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This case study documents how India, the world's second most populous country, pulled the reins on a global epidemic to stop it in its tracks from growing into a generalized epidemic. Central to the case study is the story of a government body, the National AIDS Control Organization (NACO) that, with the support of international development organizations like the World Bank, deftly collaborated with civil society organizations to engage with communities that had a high risk of HIV infection and were also highly marginalized to implement large scale behavior change in the interest of individual and public health. Above all, this is a story of courage, resilience and gumption of some of the most hidden and disenfranchised communities of India in taking charge of their destinies with respect to HIV-AIDS and demonstrating that if provided with the right programmatic structure and a supportive ecosystem, they can rise towards a better tomorrow. This case study is the story of India's fight against HIV-AIDS and the significant role played by Targeted Interventions in this fight. Targeted Interventions are a resource-effective approach to offer HIV prevention and care services to high-risk populations within communities by providing them with the information, means and skills they need to minimize HIV transmission and improving their access to care, support and treatment services.

Health, Nutrition and Population

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This multi-country study focuses on evaluating whether ART scale-up and changes in sexual risk behavior have contributed to the declining trends of HIV incidence and prevalence. The World Bank, UNAIDS, UNFPA, WHO, the Global Fund, and Imperial College London agreed upon specific criteria used to identify Botswana, Dominican Republic, Kenya, Malawi and Zambia as the five countries engaged in this study. Within Botswana, there was strong evidence that showed that ART and changes in sexual risk behavior had an impact of averting 210,000 infections in urban areas as 120,000 infections in rural areas (1975-2012). This discrepancy between urban and rural area results was thought to be due to geographical heterogeneity in HIV epidemiology or lack of power in available data. The changes in sexual risk behavior had a comparatively larger impact on the epidemic than ART, averting approximately 460,000 cumulative infections between 1982 and 2015. ART alone was found to be insufficient to explain the observed trend (approx. 44,000 FSW infections averted, 33,000 Bataeyes, and 28,000 amongst MSM). Results from Kenya showed that again that changes in sexual risk behavior, and to a much lesser extent ART, had averted approximately 4,107,000 infections between 1980-2015. An important takeaway from these results was that ART had marginal impact on prevalence trends but that it has yet to be fully optimized.

Health, Nutrition and Population

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The ongoing Ebola outbreak in West Africa has put a huge strain on already weak health systems. Ebola deaths have been disproportionately concentrated among health care workers, exacerbating existing skill shortages in Guinea, Liberia, and Sierra Leone in a way that will negatively affect the health of the populations even after Ebola has been eliminated. This paper combines data on cumulative health care worker deaths from Ebola, the stock of health care workers and mortality rates pre-Ebola, and coefficients that summarize the relationship between health care workers in a given country and rates of maternal, infant, and under-five mortality. The paper estimates how the loss of health care workers to Ebola will likely affect non-Ebola mortality even after the disease is eliminated. It then estimates the size of the resource gap that needs to be filled to avoid these deaths, and to reach the minimum thresholds of health coverage described in the Millennium Development Goals. Maternal mortality could increase by 38 percent in Guinea, 74 percent in Sierra Leone, and 111 percent in Liberia due to the reduction in health personnel caused by the epidemic. This translates to an additional 4,022 women dying per year across the three most affected countries. To avoid these deaths, 240 doctors, nurses, and midwives would need to be immediately hired across the three countries. This is a small fraction of the 43,565 doctors, nurses, and midwives that would need to be hired to achieve the adequate health coverage implied by the Millennium Development Goals. Substantial investment in health systems is urgently required not only to improve future epidemic preparedness, but also to limit the secondary health effects of the current epidemic owing to the depletion of the health workforce.

Gender --- Health, Nutrition and Population

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Previous research on sex-selective abortions has ignored the interactions between fertility, birth spacing, and sex selection, despite both fertility and birth spacing being important considerations for parents when deciding on the use of sex selection. This paper presents a novel approach that jointly estimates the determinants of sex-selective abortions, fertility, and birth spacing, using data on Hindu women from India's National Family and Health Surveys. Women with eight or more years of education in urban and rural areas are the main users of sex-selective abortions and they also have the lowest fertility. Predicted lifetime fertility for these women declined 11 percent between the 1985-1994 and 1995-2006 periods, which correspond to the periods of time before and after sex selection became illegal. Fertility is now around replacement level. This decrease in fertility has been accompanied by a 6 percent increase in the predicted number of abortions during the childbearing years between the two periods, and sex selection is increasingly used for earlier parities. Hence, the legal steps taken to combat sex selection have been unable to reverse its use. Women with fewer than eight years of education have substantially higher fertility and do not appear to use sex selection.

Gender --- Health, Nutrition and Population

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This report summarizes the findings of an allocative efficiency study of Romania's Tuberculosis (TB) response, which was conducted using the Optima-TB model. The analysis was conducted to support Romania in its decision-making on strategic TB investments during the current National Strategic Plan for the Control of Tuberculosis in Romania (NSP, 2015-20) and up to 2030. The analysis highlights the potential for Romania to maximize its impact on the TB response by reallocating spending on unnecessary hospitalization to increase the coverage of ambulatory care, treatment of drug-resistant TB and enhanced and active case finding in congregate community settings and high-risk areas.

Health, Nutrition and Population --- Tuberculosis