WORLD BANK WORKING PAPER NO. 68 HIV/AIDS in the Western Balkans Public Disclosure Authorized Priorities for Early Prevention in a High-Risk Environment Joana Godinho Nedim Jaganjac Dorothee Eckertz Adrian Renton Public Disclosure Authorized Thomas Novotny Public Disclosure Authorized Public Disclosure Authorized THE WORLD BANK WORLD BANK WORKING PAPER NO. 68 HIV/AIDS in the Western Balkans Priorities for Early Prevention in a High-Risk Environment Joana Godinho Nedim Jaganjac Dorothee Eckertz Adrian Renton Thomas Novotny Lisa Garbus THE WORLD BANK Washington, D.C. Copyright (c) 2005 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. 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All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA, Fax: 202-522-2422, email: [email protected]. ISBN-10: 0-8213-6394-8 ISBN-13: 978-0-8213-6394-2 eISBN: 0-8213-6395-6 ISSN: 1726-5878 DOI: 10.1596/978-0-8213-6394-2 Joana Godinho is a Senior Health Specialist at the World Bank. Nedim Jaganjac and Dorothee Eckertz are Health Specialists at the World Bank. Adrian Renton is a Professor of Epidemiology at the Imperial College, London. Thomas Novotny is a Professor of International Health at the University of California in San Francisco. Lisa Garbus is a Senior Researcher at the University of California in San Francisco. Photo by David Seban, Médecin du Monde: Rave Party in the Balkans Library of Congress Cataloging-in-Publication Data HIV/AIDS in the western Balkans : priorities for early prevention in a high-risk environment / Joana Godinho [et al.]. p. cm. – (World Bank working paper; no. 68) Includes bibliographical references. ISBN-13: 978-0-8213-6394-2 ISBN-10: 0-8213-6394-8 I. HIV infection–Balkan Peninsula. 2. AIDS (Disease)–Balkan Peninsula. I. Godinho, Joana. 11951-II. Series. RA643.86.A783H555 2005 362.196’9792’009496–dc22 2005053846 Contents Acknowledgments ix Acronyms and Abbreviations xi Executive Summary xv Main Issues xvii Key Actions xviii The World Bank’s Role in the Western Balkans xxi 1. Introduction 1 HIV/AIDS in ECA 2 Study Design 6 2. HIV/AIDS in the Western Balkans 9 Epidemiological Situation and Trends 9 Vulnerable Groups 11 The Context of Risk 14 3. National Responses to HIV/AIDS in the Western Balkans 17 Strategies and Regulatory Framework 17 Institutional Capacity to Tackle the Epidemic 19 Resources for HIV/AIDS Prevention and Control 21 International Support 24 4. Recommendations for Region-Wide Activities 27 Actions for the Short Term 28 Actions for the Medium and Long Term 33 Specific Actions for Countries and Territories 34 5. The World Bank Role 37 The Bank’s Role in South Eastern Europe 37 The Bank’s Role on HIV/AIDS 39 The Banks’ Role on HIV/AIDS in the Western Balkans 41 6. Profile: Albania 45 Epidemiological Overview 46 Vulnerability to HIV/AIDS: Contextual Factors 49 Health Care in Albania 58 Government and Civil Society Action on HIV/AIDS 61 iii iv Contents 7. Profile: Bosnia and Herzegovina 69 Epidemiological Overview 70 Vulnerability to HIV/AIDS: Contextual Factors 72 Health Care in Bosnia and Herzegovina 79 Government and Civil Society action on HIV/AIDS 81 8. Profile: Macedonia 91 Epidemiological Overview 92 Vulnerability to HIV/AIDS: Contextual Factors 94 Health Care in Macedonia 101 Government and Civil Society Action on HIV/AIDS 103 9. Profile: Serbia 115 Epidemiological Overview 116 Vulnerability to HIV/AIDS: Contextual Factors 121 Health Care in Serbia 129 Government and Civil Society Action on HIV/AIDS 132 10. Profile: Montenegro 141 Epidemiological Overview 142 Vulnerability to HIV/AIDS: Contextual Factors 143 Health Care in Montenegro 147 Government and Civil Society Action on HIV/AIDS 151 11 Profile: Kosovo 159 Epidemiological Overview 160 Vulnerability to HIV/AIDS: Contextual Factors 162 Health Care in Kosovo 169 Government and Civil Society Action on HIV/AIDS 171 Appendix 181 References 189 Map endpiece LIST OF TABLES 1. Specific Actions for Countries and Territories Under Study xix 2. Modeling the Macroeconomic Implications of a Generalized AIDS Epidemic in the Russian Federation 5 Contents v 3. Financing