The World Bank Invests in Ending AIDS
The TREAT Asia Report Interview: Dr. Jim Kim
September 27, 2013
Dr. Jim Kim was appointed president of the World Bank Group in July 2012. Since 1989, the World Bank has provided nearly $4.6 billion to support multi-sectoral HIV/AIDS responses in low- and middle-income countries. In 1987, Dr. Kim co-founded Partners In Health, which now provides healthcare to low-resource communities on four continents. As director of the World Health Organization's HIV/AIDS Department from 2004 to 2006, he led the "3x5" initiative, the first ever global goal for HIV treatment, which aimed to provide antiretroviral treatment to three million people in developing countries by 2005. Dr. Kim served as president of Dartmouth University from 2009 to 2012. Among many accolades, he received a MacArthur "Genius" Fellowship in 2003.
TA Report: How has your background in public health shaped your approach to addressing the epidemic as president of the World Bank Group?
Dr. Jim Kim: Earlier this year, I announced two global goals for the World Bank Group: to end poverty by 2030 and boost shared prosperity for the poorest 40% of the population in every developing country. These are ambitious goals. But my work on the "3x5" initiative at the World Health Organization (WHO) convinced me that setting ambitious targets drives change. I also saw daily how HIV implementers were generating innovative solutions to seemingly intractable problems -- from supply chain management to creative use of human resources to including voices from the community in evaluating programs.
To realize a world free of AIDS and a world free of poverty, I believe we must infuse that same appetite for innovation and action. We must invest in strong health systems and advance the science of delivery, translating the evidence on what works and what doesn't in tackling HIV into cost-effective policies and programs that can operate at scale and produce measurable impact on people's lives.
TA Report: How is the World Bank Group working to implement evidence-based strategies in the context of HIV/AIDS?
Dr. Kim: In Eastern and Southern Africa, for example, the World Bank Group is working with partners to promote male circumcision, which has proven effective in curbing the spread of HIV. Bank Group support has also played a pivotal role in turning the tide on the epidemic in India. An independent impact evaluation of the India AIDS program concluded that it will have prevented 60% of the expected number of HIV infections by 2015, primarily through targeted behavioral interventions for sex workers and their clients.
We also have some promising evidence that empowering adolescent girls and their families can have substantial effects on their sexual and reproductive health, helping them access education, delay marriage, increase self-esteem, practice safe sex, and find good jobs. Recent Bank Group studies tested the use of conditional cash transfers in Tanzania and Malawi as a tool to reduce the risk of HIV or other sexually transmitted infections, and both studies suggest that financial incentives could be an effective tool. In Tanzania, participants showed a 27% reduction in the incidence of STIs after one year. In Malawi, adolescent girls showed a two-thirds reduction in the risk of HIV infection.
TA Report: Last year, the Obama Administration released its President's Emergency Plan for AIDS Relief (PEPFAR) Blueprint identifying core priorities for accelerating progress on HIV/AIDS. How is the World Bank Group partnering with PEPFAR to bring to scale evidence-based programs including HIV treatment and prevention for children and adults?
Dr. Kim: Through PEPFAR, U.S. leadership has been, and remains, pivotal to the global fight against AIDS. The PEPFAR Blueprint is a major step forward in realizing our shared vision of a world free of AIDS and poverty. In support of the Blueprint, the World Bank Group is now working with PEPFAR to help countries scale up the most effective and efficient AIDS interventions and build the strong health systems required for sustainable AIDS prevention, treatment, and care. This support includes increasing collaboration on country health programming and improving indicators and tools to measure program impact.
TA Report: How does the World Bank Group tailor its funding approaches to ensure they fit the circumstances of individual countries?
Dr. Kim: World Bank Group financing is country-driven. We provide financing in response to government demand and in support of a country's own development strategy. Our funding modalities vary by country and project and can include loans, grants, results-based financing, and more. Bank Group support to address HIV is increasingly provided through broader projects in health or in other sectors, where we and our country partners determine that an HIV component can add critical value to the project's overall impact. Perhaps most importantly, the Bank Group provides analytical support to help countries sharpen their HIV strategies, and get more value for their money. This support can be especially important where HIV funding is tight and countries are striving towards an AIDS-free generation.
TA Report: The World Bank Group has issued multiple reports urging governments to improve their HIV programs for key populations including sex workers, MSM, and injecting drug users. However, funding for programs targeting them remains low in many places, especially in countries where one or all three populations are criminalized. How does the World Bank Group funding model work to address these key populations despite those challenges?
