Khloe Frank Quiz Section AL

Assignment #7: Global Fund Proposal for HIV/AIDS in Bolivia

1) Introduction
Bolivia, a country of 10,500,000 people, had 16,000 HIV-positive citizens as of 2012. The seemingly low HIV prevalence and the low HIV testing rate kept HIV/AIDS from becoming a major public health issue in Bolivia until the past decade, when activists started to demand change and Bolivia began to receive more international funding to address HIV/AIDS. The Bolivian government established universal healthcare as a right in their new constitution in 2009 and has also established a national HIV/AIDS program. However, lack of resources and prioritization has led to the failure of these policies to be fully implemented. The goals of this proposal are to address HIV/AIDS in Bolivia by supporting the government and active agencies to allow for effective implementation of interventions. Considering the context and specific challenges of Bolivia, the strategy outlined below focuses on reducing the disease burden of HIV/AIDS and also strengthening the national healthcare system to improve reliability of services and increase access for all Bolivians.
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2) Goals
Goals: #1: Prevent transmission of HIV HIV+ Bolivians (HSS) Impact indicators: # new HIV cases per year % Bolivians who are HIV+ referrals % people with access to comprehensive services
3

Baseline: 800* 27.44% 0.3%

6 2

Year 1: 700 33% 0.28% 25% 30%

Year 5: 200 75% 0.15% 80% 80%

#2: Increase treatment coverage % ARV coverage #3: Health System Strengthening % facilities offering comprehensive services or

No data No data

*Estimated from reference #3 data by calculating (change in prevalence) + (HIV/AIDS deaths) = (# new cases)

I propose three overarching goals for addressing the challenges of HIV/AIDS in Bolivia. Goal #1 is to prevent HIV transmission, particularly among neglected and high-risk groups, with the expected impact of reducing HIV incidence. Over time, this should also lead to a decreased prevalence of HIV in Bolivia, greatly reducing the disease burden caused by HIV, AIDS, and opportunistic infections. Goal #2 is to increase treatment coverage for HIV-positive Bolivians. This will not only improve the health, life-span, and quality of life for HIV-positive Bolivians, but it will also help reduce HIV transmission. Thus, this goal will benefit Bolivians with HIV/AIDS, Bolivians at high-risk for HIV/AIDS, and Bolivian society as a whole by helping to reduce the disease burden of HIV/AIDS in Bolivia. Goal #3 is health system strengthening focused on establishing comprehensive and reliable services with increased access for all Bolivians, as well as improving networking between various health facilities and improving national epidemiological surveillance. This will help facilitate the achievement of Goals #1 and

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#2 by directly addressing some of the main challenges to HIV/AIDS prevention and treatment in Bolivia lack of sufficient ARVs for the national need, disparities in access to HIV testing and treatment services, and lack of relevant data for proper monitoring of the disease burden and progress. The achievement of Goal #3 will help reduce the disease burden of HIV/AIDS in Bolivia while also making the national healthcare infrastructure more reliable and accessible to all Bolivians which will improve Bolivias ability to decrease the burdens of other diseases as well, including Chagas, Tuberculosis, Malaria, and noncommunicable diseases.

3) Objectives and Expected Outcomes

Objectives: #1: Increase public awareness Outcome indicators: Baseline: Year 1: Year 5:

% women who have heard of HIV/AIDS 79.4% (63.2-94.0%)1 85% (68%) 98% (94%) 1 and education about HIV/AIDS % men who have heard of HIV/AIDS 90.2% (75.3-97.9%) 93% (78%) 99% (97%) % women who believe that condom usage decreases HIV transmission risk 59.9% (37.0-78.8%)1 65% (42%) 90% (80%) % men who believe that condom usage decreases HIV transmission risk % women who know that HIV can be transmitted during pregnancy % men who know that HIV can be transmitted during pregnancy #2: Increase access to condoms % young women (15-24 years old) who know where to obtain condoms % young men (15-24 years old) who know where to obtain condoms Out of men who have had 2+ sexual partners in the past year, % who used a condom in the most recent encounter #3: Increase access to services % men know where to get an HIV test (tests, ARVS, counseling) % men tested per year % women tested per year % who receive actually ARVs out of those eligible % pregnant women tested for HIV % HIV+ women who receive ARVs during pregnancy % infants of HIV+ mothers who are infected with HIV during birth #4: Establish a reliable source of supplies and resources % facilities with sufficient drugs, equipment, personnel 21.79%
2 1 83.5% (71.4-93.6%) 86% (76%) 98% (95%) 1 69.5% (49.5-85.4%) 75% (55%) 97% (90%) 1 71.3% (53.2-84.7%) 75% (58%) 95% (88%) 1 69.4% (53.0-82.5%) 73% (56%) 93% (85%) 1 74.4% (54.3-89.6%) 78% (60%) 95% (90%)

