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III. Current responses to the epidemic.


45. The first cases of AIDS in the Sahel were reported as early as 1985-86. However, it was not until late 1987 that national programs to combat the disease were officially initiated. National AIDS Committees (NACs) were established to help prepare emergency action programs. These programs led to the development of the first three-year MTPs (1988-91) which focused primarily on health sector interventions: training of health personnel, enhancing diagnostic techniques, disseminating information (public awareness), conducting small-scale epidemiological surveys (usually in major cities), and providing a limited supply of STD medication and equipment. In Burkina Faso condoms were also promoted and distributed.

46. Although these plans and activities brought AIDS issues on to the national agenda, very little was achieved during the first phase because of the constraints described in Section II. There has evolved, however, a greater recognition of the need to develop a more aggressive information, education, and communication (IEC) strategy and to broaden the scope of interventions to deal with multi-sectoral/multi-level dimensions of the problem. The second-generation MTPs (199498) were designed to respond to these concerns. The plans emphasize: (a) integration of HIV with STD interventions; (b) an intersectoral approach and decentralized management of AIDS programs, giving greater emphasis to community health; and (c) intensification of IEC interventions, particularly peer education programs and community mobilization efforts.


47. Donors, particularly WHO and UNICEF, have actively supported these initiatives. The WHO/ Global Program on AIDS (GPA) has been instrumental in the development of the MTPs, and in the provision of technical assistance to implement national programs. As mentioned earlier, NAPs are facing increasing funding gaps, particularly since the early 1990s. IEC activities, and to a lesser extent epidemiological surveillance, have been more attractive to multilateral and bilateral agencies such as the Dutch and German governments for interventions mostly in rural areas, USATD with condom promotion and distribution, and CIDA for epidemiological surveillance in selected countries. Other donors, namely the French and the European Union, have provided support mainly for STD clinical management and laboratory equipment and supplies in major cities. Recently, however, some principal donors, in particular US AID, are beginning to concentrate their efforts at the regional level, and to disengage from "lower priority" countries.

48. The World Bank Involvement. The Bank's support for AIDS initiatives in the Sahel has been, until recently, very limited. This was due, in part, to the reluctance on the part of officials to use Bank funds to support activities to combat a problem which was not considered to be a major concern, and for which there was apparently adequate bilateral grant funding. This orientation has, however, changed over the last two years as other donor funding has decreased while funding needs have increased. There has, in fact, been a several-fold increase in IDA support during the last two years for AIDS initiatives in the Sahel. The Bank's interventions to date have been at two levels: within the Bank, to promote the inclusion of AIDS issues in sector activities in all countries and to develop a comprehensive AIDS strategy for the Sahel; and at the country level, to assist Sahelian countries launch vigorous action programs to prevent AIDS from becoming a major health problem.

49. Over the last three years, the Bank has focused attention on the following areas:

(a) Improving the knowledge base to enhance the Bank's dialogue with the countries concerned. This is being achieved by helping governments conduct Rapid Risk Assessment Surveys to build a strong data base for effective program planning and implementation (see Annex 3). This effort is aimed at better understanding the AIDS situation within countries and increasing awareness of the disease among policy makers and the population as a whole (19). Within the Bank, AIDS-related issues are being given increased priority. Information meetings have led to greater staff awareness of the need for immediate action, task managers are placing more emphasis on such issues, and effective tools for dialogue and program development are being prepared.

(b) Targeting key government officials to heighten their understanding of HIV/AIDS and of the urgency of concerted national action on all fronts to prevent the epidemic from becoming a serious public health problem. At the 1993 Annual Meetings, the need for urgent attention to AIDS prevention figured prominently among the issues discussed with national delegations. The Bank will also contact Heads of Government to express its concern regarding the need for countries to act quickly and its willingness to assist them in their fight against the disease. In the course of Bank/Government policy dialogues a concerted effort will be made to include specific actions to be taken to address the AIDS issue.

