X HIV/AIDS Prevention and Care in Resource-Constrained Settings

Edited byPeter R. Lamptey, MD, DrPHHelene D. Gayle, MD, MPHPreface byPeter Piot, MDHIV/AIDS Prevention and Carein Resource-ConstrainedSettingsA HANDBOOK FOR THE DESIGN AND MANAGEMENT OF PROGRAMSFamily Health InternationalFunded byThe United States Agency for International Development

HIV/AIDS Prevention and CareinResource-ConstrainedSettingsA HANDBOOK FOR THE DESIGN AND MANAGEMENT OF PROGRAMSEditorsPeter R. Lamptey, MD, DrPHExecutive Vice President/COOHIV/AIDS Prevention and Care DepartmentFamily Health InternationalArlington, VA U.S.A.Helene D. Gayle, MD, MPHSenior Advisor for HIV/AIDSBill and Melinda Gates FoundationSeattle, WA U.S.A.Coordinators:Kristen Ruckstuhl, MAMadaline Feinberg, MAConsulting Editors:John-Manuel Andriote, MSCatharine P. Farrington, MS

© 2001 Family Health International (FHI). Allrights reserved. This book may be freely reviewed,quoted, reproduced or translated, in full or inpart, provided the source is acknowledged. Thisbook may not be sold or used in conjunction withcommercial purposes.The views expressed in this book by namedauthors are solely the responsibility of thoseauthors and do not necessarily reflect the views ofFHI or the United States Agency for InternationalDevelopment (USAID). The mention of specificcompanies or products implies no endorsementand does not suggest that they are recommendedby FHI or USAID over others of a similar naturethat are not mentioned.This work was supported in part by theUnited States Agency for InternationalDevelopment (USAID) as part of Family HealthInternational’s (FHI) Implementing AIDS Preventionand Care (IMPACT) Project (CoorperativeAgreement HRN-A-00-97-0017-00).Family Health InternationalFHI AIDS Institute2101 Wilson BoulevardArlington, VA 22201, U.S.A.Telephone: 1-703-516-9779Fax: 1-703-516-9781Internet: http://www.fhi.orgISBN: 1-931547-02-5

table of C O N T E N T SPrefacePAGE VIntroductionPAGE VIIAchnowledgementsPAGE XXVISection EditorsPAGE XXVIAuthors, Reviewersand Section EditorsPAGE XXVIIGlossary of AcronymsPAGE XXXIIISECTION I:Chapter 1PAGE 1Chapter 2PAGE 35Chapter 3PAGE 55Chapter 4PAGE 85Chapter 5PAGE 111Peter Piot, MDPaul R. DeLay, MDKaren StaneckiGunilla EmbergDesign and Management ofHIV/AIDS ProgramsSTRATEGIC PLANNING, PROGRAM DESIGNAND MANAGEMENTClement ChanKam MB, MRCPGail Goodridge, MSRob Moodie, MBBS, MPHAPPROACHES TO ECONOMIC EVALUATIONOF HIV/AIDS INTERVENTIONSSteven Forsythe, PhDRESPONDING TO THE SOCIOECONOMICIMPACT OF HIV/AIDSAnthony Kinghorn, MBBChAlan Whiteside, MAMalcolm Steinberg, MBBCh, MScIMPROVING ACCESS TO DRUGS FORPEOPLE LIVING WITH HIV/AIDSFrançoise Renaud Thery, PharmD, Dip Public HealthJonathan D. Quick, MD, MPHEVALUATION AND SURVEILLANCEAPPROACHES FOR HIV/AIDS PROGRAMSThomas M. Rehle, MD, PhDEmil Asamoah Odei, MB, ChB, MSc, Dip VenMichel Carael, PhDBernhard Schwartländer, MD, PhDHIV/AIDS Prevention and Care in Resource-Constrained Settings I

SECTION II:Chapter 6PAGE 137Chapter 7PAGE 159Chapter 8PAGE 187Chapter 9PAGE 211Chapter 10PAGE 229Chapter 11PAGE 259Reducing Risk andVulnerability to HIV InfectionBEHAVIOR CHANGE COMMUNICATIONTO REDUCE RISK AND VULNERABILITY INRESOURCE-CONSTRAINED SETTINGSCarol Larivee, MABarbara A.K. Franklin, MDYOUTH INTERVENTION PROGRAMSArletty Pinel, MDGary R. Svenson, MSW, MScHilary Hughes, MPhil/PhD (candidate)REDUCING HIV RISK IN SEX WORKERS,THEIR CLIENTS AND PARTNERSBea Vuylsteke, MD, MScSmrajit Jana, MDHIV/AIDS PROGRAMS IN PRIVATESECTOR BUSINESSESAnthony PramualratanaBill Rau, PhDPROGRAMS FOR MOBILE POPULATIONSAND THEIR PARTNERSIvan Wolffers, MD, PhDThomas M. Painter, PhDREACHING MEN WHO HAVE SEX WITH MENRichard Parker, PhDCarlos F. Cáceres, MD, DrPHShivananda KhanPeter Aggleton, PhD, FBPsS, FRSH, FRIPHHChapter 12 SOCIAL MARKETING: TWO APPROACHESPAGE 281 TO HIV/AIDS PREVENTIONWilliam SmithChapter 13PAGE 305 Bill Rau, PhDAIDS AND DEVELOPMENTAL CONSTRAINTSII HIV/AIDS Prevention and Care in Resource-Constrained Settings

SECTION III:Chapter 14PAGE 321Chapter 15PAGE 359Chapter 16PAGE 381SECTION IV:Chapter 17PAGE 407Chapter 18PAGE 427Chapter 19PAGE 451SECTION V:Chapter 20PAGE 477Strengthening STDManagement and ServicesSTD CASE MANAGEMENT IN PRIMARYHEALTH CARE SETTINGSPhilippe Mayaud, MD, MScFrancis Ndowa, MBChB, Dip Derm, Dip GUMedISSUES IN STD CONTROL FORSPECIAL GROUPSRichard Steen, PA, MPHAntonio C. Gerbase, MD, MSSTD PROGRAM MANAGEMENT ANDEVALUATIONFrançois Crabbé, MD, MPHJohn Gallwey, MB, ChBReducing Risk of HIVTransmission to InfantsREDUCING HIV INFECTION IN WOMENAND PROVIDING FAMILY PLANNINGSERVICES TO WOMEN AT RISKIsabelle de Zoysa, MD, MScGeorgette Adjorlolo Johnson, MD, MPHREDUCING THE RISK OF MOTHER-TO-CHILDTRANSMISSION OF HIV DURINGPREGNANCY AND DELIVERYIsabelle de Vincenzi, MD, PhDEhounou Ekpini, MDMOTHER-TO-CHILD TRANSMISSION OF HIVTHROUGH BREASTFEEDING:STRATEGIES FOR PREVENTIONRuth Nduati, MBCHB, MMED, MPHJay Ross, PhDReducing Risk of ParenteralTransmissionENSURING THE SAFETY OF BLOODAND BLOOD PRODUCTSEve Lackritz, MDBrian McClelland, BSc Hons, MBChB, MRCP,Doctoraat in de Geneeskunde, FRCP, FRC PathHIV/AIDS Prevention and Care in Resource-Constrained Settings III

Chapter 21PAGE 501Chapter 22PAGE 517SECTION VI:Chapter 23PAGE 547Chapter 24PAGE 579Chapter 25PAGE 603Chapter 26PAGE 629Chapter 27PAGE 661SECTION VII:Chapter 28PAGE 679TRANSMISSION OF HIV IN HEALTHCARE SETTINGSDenise M. Cardo, MDAnne Buve, MDHIV RISK REDUCTION IN INJECTIONDRUG USERSAndrew Ball, MBNick Crofts, MB, MPH, FAFPHMManagement and Support of PeopleInfected and Affected by HIV/AIDSCOUNSELING, TESTING ANDPSYCHOSOCIAL SUPPORTRachel Baggaley, MSC, MDIgnatius KayaweDavid Miller, PhDHOME CARE FOR PEOPLE WITH AIDSHelen JacksonSandra AndersonMANAGEMENT OF HIV DISEASEAND ITS COMPLICATIONS IN RESOURCE-CONSTRAINED SETTINGSRobert Colebunders, MD, PhDEric van Praag, MD, MPHJoseph Perriens, MD, PhDORPHANS AND OTHER VULNERABLECHILDREN: APPROACHES TO CARE ANDPROTECTION PROGRAMSSusan S. Hunter, PhDSusan Parry, MDHIV/AIDS, HEALTH AND HUMAN RIGHTSSofia Gruskin, JD, MIADaniel Tarantola, MDProspects for the FutureFUTURE CHALLENGES IN HIV/AIDSPREVENTION AND CAREHelene Gayle, MD, MPHPeter Lamptey, MD, DrPHIV HIV/AIDS Prevention and Care in Resource-Constrained Settings

