions .33 5.2. Strengthening capacity .34 6. Conclusions .35 6.1. PRSP, debt relief and AIDS: just another source of funds or a new opportunity? .35 6.2. Next steps .36 References .................................................. 37 Appendix 1: Links between HIV/AIDS and poverty . ........................................ 40 Appendix 2: Indicators ................................................... 45 Appendix 3: Selected websites on AIDS, poverty and debt relief .. 47 ACKNOWLEDGEMENTS An early draft of this paper was presented and reviewed at the I st Regional Workshop on AIDS, Poverty and Debt Relief that was held in Lilongwe, Malawi in November 2000. The workshop, which was co- organized by the UNAIDS Secretariat and USAID, included country officials from Ethiopia, Ghana, Kenya, Malawi, Mozambique, Nigeria, Uganda, United Republic of Tanzania, and Zambia. Participating agencies included the UNDP, WHO, World Bank, UNAIDS Secretariat and USAID. In addition, the authors acknowledge comments on earlier drafts from the following: Paurvi Bhatt (USAID), Keith Hansen (World Bank), Jean Lennock (DflD, Nigeria Office), Namposya Nampanya- Serpell (Independent Consultant) and two reviewers at the UNAIDS Secretariat. The authors alone are responsible for the contents of this document. - 4 - FOREWORD In the past two years we have seen unprecedented levels of political and institutional interest in reversing the course of the HIV/AIDS epidemic. Political leadership has improved significantly in some of the worst-affected countries, thus providing a more favourable environment for the fight against the epidemic and its negative effects on development. At the same time, we know that other key elements necessary for a successful response to HIV/AIDS are: (i) a concerted effort to put the HIV/AIDS agenda into major development instruments, (ii) a massive mobilization of additional resources, (iii) a multisectoral approach and (iv) a scaling up of interventions that are based on the best available evidence. The Highly Indebted Poor Countries (HIPC) Debt Initiative provides a unique opportunity to bring together these four elements to address the threat posed by HIV/AIDS. Proposed by the World Bank and the IMF and agreed to by governments around the world in 1996, the Initiative is a coordinated approach among official creditors to bring down debtor countries' extemal debt to sustainable levels. An enhanced version of the Initiative was put in place in September 1999 to simplify and accelerate the process, deepen the amount of debt relief, and tighten the link to poverty reduction. The Initiative puts emphasis on structural and social policy reforms, particularly to enhance the delivery of basic health care and education services, facilitated where needed with additional financing under the HIPC Initiative. Further, governments benefiting from the debt relief are expected to make their plans for poverty reduction explicit through the preparation of a Poverty Reduction Strategy Paper (PRSP). Given the adverse effects of HIV/AIDS on poverty, plans to address the epidemic are a natural feature in most if not all PRSPs. This toolkit adds to the knowledge base to support analysts and decision-makers in their work to: (a) mainstream HIV/AIDS as a major item on countries' development agenda, and (b) mobilize the resources needed to expand promising interventions and approaches in the fight against the epidemic. Developed by a team comprising staff from the UNAIDS Secretariat and the World Bank, the toolkit offers a unifying framework for analysing HIV/AIDS in the context of PRSPs, as well as examples of how the issue has been treated in the first generation of PRSPs, interim PRSPs and debt relief agree- ments. As such, it gives country officials and their partners highly relevant information that they can use in developing inputs for similar documents in their own countries. The PRSP process is still in its infancy today and we expect that many lessons will emerge as coun- tries adapt to this new approach in development assistance. This toolkit should therefore be viewed as a living document into which new insights and information would be incorporated as experience is gained in addressing HIV/AIDS in the context of PRSPs. This first edition of the toolkit consolidates the extensive knowledge that already exists in this regard. As such, it is a very welcome addition to the menu of practical tools that our clients, partner institutions as well as others can use to develop effec- tive responses to the HIV/ADS epidemic. Awa-Marie Coll-Seck Birger Fredriksen Director Sector Director, Human Development Department of Policy, Strategy and Research Africa Region UNAIDS The World Bank SUMMARY The potential benefits of giving HIV/AIDS a prominent place in PRSPs and HIPC agreements are substantial. They include greater political attention to and increased domestic funding for the national HIV/AIDS programme, as well as a focus on achieving results in implementing a national HIV/AIDS programme. Crucially, it helps to forge greater consensus among stakeholders on the main strategies and medium-term goals in tackling the HIV/AIDS epidemic. Ideally, the HIV/AIDS contents of PRSPs and HIPC documents would include the following aspects: * HIV/AIDS as a cause of poverty, plus a discussion of poverty and income inequal- ities, and their contributions to conditions that make persons vulnerable to HIV infection and less able to cope with the consequences of being infected; * the main strategies in the national HIV/AIDS plan as a central part of the overall national poverty reduction programme, justified and costed; * medium-term goals and poverty monitoring indicators derived from the national HIV/AIDS plan; and * short-run actions for successful implementation of the national HIV/AIDS plan, with specific and monitorable targets that form agreements for debt relief. This toolkit will serve as a resource for training at the country and subregional levels for country teams and their partners from NGOs and donor agencies. It will enable country teams to develop useful materials on scaled-up HIV/AIDS programmes for inclusion in the PRSPs and HIPC documents. More work will be done to continually improve the toolkit and the processes for building coalitions of partners in support of national responses to HIV/AIDS. 6 - UNAIDS / WORLD BANK 1. INTRODUCTION Key messages in this section: * In order to link H IV/AIDS control to Poverty Reduction Strategy Papers --R(Ps) and the enhaced Heavily Indebted Poor Country (HIPC) initia- tivef ther isd-a e r creible strategies and effective netietons.. This-Toolkit is aimed at.facilitating both. * AIDS induces and dee poverty; hence it should be at the core of the poverty reuct.on agenda. 1.1. What is this Toolkit for? This Toolkit will enable country officials and their partners to prepare and negotiate effectively the inclusion of scaled-up HIV/AIDS programmes in their PRSPs and instruments of debt relief under the enhanced HIPC initiative. PRSPs document coun- try-owned strategies for poverty reduction and provide the basis for a wide range of development programmes to be financed from public funds and grants. Where a coun- try is willing, a PRSP provides a basis for concessional lending by international finan- cial institutions. The enhanced Heavily Indebted Poor Country (HIPC) Initiative adopted by the Boards of the World Bank and IMF in 1999 aimed at accelerating the delivery of HIPC Initiative assistance and linking debt relief more firmly and trans- parently to poverty reduction. At the same time, the enhancements more than doubled the amount of relief projected to be provided under the Initiative. It is expected that external debt servicing will be cut by approximately US$ 50 billion. When combined with traditional debt relief, the initiative will cut by more than two-thirds the out- standing debt of more than 30 countries. As HIV/AIDS has become recognized as a threat to development in many developing countries, so have these countries attempted to "mainstream" HIV/AIDS into instru- ments of development. For poor countries, where PRSPs serve as the country's agenda for poverty reduction, it has become crucial for country-level managers and analysts to make credible proposals for the inclusion of HIV/AIDS in the poverty reduction effort. Yet, while several countries have done so effectively, many have yet to do so. For countries that are eligible for debt relief through the enhanced HIPC initiative, there is a potential for significant increases in the public financing of HIV/AIDS pro- grammes through earmarking of funds. Only a few countries thus far have seized this opportunity. This Toolkit is intended to assist countries seeking to develop effective sections on HIV/AIDS in their PRSPs and HIPC documents. - 7 - INTRODUCTION 1.2. To whom it is addressed? The Toolkit is addressed primarily to those with responsibilities for - or interest in - getting the HIV/AIDS agenda into the broader development efforts of each country. They include ana]ysts and policy-makers in National AIDS Commissions or similar cross-sectoral bodies, Ministries of Finance/Economic Development and nongovern- mental organizations at the country level. It is also aimed at officials of agencies that work with countries on PRSPs and HIPC documents, including NGOs, the interna- tional financial institutions, United Nations agencies with a remit that includes poverty reduction and development, foundations and bilateral development agencies. 