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HIV/AIDS in Africa

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 At a Glance

·         The World Bank Group pioneered large-scale financing to fight HIV/AIDS in the early days of the emergency response, mobilizing unprecedented global funding to fight the epidemic.

·         We remain committed to supporting countries in their efforts to reverse the course of HIV/AIDS in Africa. Our contributions include sharing knowledge that helps countries to customize and adopt viable approaches to fighting HIV/AIDS, fostering effective local and regional partnerships, developing institutional capacity, and sustainable financing.

·         Of the 34 million people worldwide living with HIV at the end of 2011, 23.5 million (69 percent) are in Sub-Saharan Africa. More than 90 percent of the children who acquired HIV infection in 2011 live in sub-Saharan Africa. There, the number of children newly infected fell by 24 percent from 2009 to 2011.

·         The number of people newly infected with HIV in sub-Saharan Africa in 2011 (1.8 million) was 25 percent lower than in 2001 (2.4 million). Despite these gains, sub-Saharan Africa accounted for 71 percent of the adults and children newly infected by HIV in 2011, underscoring the importance of continuing and strengthening HIV prevention efforts in the region.

·         The number of adults and children dying from AIDS-related causes in sub-Saharan Africa declined by 32 percent from 2005 (1.8 million deaths) to 2011 (1.2 million deaths) although the region still accounted for 70 percent of all people dying from AIDS in 2011 (1.7 million deaths).

·         In 2011, for the first time, a majority (54 percent) of people eligible for antiretroviral therapy in low- and middle income countries were receiving it. This rate was modestly higher (56 percent) in sub-Saharan Africa. In the region, home to 92 percent of pregnant women living with HIV, the percentage of pregnant women living with HIV who received antiretroviral therapy or prophylaxis is now 59 percent.

·         Since 2004, TB-related deaths among people living with HIV have fallen by 25 percent worldwide and by 28 percent in sub-Saharan Africa, home to nearly 80 percent of all people living with both TB and HIV. Only 46 percent of people living with both HIV and TB initiated HIV treatment.   

·         HIV continues to profoundly affect women and girls in sub-Saharan Africa where they represent 58percent of the people living with HIV in 2011.

·         In 2011, 330,000 children acquired HIV infection worldwide. This represents a 43 percent decline since 2003 (when 560,000 children became newly infected) and a 24 percent since 2009 (when 430,000 children acquired HIV infection). More than 90 percent of the children who acquired HIV infection in 2011 live in sub-Saharan Africa. There, the number of children newly infected fell by 24 percent from 2009 to 2011.

 

What the World Bank is doing

 

The World Bank Group pioneered large scale HIV/AIDS financing in the early days of the emergency response, mobilizing unprecedented global funding for fighting the epidemic. While no longer the only large financier in this area, the Bank remains committed to the fight against HIV/AIDS. It supports national AIDS programs by focusing on sustained prevention efforts; strengthening health systems; supporting  social protection services for HIV-affected families; helping vulnerable groups; engaging with key partners to contain the epidemic;  working more closely with the middle-income countries of Southern Africa on HIV-TB co-infection;  supporting activities in fragile and post-conflict states; and contributing to the evidence base for effective and sustainable actions against HIV/AIDS.

 

Since 2000, the Bank has provided $2 billion for HIV prevention, treatment, care and support in over 30 countries in Sub-Saharan Africa and five regional programs. The Bank’s lending is demand-driven and made in response to country requests. The Bank will continue to fill financing gaps where there is demand from countries. Rigorous analyses will inform the Bank’s responses to such requests as we work to help governments meet growing needs in ways that improve both short-term effectiveness and coverage of interventions, and the long-term sustainability of their programs, particularly for treatment.

 

As of February 28, 2013, the Bank's active HIV/AIDS portfolio in Africa totals $539.03 million in net commitments. Total lending in FY12 and FY13 ($36.36 million) includes commitment amounts for the following projects: Burkina Faso Health Sector & MAP Additional Financing ($39 million – 29percent for HIV/AIDS); DRC Health Sector Rehabilitation Additional Financing ($30 million in FY12 and $75 million in FY13 – 13 percent for HIV), Madagascar Multiscetoral STI/HIV/AIDS Prevention II Additional Financing ($6 million – 29 percent for HIV/AIDS), and Kenya Health SWAP ($56.8 million – 17percent for HIV/AIDS). In addition, there are projects managed by other sectors (Education, Transport, Urban Development, etc…) with an HIV/AIDS theme for a total of $82.89 million.

