MAY 2003 — Colombia's HIV/AIDS epidemic is far worse than official case reports suggest, and it will have severe economic and social repercussions unless policymakers begin to confront the problem now. That is what the country's leaders are learning from a group of health officials and advocates armed with projections of the socioeconomic impact of HIV/AIDS in Colombia through the year 2000.
These projections were calculated during a policy development workshop funded by the Colombian Ministry of Health and the U.S. Agency for International Development mission in Bogotá. The November 1996 workshop was conducted by the AIDS Control and Prevention (AIDSCAP) Project at the request of Consultores Internacionales en Seguridad Social y Salud Limitada (CINSSA), a Colombian consulting firm that works with the National AIDS Control Program (NACP).
The invitation to hold such a workshop came during the XIth International Conference on AIDS in July 1996. CINSSA representatives were impressed by what they had heard about a similar workshop organized by AIDSCAP in Central America. They knew that their colleagues from El Salvador, Guatemala and Nicaragua were using socioeconomic impact projections to inform and influence HIV/AIDS policy development, and they wanted to achieve the same kind of results in Colombia.
Central American Workshop
The 15-day training workshop that inspired current policy advocacy efforts in Colombia began in February 1996, when interdisciplinary teams from El Salvador, Guatemala and Nicaragua arrived in Guatemala City. Chosen by their ministries of health, the teams included representatives from public health agencies, public sector economic and planning units, nongovernmental organizations (NGOs), academic and research institutions, legislative bodies, the military, social security institutes and international organizations.
The workshop was designed to help technical specialists, policy analysts and policy influencers use the results of socioeconomic impact assessments to inform and guide HIV/AIDS prevention policymaking. Team members agreed to continue working together after the workshop to develop a gender-balanced, multisectoral response to HIV/AIDS in their respective countries.
During the first two weeks of the workshop, participants learned how to use computer models and costing methodologies to make epidemiologic and economic projections of the impact of HIV/AIDS from 1995 to the year 2000. Each team used data from its own country to assess the potential effects of the epidemic.
During the third week, the country teams developed policy recommendations by analyzing the policy environment in their respective countries and determining how it might be affected by the projected social and economic effects of HIV/AIDS. Then they identified policy areas critical to effective prevention efforts, including integration of HIV/AIDS in school-based family life education, human and civil rights protection, promotion of women's rights and prevention of domestic violence, workplace and immigration HIV/AIDS policies, and public and private sector HIV testing. Policy development and advocacy strategies were created detailing the steps to be taken in support of each recommendation.
The initial action plans for the three countries were similar. Each team intended to create and strengthen support for HIV/AIDS policy initiatives by strategically presenting findings to key audiences, including government ministers, legislators, cabinet members and other national policymakers. Other presentations would be directed toward influential sectors such as the media, the religious community, parastatal institutions, academic and professional associations, NGOs, international donors and the private sector.
Once the teams returned home and began implementing their action plans, the plans were modified considerably. New strategies emerged as the teams encountered different constraints and opportunities. The strategies were adapted to realities of the political environment in each country and reflected the particular composition and coherence of each team, as well as the trends suggested by their socioeconomic projections.
El Salvador
One strength of the Salvadoran team was the commitment of its members: All but one of the eight Salvadoran workshop participants continued to contribute to the policy development effort after the workshop. In addition, the team was well-connected with policymakers, including the head of the Salvadoran NACP, the Pan American Health Organization's STD/HIV/AIDS advisor to El Salvador, the Social Security Institute and members of the legislature.
The legislative aides on the team lobbied their committees to increase attention to, and support for, HIV/AIDS prevention activities. Following the workshop, Salvadoran team members had immediate opportunities to present their study findings to members of the National Assembly. These presentations resulted in commitments by Assembly members to support passage of HIV/AIDS legislation, such as a safe blood law, being prepared for consideration in the next legislative cycle.
Particularly because El Salvador is emerging from an era of civil war, the potential for HIV/AIDS to disturb the country's fragile economic, political and social stability raised concerns. The team's analysis indicated that up to 23,000 Salvadorans had been infected with HIV by 1995, and that this number could rise to 50,000 by the year 2000. Treatment costs were projected to reach U.S.$5 million to $10 million during the same period, with lost income accounting for an additional $42 million to $100 million.
The impact assessment used both quantitative and qualitative data to emphasize the potential social and economic costs of the epidemic due to its impact on households and communities, and on the demand on social services. This approach -- focusing on HIV/AIDS as a development issue -- gained the attention of legislators and lobbyists involved in a broad range of issues, including women and families, economic development, human rights, education and environmental health.
The team also presented its projections at Instituto Salvadoreño del Seguro Social (ISSS), a parastatal organization that provides health care to private and public sector employees and their families through its own hospitals and health centers. The projected impact on health costs and ISSS operating expenses so concerned the institute's board of directors that it established an HIV/AIDS prevention program for its employees and initiated its own project to strengthen the HIV/AIDS prevention efforts of its private sector clients.
