Meeting the Challenge: The World Bank and HIV/AIDS

CHALLENGE

Most of the world’s 34 million people living with HIV/AIDS are in developing countries. Worldwide, 2.5 million people became newly-infected with HIV, and 1.5 million died of HIV-related causes in 2011—24 percent fewer deaths than in 2005. Sub-Saharan Africa accounted for 68 percent of all new infections and nearly half of all deaths globally in 2010 occurred in Southern Africa. Even where the overall HIV prevalence is low, AIDS can be a severe burden: It is the leading cause of premature death in Thailand and China. More than 8 million people living with HIV are accessing treatment globally; 7 million who need it do not have it. Moreover, for every one person on treatment, two are infected. Without effective HIV prevention, the numbers requiring treatment will become unsustainable.

Despite the global increase in funding during the past decade—from US$1.6 billion in 2001 to US$16.8 billion in 2011—financing gaps persist, and available funds are mainly for treatment. As new infections rise, country and donor investments in prevention are not being sustained. Nearly 90 percent of AIDS spending is from international sources, and the bulk of funding is jeopardized by tight donor and government budgets, household income losses, and worsened food security.

SOLUTION

The Bank’s approach has evolved with the changing HIV/AIDS landscape. When possible, the Bank participates in the pooling of funds, as part of the joint United Nations Programme on HIV/AIDS (UNAIDS) family and other partners, to ensure more effective and efficient responses in regions and countries, consistent with the UNAIDS vision of zero new infections, zero AIDS-related deaths, and zero discrimination. The Bank responds to country needs within the context of Country Partnership/Assistance Strategies, which take account of support from other partners and the governments’ funding for effective prevention of new HIV infections, care, and treatment. The Bank provides sustained funding for HIV/AIDS programs and supports countries to do “better for less” through improved efficiency, effectiveness, and sustainability of national AIDS responses.

The Bank specifically supports analytical work in six related areas: (i) increasing the efficiency of aid allocations; (ii) program and technical efficiency; (iii) effectiveness studies; (iv) financing and sustainability studies; (v) national strategic planning; and (vi) financing through grants and loans. The Bank also engages in key sectors, such as education, transport, energy, and infrastructure, to bridge gaps in HIV prevention, care and treatment, and mitigation. The Bank supports countries through its knowledge and financing for health systems strengthening; total Bank financing for health (including HIV, malaria, tuberculosis, and other diseases) was US$3 billion in FY11 and totaled US$24 billion since 2000.

RESULTS

IDA- and IBRD-financed HIV/AIDS operations are designed and implemented with a particular emphasis on helping countries achieve results and reach Millennium Development Goal Six. IDA has financed 1,500 counseling and testing sites, ultimately HIV testing nearly 7 million people. It has funded more than 65,000 civil society HIV initiatives in Sub-Saharan Africa and has helped reduce HIV risk behavior among men and women aged 15-24. IDA has also educated 173 million people about HIV/AIDS and has mitigated the impact of AIDS for 1.8 million children and half a million adults through 38,000 grassroots initiatives. IDA was the first source of substantial funding for HIV/AIDS in Sub-Saharan Africa, the Caribbean, and India, and remains the most predictable, flexible, long-term financing source. IDA’s Multi-Country AIDS Program helped increase total resources for HIV in developing countries from US$300 million in 1996 to US$14 billion in 2008, which includes domestic, public and private spending.

