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5. The collective response--broadening the paradigm.

The AIDS epidemic demands a collective, urgent response. This update of the World Bank's AIDS Strategy for Africa has reviewed the World Health Assembly's universally endorsed Global AIDS Strategy and the impressive progress made to date in mobilizing the resources to carry out the Global Strategy. A number of the strategy's interventions are highly effective, and many national and international partners have adopted these interventions to save lives. The challenge now is to intensify the implementation of these interventions to significantly slow the epidemic's rapid spread.

This chapter summarizes the achievements and shortfalls of the global response, including that of the Bank. Based on this analysis, Chapter 6 suggests new actions to enhance the work currently supported under the Bank's AIDS Strategy for Africa.

Figure 5.1 below introduces an AIDS response paradigm to assess the adequacy of prevention and mitigation. This paradigm broadens the response to include multisectorial and socio-economic concerns summarized previously in Box 4. Two types of prevention efforts, direct (square 1 in figure 5.1) and indirect (square 2), inhibit HIV transmission. Two types of mitigation efforts, those directed toward AIDS patients (square 3) and those directed toward AIDS-affected groups (square 4), help ease the adverse health and socioeconomic effects of AIDS.
Figure 5.1 Efforts that prevent HIV infection and mitigate the impacts


AIDS interventions

* Education on safe behaviors
* Condom promotion
* STD treatment
* Safe blood supply

Human resource and economic development

* Strengthening health systems
* Increasing girls education
* Increasing economic opportunities for women


Infected Individuals
Care of AIDS patients

* Treatment of infections
* Allevation of pain
* Counseling
* Financial and in land aid

Affected groups
Care of AIDS-affected families, communities, and sectors

* Counseling
* Targeted interventions for the poor
* Replacement of lost labor


Direct prevention of HIV transmission is the first priority in the response to the epidemic.

Direct efforts

The four most effective HIV prevention interventions (education on safe behavior, condom promotion, STD treatment, and a safe blood supply) can be found in every African country (square 1). Studies in Rwanda, Tanzania, Zaire, Zambia and Zimbabwe have shown these interventions to be cost-effective in reducing the incidence of HIV and other STDs in certain target groups (the military and commercial sex workers) and in larger communities of the general population. Still, these interventions have rarely attained the depth (all interventions in place at the same time) and breadth (reaching all target groups) required to substantially slow the epidemic's spread. For example, HIV prevalence rates among pregnant women continue to exceed more than 30 percent in several urban areas in southern Africa.

The Bank's role. The Bank's new freestanding AIDS projects in Burkina Faso, Chad, Kenya, and Uganda were designed to intensify the depth and breadth of the four interventions. Bank-assisted projects containing AIDS-related activities with intensified interventions are being planned in Congo, Cote d'lvoire, Guinea-Bissau, and Tanzania. But these nine countries are the exception. Many affected countries--among them Burundi, Cameroon, the Central African Republic, Ethiopia, Malawi, Nigeria, Rwanda, and Togo--lack the essential elements that intensify the depth and breadth of the interventions making up their national AIDS control programs. The progress of these interventions in preventing HIV infection is summarized below.

a.) Education on safe behaviors

Education on AIDS and safe sexual behaviors has substantially increased AIDS awareness throughout Africa. About 65 percent of rural populations and 100 percent of urban populations are aware of AIDS. How this knowledge influences the adoption of safe behaviors is less clear. Some African men are taking fewer sexual partners, and some men (about 25 percent of those surveyed in Burundi and Zambia) engaging in casual sex are regularly using condoms (Carael and Cleland 1993). Because the largest share of new HIV infections is among young adults and adolescents, this is one of the most important groups to target. Yet not all youth are being reached--sexual education courses in schools are often optional, and community activities targeting out-of-school youth are limited in number. And every year a larger cohort requires consistent and sustained messages on prevention.

It is not yet widely known how Africa's high awareness of AIDS can be internalized by Africans into the adoption of safe sexual practices continent wide. The experience and best practices on how to bring about fundamental changes in social norms is thin in Africa and elsewhere. Several European donors, U.S. and Australian institutions, and United Nations agencies have recently acknowledged the role behavior plays in AIDS (and family planning), and have substantially increased grant funding in this area. And some African universities have increased the number of social research programs. Still, few NGO's and institutions in Africa have the capacity to expand the knowledge of which factors influence behavior. Technical and financial assistance is needed to increase the number of African organizations and institutions adept in the behavioral fields.

