PAKISTAN REPORT OF AN HIV/AIDS TECHNICAL REVIEW MISSION

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized PAKISTAN REPORT OF AN HIV/AIDS TECHNICAL REVIEW MISSION At the request of the Government of Pakistan, a World Bank mission comprising Hugo Diaz (Senior Economist), Dr. Salim Habayeb (Lead Public Health Specialist) and Dr. Bashirul Haq (Senior Public Health Specialist) visited Pakistan from April 2-14, 2001, to review the situation concerning the HIV/AIDS epidemics and the Government s response to the epidemics. The mission was joined by Dr. Kristan Schoultz, UNAIDS Country Program Advisor in Pakistan, and Dr. Asma Bouhari, Deputy Program Manager of the National HIV/AIDS Program. Their valuable contributions to the work of the mission are gratefully acknowledged. The work of the mission included discussions at the Federal level with officials of the Ministry of Health, which houses the National HIV/AIDS Program, and of other interested Federal agencies (Planning Division, Ministry of Education, Ministry of Labor, Manpower & Overseas Pakistanis, Ministry of Finance, Economic Affairs Division). The mission also visited the provinces of Punjab and Sindh, where discussions were held with officials of the respective Departments of Health, including those dealing with the HIV/AIDS program and with Blood Transfusion Services, as well as with Planning and Development Department and Finance Department officials. In addition, the mission met with a number of NGOs involved in HIV/AIDS-related work, and made several field visits to NGO-managed programs involving truckers, injecting drug users and commercial sex workers. The mission also held discussions with a number of other agencies which support HIV/AIDS prevention efforts, including (in addition to UNAIDS) UNICEF, WHO, ILO, UNDCP, UNESCO, JICA, DFID, EC, CIDA, and the International Federation of Red Cross. This report presents the views and recommendations of the mission to the Government of Pakistan. It is our sincere hope that the report will contribute to encouraging the Government to step up its efforts against the spread of HIV/AIDS as an urgent matter. World Bank Washington, D.C. May

2 TABLE OF CONTENTS Page 1. Background: Epidemiology and Risk Factors 4 -Prevalence and Modes of Transmission.4 -Risk factors.4 2. Current Government Response 6 -Program interventions funded by the Federal Government.6 -Program interventions funded by Provincial Governments.7 -Program interventions funded by UN and Bilateral Agencies.8 -The role of the Social Action Program Projects (SAPPs) 9 3. Assessment of the Program and Major Issues Implications of the Current Situation.11 -Epidemiological implications.11 -Costs to society The New National Strategic Framework Recommendations 13 ANNEXES: Annex 1 Illustrative Enhanced Five-Year HIV/AIDS Program 2

3 ABBREVIATIONS: ADP: Annual Development Plan BOD: Burden of Disease (a quantitative measure of the extent of morbidity and premature mortality in a population). CIDA: Canadian International Development Agency CSW: Commercial Sex Worker DFID: Department for International Development of the United Kingdom EC: European Commission HIV/AIDS: Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome IEC: Information, Education and Communications IDU: Injecting Drug User ILO: International Labor Organization JICA: Japanese International Cooperation Agency NAPCP: National AIDS Prevention and Control Program NGO: Non-governmental Organization PC-1: Planning Commission Form No. 1 SAPPs: Social Action Program Projects I and II STI: Sexually Transmitted Infection UNAIDS: Joint United Nations Program on HIV/AIDS UNDCP: United Nations Drug Control Program UNDP: United Nations Development Program UNESCO: United Nations Education and Science Organization UNFPA: United Nations Fund for Population Activities UNHCR: United Nations High Commission for Refugees UNICEF: United Nations Children s Fund WHO: World Health Organization 3