(c) Providing support in Bank-funded operations for under-funded priority activities under NAPs. During the last two years, upon request from national authorities and in response to further analysis of national programs, the Bank has substantially increased its support for AIDS initiatives in all countries (except Sao Tome & Principe and Cape Verde). This support has primarily been in the form of health sector interventions, particularly through ongoing and newly-approved IDA-funded Health and Population projects. The following provides a brief description of the ongoing and proposed country-level activities.

(i) Burkina Faso. The Bank recognizes the critical nature of the AIDS situation in this country and has, over the last two years, undertaken vigorous action at both the policy and program levels in support of the National AIDS Program. Under the ongoing Health Project, a total of US$750,000 was allocated to finance priority activities planned during the first two years of the Second MTP (1993-1997). These include support for epidemiological surveillance (in particular conducting STD/HIV Rapid Risk Assessment Survey), laboratory equipment and training. In addition, when the Population and AIDS Project becomes effective in the next few months, the IDA credit will constitute the largest single source of external funds (US$10.6 million) for AIDS prevention activities in the country (see Box 1 below).

(ii) Cape Verde. So far there has been no direct Bank support for the AIDS Program, which is fairly well advanced and apparently well-funded. However, some support is being considered for preventive activities, particularly for IEC under the proposed Education Project (FY96). In addition the Government has expressed interest in being actively involved in the proposed Sahelian Regional Initiative (see Section TV).

(iii) Chad. Although to date only limited Bank support has been provided to the National AIDS Program, preparation is underway for major support under the proposed Population and AIDS project planned for FY95. Meanwhile, support is being provided under the Project Preparation Facility (20)(PPF) for the proposed project to undertake a STD/HIV Rapid Risk Assessment Survey to be followed by a KAP survey in early 1995. In addition, support was provided by the Bank for the preparation of the Second Multisectoral MTP in May 1994. The Chad National AIDS Program has encountered some funding difficulties in the past, and it is hoped that the support to be provided by the Bank under the proposed Population and Health Project will fill a major gap in funding needs and help achieve the objectives of the National AIDS Program.

(iv) The Gambia. Funding is being provided under the ongoing National Health Development Project for IEC activities, epidemiological surveillance, STD materials and supplies, and technical assistance for strengthening laboratory capacity. Approximately US$200,000 has been provided to date, including funding costs for conducting the STD/HIV Prevalence Survey beginning in mid-May 1994. Although The Gambia is one country in the Sahel where valid information on epidemiology of STD/HIV infections has been available since the mid- and late-1980s, the planned 1994 survey is likely to provide more recent and updated data for most of the country. Additional funding for AIDS activities will be considered under the proposed Health and Population Project (FY96).

(v) Guinea-Bissau. Support for the National Blood Donor Bank, provision of drugs for AIDS-related diseases, and AIDS prevention activities is being provided under the health component of the ongoing Social Sector Project. In addition, preparation efforts have been initiated for a Population and AIDS Project planned for FY96. This project will provide substantial funding for activities planned under the Second MTP (1994-1998).

(vi) Mali. Priority activities are being supported under the ongoing Health, Population and Rural Water Supply Project. A total of US$1.4 million has been allocated under the project in support of the last two years of the first MTP. This includes support for IEC, epidemiological surveillance (including STD/HIV Rapid Risk Assessment Survey), STD clinic management and laboratory facilities to strengthen sentinel surveillance in six selected sites, training of health personnel in clinical and laboratory procedures at district hospitals, program management and monitoring, and technical assistance for the development of the Second MTP (1994-98). Given the rapidly rising HIV/AIDS trend in Mali, further Bank support would be required to meet the program needs under the Second MTP currently under preparation.

(vii) Mauritania. Under the ongoing Second MTP (1994-1998), financial support for high priority activities is being provided through the ongoing Health and Population Project. A total of US$0.9 million has been allocated under the IDA credit to support the program during the next 3 years (1994-97). The funds include substantial support for IEC, training, and epidemiological surveillance (including a small-scale STD/HIV prevalence survey among pregnant women in Nouadhibou).

