In response to the latest grim statistics revealing the devastation wreaked in Africa by the rapid spread of the HIV/AIDS epidemic, the World Bank, the largest source of external finance for AIDS programmes in developing countries, has called on African governments to adopt a multi-pronged approach in the struggle to arrest the spread of the disease. African leaders, the Bank says, should be at the forefront and move the fight against HIV/AIDS to the centre of development agendas, gearing prevention programmes to reach young people in particular.
World Bank Vice-President for Africa Callisto Madavo announced the new
approach in June at the Twelfth World AIDS Conference in Geneva, following
a January meeting at the Bank on the demographic impact of HIV/AIDS. Statistics
released at the January meeting revealed dramatic declines in life expectancy
attributable to HIV/AIDS in many African states and the devastating impact
of the disease on development. 
Photo: UNICEF / Cindy Andrew
According to the Bank's HIV/AIDS coordinator, Ms. Debrework Zewdie, governments should "take HIV/AIDS into consideration in formulating all development policy -- whether it concerns infrastructure, education, or agriculture." This new perspective emerged from the growing realization that AIDS threatens to reverse socioeconomic gains in much of Africa.
"All of the progress of the last 20-30 years on the development front in Africa is now in jeopardy," Dr. Zewdie told Africa Recovery. "This led us to conclude that AIDS is no longer an issue for the health agenda alone. It is an issue that cuts across the entire development agenda. So in line with the new vision adopted by the Bank, as well as our partners within UNAIDS [Joint United Nations Programme on AIDS], we are urging African governments to create a policy environment which encourages the active participation of NGOs, civil society and the international community in the fight against this scourge."
Dr. Zewdie attributes the spread of the epidemic in Africa largely to the lack of serious policy attention on the part of governments and development agencies. "Policy responses have not changed significantly since the mid-1980s. As a result, the epidemic has gotten out of hand," she said.
For example, in 1985/86 there were only five reported AIDS cases in Ethiopia; in 1997 Ethiopia reported over two million cases. In 1994, only five African countries reported that more than 8 per cent of the general population was infected by the HIV virus; by 1997, as many as 21 countries reported infection levels afflicting more then 8 per cent of the population.
Crowded national agendas
are one obvious reason why governments have been unable to respond adequately
to the crisis. Numerous, more visible and seemingly more immediate problems
compete for the attention of policymakers. "If I talk to a leader of
an African government today, I try to put this epidemic in perspective by
telling him, for example, that literally 10 years from now he will lose
half of the country's teachers to AIDS. However, the next person meeting
with him might quickly divert his attention with news of the more immediate
and visible effects of the most recent flood, drought or cholera epidemic.
And unfortunately those issues take precedence in the minds of policymakers.
Also, as politicians with limited office terms, it is natural for them to
adopt a short-term perspective in policymaking, prioritizing those issues
on which it's easiest to achieve progress while still in office," lamented
Dr. Zewdie.
"All of us are to blame for the failure to engender that critical level of urgency through which HIV/AIDS becomes the issue to determine how the government is run. But because blame for past failures is not going to help us now in winning the battle against AIDS, we need to refocus our efforts."
Dr. Zewdie said that the Bank now plans to approach each African government and "challenge them" one by one to work with the Bank on its new initiative. "If two or three governments agree to work with the Bank on this new initiative, I will call that success because hopefully it will send a strong enough signal to their counterparts to begin to address the epidemic properly," she added.
That signal seems to be necessary, as fewer governments are approaching
the Bank for funding of HIV/AIDS programmes. Despite the epidemic's alarming
growth rates, Bank lending for HIV/AIDS in Africa has declined drastically
since 1995. The Bank's funding commitments for HIV/AIDS-related projects
in sub-Saharan Africa fell steeply from $67 mn in 1994, to $48 mn in 1995,
$2.3 mn in 1996 and $1.7 mn in 1997.
-- Ms. Debrework Zewdie,
HIV/AIDS Coordinator, World Bank .
"The funding has been going down, not because the Bank is reluctant to lend, but because there are no new projects in the pipeline," Dr. Zewdie explained. "To my knowledge, no country that has requested funding for HIV/AIDS has been turned down."
"The falling demand for HIV/AIDS funds is a sign that African countries have become accustomed to the news of the epidemic, following a time of general panic in the early 1980s," Dr. Zewdie declared. "There is also a dangerous sense that the AIDS work now being done by NGOs is sufficient to arrest the disease. And that is part of the reason why the epidemic is spreading at such an accelerated rate."
However, the Bank expects demand for its HIV/AIDS funds to rise in the next three-to-four years as African leaders become increasingly alarmed by the epidemic and as heightened awareness of funding availability prompts more clients to turn to it for financial assistance.
The Bank has been involved in HIV/AIDS work since 1986 and has committed over $800 mn to more than 70 projects around the world aimed at preventing and controlling HIV/AIDS and sexually transmitted diseases (STDs). Nearly half of the funding allocated so far has gone to African countries.
The Bank's HIV/AIDS activities in Africa are always carried out in cooperation with other partners including UNICEF, UNDP, UNFPA, UNESCO and WHO. Currently there are five projects dealing specifically with HIV/AIDS in Burkina Faso ($15 mn), Chad ($5 mn), Kenya ($40 mn), Uganda ($50 mn), and Zimbabwe ($64.5 mn). Activities are also incorporated in other programmes, such as the sexually transmitted diseases and HIV/AIDS prevention component built into the $3.5 bn Chad/Cameroon oil pipeline project, which will take 30 years to complete and involve thousands of single and unaccompanied male construction workers and truckers. Another project for road construction in Mozambique provides HIV infection education and condoms to workers and local populations.
