HIVAIDS and Development

Debrework Zewdie is the Director of the Global HIV/AIDS Program for the World Bank. Before coming to the Bank, Dr Zewdie worked for the AIDS Control and Prevention project (AIDSCAP) of Family Health International in Nairobi, Kenya and worked in 16 African countries. She has also held research, management and teaching positions focusing on public health issues.

Viban Hongla:
Do you meet the victims themselves or not?
Debrework Zewdie:
The answer is yes. I have a number of friends, colleagues, family members who have been affected by this epidemic, have been working in this for the past 20 years, and the most important thing I learned, poverty is considered to affect people with HIV/AIDS more than other people. Nobody would understand the way this epidemic is progressing and be part of the solution more than the people living with the virus already, so we need to make sure that we see them as a solution and not a problem.
Viban Hongla:
How do you know if your finances on the fight on AIDS IS USED EFFECTIVELY?
Debrework Zewdie:
There are several ways of making sure that the funds against HIV/AIDS is effective, we have very intensive supervision programs, monitoring and evaluation system set in place that will tell us where the money is going, who is using them, and what the effects of these are. But as you know, the epidemic is a complex epidemic, it would be very difficult for us to contribute our dollars to specific effects. This is a global effort, and this is everybody's resources that would ultimately show an impact.
Viban Hongla:
May I know your efforts towards the containment of AIDS in my country, Cameroon?
Debrework Zewdie:
Cameroon is one of the countries where we have the multicountry AIDS program (MAP). Through the multicountry AIDS program we are supporting the national strategy that Cameroon has developed, and through this hopefully we would be able to scale up and scale out the programs for prevention and treatment nationwide in Cameroon.
Viban Hongla:
What do you think is the best way to contain AIDS FOR US IN THE DEVELOPING WORLD apart from the use of condom and abstinence?
Debrework Zewdie:
The best way to contain AIDS in the developing countries is a comprehensive care and treatment program. None of these alone will be able to do it. The comprehensive program which addresses the people not yet affected by the disease, which is a prevention program, a program for people living with HIV/AIDS and a program which treats those infected by this virus. Unless a country has these three programs in place at a nationwide scale, we won't be able to mitigate the epidemic.
Ekaterina Petkova-Fall:
I understand that you have a big experience in HIV/AIDS in many countries in the world and especially in Africa. I have heard a lot about the traditional African medicine and I read about this year's Senegal international conference on traditional medicine and HIV/AIDS treatment. What do you think about the African traditional medicine in regards to HIV/AIDS? Is it anything to be taken in consideration and can the traditional medicine contribute to the HIV/AIDS treatment?
Debrework Zewdie:
85 percent of the population of sub-Saharan Africa uses traditional medicine for one reason or another. This in and of itself makes it very useful. The challenge we have here is to make sure that we use traditional medicine appropriately for fighting HIV/AIDS. This includes more treatment, prevention, and care. Especially in prevention and care, we need to use the avenue that traditional medicine provides. This is what I think we should be using traditional medicine for.
Ekaterina Petkova-Fall:
It took quite a long time to talk about HIV/AIDS pills treatment. I know that there are some vaccine tests going on and still not successful. Also I have read that Bill & Melinda Gates Foundation is preparing to start (if not already started) a big research project, mobilizing enormous resources and intelligence worldwide on vaccine research. What are your thoughts and opinion on this matter? Isn't it time to start talking about a vaccine? In world's public health history, vaccines have been discovered for a lot of viruses. Why is it taking such a long time for this one?
Debrework Zewdie:
The world has been speaking about HIV/AIDS vaccine from day one. The problem is this is a very complex virus, and it is very difficult virus to come up with a vaccine. Yes, you are right, a number of resources are being mobilized. There are a number of candidates, vaccines at different stages of trial, but this is something which will take years before we get a vaccine which is suitable for all strains and for all types all over the world. We need to make the most out of the prevention, care and treatment efforts that are available now while working on vaccines.
Ekaterina Petkova-Fall:
What is Bank's policy and vision on vaccines and Africa traditional medicine?
Debrework Zewdie:
What's the bank's policy on vaccines and African traditional medicine. On vaccines, we are the founders of the international AIDS vaccine initiative. This is an initiative which makes sure that vaccines that are useful for the whole world are worked upon. We do fund the international AIDS vaccine initiative. As to traditional medicine, we also value that over 85 percent of the population of sub-Saharan Africa has traditional medicine and through our mak program we support countries who have embarked on this effort. This is part of the community effort where we address traditional healers and traditional medicine in general.
