Multi-country AIDS program seeks epidemic's drivers

But in Accra, Ghana, in West Africa, only 2% of people are infected with HIV, though the rate among commercial sex workers is 80%, and in Nairobi, Kenya, HIV prevalence in the general population approaches 10%, and about 60% among commercial sex workers. A 2003 study estimates about half of the infections could be attributed to sex work.

Accumulating evidence shows there is no single pattern of HIV infection across sub-Saharan Africa, but a series of regional patterns, with some areas more acutely affected by HIV than others.

“We haven't seen HIV reach the levels globally we had predicted, but Southern Africa has surpassed our worst expectations,” says David Wilson of the World Bank's Global HIV/AIDS Monitoring and Evaluation Team and author of a background paper for the Bank's AIDS in Africa strategy.

“Two to three years ago we honestly thought all of Africa would be approximately as bad as Southern Africa and that it would catch up. And I think it's now a welcome surprise that East and West Africa are so much lower. It's also clear that it's not just a temporary effect. They won't catch up. They're completely different.”

The epidemic's hot spots

At least three African countries, Uganda, Kenya – in East Africa -- and Zimbabwe in Southern Africa -- have experienced nationwide declines in HIV prevalence, and another five to 10 have seen declines in urban populations, says Wilson.

“I think it's pretty clear now that countries are on different paths and by and large, we're not going to see countries stray from these too much.”

The AIDS epidemic's various forms throughout sub-Saharan Africa require a more sophisticated response than the “cookie cutter” approaches of the past, says Debrework Zewdie, Director of the Bank's Global HIV/AIDS Program.

“Now we are focusing on where are the hot spots of the epidemic. Where are the new infections happening? Knowing what is fuelling the epidemic is critical,” says Zewdie.

The Bank joins two other major funders of AIDS programs, the Global Fund for AIDS, Tuberculosis and Malaria, and the US President's Emergency Plan for AIDS Relief (PEPFAR), in Kigali, Rwanda, this week to look for ways to overcome “bottlenecks” in successfully implementing AIDS programs in Africa.

The most difficult bottleneck, says Zewdie, is “working out what's driving the epidemic in each country and coming up with an appropriate response.”

“If the epidemic is driven by commercial sex work, you need to know where this commercial sex work is happening. You need to know who the clients are, and how do we address both?” she says.

A development crisis

HIV/AIDS is “a development crisis that requires huge political will on the part of the governments of Africa to overcome,” says Zewdie.

The Bank's Multi-Country AIDS Program (MAP) was launched in 2001 to help African governments dramatically increase HIV prevention, care, and treatment.

The MAP committed US$1.286 billion for 39 national or regional HIV/AIDS programs in the program's first six-year phase (2001-2006) to counselling and testing centres, especially in rural areas, improved access to drugs for opportunistic infections. It also “paved the way” for additional funding from other sources, such as the Global Fund and PEPFAR, to fight AIDS and roll out antiretroviral treatment.

That's in contrast to a mere US$18 million a year from 1988 to 1999, when “global funding for HIV/AIDS was paltry, political inaction was common, and denial ran deep,” says a new report released in Kigali this week, “The Africa Multi-Country AIDS Program, 2000-2006: Results of the World Bank's Response to a Development Crisis.”

Global funding for HIV more than quadrupled between 2001 and 2005 from less than US$2 billion to over US$8 billion, according to the report.

Epidemic's drivers

In the beginning, “we were really responding to an emergency,” says Elizabeth Lule, manager of the AIDS Campaign Team for Africa (ACTAfrica).

“It was very important to build political commitment, establish the institutions that would coordinate a multi-sectoral approach, mobilize communities and increase awareness.

“Now five or six years later we've learned that there isn't just one epidemic, that they are so diverse. And across the region what you have in West Africa is very different from the epidemic in Southern Africa, and they differ within countries as well.”

In western Africa, the epidemic's drivers are commercial sex workers and traders travelling the transport corridors, who are often forced to wait at borders. In the Great Lakes region, conflict has displaced people and caused the weakening or breakdown of social structures. In a few countries, men who sleep with men drive the epidemic. While injecting drug use is not a big problem in Africa, “we're beginning to see evidence of it,” says Lule.

In Southern Africa, the epicentre of the epidemic, drivers of the disease include multiple concurrent sex partners, labour mobility, early sexual activity, and rape, she says.

National strategies

A new Africa Agenda for Action for the next five years says countries must understand their specific epidemics so their national strategies are prioritized, financed, and evidence-based.

For instance, research shows that Ethiopia's epidemic is spreading to rural areas, whereas before it was primarily urban.

Since most health services are concentrated in urban areas, “a strategy now might be how to increase awareness and make sure you're scaling up services to cover the rural populations, which we didn't think were at risk before,” says Lule.

Understanding it better

The Bank's response to HIV/AIDS has been challenged by often “scanty” health data. However, the policy is not to wait for “perfect data” to try to discover what is driving the epidemic, says Zewdie.

“In the absence of perfect surveillance data in many countries, there are still ways of at least getting closer to a program which will be meaningful for the country, putting more of your resources to the drivers of the epidemic rather than using your resources on the general population.”

“We are constantly searching for better ways to tackle this disease and I hope and pray that our efforts make an even bigger difference in reversing HIV over the coming months and years.”

Article courtesy of World Bank