-: - - 26888 -F- September 2003 Al A;' AI DS C:RISES S 'IN EASJIERN EUROPE. ANDCENTRAL ASIA Kara Sea c Barents . e . . .. S.. LATYIA . CZECH KP. UKRA--. toy . RO- .N.A S . . . . -',;.- .......' -. .. KAZAKICSTAN ((UNGA ... OLDO~A C:ROAIIA- ,flSNIA/HERZ.1- UZ 'EKRIS IA N MONTENG I MA ONI A - --, TURKEY _.-. *-; EN-..N, C. medite-rneon Seea- * A, > ,_*, 'ti:- *, ZE GI ON R1 ,.-.,TE GY d ~ ~ ~ H WORL BANK:- ._ RUS 1hNiEDERA W14-~ _.p Avet'xg MDS Cne SM tera$li uope Ad Centra $As' Ave(tlmig AID @n$(es$ 2 IEzotm Europe ainid ~CevtTtIR Aski A Regional Support Strategy THE WORLD BANK Washington, D.C. i) 2003 The International Bank for Reconstruction and Development! The World Bank 1818 H Street, NW Washington, DC 20433 Telephone 202-473-1000 Internet www.worldbank.org E-mail feedback.Dworldbank.org All rights reserved. 1 2 3 4 06 05 04 03 The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represcnt. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The matcrial in this work is copyrighted. Copying and/or transmitting portions or all of this work without permission may be a violation of applicable law. 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RA643.86E852A95 2003 362.196'9792'00947-dc22 2003057178 Cont~ents Preface ix Acknowledgments xi Abbreviations and Acronyms xiii Executive Summary xv 1 Introduction 1 2 The Problem and the Context 5 Why Act Now? 8 Potential Impacts of HIV/AIDS on Economic Growvth and Development 13 3 The Basis for Effective Action against HIV/AIDS and Tuberculosis 15 Factors Contributing to the Spread of H-IIV/AIDS 15 Factors Contributing to the Spread of Tuberculosis 19 Implications for Policies and Programs 21 4 Priorities and Approaches 25 Priorities 26 Approaches 34 5 Facilitating Large-Scale Implementation 37 v vi o Averting AIDS Crises in Eastern Europe and Central Asia 6 Conclusions 39 Annexes A The I-IIV/AIDS and Tuberculosis Epidemics in Eastern Europe and Central Asia 41 B The Potential Economic, Poverty, and I Juman Development Impacts of HP//AIDS in Eastern Europe and Central Asia 59 C Interventions against HTV/AIDS and Tuberculosis in Eastern Europe and Central Asia: The Evidence Base and Gaps in Knowledge 79 D Overcoming Nonfinancial Constraints 121 E Estimated Financial Resources Needed to Control HIV/AIDS and Tuberculosis in Eastern Europe and Central Asia 137 Notes 159 References 163 Index 183 About the Authors 195 Boxes 1 Subregional Patterns in Factors Contributing to Increased Vulnerability and Susceptibility to IHIV/AIDS in Eastern Furope and Central Asia 6 2 The World Bank's Response to HIV/AIDS in Eastern Europe and Central Asia 11 3 The Impact of HIV/AIDS on the Russian Economy 14 Bl The Impact of HIV/AIDS on the Russian Economy 64 Dl Reaching Agreements in a Complex Setting: The Russian Federation's Tuberculosis and AIDS Control Project 122 D2 Controlling Tuberculosis and HIV/AIDS in Moldova 124 El Using National Ilealth Accounts to Track the Source and Flow of Funds 152 Contents * vii Tables 1 AIDS, Income, and Development in Eastern Europe and Central Asia 9 BI Economic and Social Inpact of HIV/AIDS by Level, Time, and Degree 60 B2 Summary of Evidence of Macroeconomic Impact of HIV/AIDS 62 B3 Estimated Costs of Providing HAkART to People with I-FIV/AIDS in the CIS Countries 68 B4 Cost-Benefit Analysis of HIV/AIDS Prevention Programs in the Russian Federation, 2001-10 76 Cl Objectives, Target Groups, and Methods for HIV/AIDS Surveillance in Eastern Europe and Central Asia 91 El Prevention Activities, Target Populations, Default Coverage Rates, and Unit Costs 139 E2 Unit Costs of Different Types of Treatment and Care E3 Estimated Cost of Treating 'luberculosis in Eastern Europe and Central Asia, by Country, 2001-07 150 E4 International Assistance for National Responses to HIV/AlDS in Eastern Europe and Central Asia, by Program, December 2001 151 E5 GFATM Grants in Eastern Europe and Central Asia, 2002-2003 153 E6 Estimated Resource Requirements for Preventing and Treating HIV/AIDS, by Activity, 2001-07 156 Figures I Structural Factors, Vulnerability, and Risks Associated with HIV/AIDS in Eastern Europe and Central Asia 16 Al Main Risk Factors for and Intervention Strategies Applicable to Tuberculosis and H1V Co-infection 55 BI Projected Number of People with HIEV, 2001-10 67 El International Assistance for HIV/AIDS Programs in Eastern Europe and Central Asia, by Country and Subregion, December 2001 145 E2 Estimated Funding Required to Prevent and Treat HT1V/AIDS in Eastern Europe and Central Asia, by Intervention, 2001-07 146 Preface This Regional Support Strategy is in recognition of the threats that unchecked epidemics of HIfV/AIDS and tuberculosis pose to many of the World Bank's client countries. It is an instrument to guide the World Bank's role in the global development agenda, which includes the Declaration of Commitment at a Special Session of the U.N. General Assembly in June 2001. That declaration reaffirmed a pledge made by world leaders to have halted and begun to reverse the spread of HITV/AIDS by 2015. The document provides a unifying framework for the World Bank's work on HIV/AIDS in Eastern Europe and Central Asia. It identifies the potential costs of inaction, the constraints on an effective response, priority actions to resolve such constraints, and the Bank's plans for helping countries do so as part of a multi- institutional effort. fHV/AIDS is fast becoming a threat to health and economic development in parts of Eastern Europe and Central Asia. Despite the dangers, country responses to the epidemic have been patchy and limited by widespread denial. Where actions have been taken to contain the epidemic, they have tended to be pilot efforts on a scale that is too small to make a dentin the overall course of the epidemic. Governments and civil society have started to address the problem, but they need to do much more to avert HIV/AIDS crises in the region. x x o Averting AIDS Crises in Eastern Europe and Central Asia The World Bank works as part of a global coalition against 1IV/AIDS. It is a cosponsor of the Joint United Nations Program on I{IV/AIDS (UNAIDS) and a trustee of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). The Bank works in partnership with governments, nongovernmental organizations (NGOs), bilateral organizations, and multilateral agencies to sup- port country- and regional-level responses to HIV/AIDS. The World Bank is already active in the fight against HIIV/AIDS in Eastern Europe and Central Asia. It has completed subregional studies on LIV/AIDS in Poland and the Baltic States as well as in southeastern Europe, and a subregional study is under way in Cen- tral Asia. The Georgia HIV/AIDS country study was completed in 2003. Also in 2003 the Bank cofinanced, with the UNAIDS Secre- tariat, a study of resource requirements for HIV/AIDS programs in the region. The Bank is also cofinancing, with the UNAIDS Secre- tariat, the development of a directory of technical and managerial HI-V/AIDS resources, which will help countries gain better access to good technical assistance. H1V/AIDS lending operations are at vari- ous stages of preparation or implementation in Belarus, the Russian Federation, and Ukraine, and a grant from the International Devel- opment Association will support an AIDS control project in Moldova. HIV/AIDS control is included in the Poverty Reduction Support Credit in Albania. In the Russian Federation the Bank has helped develop models and estimates of the potential economic impact of the epidemic, with the aim of informing discussions among decisionmakers. Economic analyses have also been undertaken in several other countries as integral parts of lending operations. Knowledge of the dynamics of the 1HV/AIDS epidemic in East- ern Europe and Central Asia will continue to increase. That grow- ing knowledge base will be useful in tackling the epidemic. The Bank's Regional Support Strategy will be updated as more is learned about the epidemic and how to respond to it. -7 Acknowledgments This Regional Support Strategy was prepared by a team led by Olusoji Adeyi and comprising Enis Baris, Sarbani Chakraborty, Thomas Novotny, and Ross Pavis. Lynae Darbes, Shazia Kazi, and El-daw Suleiman provided research assistance. The annexes were prepared by overlapping groups, each of which was led by a mem- ber of the study team. Gizella Diaz provided administrative assis- tance. The peer reviewers were Rene Bonnel (Lead Economist, Africa Region); Patricio Marquez (Lead Health Specialist, Latin America and Caribbean Region); Agnes Soucat (Senior Health Economist, World Developmenzt Report 2004); and Susan Stout (Lead Implementation Specialist, Global I-IIV/AIDS Program). The team that prepared this Regional Support Strategy consulted with and received feedback from colleagues in the World Bank Group, including Martha Ainsworth, Annette Dixon, Armin Fidler, Joana Godinho, Dominic Haazen, Keith Hansen, Robert Hecht, Chris Lovelace, Egbe Osifo-Dawodu, Toomas Palu, Merrell Tuck- Primdahl, Nicholas Van Praag, Diana Weil, and Debrework Zewdie. At various stages of preparation the team sought and received inputs from colleagues at the World Health Organization, the UNAIDS Secretariat, AIDS Foundation East-West, and the Futures Group. This Regional Support Strategy reflects ongoing consultations among the Regional Focal Points of the eight cosponsors of UNAIDS on how to improve local capacity for developing and xi xii o Averting AIDS Crises in Eastern Europe and Central Asia managing IHIV/AIDS control programs, a consultation with the Europe and Central Asia NGO Working Group of the World Bank in January 2003, and follow-up communications with Keti Dgebuadze (Director of the International Information Center on Social Reforms and Executive Secretary of the Second Eastern Europe and Central Asia NGO Working Group on the World Bank). Annex D, on nonfinancial constraints, is based in part on materi- als discussed at the Conference of Health Project Coordination Units held in Bucharest, Romania, in November 2002. It also reflects the authors' experiences from nonlending and lending oper- ations in the Eastern Europe and Central Asia Region, including, but not limited to, those on HIV/AIDS and tuberculosis control. Annex E, on financial resource requirements, is based on the findings of a work program undertaken by the UNAIDS Secre- tariat, the World Bank, and the Futures Group. This work included extensive consultations with country officials, including those attending a regional workshop held in Minsk in November 2002. The preparation of this Regional Support Strategy was cofi- nanced by the Global HIV/AIDS Program of the World Bank and by the Europe and Central Asia Region of the World Bank. The staff members of the Office of the Publisher contributed to the quality and readability of this Regional Support Strategy, espe- cially Thaisa Ysonde Tiglao and Mary Fisk. Abbreviations and Acronyms AIDS acquired immune deficiency syndrome ARV antiretroviral therapy BCG bacille Calmette-Guerin CiS Cotnmnonwealth of Independent States DALY disability-adjusted life year DOTS directly observed treatment, short-course GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HAART highly active antiretroviral therapy I[IV human immunodeficiency virus IDU intravenous drug user MDR-TB multidrug-resistant tuberculosis MSM men who have sex with men NGO nongovernmental organization Ni-IA National Health Account NIS Newly Independent States O0 opportunistic infection PMTCT prevention of mother-to-child transmission QALY quality-adjusted life year STI sexually transmitted infection TB tuberculosis TRIPS Trade-Related Agreement on Intellectual Property Rights UNAIDS Joint United Nations Program on HIV/AIDS USAID United States Agency for International Development VCT voluntary counseling and testing WI-lO World Health Organization xiii EUROPW AND CENTRAiL ASIA REGIONC .rg ~~ -A S -.- f $ t < > j i' RUSSIAN FEDERATION POL4ND [C UKRAINE ) tKZKSA HUGR 0 VUKYAA N Sa, : . OVEN! RAA KILMEER IBRD 32588 Executive Summary Controlling HTV/AIDS and tuberculosis is a corporate priority of the World Bank Group. This Regional Support Strategy translates the Bank's corporate commitment into an agenda for action in the Eastern Europe and Central Asia Region. Its objectives are to pro- vide a unifying framework for the Bank's work as part of interna- tional efforts to control the growing problem of J1TV/AIDS and tuberculosis in the region; to clarify options for integrating effective interventions against J-IIV/AIDS and tuberculosis into the broader agenda of poverty reduction and economic development; to identify the main barriers limiting the effectiveness of FIIV/AIDS and tuber- culosis control efforts and actions to reduce them; and to define the short- to medium-term priorities for the World Bank's work in Eastern Europe and Central Asia, with emphasis on the institution's comparative advantages. The Problem and the Context The Eastern Europe and Central Asia Region is experiencing the world's fastest-growing I-rV/AIDS epidemic (UNAIDS/WIIHO 2002). In 2002 there were an estimated 250,000 new infections in the region, bringing to 1.2 million the number of people living with HIV/AIDS. The vast majority of these reported infections are xv xvi o Averting AIDS Crises in Eastern Europe and Central Asia among young people, chiefly injecting drug users (UNAIDS 2002d). The predominant role of injecting drug users in Eastern Europe and Central Asia distinguishes this epidemic from that in most other regions. Reported new cases of I-IIV are rising sharply in parts of the Newly Independent States (NIS), including the Baltic and Caucasus subregions. In contrast, the pattern is less ominous in Central Europe. Prevalence remains low in the Czech Republic, Hungary, Poland, and Slovenia. Tuberculosis is one of the most common opportunistic infec- tions in people with HIV/AIDS. The bacteria that cause tubercu- losis take advantage of the weakening of the body's immune defenses that occurs due to I-UV infection. I-V also drives the tuberculosis epidemic, particularly in highly affected areas, by pro- moting progression to active tuberculosis in people who recently acquired the disease and those who have latent tuberculosis infec- tions (WHO 20020. Rationale for Action An uncontrolled HIV/AIDS epidemic could have devastating con- sequences on health and development in Eastern Europe and Cen- tral Asia. Inaction is not an option. Fortunately, global experience shows that early and effective action can limit the spread of HIV/AIDS, as it has in Brazil and Thailand. A generalized HIV/AIDS epidemic among economically active age groups could have the following impacts in Eastern Europe and Central Asia: o Annual economic growth rates could decline by 0.5-1.0 percent- age points. o Health expenditures from activities related to caring for people with HIV/AIDS could increase by 1-3 percent. o The dependency ratio could rise, putting a strain on social pro- tection systems, especially in countries already experiencing Executive Summary * xvii declining total fertility rates, such as Belarus, Estonia, Moldova, and the Russian Federation. Household size and composition could change. The number of single-parent households and households managed by the elderly in which grandparents take care of AIDS orphans could increase. The trend could exacerbate the vulnerability of households, with negative intergenerational effects, as children are forced to drop out of school to work or take care of siblings, reinforcing the "poverty trap." Estimation of the costs and benefits of prevention programs from selected Eastern European and Central Asian countries shows that the benefits associated with prevention programs clearly outweigh the program costs. Adult prevalence rates for IHV vary across the region (see table 1). Estonia, the Russian Federation, and Ukraine had the highest adult prevalence rates as of the end of 2001. Countries in the region also vary in terms of income, dependence on foreign aid, and the local human capacity for tackling the epidemic. These differences suggest that while a regionwide perspective is important for idenri- fying major issues and articulating a unifying framework for World Bank support, more detailed analyses at the country level are required to identify the most pressing local needs and the most suit- able instruments for assistance at the country and subregional lev- els. In many middle-income countries, the World Bank's role as a financier is less significant than it is in low-income countries. Influ- encing policies in favor of effective interventions and using limited World Bank financing to leverage other resources can be more important than grants, credits, or loans. Structural and Behavioral Factors Affecting the Epidemic Structural factors increase the vulnerability of groups of people to HI-V infection. Behavioral factors determine the chances that indi- viduals will become infected. Risk is defined in this context as a probability, not a moral judgment. xviii o Averting AIDS Crises in Eastern Europe and Central Asia Groups of people at the highest risk of transmitting or becoming infected with the virus are known as "high-risk core transmitters." In Eastern Europe and Central Asia, these are mostly injecting drug users, mobile populations, and commercial sex workers. These peo- ple in turn interact with other subgroups, known as "bridge popula- tions"-typically the sex partners of injecting drug users and the clients of commercial sex workers. Eventually, the epidemic may spill into the general population. Everyone is thus at some risk, but certain subgroups are at much higher risk than others. There is therefore a compelling case for reducing vulnerability and support- ing targeted, nonstigmatizing prevention programs on a scale that is larger than most current pilot projects. Interrupting HIV transmis- sion among high-risk core transmitters and bridge populations is crucial if the countries of Eastern Europe and Central Asia are to avert generalized epidemics. Structural factors that influence HIV transmission are deep- seated and complex. In the medium or long term, they can be addressed through sustained, pro-poor economic growth; poverty-reduction policies and programs; control of drug traf- ficking; effective judicial reforms to reduce overcrowding in pris- ons; improvement of employment opportunities for young adults; curtailment of human trafficking; and improvement of the public health infrastructure to support testing, counseling, tuberculosis control, and other population-based approaches to HTV/AIDS and tuberculosis. Behavioral (risk) factors are more amenable to short- and medium-term actions. These include policy support for effective interventions aimed at reducing the risk of becoming infected, improved surveillance as a basis for effective interventions against HIV/AIDS, mass communication efforts to improve awareness of HIV/AIDS among the general population, and large-scale prevention programs. Treatment programs that are carefully designed to prevent or minimize the emergence of drug-resistant forms of the tuberculosis bacteria and HIV are also needed. Executive Summary * xix Immediate Priorities for Action The World Bank's support for 1HV/AIDS control in the region revolves around two questions: what priorities to focus on and how best to approach them. Priorities Raising Political and Social Commitment. Efforts to control the HITV/AIDS and tuberculosis epidemics require high-level politi- cal commitment to reduce the stigma associated with HIV infec- tion, to support possibly controversial programs for HIV preven- tion among injecting drug users and commercial sex workers, and to support local interventions and collaborations with civil soci- ety and the private sector. Multiple sectors and line ministries have roles to play in designing and implementing effective pro- grams. Generating and Using Essential Infornnation. Much of the Bank's sup- port in this area will be provided through analytical and advisory services undertaken in collaboration with countries and partner institutions. Cross-cutting instruments such as Country Assistance Strategies, Poverty Assessments, Development Policy Reviews, Public Expenditure Reviews, and Medium-Term Expenditure Frameworks will provide opportunities for mainstreaming policy discussions on HIV/AIDS and tuberculosis control. Emphasis would be on helping countries generate information on the status and dynamics of HIV/AIDS and apply it to their programs; iden- tifying interventions that yield the most value in terms of prevent- ing new infections, caring for those already infected, and mitigat- ing the impacts of the epidemic; identifying the optimal roles of the public sector, civil society, and the private sector in controlling HIV/AIDS; and estimating resource requirements for HIV/AIDS programs and assessing the sustainability, from all sources, of such programs. xx ° Averting AIDS Crises in Eastemn Europe and Central Asia Estimating the Econzomic and Social Impacts of HIV/AIDS and Tuber- c7ilosis. Within the Bank the Poverty Reduction and Economic Management Network (PREM) and Development Economics (DEC) Vice Presidency have roles to play in developing estimates and projections of the likely impact of HTV/AIDS on economic growth, poverty, and social inequalities in Eastern Europe and Central Asia. These estimates and projections can be used in dis- cussions with rninistries of finance, economy, and trade to enlist their support. Recent experience in the Russian Federation demonstrates that when such estimates and projections are linked to policy dialogue, they have the potential to influence thinking at high levels (Ruehl, Pokrovsky, and Vinogradov 2002) (see box D 1). o Improving Surveillance. Surveillance is the methodical collection of data on the level, distribution, and trends of disease occurrence and its determinants, with a view to enabling and increasing the effectiveness of the design, implementation, and evaluation of dis- ease control programs. Both serological and behavioral surveil- lance are weak in most Eastern European and Central Asian countries, and HIV/AIDS programs are based on information that is neither appropriate to the highest-risk groups nor reliable as a general population estimator. Currently, they neither support program planning nor help define the dynamics of the epidemic in the region. The Bank regards surveillance as a crucial part of HIV/AIDS con- trol. It can support the development or improvement of such systems in every country in the region through, or in collaboration with, the World Health Organization (WHO), the UNAIDS Secretariat, and local and international research institutions and technical networks. Surveillance is so important that the Bank regards it as part of its operational imperative in Eastern Europe and Central Asia. As a result, parts of such work could be supported through analytical and advisory services to be financed from the Bank's operational budget or as part of lending operations. The Bank will finance operations in HIV/AIDS and tuberculosis control only if they include surveillance (among other technical elements), unless the client country has Executive Summary * xxi established a surveillance system or secured alternative sources of finance to establish or strengthen such a system. Getting the Most Vahie for the Money. Even with the increasing avail- ability of international grants, credits, and loans, countries have finite organizational resources to commit to I-HV/AIDS programs. Priorities need to be set to ensure that they get the maximum ben- efit from scarce resources allocated to HEIV/AIDS programs. Even when policymakers declare their intentions to do everything, choices must be made-the only question is whether those choices are explicit or implicit. Implicit choices are more convenient from a political perspective, since they raise no questions about tradeoffs or relative emphasis. However, fighting an HIV/AIDS epidemic, par- ticularly a concentrated epidemic with low prevalence rates, requires effective prevention, which means averting the largest possible num- ber of new infections within resource constraints. Evidence from the region on the effectiveness and cost-effectiveness of HIIV prevention interventions is scant, making it difficult for analysts to make the case for large-scale programs financed from public budgets. To ensure that resources are used effectively and efficiently, policymnakers need to ensure that negotiated priorities are informed by valid data. The World Bank will provide analytical and advisory services to help countries address these issues. Estimating Resouirce Requirements. Estimates of resource require- ments for HIV/AIDS and tuberculosis programs have the poten- tial to improve program planning and strengthen advocacy for better funding. These estimates need to be refined and updated periodically (see annex E). The Bank will continue to work with countries and the UNAIDS Secretariat to update these estimates and to apply them to program planning and management at the country level. Preventing HIV and Tuberculosis Infections Prevention of HrV is the ultimate priority for the Bank's work on I-IIV/AIDS in Eastern Europe and Central Asia. Based on global xxii o Averting AIDS Crises in Eastern Europe and Central Asia and local knowledge, the Bank will help countries develop and implement interventions most likely to have the greatest impact in preventing new infections. For policy and technical intervention, the Bank will work through or with partner agencies with technical expertise or appropriate institutional mandates. The highest-priority interventions include the following: o Increasing blood safety. The transfusion of contaminated blood or blood products is an efficient way of spreading HIIV: Fortunately, it is possible to block this source of transmission. The Bank will help countries strengthen their blood safety programs to include screen- ing of donors before they donate, laboratory screening of donated blood, and a move to a fully voluntary system of blood donation. o Promoting harin reduction. Harm reduction refers to a group of interventions designed to reduce or eliminate the risk of H[V transmission to or from people engaging in behaviors that put them at higher risk than most others in the population. It includes the promotion of legal backing for such programs (decriminaliza- tion). Specific interventions include voluntary counseling and test- ing, needle exchange, and drug dependency treatment and reha- bilitation. Since young people are among the most severely affected in Eastern Europe and Central Asia, harm reduction will have a relatively large effect in preventing infections among them. o Promoting interventions with comnmercial sex workers and their clients. Commercial sex workers are among the high-risk core transmit- ters; their clients are among the "bridge" populations that can spread the virus to the general population. Wherever possible, the Bank will, upon request, support interventions aimed at these groups. These interventions include serological and behavioral surveillance, voluntary counseling and testing, peer education, diagnosis and treatment of sexually transmitted infections, and the promotion of consistent condom use by commercial sex work- ers and their clients. o Promoting interventions with prison inmates and ex-inmates. The Bank will encourage the development of programs that sustain Executive Summary * xxiii treatment of tuberculosis among inmates and ex-inmates. In some cases, such programs may require social services (as many inmates lose their rights to social program support), as well as close coop- eration between ministries of justice and ministries of health. Such cooperation is challenging, but without a special approach to prison populations, the HIIV and tuberculosis problem in pris- ons may continue to worsen. Ensuring Sustainable Care of Good Qzuality Medical treatment and psychosocial support are essential parts of care and support for people with HIV/AIDS. The range of serv- ices includes treatment and follow-up of sexually transmitted infections and opportunistic infections, palliative care to relieve pain and discomfort, and highly active antiretroviral therapy (HAART). Access to low-priced antiretrovirals has dominated the international debate on HAART. But good-quality and long-term sustained care is more complex than simply ensuring access to low-priced antiretroviral medications. Effective treatment requires that scientifically sound protocols and drug combinations be used and that patients comply with prescribed regimens. It also requires that doctors and nurses be trained and have the skills to monitor patients for adverse reactions and change their drug reg- imen as appropriate. Effective use of HAART requires laborato- ries that are well equipped to monitor changes in the patient's immune system and detect the emergence of drug-resistant forms of HIV There is a strong public health rationale for minimizing the emergence of drug-resistant HIWV The World Bank will finance the procurement of antiretroviral drugs in Eastern Europe and Central Asia only if treatment protocols are subject to inter- national peer review and there is prior or concurrent development of health systems to ensure their appropriate use, including the laboratory capacity and skills to support HAART. There is an urgent need for estimates and projections of incremental resource requirements for HAART in local settings and attention to the sustainability of such programs. xxiv o Averting AIDS Crises in Eastern Europe and Central Asia Controlling a Dual Tutbercutlosis-HIVEpidemic The World Bank's approach to this problem will be based on VWHO technical guidelines. The recommended approach for dealing with dual epidemics of HIV and tuberculosis is to improve surveillance, ensure accurate diagnosis, support effective treatment of all people with tuber- culosis, and develop local capacities to design and manage these pro- grams. A dual epidemic requires more extensive resources, careful con- sideration of priorities, sustained economic development, and continued support for prevention efforts (W1HO 20020. Facilitatinzg Large-Scale Implementation Even as countries set up programs that are constrained by financial and nonfinancial resources in the short term, they will need to pre- pare for large-scale programs. The following actions are necessary if large-scale programs are to be effective: o Developing, evaluating, and improving surveillance systems to identify high-risk core transmitter groups and bridge populations and help understand patterns of risk behaviors in order to ensure that programs focus on the major sources of infections. o Maintaining and improving high-level political leadership for HIV/AIDS and tuberculosis control, including, but not lim- ited to, advocacy based on destigmatization and recognition of the potential socioeconomic impacts of uncontrolled epi- demics. o Identifying legal barriers to large-scale programs and building social and political coalitions to reduce them. o Conducting operational research, with emphasis on behavioral change among injecting drug users and commercial sex workers and their clients, to generate locally relevant knowledge for large- scale efforts. o Conducting vaccine preparedness studies to enable coumtries to develop candidate vaccines suitable for the HIV subtypes preva- lent in the region. Executive Summary * xxv * Analyzing and disseminating information (regional public goods) on cross-border issues, including human trafficking and gender issues affecting both men and women. * Conducting country-by-country analyses of financial and non-finan- cial resource gaps, with a view to identifying ways to narrow them. Approaches The Bank's support for HIV/AIDS and tuberculosis control in East- ern Europe and Central Asia will take into account four main con- siderations: * The Bank will continue to work in partnerships with governments of client countries, UNAIDS, multilateral agencies, bilateral agen- cies, foundations, local research institutions, NGOs, civil society groups, and the private sector to address not only program devel- opment and service delivery but also how to mitigate market fail- ures in product development and access to commodities. * In terms of content the Bank's work will be based on the best available knowledge from local and international sources. The Bank will work with specialized institutions to support the adap- tation of lessons learned from global experiences to Eastern Europe and Central Asia as appropriate, taking into account the local context as well as similarities and differences in the stage of the epidemic. * In terms of processes the Bank will deploy its multisectoral and multidisciplinary capacity to support priority actions at the coun- try, subregional, and regional levels. Concerned sectors include macroeconomics, education, health, social protection, and trans- port, as well as institLtional units, such as the World Bank Insti- tute (for capacity building and training) and the International Finance Corporation (for engaging the private sector). Through its cross-sectoral engagement and high-level interactions with government, civil society, and international institutions, as well as through consultations with people with IHIV/AIDS, the Bank has xxvi o Averting AIDS Crises in Easterm Europe and Central Asia the capacity to undertake advocacy to help address gender dimen- sions, stigmatization, and discrimination. o In addition to lending operations, the Bank has a variety of instru- ments for policy dialogue and analytical and advisory services, all of which will be deployed for more intensive work on HIV/AIDS and tuberculosis in the region. These instruments include Country Assistance Strategies, Country Economic Memoranda, Medium- Term Expenditure Frameworks, Development Policy Reviews, Poverty Assessments, and other nonlending activities such as those supporting Poverty Reduction Strategy Papers. Ideally, these instruments would include examination of the potential economic consequences of H[V/AIDS in a country, including discussion of poverty and income inequalities and their contributions to the vul- nerability of societies to I-UV; the main elements of the national I-IV/AIDS strategy and resource requirements; medium-term goals and poverty-monitoring indicators; and short-run actions to jump-start implementation (Adeyi and others 2001). CHAPTER 1 Introduction Controlling IT[V/AIDS and tuberculosis is a corporate priority for the World Bank Group. This Regional Support Strategy translates the Bank's commitment into an agenda for action in Eastern Europe and Central Asia. It seeks to: * Provide a unifying framework for the Bank's work as part of inter- national efforts to control the growing problem of HIV/AJDS and tuberculosis in Eastern Europe and Central Asia. * Clarify options for integrating effective interventions against 1IV/AIDS and tuberculosis into the broader agenda of poverty reduction and economic development. * Identify the main barriers limiting the effectiveness of If-IV/AIDS and tuberculosis control and identify actions to elinminate them. * Define the short- to medium-term priorities for the World Bank's work in Eastern Europe and Central Asia, with emphasis on the Bank's comparative advantages. The Regional Support Strategy provides a framework, not a country-by-country blueprint, which is more appropriately devel- oped based on country-specific analyses and program planning led by the countries themselves. The Bank's approach to 1-HV/AIDS and tuberculosis will vary across countries and subregions, depending on the country context, the dynamics of the epidemic, the local capac- 2 o Averting AIDS Crises in Eastern Europe and Central Asia ity for program design and management, and the activities of local and international institutions in these areas. It will also evolve over time, as the knowledge base on what works in controlling HIV/AIDS and tuberculosis changes. This document does not prescribe a rigid set of protocols. Instead, it emphasizes the choices to be addressed and the role of the World Bank in meeting international and national objectives. It out- lines what the Bank will emphasize in support of country-led pro- grams. It also indicates how actions may be taken, with attention to the sociopolitical context and multisectoral issues. The strategy builds on the Bank's current support for efforts to control H1V/AIDS and tuberculosis in the region. The Regional Support Strategy has multiple audiences. Within the Bank it will be of value to the leadership of the Europe and Cen- tral Asia Region, country units, and sector units, all of which can influence the emergence of a more robust approach to JIIV/AIDS and tuberculosis control in the Bank's work in Eastern Europe and Central Asia. Sector specialists and team leaders will find the Sup- port Strategy useful in identifying needs at the subregional and country levels, in helping countries develop effective programs, and in providing high-impact support for program implementation. Outside the Bank the Support Strategy will be of interest to policy- makers; regional and country officers of major multilateral and bilateral organizations that work on THIV/AIDS and tuberculosis; nongovernmental organizations; country HIV/AIDS and tubercu- losis program managers; ministries of finance, education, health, social development, transport, justice, and economic development; and research institutions. These clients and partner agencies will find the Support Strategy helpful in understanding the World Bank's current thinking and future plans on HIV/AIDS and tuber- culosis in the region. Chapter 2 lays out the rationale for early action. Chapter 3 focuses on the basis for effective programs against HI-V/AIDS and tuberculosis in the region. Chapter 4 focuses on immediate priori- ties, while chapter 5 addresses the question of how to go from small- scale demonstration projects to countrywide programs. Chapter 6 Introducton * 3 presents the report's conclusions. The annexes, which provide the context and intellectual basis for the Regional Support Strategy, include reviews of the status and dynamics of the epidemic, the eco- nomic impact of HIV/AIDS, the evidence base for J-IV/AIDS and tuberculosis control in the region, the nonfinancial constraints on effective programs, and the resource requirements for effective pro- grams to control HIV/AIDS and tuberculosis in the region. D7 7 CHAPTER 2 The Problem and the Context The Eastern Europe and Central Asia Region is experiencing the world's fastest-growing HI-V/AIDS epidemic (UNAIDS/WJ-HO 2002). In 2002 there were an estimated 250,000 new infections in the region, bringing to 1.2 million the number of people with HIIIV/AIDS. The HIV epidemic in the region is "low level" or "concentrated," depending on the location (box 1). In a low-level epidemic, FIIV has existed for many years but has not reached significant levels in any subpopulation. In a concentrated epidemic, HIV has spread rapidly in a subpopulation but is not well established in the general popula- tion. The future course of the epidemic is determined by the fre- quency and nature of links between highly infected subpopulations and the general population. In a generalized epidemic, HrV is firmly established in the gen- eral population. Although subpopulations at high risk may con- tinue to contribute disproportionately to the spread of HIV, sexual networking in the general population is sufficient to sustain an epidemic independent of subpopulations at higher risk of infec- tion. A numerical proxy for a generalized epidemic is an HrV prevalence of more than 1 percent in pregnant women (WHO/UNAIDS 2000). Reported I-IV incidence is rising sharply in the Newly Indepen- dent States (NIS), including the Baltic and Caucasus subregions.1 The trend is less ominous in Central Europe, where the epidemic is being held at bay. Prevalence remains low in the Czech Republic, 5 6 a Averting AIDS Crises in Eastern Europe and Central Asia Box 1. Subregional Patterns in Factors Contributing to Increased Vulnerability and Susceptibility to HIV/AIDS in Eastern Europe and Central Asia The evidence on subregional trends in factors contributing to the risk environment for spread of HI3U/AIDS in the region is weak. Secondary surveillance data that can help policymakers get a bet- ter picture of the econonmic and social determinants of enhanced risk to H[V/AIDS are limited. Broad subregional trends can be identified, however. Canimonwealth of Independent States (CIS) and the Baltics The CIS countries consist of Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, the Kyrgyz Republic, the Republic of Moldova, the Russian Federation, Tajikistan, furklnenistan, Ukraine, and Uzbekistan. The Baltic countries consist of Estonia, Latvia, and Lithuania. In these countries the number of HIV diagnoses increased from 234 in 1994 to 99,499 in 2001, largely as a result of an increase in cases dliagnosed among injecting drug users. The number of HIV diagnoses among injecting drug users increased from 7 (3 percent of total) to 53,752 (54 percent of total). The number of cases linked to heterosexual contact also rose, albeit to a lesser extent, from less than 100 a year until 1994 to 4,621 a year in 2001. The spread of HIV in the CIS and the Baltics is closely linked to the rise in injecting drug use that developed after the collapse of the Soviet Union during the 1990s. This collapse occurred in the midst of a severe socioeconomic crisis, at a time when Afghanistan became the world's largest opium producer. At the same time, trafficking routes through Central Asia were being diversified, the trafficking of heroin from Afghanistan and sur- rounding countries was rising, and drug consumption was increasing. The hidden and illicit nature of drug use and the hidden nature of target populations make it hard to get an accurate picture of the problem, but the data suggest that drug abuse is rapidly on the rise. Even less information is available on the behavior of drug users, but sharing of injecting materials appears to be widespread, sexual pron-iscuity common, and HIV prevention rare. In addi- The Problem and the Context o 7 Box 1. (continued) tion, in many low-income countries in the region, shortages of disposable medical instruments, diagnostic test systems, and other means of sterilizing equipment increase the risk of contracting HIV in health care settings. The safety of blood supply is another concern. The HIV trends in this subregion correlate well with recent economic trends, although there are some outliers (Estonia and Latvia). Eastern and Southern Europe The Eastern and Southern European subregion consists of Alba- nia; Bosnia and Herzegovina; Bulgaria; Croatia; Czech Republic; Hungary; Macedonia, FYR; Poland; Romania; Slovakia; Slovenia; and Serbia and Montenegro. In these countries, a cumulative total of 16,508 diagnoses was reported by the end of 2001. Of these, 31 percent were in Romania and 44 percent were in Poland. Tn the late 1980s to early 1990s, Romania experienced a major HIV epidemic in its hospitals, in which thousands of insti- tutionalized children were injected with HIV through transfusion of blood and injection with improperly sterilized equipment. In Poland the epidemic began in the late l980s among injecting drug users, who represent the majority of all cases reported there. The number of cases attributed to heterosexual transmission in Poland has remained low and stable. In all other countries within this subregion, annual rates of new HIV diagnoses and of AIDS have remained below 10 per million people, and the main at-risk groups are homosexual and bisexual men. In both subregions the booming sex industry, the high fre- quency of other sexually transmitted diseases, and drug use among sex workers suggest that sex work may play a very important role in the future spread of HIV/AIDS. Research is required to identify more clearly the variations within and across subregions in the type and deterniinants of vulnerability and susceptibility. Source: Hamers and Downs 2003. 