What is the World Bank doing to combat the spread of HIV/AIDS?
As one of the largest long-term investors in HIV prevention, treatment and care in developing countries, we are working with our partners to "make the money work" by developing and implementing effective programs to prevent new infections and provide care and treatment for infected and affected people. HIV, the human immunodeficiency virus that causes AIDS, is continuing to spread (although there are hopeful signs in some countries). It has created an unparalleled human development problem that affects millions of people in sub-Saharan Africa, South Asia, the Caribbean and other regions of the world. To meet the global health and development challenges posed by the epidemic, we have a strong action program against HIV/AIDS.
While HIV is clearly a health problem, there is worldwide recognition that it is also a development problem that threatens human welfare, socio-economic advances, productivity, social cohesion and even national security. AIDS reaches into every corner of society. It affects parents, children and youth, teachers and health workers, rich and poor.
In partnership with national governments, community leaders, people living with HIV foundations, non-governmental organizations, UN agencies and the private sector we are striving to:
prevent new HIV infections among vulnerable groups and in the general population;
support countries' health policies and programs and promote multi-sector approaches by focusing on education, social safety nets, transport and other vital areas; and
expand care and treatment for people living with HIV, as well as care for children and other people directly or indirectly affected by AIDS.
Inside the Bank, we are integrating HIV/AIDS efforts into our work in all social and economic sectors. For example, contractors in transport sector projects are expected to incorporate HIV prevention for their workforces and the communities with whom they interact, and most education projects now include HIV interventions for teachers and students.
At the country level, we are actively engaged in policy dialogue, and we help countries to use the HIPC (Heavily Indebted Poor Country) Initiative to release funds derived from debt relief to fight the disease, and to integrate HIV into Poverty Reduction Strategy processes and other national development planning. We also conduct country-level analyses of the socioeconomic impact of HIV/AIDS, and a large proportion of our project funding is channeled to civil society and community based organizations to support local responses.
We are working to improve implementation of programs and projects and to resolve bottlenecks. In recognition of the urgent nature of the AIDS crisis, we are streamlining our policies, procedures and practices, and facilitating rapid availability of resources in countries. Our AIDS Campaign for Africa (ACTafrica) has hosted implementation workshops involving nearly 40 countries and has provided substantial on-site technical support in many countries.
Since 1986, we've made available more than $3.3 billion to countries to help prevent the spread of HIV/AIDS and mitigate its effects, and currently there are nearly 100 projects actively supporting national and regional HIV/AIDS responses.
Now that the Global Fund and US Government's PEPFAR program provide so much grant funding for HIV/AIDS, is the World Bank's involvement still needed?
Yes, absolutely. Although no longer the major financer, our technical and analytical support, funding and continued full engagement remain important. Our funding is predictable, flexible, and long term, and supports broad multi-sectoral responses to complement the work of the health sector; crucial grassroots initiatives that reach poor and remote communities; and prevention, care, and treatment outreach to marginalized groups which often drive HIV epidemics. Countries and other partners rely on us for technical, logistic, analytic and policy support to countries, and to invest in the complex, long-term system reforms and social mobilization needed to sustain treatment and prevention services. Partners look to us especially in several areas that are crucial for "making the money work" to deliver effective responses: (i) helping countries develop stronger results-focused and evidence-based national HIV and AIDS strategies and action plans; (ii) building national M&E systems to measure and manage programs to achieve results and using the data the systems generate for improving programs and policies; (iii) helping integrate HIV into the broader development agenda; and (iv) channeling money to communities for grassroots actions that are crucial to reducing stigma, changing behaviors and caring for people infected and affected by HIV; and Iv) playing a strong role in pushing forward collective efforts towards better donor coordination and harmonization with country programs, to make our support more effective and efficient.
What is the Global HIV/AIDS program?
