Document of The World Bank Report No: ICR0000741 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-7066) ON A LOAN IN THE AMOUNT OF US$15.15 MILLION TO BARBADOS FOR A BARBADOS HIV/AIDS PREVENTION AND CONTROL PROJECT June 27, 2008 Human Development Sector Management Unit Caribbean Country Management Unit Latin America and the Caribbean Region ii CURRENCY EQUIVALENTS (Exchange Rate Effective June 2001) Currency Unit = Barbadian Dollar (BBD) BBD$0.50 = US$ 1 US$ 1.00 = BBD$1.99 FISCAL YEAR January 1 ­ December 31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency LAN Local Area Networks Syndrome APL Adaptable Program Lending MNHI Ministry of Health, National Insurance and Social Security ART Anti-retroviral therapy MSM Men who have Sex with Men ARV Anti-retroviral drugs MTCT Mother to Child Transmission AZT Azido-deoxy thymidine NHAC National HIV/AIDS Commission BDS Barbados Drug Service NCB National Competitive Bidding CAREC Caribbean Epidemiology Center NGOs Non-Governmental Organizations CARICOM Caribbean Community and Common OPM Office of the Prime Minister Market CAS Country Assistance Strategy PAHO Pan American Health Organization CBO Community-Based Organization PCU Project Coordination Unit CCHI Caribbean Cooperation in Health PCD Project Concept Document Initiatives CDC Centers for Disease Control PLHIV People Living with HIV CDRC Chronic Disease Research Center PMR Project Management Report CGCED Caribbean Group for Cooperation in QEH Queen Elizabeth Hospital Economic Development CHA Caribbean Hotel Association RPA Regional Procurement Advisor CRM+ Caribbean Network of People Living SA Special Account with HIV/AIDS CSO Civil Society Organizations SOE Statement of Expenditures CSW Commercial Sex Worker STI Sexually Transmitted Infections GDP Gross Domestic Product UNAIDS Joint United Nations Program on HIV/AIDS GOB Government of Barbados UNDCP United Nations Drug Control Program HAART Highly Active Anti-retroviral UNDP United Nations Development Program Therapy HASSUS Health and Social Services UNESCO United Nations Educational, Scientific Utilization Study and Cultural Organization HIV Human Immunedeficiency Virus UWI University of the West Indies ICB International Competitive Bidding WB The World Bank IEC Information, Education and VCT Voluntary Counseling and Testing Communication KAP Knowledge, Attitude and Practices WHO World Health Organization Vice President: Pamela Cox Country Director: Yvonne Tsikata Sector Manager: Keith Hansen Project Team Leader: Joana Godinho ICR Team Leader: Joana Godinho iii BARBADOS HIV/AIDS PREVENTION AND CONTROL PROJECT CONTENTS DATA SHEET A. Basic Information .....................................................................................1 B. Key Dates................................................................................................................... 1 C. Ratings Summary....................................................................................................... 1 D. Sector and Theme Codes ........................................................................................... 2 E. Bank Staff................................................................................................................... 2 F. Results Framework Analysis...................................................................................... 3 G. Ratings of Project Performance in ISRs .................................................................... 6 H. Restructuring (if any): N/A........................................................................................ 6 I. Disbursement Graph .................................................................................................. 7 1. Project Context, Development Objectives and Design............................................... 8 2. Key Factors Affecting Implementation and Outcomes ............................................ 12 3. Assessment of Outcomes.......................................................................................... 18 4. Assessment of Risk to Development Outcome......................................................... 30 5. Assessment of Bank and Borrower Performance ..................................................... 31 6. Lessons Learned ....................................................................................................... 33 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 35 Annex 1. Project Costs and Financing.......................................................................... 36 Annex 2. Outputs by PDO and by Component............................................................. 37 Annex 3. Economic and Financial Analysis................................................................. 43 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 44 Annex 5. Beneficiary Survey Results........................................................................... 45 Annex 6. Stakeholder Workshop Report and Results................................................... 47 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR..................... 48 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders....................... 49 Annex 9. List of Supporting Documents ...................................................................... 