8 o Averting AIDS Crises in Eastern Europe and Central Asia Hungary, Poland, and Slovenia. But throughout the region young people are particularly hard-hit by the epidemic. Adult prevalence rates of HINV vary across countries (table 1). Poland, Romania, the Russian Federation, and Ukraine have the highest burdens in terms of numbers of cumulative cases of HI-V but Estonia, the Russian Federation, and Ukraine had the highest adult prevalence rates as of the end of 2001. Large cross-country variations are apparent in terms of income, dependence on foreign aid, and the local capacity for tackling the epidemic, for which the Human Development Index is used as a proxy. why i%E Now9 Countries faced with the potentially rapid spread of HIV/AIDS have two options: delay interventions while prevalence rates are still low and intervene only once the epidemic has become visible, or implement comprehensive prevention and treatment programs early on while prevalence rates are still low (Bonnel 2000) (see annex B). Under the first scenario, development efforts supported by the World Bank could be jeopardized as a result of the economic, social, and health burdens created by unchecked HIV/AIDS and tubercu- losis. Under the second scenario, HIV/AIDS-related crises could be averted through early and effective action, as they have been in Brazil and Thailand. Denial of the problem at all levels of government has long been a significant constraint in Eastern Europe and Central Asia. Tuber- culosis and HIV/AIDS were seen as affecting other parts of the world, and there was little empirical evidence to indicate that they would become problems in Eastern Europe and Central Asia. In a region going through the upheaval of transition from a command to a market economy, allocating resources to avert a "potential" prob- lem was a difficult proposition. The situation was compounded by the fact that in the early stages, the epidemic was concentrated among marginalized groups, with little or no political clout. The rise of HIV/AIDS thus caught most of the region unprepared to The Problem and the Context * 9 Table 1. AIDS, Income, and Development in Eastern Europe and Central Asia AID DEPENDENCY HIV/AIDS GROSS RATIO (AID PREVALENCE NATIONAL AS PERCENTAGE RATE AMONG TOTAL INCOME OF GROSS HUMAN ADULTS POPULATION PER CAPITA NATIONAL DEVELOPMENT 15-49 (MILLIONS) (DOLLARS) INCOME) INDEX COUNTRY (2001) (2001) (2001) (2001) (2002) Low-income Armenia 0.2 4 570 9.7 0.754 Azerbaijan <0.1 8 650 4.3 0.741 Georgia <0.1 5 590 9.2 0.748 Kyrgyz Republic <0.1 5 280 12.9 0.712 Moldova 0.2 4 400 7.5 0.701 Taiikistan <0. 1 6 180 15.5 0.667 Ukraine 1 49 720 1.4 0.748 Uzbekistan <0.1 25 550 1.4 0.727 Lower middle-income Albania - 3 1,340 6.3 0.733 Belarus 0.3 10 1,290 0.3 0.788 Bosnia and Herzegovina <0.1 4 1,240 12.8 Bulgaria <0.1 0 8 1,650 2.6 0.779 Kazakhstan 0.1 15 1,350 0.7 0.750 Latvia 0.4 2 3,230 1.4 0.800 Lithuania 0.1 3 3,350 1.1 0.808 Macedonia, FYR <0.1 2 1,690 7.3 0.772 Romania <0.1 22 1,720 1.7 0.775 Russian Federation 0.9 145 1,750 0.4 0.781 Serbia and Montenegro 0.2 11 930 12.1 Turkmenistan <0.1 5 950 1.2 0.741 Upper middle-income Croatia <0.1 4 4,550 0.6 0.809 Czech Republic <0.1 10 5,310 0.6 0.849 Estonia 1 1 3,870 1.3 0.826 Hungary 0.1 10 4,830 0.8 0.835 Poland 0.1 0 39 4,230 0.6 0.833 Slovak Republic <0.1 5 3,760 0.8 0.835 Turkey <0. 1 0 66 2,530 0.1 0.742 High-income Slovenia 0.02 2 9,780 0.7 0.879 - Not available. a. No country-specific models provided. Source: HIV/AIDS prevalence data are from UNAIDS (2002d1. Population, gross national income, and aid dependency figures are from World Bank 12003d1. Human Development Indicators are from UNDP (2002). 10 o Averting AIDS Crises in Eastern Europe and Central Asia address its impact on the health sector and even less prepared to address its impact on the society at large. Like other regions before it, Eastern Europe and Central Asia has been slow to make the perceptual leap to begin to see HIV/AIDS and tuberculosis as more than "just" health problems. "Politicians, policymakers, community leaders and academics have all denied what was patently obvious-that the epidemic of FIIV/AIDS would affect not only the health of individuals, but also the welfare and well-being of households, communities and in the end, entire soci- eties" (Barnett and Whiteside 2002, p. 5). In many countries in the region, even the more obvious health aspects of HIV/AIDS and tuberculosis have yet to be tackled with resolve. Increasingly, governments are acknowledging the importance of I-IIV/AIDS and tuberculosis and developing national programs for their control. Regional forums, such as the Commonwealth of Inde- pendent States, are making high-level commitments to fighting the epidemics. At the Southeastern Europe Conference on HTV/AIDS held in Bucharest in June 2002, governments made far-ranging cornmitments to preventing a widespread HIV epidemic in the sub- region. Civil society involvement is also increasing, involving not only small-scale implementation but also the formulation of country approaches to the HrV/AIDS problem and networking across coun- tries. The Central and Eastern Europe Harm Reduction Network (www.ceehrn.lt, wwwceehrn.org), for example, provides opportuni- ties for knowledge sharing, capacity building, and implementation support. International financing is increasing through grants, cred- its, and loans. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) has awarded grants to 10 countries in Eastern Europe and Central Asia, for a total of $78 million in the first two years and $231 million over five years. Four World Bank-financed projects on I-11V/AIDS and tuberculosis-in Belarus, Moldova, the Russian Federation, and Ukraine-are at various stages of prepara- tion or implementation in the region. The Bank is also supporting a range of analytical and advisory services (see box 2 and annexes A, B, and E). The Problem and the Context o 11 gox 2. The World BanO's Response to HV/AlDS in tEaseirn Europe and Cen1tha Asia The World Bank already provides support for regional, sub- regional, and country-level responses to HIV/AIDS in Eastern Europe and Central Asia. Most of the work is done in collabora- tion or consultation with the UNAIDS system, bilateral agencies, and, increasingly, the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Bank provides both lending and nonlending services. Its nonlending services include: o Advocacy. The Bank works with other international organiza- tions to draw political attention to the problem of HIX/AIDS. It is financing studies to inform strategic advocacy in Albania and the Kvrgyz Republic, with the expectation that the studies will serve as prototypes for other countries in the region. o Improving access to technical support. The Bank is cofinancing, with the UNAIDS Secretariat, the development of a directory of technical and managerial resources for FIXV/AIDS pro- grams in Eastern Europe and Central Asia. To further improve access to technical support, the Bank works with the UNAIDS Secretariat and the cosponsors of UNAIDS to define how the U.N. agencies and the Bank can better deploy resources at the country level.2 o Estimating resource requirement7s. Trogether wvith the UNAIDS Secretariat and the Futures Group, the Bank is developing estimates and projections of resource requirements for NIXV/AIDS programs in the region. o Analytical work at the count7y and subregional levels. In 2003 the Bank completed studies of NIIV/AIDS in Poland and the Baltics and in Southeastern Europe (case studies of Bulgaria, Croatia, and Romania); a policy note on Georgia; and a study of the eco- nomic impact of AIDS in the Russian Federation (available at www.worldbank.org.ru). It also uindertook a series of analytical and descriptive tasks in Central Asia, the first of which, a com- pilation of country profiles, was scheduled for completion in 2003. (Box continues on the following page) 12 o Averting AIDS Crises in Eastern Europe and Central Asia Box 2. (continued) Lending operations include: ^ The U-kraine Tuberculosis and AIDS Project (a $60 million loan), approved in December 2002. * The Russian Federation Tuberculosis and AIDS Control Pro- ject (a $150 million loan), approved in April 2003. * The Moldova AIDS Control Project (a $5.5 million grant from the International Development Association), approved in Juiie 2003. * The Belarus TLuberculosis and AIDS Control Project, which is at an advanced stage of preparation. In addition, HW/AIDS control is includedl in the Poverty Reduction Support Credit in Albania. Many other international organizations, including bilateral organizations, multilateral agencies (including the eight cosponsors of UNAIDS), and NGOs, are supporting analytical and program- matic work on HIV/AIDS and tuberculosis in the region. The dis- cussions leading up to these projects are themselves vital in generat- ing and building commitment among populations. Despite these initiatives, efforts to date have fallen short of what is needed to tackle the epidemics effectively. Surveillance-the methodical collection of data on disease occurrence and its determi- nants, a basis for effective programs-is weak in most countries. Prevention programs for high-risk groups are also weak or too small. Political commitment is variable, stigmatization remains a common problem, and interventions such as harm reduction face legal restrictions in many countries (Burrows 2001; Hamers and Downs 2003). A recent study from the Russian Federation suggests that local policing strategies may be an important determinant of FIIV risk among injecting drug users. Fear of police detainment or arrest among injecting drug users reportedly made users reluctant to carry needles and syringes, a practice associated with needle and The Problem and the Context * 13 syringe sharing (Rhodes and others 2003). Important nonfinancial factors also constrain local capacities to develop and implement HIV/AIDS programs (see annex D). Resource requirements signif- icantly exceed existing funding (see annex E), and programs are still on a small scale. Countries need to develop and scale up their sys- tems of surveillance and their capacities for program planning, implementation, and evaluation. Potential Impacts of HIV/AIDS on Economic Growth and Development A generalized epidemic of HTV/AIDS among economically active age groups in Eastern Europe and Central Asia could cause the fol- lowing effects: * An annual decline in economic growth of 0.5-1.0 percent. * An increase of 1-3 percent in health expenditures for caring for people living wvith I-IV/AIDS. * A potential increase in the dependency ratio (the ratio of non- economically active to economically active people), which would strain social protection systems, especially in countries already experiencing declining total fertility rates, such as Belarus, Esto- nia, Moldova, and the Russian Federation. * Potential changes in household size and composition, such as an increase in single-parent households and households in which grandparents are taking care of AIDS orphans. These changes could exacerbate the vulnerability of households, with negative inter- generational effects, as children are forced to drop out of school to work or to take care of siblings, reinforcing the "poverty trap." Estimates of the costs and benefits of prevention programs from a selected number of Eastern European and Central Asian countries reveal that the benefits associated with prevention programs out- weigh the program costs (see box Bl). 14 o Averting AIDS Crises in Eastern Europe and Central Asia Box 3. The Impact of HIV/AIDS on the Russian Economy In the absence of effective prevention policies, the number of peo- ple in the Russian Federation infected with I-UIV is e-xpected to increase markedly by 2020 (Ruehl, Pokrovsky, and Vinogradov 2002). Even in the optim1istic case (prevalence rate of 1 percent), mortality rates are projected to increase from 500 a month in 2005 to 21,000 a month in 2020, and the cumulative number of people infected with IIV is projected to rise from 1.2 million in 2005 to 2.3 million in 2010 and 5.4 million in 2020. The pessimistic scenario (prevalence rates of 2-3 percent) results in dramatically higher rates. Under this scenario: * GDP in 2010 would be as niuch as 4.15 percent lower than it would have been in the absence of H1V/AIDS; without inter- vention the loss would rise to 10.5 percent by 2020. Perhaps more significant for long-tenn development, the uninhibited spread of HIV/AIDS would diminish the economy's long-term growth rate, taking off half a percentage point annually by 2010 and a full percentage point annually by 2020. * Investment would decline by more than production. Under the pessimistic scenario, investment would fall 5.5 percent in 2010 and 14.5 percent in 2020, creating a severe stumbling block for future growth. * The effective (that is, quality-adjusted) labor supply would decrease over time, with the overall decline due more to a decline in the number of workers (total labor supply) than to the productivity losses associated with those parts of the work force infected with HIIV: his effect reflects the assumption that HIV lowers productivity by a moderate 13 percent. Using a single-sector growth model, Sharp (2002) concludes that AIDS is likely to have a significant sustained negative impact on aggregate economic growth and annual GDP, with growth falling by 0.2 percent to a litdc more than 0.5 percent by 2020. Declines in population reduce somewhat the per capita impact at the macroeconomic level. CHAPTER 3 :ii: The Basis for Effective Action against HIV/AIDS and Tuberculosis Factors Contributing to the Spread of HIV/AIDS Two groups of factors contribute to the spread of HlTV/AIDS. Struc- tural factors increase the vulnerability of groups of people to HTV infection; behavioral factors determine the chance that individuals become infected (figure 1). This conceptual framework serves two purposes. It helps identify factors driving the epidemic and inter- ventions to address the epidemic at various levels and in multiple sectors. This framework is indicative rather than definitive. It needs to be updated as better information becomes available on the dynamics of the HIV/AIDS epidemic in the region. Structural Factors In the decade following the collapse of communism, populations became more mobile, as travel restrictions were relaxed. Social free- doms were accompanied by increased trafficking in and consump- tion of narcotics, resulting in the rapid increase in the number of injecting drug users. The spread of JI[V/AIDS in Eastern Europe and Central Asia is closely linked with this rise in injecting drug use. The collapse of the Soviet Union contributed to a severe socioeco- nomic crisis at a time when Afghanistan, with a porous Russian bor- der, became the world's largest opium producer. At the same time, trafficking routes within the region became more diversified, partic- 15 16 o Averting AIDS Crises in Eastern Europe and Central Asia p6g3 m lo Structural Factors, Vulnerability, and Risks Associated with HIV/AIDS in Eastern Europe and Central Asia VCaXZf is9Mr;,2R5 vulncsma!ilicy o Eosier access to narcotic drugs o Restricted choice of safe economic activities o Overcrowded prisons o Migrant labor o Weak public health infrastructure o Poor quality of health services o Lower educational status (higher number of school dropouts) P poverty o Increased risk of o Rapid socioeconomic becoming infected changes with HIV o Increased sociol o Increased probability freedoms of transmitting HIV I to an uninfected person o Commercial sex o Casual noncommercial sex o Failure to use condoms o Needle sharing among drug users o Poor treatment of other sexuolly transmitted infections o Transfusion of contaminated blood o Lack of access to prevention of mother-to-child tronsmission services o Lock of awareness of preventive measures that work Source: Adopted from Adeyi and others 2001. ularly through Central Asia; overall trafficking of heroin from Afghanistan and surrounding countries to Europe increased; and drug consumption rose markedly (Hamers and Downs 2003). The increase in drug use may exacerbate the HIV/AIDS epi- demic because sharing of injecting equipment among drug users is common in the region. HIV/AIDS disproportionately affects younger people who, absent the disease, would remain in the labor The Basis for Effective Action against HIV/AIDs and Tuberculosis * 17 force for a long time or continue to build human capital and expert- ise (Ruehl, Pokrovsky, and Vinogradov 2002). During the economic upheavals of the 1990s, income inequality increased across population subgroups, changing the dynamics of social interactions. Prostitution and trafficking of women and girls across the region's borders increased (Einhorn 1998). Migration, mobility to seek work, and tourism increased sexual risk behavior, leading to increases in sexually transmitted diseases in much of the region (World Bank 2003c; Nicoll and Hamers 2002; Dehne and others 2000). Overcrowded prisons serve as breeding grounds for infectious diseases, including HIV/AIDS and tuberculosis. Infected ex- inmates are released into society, which has inadequate facilities for diagnosis and treatment and poorly coordinates those services with prison health services (Powell 2000; UNAIDS/V7HO 2002; Reich- man 2002). Prisons often contain large numbers of people infected with HIV, frequently drug users, who engage in risky behaviors, including physical violence, unprotected homosexual intercourse, and needle sharing. Overcrowding, poor ventilation, and the high prevalence of tuberculosis increase the vulnerability of previously uninfected inmates to tuberculosis and HIV infection. Southeastern Europe has several highly mobile populations, including construction workers, mariners, truck drivers, and peace- keeping forces. Many of these people are returning from or moving between countries in which the number of HIV cases is rising. Commercial sex workers, many of whom are young, including minors, are another vulnerable group of concern. An increase in the sex industry has been coupled with trafficking in women from East- ern Europe and the former Soviet Union for sexual exploitation. In parts of Southeastern Europe the international community, particu- larly military and peacekeeping missions, is reportedly responsible for a significant part of the demand for commercial sex (UNICEF/IOM 2002). A recent study found that casual sex was common among truck drivers and commercial sex workers in Esto- nia, Latvia, Lithuania, and Poland (World Bank 2003c). In many Eastern European and Central Asian countries, health systems began deteriorating even before the collapse of the Soviet 18 o Averting AIDS Crises in Eastern Europe and Central Asia Union (World Bank 2003a). This deterioration probably con- tributed to the growth of the I-UV epidemic, through transfusion of contaminated blood; poor diagnosis and treatment of sexually trans- mitted infections, which facilitate IV transmission; and critical gaps in the knowledge of health professionals concerning diagnosis and treatment of HV: lBehavioral Risk lFactors It is impossible to predict with precision the course of the FHV/AIDS epidemic in each country in the region. But review of current information on risk behaviors and lessons from other regions in which the epidemic has reached relatively high prevalence rates in the general population suggest that the epidemic could spread rap- idly if effective prevention is not implemented on a large scale. Central to an understanding of the dynamics of the epidemic is the recognition that behavior varies across populations and that these variations influence the spread of FITV (Over and Piot 1993; Hamers and Downs 2003). There are also differences across cultures in attri- butions about the origin and spread of the virus, as well as the nature of those groups most at risk of infection (Goodwin and others 2003). Risk refers to the probability of contracting I-IV; it is not a moral judgment of a behavior. People at highest risk of transmitting or becoming infected with the virus are known as "high-risk core transmitters." In Eastern Europe and Central Asia the evidence indicates that these are mostly injecting drug users, mobile popula- tions, and commercial sex workers. These people in turn interact with other population subgroups, known as "bridge" populations- typically the sex partners of injecting drug users and the clients of commercial sex workers. Eventually, the epidemic may spill into the general population. Thus everyone is at some risk, but certain sub- groups are at very high risk relative to others. The most vulnerable people in Eastern Europe and Central Asia are young people, but their risk depends on their behavior, particu- larly drug injection and unprotected casual sex. In some cases, drug use reflects a modern rite of passage during adolescence. The Basis for Effective Action against HIV/AIDs and Tuberculosis * 19 For an epidemic to be sustained, each infected person has to infect at least one other person on average. The number of new cases gen- erated by each infected person is known as the basic reproductive number, R. (Anderson 1999). If the HIEIV epidemic is to decline, R. must be less than one. High-risk core transmitters contribute more to R. than do other members of society. For maximum effect in pre- venting WIV there is thus a compelling case for reducing their vul- nerability (Hamers and Downs 2003; Kelly and Amirkhanian 2003) and targeted nonstigmatizing prevention programs on a scale that is larger than most pilot projects. Interrupting HI-V transmission among high-risk core transmitters and bridge populations is crucial if the region is to avert generalized epidemics. A clearer focus on the behav- iors responsible for most exposure to I-RV in a country would lead to more effective prevention efforts (Pisani and others 2003). Factors Contribuling to the Spread of Tuberculosis Tuberculosis is one of the most common opportunistic infections in AIDS. In the context of AIDS, "opportunistic" means that the bac- teria that cause tuberculosis take advantage of the weakening of the body's immune defense caused by HIV HIV also drives the tuber- culosis epidemic, particularly in high-prevalence populations, pro- moting progression to active tuberculosis in people with recendy acquired or latent tuberculosis infections (WHO 20020. The WHO describes as "critical" the tuberculosis situation in 16 of the 51 countries in its European region. All of these countries- Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, the Kyrgyz Republic, Latvia, Lithuania, Moldova, Romania, the Russ- ian Federation, Tajikistan, Turkmenistan, Ukraine, and Uzbek- istan-are in Eastern Europe or Central Asia. Together these coun- tries have a population of 313 million. All except Tajikistan experienced an increase in reported tuberculosis cases during the past two decades. In 2002 these countries had an estimated 433,000 cases of tuberculosis, or 77 percent of the total tuberculosis case- load in the WV O European Region, with Kazakhstan, Romania, 20 o Averting AIDS Crises in Eastemn Europe and Central Asia the Russian Federation, Ukraine, and Uzbekistan accounting for more than half of those cases. The tuberculosis burden on the underfunded and deteriorating health systems in these countries is substantial. Nine other countries in the region-Albania; Bosnia and Herze- govina; Bulgaria; Croatia; Hungary; Poland; Macedonia FYR: Ser- bia and Montenegro; and Turkey-are in the intermediate tubercu- losis burden category. Only Slovakia and Slovenia have low burdens (WHO 2002g). The tuberculosis epidemic in Eastern Europe and Central Asia is fueled by a combination of factors, including ineffective approaches to diagnosis and treatment, poor coverage of the population with effective treatment protocols, weak or deteriorating health systems, and the roles of prisons and detention centers as breeding grounds for tuberculosis and other infectious diseases. In the Russian Feder- ation, 1.9 percent of the nearly I million inmates tested in 2001 were found to be infected with HIV; in 2002 the tuberculosis inci- dence rate was 30 times higher in prisons than in the general popu- lation (WHO 2002d; Reichman 2002). The high number of infected inmates creates a problem for tuberculosis control in the civilian sector, as a growing number of inmates with tuberculosis are released each year without adequate public health follow-up. The serious tuberculosis problem in the region exists despite the availability of effective approaches to diagnosis and treatment pro- moted globally by the WHO. Borgdoff, Floyd, and Broekmans (2000) surveyed the literature to asses the impact of VVHO-recommended tuberculosis control measures on tuberculosis mortality and transrmis- sion. They conclude that treatment of smear-positive tuberculosis has by far the highest impact on tuberculosis outcomes, with a cost- effectiveness of $5-$40 per disability-adjusted life year (DALY) gained. Treatment of smear-negative cases has a cost per DALY gained of up to $100 in low-income countries and up to $400 in middle-income set- tings, such as those in most of Eastern Europe and Central Asia. Multidrug-resistant tuberculosis refers to strains of the tubercu- losis bacteria that are resistant to isoniazid and rifampicin, the two principal first-line tuberculosis drugs. It usually results from poor The Basis for Effective Action against HiV/AIDs and Tuberculosis * 21 initial management of tuberculosis and lack of application of appro- priate therapy and follow-up to all cases. Specific causes include the use of the wrong drugs or the wrong doses of first-line drugs to treat tuberculosis, discontinuation of treatment before the bacillus that causes tuberculosis has been killed off, and breakdowns in the drug supply chain, which makes it difficult for health care workers to pro- vide effective treatment regimens. Multidrug-resistant tuberculosis is a problem because there are insufficient alternative therapies available; when such therapies are available their cost is prohibitive for most low- and middle-income countries. Moreover, the spread of multidrug-resistant tuberculosis can become global, threatening populations outside Eastern Europe and Central Asia, where co- infections with HITV are even more common. DOTS-Plus is the method used to treat multidrug-resistant tuber- culosis. It is built on the five elements of the DOTS strategy, plus the use of so-called second-line drugs.3 It is not advisable to use DOTS- Plus in an area without an effective DOTS-based tuberculosis control program in place, since doing so in the absence of technical safeguards could increase the risk of patients developing resistance to second-line drugs, which would lead to super drug-resistant forms of the tuber- culosis bacteria and a major public health problem. DOTS-Plus could also reduce overall program effectiveness if it results in weaker DOTS programs (Sterling, Lehmann, and Frieden 2003). I-TV has been linked to multidrug resistance in small-scale out- breaks, such as those originating in hospitals. But cross-country com- parisons provide no evidence that multidrug resistance is associated with WITV (Espinal and others 2001). Multidrug resistance appears to be uncommon in Sub-Saharan African, the current epicenter of the FHIV/AIDS pandemic (Espinal and others 2000; WHO 2000a). Implications for Policies and Programs Structural factors are deep-seated and complex problems. They can be resolved in the medium term or long term, through sustained, pro-poor economic growth and poverty-reduction policies and pro- 22 o Averting AIDS Crises in Eastern Europe and Central Asia grams; control of drug trafficking; effective judicial reforms to reduce overcrowding in prisons; improvement of employment opportunities for young adults; curtailment of trafficking in humans; and improve- ment of the public health infrastructure to support testing, counsel- ing, tuberculosis control, and other population-based approaches to I-IV/AIDS and tuberculosis. Risk factors are more amenable to short- and medium-term actions. These include policy support for effective interventions aimed at reducing the risk of becoming infected, improved surveil- lance as a basis for effective interventions against HIV/AIDS, mass communication efforts to improve awareness of H1V/AIDS among the general population, and large-scale implementation of non- stigmatizing programs to prevent infections among high-risk core transmitters and bridge populations. There is a need for programs that prevent or minimize the emergence of drug-resistant forms of the tuberculosis bacteria and HIIV Efforts have begun at changing political and social attitudes to the epidenmcs. They include subnational pilot projects and the develop- ment of programs at the country level. Regional efforts include the Urgent Response of Member States of the Commonwealth of Inde- pendent States to ESIV/AIDS Epidemics, approved by the Council of the Health of Governments of the CIS in May 2002. Efforts have fallen short of what is needed to tackle the epidemics effectively at the operational level, however. There is a compelling case for greater political commitment at the country level. Better and more reliable information is needed to guide program development, management, and evaluation. Nonstigmatizing programs are required to prevent infections among high-risk core transmitters and bridge populations on a scale beyond pilot projects. institutions must be developed and local capacities increased to better undertake large-scale efforts to control both FIIV/AIDS and tuberculosis. Actions based on the regional context, the status of the epidemic, global experiences, and evidence-based tools currently available to control FIIV/AIDS and tuberculosis need to be implemented or strengthened. Lessons can be learned from other regions with high HIEV/AIDS prevalence rates. But the epidemic in Eastern Europe and Central The Basis for Effective Action against HIV/AIDs and Tuberculosis * 23 Asia differs in some important aspects from epidemics elsewhere. In Eastern Europe and Central Asia the epidemic is still at an early stage, and it is driven mainly by transmission among injecting drug users. In contrast, in much of the Caribbean, Latin America, and Sub-Saharan Africa, I-IV/AIDS prevalence rates are much higher and transmission is mainly through heterosexual contact (World Bank 2001; UNAIDS 2002d). It is essential to strike a balance between the transfer of experiences from other regions (such as the need for political commitment, destigmatization, a multisectoral approach, a strong role for civil society, and the application of proven technical interventions) and the crucial need for locally developed approaches. Even within Eastern Europe and Central Asia, conditions vary across countries and subregions (table 1). There are thus likely to be variations in the approaches taken, with countries with high HITV/AIDS prevalence rates needing to place more emphasis on treatment and impact mitigation. In Eastern Europe and Central Asia, where more than 99 percent of the popu- lation is not yet infected, the crucial need is to ensure that unin- fected people remain free of HIV while improving access to treat- ment for people with the virus. In many middle-income countries, the World Bank's role as a fin- ancier is less significant than it is in low-income countries. Influ- encing policies in favor of effective interventions and using limited World Bank financing to leverage other resources can, therefore, be more important than grants, credits, or loans alone. The Bank is well equipped and positioned to address cross-sectoral issues at the policy level and to support the adaptation of best practices from elsewhere. It will continue to work as part of the UNAIDS system and in collaboration with local and international agencies, founda- tions, and GFATM. It is already collaborating with GFATM in Moldova, where an International Development Agency grant will support HIV/AIDS control and a GFATM grant will include both HITV/AIDS and tuberculosis control activities. Such coordinated approaches are expected to continue. CHAPTER 4 Priorities and Approaches World Bank support for IHIV/AIDS control in the Eastern Europe and Central Asia Region is based on identifying priorities and selecting the best approaches with which to deal with those priori- ties. The most pressing priorities include: * Increasing and maintaining social and political commitment to controlling HIV/AIDS. * Generating public goods, particularly strategic information from baseline surveys (of HI-V prevalence and risk behaviors) and esti- mates and projections of the health and economic impacts of the epidemic. * Conducting rigorous monitoring and evaluation of prevention programs among high-risk core transmitters and bridge popula- tions. * Projecting resource requirements for HTV/AIDS control in the region. * Preventing I-IIV infection by using the best available knowledge about what works. * ControlLing a dual epidemic of tuberculosis and HIIV * Making affordable care and support available to people with HIV/AIDS, provided that the use of antiretrovirals is subject to inter- 25 26 o Averting AIDS Crises in Eastern Europe and Central Asia national peer review and improvement of health systems to ensure quality and reduce the emergence of drug-resistant strains of HI[v 0 Increasing capacity for implementing large-scale programs. The Bank will work through partnerships with the public sector, civil society, and the private sector. It will emphasize the use of knowledge-based interventions and the Bank's capacity for analyti- cal and advisory services at the country level. WVhile a regionwide perspective is important for identifying major issues and articulating a unifying framework for World Bank support, more detailed analy- ses at the country level are required to identify the most pressing local needs and the most suitable instruments for assistance at the country level. For example, upper middle-income countries with relatively high Human Development Indexes and low aid depend- ency could benefit from analytical and advisory services but might be able to finance most of their response to the epidemic from domestic sources. Low-income countries with more modest local capacities and higher aid dependency ratios could benefit from ana- lytical and advisory services and international grant assistance. Lower middle-income countries could be approached on a case-by- case basis (see annex A). There are five groups of priorities. ]Raising Political andi social Commitment Controlling the HIV/AIDS and tuberculosis epidemics requires high-level political commitment to reduce the stigma associated with FIV/AIDS, support possibly controversial programs for HIV prevention among injecting drug users and commercial sex workers, and support local interventions and collaborations with civil society. Various sectors and line ministries have roles to play in designing and implementing programs. Ministries of justice and internal Priorities and Approaches * 27 affairs, for example, need to establish pragmatic policies on the legal status of programs such as needle exchanges and drug dependency treatment and rehabilitation, which can help prevent infections among injecting drug users. If HIIV transmission is to be curbed among commercial sex workers, HWV/AIDS program workers need to have access to them, to earn their trust and operate without the threat of arrest by the police. Social marketing of condoms is needed to ensure the availability of condoms for the sexually active popula- tion, including young people. Ministries of social welfare need to be involved in efforts to support people with I]TV/AIDS, ex-prisoners with tuberculosis, and mobile and socially marginalized populations. The World Bank will support country efforts to improve local capacity, particularly leadership skills, for policy analysis and formlula- tion of HIV/AIDS and tuberculosis control programs. The World Bank Institute is well placed to design and co-convene, with technical agencies, training programs on these issues. The External Affairs Unit is collaborating with the Global HIV/AIDS Progrram and the Human Development Sector Unit of the Europe and Central Asia Region on a strategic communication program that targets high-level decision- makers in Albania and the Kyrgyz Republic. These programs will be evaluated and may be adapted to other countries in the region. Generating and Using Essential Information To help countries generate and use essential information, the Bank will provide analytical and advisory services, undertaken in collabo- ration with countries and partner institutions. Cross-cutting instru- ments, such as Country Assistance Strategies, Poverty Assessments, Development Policy Reviews, Public Expenditure Reviews, and Medium-Term Expenditure Frameworks, will provide opportuni- ties for mainstreaming policy discussions on Hil/AIDS and tuber- culosis control. Emphasis will be on helping countries generate and apply information on the status and dynamics of HIV/AIDS to their programs; supporting interventions that yield the most value in terms of preventing new infections, caring for people already infected with HI-V, and mitigating the impacts of the epidemic; 28 o Averting AIDS Crises in Eastemn Europe and Central Asia defining the optimal roles of the public sector, civil society, and pri- vate sector in EIIV/AIDS control; and determining resource requirements for JFIV/AIDS programs and assessing the sustain- ability, from all sources, of such programs. Estimating the Economnic and Social Impacts of HIV/AIDS and Tuberualosis. Within the Bank the Poverty Reduction and Economic Management Network (PREM) and Development Economics Vice Presidency (DEC) have roles to play in developing estimates and projections of the likely impact of I-IV/AIDS on economic growth, poverty, and social inequalities in the region. These estimates and projections can be used in discussions with ministries of finance, economy, and trade to enlist their support in fighting HIV/AIDS. Recent experience in the Russian Federation demonstrates that when such estimates and projections are linked to the policy dia- logue in the country, they can influence thinking at high levels (Ruehl, Pokrovsky, and Vinogradov 2002) (see box Dl). Imnproving Scluveillance. Both serological and behavioral surveil- lance are weak in most Eastern European and Central Asian coun- tries, and HTV/AIDS programs are based on information that is nei- ther appropriate to the highest-risk groups nor reliable as an esti- mator of HIV prevalence in the general population. Some country HIV/AIDS programs and healtl ministries still rely on large-scale testing for H-IV, including tests for certain occupational groups (such as the armed forces) and certain users of health services (such as pregnant women in prenatal clinics). Most systems are passive, relying on referrals to specialty hospitals without proactive volun- tary counseling and testing. This untargeted testing is of minimal use in tracking the epidemic among high-risk groups. Current sys- tems neither support program planning nor help define the dynam- ics of the epidemic in Eastern Europe and Central Asia. Under the auspices of UNAIDS and the WIHO, second-generation surveillance systems were developed to yield information that is more useful in identifying epidemic patterns and reducing the spread of IIIV/AIDS. These tools are intended to be appropriate for the state of the epidemic in each setting, to change with the epidemic, to deploy resources where they generate the most useful information, to com- Priorities and Approaches * 29 bine and compare biological and behavioral data to provide more use- ful information, to integrate information from other sources, and to use data to increase and improve the country's response to H1V/AIDS (WHO/UNAIDS 2000). The Bank regards surveillance as a crucial part of FHIV/AIDS control, and it can support the development or improvement of such systems in every country in the region. Indeed, the effective- ness of HIV/AIDS control efforts will be significantly reduced in the absence of good surveillance systems. Most of the Bank's sup- port for surveillance will be provided through or in collaboration with the WIvHO, the UNAIDS Secretariat, and local and interna- tional research institutions and technical networks. Surveillance is so important that the Bank regards it as part of its operational imperative in the Europe and Central Asia Region. As a result, parts of such work could be supported through analyt- ical and advisory services, financed from the Bank's operational budget or as part of lending operations. The Bank will finance operations in HIV/AIDS and tuberculosis control only if they include surveillance (among other technical elements), unless the client country has already established a surveillance system or secured alternative sources of financing to establish or strengthen its surveillance system. Getting the Most Value for the Money. For policymakers and ana- lysts, an important issue is how to get the maximum benefit from scarce resources allocated to HlV/AIDS programs. Even with the increasing availability of international grants, credits, and loans, countries have finite organizational resources to commit to these programs. Priorities thus have to be set. Even where there are dec- larations of intention to do everything, choices must be made-the only question is whether those choices are explicit or implicit. Implicit choices are more convenient from a political perspective, since they raise no questions about tradeoffs or relative emphasis. However, fighting an HIV/AIDS epidemic, particularly a concen- trated epidemic in which prevalence rates are low, requires effective prevention, which means preventing the largest number of new infections within resource constraints. 