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HIV/AIDS slowing in Africa with help from NGOs, drugs, and condoms

A new World Bank report on HIV/AIDS launched recently in the Rwandan capital, Kigali, says the mobilization of empowered ‘grassroots' communities, along with delivering condoms and life-saving treatments, are beginning to slow the pace of the continent's epidemic, which last year killed more than 2 million African adults and children, and left another 24.7 million Africans struggling to live with its deadly effects.

Kigali - According to the new report - The Africa Multi-Country AIDS Program 2000-2006: Results of the World Bank's Response to a Development Crisis - ultimate success in defeating HIV/AIDS will depend on marshalling effective prevention, care, and treatment, measures to boost ‘social immune systems' in African countries - changing their beliefs, perceptions, and social and individual behaviours around the disease so that eventually they can reverse the advance of HIV and stop the damage done by AIDS.

The report says these changes are taking place as the epidemic shows signs of slowing in Uganda, Kenya, and Zimbabwe, and in urban Ethiopia, Rwanda, Burundi, Malawi, and Zambia. But Southern Africa remains the epicentre of the continent's epidemic with unprecedented infection rates. In one recent household survey, a staggering 70% of women, aged 30-34, and men, aged 40-44, in Botswana's second largest city, Francistown, have HIV. In Eastern Africa, countries are facing a mixed epidemic pattern with significant numbers of new infections originating in the commercial sex trade, and in the general population.

“AIDS stole into Africa like a thief in the night, and all these years later, we still must stay vigilant against this terrible disease, even when it seems that infections are starting to fall and more and more people are being saved with treatment,” says Joy Phumaphi, Vice President of the World Bank's Human Development Network, a former WHO Assistant Director General, and former Health Minister of Botswana, 1999-2003. “Global funding for HIV has more than quadrupled between 2001 and 2005, from less than US$2 billion to over US$8 billion a year, which, along with new pledges of help from the G-8, is hugely welcome, but unfortunately still falls short of what countries need. We also have to fix the cumbersome state of the development aid system so that international donors and developing countries can better mobilize their efforts to stop HIV/AIDS.”

What did a billion dollars buy?

The Bank's new report assesses the results of its billion-dollar Multi-Country HIV/AIDS Program (MAP) for Africa set up in 2000 to offer long-term support to any country with a sound HIV/AIDS strategy and action plan. Using a combination of full grants and zero interest loans, 1[1]the Bank provided US$ 1.286 billion for HIV/AIDS in Africa in six years (FY2001-06) or almost 50% of the Bank's global investment in fighting HIV.

The mission of the MAP was to dramatically increase access to HIV prevention, care, and treatment programs, with an emphasis on encouraging local action and a cross-sectoral response at the government level, expanding programs to prevent mother-to-child transmission, supporting children affected by AIDS, building capacity for treatment, initiating regional programs to address cross-border issues, and sharing knowledge.

Using project appraisals and country feedback forms from more than 90% of the MAP countries in Africa, the report says that the Africa Multi-Country HIV/AIDS Program helped countries achieve many results, including:

* To prevent new infections, offered services to prevent mother-to-child HIV transmission to 1,546, 388 women in 23 countries; distributed 1,298,410, 996 condoms in 25 countries; set up 1,512 new counselling and testing sites in 17 countries; tested almost seven million people in 25 countries; and reached 2,258,844 workers in 23 countries with HIV awareness and care programs in the workplace
* To mitigate the impact of AIDS, financed the prevention and care work of 50,000 communities, civil society and youth groups, and organizations of people living with HIV, throughout the MAP countries; and offered care and support for 1,779,872 orphans and other vulnerable children in 21 countries affected by AIDS
* To provide treatment for opportunistic infections to 287, 805 people in 20 countries; financed anti-retroviral (ART) drugs for 26, 699 of the 554, 648 people in 27 countries who are currently on ART; trained 562, 366 people and strengthened health systems that helped to roll-out ART treatment in recent years as drugs prices fell and donor financing rose significantly.

