LATIN AMERICA AND CARIBBEAN Brazil Health, Nutrition & Population Global Practice IBRD/IDA Specific Investment Loan FY 2010 Seq No: 11 ARCHIVED on 24-Dec-2015 ISR21939 Implementing Agencies: Departamento de Vigilancia, Prevencao e Controle de DST e AIDS e Hepatite Viral Key Dates Key Project Dates Bank Approval Date:18-May-2010 Planned Mid Term Review Date:18-Mar-2013 Original Closing Date:31-Dec-2014 Effectiveness Date:01-Dec-2010 Actual Mid-Term Review Date:22-Mar-2013 Revised Closing Date:31-Dec-2015 Project Development Objectives Project Development Objective (from Project Appraisal Document) The proposed project development objectives are the following: (i) Increase access and utilization of HIV/AIDS and Sexually-Transmitted Diseases (STD) prevention, care and treatment services by Groups Most at Risk; and, (ii) Improve the performance of the National HIV/AIDS and STD Program through decentralized implementation, improved governance and results-based management. Has the Project Development Objective been changed since Board Approval of the Project Objective? No PHRPDODEL Components Name Improving Surveillance, Prevention and Control of HIV/AIDS and STD:(Cost $192.00 M) Building Decentralized Governance and Innovation Capacity:(Cost $7.83 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Moderately Satisfactory Moderately Unsatisfactory Overall Implementation Progress (IP) Moderately Unsatisfactory Moderately Unsatisfactory Overall Risk Rating Moderate Moderate Implementation Status and Key Decisions 12/24/2015 Page 1 of 13
The achievement of development objective is expected to be moderately unsatisfactory by the end of Project. A closing mission was carried out during December 7-9, 2015, in which the World Bank team reviewed and confirmed the many achievements of the National Response to HIV in Brazil; however, it s difficult to attribute such achievements to the AIDS-SUS Project. The Brazilian AIDS policy is driven by the following considerations: innovation ( Inovação ), scientific evidence ( Evidência científica ), broad-based dialogue ( Diálogo com todos os atores ), integration with the national health care system ( Atuação inserida no SUS ), and international cooperation ( Inserção internacional ). Overall, incidence rates of AIDS remain fairly stable in Brazil. But this masks important changes. Rates have gone down in some of the areas that were originally hit hardest by the epidemic but have gone up in other areas, such as the Northeast, that initially had much lower rates. Rates in young adults ages 15-24 have been going up. After years in which the epidemic seemed to be spreading beyond the most affected groups to the general population, this trend now seems to have reversed, with the male to female ratio of cases having gone back up to 2.0 after having fallen to 1.5 several years ago. This reconcentration seems mainly driven by rising rates of infection in young gay men. The most recent national survey of the general population in Brazil (PCAP, 2013), financed by the Bank-financed project, demonstrates that, despite high rates of knowledge about condoms, rates of condom use with casual partners remains stagnant. About 67% report using a condom the last time they had casual sex and 55% report always using a condom with casual partners, and condom use with regular partners is much lower (about 20%). This is despite many years of promotion of condoms in Brazil. This is in the context of increasing sexual risk in terms of numbers of people reporting multiple sexual partners. From 2004 to 2013, the proportion of Brazilian adults reporting more than 10 partners in their life rose from 19.2% to 43.9% and the proportion reporting more than five casual partners in the past year rose from 4.1% to 12.1%. Whether this is because people are now less fearful of AIDS or whether it is due to societal changes that have nothing to do with AIDS is unknown. Because of this reality, Brazil needs additional prevention strategies to supplement condom promotion. DDAHV has moved from a condom-centric approach towards Prevenção combinada, in which individuals are offered multiple options for prevention. The Ministry of Health endorsed the recent Vancouver consensus that the scientific data now show that it is clearly beneficial, both for individual patients and from the public health perspective (to reduce the chance of transmission to others), to start antiretroviral treatment as early as possible