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The Global HIV/AIDS Program the World Bank Global AIDS Monitoring and Evaluation Team (GAMET) The Global HIV/AIDS Program The World Bank Global AIDS Monitoring and Evaluation Team (GAMET) West Africa HIV/AIDS Epidemiology and Response Synthesis Implications for prevention WWW.WORLDBANK.ORG/AIDS NIGER CAPE VERDE MALI SENEGAL THE GAMBIA BURKINA GUINEA-BISSAU FASO GUINEA BENIN NIGERIA SIERRA LEONE CÔTE GHANA D’IVOIRE LIBERIA TOGO IBRD 36588 november 2008 For more information, please contact: The Global HIV/AIDS Program World Bank Group 1818 H St. NW Washington, DC 20433 Tel: +1 202 458 4946 Fax: +1 202 522 1252 [email protected] November 2008 Titles in this publication series available at: www.worldbank/aids > publications 1. Lessons from World Bank-Supported Initiatives to Fight HIV/AIDS in Countries with IBRD Loans and IDA Credits in Nonaccrual. May 2005. 2. Lessons Learned to date from HIV/AIDS Transport Corridor Projects. August 2005. 3. Accelerating the Education Sector Response to HIV/AIDS in Africa: A Review of World Bank Assistance. August 2005 4. Australia’s Successful Response to AIDS and the Role of Law Reform. June 2006. 5. Reducing HIV/AIDS Vulnerability in Central America. December 2006. (English, Spanish) 6. Reducing HIV/AIDS Vulnerability in Central America: Costa Rica: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 7. Reducing HIV/AIDS Vulnerability in Central America: El Salvador: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 8. Reducing HIV/AIDS Vulnerability in Central America: Guatemala: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 9. Reducing HIV/AIDS Vulnerability in Central America: Honduras: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 10. Reducing HIV/AIDS Vulnerability in Central America: Nicaragua: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 11. Reducing HIV/AIDS Vulnerability in Central America: Panama: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 12. Planning and Managing for HIV/AIDS Results – A Handbook September 2007 (English, Spanish, French, Russian) 13. Rapid analysis of HIV epidemiological and HIV response data about vulnerable populations in the Great Lakes Region of Africa. January 2008. (English, French) Published with the Great Lakes Initiative on AIDS. 14. HIV/AIDS in Ethiopia - an Epidemiological Synthesis. April 2008. Published with the Ethiopia HIV/AIDS Prevention and Control Office (HAPCO). 15. Blood Services in Central Asian Health Systems: A Clear and Present Danger of Spreading HIV/AIDS and Other Infectious Diseases. May 2008. (English, Russian) Published with World Bank Europe and Central Asia Region. 16. Knowledge, Attitudes and Behavior Related to HIV/AIDS among Transport Sector Workers - A Case Study of Georgia. June 2008. Published with World Bank Europe and Central Asia Region. 17. Building on Evidence: A Situational Analysis of the HIV Epidemic and Policy Response in Honduras. October 2008. 18. West Africa HIV/AIDS Epidemiology and Response Synthesis. Characterisation of the HIV epidemic and response in West Africa: Implications for prevention. October 2008. (English, French, and summary only in Portuguese) WEST AFRICA HIV/AIDS EPIDEMIOLOGY AND RESPONSE SYNTHESIS Characterisation of the HIV epidemic and response in West Africa: Implications for prevention World Bank Global HIV/AIDS Program Report November 2008 World Bank Global HIV/AIDS Program Reports This series, published by the Global HIV/AIDS Program of the World Bank's Human Development Network, makes interesting new work on HIV/AIDS widely available, quickly. The findings, interpretations, and conclusions expressed in this report are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account that it may be provisional. Papers are posted at www.worldbank.org/AIDS (go to “publications”). For free print copies of reports in this series please contact the corresponding author whose name appears the bottom of page iii of the report. Enquiries about the series and submissions should be made directly to Joy de Beyer (jdebeyer@worldbank). Cover photographs by Curt Carnemark, Ray Witlin © 2008 World Bank © 2008 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. ii West Africa HIV/AIDS Epidemiology and Response Synthesis Characterisation of the HIV epidemic and response in West Africa: Implications for prevention Catherine M. Lowndesa, Michel Alaryb, Michelyne Belleauc, William Kofi Bosuc, Denagnon Frédéric Kintinc, Joseph Asonye Nnoromc, Karim Seckc, Juliana Victor-Ahuchogud and David Wilsond a Health Protection Agency UK; London School of Hygiene and Tropical