1.3. Links between HIV/AIDS and poverty There are two sets of issues: (a) AIDS as a cause of poverty or AIDS deepening poverty and (b) the combined effect of poverty and income inequalities on social transactions - including sex, patterns of vulnerability and patterns of risky behaviour in relation to HIV infection and AIDS. A simplified illustration of the links between AIDS and poverty is presented in Figure 1 below. More details are shown in Appendix 1. Figure 1. Relationship between poverty and HIV/AIDS: a simplified view : t:0:i; j:g:- Str ucturol vulneiability -> high-risk situations 0000 - Lack oe access to prevenive interventions - Lock of access to affordable care - eLower ducational sttus->reducedoaccess tolintomntononAIDS igi$iPOVERTY 00:0 0:0HiiAjbs0 -Lost procductivity -Cotastrophic costs of health care 0 :: f: :: -Increased dependency ratioi E ; -Orphans with worse nutrition, lower school enrolment 0 00t000 Decreased capacity to manage households headed by; i0 : :f;;g;:;ii;;;;; orphans, elderly S :003 X} ll 00 :: 0;:00 : -Reduced national income 00 ;t 0000000 0 00000 -Fewer national resoutces for HIVJAIDS control $00 0 i:0 $ffful#ffffffffff u?S00:Xfa:S ;'S;S: ;0:'S:?l' ' :: fS0 ttt00000000 00:: u0000 ;Vtt0t;;;D:8000 UNAIDS / WORLD BANK Although some links have been demonstrated convincingly (Box 1), there are others for which the evidence is currently weak (Appendix 1). For the affected families and national policy-makers in many countries, however, the case is straightforward:, AIDS is condemning millions to misery and poverty. So far, AIDS has left behind 13.2 mil- lion orphans - children who, before the age of 15, lost either their mother or both par- ents to AIDS. Many of these children have died, but many more survive, not only in Africa (where 95% currently live), but also in developing countries throughout Asia and the Americas. In African countries that have had long, severe epidemics, AIDS is generating orphans so quickly that family structures can no longer cope (UNAIDS, 2000a). In the absence of effective efforts to mitigate the effect of AIDS on this gen- eration, whole societies will become dysfunctional, with negative consequences for human development and even basic security. I Poverty covers not onlY low income and consumption but also low achievement in education, health, nutrition and overall humiani development. It includes powerlessness and vulnerability. ..O h.9 .. s.- INTRODUCTION Box 1: How does AIDS induce or deepen poverty? * The few surveys of the impact of having a family member with AIDS show that households suffer a significant decrease in income and huge rises in medical care spending. Decreased, income leads to fewer purchases, diminished savings and dissavings. * In a study in Thailand, one-third of rural famnilies affected by AIDS experienced a halving of their agri- cultural output, which threatened their food security. Another 15% had to lake their children out of school, and over half of the elderly people were left to take care of themselves. Families spent on aver- age US$ 1,000 for medical care during the last year of an AIDS patient's life - the equivalent of an average armual income. • In urban areas in C6te d'Ivoire, the outlay on school education was halved; food consumption went down by 41% per capita and expenditure on health more than quadrupled. When family members in urban areas fall ill, they often return to their villages to be cared for by their families, thus adding to the pressure on scarce resources and increasing the probability that a spouse or others in the rural com- munity will be affected. • As the number of orphans grows and the number of potential caregivers shrinks, traditional coping mechanisms are stretched to breaking point. Households headed by orphans are becoming common in high-prevalence countries. Studies in Uganda have shown that following the death of one or both parents, the chance of orphans going to school is halved and those who do go to school spend less time there than they did formnerly. Other work from Uganda has suggested that orphans face an increased risk of stunting and malnutrition. • AIDS threatens the educational system and so undermines the social capital of the country. In high- prevalence countries like Central African Republic, Cote d'lvoire and Zambia, it is eroding the supply of teachers and thus increasing class sizes, which is likely to reduce the quality of education. T The effects on agricultural production can be serious. In West Africa, many cases have been reported of reduced cultivation of cash crops or food products. These include market gardening in the provinces of Sanguie and Boulkiemde in Burkina Faso and cotton, coffee and cocoa plantations in parts of C6te d'Ivoire. A study in Namibia by the Food and Agricultural Organization (FAO) concluded that the impact on livestock was considerable, with a heavy gender bias: households headed by women and children generally lose their cattle, thus jeopardizing the food security of the surviving members. * Some companies in Africa have already experienced the impact of HIV/AIDS on their balance sheets. Managers at one sugar estate in Kenya have noted increased absenteeism (8,000 days of work lost due to sickness between 1995 and 1997), lower productivity (a 50% drop in the ratio of processed sugar recovered from raw cane between 1994 and 1997) and higher overtime costs for workers obliged to work longer hours to fill in for sick colleagues. Costs of social bencfits relatcd to IIIV infection have risen sharply in the same company, due to funerals and health care costs. * A recent study estimated that Africa's income growth per capita is being reduced by about 0.7 percent per year because of HIV/AIDS. Had the HIV prevalence not reached 8.6 percent in 1999, Africa's income per capita would have grown at 1. 1 percent per year - or nearly three times the growth rate of 0.4 percent per year achieved in 1990-1997 (World Bank, 2000b). A country-specific econometric model of the South African economy suggests that overall GDP will be 17% lower by 2010 than it would have been without AIDS and that average per capita income will be 7-10% lower because of AIDS (Lewis and Arndt, 2000). Source: tUNAIDS (2000a). pp. 26-36. 10 UNAIDS / WORLD BANK 2. THE NATIONAL AIDS PROGRAMME AS A CONTRIBUTION TO POVERTY REDUCTION Key messages in this section: With a rigorous national plan, it becomes easier: to ma case for. HlV/AIDS in poverty reduction. By using evidence of what wor -. whereP such evidence is available, country teams can be more effectie a":" cates of the AIDS agenda. * Effective responses take into account approachesthatwo (the "howl and interventions that are effective (the 'what"). * Costed national plans make moro concrete the case--for i(r4er resource allocation to fighting AIDSf. 2.1. Rationale Despite increasing recognition of its negative impact on development, HIV/AIDS is only one of many problems that countries will address in their PRSPs and HIPC doc- uments. With so many ministries, sectors and civil society groups competing for attention and funding in PRSPs and HIPC documents, the case for HIV/AIDS must be highly compelling: that HIV/AIDS jeopardizes poverty reduction efforts, that by fighting AIDS poverty will also be tackled, that money can be spent efficiently to reverse the epidemic and improve people's lives. Therefore, any effort to mainstream HIV/AIDS in the development agenda must be well articulated to ensure buy-in from multiple sectors and the highest levels of government. In order to be convincing, advocates of the use of debt relief savings for HIV/AIDS need to demonstrate that an effective national HIV/AIDS programme will contribute to the fight against poverty. They must also lay out the financial case for debt relief, including how much will it cost to implement a far-reaching HIV/AIDS programme. 2.2. What works against HIV/AIDS?2 In general, effective responses would address the needs of each country, taking into account the status of the epidemic, the likely impact of a range of cost-effective inter- ventions in a given context, as well as the capacity for large-scale programme plan- ning, funding and implementation. The range of actions would include the develop- ment or strengthening of institutions for planning and coordination, multisectoral approaches to programme development and implementation, prevention of new infec- 2 A full review of interventions against HIV/AIDS is beyond the scope of this document. Readers who wish to explore these in detail are encouraged to examine the growing literature on prevention, care and impact miti- gation, including Merson et al. (2000), UNAIDS (2000a), Ainsworth and Teokul (2000), Jha et al. (2000) and Hunter (2000). 11 CHAPTER 2 tions, affordable care for persons living with HIV/AIDS (PLWHAs), social support to mitigate the impact of AIDS on families and orphans, as well as effective monitoring and evaluation of programme efforts. Country teams are likely to be more credible and effective advocates if their proposals are based on evidence of what works against HIV/AIDS, with clear outlines of the approaches to be taken in the national response to the epidemic and its consequences. Although a great deal remains to be understood about the evolution of the epidemic and its consequences, much has been learned regarding effective interventions for HIV prevention, cost-effective care for persons who are already infected, and actions to mit- igate the impact on orphans, families and communities. When the first cases of AIDS were reported in the early 1980s, individuals and groups acted to alert people to this dangerous new disease and the steps that could be taken to protect against it. Even before HIV was isolated, safer sex and safer drug use guidelines had been developed based upon epidemiological evidence concerning patterns of transmission. However, providing people with information about how to protect against infection has proven to be insufficient in and of itself. People require enabling environments that will reduce their susceptibility and vulnerability, and allow them to modify their behaviour based on their knowledge gained through information provision (UNAIDS, 2000a). 