in everyone with HIV infection. This consensus also encourages making pre-exposure prophylaxis (PrEP). PrEP available to people at high risk for infection. Brazil was one of the first countries to adopt treatment as prevention or TasP (i.e., treating everyone with HIV as soon as they are known to be infected.) This requires people to know their HIV status to be effective, so a top priority of DDAHV is to increase testing. There is certainly room for improvement in this regard, as 37% of Brazilians report having ever been tested for HIV, and 14% have been tested in the past year. Current efforts to increase testing focus on those at highest risk rather than massive screening of the general population, which has had very low yields in the past in terms of positives detected. Measures to increase testing have included providing more test kits and increasing capacity for laboratory testing. The program Viva Melhor Sabendo has gone outside of health care settings to provide HIV saliva testing to key populations. Use of HIV rapid testing has increased, and new legislation will now allow sales of self-administered HIV saliva test kits in pharmacies. Pilot projects include testing done by community health workers and peer testing by NGOs. Progress has been made in implementing TasP and moving toward the 90-90-90 goals. The 90% goal for viral suppression among patients receiving TARV is already being met. It is estimated that 83% of infected people know their status, although this number is harder to measure and based on mathematical modeling. The middle step has so far proven the hardest, with 63% of known HIV-positives currently receiving TARV, but this number has been going up. In 2015, the number of people on TARV increased from 404,000 to 450,000, and 41% of people starting TARV have a CD4 count of over 500. Other strategies included in prevenção combinada include expanded use of antiretroviral drugs for prevention in HIV-negative persons, including postexposure prophylaxis (PEP) and pre exposure prophylaxis (PrEP). Guidelines for PEP have recently been streamlined and simplified. Demonstration projects testing PrEP are currently underway, and general implementation is planned for 2016. Cooperation with civil society continues with funding of NGOs working with HIV/AIDS at both the national and decentralized level. Risks Systematic Operations Risk-rating Tool 12/24/2015 Page 2 of 13
Risk Category Rating at Approval Previous Rating Current Rating Political and Governance -- Moderate Moderate Macroeconomic -- Moderate Moderate Sector Strategies and Policies -- Low Low Technical Design of Project or Program -- Low Low Institutional Capacity for Implementation and Sustainability -- Substantial Moderate Fiduciary -- Moderate Moderate Environment and Social -- Low Low Stakeholders -- Low Low Other -- -- -- Overall -- Moderate Moderate Results Project Development Objective Indicators Indicator 1: Proportion of MSM reporting condom use the last time they had sex in the last 12 months (Percentage, Custom) Value 63.00 -- 68.00 73.00 Date 31-Dec-2010 31-Dec-2014 31-Oct-2014 31-Dec-2015 Positive trend. As there was no alternative source of data, results would be measured only twice during Project life: at the beginning (baseline) and at the end of the Project (through a new research that would be financed by the loan). As previously mentioned in the "Issues for Management Attention" section, results for this indicator will not be available by the end of the Project nor for the ICR due to delays in the consultants' selection process to carry out the research. According to the Borrower's estimates, results for this indicator are expected to be available in December 2016. Following the May 2015 Bank mission, the Ministry of Health prepared a technical note (dated August 31, 2015) providing an alternative source to calculate this indicator. The research on Behaviors, Attitudes and Practices of the Brazilian Population aged 15 to 64 years old (PCAP) was used to extract the MSM population, and results for this indicator were 67.8% (2013) - 95% confidence interval 58.5% - 75.8%, which shows important progress compared to the baseline. Also note N=175 MSM, while upcoming research will cover a total of 4,200 MSM in 12 municipalities. Indicator 2: Proportion of female SW reporting condom use at last sex with client in the last 12 months (Percentage, Custom) 12/24/2015 Page 3 of 13