In 2002, we created the Global HIV/AIDS Program within our Human Development Network to better coordinate our efforts to address the HIV pandemic across all social and economic sectors. A key function of the program is to lead the efforts of the UNAIDS (United Nations Program on HIV/AIDS) partners to help countries develop well prioritized, strategic, costed national strategies and action plans (through the ASAP service), and to build capacity and national HIV/AIDS monitoring and evaluation systems, through the work of the Global HIV/AIDS Monitoring and Evaluation Team (GAMET). The Global HIV/AIDS Program also facilitates learning and knowledge sharing on addressing HIV, and supports Bank staff efforts to make HIV a mainstream part of our work in all economic and social sectors. Our staff is actively working to:
support more effective national HIV/AIDS responses, through the actions of governments, civil society, people living with HIV and other stakeholders;
share and expand available knowledge about effective approaches to combat HIV and develop new approaches;
improve the quality of HIV/AIDS monitoring and evaluation and build national capacity in this area among partners working in AIDS-related projects and programs within countries;
work to realize the "Three Ones" vision of one national action framework for coordinating the work of all partners; one national AIDS coordinating authority with a broad multisector mandate, and one agreed country-level monitoring and evaluation system;
carry out our work in ways that improve coordination and harmonization of global efforts to make our individual and collective support to countries more effective and efficient, to achieve stronger results.
Which region has been hardest hit by the HIV/AIDS epidemic?
Africa is the region worst affected by HIV, with two-thirds of the world's 33 million infected people. The countries of sub-Saharan Africa have been hardest hit by the AIDS epidemic. AIDS is now the leading cause of death in sub-Saharan Africa and the paramount threat to the region's development.
More than 27 million Africans have died, and 12 million more have been orphaned by AIDS. About 25 million people in Africa are living with HIV, the vast majority in the prime of their lives as workers and parents. In the most severely affected countries, life expectancy has fallen precipitously, family incomes are being decimated, and agricultural and industrial efficiency is declining.
Nearly 5 million people with HIV in Africa are estimated to have advanced to the stage where antiretroviral drugs are necessary to forestall or reverse the onset of full-blown AIDS. As of June 2007, WHO reported that over a million people with AIDS in Africa had access to treatment – still only about one quarter of those who need ART, but a very marked increase in recent years.
In 10 countries, more than one of every ten adults is HIV-positive. In 2006, 2.8 million Africans became newly infected. There is evidence that the epidemic is beginning to diminish in a few countries, and has stabilized in many others, but there is no room for complacency. Intensified efforts are needed to prevent new infections, and maintain and increase access to care and treatment.
How do you help poor countries respond to HIV/AIDS, particularly in Africa?
Our primary financing vehicle for helping poor countries respond to HIV/AIDS is the Multi-Country HIV/AIDS Program, known as the MAP. As of July 2007, the MAP for Africa had channeled $1.3 billion in grants and credits to 31 African countries. About 38% of this has supported community-based, grass-roots activities, through about 50,000 sub-projects to educate and inform people about HIV/AIDS, reduce stigma and discrimination, care for children affected by HIV, and offer training and alternative livelihoods for sex workers and others at high risk of HIV. Case studies from 3 countries described the impacts in The Multi-Country AIDS Program 2000-2006, the World Bank's Response to a Development Crisis (World Bank, 2007).
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Some of the support is for multi-country, sub-regional and cross-border HIV/AIDS projects. One example, the Abidjan-Lagos Transport Corridor HIV/AIDS project, focuses on HIV prevention among high-risk groups situated along the main highway linking the five West African countries of Cote d'Ivoire, Ghana, Togo, Benin and Nigeria. Multi-country assistance is vital because of the role that trade, transport, migration and conflict can play in spreading HIV. Another multi-country MAP project is building capacity among medical and paramedical staff in the three East African nations of Ethiopia, Kenya and Uganda.
To increase access to care and antiretroviral therapy, we've made $59.8 million available through a pilot project in Burkina Faso, Ghana and Mozambique. This "Treatment Acceleration Project" builds on the April 2004 partnership agreement that we signed with the Global Fund, UNICEF and the Clinton Foundation to make high-quality AIDS medicine available at low prices to developing countries, and explores ways to scale up access to treatment in low-income settings.
The multi-sector AIDS Campaign Team for Africa (ACTAfrica), located in the Africa Region's Quality Knowledge unit, supports implementation of our HIV/AIDS strategy and MAP for Africa.
The Multi-Country HIV/AIDS Program (MAP) is our long-term commitment to combat HIV/AIDS. MAP funds -- grants, loans or credits (zero interest) depending on country debt and income levels -- are available to any borrowing country that meets eligibility criteria. The MAP is flexible, open-ended, quick, client-driven and collaborative.
The overall goal of the MAP is to increase dramatically access to HIV/AIDS prevention, care, support and treatment-with emphasis on vulnerable groups, such as youth, women of childbearing age and other groups at high risk. The specific development objectives of each individual country project, as stated in its national strategic plan, provide the basis for this program. These objectives are agreed upon at the time of appraisal of the national projects.