30 o Averting AIDS Crises in Eastem Europe and Central Asia Evidence from the region on the effectiveness and cost-effec- tiveness of prevention interventions is scant, making it difficult to make the case for large-scale programs financed from public budg- ets. Even if such evidence were available, however, it would only guide, not eliminate, the need to set priorities. From the point of view of effective and efficient use of resource, it is crucial to ensure that negotiated sets of priorities are informed by valid data from surveillance that sheds light on the size and location of the prob- lem, the cost-effectiveness of interventions (how much value for money different interventions aimed at achieving the same out- come provide), their feasibility, and social values. The Bank will provide analytical and advisory services to help countries address these issues. Estimating Resource Requirements. Estimates of resource require- ments for HIV/AIDS and tuberculosis programs have the potential to improve program planning and advocacy for better funding. Estimates need to be refined and updated periodically (see annex E). The Bank will continue to work with countries to update these esti- mates and apply them to program planning and management at the country level. IPreventing HU[V Enfections Prevention is the Bank's ultimate priority in Eastern Europe and Cen- tral Asia. The Bank will help countries develop and implement inter- ventions that are most likely to have the greatest impact in preventing HIIV infections, based on global and local knowledge. For each type of intervention, the Bank will work through or with partner agencies with the relevant technical expertise or institutional mandates. High-priority interventions include the following: o Improving blood safety. The transfusion of contaminated blood or blood products is an efficient way of spreading HIV. Fortunately, it is possible to block this source of transmission. The Bank will help countries strengthen their blood safety programs through a variety of measures, including donor screening, laboratory Priorities and Approaches * 31 screening of donated blood, and a move to a fully voluntary sys- tem of blood donation. * Pronmoting harm1n, redzuction. Harm reduction refers to a group of interventions designed to reduce or eliminate the risk of I-HIV transmission to or from people engaging in behaviors that put them at higher risk than most others in the population. It includes voluntary counseling and testing, needle exchange, and drug dependency treatment and rehabilitation, as well as promotion of legal backing for such programs (decriminalization). Since young people are the most severely affected group in Eastern Europe and Central Asia, harm reduction will have a relatively large effect in preventing infections among them. * Interventions amonzg commercial sex workers and their clients. Com- mercial sex workers are among the high-risk core transmitters; their clients are among the bridge populations that can spread the virus to the general population. The Bank will support interven- tions aimed at these groups, includinig serological and behavioral surveillance, voluntary counseling and testing, peer education, diagnosis and treatment of sexually transmitted diseases, and the promotion of consistent condom use by commercial sex workers and their clients. * Interventions anmong inmates and ex-in7nntes. The Bank will encour- age the development of programs that sustain treatment of tuber- culosis among released inmates. In some cases, this will require social services (as many inmates lose their rights to social program support), as well as close cooperation between ministries of justice and ministries of health. Such cooperation is challenging, but without a special approach to prison populations the HI-IV and tuberculosis problem in prisons may continue to worsen. Controlling a Dual Tuberculosis-HIV Epidemic The World Bank's approach to controlling a dual tuberculosis- HIIIV epidemic will be based on WHO technical guidelines. Those guide- 32 o Averting AIDS Crises in Eastemn Europe and Central Asia lines emphasize improving surveillance, ensuring accurate diagnosis, supporting effective treatment of all people with tuberculosis, and developing local capacities to design and manage these programs. Dealing with a dual epidemnic will require greater resources, care- ful consideration of priorities, sustained economic development, and continued support for prevention efforts (WHO 2002b, 2002f). Specific objectives include the following: o Strengthen tuberculosis and EI-V/AIDS surveillance (that is, con- duct 9IIV serological surveillance among people with tuberculo- sis and tuberculosis surveillance among people with HIV/AIDS). o Prevent and treat tuberculosis in people with HIIV, beginning with tuberculosis testing for people infected with HIfV o Develop models of tuberculosis prevention and treatment among people with HIV/AIDS based on field experience. o Develop a system for referring people with H1V/AIDS for pre- ventive or therapeutic treatment of tuberculosis. o Provide ongoing comprehensive care for people with I-IV and tuberculosis. The health sector starting point is I-IIV testing among people with tuberculosis. People found to be HIV-positive (through voluntary counseling and testing) need referral for ongo- ing comprehensive HIV/AIDS care during and after tuberculosis treatment, when many people with both HIV and tuberculosis develop other IlIV-related diseases. Ensuring Sustainable Care of Good (Quality Medical treatment and psychosocial support are essential parts of care and support for people with HTV/AIDS. The range of services includes treatment and follow-up of sexually transmitted infections, treatment of opportunistic infections, palliative care to relieve pain and discomfort, and the use of multiple combinations of antiretro- viral medications, known as highly active antiretroviral therapy (HAART). Access to low-priced antiretrovirals has dominated the Priorities and Approaches * 33 international debate on HAART. But providing good-quality and long-term sustained care involves more than just ensuring access to low-priced antiretroviral medications. Effective treatment requires that scientifically sound protocols and drug combinations be used and that patients comply with the prescribed regimens. It also requires that doctors and nurses be trained and have the skills to monitor patients for adverse reactions and change their drug regi- mens as appropriate. Laboratories must be equipped to monitor changes in the patient's immune system and detect the emergence of drug-resistant forms of JIV The need to prevent drug-resistant strains of HIV provides a strong public health rationale for intervention, since the emergence of such strains could make it much more difficult to control the epi- demic. Key items for attention include the development of the health system infrastructure and skills necessary to monitor the clinical and public health effects of HIV therapy, including assessment of the effect of HAART on HIV-related illness and death, adherence to treatment regimens, and the development of drug resistance. Sus- taining the availability of antiretroviral drugs and avoiding sub- optimal antiretroviral drugs regimens are essential (Reynolds and others 2003). In addition, there is an urgent need for estimates and projections of the incremental resource requirements for HAART in local settings, as well as assessment of thle sustainability of such pro- grams. The Bank will finance the purchase of antiretroviral drugs only if there is prior or concurrent development of systems to ensure their appropriate use, including the laboratory capacity to support HAART, and treatnment protocols that are subject to international peer review. In many places psychosocial support for people with HIV/AIDS is provided primarily by NGOs. These efforts need to be better integrated into health systems. The right approach in some coun- tries may be for a subcontracting mechanism to be developed to support NGOs with expertise in this area. In other countries gov- ernment efforts through ministerial programs may be the best approach. 34 o Averting AJDS Crises in Eastern Europe and Central Asia Approaches The Bank's support for HIV/AIDS and tuberculosis control in East- ern Europe and Central Asia will take into account four main con- siderations: o The Bank will continue to work in partnerships with govern- ments of client countries, UNAIDS, multilateral agencies, bilat- eral agencies, foundations, local research institutions, NGOs, civil society groups, and the private sector to address not only program development and service delivery but also how to miti- gate market failures in product development and access to com- modities. o In terms of content the Bank's work will be based on the best available knowledge from local and international sources. As appropriate, the Bank will work with specialized institutions to support the adaptation of global experiences to the region, taking into account the local context and siimiilarities and differences in the stage of the epidemic. In the near term, interventions and approaches in Eastern Europe and Central Asia may differ from those in countries in which the main modes of transmission are different, prevalence rates of HIV/AIDS are higher, and there is a greater need for care support and impact mitigation. The main challenge is to avoid, through effective prevention, reaching high prevalence rates. o In terms of processes the Bank will deploy its multisectoral and multidisciplinary capacity to support priority actions at the coun- try, subregional, and regional levels. Within the Bank the con- cerned sectors include macroeconomics, education, health, social protection, and transport, as well as institutional units such as the World Bank Institute (for capacity building and training) and the International Finance Corporation (for engaging the private sec- tor). Through cross-sectoral engagement and high-level interac- tions with government, international institutions, and civil soci- ety, including consultations with people with HIVI/AIDS, the Priorities and Approaches * 35 Bank has the capacity to undertake advocacy to help address gen- der dimensions, stigmatization, and discrimination. Much of the work on raising social and political commitment, monitoring, and evaluation will be done in collaboration with the Bank's Global HIlI/AIDS Program. The Bank has a variety of instruments for policy dialogue, analy- tical and advisory services, and lending operations, all of which will be deployed for more intensive work on -HW/AIDS and tubercu- losis in the region. Instruments for nonlending operations include Country Assistance Strategies, Country Economic Memoranda, Medium-Term Expenditure Frameworks, Development Policy Reviews, Poverty Assessments, and other nonlending instruments, such as those supporting Poverty Reduction Strategy Papers. Ide- ally, these nonlending instruments should include examinations of the potential economic consequences of IEIV/AIDS in a country, including a discussion of poverty and income inequalities and their contributions to measuring the vulnerability of societies to HIV/AIDS; the main elements of the national HIV/AIDS strategy and resource requirements; medium-term goals and poverty mon- itoring indicators; and short-run actions to jump-start implemen- tation (Adeyi and others 2001). V C1HAPTER 5 V. A Facilitating Large-Scale Implementation Even as countries set up programs in the short term, they will need to prepare for large-scale programs in the future. The fol- lowing actions are necessary if large-scale programs are to be effective: * Developing, evaluating, and improving surveillance systems to identify high-risk core transmitter groups and bridge populations and to help understand patterns of risk behaviors in order to ensure that programs focus on the major sources of infections. * Maintaining and improving high-level political leadership for I-fIV/AIDS and tuberculosis control, including, but not limited to, advocacy based on destigmatization and recognition of the potential socioeconomic impacts of uncontrolled epidemics. * Identifying legal barriers to large-scale programs and building social and political coalitions to reduce them. * Conducting operational research, with emphasis on behavioral change among injecting drug users and among commercial sex workers and their clients, to generate locally relevant knowledge for large-scale efforts. * Conducting vaccine preparedness studies to enable countries to develop candidate vaccines suitable for the I-TV subtypes preva- lent in the region. 37 38 o Averting AIDS Crises in Eastern Europe and Central Asia o Analyzing and disseminating information (regional public goods) on cross-border issues, including human trafficking and gender issues affecting both men and women. o Conducting country-by-country analyses of financial and non- financial resource gaps, with a view to identifying ways to narrow them. The World Bank will support national and regional efforts in these areas, working in partnerships with governments, local and international NGOs and networks, the private sector, research insti- tutions, multilateral agencies, bilateral agencies, foundations, and the UNAIDS system. Cl-APTER 6 Conclusions Countries in Eastern Europe and Central Asia face uncertain but potentially serious epidemics of HI[V/AIDS and tuberculosis. Early actions are needed to avert major crises, which would negatively affect health as well as economic growth, the labor force, and the welfare of households. There is a compelling case for greater political commitmiient at the country level. Better and more reliable information is needed to generate political commitment and guide program development, management, and evaluation. Nonstigmatizing programs are required to prevent infections among high-risk core transmitters and bridge populations on a scale beyond pilot projects. Institutions must be developed and local capacities increased to better undertake large-scale efforts to control both HIV/AIDS and tuberculosis. Prevention of HIV infection and effective diagnosis and treat- ment of tuberculosis are the highest priorities for World Bank sup- port in controlling these epidemics. As treatment programs are implemented, the Bank's emphasis will be on ensuring that access to antiretroviral therapy is expanded in line with effective clinical pro- tocols and backed by effective health systems, including good labo- ratory services to monitor patients' clinical condition and detect drug-resistant strains of HIV and tuberculosis bacteria. The World Bank Group will work with countries and partner institutions to ensure early action through knowledge-based pro- grams to control the epidemics, the mobilization of multiple sectors 39 40 o Averting AIDS Crises in Eastern Europe and Central Asia at the country level, engagement of civil society at the national and local levels, improvement of the public health infrastructure, and support for implementation. It will mainstream HIV/AIDS control efforts through its nonlending and lending services, integrating these efforts into the core institutional objectives of poverty reduc- tion and human development. ANNEX A The HIV/AJDS and Tuberculosis Epidemics in Eastem Europe and Central Asia Size and Trends: How Big Is the Problem? Eastern Europe and Central Asia is experiencing the world's fastest- growing HTV/AIDS epidemic (UNAIDS/WHO 2002). In 2002 there were an estimated 250,000 new infections, bringing to 1.2 million the number of people with HTV/AIDS in the region. Registered H-V/AIDS cases likely underestimate the number of people with HIV/AIDS by a large margin. In addition, reported cases may not accurately reflect the possible changes in the patterns of -IIV transmission in terms of the mocdes of transmission and the gender and age groups of people being infected. The inadequacy of current surveillance and voluntary counseling and testing services means that most HTV tests occur as part of routine screening of people who encounter the law enforcement system or use health care services. Reported HIV incidence is rising sharply in the NIS, including the Baltic and Caucasus subregions. In contrast, the pattern is less ominous in Central Europe, where countries continue to hold the epidemic at bay. Prevalence remains low in the Czech Republic, Hungary, Poland, and Slovenia. Throughout the region young peo- ple are being hit particularly hard by the epidemic. 41 42 o Averting AIDS Crises in Easteni Europe and Central Asia sublrsaund3 ''' - 'd d \D]ajns The state of the I1UV/AIDS epidemic in the region is "low level" or "concentrated," depending on the location. In a low-level epidemic, IHV/AIDS has existed for many years, but it has not spread to sig- nificant levels in any subpopulation. In a concentrated epidemic, 1-IV/AIDS has spread rapidly in a defined subpopulation, but it is not well established in the general population. The course of the epidemic is determined by the frequency and nature of links between highly infected subpopulations and the general population. In a generalized epidemic, FIV/AIDS is firmly established in the general population. Although subpopulations at high risk may con- tinue to contribute disproportionately to the spread of HIV, sexual networking in the general population may be sufficient to sustain an epidemic independent of subpopulations at higher risk of infection. A numerical proxy for a generalized epidemic is IIIV prevalence of more than 1 percent in pregnant women (WHO/UNNAIDS 2000). Adult prevalence rates of HIV vary across countries. Poland, Romania, the Russian Federation, and Ukraine have the highest burdens in terms of numbers of cumulative cases of HIV, but Esto- ria, the Russian Federation, and Ukraine had the highest adult prevalence rates as of the end of 2001. Income, dependence on for- eign aid, and the local human capacity for tackling the epidemic also vary widely across countries (table 1). Thus while a regionwide per- spective is important for identifying major issues and articulating a unifying framework for World Bank support, more detailed analy- ses at the country level are required to identify the most pressing local needs and the most suitable instruments for assistance. Upper middle-income countries with relatively high human development indexes and low aid dependency, for example, could benefit from analytical and advisory services, but they might be able to finance most of their response to the epidemic from domestic sources. Low- income countries with more modest local capacities and higher aid dependency ratios could benefit from analytical and advisory serv- ices and international grant assistance. Lower middle-income coun- tries could be approached on a case-by-case basis. Annex A. The H1IVAIDS and Tuberculosis Epidemnics * 43 Incomplete data make it difficult to make comparisons across countries. Data on HIV prevalence in Eastern Europe and Central Asia come from two main sources. One is epidemiological surveys among specific subpopulations. Since the most affected subpopula- tions are often stigmatized and difficult to reach, these data tend to be incomplete and limited to small geographic areas. A second source is large-scale testing, including compulsory testing (of blood donors and military recruits, for example) and voluntary testing (for pregnant women, for example). These data are not representative of the general population. Despite the limitations of the data, certain patterns are beginning to emerge in the region. Overall, the NIS are more severely affected than the countries of Central and Southeastern Europe. In 2001 the NIS, with a population of 291.5 million, had 234,729 cumulative cases of HIV/AIDS; Central and Southeastern Europe, with a pop- ulation of 121.2 million, had 16,508 cumulative cases. HTV preva- lence in 2001 ranged from 1.5 per million in Bosnia and Herzegov- ina to 139.3 per million in Ukraine, 594.4 per million in the Russian Federation, and 1,067.3 per million in Estonia, which has the high- est prevalence rate in the region (Hamers and Downs 2003). The Baltic countries are vulnerable to further spread of HIV/AIDS for several reasons. First, the prevalence of HIV/AIDS is relatively high and is rapidly increasing in neighboring countries to the east, such as Belarus and Ukraine, where public health condi- tions are deteriorating. Second, Estonia, Latvia, Lithuania, and Poland stand at the crossroads of the main East-West and North- South transport corridors linking the countries of the former Soviet Union and Western Europe (World Bank 2003c). Open borders and movement of people could facilitate the spread of the epidemic. There is already evidence of a sharp increase in the prevalence of HIIV in this subregion. The first registered case of I-HIV appeared in 1985 in Poland, in 1987 in Latvia, and in 1988 in Lithuania and Estonia, but very few new cases were diagnosed before 1995. Recent years have seen an exponential rise in new HIV cases, particularly in Estonia, Latvia, and Lithuania. In 2000, following an outbreak of -1V among injecting drug users in Estonia, the number of new cases 44 o Averting AIDS Crises in Eastern Europe and Central Asia increased by a factor of 32 over the previous year and the number of HIV/AIDS cases increased by a factor of 4. In Latvia the cumulative number of HIV/AIDS cases stood at 492 at the end of 1999 but reached 2,385 by October 2002 (World Bank 2003c). (These data must be interpreted with caution, since the number of tests carried out, the denominator, is not known.) In the Czech Republic, Hungary, and Slovakia, a large proportion (20-40 percent ) of reported HIV infections has been diagnosed in foreigners, often migrants from the former Soviet Union and, in the case of Hungary, Romania (Domok 2001). In Southeastern Europe wide variations are apparent across coun- tries, but they are hard to interpret due to weaknesses in information systems (UNICEF 2002a; Novotny, Haazen, and Adeyi 2003). Het- erosexual contact is the main mode of transmission in Bulgaria (80 percent of cases) and Croatia (39 percent of cases). Moldova reports 10 times as many cases per capita as Macedonia, FYR. Injecting drug use is the main mode of transmission in Moldova, whereas FIIV is spread primarily through heterosexual contact in MA-acedonia, FYR. The recent pattern of spread in Moldova appears to share character- istics that are more similar to those in Central European and Central Asian countries than it does with countries in Southeastern Europe. Romania's epidemic among children, which resulted from hospital- acquired infections, is a peculiarity that is not shared by other coun- tries in the region. Who0C3 DOE*rives Xuh, _J-_.'/A1D05 Epodleono: in Eas§85'n J.-C S - and CenyaD Asia? Two groups of factors contribute to the spread of HIV/AIDS. Struc- tural factors increase the vulnerahility of groups of people to HIV infection, while behavioral factors determine the chances that indi- viduals become infected. The conceptual framework depicted in fig- ure 1 (see page 16) helps identify factors driving the epidemic in Eastern Europe and Central Asia and identify interventions to address the epidemic at various levels and in multiple sectors. Annex A: The IHV/AIDS and Tuberculosis Epidemics * 45 Structural Factors Structural factors increase the vulnerability of societies to an epi- demic. In the decade after the collapse of communism, populations in the region became more mobile, as travel restrictions were relaxed. Social freedoms were accompanied by increased trafficking in and consumption of narcotics, resulting in a rapid increase in the number of injecting drug users. The spread of HIV in Eastern Europe and Central Asia is closely linked with the rise in injecting drug use that occurred after the collapse of the Soviet Union. That increase occurred in the midst of a severe socioeconomic crisis, at a time when Afghanistan became the world's largest opium producer. The increase in opium production was paralleled by the diversifica- tion of trafficking routes through the region, particularly in Central Asia; an increase in overall trafficking of heroin from Afghanistan and surrounding countries to Europe; and a significant rise in drug consumption (Hamers and Downs 2003) HIV is spreading most rapidly amonig young people in Eastern Europe and Central Asia. Adolescents and young adults account for most reported cases among injecting drug users (Hiamers and Downs 2003). The virus disproportionately affects people who oth- ervise would have remained in the labor force for a long time or continue to build up human capital and expertise (Ruehl, Pokrovsky, and Vinogradov 2002). The age at which young people start injecting drugs is falling. In St. Petersburg more than 40 percent of injecting drug users attend- ing an HTIV prevention center in 1999 were under 20, up from just 13 percent in 1997. Sharing of injecting equipment is common. In December 2001, 62 percent of HI-V-positive men and 57 percent of HlV-positive women in the Russian Federation were between 20 and 30. Most of the diagnosed cases are males, who represent 78 percent of all registered cases, although the female-to-male ratio is steadily growing. Income inequality has increased in the region, changing the dynamics of social interactions. Partly as a result, commercial sex work has become more common, as has casual premarital sex. 46 o Averting AIDS Crises in Eastern Europe and Central Asia Overcrowded prisons serve as breeding grounds for infectious diseases, particularly HIV/AIDS and tuberculosis. Infected people are released into society, which has inadequate facilities for diagno- sis and treatment. Moreover, services outside of prison are poorly coordinated with prison health services (Powell 2000; LTNAIDS/VVHO 2002; Reichman 2002). Prisons often contain high numbers of people with IIV, frequently drug users. Some inmates engage in high-risk behaviors, including physical violence, unpro- tected sexual intercourse, and needle sharing. Together with over- crowding, poor ventilation systems, and high tuberculosis preva- lence, these behaviors make them highly vulnerable to HIV In Uzbekistan a third of all reported I-UV infections are among inmates. In Ukraine 7 percent of 11,841 inmates tested in 2000 had FIIV: In the Russian Federation 1.9 percent of the nearly 1 million inmates tested in 2001 had HIV; in 2002 the tuberculosis notifica- tion rate was 30 times higher in prisons than in the general popula- tion (WHO 2002d; Reichman 2002). Southeastern Europe has a highly mobile population that includes refugees, internally displaced people, rural-to-urban migrants, returnees, commercial sex workers, victims of trafficking, international peacekeepers, and humanitarian workers. This group also includes people whose work involves traveling (construction workers, pilots, mariners, truck drivers). Many labor migrants and people returning from abroad are coming back from or moving between countries in which the prevalence of HIV is rising. Sex workers, many of whom are young, including minors, are another vulnerable group. An increase in the sex industry has been coupled with the trafficking in women from Central and Eastern Europe and the CIS for sexual exploitation. In parts of Southeastern Europe there are reports that the international community, particu- larly military and peacekeeping missions, is providing a significant part of the demand for commercial sex. Few data exist on the sexual behav- ior of clients and sex workers in the region (UNICEF/IOM 2002). In a recent study of casual sex among truck drivers and commer- cial sex workers in Estonia, Latvia, Lithuania, and Poland, 91 per- cent of respondents responded positively to a direct question about Annex A: The HIV/AIDS and Tuberculosis Epideniics * 47 having sexual contacts while on the road-that is, sex with partners other than their regular partners (World Bank 2003c). In the Russian Federation and many Central Asian republics, the wave of injecting drug use is closely correlated with socioeconomic upheavals that have sent the living standards of tens of millions of people plummeting, amid rising unemployment and poverty. Oth- ers factors accounting for the rise in drug use are the fourfold increase in world production of heroin in the past decade and the opening of new trafficking routes across Central Asia. The epidemic is growing in Kazakhstan, where 1,926 HIIV infections had been reported by June 2001. More rapid spread of JIEV is evident in Azerbaijan, Georgia, Kyrgyz Republic, Tajikistan, and Uzbekistan. In Tajikistan and Uzbekistan recent evidence of rising heroin use heightens concerns that a larger HIV/AIDS epidemic could be imminent. Already a steep rise in reported HIV infections has been noted in Uzbekistan, where 620 new infections were registered in the first six months of 2002-six times the number of new infections registered in the first six months of 2001 (UNAIDS/WHO 2002). In several Eastern Europe and Central Asia countries, health sys- tems have continued a deterioration that began even before the col- lapse of the Soviet Union. The extent to which this deterioration is contributing to transmission through contaminated blood (during transfusion) and poor diagnosis and treatment of other sexually transmitted infections (which facilitate HIIV transmission) remains unknown. Behavioral Risk Factors and Core Transmitters Although it is not possible to predict with precision the course of the HIV/AIDS epidemic, there is reason to anticipate its rapid spread in the region. Concern over the spread of the epidemic is based on a review of current information on risk behaviors and the lessons of experience in regions in which the epidemic has reached relatively high prevalence rates in the general population. Central to an understanding of the dynamics of the epidemic is the recog- nition that behaviors vary across populations and that these varia- 48 o Averting AIDS Crises in Eastemn Europe and Central Asia tions affect the spread of I-IIV (Over and Piot 1993; Hamers and Downs 2003). Risk is the probability of becoming infected. It is not a judgment about the morality of a particular behavior. People at highest risk of transmitting or becoming infected with the virus are high-risk core transmitters. In Eastern Europe and Central Asia, high-risk core transmitters are mostly injecting drug users, mobile populations, and commercial sex workers. High-risk core transmitters in turn interact with other subgroups that have a moderate risk of becom- ing infected or transmitting the virus. These are the so-called bridge populations, typically tlhe sex partners of injecting drug users and the clients of commercial sex workers. Eventually, the epidemic may spill into the general population. For an epidemic to be sustained, each infected person has to infect at least one other person on average. The number of new cases generated by each infected person is known as the basic reproductive number, R. (Anderson 1999). If the HIIV epidemic is to decline, R,, must be less than one. High-risk core transmitters contribute more to R. than do other members of the society. There is thus a compelling case to provide tar- geted, nondiscriminatory prevention programs (Hamers and Downs 2003) on a scale that is larger than the current pilot projects. Injecting Drug Use The HIV/AIDS epidemic in Eastern Europe and Central Asia is linked to the surge in injecting drug use among young people. Esti- mates vary, but most indicate that injecting drug users account for 70-90 percent of new HIV infections. Most of these people appear to have contracted the virus through contaminated needles. Studies measuring HIV prevalence among injecting drug users reveal prevalence rates of more than 50 percent in Svetlogorsk (Belarus) and in Irkutsk, Kaliningrad, Togliatti City, and Tver (the Russian Federation). Prevalence rates of more than 30 percent were reported in Poltava (Ukraine) and Rostov, Samara, and St. Peters- burg (the Russian Federation). Prevalence rates of more than 15 percent were found in Minsk (Belarus), Moldova, Ekaterinburg (the Russian Federation), and Kharkiv (Ukraine). HIV prevalence Annex A: The HIV/AIDS and Tuberculosis Epidemics * 49 remains low among injecting drug users in most Central and South- eastern European countries (Rhodes, Lowndes, and others 2002). Studies provide reason for significant concern in many of these countries. In the Russian Federation, for example, between Septem- ber and October 2001, 426 injecting drug users were tested for HIV in Togliatti City, Samara Oblast. Of those tested, 56 percent had HIV antibodies; 74 percent of those with antibodies were unaware of their positive status. The high prevalence of HIV and a recent increase in HIV detected through routine tests since 2000 suggest that an explosive epidemic has occurred among injecting drug users in Togliatti City. This finding has urgent implications for maximiz- ing the distribution of sterile injecting equipment as well as enhanc- ing sexual risk reduction. Recognizing that similar explosive epi- demics could be taking place in other Russian cities, the authors of the study recommended communitywide HIAT prevention coverage supported by city and state policies oriented to harm reduction (Rhodes and others 2002). These worrisome trends require rapid interventions. Most initia- tives have focused on noninjecting or frequent injecting drug users. Infrequent injectors who have not yet developed fixed injection pat- terns have been largely ignored. Targeting infrequent injectors, however, may be crucial to controlling the epidemic. Follow-up studies of young injectors who only recently began injecting show a high incidence of infection within the First thlree years of injecting. A recent WHO rapid assessment report in St. Petersburg reveals that new and random injectors are most vulnerable to HIV Effec- tively targeting this population could control the growth of the injecting drug user population (Defy 2002). Infrequent injectors are a difficult population to target, however, because they stand between two worlds. Many do not yet fully iden- tify themselves as injecting drug users and therefore have greater fear of and attach greater stigma to harm reduction strategies, such as nee- dle exchange programs. Limited contact with drug networks may also limit their awareness of outreach programs. Whereas frequent injec- tors can easily be reached where drug prevention schemes and street- outreach exist, infrequent users form a more hidden population. 50 o Averting AIDS Crises in Eastemn Europe and Central Asia Unprotected casual sex among injecting drug users increases the rate of transmission. Little empirical evidence is available on pat- terns of sexual behavior and condom use among injecting drug users, but the majority of injecting drug users are believed to be sex- ually active. Drug injecting and the sharing of injecting equipment remain the most important risk factors for sex workers. But the proportion of newly detected I-RV cases from heterosexual transmission appears to be rising in places in which the incidence of I-IIV among inject- ing drug users is growing. In Odessa and Kaliningrad, for example, the proportion of new cases associated with sexual transmission rose from 5-10 percent in 1996 to 30-3 5 percent in 2001 (Rhodes, Platt, Davis, Filatova, and Sarang 2002). At the same time, the proportion of new cases among injecting drug users declined from about 90 percent in 1996 to 65 percent in 2001. The male-to-female ratio of reported cases declined from 4:1 to 2:1 between 1987 and 2001, suggesting that young women are increasingly at risk of contracting -IIV through sexual contact with an injecting drug user partner, sex- ual contact with a client, or injecting drug use, which is growing among women. Low awareness and unsafe behavior among injecting drug users, including the sharing of injecting equipment, are important reasons why the epidemic has spread so rapidly. In Belarus and Ukraine, where the epidemic appeared earliest, an increasing share of new infections is now occurring through sexual-overwhelmingly het- erosexual-transmission. Data based on the October 2001 Russia Longitudinal Monitor- ing Survey indicate a strong potential for rapid heterosexual spread of HIV in the Russian Federation (Vannappagari and Ryder 2002): o One third of all 14- to 20-year-old respondents reported being sexually active during the previous year, with the proportion higher among men than women. The average age at first inter- course has declined. o Within the 14- to 20-age group, 75 percent of sexually active respondents reported having a friend or casual acquaintance as Annex A. The HIV/AIDS and Tuberculosis Epidemics * 51 their current partner. Among all sexually active 14- to 20-year- olds, 44 percent did not use a condom the last time they had sex. * Among those who had sex with a casual acquaintance, 48 percent of 14- to 20-year-olds, 36.5 percent of 21- to 30-year-olds, 61.3 percent of 31- to 40-year-olds, and 69 percent of 41- to 49-year- olds did not use a condom during the most recent sexual act. Among those who had sex in exchange for money or gifts, 35.6 percent of 21- to 30-year-olds and 43.5 percent of 41- to 49-year- olds did not use a condom. * The male-to-female ratio among newly detected FIIV cases fell from 4:1 in the late 1990s to 2:1 in 2001, indicating that girls and young women are increasingly at risk of -HrV infection. The rise in prostitution and the common practice of unprotected casual sex are contributing to the spread of IE-V beyond the drug-user subpopu- lation. Sexually T7ins-mitted Infections Another important risk factor is the high prevalence of sexually transmitted infections in many parts of Eastern Europe and Central Asia. Certain sexually transmitted infections increase the probability of HIV transmission during unprotected sex. The rates of sexually transmitted diseases in the Russian Federation have remained at epi- demic levels for the past decade. In 1999, 188 cases of syphilis and 176 cases of gonorrhea per 100,000 people were reported-128 and 24 times higher than the corresponding figures in Western European countries-and rates are even higher in many regions of the Russian Federation. The incidence of sexually transmitted infections among adolescents is continuing to rise in parts of the country. Commercial Sex Commercial sex is on the rise in the region, with an east-to-west migration of sex workers (Dehne and others 2000). In Plovidv, Bul- garia, 13 percent of 200 prostitutes surveyed were Russian and a quarter were on their way to Western Europe or Turkey (Tchoudomirova, Domeika, and Mardh 1997). 52 o Averting A]IDS Crises in Eastern Europe and Central Asia A high prevalence of sexually transmitted diseases in the general population and specifically among sex workers indicates a high potential for transmission of HIV through sexual contact between commercial sex workers and their partners. In the Russian Feder- ation, among 70 street prostitutes participating in a voluntary anonymous study in Moscow, 44 percent were injecting drug users, 31 percent had syphilis, and 20 percent never used condoms. Overall 30-60 percent of Russian sex workers are estimated to inject drugs. Estimates are slightly lower in Southeastern Europe, where 22 percent of sex workers in Serbia and 30 percent in Alba- nia are estimated to inject drugs. Among female injecting drug users, 20-50 percent in Eastern Europe and 10-25 percent in Central Asia are estimated to work as sex workers (Rhodes, Platt, and others 2002). The booming sex industry, the high frequency of other sexually transmitted diseases, and the high rate of drug use among prostitutes suggest that prostitution may play an important role in the future spread of HIV/AIDS in Eastern Europe and Central Asia. YubsrcuDos5s andS .-. DES Tuberculosis is caused by Mycobacteri*nm tuberculosis, which is trans- mitted through droplets released into the air by infected people. About a third of the world's population has latent tuberculosis, from which there is lifelong risk of reactivation. About 95 percent of people infected with tuberculosis initially enter a latent phase, during which the infection goes unnoticed. In about 5 percent of cases, the initial infection progresses directly to pulmonary tuberculosis; organs other than the lungs can also be involved (extra- pulmonary tuberculosis). Serious outcomes of the initial infection are more frequent in infants, adolescents, and young adults. In the absence of effective treatment for active disease, a chronic wasting course is usual and death ultimately occurs (Daniel 1991). Jack (2001) argues for public intervention on efficiency grounds, by identifying public goods attributes of tuberculosis control, exter- Annex A: The HIV/AIDS and Tuberculosis Epidemics * 53 nalities in its consumption, and supply-side failures. Tuberculosis control also serves the important cause of reducing poverty. Tuberculosis with HIV co-infection is a major emerging health problem in developing countries. People with HIV/AIDS are par- ticularly susceptible to opportunistic infections, namely, tuberculo- sis, pneumonia, and diarrhea. Tuberculosis is easily diagnosed and is usually treatable with antibiotics, at a cost of about $10-$20 a patient. Yet it remains a major cause of sickness and death in people with HIV/AIDS, among whom the lifetime risk of developing the disease is 5-10 times that of people without HIV/AIDS. HIV is the most power- ful known risk factor for reactivation of latent tuberculosis infec- tion to active disease; people with HlV who become infected with Mycobacteriuim? tuberculosis rapidly progress to active tuberculosis. Tuberculosis-HIIV co-infection also undermines treatment and care, reduces survival substantially, and increases healthcare costs. The burden will be higher in countries that do not meet WHO targets of at least 70 percent detection of new smear-positive cases and an 85 percent cure rate with DOTS coverage, a cate- gory into which the Russian Federation and most CIS countries fall (WVHO 2002b, d, f, g). At the regional level the WHO describes as "critical" the tuber- culosis situation in 16 of the 51 countries in its European region, all of which are in Eastern Europe and Central Asia: Armenia, Azer- haijan, Belarus, Estonia, Georgia, Kazakhstan, the Kyrgyz Republic, Latvia, Lithuania, Moldova, Romania, the Russian Federation, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan. Together these countries, with a combined population of 313 million, had an esti- mated 433,000 cases of tuberculosis in 2002, or 77 percent of the total tuberculosis caseload in the European Region of the WHO. The estimated number of tuberculosis cases in these countries has risen during the past 10-20 years. Notification has also risen (except in Tajikistan), and the tuberculosis burden has grown. Five coun- tries-Kazakhstan, Romania, the Russian Federation, Ukraine, and Uzbekistan-account for more than half of the tuberculosis burden in the European Region of the WHO. 54 o Averting AIIIDS Crises in Eastern Europe and Central Asia Eight other Eastern Europe and Central Asia countries-Alba- nia; Bosnia and Herzegovina; Bulgaria; Croatia; Hungary; Poland; Macedonia, FYR; Serbia and Montenegro; and Turkey-are in the intermediate tuberculosis burden category. In the region only Slo- vakia and Slovenia have a low tuberculosis burden (WIHO 2002g). The tuberculosis problem is being fueled by a combination of fac- tors, including poverty (Vinokur and others 2001), ineffective approaches to diagnosis and treatment, poor coverage of the population with effective treatment protocols, weak or deteriorating health sys- tems, and the roles of prisons as breeding grounds for infectious dis- eases (figure Al). In the Russian Federation case rates and death rates among inmates are 10 times higher than in the civilian sector. The case notification rate in the penitentiary system in 2000 was 3,118 per 100,000 convicts and people under criminal investigation. This high rate of tuberculosis among the prison population represents a problem for tuberculosis control in the civilian sector, as a growing number of inmates with tuberculosis are being released from prison. The prison system serves as one of the epidemiological pumps for the tuberculosis epidemic, helping breed a pool of infected people who are then released into the general population with no guarantee of follow-up or adequate treatment by health facilities that serve the population at large. Despite the availability of cost-effective approaches to diagnosis and treatment, tuberculosis remains a serious problem in Eastern Europe and Central Asia. Borgdoff, Floyd, and Broekmans (2000) reviewed the literature on the impact of tuberculosis control meas- ures on mortality and transmission and constraints to scaling up. They concluded that treatment of smear-positive tuberculosis using DOTS has by far the greatest impact, with a cost-effectiveness of $5-$40 per DALY gained. Treatment of smear-negative cases has a cost per DALY gained of up to $100 in low-income countries and up to $400 in middle-income settings. Multidrug-Resistznt Tuberculosis Multidrug-resistant tuberculosis is caused by strains of the tubercu- losis bacteria that are resistant to at least isoniazid and rifampicin, Annex A. The HIIV/A1DS and Tuberculosis Epidemics * 55 Figure Al. Main Risk Factors for and Intervention Strategies Applicable to Tuberculosis and HIV Coinfection Role of HIV/AIDS in fueling the TB epidemic in Eastern Europe and Central Asia Sociostructurol factors Epidemiological factors Lock of access to * Overcrowded prisons * Prevolence of TB in PLWH * HAART * Poverty&reloted commercial * MDR-TB prevalence in PLWH * STI treatment sex * Durotion of infectiousness * Harm reduction for IDUs . Sale ond transfusion of in PLWH * Condom use contominoted blood * STI and other comorbidifies .