33.6 (23.9-46.5%)

1 1

38% (28%) 80% (75%)

42.0% (24.6-55.2%) 46% (28%) 85% (75%) 2 4.0% 1.9% 2.5% 2.2%
2

3.0%
2

5.0% 75% 90% 90% 5% 80%

27.44% 50%
3

33% 55%

52.17%

57% 19% 25%

No data

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#5: Increase human resources (healthcare workers) #6: Improve networking of facilities and integration of health services % healthcare workers trained to address HIV/AIDS % people with direct access or successful referral to necessary services at their nearest health facility % who receive treatments for both HIV and TB out of those with co-infection #7: Improve epidemiological surveillance for monitoring HIV/AIDS indicators and progress #8: Improve equal access to 46.67%
2

No data

20%

75%

No data

30% 50% 20%

80% 85% 90%

% Bolivians registered in national data 0% (program net yet system established) % access rural Bolivians 23.2% 30% 3%
4 4 1

28% 35% 8%

75% 80% 60%

HIV services for all by targeting % access sex workers neglected and high-risk groups % access MSM
and 5 indicated data for the worst region (see map)

*For the first 3 rows of this table, the parentheses under Baseline indicate range by region, and the parentheses under Yea rs 1

Objective #1 is to increase public awareness and education about HIV/AIDS. Increasing the percentages of Bolivians who have heard of HIV/AIDS, understand that condom usage can reduce the risk of transmission, and know that HIV can be transmitted during pregnancy will contribute to Goals #1 and #2 because being informed will allow people to practice better preventative behaviors and empower them to seek out treatment if they are infected. Objective #2 is to increase access to condoms. This will likely increase condom usage and thus decrease rates of HIV transmission, which contributes to Goal #1. Objective #3 is to increase access to HIV-related services (tests, ARVS, counseling). Although the Bolivian constitution grants all citizens the right to these services, access is a major challenge for many 2,9 HIV-positive Bolivians. Improving access will directly contribute to Goal #2. Objective #4 is to establish a reliable source of supplies and resources specifically pharmaceuticals, equipment, and healthcare workers. This will improve access to services by making them more reliable at each facility, which is important because fluctuations in ARV and other supply availability are a major barrier to the ability of Bolivian healthcare facilities to consistently offer treatment. contribute to Goal #2.
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This will also

Objective #5 is to increase human resources, specifically the number and percentage of healthcare workers qualified to address HIV/AIDS. This is important so that Bolivians across the country have access to care providers who can inform them about HIV transmission (sexual, mother-to-child, through needles, etc.), as well as offer HIV testing, treatment, and counseling. This contributes to Goals #1 and #2. Objective #6 is to improve networking of facilities and integration of health services. This will increase access to comprehensive health services for Bolivians across the country, which will increase the ARV treatment rate and the rate of proper treatment for those with HIV co-infections, while also strengthening the healthcare system as a whole. This contributes to Goals #2 and #3.