50 1 A. Basic Information Caribbean HIV/AIDS I Country: Barbados Project Name: - Barbados Project ID: P075220 L/C/TF Number(s): IBRD-7066 ICR Date: 12/15/2008 ICR Type: Core ICR Government of Lending Instrument: APL Borrower: Barbados Original Total USD 15.15M Disbursed Amount: USD 15.15M Commitment: Environmental Category: B Implementing Agencies: National HIV/AIDS Commission Cofinanciers and Other External Partners: NA B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 11/15/2000 Effectiveness: 12/20/2001 12/20/2001 Appraisal: 04/23/2001 Restructuring(s): Approval: 06/28/2001 Mid-term Review: 11/03/2003 Closing: 12/31/2006 12/31/2007 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Satisfactory Risk to Development Outcome: Negligible to Low Bank Performance: Satisfactory Borrower Performance: Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Satisfactory Quality of Supervision: Satisfactory Implementing Agency/Agencies: Satisfactory Overall Bank Overall Borrower Performance: Satisfactory Performance: Satisfactory 2 C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Performance Indicators (if any) Rating Potential Problem Project Quality at Entry No NA at any time (Yes/No): (QEA): Problem Project at any Quality of No Moderately Satisfactory time (Yes/No): Supervision (QSA): DO rating before Satisfactory Closing/Inactive status: D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central Government Administration 5 Health 95 Theme Code (Primary/Secondary) Child health Secondary Gender Secondary HIV/AIDS Primary Health system performance Secondary Participation and civic engagement Secondary E. Bank Staff Positions At ICR At Approval Vice President: Pamela Cox David De Ferranti Country Director: Yvonne Tsikata Orsalia Kalantzopoulos Sector Manager: Keith Hansen Xavier Coll, Director Project Team Leader: Joana Godinho Patricio Marquez ICR Team Leader: Joana Godinho ICR Primary Author: Marcelo Castrillo 3 F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The proposed HIV/AIDS Prevention and Control Project would assist the Government of Barbados to: (i) Reduce the rate of new HIV reported cases; (ii) Increase the life expectancy of persons living with HIV (PLHIV); (iii) Improve quality of life for PLHIV; and (iv) Build sustainable institutional arrangements for managing the HIV/AIDS epidemic. Revised Project Development Objectives (as approved by original approving authority): NA (a) PDO Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years Indicator 1 Percentage of adults with HIV still alive 12 months after initiation of therapy Value 93.0 95 97 Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Target achieved. Case management was highly satisfactory. Indicator 2 Percentage of men and women with advanced HIV infection receiving ARV in the last 12 months. Value 12.4% 80% 84.9% Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Target achieved. Case management was highly satisfactory. Indicator 3 Percentage of HIV-positive pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of mother-to-child transmission. Value 76% 95% 96% Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Target achieved. Case management was highly satisfactory. Indicator 4 Percentage of infants born to HIV infected mothers who are infected. Value 5.5% <10% 2.6% Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Target achieved. Case management was highly satisfactory. 4 Indicator 5 Median age at first sex among young men and women. Value Males 15 years 12-18 months Males 15 years Females 16 years increase in age at first sex Females 16 years Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Target not achieved, and no change was observed over the life of the project. This is a controversial indicator as it rarely changes, and when it does, this does not necessarily mean the adoption of safe sexual practices. (b) Intermediate Outcome Indicator(s) Percentage of young men and women aged 15 to 24 who both correctly identify Indicator 6 ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission. Value 0.1% 10% 1% Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Target not achieved. However, evidence from 2001, 2003 and 2005 KAP surveys indicate that knowledge about HIV and AIDS increased among youth. Percentage of young men and women aged 15 to 24 reporting the use of a Indicator 7 condom the last time they had sex with a non-marital, non-cohabitating sexual partner. Value Males 35.3% Males 85% Males 26.6% Females 32.6% Females 85% Females 15.9% Both 34.5% Both 85% Both 21.6% Date achieved 12/31/2002 12/31/2006 12/31/2005 Comments Target not achieved. However, condom use with clients among sex workers is reported to be 80%. Indicator 8 Number of persons receiving post-test counseling and results. Value >20, 000 >20,000 24, 509 Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Indicator 9 Percentage of schools with teachers who have been trained in life-skills-based HIV education and who taught it during the last academic year Value NA 40.8% Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments 5 Percentage of population expressing accepting attitudes towards PLHIV as measured by: % saying that they would be willing to care for a family member who became Indicator 10 sick with the AIDS virus; % saying that they would buy food from a PLWHA/eating in a restaurant; % saying that a teacher/child who is HIV+ should be allowed to continue to teach/attend school. Care for Family 71% Care for Family Care for Family Value Buy food 18% 95% 90% Teachers allowed to teach Buy food 40% Buy food 31% 54% Teachers allowed Teachers allowed to to teach 90% teach 86% Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Targets almost achieved. Indicator 11 Establishment of National HIV/AIDS Commission. Value Established Functioning Fully Functional Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Indicator 12 Establishment of a fully operational national HIV/AIDS M&E System including a database populated with program activity data. Value NA Fully operational Fully operational 50% populated Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Target partly achieved. The database will be fully populated under the new project. Indicator 13 Percentage of relevant public sector agencies reporting at least annually on their AIDS policies and program. Value 50% 87.5% 9 out of 18 80% 14 out of 16 Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Indicator 14 Number of civil society organizations reporting annually on their AIDS policies and