The 2007 stock-taking of the aggregate results to which Africa MAP projects have contributed over five years found that an additional 1.5 million women have accessed services to prevent mother-to-child HIV transmission, 1,500 new voluntary counseling and testing sites enabled 7 million more people to be tested for HIV, half a million providers were trained to provide HIV services and 41,100 organizations provided with technical support, 173 million people were reached with information about HIV and AIDS and 1.3 billion condoms distributed, 27,000 people treated with ARV, and minor HIV-related infections treated in 300,000 more people, and half a million adults and 1.8 million children provided with education, nutrition, or income generating support.
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A key feature of the MAP is our direct support to community organizations, non-governmental organizations and the private sector for the delivery of local HIV/AIDS services. MAP funds the entire continuum of care-from basic prevention through anti-retroviral therapy-and all aspects of a multi-sector response. MAP contributes in three principal ways. The program:
Channels support to the full range of stakeholders, including civil society;
Strengthens capacity for program implementation; and
Promotes the ongoing exchange of knowledge, both within and among countries.
While project components vary from country to country, MAP projects typically include provisions for:
Capacity building for government agencies and civil society
Expansion of governments' responses to HIV/AIDS in many sectors
Grants for civil society HIV/AIDS initiatives that include funding for local community organizations, non-governmental organizations, faith-based organizations and the private sector [Nearly 50% of all MAP funds are programmed for this purpose.]
Project coordination, management, monitoring and evaluation
What are the eligibility criteria for inclusion in the MAP program?
To participate in the MAP program, countries must demonstrate:
satisfactory evidence of a strategic approach to HIV/AIDS, developed in a participatory manner;
existence of a high-level HIV/AIDS coordinating body, with broad representation of key stakeholders from all sectors, including people living with HIV/AIDS;
government commitment to quick implementation arrangements, including channeling grant funds for HIV/AIDS activities directly to communities, civil society and the private sector; and
government agreement to use multiple implementation agencies, especially non-governmental and community based organizations.
What is the Bank doing to curb the HIV/AIDS epidemic in the South Asia region?
In South Asia, the Bank has committed a total of US$647 million to support national HIV/AIDS programs, starting with the first India project in 1992. The main components of the projects in India and other countries in the region are surveillance, monitoring and evaluation, targeted interventions for vulnerable populations, blood safety, and efforts aimed at reducing stigma among the general population and strengthening public and private institutions for a multi sector response.
In 2004, we decided to scale up the response to AIDS drawing on our comparative advantage, and a South Asia regional AIDS team was established to coordinate and support economic sector work, provide technical assistance and build capacity, foster internal and external partnership and communication, and mainstream AIDS across sectors. Some of the major recent actions are: preparation of the third national AIDS program in India; a regional epidemic and response synthesis paper; a costing study of anti retroviral therapy (India); institutional analysis and preparation of a first HIV project (Nepal); an HIV/AIDS assessment and HIV prevention project (Afghanistan); inter-country consultations on injecting drug use and effective harm reduction strategies; integration of AIDS in school health; development of private sector workplace programs; and implementation of a regional communication strategy. We aim to support countries in reaching their national goals, curbing the epidemic in South Asia.
What are you doing to combat HIV/AIDS in the Latin America and the Caribbean region?
We've made $155 million available through the Caribbean MAP to the Latin American and Caribbean region to fight HIV/AIDS. As of August  2007, $117.65 million had been committed in 9 countries (Barbados, Dominican Republic, Jamaica, Grenada, St Kitts & Nevis, Trinidad and Tobago, Guyana, St. Lucia, and St. Vincent and the Grenadines) and through a Pan-Caribbean project, to reduce HIV infections, to provide treatment for people living with HIV/AIDS, and to strengthen institutional capacity for HIV/AIDS prevention and control activities. In addition, active projects in Brazil, Mexico, Honduras, El Salvador, Venezuela, Argentina and Central America are providing approximately $143 million in funding for HIV/AIDS.
How is the Bank tackling HIV/AIDS in the Europe and Central Asia region?
We encourage the integration of HIV/AIDS and tuberculosis control strategies into European and Central Asian (ECA) governments' economic development agendas and support country-led responses to the epidemic. We also encourage governments to involve non-governmental organizations, people living with HIV/AIDS and community based groups in carrying out prevention and treatment aspects of public sector projects, especially in the area of harm reduction, since such groups already have a good track record.