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Objective #7 is to improve epidemiological surveillance for monitoring HIV/AIDS indicators and progress. This is important for all three goals because one of the main challenges to evidence-based evaluation for the effective implementation or improvement of health programs and interventions in Bolivia is a lack of data for the most relevant indicators. Reliable national data will allow for better interventions for the prevention and treatment of HIV/AIDS, and will also strengthen the entire health system. Objective #8 is to improve equal access to HIV services for all by targeting neglected and high-risk groups. This will increase access for rural Bolivians, sex workers, men who have sex with men (MSM), and others. Increased access for these groups will greatly increase HIV treatment coverage and thus decrease HIV incidence by decreasing transmission rates. Over time, this should decrease the HIB/AIDS prevalence in Bolivia. This contributes to Goals #1 and #2.
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Practical activities
Main activities: #1: Integrate an HIV/AIDS education program into school curricula Process Indicators: % public and private primary and secondary schools teaching the program #2: Hold more public health festivals and community events focused on HIV/AIDS #3: Execute advertising micro buses, and public parks #4: Provide free condoms at healthcare facilities and visits from community health workers #5: Establish a travel compensation program to complement ARV treatment campaigns that target buildings, region # events held per year per Unknown likely 4 region to be 0 (no data found) # total advertisements per 0 (campaign not yet established) % healthcare facilities, % 0% community health workers 0% providing free condoms (program not yet established) % enrolled in the program 0% out of Bolivians eligible for (program not yet ARV treatment established) No data No data 10% 5% 60% 40% Bolivian MOH in conjunction with Brazilian government No data 5 10 Bolivian MOH in conjunction with 5% 30% Bolivian MOH, REDBOL 10% 5% 60% 40% 10 50 12 Baseline: 0% (program not yet established) Year 1: 5% Year 5: Implementing agency or agencies: 40% Bolivian MOH, Bolivian Ministry of Education., private school administrations, REDBOL Bolivian MOH, REDBOL, local community leaders Bolivian MOH, REDBOL, Bolivian government Bolivian MOH

#6: Establish a steady supply of % health facilities, % ARVs, laboratory equipment, community healthcare and other medical supplies workers with sufficient ARVs and supplies #7: Train current healthcare workers to address HIV/AIDS # HIV/AIDS training programs per region per

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year #8: Train more community health workers # community healthcare workers trained per year 30% Bolivian MOH, UNFPA No data 100 600 Brazilian government Bolivian MOH, UNFPA

#9: Integrate culturally sensitive % health worker schools 0% 5% HIV/AIDS training into health that have incorporated the (program not yet worker schools and programs program established) #10: Design and implement a % HIV+ Bolivians on HIV 0% national HIV registry and a registry national healthcare data system % total Bolivians in data 0% system #11: Design and implement a system to facilitate networking between health facilities and programs #12: Establish a program to monitor inclusion of high-risk groups and facilitate further inclusion with established resources (programs not yet established) # facilities participating in 0 the network established) % access rural Bolivians % access sex workers % access MSM 23.2% 30% 3%
4 4 1

25% 20%

90% 90%

Bolivian MOH, government of Brazil

5 per

25 per Bolivian MOH, region specialized clinics, private hospitals and clinics MOH, REDBOL

(program not yet region

28% 35% 8%

75% 80% 60%

Activity #1 is to integrate an HIV/AIDS education program into school curricula. Specifically, this will require the design of such a program under the collaboration of the Bolivian MOH and REDBOL in order to create a program that incorporates the necessary HIV/AIDS information. The MOH and Ministry of Education will then implement this program in public schools and encourage private schools to adopt it too. This will help achieve Objective #1 by directly increasing awareness and understanding of HIV/AIDS among students, as well as indirectly because these students are likely to pass this knowledge along to family members and friends. Activity #2 is to hold more public health festivals and community events focused on HIV/AIDS awareness and education. Specifically, this will involve the coordinate of REDBOL and the Bolivian MOH in the planning, promoting, and implementation of public events that provide information about HIV/AIDS. Bolivian culture is very community-focused, and public events are common. This will help achieve Objective #1 by spreading awareness and understanding of HIV/AIDS in communities across Bolivia. By year 5, these events may have been established a consistent, annual occurrence in many cities and may then be used to also test community members for HIV and add Bolivians to the data system. Activity #3 is to execute advertising campaigns that target buildings, micro buses, and public parks which are frequently viewed and used by Bolivians across a broad range of socioeconomic backgrounds. As domestic agencies, the Bolivian MOH and REDBOL will be consulted for ideas on how to maximize advertising efficiency with messages that raise awareness about HIV/AIDS (Objective #1), provide basic facts (Objective #1), and name a local facility where Bolivians can be tested (Objective #3).