“Once it became clear to us that AIDS was a development emergency unlike anything we'd ever seen before, we realized that countries would need a new development credit line that was fast, flexible, and innovative, and so we set up the Multi-Country AIDS Program for Africa,” says Debrework Zewdie, Director of the World Bank's Global HIV/AIDS Programme, who pioneered the MAP approach in the Africa Region in 2000. “I'm struck by how far we have come from the bleak situation of 2000 when global funding for HIV/AIDS was paltry, political inaction was common, and denial ran deep. The MAP was designed to remedy these failings by focusing on high-level leadership, supporting strong engagement of civil society, and providing unprecedented amounts of money and technical backing. By offering united (but not uniform) support for African countries, the MAP underscored that HIV was a shared threat confronting the continent, and made it easier for leaders to break the silence.”

Zewdie says the MAP approach showed that it was possible to respond swiftly to emergency situations, using an innovative, large-scale program, which subsequently laid the foundation for countries to use billions of dollars in new HIV/AIDS financing which became available from 2003 onwards through the Global Fund and PEPFAR (The President's Emergency Plan for AIDS Relief). A MAP program was set up in the Caribbean, and a MAP-like approach has been followed in Central Asia. Because of its speed and flexibility, the MAP was used as the model for the Bank's avian flu program.

Mobilizing communities

Mindful of evidence that no country has successfully stopped the spread of HIV, and cared for its sick and dying adults and orphaned children, without the active engagement of community-based groups and NGOs, the World Bank's Africa MAP channelled US$502 million to more than 50,000 community groups, NGOs, and other organizations, for grassroots action to reduce stigma, change risky behaviours, and care for people living with, and affected, by the disease.

Of the more than half a billion dollars committed to the community level, groups spent 56% on prevention activities; 15% on care and treatment; 11% on mitigation work such as caring for orphans, and micro-credit for widows and women living with AIDS; 18% on work that trained and supervised small NGOs that offered care and support at local levels.

According to Michel Kazatchkine, the Executive Director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the MAP's approach to financing the AIDS work of NGOs and other community groups paved the way for the Global Fund and other major development agencies to follow suit:

“It (MAP) was a precursor because of its specific objective of supporting civil society, which we know is a key component of the response against HIV/AIDS. In addition, the World Bank is in a privileged position to bring in the fight against HIV/ADS within the frame work of the fight against poverty and the fight for development and for promoting health in development,” says Kazatchkine. “I wouldn't foresee in any way that the Global Fund could replace the input of the World Bank and I would be very concerned if the World Bank was to ever neglect the health sector and neglect HIV/AIDS programs in the future.”

The Bank and HIV/AIDS over the next 5-10 years

In updating its HIV/AIDS strategy for Africa over the next five years and beyond, the Bank says that HIV/AIDS will remain an enormous economic, social and human challenge to sub-Saharan Africa for the foreseeable future. The region is the global epicentre of the disease. More than 25 million Africans are HIV positive, and AIDS is the leading cause of premature death on that Continent. HIV/AIDS affects young people and women disproportionately. Young women are three times as likely to be infected as young men. Due to the pandemic, there are an estimated 12 million children under the age of 18 with one or no parents. Its impact on households, human capital, the private sector and public sector, affects the alleviation of poverty, the Bank's overarching mandate. In sum, HIV/AIDS threatens the development goals in the region unlike anywhere else in the world.

According to the new report, it is now clear that there is no single ideal AIDS program. Each country must understand the drivers of the epidemic and design prioritized national programs, building on strong local evidence and learning from its successes and mistakes alike. The report goes on to say that the process has not always been smooth sailing, and still there are ups and downs, but through continuous learning and improvement, the Multi-Country AIDS Program for Africa is supporting national prevention, treatment, care, and mitigation services that reach millions of infected and affected people across Africa.

“We are starting to see uplifting examples of where countries are starting to gain the upper hand with the disease, but to multiply these results, we have to be unrelenting,” says Elizabeth Lule, Manager of ACTafrica, the World Bank's Africa AIDS Campaign team.

“Looking ahead to the next five years, past experience has been an invaluable teacher that country-inspired and directed responses, grounded in careful analysis of the local epidemic and the factors driving it, that are coordinated and efficiently carried out by a broad range of parties - including countries themselves, the international development community and its aid-giving complex, local community and NGO groups, organizations of people living with AIDS, the media, and others - and carefully monitored and coordinated - are the only sustainable way to help the people of Africa to prevail over HIV/AIDS.”

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