programs. Value 4 8 11 Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments 6 Indicator 15 Percentage of large companies/enterprises with HIV/AIDS workplace policies and programs. Value 5% NA 75% Date achieved 12/31/2003 12/31/2006 12/31/2007 Comments Source: ILO/US Department of Labor workplace education project. Indicator 16 Establishment of a fully operational Bio-Medical Waste System Value 5% Fully operational BMWS 67% Date achieved 12/31/2002 12/31/2006 12/31/2007 Comments Target almost achieved. The system will be fully operational by the end of 2008. G. Ratings of Project Performance in ISRs Actual No. Date ISR Archived DO IP Disbursements (USD millions) 1 11/09/2001 Satisfactory Satisfactory 0.00 2 06/10/2002 Satisfactory Satisfactory 0.15 3 12/11/2002 Satisfactory Highly Satisfactory 0.85 4 06/02/2003 Satisfactory Highly Satisfactory 1.55 5 06/25/2003 Satisfactory Satisfactory 1.55 6 12/04/2003 Satisfactory Satisfactory 3.66 7 05/27/2004 Satisfactory Satisfactory 5.00 8 12/07/2004 Satisfactory Satisfactory 5.39 9 12/16/2004 Satisfactory Satisfactory 5.40 10 04/29/2005 Satisfactory Satisfactory 7.54 11 07/14/2005 Satisfactory Moderately Satisfactory 7.56 12 06/12/2006 Satisfactory Satisfactory 10.94 13 12/22/2006 Satisfactory Moderately Satisfactory 12.25 14 06/12/2007 Satisfactory Moderately Satisfactory 13.38 15 08/29/2007 Satisfactory Moderately Satisfactory 13.93 16 01/09/2008 Satisfactory Satisfactory 14.77 17 06/26/2008 Satisfactory Satisfactory 15.15 H. Restructuring (if any): NA 7 I. Disbursement Profile 8 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal In 2000, when the project was designed, HIV was spreading rapidly and the Caribbean was - and still is - second only to sub-Saharan Africa in terms of the percentage of adult population affected. Data showed a high acceleration rate, and HIV was spreading beyond highly vulnerable groups into the general population. Although many Caribbean governments had developed a response to the epidemic, efforts had not been comprehensive enough to stop the disease's regional trajectory. In response, the Bank launched a horizontal Adaptable Program Loan (APL) to provide rapid assistance across the region. Although Barbados had already graduated from Bank lending, it was one of the first two countries to receive support under the APL. The rationale for Bank assistance was clear. Although Barbados was a middle-income country, with a well established national health delivery system, it was estimated that more than 2 percent of the population was infected with HIV in 2001. The country also has a strong leadership role in the region, its health infrastructure is used by smaller neighboring countries, and it has a large, active tourism industry and is a hub for regional transportation. In addition, the country was not able to obtain financing for program expansion from other sources, since international donors were focusing their resources on poorer countries throughout the world. An important factor in the Barbados program was the Government's strong commitment to fighting the disease. In September 2000, Barbados took the lead in organizing the first regional conference on the disease. The same year, the Barbadian Parliament approved increased funding for HIV/AIDS activities, and launched the high-level National Advisory Committee on HIV/AIDS (NACA), which in 2001 became the National HIV/AIDS Commission (NHAC), reporting directly to the Prime Minister. At the time of project appraisal, Barbados had already formulated a proactive and multi-sectoral response, and was using antiretroviral treatment (ART), which at the time was cutting- edge. Both the Bank and the GOB saw the opportunity to scale up existing initiatives and to integrate best practices into the national plan. The GOB contributed $8.5 million for the $23.65 million project. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) The project was designed to assist the Government of Barbados to achieve the following objectives: (i) Reduce the rate of new HIV reported cases; (ii) Increase the life expectancy of persons living with HIV/AIDS (PLHIV); (iii) Improve the quality of life of PLHIV; and (iv) Build sustainable institutional arrangements for managing the HIV/AIDS epidemic. 9 Original Project Development Indicators 1. Annual percentage of reported new HIV cases. 2. Mortality rate attributed to AIDS. 3. Life expectancy of PLHIV. 4. Changes in high-risk sexual behavior and attitudes, as measured by changes in condom use, age at first sexual encounter for men and women, and reporting of unsafe sex practices. 5. Percent of HIV/AIDS cases due to mother-to-child transmission. 6. Percent transmission through blood transfusion. 7. Quantitative and qualitative changes in the quality of life of PLHIV. Revised Project Development Indicators 1. Percentage of adults with HIV still alive 12 months after initiation of antiretroviral therapy. 2. Percentage of men and women with advanced HIV infection receiving ARV in the last 12 months. 3. Percentage of HIV-positive pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of mother-to-child transmission. 4. Percentage of infants born to HIV infected mothers who are infected. 5. Median age at first sex. 6. Percentage of young men and women aged 15 to 24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission. 7. Percentage of young men and women aged 15 to 24 reporting the use of a condom the last time they had sex with a non-marital, non-cohabitating sexual partner. 8. Number of persons receiving post-test counseling and results. 9. Percentage of schools with teachers who have been trained in life-skills-based HIV education and who taught it during the last academic year. 10. Percentage of population expressing accepting attitudes towards PLHIV as measured by % of respondents saying that they would be willing to care for a family member who became sick with the AIDS virus; % of respondents saying that they would buy food from a PLHIV/eating in a restaurant; and % of respondents saying that a teacher/child who is HIV+ should be allowed to continue to teach/attend school. 