Medicine; Centre hospitalier affilié universitaire de Québec b Centre hospitalier affilié universitaire de Québec, National Research Scholar of the Fonds de la recherche en santé du Québec (grant no. 8722) c Centre hospitalier affilié universitaire de Québec d World Bank This paper was written as part of the work program by the Global AIDS Monitoring and Evaluation Team (GAMET) to support countries to “know your epidemic, know your response”, to be able to develop effective HIV/AIDS responses that are results-focused, evidence-based, and where interventions are carefully chosen and prioritized based on a careful characterization of each country’s epidemic. The work was funded under the UNAIDS Unified Budget and Workplan, and carried out in partnership between the World Bank and UNAIDS. Abstract: This synthesis paper analyses all available relevant data to carefully characterise the HIV epidemics in 15 West African countries, to gain an improved understanding of HIV transmission dynamics in this sub-region, assess the extent to which existing responses address these specific transmission dynamics, and recommend ways to improve the effectiveness of West Africa’s epidemic response. Keywords: HIV/AIDS, HIV, AIDS, Epidemic, Response, Epidemiology, Burkina Faso, Benin, Côte d’Ivoire, Cape Verde, The Gambia, Guinea Bissau, Ghana, Guinea, Liberia, Mali, Nigeria, Niger, Sierra Leone, Senegal, Togo, World Bank, GAMET Correspondence Details: David Wilson, World Bank, 1818 H Street, NW, Washington DC, 20433. tel: (202) 473- fax: (202) 477- email: [email protected] Vice President Joy Phumaphi Human Development Network Director Debrework Zewdie Global HIV/AIDS Program Coordinator, Global AIDS Monitoring Jody Zall Jusek and Evaluation Team (GAMET) Juliana Victor-Ahuchogu, Task Team Leaders David Wilson iii iv Table of Contents Acknowledgements............................................................................................................ ix Executive Summary........................................................................................................... xi 1. Background and Rationale .......................................................................................... 1 2. Objectives, scope and limitations of report ................................................................ 2 2.1. Objectives of report.................................................................................................. 2 2.2. Scope and limitations of report ................................................................................ 3 3. Conceptual framework................................................................................................. 5 3.1. Heterogeneity of HIV epidemics.............................................................................. 5 3.2. A conceptual framework for transmission of HIV in the sub-Saharan African context ............................................................................................................................. 7 3.3. Core and bridging groups in West Africa .............................................................. 11 3.3.1. Sex work in West Africa................................................................................... 11 3.3.2. Clients and other sex partners of FSWs .......................................................... 13 3.3.3. Men who have sex with men (MSM)................................................................ 15 3.3.4. Injection drug users (IDUs)............................................................................. 15 4. The HIV epidemic in West Africa............................................................................. 16 4.1. The West African epidemic in the context of the African continent ..................... 16 4.2. The socio-economic context .................................................................................. 21 4.3. Data sources ........................................................................................................... 23 4.4. Epidemiology of HIV and related socio-demographic and behavioural factors in the general population................................................................................................... 24 4.4.1. Geographical distribution of HIV in population-based studies ...................... 28 4.4.2. Gender distribution of HIV in population-based studies ................................ 29 4.4.3. Comparison of ANC and population-based HIV prevalence data .................. 30 4.4.4. Sexual behaviour indicators in the general population
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