IDA RESULTS

• Multi-Country AIDS Program: Since 2000, the Bank has committed US$2 billion to 33 countries and four regional, cross-border projects in Africa, to expand national HIV/AIDS efforts. IDA has funded more than 65,000 civil society projects; purchased and/or distributed 1.3 billion male condoms and delivered 4 million female condoms for the prevention of HIV, sexually transmitted diseases, and unwanted pregnancies; allowed 3 million pregnant women to receive antenatal care; and delivered antiretroviral therapies to almost 2 million adults and children with HIV, and treatment for HIV-related infections for nearly 300,000 more. Other results in Sub-Saharan Africa included offering services to prevent mother-to-child HIV transmission for more than 1.5 million women; establishing 1,500 voluntary counseling and testing sites (where 7 million people were tested for HIV); training to provide HIV services for more than half a million people; reaching more than 173 million people with information about HIV/AIDS; workplace HIV information, testing, counseling, and treatment programs to serve 2.3 million employees; supporting about 40,100 organizations with advice and financing in 36 countries; and the impact of AIDS was mitigated for more than half a million adults and 1.8 million children through education, nutrition, and income-generating activities delivered by 38,000 grassroots initiatives.
• Abidjan-Lagos Corridor: The Bank-supported Abidjan-Lagos Corridor HIV initiative, which covers the largest transport corridor in Africa, supported a 22 percent reduction in sexually transmitted infections, a 30 percent increase in knowledge of how to prevent HIV—underpinned by a 20-fold increase in condom distribution—and major declines in risky behavior.
• Djibouti: The Bank has supported Djibouti’s national HIV/AIDS program, which has reduced HIV sero-prevalence among 15-to-24-year-old pregnant women from 2.9 percent in 2002 to 2 percent in 2009. More than 2,000 persons living with HIV/AIDS registered for HIV/AIDS case management, and of these, 1,541 received antiretroviral treatment.
• India: The Bank has supported the foundation of a national program that is averting 3 million new infections—a 60 percent reduction in the HIV epidemic from around 5.5 million cases to 2.5 million cases—during the period 1995-2015. More than US$640 million in IDA financing has helped to create the institutional framework of India’s HIV response at national and state levels, including a strong surveillance system. The Bank has also financed, through pooled funding with the Indian government and other partners, more than 1,300 targeted interventions for those most at risk, reaching more than 70 percent of female sex workers and increasing the use of condoms. This intervention has helped contain HIV prevalence in the general population.  “There has been a tremendous scale-up of prevention interventions under this program, which has led to an overall reduction in new infections and AIDS-related deaths in India,” said Sayan Chatterjee, Secretary and Director General of India’s National AIDS Control Organisation. “With expanding coverage of treatment, the program has to ensure that the treatment requirements are fully met without sacrificing the needs of prevention.”
• Rwanda: An integrated, incentivized AIDS service delivery supported by the Bank contributed to a 76 percent increase in overall health service utilization.
• Vietnam: Since 2006, IDA and the United Kingdom’s Department for International Development (DFID) have promoted safe injecting and sexual behaviors to reduce HIV transmission among vulnerable populations in 32 provinces in Vietnam. In 2010 alone, provincial services reached 56,459 injecting drug users (70 percent of total injecting drug users in the 32 provinces) with harm reduction interventions, and 44,386 female sex workers (representing 75 percent of this population in the 32 provinces) with interventions to promote the use of condoms

IBRD Results

• Botswana: In Botswana, IBRD has increased the coverage, efficiency, and sustainability of targeted HIV/AIDS interventions. The country scaled up access to treatment from less than 5 percent in 2000 to more than 80 percent (including 95 percent coverage for pregnant women living with HIV), which it has maintained since 2009. The annual number of new infections has declined by more than two-thirds since the late nineties and data suggests that the number of new HIV infections in Botswana is 30-50 percent lower today than it would have been in the absence of antiretroviral therapy. Estimated annual AIDS-related deaths fell by more than half—from 15,500 in 2003 to 7,400 in 2007—while the annual number of new HIV infections among children declined five-fold from 4,600 in 1999 to 890 in 2007.
• Jamaica : The Bank recently concluded a financial sustainability study of the national response which recommends three priority areas for government: (i) develop a long-term sustainability plan with different financing options that defines the roles of different national agencies (as well as donor support); (ii) assess the allocation efficiency of the national response to HIV/AIDS, taking into account not only the immediate health consequences but also the epidemiological and financial repercussions of alternative HIV/AIDS interventions; and (iii) focus on targeted prevention efforts particularly for most at risk populations since effective prevention in the short term will result in lower spending on treatment in the long term.

IDA-IBRD Combined Results

• Caribbean Region: The region has made significant strides in increasing access to HIV treatment. Caribbean residents in need of treatment—and receiving antiretroviral drugs—increased from 10 percent in 2004 to 51 percent by December 2008, surpassing the global average of 41 percent for low- and middle-income countries. Approximately 21,276 people living with HIV are receiving antiretroviral treatment in Barbados, Dominican Republic, Grenada, Guyana, Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, and Trinidad and Tobago. Expansion of services to prevent mother-to-child-transmission of HIV has reduced mother-to child transmission of HIV from 10 percent in 2006 to less than 5 percent in 2010 in Jamaica, and no baby was born HIV-positive from HIV-positive mothers in the past four years in Barbados.

