Additional Annex 13: Lessons learned from international experience.

1. Senegal's experience: Senegal is one of the few countries that has maintained a stable low prevalence since the detection of HIV/ATDS in the country. The three major behavior-factors that have contributed to this success have been identified as follows (UNAIDS, 1999 The Case of Senegal): (i) sexual activity begins relatively late, (ii) extramarital sex is limited, and (iii) condom use during extramarital sex and commercial sex is high. After the first HIV/AIDS cases were identified, the government of Senegal reacted immediately with: a) an intensified STI treatment program; b) massive training of health sector personnel; c) informing and promoting active involvement of religious leaders; d) promotion of active community involvement; and e) reaching young people through schools and youth clubs. Program-factors that have contributed to the success are the sex worker registration since 1969 and the successful STI treatment program. The MSPP for Madagascar will be looking closely at these factors and drawing on the lessons learned that are applicable to the Malagasy situation, in particular the involvement of religious leaders, registration of sex workers and intensification of the STI treatment program.

2. The Thai experience: Thailand was very successful in curbing the spread of the HIV/AIDS epidemic in the early 90s ("Relationships of HIV and STI declines in Thailand to Behavioral Change ", UNAIDS 1998 ). Immediate action from the government through the use of mass media awareness campaigns--such as the promotion of 100% condom use for commercial sex, expansion of STI treatment, involvement of NGOs and private sector--was the main factor for its success. Once the effectiveness of the 100% condom use for commercial sex program was established in the pilot areas, it was rapidly expanded nationwide. The main strategy of the 100% condom use program was to gain the agreement of the owners and managers of all sex establishments to enforce condom use as a condition of commercial sex. When they would not cooperate, they faced serious sanctions. Thailand took a very open approach to reporting HIV prevalence; from the sentinel surveillance system, making the public quickly aware of the dangers of commercial sex. Condom use in commercial sex rapidly became the norm, numbers of clients were halved, and new HTV infections and STI rates dropped by almost 80% nationwide. However, enforcement of 100% condom use appears to have led to an increase of commercial sex in indirect sites that are more difficult to identify. Another important finding is that the dominant route of infection for women is now husband-to-wife transmission. The lessons from Thailand demonstrate that the epidemic is not static; it evolves and changes over time and so should the responses. The MSPP will take these valuable lessons learned from Thailand and apply them to its project design. Opportunities to involve Thai experts and study tours to Thailand will be explored.

3. Bangladesh experience: The HTV/AIDS epidemic in Bangladesh is comparable to the epidemic in Madagascar. Low prevalence, 0.6 percent among sex workers but rising rapidly and existence of numerous risk factors; high STI levels; low condom use among commercial sex workers; large commercial sex industry; and substantial risk behavior among various population groups such as sailors, truckers, and sex workers. As in Madagascar awareness levels of the dangers of HTV/AIDS and the routes of transmission are very low. Therefore lessons learned from this project and the design of a Bank financed project will be taken by the MSPP with particular emphasis on systematically addressing risk factors to prevent the spread of HTV/AIDS. Lesson learned from Bangladesh to date include (report no. 21299-BD): (a) providing information on safe behavior alone is not sufficient to bring about behavioral change. Interventions for promoting safe behavior should not only aim at providing information, but also at removing constraints that prevent people from choosing safe behavior and practices; (b) AIDS is a development issue: social factors such as violence, migration, marginalization, human trafficking and discrimination affect HTV/AIDS prevention; and (c) existing NGO efforts in reproductive health work have paved the way for STI and HTV/AIDS work by establishing communication channels and developing strong relationships with local people.