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Executive summary.


1. The objective of this report is to define strategies for the World Bank ('the Bank') to effectively assist Sahelian countries in taking advantage of the window of opportunity that currently exists to carry the fight against the HIV/AIDS epidemic to a higher level. The report discusses the main issues and manifestations of the epidemic, identifies constraints to effective policy and program development and implementation, and proposes an agenda for action. It also spells out the key elements of donor collaboration and identifies areas and activities for Bank intervention. The report aims to enhance Bank staffs awareness and understanding of the dynamics of the epidemic in the Sahel and to help them engage in effective dialogue with government agencies, industry, NGOs, community organizations and donors.

2. The report argues that while the level of HIV seroprevalence and the number of AIDS cases in the Sahel are still relatively low in the general population compared to other regions of Sub-Saharan Africa (SSA), the rapidly rising trend and pattern of spread of the epidemic do not augur well for the future. The case is made that the late arrival of HIV/AIDS in Sahelian countries provides governments with a unique opportunity to draw upon the lessons learned about the disease and experience gained in combating it and to take action now and implement cost-effective AIDS prevention interventions before the epidemic takes hold in the general population.

3. Epidemiology of the disease. While available data are incomplete, current estimates suggest a rapidly increasing trend in the spread of the disease. Short-term projections indicate a tripling of the number of HIV-infected persons from about 782,000 in 1992 to approximately 2 million in 1997. The trend is even more alarming when the projected number of AIDS cases is considered. Based on estimated HIV seroprevalence, the cumulative number of AIDS cases is expected to rise from about 22,000 in 1992 to over 300,000 by 1997, a 15-fold increase in only 5 years. In addition, while HIV-2 infections are still predominant in countries such as Senegal, The Gambia and Guinea Bissau, HIV-1 infections are the most prevalent in the rest of the Sahel and are increasing at a much faster rate in all countries (the former is known to have a longer latency period and a lower pathogenicity than the latter). Thus, morbidity and consequent mortality rates are likely to rise rapidly over the next few years. Furthermore, there is evidence of a rapidly declining median age at infection, particularly among women, and there are as many women infected as men, suggesting higher proportions of heterosexual transmission.

4. Consequences. Although the demographic implications of the AIDS epidemic can be far-reaching, its effect on the rate of population growth in SSA and in the Sahel in particular is unlikely to be dramatic. It is estimated that even under the worst-case scenario, the Sahelian population will continue to grow at a rate higher than 2 percent per annum. However, the high morbidity and mortality impact of AIDS on the most economically active age group would have severe socio-economic consequences, leading to the disruption and disintegration of households and the creation of new poverty groups.

5. The rising trend in morbidity and mortality would also have a negative impact on all sectors, in particular on the provision and financing of health care. It is estimated that by 1997 deaths due to AIDS would account for no less than 30% of all adult mortality annually in the Sahel. In Burkina Faso, for example, about half of all beds in some wards at the National Hospital in Ouagadougou are already occupied by HIV/AIDS patients. Current direct lifetime costs of

AIDS in Burkina Faso are estimated at about 4% of total health expenditures, and could easily exceed 20% by 1997. Indirect lifetime costs (the value of healthy life years lost from the disease) is estimated to be about 17 times higher than the direct cost. The HIV/AIDS situation in Burkina Faso is increasingly resembling the situation found in Cote d'Ivoire, and presents a likely scenario for other Sahelian countries, in particular Mali, Chad, Niger and The Gambia, where the number of AIDS cases is increasing rapidly.

Main issues

6. Two broad categories of issues are discussed in the paper:

(a) Factors affecting the spread of the disease, which include: (i) limited understanding of the determinants and consequences of the disease among all segments of society (policy makers, opinion leaders, service providers, and the general population); (ii) high population mobility, particularly inter-country migration to the high endemic coastal countries such as Cote d'Ivoire, Ghana, Togo and Benin; and (iii) relatively higher vulnerability of women to STD/HIV infection due mainly to socio-cultural factors (such as early marriages, low levels of education, adverse cultural and religious practices, including in particular female circumcision) and poverty;

(b) Impediments to effective program implementation, which include: (i) limited political commitment, the absence of a multisectoral approach to program planning and implementation, limited involvement of NGOs and community organizations, and lack of funding; and (ii) program-related issues including the lack of effective information, education and communication (IEC) programs, limited initiatives on condom promotion, and weak epidemiological surveillance, laboratory capacity, STD clinical management and program management capacities.