Other Results

• The World Bank, in partnership with various organizations, led three separate studies in a three-part series on key populations at higher risk (sex workers, people who inject drugs, and men who have sex with men ) in low- and middle-income countries:
  • Partnership with UNAIDS, the United Nations Development Programme (UNDP), and the World Health Organization (WHO): A study by the Bank and these partners, entitled “The Global HIV Epidemics Among Men Who Have Sex with Men (MSM): Epidemiology, Prevention, Access to Care, and Human Rights,” evaluates global costs of inaction in addressing HIV within this population, critically reviews epidemiological evidence of HIV transmission, rigorously reviews the evidence of efficacy and intervention costs, and models the costs and impact of addressing the needs of this population in various epidemic contexts. The report has found that addressing this aspect significantly affects a country’s HIV epidemic—even in generalized epidemic scenarios such as those in Sub- Saharan Africa.
  • Partnerships with United Nations Population Fund (UNFPA) and Johns Hopkins Bloomberg School of Public Health: A study by the Bank and these partners, entitled “The Global HIV Epidemics Among Sex Workers: Epidemiology, Prevention, Access to Care, and Human Rights,” found that a community empowerment approach to HIV prevention, treatment, and care is cost-effective, with significant projected impact on HIV incidence among sex workers and transmission beyond the sex worker community. The study emphasizes the central importance of adopting a rights-affirming, empowerment-based approach to scale up comprehensive HIV services, and addressing stigma, discrimination, and violence against sex workers.
  • Partnerships with the Futures Group and Johns Hopkins Bloomberg School of Public Health: A study by the Bank and these partners, entitled “The Global HIV Epidemics Among People who Inject Drugs: Epidemiology, Prevention, Access to Care, and Human Rights,” predicted that continuing to specifically target injecting drug users with needle and syringe programs, medically assisted therapy and HIV counseling and testing, as well as increased access to antiretroviral treatment, could avert thousands of infections from 2012-2015, including 1,300 in Kenya, 4,130 in Pakistan, 1,570 in Thailand, and 3,900 in Ukraine. Interventions for people who inject drugs are cost-effective or highly cost-effective investment choices across the breadth of the global epidemic.
• Argentina, Ecuador, El Salvador, Guatemala, Panama, Paraguay: In 2010, following a Bank study, several governments reallocated their budgets to more effectively target prevention, a critical step in the process of scaling up programs and ensuring that they are sustainable. Resource allocation to most at-risk populations increased nine-fold, compared with 2008. A total of US$27 million was allocated to men who have sex with men in 2010, up from US$1.1 million in 2008. Projects focused on sex workers saw similar gains, with US$10 million allocated in 2010 instead of the US$1.8 million spent in 2008. There were also significant increases in money allocated to campaigns aimed at prisoners and injecting drug users.
• Burkina Faso, Kenya, Lesotho, India, Nigeria, Senegal, South Africa, Zimbabwe: In partnership with DFID, the United Kingdom Consortium on AIDS and International Development, and other partners, the Bank completed a three-year evaluation, Investing in Communities Achieves Results, an evaluation to better understand the impact of the community response to HIV and AIDS in eight countries.  Findings indicate that investments have produced results at the community level that contributes to the desired outcomes of the global response to AIDS. Ten evaluation studies provide strong evidence that specific community interventions can affect the course of the epidemic by increasing HIV knowledge, reducing stigma, and increasing condom use, HIV testing uptake, treatment adherence, and use of services. The studies also show that community-based actions play a pivotal complementary role to national programs by providing services to rural communities and high-risk groups, which would otherwise have none. Further, the studies reveal that community-based organizations—many of which operate on small annual budgets between US$15,000 and $25,000—are doing much with little. The Bank leveraged DFID financing for the evaluation by mobilizing additional funding by 30 percent and increasing intra-Bank collaboration. The evaluation has attracted support from other global partners including the Bill & Melinda Gates Foundation, USAID, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund and UNAIDS. The new UNAIDS investment framework, unveiled in July 2011, places community mobilization at the center of AIDS programming, and the evaluation is contributing valuable data to this global effort. Finally, the active involvement of civil society in all eight countries and globally through the United Kingdom Consortium on AIDS and International Development has demonstrated the strong engagement of civil society in the evaluation and the Bank’s commitment to work effectively with them.
• East Asia and the Pacific: The Bank has provided technical assistance to countries to ensure that available resources for HIV/AIDS are prioritized and targeted to effective interventions. Since 2010, the Bank has provided cost-effectiveness analysis trainings and results-management workshops in Indonesia, Thailand, and China, which have trained more than 70 public officials in the use of economic tools to improve national and sub-national strategic planning for HIV/AIDS.
• Kenya, Lesotho, Mozambique, South Africa, Swaziland, Uganda, and Zambia: The Bank’s analytical work on HIV transmission dynamics and impact evaluations to generate evidence on what works in prevention in various epidemic contexts has resulted in major policy and program shifts. In Uganda, Kenya, Lesotho, Swaziland, Zambia, Mozambique, and South Africa, the Bank’s support to HIV epidemiological, policy, and response syntheses has resulted in the development and/or revision of national HIV programs. Uganda doubled its prevention funding and agreed to focus on couples in HIV prevention. The synthesis report helped Kenya shape its national strategy and operational plans; in Lesotho and Mozambique, the findings helped inform strategic planning; and Zambia held its first HIV prevention summit. In South Africa, the new national HIV strategic plan reflects the Bank’s policy advice to characterize the epidemic and improve prevention programming.
• Malawi, Tanzania: A study by the Bank showed that conditional cash payments to men and young women in Malawi and Tanzania were linked to significantly lower HIV and other sexually transmitted infection rates than in other groups in the same communities. Eighteen months after the program began, new HIV infections among girls in the program were 60 percent lower than among those who were part of a control group and did not receive payments.
• Niger: In Niger the Bank supported the epidemiological analysis of HIV transmission dynamics and the adequacy of the government response. This support helped to identify new priorities and to inform the design of the Bank-funded US$20-million AIDS project, which focuses resources on most at-risk populations, increasing the efficiency of the health system. Similar epidemiological analysis in Benin and Ghana informed the priority setting and allocation of resources for key populations at risk in the two countries.
• Middle East and North Africa: The Bank developed a groundbreaking HIV report that has led to program shifts. “Characterizing the HIV/AIDS Epidemic in MENA” shows how focusing investments on prevention efforts for priority populations at increased risk of HIV infection can yield long-term health and social benefits. As a result, the governments of Egypt, Morocco, Jordan, Sudan, and Syria have increased their resource allocation to most at-risk populations, placing them at the center of their response.
• Colombia: In Colombia, the Bank worked closely with the ministry of health to conduct a study of the implementation efficiency of the national HIV/AIDS program. The study addressed three main domains: efficiency of resource allocations, programmatic efficiency, and services delivery efficiency. The study shows that while the AIDS program is fully embedded in the national social security system, the complexity of the services delivery system poses challenges for coordination of services.
• South Africa: In Kwa-Zulu Natal, the province in South Africa with the highest HIV prevalence, the Bank has initiated a fund-tracking study to look at whether the significant HIV funds Kwa-Zulu Natal attracts from the national government and donors – as well as the province’s own funds – are reaching the intended beneficiaries, and are targeting the right prevention priorities. Data will enable the provincial government to assess the effectiveness and efficiency of public spending on HIV/AIDS programs, and ultimately make appropriate changes to improve HIV responses across Kwa-Zulu Natal.
• Ukraine: Through its strategic planning role, the Bank is focusing on the most-at-risk groups such as injecting drug users and sex workers. Ukraine is the country most affected by the HIV epidemic in the Europe and Central Asia region.