11. Establishment of National HIV/AIDS Commission. 12. Establishment of a fully operational national M&E System database populated with program activity data. 13. Number of relevant public sector agencies reporting at least annually on their AIDS policies and program. 14. Number of civil society organizations reporting annually on their AIDS policies and programs 15. Percentage of large companies/enterprises which have HIV/AIDS workplace policies and programs. 16. Establishment of a fully operational Bio-Medical Waste System. 10 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification PDOs were not revised during the life of the project. In July 2006, the Bank agreed to amend the Loan Agreement and the project indicators set forth in the Attachment to the Loan Agreement. There were two primary reasons for revising the indicators. First, both the Government and the Bank realized that the initial matrix of project indicators had significant gaps and deficiencies, making it difficult to assess progress, and outcome indicators were not measurable or compatible with UN General Assembly Special Session - UNGASS indicators. The indicators were insufficient for measuring project achievements and inadequate for managing project progress towards strategic objectives. The second reason for revising the indicators related to the implementation of monitoring and evaluation (M&E) activities, which were considered unsatisfactory by the Bank. The Barbados health information system were not capturing nor producing sufficient relevant information. The information that was captured focused mainly on clinic-level activities, rather than on population-based prevention activities. The Bank urged the Government to recruit qualified staff to manage the M&E system and to submit a list of new indicators, which would include baseline data and progress data at both clinical and population levels. 1.4 Main Beneficiaries The main project beneficiaries were key populations at higher risk, including: · Adolescents in and out of school; · Pregnant women; · Sex workers and "beach boys"; · Men who have sex with men; · People living with HIV/AIDS; · Persons with sexually transmitted infections (STIs); · Health workers; · Uniformed personnel; and · Hotel and tourism personnel. 1.5 Original Components (as approved) Component 1: Prevention and Control of HIV/AIDS Transmission (US$5.7 million total component cost, US$4.1 million loan). This component was designed to implement prevention and control activities across the country. At a workshop in early 2001, prevention programs were reviewed and work plans designed by six ministries1 and the 11) Ministry of Health (MH); 2) Ministry of Education, Youth Affairs and Culture (MEC); 3) Ministry of Social Transformation (MST); 4) Office of the Attorney General and Ministry of Home Affairs (MAG); 5) Ministry of Tourism (MTIT); and 6) Ministry of Labor, Sports and Public Sector Reform (MLS). 11 Government Information Service. Each ministry agreed to establish an HIV/AIDS Coordination Unit to manage a focused work program and establish an outreach program to cover the ministry's respective constituency. Oversight and M&E would be provided by the NHAC, with technical assistance rendered by the Ministry of Health (MH). All work would be coordinated by NHAC and would emphasize five categories of prevention activities. First, each ministry would consider Information, Education and Communication (IEC) programs that would maintain or increase HIV awareness, and would promote behavior changes among the general population. Second, condom distribution would be increased by social marketing, peer groups, and vending machines, with each ministry focusing on prevention and control of sexually transmitted infections (STI). The third activity focused on the continuation of the already successful prevention of Mother-to-Child Transmission Program. Finally, the fourth activity would further strengthen laboratories and ensure a safe blood supply. Component 2: Diagnosis, Treatment, and Care for HIV/AIDS (US$14.3 million total component cost, US$9.45 million loan). This Component was designed to scale up existing programs for the diagnosis, treatment and care of HIV/AIDS patients. Under this component, the project would support scaling up the following interventions: voluntary testing and counseling; laboratory strengthening; pharmacy strengthening; community and home care; and facilities for opportunistic infections (OI) treatment and antiretroviral treatment (ART). While these activities were already being implemented in 2001, their scope was very limited. In addition to diagnosis, the GOB wanted to scale up actions to respond to patients' needs, by reducing opportunistic infections and work disability, and improving quality of life for PLHIV. Five subcomponents were identified. First, voluntary counseling and confidential testing services would be expanded, primarily through upgrading eight polyclinics and training 50 HIV/AIDS counselors. Strengthening the capacity of medical laboratories was also deemed critical, given the repercussions of ART provision on lab testing capacity and patient follow-up. Both staff and equipment were to be upgraded under the subcomponent. The third subcomponent focused on strengthening pharmaceutical services, and activities would build on the strong infrastructure already in place. The project would support the Barbados Drug Service (BDS) negotiations with UNAIDS to obtain lower-cost ARVs. In addition, expanded pharmacy services and patient education programs were planned for the HIV/AIDS Reference Center. The fourth subcomponent was designed to improve community health services, specifically