Although HIV prevalence is stabilizing and declining in some countries1, Southern Africa remains the epicenter of the AIDS epidemic with 35% of new infections and 38% of AIDS deaths. Women account for 61 percent of those living with HIV and young women are three times more likely to be HIV positive than young men. The children of Africa represent 90 percent of the estimated 2 million children under the age of 15 living with HIV globally. Twelve million children in Africa under age 18 have lost one or both parents to AIDS. Treatment coverage in Sub-Saharan Africa is far from the 80% universal access goal. Given that new infections outpace those starting treatment — for every two people on treatment, another five are newly infected – prevention remains central to an effective AIDS response, particularly among groups at most risk (e.g. men who have sex with men, sex workers).
Key Issues in HIV/AIDS
Despite the increase in AIDS funding over the past decade, financing gaps persist (an estimated $18 billion2 in 2007 for Africa), and the bulk of likely available funds is unpredictable and mainly covers treatment. As new infections are on the rise in some countries, country and donor investments in prevention are not being sustained. Further, countries dependent on donor support for providing treatment have been encouraged to identify other sources of funding. Balancing investments in treatment and prevention remains a challenge.
The impact of the global economic crisis may result in increased country demand for IDA support of national HIV/AIDS programs and uncertainty in ODA.The GFATM will require an additional $20 billion over the next three years amidst increasing funding requests from eligible countries while several African countries have reported limiting uptake of new patients for antiretroviral treatment.3 Decreasing non-agricultural commodity prices and increases in unemployment have negative implications for HIV/AIDS affected households. The sharp rise in food prices has forced people dependent on ART to choose between taking ART on an empty stomach or foregoing treatment to keep food on the table.
World Bank Programs – Africa Region Response
Since 2000, the Bank has provided $1.9 billion for HIV prevention, treatment, care and support in over 30 Sub-Saharan African countries and 5 regional programs. FY09 HIV/AIDS commitments totaled $293 million – an increase from $64 million in FY08 – while the FY10 pipeline is projected at $55 million as of April 2010, and includes $5 million for Lesotho, and additional financing in Malawi (US$30 million) and Chad ($20 million). FY11 pipeline projects under preparation would support national HIV/AIDS programs and health systems in Swaziland and Niger. In addition, ongoing analytical work has supported the African region, including: an ESW on the fiscal dimensions of HIV/AIDS; impact evaluations to assist countries’ in developing an evidence-based response to HIV; and guidelines for mainstreaming HIV in non-health operations; and a Southern African HIV/AIDS and TB Action Plan for a coordinated response to an emerging co-epidemic.
Through lending, technical support and analytical work, the Bank increasingly places emphasis on strengthening aspects of health systems which will improve HIV outcomes, sustained prevention efforts and social protection services, addressing gender aspects and vulnerable groups, and working in fragile and conflict–affected States. Further, the Bank continues to engage in key sectors such as education, transport, energy and infrastructure. Special efforts need to continue engaging the middle income IBRD countries of southern Africa in the fight against HIV/AIDS.
Implementation of the Africa HIV/AIDS Agenda for Action (AFA), 2007-20114has made considerable progress in:Accelerating implementation and closing funding gaps by responding to demands from hyper-epidemic middle income countries facing the economic crisis including assessing the fiscal implications of scaling up national AIDS programs in Botswana and South Africa and addressing groups at most risk to HIV; Supporting long term sustainable strategies and strengthening national systems including improved strategic planning, institutional effectiveness, integration with health systems to address TB/HIV co-infection and linkages with reproductive health and nutrition, governance and social accountability, supply chain management, HIV/AIDS impact evaluation, and monitoring and evaluation; Contributing to knowledge generation and learningthrough building capacity and promoting cross-country knowledge sharing; and Improving donor coordination through joint annual planning and support to the Three Ones.5 In addition the Bank has developed a Plan of Action for the middle income countries of Southern Africa with an emphasis on addressing the HIV-TB co-epidemic6.
As one of 10 UNAIDS cosponsors, the Bank has been designated the lead organization in providing support to strategic, prioritized and costed national plans; financial management; human resources; supply chain management; capacity and infrastructure development; impact alleviation and analytical work. Funds from the UNAIDS Unified Budget and Workplan supplement IDA and IBRD investments to enable the Bank to play this role.7The Bank is moving forward on its UN designated role to ‘Make the Money Work’by strengthening partnerships with donors and other stakeholders including civil society. Joint collaboration between UNAIDS, WHO, and the Bank is working to quantify the impact of the economic crisis on HIV/AIDS treatment and prevention programs at the country level and define how partners can best help countries minimize negative impact. The Bank is also working closely with USAID/PEPFAR, DfID, the European Commission and all bilaterals at national and regional levels.
Challenges and Next Steps
The Bank’s investments in HIV/AIDS in Africa face challenges in: Mitigating the negative impact of the financial crisis in scaling up access to HIV/AIDS treatment, addressing the HIV-TB co epidemic, particularly in Southern Africa, sustaining investments in prevention efforts, and strengthening weak national systems (fiduciary, M&E ), and civil society capacity.
In light of the economic crisis, the Bank is supporting countries through technical assistance and collaborative efforts for a joint response byassessing the fiscal implications of scaling up national AIDS programs in Botswana, South Africa, Uganda and Swaziland.
2 “The World Bank’s Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011,” World Bank, 2008
3 “The Global Economic Crisis and HIV Prevention and Treatment Programmes,” World Bank/UNAIDS, 2009
4 The World Bank Africa Region’s Agenda for Action, 2007-2011was endorsed by the Executive Board in 2007.
5 One national strategic plan, one coordinating body, and one national monitoring and evaluation framework
6 Southern HIV/AIDS and Tuberculosis Plan of Action 2010-2011 for Botswana, Lesotho, Namibia, South Africa and Swaziland, March 2010
7 The Unified Budget Workplan combines the work of ten UNAIDS cosponsors and a Secretariat in a biennial budget and workplan which aims to maximize the coherence, coordination and impact of the UN’s response to AIDS.