~~~~~~~~~~~n s {t infedhin 4 * TB } Recurrence transmission CG] | *TB preventive * Intensified . TB preventive treatment case finding treatment *Decreased delay * Access to in case detection second-line and DOTS drugs Interventions to avert the TB epidemic fueled by HIV/AIDS Source: Authors. the two principal first-line drugs used in combination chemother- apy. It results from poor management of drug-sensitive tuberculo- sis, a big problem that arises from failure to manage a smaller prob- lem effectively. It is the result of one or more failures in the disease control or broader health care system, including the use of incorrect drugs or incorrect doses of the right drugs to treat tuberculosis; dis- continuation of treatment before the bacteria that cause tuberculo- sis have been killed off, making it possible for them to develop into stronger versions of the same bacteria; and breakdowns in the drug supply chain, which make it difficult for doctors, nurses, and other health care workers to provide the right treatment. Cross-country comparisons indicate that the multidrug-resistant rate among previously untreated cases is inversely correlated with 56 0 Averting AI[DS Crises in Eastern Europe and Central Asia treatment success under short-course chemotherapy (Dye and oth- ers 2002). The straightforward conclusion is that high cure rates have prevented the emergence of resistance in countries that have effectively used short-course chemotherapy. Cure rates of more than 90 percent can be achieved under such chemotherapy; if few patients fail treatment, fewer still can develop resistance. High rates of resistance tend to be associated with low treatment success. In Ivanovo Oblast, in the Russian Federation, the reported treatment success for patients carrying fully sensitive strains is 63 percent. With a cure rate this low, it is not surprising that 9 percent of new tuberculosis cases are multidrug resistant (Espinal and others 2000). HIlV-Related Tuberculosis Tuberculosis is one of the most common opportunistic infections in people with AIDS. HTV also drives the tuberculosis epidemic, partic- ularly in areas in which the prevalence of the virus is high. I-ITV pro- motes progression to active tuberculosis in both people with recently acquired and people with latent tuberculosis infections (WHO 2002b, f). It has been linked to multidrug resistanlce in small-scale outbreaks, such as those originating in hospitals, but there is no evidence that multidrug resistance is associated with I-IV in cross-country compar- isons. Multidrug resistance appears to be uncommon in Sub-Saharan Africa, the current epicenter of the HIEV/AIDS pandemic (Espinal and others 2000 2001; WHO 2000). The serious tuberculosis problems in Eastern Europe and Cen- tral Asia stem in part from the difficulties of the transition from the Soviet era approaches to contemporary practices. Health systems in most of the former Soviet republics experienced major destabiliza- tion and underinvestment, and the quality of care is poor, a legacy of the late Soviet era (McKee, Healy, and Falkingham 2002; Reich- man 2002). The centrally planned Soviet tuberculosis control sys- tem had its successes, but the approach was costly because of over- reliance on mass x-ray screening for diagnosis and on lengthy hospitalizations for treatment. Nonetheless, the system was held in high esteem by the Soviet health establishment, partly because the Annex A. The HIV/AIDS and Tuberculosis Epidemics * 57 tuberculosis burden in the late Soviet era was not the problem it became in the 1990s, according to official Soviet data. In addition, incentives strongly favored the maintenance of large tuberculosis hospitals, as financing for tuberculosis services was based on the number of beds. An input-driven incentive system does not improve performance on the basis of outcomes. Furthermore, at least one generation of medical practitioners had much to lose from the rapid change of approach from the familiar to the new. As a result of these factors, despite several pilot projects in the region, most countries have not come close to nationwide imple- mentation of internationally recognized approaches to tuberculosis control. A large majority of the population still receives mostly inap- propriate diagnostic and treatment services of uncertain quality, with wide variations across and within countries-a perfect scenario for breeding multidrug-resistant tuberculosis (Reichman 2002). In Uzbekistan, for example, the failing tuberculosis system is con- tributing to some of the highest rates of multidrug-resistant tuber- culosis in the world, with 13 percent of new patients at Medecins Sans Frontieres clinics in the Karakalpakstan region presenting with multidrug-resistant tuberculosis. In addition to drug resistance, the deteriorating Soviet-era system has created a large pool of patients who previously received more than a month of tuberculosis treat- ment (so-called retreatment cases). These cases make up about half of the smear-positive cases seen in the Medecins Sans Frontieres program, less than 10 percent of whom received DOTS in the past. More than 40 percent of these retreatment cases have multidrug- resistant tuberculosis (Cox and Hargreaves 2003). Controlling Tuberculosis in an Era of Dual Infection with HIV For many years people involved primarily with tackling tuberculo- sis and those involved primarily with tackling HIV/AIDS pursued largely separate courses. Separate funding of tuberculosis and HIV/AIDS programs often maintained these separate courses (WVHO 20020. In Eastern Europe and Central Asia there is a strong tradition of vertical programs. 58 o Averting AIDS Crises in Eastern Europe and Central Asia A new Strategic Framework to Decrease the Burden of Tubercu- losis/HIV (WI-O 2002) represents a unified health sector strategy to control HIV-related tuberculosis as an integral part of the strat- egy for fighting HIV/AIDS. Efforts to control tuberculosis among people with HIV have focused mainly on implementing the DOTS strategy for tuberculosis control-that is, identifying and curing infectious tuberculosis cases among people presenting at general health services. This strategy targets the final step in the sequence of events by which H[IV fuels tuberculosis, namely, the transmission of Mycobactetium tzubercutlosis infection. The expanded scope of the new strategy for tuberculosis control in high HIV prevalence populations includes interventions against tuberculosis (intensified case finding and cure and tuberculosis pre- ventive treatment) and interventions against HIV (and therefore indirectly tuberculosis). These interventions include promotion of condoms, treatrnent of sexually transmitted diseases, promotion of safe injecting drug use, and HAART. Although the main focus of the strategy is on Sub-Saharan Africa, which bears the heaviest burden of HIV-related tuberculosis, it may be relevant to parts of Eastern Europe and Central Asia with particularly high concentrations of tuberculosis, such as prisons in the Russian Federation. The priority is to improve surveillance and ensure accurate diagnosis and effective treatment among members of risk groups. A coherent health service response to tuberculosis and HI-V includes criteria for determining priority interventions; poverty alleviation; an attempt to deal with market failure; and estimates and use in program planning of the cost and cost-effectiveness of interventions (WHO 2002Q. ANNEX B The Potential Economic, Poverty, and Human Development Impacts of HIV/AIDS in Eastern Europe and Central Asia This annex describes the potential impact of the -IIV/AIDS epi- demic in Eastern Europe and Central Asia on the economy, society, communiity, and households. Economic impact refers to the effects on macroeconomic and microeconomic indicators, such as eco- nomic growth, per capita income, the Gini coefficient,4 labor sup- ply and procluctivity, pul)lic and private consumptioni, and domestic savings. Social impact refers to the effects on social reproductive labor (for example, parenting); social cohesion; and the organization of communities and households. Economic and social impact analyses are based on the premise that once the HTV/AIDS epidemic begins to spread, certain conse- quences are likely that are not evident in the early stages of the epi- demic. Without an accelerated response to control the spread of the disease, the epidemic could move from concentration within high- risk groups to a generalized epidemic transmitted predominantly through heterosexual contact. Over time people with HIlV develop full-blown AIDS, the nwnber of people with I-UV increases, and the impacts of taking care of people with AIDS and AIDS deaths among people in the productive age groups of 15-50 is felt at various levels of the economy and society (table B1). Estimation of the potential economic and social impacts is based on pro- 59 60 * Averting AIDS Crises in Eastern Europe and Central Asia Table B1. Economic and Social Impact of HIV/AIDS, by Level, Time, and Degree LEVEL OF IMPACr TIME OF IMPACT DEGREE OF IMPACT EVIDENCE OF IMPACT Individual Early (immediate) Always severe; varies by Death and illness age and gender. Household Early, middle Severe emotional, variable Household studies (1-5 years), and financial depending on suggest that orphans late (10 years socioeconomic status, and the elderly and beyond, gender, ethnicity, and are especially intergenerational) other social variable. affected. Community Early, middle, Depends on scale and resource Services for orphans and late base of community but likely and the elderly to be long term and profound, and local service albeit not necessarily easy to see, provision are affected. Production Middle and late Depends on nature of Yes unit/ organization's or institution's institution activities or type of production and labor mix. Sector Late Depends on location, use Some evidence of labor. exists, but it is limited. Notion Late Economic impact is probably No empirical evi- slight; other effects may be dence, only eco- present. nomic models and anecdotal evidence about effects on government infra- structure Source: Barnett and Whiteside 2002. jections and evidence from other regions of the world that had low I-UV prevalence rates but are now facing a generaliied -IrV/AIDS epidemic. Macroeconomic Impact of HIV/AIDS Maintaining a healthy rate of economic growth is an important macroeconomic policy objective. In addition, technological innova- Annex B: The Econonic, Poverty, and Human Development Impacts * 61 tion and development are important for countries to maintain their economic edge and coimnparative advantage. Human capital forma- tion is critical for sustaining economic growth and development. By increasing illness and death among people of productive age, HIV/AIDS has the potential to negatively affect population dynam- ics, labor supply, and productivity; raise public and private con- sumption; and reduce income and savings. With a lower savings rate, the rate of investment is likely to fall, reinforcing the decline in economic growth. Estimating the effect of HIV/AIDS on economic growth requires using current prevalence rates and assumptions about future inci- dence rates to project the number of future illnesses and deaths. Once these projections are made, estimates of demographic impacts, health expenditures, labor supply and productivity, and other economic parameters can be made. These parameters are then used to model economic growth scenarios with and without HIV/AIDS. About a dozen studies look at the impact of -1V/AIDS onl eco- nomic growth (table B2). Only two are specific to the Eastern Europe and Central Asia Region, both of which focus on the Russ- ian Federation (box B1). Although these studies used different projection scenarios, all of them show that HIV/AIDS has the potential to reduce economic growth. The impact on GDP per capita is less clear and depends largely on the skill level of the group most affected by the virus and whether the costs of 1-1V/AIDS are financed from savings. If the cost of H1V/AIDS is not financed from savings and the epidemic is concentrated largely among people with lower skill levels, per capita income rises an estimated 0.13-0.17 percent in the worst affected countries. If the cost of HIV/AIDS is financed from savings and the epidemic is concentrated largely among people with higher skill lev- els, per capita income falls an estimated 0.35-0.60 percent. An economic growth model currently being developed asserts that other models underestimate the economic impact of MfV/AIDS by not fully capturing the extent and future implications of the destruc- tion of human capital (Bell, Devarajan, and Gersbach 2003). The V,Ha 523o Summary of Evidence of Macroeconomic Impact of HIV/AIDS REGION/COUNTRY IMPACT AJTHOR PERIOD Africa and Annual GDP declines 0.56-1.47 percent. Annual per capita growth Over (1992) 1990-2025 Sub-Saharan Africa is 0.6 percent lower to 0.17 percent higher. Sub-Saharan Economic growth was reduced by 0.8 percent in the 1990s. Annual per Bonnel (2000) 1990-97 Africa (ordinary capita growth was reduced 1.2 percent between 1990 and 1995. least squares and two-stage least squares growth equations) Tanzania Solow-type growth Annual GDP growth declines hrom 3.9 percent without HIV/AIDS to Cuddington (1993a) 1985-2010 model 2.8-3.3 percent. Annual GDP per capita growth declines from 0.7 percent without HIV/AIDS to 0.2-0.7 percent. Solow-type growth AIDS reduces real GDP 11-28 percent over period. Per capita income Cuddington (1993b) 1985-2010 model with dual change ranges from increase of 3.6 percent to decrease of 16.1 labor market percent over period. Malawi Solow-type growth Annual GDP growth rate declines 0.2-1.5 percent. Annual GDP Cuddington and 1985-2010 model per capita growth declines 0.1-0.3 percent Hancock (1993a) Solow-type growth Annual GDP growth declines 3-9 percent. Annual GDP per capita Cuddington and 1985-2010 model with dual growth unchanged or increases by 3 percent. Hancock (1993b) labor market Botswana Annual GDP growth declines 3.9 percent to 2.0-3.1 percent. BIDPA (2000) 1996-2021 (Cobb-Douglas After 25 years economy is 24-38 percent smcller. In best-case production function) scenario per capita GDP rises 1.5-1.9 percent a year and average incomes rise 9 percent after 25 years. In worst-case scenario GDP per copita growth declines 1 percent a year and is 13 percent lower after 25 years. South Africa Full supply-demand Real GDP falls 0.3 percent lower in 2001, 0.4 percent in 2006-10. Quatteck (2000) 2001-15 econometric model (annually through 2005, then 2006-10 and 2011-15) Computoble GDP growth decline 2.6 percent in 2008. By 2010 economy is 17 Arndt and lewis 1997-2010 generol equilibrium percent smaller, per capita income is 8 percent lower. (2000) model Trindad and GDP is 4.2 percent lower in Trindad and Tobago and 6.4 percent Nicholls and 1997-2005, Tobago, Jamaica lower in Jamaica in 2005. others (2000) but results seem to be for 2005 Source: Barnett 2003. 64 o Averting AIDS Crises in Eastern Europe and Central Asia Box B1. The Impact of HIV/AIDS on the Russian Economy In the absence of strong prevention policies, the number of people in the Russian Federation infected with 1ITV is expected to increase marlkedly by 2020 (Ruehil, Pokrovsky, and Vino- gradov 2002). Fven in the optimistic case (prevalence rate of 1 percent), mortality rates are projected to increase frotn 500 a month in 2005 to 21,000 a month in 2020, and the cumulative number of people infected with HIV is projected to rise from 1.2 mnillion in 2005 to 2.3 million in 2010 and 5.4 million in 2020. The pessimistic scenario (prevalence rates of 2--3 percent) results in dramatically higher rates. Under this scenario: * GDP in 2010 would be as much as 4.15 percent lower than it would have been in the absence of HIV/AIDS; wvithout inter- vention the loss would rise to 10.5 percent by 2020. Perhaps more significant for long-term development, the uninhibite(d spread of ITV/AIDS would diminish the economy's long-term growth rate, taking off half a percentage point annually by 2010 and a full percentage point annually by 2020. * Investment would decline by nore than production. Under the pessimistic scenario, investment would fall 5.5 percent in 2010 and 14.5 percent in 2020, creating a severe stumbling block for future growth. * The effective (thlat is, quality-adjusted) labor supply would decrease over time, with the overall decline due more to a decline in the number of workers (total labor supply) than to the productivity losses associated witb those parts of the work force infected with H-f. This effect reflects the assumption that 7IIV lowers productivity by a moderate 13 percent. Using a single-sector growth model, Sharp (2002) concludes that AIDS is likely to have a significant sustained negative imnpact on aggregate economic growth and annual GDP, with growth falling by 0.2 percent to a little more than 0.5 percent by 2020. Declines in population reduce somewhat the per capita impact at the macroeconomic level. Annex B: The Economic, Poverty, and Human Development Impacts * 65 hypothesis of this model is that by destroying human capital and weakening the transmission of human capital to subsequent genera- tions, 1I1V/AIDS severely weakens the foundations for economic growth and development. The application of this model to South Africa shows that if nothing is done to combat the epidemnic, a com- plete economic collapse will occur within four generations. If opti- mal spending on combating the disease and "pooling" (a custoill in which children are cared for by extended families) are maintained, growth continues, albeit at a slower pace than in the benchmark case. If pooling breaks down and is replaced by nuclear families, growth will be slower still, even with optimal spending. If school attendance subsidies are not provided, growth will be very sluggish. In all three cases the additional fiscal burden of the interventions is considerable, reinforcing the need for early action to prevent the spread of the epi- demic. Interpretation of the results of the growing number of macro- economic impact studies being conducted needs to take into account the limitations of such models. Economic modeling is coIml- plex, and incorporating an HIV/AIDS scenario requires mak-ing assumptions about the rate at which IEIV will spread, the number of people infected, their skills and employment, the time from illness to deaths, and the types of care that will be provided. The results depend on the validity of the assumptions. Macro-modeling involves simplification and cannot reflect frilly how economies operate in reality. Moreover, to show even small impacts of HIV/AIDS on economic growth, the HIV/AIDS epidemic has to be projected 15-30 years. From the perspective of policymakers strug- gling with more immediate development challenges, this can reduce the credibility of the impact on economic growth prospects. The potential negative impact of HTV/AIDS on economic growth becomes more real for policymakers when meso and micro impacts of the epidemic-increased government expenditures on treatment and care, increased absenteeism, the costs of replacing skilled labor-are felt at the country level. This tendency reinforces the importance of monitoring and measuring the impact of the epi- demic at these levels. 66 o Averting AIDS Crises in Eastern Europe and Central Asia aeso-Leve4 nmcfts of~ HW/AD)S HIV/AIDS would have significant impacts at the sectoral level in Eastern Europe and Central Asia. 1H[ealth Sector People with HIV/,ADS have a wide range of health care needs. Some HIV-related conditions can be managed at the primary health care level. As the disease progresses, demands on the health care system change, and care is needed for treatable acute condi- tions as well as terminal conditions. As countries adopt HAART, new infrastructure is needed to man- age and ensure compliance with complex therapies. If the HTV/AIDS epidemic continues to grow in Eastern Europe and Central Asia, health systems there are likely to face new challenges. These challenges have implications for both public and private health expenditures. The cost of providing HAART to all people with HIV/AIDS was calculated for each country in Eastern Europe and Central Asia. Based on a low-case (HIV prevalence of 0.50 percent) and a high-case (HIV prevalence of 1 percent) scenario, the number of people with JITV and the number of people with AIDS were calcu- lated.5 Under the high-case scenario, the number of people with FtIIV is projected to increase from about 1 million in 2000 to about 5 million in 2010 (figure B1). The number of people with AIDS is projected to increase from 63,000 to about 277,000, while the number of people with tuberculosis is projected to increase from 205,000 to 610,000. Treatment costs cover treatment for opportunistic infections, diagnostic HI-V testing, opportunistic infection prophylaxis, and HAART. Much uncertainty surrounds the future costs of HIAART drugs. As a result of the Trade-Related Agreement on Intellectual Property Rights (TRIPS) or local production of HIAART drugs (in Brazil and India, for example), the price of HAART has fallen dra- matically in many countries. In Eastern Europe and Central Asia, Annex B: The Economic, Poverty, and Human Development Impacts * 67 Figure B1i. Projected Number of People with HIV, 2001-10 Number of cases 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Yeor Source: World Bank estimates 2003. the annual per patient cost of HIAART ranges from $200 in Arme- nia to about $3,600 in Kazakhstan, with an unweighted average of $1,600.6 Other treatment costs come to $570 per person a year. A range of treatment costs is used to estimate the potential health expenditures associated with treating people with HIV/AIDS. For low-income countries in the region (that is, countries with per capita GDP of less than $1,200 a year), the lower-range estimates of $970 ($200 for HAART drugs and $570 for other treatment costs) to $2,170 ($1,600 for HAART drugs plus treatment costs and $570 for other treatment costs) are used. For the medium- to high- income countries in the region, estimates of $2,170-$4,170 are used ($3,600 for HAART plus other treatment costs). These ranges are then applied to the low- and high-case scenarios to obtain estimates of health expenditures (table B3). All people with HWV/AIDS are assumed to have access to HAART. It is assumed that each person on HAART will survive two years, during which time treatment will 68 * Averting AIDS Crises in Eastern Europe and Central Asia Table B3. Estimated Costs of Providing HAART to People with HIV/AIDS in the 11 CIS Countries LOW HIV/AIDS SCENARIO HIGH HIV/AIDS SCENARIO YEAR LOW ESflMATE HIGH ESTIMATE LOW ESTIMATE HIGH ESTIMATE 2001 135,063 260,063 135,063 260,063 2002 155,366, 299,189 155,900 300,244 2003 174,679 336,464 179,417 345,686 2004 191,582 369,193 204,161 393,691 2005 207,716 400,556 233,737 451,213 2006 223,099 430,624 268,969 519,928 2007 237,452 458,887 310,978 602,043 2008 252,197 488,121 361,496 700,975 2009 268,415 520,438 422,891 821,342 2010 285,904 558,547 496,006 964,864 Total 2,131,475 4,122,100 2,619,000 5,049,000 Countries: Armenia, Azerboijan, Belarus, Georgia, Kazakhstan, Kyrgyz Republic, Republic of Moldova, Russian Federation, Taiikstan, Ukraine, and Uzbekistan. Source: World Bank estimates 2003. be provided. This is a conservative estimate, since people on HAART could survive longer, in which case cumulative lifetime HAART costs would be much higher. By 2010 Eastern European and Central Asian countries will be spending more than $1 billion on HAART, or 1-3 percent of total health expenditures. The bulk of the expenditures will be made by CIS countries such as Kazakhstan, the Russian Federation, and Ukraine. During 1990-98 all Eastern European and Central Asian countries combined spent $60 billion on health care. Potential expenditures on HAART thus do not represent a large percentage of total health care spending, especially when addressed in the con- text of social or health insurance systems that could effectively pool risks. Health and social insurance systems are still evolving in many Eastern Europe and Central Asia countries, however, and out-of- pocket payments continue to be an important source of health care financing in the region, especially in many low-income CIS coun- tries. Huge disparities exist in annual per capita health care spend- Annex B: The Economic, Poverty, and Human Development Impacts * 69 ing, ranging from less than $13 in the poorer Central Asian coun- tries to about $700 in Slovenia (World Bank 2002c). An optimistic scenario is that by 2010 social insurance systems will be well developed, effectively pooling public and private contributions. A pessimistic scenario is that out-of-pocket pay- ments at the point of service will continue to be a major source of health care financing. In this case treatment costs for HAART are likely to further exacerbate the gap between those who have the ability to pay for treatment and those who do not. More important are concerns about the opportunity cost of public resources for health care and the need to make the best use of available health care resources. Many countries in the region face the challenge of improving health outcomes to achieve levels closer to those in Western Europe. The region's low-income countries, which are facing a combination of communicable and noncommunicable diseases, face very serious resource con- straints. Achieving adequate levels of financing for public health programs is a priority in many of these countries. Potential pub- lic expenditures on HAART need to be looked at within the broader context of needs, the availability of health care resources, and allocative efficiency concerns. From the perspec- tives of both public and private financing, a better scenario is to prevent the growth in the number of HIV/AIDS cases through comprehensive prevention programs. Social Protection Social protection programs address the needs of vulnerable groups in a society, such as the elderly, children, and the disabled. Prema- ture adult illness and death due to HIV/AIDS will generate impor- tant demographic impacts in Eastern Europe and Central Asia. These changes have implications for social protection programs, which are typically funded out of contributions by economically productive age groups and general government revenues. Based on current demographic indicators, such as total fertility rates, life expectancy, and migration rates, Eastern Europe and Cen- 70 o Averting AIDS Crises in Eastern Europe and Central Asia tral Asia can be broken into four demographic groups (UNDP 2003):7 1. Countries in which the population is aging, most of the popula- tion is 20-60, and the birthrate is declining. This group of coun- tries includes Bosnia and Herzegovina; Belarus; Bulgaria; the Czech Republic; Estonia; Georgia; Hungary; Latvia; Lithuania; Macedonia, FYR; Moldova; Poland; Romania; the Russian Fed- eration; Serbia and Montenegro; Slovakia; Slovenia; and Ukraine. 2. Countries in which birthrates are high, life expectancy low, and the population young. This group of countries includes Tajik- istan, Turktmenistan, and Uzbekistan. 3. Countries in which the population is older than in the first two groups and there are fewer children, due to falling birthrates. This group of countries includes Azerbaijan, Kazakhstan, and the Kyrgyz Republic. 4. A residual group of countries that includes Albania and Armenia. The first group of countries includes all of the countries in the region in which FIIV/AIDS is spreading fastest (Belarus, Estonia, Latvia, Moldova, the Russian Federation, and Ukraine). The high prevalence of HIV/AIDS in countries with declining fertility is an indication of the possible future demographic impact of the epi- demic. The dependency ratio in these countries is likely to increase as a result of premature mortality. For example, by 2015 the Rus- sian Federation is projected to have just four workers for every three nonworkers. Changes in the dependency ratio in Russia will affect social security and pensions (Sharp 2002). In the second group of countries, where total fertility rates are still at replacement levels, the HIIV/AIDS epidemic has the poten- tial to increase the number of orphans. Orphans face a bleak future, and providing for them will greatly increase the costs of social pro- tection programs. Annex B: The Econonic, Poverty, and Human Development Impacts * 71 In the third group of countries, the combination of elderly peo- ple and children under 15 will generate substantial social protection needs in the short to medium terms. In addition, social protection programs will most likely have to be expanded to include home or community-based care for people with AIDS. Finn-Level Impacts The spread of HIIV/AIDS affects industry and commerce. For firms to earn a profit, the total cost of production has to be less than total revenues. Production costs are a function of inputs, such as labor, materials, and utilities. The increased prevalence of I-IV/AIDS raises the costs of doing business by increasing labor costs. Specific effects include the following (Barnett and Vhiteside 2002): * Absenteeism increases among employees who are sick or who take time off to care for sick family members. * Worker productivity falls. * Labor turnover is high, as sick employees take early retirement or die. Firms bear additional costs associated with training new staff. * Firms need to maintain a larger workforce on their payrolls as a contingency measure and to maintain production schedules. * As skilled workers become scarce, the wages of remaining work- ers may rise. * The business environment may change, with investors reluctant to commit funds if they think HIV/AIDS and its impact will com- promise their investments and returns. Only a few studies have been conducted on the impact of HIV/AIDS on firms, most of them concentrated in Southern Africa, particularly South Africa. These studies show that one of the most critical problems faced by firms in countries with high IfV/AIDS prevalence is absenteeism, which can increase labor costs 37 per- 72 o Averting AIDS Crises in Eastern Europe and Central Asia cent. Fifteen percent of absenteeism is attributable to FHATY/AIDS (Roberts, Rau, and Emery 1996). Another major source of increased costs are the benefits that have to be paid to workers with HIV/AIDS-a lump-sum payment upon death, a pension to the surviving spouse, and a disability pension. These benefits accounted for 7 percent of payroll costs in 2001. By 2010 they are projected to rise to 18 percent. The firm-level impacts of HIV/AIDS could have serious implica- tions for Eastern European and Central Asian countries, many of which are emerging markets. A World Bank report (2002f) notes the key role of the entry and growth of new firms-especially small and medium-size enterprises-in generating economic growth and cre- ating employment. In the next 10 years, the I/Vorld Bank will be encouraging countries that are lagging behind in the development of new firms, especially small and medium-size enterprises, to focus on this issue and improve the environment for their entry and devel- opment. Among this group are most of the CIS countries in which HIIV infection rates are rapidly increasing, including Belarus, the Russian Federation, and Ukraine. In encouraging the development of new firms, however, the continued growth of the HIEV/AIDS epi- demic needs to be taken into account. A rapid rise in HTV/AIDS in the generalized population could seriously threaten the ability of new private firms, especially small and medium-size enterprises, to survive in an increasingly competitive environment. ILmpact on IHiousehokls HIIV/AIDS can have a profound effect on households. The death of a breadwinner can cause a household to face a shock in terms of its daily sustenance. It can cause older children to drop out of school to join the labor force and younger children to take on new household duties, including caring for younger siblings. Dropping out of for- mal education can have serious intergenerational impacts on the household, essentially relegating it to a lower socioeconomic status than it might have had if the breadwinner had not died. Where mul- tiple members of the household are infected with I-IIV, the house- Annex B: The Econonic, Poverty, and Human Development Impacts * 73 hold may disintegrate and disappear. There are methodological challenges to identifying these disappeared households, which makes it difficult to measure this dimension of household impact. The impact of I-IV/AIDS is also felt in terms of changes in household composition and structure. In countries with high preva- lence, new forms of households have emerged after people between 15 and 45 die. These include households with elderly household heads with young children (usually their grandchildren), large households with unrelated foster or orphaned children, households headed by children, and single-parent households. Some evidence suggests that these new forms of households are not as efficient as traditional households and are highly susceptible to poverty and deprivation (Shell 2000). The limited evidence on the impact of HIV/AIDS on household expenditures and consumption suggests that the share of food and nonfood expenditures changes. Households in which an adult dies spend 33 percent less on nonfood items such as clothing, soap, and batteries, and their food purchases decrease as Nvell (Ainswvorth, Frasen, and Over 1998). A household survey in Thailand found that out-of-pocket med- ical care for people with H1V/AIDS equals about six months of average total household income (Pitayanon, Kongsin, and Janjareon 2000). However, the largest economic cost of an HIV/AIDS-related death is forgone earnings, which are higher than average for people who die of AIDS because they die earlier. Taking care of a person with NIXV/AIDS also affects the household labor supply. Poverty, Inequality, and Human Development Impacts The impact of ITV/AIDS on poverty can be looked at from a macro or a micro perspective. At the macro level, changes in the Gini coef- ficient are an important measure of the impact on poverty and inequality. There is litde evidence of these impacts. However, it has been hypothesized that HIV/AIDS has the potential to exacerbate inequality, since certain groups have better access to health care 74 o Averting AIDS Crises in Eastern Europe and Central Asia services than others. Better-off groups are able to afford antiretrovi- ral drug therapy, thereby reducing the negative health effects and disability associated with full-blown AIDS. In contrast, poor house- holds are not able to afford antiretroviral drugs or treatment for opportunistic infections. These differences have welfare implica- tions for households. In many countries (South Africa, Thailand, the United States), the HIV/AIDS epidemic was initially concentrated among the wealthy and the better educated. As the epidemic matured, it tended to con- centrate among low-income groups. This shift in the concentration of the epidemic has implications at the intercountry and intracoun- try levels. It has been hypothesized that over time HIV/AIDS will become more closely associated with poverty and increase the vul- nerability of countries and groups within countries to poverty, poten- tially exacerbating the "poverty trap" (Bloom and Jaypee 2002). Health is an important nonincome dimension of poverty. Insofar as HIV/AIDS affects health and well-being and reduces human capability, it increases poverty. How,ever, to understand the impact of HIV/AIDS on poverty, it is necessary to compare its health impacts with those of other highly prevalent diseases in a country. No known studies have attempted to compare HIIV/AIDS with other diseases using comparable measures, such as DALYs or quality-adjusted life years (QALYs). The coshs oi DeAU°uR A6i0on Countries faced with the potentially rapid spread of HIV/AIDS have two options: delay HIV/AIDS interventions while prevalence rates are still low and intervene only once the HWV/AIDS epidemic has become visible, or implement comprehensive prevention and treatment programs early on while prevalence rates are still low (Bonnel 2000). Cost-benefit and cost-effectiveness analyses of HIV/AIDS programs can help policymakers make informed deci- sions about resource allocation. By measuring and comparing the costs and consequences of different interventions, they can evaluate Annex B: The Economic, Poverty, and Human Development Impacts * 75 the relative efficiency of these interventions and estimate resource requirements. Cost-benefit analysis measures consequences in mon- etary terms and requires analysts to make decisions about the mon- etary value to be attached to, for example, an AIDS death. In cost- effectiveness analysis such value judgments are not required, and consequences are measured in terms of infections or deaths averted. Cost-benefit analysis of H[V/AIDS programs for all Eastern European and Central Asian countries was conducted for 2001-10. For each country the costs of implementing a comprehensive pre- vention program were obtained and assumptions made about cover- age rates and population risk groups. The cost, population, and cov- erage data were derived from estimates by the U.N. General Assembly Special Session on AIDS (UNGASS) for global I-fV/AIDS program resource needs, which were then refined for countries in the region (Schwartlander and others 2001b). The num- ber of HIV/AIDS infections averted as a result of implementing pre- vention programs was calculated using the AIDS Impact Model (ALMS).8 The direct benefits of HIV prevention programs are saved lives, prevented disease, avoided or diminished disability, reduced absenteeism, and saved treatment costs. These benefits can be con- verted into monetary terms and compared with program costs to derive net benefits (benefits net of investments in prevention). Direct costs refer to the costs of treating people with I-ITV/AIDS; indirect costs refer to the averted costs from an AIDS death measured in terms of productive life years and wages. Costs minus benefits (both measured in dollar terms) produce net benefits. Since a dollar earned in the future is less valuable than a dollar earned in the present, all future net benefits are discounted, at a rate of 10 percent. Comparison of the costs of prevention programs and economic benefits shows that benefits from averted HIV infections far exceed the costs. Cost-benefit analyses of HIV/AIDS prevention programs in the Russian Federation, for example, show that net benefits are potentially large, with the benefit-cost ratio clearly in favor of pre- vention (table B4). Governments in Eastern Europe and Central Asia would thus be well served by adopting EIV/AIDS prevention programs early. 76 * Averting AIDS Crises in Eastern Eu'rope and Central Asia Table B4. Cost-Benefit Analysis of HIV/AIDS Prevention Programs in the Russian Federation, 2001-10 (current dollars) COSTS OF DIRECT INDIRECT TOTAL NET TOTAL YEAR INTERVENTION BENEFITS BENEFITS BENEFITS BENEFITS BENEFITS 2001 0 0 0 0 0 0 2002 0 0 0 0 0 0 2003 85,784 0 0 0 -85,784 -85,784 2004 100,271 0 0 0 -100,271 -100,271 2005 115,174 33,689 1,034,849 1,068,538 953,364 787,904 2006 131,082 58,286 2,032,935 2,091,221 1,960,139 1,472,681 2007 150,001 92,356 3,458,975 3,551,331 3,401,330 2,323,154 2008 168,001 135,549 5,435243 5,570,792 5,402,791 3,354,708 2009 188,161 189,976 7,937,567 8,127,542 7,939,381 4,481,574 2010 225,793 256,401 11,083,955 11,340,355 11,114,562 5,703,527 Source: World Bank Estimates 2003. Conclusion The potential economic and social impacts of a generalized HIV/AIDS epiclemic in Eastern Europe and Central Asia are large. In the case of a generallized epidenmic causing premature illness and death in the productive age groups, the following impacts are possible: * Economic growth rates could decline by 0.5-1.0 percentage points a year. * Health expenditures for treating people with HIV/AIDS could increase 1-3 percent. These expenditures could be effectively addressed through social and health insurance systems. However, evidence from many Eastern Europe and Central Asia countries, particularly the CIS countries, shows that social insurance systems are still evolving. In several cotntries, especially the low-income CIS countries, out-of-pocket spending is one of the most impor- tant sources of health care financing. There is a risk that expendi- tures for HAART would be borne by households, contributing to a growing gap in health status between different income groups in Annex B: The Economic, Poverty, and Human Development Impacts * 77 society. Potential public expenditures on HAART need to be looked at in the broader context of health care needs, the availabil- ity of resources, and allocative efficiency concerns. Both in terms of potential public and private spending on HAART, a better option is to invest now in averting new infections. * The dependency ratio could change, putting strain on social pro- tection systems, especially in countries already experiencing declining fertility rates (Belarus, Estonia, Moldova, the Russian Federation). * Household size and composition could change, with an increase in single-parent households, households managed by the elderly, and households headed by children. This change could exacerbate the vulnerability of households, with negative intergenerational effects on households as children are forced to drop out of school to work or take care of siblings, thereby reinforcing the "poverty trap." Estimates of the costs and benefits of prevention programs clearly show that the benefits associated with prevention programs out- weigh program costs. Countries thus need to emphasize prevention as part of a program that also includes treatment. ANNEX C Interventions against HIV/AIDS and Tuberculosis in Eastern Europe and Central Asia: The Evidence Base and Gaps in Knowledge This annex reviews the evidence on the effectiveness of interventions against HIV/AIDS and tuberculosis, primarily at the population level. It draws on examples and lessons learned globally while focus- ing on Eastern Europe and Central Asia. Because HIV prevalence rates are low throughout the region (with the exception of high- prevalence pockets, such as St. Petersburg, Russia), the discussion emphasizes prevention efforts. Most of these rely on population- based and multisectoral public health approaches, including surveil- lance, education, evaluation, and data-based policy implementation. Prevention Strategies In many countries in the region, the overall prevalence of LilY is low but rates are high among vulnerable subgroups, such as injecting drug users, commercial sex workers, and, to a much smaller extent, men who have sex with men. Even where HIEIV prevalence is low in vulner- able subpopulations, other sexually transmitted infections and high- 79 80 o Averting AIDS Crises in Eastern Europe and Central Asia risk behaviors, such as sharing needles, may be common, signaling that I-UV prevalence may increase in the future. In most countries, there- fore, there is a historical opportunity to prevent the potential explosion of HIIV infection. It is often difficult to mobilize the necessary politi- cal commitmnent in a low-prevalence setting. The prevention approach thus necessitates calling attention to the history of other countries in which prevalence was low in the early stages of the epidemic and exploded due to widespread precursor risks and inaction. Given this low prevalence in most of the region, understanding the efficacy and cost-effectiveness of prevention efforts is critical to the efficient use of scarce health system resources. It may take con- siderable time for prevalence to increase to high levels in the region, but low prevalence does not justify complacency: if each infected person transmits HIV to more than one other person on average, the epidemic will inevitably grow. If the precursor social and behav- ioral conditions to the spread of -HLV are recognized, this growth can be abated. In Eastern Europe and Central Asia, such precursors are evident. Poverty, the degradation of national health systems, and postcon- flict and post-Soviet social disruption have created vulnerahilities and risk conditions in the region. This section examines public health approaches to these risk conditions and to prevention prac- tices, considering the broader social context and the need for a mul- tisectoral approach.9 It does not focus on interventions targeting people already infected with H1V, except as these interventions can prevent the spread of HIV from them. To better understand the concept of prevention in the context of the HIV/AIDS epidemic in the region, it is helpful to review the theoretical bases for prevention science. Three stages of prevention can be distinguished: o Primary prevention refers to interventions applied before infec- tion or onset of disease. Examples include treatment of sexually transmitted infections other than -HIV, condom use to protect uninfected people, and school-based education about the risk fac- tors associated with HIV transmission. Annex C: Interventions against HllY/AIDS and Tuberculosis * 81 * Secondary prevention refers to interventions applied after the acquisition of the virus but before the onset of symptomatic ill- ness. Interventions include IH-AART, which delays the progression from HIV infection to AIDS and may prevent transmission to others by lowering the potential of the carrier to infect others (an example of primary prevention for the individual yet to be infected). An example of secondary prevention of syphilis would be treatment of primary syphilis in order to prevent progression to secondary syphilis. * Tertiary prevention refers to interventions applied after a disease has been contracted but before significant disability has occurred. After the onset of AIDS, tertiary prevention may include social services and palliative care to prevent destitution and physical suf- fering experienced in the end stages of AIDS. Many modes of primary HIV prevention exist, the efficacy of which may vary by country. In the low-prevalence nations of East- ern Europe and Central Asia, broad-based population approaches alone will not be as cost-effective as approaches focusing on highly vulnerable grooups (Brown and others 2001; Walker 2003). It is also important to target not only particular risk groups hut also their sex partners and sexual networks. Strategies developed in other regions to prevent the spread of HRV include: * Blood screening and promotion of blood safety. * Mass media campaigns. * Educational projects targeting young people. * Social marketing of concloms. * Treatment of sexually transmitted infections. * Educational projects targeting commercial sex workers and their clients. * Harm reduction strategies among injecting drug users. 