1. In Latin America and the Caribbean Thomas E. Novotny, MD MPH San Diego State University

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

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

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

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

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

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

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

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

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

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

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

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

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

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

16. Forthcoming, 2012 HNP LAC