Value 90.10 -- 65.00 90.10 Date 31-Dec-2010 31-Dec-2014 31-Oct-2015 31-Dec-2015 Negative trend, although questionable because of the wide confidence interval. As there was no alternative source of data, results would be measured only twice during Project life: at the beginning (baseline) and at the end of the Project (through a new research that would be financed by the loan). As previously mentioned in the "Issues for Management Attention" section, results for this indicator will not be available by the end of the Project nor for the ICR due to delays in the consultants' selection process to carry out the research. According to the Borrower's estimates, results for this indicator are expected to be available in December 2016. Following the May 2015 Bank mission, the Ministry of Health prepared a technical note (dated August 31, 2015) providing an alternative source to calculate this indicator. The research on Behaviors, Attitudes and Practices of the Brazilian Population aged 15 to 64 years old(pcap) was used to extract the SW population, and results for this indicator were 65.2% (2013) - 95% confidence interval (CI) 49.2% - 78.5%, which shows deterioration of this indicator compared to the baseline. However, because of the wide CI, these results may not reflect the reality. Also note N=52 SW, while upcoming research will cover a total of 4,200 SW in 12 municipalities. Indicator 3: Proportion of People who use Drugs (PUD) reporting condom use at last sex in the last 12 months. (Percentage, Custom) Value 38.00 24.00 24.00 44.00 Date 31-Dec-2010 31-Dec-2013 31-Oct-2015 31-Dec-2015 Target not achieved. Actual results below baseline. Latest and final results (2013). No more updates expected. Indicator 4: Coverage of PLWHA accessing condoms (Percentage, Custom) Value 37.00 70.00 70.00 77.00 Date 31-Dec-2009 31-Dec-2014 31-Dec-2014 31-Dec-2015 Positive trend, substantial increase compared to the baseline. Indicator to be measured again on December 31, 2015. Updated results will be available for the ICR. 12/24/2015 Page 4 of 13
Indicator 5: Coverage of persons deprived of liberty accessing condoms (Percentage, Custom) Value 50.50 53.00 53.00 80.00 Date 31-Dec-2009 31-Dec-2014 31-Dec-2014 31-Dec-2015 Positive trend, although showing slow progress compared to the baseline. Indicator to be measured again on December 31, 2015. Updated results will be available for the ICR. Indicator 6: Proportion of SES with epidemiological information on STDs, HIV and AIDS on institutional websites (Percentage, Custom) Value 19.00 96.00 96.00 78.00 Date 31-Dec-2010 31-Dec-2014 31-Dec-2014 31-Dec-2015 End target surpassed (2014). Indicator to be measured again on December 31, 2015. Updated results will be available for the ICR. Indicator 7: Proportion of SMS Capital Cities with epidemiological information on STDs, HIV and AIDS on institutional websites (Percentage, Custom) Value 15.00 73.00 73.00 65.00 Date 31-Dec-2010 31-Dec-2014 31-Dec-2014 31-Dec-2015 End target surpassed (2014). Indicator to be measured again on December 31, 2015. Updated results will be available for the ICR. Indicator 8: Proportion of CSO projects with disbursements linked to DDAHV s implementation index for timeliness, financial compliance and achievement of objectives (Percentage, Custom) 12/24/2015 Page 5 of 13
Value 2.50 -- 87.00 90.00 Date 31-Dec-2008 31-Dec-2014 31-Oct-2015 31-Dec-2015 Positive trend, substantial increase compared to the baseline. This indicator will be measured again on December 31, 2015. Six projects are subject to be assessed, which could increase achievement to 96%, surpassing end target. Indicator 9: Strategic agenda for the period 2011-2015 for STD/ HIV/AIDS (Text, Custom) Value NA Proposal sent to Secretariat of Surveillance in March 2015 Agenda estrategica revisada para 2015-2019 Strategic agenda revised and available on the web for 2015-2019 Date 31-Dec-2010 31-Mar-2015 31-Oct-2015 31-Dec-2015 Target achieved. No more updates expected. Percentage of PVHA aged 18+ on ART at least in the last six months who are virologically suppressed (VL level < or equal 1000 copies/ml) (Percentage, Custom) Value 84.90 -- 90.00 90.00 Date 31-Dec-2009 -- 31-Oct-2015 31-Dec-2020 Target achieved. End target refers to the 90-90-90 target established as part of the Sustainable Development Goals. Percentage of people on ART at least in the last six months who are virologically suppressed (VL level < or equal 1000 copies/ml) (Percentage, Custom) 12/24/2015 Page 6 of 13