82 o Averting AIDS Crises in Eastern Europe and Central Asia o Voluntary counseling and testing. o Prevention of mother-to-child transmission. o Use of microbicides and female-controlled methods for prevent- ing sexually transmitted diseases. The appropriate mix of primary prevention strategies can be effective in changing risk behavior and subsequently HIV transmis- sion in low- and middle-income countries (Merson, Dayton, and O'Reilly 2000). If applied early enough, primary prevention tech- niques can even significantly reduce the national prevalence of HrV/AIDS in more well-established epidemics. However, little evi- dence has been compiled on the relative cost and likely impact of dif- ferent interventions in Eastern Europe and Central Asia. Infrastructure for HIV prevention is needed as part of health system development. So, too, are development efforts in other sec- tors, such as labor, military, education, and civil society. Creation of this infrastructure requires identification of risk groups, surveil- lance of trends of infection within these subpopulations, assess- ment of behaviors leading to the spread of HIV, and surveillance of risk factors such as injecting drug use (particularly needle shar- ing), sexually transmitted infection incidence and treatment, and sexual practices associated with HIV/AIDS. In low-prevalence countries, behavioral change may be the most important primary prevention channel. Thus behavioral surveillance, especially among vulnerable subpopulations, is an important surveillance need. Without clear identification of patterns of risk behavior, monitoring of behavior change in response to education and pol- icy interventions, and development of knowledge on risk group behaviors in general, primary prevention efforts cannot be scien- tifically applied. In Eastern Europe and Central Asia, health system projects funded by the World Bank often address reforms in terms of financ- ing, rationalizing, and increasing access to packages of services. In a multisectoral approach, improving public health requires expanded thinking to ensure financing for public goods (such as surveillance Annex C: Interventions against HIV/AIDS and Tuberculosis * 83 systems and clinical trials specific to pilot projects among high-risk groups) that might not be included in financing packages for direct medical care services. Promoting health, tracing and testing con- tacts of high-risk people, and addressing marginalized populations' needs have not been prominent in health systems projects. Some- times this may mean adding specific components to address public health infrastructure; in other cases it may mean providing for spe- cific training and technical assistance in the fields of HIV/AIDS and tuberculosis control. Surveillance Effective surveillance systems are key to controlling any infectious disease, but HIV surveillance systems need to be tailored to the state of the epidemic (Schwartlander, Ghys, and others 2001). In low- level and concentrated settings, doing so requires focusing on mon- itoring key population subgroups with higher risk levels rather than general population groups, such as prenatal clinic attendees (Brown and others 2001). Surveillance data can also be used to mobilize public opinion and to monitor the success of a government's or community's response to an epidemic in terms of observing both behavior change and changes in sero-prevalence. In Eastern Europe and Central Asia, very little is known about the true extent of the epidemic or the response of various risk pop- ulations to any of the interventions undertaken to date (Hamers and Downs 2003; Novotny, Haazen, and Adeyi 2003). Data on newly diagnosed HIV infections depend on patterns of HIV testing and reporting, and coverage in Eastern Europe and Central Asia is very incomplete (EuroHTV 2002). There is little evidence, for example, of the spread of HITV among men who have sex with men in the region, although this lack of evidence probably reflects the margin- alization of this subgroup rather than the low level of sero- prevalence. Biological surveillance is a key element for planning and assess- ing primary and secondary prevention activities. This type of sur- veillance includes: 84 o Averting AIDS Crises in Eastern Europe and Central Asia • Ongoing HI-V screening of donated blood, which also serves as a tool for eliminating the spread of HIV through blood transfusion. o Sentinel serological surveillance of defined risk group subpopula- tions (such as injecting drug users, commercial sex workers, mobile populations). This type of surveillance can be done through special clinics, treatment facilities for injecting drug users, sexually trans- mitted infection clinics, and employment sites. o Anonymous HI[V testing of blood samples of specimens taken from general population surveys used for other purposes (blood lead screening, cholesterol levels, and so forth). If a demographic and health survey that includes blood sampling is undertaken, sera could be submitted for I-UV screening as anonymnous, unlinked specimens. o Anonymous or nonanonymous IITV screening of specimens taken as part of special population surveys (as in research or eval- uation studies). o Anonymous or nonanonymous HITV testing of people using vol- untary counseling and testing sites. Limitations exist in each of these serological access points. The sensitivity and specificity of laboratory tests are important, because in low-prevalence settings, even with highly sensitive tests, the pre- dictive value of such tests is very limited.'0 Thus screening in East- ern Europe and Central Asia should be limited to people with high- risk profiles. Given the limited, passive surveillance systems now in place, most of the high-risk groups will not be screened. However, with a broader collection of serologic data, these disparate sources can provide a broad picture of the epidemic in a region or country. In Western Europe the most frequently used methods of popula- tion screening for HIV include sampling pregnant women, testing blood donors, and testing drug users and people with sexually trans- mitted infections who volunteer to be tested (Hamers and others 2003). Beginning in 1999 some sentinel surveillance activities of commercial sex workers and men who have sex with men were Annex C: Interventions against HIV/AIDS and Tuberculosis * 85 implemented in Eastern Europe and Central Asia, but these activi- ties have not been integrated into national program activities to monitor HIV/AIDS epidemics. Because of low utilization, little use- ful population-based information has come from anonymous volun- tary counseling and testing sites (Grund 2001; Dehne and others 2000). Data based on diagnostic testing from referral hospitals and specialty clinics are subject-to significant participation bias because of the stigmatization associated with HIV infection and the nonrep- resentative nature of such data collection. Sentinel surveillance may track infection in subpopulations by drawing blood for other diagnostic purposes or during routine check-ups. It can either be stripped of identifying markers to ensure anonymity and minimal bias or reported back to the patient (together with pre- and posttest counseling). When samples are purposefully collected for HIV testing, informed consent is neces- sary. Positive test results require referral and possible treatment, which nmay not be available in all health systems in the region. With informed consent comes participation bias: people who do not Nwish to know their HrV status or have it reported will not be tested. Another area in critical need of improvement is behavioral sur- veillance. Good cross-sectional behavioral surveillance data will identify subpopulations at risk and help focus serological sampling efforts to yield maximum population information. Behavioral sur- veillance can identify risk behaviors associated with HIV transmis- sion in both the general population and subpopulations, such as vul- nerable young people, to help target future prevention interventions. National and risk group-targeted surveys include questions on behaviors that lead to risk (sharing needles, not using condoms, trading sex for drugs), as well as questions about attitudes and knowledge of transmission methods and prevention practices. In order to tailor behavioral surveillance systems to specific epi- demic conditions, it may be useful to consider several key questions posed by Pisani (2002) regarding low-level and concentrated epi- demics such as found in Eastern Europe and Central Asia: * Are there risk behaviors that might lead to an HIV epidemic? 86 o Averting AIDS Crises in Eastern Europe and Central Asia o In which subpopulations are those behaviors concentrated? o How common are the risk behaviors? o How large are these subpopulations? o How high is HIV prevalence in these subpopulations? o What are the links between subpopulations? Behavioral surveillance is seldom integrated into national surveil- lance programs for iIEV/AIDS, but reports have shown the value of such information. A study of 2 39 injecting drug users recruited from community sites in St. Petersburg reported that 41 percent regu- larly shared needles, most had multiple sexual partners, and 70 per- cent engaged in intercourse without condoms (Somlai and others 2002). Given the high rates of syphilis and other sexually transmit- ted infections in St. Petersburg, the potential for transmission among bridge populations is enormous. Reported behavioral indicators of risk include (Pisani 2002): o Having had sex with a nonregular partner in the past 12 months. o Not having used a condom during last sexual contact with a non- regular partner. o Having early onset of sexual activity (younger than age 13). o Sharing unclean injecting equipment. o Having multiple sexual partners (injecting drug users). o Having large number of clients per week, irregularly using con- doms, and having poor access to condoms (for commercial sex workers). o Being highly mobile. Reporting of HIV/AIDS cases to the WvHO and the EuroHIV Centre, required of all countries, may represent only a population- based assessment of the tertiary disease burden (that is, flll-blown Annex C: Interventions against HIV/AIDS and Tuberculosis * 87 AIDS rather than HIV sero-positivity among vulnerable or general populations). FIIV/AIDS data include reporting country, age at diagnosis, gender, date of diagnosis, date of report, transmission cat- egory, IXV/AIDS indicative diseases at diagnosis, type of virus, date of first I-iV-positive test, vital status (alive or deceased), and date of death. Reporting of AIDS cases does not, however, adequately con- vey the nature and rapidly changing dynamics of the FIIV epidemic. The number of people with AIDS increases only years after HTV incidence rates increase. Forty-one countries in the European Region of the WHO had nationwide reporting systems for HIV by the end of 2000. Data through the end of 2001 indicate that rates of HIV infection have increased much more rapidly rate in Eastern Europe than in West- ern or Central Europe. The largest increases were in the Russian Federation (374 per million), Estonia (276 per million), and Latvia (195 per million) (Hnamers and Downs 2003). WVhile heterosexual transmission has increased in the region, infection by injecting drug users remains the main source of new reported infections. Thus behavioral and sentinel biologic surveillance among injecting drug users is critical to understanding the HFIV/AIDS epidemic in the region. Although efforts are currently being made to improve both biological and behavioral surveillance in the region (surveys in major cities in the Russian Federation were conducted by the Vozrastcheniye Foundation and the Research Institute for Complex Social Studies of the St. Petersburg State University in 1997-98, for example [Smolskaya 1999]), additional targeted efforts are needed. Evidence suggests that both Uganda and Thailand have improved intervention programs based on the results of behavioral and biological surveillance. In Thailand, where surveillance of NIXV/AIDS is comprehensive, data from population-based behav- ioral surveys showed that about 25 percent of all men visited com- mercial sex workers; sentinel serologic surveillance data indicated that 44 percent of commercial sex workers in Chiang Mai were infected with HIV (WHO and others 2000). Publication of these data encouraged the development of a 100 percent condom use policy for brothels; implementation of broad-based public educa- 88 o Averting AIDS Crises in Eastern Europe and Central Asia tion about HAIV/AIDS risks; involvement of multiple other sectors of society, such as media, transportation, and labor; and develop- ment of human rights protections for infected people. The inci- dence of HIIV infection in Thailand fell 80 percent from the level reported before implementation of the national program (USAID and the Synergy Project 2002). In Uganda sentinel sites showed a significant decline in incidence after high-level political support was declared by the President of Uganda and multisectoral responses were supported, including responses by the education, transportation, entertainment, and media sectors (USAID and the Synergy Project 2002). Without appropriate sentinel surveillance, linkage of program efforts to out- comes might not have been possible. Other sources of information for I-IIV surveillance include track- ing death registration, behavioral studies, and sexually transmitted infection data (which reveal unprotected sex outside of monoga- mous relationships). The results of syphilis testing among pregnant women, for example, may be a part of HIV surveillance systems if used as an indicator of risk behavior. Surveillance of other condi- tions, such as hepatitis B and C and tuberculosis, can also be used to indicate population risks for HIV infection. The new surveillance system for sexually transmitted diseases being implemented across Europe will improve public health tracking of sexual behavior indi- cators (Hamers and Downs 2003). Newer techniques, such as rapid HTV testing using non- laboratory-based methodologies (OraQuick HIIV rapid test [U.S. CDC 2003a]), could improve the ability to conduct surveillance, particularly in difficult to reach populations (Phili and Vardas 2002). These techniques do not depend on referral to specialist clinics and laboratories or on later follow-up for feedback of results They do, however, depend on outreach by trained testers and counselors and on the availability of referral mechanisms for people who test posi- tive. They provide patients with their results immediately, so that they may be encouraged to refer their sex partners (and needle-shar- ing partners) for testing and be encouraged to change their risk behavior to prevent the spread of lIlI Annex C: Interventions against HIV/AIDS and Tuberculosis * 89 Surveillance data can generate a public response to the HIV epi- demic, especially in regions where it is still invisible. Identifying the links between risk groups and the general population is critical to understanding the nature of EI]V/AIDS epidemics in the region. In addition, it is important to understand the beliefs and attitudes of health care professionals and political decisionmakers who can shape national responses to HIV/AIDS. Given the evidence that surveillance systems in other regions have been an important tool for tracking and identifying the course of the HIV epidemic, the World Bank will encourage efforts to improve public health infrastructure as part of health system reform. Specific HIV/AIDS surveillance indicators should be incorporated into any new health information system programs at their inception (Hamers and others 2003). The World Bank's comparative advan- tage in this area is in supporting public health surveillance system development as part of overall health systems operations and broader disease prevention programs. It could support operational research to understand the bridging between risk groups and gen- eral populations, to evaluate specific program applications among high-risk groups, and to inform dialogue with decisionmakers across disciplines and levels of government to ensure leadership on the prevention of HLV/AIDS in Eastern Europe and Central Asia. Table Cl summarizes the specific key objectives, target groups, methods, and possible priorities for developing FI-V/AIDS surveil- lance systems in the region. The World Bank's comparative advan- tage in each of these areas will vary from country to country, depending on the most important risk groups, the status of the epi- demic, the technical capacity of the client country, and cooperation with partner agencies. Voluntary Counseling and Testing The crucial role of voluntary counseling and testing has been recog- nized in Sub-Saharan Africa and Southeast Asia, the regions hardest hit by the I[V/AIDS epidemic. Voluntary counseling and testing are of paramount importance in both preventing and treating 90 o Averting AIDS Crises in Eastern Europe and Central Asia I-IV/AIDS. This process involves pretest counseling, posttest coun- seling, and biologic testing for the presence of -IIV antibodies, usu- ally by blood or saliva. In addition to testing for the presence of FIV, this intervention, usually performed by a specially trained health educator or counselor, helps identify risk behaviors that should be changed to prevent further transmission, encourages sex and needle- sharing partners to be tested for HIV and provides information about services for people infected with H[V (including possible treatment). This process is often anonymous, but when conducted as a referral to a specialty hospital-the usual pattern in Eastern Europe and Central Asia-this is not always the case. Depending on the resources of the clinic or testing center, participants may receive their results immediately or they may have to return in several days to receive their results. Not surprisingly, most people express a strong preference for receiving their results immediately (Respess, Rayfield, and Dondero 2001). Newer, faster testing technology may increase utilization of voluntary counseling and testing. Voluntary counseling and testing in Eastern Europe and Central Asia is usually not provided in stand-alone centers. Instead, this intervention is usually provided by general hospitals or clinics, typi- cally within the reproductive health or infectious disease depart- ments. These services are also provided by NGO-based clinical proj- ects facilities such as Medicins Sans Frontieres, the Open Society Institute, and the International Committee of the Red Cross. Novel approaches to providing this service include mobile testing services in rural communities, in places where drug users congregate, in places where commercial sex workers are active, and in populations groups with marginal medical care (for example, in Roma communi- ties). Mobile outreach work, including referral to voluntary counsel- ing and testing, has been conducted in Bulgaria, along with needle exchange and education, but the outcomes have not yet been evalu- ated. Participants are counseled on various strategies to inform their sexual partners of their status and to encourage them to be tested. Several potential positive outcomes result from participating in voluntary counseling and testing services, but there is a significant risk that identification of HTV status among already highly stigma- Table C1. Objectives, Target Groups, and Methods for HIV/AIDS Surveillance in Eastern Europe and Central Asia SURVEILLANCE OBJECTIVE TARGET GROUP METHOD PRTORIMYI Risk behavior in vulnerable Injecting drug users, commercial sex workers, Cross-sectional surveys among target groups 1 groups young people, mobile populations Knowledge among young Out-of-school young people, students, School-based behavioral surveys; special 2 people military recruits research for out-of-school young people Knowledge/attitudes Physicians, health policymakers, insurance Special research studies 1 among health professionals program managers Population behavioral and Pregnant women, general population Prenatal clinic blood sampling, blood 4 sero-prevalence (bridge sampling and questions from demographic population) and health surveys Risk group sero-prevolence Injecting drug users, commercial sex workers, Inclusion of HIV testing on specimens, work 2 mobile populations, military personnel, patients with NGOs for access of sexually transmitted infection clinics Serological trends over Injecting drug users, commercial sex workers, Inclusion of HIV testing on specimens, work 4 time in risk groups mobile populations, military personnel, patients with NGOs for access of sexually transmitted infection clinics Virologic resistance All people tested Any specimen referred for HIV testing 5 and subtypes Program evaluation Injecting drug users, commercial sex workers, Any specimen referred for HIV testing 4 mobile populations, military personnel, patients of sexually transmitted infection clinics Note: I = now, high priority; 2 = soon, high priority; 3 = soon, medium priority; 4 = future, medium priority; 5 = future, low priority. Source: World Bank. 92 o Averting A.IDS Crises in Eastern Europe and Central Asia tized populations will lead to job loss, social disruption, and increased marginalization. Testing can help alter the risk behavior of those who test negative, however, improving their chances of remaining so. In low-prevalence countries, people may not feel comfortable visiting stand-alone voluntary counseling and testing centers for fear of being identified as at risk for HIIV. For this rea- son, where appropriate, voluntary counseling and testing services may need to be further integrated into health service activities, by including HIV testing as a routine part of medical care when indi- cated by the risk profile of the patient population. Simplified I-lV-testing procedures (rapid diagnostic tests) may also be applied. Such procedures are part of a new HIV/AIDS initiative now under evaluation by the Centers for Disease Control and Prevention in the United States (U.S. CDC 2003a). Voluntary counseling and testing should be seen as a gateway to services rather than simply a surveil- lance or information collection tool. Clinical trials in Kenya, Tanzania, and Trinidad demonstrated the cost-effectiveness of voluntary counseling and testing in reducing HFIV risk behavior (Coates 2000; Walker 2003). Similar results were found in a voluntary counseling and testing program in Rwanda (Allen and others 1992). Results from Uganda highlight the link between voluntary counseling and testing and changes in risk behavior. After the widespread introduction of voluntary counseling and testing in 1990, condom use rose from 10 percent to 89 percent with steady partners and from 28 percent to 100 percent with non- steady partners within several years of program implementation (USAID and Synergy Project 2002). Similar findings have been documented in the United States, where anonynmious testing has been linked to earlier medical treatment for people with HIV and reductions in HITV risk behavior (Valdiserri and others 2000). In most of Eastern Europe and Central Asia, there is a need to increase public awareness of the availability of voluntary counseling and testing and to diversify the locations of testing centers. Good- win and others (2003) report that 40 percent of a sample of people from business communities in Georgia and Poland did not know where they could be tested for IHIV Annex C: Interventions against HIVIAIDS and Tuberculosis * 93 Further complicating the implementation of targeted voluntary counseling and testing in Eastern Europe is the history of testing in the region. Bulgaria and the Russian Federation had compulsory testing in the early 1990s, which served to identify people with HIV as "social deviants." Discrimination against people with the disease persists today (Rhodes and others 1999). The lack of testing facilities, the lack of culturally appropriate approaches to testing, and the general public's limited knowledge about HI-V are all barriers to voluntary counseling and testing. These issues need to be addressed if voluntary counseling and test- ing is to become an effective intervention in the region, particularly among high-risk groups. In countries with high prevalence rates, there is strong evidence that voluntary counseling and testing can have a positive impact on changing high-risk behavior and that informing people of their -IIV status is useful. In countries with low-level and concentrated epidemics, where appropriate, voluntary counseling and testing services could be incorporated into general health centers and special facilities for marginalized groups, not provided at stand-alone testing centers. In addition, public informa- tion about the availability of voluntary counseling and testing for those at high risk may need to be socially marketed in order to edu- cate both the groups themselves and the general public about its availability and appropriateness (Global HIV Prevention Working Group 2002). This does not mean that everyone in Eastern Europe and Central Asia should be tested; resources are insufficient for this inefficient and cost-ineffective approach. Voluntary counseling and testing should target high-risk groups, and the barriers for voluntary counseling and testing among these groups should be addressed. Voluntary counseling and testing can also be used in conjunction with National Tuberculosis Program activities. In 1998 the VWHO launched the ProTEST initiative, to set up operational [inks between HUV prevention and control and National Tuberculosis Program or general health services. The initiative involves both provision of and demand for voluntary counseling and testing for HIIV as entry points to a range of 1I1V and tuberculosis prevention and care interventions. In addition to voluntary counseling and testing, the range of services 94 o Averting AIDS Crises in Eastern Europe and Central Asia provided under ProTEST includes tuberculosis screening and active case finding, treatment of active cases, secondary and tertiary preven- tive interventions for people with HIV or AIDS, treatment of sexu- ally transmitted diseases, and support and care for people with EIIV/AIDS. The initiative is still experimental in a few countries in Sub-Saharan Africa; national coverage is expected in three to five years (http://www.who.int/gtb/policyrd/TBHIVhtm#ProTEST). Preliminary cost-effectiveness analyses indicate that voluntary counsel- ing and testing, and the subsequent treatment of active cases or pre- ventive therapy, are relatively affordable (http://www.who.int/gtb/ tuberculosisHJV/Durban_febO3/index.htm). The World Bank's comparative advantage in this intervention lies in its capacity for multisectoral policy dialogue concerning the high- risk groups who bridge to the larger population. Increased availabil- ity of voluntary counseling and testing through targeted approaches can be integrated into multisectoral and health system operations supported by the Bank. IHlarm Reduction Strategies Injecting drug use was not widespread before the fall of the Soviet Union. In fact, draconian police policies probably had a great deal of impact in preventing drug trafficking in the Soviet Union (Kelly and Amirkhanian 2003). Studies of injecting drug users in Southeast Asia provide clear evidence of the risk for the explosive spread of JITV associated with such groups (USAID and the Synergy Project 2002). HIV trans- mission through commercial sex workers in Southeast Asia has been attenuated through 100 percent condom use in brothels, but the epidemic among injecting drug users continues unabated. The populations of commercial sex workers and injecting drug users overlap significantly. Western countries have reported little success in controlling the HI-V epidemic among injecting drug users through supply-side drug interdiction modalities. However, supply- side interventions in Eastern Europe and Central Asia may require further investigation; as yet, little investigation of such interventions Annex C: Interventions against IGV/AIDS and Tuberculosis * 95 has been undertaken. Given the youth, mobility, and behavioral pat- terns supporting spread to bridge populations of injecting drugs users, it is unlikely that the HIV epidemic will remain confined to this group (Kelly and Amirkhanian 2003). Harm reduction is a somewhat controversial approach to reducing risk among subpopulations, primarily injecting drug users and com- mercial sex workers. It recognizes that drug treatment programs rarely attain total abstinence and that the number of commercial sex workers will expand in the face of economic deprivation in Eastern Europe and Central Asia (Singer 1997; Open Society Institute and International Harm Reduction Development 2002). This approach promotes pro- grains that minimize or reduce transmission in the face of persistent risk behavior, lowering but not eliminating risk. Harm reduction pro- grams include needle and syringe exchanges, drug dependency treat- ment and rehabilitation, and 100 percent condom use programs for commnercial sex workers. In New York City an advanced epidemic among injecting drug users vas reversed through legal, widespread needle and syrinige exchange programs; counseling; testing; and outreach activities (Des Jarlais and others 1996, 2000). Betwveen 1991 and 1996 HTV inci- dence among injecting drug users declined more than 40 percent. Needle and syringe exchange programs are often linked to other services, thus providing a bridge to FIV/AIDS information, risk reduction materials (bleach and condoms), voluntary counseling and testing, and referrals to drug abuse treatment and other social serv- ices (Global HIV Prevention Working Group 2002). Little is known about behaviors among injecting drug users in Eastern Europe and Central Asia, and there have been no rigorous evaluation studies of harm reduction programs provided to this sub- population. It is likely that harm reduction programs for injecting drug users are cost-effective, though. In Belarus, for example, the cost of averting a single H-IIV infection was estimated at $68 (UNAIDS 2000). Most needle and syringe exchange programs in Eastern Europe and Central Asia are conducted by local NGOs funded by the Open Society Institute. The Open Society Institute established the inter- 96 o Averting AIDS Crises in Eastern Europe and Central Asia national harm reduction program in 2000 to fund NGOs in 12 countries in the region. This effort reaches injecting drug users and commercial sex workers with information, education, counseling, referrals, and follow-up services. Integrating such programs into the national plan is problematic, in large part because of the stigma associated with injecting drug users and the perception that such programs support illegal activities. Other groups also support harm reduction in the region, includ- ing the Red Cross (needle exchange), the Transnational AIDS/STD Prevention Among Migrant Prostitutes in Europe Project (TAM- PEP) (commercial sex worker outreach and networks), the Interna- tional Organization on Migration (commercial sex workers and injecting drug users), and M6decins Sans Frontieres (clinical and harm reduction services). USAID supports demand reduction through school-based and other education programs for young peo- ple on the relationship between injecting drug use and HJIV/AIDS. Commercial sex workers are a high-risk group for HIV because of their multiple sexual partners and because of their exposure to concomitant sexually transmitted infections that facilitate HIV spread. Studies from India, Thailand, WVestern Africa, Uganda, and elsewhere have shown the cost-effectiveness of condom promotion, peer education, and availability of treatment for sexually transmitted infections for commercial sex workers (Global HIV Prevention Working Group 2002). A related issue for many commercial sex workers in Eastern Europe and Central Asia relates to trafficking in women and girls, a phenom- enon associated with the financial and social disruptions following the dissolution of the Soviet Union and with postconflict situations, including lack of governance, in parts of the region. In 1997 the Inter- national Organization on Migration estimated that such trafficking involved 175,000 women and girls from Central and Eastern Europe and the NIS, representing one-quarter of all women involved in such trade worldwide (IOM 2002). Experience in other regions of the world reveals the high vulnerability of trafficked women and children to HIV/AIDS and sexually transmitted infections. Little evidence for effective interventions and awareness is seen in Eastern Europe and Annex C: Interventions against HIV/AIDS and Tuberculosis * 97 Central Asia. Most interventions are by NGOs, and integration of these programs into national HIV/AIDS activities is lacking. Stigma- tization, marginalization, and legal barriers (prostitution is illegal throughout the region, and returning sex workers are often ostracized by home country authorities) complicate effective interventions. The World Bank's comparative advantage in harm reduction includes its capacity to integrate different approaches into policy discussions in multiple sectors, including ministries of justice. Efforts could include providing nonlending (analytical and advisory) services and support for operational research in grant-, credit- or loan-supported projects to assess efficacy and cost-effectiveness of harm reduction and other prevention programs; involving NGOs working on harm reduction in policy dialogue at the country level; and, where allowed by governments, financing drug dependency treatment and rehabilitation programs, needle and syringe exchange programs, and outreach work with commercial sex workers and injecting drug users to reduce risk behavior among them. Most important, the WA;orld Bank needs to engage governments and local institutions in policy dialogue to recognize the public goods involved in providing special attention to injecting drug users and commercial sex workers and their partners, the bridges to the gen- eral population. Where legal reform has been applied during low- level epidemics (as it has in Switzerland), the spread of HIV spread has not been explosive. Where there has already been an explosion, harm reduction has helped reverse a growing epidemic (in New York City), albeit at high cost. Decriminalizing injecting drug users, commercial sex workers, and homosexuals should at least be consid- ered. This legal reform-based approach has had success in Western European programs that address HIV/AIDS in highly marginalized populations (Open Society Institute and International Harm Reduction Development 2003). Health Promotion and Education Health promotion and education are widely recognized as necessary primary prevention approaches to HIV/AIDS as part of modern 98 o Averting AIEDS Crises in Eastern Europe and (Central Asia public health practice. These approaches in Eastern Europe are based primarily in the school system. Broader-based educational activities addressing out-of-school youth, the general public, health professionals, and policymakers are also needed. Health Education for- Young People Education about HIV/AIDS is an important tool for informing young people about behaviors that put them at risk for HITV infec- tion. Worldwide young people account for more than half of new HIV infections, with more than 2.5 million people between the ages of 15 and 24 diagnosed every year (UNAIDS 2002d). Young people are often ill informed about HIIV/AIDS and vastly underestimate their risk of becoming infected. It is preferable that young people obtain information about potential prevention of IIV before becoming sexually active. Evidence from Uganda, where HIV inci- dence has declined measurably, suggests the effectiveness of educa- tion and increased availability of prevention tools to alter risky sex- ual behavior (USAID 2002). Interventions with young people have been shown to be cost- effective in WATestern HIIV prevention programs (Pinkerton, Cecil, and Holtgrave 1998). These strategies include: o Peer programs, the effectiveness of which has been shown in industrial countries for developing safer sex norms among young men who have sex with men. o Social marketing of condom use, safer sex, and other healthy behaviors. o School-based sex education (lacking in most countries in Eastern Europe and Central Asia). o Special services that attract young people to health services, peer counseling, and other services. In Eastern Europe and Central Asia as well as in other regions, pre- vention interventions have been implemented through the school sys- tems. Young people in most countries are required to attend school Annex C: Interventions against IRV/AIDS and Tuberculosis * 99 through early adolescence. In many countries prevention programs targeting students have been highly effective in reducing risk behav- ior that places them at risk for HYIV (Global FIIV Prevention Work- ing Group 2002). All programs provide education and information about FIIV transmission and prevention; some may also seek to change risk behaviors (promoting condom use and encouraging fewer sexual partners or the delaying of sexual intercourse until marriage). Several surveys have found that awareness and knowledge of HIV/AIDS by young people in Eastern Europe is low (Amirkhan- ian, Tiunov, and Kelly 2001; Lunin and others 1995; Westhoff and others 1996). Although the evidence demonstrating the importance of early HIV prevention education is clear, many young people in the region remain at risk because they leave school early and may not be exposed to HJTV-related information that may be delivered during their school careers. Information on high-risk behaviors is also needed. Young people in Eastern Europe are becoming sexually active at an earlier age, and an increase in drug use has been observed (UNAIDS 2002d). Sexu- ally active adolescents who use contraception to prevent pregnancy may also be reducing their risk of HIV if condom use is part of their contraceptive behavior. Contraception is often not used in parts of Eastern Europe, however, because of cost and lack of availability (Novotny, Haazen, and Adeyi 2003). Methods of facilitating access to condoms for young people (increasing access to health clinics that are receptive to young people, providing condoms at schools and youth clubs) need to be explored. Providing focused skills training-teaching young people how to resist negative media and social influence, for example-is another important aspect of education (UNAIDS 1997b). Peer education has also been shown to be effective in reducing HIV risk behavior Cemmott, Jemmott, and Fong 1998). Most programs for young people also include information about the risk of HIV transmission associated with injection drug use and how to prevent drug-related transmission. The importance of these programs lies in their ability to help develop positive intentions regarding sexual behavior before an adolescent's initiation into sexual activity. It is much easier to 100 o Averting AIDS Crises in Eastern Europe and Central Asia adopt preventive behaviors from the start than to try to change established behaviors. School-based programs can combine provi- sion of information with social norms for positive behavior (Peers- man and Levy 1998). In a Rapid Assessment and Response Survey of young people in Eastern Europe conducted by UNICEF (2002a), about half of sex- ually active respondents reported using condoms. Some respon- dents reported that condom use is not necessary with "clean" part- ners; condom use was used primarily for contraception rather than for prevention of sexually transmitted infections. The survey found that TiV/AIDS, drug, and sex education was either nonexistent or inadequate from any source (schools, parents). It also found that young people would get tested for HIV if testing were free, anony- mous, and accessible. Anonymous testing was usually not available in the respondents' communities. Many Eastern European and Central Asian countries are constrained in facilities and funding. But low-resource countries such as Uganda have produced inter- ventions that have reduced the incidence of HIV (UNAIDS 2002c). The evidence argues for inclusion of HIV/AIDS education in schools, but implementation of educational programs is often ham- pered by shortages of funds and a lack of trained teachers with cur- rent information ('1lrabi and others 2000), legal barriers, or social taboos. When conducted properly, however, school-based HrV/AIDS education has been found to be effective. A video-based educational intervention in Russian schools was successful in improving both knowledge scores and attitudes in school children (Torabi and others 2000). Educational programs have been success- fully implemented in other regions with few economic resources, including Sub-Saharan Africa. These types of programs thus seem feasible for Eastern Europe and Central Asia. Education of young people or the general public must be accompanied by infrastructure changes that permit young people-friendly services, widespread availability of condoms at low prices, and social marketing of pre- vention-oriented behavior (that is, the use of mass media, including commercials, public service announcements, and billboards, to pro- vide information). Annex C: Interventions against fHIV/AIDS and Tuberculosis * 101 The Bank's comparative advantage in the field of public informa- tion and health education is significant. Operational research to evaluate the penetration of such messages may be financed by Bank- supported programs. Cooperation across education, health, and social protection sectors is essential to reaching young people and other vulnerable groups with prevention messages, both as part of school education and as part of community-based education. Work- ing with educational teams, human development health profession- als within the World Bank need to identify best practices from other regions for possible adaptation to Eastern European and Central Asian countries. The Bank's greatest challenge may be in promoting collaborative work between ministries. Input into such cross-sec- toral programming could occur within national HIV/AIDS over- sight groups. Edutcation of the General Public