Bank funding for HIV/AIDS-related projects is provided as "soft loans" to low-income countries through the International Development Association. These credits are interest free and have maturities of 35 or 40 years with a 10-year grace period before repayment of principal is required. Borrowers are subject to a small service charge, currently 0.75 percent on undisbursed balances.
"The value of the money by the time it comes back to the Bank is really just 15 to 20 per cent of the amount originally loaned. Not many countries understand that 80 to 85 per cent of the amount loaned is actually a grant. We need to boost awareness of this," Dr. Zewdie said.
Dr. Zewdie stressed the commitment symbolized by a country borrowing from the Bank to combat the epidemic. "For me," she said, "whether a country has to pay back 15 per cent or 20 per cent or even 1 per cent to the Bank, the act of taking out the loan to help fund work on HIV/AIDS is significant because of the policy commitment it symbolizes."
A main reason why the epidemic has spiraled out of control, according to Dr. Zewdie, is Africa's lack of progress in giving proper policy emphasis to preventive measures which have been known to work in some countries. Boosting public awareness is a critical aspect of prevention. In Thailand and Uganda, and to some extent Senegal, anti-AIDS education programmes have resulted in falling infection rates. But on the whole, African countries have not succeeded in achieving full public awareness of the risks of HIV infection. In fact, there is "not a single country that has cleaned up its blood supply system, or succeeded in treating classical STDs which costs so little compared to the sophisticated and expensive drug regimes in use in the developed countries," according to Dr. Zewdie.
"We need to focus on encouraging prevention, specifically among African youth before they become sexually active," she said
Part of the problem has been the way in which public information campaigns have been conducted since the early 1980s. "For the first couple of years, we were warning the African public that the death toll could number in the millions. Of course, that prophecy has not been realized and it has become more difficult to convince national leaders of the priority they must accord to communicating the devastating effects of AIDS."
The need to boost awareness is all the more critical in light of recent data showing that HIV prevalence among adults already exceeds 8 per cent in almost half of Africa. Yet a large number of people remain unaware that they are at risk of contracting the disease and lack information on how to protect themselves. Surveys show that only about half of Africans with non-regular sex partners mentioned using condoms as a means of protection.
Moreover, Dr. Zewdie believes that merely distributing condoms to at-risk populations is not enough. "It is not as simple as providing condoms and telling people to use them. For example, if you were to introduce this foreign instrument to many of the people living in my native, rural Ethiopia, they would not just accept it as easily as that. So we must ensure that we fully inform people of the importance of condoms in preventing the spread of AIDS. In areas throughout the world where the issue has been effectively communicated to the people, I do not know of a single population that has rejected this means of protection from early death."
Table source: World Health Organization
At this time, the Bank favours AIDS prevention measures over the funding of miracle drugs that prolong life and reduce suffering in industrialized countries but may not be cost-effective in Africa.
Dr. Zewdie explained: "If you take into consideration that the Bank is a development agency, whose major objective is to alleviate poverty, together with the fact that these drugs can cost up to $60,000 per person per year and there are 21 million people today affected by this epidemic in Africa, then it becomes ridiculous to venture into something such as this. It is not going to be sustainable. It is not going to profit the poor, the group who should benefit from the Bank's work.
"Even if the drugs somehow were to be distributed free of cost, the infrastructure required by these sophisticated regimes is not in place in Africa. We have not even succeeded in administering malaria prophylaxis [preventive therapy] in Africa. So the Bank does not want to foster unrealistic hope. Having said that, science progresses rapidly and nothing about policy responses for the medium-term can be written in stone."
AIDS in Africa: grim facts-- With only 10 per cent of the world's population, Africa has 63 per cent of global HIV/AIDS cases. Today there are 21 million Africans infected with HIV/AIDS, and an average of more than 3,800 adults are infected with the virus every day in Africa -- Some 95 per cent of Africans infected with HIV/AIDS live in abject poverty, with no hope of obtaining the new miracle drugs that patients in developed countries use to combat the virus and lead comparatively normal lives. -- About 90 per cent of all HIV transmission in Africa occurs via heterosexual sex. This is 100 per cent preventable. -- An estimated 87 per cent of the world's children infected with the HIV virus live in Africa. More than eight million children in sub-Saharan Africa have been orphaned by AIDS. -- AIDS has lowered average life expectancy levels by as much as 10-17 years in some African countries. In hardest-hit Zimbabwe, AIDS has reduced life expectancy by more than 20 years. -- In the early 1980s HIV was found mainly in the swathe of territory stretching from West Africa to Eastern Africa; countries north of the Sahara and in Southern Africa apparently were untouched. Today, no part of the African continent is unaffected. -- AIDS has overtaken malaria and other diseases as the leading cause of death for adults between the ages of 15 and 49 in Botswana, Burundi, Malawi, Rwanda, Tanzania, Uganda, Zambia, Zimbabwe and in capital cities such as Abidjan, Addis Ababa, Nairobi and Ouagadougou. -- HIV infection has spread far beyond the original sub-populations with high-risk behaviour into the general population of as many as 19 African countries. -- Up to 50 per cent of hospital beds are occupied by HIV/AIDS patients in many parts of sub-Saharan Africa. |