home-based care for PLHIV. The project would train 40 health workers and NGO volunteers on the WHO model of continuum AIDS care, including education for family members, moral and psychosocial support and referrals where necessary. Finally, the fifth subcomponent planned to expand and upgrade infrastructure for OI treatment and ART, and would include improved processes for handling medical waste. Component 3: Management and Institutional Strengthening (US$3.5 million total Component cost, US$1.45 million loan). This component focused on capacity building and institutional strengthening, and was designed to support the restructuring of Barbados' existing HIV/AIDS program so that it could effectively control and prevent HIV/AIDS and care for PLHIV over the long term. Efforts were to be coordinated 12 through NHAC, which would function as the Project Coordination Unit. NHAC included representatives from the private sector, the Church, trade unions, NGO, PLHIV and the Director of the AIDS Management Team at Queen Elizabeth Hospital (QEH), the primary service provider for PLHIV. Component 3 would also finance the project M&E, including research activities, and would support the Ministry of Health (MH) in issues related to surveillance, protocols of care, and technology. 1.6 Revised Components: NA 1.7 Other significant changes This was the first project ever to involve Bank finance for anti-retroviral treatment (ART). Although it stirred a fair share of controversy at inception, it has unquestionably proven a success, and enabled Barbados to establish an early and positive example that helped inspire later donors and new agencies to make HIV treatment a worldwide priority. As ARVs became more affordable, the treatment agenda became much more prominent and relevant. In response, MH procurement included more ARVs than was initially planned, and the MH made treatment available to all patients under the program. When the project was designed, viral load tests were not available in Barbados and had to be performed out of the country at a cost of US$300 per test. The situation changed during project implementation, with pharmacy and lab capacity significantly increased. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry Project planning was participatory and inclusive. The project was prepared by the MH and PLHIV. The project design took into account both the existing regional approach ­ the Caribbean Regional Strategic Plan of Action formulated by the Regional Task Force on HIV/AIDS - and the Government of Barbados (GOB)'s HIV/AIDS Strategic Plan. At the time of project design, lessons learned from global HIV/AIDS programs were considered, including the importance of setting realistic priorities, building the capacity of government, focusing on behavior change, ensuring access and treatment of STI, and supporting the development of public goods. Most importantly, the project team reviewed experiences of HIV/AIDS programs that were scaled up to national level. In addition, lessons learned from other World Bank-financed projects in the Caribbean were taken into account, including the importance of donor coordination in emergency situations, clearly defining the responsibilities of implementing agencies, flexibility in procurement procedures and the need for greater involvement of civil society. Finally, lessons learned from Barbados were taken into account, such as the difficulty of encouraging adoption of new practices in individuals who resist change even when they are well-informed about risks. 13 In hindsight, based on the knowledge accumulated since the project was prepared in 2001, the project design had the following weaknesses: Interventions with key populations at higher risk (sex workers, beach boys, men who have sex with men, prisoners and others) were poorly defined. The PAD discussed the need for preventive interventions for HIV-vulnerable groups, which was technically sound and relevant, but the project design did not elaborate enough on how the interventions would be actually carried out and monitored; nor did it delineate the human resources and skills required to accomplish it. This affected project implementation, which could have been more strongly focused on the most vulnerable groups. There was a limited relation between project components (e.g. the link between prevention and treatment activities and between different implementers at different levels). Implementation could have been more effective in reaching key groups at higher risk of HIV if there was closer relation between surveillance, monitoring and evaluation, prevention and treatment. As previously mentioned, initial indicators were insufficient for measuring project achievements and inadequate for managing project progress towards strategic objectives; and there was a significant delay in putting in place the M&E system. The PAD mentioned that Barbados had a shortage of qualified human resources that could move forward with a multisectoral program, particularly CSO and the private sector. The National Program would have benefited from having more skilled staff to support NHAC, CSO and private sector. Capacity building was not designed thoroughly for some stakeholders that had limited capacity, particularly CSO. Certain organizations required more robust training than that envisioned in the PAD. This affected implementation, as the CSO working with key groups at higher risk of HIV could be stronger than they presently are. 2.2 Implementation The Project was not formally restructured, nor did it have "at risk" status at any time during implementation. The main project achievements at mid-term are indicated in the box below. The mid-term review (MTR), which took place November 2-7, 2003, recommended taking several strategic actions that would consolidate the program's achievements and establish the institutional basis for its long-term sustainability, including consolidating the strategic framework, initiating project performance studies, and facilitating the implementation of specific activities. In particular, the MTR suggested increased emphasis on advocacy and behavior change; enacting anti- discrimination legislation to protect the rights of PLHIV; developing the protocol for adapting and using rapid tests; concluding arrangements to include generic compounds into ART; procurement of quality generic ARV drugs at significantly reduced prices; facility construction, remodeling and expansion; preparation of budget and financing plans; and specific capacity building activities for program-related staff. 