Value 75.00 -- 88.00 88.60 Date 31-Dec-2012 -- 31-Oct-2015 31-Dec-2015 Positive trend. End target refers to the target established at the Strategic Agenda of the Ministry of Health. Overall Intermediate Results Indicators Indicator 1: Proportion of MSM reporting having been tested for HIV in the last 12 months (Percentage, Custom) Value 23.50 -- 17.00 30.00 Date 31-Dec-2010 31-Dec-2014 31-Oct-2015 31-Dec-2015 Negative trend. Results below the baseline. As there was no alternative source of data, results would be measured only twice during Project life: at the beginning (baseline) and at the end of the Project (through a new research that would be financed by the loan). As previously mentioned in the "Issues for Management Attention" section, results for this indicator will not be available by the end of the Project nor for the ICR due to delays in the consultants' selection process to carry out the research. According to the Borrower's estimates, results for this indicator are expected to be available in December 2016. Following the May 2015 Bank mission, the Ministry of Health prepared a technical note (dated August 31, 2015) providing an alternative source to calculate this indicator. The research on Behaviors, Attitudes and Practices of the Brazilian Population aged 15 to 64 years old (PCAP) was used to extract the MSM population, and results for this indicator were 17.1% (2013) - 95% confidence interval 11.1% - 25.3%. Also note N=175 MSM, while upcoming research will cover a total of 4,200 MSM in 12 municipalities. In 2013, the MOH launched the "test by peers" outreach program (Live Better Knowing - Viva Melhor Sabendo) in partnership with CSOs, aimed at testing the most vulnerable population. In total, partnership agreements were established with 53 CSOs, and 30,000 tests were performed in 20 out of 27 states. Covered population included 1,125 travesties, 487 transsexuals, 1,051 male sex workers, and 5,364 MSM. A new round of the program has already been launched. 12/24/2015 Page 7 of 13
Indicator 2: Proportion of female SW reporting having been tested for HIV in the last 12 months (Percentage, Custom) Value 19.80 -- 21.00 25.00 Date 31-Dec-2010 31-Dec-2014 31-Oct-2015 31-Dec-2015 Positve trend, although questionable because of the wide confidence interval. As there was no alternative source of data, results would be measured only twice during Project life: at the beginning (baseline) and at the end of the Project (through a new research that would be financed by the loan). As previously mentioned in the "Issues for Management Attention" section, results for this indicator will not be available by the end of the Project nor for the ICR due to delays in the consultants' selection process to carry out the research. According to the Borrower's estimates, results for this indicator are expected to be available in December 2016. Following the May 2015 Bank mission, the Ministry of Health prepared a technical note (dated August 31, 2015) providing an alternative source to calculate this indicator. The research on Behaviors, Attitudes and Practices of the Brazilian Population aged 15 to 64 years old (CAP) was used to extract the SW population, and results were 21.0% (2013) - 95% confidence interval 5.0% - 26.0%, which shows a positive trend compared to the baseline. However, because of the wide CI, these results may not reflect the reality. Also note N=52 SW, while upcoming research will cover a total of 4,200 SW in 12 municipalities. The MOH launched the "test by peers" outreach program (Viva Melhor Sabendo) in partnership with CSOs in 2013, aimed at testing the most vulnerable population. In total, partnership agreements were established with 53 CSOs, and 30,000 tests were performed in 20 out of 27 states. Covered population included 5,577 female sex workers. A new round of the program has already been launched. Indicator 3: Proportion of PUD reporting having been tested for HIV in the last 12 months (Percentage, Custom) Value 14.40 46.00 46.00 20.00 Date 31-Dec-2010 31-Dec-2013 31-Oct-2015 31-Dec-2015 End target surpassed. Latest and final results (2013). No more updates expected. In 2013, the MOH launched the "test by peers" outreach program (Live Better Knowing - Viva Melhor Sabendo) in partnership with CSOs, aimed at testing the most vulnerable population. In total, partnership agreements were established with 53 CSOs, and 30,000 tests were performed in 20 out of 27 states. Covered population included 4,215 drug users. A new round of the program has already been launched. 12/24/2015 Page 8 of 13