Responses to the epidemic

7. National programs to combat the AIDS epidemic in the Sahel were initiated in 1987 with the development of emergency action programs and the establishment of National AIDS Committees (NACs) with assistance from the WHO/Global Program on AIDS (GPA). These led to the development of the first medium-term plans (MTPs, 1988-91) which focused primarily on health sector interventions. These plans and activities brought AIDS to the national agenda, but very Utile was achieved, due to the constraints outlined above. All Sahelian countries are now in the process of either initiating or implementing their second MTPs (1994-98). These plans emphasize: (a) the integration of HIV prevention activities into STD interventions; (b) an intersectoral approach and decentralized management of AIDS programs, giving greater responsibility to community health; and (c) an intensification of IEC interventions, particularly peer education programs and community mobilization efforts.

8. Donors, particularly WHO and UNICEF, have actively supported these initiatives. WHO/GPA has been instrumental in developing the medium-term plans and in providing technical assistance for the implementation of national programs. Major bilateral donors active in this area include USAID, the Dutch, the Germans, the French, the Canadians and the European Union.

9. The World Bank involvement The Bank's support for HIV/AIDS initiatives in the Sahel has been, until recently, very limited. This was due, in part, to the reluctance of governments 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. However, during the last two years, there has been a several-fold increase in Bank funding (under the soft loan facility of the Bank, the International Development Association (IDA)), as other donor funding has decreased while funding needs have increased.

10. 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. Within the Bank, AID S-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. The Bank will 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 addition, 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 National AIDS Programs (NAPs), and integrating free-standing AIDS components into future IDA-financed projects in health (free-standing AIDS components were added to two Population Projects in the 1994 fiscal year (FY94) and other sectors such as Education and Agriculture. Proposed and ongoing IDA-funded activities are defined in detail in Section III of the report.

11. Local and international non-governmental organizations (NGOs) have become increasingly involved in activities dealing with women's reproductive health issues and AIDS. These organizations provide support for AIDS prevention and control activities, including the undertaking of research on cross-country issues such as migration and the spread of AIDS, the promotion of social marketing of condoms, and TEC programs. These include Care International, SIDALERTE, Society for Women Against AIDS in Africa (SWAA), Save the Children Fund (US and UK), ENDA Tiers Monde, Family Health International under AIDSCAP, and a number of independent local organizations.

12. Lessons learned. The main findings over the last decade in developing and implementing AIDS interventions in Africa and elsewhere are that: (a) behavioral change is difficult and slow; (b) comprehensive programs are essential; (c) TEC programs should attempt to disseminate more positive messages; (d) understanding gender issues is important in determining the degree of behavioral responses; (e) targeting youth is cost-effective; (f) involving NGOs, communities, and the private sector is critical for the success of programs; (g) local institutional capacity building is essential; (h) regional/ provincial approaches are important in expediting the process of program impact; and (i) technical assistance is required to ensure effective program development and implementation.

Proposed Bank strategy and interventions

13. The Bank's proposed HIV/AID S Prevention and Control Strategy for the Sahelian countries is aimed at promoting a full-scale, broad-based attack on the problem with the objective of helping Sahelian countries avoid a generalized epidemic and a major developmental setback. This strategy will use a two-pronged approach consisting of country-level activities supported through the lending program and regional activities supported through grant funding. These two approaches are summarized below and described in detail in Section IV of this report.

14. Country-level activities supported through lending program. Based on the perceived trend of the epidemic in the country, program quality and availability of funding, Sahelian countries have been ranked in order of priority for action. Burkina Faso, Mali, and Niger are ranked as high priority countries for Bank support, followed by Chad, The Gambia, and Mauritania, as medium priority, and Senegal and Cape Verde as low priority. Guinea Bissau and Sao Tome & Principe are not rated due to lack of relevant information.