14 From the time of the MTR to project completion, the program addressed several of the recommended actions, which allowed it to achieve most PDOs and PDIs. Among the positive factors and events which influenced the project's implementation was the strong and continuous commitment at the highest political levels in the GOB. Most notably, the Prime Minister, his senior staff and members of the Cabinet actively promoted HIV/AIDS awareness and set the tone for the prevention and control program. Also, the GOB solidified the high priority of the issue by including HIV/AIDS funding in the national budget, thus providing an incentive for all line ministries to create activities in support of the national strategy (US $53,192,510 budgeted in the period 2001-2007). In addition, the number of ministries involved increased during implementation, as well as the participation of CSO and private sector. Achievements in the first two years of project implementation Population-wide awareness and sensitization on HIV/AIDS. Young people believing that "a healthy looking person cannot have HIV" decreased from 9% in 2001 to 2% in 2003. 63% of primary school and 75% of secondary school teachers were trained in HIV/AIDS life skills. The number of patients attending the new Ladymeade Reference Unit increased by 52% since 2002. 76% of all HIV/AIDS infected pregnant women received ARV drugs. HIV + children born of HIV + mothers decreased from 28% in 1998 to less than 6% in 2003. 69% of patients under treatment achieved virologic success. Hospital admissions for treatment of opportunistic infections in HIV + patients decreased by 42% between 2001 and 2003. Total hospital days of HIV patients decreased by 59% and average length of stay by 30% between 2001 and 2003. Outpatient visits increased 128% from 4,727 per year to 10,782. In 2003, after ART became universally available, the number of deaths due to AIDS declined by 43%, from 95 in 2001 to 55 in 2002. In-patient costs post-ART declined by 41%. 90% of patients under treatment at Ladymeade Reference Unit considered the quality of medical care received excellent or very good. 12 agencies carried out 30 research studies (surveys, KAPs, focus groups, etc.); 8 posters presented at the 2nd International AIDS Society Conference and other 8 studies were presented at the Caribbean Health Research Council's Scientific Symposium, Barbados being the largest scientific contributor to the forum. As recommended by the MTR, the HIV strategic framework was consolidated, an anti- discrimination policy to protect the rights of PLHIV was enacted, and a behavior change communication strategy was prepared. The BCC Strategy was approved in 2007, and the National Policy on HIV/AIDS and Strategic Framework 2008-2013, which will be implemented under the follow on project, were approved by Cabinet in 2008. The MH started developing the protocol for adapting and using rapid tests, which will be implemented under the new project; and procured quality generic ARV drugs at significantly reduced prices. Facilities were constructed and remodeled. The NHAC and 15 implementing agencies started preparing budgets and financing plans; and significant capacity building activities for program staff took place during the first project. Factors and events which negatively influenced the project's implementation included the following: Limited involvement of key groups at higher risk of HIV on preventive interventions. Although targeted preventive interventions were featured in the project design, implementation of this approach was limited. In general, with regard to prevention, there was more focus on IEC for the general population than on outreach work with key groups at higher risk of HIV. The program relied on IEC models that did not provide sufficient incentive to cause changes in practices. In retrospect, a broader BCC strategy and a separate communications component should have been planned since the beginning, including strategies to overcome traditional sensitivities about working with hard- to-reach groups and speaking openly about high-risk behaviors. There was reduced emphasis on prevention compared to treatment and care. While the increasingly prominent ART agenda was a positive factor, it might have skewed or diluted prevention efforts. With the advent of ART, there seemed to be a perception of HIV/AIDS as a reduced threat that no longer demanded sustained response at all levels. Condom use and distribution was a relatively low priority as a HIV prevention strategy. The Barbados IEC strategy was synonymous with the ABC approach (Abstain, Be faithful, use Condoms), but some stakeholders mostly emphasized A and B, and had a timid approach on C. National and free distribution of condoms was limited to less than 1% of the total condoms procured and sold in the country. Identifying and recruiting human resources was consistently an issue for NHAC and implementing partners. The system was slow and inflexible, often taking a year or more to complete the hiring process for a civil servant. The M&E framework was not adequately structured, as explained below. 