4 1. Background: Epidemiology and Risk Factors 1.1. This section summarizes the current state of the HIV/AIDS epidemic and existing risk factors. Prevalence and Modes of Transmission 1.2. Pakistan is a low-prevalence, high-risk country for Human Immuno-deficiency Virus (HIV) infections. Based on limited surveillance data, computer modeling estimates range from 70,000 to 80,000 persons with HIV, or about 0.1 percent of the adult population. Till the end of 2000, 1,549 HIV cases and 202 AIDS cases were reported to the National AIDS Control Program. Reported cases originated from surveillance of various risk group categories, screening of blood transfusions, and voluntary testing The numbers of reported cases have been steadily rising since the late 1980s. HIV has been identified in all geographic regions of the country, including all provinces and the federally administered territories The most important mode of transmission is sexual (mostly heterosexual) transmission, which was identified as the mode of transmission in about 42 percent of the reported cases. Exposure to infected blood or blood products accounted for 18 percent of the cases while injecting drugs accounted for about four percent. In 35 percent of the cases the mode of transmission was unknown. However, it is likely that the majority of these cases would be due to sexual transmission. So far, the great majority of infections are among males, with a male to female ratio of 7:1, which is to be expected in the early stages of an HIV epidemic. Most cases are in the age group years No HIV has been detected in samples from pregnant women in various cities, except for 0.6 percent in Lahore, where the sample was taken from a facility adjacent to a red light area. In Lahore, 11.5 percent of drug users attending a psychiatric center were found to be HIV-positive. In Karachi, a 1996 survey found that 1 percent of injecting drug users were infected with HIV. In Quetta, in a sample of 210 tuberculosis patients, 2.8 percent were found to be HIV-positive. Risk Factors 1.6. Risk factors are numerous and significant. They put Pakistan under a formidable threat of a widespread epidemic and include the following. Injecting Drug Users. In most Asian countries, injecting drug users are the first group to be affected by HIV. The number of injecting drug users in Pakistan is estimated at about 60,000, and sharing of injection equipment among these addicts is widespread. It is generally believed that an increasing proportion of drug users are shifting to injecting drugs, mostly heroin. An update in the situation concerning drug use in Pakistan will soon be available when the results of a rapid assessment recently carried out by UNDCP are made public. Commercial Sex Workers. Commercial sex is widespread in all major cities and along truck routes. Commercial sex workers and their clients have insufficient 4

5 information about HIV and sexually transmitted diseases. A 1996 survey of sex workers in Karachi found that only 44 percent knew that HIV was sexually transmitted. In addition to lack of knowledge, the ability of sex workers to negotiate safe sex with their clients is very limited. Partial Blood Transfusion Screening and Professional Donors. It is generally estimated that nationwide about 60 percent of the approximate 1.5 million annual blood transfusions are screened for HIV. Deficiencies in blood screening are present in both public and private blood banks. For example, in Sindh, Department of Health staff estimate that no more than 50 percent of blood transfusions in public sector hospitals are screened for HIV, and that the percentage screened is probably lower in the private sector. Professional blood donations are common. In 1998, the AIDS Surveillance Center in Karachi conducted a study of professional blood donors and found that 20 percent were infected with Hepatitis C, 10 percent with Hepatitis B, and 1 percent with HIV. Sexually Transmitted Infections and Low Condom Use for Disease Prevention. Data on the prevalence of STIs in Pakistan is scant. A 1997 study of the Burden of Disease (BOD) by the World Bank estimated that STIs (syphilis, gonorrhea, chlamydia, and pelvic inflammatory disease) may account for about 2 percent of the total BOD in the country. In a sample of 402 STI clinic attendees in Karachi, 17.1 percent were found to be infected with syphilis and 2.9 percent with gonorrhea. Few health facilities provide effective services to screen and treat STIs. Surveys show that the use of condoms for disease prevention is negligible, though condoms are more commonly used for family planning purposes. Migration. Large numbers of workers leave their villages to seek work in the larger cities or on industrial sites. Away from their homes for extended periods of time, they are at higher risk of engaging in unprotected sex and/or abusing drugs, and hence at higher risk of contracting HIV. Those who become infected bring HIV back to their spouses or other sexual partners. Large numbers of Pakistani men also seek employment overseas or serve in U.N.-sponsored army units. These men often seek commercial sex. There have been numerous cases of HIV among Pakistanis who have worked in the Gulf Countries (and were repatriated when found to be infected, as this group is systematically tested). Long-distance truckers are another group at high risk of infection because they often engage in commercial sex. Unsafe Injection Practices. With 4.5 injections per capita per year, Pakistan has one of the highest rates of injection use in the world. Studies indicate that 94 percent of injections are administered with re-used injection equipment. There is widespread use of un-sterilized needles at medical facilities. According to WHO estimates, unsafe injections in Pakistan account for 62 percent of Hepatitis B, 84 percent of Hepatitis C, and 3 percent of HIV cases. Low Levels of Literacy and Education. The low levels of education, especially among women, are a major constraint to increasing awareness about HIV among the general population. Large Proportion of Young People. Because of rapid population growth, Pakistan has a large proportion of adolescents and young adults. This group of 5