PREFACEIn 20 years of responses to the AIDS pandemic theworld has learned many hard lessons. We havelearned that half-measures do not work: progress ismade only when communities and nations wholeheartedlyembrace the fight against AIDS. We havelearned that there is no “one-size-fits-all” solution indesigning and delivering the most effective preventionand care initiatives. We have learned that HIV feedson social inequality, especially the inequality betweenmen and women. This is why we must confront theneed for long-term, structural change to effectivelyaddress the pandemic.Above all, we have learned that we are not powerlessto change the course of the pandemic.Communities and whole nations have demonstratedthat it is possible to reduce the spread of HIV.Many have taken action before the epidemic has takenhold, but others have managed to pull back the epidemiceven in their countries after its growth to devastatingscale. And while scientists continue working tofind a cure or an effective vaccine, great advances havebeen made in care and treatment. Where these havebeen within financial reach they have immenselyimproved the quality of life of people living withHIV/AIDS (PLHA).This Handbook is a valuable tool for extendingthe reach of effective responses to HIV/AIDS wherethey are needed most. There are 40 million PLHAin the world today, and 95 percent live in resourceconstrainedcountries. Until and unless the impact ofAIDS is reduced, these countries face little prospect ofbuilding a more secure and prosperous future.While every community needs to devise the preventionand care solutions that are most effective in itsown local context, there are some universal principleson which success has been built:■ Leadership is required at every level of society toensure a comprehensive and coordinated effortagainst HIV/AIDS. Leadership is the key to liftingthe veils of denial and discrimination as well as tomobilizing resources and creating synergy betweendifferent elements of the response.■ We must know what drives the pandemic torespond effectively to it. This means understandingpatterns of sexual practice and drug use, as wellas the distribution of HIV infection.■ Prevention and care are not competing priorities;they are mutually reinforcing strategies.Extending access to comprehensive care, includingantiretroviral therapy, is a priority even in the mostresource-constrained settings, because it bringsrenewed hope and greater energy to the response.■ Social exclusion must be tackled as one of thedrivers of the pandemic. People are more vulnerableto HIV when they are deprived of respect andcommunity support. The most successful responsestrategies are those that have given a leading role toPLHA and others seen to be most at risk.■ At this stage in the global pandemic the overwhelmingneed is for an increase in the scale ofresponses. An AIDS response must take rootacross every region, throughout every nation, fromtown to town and village to village.Reversing the AIDS pandemic is about changingthe world we live in—our behaviors and relationships,where money flows and who makes decisions. Itrequires every one of us to play our part.PETER PIOT, MDExecutive DirectorJoint United Nations Programme on HIV/AIDS(UNAIDS)HIV/AIDS Prevention and Care in Resource-Constrained Settings V

I N T R O D U C T I O NPAUL R. DE LAYGUNILA ERNBERGKAREN STANECKI

INTRODUCTIONWe are in the third decade of what hasbecome the most important infectiousdisease epidemic of the last century. SinceAIDS was first recognized in 1981, an estimated 60million men, women and children have becomeinfected with the virus worldwide. Nearly half of allpersons who acquire HIV are under age 25 and mostwill die before they reach 35. As of the end of 2000,22 million people had died of AIDS. Approximately13 million children under age 15 have lost one orboth parents to AIDS, and the number of AIDSorphans is expected to exceed 40 million by 2010.HIV/AIDS is now the fourth leading cause of deathworldwide, and the single leading cause of death insub-Saharan Africa.Over the past 20 years, we have continued to besurprised, shocked and devastated by this pandemic,which the global community has consistently underestimated.We have underestimated the level of HIVprevalence that has been attained in some generaladult populations (such as in Botswana andZimbabwe); the scope of the pandemic around theworld (HIV infection is now found in even the mostremote and isolated countries such as Bhutan andMongolia); and the rapid growth of specific countryepidemics (such as those in Cambodia and the countriesof Southern Africa). At the beginning of the 21stcentury, HIV/AIDS prevalence among adults hasexceeded 20 percent in seven countries in the developingworld—all in Africa—and is above 10 percent innine additional countries. In another 38 countries,prevalence equals or exceeds one percent; 22 of theseare in Africa, 11 in Latin America, four in Asia andone in Eurasia. In contrast, HIV/AIDS prevalence inthe United States was 0.6 percent at the end of 2000.AIDS was first described in 1981, and it appearslikely that the virus is less than 100 years old. It istheorized that the various strains and subtypes of HIVoriginated through multiple mutations of animalretroviruses, which facilitated a “species leap” tohumans. Through back-estimating the time needed toachieve the existing varieties of viral mutations, itappears this jump from animal to humans probablyoccurred in the late 1930s or early 1940s. The mutationsthat resulted in HIV-1 most likely arose in westcentralAfrica, in the countries of Gabon, EquatorialGuinea and Cameroon. What occurred after humansbecame infected demonstrates a pattern that we haveseen repeatedly throughout the world. Due to theupheavals that were occurring in the Belgian Congoduring the 1950s, it is likely that the earliest infectedhumans seeded the Great Lakes region of the AfricanRift Valley. Mass movements of people, disruptions offamilies and culture, changing sexual behavior, anincrease of other risk behaviors and fluxes in economicstatus have all fueled the pandemic—in Africa andaround the world. Because HIV is new to humanity,we still have much to learn.PAUL R. DE LAYGUNILA ERNBERGKAREN STANECKIHIV/AIDS Prevention and Care in Resource-Constrained Settings VII

F igure 1Factors That InfluenceThe Spread of HIVViral Factors■ HIV-1 strains■ ViremiaLocal Genital Factors■ Presence of STDs■ Male cicumcision■ Use of vaginal productsSexual Behavior■ Rate of partner exchange■ Sexual mixing patterns■ Type of intercourse■ Size and rate of contact with core groups■ Level of condom useDemographic Factors■ Percentage of sexually active age groups toother age groups■ Male to female ratio■ Urban: rural percentage■ Migration patternsEconomic and Political Factors■ Level of poverty■ War and social conflicts■ Status of transport and mobility of population■ Performance of health care system■ Response to epidemic(from Piot-1994)STATUS AND TRENDS OFTHE HIV/AIDS EPIDEMICSAlthough the AIDS pandemic is complex, trackingand analyzing its evolution and diversity enables us tointervene more effectively and to more accuratelypredict future trends. We assumed in the late 1980sthat any country with evidence of widespread riskconditions for HIV transmission would inevitablysuffer an extensive epidemic once HIV was introducedinto the population. This “evidence” of risk behaviorsincluded the presence of a commercial sex industry,high background prevalence of other sexually transmitteddiseases (STDs) in the population, low condomuse by men and the existence of injection druguse (IDU). But this was a far too simplistic view of theunderlying dynamics of the pandemic. In Asia, forexample, we have seen the epidemic explode inCambodia, Burma, Thailand and in some states ofIndia, yet remain very concentrated and in low prevalencein the Philippines and Indonesia.The pandemic continues to defy simple modelsand formulas. We now recognize that there are anumber of host, viral and social factors that determinetransmission and vulnerability. These interact in acomplex manner in the mosaic of global settings.Figure 1 lists the most predominant determinants.It has become increasingly important to integrateimproved biological surveillance data with detailedinformation about the social and economic patternsthat lead to increased risk behaviors and vulnerability.These “second generation” surveillance systems willimprove our ability to describe the state of local epidemicsand target our interventions for the future. Butit is challenging to collect this range and depth of datafor each country. Among this array of determinants,there are a number of predominant factors. Sexualbehaviors and the pattern of sexual networks areclearly the most important factors in the most severesexually transmitted epidemics. We have recentlylearned that subtle quantitative differences in behaviorcan either cause the epidemic to explode or stabilize ata relatively low level of prevalence. It is not a matterof whether commercial or casual sex exists in a society,but how much, of what kinds, when it is practicedand by whom.Besides risk behavior patterns, there are increasingdata on the possible role of STDs, HIV-1 subtypesand male circumcision in the efficiency of variousVIII HIV/AIDS Prevention and Care in Resource-Constrained Settings

F igure 2Comparison of Average Number of Clients PerCommercial Sex Worker (CSW) Versus Percentageof Young Men Who Utilized Sex WorkersAverage # of CSW clients/day43.532.521.510.50■ Indonesia■ Philippines■ Cambodia■ Thailand0 10 20 30 40 50 60% of males using sex workersmodes of transmission. These have yet to be adequatelydelineated and entered into the complex equation ofepidemic dynamics.T HE EPIDEMICS OFSUB-SAHARAN AFRICAThe global pandemic consists of a mosaic of individualepidemics in countries around the world. Theoldest set of epidemics can be found in sub-SaharanAfrica. Of the 36 million people living withHIV/AIDS globally, more than 25 million (70 percent)are in sub-Saharan Africa. This region includesonly 11 percent of the world’s population. Nearly onein 10 adults between the ages of 15 and 49 is alreadyliving with the virus throughout the sub-continent.In Africa women are harder hit than men, theopposite of what is found on all other continents. Thedifference between men and women is most pronouncedin those under age 25. A population-basedsurvey in Kisumu, Kenya, showed HIV rates in 15-and 16-year-old girls of 8 percent and 18 percent,while no infections were documented in boys of thesame age. In 19-year-old girls the rates were up to 33percent, and only 9 percent inboys. We do not fully understandthe reasons for these extremelyhigh rates in girls. Young girls’biological vulnerability and the factthat girls frequently have sex partnersof much higher age—withhigh levels of infection—likely playa role.There are at least three patternsof transmission in sub-SaharanAfrica:In the countries of EastAfrica, the oldest HIV epidemicsin the world have had slow, steadyprogress over the past 30 years.These are seen in the Great Lakesregions of East Africa—in thecountries of Uganda, Tanzania,Malawi, Kenya, Zambia and the Democratic Republicof the Congo (formerly Zaire).In the countries of West Africa, where theepidemic seems to have started about 10 years later,progression of the epidemic has been more indolentand is further complicated by the presence of bothHIV-1 and HIV-2. The national prevalence ratesare generally lower, between one percent and eightpercent, except for Côte d’Ivoire.In Southern Africa, where the epidemic startedin the mid-to late 1980s, there has been a series ofexplosive epidemics over the past eight years, reachingthe highest prevalence levels on earth, 20 percent to40 percent. These countries include South Africa,Namibia, Zimbabwe, Botswana, Swaziland andLesotho.Among the features of the epidemics in this region:■■Half of new infections in Africa are among 16- to23-year-olds, three-quarters of them young girlsand women. More than 80 percent of HIV transmissionis heterosexual, with more than 55 percentof infections in sub-Saharan Africa occurring inwomen due to increased physiological and socioeconomicvulnerability.Several studies in sub-Saharan Africa have notedthat HIV prevalence is high in young womenwithin the first few years of sexual activity, but risesHIV/AIDS Prevention and Care in Resource-Constrained Settings IX