2.3 Monitoring and Evaluation Design, Implementation and Utilization The Barbados HIV/AIDS and STI Program M&E system is only now becoming fully functional. Before loan closing, the NHAC completed the development of the national M&E Framework, and developed a complete inventory of all studies carried out to date, including databases and instruments utilized, and analysis plans. It is anticipated that in the near future, under the new project, Barbados will have a considerable amount of information from regular information systems, disease surveillance and special studies. This will be a golden opportunity for the NHAC to consolidate all that information and fill key indicators, which will be crucial for further strategy development. The NHAC collects and reports on some key indicators to UNGASS and the Bank. HIV surveillance data from VCT, PMTCT and the Blood Bank is collected regularly, and a model to estimate national prevalence rates was developed and applied in 2002 and 2006, which was the basis for describing the epidemic in the country. Although M&E faced multiple challenges, the quality of health facility records is high. One of the major 16 strengths of the Barbados health system is the high quality of surveillance information from laboratories and VCT services, Blood Bank, and ante-natal care and other clinical records. Information on care and treatment is highly sophisticated and complete, including the databases developed and implemented by the Ladymeade Reference Unit (LRU) and QEH. An improved M&E framework will enable NHAC to utilize that data more effectively. Population-based studies were carried out on knowledge, attitudes and practices (KAP) in the country, targeting the general population and adolescents. However, the Division of Youth Affairs of the Ministry of Education, Youth Affairs and Sports (MES) changed operational definitions of the indicators during project implementation, so trends over time could not be drawn with a reasonable level of confidence. In addition, there is little data on the preventive services delivered and education activities carried out with key populations at higher risk of infection by these implementing partners, except for youth. Program interventions of other line ministries and private sector, including CSO, will be collected in a systematic and standardized manner in the future. The initial design of the M&E activities was assessed as unsatisfactory during implementation and was revised in 2006. In general, the M&E program relied on clinical-based records and special studies, but lacked systematic data collection tools at all levels and input from different implementing partners. The initial design was based on an IT platform that turned out to be unrealistic. This problem delayed monitoring of program activities, and strategies and methodologies for data collection were not correctly envisioned from the beginning. Roles and responsibilities also lacked sufficient definition. In addition to framework weaknesses, the set of initial indicators used during implementation to determine the magnitude of the epidemic and its drivers was not useful. The MTR recommended reviewing and simplifying reporting formats, which was done. While some components and subsystems are already in place, the integrated analysis and decision making processes need further strengthening. Some data have not been collected, analyzed or shared, and in other cases data have not been routinely collected. These gaps not only prevent managers from being able to assess program performance, hindering their ability to make corrections, but prevent Barbados from knowing if HIV/AIDS investments have been effective. Finally, improved human resources will allow NHAC to support and institutionalize the work that is being carried out by the implementing partners. 2.4 Safeguard and Fiduciary Compliance The Biomedical Waste System is expected to be fully operational by the end of 2008. Under the project, there was significant progress on safeguards issues, including a marked improvement in the separation of hospital waste. In January 2007, the Government and World Bank agreed on an action plan to ensure compliance with Bank Safeguard Policies prior to loan closing. The action plan reflected recommendations of the consultancy carried out by Garry Struthers Associates, INC, on environmental impact of hospital waste. Over the last year of the project, the infectious disease control 17 committee of the Queen Elizabeth Hospital (QEH) implemented key actions to improve health care waste management at the hospital with the effect that health care waste is appropriately sorted throughout the facility. Actions include the implementation and enforcement of a manifest system. Before loan closing, the MHNI started the tender process for a new incinerator, which is scheduled to be operational in October 2008. A review of the contract for the construction of the Food Bank and Personal Center raised questions about the norms and practices of the use of "Demon" whose active chemical is cypermethrin ­ a moderately hazardous (Class II) pesticide. The Bank does not finance formulations of products in Class II (WHO) unless (a) the country restricts their distribution and use; and (b) they are not likely to be used by, or be accessible to, lay personnel, farmers, or others without training, equipment, and facilities to handle, store, and apply these products properly. It was determined that both conditions have been met. Demon PC (Pest Control) is a product that can only be purchased by registered firms. In the case of the Food Bank, the contractor sub-contracted the pesticide application to a registered pest control firm. Given that the product has a restricted distribution, it is not likely to be used by, or be accessible to, lay personnel, farmers, or others without training, equipment, and facilities to handle, store, and apply these products properly. Health Care Waste Management (HCWM) Action Plan Results 1) MoH adopted WHO HCWM guidelines; 2) An old