6 the population is more likely to experiment with unsafe sex and the use of drugs, including injecting drugs. 2. Current Government Response 2.1. This section describes the current Government s response to HIV/AIDS, the associated expenditure, and its financing. We include as part of the Government s response various programs that are funded off-budget by UN agencies, in some cases implemented through NGOs. Since these programs have been negotiated and agreed with the Government, in a broad sense they also are an important part of the Government s response to the epidemics. Program Interventions Funded by the Federal Government 2.2. The Federally-funded National AIDS Prevention and Control Program (NAPCP) received a budget allocation of Rs. 92 million in the current fiscal year 2000/01, or about US$1.53 million (using an average exchange rate for the year of Rs. 60/US$) Activities funded from this allocation, and their corresponding budget shares as planned at the beginning of the fiscal year, were as follows: Program Management Rs. 6.3 million or 6.8% of total. Screening of Blood Transfusions Rs million or 45.1% of total. Information, Education and Communications (IEC) Rs million or 37.3% of total. Surveillance Rs. 3.8 million or 4.1% of total. Research Rs. 4.0 million or 4.3% of total. Training for Syndromic Approach to STIs Rs. 1.0 million or 1.1% of total. HIV Clinical Case Management Guidelines Rs. 1.0 million or 1.1% of total. A brief explanation of each activity follows Program Management. The budget for this activity pays for the salaries of the program management staff, located at the National Institute of Health in Islamabad. It also includes provision for non-salary inputs related to the work of program staff Screening of Blood Transfusions. The budget for this activity pays for the procurement of HIV screening kits and Hepatitis B screening kits, sufficient in number to enable the screening of approximately 600,000 blood bags per year. The kits, which are procured through WHO, are provided to the Provinces as a grant. The actual screening is the responsibility of the provincial Departments of Health. The kits are used to screen blood in public sector hospitals only. 6

7 2.6. Information, Education and Communications. The budget for this activity mostly goes to paying for TV spots (Rs million in the current fiscal year). Other items included here are radio spots (Rs. 4.0 million), production of posters and leaflets (Rs. 4.5 million), and support of provincial IEC campaigns (Rs. 4.0 million) Surveillance. The budget for this activity pays for the procurement of HIV diagnostic kits and related equipment and consumables for the screening and diagnosis of approximately 25,000 persons per year nationwide. The kits and related materials are provided to the Provinces as a grant, to be used in 45 voluntary testing centers throughout the country. Actual testing is conducted by the provincial Departments of Health Research. The current year s budget includes provision for two operational studies: Impact Assessment of Program Activities and External Review of the NAPCP. In addition, the program is coordinating a Second HIV Sero-Prevalence Study which had been budgeted in the previous fiscal year. (A Sexually Transmitted Infections prevalence study is also ongoing, with support from WHO) Training for Syndromic Approach to STIs. This activity comprises the printing of national guidelines on the syndromic approach (training modules and case management guidelines), for distribution to the Provinces. The Provinces in turn use these guidelines to train their health staff involved in STI treatment HIV Clinical Case Management Guidelines. This activity comprises the printing of guidelines on the clinical management of HIV/AIDS patients, for distribution to the Provinces. Clinical management is not an important component of the program at this time because the number of patients with manifest overt AIDS is still small, but it is certain to become more important in the future In addition to managing the activities included in its own budget, the NAPCP helps to coordinate a number of HIV/AIDS-related programs which are funded offbudget (as grants) by several UN agencies (see below). Program Interventions Funded by Provincial Governments In recent times, the provincial governments have allocated some of their own funds to HIV prevention, to supplement the inputs financed by the NAPCP, but the amounts involved are small. For example, while Punjab s PC-1 for its HIV/AIDS program was approved in March 2001, the provincial contribution (to be budgeted in the provincial Development budget) is only Rs. 5 million (about US$83,000) over three years. Moreover, until recently, Punjab had only one full-time officer (the Program Manager) assigned to the program, though two additional medical officers have now been seconded to the program. Punjab is the only province, however, which has organized its Blood Transfusion Services as a distinct organization within the Department of Health, and in FY2000/01 it allocated Rs. 50 million (US$0.83 million) in the Current budget for these services. Since part of the work of the Blood Transfusion Services is to screen blood for HIV, these resources also make a contribution to HIV prevention. 7

