USAID CBJ FY 2002: Brazil

Summary: The majority (52%) of the AIDS cases in Latin America and the Caribbean are found in Brazil, a disproportionate amount of AIDS victims given the fact that Brazilians account for only about one third of the population of this geographic region. The Brazilian Ministry of Health (MOH) reported 196,016 cases of AIDS from 1980 to September 2000, which probably significantly underreports the number of cases. In 1999 alone, it is estimated that 18,000 Brazilians died from AIDS. Approximately 41,000 children under the age of fifteen lost one or both of their parents to AIDS during the last decade. The MOH further estimates that about 540,000 individuals are infected with HIV/AIDS, of whom about 24% are women and 2% are children. HIV/AIDS transmission in Brazil is predominantly sexual (75%), as opposed to drug or transfusion-related. Transmission is increasingly occurring via heterosexual encounters. AIDS patients infected through heterosexual means increased in 2000 to 43% from only 9% in 1990. Infection rates are also increasing among young people and those with the lowest level of education, resulting in the increasing concentration of HIV/AIDS victims among the poorest and most marginalized populations. Since Brazil borders most other South American countries, it is a serious potential epicenter for the spread of the disease. Factors that increase the risk of the epidemic spreading across borders are the flow of tourists and immigrants, plus prostitution and drug trafficking routes in outlying areas where health services are the weakest. The GOB allocates most of its AIDS-related financial resources for the purchase of medicines for universal access to treatment, benefiting some 90,000 HIV/AIDS patients. Less than 20% of the MOH's AIDS budget is directed to AIDS prevention.

USAID's HIV/AIDS strategy is designed to increase sustainable and effective programs to prevent sexual transmission of HIV. This strategy is focussed on low income populations, women, adolescents, prostitutes, and selected male groups within four Brazilian states: two with the highest prevalence rates, Rio de Janeiro and Sao Paulo, and two of the poorer states, Ceará and Bahia. The strategy also integrates AIDS programs with previously USAID-funded reproductive health programs in the two states of Ceará and Bahia, as well as on-going USAID-financed at-risk youth activities in Ceará and Bahia.

Key Results: Although USAID is the second largest donor in Brazil's effort to combat the significant AIDS epidemic, USAID's funding levels for the five-year AIDS prevention strategy (1998-2002) are less than the World Bank's AIDS II loan that covers essentially the same time period. Our two roles are very distinct, yet highly complementary: the World Bank loan and its host country counterpart funds finance the implementation of AIDS prevention programs in Brazil, while USAID provides the technical assistance and training necessary to effectively use these loan resources in a timely fashion for the provision of quality AIDS prevention services as an integral part of Brazil's health systems.

The MOH's National AIDS Coordinating unit (CN) is charged with approving annual AIDS plans and budgets from all 177 state and municipal health agencies requesting annual operating funds for their AIDS programs. This year the CN commended the annual plans submitted from the nine states and municipalities, which received USAID-financed technical assistance and training as very well thought out and superior to others. As a result, the CN has requested USAID's assistance to expand training so that the USAID-assisted model will become the standard for all 177 decentralized agencies. While the results to date show more effective use of financial resources at these nine sites, a significant long term impact will be the replication of USAID efforts at the national level.

Performance and Prospects: FY 2000 was the second full year of program implementation of USAID's five-year strategy to prevent the spread of HIV/AIDS. FY 2000 funds were used to finance a mid-term evaluation undertaken in early FY 2001. Major conclusions of the evaluation point to the need for a "scaling up" of USAID's successful activities by using the CN, as well as state and municipal resources. It also called for the need to expand access to vulnerable groups (especially adolescents and other "high risk" groups) to current services, where feasible, and, if resources permit, establish several new "pilot" service centers for these groups.

A recent joint CN/USAID strategic planning session resulted in the identification of a number of crucial areas for work with the CN in which the USG and its partners have a comparative advantage over other donors, such as joint research and quality service provision, as a result of USAID's previous work here and elsewhere. The additional HIV/AIDS funding made available in FY 2001 will enable USAID to have an even greater impact at the federal level. The quality of the USAID's policy dialogue with the Government has increased immeasurably, now that the GOB has seen our ability to integrate quality HIV/Sexual Transmitted Infection (STI) services with existing family health programs in the Brazilian public health delivery system. We are hoping that integration with TB will be equally successful. Among other areas, the MOH has requested USAID's assistance in carrying out a national marking campaign that effectively promotes accessibility and affordability of condoms for low-income consumers. We will also seek out additional opportunities to work with the public sector and assist the Government in establishing public-private partnerships, where possible.

USAID has aimed to strengthen local institutional capacity to plan, implement and evaluate STD/HIV programs, USAID, through Family Health International (FHI) and Management Sciences for Health (MSH), provided assistance in management and technical strengthening to the AIDS programs of nine state and municipal health secretariats that have the potential to receive funding under the World Bank AIDS II loan. As a result of USAID-funded management assessments technical assistance was provided in three major areas in FY 2000: team building, strategic planning and development of manuals to define roles and responsibilities. As a result of technical capacity assessments, five technical workshops were conducted in design, implementation and evaluation, supervision and monitoring, harm reduction for injecting drug users, counseling and testing, and condom social marketing. As a result of this technical assistance, the annual work plans for 2000 World Bank funding for the nine programs were well prepared and implementation is on track. Also, USAID-funded technical assistance through Pathfinder Intentional continued with two state (Bahia and Ceara) and two municipal secretariats of health in Salvador and Fortaleza, and 20 selected public health units to integrate quality STD/HIV health services into the larger overall reproductive health programs of these four health departments. As a result, USAID is now in a position to expand technical assistance and training to additional central level health programs which will focus on integration of quality STD/HIV services at the health post level.