of Prevention and Treatment in the Western Balkans 23 4. Four Key Priority Areas for Action 29 5. Areas of Bank Assistance (Actual and Potential) 42 6. Epidemiology—Albania 45 7. HIV Notifications in Albania by Mode of Acquisition, 1999–2004 47 8. Vulnerability Factors—Albania 50 9. UNICEF Rapid Assessment—Albania 55 10. Knowledge, Attitudes and Practices—Albania 56 11. Health Expenditure and GDP Trends in Albania, 1990–2001 60 12. Government Intervention and Institutional Arrangements—Albania 61 13. Government Intervention and Institutional Arrangements—Albania 62 14. HIV Prevalence in Blood Donations, Albania 1996–2001 63 15. NGO Sector in Albania 65 16. World Bank Support—Albania 66 17. International Support—Albania 67 18. Epidemiology—Bosnia and Herzegovina 69 19. Vulnerability Factors in Bosnia and Herzegovina 74 20. Knowledge, Attitudes, and Practices in Bosnia and Herzegovina 78 21. Government Intervention and Institutional Arrangements in Bosnia and Herzegovina 82 22. Government Intervention and Institutional Arrangements in Bosnia and Herzegovina 84 23. NGO Sector in Bosnia and Herzegovina 87 24. World Bank Support in Bosnia and Herzegovina 88 25. International Support in Bosnia and Herzegovina 89 26. Epidemiology—Macedonia 91 27. Vulnerability Factors—Macedonia 95 28. Knowledge, Attitudes, and Practices—Macedonia 100 29. Health Expenditure and GDP Trends in Macedonia, 1990–2001 102 30. Estimated Resource Needs and Funding Gaps for HIV/AIDS Treatment—Macedonia 104 31. Government Intervention and Institutional Arrangements—Macedonia 105 32. Government Intervention and Institutional Arrangements—Macedonia 107 33. NGO Sector in Macedonia 111 34. World Bank Support—Macedonia 111 35. International Support—Macedonia 113 36. Epidemiology—Serbia 115 vi Contents 37. Notifications of Syphilis by Sex, 1992–2003 119 38. Notifications of Gonorrhea by Sex, 1992–2003 120 39. Vulnerability Factors—Serbia 122 40. Knowledge, Attitudes, and Practices—Serbia 126 41. Estimated Resource Needs and Funding Gaps for HIV/AIDS Treatment, Serbia 132 42. Government Intervention and Institutional Arrangements—Serbia 133 43. Government Intervention and Institutional Arrangements—Serbia 135 44. NGO Sector in Serbia 137 45. World Bank Support—Serbia 137 46. International Support—Serbia 138 47. Epidemiology—Montenegro 141 48. Notified Syphilis Cases in Montenegro,1990–2002 142 49. Notified Cases of Gonorrhea in Montenegro, 1990–2002 143 50. Vulnerability Factors—Montenegro 144 51. UNICEF's Rapid Assessment and Response in Montenegro, 2002 148 52. Knowledge, Attitudes, and Practices—Montenegro 149 53. Estimated Resource Needs and Funding Gaps for HIV/AIDS Treatment, Montenegro 151 54. Government Intervention and Institutional Arrangements—Montenegro 152 55. Government Intervention and Institutional Arrangements—Montenegro 154 56. NGO Sector in Montenegro 155 57. World Bank Support—Montenegro 156 58. International Support—Montenegro 156 59. Epidemiology—Kosovo 159 60. Vulnerability Factors—Kosovo 163 61. Knowledge, Attitudes, and Practices—Kosovo 168 62. Estimated Costs of HIV/AIDS Activities in Kosovo 171 63. Government Intervention and Institutional Arrangements—Kosovo 172 64. Government Intervention and Institutional Arrangements—Kosovo 173 65. NGO Sector in Kosovo 176 66. World Bank Support—Kosovo 177 67. International Support—Kosovo 177 68. Epidemiological Situation in the Western Balkans 182 69. Vulnerable Groups in the Western Balkans 183 70. National Response to HIV/AIDS in the Western Balkans 185 71. HIV/AIDS Prevention and Treatment in the Western Balkans 187 Contents vii LIST OF FIGURES 1. HIV—Recent Changes in HIV/AIDS Prevalence 2 2. Growth Rate of Newly Diagnosed HIV Infections in the European Region, 1993–2000 3 3. Newly Diagnosed HIV Infections in the European Region, 2003 4 4. Epidemic Drivers in the Western Balkans 15 5. Notified Syphilis Cases in Albania, 1960–2001 48 6. Notified Gonorrhea Cases in Albania, 1960–2001 49 7. AIDS Cases in Bosnia and Herzegovina, 1986–2002 71 8. Notified Syphilis Cases in Bosnia and Herzegovina, 1987–2003 71 9.