8 2.13. In the case of Sindh, there is a well-staffed HIV/AIDS program management unit, which sets it apart in this respect from the other provinces. The provincial contribution to the program in the Development budget, as per the current PC-1 (2000/ /03), is Rs million (US$161,000) over three years. In addition, five posts in the program management unit are funded from the provincial Current budget, as is the case with the staff of 12 HIV testing centers in the province. The Department of Health has also established 42 STI Clinics at teaching and District Headquarters hospitals which use the syndromic approach. These clinics, whose costs are funded from the provincial Current budget, should be making an indirect contribution to HIV prevention (since the presence of STIs raises the likelihood of acquiring HIV), but the effectiveness of their work has not been documented NWFP and Balochistan have not yet developed their HIV program management units. Both Provinces, however, have an approved provincial PC-1 for the program, and in FY2000/01 they included allocations for the program in the Development budget of Rs. 7 million in NWFP (US$117,000) and Rs. 4 million in Balochistan (US$67,000). Program Interventions Funded by UN and Bilateral Agencies A number of UN and bilateral agencies have made important contributions to the nascent HIV/AIDS program in Pakistan. These contributions are all in the form of grants, and are not reflected in either the Federal or the provincial budgets. According to UNAIDS sources, the combined annual cost of these contributions is currently about US$1.0 million. Agencies currently contributing include (in order of approximate importance as measured by amounts being contributed to fighting HIV) UNICEF, UNAIDS, WHO, UNDCP, ILO, UNESCO, and UNHCR. UNDP and UNFPA contribute to the program indirectly as global UNAIDS co-sponsors. UNFPA s assistance also includes the provision of condoms for the family planning program, some of which have been made available to the HIV/AIDS program for the promotion of safe sex. The Government of Japan is also contributing to the program under the UNAIDS umbrella (UNAIDS Joint Project) The main activities currently being supported by the agencies mentioned in the previous paragraph include: Support to NGOs working with high-risk groups. There are currently 13 NGOs actively involved in HIV prevention work among high-risk groups (mainly commercial sex workers, injecting drug users, and truck drivers) throughout the country. Technical Training. This includes a variety of short-term courses for health sector staff (mostly at provincial level) on a variety of subjects including STI syndromic case management, training for HIV testing centers staff, and clinical management and counseling. Other Training. This includes a large number of orientation seminars and workshops for categories of people who are in a position to advise others about 8

9 the dangers of HIV or influence public opinion, including health educators from the public and private sectors, travel agents (who work with migrant workers), media editors, students in medical and dental colleges, journalists, lawyers, and teachers. The Directorate of Workers Education of the Ministry of Labor, Manpower & Overseas Pakistanis is implementing a program of HIV/AIDS awareness training for workers in the organized sector of the labor force. National Strategic Framework for the HIV/AIDS Program. A key activity recently completed was the formulation of a National Strategic Framework for the program, through a major participatory exercise which was coordinated by the NAPCP and UNAIDS staff. This is further discussed in Section 5 below Based on the above, total public expenditure on HIV/AIDS prevention broadly defined in FY2000/01 would amount to approximately Rs. 218 million (US$3.63 million). This amount is arrived at by adding the following components: Federal NAPCP, Rs. 92 million; Punjab Blood Transfusion Services, Rs. 50 million; U.N. agencies programs, Rs. 60 million; and the Provinces contributions to their HIV/AIDS program budgeted in their ADPs. (Note however that since these are budget allocations rather than actual expenditure, actual expenditure could turn out to be lower than the amounts indicated above). The Role of the SAPPs Since 1994, the NAPCP has been also supported by the consortium of donors in the Social Action Program Projects (SAPP I and SAPP II), which included the World Bank, the Asian Development Bank, the European Commission (EC), DFID, and the Government of the Netherlands. This support has consisted of the following: The reimbursement of a certain percentage of the actual expenditures incurred by the Government (both Federal and provincial) on its HIV/AIDS program. Reimbursement percentages have varied by category of expenditure and over time, but in the current year the Government is entitled to claim 75% of nonsalary expenditures, which constitute the major portion of expenditures under the NAPCP. Lobbying and support for increased budget allocations for the program, for the timely releases of these allocations, and to ward off allocation cutbacks during the fiscal year. Allocations were generally protected and fully released, but the program has grown very little over the years. Technical advice on various aspects of the program, mostly in the context of SAPP review missions and their follow-up. The present technical assistance mission (to which this report refers) also originated from the SAPP dialogue. 3. Assessment of the Program and Major Issues 3.1. The AIDS Prevention and Control Program was started in In its early stages the program was laboratory-oriented, but its scope has broadened (as implied by 9