The epidemic in the region is concentrated among certain risk groups. Some of these groups are nearly invisible due to stigmatiza- tion. Others-sex partners of commercial sex workers, injecting drug users, and men who have sex with men-mav not even recog- nize that they are at risk. Thus it is important for the general popu- lation to be informed about HIV/AIDS, partly to improve basic knowledge about real risks and partly to reduce the stigma associ- ated with risk for or infection with HIV The general public should be informed about modes of transmission, prevention, and treat- ment options. Social marketing is a proactive approach to noncommercial, pub- lic education on health issues designed to match public needs with products and services (Rogers 1983). It involves informational cam- paigns to diffuse socially beneficial ideas (such as condom use) that address the increases in the incidence of sexually transmitted dis- ease. Such campaigns have recently been used in Albania, Kosovo, and Romania. This may be a useful approach to the epidemic of sex- ually transmitted diseases in other parts of the region as well. In addition, it will be important to address the public's level of comfort with and trust of the health care system and the government in deal- 102 o Averting AIDS Crises in Eastern Europe and Central Asia ing with sensitive personal issues such as HIV and sexually trans- mitted diseases. Social marketing of safer sex to the general public has been shown to be cost-effective in preventing HIV infection (Walker 2003). It should therefore be included in education programs in the region. In addition, access to condoms needs to be increased and their price lowered. Educational messages for the general public need strengthening, and practices among clinical providers who have first contact with patients at risk need improving. Given the high levels of literacy, expanding access to electronic media, and potential channels for transmission (television, radio, Internet) in Eastern Europe and Central Asia, the media may be a particularly important avenue for increasing the low level of knowledge about HIV/AIDS in the region. Studies have already shown the efficacy of social marketing in the region. A survey conducted in Estonia, Georgia, Hungary, Poland, and the Russian Federation revealed that 72 percent of respondents learned about HIV/AIDS primarily through the media (Goodwin and others 2003). In Moscow, a social marketing campaign involved leaflets, television commercials, and advertisements in newspapers and magazines (UNAIDS 1997a). Eighty percent of 1,228 people surveyed reported having seen the campaign, 83 percent found the information important for someone their age, and 93 percent said they would support the introduction of sex education in schools. The media can also propagate false information-reporting, for example, that a cure for AIDS exists. Messages about HIV/AIDS thus need to be monitored for accuracy and validity (Goodwin and others 2003; Dilley, Woods, and McFarland 1997). In addition, in some Eastern European and Central Asian countries, such as Poland, religious institutions (particularly the Catholic Church) may exert a strong influence on the media, which they use to oppose dissemination of the message that safer sex can help prevent HIV prevention (Danziger 1996). Governments must play a role in educating the general public about HIV/AIDS through a clear political commitment. In the United States the I-HV/AIDS epidemic was peaking in the late Annex C: Interventions against HIV/AIDS and Tuberculosis * 103 1980s. At that time, most of the general public was not well informed about HIV/AIDS, and misconceptions were very com- mon. The U.S. Department of Health and Human Services issued pamphlets to every household in the country providing frank infor- mation regarding the risks of transmission of HIV/AIDS and addressing some common misperceptions and myths about the dis- ease and the epidemic (U.S. Surgeon General 1988). Political commitment has been a key component in Thailand and Uganda, where national programs were implemented with national leadership and local support. This political leadership, often mani- fested through media approaches, is key to successful prevention interventions. The Bank's comparative advantage in this area lies in its capacity to conduct policy dialogue with senior decisionmakers at the coun- try level and in providing loans or grants for communications cam- paigns on HIV/AIDS. The Bank funds numerous communications activities, primarily related to health system reform. These activities are often used to explain the need for reform and citizens' rights and responsibilities under reform. They can also be used to provide spe- cific information on HIV/AIDS. Information also needs to be specifically tailored to policymakers, risk groups, young people, and ethnic groups. Employment Group Approaches HIV/AIDS is a multisectoral crisis, necessitating intervention beyond the health sector. Prevention activities targeting health professionals, teachers, military personnel, and transport workers can be effective. Health Care Providers Health behavior, attitudes, and practices among the general public may be influenced by health professionals. Health care providers are often the first point of contact for at-risk or recently infected peo- ple. They must be able to marshal up-to-date information and pro- vide caring treatment to people living with HIV/AIDS. Health providers need training in HIV/AIDS care in order to: 104 o Averting AIDS Cirises in Eastern Europe and Central Asia o Ensure that they can recognize behavior that places people at risk for transmitting or contracting I-RIV o Demonstrate sensitivity in dealing with people with HNV/AIDS. o Refer people with or at risk for HI-V to appropriate specialty and social service resources. o Treat people with NW/AIDS with scientifically based (peer- reviewed) methodologies and drug regimens in order to minimize drug resistance. o Prevent hospital-acquired infection from contaminated blood, reused needles, and unnecessary injection treatments. To perform these activities, health care workers must be ade- quately informed about and sensitive to issues regarding IWV/AIDS, especially issues affecting members of marginalized risk groups. Data are needed on attitudes of health professionals toward HNV and risk group categories. Health professionals' attitudes con- tribute to stigmatization; interventions against stigrmatization must include the health profession. Universal precautions-wearing gloves and goggles, properly disposing of needles and syringes, and carefully handling blood and blood products-are necessary in all health care settings to prevent accidental transmission of NIV to health care workers or patients through reuse of needles, lack of sterilization procedures, or inap- propriate disposal of medical waste. The Bank's comparative advantage here is in support of training and retraining of health professionals, a common component of health system operations in Eastern Europe and Central Asia. This training could focus on: o Reducing the stigma associated with HNV/AIDS and risk profiles. o Updating practices for identifying, testing, treating, and referring people with sexually transmitted infections and NW/AIDS, espe- cially people with opportunistic infections. Annex C: Interventions against HIV/AIDS and Tuberculosis * 105 * Recognizing the social needs of people with HIV/AIDS and developing referral mechanisms for them. * Working with NGOs and advocacy groups to provide extended services and to lobby for appropriate expansion of health services for people with HIV/AIDS. * Using HAART appropriately. * Using injection therapies appropriately and properly disposing of medical waste, including needles and syringes. Milita7y Personnel and International Peacekeepers People serving in the armed forces or in peacekeeping units are at above-average risk of contracting HIIV This group also serves as a bridge for introducing the virus into the general population (UNAIDS/WHO 2002). The risk of military personnel being infected by a sexually transmitted infection (including HIV) is esti- mated at two to five times that of civilians (UNAIDS 1998). The risk is particularly high for men serving in areas of high HIV preva- lence. Forty-five percenit of Dutch naval and marine personnel serv- ing as peacekeepers in Cambodia reported having sex with com- mercial sex workers or other local people (UNAIDS 1998). Little is known about the rates of infection among peacekeepers. The United Nations does not require mandatory testing of deployed soldiers, and countries vary in their policies on testing mil- itary personnel. A WHO study reported that 27 of 52 countries sur- veyed (representing 44 percent of the world's population) per- formed mandatory HIV tests as part of military recruitment. The situation in Eastern Europe and Central Asia is not known, but sev- eral countries in the region provide peacekeepers to the United Nations (D'Amelio and others 2001). Some countries have implemented HIV education programs as a part of basic military training. These programs typically provide voluntary counseling and testing services, condoms, and HrV edu- cation and awareness training. 106 o Averting AIDS Crises in Eastern Europe and Central Asia The United Nations recently passed Resolution 1308, which states that the increased risk of HIV infection for peacekeepers could jeopardize the purpose and success of their missions (Bazer- gan and Easterbrook 2003). Services provided to U.N. troops have been criticized for not taking cultural differences into account, and there is little evidence that specific interventions aimed at reducing HI\V risk behavior among U.N. forces have succeeded. Neverthe- less, given the evidence from successful behavior change interven- tions conducted anmong other high-risk groups, well-designed and -implemented interventions-including social marketing of con- doms, treatment of sexually transmitted infections, and risk educa- tion-could be an important aspect of prevention programs for mil- itary and peacekeeping personnel, even in countries where the overall prevalence rate may be low. Future interventions with mili- tary personnel and peacekeepers should include baseline surveys of knowledge, attitudes, and behavior in order to track the epidemic in these groups and compare these measures with sentinel biological measures of EIIV infection. The Bank's comparative advantage here is in policy dialogue that encourages interministerial cooperation. Defense ministries need to be included in national -LTV/AIDS coalitions or steering groups. The risks associated with peacekeepers need to be measured and understood as a potential entry point for HIV infection. Tru7ckers anzd Mariniers In the Baltics, Southeastern Europe, and elsewhere, high-risk behavior takes place along major transportation routes, including ports (World Bank 2003c; Novotny, Haazen, and Adeyi 2003). Increased rates of sexually transmitted diseases, including JIIV and hepatitis B and C, have been documented in these settings. These corridors and ports are often the location for concentrated commercial sex work and injecting drug use. A study in Uganda found that 35 percent of truck drivers were HIIV-positive (Nzyuko and others 1997). In South Africa 66 per- cent of truck drivers had had a sexually transmitted disease in the pre- vious siX months and 29 percent reported having had sex with com- mercial sex workers without a condom (Ramjee and Gouws 2002). Annex C: Interventions against HIV/AIDS and Tuberculosis * 107 Eastern Europe and Central Asia's transportation corridors and port cities expose the region to these risks. Bulgaria, Croatia, Esto- nia, Latvia, Lithuania, and Poland may be particularly vulnerable, because of their proximity to main transportation routes to coun- tries in which the rate of HITV infection has increased (Belarus, the Russian Federation, and Ukraine) or because they have busy inter- national ports. Prevalence data on HrV infection among truck driv- ers in Eastern Europe and Central Asia are not available, but there are indications that some truck drivers and mariners engage in behavior that places them at risk for HrV infection. An intervention to reduce risk behavior among truckers was imple- mented in Tanzania (Laukamm-Josten and others 2000). The interven- tion used peer education and condom promotion to reduce risk among truck drivers and their sexual partners. The intervention increased con- dom use by men from 56 percent to 74 percent; condom use by their female sexual partners rose from 51 percent to 91 percent. Similar resu-lts occurred in India, where an intervention provided truckers with condoms and targeted education about I-IIV ("sex without condoms is like driving without brakes") (Singhal and Rogers 2003). The Bank's comparative advantage here lies in its capacity to conduct policy dialogue to increase the visibility of the sector as a risk group and to work with industry and civil society groups to improve services, provide risk reduction education, and promote risk reduction tools (such as social marketing of condoms in ports and along transport routes) that are best implemented outside of hospitals or standard clinical environments. Health System Issues The health system is the focus of several preventive opportunities. First, people already infected with -HTV need counseling and refer- ral. This referral may often involve HAART. For the most part, countries in Eastern Europe and Central Asia retain health systems that guarantee treatment for established illness. Providing HAART may represent a major economic burden. Nonetheless, strategies 108 - Averting AIDS Crises in Eastern Europe and Central Asia must be developed to respond to the increasing burden of people infected with HI-V for whom HIAART is indicated. Second, the treat- ment and prevention strategies necessary for sexually transmitted infections have a direct implication for prevention of HTV spread. Providing Eighly Active Anti-retroviral Treatxnent 1AAJRT) H-AART has lowered mortality from AIDS in industrial countries. This therapy is available in many Eastern Europe and Central Asia countries, although it is not clear how widely available it is within each country or whether international standards for quality, moni- toring effectiveness, and minimizing the emergence of drug-resist- ant forms of IHV are being followed. HAART reduces the viral load of people infected with IHV and is associated with several potential prevention benefits. It may increase incentives for voluntary counseling and testing, reduce stigmatization, and reduce the risk of infection by lowering circu- lating viral loads and infectivity. Several significant potential downsides are associated with making HAART more widely available, however. First, HAART may not reduce the incidence of HLIV, because people who continue to live with infection and engage in risk behavior may fuel the epidemic. Second, the presence of a treatmnent that is (erroneously) perceived as a cure may make high-risk groups more prone to reduce preven- tion efforts. Third, inappropriate therapy, self-therapy, or counterfeit drugs used in HAART may lead to avoidable high rates of drug resistance, heavy burdens on health financing systems, and inappro- priate therapeutic regimes resulting from financial deficiencies, all of which can reduce the benefits of HAART to the general population. Preventing Sexuzlly Tlransmitted infections and Reducing the Risk of IUIV Information, education, and behavior change aimed at reducing sex- ually transmitted infections will also reduce the risk of I-UV trans- Annex C: Interventions against IIIV/AIDS and Tuberculosis * 109 mission. Ulcerative sexually transmitted infections may increase the risk of HI-V transmission. Of concern is the fact that syphilis rates are rising in several Eastern European and Central Asian countries. The reported syphilis rate in the Russian Federation, for example, rose from 4.2 per 100,000 in 1987 to 277 per 100,000 in 1997 (Amirkhanian, Tiunov, and Kelly 2001). Transmission of sexually transmitted infections in Eastern Europe and Central Asia is primarily heterosexual. The presence of gonorrhea or syphilis is an indicator of sexual behavior that places one at risk for RIV (Nicoll and Hamers 2002). Thus strategies developed to prevent and treat sexually transmitted infections can also target HIV/AIDS. Reporting of sexually transmitted diseases discovered among pregnant women and commercial sex workers is particularly important. These diagnoses provide an access point for HI-V testing and related behaviorally based prevention. However, such testing programs and the surveillance systems in which report- ing is required are generally weak and unsystematic. Considerable evidence appears to support the need to strengthen and build capacity for prevention and care of sexually transmitted infections. Other strategies for linking approaches to sexually trans- mitted infection ancl HTV1-Include conducting routine HIV screen- ing of patients at sexually transmitted infection clinics. This strategy has been demonstrated to be cost-effective even in low HI-V preva- lence settings (Bos and others 2002). A community-level trial in Tanzania that provided training to health center staff in the treat- ment and management of sexually transmitted infection, antibiotics to patients, and outreach to sexual contacts reported a 40 percent reduction in 1-HV incidence (Grosskurth and others 1995). People most at risk for sexually transmitted infection (such as com- mercial sex workers and men who have sex with men) may fear stigma- tization or prosecution. These fears could be addressed through social marketing of beneficial products and services provided through the health system, with an emphasis on confidentiahty or anonymity. The evidence shows that treatment of sexually transmitted infec- tion is a cost-effective means of preventing HIV infection (Walker 2003). The Bank has a significant comparative advantage in financ- 110 o Averting ADS Crises in Eastern Europe and Central Asia ing-through grants, credits, or loans-large-scale operations that could include service delivery, surveillance, and access to treatment of good quality. Communications activities within operations sup- ported by the Bank could promote socially beneficial ideas that address the growing epidemics of sexually transmitted infection as an intervention opportunity for primary HTV prevention. Controlling Tuberculosis in People with HMA/ADD HIV prevention is a priority for tuberculosis control, since worldwide almost half of people with H[V eventually develop tuberculosis. Pre- vention of active tuberculosis infection and treatment is also a prior- ity to prevent and reduce co-illness and death in people with HI All tuberculosis prevention and treatment activities are applicable regardless of I-UV serologic status. However, special measures to expand and intensify tuberculosis case finding and cure, as well as pre- ventive tuberculosis therapy (treatment of sputum-negative but exposed people using single drug therapy for up to six months), are needed in settings where HIV infection is concentrated, such as among injecting drug users, inmates, commercial sex workers, and contacts of newly identified IIV-positive tuberculosis patients. The ProTest initiative (see annex A), including voluntary counseling and testing and either treatnment or preventive therapy, is likely to be cost- effective (http://wwwwho.int/gtb/pohcyrd/TBHIVhtmn#ProTEST). Tuberculosis prevention in people with HIV/AIDS involves a six- month course of isoniazid preventive treatmnent, which reduces the risk of developing active tuberculosis as much as 40 percent. How- ever, this effect is unlikely to last after treatment, especially in high tuberculosis exposure settings, such as prisons. Complicating the public health approach to tuberculosis is the fact that more pro- longed isoniazid preventive treatment often results in lower compli- ance and possible drug resistance. Thus this secondary prevention approach to tuberculosis should be used only as an individual pre- ventive measure rather than as a large-scale population intervention. The tuberculosis treatment of choice for people with HIV/AIDS is one of three variants of directly observed therapy, Annex C: Interventions against HTI/AIDS and Tuberculosis * 111 short-course (DOTS) for six to eight months. These regimens are clinically proven to result in high cure rates and low tuberculosis recurrence among people infected with HIV. As for chronic and multidrug-resistant tuberculosis cases, second-line drugs are used in specialized settings; cure rates are lower and costs much higher (Maher, Floyd, and Raviglone 2002). Emerging evidence suggests that community-based therapy for multidrug-resistant tuberculo- sis can reach high cure rates in poorer developing country set- tings (Mitnick and others 2003). Any attempt to provide treat- ment and care to multidrug-resistant tuberculosis cases should avoid doing so at the expense of the basic population-based DOTS approach, however. Tuberculosis patients found to be HIV-positive also need referral and possible care for AIDS along with tuberculosis treatment. Sterling, Lehmann, and Frieden (2003) sought to determine the impact of the WI-HO's DOTS strategy compared with that of DOTS-Plus on tuberculosis deaths, mainly in the developing world. They used a study design of decision analysis with Monte Carlo simulation of a Markov decision tree, with data from people with smear-positive pulmonary tuberculosis. The analyses modeled dif- ferent levels of program effectiveness of DOTS and DOTS-Plus and high (10 percent) and intermediate (3 percent) shares of primary multidrug-resistant tuberculosis while accounting for exogenous reinfection. The main outcome measure was the cumulative num- ber of tuberculosis deaths per 100,000 population over 10 years. The findings led to the conclusion that, under optimal implementa- tion, fewer tuberculosis deaths would occur under DOTS-Plus than under DOTS. If, however, implementation of DOTS-Plus were associated with even minimal decreases in the effectiveness of treat- ment, substantially more patients would die than under DOTS. The policy implications are that countries should be encouraged to establish effective DOTS programs before venturing into DOTS- Plus, DOTS-Plus should not be implemented in a way that draws financial resources or managerial attention away from DOTS, and tuberculosis/HIV surveillance should be strengthened, including testing all tuberculosis patients for HIIV 112 o Averting AIDS Crises in Eastern Europe and Central Asia Meeing Social Service Needs Improvement is needed in nonmedical services for people who test pos- itive for HBI Some people may be hesitant to discover their H1V sta- tus, because they believe that they have no recourse should they end up testing positive (Vermund and Wilson 2002). Adequate social and psy- chological counseling services for people with -IIV need to be in place as testing resources become more widely available. These services can take many forms. They can be provided in the context of community centers that provide referrals, medication, information on housing, and care for sick people. These services could be provided by general or specific medical clinics or through social service agencies. Assessments should be conducted to deternine the best vehicle for various groups (several approaches may be necessary). It will also be necessary to cre- ate a workforce able to provide these services, which may entail special recruitment as well as money for specialized training. The development of social services that meet the needs of people with HIV/AIDS should occur simultaneously with the development of prevention services, voluntary counseling and testing services, and surveillance activities. It is essential that services be in place so that people newly diagnosed with HrV have access to information, social services, and medical treatment for AIDS-related diagnoses and full-blown AIDS. The Pole o§ onqoernmena (Or$n ons NGOs provide the backbone for many of the harm reduction and social service support activities for people at risk for or living with HIV/AIDS in parts of the region (Novotny, Haazen, and Adeyi 2003). The Open Society Institute funds NGOs throughout the region to conduct harm reduction and outreach programs among injecting drug users and inmnates. Some countries, such as Croatia, have small gov- ernment offices that support NGO activities as part of national strate- gies (Novotny, Haazen, and Adeyi, 2003). Throughout the region USAID supports NGOs through project-oriented activities focusing Annex C: Interventions against HIV/AIDS and Tuberculosis * 113 on reproductive health, school-based education, social marketing of condoms, and other proven interventions. In several countries, such as Bulgaria, NGOs such as Medicins Sans Frontieres provide direct med- ical care to isolated populations through outreach clinics; voluntary counseling and testing is sometimes also offered in such settings. Mobile populations may need such clinics because of their lack of offi- cial status and subsequent lack of access to government-financed med- ical care in many countries. In Rijeka, Croatia, the local government, using some national government funding and NGO implementation, provides services to injecting drug users and other vulnerable popula- tions outside of official health system physical facilities. Scaling up the project-oriented approach will be the responsibil- ity of governments. The challenge is to retain the independent nature of NGO-delivered services while integrating these activities with national or regional goals for reducing risk and providing serv- ices to vulnerable populations. Political and Social Issues Several legal, political, and social barriers impede implementation of proven preventive actions against H1V/AIDS and tuberculosis epidemics. These barriers may justify revision of legal codes restricting access to publicly financed medical care so that the pub- lic good can be better served through treatment of HIV and tuber- culosis in noncovered patients. Insuring treatment of dangerous public health threats such as these will help prevent spread to the general population. They thus need to be addressed through special exceptions to financing restrictions. If they are not, such restrictions may exacerbate the associated epidemics, thereby creating addi- tional economic burdens on health systems. Mobile and Minority Populations Migrant and other mobile populations are at increased risk for 1-HY Factors that contribute to this increased risk are structural factors, 11i4 o Averting A]IDS Crises in Eastern Europe and Central Asia including poverty, marginal knowledge of health information, and a discontinuation of cultural beliefs that may have been protective against HIV infection (for example, religious and cultural sanctions against sexual promiscuity, drug use, and community disruption). A history of internal and cross-national conflicts contributes to this risk (Axmann 1998), as well as negative attitudes toward the groups most affected. These populations often also lack psychosocial and government health financing resources and thus have low utilization of health services (Soskolne and Shtarkshall 2002). In some Euro- pean countries, 70 percent of sex workers are niigrants. Because migrant and mobile populations are frequently not included in sur- veillance activities, information about their behavior is limited, con- straining the ability to tailor prevention activities for them (Salama and Dondero 2001). Interventions aimed at migrant and ethnic minority populations should be tailored to the characteristics of the group targeted. The Swiss Migrants Project is an example of a successful government- sponsored intervention aimed at reducing the HITV risk behavior of migrants (Haour-Knipe, Gleury, and Dubois-Arber 1999). The pro- gram's success was attributed to the fact that the intervention was delivered by trained cormnunity members, increasing the receptivity of the target audience. Other successful interventions in migrant com- munities have also used peer education (Kocken and others 2001). In creating programs targeting migrants, however, it is important not to contribute to fears about migrant populations or to increase stigmati- zation of these groups by identifying them as "high risk." Ethnic minority populations can be at increased risk for HIV because of economic and educational factors as well as lack of social protection services. In the United States, for example, African Amer- icans represent more than 50 percent of new HITV infections, although they represent only 12 percent of the population (U.S. CDC 2000). Evidence from the United States and Canada suggests that interventions targeting these groups can reduce risk. A meta- analysis of FIIV prevention interventions conducted among 7,010 heterosexual African Americans found that behavioral prevention interventions significantly increased the rates of protective behavior Annex C: Interventions against HLV/AIDS and Tuberculosis * 115 (Darbes and others 2002). Successful interventions included educa- tion and information; risk sensitization (for example, altering the perception of risk for HIV infection); and skill building (for example, teaching negotiation skills about condom use, improving communi- cation skills about safer sex). Cultural sensitivity was also shown to be an important aspect of the interventions. It is likely that such evi- dence will support targeted efforts among Roma and other ethnic minorities in Eastern Europe and Central Asia. Eastern Europe and Central Asia is home to 5-10 million Roma, a minority population that has been isolated and oppressed for cen- turies. Given their isolation and lack of trust of medical systems, few data are available on their behavior. Drug use among Roma popula- tions appears to be increasing, however, especially among disaffected and unemployed young people. HIIV prevalence among Roma youth in Budapest has been estimated at 5-20 percent; about 10 percent of young Roma injecting drug users in the Czech Republic are believed to be I-IlV-positive (Grund, Ofner, and Verbraeck 2002). Evidence on the health needs of Roma indicate high burdens of infectious diseases, poor communication between Roma and health workers, and low use of preventive care (Koupilova and others 2001). Evidence on effective interventions among the Roma is lack- ing. The admission process into the European Union may offer an opportunity to improve conditions for Roma in Eastern Europe and Central Asia. However, lack of advocacy and the absence of research into effective health interventions are barriers to improved support for this marginalized population. Regarding intravenous drug use and commercial sex work, harm reduction programs among the Roma are even more difficult to implement than for the general population because of the tradi- tional difficulties these programs have with police agencies. Needle exchange and education of commercial sex workers are difficult to implement under any circumstance, but the longstanding suspicion of Roma by the police complicate legalization of these approaches even further. Repressive drug legislation will likely have an even greater adverse effect on prevention efforts among the Roma. Most outreach activities for commercial sex workers and injecting drug 116 - Averting A][DS Crises in Eastern Europe and Central Asia users do not address Roma populations, and many of the standard educational approaches will be ineffective because of cultural taboos. Drug dependency treatment programs have attracted Roma in Slovakia, but it is not clear whether repressive new legislation will permit utilization of such services (Grund, Ofner, and Verbraeck 2002). Romani leaders emphasize the need for culturally appropri- ate, community-based approaches. Stigmatization In Eastern Europe and Central Asia, as in other parts of the world, a high level of stigma is associated with rTV/AIDS. Stigma was identified as one of the most pressing items on the agenda for the world community (Piot 2000). A recent review of interventions to combat HTV/AIDS stigma categorized types of interventions as information-based approaches, skills building, counseling approaches, or contact with affected groups (Brown, Macintyre, and Trujillo 2003). Alost of the studies were conducted in the United States, but some took place in Sub- Saharan Africa, Thailand, and the United Kingdom. The results varied in terms of success in reducing stigma. The most successful studies reported positive change for short periods of time. Most of the studies aimed at changing individual-level behavior and were based on individual theories of behavior and attitude change. Parker and Aggleton (2003) argue that stigma may be successfully fought only at the social and community levels. They advocate for the implementation of community-based interventions aimed at broad societal change. They acknowledge that such change requires widespread community changes-in issues concerning power and inequality, for example. The need for community change demands broad structural interventions, but, as Brown, Macintyre, and Tru- jillo (2003) note, no such interventions have been implemented. However, there seems to be an underlying agreement on the need for such a broad-based approach to the human rights issues that underlie stigma. In fact, in the U.N. Declaration of Commitment on HIV/AIDS (2001), 189 member nations committed themselves Annex C: Interventions against HIV/AIDS and Tuberculosis * 117 to "enact, strengthen or enforce legal measures to eradicate HIV-related discrimination and to protect the human rights of people with HIV/AIDS." Discrimination against men who have sex with men is widespread in the region, and homosexuality is still illegal in many countries. Men who have sex with men often find themselves deeply closeted, and they may have become fearful of further testing approaches due to the lack of anonymity associated with earlier compulsory screen- ing efforts in the region (Kelly and Amirkhanian 2003). Personal privacy and confidentiality safeguards need to be built into any sur- veillance or voluntary counseling and testing systems. The evidence base from industrial countries suggests that such safeguards will increase the rate of voluntary counseling and testing among high- risk populations and that this will subsequently support behavior change that will reduce HIV transmission (U.S. CDC 2003b). Value for Money: Cost-Effectiveness of Interventions to Control HIV/AIDS Even with the increasing availability of international grants, credits, and loans, countries have finite organizational resources to commit to H-V/AIDS in the short term. Priorities thus have to be set. Even where there are declarations of intention to do everything immedi- ately, choices must be made in light of operational, capacity, and resource constraints, at least in the short term. The only question is whether those choices are explicit or implicit. Implicit choices are more convenient from a political perspective, since they raise no questions about tradeoffs or relative emphasis. However, fighting an HIV/AIDS epidemic, particularly a concentrated epidemic at low prevalence rates, requires political recognition of the potential for a major increase in I-UV cases and the acceptance of the most effec- tive combinations of prevention efforts. In making resource allocation decisions, policymakers consider a range of issues. Ideally, they would consider the likely impact on the epidemic, or the centrality of any proposed intervention to the 118 ° Averting AIDS Crises in Eastern Europe and Cenrral Asia course of the epidemic Gha and others 2001). In relative terms, for example, interrupting interventions among high-risk core transmit- ters, such as injecting drug users, is arguably a more efficient use of resources than preventing mother-to-child transmission in a con- centrated epidemic that is driven by transmission among intra- venous drug users. The public policy choice is seldom of a binary nature, however; often, it is a matter of relative emphasis that arises after negotiations among interest groups. From the point of view of effective and efficient use of resources, it becomes crucial to ensure that those negotiated sets of priorities are informed by valid data from surveillance (where is the problem and what is its size?), the cost-effectiveness of interventions (how much value for money from different interventions aimed at achieving the same outcome?), and feasibility. Optimization models can inform the resource allocation process by helping estimate the maximum number of infections at any given budget level. They involve identifying population subgroups for intervention, estimating the proportion of these subgroups that can be reached, estimating the total number of new infections expected in each of these subpopulations, defining the set of HIV prevention interventions to be considered, estimating the unit cost of each intervention, and estimating the expected effectiveness of each intervention (World Bank 2002e). Due to the weaknesses in surveil- lance systems in Eastern Europe and Central Asia and the paucity of cost data on HIV/AIDS programs, these exercises require consider- able guesswork. However, they are necessary in order to generate discussions, make assumptions explicit, and draw attention to the need for better data. The international evidence on cost-effectiveness is limited in scope and often of questionable quality (Creese and others 2002).) After reviewing the cost and cost-effectiveness evidence on HIV/AIDS prevention programs in low- and middle-income coun- tries, Walker (2003) concluded that the methods applied and results obtained raised questions about reliability, validity, and trans- parency. First, not all of the studies reported the methods used to calculate the costs; some failed to provide the data needed to allow Annex C: Interventions against HIV/A1IDS and Tuberculosis * 119 the results to be recalculated. Second, methods varied widely, ren- dering different studies, even within the same country and program setting, largely incomparable. Third, even with consistent and replicable measurement, most results were not comparable because of the lack of a common outcome measure. There is an urgent need for well-crafted studies of cost and cost-effectiveness that will help in planning and decisionmaking. This is an area in which the World Bank has a comparative advantage. Summary Several important conclusions emerge from the lessons of the first two decades of the -HV epidemic in Eastern Europe and Central Asia: * Effective prevention is complex; there is no "magic bullet." No single prevention approach or program can work in everv sub- population. Simplistic prevention approaches, such as providing information alone, are likely to prove ineffective. * Effective prevention takes time; behavior change does not occur overnight. Putting the components into place to address the factors affecting risk and vulnerability requires planning, time, effort, and resources. Moving prevention efforts from a small pilot project to a national scale also takes time-to build capacity, address the changes required, and allow the efforts to have an impact. * Prevention efforts must begin early, while I-IV prevalence is still low, if cotntries are to avoid major epidemics. Once [IIV has reached sig- nificant levels in a subpopulation, prevention efforts need to play catch-up with the epidemic, and an opportunity to keep I-IV preva- lence at low levels will have been lost. Efforts initiated earlier will prove much more effective in the long run and significantly reduce the ultimate burden IIV/AIDS presents to a country. * Prevention must take a long-term perspective. The FIIV/AIDS epi- demic will be a long-term challenge for health and social systems. 120 o Averting AIDS Crises in Eastern Europe and Central Asia An effective vaccine is not yet on the horizon. Failing to undertake proven multisectoral/multilevel preventive efforts on HLV/AIDS and tuberculosis will result in increased economic, medical, and social burdens from these largely preventable diseases. The concept of focused prevention remains at the center of efforts to address the HEV/AIDS and tuberculosis epidemics in Eastern Europe and Central Asia. This entails: o Providing political leadership and commitment. o Interrupting transmission early among subpopulations at higher risk. o Initially focusing prevention resources on people at higher risk or vulnerability but steadily expanding prevention efforts outward to reach those at lower risk. o Creating a supportive environment within the general population and the health profession to address vulnerablc subpopulations and to reach particularly high-risk, marginalized populations. ANNEX D Overcoming Nonfinancial Constraints Identifiable roadblocks, or constraints, impede successful imple- mentation of programs to combat tuberculosis and HIV/AIDS. It is often suggested that these constraints are predominantly financial in nature-that is, that an increase in funding would remove the con- straint. Often overlooked, however, is the question of how the monley, once secured, would be applied to the problem and what issues would need to be addressed in the process (boxes D1 and D2). Put another way, if there were no constraints on financial resources, wlhat nonfinancial constraints would limit the successful implemen- tation of programs to control HIV/AIDS and tuberculosis? This question needs to encompass not only the internal institutions in a given country but also the external impediments created by a range of international development institutions, including the World Bank, the broader donor community, national governments, local populations, and specific sectors within countries. Internal Constraints Internal constraints exist at every level of government, as well as in the multiple layers of society. They include everything from polit- ical will to societal taboos and stigmas to inadequate technical capacity. 121 122 o Averting AIDS Crises in Eastern Europe and Central Asia Box DI. Reaching Agreements in a Complex Setting: The Russian Federation's Tuberculosis and AIDS Control Project By the end of 2002 the Russian Federation had more than 200,000 registered HIV cases, with the total number of infec- tions estimated at 1 million. Without effective control, the epi- demic would likely spread frorn the high-risk core transmritters to the bridge populations and the general population. The Russ- ian Federation also had an epidemic of multidrug-resistant tuberculosis. Despite the obvious need to act quickly, in early 2001 discus- sions over a large-scale project to control tuberculosis and H1V/AIDS reached an impasse. It took two years for the govern- ment and the World Bank to reach an agreement on countrywide implementation of effective tuberculosis and HIV/AIDS control strategies. Why was the Russian Federation so slow to act in the face of these problems? How was the breakthrough accomplished? The shift was facilitated by the removal, through negotiations, of the following chokepoints in the decisionmaking process: 1. The leadership of the Russian health sector eventually became convinced that it was in the country's best interest to move for- ward: estimates and projections of the epidemic suggested potentially serious problems if the Russian Federation opted for business as usual through the traditional approaches to tuberculosis control and the patchy efforts to control HIV/AIDS (Ruehl, Pokrovsky, and Vinogradov 2002). Once senior Russian analysts became concerned about the potential demographic impact of the epidemic, decisionmakers began to view the epidemic as more than a problem affecting only socially marginalized groups. 