Indicator 4: Proportion of Specialized Care Services (SAE-SUS) that provide condoms. (Percentage, Custom) Value 32.00 47.00 98.00 80.00 Date 31-Dec-2007 31-Dec-2014 07-Dec-2015 31-Dec-2015 End target surpassed. Latest and final results. No more updates expected. Indicator 5: Proportion of pregnant women tested for HIV during prenatal visits (Percentage, Custom) Value 62.30 84.00 84.00 84.00 Date 31-Dec-2006 31-Dec-2014 31-Oct-2015 31-Dec-2015 End target achieved. Latest and final results (2013). No more updates expected. Indicator 6: Proportion of pregnant women tested for syphilis during prenatal visits (Percentage, Custom) Value 16.90 41.00 41.00 40.00 Date 31-Dec-2006 31-Dec-2014 31-Oct-2015 31-Dec-2015 End target achieved. Latest and final results (2013). No more updates expected. 12/24/2015 Page 9 of 13
Indicator 7: Sexually active population reporting having been tested at least once for HIV (Percentage, Custom) Value 38.00 37.00 37.00 44.00 Date 31-Dec-2008 31-Dec-2013 31-Oct-2015 31-Dec-2015 End target not achieved. Latest and final results (PCAP 2013). No more updates expected. Indicator 8: Proportion of HIV-positive patients with first CD4 count below 200 cells/mm3 (Percentage, Custom) Value 29.00 26.00 25.00 22.00 Date 31-Dec-2012 31-Dec-2014 31-Oct-2015 31-Dec-2015 Positive trend. Indicator to be measured again in December 31, 2015. Updated results will be available for the ICR. Indicator 9: Proportion of eligible municipalities that receive Incentive Policy funds. (Percentage, Custom) Value 88.00 97.00 149.00 100.00 Date 31-Dec-2012 31-Dec-2014 31-Oct-2015 31-Dec-2015 End target surpassed. Criteria changed, increasing the number of municipalities eligible to receive fund to fund incentives. Latest and final results. No more updates expected. 12/24/2015 Page 10 of 13
Indicator 10: SES that carried out training in management and governance (Percentage, Custom) Value 0.00 100.00 100.00 50.00 Date -- 31-Dec-2014 31-Oct-2015 31-Dec-2015 End target surpassed. Latest and final results. Indicator 11: All SES and SMS Capital City trained on epidemiological surveillance (Number, Custom) Value 0.00 100.00 100.00 53.00 Date 31-Dec-2008 31-Dec-2014 31-Oct-2015 -- End target surpassed. Latest and final results. Indicator 12: Number of analytical studies carried out. (Text, Custom) Value 0 Procurement processes finalized. Pending contract signing 1 carried out 5 carried out Date 31-Dec-2013 13-Oct-2015 13-Oct-2015 31-Dec-2015 End target not achieved. The Behavioral Survey for the Brazilian population (PCAP 2013) was financed by the Bank. The DDAHV is preparing a list of analytical studies concluded and and financed by Govt's funds and this data will be available for the ICR. 12/24/2015 Page 11 of 13
Indicator 13: Proportion of DSEI with plan to control HIV/AIDS and other STDs implemented (Percentage, Custom) Value 76.00 91.00 100.00 100.00 Date 31-Dec-2010 30-Jun-2015 31-Oct-2015 31-Dec-2015 End target achieved. Latest and final results. The indicator is measured by: (a) implementation of STI syndromic approach, (b) availability of HIV and syphilis diagnosis; (c) availability of prevention of mother to child transmission of HIV/AIDS and syphilis; and (d) distribution of condoms. Data collection was monitored since 2012 with much difficulties, and there were many gaps in 2013. The information system SIASI v.4 was introduced in 2014. To-date data collection is almost up-to-date for 2014 and first quarter of 2015. The Action Plans (4 actions) have been fully implemented in the 34 DSEI, meeting the indicator to satisfaction. Indicator 14: Proportion of individuals with HIV, followed up by SISCEL, who are notified by SINAN (Percentage, Custom) Value 0.00 56.20 56.20 10.00 Date 31-Dec-2011 30-Jun-2015 30-Jun-2015 31-Dec-2015 End target surpassed. Indicator to be measured again on December 31, 2015. Updated results will be available for the ICR. Overall Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed Disbursed P113540 IBRD-79010 Effective USD 67.00 41.85 25.15 35.59 6.26 85% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P113540 IBRD-79010 Effective 18-May-2010 05-Oct-2010 01-Dec-2010 31-Dec-2014 31-Dec-2015 12/24/2015 Page 12 of 13
Cumulative Disbursements Restructuring History Level 2 Approved on 15-Oct-2014 Related Project(s) There are no related projects. 12/24/2015 Page 13 of 13