2.2.1. An enabling environment across multiple sectors At the national level, political commitment at all levels has been shown to be essen- tial for programnme success. Multilevel interventions that seek to involve a variety of partners in coordinated action have been shown to be more successful than those that work in isolation (UNAIDS, 1999, 2000a). Furthermore, coordinated economic, polit- ical and social effort are required to reduce societal vulnerability, alongside pro- grammes and interventions operating at individual and community levels. Global experience has shown the following elements to be among those central to effective national HlV prevention efforts (Piot and Aggleton, 1998): * General awareness-raising activities to provide information and counter negative reactions among the population at large * Focused persuasive action to meet the needs of specially vulnerable groups and communities, with steadily expanding coverage * Multisectoral and multilevel partnerships to deliver programmes and services across a range of contexts * Community ownership of programmes, and building upon the will of groups and individuals to contribute to national HIV prevention efforts * Greater integration between prevention and care to reduce costs and to reduce lev- els of discrimination and stigmatization * Action to build societal resistance to HIV transmission and reduce the systematic vulnerability of particular individuals, groups and sections of society - 12 - UNAIDS I WORLD BANK 2.2.2. Preventing HIV infection There are still few systematic reviews of the evidence on preventive interventions in the published literature. Merson et al. (2000) reviewed the effectiveness of projects and programmes in developing countries that aim to reduce sexual transmission of HIV infection or transmission related to injection drug use. They found that behav- ioural change interventions are effective when targeted to populations at high risk, particularly female sex workers and their clients. Few studies have evaluated harm reduction interventions in injecting drug users (IDUs). Evidence on the effectiveness of voluntary counselling and testing programmes was mixed, and results varied according to the population being studied. STI treatment appeared highly effective in reducing HIV/STI transmission, particularly in the earlier stages of the epidemic. Structural and environmental interventions show great promise, although more eval- uation is needed. Merson et al. concluded that: * HIV prevention interventions can be effective in changing risk behaviours and preventing transmission in low- and middle-income countries; - when the appropriate mix of interventions is applied, they can lead to significant reductions in the prevalence of HIV at the national level; and * additional research is needed to identify effective interventions, particularly in men who have sex with men, youth, IDUs and HIV-infected persons. In practice, countries will strike a pragmatic balance, based on the capacity for pro- gramme implementation, the expected effects of interventions, their political feasibil- ity and the availability of financial resources. For practical purposes, countries would need to consider interventions aimed at reducing risk and those aimed at reducing vul- nerability (Table 1). - 13- CHAPTER 2 Table 1. Interventions for prevention of HIV infection Factors influencing Interventions transmission of HIV "Risk"-oriented strategies * Sexual transmission IEC for behaviour change addressing immediate fac- School education tors of transmission Life skills Condoms (promotion of 100% con- dom use among the most vulnerable, including CSWs and the military) Voluntary counselling and testing Counselling STI treatment * Blood transmission Blood safety Universal precautions Safe injections / needle exchange * Mother-to-child Prevention of mother-to-child trans- transmission mission "Vulnerability"-oriented * Sexual behaviour * Behaviour change education strategies addressing * Intravenous drug use * Life skills and education for in- underlying factors of trans- * Cultural and religious school and out-of-school youth mission factors * Harm reduction, * Poverty * IEC for behaviour change * Illiteracy * Community mobilization * Discrimination * Poverty reduction * Education * Migration * Legislation . Human rights * Rural development, etc. 14 UNAIDS / WORLD BANK 2.2.3. Care, support and impact mitigation With millions infected and many more affected by HIV, the need has become urgent for improved access to affordable care, support and mitigation of the impact on indi- viduals, communities and countries. Table 2 shows a summary of interventions to be considered for care, support and impact mitigation. Table 2. Care and support packages, according to resource availability Package Contents The essential package * Voluntary HIV counselling and testing * Psychosocial support for HIV-positive people and their families * Palliative care and treatment for pneumonia, oral thrush, vaginal candidiasis and pulmonary tuberculosis * Prevention of infections with cotrimoxazole prophylaxis for symptomatic HIV-positive people * Official recognition and facilitation of community activi- ties that reduce the impact of HIV infection The intermediate package All of the above plus one or more of the following: * Active case-finding (and treatment) of tuberculosis among HIV-positive people * Preventive therapy for tuberculosis for HIV-positive people * Systemic antifungals for systemic fungal infections (such as cryptococcosis) * Treatment of Kaposi sarcoma * Surgical treatment of cervical cancer * Treatment of extensive herpes with acyclovir * Funding for community activities that reduce the impact of HIV infection The advanced package All of the above plus: * Triple antiretroviral therapy * Diagnosis and treatment of opportunistic infections that are difficult to diagnose and/or expensive to treat, such as atypical mycobacterial infections, cytomegalovirus infection, multiresistant tuberculosis, toxoplasmosis and HIV-associated cancers * Specific public services that reduce the economic and social impacts of HIV, to supplement community efforts that reduce the impact of HIV infection Source: UNAIDS (2000a), pp. 96-98. - 15 - CHAPTER 2 2.2.4. Mobilization of resources It is important to mobilize resources for all aspects of the response to HIV/AIDS described above. For sub-Saharan Africa alone, scaling up a wide range of interven- tions would require US$1.5-2.3 billion per year. Providing highly active antiretroviral therapy (HAART) would add another US$1.5-2.4 billion depending on the prices at which drugs would be available. These estimates are based on relatively conservative estimates of likely coverage that can be achieved by 2005 (World Bank, 2000c). Country-specific estimates of the resource gaps will make the case for additional resources highly compelling. In Zambia, resources required for implementing the National HIV/AIDS Strategic Framework were estimated at US$558.6 million for 2001-2003. A total of US$25.5 million had been committed by October 2000, leaving a resource gap of US$382 million (Bail and Mwikisa, 2000). - 16 - UNAIDS / WORLD BANK 3. THE ESSENTIAL HIV/AIDS CONTENT IN THE PRSP AND HIPC DOCUMENTS :....,.. . . . . . . . . . . . . . .-' .;..S..... . '-'- ' '" '-'-'' "° °-° ' '°"°' ""' 94a i a.&. . Key messages in this section. Ideally, the HIV/AIDS contents of PRSPs and HIPC documents would include the following aspects: * AIDS as a cause of poverty, plus a discussion of poverty and income inequal- ities, and their contributions to conditions that make persons vulnerable to HIV infection and less able to cope with the consequences of being infected; * the main strategies in the national AIDS plan as a central part of the overall national poverty reduction programme, justified and costed; * medium-term goals and poverty monitoring indicators derived from the national AIDS plan; and - short-run actions for successful implementation of the naftonal AIDS plan, with specific and monitorable targets that could form agreements for debt relief. 3.1. What are PRSPs? Poverty Reduction Strategy Papers (PRSPs) are documents that are intended to spec- ify the issues and approaches to poverty reduction in many developing countries, most immediately in the countries receiving debt relief under the enhanced HIPC. An effec- tive poverty reduction strategy would be expected to: (a) be prepared by the country; (b) focus on faster and broad-based economic growth; (c) reflect a comprehensive understanding of poverty and its determinants; (d) assist in choosing public actions that have the highest poverty impact; and (e) establish outcome indicators that are set and monitored using participatory processes. Most low-income countries are not immediately in a position to fully address each of the elements of a PRSP. Interim PRSPs (I-PRSPs) outline the process for producing full PRSPs, identify the gaps that need to be filled, and outline how this might be done (World Bank, 2000a). As of mid- January 2001, three countries had prepared PRSPs3 while 29 had prepared I-PRSPs.4 3 Burkina Faso, Uganlda and United Republic of Tanzania. 4In h4rica: Ben in, Camei-oon, CentralA fiicani Republic, Chad, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Madagascar Mfalawi, .lali, Mozambique, Niger. Rwanda, Sao Tome and Principe, Senegal. United Republic of Tanzania, ancd Zambia. In Europe and CentralAsia: Albania, FYR Macedonia, Georgia. Moldova, Tajikistan. In Latin America/'Caribbean: Bolivia. Guvana, Honduras and Nicaragua. In .4sia antI the Pacific: Camnbodia. 