2. In the mid-1990s international experts assumed that, faced with a fast-growing epidemic, the Russian Federation would automatically opt for the most effective interventions based on international guidelines. In fact, the Russian health estab- lishment saw no need for major changes and preferred to develop its own protocols. The association of DOTS with less developed countries made it unacceptable to some par- ties. What turned out to be more feasible was an approach Annex D: Overcoming Nonfinancial Constraints o 123 Box W1. (confinued) designed specifically for the Russian Federation that repre- sented a transition from the old system to a new one. The approach retained international guidelines at its core. This helped overcome institutional reluctance to change. 3. Some stakeholders in the Russian Federation had expressed opposition to the Bank's requirement that procurement by suppliers of therapeutic drugs be facilitated by the WHO's Green Light Committee. (The measure is essentially a quality assurance mechanism that helps ensure that coun- tries meet technical criteria before they can have access to second-line drugs at preferential prices. It is intended to prevent the inappropriate use of second-line drugs, which could lead to resistance and the emergence of super drug-resistant strains of the tuberculosis bacillus.) The World Bank had taken extraordinary steps to enable the Russian Federation to procure quality-assured second-line drugs at low prices, but local drug suppliers perceived this as an attempt to stifle the Russian domestic market, creat- ing a significant impasse. Ultimately, the World Bank reached an arrangement with the Russian government in which the government agreed to make the use of loan pro- ceeds to purchase second-line tuberculosis drugs contin- gent on adherence to technical guidelines on quality, to be verified by the WVO. In addition, the Bank agreed that international competitive bidding could be used to create greater opportunities for Russian firms to compete. The Russian Federation would use its own funds to procure first-line drugs from the domestic market, with a buffer froni the loan in case of budgetary shortfalls. This resolved one of the biggest obstacles to the agreement. Source: Project Appraisal Document 21239-RU on a proposed loan to the Russian Federation for a tLuberculosis and AIDS con- trol project, March 10, 2003. 124 o Averting AIDS Crises in Eastern Europe and Central Asia Box D2. Controlling Tuberculosis and HIV/AIDS in Moldova After a decade of deteriorating economic performance, Moldova has shown the first signs of recovery, withl rising GDP growth and a leveling off of poverty. Nevertheless, it remains the poorest country in Europe, with 55 percent of the population living on less than $2 per day. The prevalence of FIIV/AII)S in Moldova remained at a very low level during the first 10 years of the epidemnic (less than 0.001 percent during 1987-96). Since the mid-1990s, however, there has been a surge in HI{V infections, and EHIV/AIDS prevalence has reached 0.2 percent among adults 15-49. The tuberculosis epidemic has also increased over the past decade, due to worsening economic and social conditions that increase susceptibility to the disease, reduce access to care (including access to drugs), and lead to improper identification and treatment of people with tuberculosis. The incidence of tuberculosis increased 53 percent (luring the 1990s, and the trend has accelerated since tben. To address many of these issues, the government approved appropriate tuberculosis and HIIV/AIDS strategies and designed the Moldova tuberculosis/AIDS program, with assistance from the Bank, the WHO, UNAIDS, UNICEF; the Dutch govern- ment, and the Swedish International Development Agency. It has sought fimding to implement the program in the next five years. GFATM has already provided $5.2 million for fighting tuberculo- sis and AIDS. In June 2003 the Bantk approved an International Development Association grant of $5.5 million for AIDS. USAID is expected to finance the tuberculosis program component with a grant of $4 million. Working with vulnerable groups is a key component of Moldova's program, which includes identifying and then target- ing interventions for injecting drug users, commercial sex work- ers, men who have sex with men, inmates, military persomnel, and people who attend sexually transmitted infection clinics. The public health system lacks the capacity to carry out these outreach activities, while NTGOs have experience working with these groups. It was therefore agreed that the Soros Foundation- Annex D: Overcoming Nonfinancial Constraints o 125 MBx D2. (conlhnued) Moldova, which has been working for many years with NGOs that provide assistance to highly vulnerable groups, would man- age these activities under the program. Ultimately, intensive col- laboration between the government, NGOs, and international partners was an essential ingredient to the success of the process of establishing an appropriate program to control tuberculosis and FIV/AIDS in Moldova. Source: Project Appraisal Document 25344-MD on proposed IDA grant to the Republic of Moldova for an AIDS control proj- ect, May 14, 2003. Lack of Political Will and Recognition of the Problem For years in Eastern Europe and Central Asia, denial of the prob- lem by governments at all levels has been a significant constrailnt. Tuberculosis and HrV/AIDS were seen as problems of other parts of the world, and there was little empirical evidence to indicate they would become a problem in Eastern Europe and Central Asia. In a region going through the upheaval of transition from command to market economies, transferring resources to a potential problem was a difficult proposition. Governments, not without some logic, were able to make the case that in an environment of dwindling resources, dealing with tuberculosis and HIIV/AIDS was not the most urgent priority. The rise of tuberculosis and HIV/AIDS caught most of the region unprepared to address its impact on the health sector-and even less prepared to address its impact on the society at large. Like other regions before it, Eastern Europe and Central Asia has been slow to make the perceptual leap to begin to see HIV/AIDS and tuberculosis as more than "just" health problems. "Politicians, poli- 126 o Averting AIDS Crises in Eastern Europe and Central Asia cymakers, community leaders, and academics have all denied what was patently obvious-that the epidemic of 1IEV/AIDS would affect not only the health of individuals, but also the welfare and well- being of households, communities, and, in the end, entire societies" (Barnett and Whiteside 2002, p. 5). Until there is a broader recog- nition of the magnitude of the potential crisis, countries will not be willing to divert the necessary scarce resources. Efforts have begun at changing the political and societal land- scape. Increasingly, governments are acknowledging the importance of 1-V/AIDS and tuberculosis. Countries are developing national programs for HI-V/AIDS and tuberculosis control. International financing is increasing, through grants, credits, and loans. Four World Bank-financed projects on HIV/AIDS and tuberculosis are at various stages of development in the region (in Belarus, Moldova, the Russian Federation, and Ukraine). The Bank is also supporting a range of analytical and advisory services in the region (see annexes A, B, and E). Bilateral organizations (including the Canadian Inter- national Development Agency, the Department for International Development, the Swedish International Development Agency, and USAID); multilateral agencies (the eight cosponsors of UNAIDS); and NGOs are supporting analytical and programmatic work on iHlV/AIDS and tuberculosis in the region. The discussions and preparation processes leading up to these projects are themselves vital in generating and building commitment among populations. The projects generally rely on a broad battery of actions to address political will, such as media campaigns that increase public aware- ness, multisectoral partnerships, training for workers and govern- ment staff, educational programs, and the development of new legal frameworks. These actions help create broader recognition of the threats posed by tuberculosis and HIV/AIDS and help build com- mitment to take action by the many players involved in implement- ing a program. The political will that has helped bring about these projects reflects progress in raising the level of awareness, but it is still only the beginning of a long and challenging process. In Central Asia, for example, although all five governments have either approved or are Annex D: Overcoming Nonfinancial Constraints * 127 considering approving strategic plans to combat 1-IIV/AIDS, there is considerable room for improvement in the knowledge, attitudes, and practices of decisionmakers, opinionmakers, and health professionals to control the epidemic (Godinho, Lundberg, and Bravo 2002). Success in transforming political will has been achieved through a process that includes: * Demonstrating to senior analysts and policymakers the potential economic and epidemniological consequences of inaction. * Obtaining the commitment of public funds, not just assurances of cooperation. * Working closely with the health community, at the government, community, and rural levels, to raise awareness and prioritize issues. * Building consensus through a multisectoral approach, with active involvement of ministries other than health ministries (education, justice, labor), as well as with NGOs, donors, and other partners. * Building public awareness through public information cam- paigns, while recognizing that awareness alone is not sufficient. Social Constraints and Stigmatization One reason societies are slow to come to grips with the HIV/AIDS crisis is that many aspects of the problem are considered taboo or are frowned on by large segments of the population. It is difficult to raise awareness or build consensus on an issue that cannot be dis- cussed openly. The problem is exacerbated by the fact that the majority of people affected by AIIV/AIDS belong to groups that are marginalized by society. The primary groups affected by HIV/AIDS-injecting drug users, commercial sex workers, and inmates-have limited access to community service infrastructures. They are also among the least likely to be well informed about safe sex practices and disease pre- vention. Since HIV/AIDS is still largely identified with these mar- 128 o Averting AJIDS Crises in Eastern Europe and Central Asia ginalized groups, there is a sizable element of society that is willing to adopt the logic of "it's not us, it's them." As long as the disease is perceived to affect only marginalized groups, it is not considered a threat to the larger community. When HTV/AIDS does begin to expand beyond these groups, people are afraid to come forward-to be tested, to seek treatment, to take an activist position-because they fear being tarred as a member of one of these groups. Once the disease becomes stigma- tized as something aberrant, people seeking treatment are discrimi- nated against, and sources of support (funding, testing, and coun- seling) become scarce. Personal and ethnic taboos create environments that are not con- ducive to treating these diseases. For example, the Roma, one of the poorest minorities in Europe (Ringold 2002), have historically avoided certain types of medical care, such as immunizations and Pap smears, for personal and cultural reasons (Acton and Mundy 1997). Involving such groups in dialogue on safe sexual practices is a complex and difficult process. Other religious and ethnic tradi- tions can also affect willingness to participate in screening, preven- tion, and treatment. Health care workers often carry the same biases and stereotypes regarding groups affected by the disease. Education and training for these front-line workers is a critically important first step. Changing the environment of social constraints and stigmatiza- tion is fundamental to eliminating other constraints-to building political will and commitment, changing the legislative framework, and building capacity at the state and local levels. Critical steps that must be undertaken include: o Achieving an understanding of social contexts and influences. o Disseminating public information at every level. Campaigns on disease awareness, prevention, and treatment must be focused and strategically targeted to high-risk groups, including ethnic minorities and young people. In addition, efforts need to focus on destigmatizing the disease. Annex D: Overcomning Nonfinancial Constraints * 129 * Providing education, in schools and communities. Efforts need to include production of educational materials, such as brochures, booklets, and films. * Conducting workshops and seminars for health workers, educa- tors, and community groups. Inadequate Capacity at the Community Level Community infrastructure, or the lack thereof, is increasingly seen as having a major impact on health-related issues, including the implementation of tuberculosis and HIV/AIDS programs. Espe- cially in countries with weak central governments, communities can play a vital role in education, treatment, and care. Unfortunately, many communities throughout the region are still recovering from the transition and lack the self-reliance required to support these initiatives. Efforts must be made to build capacity for community support and outreach programs. Gender inequality is another critical factor that needs to be addressed. In many Eastern European and Central Asian countries, womiien remain excluded from decisionmaking bodies in communitv councils and local government. Low levels of education among women, particularly among some minorities, contribute to a low level of awareness about the disease, its transmission, and preven- tion (Paci 2002). At the same time, men are more affected than women in the current epidemiological profile; the epidemic has not become feminized. High-risk behaviors such as unprotected sex, multiple partners, and injecting drug use have increased; the rigid social control of the past has eroded; and new common norms and values have yet to become firmly grounded (UNAIDS 2002d). Modifying risk behav- iors in this context must become a multisectoral effort that involves schools, religious groups, and other commumity organizations. Community development and outreach programs should be built into project and components, and alliances with NGOs should be forged to foster community development. 130 o Averting AIDS Crises in Eastern Europe and Central Asia Inadequate lnstitutionail Capacity Perhaps more than other constraints, institutional capacity varies dramatically across and within countries. Levels of poverty, educa- tion, technical development, ethnicity, geography, and myriad other factors all have critical importance in determining a society's ability to implement a program of prevention and treatment of tuberculosis and HIV/AIDS. That said, all countries in Eastern Europe and Central Asia must strive to improve their competence in certain key areas. The World Bank has a wealth of experience in supporting and implementing complex projects, not only in health but in other social sectors and technical areas as well. To some extent, the prob- lems associated with implementing any project reflect the level and sophistication of systems in place in a country. These include the ways in which people conduct business and the level of openness, corruption, and entrepreneurship in the society. Just as successful implementation of a project depends on these variables, creating or nurturing an environment for conducting a tuberculosis or HIV/AIDS control program depends on a confluence of associated factors. These issues take on special importance when it comes to imple- menting effective intervention strategies (see annex C). For exam- ple, initiating and carrying out effective biological and behavioral surveillance systems depends on many factors, including the capac- ity to screen and analyze donated blood, conduct demographic and health surveys, maintain voluntary counseling and testing sites, and track and analyze mobile populations (Pisani 2002). Although some Eastern European and Central Asian countries have effective levels of these capacities, many others do not. Skilled scientists, laboratory technicians, demographers, analysts who can assess gaps in program management skills at the country level (gap analysis), educators, and counselors are all in short supply, as are the underlying infrastruc- tures that support them. Also in short supply are the management skills necessary for planning and administering large and intersec- toral programs at the national and local levels. Annex D: Overcoming Nonfinancial Constraints * 131 Harm reduction strategies require mechanisms and supplies that are often not available in Eastern Europe and Central Asia. Needle and syringe exchange projects require not only medical equipment but legal authorization and acceptance by the community. The same is true for drug dependency treatment programs and condom dis- tribution among commercial sex workers. To gain acceptance and support, these issues need to be tackled at multiple levels-through government, education, and public awareness building. Many parts of the region, including Bosnia and Herzegovina, Kosovo, and Tajikistan, also face postconflict issues that exacerbate the problems associated with IHIV/AIDS. Not only have these con- flicts drained resources and disrupted already deteriorating service infrastructures, they have generated new problems, including grow- ing numbers of illegal migrants (who are unable or afraid to seek treatment), trafficked women and girls, and injecting drug users. Another fundamental capacity issue is geographic, social, and financial access to services. In Tajikistan 80 percent of the country is mountainous, much of it remote. Providing health services in these areas is difficult. All of Central Asia is affected by this problem. In Slovakia 8-10 percent of the population are Roma (World Bank and others 2002), who live in sequestered settlements with limited access to healthcare. In Belarus injecting drug users are isolated and diffi- cult to reach because of their infrequent contacts with the formal sector (World Bank 2002a). Physical access to testing and treatment is a critical first step that must be achieved throughout the region. Underlying many of these problems are weaknesses in educa- tional systems across the region. Education on HIV/AIDS is a crit- ical component in the prevention of I-flY/AIDS, through school prevention programs targeted at high-risk groups, awareness train- ing, and dissemination of information to the public. Just as impor- tant, education is essential to train the community workers, coun- selors, and other health sector professionals required to address the crisis. Other services are more dependent on financial resources. These include local and national distribution systems for pharmaceuticals, adequate laboratories, diagnostic infrastructures, and blood supply 132 o Avertng AIDS Crises in Eastern Europe and Central Asia systems. The level of public information and communication pro- vided also depends on financial resources. Critical steps to raising institutional capacity include the following: o Improving skills for gap analysis, program design, and manage- ment. o Providing extensive education and training in testing and screen- ing for tuberculosis and HITV infection; treatment and counseling; public education on tuberculosis and HI-IV/AIDS; program devel- opment and management; public information campaigns and dis- ease awareness; and prevention programs that target commercial sex workers, injecting drug users, migrant workers, truckers, mariners, and peacekeepers. o Developing distribution systems for pharmaceuticals and treat- ment, including in remote areas. o Improving diagnostic infrastructures. o Developing and disseminating public information materials. Regulatory System Ilmpediments and Other Legal H1ssues Because of the nature of HIV/AIDS, the ways in which is transmit- ted, and the groups initially affected, an array of legal issues arises in implementing testing and treatment programs. For example, a key component in the harm reduction strategy is needle exchange, which is illegal in some countries. Many local regulatory frame- works do not allow key steps recommended under harm reduction practices. Legal issues also arise in prisons, a primary source of HIV transmission, where local regulations sometimes counter best prac- tice for both tuberculosis and HIV/AIDS prevention and treatment. Legal and regulatory frameworks are also critical in many periph- eral areas of combating HIIV/AIDS and tuberculosis. Often legal frameworks must be developed or altered to allow for the licensing and accreditation of health professionals and new educational pro- grams. Insurance and risk pooling are other areas that need to be Annex D: Overcoming Nonfinancial Constraints * 133 updated and sometimes restructured to deal with the changes neces- sitated by new treatments and expensive long-term regimens. A range of societal issues, such as privacy and worker rights, also needs to be addressed. The laws governing the national and international procurement and local distribution of therapeutic drugs also require attention. International pressures have mounted on pharmaceutical companies to provide antiretroviral drugs to developing countries at a lower cost. However, the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights obligates its member states to grant pharmaceutical patents, which increases the difficulty of providing low-cost drugs to the neediest populations. The Bank and other development agencies can assist countries in the region by providing technical assistance in designing legal frameworks, specifically with regard to harm reduction practices, insurance, pharmaceuticals, and privacy, and prison initiatives or reforms allowing a variety of steps, such as harm reduction, rreat- ment, and care. External Constraints Addressing the internal constraints of 28 countries, with their broad ranges of poverty, differing demographics and country landscapes, and other factors, is a challenging task. In addition, a variety of important external constraints affects the success of the objectives and the progress of regional country programs on tuberculosis and HIV/AIDS. During the past five years, increasing attention and financial resources have been allocated to programs for tuberculosis and HIEV/AIDS. Along with the attention and resources has come a wave of heightened interest, new partners, and new strategies-galva- nized in part by the adoption of the Millennium Development Goals. Millennium Development Goal six states that by 2015 the spread of HIV/AIDS, malaria, and other diseases will have been halted and their spread begun to be reversed. Institutions that have 1134 o Averting AEIDS Crises in Eastern Europe and Central Asia adopted the Millennium Development Goals face internal pressures to pursue these goals, even in countries in which the problem may not be as acute as in others and in which achieving the goals may be difficult (Goldman and Wright 2003). With the rapid influx of funding, staff, and new programs, there is a risk of misapplying scarce resources. Some risks arise from the desire to disburse funds very rapidly-even in the absence of local capacity to absorb and manage them effectively. These risks include waste, inefficiencies, and the inappropriate use of drugs, which could lead to drug resistance (Reynolds and others 2003). An important new player in the donor field is a new financing mechanism, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Endowed with growing financial resources, GFATM coordinates with the World Bank and a variety of other partners in the region to help halt and reverse the spread of tuber- culosis and HIV/AIDS. Partly due to its newness, GFATM is still in the process of working through its approaches to country-level operations, and there have been delays in implementation (Sum- mers 2002 ). There is a potential conflict between a rapidly changing-and still relatively unknown-disease profile and the slow-moving processes that are characteristic of large international institutions such as the World Bank. Programmatic decisions at the Bank are generated by lengthy processes, such as the development of a Coun- try Assistance Strategy, which sets out the basis targets for analyti- cal, advisory, and lending services for a period of years. To be of maximum benefit to client countries, it is essential that institutions be vigilant to changes in the operating environment and ensure that there is enough flexibility in programmatic decisions that they are not locked into a single course of action and thus miss important developments in the epidemics. Time and other institutional pressures also affect policy deci- sions. Preparation of grants, credits, and loans may require policy decisions before the evidence is in. To some extent, this problem is inherent in large and complex institutions. Several areas call for reform: Annex D: Overcoming Nonfinancial Constraints * 135 * Increased attention should be given to disease surveillance and to estimates and projections of the economic impact of HITV/AIDS and tuberculosis in World Bank instruments such as Country Assistance Strategy and analytical activities in support of Poverty Reduction Strategy Papers, regardless of the prospect of lending to a given country. * More should be done to ensure that Bank-supported operations are derived from, and integrated into, country strategies and programs. * Greater emphasis should be placed on interagency coordination and country leadership. The coordination of programming and strategy is essential for the World Bank and its many interna- tional, national, and local partners in the region. It is critical, however, not to lose sight of the fact that agencies must support country-driven strategies and not become the primary drivers of a country's health policy. Agencies must cooperate and strategize with the country's health sector at the earliest stage possible, to design and implement programs that play to their respective strengths. Cofinancing of projects, sharing of research and data, and complementary planning are essential if impact is to be max- imized. Bureaucratic procedures are common in large organizations with complex missions, but the procedures for lending operations at the Bank remain excessively complex. Three areas in particular warrant attention: * Thsttfitnds. Lengthy and time-consuming application procedures, as well as restrictions on the use of consultant trust funds, create a disincentive for using this mechanism. Donor trust funds, which provide cofinancing or other forms of project support, often face significant delays due to the numerous clearances demanded by either the donor or the Bank. * Reporting and documentation requireinemets. During the past several years, work on tuberculosis and HTV/AIDS, like much of the work in the social sectors, has increasingly become a patchwork of 136 o Averting A]IDS Crises in Eastern Europe and Central Asia interrelated activities. These activities include projects, large and small grants, and trust funds, with requirements for inputs and clearances from multiple institutional units. Each type of activity has multiple internal and external time-consuming reporting and clearance requirements, which are frequently excessive and likely redundant. 0 Procurement. Cumbersome procurement procedures and the need to reconcile different donors' procedures slow down implementation. Recently, the Bank has undertaken a program of modernizing and simplifying procedures to address some of these issues. The Opera- tions Policy and Country Services Department (OPCS), the Legal Department, and the Environmentally and Socially Sustainable Development Network (ESSD) have embarked on a program aimed at simplifying processing requirements for HTV/AIDS projects. This is a promising initiative. ANNEX E Estimated Financial Resources Needed to Control HIV/AIDS and Tuberculosis in Eastem Europe and Central Asia Scaling up HIV/AIDS and tuberculosis programs in Eastern Europe and Central Asia has resource implications. Estimating the costs of these programs can help policymakers obtain a more accu- rate picture of resource needs and plan accordingly. This is particu- larly important in countries in which public expenditures on health care are low and governments are under pressure to finance a grow- ing basket of health services. This annex describes the resource needs for scaling up HTV/AIDS and tuberculosis programs, identi- fies potential resource gaps, and examines the implications for pub- lic expenditure and the role of donors. Estimated Financial Resources Needed to Control and Treat HIV/AIDS The materials presented in this section are from a joint World Bank- UNAIDS exercise that included consultations with country officials. Methodology The methodology for calculating HIV/AIDS resource needs is based on the resource needs model (Bollinger and others 2002). 137 138 o Averting AIDS Crises in Eastern Europe and Central Asia This model, developed by the Futures Group, calculates the total national resources needed for I-UV prevention, HIV/AIDS treat- ment, and orphan care programs.11 The model consists of three submodels: the prevention model, which includes the costs of 12 programs; the care and treatment model; and the orphan care model (tables El and E2).'2 The three main parameters of the model driving the calculations include unit cost estimates for each of the programs in the submodels, population or target groups, and coverage or access targets. The model includes parameters for all three parameters that can be adjusted based on expert opinion by country specialists and country-specific data.13 Unit cost estimates for prevention, treatment, and orphan care were obtained from 125 published and unpublished studies, most from Latin America and Sub-Saharan Africa. If the "default" values are used, the lower values are used for low-income countries and the values in the upper end of the range are used for middle-income countries. The population or target group calculations are made in a different way for the prevention and care models. For each preven- tion activity, the model first estimates the population target group in need of prevention services that could potentially have access to those services given existing infrastructure. For facility-based serv- ices, such as treatment for sexually transmitted diseases and volun- tary testing and counseling services, access is estimated as the median of four variables: the percentage of the population with access to tuberculosis treatment (DOTS); essential immunizations (diphthe- ria, tetanus, and pertussis); attended births; and prenatal care. The population target groups for other interventions consist of the relevant population subgroup (the population target group for school-based programs, for example, is children enrolled in school). The population needing care in a particular year is assumed to be equal to the number of people with HIV/AIDS who are newly symptomatic during that year. This number is estimated as equal to the number of people who would be expected to die of AIDS two years hence in the absence of treatment. People needing ongoing treatment (HAART and prophylaxis for opportunistic infections) include those who are newly symptomatic and those who were Table El. Prevention Activities, Target Populations, Default Coverage Rates, and Unit Costs DEFAULT COVERAGE DEFAULT UNIT COSTS (VARIES BY SEVERITY OF EPIDEMIC OR (AT 2000 PRICES: CATEGORY ACTIVITY TARGET POPULATION LEVEL OF ECONOMIC DEVELOPMENT) MAY VARY BY REGION) In-school youth Teacher training, Primary and 10-33 percent of primary teachers $26-$84 per primary teacher peer education secondary students trained 2-12 percent of secondary teachers $15-$50 per secondary teacher trained Out-of-school Peer education Out-of-school youth 1 0-50 percent of out-of-school youth $8 per out-of-school youth reached youth ages 6-11 and 12-15 Commercial sex Male and female Commercial sex 60 percent of commercial sex $15.83 per commercial sex workers and condoms workers workers reached worker reached their clients 60-80 percent condom use $0.10 per male condom by those reached distributed 5 percent are female condoms $ 1.00 per female condom distributed Public and com- Condom Single and married Condoms used in 20-60 percent $0.15 per male condom mercial sector promotion men with casual of casual sex acts distributed condoms partners 10-30 percent of married couples with casual partners use condoms in marital sex 70-80 percent of condoms distributed by public and commercial sector ITable continues on the following page.) 'OgHsi H.D (continued) DEFALLT COVElASE DEFAU T UNIT COS-S (VARIES 2Y SEVERiTY O, E?D&-AIC O1 'AT 2CDD FPICES; CATEGORY ACTtViTY TARGET POPUIAT;CN LEVEL OF ECONOMIC DEVELOPMENT} MAAY VARY 6Y RUG!CN) Social marketing Condom Single and married 10-20 percent of condoms distributed $0.12-$0.25 per male condom of condoms promotion men with casual through social marketing distributed partners 10 percent of condoms are female $ 1.00 per female condom condoms distributed Sexually Treatment of Men and women 60-100 percent of symptomatic $8.34-$9.26 per sexually transmitted sexually with symptomatic sexually transmitted infection cases transmitted infection case treated infections transmitted sexually transmitted with access to heolth facilities $0.91 per woman screened for infections infections with access 60-100 percent of pregnant women syphilis at prenatal clinics to health system with syphilis attending prenatal $8.34-$9.26 per syphilis case services clinics treated at prenatal clinics Voluntary Testing and Those desiring to Estimated as twice the number of $10.60 per person counseled and counseling counseling be tested people infected with HIV with access to tested and testing health facilities, tested every five years Workplace Condom Men employed in the 3-50 percent for peer counseling $3.36 per employee reached with prevention promotion formal sector with peer education Treatment of casual partners 70 percent of employees with $8.34-$9.26 per sexually sexuolly Men and women symptomatic sexually transmitted transmitted infection case treated transmitted employed in the infections treated infections formal sector with 10 percent of all condoms distributed $0.10 per male condom symptomatic sexually through workplace programs distributed transmitted infections Blood safety Screening blood Units of blood 100 percent of blood tested $4.88-$ 15.00 per safe blood unit for transfusions required for transfusion available Prevention of Testing mother-to-child Short-course Pregnant women 10-50 percent of women attending $3.80 per woman screened transmission of antiretroviral attending prenatal prenatal clinics tested $18.70 per woman receiving HIV treatment, replace- clinics 90 percent of those found to be antiretroviral regimen (includes ment feeding HIV-positive pregnant HIV-positive accept treatment drugs and service strengthening) women attending 50 percent of those found to be $50 per women receiving formula prenatal clinics HIV-positive use replacement feeding Mass media Mass media Country Two to six compaigns per country $490,000 per campaign campaigns per year Harm reduction Harm reduction Intravenous drug 25-75 percent of intravenous $3.21-$12.50 per person programs users drug users reached Men who have Peer counseling Men who have sex 60 percent of men who have sex with $1 5.83 per person reached sex with men with men men reached by peer counseling 60-80 percent condom use among $0.10 per male condom those reached distributed Source: Bollinger, L., S. Bertozzi, J. Gutierrez, ond J. Stover. 2002. Resource Needs Model for Estimating the Resource Needs For HIV/AIDS. The Futures Group. Available at www.Futuresgroup.com. 142 0 Averting AIDS Crises in Eastern Europe and Central Asia ThhbO EMO Unit Costs of Different Types of Treatment and Care (2000 dollars) AI-'NNL'A'S. COST CAIECORY ACTIVF'I PF P 7. 2r. Palliative care Symptomatic care and support provided to $750 people near death Diagnostic HIV Testing of symptomatic patients before provision $5 testing of prophylaxis for prevention of opportunistic infections or HAART Treatment of Medications and medical care for common $300a opportunistic opportunistic infections associated with HIV infections Prophylaxis of Isoniazid (to prevent reactivation of latent $32 opportunistic tuberculosis) and cotrimoxazole (to protect infections against the pathogens responsible for pneumonia and diarrhea) HAART Treatment with three antiretroviral drugs $350-$2,900, depending on country wealth Laboratory testing to enable monitoring $140 of HAART treatment a Lifetime cost. Source: Bollinger, L., S. Bertozzi, J. Gutierrez, and J. Stover. 2002. Resource Needs Model for Estimating the Resource Needs for HIV/AIDS. The Futures Group. Avoilablo at www.futuresgroup.com. receiving treatment the previous year. Newly symptomatic people initiating opportunistic infection prophylaxis without HAART are assumed to live two years on average; a Poisson distribution is used to determine the probability of death in a given year. Coverage targets for prevention programs are calculated on the basis of several different factors, such as the level of coverage needed for program effectiveness, HIV prevalence rates, and the level of economic development. In low-income countries, coverage is natu- rally expected to be less than in middle-income countries with good health infrastructure. Coverage targets for treatment are calculated on the basis of available studies. Coverage rates are assumed to be higher for less sophisticated services. For example, more people Annex E: Estimated Financial Resources Needed * 143 would have access to palliative care than to HAART or treatment for opportunistic infections. Caveats about the model should be noted. First, the model esti- mates feasible coverage targets assuming an ambitious expansion of current coverage unfettered by current financial resource con- straints but without significant development in infrastructure. That is, no additional expenditures are provided for infrastructure devel- opment, with two exceptions. Expenditures on in-school education interventions consist mainly of teacher training; as such they repre- sent investment in human infrastructure. A cost is also built in for strengthening the infrastructure needed to deliver interventions to prevent mother-to-child transmission. Second, the issue of sources of funding is not addressed. Instead, activities covered by all sources of funding are included. Costs related to capital and recurrent costs for surveillance activities are not included. Using default parameters and other country-specific information, estimates were made for 135 countries in preparation for the U.N. General Assembly Special Session on AIDS (Schwartlander, Stover and others 2001). These initial estimates provided the basis for fine- tuning based on expert opinion and country-specific data. To pro- duce country-specific estimates, a joint UNAIDS-World Bank workshop was organized in Minsk, Belarus, in November 2002. Representatives from eight CIS countries (Armenia, Azerbaijan, Belarus, Kazakhstan, the Republic of Moldova, the Russian Federa- tion, Tajikistan, and Uzbekistan) attended the workshop. During the workshop the unit cost estimates were revised for each country on the basis of expert opinion. Selected countries in the Baltics and Southeastern Europe were also sent the resource needs model for revising the unit cost data. Based on this informa- tion, country-level estimates were derived. The results presented here are mostly aggregates, with a few country-specific examples. Results Effective scaling up of essential programs for HIV/AIDS preven- tion, care, and treatment programs will require that funding from all R144 o Averting AIDS Crises in Eastern Europe and Central Asia source increase from about $300 million in 2001 to $1.5 billion by 2007 (see table E6). Needs by country will vary with the size of the population, the severity of the epidemic, and the unit costs of the prevention and care activities (see figure El, which shows interna- tional assistance estimates, and table El). Of the $1.5 billion required in 2007, three-fifths will be needed in the three countries with the largest populations (Kazakhstan, the Russian Federation, and Ukraine). Distribution between Prevention and Care In 2007, 40 percent of total funding will be needed for prevention; 55 percent for care and treatment; and 5 percent for policy, adminis- tration, research, and evaluation (figure E2). Provision of HLAART, including laboratory monitoring costs, requires the largest percent- age of funds (45 percent). Funding for HAART will need to increase from about $60 million in 2002 to more than $600 million by 2007. Three other important interventions together claim one-quarter of all funding requirements by 2007: treatment and prophylaxis for opportunistic infections (9 percent), workplace programs (7 percent), and condom promotion and distribution programs (6.3 percent). The workshop in Minsk and the country review resulted in sig- nificant changes to the estimated resource requirements. The esti- mate of funding required for all interventions in 2007 rose 9 per- cent. Prevention needs were 38 percent higher and care needs 4 percent lower. Large increases were seen in the estimated costs of youth-focused programs (largely due to higher teacher training costs), management of sexually transmitted infections, and volun- tary counseling and testing services. Estimated needs for workplace programs and mass media were significantly lower. The estimates of costs for laboratory monitory of HIIV were somewhat lower in 2007. Relative Emphasis on Selected Interventions Despite the concentration of the epidemic among injecting drug users, fewer resources are allocated to programs for them than to programs targeting commercial sex workers and men who have sex with men. These estimates reflect not just the scale and unit costs Annex E: Estimated Financial Resources Needed * 145 Figure El. International Assistance for HIV/AIDS Programs in Eastern Europe and Central Asia, by Country and Subregion, December 2001 Thousands of $ 30,000 25,000- 20,000 15,000 10,000 . 0 Russian Western Baltic Caucasus Central Southeastern Central Federation NIS states Asia Europe Europe Source: UNAIDS 2002b. but also what is considered feasible by country officials in terms of expanding the scale of their H-tV/AIDS programs. The numbers reflect a certain degree of resignation by country participants. A more rapid expansion of harm reduction is not possible in some instances due to nonfinancial restraints, such as legal constraints. The problem cannot be tackled effectively without sufficient fund- ing, but more funding cannot be used if the social and judicial con- straints on harm reduction (for example) are not alleviated. Since many participants in the Minsk workshop are used to these con- straints, they probably assumed that the constraints would remain, reducing their expectation of what could be done on some inter- ventions by 2007. A key challenge is to alleviate nonfinancial con- straints, such as judicial constraint on the expansion of harm reduc- tion programs. This resource estimation exercise needs to be updated periodically to take account of changes in the operating environment and the scale of the epidemic. 