F igure 3HIV Seroprevalence for Pregnant Womenin Selected Urban Areas of Africa: 1985–199950HIV Seroprevalence (%)45Francistown4035BlantyreKwazulu/Natal3025201510LusakaKampalaHarareNairobiAbidjanLagos50DakarYaounde1985 1987 1989 1991 1993 1995 1997 1999Note: Includes infection from HIV-1 and/or HIV-2.Source: U.S. Census Bureau, HIV/AIDS Surveillance Data Base, 2000.■more slowly in young men. Recent data from foururban populations and one rural population confirmdramatic male-female differences (see Figure4). In this vicious cycle young girls are infected byolder men; the girls as they age then infect theirsame-age partners and husbands; and these men asthey age in turn infect young girls.The increasing number of HIV-infected womenhas led to the infection of nearly 600,000 infantseach year. Although new, more realistic interventionsto reduce mother-to-child transmission(MTCT) of the virus are being developed, fewerthan five percent of women in sub-Saharan Africahave access to these treatment regimens.T HE EPIDEMICS OF ASIAWith a population of nearly 3.5 billion—representingnearly 60 percent of the world’s population—theAsia-Pacific region has the potential to greatly influencethe course and overall impact of the global HIV-AIDSpandemic. 1 HIV began to spread in this region in theearly to mid-1980s, reflecting risk behavior in two discreteareas: commercial sex work (CSW) and injectiondrug use (IDU). During the 1980s and early 1990s,there was extensive spread among men who have sexwith men (MSM) in several Asian Pacific countries,including Australia, New Zealand, Japan, Malaysia,X HIV/AIDS Prevention and Care in Resource-Constrained Settings

Singapore and Hong Kong. Therewere intense focal epidemics in thelate 1980s among IDU populationsin Australia, Thailand, northeastIndia, several provinces inChina, Malaysia, Myanmar,Vietnam and, most recently, Nepal.Major heterosexual epidemics, primarilydriven by sex work, havereached seroprevalence levels of onepercent to three percent among the15- to 49-year-old population inCambodia, Myanmar, Thailandand several states in India.Epidemiological studies over thepast decade also have shown thatHIV epidemics among MSM,IDUs and heterosexual populationsmay develop independently of eachother, depending upon the sexualbridges between these populations.HIV prevalence has remainedrelatively low (less than .01 percent)in the total 15- to 49-year-old age group insome developing countries in the region, despite comparablyhigh levels of other STDs in segments of thispopulation. Even among CSWs in the Philippines andIndonesia, HIV infection levels have remained minimal.As we come to better appreciate the quantitativedifferences in sexual behavior—as influenced by cultureand religion—between these countries and thosethat have experienced severe sexual spread, it shouldbe increasingly possible to make longer term predictionsof the trends in the spread of the epidemic overthe next several decades.From a regional perspective, the ultimate impact ofHIV/AIDS in this region will be determined by theextent of ongoing epidemics in a number of key countries:Cambodia, Myanmar, Thailand, and, because oftheir population size, Indonesia, India and China.■The epidemics in this region feature:An exceedingly complex epidemic in India thatinvolves multiple epidemic foci, such as outbreaksamong IDUs and extensive HIV spread amongfemale CSWs and their clients in several regions.F igure 4HIV Prevalence for General Population bySex, 1995–1996, Zambia, UrbanHIV Prevalence (%)■■FemalesMales15-19 20-24 25-29 30-39FylkenesSubstantial heterosexual epidemics with comparablyhigh levels of HIV in pregnant women inThailand, Cambodia and parts of Myanmar, withconcentrations among IDUs and CSWs in othercountries, such as Vietnam.Ongoing low HIV prevalence (less than 0.1 percent)in the total 15- to 49-year-old population insome countries. In the Philippines, HIV surveillancehas found only a few cases of HIV infectionamong female CSWs, male STD clinic patientsand MSM. Indonesia likewise has reported only asmall number of AIDS cases and low levels of HIVinfection.T HE EPIDEMICS OF LATIN AMERICAAND THE CARIBBEANThere are two distinct epidemics in Latin Americaand the Caribbean, one in the island and coastal countriesof the Caribbean, another in mainland SouthAmerica. With eight percent of the world’s population,the Latin American and Caribbean region is home toHIV/AIDS Prevention and Care in Resource-Constrained Settings XI

F igure 5HIV Seroprevalence for Commercial SexWorkers in Selected Urban Areas of Asia: 1987–1999HIV Seroprevalence (%)60Phnom PenhMumbai (Bombay)40200KatmanduNortheastCalcuttaNorthCentralSouthernThailandHa NoiHo Chi Minh1987 1989 1991 1993 1995 1997 1999Source: U.S. Bureau of the Census, HIV/AIDS Surveillance Data Base, 2000.4.9 percent of all people living with HIV/AIDS(PLHA) at the beginning of the 21st century. Thereare close to 1.3 million PLHA in Latin America andanother 360,000 in the Caribbean. Because of thewide diversity of HIV epidemics, these regional figuresmask huge differences in epidemic levels and patternsof transmission.Although the Caribbean is geographically small, ithas a total population of more than six million. Someparts of Haiti and the Dominican Republic have HIVprevalence rates higher than any other country in theworld outside of sub-Saharan Africa. HIV testing ofpregnant women attending antenatal clinics suggeststhat at least one in 12 adults between ages 15 and 49is living with HIV. Guyana has also been hit harshlyby HIV. In 1996, 7.1 percent of pregnant Guyanesewomen tested for HIV were found to be infected.Outside the Caribbean, the hardest hit area in thisregion is Central America. In Honduras, Guatemalaand Belize, the epidemic appears to be heterosexuallydriven and increasing. In San Pedro Sula, the HIV epicenterin Honduras, HIV infection among pregnantwomen has fluctuated between two percent and fivepercent for several years. In Costa Rica, on the otherhand, HIV is concentrated among MSM and seems tobe contained at relatively low levels.XII HIV/AIDS Prevention and Care in Resource-Constrained Settings

F igure 6HIV Seroprevalence for PregnantWomen in Selected Urban Areas of Asia: 1989–1999HIV Seroprevalence (%)54Phnom Penh3Mumbai2BangkokMandalay101989 1991 1993 1995 1997 1999Source: U.S. Census Bureau, HIV/AIDS Surveillance Data Base, 2000.Cambodia Data: married women of reproductive age.Sixty percent of those currently living with HIV inBrazil are believed to be concentrated in the majorurban areas of São Paulo and Rio de Janeiro. AIDScase reporting suggests that the vast majority of earlyinfections were among MSM. But that picture haschanged in recent years, with unprotected sex betweenmen and women now accounting for more AIDScases than ever before. This does not mean that otherrisk behaviors can be neglected. Recent studies showthat MSM and IDUs continue to be at high risk forHIV infection.The Andean region and the Southern Cone so farseem to be relatively little affected by HIV. Colombiain 1998 estimated that 67,000 people were living withHIV in the country, but the pattern of infection seemsto vary between regions. In Peru, an estimated 44,200people were living with HIV in 1999. In 1998, 0.23percent of pregnant women tested in Lima were HIVpositive. Chile performs sentinel surveillance in pregnantwomen and STD patients, and has found little orno HIV infection in the general population in severalareas of the country, including Santiago, the capital. InArgentina a high proportion of pregnant womenattending antenatal clinics choose to be tested for HIVin order to receive help in preventing transmission ofthe virus to their baby if necessary. Of more thanHIV/AIDS Prevention and Care in Resource-Constrained Settings XIII

F igure 7HIV Seroprevalence for Pregnant Women inSelected Urban Areas of Latin America: 1986–199715HIV Seroprevalence (%)10Cite Soleil, HaitiGeorgetown, Guyana5San Pedro Sula, HondurasSao Paulo, BrazilRio de Janeiro01986 1988 1990 1992 1994 1996 1998Source: U.S. Bureau of the Census, HIV/AIDS Surveillance Data Base, 2000.66,000 Argentine women tested in 2000, 0.56 percentwere HIV positive.The epidemics in this region feature:■■■Severely affected populations of several Caribbeancountries. Some countries are more affected bythe epidemic than any other country in the worldoutside of sub-Saharan Africa.An epidemic in Mexico driven largely by unprotectedsex between men. Studies among MSM haveshown that some 14.2 percent are infected withHIV.The largest number of PLHA—an estimated540,000 by the end of 1999—are in Brazil, themost populous country in the region.■Of all of continental Latin America, the northerncountries of Central America appear to be thehardest hit by HIV, though there is considerablediversity even within the isthmus.T HE EPIDEMICS OF EASTERN EUROPEIn the countries of the former Soviet Union, theHIV epidemics continue to be mainly concentratedamong IDUs. Although the IDU-associated epidemicin the Newly Independent States began in 1995-6, italready affects a large number of cities and virtually alladministrative regions in Ukraine, Russia, Belarus andMoldova. More than 5,000 IDUs were identified asHIV infected in Moscow alone as of 1999. Due to thisoutbreak in the Moscow region, more HIV infectionsin Russia were registered in 1999 than in all previousXIV HIV/AIDS Prevention and Care in Resource-Constrained Settings

years combined. HIV prevalencevaries from fewer than two percentof IDUs registered officially inRussia, to about 30 percent in sentinelsurveys in Ukraine andRussia, and more than 60 percentin Svetlogorsk in Belarus and indrug-injecting CSWs inKaliningrad. HIV prevalenceamong other population groupsseems to have remained low so far.While about 130,000 Russiansare believed already to be livingwith HIV, the Russian Ministry ofHealth estimates the number ofIDUs in Russia at about threemillion—two percent of the totalpopulation—providing a largepool of highly vulnerable but notyet infected persons. Although notconfirmed in scientific studies,similarly high estimates also havebeen made for Ukraine and otherNewly Independent States. Withthe deteriorating economic situationof women, the number ofwomen engaging in sex work andpotentially at high risk of infection is believed to haveincreased considerably.At the same time, large epidemics of syphilis andother STDs have been reported from these countries.In Russia alone, between 200,000 and 400,000 newcases of syphilis have been reported annually in thepast few years. This may be only the tip of the iceberg,as under-reporting is believed to be high. Althoughmajor spread of HIV via heterosexual transmission inthe population at large has not yet been confirmed,the massive increase in STDs in the populations ofEastern European countries proves the potential formore widespread HIV/AIDS epidemics.F igure 8Annual Number of Newly Registered HIVInfections, Russia, 1993–1999161412106420Number of HIV infections (thousands)93 94 95 96 97 98 99Year of registrationSource: Russian Federal AIDS Centre, Moscow.■■■The epidemics in this region feature:An estimated 420,000 adults and children livingwith HIV in Eastern Europe and in the countriesof the former Soviet Union by the end of 1999.Only a year later that number was estimated to bemore than 700,000, with the Russian Federation,Ukraine, Belarus, Kazakhstan and Moldova themost severely affected.Most HIV infections in this region are due toIDU, with HIV prevalence rates greater than 60percent in some cities, including Odessa andNikolaev in the Ukraine, Svetlogorsk in Belarusand Kaliningrad in the Russian Federation.Men account for three-quarters of all HIV infectionsregistered in the region, with as many as 60percent of infected persons between the ages of 15and 24.HIV/AIDS Prevention and Care in Resource-Constrained Settings XV

