- Understanding the epidemic is crucial to directing resources toward most affected populations
- Targeted, data-driven strategies are key to containing HIV and AIDS
- Widespread stigma still prevents people from getting tested and receiving treatment in time
August 1, 2008—Botswana has one of the worst HIV epidemics on the planet. Nearly 24% of people live with the virus. But recent progress has some envisioning an AIDS-free future.
Thanks to nearly universal testing of pregnant women and wide distribution of free antiretroviral drugs, fewer than 4% of babies born to HIV-positive mothers are infected with the virus.
“It’s that kind of success we are looking for in Southern Africa,” where a quarter of the population is living with HIV, says Elizabeth Lule, Manager of the AIDS Campaign Team for Africa (ACTAfrica)at the World Bank. “Botswana is a great success story for Africa to reach this low level of infection among children born to HIV-positive women.”
But she adds Botswana is an isolated case in the region for various reasons, such as lack of political commitment, weak health systems that limit a country’s ability to scale up services, stigma, and other weak national systems that limit effectiveness and efficiency of AIDS financing.
“When you have a region where one in four people are living with the virus, you need leadership to really galvanize all levels of society—community leaders, religious leaders, everybody—to really recognize this as a region of catastrophe.”
Despite progress on mother-to-child HIV transmission and widely available antiretroviral treatment, Botswana acknowledges it still has a lot of work to do to quell its epidemic. It’s stepping up prevention with a new five-year, US$50 million project with the World Bank—the first in 20 years. The goal is to help the country use epidemiological and other evidence to more effectively target interventions to stop the virus from spreading.
HIV positive woman being cared
for in a hospital in India.
A key reason why prevention efforts fail is because “we are not addressing the drivers of the epidemic,” Joy Phumaphi, World Bank Vice President for Human Development, said recently in Science magazine, referring primarily to heterosexual behaviors. “We have to be much more methodical,” she continued.
New data from UNAIDS released this week reveal the epidemic is stabilizing but the overall number of people with HIV has increased both because people continue to get infected and those with HIV are living longer because of better access to ARV treatment. Sub-Saharan Africa remains the most heavily affected, accounting for 67% of all people living with HIV and 75% of AIDS deaths in 2007.
The 24,000 delegates gathering in Mexico City August 3 to 8 for the 17th International AIDS Conferenceare looking for ways to effectively use the US$10 billion a year in global AIDS commitments to stem the epidemic in places where it has continued virtually unabated, or become stubbornly entrenched.
‘You Need to Understand the Epidemic’
In the past, lack of data meant AIDS resources didn’t always go where they were most needed.
The Bank’s Global AIDS Monitoring and Evaluation Team (GAMET) has done much to address this gap, says Robert Oelrichs, a World Bank senior HIV/AIDS specialist who coordinates operational research on HIV and AIDS.
“We were amongst the first to say you really need to understand your epidemic. Where were the last 1,000 infections? Who’s getting infected and why? And then to assist countries to direct their resources toward those most affected populations,” says Oelrichs.
Today, the World Bank, working with other UN agencies and partners, helps countries develop strategic plans based on hard evidence. This kind of analysis is already going on in many countries, including 15 in Africa.
“Money needs to be spent with the greatest possible impact, and the way you do that is to have a clearer idea about what is actually driving the epidemic in any particular country and having a response that actually reflects the reality of the epidemic,” says Janet Leno, a member of the AIDS Strategy and Action Plan Service(ASAP), hosted by the World Bank on behalf on UNAIDS.
The ASAP team helps train policy-makers, HIV program managers, and consultants to develop strategic plans tailored to their specific epidemic and which aim to achieve clear results. Representatives from about 50 countries will be trained by the end of the year.
“It’s to help people really understand how you can go wrong and invest in the wrong interventions if you don’t have the right data and how important it is to have the evidence,” says Leno.
Making the Money Work in South Asia
In South Asia, the Bank found that targeted, data-driven strategies are the key to containing HIV and AIDS. To get data and increase the reach of services, it supports national programs working with people living with HIV and AIDS, and with other, often marginalized groups, such as sex workers and their clients, injecting drug users, and men who have sex with men. National AIDS programs achieve results with the help of non-governmental and civil society organizations, says Mariam Claeson, HIV/AIDS Coordinator for the region.
“We realized you cannot be effective in tackling concentrated epidemics if you do not work with civil society, and peers who have contact with vulnerable groups at highest risk know how to make the money work,” she says.
The result is programs that reduce HIV transmission in the general population. In India, prevalence fell in Tamil Nadu antenatal clinics from 1% in 1998 to 0.65% in 2006.
A new project in India, the third since the mid-1990s, devotes 70% of resources to prevention. The number of antiretroviral therapy centers is also increasing, and a “link-worker” program will ensure that rural women at risk will be able to maintain prevention, treatment, and care. Overcoming stigma about HIV/AIDS is a major part of the effort, says Claeson.
‘Stigma is a Major Killer’
‘Stigma is a major killer, because it actually prevents people from getting tested and also from receiving treatment in time,” adds Lule. “That has become the number one enemy in many ways.”
A lot of stigma and discrimination still exists against sexual minorities and other marginalized groups, she says. Women are also more likely to face stigma and discrimination than men, including harassment, abuse, violence, and lack of rights to productive assets and other property. As a result, women are often afraid to get tested or disclose their HIV status.
Unlike other regions of the world, 60% of those living with HIV/AIDS in Africa are women, and young women are three times more likely to be HIV positive than young men. The feminization of the epidemic in Africa may be the single most important reason to link HIV/AIDS and sexual and reproductive health programs, as Botswana is doing, says Lule.
Better access for children and women by linking programs is a concept being tested in Cambodia by the government with the Clinton Foundation and other partners. The World Bank is assisting with an impact evaluation to measure the effectiveness of the intervention, says Oelrichs.
The Bank’s role among UN agencies is also to improve accountability, transparency, and monitoring, to make sure money is being used efficiently and effectively, says Lule.
“Unless we show impact and sustainable results, it will be very difficult to sustain the investments and level of financing which we very much need to continue, because HIV/AIDS will remain for the foreseeable future an unprecedented economic, social, and human challenge to Africa.”