Emmanuel Asomb:
How do governments engage and strengthen the establishment of public/private partnerships with advocacy programs at the grass-roots levels? And secondly, in our current system of economic and market led development, what are the incentives to engage proper provisions and allocation of public goods benefits within the foray of health care management, and public expenditure allocations? On a last note, what would be the proper types of governance structures reflective of sound and accountable practices vis-à-vis social inclusion, and funding partnerships in the AIDS challenge?
Debrework Zewdie:
First of all, governments that have enabling environment throughout the nation, then problems in grass roots level would be much stronger than they are now. And this is one of the areas where the bank has put a lot of emphasis. Governments of developing countries have agreed to channel most of their resources to grassroots levels. We have examples from Kenya, Ethiopia and Ghana where thousands of grassroots organizations have been reached, and this shows the flexibility of the government itself and the importance it puts in the engagement of people at the grassroots level. The second question, the current system for market led development, what are the incentive to engage, there are a number of incentives. One, unless the public/private partnership is strengthened, the main capacity in most of these countries will be drained because of HIV/AIDS. It is correct that the public/private partnership builds atmosphere for there to have a prevention care and treatment program in place, and look at the appropriate resources so they can deal with this epidemic. What do the proper type of governments reflect sound and accountable practices vis a vis social inclusion, this is an epidemic which does not spare anybody, so unless we have an inclusive strategy in place and atmosphere which includes, especially with people living with HIV/AIDS, we won't make much of a difference in this epidemic. A good policy would be a policy to look at people living with HIV/AIDS as solutions and not problems.
Jonathen:
How many different kind of strains of HIV virus have been discovered until now? Can all of these be detected in HIV testing? How accurate is the the HIV antibody test (Elisa test) - is there a chance that some strain of HIV does not produce antibodies which can be detected in the Elisa test ?
Debrework Zewdie:
There are several different strains of HIV virus. I would only name two of the major ones. This is HIV-1 and HIV-2. HIV-1 is the predominant one, which is in most parts of the world. HIV-2 is confined to western and central Africa and some parts of Asia. What's more important is the subtypes, there are several types in all of these countries. Can all of these be detected in HIV testing? The answer is yes. Most of them can be detected by HIV testing, and the Elisa test now has a 99.9 percent sensitivity and specificity. Is there a chance some strains of HIV do not produce antibodies? They would produce antibodies, but the issue is the time when these antibodies are produced and when they would be able to be detected by Elisa in cases where one finds it difficult to detect antibodies, there is what's known as an antigen test which is much more specific and sensitive. This can be detected very early. This is the test which is mainly used; for example, to detect whether a child is carrying the antibody from the mother or has, indeed, the antigen so the child can be put in treatment.
Patrizia Cocca:
I'm a graduate student at Emerson College studying Global Marketing Communications. As part of my studies, I worked on a marketing plan for a new hospice for HIV patients in Swaziland. How can a freelancer's project interact with or be supported by the World Bank? There is any global plan to support and coordinate all the different existing aid projects? There is any outline that a project would have to follow?
Debrework Zewdie:
Any freelancer who is interested in participating in programs, especially World Bank funded programs, could contact us, and we would be able to connect you with people who are in different countries. Alternatively, if you write to the national programs of the countries which are supported by the World Bank, by and large, they would be able to support you. There is a global plan, and there is a global body which coordinates the different existing projects. This is the U.N. AIDS, the United Nations AIDS program. Again, if you write to us, we would be able to provide you with contacts of both.
Stuart Gillespie:
We now know a lot about the devastating interactions between HIV/AIDS and food insecurity and food crises. What is the Bank's approach to supporting the mainstreaming of HIV/AIDS within broader (non-health) policies and programs -- particularly those aimed at ensuring food security? What approaches and tools are being used for this?
Debrework Zewdie:
In the Africa region of the bank where we have an extensive multisectoral program, everything we do in that includes a strategy on HIV/AIDS and includes food security. What is more important, the nine agencies that make up UNAIDS, the World Food Program is one of them, and in this consortium, each one of us do follow what our comparative advantage is, and the issue of food security is mainly dealt in collaboration with the World Food Program.
sid:
Promoting condom use has been described as one of the most effective ways to reduce the spread of the disease. Are governments in developing countries doing enough to promote condom use? Also how much of an obstacle have entrenched social and religious traditions been to fighting HIV/AIDS in some of the countries which have been worst affected by the epidemic?