F igure 9Life Expectancy With and WithoutThe AIDS Epidemic in 2000BotswanaZimbabweSouth AfricaNamibiaKenyaTanzaniaLesothoCameroonTogoGhanaZambiaCARCôte d’IvoireSwazilandCongo (Brazzaville)NigeriaBurundiEthiopiaBurkina FasoGabonCongo (Kinshasa)UgandaMalawiRwandaBeninMozambiqueBahamasHondurasBrazilGuyanaHaitiThailandCambodiaWith AIDSWithout AIDSIMPACT OFTHE EPIDEMICSThe pandemic has not only affected the health sector,but it cuts across societies and affects every aspectof human development. There are significant differencesin the impact of AIDS throughout the worlddepending upon the stage of the epidemic within acountry and the level of society under examination.The magnitude, severity and timeframe in whichchange is seen vary according to the type of analysis—whether the effects are examined at the householdlevel, in specific labor sectors, at the level of populationdemographics or a country’s macroeconomic status.H EALTHWithout access to the combination antiretroviraldrug (ARV) therapies now used in the United Statesand other industrialized countries, essentially allnewly infected adults will sicken and die of HIVrelateddisease within three to eight years of becominginfected—many without ever truly knowing theirHIV status. The impact will be especially severe forwomen who are not only biologically more vulnerableto infection but also bear the burden of care for thesick. HIV/AIDS will undoubtedly be a major cause ofmortality in both adults and children for many moreyears to come. AIDS in sub-Saharan Africa alreadyimposes a huge burden on the health infrastructure:More than 60 percent of hospital beds are occupiedby persons with HIV- related disease. One disturbingeffect of the growing burden of HIV disease is anincreasing rate of inpatient mortality in HIV-negativepatients. This is the result of losing key health carestaff, a steady deterioration of health service deliverysystems and overcrowding of hospitals with AIDSpatients that forces HIV-negative patients to waitlonger before being admitted—often in more severe,if not terminal, condition. And because tuberculosis(TB) is so common in HIV-infected persons—and isthe leading cause of death in AIDS patients—the TBepidemic in areas of sub-Saharan Africa has increasedby more than 400 percent.Burma0 10 20 30 40 50 60 70 80 90Life expectancy at birth (years)Source: U.S. Census Bureau, International Data Base and unpublished tables.XVI HIV/AIDS Prevention and Care in Resource-Constrained Settings

D EMOGRAPHIC IMPACTIn some countries, such as Botswana andZimbabwe, life expectancy is plummeting while infantand child mortality is increasing. In countries withhigh HIV prevalence levels and low fertility rates,population growth rates have been reduced to nearzero. Other countries with sharply reduced growthrates include Malawi, Namibia, South Africa,Swaziland and Zambia.Life expectancies in many countries in sub-SaharanAfrica have fallen dramatically from the levels theywould have been without AIDS. In Botswana, lifeexpectancy is now 39 years rather than 71 years; inZimbabwe it is 38 years rather than 70 years. In fact,six countries in sub-Saharan Africa (Botswana, Malawi,Mozambique, Rwanda, Zambia and Zimbabwe) havelife expectancies below 40 years. They would have been50 years or greater without AIDS.In some sub-Saharan African countries, AIDSmortality has reversed the declines in infant mortalityin the 1980s and early 1990s, and the rates are nowhigher than they were in 1990. The relative impact ofAIDS on infant mortality will depend on both thelevels of HIV prevalence in the population and theinfant mortality rate from other causes. In 1990 theinfant mortality rate in Zimbabwe was 54, and in2000 it was 62. In Kenya the 1990 rate was 67, andin 2000 it was 69. Without AIDS, these rates wouldhave been 30 in Zimbabwe and 55 in Kenya.Altogether 26 sub-Saharan African countries haveexperienced increases in child mortality rates becauseof AIDS. The impact on child mortality is highest incountries that had significantly reduced child mortalitydue to other causes and where HIV prevalence ishigh. Many HIV-infected children survive their firstbirthdays, only to die before age five. Seventy percentof all deaths among children under age five inZimbabwe, and 45 percent of the same age cohort inSouth Africa, are AIDS-related.The impact of AIDS is most profound onpopulation structures. Recent national census surveysin Kenya and Malawi show significant overall AIDSrelatedmortality that has not been anticipated inF igure 10Growth Rate With and WithoutThe AIDS Epidemic in 2000South AfricaGabonRwandaGhanaZimbabweKenyaLesothoMozambiqueBotswanaCARMalawiCongo (Brazzaville)CameroonNamibiaCôte d’IvoireNigeriaTogoSwazilandTanzaniaZambiaBurkina FasoBeninUgandaEthiopiaCongo (Kinshasa)BurundiGuyanaBahamasBrazilHaitiHondurasBurmaThailandCambodiaWith AIDSWithout AIDS0 1 2 3 4 5PercentSource: U.S. Census Bureau, International Data Base and unpublished tables.HIV/AIDS Prevention and Care in Resource-Constrained Settings XVII

F igure 11Population of Zimbabwe,With and Without AIDS: 20108075MalesFemalesWith AIDS70Without AIDS656055504540353025201510501000 800 600 400 200 0 200 400 600 800 1000ThousandsSource: U.S. Census Bureau, World Population Profile 2000.current population projection modeling. The mostextreme examples are those countries—such asBotswana, Zimbabwe and South Africa—where therewill be negative population growth within the nextthree to four years. The resulting population pyramidsshow a dramatic restructuring of the population, withdecreasing numbers of children and middle-agedadults and more males than females.O RPHANSBy 2010, at least 44 million children under age 15will have lost one or both parents to all causes in the34 countries most severely affected by HIV/AIDS. Ofthese orphans, 68 percent will have lost their parentsdue to AIDS. This represents a dramatic increase from1990, when AIDS accounted for 16.4 percent ofparental deaths. Orphans are distributed among areasof the world in the same patterns as HIV prevalence,so that countries with the highest infection levels alsotend to have the highest orphan rates. The orphancrisis is most acute in sub-Saharan Africa, where asmany as 35 percent of children under age 15 in at leasteight countries have lost one or both parents. Elevencountries will reach this rate by 2010.XVIII HIV/AIDS Prevention and Care in Resource-Constrained Settings

E C ONOMIC IMPACTEarly research on the economic impact of AIDSfocused on the macroeconomic aspects. This showedthat increased deaths and decreased investment couldbe expected to slow economic growth and reduce percapita income, albeit not dramatically. 2There have also been attempts to examine howAIDS would affect the private sector and households.Not surprisingly, it has proved difficult to collect completeand credible data. Indeed, poor managementinformation systems were a constant source of frustrationfor researchers who were working with companiesin affected countries. 3 AIDS clearly had measurablecosts in the private sector, mainly through absenteeismand the payment of benefits. These costs could be ashigh as eight percent of the payroll, depending on thenature of the industry and scale of the problem. Butin general the impact was not great, manageable ortransferred onto the households. 4The relatively limited number of studies of householdimpact have shown that HIV/AIDS leads toimpoverishment of those affected. In Ethiopia andTanzania, the average cost of basic symptomatic treatment,funeral and mourning expenses amounts to severaltimes the average annual household income.Affected children are more likely to be malnourishedand, particularly the girls, removed from school. 5Although the importance of these dramatic increasesin the number of orphans has been recognized, theirlong-term economic implications have not beenassessed.Part of the problem in assessing the impact ofHIV/AIDS is that it is long term and the data havenot been available. But in the last few years a numberof new publications have appeared that give a muchmore pessimistic view of the potential and actualimpact of the disease at all levels. The most significantmay be studies suggesting that the impact on nationaleconomies and growth is more complex and seriousthan previously modeled, perhaps because the speedand scale of HIV/AIDS have been much worse thanexpected; HIV/AIDS reduces the stock of human andphysical capital because it also reduces the incentive toF igure 12Infant Mortality With and WithoutThe AIDS Epidemic in 2000BotswanaZimbabweSouth AfricaNamibiaGhanaKenyaBurundiLesothoCameroonTogoNigeriaZambiaTanzaniaUgandaCôte d’IvoireSwazilandBeninGabonEthiopiaCongo (Brazzaville)CARCongo (Kinshasa)Burkina FasoMalawiRwandaMozambiqueBahamasHondurasBrazilGuyanaHaitiThailandCambodiaBurmaWithout AIDSWith AIDS0 50 100 150Infant deaths per 1,000 live birthsSource: U.S. Census Bureau, International Data Base and unpublished tables.HIV/AIDS Prevention and Care in Resource-Constrained Settings XIX