(viii) Niger. The first Bank support for AIDS in the Sahel was provided in 1987 under the ongoing Health Project for the procurement of laboratory equipment to ensure blood safety. Since then, considerable support has been provided through both the Health Project and the new Population Project. Funding has focused primarily on IEC initiatives, epidemiological surveillance, procurement of STD and anti-tuberculosis drugs, and strengthening laboratory capabilities at the national and selected regional hospitals, particularly to ensure safe blood transfusions. Total Bank support under the two credits is US$1.3 million. Following Senegal, Niger is the second country in the Sahel to benefit from Bank support in conducting a STD/HIV Rapid Risk Assessment Survey, which was completed in June 1993. The survey has significantly improved the knowledge about the prevalence of major STDs in the agglomeration of Niamey, and therefore provides valid data for strengthening the National STD and AIDS Program (see Annex 1, item 6, for further details). It is also envisaged that the new Health Project (FY96), currently under preparation, will provide substantial support for AIDS prevention activities.

(ix) Senegal. Direct financial support to the National AIDS Program has not yet been provided, although an official request is expected for support of planned activities during the 1994-1998 five-year Strategic Plan. However, support is being provided for IEC activities for youth through the Family Life Education program financed under the ongoing Human Resource Development Project. Total Bank support for AIDS prevention activities is estimated at US$600,000.
Box 1: BURKINA FASO: Population and AIDS Control Project

This project will be the first IDA-funded project in the Sahel to
include a full-fledged AIDS component. The AIDS control component
aims at slowing down the spread of HIV/AIDS by promoting behavioral
change, through increasing public awareness of HIV/AIDS. Particular
emphasis would be placed on strengthening management capacity at
the national and community levels, and on increasing the
involvement of the private sector and NGOs in project activities.
Specific activities include:

(a) Social marketing and public sector distribution of condoms;

(b) Establishment of a Fund to provide grant financing for projects
in the areas of population, family planning, and AIDS prevention
and control activities undertaken largely by NGOs;

(c) IEC campaigns using various media channels such as radio spots,
serial dramas, dance and singing groups, folk theater, etc to raise
awareness of HIV/AIDS and other STDs and to promote behavioral
changes; and

(d) Institutional strerigthening of clinical management and
community care capacities within the country.


50. Over the past few years the changing political situation has given rise to the creation of a number of local NGOs either as local affiliates of international NGOs, such as SIDALERTE, Society for Women Against AIDS in Africa (SWAA), Save the Children Fund (US and UK), and ENDA Tiers Monde, or as independent local organizations venturing into community activities dealing with women's reproductive health issues and AIDS. There is also a number of well-established international NGOs doing interesting work on AIDS prevention. Notable among these are Care International, focusing primarily on migration issues, and Population Services International and the Futures Group, both promoting social marketing of condoms. Family Health International, through its AIDSCAP programs, is also targeting specific groups for AIDS prevention activities. These international NGOs are primarily funded through US AID. In addition, considerable support for epidemiological surveillance is being provided in four countries through CIDA under the PASE project (Projet d'Appui a la Surveillance Epidimiologique),


51. Over the last 10 years a series of programs in communicable disease prevention, family planning, and, more recently, AIDS has been developed in the Sahelian region. The success of these interventions has varied. While some small-scale interventions have been notably successful, few state-organized national level interventions have demonstrated similar results. The varying impacts are illustrative of the difficulty faced in changing one of the most complex social behaviors--sex--and accepted norms of sexuality, are intimately linked to gender relations and religious norms, and are shrouded by social taboos that limit public discussion. AIDS forces discussion of sex and its relationship to disease, death, and life. Some of the main lessons learned over the last decade in developing AIDS interventions in Africa and elsewhere are:

(a) Behavioral change is difficult and slow. There is a need to address the non-cognitive determinants of behavior. In the earlier stages of the global response to AIDS, the exhortation to provide information in an attempt to halt its spread led to a profusion of biomedical jargon directed at the public. This strategy increased recall of the name of the disease but it did not increase knowledge of the causes, symptoms, and treatment options available for the opportunistic infections associated with AIDS. More importantly, recall of the disease did not produce the desired behavioral responses. Changing sexual behaviors requires research on the non-cognitive aspects of these behaviors, and the belief systems that exist about death, sickness, disease, and sexual practices. Effective AIDS education initiatives must be based on an understanding of the socio-cultural dynamics and the nexus between treatment options, service delivery modes, gender relations, and the belief systems mentioned above. It is necessary to convince policy makers to have more realistic expectations for behavioral change.

(b) Comprehensive programs are essential. While the demand for condoms should be addressed at the early stage of programs, supply side issues must also be addressed very early in program development. Communication is frequently associated with the production of materials and diffusion of information that stimulates the demand for services. Demand-side approaches to communication fail to address service delivery concerns. Stimulating demand for services that do not exist, or that cannot adequately serve the population, reduces the credibility of the source of information and prejudices the target audience's attentiveness to future messages. Attention must also be paid to the quality of the services provided. One of the main reasons for low levels of service utilization in the Sahel is that the client's negative perceptions or experiences are communicated within the social networks. To improve the utilization of services, clients must be provided with quality services; quality being defined from both cultural and technological perspectives. Strategies for stimulating demand and providing quantitative and qualitative inputs into the supply for services must be incorporated within a comprehensive AIDS communication plan. Attempts at coordination between supply- and demand-side approaches are difficult when communication strategies have been developed independently, or in an ad hoc manner.

(c) Local institutional capacity building is essential. Response to the AIDS epidemic comes spontaneously from within. It is necessary to relate to what is happening at the country level and build upon these efforts. Decentralization of decision-making should be encouraged. Multiple actions with significant amounts of funding (i.e. dosage effect) can be effective. However, donor agencies need to be careful not to thwart community-level institutional infrastructure through the creation of new organizational structures and/or through overfunding. In some instances, the best strategy might be to leave communities alone.

(d) The importance of targeting youth. Interventions targeting youth constitute an important cost-effective means of preventing and mitigating the spread of STD/HIV. However, perceptions that sex education and teaching about reproductive health may encourage early sexual activity among youth represent highly negative barriers to the implementation of effective prevention programs for young people. Various studies, however, have shown no evidence of increased sexual promiscuity and precocious sexual activity among youth receiving sex education. (21) In addition, some of these studies (6 out of 19) concluded that "sex education either delays the onset of sexual activity or decreases the level of sexual activity." In many of the studies (10 out of 19), it was found that sex education has increased adoption of safer practices by sexually active youth. Therefore, there is strong evidence that effective school-based sex education programs may serve as effective mechanisms for promoting changes in sexual behavior.

(e) The importance of provincial/regional approaches. The ethnic and social variations in the sub-region necessitate a mosaic of communication approaches within a country. These approaches have a greater appeal to the intended audience and are cost-effective. National boundaries are not indicative of cultural differences and strategies can be tailored to the linguistic and cultural diversity of the region. Programs developed in one country may be relevant to populations residing in another country when the socioeconomic as well as infrastructure realities within countries are taken into account. Innovation is key; it is therefore important to learn from others.

(f) The important role of technical assistance. Specialists' assistance is often required in project development, implementation, and evaluation given the relative inexperience and limited manpower capabilities of local implementing agencies. Technical assistance must be planned to build institutional capacity and reduce the reliance on external assistance.
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Title Annotation:Regional AIDS Strategy for the Sahel
Publication:Africa - Regional AIDS Strategy For the Sahel
Date:Jan 1, 1995
Previous Article:II. Main issues.
Next Article:IV. Proposed bank strategy and interventions.

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