10 the description in the previous section). The program s main objective is the prevention of HIV transmission. Related objectives are achieving safe blood transfusions and reducing STI transmission A full assessment of the program was not feasible within the timeframe of this technical assistance mission and available information. Nevertheless, several salient conclusions can be drawn from discussions and observation during the mission and the experience with HIV elsewhere in South Asia and around the world. At an early stage of the HIV epidemic, which is the case in Pakistan, the most important intervention consists of efforts to change behavior among highrisk/high-transmission groups, especially commercial sex workers and their clients. This work usually involves interpersonal communication to induce behavioral change and the facilitation of such behavioral change e.g., by facilitating access to condoms in the case of commercial sex workers, or providing needle exchanges in the case of injecting drug users. While such activities are a component of Pakistan s HIV program, the coverage at present is too small to make a real difference to the progression of the epidemic. It is likely that current, NGO-led programs are not reaching more than 2-3 percent of all commercial sex workers in the country. A similar situation prevails with injecting drug users. The program has had a relatively strong focus on blood safety, but the objective of achieving 100 percent safe blood transfusions is far from having been achieved (as noted in paragraph (1.6) above). A substantial share of the budget of the NAPCP goes to IEC activities, but more needs to be done in this regard. Messages need to be given in local languages and adapted to the needs of large groups of the population with very low levels of education. The diagnosis and treatment of STIs is a weak area in Pakistan, in both the public and the private segments of the health sector, and the limited efforts made through the NAPCP so far probably have not made much of a dent on this problem. Department of Health staff in Sindh indicated that the subject of STIs is not adequately covered in basic medical training. The surveillance component of the NAPCP is at a low level of development. In its present form it is not adequate to provide the information required to track the progression of the epidemic and for informed decision-making. Ownership of the HIV/AIDS program in the provinces/areas has been generally weak, although better in Sindh than in the rest of the country. Few high-level officials in the Provinces seem to be sufficiently aware of the tremendous risks to society posed by HIV/AIDS. 10

11 In sum, while the program already contains the right types of interventions needed to check the progression of HIV, it needs to be further developed and scaled up. And while scaling up, there is also a need to sharpen the program s priorities. Top priority should be given to interventions that seek to slow the transmission among high-risk groups, especially commercial sex workers and their clients. 4. Implications of the Current Situation Epidemiological Implications 4.1. Without an effective response to confront HIV, the spread of the infection would accelerate. Intensification of the epidemic would first occur in high-risk groups and then spill over to the general population, as it has happened in a number of other countries. As the epidemic matures, there would be increasing numbers of patients with full-blown AIDS. These patients would suffer from significant morbidity in the form of opportunistic infections for a period of several years before finally dying. Tuberculosis would become more prevalent because a large proportion of AIDS patients would develop clinical tuberculosis as their immunity is weakened by AIDS. As the epidemic spreads to the general population, perinatal transmission from mother to child would become a public health problem Based on observations of HIV progression in South Asia, a probable scenario for Pakistan would consist of a doubling of HIV prevalence every two years or so. This means that Pakistan would have some 2.2 million people infected with HIV in ten years time (assuming a base figure right now of 70,000 people; see paragraph (1.2) above). Obviously, there are other lower and higher scenarios as observed in other regions, including an extreme scenario of yearly doubling of prevalence. Costs to Society 4.3 The costs to Pakistan s society from an unchecked HIV/AIDS epidemic would be enormous. HIV-infected people go through an initial stage in which they are seemingly healthy, but once they develop full-blown AIDS they enter a period of several years leading to their deaths during which their health is severely diminished. During this latter stage, they impose very large costs on the health system and the society at large. 4.4 Recent World Bank estimates for Sub-Saharan Africa indicate that the annual cost per AIDS patient of caring for opportunistic infections related to the disease and other palliative treatment (but assuming that no treatment with anti-retroviral drugs is administered, which would increase the cost of care further) is in the range of US$ To put this figure in perspective, it may be noted that the Government of Pakistan (federal and provincial combined) currently spends about US$5/person/year for all the health services it provides. If both Government and private expenditures are considered, 11