Debrework Zewdie:
Condom use is, indeed, one of the most effective methods for prevention, and this, unfortunately, has not been promoted in all the developing countries. Yes, some leaders have come out and spoken about the use of condoms. There is a number of folks, these are religious and cultural issues. And also, the reluctance for society to make sure that counseling people are protected from being affected by this epidemic. These are some of the reasons. The worst affected countries, there is much more effort now than it used to be before, but the problem of condom use is not only religion and culture. It's also distribution. We talk about the use, but to put an effective distribution system in place so anybody who wants condoms have easy access is really one of the most difficult tasks.
sid:
The AIDS figures released last week showed that the HIV/AIDS infection rate had reached around one in four in South Africa. Given that the epidemic is described as being in an early stage in South Africa, what is your best prediction of the likely infection rate when it reaches "maturity"?
Debrework Zewdie:
I would be reluctant to predict anything for a number of reasons. One, most of the predictions that have been made so far have always been an underestimate. Secondly, I'm not an expert, so I wouldn't venture into prediction. However, the most important issue here is already the epidemic in South Africa has reached a proportion where it is, indeed, a crisis, not only for the country but for the region in general. Officially, the Government of South Africa has stepped up its response to HIV/AIDS where they are going to roll out a treatment for people who have HIV/AIDS. That will be able to mitigate some of the spread of it.
sid:
We've seen in figures released in the past week that the major epicenter of the epidemic appears to be in Africa - with India and parts of Eastern Europe being areas for concern. Given these concentrations, is HIV/AIDS exclusively a developing country issue? And what are the implications for rich countries of not doing all they can to fight the epidemic in the worst affected regions?
Debrework Zewdie:
I don't see any contradiction in this. If anything. HIV/AIDS is now more than ever a global epidemic. There is no region and there is no continent and no country spared from this epidemic, of the extent of the epidemic. Yes, it is still Africa that has the highest number of people living with HIV/AIDS, India, and parts of eastern Europe. Yes, poverty and the existence of other sexually transmitted diseases that have not been treated plays a role, but I don't see a contradiction in this.
Nicole:
What does your role as Director of the Bank's AIDS program encompass?
Debrework Zewdie:
My role as Director of the Bank's program is many-fold. The first and most important one is to increase the Bank's capacity to respond to the epidemic adequately, and we do it a number of ways. The first one is by assuring that AIDS becomes the center of the Bank's development agenda. All Bank staff, including senior management, go and have a development dialogue with the countries, armed with the facts about the epidemic, and this becomes an important part of the dialogue. The second one is to make sure that Bank staff are aware of the effects of HIV/AIDS, especially on social development, and strengthening their capacity to respond, making sure that HIV/AIDS is at the core of their activity. The third one is to reach the global agenda on HIV/AIDS. With the U.N. partnership we are influencing the agenda in the global fora for more resources, with the focus on HIV/AIDS not merely as a complete problem but also as part of the broader development agenda.
Nicole:
How Does the Bank work with the Global Fund and US Emergency relief fund to combat AIDS in developing countries? Is there coordination or do they all work independently?
Debrework Zewdie:
The bank works with the Global Fund and the President's Initiative. Both the Global Fund and the President's Initiative are new. We have been on the ground for a long time. And what the bank is trying to do now is to work very closely both with the Global Fund and with the President's Initiative so that we can ease the burden on these countries. It is the countries that matter when these huge funding agencies descend on them at the same time, so we are trying to follow what is known as one strategy, one national coordinating body and one monitoring and evaluation strategy. We are not there yet, but all three of us are trying to make sure that we collaborate.
T. Anderson:
Several years ago, the World Bank had, I believe, an official policy that it would not hire people with HIV infection. What is the World Bank's current policy regarding the hiring of people with HIV infection?
Debrework Zewdie:
First of all, the Bank has never had a policy against hiring people with HIV/AIDS; I want to make sure that's very clear. The Bank does not have a special policy against people living with HIV/AIDS. If anything, we have a very conducive environment for people living with HIV/AIDS who work at the World Bank.
Nicole:
We always hear bad news about AIDS all over the world. Is there hope in some areas? What is going well and where?