17 CHAPTER 3 3.2. An introduction to debt relief The principal objective of debt relief for the heavily indebted poor countries (HIPCs) is to bring the country's debt burden to sustainable levels, subject to satisfactory pol- icy performance, so as to ensure that adjustment and reform efforts are not put at risk by continued high debt and debt service burdens. The process involves two key phases, the first culminating in the "decision point", and the second, in the "comple- tion point". To reach the decision point a debtor country must have achieved a three- year period of satisfactory performance on the macroeconomic adjustment and reform programmes supported by the IMF and the World Bank. At the decision point, the Executive Boards of the IMF and the World Bank formally decide on a country's eligibility for debt relief and the international community commit to providing suffi- cient assistance by completion point for the country to achieve debt sustainability as assessed at the decision point. Under the HIPC initiative, debt sustainability is usually defined as 150% of the level of export at net present value. Most eligible countries will reduce their debt-to-export and debt-to-revenue ratios (net present value) between the decision and completion points. In short, under the enhanced framework, the benefits of export and central government revenue will accrue fully to the county, allowing for greater investment in poverty reduction strategies.5 At decision point, the country usually benefits from about 30% of the total amount of debt relief to be granted. After passing the decision point, a country enters the second phase and progresses toward the completion point when the bulk of assistance under the Enhanced HIPC Initiative is delivered. Interim assistance can be made available between the decision point and the completion point, with any remaining assistance provided at the com- pletion point. The term "floating completion point" refers to an arrangement in which the timing of completion point is tied to the implementation of policies determined at decision point. Figure 2 illustrates some of these key features of debt relief under the enhanced HIPC initiative. Twenty-two countries6 have reached their decision point under the enhanced HIPC Initiative and one country (Uganda) reached its completion point under the original HIPC Initiative. These 22 countries are now receiving relief that will amount to some $34 billion over time. 5Source: World Bank wehsite on HIPC: http://wwwworldbank.org/hipc/about/hipcbrl'hipcbrhtnm 6 In Africa: Benin, Burkina Faso, Cameroon, Gambia, Guinea, Guinea-Bissau! Madagascar; Malawi, Mfali, Mauritania, Mozambique, Niger, Rwanda, Sao Tome and Principe, Senegal, Uganda, United Republic of Tanzania, Zambia. (Source: World Bank website, News release number 2001/190/S. December 22, 2000j. In Latin American and Caribbean: Bolivia, Guyana, Honduras, Nicaragua. (Source: World Bank website, "The HIPC Initiative: Background and Progress Through December 2000 http://ww,w worldbank.org/hipc/progress-to-date/May99v3/may99v3. htm) 18 UNAIDS / WORLD BANK Figure 2. Key features of debt relief Decision 7oint ,700 - la > 600 3-% ° 500- 400 Completion ,, 400 - ~~~70% point £ 300- 0 °- 200- 80 100 I 0 Export Sustainable level Current debt 3.3. Making the case for HIV/AIDS control in the PRSP and HIPC documents Even though there is no pre-set formula for drafting Poverty Reduction Strategy Papers and HIPC debt relief documents, in practice they have tended to follow a fairly standard format. Since teams responsible for PRSP and HIPC in each country and their World Bank/IMF counterparts are likely to use this format, it is possible for those focusing on HIV/AIDS to prepare a set of materials that fit into the main sec- tions of the poverty and debt relief documents. These materials would cover at least four essential aspects: (a) AIDS as a cause of poverty, and possibly a discussion of poverty and income inequalities as contributors to conditions that make persons vulnerable to HIV infection and less able to cope with the consequences of being infected; (b) the main strategies in the national AIDS plan as a central part of the overall national poverty reduction programme, justified and costed; (c) medium-term goals and poverty monitoring indicators derived from the national AIDS plan; and (d) short-run actions for the successful implementation of the national AIDS plan, which could form agreements for debt relief. In Table 3 below, the asterisks indicate the relative emphasis that county teams could put on each of these aspects in their PRSPs and HIPC documents. - 19 - CHAPTER 3 Table 3. Essential sections on AIDS in PRSPs and HIPC documents Aspects to be covered PRSPs Debt relief (HIPC) agreements Country-specific analysis of the ** AIDS-poverty complex Main strategies from the national * AIDS plan Medium-term goals and poverty **** ** monitoring indicators Short-run actions, with ** "conditions" for debt relief 3.3.1. AIDS as a cause of poverty and poverty as a contributor to AIDS Here, the general linkages between AIDS and poverty would be mentioned - and then documented with specific data and examples from the country or from neighbouring countries where similar conditions prevail. Sources of data for this analysis include household surveys such as the Demographic and Health Surveys (DHS), special stud- ies conducted under the national AIDS programme, macroeconomic models that fac- tor in HIV/AIDS as a variable affecting labour productivity, health spending and budget analyses that try to quantify public expenditures on AIDS. Impact indicators that help to portray the effects of AIDS on poverty include: * decrease in growth rate of per capita income, * increase in number of AIDS orphans, their corresponding poorer nutrition and lowered school attendance rates, * reductions in output and cash income in households with an AIDS death, and * increases in household out-of-pocket health spending. When initiating the development of a PRSP or preparing an interim PRSP for the pur- pose of accessing debt relief, it is important for HIV/AIDS decision-makers to be able to present an overview of the relationship between HIV/AIDS and poverty. This analysis will help as an advocacy tool to make a case for HIV/AIDS and to prepare the analytical rationale for choosing the most appropriate and cost-effective interven- tions in a context of poverty reduction. Basic analysis would include an assessment of the current situation, its seriousness as well as the threat it poses to the future. These subjects could be covered by means of a presentation of the evolution of the HIV epi- demic countrywide and a projection of the development of the epidemic if the response is not accelerated. - 20- UNAIDS / WORLD BANK An analysis of the HIV prevalence between regions of different economic develop- ment and among different vulnerable groups helps identify high-prevalence areas and link them with behaviours as well as economic exchange patterns (HIV epidemic mapping). A disaggregated analysis of the HIV prevalence by gender and age group is useful, to demonstrate that young girls are among the groups most threatened by HIV Vulnerability factors can also be discussed using both quantitative and qualitative information. This analysis would attempt to disentangle how some key socioeconomic determinants may affect the spread of HIV and what is the hard evidence available on this issue. Finally a rapid analysis of the response can be conducted including an assessment of the proportion of cities covered by a programme for commercial sex workers, the proportion of roads covered by a programme for truck drivers, etc. 3.3.2. Strategies derived from the national AIDS plan These would include four to six well-defined strategies from the country's plan for an expanded response for prevention, care, support and impact mitigation, based on expected impact, cost-effectiveness and feasibility, with cost estimates. Even if the national AIDS plan contains many more strategies, it will probably be necessary to select the most important ones, since the PRSP is quite a brief document. Country teams might also choose to specify the incremental resources required for recurrent line items, such as for personnel, transportation, supplies and materials. In a few well- documented Poverty Reduction Strategies to date in high HIV prevalence countries, AIDS is presented in the PRSP as requiring a strategic response that cuts across the conventional sectors, spanning health, education, defence, transport, youth, commu- nications, and others. In other words, the main lines of the national AIDS plan are first portrayed as a "supra-sectoral" or "cross-cutting" concern, and this is then reinforced in the paragraphs devoted to the main poverty-fighting sectors, where AIDS again appears as a threat requiring specific actions from each sector agency and from civil society groups and donors focusing on the sector. The Malawi PRSP is a useful exam- ple of this approach (Table 4). 3.3.3. Medium-term goals and poverty monitoring indicators These also need to be selective, as only a small number of AIDS strategies are likely to be listed in the PRSP. In the ideal circumstances, these goals and indicators will have been developed with technical expertise, and negotiated among stakeholders as part of the AIDS national planning process. In many cases this will not have hap- pened, either because the national AIDS plan is not complete or because goal/target setting was not carried out as part of the national planning process. Since the medium term covers five years or more into the future, the goals would relate to results of the national AIDS response - outcomes ideally, or at least major outputs of the AIDS pro- gramme. Each country team will need to formulate medium-term goals and targets - 21 - CHAPTER 3 that are right for national circumstances. Uganda has specified a 25% decline in HIV prevalence (Table 4). 