12 spending on health goods and services probably does not exceed US$20/person/year. In practice, if the number of AIDS patients in Pakistan were of the order indicated in paragraph (4.2), most patients would likely have to do without adequate care for opportunistic infections. But if even a fraction were to receive such treatment, the cost to the economy would still be quite large, as would be the burden imposed on government health facilities. 4.5 Furthermore, the cost of care for opportunistic infections and other palliative care for AIDS patients would not be the only cost to society of the HIV/AIDS epidemic. AIDS mostly strikes people in the prime of life --men who are active participants in the labor force, women who perform critical household tasks such as caring for their children. AIDS greatly impairs the capacity to work, resulting in output losses. And a widespread AIDS epidemic would create a legion of orphans as young parents begin to die. In sum, HIV/AIDS is a disease with the potential to truly devastate Pakistani society. 5. The New National Strategic Framework 5.1. The NAPCP, with the assistance of UNAIDS, has recently formulated a National HIV/AIDS Strategic Framework for the period This National Strategic Framework was arrived at as the result of a participatory exercise with inputs from a wide variety of government, non-government, and donor agencies. It is intended to guide the activities of all HIV/AIDS stakeholders in the country in order to enhance and expand the nation s response to the threat of HIV/AIDS. The final draft of the National Strategic Framework was submitted to the Ministry of Health in December The National Strategic Framework contains an extensive list of strategies (interventions) organized around the following nine goals: To ensure an effective, well-coordinated, and sustainable multi-sectoral response to HIV/AIDS in Pakistan. To reduce the risk of HIV infection among vulnerable and high-risk groups. To reduce the vulnerability of young people to HIV/AIDS. To expand the knowledge base in order to facilitate planning, implementation and evaluation of STI/HIV/AIDS programs. To reduce the prevalence and prevent the transmission of sexually transmitted infections (STIs), both as an important public health issue in its own right and as part of the effort to reduce HIV transmission. To reduce the risk of infection among the general public through an increase in awareness levels. To reduce the risk of transmission through blood transfusions of HIV and other blood-borne infections. To prevent transmission of HIV in formal and non-formal health care settings through enhancing knowledge about and compliance with universal precautions. To improve the quality of life of people living with HIV/AIDS through the provision of quality care and support (including meeting their medical, social, and 12

13 sometimes material needs), and ensuring a secure environment for all people infected and affected by HIV/AIDS The National Strategic Framework is a critical step forward towards an enhanced response to HIV/AIDS. The important question now is how to take this effort forward, taking advantage of the favorable environment and momentum created by the process of formulating the National Strategic Framework The National Strategic Framework did not include an attempt to draw the cost implications of carrying out its proposed interventions. These costs would be substantial. For a rough guide, the Government of Bangladesh --a country with a population slightly lower than Pakistan, and at about the same stage of the HIV epidemic- - is set to spend about US$10 million/year for the next five years to carry out a somewhat narrower program than the one envisaged in the National Strategic Framework. 6. Recommendations 6.1. The mission recommends that the NAPCP be scaled up in the next several years. This is necessary to make a real impact on the progression of the HIV/AIDS epidemic The program s current activities and the National Strategic Framework provide a solid platform for program expansion. At the same time, the mission is of the view that it would be desirable to set some priorities among and within the interventions included in the National Strategic Framework. The program needs to focus first and foremost on those interventions that can do the most to interrupt transmission, and these interventions need to be carried out on a sufficiently large scale in order to make a difference. Specifically, interventions that focus on prevention/behavioral change among those most likely to contract and pass HIV to others, especially high-volume commercial sex workers and their clients, should have top priority right now. Such interventions should comprise a package that include educating commercial sex workers on the basics of HIV transmission and prevention, motivating them and their clients to make use of condoms, facilitating access to condoms, and providing STI treatment for commercial sex workers and their clients Improving blood transfusion safety and enhancing general awareness about HIV/AIDS would be next in importance, and it would also be necessary to improve surveillance in order to track the progress of the epidemics The roles of the Federal, provincial and district governments and of the private sector (including NGOs) in an expanded HIV/AIDS program would need to be carefully defined. This definition encompasses four broad dimensions, namely: (i) program design; (ii) financing; (iii) implementation; and (iv) monitoring and evaluation. 13