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Activity #4 is to provide free condoms at healthcare facilities and during visits from community health workers. Specifically, the MOH will purchase and distribute condoms to health facilities and community health workers across the country. This will help achieve Objective #2. Activity #5 is to establish a travel compensation program to complement ARV treatment, similar to that described in Reimagining Global Health. This will help achieve Objective #3 because considering that 24.9% of Bolivians live on less than $2.00 per day, more Bolivians will be able to access HIV/AIDS12 related services if they can travel to a health facility for free. Activity #6 is to establish a steady supply of ARVs, laboratory equipment, and other medical supplies. This will involve continued collaboration between the Bolivian MOH and the Brazilian government, who 11 currently work together, in order to scale-up. This will directly help achieve Objective #4. Activity #7 is to train current healthcare workers to address HIV/AIDS. Like Activity #6, this will involve the Bolivian MOH and the Brazilian government continuing their currently-established partnership that offers 11 training. This will directly help achieve Objective #5. Activity #8 is to train more community health workers. Specifically, this will involve the Bolivian MOH and UNFPA coordinating to train healthcare workers in a culturally sensitive way compatible with the diversity 7 of Bolivia, as UNFPA has been doing already. This will directly help achieve Objective #5. Activity #9 is to integrate culturally sensitive HIV/AIDS training into health worker schools and programs. Specifically, this will involve the Bolivian MOH and UNFPA coordinating to design such a program (based on what UNFPA already does) and then implement it through the government connections of the MOH. This will directly help achieve Objective #5. Activity #10 is to design and implement a national HIV registry and a national healthcare data system. This will involve collaboration between the Bolivian MOH (for implementation) and the government of Brazil (to help with system design) to help achieve Objective #7.
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The HIV registry and data system may

be integrated into healthcare facilities as they join the network detailed below in Activity #11, allowing for easier implementation. Activity #11 is to design and implement a system to facilitate networking between health facilities and programs. This will require the Bolivian MOH to incorporate all existing health facilities and programs into a comprehensive network, including public hospitals and clinics, private hospitals and clinics, diseased specialized clinics and community public health programs (such as those addressing Chagas, TB, Hanta virus, etc.). This will help achieve Objective #6. Activity #12 is to establish a program to monitor inclusion of high-risk groups and facilitate further inclusion with established resources. This will involve first including indicators such as sexual orientation, rural/urban location, and profession (particularly asking about sex workers) among the data collected for the surveillance system detailed above in Activity #10. Secondly, the Bolivian MOH and REDBOL will each contribute several members to form a team that will monitor these data to evaluate gaps in the access of high-risk groups to information, preventative measures, testing, and treatment of HIV/AIDS. This team will be asked to brainstorm further methods/programs for increasing access among high-risk

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groups and provided with adequate resources to implement these methods/programs. This will help achieve Objective #8.

5) Complementation for Successful Implementation

The goals, objectives, and activities of this proposal complement those already being pursued to address HIV/AIDS in Bolivia. Previous global fund proposals have focused on reducing the burden of HIV/AIDS by improving access to health services in La Paz, Cochabamba, and Santa Cruz, the three regions of Bolivia with the most cases of HIV. These proposals have also targeted interventions for high-risk groups such as sex workers and MSM. This proposal continues to support these aspects of previous proposals, but also focuses on expanding to address neglected rural populations and strengthening the health system across Bolivia to improve access to proper treatment and care for Bolivians in all nine regions of the country. By utilizing the Bolivian MOH and community networks such as REDBOL as the implementing agencies for most activities, this proposal aims to allow for these agencies to pursue the goals in a way compatible with Bolivian society and cultural, and also adjust their approaches as necessary. The proposal also builds on work done currently being done by international organizations such as UNFPA. Finally, this proposal seeks to address gaps between national policies (such as universal healthcare for Bolivians) and the actual infrastructure and resources to fulfill these policies. The activities focused on networking between health facilities and integration of health services will improve the efficiency of the existing healthcare infrastructure by improving its organization. It will also establish a data system to better organize the national health data of Bolivians, which may be useful for improving health programs for HIV/AIDS as well as other diseases.
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6) Issues
The proposed goals address the Involvement of beneficiaries such as people living with HIV/AIDS. By utilizing and consulting REDBOL as an implementing agency for many of the practical activities listed above, this proposal seeks to get input and activism from Bolivians living with HIV/AIDS. REDBOL is a community-based organization that includes various groups across the country and works on advocacy 8 and policy. Community participation is also addressed. For example, Activity #2 involves community outreach and includes local community leaders as one of the implementing agencies so that events can be planned and executed in a way that is compatible with each individual community. Gender equality issues are addressed as well. Bolivia has a culture of male promiscuity and also regions with high percentages of men who engage is high-risk sexual behaviors, such as not using a condom despite having two or more sexual partners or not using a condom while have sexual encounters with prostitutes. Although the promiscuity itself seems to be based in culture and therefore difficult to address, this proposal seeks to increase awareness of safe sexual practices and access to condoms for both men and women in Bolivian in order to reduce HIV transmission to women from promiscuous sexual partners. It seems that Bolivian women have at least equal if not greater access to HIV tests than men, which is
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likely due to the higher testing rates for women during pregnancy. There is no data on discrepancies between men and women in access to HIV/AIDS treatment and counseling, but the establishment of an HIV registry and national healthcare data system proposed here could help provide data to analyze possible gaps in the future. Additionally, the goals of this proposal address social equality issues. For example, Activity #12 targets neglected and high-risk groups, while Activities #4 and #5 try to improve access by addressing socioeconomic and cultural factors that may act as barriers (e.g. many poor and/or indigenous Bolivians 1,12 live in rural areas far from health facilities and cannot easily afford transportation costs. Finally, human resources development is a main focus of this proposal. Objectives #4 and #5 directly address this, focusing on both increasing the numbers of healthcare workers in Bolivia and also specifically increased the percentage of healthcare workers who are qualified to care for HIV/AIDS patients and promote the prevention of HIV transmission among non-infected Bolivians. Practical activities #7, #8, and #9 focus on training current healthcare workers to address HIV/AIDS, establishing HIV/AIDS training programs as part of the curricula for healthcare worker schools (medical school, nursing school, etc.), and also increasing the number of community healthcare workers trained per year.
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7) Response to Potential Opposition