The Bank's role: Through its regional programs, the Bank is expanding the efforts of three nongovernmental organizations and one institute in carrying out behavior research and interventions across country borders in East, Southern and West Africa. In addition, nearly twothirds of thirty-six Bank-assisted projects with AIDS components promote safe sexual behaviors.

b.) Condom promotion

The explosive increase in sales of socially marketed condoms (from 2 million in 1988 to 120 million in 1994) suggests that consistent demand for condoms can be created if the condoms are affordable, accessible, and of good quality. With safer sexual behaviors becoming more common, condoms requirements in Africa are expected to reach 932 million condoms a year by 2000 (WHO 1993). Thus the twenty-five African countries without social marketing programs for condoms must immediately establish them to fill this projected need. In addition to socially marketed condoms, the demand for condoms will have to be met by free condoms procured internationally by the United Nations Fund for Population Activities, the U.S. Agency for International Development, the WHO, and governments with Bank financing, and possibly by condoms manufactured in Ghana and Nigeria and sold for profit regionally. On a parallel course, testing of the new female condom and research for a female controlled virucide must continue.

The Bank's role. The freestanding Bank-assisted AIDS projects in Burkina Faso, Chad, Kenya, and Uganda and health projects in Benin and Guinea include procurement and distribution of free condoms for HIV/STD prevention. The projects in Burkina Faso and Chad also support social marketing programs. The proposed STD prevention project in Nigeria includes the plan to explore the profitability of manufacturing condoms locally.

c.) STD treatment

Many capital cities can boast one clinic providing quality STD care--but few countries have the drugs, training, and personnel to integrate STD care with their primary health care services. The importance of STD treatment was highlighted by the recent findings of a Mwanza, Tanzania study, which found that effective treatment of curable STDs lowered HIV incidence by 42 percent.

The Bank's role. Studies assessing STD prevalence and related risk factors have been sponsored by the Bank in eight countries and are planned in three more, in Central and Western Africa. Working with the WHO, the Canadian International Development Agency, and the U.S. Agency for International Development (USAID), the Bank is increasing the University of Nairobi's ability to meet countries' needs for STD training. The Bank is also one of the few international organizations financing the procurement of drugs for STD care.

d.) Safe blood supply

Although HIV transmission through blood products contributes only minimally to the African epidemic, safe blood is a necessary objective of any AIDS control program. Only ten countries in Africa screen all blood and blood products for HIV. Testing equipment is expensive and in short supply in most countries, especially in rural areas. The testing equipment that is available is usually supplied by the European Union, the WHO, and the Danish International Development Agency, in addition to the Bank.

The Bank's role. Fourteen Bank-assisted health projects support the screening of blood for HIV. This intervention includes procuring tests and testing equipment and setting up management and logistical systems for screening, referral, and reporting. Of critical importance is ensuring that confidential mechanisms exist to exclude blood donors of high risk to HIV and all persons are counseled before (and after if HIV-positive,) while donating blood.

Indirect efforts

Human resource and economic development efforts (square 2 in figure 5.1) are addressing many of the socioeconomic conditions that make people--especially women--more vulnerable to HIV. These prevention activities often require a longer time frame than the direct interventions just discussed. The United Nations Development Programme (UNDP), bilateral donors, and the African Development Bank are the main international actors, in addition to the Bank, assisting African governments with these development efforts.

a.) Strengthening health systems

A number of national and international organizations--public and private--have made tremendous strides toward improving the delivery of health services throughout Africa. The decreases in child and adult mortality witnessed in Africa over the past decades attest to this progress. But much more can be done. An additional $1.6 billion a year is needed to ensure a basic package of health services in the rural and periurban areas of low-income Africa. Strengthening the health system will involve improving the physical and managerial operations of health systems, with an emphasis on facility renovations, pharmaceutical procurement, and better management and training of personnel.

The Bank's role. Bank-assisted health projects implemented in Angola, Burkina Faso, Guinea, Madagascar, Malawi, Mali, Mauritania, Niger, Nigeria, Uganda, and Zimbabwe. Bank assisted-health reform projects have recently begun in Ethiopia, Kenya, Mozambique, Tanzania, and Zambia. New lending in health to Sub-Saharan countries averaged more than $200 million a year during 1993-95. This total will rise to more than $400 million during 199698.

b.) Increasing girls' education

Educating girls is widely recognized as one of the most important steps in development. Education for girls has a catalytic effect on every dimension of development: lower child and maternal mortality rates, reduced fertility rates, increased educational attainment by daughters and sons, higher productivity, and better environmental management. Yet less than 70 percent of eligible African girls enroll in primary school, and only 68 percent of those girls enrolled in first grade complete primary school (Carr-Hill and King 1992). The United Nations Children's Fund, the United Nations Educational, Scientific, and Cultural Organization, and the African Development Bank follow the Bank as the leading multinational and bilateral supporters of education.