14 6.5. NGOs would need to play a key role in the program, especially for scaling up the work with high-risk groups. So far, financing of NGO work within the NAPCP has been entirely from donor agencies off-budget grants. In an expanded program, it may be necessary to use regular government funds to support NGO work. The government (Federal, provincial and district government) would need a more clear and explicit policy towards contracting out with NGOs in this context. It would also need to develop suitable administrative mechanisms to this effect While the government health services would have to be at the center of an expanded HIV/AIDS program, other government agencies should also make a contribution to preventing HIV/AIDS -- including for example those responsible for education, labor/migration, and the armed forces Cost estimates for an illustrative five-year enhanced HIV/AIDS program are presented in Annex 1, along with an explanation of the assumptions used. The illustrative program highlights the expansion of interventions that address prevention among high-risk groups, including commercial sex workers, injecting drug users, and long-distance truckers. Unit costs for these interventions were derived from discussions during the mission but are in line with international experience. The program also envisages that blood transfusion safety is addressed for all hospitals in the public sector; that expenditure on mass media and other activities for enhancing general awareness is about doubled; and that surveillance is sharply scaled up and improved. The total cost of the illustrative program over five years is about US$36.8 million equivalent, or about US$7.4 million/year on average. These amounts represent total program costs rather than incremental costs. (Since total FY2000/01 public expenditure on HIV/AIDS prevention as broadly defined in paragraph 2.17 above is about US$3.6 million, it follows that incremental costs of the illustrative program amount to about US$3.8 million per year on average). These are rough estimates and they would need to be refined when an actual enhanced program is developed in greater detail If an enhanced program along the lines indicated in this report were put in place and effectively implemented, it would make a significant difference to the progression of the HIV/AIDS epidemic. A reasonable estimate is that such a program would avert about 50 percent of new HIV infections in the next decade, or approximately 1.1 million cases under the probable scenario noted in paragraph (4.2) above. The economic benefits from averting these cases would greatly exceed the cost of the enhanced program. 14

15 ANNEX 1 Illustrative Enhanced Five-Year HIV/AIDS Program Explanatory Notes to Cost Table 1. Sentinel Surveillance and Research: 1.1. Sentinel Surveillance: This would include an annual round of sentinel sero-surveillance involving selected highrisk groups (commercial sex workers, injecting drug users, truckers, STI patients, and TB patients), as well as pregnant women visiting ante-natal clinics. The samples would be selected from various sites around the country, according to a uniform procedure. Behavioral surveillance of high-risk groups would also be undertaken in selected sites. A notional lump-sum figure has been included in the cost table Operational Research: This would include studies that would provide the basis for refining and redirecting the program interventions when relevant. A notional lump-sum figure has been included in the cost table. 2. Commercial Sex Workers: The size of this heterogeneous population is difficult to estimate. However, consensus from various sources consulted during the mission would seem to indicate that an approximate number of CSWs nationwide could be 400,000. It is assumed that of this total, about 50,000 are hard core CSWs, with at least 5-10 clients per day on average, thus having the potential for high transmission. Because of capacity limitations, it is this latter group that would primarily be targeted under the enhanced program. The intervention would be carried out largely through NGOs and it would consist of health promotion interventions which include awareness and peer education, promotion and distribution of condoms, and STI treatment where possible. Present coverage of the hard core target group is assumed to be about 2%. Cumulative target coverage assumed in the cost table is 6% in Year 1, 10% in Year 2, 20% in Year 3, 40% in Year 4, and 66% in Year 5. This would be achieved through scaling up the operations of current NGO programs and the recruitment of new NGOs. Cost figures under this category in the cost table do not include the cost of treating STIs, which is shown separately. The cost table assumes a unit cost of US$50 per CSW per year. In addition, a start-up cost for capacity building and organization equal to 10% of the operational cost of the intervention has been assumed. 3. Injecting Drug Users: According to a recent survey by UNDCP, there are some 60,000 IDUs in the country. Of these, it is assumed that only 20,000 could realistically be reached within five years (this sub-group consists mostly of addicts who usually gather in larger groups to engage in drug injecting and who share needles). Present coverage by several NGO programs is about 1,200 IDUs. Cumulative target coverage assumed in the cost table is 2,400 IDUs 15

16 in Year 1, 4,000 in Year 2, 5,000 in Year 3, 15,000 in Year 4, and 18,000 in Year 5. The intervention would be carried out largely through NGOs and would include health education through peers, provision of safe needles and syringes, basic primary health care (e.g., abscess treatment), and condom promotion and distribution. The cost table assumes a unit cost of US$60 per IDU per year. In addition, a start-up cost for capacity building and organization equal to 10% of the operational cost of the intervention has been assumed. 4. Long-Distance Truckers: There would be two types of interventions involving truckers: at truck stands in selected cities, and at hotels along busy routes Interventions at Truck Stands: It is estimated that there may be some 60,000 long-distance truckers in the nation. The number of truck stands is not known with certainty, but it would be several thousand. For example, there are 360 truck stands in and around Taxila, and some 600 truck stands in Lahore. Taking into account capacity limitations and feasibility, the enhanced program would target 3,000 truck stands spread among 10 cities considered to be of primary importance in the transport network. The intervention would include health education, and the promotion and distribution of condoms. While there are some NGO programs targeting long-distance truckers, coverage presently is small. Moreover, the 3,000 truck stands in the enhanced program would have to be identified first, before stock can be taken of initial coverage. Hence initial coverage is not known at this time, but it would be limited. Cumulative target coverage is 300 truck stands in Year 1, 600 in Year 2, 1,500 in Year 3, 2,000 in Year 4, and 3,000 in Year 5. The cost table assumes a unit cost of US$50 per stand per year. In addition, a start-up cost for capacity building and organization equal to 10% of the operational cost of the intervention has been assumed Interventions at Route Hotels: A second intervention for long-distance truckers would take place at hotels frequented by truckers along certain busy routes. This intervention would include similar activities as in (4.1), but with the involvement of hotel staff upon suitable sensitization and training. The enhanced program would seek coverage of about 50 hotels during the five-year period. Cumulative target coverage is 5 hotels in Year 1, 10 hotels in Year 2, 25 in Year 3, 40 in Year 4, and 50 in Year 5. The cost table assumes a unit cost of US$500 per hotel per year. 5. General Awareness: 5.1. Mass Media: The present cost estimates are based on the Federal program staff s assessment of what would be required for an effective mass media effort over the next five years. 16