There may be conflicts between the Bolivian MOH and REDBOL, seeing as REDBOL views the MOH as inefficient (wasteful with resources) and also advocates for more funds to go directly to communityimplemented projects (rather than those implemented by the national government). This proposal, however, offers a good mix of nationally focused and community-based interventions, which will likely satisfy both parties. In addition, facilitating collaboration between the Bolivian MOH and REDBOL on various projects will allow the two groups to learn from each other and share the benefits of having different perspectives, which may lead to better ideas and more effective implementation. Other than the aforementioned possibility, direct opposition to this proposal will likely be limited. Another challenge, however, will be indirect opposition through failures in follow-through. The Bolivian government has a history of failing to implement all of the policies it has passed, for example, failing to provide the amount of ARVs promised.
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This is likely due to a history of low-prioritization of HIV/AIDS as a public

health problem, to a lack of resources, and to cultural attitudes (which are not aggressive about followthrough and implementation). This proposal seeks to overcome these barriers by promoting public awareness about HIV/AIDS, establishing reliable resources to implement the promised services, and appointing several implementing agencies per activity so that more active groups such as REDBOL will hold less active groups such as the MOH accountable for follow-through.

Khloe Frank Quiz Section AL 8) Map

Link: https://mapsengine.google.com/map/edit?mid=zz74nC3W0HBY.kLzRdjB6fB4k Screenshot:

9) References
1.) http://dhsprogram.com/pubs/pdf/FR228/FR228%5B08Feb2010%5D.pdf 2.)http://www.unaids.org/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ce_B O_Narrative_Report%5B1%5D.pdf 3.) http://apps.who.int/gho/data/node.main.627?lang=en 4.) http://portfolio.theglobalfund.org/en/Country/Index/BOL (download Proposal Form R09 HIV/AIDS) 5.) http://www.thebody.com/content/art58851.html 6.) http://www.unaids.org/en/regionscountries/countries/bolivia/ 7.) http://www.unfpa.org/public/home/news/pid/2614 8.) http://www.gadnetwork.org.uk/storage/REDBOL%20'Voice%20from%20Bolivia'.pdf 9.) http://pdba.georgetown.edu/Constitutions/Bolivia/bolivia09.html 10.) http://www.treatmentactiongroup.org/tagline/2004/january/world-aids-day-bolivia

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11.) http://www.abiaids.org.br/_img/media/access_aids_treatment_ingles.pdf 12.) http://www.ophi.org.uk/wp-content/uploads/Bolivia-2013.pdf?cc8bca

10) Final Notes

Predicted indicators for years 1 and 5 were estimated based on trends over the past few years as well as how many agencies would be contributing to the progress. Items that had no data for the baseline information are expected to have data for years 1 and 5 due to implementation of the healthcare data system as mentioned in Activity #10.