Evaluation of the World Bank's Assistance in Responding to the AIDS Epidemic: Brazil Case Study

The objectives of this study are to: a) assess the impact of the World Bank’s HIV/IDS assistance to Brazil relative to the counterfactual of no Bank assistance; and b) distill lessons for future HIV/AIDS activities. It is one of four case studies included in a larger evaluation by the Operations Evaluation Department (OED) of the World Bank, which aims to assess the development effectiveness of country-level World Bank HIV/AIDS assistance. The findings reflect the situation through the end of 2003, shortly after the field visit of the evaluation team. Previous experience in campaigns against the military government and for expanded access to health care inspired civil society in Brazil to mobilize aggressively against AIDS when domestic cases first appeared in 1982. The epidemic first spread rapidly among men who have sex with men (MSM) and them among injecting drug users (IDU), after which a wave of heterosexual transmission took off. Several states, particularly Sao Paulo, led the response. By 1989, the federal government had established a national program, regulated the blood supply, and established a national AIDS commission composed of government and non-governmental representatives. The World Bank provided important assistance to Brazil’s response in the form of two projects totaling US$550 million (funded in part by US$325 million in loans from the Bank) that were in operation from 1993-2003. A third, US$200 million project was approved in June, 2003. In addition, the Northeast Endemic Disease Control Project financed $7.4 million dollars toward media campaigns on HIV/AIDS, the establishment of the National AIDS and STD Control Program, and the preparation of the first AIDS project. It was Brazil that approached the Bank about an interest in borrowing to support its HIV/AIDS program in the early 1990s, a time when the Bank did not have an explicit AIDS strategy for Brazil, nor was it already engaged in AIDS policy dialogue with the government. In 1993, when the first AIDS project began, prevention was not yet active outside selected major metropolitan areas, nor among certain high-risk groups. Brazil had not developed the laboratory network that would facilitate its testing and especially its treatment programs. The National Coordination on HIV/AIDS/STDs was reconstituting after a difficult period from 1990-1992 and many states and municipalities did not have HIV/AIDS programs at all. The Bank’s implicit assistance strategy focused on preventive efforts, institutional strengthening (especially surveillance, monitoring, and evaluation), and public goods to promote cost-effectiveness in treatment. These emphases were and remain relevant.