3.3.4. Short-run actions that could be part of agreements for debt relief Selectivity is also required here. These actions are the agreed steps for decision and completion points, and that could be inserted into the matrix in the HIPC document. Ideally, they would have the characteristics outlined below. (a) Be derived from and closely linked to the key strategies in the national AIDS plan, spelled out earlier in the PRSP/HIPC document - in this sense, they should be seen as "sentinel" actions that tell us whether the AIDS plan itself is being suc- cessfully implemented. (b) Be relatively easy to measure. Since programme implementation will be moni- tored closely under HIPC by government, civil society, and international agen- cies, it is crucial to put in place an effective monitoring system that can generate results quickly. (c) Be carefully selected to match the expected timetable for HIPC, especially the trigger points for entering debt relief (decision point), and intermediate and final (completion) debt forgiveness points. (d) Be well understood and accepted by the political figures and programme man- agers who will be accountable for carrying out this series of actions. Fortunately, there is a wide range of indicators for monitoring and assessing progress in implementing national AIDS programme strategies, which have already been developed, and for which corresponding data collection and analysis methods are fairly well established. The UNAIDS Guide to Monitoring and Evaluation (UNAIDS, 2000c) is a handy compendium of these indicators, an abbreviated set of which is pre- sented in Appendix 2. At country level, too, national specialists on HIV/AIDS and international staff serving on the "technical working groups" of the United Nations Theme Groups on HIV/AIDS can help to select and validate the best performance tar- gets for the period of HIPC debt relief. 3.3.5. How has HIV/AIDS been included in PRSPs? Most I-PRSPs in sub-Saharan Africa have included HIV/AIDS as an issue to be tack- led (Table 4). Yet the relationship between HIV/AIDS and poverty has rarely been examined and the strategies do not appear very well defined. In particular the vision of how the country will scale up a response to mitigate the negative effect of HIV/AIDS on human capital and economic growth has not been articulated in any of the PRSPs. However, Uganda is revising its strategy to better mainstream the issue of HIV/AIDS within its vision of poverty reduction. - 22 UNAIDS / WORLD BANK 3.3.6. HIV/AIDS conditionalities used in HIPC in 2000 As part of the policy dialogue surrounding debt relief, some countries have commit- ted to increasing their efforts towards curtailing the HIV/AIDS epidemic. This com- mitment has sometimes translated into some conditionalities for the country to reach the completion point at which the bulk of debt relief will be granted. Most of these conditionalities are process-related, yet some countries have committed to triggering a real behaviour change as in Cameroon, where increased condom use among men in uniform, truck drivers and commercial sex workers was included as a conditionality. 23 CHAPTER 3 Table 4. Selected examples of PRSPs and their HIV/AIDS contents* Country Country-specific analysis of Main strategies from the Medium-term Short-run the AIDS-poverty complex national AIDS plan goals and poverty actions monitoring indicators Cameroon HIV/AIDS not mentioned under Subsumed under health sec- "Rate of HIV/AIDS Set up (Interim "determinants of poverty". tor: "the principal and most incidence". HIV/AIDS infor- PRSP, urgent concern is the spread mation and August, of HIV/AIDS". Specific actions awareness cam- 2000) to slow the progression: IEC, paigns in public VCT, and blood safety. and private media. Brief mention under "Urban Poverty", focusing on com- mercial sex workers. Emphasis on education cam- paigns. Malawi Included as part of "Super- Under "strategies and meas- Not specified. Not specified. (Interim Sectoral Analysis", with refer- ures". PRSP, ences to country-specific statis- August tics on seroprevalence. There Mainstream HIWAIDS into all 2000) are explicit notes on the effects sectors and improve orphan on growth, poverty, productiv- care. ity and savings. Orphans and families get specific attention. Intensify efforts on primary Reference to the National prevention. Strategic Framework for HIV/AIDS and the Resource Integrate AIDS and tuberculo- Mobilization Round Table of sis control programmes. March 2000. Strengthen AIDS Secretariat. Uganda Under "improving health of the Expenditures for service deliv- 25% decline in HIV Not specified. (PRSP - people". There are notes on ery to be included in health prevalence. Poverty prevalence rates, effects on life and other sectors. Eradication expectancy, as well as a brief Action acknowledgement of interac- Note: Based on its National Plan, tions among AIDS, cultural fac- Strategic Framework, Uganda March tors and poverty. subsequently revised its 2000) Poverty Eradication Action Plan to include AIDS in each of the four goals. The National Strategic Framework emphasizes prevention, impact mitigation and capac- ity building. * A convenience sample of three countries, for illustration. Source: World Bank Website on PRSPs. http://www.worldbank.org/prsp/. Accessed on 31 January 2001. 24 UNAIDS / WORLD BANK Table 5. Measures to reach the floating completion point under the HIPC Initiative* Country-specific analysis of Main strategies from Medium-term Short-run indica- the AIDS-poverty complex the national AIDS plan goals and poverty tors, with "condi- monitoring tions" for debt indicators relief Cameroon Under "overall policy frame- Included explicitly. Limit infection rate Prioritize HIWAIDS work". Based on interim PRSP. Covers coordination to below 10%. in overall agenda. mechanisms, overall goal, interventions and US$8.9 million Curb infection coverage indicators. over 3 years from rates among pop- Mentions line ministries HIPC proceeds for ulation, with involved. HIV/AIDS increased use of condoms among port workers, truckers, soldiers and commercial sex workers. Malawi Impact on life expectancy. Proposed institutional Not explicit. Policy areas to be framework: make "Slowing the monitored include Large number of orphans. National AIDS Control spread of AIDS' is a fully staffed, Programme secretariat a floating comple- functional and Potential to reduce economic autonomous, outside the tion point trigger. autonomous growth, not country-specific. control of any specific National AIDS sectors. Control Secretariat. Summary of interven- tions for prevention, care and impact mitigation. Uganda Specific notes in the Second Poverty Reduction Not specified. Government Decision Point Document, Strategy for 1990/2000 - established a including prevalence, life 2001/2002. Poverty Action expectancy and Human Fund, under which Development Index. The poor Establishment of func- programmes are are more likely to include wid- tional coordination outcome-oriented. ows, orphans and those living mechanisms, at the cen- Outcomes are with HIV/AIDS. tral and district levels, for reviewed on a the national multisectoral quarterly basis response to HIV/AIDS. with donors and representatives of Expanded outreach of civil society. education for behaviour change. * A convenience sample of three countries, for illustration. Source: World Bank Website on HIPC, http://www.worldbank.org/hipc/country-cases/country-cases.html. Accessed on 31 January 2001. Y-- 25 --- The Cameroonian experience illustrates several elements of a successful effort to inte- grate HIVAIDS into an interim PRSP and a debt relief agreemnent (Box 2). Box 2. Focus on Cameroon: how was it done? Over the last few years, the pace of activities had stalled in Cameroon's response to HIV/AIDS. The National AIDS Control Programme included a number of projects that were considered successful. The overall response was small-scale, fragmented and incomplete, however. Meanwhile, the epi- demic continued to spread. with more than 540.000 Cameroonians infected with HIV by the end of 1999 (a prevalence rate of 7.7% among adults; UNAIDS, 2000a) The debt relief discussions and the preparation of the Interim PRSP, which started in mid-2000, helped to trigger a more vigorous response to HIV/AIDS. The I-PRSP was prepared during April- August 2000 with broad input from government and civil society, including NGOs and religious leaders, and published in September 2000. It highlighted HIV/AIDS as a factor in worsening the country's poverty and as a serious threat to overall social and economic development. Similarly, early in the debt negotiations, the government and World Bank officials identified AIDS as one of the most important areas that could benefit from additional resources from debt relief. This in turn encouraged the Government of Cameroon to accelerate the development of a nationwide plan to curtail the epidemic. An HIV/AIDS strategic planning process already under way in Cameroon was speeded up to coincide with the debt negotiations. Completing this AIDS strategic plan became a precondition for finalizing the debt relief agreement, and the plan was also needed to specify the priority actions in AIDS prevention and care that could be funded with debt relief savings. As a result. the government completed a comprehensive national HIV!AIDS strategic plan for 2001-2003, in collaboration with UNAIDS and other partners. It was launched by the Prime Minister of Cameroon in September 2000. The plan contains a set of highly focused emergency actions costing about US$9 million over three years, to be funded by the government using debt relief savings: * promoting behaviour change among young people aged 15-24 through information, education and communication at the national and local levels, * making voluntary testing and counselling widely available throughout the country and pre- venting HIV transmission from pregnant women to their babies, and * supporting a 100% condom use campaign including free provision of condoms among key vul- nerable groups: trtuckers. plantation workers, university students, military, police, workers in the customs service, prisoners, prison wardens and commercial sex workers In parallel with the debt relief process, the government and World Bank together prepared a major project, the Multisectoral Programme to Fight against HIV/AIDS. to be funded with a combination of a US$50 million World Bank credit (soft loan, partial grant) and national funding from debt relief savings. The World Bank credit was approved in December 2000, and the project was offi- cially launched in February 2001. To manage the implementation of the ambitious national AIDS plan and the Bank-funded project, the government decided to establish a new Central Technical Group with a wide range of skills in managing local and sectoral AIDS responses, communications, and monitoring and evaluation. The Cameroonian experience reflects the importance of high-level political commitment. a multi- sectoral approach, and a simultaneous focus on actions that are likely to have a significant impact on the epidemic. PRSP, HIPC, national AIDS planning, and a focus on implementation are closely intertwined. 