Different response is eyed for hotspot of epidemic in southern Africa.
'Expanded engagement' is strategy for middle-income countries.
Conflict-affected and fragile states are a special focus.
November 27, 2007— Revised UNAIDS estimates reveal the global HIV/AIDS epidemic has leveled off and the number of new infections is falling, even in Africa.
While the new estimates suggest HIV programs are having an impact, they are also the result of new studies that provide more precise information about HIV prevalence, along with better data collection in many countries, most notably in Asia and Sub-Saharan Africa, according to 2007 AIDS Epidemic Update.
But AIDS is still the primary cause of death in Sub-Saharan Africa, where an estimated 22.5 million people live with HIV, according to UNAIDS.
By World AIDS Day on December 1, international donors will have contributed nearly US$9 billion to the AIDS fight globally. That’s up from US$1.6 billion in 2000.
But this dramatic increase in global funding does not meet the extensive need for treatment, notes UNAIDS.
In fact, it’s only half of what is needed to provide universal access to treatment, according to the World Bank’s AIDS Campaign Team for Africa (ACTafrica).
“HIV/AIDS threatens the well-being of the Continent like no other single challenge,” says Elizabeth Lule, Manager of ACTafrica.
“HIV/AIDS remains—and will remain for the foreseeable future—an enormous economic, social, and human challenge to Sub-Saharan Africa.”
But new information about the nature of the epidemic in Africa is enabling the World Bank to redefine its role to play off its strengths for maximum impact, says Lule.
The Bank’s evolving strategy calls for a flexible multi-layered approach including balancing treatment and prevention efforts tailored to conditions within regions and countries, and bringing the Bank’s experience to partnerships with the widening donor community in the fight against HIV/AIDS.
The strategy includes expanding assistance to the hardest hit countries of southern Africa, where 35 percent of all HIV-positive people in the world live. More than 15 percent of adults live with HIV/AIDS in Botswana, Lesotho, Mozambique, Namibia, South Africa, Swaziland, Zambia. and Zimbabwe, according to the latest research.
A Need to Intensify Efforts in Southern Africa
“It’s very clear from the hyper epidemics in southern Africa that we need to intensify our efforts there,” says Lule. “The epidemic is completely getting out of hand. It has reached prevalence levels we never dreamed it would reach. And therefore a very different response is required. The partners and countries need to work together to formulate an intensified response.”
In 2000, the Bank was the largest financier of HIV/AIDS programs in Sub-Saharan Africa. Its Africa Multi-Country AIDS Program (MAP) was the first to offer countries substantial, long-term funding to confront their AIDS epidemics.
The Bank committed US$1.5 billion for AIDS programs in over 30 countries and five sub-regional projects, contributing “significant results” in prevention, care and treatment, mitigation, and system strengthening, according to the Bank’s recent assessment of the MAP.
In Kenya, for instance, HIV prevalence has fallen from 10 percent to 6 percent. Zimbabwe’s HIV prevalence has declined recently “because of investments made in the 1990s” in prevention programs that helped change behavior, says Lule.
Strategy of ‘Expanded Engagement’ in Middle-Income Countries
The new strategy, Our Commitment: The World Bank’s Africa Region HIV/AIDS Agenda for Action 2007-2011, would, among other things, “expand engagement” in middle-income countries in Southern Africa where AIDS has “reversed life expectancy gains and diluted poverty reduction efforts,” Obiageli Ezekwesili, Vice President of the Bank’ Africa Region, told the Bank’s Board of Directors early this month.
Life expectancy in Botswana fell from 58 years old in 1980 to 46 in 1998 to 35 in 2005, according to World Bank data.
Middle-income countries such as Botswana have invested considerable amounts in their response to AIDS, says Lule.
“It’s not just a question of not having resources. It’s a question of tackling the drivers of the epidemic, really figuring out which interventions work to reduce multiple concurrent sex partners, for example, and gender inequalities that fuel the epidemic.”
No One Pattern, but Instead a Cluster of Regional Patterns
Accumulating evidence shows there is no single pattern of HIV infection across Sub-Saharan Africa, but a series of regional patterns, with some areas more acutely affected by HIV than others and even differences within countries. Recent evidence suggests that infection rates outside of southern Africa have not reached the high levels that had been projected.
In southern Africa, the epicenter of the epidemic, drivers of the disease include multiple concurrent sex partners, labor mobility, early sexual activity, and rape, says Lule. Male circumcision, linked to lower HIV-infection rates, is also rare in southern Africa, she adds.
Southern Africa's epidemic requires a new understanding and new interventions, reflecting sweeping social change led by political, religious and community leaders, says Lule. She says the Bank is working with other major partners to support a high level think tank on HIV prevention in Southern Africa's hyper-endemic countries.
Lule says innovative financial instruments could help southern African countries sustain treatment programs and increase access to them, especially in places where income inequalities persist. The Bank can also “play an important role by using our unique experiences in different sectors, looking at long term financial sustainability, and providing analytical work,” she adds.
A new Africa HIV/AIDS Incentive Fund would allow to Bank to offer knowledge and technical assistance to non-borrowing countries.
“Southern African countries want the Bank to help with technical advice and health systems strengthening,” says Lule.
Under the new plan, the Bank would continue to support country-driven AIDS programs throughout Sub-Saharan Africa by emphasizing four areas:
Focused, evidence-based, prioritized, and costed strategies to combat HIV/AIDS.
A multi-sectoral approach in key sectors, strengthening health systems, implementing education and school-based prevention programs, and promoting gender equality.
Better monitoring and evaluation of the AIDS response through improved governance.
Coordination of donor funds to increase effectiveness of the global response within countries.
Support for Conflict-Affected and Fragile Countries
The Bank would help fill financing gaps not met by other donors, such as by supporting vulnerable groups, including sex workers and men who have sex with men. It would also support conflict-affected and fragile countries, provide technical and analytical work, and fund regional initiatives aimed at reducing the spread of HIV across borders, adds Lule.
Lule says the Bank’s financial contribution to fighting AIDS in Africa, while remaining at around US$250 million annually, has fallen to 7 percent of the total of surging global funding from all donors.
“Nevertheless, we have very unique contributions to make in the fight against HIV/AIDS to make sure donors’ money, including ours, is working effectively and efficiently,” says Lule. “We will remain in the fight against HIV/AIDS for the long run.”
RSS