The Bank's role. Bank lending for education has increased significantly the past decade. Annual lending to Africa for education averaged $122.8 million during FY 198589, and reached $325.5 million in FY 1994. Since 1990, about 40 percent of Bank-assisted education projects in Africa have included female education components, from providing scholarships to training female teachers.

c.) Increasing economic opportunities for women

Improving women's productive capacity can contribute to growth, efficiency, and poverty alleviation--key development goals everywhere. Yet numerous barriers continue to shut out women and limit their opportunities. Effective strategies for reducing the barriers to women's economic participation have emerged over the past two decades through work performed by nongovernmental organizations, women's groups, and the Bank.

The Bank's role. Since 1992, 57 percent of Bank lending to Africa has promoted macroeconomic adjustments that foster growth, and 17 percent is directed to narrowly targeted services whose main beneficiaries are the poor. Between 1987 and 1990 the Bank introduced eighty-one projects with enterprise development and financial services for women components-the majority of them in Africa--to raise incomes and generate new employment. These activities are found in agriculture, industry, and urban development projects. The Bank also supports through a regional program legal reforms (in land ownership and credit access) for women in Africa.

Although these human resource and development efforts occur outside the health sector, they can be used to target populations specifically at risk of HIV infection. For example, programs to educate girls and increase women's access to credit could include female sex workers, orphans, and street children. More communication and collaboration between the sectors and among community leaders would strengthen the program linkages between development and HIV vulnerability.


Although efforts to mitigate the consequences of AIDS (squares 3 and 4 in figure 5.1) are less urgently needed than those to prevent HIV, mitigation is still important. People living with AIDS can lead productive lives if they receive support from their families and communities. They can also contribute to prevention efforts in their communities, as agents of change and peer educators. In addition, families that are affected by AIDS suffer from personal loss, increased medical costs and burial fees, and reduced income. These larger socioeconomic impacts are significant--and should be addressed.

Improving care for AIDS patients

None of the thirteen countries most severely affected by HIV has experienced its peak of AIDS cases. Thus the number of AIDS patients requiring care in these countries is going to increase. Several NGO's (Tanzania NGO to assist People with AIDS--WAMATA and The AIDS Support Organization--TASO) have shown that AIDS patients and their survivors can receive appropriate care and counseling away from the overburdened hospital systems. In fact, twenty-seven countries have some form of community-based care for AIDS patients. Questions regarding the cost-effectiveness and sustainability of these programs have yet to be answered, however. Thus, more information is needed on the costs of various approaches to service provision, and on who bears these costs.

The Bank's role. Bank-assisted research into alternative, cost-effective modes of caring for the increasing number of AIDS patients has been performed in Tanzania and Uganda, and is planned in Botswana and Cote d'lvoire. This research complements the work performed by others in Kenya and Zambia. A Bank-assisted project in Zimbabwe has increased the availability of drugs for tuberculosis and other opportunistic infections by 21 percent. Similar results are expected in Burkina Faso, Chad, Kenya, and Uganda.

Caring for AIDS-affected families, communities, and sectors

USAID, UNDP, the FAO, and several other international organizations have studied the consequences of AIDS, most recently in Kenya, Malawi, South Africa and Zambia. For example, the average Malawian family loses, in addition to a personal loss, a contribution of more than fifteen years of productive life when a male family member dies of AIDS (Family Health International 1994).

The Bank's role. Three comprehensive Bank studies in Tanzania and Uganda and other analytical work sponsored by the Bank assess the socioeconomic impact AIDS is having or will have on African households and communities, as well as on the public and private sectors. This information helps convince policymakers of the need for a multisectoral response to AIDS and of the epidemic's dramatic impact on development. Still, few policies addressing these impacts have been developed as a result of such efforts. An abbreviated form of these studies, with better use of the data for policy and program decisionmaking, is planned for many of the other severely affected African countries, including Botswana, Burundi, Congo, Cote d'lvoire, and Rwanda.

Outside the health sector, integration of the findings of AIDS-related sector work with Bank operations has been limited. Among twelve most severely affected countries, the five poverty assessments and nine policy framework papers completed since 1991 make reference to AIDS. In addition, eight of ten Country Assistance Strategies and four of six public expenditure reviews mention the disease. But few of these documents factor the consequences of AIDS (for example, loss of skilled labor, increased economic hardship, and the impact on adult mortality) into their analyses of sector development or recommendations for poverty alleviation.
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Title Annotation:AIDS Prevention and Mitigation in Sub-Saharan Africa: An Updated World Bank Strategy
Publication:AIDS Prevention and Mitigation In Sub-Saharan Africa: An Updated World Bank Strategy
Date:Apr 1, 1996
Previous Article:4. Bank's contribution to the response--making progress.
Next Article:6. Enhancing the bank's strategy 1996-2000.

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