15. For each of these countries the nature and level of Bank support would depend on the priorities already defined in the second MTPs and the extent of resources committed by the governments as well as other donors. However, the Bank's strategy for country assistance programs would cover activities in these key areas: (a) strengthening and expanding ongoing HIV/AIDS communication programs, targeting in particular decision-makers, opinion leaders, service providers, women and youth; (b) accelerating the establishment of social marketing programs to promote condom use, by strengthening and expanding existing public sector distribution networks and encouraging the development of private retail outlets; (c) expanding clinical management and care of STDs/HIV, and strengthening epidemiological surveillance and laboratory capacity, with particular emphasis on the integration of STD/HIV case detection and counseling into primary health care and family planning programs, and enhancing clinical capacity to enable screening and diagnosis of STDs/HIV, particularly among women; (d) increasing assistance to community, NGO and private sector initiatives; (e) encouraging multisectoral interventions; and (f) improving collaboration and coordination with other donors.

16. Regional program supported through grants. The focus of the Bank's work program for FY95-97 will be on developing integrated strategies and fostering cooperation at the regional level to increase the effectiveness of HIV/AIDS interventions. The thrust of the proposed regional program will be to: (a) establish a full-scale information, education and communication (TEC) program, using a variety of communication channels, to widely disseminate information on the disease and its prevention; and (b) foster regional cooperation and explore innovative approaches to controlling the spread of the epidemic. Such extensive, high impact programs are difficult to launch and implement through country lending programs, which lack the synergistic advantages and economies of scale of a regional approach. A regional program could recruit the best program/technical specialists, often unavailable at the country level, to develop a wide-based campaign having the maximum regional impact in the shortest period of time. Specific attention would be given to the following activities:

(a) Mobilizing political and opinion leaders and organizations throughout the region to address HIV/AIDS issues at the highest level. Regional workshops, seminars, study tours and other kinds of group initiatives would be organized to exchange ideas and build a regional consensus at the highest level. Semiannual consultations would be conducted to evaluate progress and identify areas for further action;

(b) Identifying and working with national figures/local heroes (political, religious and sports personalities) with regional appeal to develop strong advocacy roles and mount aggressive education and information campaigns;

(c) Supporting pilot projects to test innovative ideas, particularly those relating to cross-border issues, such as migration (developing sub-projects around border towns and areas of affinity), condom promotion, etc.;

(d) Promoting studies and research of regional significance by universities and research centers in the region, establishing collaborative arrangements with research centers, developing research networks, and providing opportunities for research results to be incorporated into programs at the national level; and

(e) Providing technical support and training to NAPs to improve their capacity to manage multisectoral national programs and upgrading the quality of the response to the national HIV/AIDS issue.

17. Support will be provided for the development of effective mechanisms/structures to coordinate and facilitate the implementation of the regional activities. The nature and form of the mechanisms/structures were discussed during a regional technical planning workshop held in Ouagadougou, Burkina Faso from September 11-15, 1994. The workshop brought together 61 participants including NAP managers and observers from UNDP, UNICEF, AIDSCAP, CARE International, SIDALERTE, and Save the Children Fund (US and UK), as well as representatives of local NGOs. Participants identified priority problem areas at the regional level and selected specific interventions to address these priority areas. Constraints to program development and execution were identified and complementary interventions required to ensure effective implementation were discussed.

18. The total budget for this program is estimated at US$6.0 million, over a 3-year period--FY9597-(US$2.0 million per year), of which US$1.2 million is expected to be provided through the Special Grant Program (SGP) as the World Bank's contribution. The SGP has approved funding (US$300,000) for the first year (FY95) of this program. The remaining US$1.6 million for FY95 would be funded from external sources yet to be determined. It is anticipated, however, that the complementary donor financing would be readily forthcoming since such a program is widely seen as a high priority in the Sahel.
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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:List of acronyms.
Next Article:I. Introduction and overview.

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