In addition, we've undertaken analytical work that helps make the case for increased support to fight the epidemic in the region, and especially to address injecting drug use, which is a major driving factor in HIV transmission. We published a Regional Support Strategy, "Averting AIDS Crises in Eastern Europe and Central Asia, (2003); a policy note on Georgia (2004); a study of the economic impact of AIDS in the Russian Federation (2004) and in Ukraine (2006); sub-regional studies on Poland and the Baltic countries, Southeastern Europe and Central Asia (2005); Prevention of HIV/AIDS in the Western Balkans (2005); Report on "Epidemiologic Surveillance Systems in Eastern Europe and Central Asia" (2006 - English and Russian); Assessment of Intellectual Property Issues in Relation to ARV Drugs in the Russian Federation (2006, with Clinton Foundation, WHO, UNAIDS), Assessment of Best Practices in HIV/AIDS Harm Reduction Programs Among Civilian Populations and Prisoners in the Russian Federation (2006 with the Open Health Institute); and an Assessment on HIV/AIDS Control in Prison Systems in ECA countries (2007).Along with UNAIDS we co-financed a Technical Resource Directory for AIDS Programmes to improve access to technical advice for AIDS program managers in Europe and Central Asia.
Our financial support for the region includes the following country programs for HIV/AIDS and tuberculosis control: the Ukraine Tuberculosis and AIDS Project ($60 million), approved in December 2002; the US Russian Federation Tuberculosis and AIDS Control Project ($150 million), approved in April 2003: the Moldova AIDS Control Project ($5.5 million through an IDA grant), approved in June 2003; and a $26 million grant for a Central Asia AIDS Control Project approved in March 2005. The project aims to minimize the human and economic impact of the HIV/AIDS epidemic in four Central Asian countries - Kazakhstan, Kyrgyz Republic, Tajikistan and Uzbekistan.
Aid harmonization and donor coordination are being realized through participation of various agencies (e.g., UNAIDS, DFID, WHO, Global Fund, UNDP, USAID CAPACITY Project, CDC, and UNICEF) in project preparation and supervision. In the Central Asia AIDS Project, memoranda of understanding with different donors helped achieve pooling of resources for joint activities (e.g., with UNAIDS, USAID-Capacity Project, CDC, UNICEF, UNIFEM). UNDP also supports project implementation in Central Asia by providing technical assistance in different fields and fiduciary services at the country level.
Of all the projects in the region, the Moldova program is furthest along, thanks in part to resources from the Global Fund to fight AIDS, TB and Malaria. These resources have allowed for the purchase of antiretroviral drugs, which are being administered free of charge. The Russian Federation has begun scaling up treatment with combined support from the World Bank and Global Fund, and a significantly increased allocation to the national program by the Government: our funding is helping strengthen health system infrastructure (e.g., development of guidelines, training of personnel, purchase of laboratory equipment), and the Global Fund funds purchase of ARV drugs. A country-wide needs assessment provided a baseline on epidemiology, the institutional response and gaps that the project should address. The Central Asia project is a promising development instrument to promote regional cooperation and foster aid harmonization and coordinated work on cross-country issues. Participation of high level officials in the Regional Steering Committee and other important political and social actors such as parliamentarians and regional leaders is helping the project move ahead.
The goal in the Russian Federation is to obtain a negotiated price of less than US$1,500 as stipulated in the grant agreement with the Global Fund. In the meantime, the scaling up of treatment has began with the combined support of the World Bank and the Global Fund: the World Bank-funded project is helping strengthen the health system infrastructure in different regions of the country (e.g., development of guidelines, training of personnel, purchase of laboratory equipment), and the Global Fund project provides will support the purchase of ARV drugs. A country-wide needs assessment has been conducted and provides a baseline on the epidemiological situation, institutional response and gaps that need to be addressed through investments supported under the World Bank project. The Government has also allocated additional budgetary resources to accelerate scaling up treatment.
Do you support the call for Universal Access to prevention, treatment and care for all who need them?
Yes. We are a part of global efforts to expand access to sustainable treatment and care and effective prevention efforts, and work closely with countries and partner agencies to support and strengthen national HIV/AIDS programs. The Universal Access goal, like the Millennium Development Goal of halting and reversing the HIV epidemic by 2015, has been very widely endorsed and embraced. While not a cure for HIV/AIDS, antiretroviral therapy can prolong healthy life. All agencies, including the World Bank, are working together to improve access to treatment, and expand effective prevention efforts.
