 The HIV/AIDS pandemic in Sub-Saharan Africa remains a long-term development challenge for the region. Nearly 12 million African children have been orphaned as a result of the disease, and 22.5 million people in Africa—61 percent of them women—live with HIV. The hyperepidemics in Southern Africa have diluted poverty reduction efforts and in several countries substantially reduced life expectancy. The critical need to address this development problem is reflected in the sixth Millennium Development Goal (MDG), which seeks to halt and begin to reverse the spread of HIV/AIDS by 2015 and to make access to treatment for HIV/AIDS universal for all those who need it by 2010. Prospects for Sub-Saharan Africa reaching any of the MDG goals will require a sustained response to HIV/AIDS. Reversing the spread of HIV/AIDS is closely linked to combating other major diseases referenced in MDG 6, promoting gender equality (MDG 3), reducing child mortality (MDG 4) and improving maternal health (MDG 5). In 2000, the World Bank began emergency operations in Sub-Saharan Africa through the Multi-Country HIV/AIDS Program for Africa (MAP). By 2008, International Development Association (IDA) funds provided $1.6 billion for over thirty countries and five sub regional activities to address cross border issues. By early 2006, however, it was clear to World Bank leadership in Africa that much had changed; that countries and partners had entered a new phase, and that the Bank needed to rethink its approach, adjust to the new environment on the ground as well as to other technological and financial changes. The Bank also needed to move from its initial emergency response to a long term sustainable response. This shift in the World Bank’s approach is reflected in a strategy document, The World Bank’s Commitment to HIV/AIDS in Africa: Our Agenda for Action (AFA), 2007–2011, presented to the Bank’s Executive Board in November 2007, and formally released on World AIDS Day, December 1, 2007. AFA was based on an extensive consultative and analytical process, which produced several background papers dealing with evidentiary matters, partnership relations, financing, and operational aspects. Through the AFA process and as the AFA background papers were produced, the World Bank’s AIDS Campaign Team for Africa (ACTafrica) concluded that expanding selected pieces of this work and bringing together the results in a single volume would be of value to a wide ranging audience of experts, policy makers, program managers and other generalists. The two chapters in Part I, Epidemiology and Technology, provide insights into the new epidemiological realities, which are based on more reliable estimates, the need to understand the underlying transmission dynamics of the virus and their implications for action, and the importance of supporting and sustaining prevention efforts. New and promising additions to the traditional arsenal of prevention tools are coming on stream. They include post-exposure prophylaxis (PEP), male circumcision, and the integration of prevention of mother-to-child-transmission (PMTCT) activities and nutritional considerations with drug therapy. Because the incidence of HIV is the key to understanding the dynamics of the disease, its measurement can shape more effective responses. New techniques for monitoring incidence are therefore being tested. Chapters 3 through 6 in Part II, Economic Aspects and Economic Policy Issues, discuss the links between HIV/AIDS and economic development. While there is a growing consensus that HIV/AIDS is related to growth and poverty, there is no agreement on the direction of causality, the specific channels through which those variables are related, or the magnitude of short- or long-term effects. The chapters in Part II review and critically discuss theoretical channels and the empirical evidence on the associations between HIV/AIDS and development outcomes. Chapter 4, in particular, discusses methodological issues that confront empirical investigations on the associations between HIV and socioeconomic status. It challenges some of the commonly held views on the links between HIV/AIDS and three areas: poverty, early marriage, and serodiscordant couples (couples in which person is HIV positive and the other HIV negative). The methodological debate is crucial, because misconceptions about the epidemic can effectively hamper initiatives to respond to HIV/AIDS. The debate also highlights the need to continue to improve efforts to collect adequate data and improve the evidence base. Chapter 6 discusses financial sustainability and economic policy problems that arise when considering how to finance the expenditures needed to respond to HIV/AIDS in a fiscally sustainable manner over the medium term and how to ensure that resources are spent effectively. As the disease impacts will persist in the long term, countries should attempt to establish consistent, reliable sources of long-term finance that will complement international aid. Chapters 7 through 10 in Part III, Policy Challenges, examine the global financial architecture, public sector policy responses and cross-cutting stakeholder dimensions. Noting the increase in the number of HIV–specific programs and new actors, the rise in transaction costs, the limited institutional capacity, and the heavy influence of external players on developing countries’ politics and policies, chapter 7 suggests that the current “business model” is unsustainable. Future efforts should be more evidence-based, should focus on better external donor coordination, and on alignment with national priorities and programs. A plethora of public policy challenges linked to the HIV epidemic is discussed in chapter 8. These include predictability of donor financing, the deterioration of public sector revenues, the reduced ability of public sector staff to provide services in all sectors, the challenges facing in the health sector system, and the emigration of health professionals, among others. Chapter 9 discusses another aspect of critical importance—the gender dimensions of HIV, in particular the vulnerability of women. Gender inequality and vulnerability create significant barriers to effective prevention and treatment. In addition to purely physiological vulnerability, social susceptibility created by a set of interrelated economic and cultural determinants makes young girls and women more vulnerable to infection. While women and young girls are particularly at risk, some male populations—including men who have sex with men, prisoners, and soldiers—are at high risk of HIV infection. The private sector has a role to play in both the demand of and supply for HIV–related services. Private sector employees with HIV reduce productivity and increase the costs of providing prevention and treatment services. The private sector is also a supplier of HIV services, through both direct service provision and financing mechanisms, such as insurance schemes. Chapter 10 explores the interface with public sector policies and programs by examining the leveraging private sector health resources through public-private partnerships. Communities are critical stakeholders in scaling up responses to achieve universal access to prevention, treatment, care, and support. Because most determinants of sexual behavior are rooted in cultural norms, social environments, beliefs, roles, and practices that are established, maintained, enforced, and modified at the local level, their formal and informal institutions must directly cope with illness, deaths, and dependency and play a major role in addressing behavior change. Chapter 11 provides examples of what has been done and which factors affect the impact of interventions. In Part IV, Strengthening National Health Systems, chapters 12 through 14 take into account that Sub-Saharan African’s health sector has been forced to bear enormous additional burdens since the advent of the HIV crisis. Stakeholders are paying more and more attention to health sector weaknesses, including human resource gaps, inadequate linkages with other disease and critical non-disease responses, and the crucial role supply chains play in effective responses. Indeed, the demand for human resources for health in Sub- Saharan Africa has increased steadily with the need to deal with complex treatment processes. The inadequate supply of health workers, outward migration, and insufficient training and levels of health worker performance and supervision represent significant obstacles to HIV scale-up efforts. The most responsive policies will be those that minimize the demand for health workers by implementing prevention and treatment models that take into account the acute shortage and suboptimal distribution of health workers. The case for examining the synergies between HIV/AIDS, sexual and reproductive health, tuberculosis, and nutrition is compelling. Chapter 13 explores both the basis of and the challenges in maximizing such linkages while taking account of the critical role of health systems. The management of supply chains is often given lower priority than it deserves in mounting an effective campaign to reach the MDG goals, in particular those related to HIV/AIDS. The discussion in chapter 14 highlights the factors needed to strengthen supply chains and identifies options for achieving greater efficiency, reliability, and timeliness of crucial supplies. Part V, The Future, discusses simulations of the likely impact of the HIV/AIDS epidemic from 2007 to 2011 as well as the effectiveness and impact of various responses. Chapter 15 explores three different scenarios, providing recommendations that will be of broad interest, debate and application to the HIV/AIDS and development community. Top |
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