USAID continued to sponsor social marketing activities through DKT, Population Services International's (PSI) branch in Brazil. DKT's social marketing activities targeted increased access and use of male and female condoms, making them available at low prices to the general public. In the process, DKT exceeded the planned target of 90% sustainability by the end of FY 2000 by achieving 93% cost recovery. In fact, DKT's market share grew from 13% in FY 1999 to 18% in FY 2000. 52% of its sales of male condoms and 60% of sales of female condoms occurred in USAID's four target states. Also during FY 2000, DKT significantly expanded its association with local AIDS NGOs as an integral part of its social marketing strategy, including a partnership with a local NGO that works in a favela in Rio de Janeiro focussing on the development of alternative activities that creatively occupy pre-teens and adolescents. During this year, these pre-teens and adolescents, in their own words and based on their own experiences with AIDS, developed a drama, performing in the Favela's town square. This success has led to additional new commitments from sports trainers and art, music and drama teachers to donate time to help these youths over the coming year.

In FY 2001, USAID will provide $3,892,000 to strengthen institutional capacity related to sexually transmitted illnesses (STI) and support a sustainable condom-marketing program. Starting in FY 2001, USAID will also provide $2,594,000 to reduce TB incidence in support of decreasing the AIDS epidemic. In FY 2002, USAID will provide $1,660,000 to strengthen state and municipal government's institutional capacity to plan, implement, and evaluate STI programs and $1,020,000 to strengthen institutional capacity to integrate HIV/AIDS prevention programs into existing public reproductive health services in Bahia and Ceará. In addition, USAID will provide $1,470,000 to support the sustainable condom social marketing program and $2,600,000 to reduce TB.

Possible Adjustments to Plans: USAID is in the process of developing a tuberculosis component to its AIDS SO. The number of cases of TB is the highest in the region, with some 90,000 cases. Similarly, Brazil ranks number one in the region in terms of total number of people infected with HIV. USAID is planning to create synergies in the development of the TB strategy between its ongoing HIV/AIDS activities and any new TB activities, as it appears that about 50% of all AIDS cases also have TB.

In addition, in FY 2000, USAID began funding a study on cross-border transmission of HIV/AIDS to six areas, which will be increased to ten, as a result of GOB, Pan-American Health Organization and UNAIDS requests. The results of this study will form the basis of any follow-on activity in FY 2002, designed to deal with the situation this study uncovers. USAID is also consulting with neighboring USAID Missions on this study and will work closely and collaboratively with all parties on follow-on activities.

Host Country and Other Donor Programs: USAID has been working closely with other international donors to achieve the results under this activity. Coordination with the MOH is done through the United Nations AIDS Program (UNAIDS) Thematic Group that, besides USAID, includes IBRD (U.S.$300 million for 1998-2002), the United Nations Drug Control Program (UNDCP, U.S.$22 million, 1998-1999), the Pan-American Health Organization (PAHO), the United Nations Education, Scientific and Cultural Organization (UNESCO), the United Nations Children's Fund (UNICEF, U.S.$11 million for health activities) and selected bilateral donors and NGOs.

Principal Contractors, Grantees, or Agencies: USAID implements activities through U.S. PVOs: the Population Council, Family Health International, Management Sciences for Health, Population Services International and the Pathfinder Fund local office, in cooperation with Brazilian NGOs.

FY 2002 Performance Table

Brazil 512-003

U.S. Financing

(In thousands of dollars)

	Obligations		Expenditures		Unliquidated
Through September 30, 1999	0	DA	0	DA	0	DA
	4,000	CSD	4,000	CSD	0	CSD
	0	ESF	0	ESF	0	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	0	DFA	0	DFA	0	DFA
Fiscal Year 2000	0	DA	0	DA
	2,000	CSD	2,000	CSD
	0	ESF	0	ESF
	0	SEED	0	SEED
	0	FSA	0	FSA
	0	DFA	0	DFA
Through September 30, 2000	0	DA	0	DA	0	DA
	6,000	CSD	6,000	CSD	0	CSD
	0	ESF	0	ESF	0	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	0	DFA	0	DFA	0	DFA
Prior Year Unobligated Funds	0	DA
	0	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
Planned Fiscal Year 2001 NOA	0	DA
	6,486	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
Total Planned Fiscal Year 2001	0	DA
	6,486	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
			Future Obligations		Est. Total Cost
Proposed Fiscal Year 2002 NOA	0	DA	0	DA	0	DA
	6,750	CSD	0	CSD	19,236	CSD
	0	ESF	0	ESF	0	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	0	DFA	0	DFA	0	DFA

Brazil

Activity Data Sheet

FY 2002 Performance Table

Brazil 512-003

U.S. Financing