26 CD -c; 4j 2.~~~~~r 0 c 0 Y- -t ~ W R0 0 CD 0 Ca ~.' ~ 0 -. 0~~,W CrOQO C~~~ ~ C ~~~ 0 2 ~~~~~~~~~~ S~7 CDo-, ts Al UNAIDS / WORLD BANK 4. USES OF FUNDS RELEASED THROUGH HIPC - EARMARKING, CHANNELLING, AND ACCOUNTABILITY Key messages in this section: i To ensure that funds go to HIV/AIDS control, consider earmarking of sav- ings from HIPC * Design effective approaches to get funds to community initiatives * Ensure transparency and accountability 4.1. Earmarking In growing numbers of the HIPC debt relief documents, the budgetary savings from debt relief are explicitly calculated for a number of years to come. There is thus an opportunity in the HIPC document to specify or "earmark" how much of the savings (either as a percentage of the actual savings, or in absolute dollar terms) will be allo- cated to the national AIDS programme. If so, the teams working on HIV/AIDS in the HIPC process have a chance to lobby for a sizeable allocation to the national AIDS programme. This can be justified both on the basis of the estimated cost of a large-scale national response to the epidemic, and by demonstrating how fundamental the fight against AIDS is in the overall effort to reduce poverty and promote economic and social development. In high-prevalence countries, a minimum of US$1.50-2.00 per capita is needed for a strong national AIDS programme, e.g., US$15-20 million annu- ally in a country with 10 million inhabitants. If one-quarter or one-half of these costs (in the above example, this would amount to say, US$5-10 million a year) can be met through debt relief, with the balance funded from external development partners, this would constitute an important financial and political investment by the government. Since HIV/AIDS is a cross-cutting issue that extends beyond any individual sector, a supra-sectoral budgeting/allocation is advisable. Earmarking debt relief savings for HIV/AIDS could itself be one of the HIPC conditions to be monitored for successful completion of the debt relief process. For example, "during the period from 2001- 2003, the government will spend US$xx million of debt relief savings on its national AIDS programme". - 29 CHAPTER 4 4.2. Channelling funds to local initiatives In a number of HIPC countries, there is also strong interest in seeing that a major por- tion of the debt relief savings assigned to AIDS - and indeed, the entire budget to sup- port the national AIDS plan - is channelled rapidly and efficiently to local initiatives. These include local government units, local NGOs, and community organizations that are trying to carry out prevention, care and support activities. Under these circumstances, the HIPC process can be an opportunity to develop and put in place effective mechanisms for moving financial and technical resources to local groups implementing AIDS control activities. This can be done through a variety of means that might be specified and monitored as part of national compliance with the conditions for debt relief - for example, by setting up a special "Poverty Action Fund" that receives the debt relief savings and uses them exclusively for local initiatives. These Poverty Action Funds are partly an accounting mechanism, but when combined with resource transfer features, such as matching grants for local government bodies and NGOs, they can be a way to get the resources out to the frontlines. In Uganda, the Poverty Action Fund (PAF) includes the highest-priority expenditures from the per- spective of poverty eradication. The eligibility of a particular sector or programme for funding from the Uganda PAF is based on high economic and/or social returns to the expenditure, by pro-poor targeting and by the priority accorded such programmes by the poor themselves, as demonstrated by prior participatory work. In collaboration with the UNAIDS Secretariat and the World Bank, managers of the Malawi Social Action Fund (MASAF) are examining options to channel funds to communities for a more rapid implementation of activities to mitigate the impact of AIDS. Direct funding of community-based activities is a key feature of the Africa Multicountry AIDS Programme that was launched by the World Bank in 2000 (World Bank, 2000b). Similarly, if all or part of the debt relief savings was deposited in a national social development fund or micro-projects fund with an explicit HIV/AIDS component, this could be another way to ensure that the savings reach local public and/or private insti- tutions (e.g. youth clubs, women's groups, NGOs assisting commercial sex workers, village AIDS committees). The establishment of these kinds of arrangements for transferring debt relief savings to local groups could be explicitly laid out in the HIPC documents as completion point actions. 4.3. Accountability Finally, the HIPC process affords an opportunity to create strong mechanisms for accountability for uses of financial resources and for results. In a number of countries, civil society groups and international donors are calling for procedures that make the - 30 UNAIDS / WORLD BANK use of debt relief savings and donor funds more transparent and linked to measurable programme results. One idea has been to establish mixed bodies (composed of repre- sentatives of government, civil society, and donor agencies) to monitor progress and use of funds in parts or all of the national AIDS programme. This is the approach taken in Uganda, where quarterly reviews are carried out with representation from donors and civil society. In Malawi, the expenditure monitoring mechanisms for HIPC resources include public reporting of expenditures. As much as possible, assessments of output, outcome and impact should be under- taken to determine the benefits of inputs through various financing mechanisms. Disbursement of funds could be accompanied by the collection of household and community-level data as part of a baseline assessment. This would facilitate the eval- uation of a funding mechanisms as well as the projects financed by through the fund- ing mechanism (Ram, 2000). 31 UNAIDS / WORLD BANK 5. INFLUENCING POLICIES Key messages in this section * Build a coalition to ensure that HIV/AIDS gets on the PRSP and-debt relief agenda * Develop a team with the skills to manage the process The previous sections focused on why HIV/AIDS belongs in PRSP and HIPC, and on what should go into Poverty Reduction Strategies and debt relief agreements con- cerning HIV/AIDS. This section deals with the how - the difficult process of getting HIV/AIDS issues into the PRSP/debt relief agenda. There are two key considerations: building coalitions to influence policies and developing local capacity. 5.1. Building coalitions To build coalitions, it is important that the diverse groups that are already committed to fighting the HIV epidemic are brought together, and that they draw in others who are not yet fully convinced. These could include parts of government including the national AIDS secretariat or coordinating body, the national AIDS council or inter- ministerial committee, AIDS units in some ministries, civil society groups that are already active and often have one or several national umbrella organizations, associa- tions of people living with HIV/AIDS and a wide assortment of multilateral, bilateral, and international nongovernmental agencies. To support the PRSP and HIPC process, these various individuals and institutions can be engaged as members of task forces, inter-agency working groups, etc., led by government and other national actors. To influence the process and content of the PRSP and debt relief agreements, the HIV/AIDS "coalition" must not only articulate a strong case for including HIV/AIDS on "technical" grounds. It is also important for coalition members to be closely engaged with those responsible for overall preparation and negotiation of the PRSP/HIPC instruments. These are typically senior officials of the Ministry of Finance and/or national economics and planning agency, and technical officers from the World Bank and International Monetary Fund. Again, it is helpful to have an inter- agency committee or technical working group supporting the Ministry of Finance team, on which certain persons from the HIV/AIDS coalition can serve. Relevant ministries include those of education, social development, youth, defence, agriculture and transport. Focusing national media attention on AIDS as a poverty issue and a threat to development can also be effective in influencing national policy on AIDS in the PRSP and debt relief processes. The Uganda AIDS Commission led a process that was both inclusive and participatory, the success of which provided a basis for incor- porating AIDS into all the goals of the country's Poverty Eradication Action Plan. 33 - CHAPTER 5 Finally, PRSP/HIPC can be an opportunity to build greater technical capacity in- country to deal with a range of analytical and managerial challenges inherent in mounting and sustaining a strong national AIDS programme. As can be seen from the above, effective inclusion of HIV/AlDS in the PRSP and HIPC requires skills in analysing the impact of AIDS on poverty, programme priority setting and costing, negotiation, and monitoring and evaluation, to name just a few of the most important areas. For each of these areas, a small but critical number of capable individuals must be located in key institutions, including the national AIDS secretariat, the Ministry of Finance, and national NGO umbrella organizations and associations of people living with HIV/AIDS. 5.2. Strengthening capacity As part of PRSP/HIPC, members of the AIDS "coalition" in the country should develop, fund, and implement a scenario for minimum capacity building to support the process. Such a minimum scheme should specify the required skills and the insti- tutions to house these. For example: X National AIDS Secretariat: one planner and one economist trained in program- ming, priority setting, costing, and monitoring/evaluation. In Uganda, an econo- mist was deployed to work on HIV/AIDS in the AIDS Commission. * Ministry of Finance: one economist tied to PRSP/HIPC who can assemble data on the poverty-AIDS linkage and articulate AIDS commitments under debt relief. * Poverty Action Fund and/or AIDS portfolio within the national social develop- ment fund: 2-3-person management teams trained to handle both the program- matic and financial dimensions of a major transfer of resources to local AIDS ini- tiatives. * The umbrella NGO organization and PLWHA association: at least one person in each who can help in articulating key commitments on AIDS under debt relief and assist in monitoring compliance with AIDS conditions under HIPC. Carrying out this capacity building could also be one of the related objectives under PRSP and debt relief, and could be explicitly financed and monitored as part of HIPC. 34 UNAIDS / WORLD BANK 6. CONCLUSIONS 6.1. PRSP, debt relief and AIDS: just another source of fund- ing or a new opportunity? In many countries accessing debt relief, HIV/AIDS programme managers and deci- sion-makers have the opportunity to claim more funding for HIV/AIDS in a context of the development of poverty reduction strategies. Debt relief does not only provide the possibility of having fresh resources injected in the fight against HIV It gives the opportunity to place HIV/AIDS at the centre of the development and aid agenda and to discuss country issues linked to policy development and budgeting. Despite the availability of external resources through various initiatives, many HIV/AIDS pro- grammes in poor countries have not yet reached a scale that will make an impact on the epidemic. Increases in internal revenue available for the social sectors may pro- vide the opportunity to reach that scale by: * placing HIV/AIDS within the framework of budgetary discussions, and breaking the cycle of donor-driven programme design and financing; * institutionalizing the response to HIV/AIDS in all activities of the government, using the new fiscal space to provide additional resources to each sector for this specific purpose; * transforming fragmented activities into sustained programmes, thus freeing the country from extreme dependence on donors for key inputs (for example, financ- ing drugs for tuberculosis control or condoms for the military) and ensuring a more stable supply of such commodities; and * addressing broader issues not always directly linked to HIV/AIDS but often strongly affecting the response and contributing to dysfunction in the sectors through staff attrition, poor remuneration and lack of funds for recurrent expenditures. Policy-makers and managers thus have a reason to think strategically about how dif- ferent sources of funding can complement one another rather than compete to fund the same programmes. Debt relief funds may be used wisely to develop the capacity to exert leverage and absorb further available external funding. In Mali for example, while the health sector benefits from a large externally funded sector investment pro- gramme, HIPC funds are likely to be used to reinforce the implementation capacity by financing basic training as well as contracting of staff and providing incentives for them to deliver essential public health interventions. - 35 - CHAPTER 6 6.2. Next steps The record of poor countries to date in integrating HIV/AIDS in poverty strategies and debt relief has been mixed. There have been some notable successes, but also a number of failures and missed opportunities. 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Selected background papers for the World Bank Policy Research Report, Confronting AIDS: Public Priorities in a global epidemic. European Commission, Brussels, pp. 95-109. Piot, P., Aggleton, P. 1998. "The Global Epidemic." AIDS Care, 10 (Suppl. 12) S200- 208. Ram, S. 2000. A Summary of Resource Transfer Mechanisms. A discussion paper pre- sented at the UNAIDS Workshop on the Role of Debt Relief in Financing National HIV/AIDS Programmes. Lilongwe, Malawi. November, 2000. Unpublished manu- script, pp. 24-26. UNAIDS. 1999. Summary Booklet of Best Practice Collection. Issue 1. Geneva. UNAIDS. 2000a. Report on the Global HIV/AIDS epidemic. Geneva, pp. 26-36. UNAIDS. 2000b. Innovative Approaches to HIV Prevention. Selected Case Studies. Geneva. p. 6. UNAIDS. 2000c. National AIDS Programmes: A Guide to Monitoring and Evaluation. Geneva, pp. 26-27. - 38 UNAIDS / WORLD BANK World Bank. 2000a. Poverty Reduction Sourcebook. http://wwwworldbank.org/poverty. Accessed on 24 January 2001. World Bank. 2000b. ProjectAppraisal Documentfor Proposed Credits in the amount of US$59.7 million and US$50 million, respectively, to the Federal Democratic Republic of Ethiopia and the Republic of Kenya in support of the first phase of the US$500 million multi-country HIV/AIDS Programme for the Africa Region. Washington, DC, pp. 65-79. World Bank, 2000c. Costs of Scaling HIV Programme Activities to a National Level in Sub-Saharan Africa: Methods and Estimates. AIDS Campaign Team for Africa, pp. 1-5. - 39- APPENDIX 1 APPENDIX 1. LINKS BETWEEN HIV/AIDS AND POVERTY AIDS causing or deepening poverty The relationships are examined at the levels of the individual, the household and the national economy. Once infected, the individual faces direct catastrophic costs in terms of health and social care, plus indirect costs in terms of lost productivity. The household is more likely than not to experience reduced income. Business productiv- ity is more likely than not to decline, due to lost productivity, high absenteeism, increased payments for treatment and funerals, as well as increased costs of training and retraining of replacements for dead workers. Figures Al and A2 indicate the path- ways from HIV infection to increased poverty. Figure Al. HIV/AIDS induces and deepens poverty CONTRIBUTORS TO POVERTY * Loss of income * Catastrophic cost of care * Increased dependency ratio * Loss of productivity (firms, agriculture) * Loss of social capital (countries) * Reduced national HIV infection AIDS income -~ 40 UNAIDS / WORLD BANK Poverty and income inequalities increasing the likelihood of HIV infection The plausible pathways by which poverty and income inequalities increase an indi- vidual's chances of becoming infected with HIV are perhaps indirect. Increased vui- nerability to HIV infection is important because it increases the probability of transmitting or becoming infected with HIV. In this regard, poverty may reduce an individual's ability or willingness to avoid becoming infected. For example, income poverty may lead people to engage in high-risk income-generating activities such as commercial sex work. Commercial sex workers may engage in sex without condoms for the sake of higher fees. Poverty is often associated with lower education, which may in turn be associated with lower awareness of effective measures to prevent HIV infection. Figure A2 and Box Al indicate the plausible pathways through which poverty leads to increased risks of HIV infection. As yet, there is not sufficient sys- tematic evidence to support an assertion that poverty causes AIDS. While it is highly likely that some of the characteristics of poverty (e.g. lower educational level, fewer livelihood choices, lower capacity to negotiate safe sex) also increase the risk of being infected with HIM it would be overly simplistic to see HIV purely as a "disease of the poor". Many groups and individuals at increased risk of being infected with HIV in Africa (urban elite who purchase sex, travelling businessmen who have casual sex, officers in the armed forces) are not among the poor. At this stage of the epidemic, HIIV/AIDS continues to cut across household economic boundaries. For prevention, it is evident from the literature that in the short to medium term, the high-impact interventions are those that reduce the risk of transmitting the virus or the risk of becoming infected. Risk factors are those elements that increase directly the probability that an individual will become infected with HIV or transmit HIV to another person. Interventions focusing on vulnerability reduction are structural or more deep-seated development challenges. They could have indirect effects on the dynamics of the epidemic. Clearly, they need to be addressed for medium- to long- term success against HIV/AIDS. However, the dynamics of the epidemic are such that failure to act on risk reduction would result in a substantially larger number of infected persons, further limiting the gains from structural interventions against vul- nerability. 