Debrework Zewdie:
Yes, there is a lot of hope. In fact, we are now beginning to see the efforts that have been put in place and the investments of the last decade. There are a number of countries that are showing declines in young women in Kigali, Addis Ababa, Luanda. Uganda has been showing a steady decline for the last 12 years. So those are reasons for hoping and showing that the epidemic, if we do the right things at the right time, could indeed turn around.
Nicole:
What does the Bank feel about the Three x Five initiative of the WHO?
Debrework Zewdie:
The three by five initiative is an initiative to treat three million of the six million people living with HIV/AIDS by December 1st, 2005. It is an ambitious initiative. It is a necessary initiative which will lead to contributing to funding agencies. People working on HIV/AIDS need to rally around this program because as we have seen now, this is the only ammunition we have for millions of people who are already infected by this virus, and whose life could be extended if they have access to treatment. Although it is the World Health Organization leading this initiative, all agencies, including the World Bank, will be part of this initiative to make sure that the goal is reached.
MAUREEN KISAKYE:
Which countries have successfully confronted the AIDS crisis? What have those countries done that differs from other countries? Which government policies are especially effective?
Debrework Zewdie:
There are several countries that have successfully confronted the AIDS crisis. The first one is Uganda. There is Thailand, and there are a number of countries, such as Botswana. The critical element and what makes these countries different is the governments have in-house policies so that everyone in a country would play a role in fighting this epidemic. So, it's literally having an enabling environment for everyone to fight this epidemic. Still, Uganda, Thailand, Senegal, Botswana, Brazil stand out as good examples.
Nicole:
How does the Bank measure results for its AIDS programs?
Debrework Zewdie:
The bank measures results for its AIDS programs by following what we lay out up front in our project. Every project should have a short-term and long-term goal, and if these are achieved, then we see that the Bank's programs have been put in place appropriately. The difficulty with HIV/AIDS is it takes a very long time before one sees a result, and this is not unique to the Bank. It is what everybody has to deal with. What we see now, the decline in some of the cities in Africa we see now are results of investments that have been put in place in the last 10 or 15 years. It takes a long time, but we have instruments in place to measure results.
Nicole:
The AIDS epidemic has had many stages. What do you think will be the next important stage and how is the bank preparing to combat it?
Debrework Zewdie:
The next stage of the epidemic will be many more people who have been infected who would, one, need treatment; and the second one, need care. This will be much more than the newly infected cases. That is because prevention efforts that are being mounted by many countries are bearing fruit already. We will also see the globalization of the epidemic, and also the disproportionate infection in women. So, those are the next stages of the epidemic which would need a very different focus, much more focus on prevention, much more focus on treatment and care because we will have millions of people who will be on treatment and who will be dying. So, this would be the next phase of the epidemic. The Bank's engagement with countries to fight this epidemic sufficiently in sub-Saharan Africa is long term, a 15 to 20 year commitment. When we have put this in place we have taken the next stage of the epidemic into consideration. Which is millions of people requiring care and treatment. As we remember World AIDS Day, the first thing that should come to our mind is not 40 million people or the numbers that are repeated. It should be individuals whose lives have been completely turned upside down. These are mothers, these are fathers, our own colleagues at work, our brothers, our husbands and our children. And this is the responsibility of each and every individual. This is a global epidemic. It requires global solidarity. That's one thing that we should keep in mind. Not only today on World AIDS Day, but until we find a means to revert this epidemic.
Shaun Sanderson:
What are you doing to support the rights of sexual minorities around the world? As fighting AIDS also means protecting their rights, how are you engaged?
Debrework Zewdie:
All the agencies, including the World Bank, that are working on HIV/AIDS address this issue because the epidemic does not know any boundaries, and unless everyone addresses prevention, care and treatment activities, we will not be able to mitigate this epidemic. In our programs, we make sure that sexual minorities around the world are addressed and that appropriate programs are put in place. We also look into the rights issue and work with organizations who are experts in there to make sure the rights of people living with HIV/AIDS are protected.
Nicole:
Which programs have been most successful in curbing HIV/AIDS in developing countries? Health programs? Condom distribution, etc?
Debrework Zewdie:
It is a combination of health programs, condom distribution, and a number of other things. A program is considered successful when it has a nationwide prevention, care, and treatment program, a realistic program which would encompass all of this.

Thank you for participating in the discussion.



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Director for Health, Nutrition and Population