invest; and feedback further amplifies the impact ofHIV/AIDS on economic growth.This can result in a vicious cycle in which AIDSreduces growth and increases poverty, thereby acceleratingthe spread of HIV. 6 These concepts have beenenumerated in a recent paper from the HarvardInstitute of International Development which suggeststhat the impact of AIDS has been systematicallyunderstated because these feedback effects have beenignored. 7 The impact on productivity due to HIVstatus is particularly important. The study focuses onZambia and suggests that by “stripping countries ofsome of their best talent and undermining the incentiveto invest, these difficulties may be condemningAfrican countries to extended periods of stagnationand decline.” Macroeconomic analysis is clearly enteringa new phase.Recent work on the private sector shows that companiesalso are beginning to take AIDS more seriously.But the tendency—which is economically rational—isto avoid or shift the costs of the disease, though thismay not be in the interests of the national economy orworkforce. A classic example is a company in SouthAfrica that diversified to Eastern Europe after lookingat the impact of AIDS on its market. 8The worst impact is at the household level, andhere the data are limited. Mitigation will need to focuson the household level because it is there that caremust be delivered and prevention messages may havethe most meaning.RESPONSE TO THEHIV/AIDS EPIDEMICS:COMPONENTS FOR ANEXPANDEDCOMPREHENSIVERESPONSEEven as we recognize the devastation of AIDSduring the nearly two decades since HIV was firstidentified, it is important to note that there has beenremarkable progress in our understanding of variousaspects of the global HIV/AIDS pandemic. There isnow an abundance of information on the basicpathogenesis of the infection; the epidemiologicadvancement of the disease around the globe; themultiple factors that determine vulnerability; the scopeof the pandemic’s macro- and microeconomic impacts;the development and use of highly active antiretroviraltherapies (HAART) to retard the clinical progressionof HIV-related disease; the financial and politicalenvironment that can facilitate an effective response;and, most critically, the constellation of interventionsneeded to achieve a national-level impact on HIVtransmission.R EDUCING RISK BEHAVIORSOur ability as a global community to achievereductions in new HIV infections is predicated on avery basic principle: We can reduce unsafe sexual andother risk behavior in a sustainable way. We nowhave ample evidence that public health programs canaffect change in the most private and basic of humanbehavior—sex. While it is impossible to attributedeclining national HIV rates to any single program, itis increasingly evident that people are responding towidespread, consistent education messages aboutHIV/AIDS prevention and care, and to dramaticincreases in the availability of key tools and services.In poor urban neighborhoods in the DominicanRepublic, for example, rates of sexually active youthdeclined from 73 percent in 1993 to 30 percent in1996, and rates of participation in “transactional sex”(exchanging food, money, school fees, etc. for sex)declined from 27 percent to 7 percent among males.In Bali, Indonesia, a peer education project with sexuallyactive 15- to 25-year-olds led to an increase inconsistent condom use from 22 percent to 72 percent.Sustained investments in a select number of countrieshave resulted in two kinds of national-level success:maintaining low HIV rates in countries at riskand reducing national-level HIV prevalence during asevere generalized epidemic. Senegal has maintainedone of the lowest HIV prevalence rates in sub-SaharanAfrica, with rates rising only slightly—from 1.2 percentfor the general adult population in 1995, to 1.8percent at the end of 1999.XX HIV/AIDS Prevention and Care in Resource-Constrained Settings

Prevention activities in the state of Tamil Nadu inIndia began in 1996. By the end of 1998 the vulnerablegroups served by the program achieved significant,sustained change in sexual behavior and demonstratedsignificantly increased condom use among CSWs andtheir clients. Consistent condom use with non-regularsex partners increased from 56 percent to 80 percentamong CSWs, and by male factory workers from 17percent to 50 percent.Uganda has become a model for curbing a severeHIV epidemic in developing countries. Behavioralsurveillance has demonstrated significant increases incondom use, decreased casual partners and delayedsexual debut by one to two years. The proportion ofUgandan girls who have ever had sex declined byalmost half between 1989 and 1995, and more thanhalf of young sexually active Ugandans report usingcondoms in their last sexual contact. This rate wasclose to zero at the outset of the epidemic. As a result,HIV infection rates among 15- to 19-year-old girlsdeclined from 22 percent in the early 1990s to 8percent by 1998. National HIV adult prevalencedecreased from 14 percent in the early 1990s to 8.3percent at the end of 1999. Recent surveys in Zambiashow a 42 percent reduction in prevalence rates forthe 15- to 19-year-old age group in Lusaka and otherurban areas, from 28 percent to 15 percent between1994 and 1998.But there are no magic bullets. Implementing aneffective behavior change program is complicated,resource- and time-intensive and must be based onlocally collected information and careful strategicplanning. We have also learned that we must appropriatelytarget our behavior change interventions tothose most likely to transmit or contract HIV infection.The specific targeted groups may differ fromcountry to country, but across all regions of the worldthey invariably involve men, single women and youth.Knowledge alone is not enough. Behavior change iscomplex and painstaking for individuals, communitiesand societies as a whole. It requires far more thanhaving basic knowledge about AIDS, or even beingdisturbed or concerned about it. Knowledge surveyshave demonstrated that more than 95 percent of theadult population of Zimbabwe has learned aboutAIDS and more than 80 percent know two or moremodes of prevention. Yet the epidemic in Zimbabwe isstill out of control, with nearly one in every fouradults now infected with HIV and the number of newinfections continuing to rise.This gap between knowledge and practice has beenobserved all over the world. It has forced publichealth and development specialists to deal with individualhealth behavior—including sex—in its socialand cultural context. In much of the world, traditionsmake it unnecessary for individual men, and unthinkablefor women, to refuse sexual relations. We havelearned that promoting monogamy and condom use,and encouraging young people to wait, involves mobilizingwomen and men, individuals, communities andopinion-leaders to rethink policies and social normsand create environments where individuals who “getthe message” are supported, not derided, shunned orbeaten. We have learned that HIV/AIDS risk reductioninvolves positive social change that links health,gender and human rights in new and productive ways.This is why we should not be surprised that in theabsence of such social change—even in countries withraging, visible epidemics such as Botswana, SouthAfrica and Zimbabwe—people have continued todeny their own danger of becoming infected. This isone of the pernicious effects of the stigma associatedwith AIDS: AIDS is always someone else’s problem.We have seen this phenomenon in virtually everycountry in the world, including the United States.To counter this lack of perceived personal risk, we arenow using what we call a “second generation” ofbehavior change tools that include social mobilization,skills building, intensive interpersonal counseling and,increasingly, the addition of HIV testing. Having anHIV test often provokes a critical moment of personalawareness.HIV/AIDS Prevention and Care in Resource-Constrained Settings XXI

R EDUCING MOTHER-TO-CHILDTRANSMISSIONThe number of infants infected with HIV eachyear through mother-to-child transmission (MTCT) isgrowing with the increasing number of womeninfected with HIV. About 55 percent of all new HIVinfections in Africa occur among women, most ofwhom are in their childbearing years. Ten percent ofinfections—representing some half a million infants—are believed to be attributable to MTCT.The 1998 findings from the Thai Short CourseZidovudine (AZT) Regimen study in Thailand, and1999 findings from the Nevirapene Field Trial inUganda, demonstrated that even simple, relativelyinexpensive ARV regimens can substantially reduceMTCT. Recognizing that comprehensive interventionscan reduce MTCT rates by as much as half, we nowhave the tools to expand MTCT prevention programs,especially in those countries with high HIV prevalence.These programs must set standards; promotevoluntary counseling and testing (VCT); providetraining to health care workers; establish linkages tocommunity-based care services; and scale-up primaryprevention for all women.C ARE AND TREATMENTBasic HIV care services are minimal in manyresource-constrained countries. Few infected personsknow their HIV status; most health care workers lackthe training to treat HIV and its associated infections;and only a few settings have the capacity to use stateof-the-artARVs, which remain unavailable to themajority of those infected.Even without ARVs, much can be done to improvethe well-being of HIV-infected persons and theirfamilies. Foremost must be assuring access to a basicpackage of care that includes treatment of TB, treatmentand prevention of other opportunistic and AIDSrelatedillnesses and palliative care to reduce sufferingand enhance the quality of life. To achieve this goal,networks will have to be established to connect hospital,clinic, faith-based and community-based services.There must be an investment in expanding effectiveTB prevention and control programs in key countries.TB is a growing epidemic itself with two milliondeaths per year worldwide. Because it is the leadingcause of death for people with AIDS, efforts to preventand treat TB must receive special attention.There is increasing interest in the developing worldin the use of combination regimens of ARVs, whichcan prolong the lives of PLHA. It is inevitable thatthe cost of these drugs will decrease. Even now, localproduction of generic drug equivalents and recent pricereductions by the pharmaceutical companies havelowered the annual cost for a combination of ARVs toapproximately US$1500 per patient. But it is criticalto grasp the complexity of providing ARV therapy in adeveloping country setting. An effective ARV programrequires, at a minimum, four basic components:1. A sustainable supply of drugs: This is life-longtreatment and improper use will result in drugresistance.2. The capacity to use the drugs: Most Africancountries lack the necessary trained health careworkers, labs, drug management systems, etc. It isimportant to remember that the health infrastructurein many of the hardest hit countries is on theverge of collapse. Such basic services as childhoodimmunization rates are often less than 50 percent(Uganda), the number of attended births is only33 percent (Nigeria) and the number of trainedphysicians can amount to only one for every13,000 persons (Zambia).3. An equitable system to apportion treatment insettings where there is not enough to go around.4. Recognition that treatment of HIV does not preventnew infections and cannot replace soundprevention programs. As ARVs become less costlyand the regimens simpler, HIV/AIDS efforts mustincorporate ARVs as critical components of theirprograms.XXII HIV/AIDS Prevention and Care in Resource-Constrained Settings

