Multi-Country HIV/AIDS Program for Africa --Disseminating Good Practices--

1. Multi-Country HIV/AIDS Program for Africa--Disseminating Good Practices-- Miriam Schneidman WORLD BANK MAP Consultation Workshop ADDIS ABABA, February 15, 2005

2. Overview of Presentation • Background • Rationale • Vision & Design • Key Challenges

3. “Learn by doing” approach requires good documentation & transfer of experiences and knowledge Learning initiatives are often fragmented & it is not easy to learn from many good examples Pressures on Bank & Clients to show results and demonstrate impact Enormous opportunities to take advantage of initiatives underway (UNAIDS, WB) BACKGROUND

4. Documenting best practices facilitates sharing of experiences, drawing lessons, & improving effectiveness of investments Empowering clients to create, share & apply knowledge enhances ownership Informing key stakeholders internally and externally about MAP-funded activities RATIONALE

5. VISION OF MAP LEARNING

6. UNICEF World Bank MAP Network of Practitioners in Action ACT Africa Global AIDS Unit Bank Research MAP II Preparation in Madagascar

7. Capturing “what works” and why through case studies will inform investments & avoid reinventing the wheel Collecting information systematically will facilitate task of producing comparable case studies Using participatory approaches which involve stakeholders will be more empowering Establishing mechanisms for analyzing results and modifying what is funded as a result is critical to the learning process DESIGNING CASE STUDIES

8. Series of UNAIDS information materials that promote learning & sharing experiences among those engaged in expanded response Provides voice to those combating epidemic Provides information about what has worked for benefit of those facing similar challenges Provides state of the art knowledge on prevention, care and impact alleviation Stimulates new initiatives to scale up response to HIV/AIDS Represents a UNAIDS interagency effort in partnership with other organizations & parties UNAIDSBest Practice Collection

9. EFFECTIVE: success of practice in producing desired outcome and its impact on HIV/AIDS RELEVANT: intervention responds to a given setting and respects cultural & traditional norms ETHICAL: intervention follows acceptable social & professional conduct COST-EFFICIENT: relationship between costs & results REPLICABLE: ability of program to be adapted to other settings SUSTAINABLE: ability of program to continue after external support has ended UNAIDS Best Practice Case Study Criteria

10. ”Millions Saved”Selection Criteria • SCALE: National, regional or global • DURATION: At scale for at least five years • COST-EFFECTIVENESS:Used cost-effective intervention • IMPORTANCE: Addressed health condition of public health significance • IMPACT:Had a large positive impact on public health

11. ”Millions Saved”Preventing AIDS in Thailand Health Condition: At the end of the 1980s, HIV was a growing threat in Thailand, particularly among “sentinel” groups such as sex workers. Between 1989 and 1991, the proportion of brothel-based sex workers infected with HIV rose from 3.1 percent to 15 percent Intervention or Program: In 1991, the National AIDS Committee led by Thailand’s prime minister implemented the “100 percent condom program,” in which all sex workers in brothels were required to use condoms with clients. Health officials provided boxes of condoms free of charge, and local police held meetings with brothel owners and sex works

12. ”Millions Saved”Preventing AIDS in Thailand Impact: • Condom use in brothels nationwide increased from 14 percent in early 1989 to more than 90 percent by June 1992 • An estimated 200,000 new infections were averted between 1993 and 2000 • The number of new STI cases fell from 200,000 in 1989 to 15,000 in 2001 • The rate of new HIV infections fell fivefold between 1991 and 1993-95 Cost and Cost-Effectiveness: Total government expenditure on the national AIDS program has remained steady at approximately $375 million from 1998 to 2001. This investment represents 1.9 percent of the nation’s overall health budget

13. Benin MAP:--Using voodoo leaders to disseminate messages about HIV/AIDS & stimulate the demand for VCT-- • EFFECTIVE: increased demand for VCT and improved awareness of HIV/AIDS among voodoo leaders • RELEVANT: intervention creatively uses cultural & traditional norms to disseminate messages about HIV/AIDS • ETHICAL: intervention appears to follow acceptable social & professional conduct --Mobilizing voodoo leaders--

14. Benin MAP: • COST-EFFICIENT: relationship between costs & results needs to be verified • REPLICABLE: general approach of coupling HIV/AIDS messages with provision of VCT being replicated to other settings • SUSTAINABLE: ability of program to continue after external support has ended is uncertain

15. EFFECTIVE: Expanding quality of life and longevity for PLWHA with roughly 1000 patients under ART Getting good treatment success with an adherence rate of 95%, which is line with international norms Having a positive impact in terms of averted number of OVCs but ultimate impact on prevention and epidemic remain to be assessed RELEVANT:majority of patients (70%) are female who are disproportionately affected by the epidemic; program targeted to remote areas, ensuring pro-poor focus ETHICAL: patients selected by therapeutic committee; provision of ART is done in confidential manner, according to norms and protocols issued by TRAC and follows social & professional ethical practices Rwanda MAP:-- Providing life saving ART to patients in underserved provinces at highly subsidized prices within the context of the national plan --

16. COST-EFFICIENT: collaboration with CF has generated important savings on drugs & diagnostics, allowing MAP to fund a higher number of patients than planned at appraisal REPLICABLE: provincial model of ART care developed under the MAP is now being replicated and scaled up with other donor funds (PEPFAR, GFATM) SUSTAINABLE: ability of program to continue after external support has ended is good in terms of ‘institutional sustainability’ but probably less so in terms of ‘financial sustainability’ Rwanda MAP:

17. EDOUARD’S EXPERIENCE WITH ARTIn 2002 Edouard, a 36-year old male, suffered from frequent episodes of opportunistic infections. He was treated for meningitis, TB, pneumonia and skin infections. By 2004, when the IDA-funded ARV program started at Butare Hospital, his weight plummeted to 35 kilos. The father of two was completely bedridden and needed to be looked after by his HIV+ wife. Following the initiation of ARV treatment Edouard’s weight rose to 56 kilos and the CD4 count bounced up to about 650. Even though he experienced side effects initially after 3 months these were under control. Edouard was able to take advantage of the government’s highly subsidized treatment for ARV drugs and exams as he, like most other Rwandans participating in the program and earning $3 days per day, receive free treatment.

18. He was able to return to the fields to cultivate food for his family. Edouard’s infected wife, who had recently given birth, was referred to the ARV program to determine whether she is yet eligible for treatment. In the words of one of the nurses working at the Butare Hospital, the “availability of life saving ARV drugs is not only providing hope to people who are desperately ill but is also leading to a greater acceptance of PLWHA, as there is a discernible reduction in stigma associated with expanded access to ARV therapy”. Decreased stigma is reflected in reduced number of patients reporting complaints about abusive behavior of community members, a willingness to come out and discuss their status, and an increased demand for HIV testing.

19. Making knowledge management under MAP operations systematic, strategic & mainstreamed Supporting an enabling environment for knowledge management requires: Capacities & Skills Incentives & Rewards Leaders Networks Fostering creativity & accountability and ensuring reliability of information Building strategic partnerships (Bank/UNAIDS & others) to exploit synergies between initiatives KEY CHALLENGES

20. Enhancing Client Capacity • Recruit & train personnel in techniques of producing and disseminating best practice case studies • Organize workshops in country to review & discuss results of case studies • Support networks of practitioners within & across countries to capture, organize and disseminate knowledge

21. Africa’s tomorrow depends on what we, together, do about HIV/AIDS today