41 APPENDIX 1 Figure A2. Poverty increases the likelihood of HIV infection and AIDS VULNERABILITY * Restricted choice of safe economic activities * Migrant labour * Lack of access to health services * Lower educational status P Increased risk of O becoming infected V with HIV E and/or R Increased probability T of transmitting HIV to y an uninfected person * Commercial sex * Failure to use condoms * Needle sharing among IDUs * Poor treatment of other STIs * Lack of access to a service for preventing mother-to-child transmission * Lack of awareness of preventive measures that work - 42 Box Al. Does poverty increase the likelihood of HIV infection? In the early years of the HIV/AIDS epidemic, persons of higher socioeconomic status Were more likely than others to become infected with [LIV. As HIV/AIDS becomes endemic in most African countries, the positive correlation between socioeconomic status and HlIV infection could be expected to disappear. The evidence is mixed, as inidicated in the following paragraphs. Among the issues needing attention is the com- bined etffect of poverty and income inequalities in social transactions - including sex, patterns of vulnerability and patterns of risky behaviour in relation to HIV infection. IIUNAIDS analysed the results of studies conducted mostly among 15-19-year olds in 1 7 African and four Latin American countries. A risk pattern, seen in both sexes, was that better-educated individuals were generally more likely to have casual partniers (UNAIDS, 2000a). The results also suggested that the best-edu- cated people in the hardest-hit countries in Africa may be shifting towards less risky behaviour (UNAIDS, 2000a). Although it is too soon to tell, this pattern seemlls like that in Brazil, where there has been a shift in the socioeconomic dis- tribution of AIDS cases: in the early 1980s, three-quarters of those newly diag- nlsed with AIDS had a secondary or utiversity education; by the early 1 990s this share had fallen to one-third (Parker, 1998). Poverty and illiteracy might be expected to raise the probability of infection with sexually transmitted diseases, including HIV/AlDS. since people with low incom-ies may be less able than those with higlher incomcs to afford condoms or STI treatment and those with little education may have less access to information aboLit the dangers of high-risk behaviour or may be less able to understand pre- ention messages. This explains why, for most STIs, the poor and uneducated have higher infection rates (Lacey el al., 1997). It also appears to be the case for the spread of HIV in industrialized countries (Cowan et al., 1994; Krueger et aL, 1990. McCoy et al., 1996). In the first decade of the HIV/AIDS epidemic in Africa, HIV infections did not follow this pattern. A number of studies showed a positive correlation between I IIV infection and socioeconomic status, measured by schooling, income or occu- pation (Ainsworth and Semali, 1998). Analysis of data from demographic and health sturveys carried out during the early 1 990s and surveys of sexual behaviour sponsored by the WHO Global Programme on AIDS (GPA) conducted in 1989- 1'991 shows that the probability of having a non-regular or commercial sexual partner rises with education, potentially increasing exposure to contracting STIs, including HIV (Filmer 1998: Deheneffe ettal., 1998). The demand for commercial sex and/or the ability to support multiple partners would rise with income. Also, persons with hiigher education and higher incomes have more disposable cash and are iiore likely to travel - thus having more opportunities for casual sex. 43 APPENDIX I *:Aggreateincolmeaoeisnot af pre&dictro tre;nds in HLV prevalene:. intra- countr sial ad cullf s play i t res in the dynamics of the epi- demic. :While well-meag eessins lie " rty causes" AIDS ma appear implictp rooh atulyhmper con o and ofther on- the-ground preventionefforts (Halperin, 2000)44 :~~ ~ 44 - CSt:WV:;,Ct$ g:S0 0 ; S P S : UNAIDS / WORLD BANK APPENDIX 2. INDICATORS 1. Overview of indicators by ro'ramme areas, tools for measurement, and priority for different epidemic states* (C=Core indicator; A=Additional indicator) Note: Country teams are encouraged to refer to the full text for definitions and to be highly selective in their use of indicators. Programme area indicator Priority Priority Generalized Concentrated/ ___________ epidemic low-level Policy 1. Spending on HIV prevention C C Condom availability and quality 1 Condoms available, nationwide C C 2 Condoms available, retail C A Stigma and discrimination 1 Accepting attitudes toward HIV+ people C C 2 Employers not discriminating C C Knowledge 1. Knowledge of HIV prevention C C Voluntary counselling and testing 1 People who requested test and received results C A 2 Districts with VCT services C 3 VCT centres with minimum conditions C A 4 Quality of VCT laboratories A A Mother-to-child transmission 1 Pregnant women counselled and tested C 2 Antenatal clinics offering and referring for antenatal care C 3 Quality HIV counselling for pregnant women A 4 Provision of antiretroviral therapy A Sexual negotiation and attitudes 1 Women's ability to negotiate safe sex A Sexual behaviour 1 Higher-risk sex in the last year C C 2 Condom use at last higher-risk sex C C 3 Commercial sex in last year A C 4 Condom use by clients at last paid sex A C 5 Condom use by sex workers with last client A A * Part of the Behavioural surveillance surveys (BSS): Guidelines for repeated behavioural surveys in population groups at risk for HIV - 45 APPENDIX 2 Appendix 2 (contd): 2. Overview of indicators by programme areas, tools for measurement, and priority for different epidemic states* (C=Core indicator; A=Additional indicator) Note: Country teams are encouraged to refer to the full text for definitions and to be highly selective in their use of indicators. Programme area indicator Priority Priority Generalized Concentrated/ epidemic low-level Young people's sexual behaviour 1 Median age at first sex C 2 Young people having premarital sex C A 3 Condom use at last premarital sex C A 4 Young people with multiple partners C A 5 Condom use at last higher-risk sex C A 6 Condom use at first sex A A 7 Age-mixing in sexual relationships A Injecting drug use 1 Injecting drug users sharing equipment C 2 Injecting drug users never sharing equipment C 3 Drug injectors using condom at last sex A Blood safety / nosocomial transmission 1 Screening of blood units for transfusion C C 2 Reduction of blood transfusions A A 3 Districts / regions with blood bank C C 4 Accidental transmission in health care settings A STI care and prevention 1 Appropriate diagnosis and treatment of STI C C 2 Advice on prevention and HIV testing C C 3 Drug supply at STI care services C A 4 Treatment seeking for STI A C Care and support 1 Medical personnel trained in AIDS A A CN 2 Health facilities with capacity to deliver care C Q 3 Health facilities with drugs in stock A 4 Households helped with care of young adults C o 5 Households helped with care of orphans A Health and social impact 1 HIV prevalence among pregnant women C C < 2 Syphilis prevalence among pregnant women C C z 3 HIV prevalence in sub-populations at risk A C 4 Prevalence of orphanhood C 5 Schooling of orphans A o_ _ * Part of the Behavioural surveillance surveys (BSS): Guidelines for repeated behavioural surveys in population groups at risk for HIV 46 UNAIDS / WORLD BANK APPENDIX 3. SELECTED WEBSITES ON AIDS, POVERTY AND DEBT RELIEF http://www.unaids.org/publications/documents/index.htmI http://www.worldbank.org/hipc/ http://www.worldbank.org/aids-econ/ http://www.worldbank.org/poverty/ http://www.oxfam.org/advocacy/human_f.htm http://www.dfid.gov.uk/public/what/strategy-papers/targetLstrategy.html http://'www.usaid.gov/pop-health/aids/index.html http://wwwj2000.usa.org 47 - UNAIDS THE WORLD BANK 20 avenue Appia 1818 H Street, N.W. 1211 Geneva 27 Washington, D.C. 20433 Switzerland U.S.A. Telephone: (+41 22) 791 46 51 Telephone: 202 477 1234 Facsimile: (+41 22) 791 41 87 Facsimile: 202 477 6391 Internet: www.unaids.org Internet: www.worldbank.org E-mail: unaids@unaids.org E-mail: afrhdseries@worldbank.org Recently, there has been unprecedented levels of political and institutional in- terest in reversing the course of the HIV/AIDS epidemic. Political leadership has improved significantly in some of the worst-affected countries, thus pro- viding a more favorable environment for the fight against the epidemic and its negative effects on development. The Heavily Indebted Poor Countries (HIPC) Initiative, which emphasizes structural and social policy reforms, par- ticularly to enhance the delivery of basic health care and education services, provides a unique opportunity to address the threat posed by HIV/AIDS. Further, governments benefiting from debt relief are expected to make their plans for poverty reduction through the preparation of Poverty Reduction Strategy Papers (PRSPs). Given the adverse effects of HIV/AIDS on poverty, plans to address the epidemic are a natural feature in most if not all PRSPs. Developed by the staff from UNAIDS secretariat and the World Bank, AIDS, Poverty Reduction and Debt Relief: A Toolkit for Mainstreaming HIV/AIDS Programs in Development Instruments offers a unifying framework for analyzing HIV/AIDS in the context of PRSPs, as well as examples of how the issue has been treated in the first generation of PRSPs, interim PRSPs and debt relief agreements. As such, it is hoped that it will provide country of- ficials and their partners information for training at the county and sub-re- gional levels for country teams to develop useful materials on scaled-up HIV/AIDS programs for inclusion in the PRSPs and HIPC documents. It is also hoped that it will support governments and policy makers in their work to mainstream HIV/AIDS into countries' development agendas and mobilize the resources needed to expand promising interventions and approaches in the fight against the epidemic.