The ISSS board used quantitative and qualitative study data from the AIDSCAP workshop to demonstrate the impact of HIV/AIDS on the workplace as HIV prevalence rises, including potential increases in the employers' required contribution to the social security fund. This effort was launched with presentations to journalists and business leaders about the socioeconomic impact of HIV/AIDS on Salvadoran businesses and the ISSS. Shrewdly, ISSS board members gave the first presentation to journalists to encourage media coverage of the session with business leaders.
Guatemala
The Guatemalan team benefited from the participation of the chief of the military health service (Servicio de Sanidad Militar, or SSM), Dr. Cesar A. Rodríguez Duarte. His experience with policy development within the national bureaucracy allowed him to take a lead role in orienting other team members to the Guatemalan policy environment, and his participation in the workshop led him to become an advocate for HIV/AIDS prevention and care within the military.
Dr. Rodríguez also represented the military on a newly formed National HIV/AIDS Coordinating Committee, assuring his continued involvement in dissemination of the study results and in policy development. Since the training, this influential policymaker has publicly called for a review of policies and practices related to HIV-positive members of the military.
The willingness of the SSM chief to become involved in HIV/AIDS advocacy appeared motivated, in part, by the results of the assessment, which he quoted in several radio and print interviews. The assessment estimated that by the year 2000, 1 of every 100 Guatemalans could be HIV-positive, resulting in 300 AIDS deaths every week. HIV/AIDS treatment costs, estimated at over U.S.$2,000 per patient, could total $22 million. As was the case in El Salvador, productivity losses (projected to reach $140 million to $220 million by the end of the decade) were expected to be much greater than health care costs.
In addition to Dr. Rodríguez's active involvement in policy advocacy, another unexpected benefit of the AIDSCAP workshop is the improved relationship between the NACP and the Asociación Guatemalteca para la Prevención y Control de SIDA, an HIV/AIDS service and advocacy organization. Despite prior tensions, representatives of the two groups were able to work together on the socioeconomic impact project. This collaboration bodes well for the efforts of the National HIV/AIDS Coordinating Committee, a multisectoral coalition that brings together diverse, and in some cases historically antagonistic, interests and perspectives to strengthen Guatemala's HIV/AIDS prevention and care programs.
Nicaragua
The Nicaraguan team benefited from high levels of collaboration among team members. A severe economic downturn, a series of public health crises and an upcoming national election, however, made it difficult for the team to follow through on the activities defined in its action plan.
Fortunately, there were fewer hurdles to policy development in the NGO sector in Nicaragua. Fundación Nimehautzin, a Nicaraguan NGO that was unable to participate in the workshop but was involved in follow-up meetings and strategic planning, was thus able to use the results of the workshop for advocacy purposes and to work with the NACP to pass legislation to protect the human rights of people living with HIV/AIDS. When this legislative effort led to the reconvening of Nicaragua's National AIDS Committee, the assessment team used the opportunity to share their study results with committee members.
The results of the workshop indicated that although the prevalence rate is relatively low in Nicaragua at the moment, HIV/AIDS is expected to be one of the fastest growing epidemics in the country's history. Currently between 2,500 and 8,000 adults have been infected with HIV. By the year 2000 that number may rise as high as 25,000, resulting in more than 70 AIDS deaths a week. Treatment costs could reach more than U.S.$1 million, and productivity losses could exceed $50 million.
These socioeconomic impact projections bolstered Fundación Nimehautzin's advocacy efforts, while the NGO provided assistance in the dissemination and policy development efforts of the Nicaraguan team.
Opportunity and Success
Success in policy development is often incremental and can take unexpected forms, as the experiences of the three Central American teams illustrate. For example, in El Salvador the Social Security Institute's use of socioeconomic impact analysis to sensitize other members of the private sector was not planned. But this form of policy peer education has moved El Salvador into position to engage a critical sector in HIV/AIDS prevention at an early stage of the epidemic. Likewise, the collaboration fostered by the workshop had unanticipated benefits in Guatemala, where it contributed to energizing the National Coordinating Committee -- a small but important step in the prevention process in that country. And in Nicaragua, an NGO that was not even involved in the AIDSCAP training linked data generated by the team and advocacy to help steer the country's legislative response to the epidemic.
The experiences of all three country teams reflect a central lesson from AIDSCAP's experience: that policy development success arises from good data, sound analysis, thorough planning and true collaboration. The way that these elements come together depends, in part, on recognition that policy development is a process. Like all good processes, it can be enhanced with strategic planning and the ability to take advantage of unexpected opportunities.
-- Bill Rau, Steven Forsythe and Galia Siegel
Bill Rau is associate director of policy and Steven Forsythe is a health economics officer at AIDSCAP. Galia Siegel was formerly an associate policy officer with the project