BANK CONTRIBUTION

IDA has committed more than US$3.6 billion since 1988 to support HIV/AIDS responses in 67 countries, while IBRD has provided US$1.1 billion in 18 middle-income countries since 1993. Bank-supported projects have helped raise political awareness and mobilize societies, build systems and institutions to channel resources to affected communities, and bring the public, private, and nonprofit sectors together to deliver effective, evidence-based strategies and policies. Bank financing is used flexibly to complement other sources, deliver sustained support to strengthen health systems, support investments and outreach among marginalized groups, (key to preventing transmission in concentrated HIV epidemics), and sustain grassroots initiatives that reach poor, remote, and marginalized communities, empowering infected and affected people to cope better.

PARTNERS

Today, with the large grant resources of the Global Fund and PEPFAR, the Bank is no longer the major financier for AIDS, but remains a key source of support—continuing to strengthen national and sub-national capacity for planning, managing, and monitoring HIV responses and thus enabling countries to use other sources of global funding more effectively. The Bank continues to finance specific country projects as well as use policy lending to strengthen these national HIV/AIDS responses.

The Bank plays a global leadership role and is a founding cosponsor of UNAIDS, and works closely with global partners in the UNAIDS family to deliver results. The Bank also helped create the Global Fund and serves on its board and as trustee. The Bank plays a strong role in promoting donor harmonization, coordination, and alignment.

In partnership with DFID, the Bank is developing multi-method approaches for large scale population level evaluations of complex AIDS interventions and has recently completed a 3 year study on Investing in Communities Achieves Results, an evaluation of the community response to HIV and AIDS.  Furthermore, the Bank is helping countries improve efficiency, effectiveness and sustainability of their national AIDS response as well as project the fiscal dimensions of AIDS so they can transition from an emergency response effort to sustainable, nationally owned and integrated plans in partnership with the United States governments.  Finally, the Bank is working with the International AIDS Vaccine Initiative to support research on a vaccine to bring an end to the AIDS pandemic.

MOVING FORWARD

The Bank continues to view HIV/AIDS as a fundamental development problem, focusing especially on HIV strategic planning, prevention, care, and treatment services, along with social protection for people affected by HIV. The Bank will continue to support countries to achieve the greatest impact, utilize the most cost-effective prevention activities, utilizing our analytical and advisory work and funding. Additionally, the Bank will make a targeted effort utilizing results-based financing to scale up prevention of mother-to-child transmission of HIV, in support of our pledge to help countries accelerate progress on maternal and child health, in line with the Millennium Development Goals.  The Bank will continue to broaden its analytic support to countries to bolster the efficiency and effectiveness of their disease programs, and work with them to assess their fiscal capacities to make the best-informed decisions about financing priorities.