P ROVIDING ASSISTANCE TO ORPHANSAND OTHER CHILDREN MADEVULNERABLE BY HIV/AIDSAn estimated 13.2 million children worldwide havelost a mother or both parents to AIDS. Many morechildren have lost a father to AIDS. Still others areliving with and often caring for an ill parent. Ninetyfivepercent of the children orphaned by AIDS live inAfrica. The overwhelming majority of childrenorphaned and otherwise made vulnerable byHIV/AIDS are living within their extended familiesand communities. But unfortunately, AIDS is underminingfamily and community capacity to protect andcare for the growing number of vulnerable children.As part of an expanded comprehensive program,the global community must help build and supportlocal responses through which public, private and voluntarysector donors in the industrialized world canchannel resources to national and grassroots programsin the countries hardest hit by HIV/AIDS. The mostpromising interventions for strengthening the capacityof families and communities to protect and care fororphans and other vulnerable children are systematiccommunity mobilization, capacity building andmicrofinance services. Together these approaches canbe mutually supportive and produce significant, sustainableresults.Community-based programs must support interventionsthat improve access to education for themost vulnerable children in areas seriously affected byHIV/AIDS. This will include a wide variety ofinterventions, ranging from policy reforms to directinterventions that enable orphans and other vulnerablechildren to return to or stay in school.Grassroots groups urgently need funds and food tosupport home care for PLHA and to integrate theidentification and support for vulnerable children intosuch programs. These programs need ongoing accessto food and medicines to treat the most commonopportunistic infections. This can enable parentsliving with HIV/AIDS to live longer and more comfortablyand can also greatly benefit their children.Strengthening these programs can make them aninitial point of identification and support for childrenwhose safety and well-being are being undermined byHIV/AIDS.CHALLENGES IN HIV/AIDSPREVENTION AND CARE, ANDMITIGATING THE IMPACT OFTHE HIV/AIDS EPIDEMICOur children’s children will confront the legacy ofthis pandemic, and what we are now doing inHIV/AIDS prevention and care will significantlydetermine the size of the social and economic burdenthey will have to bear. We are not powerless against theepidemic—there are large-scale responses that haveproven successful. Key elements of such responsesinclude strong leadership, openness about the issuesand broad-based multisectoral programs at all levels inthe community. But the global response thus far hasbeen limited by the following major factors:■■■Political commitment: There is still a profoundlack of political commitment at all levels of governmentin some of the most severely affected countries,though there has been considerable progress inpolitical mobilization in many countries throughoutthe world during the past several years.Available resources: The global pandemic has outstrippedavailable resources. About US$500 millionfrom all sources (donors, lending agencies andhost country contributions) is now being spent onHIV/AIDS prevention programs in all of sub-Saharan Africa. The World Bank, United NationsJoint Programme on AIDS (UNAIDS), U.S.Agency for International Development (USAID)and others in the international community haveanalyzed the costs of successful programs anddeveloped models to estimate resource needs forthe basic components of prevention and care.The estimated costs for sub-Saharan Africa rangebetween US$2.5 and US$5 billion per year. Thisfunding would provide prevention services for amajority of the population and basic care andsupport services for approximately 30 percent ofthose infected. These funding levels include accessto ARV therapies for only about three percent.Stigmatization: This epidemic is still plagued bythe immense problem of stigma. Until persons cantalk openly about risk behaviors and whether theyare infected or not, we will continue to have weakbehavior change and care and support programs.HIV/AIDS Prevention and Care in Resource-Constrained Settings XXIII

F igure 13HIV Seroprevalence in AdultPopulations at the End of 2000■Rank Country %PrevalenceAFRICA1 Botswana 362 Swaziland 253 Zimbabwe 254 Lesotho 245 Zambia 206 South Africa 207 Namibia 208 Malawi 169 Kenya 1410 Central African 14Republic11 Mozambique 1312 Djibouti 1213 Burundi 1114 Rwanda 1115 Cote d’Ivoire 1116 Ethiopia 1117 Uganda 818 United Rep. of 8Tanzania19 Cameroon 820 Burkina Faso 621 Congo 622 Togo 623 Dem. Republic 5of Congo24 Nigeria 525 Gabon 426 Ghana 427 Sierra Leone 328 Eritrea 329 Liberia 330 Angola 331 Chad 332 Guinea-Bissau 3Gender vulnerability: For both biological andsocioeconomic reasons, girls and women are particularlyvulnerable to HIV/AIDS. To counter theseinherent gender inequities, innovative programshave been implemented that involve a range ofactivities—such as improving girls’ access to basiceducation, providing women with microfinanceopportunities and modifying or adapting culturalRank Country %PrevalenceAFRICA — continued33 Benin 234 Mali 235 Gambia 236 Senegal 237 Guinea 238 Niger 1LATIN AMERICA / CARIBBEAN1 Haiti 52 Bahamas 43 Guyana 34 Dominican 3Republic5 Belize 26 Honduras 27 Panama 28 Guatemala 19 Suriname 110 Barbados 111 Trinidad and 1TobagoASIA AND THE NEAR EAST1 Cambodia 42 Thailand 23 Myanmar 24 Sudan 1EUROPE AND EURASIAUkraine 1■■practices and legislation that canempower women. But the realimpact of these programs hasyet to be determined.The scale of interventions:Existing prevention programsare not large enough. It is likelythat prevention services reachonly 10 percent of the world’svulnerable populations. Thislack of scale is further complicatedby the fact that the globalcommunity urgently needs abetter understanding of thenumbers of persons (coveragewithin a targeted community)and level of behavior change(e.g., condom use in casual relations)that must be reached toachieve measurable changes inincident infections.Basic care and support:Incorporating basic care andsupport for HIV-infected individuals,their families and theirsurvivors (orphans), as well asintroducing new interventions—suchas the short-courseARV regimens to reduceMTCT—must be done in waysthat will enhance rather thandiminish the primary preventionagenda.■ The need for vaccines andmicrobicides: There is still alack of critical technologies thatwould radically alter our abilityto reduce new infections andprovide compassionate care tothe infected. These includerapid, simple diagnostics for STDs; a vaginalmicrobicide; simpler, cost-realistic ARV regimens;and, most important of all, an effective preventivevaccine. We urgently need an HIV vaccine and aneffective topical microbicide. Our existing interventionsdo work, if implemented properly and toscale. But these additional tools would make anenormous difference in our ability to combatHIV/AIDS.XXIV HIV/AIDS Prevention and Care in Resource-Constrained Settings

INTRODUCTIONTO THE HANDBOOKThe Handbook is intended to provide a comprehensivesource of information on the design and managementof HIV/AIDS prevention and care programsin resource-constrained settings. It is designed to helpin the strategic planning, technical and programmaticdesign of interventions, management of public healthprograms and resource allocation, and budgeting andfinancial management.The Handbook emphasizes cross-cutting issuessuch as gender, human rights, capacity building, sustainabilityand community involvement in the designand implementation of interventions.The Handbook’s intended audience includes:■Program managers, and technical and programmaticfield staff.■ Staff of donor and international partner agencies.■ Health care providers.■ Field researchers.The Handbook chapters are grouped into sevensections:I: Design and Management of HIV/AIDS ProgramsII: Reducing Risk and Vulnerability to HIVInfectionIII: Strengthening STD Management and ServicesIV: Reducing Risk of HIV Infection to InfantsV: Reducing Risk of Parenteral TransmissionVI: Management and Support of People Infected andAffected by HIV/AIDSVII: Prospects for the FutureEach chapter addresses state-of-the-art knowledgeon its topic, relevant strategies and approaches, keylessons learned in resource-constrained settings,selected case studies illustrating successful approachesto HIV/AIDS prevention and care in different environments,and offers suggested further reading on thesubject.The editors and authors hope the Handbook willlead to the improved allocation of funds and enhancedknowledge and skill in the management of interventionsand control of the HIV/AIDS epidemic.REFERENCES1. Monitoring the AIDS Pandemic (MAP): AIDSCAPand Francoise Xavier Bagnaud Centre for Health andHuman Rights of the Harvard School of PublicHealth. Status and Trends of the HIV/AIDS/STDEpidemics in Asia and the Pacific. Fourth InternationalConference on AIDS, Manila, Philippines, October25-29, 1997.2. Stover J, Bollinger L. The Economic impact of AIDS(23 country studies). Glastonbury, CT: The FuturesGroup International, 1999.3. Barnett T, Whiteside A. AIDS: The First Epidemic ofGlobalisation, draft manuscript 2001.4. Simon J, Rosen S, Whiteside A, et al. The Response ofAfrican Business to HIV/AIDS, HIV/AIDS in theCommonwealth 2000/01. Kensington Press for theCommonwealth Secretariat, June 2000.5. World Bank. Confronting AIDS: Public Priorities in aGlobal Epidemic, Washington, D.C.: OxfordUniversity Press, 1997.HIV/AIDS Prevention and Care in Resource-Constrained Settings XXV

ACKNOWLEDGEMENTSWe wish to express our gratitude and appreciationto the authors, reviewers and section editors who,despite their extremely busy schedules, put forth animpressive effort in the development and success of thisHandbook. The development of this Handbook was along process and the continued patience and contributionsof all involved are much appreciated.We would like to thank several particular currentand past members of the Family Health Internationalstaff for their assistance in various capacities. A specialthanks to Catharine Farrington who wove together thework of different authors on various subjects into cohesivetext. Kristen Ruckstuhl and Madaline Feinbergplayed important roles behind the scenes as coordinatorsof the entire process. They ensured that authors,reviewers and section editors carried out their commitments,and provided valuable update communicationsthroughout the life of the project. Thanks for the earlyadministrative support from Kelly Matthews and, later,from Lembe Tayilo. Mary O’Grady and KathleenHenry provided important editorial and managementsupport throughout much of the project and werealways available for meetings and brainstorming.Thank you to Dorothy “Duffy” Miller for her excellentcopy-editing. Thank you to John-Manuel Andriote,who coordinated the editorial, design, production andprinting processes. And thank you to Dever Designs,Inc., for their good work in transforming text andfigures into the book you now see. The design team ofChris Komisar and Joan Stevenson has worked wonders.At the Centers for Disease Control and Prevention,Drs. Eve Lackritz, Tim Mastro, Lynn Paxton andNathan Shaffer provided valuable technical advice,while Lynne Stockton and Carol McCurley providedmuch appreciated editorial and technical input.SECTION EDITORSSpecial thanks to the following individuals for overseeingthe editing of the book’s seven sections. Some ofthem are also chapter authors. Contact information islisted in the next section.Section 1Gail Goodridge, MSSection 2Peter Lamptey, MD, DrPHDonna Flanagan, MSW, MASection 3Gina Dallabetta, MDMarie Laga, MDSection 4Claudes Kamenga, MD, MSPHSection 5Sheila Mitchell, MBAAlex Wodak, MDSection 6Joan MacNeil, PhDSection 7Ward Cates, MD, MPHXXVI HIV/AIDS Prevention and Care in Resource-Constrained Settings