Does the Bank support the World Health Organization's 3 by 5 Initiative?
Yes, absolutely. The 3 by 5 Initiative is an effort endorsed by 192 countries to provide HIV/AIDS treatment to three million people by the end of 2005. Although the World Health Organization is leading this initiative, all agencies, including the World Bank, are working together to improve access to treatment. While not a cure for HIV/AIDS, antiretroviral therapy can prolong a person's life.
Is there any hope that the HIV/AIDS epidemic can be brought under control in some of the worst affected areas?
Yes, there is hope, since global political commitment remains strong, grass-roots mobilization has become more dynamic, funding has increased, treatment programs continue to expand rapidly, and prevention efforts are becoming more targeted to the main factors driving the epidemic. The good news is that there are a number of countries that show declines in HIV infection rates: Senegal, Ethiopia, Uganda and Zimbabwe, with some declines also in Kenya, Burkina Faso, Ghana, Rwanda, Tanzania and, beyond Africa, large declines in Brazil and Thailand, and signs of decline in parts of India, urban parts of Haiti. Over 2 million people now have access to antiretroviral drugs, with dramatic benefits in life-years gained. However, the latest estimates from UNAIDS also show that the total number of people with HIV continues to grow, as does the number of deaths from AIDS, and three quarters of the fast-growing number of people who need ART still lack access.
Which countries have successfully confronted the AIDS crisis? What have these countries done that is different from other countries?
Uganda, Thailand, Botswana, Senegal and Brazil have successfully confronted the AIDS crisis. They have demonstrated a high level of political commitment and have mounted prevention, care and treatment programs simultaneously. For more information on how the World Bank has supported the AIDS response in different countries, go to Project Portfolio Advanced Search; enter keyword, "HIV/AIDS"; select a country and view project documents.
Which programs have been most successful in curbing HIV/AIDS in developing countries?
Prevention has maximum impact as part of a comprehensive intervention program. Effective prevention programs support changes in sexual and injecting drug-use behaviors that put people at risk of infection, and also ensure a safe blood supply and avert mother-to-child transmission including through voluntary testing and counseling and antiretroviral drug treatment. Effective prevention programs also seek to end stigma and silence on HIV/AIDS, and to address the underlying socio-economic causes that leave people vulnerable to HIV infection. They address vulnerabilities arising from gender inequality, denial of human rights and discrimination against marginalized groups. Of course, prevention should be linked to the provision of treatment, care and support. Political commitment and sufficient human and financial resources are imperative.
How does the Bank measure the results of its AIDS programs?
We evaluate all Bank projects and spend around $50 million, or three percent of our administrative budget, on evaluation. This amounts to about a quarter of our spending on analytic work and knowledge management. Projects are first evaluated by operational staff, who compile an Implementation Completion Report. This report is then reviewed by staff in our Independent Evaluations Group (IEG, formerly called OED). IEG is independent of management. It uses an evaluation approach called objective based evaluation and looks at three main factors:
Relevance of a project's objectives in relation to the needs of the country
Project effectiveness in meeting its goals
Project efficiency in terms of using no more resources than necessary
IEG also under takes field inspections for 25% of all of our completed projects and carries out impact reviews of strategically selected projects.
Being able to assess whether or not our AIDS projects achieve their development objectives starts with good project design, including a measurable results framework. This is the responsibility of each Task Team Leader, working closely with government counterparts. The Global AIDS Monitoring and Evaluation Support Team (GAMET), which is part of our Global HIV/AIDS Program, provides operational support to identify appropriate indicators to measure progress and success of each project or program. GAMET also works with governments to design, build and use a national HIV/AIDS monitoring and evaluation system that can measure progress for both Bank-funded projects and national HIV/AIDS objectives and goals. GAMET includes experts based in headquarters and a Country Support Team of M&E experts who live in countries across the globe, traveling extensively to provide hands-on support in 45 countries. GAMET also offers training in tools that are suitable to be used at the local level by service providers that require relatively little time to collect data and produce information that is reliable and easy to interpret.
We oppose any health system that excludes the poor from access to diagnosis and care. We support the provision of free basic health services to poor people. In the case of HIV/AIDS, we discourage user fees and instead help countries finance these services using other measures. In very-low-income communities where a government's resources are extremely limited, well-designed and implemented user fees applied to better-off groups can mobilize additional resources. In turn, these fees can be used to improve services for poorer groups. Where countries choose this option, we work closely to make sure that the poor face zero or minimal costs.