Dr. Kim: The evidence is clear that focusing on the most at-risk populations is critical to ending the epidemic. In many countries, sex workers, people who inject drugs, and men who have sex with men remain marginalized in society and are at a significantly higher risk of HIV infection than other groups in low- and middle-income countries. Even in countries with epidemic-level HIV rates in the general population, these groups are disproportionately affected. Targeted interventions not only protect members of these marginalized communities, but also make a major contribution to averting a wider epidemic.
World Bank Group financing for HIV interventions in countries as disparate as India, Vietnam, Nigeria, Niger, and Brazil explicitly focuses on these key populations. For example, in Nigeria -- where these key populations are estimated to contribute about 40% of new HIV infections -- the Bank Group supported the Nigerian government in conducting local epidemic appraisals that have improved understanding on the nature of sex work and other epidemic drivers, and how to best formulate local programs to address them. The emerging evidence led the government to scale up its HIV prevention program and prioritize these target populations and specific geographical areas most at risk.
TA Report: A World Bank Group report states that HIV programs targeting and empowering sex workers in India have averted three million new infections since 1995. How is the World Bank Group utilizing these findings in its work in other countries in the Asia and Pacific region and around the world?
Dr. Kim: Since its launch of the National AIDS Control Program in 1991, India has worked in close partnership with the World Bank Group and other development partners to focus on prevention among vulnerable populations at highest risk of contracting HIV. More than $640 million in Bank Group financing has helped to create the institutional framework of India's HIV response at national and state levels. The Bank Group has also financed, through pooled funding with the Indian government and other partners, more than 1,300 targeted HIV prevention interventions for those most at risk, reaching more than 70% of female sex workers and increasing the use of condoms. We estimate that three million HIV infections are being averted by this strategic approach from 1995-2015 -- demonstrating the cost-effectiveness of these targeted HIV prevention interventions for female sex workers.
The India experience offers very useful lessons for other countries even in different epidemic settings. It demonstrates the huge benefits from having a well-planned and targeted HIV prevention program and the population-level effectiveness of such an approach. Our package of support for Nigeria's national HIV plan is informed by the India experience. We also are supporting the Indian Government to develop its own South-South learning initiative to share the lessons of India's successful AIDS response with other countries.
TA Report: In multiple countries in Asia, the HIV rate in injection drug users is over 20%, but harm reduction programs, including syringe exchanges, remain scarce. How can the World Bank Group use its influence to persuade governments to establish effective harm reduction programs?
Dr. Kim: We are conducting numerous economic and policy studies to inform evidence-based policies. For example, we are working with the government of Malaysia to evaluate community-based alternatives to compulsory detention. Initial findings suggest far lower rates of relapse in voluntary, community-based treatment.
TA Report: How is the World Bank Group working to include and fund civil society in its efforts to address HIV/AIDS?
Dr. Kim: Community organizations have been on the front lines of responding to the epidemic. Of the first $1 billion the Bank Group contributed to the global AIDS response, nearly 40% went to community organizations for grassroots actions to reduce stigma, change behaviors and social norms to prevent infection, and care for people and orphans affected by HIV. Overall, the Bank has provided support to some 50,000 community-based organizations in more than 50 countries to address HIV and AIDS. The Bank Group also collaborated with civil society organizations and with the U.K. Government on a multi-country study that demonstrated the effectiveness of community responses to HIV/AIDS in 2012. If we are to sustain progress, governments and development partners such as the Bank Group must continue to work closely with civil society.
TA Report: You have been president of the World Bank Group for over a year. How would you say the Bank's response to HIV has changed over that time, and what further changes do you expect in the coming years?
Dr. Kim: I would like to highlight three things. First, we have expanded our focus on evidence and especially South-South learning to understand and share what works and how it is delivered. Second, we have intensified our emphasis on rapidly accessible solutions, assisting governments to plan their responses and prepare for future needs and costs. And third, we have integrated the response to AIDS into the Bank's new vision of a world free of extreme poverty and shaped by shared growth, especially through universal health coverage.
As we move forward, our support for HIV responses must be fully integrated with countries' efforts to advance universal health coverage. We must ensure that everyone, everywhere has access to the affordable, quality healthcare they need, regardless of their HIV status, their social status, or their ability to pay. This is about equity and social justice.
This article was provided by amfAR, The Foundation for AIDS Research. Visit amfAR's website to find out more about their activities and publications.
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