17 5.2. Other: In addition to communication trough mass media, the program would include other media such as posters, pamphlets, slides, films, and plays and folk media. A notional lump-sum figure has been included in the cost table. 6. Blood Transfusion Safety: The cost estimate under this component of the enhanced program relates only to ensuring safety of blood transfusion in the public sector. It is a very rough estimate based on: (i) expenditure in the current fiscal year (Rs million by the NAPCP, Rs. 50 million by the Punjab Department of Health which are budgeted for its Blood Transfusion Services in the Current budget), plus (ii) Punjab s own assessment of the additional resources that would be needed in that province over a five-year period in order to ensure safe blood transfusions in all public sector institutions (Rs 250 million), multiplied times 1/0.55 (since Punjab is approximately 55% of the country s population). This method would tend to under-estimate the required resources nationwide, because the other provinces/areas at present have a less developed blood transfusion infrastructure than Punjab. 7. Treatment of Other Sexually Transmitted Diseases: This intervention would support the treatment of sexually transmitted diseases, but only among high-risk groups. Treatment would be provided by the same NGOs working with these groups in interventions 2-4 above, using the syndromic approach to STI management. For the purposes of the present cost estimates, a lump-sum has been assumed. More detailed calculations would be needed once the enhanced program is specified in further detail. 8. Youth Interventions: This intervention would consist of health education for youth in- and out- of school. A notional lump-sum allocation has been included in the cost table. 9. Infection Control: This intervention would include inter alia training of health staff and guidelines development for aseptic techniques. A notional lump-sum figure has been included in the cost table. 10. Mother to Child Transmission: It is assumed that pregnant women would be offered voluntary testing for HIV in major health facilities. Those who do get tested and are found to be positive would be provided with a short course of Nevirapine or similar drug. Cost of this intervention would be small in the next few years because prevalence in the general population is still very low, and because it is likely that only a small number of pregnant women would choose to be tested. A notional lump-sum figure has been included in the cost table. 17

18 11. Care and Support for People Living with HIV/AIDS: This set of interventions would be implemented through NGOs. It would include: counseling and other types of support for HIV-positive persons and those who have developed AIDS and their families. A notional lump-sum figure has been included in the cost table. This figure excludes anti-retroviral therapy. 12. Program Management and Coordination: There will be a need to devote more resources to program management and coordination, including among various sectors, in line with the enhanced scope of the program. A notional lump-sum figure has been included in the cost table, approximately equal to 10% of the cost of the other interventions. 18

19 PAKISTAN - ILLUSTRATIVE FIVE-YEAR ENHANCED HIV/AIDS PROGRAM ANNEX 1 Cost Estimates in Rs. Million (in constant 2001 prices) Interventions Year 1 Year 2 Year 3 Year 4 Year 5 Total 1. Sentinel Surveillance and Research Five Years 1.1. Sentinel Surveillance Operational Research Commercial Sex Workers 2.1. Operational Costs Capacity Building Injecting Drug Users 3.1. Operational Costs Capacity Building Long-Distance Truckers 4.1. Interventions at Truck Stands Interventions at Route Hotels Capacity Building General Awareness 5.1. Mass Media Other Blood Transfusion Safety Treatment of Sexually Transmitted Diseases Among High-Risk Groups Youth Interventions Infection Control Mother to Child Transmission Care and Support for People Living with HIV/AIDS Program Management and Coordination Total in Rs. Million Total in US$ Million with Exchange Rate of Rs. 60/US$ 19