Two Decades of World Bank Support for HIV/AIDS

1. Two Decades of World Bank Support for HIV/AIDS In Latin America and the Caribbean Thomas E. Novotny, MD MPH San Diego State University

2. Overview: Two Decades of Action on HIV/AIDS in LAC – Lessons Learned • The epidemic then, now, and in the future • Main Bank assistance strategies • Regional approaches • Strategic planning and policy development • M&E system development • Convening, knowledge development, financial services • Persistent challenges for governments going forward • Financing and the economic crisis • Coordination and multiple donors • Conclusions

3. A ‘Stable’ Epidemic? Latin and Central America Newly Infected with HIV : UNAIDS 2010 Dotted lines are estimate ranges and solid lines best estimate

4. People Living With HIV/AIDS 2009 Latin and Central America Caribbean Sub-region Source: UNAIDS 2010 Dotted lines are estimate ranges and solid lines best estimate

5. The Bank’s Work 1988 onward • First component part of Brazil Endemic Diseases Project • Brazil HIV/AIDS Projects I, II, and III starting 1991 • National AIDS-SUS Project now • Multi-Country HIV/AIDS Program (MAP) in the Caribbean • Health Projects in Argentina, El Salvador, Honduras, and Venezuela included HIV/AIDS • Central America Regional Project • $697 million committed by Bank to HIV/AIDS in LAC • $557.5 million disbursed 1988-2011 • Current portfolio: $117.6 million IBRD and IDA

6. Regional Approaches • Regional Projects • Caribbean: allowed fast-tracking project preparation and implementation in 9 country projects and a regional Pan Caribbean Partnership Against HIV/AIDS (PANCAP). • Central America: capacity strengthening and legal frameworks; knowledge-sharing by bringing together key staff of national programs, laboratories, and surveillance systems; • Regional laboratory not fully implemented • Disbursement hampered by difficulties in regional financial coordination • Helped get Global Fund Regional Grant

7. Strategic Planning andPolicy Development New Structures Successes • National AIDS Programs • National AIDS Commissions • Multi-sectoral collaborations • CSOs • Country Coordinating Mechanisms (Global Fund) • Private-Public Partnerships • National Plans in place throughout LAC by 2001; • Comprehensive approach • prevention • care and treatment • institutional development, management and coordination, including M&E; • Most projects engage beneficiaries, NGOs, and non-health sectors.

8. Monitoring and Evaluation • Bank invested heavily in surveillance systems • In 2010 • 5 national surveillance systems scored as fully functioning • 11 partially functioning • 11 poorly functioning • AIDS Strategy and Action Planning group (ASAP) • Database and References for an Evidence- Based Strategy • Worked with 8 Ministries of Health to compile regional HIV data over 15 years • Bank hosts the Global Monitoring and Evaluation Team (GAMET) on behalf of UNAIDS partners • Handbook for Planning and Managing for HIV/AIDS Results • Regional M&E steering groups in Caribbean

9. Knowledge Development • HIV/AIDS in the Caribbean—Issues and Options: A Background Paper 2000. • HNP Discussion Paper: HIV/AIDS in Latin America-The Challenges Ahead 2003. • HIV/AIDS in Central America: An Overview of the Epidemic and Priorities for Prevention 2003. • HIV/AIDS in Latin American Countries: The Challenges Ahead to facilitate the implementation of prevention and control strategies 2003. • A Multi-Agency Review of the HIV/AIDS response in the countries and regional organization under the Caribbean Multi-Country AIDS Program 2005 • Improving the Effectiveness of HIV/AIDS Assistance. Evaluation of the World Bank’s Assistance for HIV/AIDS Control 2005. • Optimizing the Allocation of Resources among HIV prevention interventions in Argentina, Honduras, and CA 2006. • Protecting Children Affected by AIDS in the Caribbean: Legal Reform in St. Vincent and the Grenadines, Guyana, St. Lucia and Grenada 2006. • The World Bank’s Assistance in Responding to the AIDS Epidemic: Brazil Case study 2005. • World Bank-financed HIV Projects in the Caribbean: Lessons for Working with Small States 2010.

10. Convening • Regional Workshop on strengthening implementation and strategic planning for the Caribbean HIV/AIDS MAP projects (9 country and one regional project) 2006. • Bank with UNESCO, other UN agencies, and the Caribbean Community Secretariat (CARICOM) to support Education Sector Response to HIV/AIDS in the Caribbean Region. • Workshop December 12-14, 2011, Salvador, Brazil, to review Two Decades of Support to Prevent and Control HIV/AIDS in Latin America and the Caribbean. • Session on sustainability of AIDS response in LAC. • XX AIDS Conference July 2012.

11. Where are we now? Achievements Challenges • Improved incidence data • Improved mortality data • Second generation surveillance • Regional laboratory development • Improved human resource capacity • Improved multinational cooperation • GAMET technical assistance • Functional treatment program in Barbados • Persistent difficulties in assessing MARP HIV prevalence as well as KAB • Social determinants of risk behavior (mobility) • Stigma and discrimination affects surveillance, M&E • Data for decision making-- critical for strategic planning • Third generation surveillance • Integration into health systems strengthening

12. Spending and resource allocation to HIV Programs in LAC Source: Aran-Matero D. 2011

13. Challenges Going Forward • World Bank’s main comparative advantage in HIV/AIDS response is in systemic health sector capacity building • Integration of HIV/AIDS and Health Systems Development • Identification of vulnerable groups, monitoring of risk behavior, and surveillance of HIV incidence among the most at-risk groups in the region still inadequate • CSO, M & E, VCT • Stigma and discrimination • Financing needs going forward require detailed economic analysis, increased public funds, and donor coordination (UNAID NASA) • Test and treat for prevention • Maintain current successes • Expanded need for social services and social integration for PLHIV • Results based funding?

14. Results based financing • Brazil: GF financing found to be complex, burdensome and beyond the capacity of existing M&E systems • Usual focus is on inputs and outputs • Barbados: • PMTCT above 90% allowed disbursement • Condom use and knowledge of transmission risk >90% among young persons allowed disbursement

15. Conclusions • The Bank has made significant contributions in knowledge development, convening, and financial services • Persistent stigma, discrimination, homophobia and lack of attention to MARPS still need more focused attention • Progress made so far is threatened by global financial crisis, limitations of donor funding, and continued high costs of treatment strategies • Compounded by the chronic disease challenges of HIV/AIDS • Social service needs of survivors • Drug resistance • Regional coordination has been challenging but is essential, especially with small countries, the need for standardized M & E, and mobile populations

16. Two Decades of Action on HIV/AIDS in LAC –Lessons Learned Forthcoming, 2012 HNP LAC