AUTHORS, REVIEWERS ANDSECTION EDITORSPETER AGGLETON, PHD,FBPSS, FRSH, FRIPHHDirector,Thomas Coram Research UnitInstitute of EducationUniversity of London27-28 Woburn SquareLondon WC1H 0AAUnited KingdomSANDRA ANDERSONUNAIDS Intercountry TeamE&S AfricaCare and Support Advisor351 Schoeman StreetPO Box 6541Pretoria 0001South AfricaGRETCHEN BACHMAN, MIMAssociate Director, Resource DevelopmentHIV/AIDS Prevention andCare DepartmentFamily Health International2101 Wilson Boulevard, Suite 700Arlington, VA 22201USARACHEL BAGGALEY, MSC, MDHonorary research fellowLondon School of Hygiene andTropical MedicineKeppel StreetLondon WCIUnited KingdomANDREW BALL, MBHIV/AIDS PreventionDepartment of HIV/AIDSWorld Health Organization20 Avenue Appia1211, Geneva 27SwitzerlandANTHONY BENNETT, MSCAssociate Director, Field ProgramsHIV/AIDS Prevention andCare DepartmentFamily Health International2101 Wilson Boulevard, Suite 700Arlington, VA 22201USAJANE BERTRAND, PHD, MBADept. of Population and FamilyDirector, Center forCommunication ProgramsHealth SciencesJohns Hopkins University111 Market Place, Suite 310Baltimore, MD 21202USAPAURVI BHATTDirector, International HIV Programs,Abbott FundDeputy Executive Director,Step Forward for Children InitiativeAbbott Fund1710 Rhode Island Ave, NWSuite 500Washington, DC 20036USADR. OLIVIER BRASSEUR MD,PHD, MPH, MSC.UNFPA RepresentativePakistan & AfghanistanUNFPA - Saudi Pak Tower, 61-A,Jinnah AvenueP.O. Box 1051IslamabadPakistanANNE BUVE, MDSTD/HIV Research andIntervention UnitDepartment of MicrobiologyInstitute of Tropical MedicineNationalestraat 155B 2000 AntwerpBelgiumCARLOS F. CÁCERES, MD, DRPHProfessor of Public Health, CayetanoHeredia University, Lima, Peru;Assistant Professor, Center for AIDSPrevention Studies/AIDS ResearchInstitute, University of California,San Francisco, USA;Director of Research, Peruvian Networkfor Youth Education, Sexual Health andDevelopment, Lima, PeruAddress: Av. Armendáriz 445Miraflores, Lima 18PeruMICHEL CARAEL, PHDChief, EvaluationUNAIDS20, Avenue AppiaCH 1211 Geneva 27SwitzerlandDENISE M. CARDO, MDChief, Prevention and Evaluation BranchDivision of Healthcare QualityPromotion, National Center forInfectious DiseasesCenters for Disease Controland Prevention1600 Clifton Road,Mail Stop E-68Atlanta, GA 30333USAWARD CATES, MD, MPHPresidentFamily Health InternationalP.O. Box 13950Research Triangle Park, NC 27709USACLEMENT CHANKAM, MB, MRCPChief, Theme Group Support UnitCountry and Regional SupportDepartmentUNAIDS20 Avenue Appia1211 Geneva 27SwitzerlandJULIA CLEVESSenior Policy Advisor and HeadPolicy Coordination UnitUNAIDS20 Avenue AppiaCH-1211 Geneva 27SwitzerlandROBERT COLEBUNDERS, MD, PHDDepartment of Clinical SciencesInstitute of Tropical MedicineNationalestraat 155B 2000 AntwerpBelgiumHIV/AIDS Prevention and Care in Resource-Constrained Settings XXVII

SOFIA GRUSKIN, JD, MIAAssistant Professor on Healthand Human RightsDirector, International Program onHealth and Human RightsFrançois Xavier Bagnoud Center forHealth and Human RightsHarvard School of Public Health651 Huntington Avenue, 7th floorBoston, MA 02115USAJEFFREY A. HOFFMAN, PHDPresident and CEODanya International, Inc.8737 Colesville Road, Suite 1200Silver Spring, MD 20910USAHILARY HUGHES, MPHIL/PHD(CANDIDATE)Consultant63 Victoria RoadEmsworthHampshire PO10 7NJUnited KingdomSUSAN S. HUNTER, PHDInternational Health ConsultantP.O. Box 590Lake Luzerne, New York 12846USAHELEN JACKSONRegional AIDS AdvisorUNFPA Country Support TeamUNFPAP.O. Box 477567/69 Union AvenueHarareZimbabweSMRAJIT JANA, MDHIV Program CoordinatorCARE BangladeshHouse #59, Road #7ADhahnmondi R/ADhaka 1209BangladeshGEORGETTE ADJORLOLO JOHNSON, MD,MPHProjet RETRO CI/CDC HIV01 BP 1712 Abidjan 01Côte d’IvoireSAMUEL KALIBALA, MDMedical AssociatePopulation Council Horizons ProjectGeneral Accident House, Ralph BuncheRoad NairobiP.O. Box 17643 NairobiKenyaCLAUDES KAMENGA, MD, MSPHRegional Senior Technical AdvisorHIV/AIDS Prevention andCare DepartmentFamily Health International2101 Wilson Boulevard, Suite 700Arlington, VA 22201USAIGNATIUS KAYAWEDirectorKara Counselling andTraining TrustPO Box 37559LusakaZambiaGERALD T. KEUSCH, MDDirector, Fogarty International CenterAssociate Director forInternational ResearchNational Institutes of Health31 Center Drive, Room B2C02Bethesda, MD 20892-2220USASHIVANANDA KHANNaz Foundation InternationalPalingswick House241 King StreetLondonW6 9LPUnited KingdomANTHONY KINGHORN, MBBCHAbt Associates South Africa IncIOTA Place, 27 Fricker RdIllovo, JohannesburgSouth AfricaPostal: Postnet Suite #131,PBag X11Birnam Park, 2015South AfricaSTEVEN J. KRAUS, MPH, MSW, MSC,DPTMHProgramme and ExternalRelations AdvisorUNAIDS South-East Asia andPacific Intercountry TeamThird FloorUnited Nations BuildingRajadamnern Nok AvenueBangkok 10200ThailandEVE LACKRITZ, MDAssistant Chief for ScienceInternational Activities BranchDivision of HIV/AIDS PreventionNational Center for HIV, STD,and TB Prevention Centers forDisease Control and Prevention1600 Clifton RoadAtlanta, GA 30333USAMARIE LAGA, MDSTD/HIV Research and Intervention UnitInstitute of Tropical MedicineNationalestraat 1552000 AntwerpBelgiumVEENA LAKHUMALANIManager - Governance, SocialJustice and HealthThe British Council5 Shakespeare SaraniCalcutta 700 071IndiaHIV/AIDS Prevention and Care in Resource-Constrained Settings XXIX

PETER R. LAMPTEY, MD, DRPHExecutive Vice President, ChiefOperating OfficerHIV/AIDS Prevention andCare DepartmentFamily Health International2101 Wilson Boulevard, Suite 700Arlington, VA 22201USACAROL LARIVEE, MAAssociate DirectorHIV/AIDS Preventionand Care DepartmentFamily Health International2101 Wilson Blvd. Suite 700Arlington, VA 22201USAPURNIMA MANE, PHDVice PresidentInternational Programs DivisionPopulation CouncilOne Dag Hammarskjöld PlazaNew York, New York 10017USAPHILIPPE MAYAUD, MD, MSCClinical Research UnitDepartment of Infectious &Tropical DiseasesLondon School of Hygiene &Tropical MedicineKeppel StreetLondon WC1E 7HTUnited KingdomANN P. MCCAULEY, PHDProgram OfficerICRW seconded to theHorizons Project4301 Connecticut Avenue, NWSuite 280Washington, D.C. 20008USABRIAN MCCLELLAND,BSC HONS, MBCHB, MRCP,DOCTORAAT IN DE GENEESKUNDE,FRCP, FRC PATHClinical DirectorEdinburgh & South East ScotlandBlood Transfusion ServiceRoyal InfirmaryEdinburgh EH3 9HBScotlandJOAN MCNEIL, PHDSenior Technical OfficerFamily Health InternationalIMPACT/PhilippinesDept. of Health STD/AIDS UnitBldg. 12, 3rd Floor, San LazaroCompoundSta. Cruz, ManilaPhilippinesDAVID MILLER, PHDPsychosocial AdvisorUNAIDS20 Avenue AppiaCH 1211 Geneva 27SwitzerlandSHEILA MITCHELL, MBAVice PresidentHIV/AIDS Preventionand Care DepartmentFamily Health International2101 Wilson Boulevard, Suite 700Arlington, VA 22201USALYNNE MOFENSON, MDAssociate Branch Chief forClinical ResearchPediatric, Adolescent &Maternal AIDS BranchNational Institute of Child Health &Human DevelopmentNational Institutes of Health6100 Executive Blvd, Room 4B11Rockville, MD 20852USAROB MOODIE, MBBS, MPHChief Executive OfficerVictorian Health Promotion Foundation(PO Box 154)Building B, Ground Floor,15 31 Pelham StreetCarlton South VIC 3053AustraliaJOHN S. MORAN, MD, MPHDivision of STD Prevention, NationalCenter for HIV, STD, andTB PreventionMailstop E-02Centers for Disease Control andPrevention (CDC)Atlanta, Georgia 30333USAFRANCIS NDOWA, MB, CHB, DIPDERM, DIP GUMEDDepartment of HIV/AIDSSTI UnitWorld Health Organisation20, Avenue AppiaCH 1211Geneva 27SwitzerlandRUTH NDUATI,MBCHB, MMED, MPHSenior LecturerDepartment of PaediatricsUniversity of NairobiP. O. Box 30197 NairobiKenyaEMIL ASAMOAH ODEI,MB CHB, MSC, DIP VENMedical OfficerWHO Regional Office for AfricaP. O. Box BE 773, HarareZimbabweCONNIE M. OSBORNE, MB, CHB,DCH, MMED, MSCMTCT/VCT Focal PointDepartment of Social Mobilisationand InformationUNAIDS20, Avenue Appia.CH-1211 Geneva 27SwitzerlandXXX HIV/AIDS Prevention and Care in Resource-Constrained Settings