 

In the World Bank’s new Africa Strategy, our HIV/AIDS response fits under Pillar 2 (Vulnerability and Resilience), which includes a focus on better health care and strengthening of public agencies to share resources more fairly and build consensus. This will be accomplished by expanding our support for country-led work on strengthening health systems, as well as for programs that expand access to life-saving technologies in ways that are both cost-effective and sustainable.  Our analytical work will address allocative and technical efficiency, return on investment, alternative approaches to implementation in different country contexts, and financial sustainability in each setting.  Bank financing through IDA will fit within country IDA allocations as prioritized by each country during consultations with the Bank.

 

Results

 

In addition to those newly infected every year, HIV-infected people on antiretroviral therapy and care now tend to survive longer.  This explains the increase in the total number of people living with HIV in Sub-Saharan Africa. Since 2005, the number of people dying from AIDS-related causes has steadily decreased, as free or relatively low-cost antiretroviral therapy became more widely available in the region. Local studies are confirming that expanded access to antiretroviral therapy is reducing AIDS mortality rates in Sub-Saharan Africa. The incidence of HIV has been declining in almost half the region’s countries. Among the five countries in Sub-Saharan Africa with the largest HIV epidemics, four—Ethiopia, South Africa, Zambia and Zimbabwe—reduced new HIV infections by more than 25 percent between 2001 and 2009, while Nigeria’s HIV epidemic stabilized. With fewer new HIV infections and better quality of life for infected people on treatment, the productivity among bread winners has increased in many countries, thus contributing to economic growth and poverty reduction in many parts of Africa or, at least, mitigating the otherwise negative effects of the epidemic on productivity. 

 

The World Bank contributed to these results by supporting programs for HIV/AIDS prevention and capacity building. The Bank has also helped clients to strengthen the supply chain management of pharmaceuticals and to improve the diagnostic capacity of local laboratories in some countries. The Bank contributed to improved understanding of the epidemic analyses of country-specific HIV epidemiological profiles, improved design of HIV/AIDS programs, and studies of the economics and financing of HIV/AIDS programs.  As an example, the Bank is supporting HIV program efficiency studies in Lesotho, Kenya, Nigeria, South Africa, Zambia and Zimbabwe.  These studies, which are linked to implementation support for HIV/AIDS programs, will inform improvements in program effectiveness and efficiency.  

 

Rwanda is an example of a country where the Government recognized early on the interface between strengthening the health system and scaling up HIV/AIDS efforts. World Bank funds were used to scale up AIDS treatment and to strengthen the health system through performance-based financing (PBF) for HIV/AIDS services and annual grants to facilities. As a result:

 

  • HIV/AIDS treatment has reached more than 9,200 patients in Rwanda.
  • HIV/AIDS-related deaths have fallen steeply following the introduction of AIDS treatment and people living with HIV/AIDS report lower levels of sexual activity and higher rates of condom use than non-patients, as documented in household surveys.
  • PBF provinces experienced higher rates of increases in HIV testing (before/after comparisons) than non PBF provinces. An impact evaluation is underway to assess the impact of incentives on quantity and quality of services and patient satisfaction.
  • Community health insurance mechanisms (mutuelles) subsidized coverage for over 52,000 households, reaching about a quarter million people to improve their financial access to general health services.

Policies that address access, effectiveness and sustainability

 

Countries and their development partners are currently grappling with the magnitude of the needs alongside resource constraints, which raises the importance of getting the most value for money, improving efficiency and effectiveness, and attention to the financial sustainability of investments in HIV/AIDS programs. A critical objective that addresses both humane and financial challenges is to curb new infections, thereby reducing the number of people who need treatment in the future.  This does not mean a return to the false dichotomy of treatment versus prevention; treatment contributes to the prevention of HIV infection.  It means a far more aggressive approach to evidence-based prevention that uses all available tools: behavioral, medical and technological. It also means continued attention to treatment, with concurrent emphasis on coverage, quality and sustainability. For both prevention and treatment, it is important to keep learning about the most effective—and cost-effective—approaches, including through operational research/ implementation science. The idea is to address immediate human needs while keeping the costs of effective HIV/AIDS programs on a sustainable trajectory in the medium and long term.

 

In addition, countries, especially low-income countries that rely heavily on donor assistance for treatment, need to move towards a more integrated response to HIV/AIDS to sustain their gains. This transition in the approach to financing and delivery requires integration of the response at the national level, across funders and service providers within the health sector, and across sectors on the prevention side.  Stronger health systems should deliver higher-quality services and interventions, getting the most value from resources, and paying attention to measurable improvements in health outcomes. This approach transcends the debate that pitches health system strengthening against specific interventions to fight individual diseases. It also promotes a transition from small-scale innovation to robust, systemic, and multi-sectoral responses that match the needs of the population.

 

Contacts:  Kavita Watsa, (202) 458-8810, kwatsa@worldbank.org

                  Aby Toure, (202) 473-8302, akonate@worldbank.org

 

Updated: March 5, 2013




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