146 o Averting AIDS Crises in Eastern Europe and Central Asia PigDuv M2 Estimated Funding Required to Prevent and Treat HIV/AIDS in Eastern Europe and Central Asia, by Intervention, 2001-07 MiiHions c dolkws 1,800 1,600 1,400- 1,200- 1,000 1 600- 400- 200 - I 2001 2002 2003 2004 2005 2006 2007 0 Policy/administration 0 Other populations . :VCT 0 ARV 0 MSM o STIs 0 Laboratory 0 Harm reduction El Condoms 0 01 prophylaxis 0 Moss media O Social marketing 0 01 treatment 0 PMTCT Commercial 0 HIV testing 5i Blood safety sex workers O Palliative core 0 Workplace programs 0 Youth Between 2001 and 2007 the resource needs for some prevention interventions (condom distribution, treatment of sexually transmit- ted diseases, interventions for commercial sex workers and their clients) increase rapidly, while the resource needs for others (inter- ventions targeting young people) grow only marginally (see table E6). These differences are related largely to changes in coverage targets between 2001 and 2007. The resource needs model assumes Annex E: Estimated Financial Resources Needed * 147 that coverage increases over time. Increases in coverage are based on several assumptions, including current HIV prevalence rates and the economic classification of the country. Current HIV prevalence rates determine coverage rates, since in low-prevalence countries in order to effectively prevent new EWV infections only a certain per- centage of the population needs to adopt a certain behavior. In addi- tion, during the country consultations, coverage levels were refined after taking account of nonfinancial constraints for specific preven- tion interventions. Ftture Costs of HAART Country specialists made their best estimates of likely unit costs, cov- erage, and total expenditures for HAART in 2007. They expect East- ern European and Central Asian countries to spend more than $600 million on HIAART, or 40 percent of the total 1EIV/AIDS budget. The country specialist estimates of annual unit costs varied from $200 to $3,600 per person, with an unweighted average of $1,600 per person. The specialists were asked to estimate prices and coverage for each year from 2001 through 2007. In general, they estimated that coverage would increase and unit prices, especially for pharma- ceuticals, would decrease for low-income countries in Central Asia but increase or remain the same for most others, including Armenia, Kazakhstan, the Russian Federation, and Ukraine. Making predictions as far into the future as 2007 requires con- siderable guesswork. The per person cost of HAART in Mexico declined about 90 percent between 1998 and 2002, due largely to the ability of the Mexican social security system to negotiate a lower price for drugs from pharmaceutical companies. In early 2002 a Thai pharmaceutical firm announced that it had succeeded in pro- ducing a single triple-therapy pill to be taken daily, which it expected to sell for $0.50 per dose ($185 a year). The TRIPS agree- ment remains a point of contention in international negotiations in the Doha Round on world trade. Pharmaceutical companies may have an interest in a high degree of price discrimination, often referred to as Ramsay pricing, maximizing their profits by selling at high prices in high-income countries and at lower prices in middle- 148 o Averting AIDS Crises in Eastern Europe and Central Asia and low-income countries (Scherer and Watal 2002). These condi- tions make it difficult to predict future unit costs for this therapy. Moreover, if prices fall, coverage can be increased at the same total expenditure level. ThEulr¢: imX Tuberculosis is likely to be the most common opportunistic infec- tion and the number one killer of people with THV/AIDS in East- ern Europe and Central Asia. The co-epidemic of HIIV/AIDS and tuberculosis will add to the already growing problem of tuberculo- sis in the region. Since tuberculosis is spread through droplets released into the air by infected people, it is especially problematic among the poor and among institutionalized people, who typically live in crowded conditions. Tuberculosis control is a public good with large externalities. It should be a priority for public funding in all countries in the region. In order to scale up tuberculosis programs it is useful to have infor- mation on potential resource needs. MethodolDogy Resource needs for tuberculosis were calculated using the following methodology: First, for each country in the region, estimates were made for the increase in the number of tuberculosis cases between 2001 and 2007. Estimates were made for a low-case and a high-case scenario. The low-case scenario assumes that the incidence of tuberculosis without FIIV will double between 1999 and 2010; the incidence of tuberculosis with I-lIV is assumed to be one out of three (33.3 percent). The high-case scenario assumes the same incidence rates, but the number of tuberculosis cases is larger because more people have I-IIV/AIDS. Unit cost data on management of tuberculosis using current pro- tocols were available only for the Russian Federation (WHO 2002a). Annex E: Estimated Financial Resources Needed * 149 Costs there are high compared with other countries with similar income levels outside Eastern Europe and Central Asia. The higher costs reflect the longer average length of hospital stay for tuberculo- sis patients and mass screening, practices that are common in most other Eastern Europe and Central Asia countries as well. As coun- tries in the region shift toward current WHO-approved methods for tuberculosis control, which call for less reliance on mass screening by x-ray and less hospitalization, these unit costs are likely to drop. Unit costs from the Russian Federation were adjusted for each country in the region with gross national incomes of less than $1,000 in 2002 (Armenia, Azerbaijan, Georgia, Kyrgyz Republic, Moldova, Tajikistan, and Uzbekistan). Coverage was based on WHO targets for DOTS programs-that is, detection of 70 percent of new smear-positive cases and a cure rate of 85 percent. This methodology for calculating resource needs was used by the WHO's Stop Tuberculosis Department to calculate resource needs for 22 high-burden countries, including the Russian Federation, between 2001 and 2005 (Floyd and others 2002). Results Under the low-case scenario, resource needs increase from about $951 million in 2001 to $1.4 billion in 2007 (table E3). Under the high-case scenario, by 2007 annual tuberculosis control costs will be about $1.9 billion. These costs include the cost of treating all peo- ple detected with tuberculosis, including people with HI-V Potential Resource Gaps and Policy Implications By 2007 about $1.5 billion will be needed to treat 11V/AIDS and $1.9 billion to treat tuberculosis. These figures include some double counting, as the EHIV/AIDS treatment costs include the costs of treating opportunistic infection treatment and prophylaxis. These figures have implications for international assistance to countries in the region and for allocation of public resources for 150 * Averting AIDS Crises in Eastern Europe and Central Asia Table E3. Estimated Cost of Treating Tuberculosis in Eastern Europe and Central Asia, by Country, 2001-07 (thousands of current dollars) YEAR LOW-CASE SCENARIO HIGHCASE SCENARIO 2001 951,262 951,262 2002 1,001,658 1,046,292 2003 1,056,837 1,151,150 2004 1,123,256 1,294,500 2005 1,198,338 1,464,213 2006 1,280,210 1,660,076 2007 1,368,337 1,883,076 Total 7,979,898 9,450,569 Source: World Bank estimates 2003. health care within countries. The data do not easily allow disaggre- gation of current spending on HIV/AIDS. In particular, they do not allowN, disaggregation of HI-V prevention, a public good, which should be financed from public resources. (Treatment of sexually transmitted infections that reduces HIV transmission is a private good with positive externalities.) Disease surveillance systems also yield important social benefits and can be considered public goods. Most public funding for health care in Eastern European and Cen- tral Asia is still allocated to hospital care, 'followed by primary care. Although accurate estimates are not available, it is clear that public health spending has the least important place in government budg- ets.14 Improving the allocative efficiency of public resources for health care, especially in the context of HTIV/AIDS, is a critical issue that 'will need to be a high-priority item in the policy dialogue between the Bank and countries in the region. It would also be useful to collect better information on the source and flow of funds in coun- tries in the region, perhaps through national health accounts (box El). The most recent comprehensive data on financing by cosponsors, bilateral agencies, and NGOs are for December 2001, when total international assistance for HIIV/AIDS programs amounted to $51.7 million (UTNAIDS 2002b) (table E4). Annex E: Estimated Financial Resources Needed * 151 Table E4. International Assistance for National Responses to HIV/AIDS in Eastern Europe and Central Asia, by Program, December 2001 TOTAL INVESTED PERCENTAGE PROGRAM AREA OF TOTAL Prevention of HIV transmission related to 14,668,169 28 intravenous drug use Prevention among young people 12,277,935 24 Prevention among other vulnerable groups 8,136,884 16 (men who have sex with men, sex workersl Prevention of sexually transmitted diseases, HIV, 7,239,456 14 mother-to-child transmission Prevention through advocacy, information sharing, 4,353,491 8 and networking Care, counseling, and social support for people 1,826,125 4 with HIV/AIDS Blood safety 357,190 1 Surveillance, epidemiology, and research 106,000 0.20 Strategic planning, coordination, resource 1,475,239 3 mobilization Legal, policy, and ethical issues Condom programming 1,284,424 2 Total 51,724,913 100 Source: UNAIDS 2002b. In 2002-03 GFATM became an additional source of funding on tuberculosis and HIV/AIDS in the region. Ten Eastern European and Central Asian countries received GFATM grants in rounds one and two of the proposal review process. Amounts granted for the first two years total $78.3 million, with $231.0 provided for the first five years (table E5). The World Bank is also becoming an important source of fund- ing for I-HV/AIDS and tuberculosis control in Eastern Europe and Central Asia. Four World Bank-financed projects on HIV/AIDS and tuberculosis are at various stages of development in the region, in Belarus, Moldova, the Russian Federation, and Ukraine. 152 o Averting AIDS Crises in Eastern Europe and Central Asia Box El. Using National Health Accounts to Track the Source and Flow of Funds National Health Accounts (NHAs) are a standard set of tables that present various aspects of a nation's health expenditures. They encompass total health spending in a country, including public, private, and donor expenditures. In addition to deternin- ing how much these financing sources allocate to health, NILAs carefully track the flow of funds from one health care actor to another, such as the distribution of funds from the Ministry of Health to each government health provider and health service. The NHA framework also allows for the analysis of data on tar- geted populations or disease-specific activities, such as expendi- tures related to maternal and child health or HIV/AIDS. This type of disaggregation of public and private spending by illness or disease category is critical, since I-{IV/AIDS and tuberculosis are infectious diseases for which private demand for treatment is likely to be lower than expected social benefits. This creates a rationale for public financing for prevention and treatment of infectious diseases. Under the Latin America and Caribbean Regional initiative on HIV/AIDS (SIDALAC), data on public and private spend- ing on HIV/AIDS were collected in 15 countries using the NHA framework. These data reveal that the region under- spends on prevention and devotes too little attention to key groups (men who have sex with men, commercial sex workers, injecting drug users). Moreover, there is no clear pattern of spending priorities, and spending does not always match iden- tified program priorities. The Europe and Central Asia Region of the World Bank has recentdy launched an initiative in which several countries in the region will be developing N-HAs. Given the importance of tuberculosis and EIIV/AIDS in the region, these problems could be included in the NHA following the SIDALAC model. Source: Abt Associates 2003; McGreevey 2003. Annex E: Estimated Financial Resources Needed * 153 Table E5. GFATM Grants in Eastern Europe and Central Asia, 2002-2003 (millions of dollars) COUNTRY YEARS IAND 2 TOTAL (YEARS 1-5) Armenia 3.2 7.2 Croatia 3.3 4.9 Estonia 3.9 10.2 Georgia 4.0 12.1 Kazakhstan 6.5 22.4 Kyrgyz Republic 5.6 18.3 Moldova (Round 1) 1.7 11.7 Romania 40.0 48.4 Ukraine (Round 1) 9.0 92.2 Serbia and Montenegro IRound 1, deferred funding) 1.1 3.6 Total 78.3 231.0 Note: Seven countries applied for but did not receive grants. Nine countries did not apply for grants. Source: GFATM (www.theglobalfund.org) and Global Fund Observer. In 2002 health care spending in Eastern Europe and Central Asia was $150 billion measured in purchasing power parity dollars (about $60 billion measured at 1997 exchange rates). A similar or larger amount is likely to be spent in 2007. Spending requirements for I-V/AIDS prevention and care, at $1.4 billion in 2007, would con- stitute no more than 1-3 percent of total health spending that year (depending on whether nominal exchange rate or purchasing power parity dollars are used). Detection and treatment of tuberculosis would consume 5-6 percent of health care costs. If efficiency were improved through adoption of cost-effective tuberculosis control strategies, these costs would likely drop significantly, to 2-3 percent of health expenditures.15 These figures suggest that it should be fea- sible to finance the prospective level of spending required (although considerable donor support will be needed in the Caucasus and Cen- tral Asia). Much depends, however, on whether actions taken now can effectively restrain the epidemic, limiting the number of new infections. The high share of HAART spending in regional budget requirements, coupled with uncertainties about the cost of pharina- ceuticals, leave a host of unanswered questions about financing. 154 o Averting ARDS Crises in Eastern Europe and Central Asia Several countries in the region have effective social and private insurance arrangements that cover health care services. An ongoing policy debate may focus on the nature and extent of coverage these insurance institutions offer. Out-of-pocket spending may prove to be important in some countries as their health care financing sys- tems evolve. The most important source of finance is likely to be national and local governments, which will need to support the poor with subsi- dized health care and finance a large part of prevention services. Governments may prove to be the entities best able to negotiate for lower prices for HAART pharmaceuticals. Aggregate figures mask huge disparities in per capita health expenditures across the region. During 1990-98 annual per capita spending on health care was $746 in Slovenia but just $13 in the Kyrgyz Republic and $6 in Tajikistan (World Bank 2002c). Some of the most economically challenged countries of the region (countries in the Caucasus, the Central Asian countries, and Moldova) are faced with a growing problem of NIIV/AIDS. In these countries domestic and international resources will have to be mobilized for comprehensive HIV/AIDS prevention and treatment programs. summugry A substantial increase in resources is needed to fight HIV/AIDS in Eastern Europe and Central Asia. Funding needs to increase from about $300 million in 2001 to about $1.5 billion in 2007. That increase in resources requires that expenditures rise at a cumulative annual rate of 30 percent. This substantial rate of increase must be accompanied by staff training, testing equipment, better skills in policy and advocacy for behavioral changes, and a host of related practical responses. Increased funding can facilitate an effective response, but many organizational and operational changes must also take place to ensure effective implementation. On a more optimistic note, fully scaling up the required program for H-IIV/AIDS care and support would require expenditures of no Annex E: Estiniated Financial Resources Needed * 155 more than 3 percent of total likely health care spending in the region by 2007. This share suggests that resource mobilization is feasible. Failure to mobilize resources and implement the care and sup- port programs outlined here can only exacerbate the problems aris- ing from the HIV/AIDS and tuberculosis epidemics. The likely future costs will be all the greater should there be delays in imple- menting these essential interventions. VoiNa M). Estimated Resource Requirements for Preventing and Treating HIV/AIDS, by Activity, 2001-07 (thousands of dollars) ACTIVITY 2COi 2002 2C03 2004 2CO5 2CD6 2007 [PravaftnnOiiaVad- CCVvjjVq5O 213 | 4,Z 29o' Sg ,! B 3,5),3yS 4 m,(m | 683, 11 2@ 34g,86g9 62 ,70$ Youth-focused interventions 25,261 25,506 25,685 25,874 26,861 27,832 28,908 Interventions focused on commercial sex workers and their clients 1,648 3,848 6,444 9,496 12,949 16,890 21,373 Social marketing of condoms 3,691 7,200 11,691 16,422 21,791 27,366 34,572 Public and commercial sector condom provision 21,299 34,836 47,551 59,748 72,411 84,063 96,045 Improving management of sexually transmitted infections 35,924 45,048 54,450 64,058 73,816 83,680 93,618 Voluntary counseling and treatment 34,824 37,532 37,621 37,738 37,823 38,203 38,327 Workplace measures 14,906 31,747 45,797 59,801 73,789 89,082 106,783 Blood safety 54,422 54,469 54,587 54,642 54,701 54,765 54,833 Prevention of mother-to-child transmission 6,613 7,939 9,362 10,893 12,535 14,299 16,193 Mass media 19,646 21,443 23,319 25,195 26,972 28,669 30,445 Harm reduction programs 4,687 6,729 8,734 10,754 12,743 14,717 16,675 Interventions focused on men who have sex with men 2,382 4,829 7,466 10,303 13,334 16,551 19,935 Interventions focused on other vulnerable groups 6,150 15,388 24,669 34,093 43,397 52,752 61,996 Panllitiv care 1m;nt, sm7UNO$,8 13,707 E05,w3 15,S,801 3 2 62,1,22 024,570 Y, 8528,340 Palliative care 11,855 13,705 15,801 18,322 21,222 24,570 28,305 Testing 43 79 133 213 323 467 642 Treatment of opportunistic infections 23,744 29,885 38,289 49,998 65,603 85,996 111,516 Prophylaxis of opportunistic infections 1,590 2,803 4,687 7,593 11,821 17,721 25,526 Lab HAART 1,057 3,655 8,559 16,810 29,665 48,419 74,270 Antiretroviral therapy 16,898 58,307 127,494 223,110 321,751 452,498 612,089 Policy, advocacy, administration, and research 14,332 20,247 27,617 36,753 46,675 58,927 73,603 Total 295,548 418,037 570,557 760,002 965,873 1,220,994 1,527,212 Source: Work performed by the UNAIDS Secretariat, the World Bank, and the Futures Group 2002. Notes 1. Incidence refers to the number of new cases of JIIV Preva- lence refers to the total number of cases of HIV 2. The eight cosponsors are the International Labor Organiza- tion (ILO); the WHO; the United Nations Development Pro- grammiie (UNDP); the United Nations Children's Fun(d (UNICEF); the United Nations Educational, Scientific and Cultural Organiza- tion (UNESCO); the United Nations Office on Drugs and Crime (UNODC); the United Nations Population Fund (UNFPA); and the World Bank. 3. The five elements of DOTS are political commitment to effec- tive tuberculosis control; case detection among symptomatic patients self-reporting to health services, using sputum-smear microscopy; a standardized treatment regimen of six to eight months of short-course chemotherapy with first-line antituberculosis drugs, administered under proper case management conditions, including direct observation; uninterrupted supply of all essential antitubercu- losis drugs; and establishment and maintenance of a standardized recording and reporting system, allowing assessment of treatment results. 4. The Gini coefficient is a number between zero and one that measures the degree of inequality in the distribution of income in a 159 160 o Averting MID§ Crises in Eastern Europe and Central Asia given society. In a society in which everyone received exactly the same income, the Gini coefficient would be zero. In a society in which one person received 100 percent of income and the rest of the society earned nothing, the Gini coefficient would 1.0. 5. The low-case and high-case prevalences for the Russian Fed- eration and Ukraine were slightly different because, by some unof- ficial estimates, both countries are already at or close to the 1 per- cent prevalence level. For these countries, the low case was taken as 1.5 percent and the high case was taken as 2 percent. 6. These costs are based on country consultations conducted to estimate the resource needs for HIV/AIDS prevention and treat- ment programs in Europe and Central Asia. For details on the work- shop and the data, see annex E. 7. The total fertility rate refers to the average number of children a woman would bear over her lifetime if she experienced the current age cohort-adjusted fertility rates for specific years. The replace- ment level is a total fertility rate of 2.14. Life expectancy describes mortality levels in a given population at a particular point in time, as measured in years of life. It is affected by childhood and adult mor- tality rates. The lower the death rate, the more people survive throughout an entire age cohort and the greater the number of years they live. 8. According to the models developed by the Futures Group, as many as 60 percent of IEIV/AIDS cases can be averted by imple- menting the package of prevention activities, provided a certain level of coverage is achieved. 9. Public health prevents epidemics and the spread of disease, protects against environmental hazards, prevents injuries, promotes and encourages healthy behaviors and mental health, responds to disasters and assists communities in recovery, and ensures the qual- ity and accessibility of health services. Essential public health serv- Notes * 161 ices include monitoring health status to identify and solve commu- nity health problems; diagnosing and investigating health problems and health hazards in the community; informing, educating, and empowering people about health issues; mobilizing community partnerships and action to identify and solve health problems; devel- oping policies and plans that support individual and community health efforts; enforcing laws and regulations that protect health and ensure safety; linking people to needed personal health services and ensuring the provision of health care when otherwise unavailable; ensuring a competent public health and personal health care work- force; evaluating effectiveness, accessibility, and quality of personal and population-based health services; and researching new insights and innovative solutions to health problems (U.S. CDC 1995). 10. Sensitivity refers to how accurate a test is in detecting true pos- itive cases among those tested. Specificity refers to how well a test correctly identifies people who are not infected (Dawson-Saunders and Trapp 1994). 11. The Futures Group based the model on work done by Lilani Kumaranayake and Charlotte Watts, staff members of the London School of Hygiene and Tropical Medicine, and meta-analyses of cost- effectiveness studies managed by Bernhard Schwartlander, the former manager of strategic information at UNAIDS and the current director of [IIV/AIDS programs at the WHO. 12. The 12 programs in the prevention model include interven- tions with young people, interventions with sex workers and their clients, interventions with men who have sex with men, social mar- keting of condoms, public and commercial provision of condoms, improved management of sexually transmitted diseases, voluntary counseling and testing, workplace programs, blood safety programs, prevention of mother-to-child transmission, mass media campaigns, and harm reduction programs. The care and treatment model includes palliative care, treatment of opportunistic infections, diag- nostic HIV testing, prophylaxis for opportunistic infection in symp- 162 o Averting AIDS Crises in Eastern Europe and Central Asia tomatic patients, and HAART and its associated laboratory support. Orphan care includes care in orphanages, community assistance, and subsidies for school expenses. 13. 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"Russian Federation, Tuberculosis and AIDS Control Project." Project Appraisal Document. Europe and Central Asia Region, Washington, D.C. . 2003c. "Truck Drivers and Casual Sex: An Inquiry into the Potential Spread of HTV/A1DS in the Baltic Region." Europe and Central Asia Region, Washington, D.C. 2003d. World Development Indicators. Washington, D.C. Forthcoming. "Georgia: HIV/AIDS Policy Note." Europe and Central Asia Region, Washington, D.C. World Bank, Open Society Institute, INEKO, and Foundation SPACE. 2002. "Poverty and Welfare of Roma in the Slovak Republic." April. Index Afghanistan, 15, 16, 45 Belarus Tuberculosis and AIDS Agreement on Trade-Related Control Project, 12b Aspects of Intellectual birthrates, declining, 70 Property, 133 blood safety, xxii, 30 AIDS Impact Model (AIMS), Bosnia, 43 75 Brazil, xvi, 8, 66 Albania, x, 27, 52, 101 bridge populations, xviii, 18, 48 antiretroviral therapy, xxiii, See (lso commercial sex 32-3 3. See also highly workers; mobile popula- active antiretroviral ther- tions apy Bulgaria, 44, 90, 93 Bank support of, 33, 39 Canadian International Devel- Baltic States, x, 6b, 41 opment Agency, 126 spread of I-11V 6b Caribbean, 23, 152b, 162 susceptibility to -HJV 43 Caucasus region, 41 basic reproductive number, 19, Central and Eastern Europe 48 Harm Reduction Net- behavioral factors, 44, 47-52 work, 10 of HIIV/AIDS, xvii-xviii, 15, Central Asia 18-19, 86 demographic groups, 70 Belarus, x, xvii, 95 GFATM grants, 153t -IIIV prevalence among HAART costs, 66-67, injecting drug users, 48 147 183 184 o Averting A]IDS Crises in Eastern Europe and Central Asia health care expenditures, per chemotherapy, 56 capita, 154 CIS. See Conmmonwealth of health care spending, 153 Independent States health care spending dispari- commercial sex workers, xxviv, ties, 154 17, 18, 46, 127 heroin use in, 47 Bank interventions, xxii heterosexual spread of HEIV and FIIV intervention, 31 50 and injecting drug users, 94 IIIV/AIDS epidemic, 41 and spread of HIV, 7b effects on, 13, 14b Thailand, 87 recognition of, 8, 10, 1 lb, Commonwealth of Independent 125-126 States (CIS), 6b, 10 HIIV/AIDS prevalence, ix projected HAART costs, 68t increase in, 43-44 spread of THIV 6b among injecting drug Urgent Response of Member users, 48, 50 States, 22 rates, 9t, 42 concentrated epidemic EfEV/AIDS prevention vs. low-level epidemic, 5, 42 efforts, 10 condom use, 87, 92, 94, 100, funds required, 146f 107 international assistance, coverage targets 145f, 151t calculating, 142, 143 strategies, 81-82 HIIV intervention, 142-143 injecting drug users, 52 Croatia, 44 international aid, 151 Czech Republic, xvi, 41 Roma population, 115-116 HIlV prevalence in, 5 sex workers, 52 surveillance objectives, meth- data collection, NHAs, 152 ods, 91t DEC. See AVTorld Bank, Devel- syphilis, 109 opment Economics Vice trafficking of women, girls, 96 Presidency tuberculosis, 53, 54 dependency ratio, 13, 77 recognition of problem, 8, diarrhea, 53 10, 125-126 disaggregation of spending, treatment cost, 150t 150 Index * 185 DOTS (directly observed ther- surveillance objectives, meth- apy, short-course), 53, 54, ods, 91t 57, 58 syphilis, 109 co-infection treatment effec- trafficking of women, girls, 96 tiveness, 110-111 tuberculosis, 53, 54 elements of, 159 problem, recognition of, 8, programs, 149 10, 125-126 DOTS-Plus, 21, 111 treatment cost, 150t drug use, 47, 144. See also economic impact, description injecting drug users of, 59 and spread of I-UV, 6b, 15-16 epidemic dual epidemic, controlling, generalized, 5, 42, 76-77 31-32, 57-58 lowv level vs. concentrated, 5, 42 Eastern Europe Estonia, 42, 43, 87 condom use, 100 adult prevalence rates of HIV demographic groups, 70 xvii GFATM grants, 153t HAART costs, 66-67 fertility rate, 160 [IIV/AIDS epidemic, 41, Futures Group, 1lb, 138, 160, 113 161 HIV/AIDS intervention funds required, 146f gender inequality, 129 international assistance, generalized epidemic, 5, 42 145f, 151t impacts of, 76-77 prevention strategies, 10, Georgia, x, 92 81-82 Gini coefficient, 59, 73, for young people, 99 159-160 HIrV/AIDS prevalence, ix, 7b Global Fund to Fight AIDS, rates, 9t Tuberculosis and Malaria FIIV/AIDS problem, recogni- (GFATM), x, 10, 23, 124b, tion of, 8-10, 11b, 125-126 134, 151 injecting drug users, 52 grants, 153, 153t Roma population, 115-116 gonorrhea, 51, 109 sex workers, 52 Green Light Committee, 123b 186 o Averting AIDS Crises in Eastern Europe and Central Asia HAART. See highly active anti- HIV prevention retroviral therapy coverage targets, calculating, harm reduction, xxii, 12, 31 142, 143 approach, programs, 95-97 funding, 145 Central and Eastern Europe large-scale implementations, network, 10 xxviv needle and syringe exchange required actions, 37-38 programs, 95-96 prevention model, programs, supporters of, 96 161 health care providers strategies, 81-82 HIV/AIDS training, HIV treatment 103-104 cost, 142t universal precautions, 104 vs. prevention, costs, 144 health care system deterioration HIV/AIDS and spread of i-HEV 17-18 behavioral factors, xxi-xxiii, health education 15, 18-19, 86 Bank efforts, 101 care and treatment model, for general public, 101-103 138 social marketing, 101-102 drug-resistant forms, xxiii, 33 U.S. government efforts, economic, social impacts of, 102-103 28, 59, 60t for young people, 98-101 effect on dependency ratio, 13 hepatitis B and C, 88, 106 effect on households, 13, heroin use, 47 72-73 Herzegovina, 43 effects on industry, com- high-risk core transmitters, merce, 71-72 xviii, 18, 48 HAART costs, 66-69, 68t highly active antiretroviral ther- information gathering, 27-30 apy (HAART), xxiii, lessons learned, 22-23, 32-33, 142 119-120 advantages of, 108 macroeconomic impact of, costs, 66-69, 77, 147-148 60-61, 62t-63t, 64b, 65 downsides to, 108 political commitment to funding, 144 avert, xix, 26-27 projected costs for CIS, 68t and poverty, 73-74 Index * 187 rapid testing, 88 care and treatment model, relationship to tuberculosis 161-162 spread, 19 cost-effectiveness, 30, reporting, 86-87 117-119 resources, calculating, coverage targets, 142-143 137-138, 142-143 funds required, 131-132, 146f risk factors, 16f and institutional capacity, social services for, 112 130-132 structural factors, 15-18, 16f, judicial constraints, 145-146 44, 45-47 legal issues, 132-133 subregional patterns affecting minority populations, vulnerability, susceptibility, 114-115 6-7b nonfinancial constraints, surveillance objectives, meth- 145-146 ods, 91t priorities, xxii-xxiii, 25-26 and tuberculosis, xvi role of NGOs, 112-113 tuberculosis co-infection, among Roma population, 31-32, 53, 55f 115-116 and tuberculosis prevention, social constraints, 127-129 110-111 and stigmatization, 115-116 HIV/AIDS epidemic for young people, 98-99 behavioral factors, xvii-xviii HIV/AIDS policies, programs in Eastern Europe, Central political factors, 22 Asia, xv-xvi structural factors affecting, effects on Eastern Europe, 21-23 Central Asia, xvi-xvii HIV/AIDS prevalence generalized, 5, 42, 76-77 in Central Asia, 42, 43-44 low level vs. concentrated, 5, in Czech Republic, 5 42 data sources, 43 structural factors, xvii-xviii and injecting drug use, 48-49 HIV/AIDS information gather- in Moldova, 124b ing. See also surveillance mother-to-child transmission, Bank's role in, 27-30 143 HIV/AIDS intervention, 58, projected, 66, 67f 144-145 rates, xvii, 9t, 42 188 o Averting AiDS Crises in Eastern Europe and Central Asia among Roma population, 115 resource requirements for among truckers, mariners, 2001-2007, 156t-157t 106-107 screening, 84 vulnerable subgroups, 79-80 secondary, 81 HTV/AIDS prevention stages of, 80-81 activities, 139-141, 139t-141t and STDs, 109 Bank approach to, 34-35 tertiary, 81 Bank efforts, 30-31 vs. care, treatment, 144 constraints, nonfinancial and HITV/AIDS target groups, 138, judicial, 145-146 139t-141t core efforts, 120 HIV/AIDS treatrnent cost-benefit analysis of, costs, 139t-141t 74-75, 76t funding for, 156t-157t cost-effectiveness of, 30 model, 161-162 coverage targets, 142 resource requirements for early adoption of, 74-75 2001-2007, 156t-157t funding, 143-144, 144, 154, sustainable care of affected 156t-157t people, 32-33 infrastructure required, 82 types of care, 142t large-scale implementations households of, xxviv, 37-38 HIIV/AIDS impact on, 72-73, lessons learned, 22-23, 77 119-120 Hungary, xvi, 8, 41, 44 low-prevalence, 79-80, 82 methodology, resource needs, incidence 137-138 vs. prevalence, 159 model, 138 India, 66 model, resource needs, industry 137 I-lV/AIDS impact on, 71-72 needle and syringe exchange infrastructure, community, 129 programs, 95-96 injecting drug users, xvi, xxviv, nonfinancial constraints, 12, 18, 45, 47, 87, 127 145-146 and HIV prevalence, 48-49 primary, 80 institutional capacity, 130-132 programs, 12 insurance, private, 154 Index * 189 internal constraints, 121 Macedonia, 44 International Committee of the mariners Red Cross, 90 FIIV prevalence, 106-107 International Development Medecins Sans Frontieres, 57, Agency, 23 90, 96 International Development Mexico, 147 Association, x, 124b migrant workers International Finance Corpora- I-IIV risk, intervention, tion, xxv, 34 114 International Organization of military personnel, 105 Migration, 96 Bank efforts, 106 isoniazid, 54 Millennium Development Goals, 133, 134 Joint United Nations Program on minority populations, 113-116 HIV/AIDS (UNAIDS), x AMinsk workshop, 144, 145 mobile populations, 17, 18, 46, Kazakhstan, 19, 47 113-116 tuberculosis, 19, 53 Moldova, xvii, 23, 44 Kenya, 92 controlling tuberculosis, Kosovo, 101 HIV/AIDS in, Kumaranayake, Lilani, 161 124b-125b Kyrgyz Republic, 27, 154 Moldova AIDS Control Pro- ject, 12b Latin America, 23, 152b, 162 mother-to-child transmission, Latin America and Caribbean 143 Regional initiative on multidrug-resistant tuberculo- AIDS, 152 sis, 20-21, 54-56, 57, 111. Latvia, 43, 44, 87 See also tuberculosis legal issues HI[V intervention, 132-13 3 National Health Accounts life expectancy, 160 (NHA), 152, 152b Lithuania, 43 National Tuberculosis Program, low-level epidemic 93, 94 vs. concentrated epidemic, 5, needle and syringe exchange 42 programs, 95-96 190 o Averting AIDS Crises in Eastern Europe and Central Asia New York City to avert HIV/AIDS, 126-127 needle and syringe exchange Bank efforts, 103 programs, 95 population calculations, 138 Newly Independent States poverty (NIS) HIV/AIDS impact on, 73-74 HIIV incidences in, 5, 8 Poverty Reduction and Eco- susceptibility to HTV, 43 nomic Management Net- NIHA. See National Health work (PREM), xx, 28 Accounts Poverty Reduction Support nongovernmental organizations Credit, x (NGO) prevalence role in H[V intervention, vs. incidence, 159 112-113 primary prevention, 80 prison inmates, ex-inmates, 127 Open Society Institute, 90, 95, Bank interventions for, 112 xxii-xxiii opium production, 45 and IHV interventions, 31 OraQuick HIV rapid test, 88 and H[IV prevalence, 17, 46 orphans, 70 and tuberculosis, 17, 20, 54 private insurance, 154 palliative care, 142 procurement, 136 peacekeeping units, 105, 106 prophylaxis, 142 Bank efforts, 106 ProTEST, 93-94 pharmaceutical companies, public health services, 160-161 147 public health spending, 150 pneumonia, 53 Poland, x, xvi, 8, 41, 42, 43, 92 Ramsay pricing, 147 spread of HIV, 7b Red Cross, 96 policing strategies, 12 Regional Support Strategy policy instruments, xix, xxvi, 27, audience of, 2 35 Bank methods, 26 political attitudes intervention priorities, effect on I-UV policies, pro- xxii-xxiii gram, 22 program priorities, xix-xv political commitment, 12, 103 purpose of, ix, xv, 1-2 Index * 191 replacement level, 160 resource needs, 149 reporting systems Russian Federation Tuberculo- for 1-HV/AIDS, 87 sis and AIDS Control Pro- Research Institute for Complex ject, 12b Social Studies, 87 reaching agreement on, resource needs model, 137-138 122b-123b assumptions, 143 resource requirements, xxi, 29 Schwartlander, Bernhard, 161 2001-2007 estimates, secondary prevention, 81 156t-157t Serbia, 52 rifampicin, 54 sex. See also commercial sex Roma population, 115-116, 128 workers Romania, 19, 42, 44, 101 sex, casual, 50, 51 spread of HI-Il 7b sex, unprotected, 51 tuberculosis, 19, 53 sexually transmitted infections Russia Longitudinal Monitor- (STIs), 51, 106 ing Survey, 50 and HIV prevention, 109 Russian Federation, x, 42, 87 preventing, 108-110 adult prevalence rates of FINl among sex workers, 52 xvii Slovakia, 54 compulsory 1I1V testing, 93 Slovenia, xvi, 8, 41, 54, 154 effects of FHV/AIDS epi- social impact, description of, demic, 14b 59 inmates with J]IV 46 social mar-keting, 101-102 low-case, high-case preva- social protection programs, lence, 160 69-71 macroeconomic impact of social services IV/AIDS, 64b for HTV patients, 112 sex workers and injecting Soros Foundation-Moldova, drug users, 48, 49, 52 124b-125b sexually transmitted infec- South Africa, 106 tions, 51 Southeast Asia, 89 syphilis rate, 109 Southeastern Europe tuberculosis, 20, 53, 149 sex workers and injecting among inmates, 54 drug users, 52 192 o Averting AIDS Crises in Eastern Europe and Central Asia Southeastern Europe Confer- Swedish International Develop- ence on HV/AIDS, 10 ment Agency, 124b, 126 Southern Europe Switzerland, 97 I-UV prevalence, 7b syphilis, 51, 88, 109 Soviet Union drug use, 94 Tajikistan, 19, 154 St. Petersburg, 86 Tanzania, 92, 107, 109 St. Petersburg State University, target groups, 139t-141t 87 target populations, 139-141 STIs. See sexually transmitted testing, 142 infections sensitivity vs. specificity, 161 stigmatization, 116-117, Thailand, xvi, 8, 73, 87, 88 127-128 political commitment, 103 overcoming, 128-129 Trade-Related Agreement on Stop Tuberculosis Department, Intellectual Property 149 Rights (TRIPS), 66, 147 Strategic Framework to Transnational AlDS/STD Pre- Decrease the Burden of vention Among Migrant Tuberculosis/HIV, 58 Prostitutes in Europe Pro- structural factors, 44, 45-47 ject, 96 affecting I-I/AIDS, Treatments, 142 xvii-xviii, 15-18 Trinidad, 92 affecting HI1V policies, pro- truckers grams, 21-23 HIV prevalence among, Sub-Saharan Africa, 23, 58, 106-107 89 trust funds, 135 ProTEST, 94 tuberculosis, 148-149 surveillance, xxviv, 83-89 chemotherapy, 56 behavioral, 82, 85-86 contributing factors, 54 biological, 83-84 critical situations, 19 description of, xx, 12 description of, 52 importance of, xx, 29, 89 DOTS, 53, 54 improvement of, xx, 28-29 Eastern Europe and Central second-generation, 28 Asia, 150 sentinel, 85 factors contributing to spread Index * 193 of, 19-21 political commitment, 103 WIIV co-infection, 19, 31-32, Ukraine, x, 42, 43 53, 5Sf, 56 HIV prevalence, xvii and importance of surveil- among injecting drug users, lance, 29 48 in Moldova, 124b among inmates, 46 multidrug-resistant, 20-21, low-case, high-case, 160 54-56, 57, 111 tuberculosis, 20, 53 among prisoners, xxiii, 17 Ukraine Tuberculosis and AIDS projected prevalence, 66 Project, 12b relationship to HIV/AIDS, United Nations xvi, 19, 56 Declaration of Commitment resource needs, 148-149 on HIV/AIDS, 116-117 Soviet control system, 56-57 General Assembly Special spread of, 148 Session on AIDS, 75, 143 unit costs, 148-149 peacekeeping units, 105, 106 tuberculosis control Resolution 1308, 106 Bank approach to, 34-35 UNAIDS-World Bank work- Bank funding, 151 shop, 143, 144 resource needs, 148-149 unprotected sex, 51 tuberculosis epidemic Urgent Response of Member factors, 20-21 States of the Common- THV co-infection, 19, 31-32, wealth of Independent 53, 55f, 56 States, 22 among prisoners, 20 Uzbekistan tuberculosis prevention inmates with I-1V, 46 core efforts, 120 tuberculosis, 20, 53 among HI-V/AIDS patients, 110-111 vaccine preparedness studies, tuberculosis treatment, 56 xxiv, 37 cost, 53, 54 voluntary counseling, testing, quality, 57 89-90, 92-94 in Africa, 92 Uganda, 87, 88, 92, 98 awareness of, 92 HIIV prevalence, 106 barriers to, 93 194 o Averting AIDS Crises in Eastern Europe and Central Asia benefits of participation, 92, HIV/AIDS priorities, 25-26 94 HIV interventions, 30-31 in Eastern Europe, Central information, generation and Asia, 90 use of, xix process of, 90 instruments for nonlending and tuberculosis prevention, operations, 35 93-94 intervention priorities, Vozrastcheniye Foundation, 87 xxii-xxiii Legal Department, 136 Watts, Charlotte, 161 lending services, 12b World Bank Moldova AIDS Control Pro- and antiretroviral medica- ject, 12b tions, 33 nonlending services, 11 b Belarus Tuberculosis and Operations Policy and Coun- AIDS Control Project, try Services Department, 12b 136 Declaration of ConmLitment, partnerships with, x, xxv, 34, ix 159 Development Economics policy instruments, xix, .XXvi, Vice Presidency, xx, 28 27, 35 dual epidemic, approach to political efforts, 103 controlling, 31-32 PREM, xx, 28 and efforts with UN Secre- reform areas, 135-136 tariat, x, xxi Russian Federation Tubercu- Environmentally and Socially losis and AIDS Control Sustainable Development Project, 12b, 122b-123b Network (ESSD), 136 tuberculosis control, approach External Affairs Unit, 27 to, 34-35 harm reduction efforts, 97 tuberculosis control, funding, health care efforts, 104-105 151 health education efforts, 101 World Bank Institute, xxv, 27, health system projects, 82-83 34 HIV/AIDS control, approach World Health Organization to, 34-35 (WHO), 149 About the Authors Olusoji Adeyi, MD, MPH, DrPH, is a lead health specialist in the Europe and Central Asia Region of the World Bank, where he serves as team leader for health programs in the Russian Federation and as regional focal point for HIV/AIDS Control. He has worked extensively on health system development in Central and Eastern Europe and in Africa. From 1999 to 2001 he served as senior advi- sor at UNAIDS in Geneva, on secondment from the 'WAorld Bank, developing tools and strategies for linking HAIIV/AIDS control pro- grams to poverty reduction strategies and debt relief as well as methods to improve the technical content of these programs. He is an adjunct assistant professor at the Johns Hopkins Bloomberg School of Public Health. He also serves as associate director of the AIDS Prevention Initiative in Nigeria, a program funded by the Bill & Melinda Gates Foundation through a grant to the Harvard School of Public Health. Enis Baris, MD, MSc, PhD, is a senior public health specialist in the Europe and Central Asia Region of the World Bank, where he works as team leader for health projects in Azerbaijan, Bulgaria, and Turkey. He is also adjunct professor in the Department of Health Administration of the University of Montreal. At the World Bank he has worked extensively on health and development issues, includ- ing HIV/AIDS, in East Asia. Before joining the Bank he worked in Canada and for the WHO, where he conducted research on tobacco 195 196 o Averting AIDS Crises in Eastern Europe and Central Asia control, tuberculosis, and comparative analysis of health care sys- tems in Eastern Europe, Latin America, and Sub-Saharan Africa. Sarbani Chakraborty, MSc, PhD, is a health economist at the World Bank. She has worked on analytical and programmatic operations in several countries, including Georgia, the Kyrgyz Republic, and Slo- vakia. Her areas of technical expertise and interest include the pub- lic-private mix in the financing and delivery of health services, decentralization, provider payment systems, poverty reduction strategies, and the economic impacts of HIV/AIDS. Thomas Novotny, MD, MPH, is the director of International Pro- grams at the University of California, San Francisco, School of Medicine. He is a graduate of the University of Nebraska Medical Center, the University of California (San Francisco) Family Practice Residency Program, the U.S. Centers for Disease Control and Pre- vention's Preventive Medicine Residency Program, and the Johns Hopkins University School of Public Health. He has worked exten- sively as a World Bank public health consultant on health system reform, particularly in Eastern Europe. Dr. Novotny was a commis- sioned officer in the U.S. Public Health Service, serving as assistant surgeon general and deputy assistant secretary for International and Refugee Health. He has published widely on tobacco control, HIV/AIDS, and public health. Ross Pavis, MFA, MPA, is an operations officer in the Europe and Central Asia Region of the World Bank. Heeee is a team leader of a social investment fund in Tajikistan and has worked on health projects in many countries in the region, including Albania, Croatia, Estonia, Romania, Slovenia, and Tajikistan. He has worked extensively with Roma, managing work programs in Hungary and Slovakia on capac- ity building, education, and poverty financed by the Institutional Development Fund and the Development Grant Facility. - 00 O o 7 X X S E D Q D~~~~~9 i b 0 oQDQ 00 t 0 ° fid b b(dQI o 0 a 4 X@ 0| 00 00 --11: 01U B k^