THOMAS M. PAINTER, PHDBehavioral Scientist (Sociologist)Prevention Services Research Branch,MS E-46Division of HIV/AIDS Prevention,Surveillance & Epidemiology,National Center for HIV, STD andTB PreventionCenters for Disease Control andPrevention1600 Clifton Road NEAtlanta, Georgia 30333USARICHARD PARKER, PHDProfessor of Social Medicine, StateUniversity of Rio de JaneiroAssociate Professor of Public Health,Columbia University;Director and President, BrazilianInterdisciplinary AIDS Association (ABIA)Rua da Candelária 79, 10th FloorCep 20091 020, CentroRio de Janeiro, RJ.BrazilSUSAN PARRY, MDChairpersonFarm Orphan Support Trust ofZimbabwe (FOST)CFU—FOSTP.O. Box WGT 390Westgate, HarareZimbabweJOSEPH PERRIENS, MD, PHDManager, Strategy Developmentfor ResponsesUNAIDS20, Avenue AppiaCH 1211 Geneve 11SwitzerlandARLETTY PINEL, MDAssociate Director, TechnicalProgramming and SupportHIV/AIDS Preventionand Care DepartmentFamily Health International2101 Wilson Blvd., Suite 700Arlington, VA 22201USAANTHONY PRAMUALRATANAExecutive DirectorThailand BusinessCoalition on AIDS65/62 Chamnan PhenjatiBusiness Center, Rama 9 Road,HuaykwangBangkok 10320ThailandJONATHAN D. QUICK, MD, MPHDirectorEssential Drugs and Medicines Policy(EDM)Health Technology and Pharmaceuticals(HTP)World Health Organization20 Avenue AppiaCH 1211 Geneva 27SwitzerlandBILL RAU, PHDConsultant on HIV/AIDS andDevelopment8319 Haddon DriveTakoma Park, MD 20912USATHOMAS M. REHLE, MD, PHDAdjunct Associate ProfessorDepartment of International HealthSchool of Hygiene and Public HealthJohns Hopkins University615 North Wolfe StreetBaltimore, MD 21205USAALLAN RONALD, MDProfessor EmeritusUniversity of Manitoba709-99 Wellington CrescentWinnipegManitoba R3M0A2CanadaJAY ROSS, PHDPolicy Coordinator, LINKAGESAcademy for Educational Development31 Macken Rd, RR4Antigonish, Nova ScotiaB2G 2L2CanadaNAOMI RUTENBERG, PHDSenior Program AssociatePopulation Council4301 Connecticut Avenue NWSuite 280Washington, DC 20008USACAROLINE A. RYAN, MD, MPHAssociate Director, International ActivitiesDivision of STD PreventionNational Center for HIV, STD andTB PreventionCenters for Disease Control andPrevention1600 Clifton Road MS: E-02Atlanta, GA 30333USAWILLIAM SCHELLESTEDE, BASenior Vice PresidentInternational Operations/ControllerHIV/AIDS Prevention andCare DepartmentFamily Health International2101 Wilson Boulevard, Suite 700Arlington, VA 22201USARICHARD SCHWARTLÄNDER, MD, PHDChief, Strategic Information DivisionUNAIDS20 Avenue AppiaCH 1211 Geneva 27SwitzerlandNATHAN SHAFFER, MDChief, MTCT UnitGlobal AIDS ProgramCenters for Disease Control andPrevention (CDC)1600 Clifton Rd. (MS E-41)Atlanta, GA 30333USAHIV/AIDS Prevention and Care in Resource-Constrained Settings XXXI

WILLIAM SMITHExecutive Vice PresidentAcademy for Educational Development1825 Connecticut Ave., NWWashington, DC 20009USARON STALL, PHD, MPHBranch ChiefBehavioral InterventionsResearch BranchDivision of HIV/AIDS PreventionCenters for Disease Control andPrevention1600 Clifton Rd., NE (M/S E-37)Atlanta, GA 30333USAKAREN STANECKIChief, Health Studies BranchU.S. Bureau of the CensusWashington, DC 20233USABEVERLY STAUFFER, RN, MPHConsultant3060 16th St. NW, #702Washington DC 20009USARICHARD STEEN, PA, MPHSTD AdvisorHIV/AIDS Prevention andCare DepartmentFamily Health International2101 Wilson Blvd. Suite 700Arlington, VA 22201USAMALCOLM STEINBERG, MBBCH, MSCEPIDEMIOLOGYAbt Associates South Africa IncIOTA Place, 27 Fricker RdIllovo, JohannesburgSouth AfricaPostal: Postnet Suite #131, PBag X11Birnam Park, 2015South AfricaGARY R SVENSON, MSW, MSCManagerEuropean Joint Action Plan on YouthPeer Education (EUROPEER)Department of Community MedicineLund UniversityMedical Research CenterEntrance 59Malmo University HospitalSE 20502 MalmöSwedenMICHAEL D. SWEAT, PHDAssistant Professor ofInternational HealthJohns Hopkins UniversitySchool of Public Health615 North Wolfe StreetRoom E7140Baltimore, MD 21205USADANIEL TARANTOLA, MDSenior Policy Advisor to theDirector GeneralWorld Health Organization20 Avenue AppiaCH 1211 Geneva 27SwitzerlandFRANÇOISE RENAUD THERY, PHARMD,DIP. PUBLIC HEALTHAccess to HIV Drugs AdvisorSocial mobilization and InformationDepartment (SMI)Strategy for ResponsesUNAIDS20 Avenue AppiaCH 1211Geneva 27SwitzerlandERIC VAN PRAAG, MD, MPHDirector, HIV CareHIV/AIDS Prevention andCare DepartmentFamily Health International2101 Wilson Blvd. Suite 700Arlington VA 22201USABEA VUYLSTEKE, MD, MSCProjet RETRO-CI01 BP 1712 Abidjan 01Côte d’IvoireALAN WHITESIDE, MADirector Health Economics andHIV/AIDS Research DivisionUniversity of NatalDurban 4041South AfricaALEX WODAK, MDDirector, Alcohol and Drug ServiceSt Vincent’s Hospital,Darlinghurst, NSW, 2010AustraliaIVAN WOLFFERS, MD, PHDProfessor, Health Care inDeveloping CountriesHealth Care and CultureFaculty of MedicineVrije Universiteit,Van de Boechorststraat 71081BT AmsterdamThe NetherlandsFERNANDO ZACARIAS, MD, DRPHPan American Health Organization(PAHO)Regional Office of the World HealthOrganization (WHO)525 23rd Street N.W.Washington, DC 20037USALÉOPOLD ZEKENG, PHDLaboratoire d’Hématologie du CentreHospitalier et Universitaire (CHU)BP 30.254YaoundéCameroonXXXII HIV/AIDS Prevention and Care in Resource-Constrained Settings

glossary of A C R O N Y M SACTG AIDS Clinical Trials GroupAED Academy for EducationalDevelopmentAcquired Immune DeficiencySyndromeAIDS Control and Prevention ProjectANC Antenatal clinicART Antiretroviral therapyARV AntiretroviralAZT Zidovudine (also ZDV, generic name)or azidothymidineBCC Behavior change communicationBSS Behavioral surveillance surveysC & T Counseling and testingCAPS Center for AIDS Prevention Studies(University of California-San Francisco)Coordination of Action Research onAIDS and MigrationCBA Cost-benefit analysisCBO Community-based organizationCDC U.S. Centers for Disease Control andPreventionCEA Cost-effectiveness analysisCMV CytomegalovirusCSM Condom social marketingCSW Commercial sex workerCUA Cost-utility analysisDAC District AIDS CommitteeDAI HIV/AIDS Drug Access InitiativeDFID Department for InternationalDevelopment (United Kingdom)DHS Demographic health surveyDOTS Directly observed therapy(short-course)ECR Expanded and comprehensiveresponseAIDS/SIDAAIDSCAPCARAMFCO Final cost objectiveFHI Family Health InternationalFP Family planningGDP Gross domestic productGPA Global Programme on AIDS(World Health Organization)HAART Highly active antiretroviral therapyHCP Health care providerHIV Human immunodeficiency virusIA Implementing agencyIAA Inter-agency agreementID Infectious diseaseIDU Injection drug use(r)IEC Information, education andcommunicationImplementing AIDS Prevention andCare Project (administered by FHI,funded by USAID)KABP Knowledge, attitudes, behavior andpracticesKS Kaposi’s sarcomaLE Life expectancyLOA Letter of agreementLTP Long-term planM & E Monitoring and evaluationMAC Mycobacterium avium complexMAP Multi-country HIV/AIDS Program(sponsored by UNAIDS and theWorld Bank)MCH Maternal and child healthMOH Ministry of HealthIMPACTHIV/AIDS Prevention and Care in Resource-Constrained Settings XXXIII

MSM Men who have sex with menMTCT Mother-to-child transmissionMTP Medium-term planNACP National AIDS Control ProgramNAP National AIDS ProgramNational AIDS and STDControl ProgramNGO Non-governmental organizationOI Opportunistic infectionOVC Orphans and other vulnerablechildrenOW Outreach workerPCP Pneumocystis carinii pneumoniaPEP Post-exposure prophylaxisPHC Primary health carePI Protease inhibitor (PI is also anacronym for prevention indicators)PLHA Person (or people) living withHIV/AIDSPSI Population Services InternationalPVO Private voluntary organization(U.S.-based, registered with USAID)RA Resident advisorRegional Economic andDevelopment Support OfficeRH Reproductive healthNASCOPREDSOSOTAState-of-the-artSTD/STI Sexually transmitted disease/infectionSTGs Standard treatment guidelinesTA Technical assistanceTB TuberculosisTBPT Tuberculosis preventive therapyUNAIDS Joint United Nations Programme onHIV/AIDSUNDP United Nations DevelopmentProgrammeUNICEF United Nations Children’s FundUSAID U.S. Agency for InternationalDevelopmentVCT Voluntary counseling and testingWHO World Health OrganizationWTO World Trade OrganizationXXXIV HIV/AIDS Prevention and Care in Resource-Constrained Settings