incinerator was demolished; the existing incinerator was improved to function as back up for the new one; 3) A HCWM committee was formed and is functioning with quarterly meetings; 4) The Final Report from the Consultancy "To Design a Medical Waste Management System for Barbados" was accepted by the MoH, and was reviewed by the Bank; 5) The tender process for the incinerator was initiated; 6) Public education & awareness on disposal of sharps is periodically done by the MoH. Actions pending 1) HCWM Stakeholders Forum; 2) Continuous capacity building program; 3) Procurement and installation of incinerator, which is scheduled for October 2008. The inherent fiduciary risk of the operation was low because of the transparent fiduciary environment prevailing in Barbados. Barbados generally has high marks from Transparency International (6.9 in 2007). However, a QAG Panel rated the overall quality of supervision of this project as Moderately Satisfactory (3 on the 6 point rating scale). It rated the Focus on Development Effectiveness and Adequacy of Supervision Inputs and Processes as Satisfactory (2) and the Supervision of Fiduciary/Safeguard Aspects and Candor and quality of ISR as Moderately Satisfactory (3). The reasons for this were the following: audit reports for the years ending 31 March 2002, 2003, and 2005 were submitted late without remedies taken by the Bank team. The review of the 2004 audit report was done untimely due to a switch in responsibilities in the FM unit. Between 2001 and 2005, the client did not comply with the legal covenant to submit 18 quarterly PMRs. Only in 2006 effective steps were taken to ensure that these reports were submitted. The supervision mission in November 2004 (not joined by a FMS) identified FM staff shortages (not the lack of skills of current staff) as the main reason for the sub- standard fiduciary performance. There was little evidence of FM supervision activity and/or support provided during FY05 apart from reviewing audit reports. However, the situation was eventually corrected, and the QAG considered FM supervision conducted in FY06 highly satisfactory. In 2007, both Government and Bank fiduciary performance were satisfactory. All withdrawal applications to fully utilize loan funds were submitted before the revised closing date. 2.5 Post-completion Operation/Next Phase Given the satisfactory progress of the first project and the remaining unfinished work, the GOB has requested a loan that would contribute to tackling the outstanding challenges posed by the HIV epidemic. The request has come from the highest levels of the GOB. The Bank responded to the specific request of the GOB with the preparation of a project that will follow a results-based financing approach, and support the implementation of the 2008-2013 Barbados National HIV/AIDS Strategic Plan, specifically to increase: · Adoption of safe behaviors, in particular amongst key groups at higher risk. · Access to prevention, treatment and social care, in particular for key groups at higher risk. · Capacity of organizational and institutional structures that govern the NAP. · Use of quality data for problem identification, strategy definition and measuring results. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation The initial design of the project, focusing on supporting and expanding Government efforts, was very relevant to the situation in Barbados at the time of loan approval, and it continues to be highly relevant today. The PDOs and plan of action to achieve the 5-year strategic objectives of Barbados on HIV/AIDS followed a structure that responded to the needs for HIV/AIDS care and treatment in the country in 2001. The original PDOs were relevant, considering the projected course of the epidemic that was valid at the time, in which the number of known PLHIV and of those under treatment was expected to be high in the years following loan approval. However, the project did not have a specific PDO related to prevention and the adoption of protective behaviors by youth and hard-to- reach groups at higher risk. Barbados was the first country in the world in which the Bank financed ARV, which had favorable impacts on mortality, hospital length-of-stay, and health system costs. However, as previously stated, the introduction of ART in Barbados predated the program, and its use was expanded during program implementation, which might have contributed to dilute the importance of prevention activities. The project components, activities and 19 institutional arrangements reflected most of the current thinking and experience formulating a multi-sector approach to HIV/AIDS at the time the project was approved. These were still substantially relevant by loan closing. However, component activities tended to be skewed towards care and treatment at the expense of initiatives to improve knowledge, attitudes and practices. More analysis could have been done on NHAC's ability to prioritize interventions given that baseline data were mostly unavailable when the project started. The second project will strive to reach a better balance between prevention and treatment, and to develop a specific plan to reach key groups at higher risk of HIV. 3.2 Achievement of Project Development Objectives: Satisfactory Today, HIV/AIDS is under control in Barbados, and the challenge is to continue reducing transmission while sustaining treatment and quality of life for those living with the disease. To date, through the initial support of the Bank, the Barbados HIV/AIDS Program has achieved high levels of awareness, treatment and care. However, it has been less successful in inducing the level of sustained behavior change required for prevention and control of the epidemic. Main Project Achievements Barbados has put in place a comprehensive prevention and treatment program, with the following main results: · AIDS mortality declined by 72% between 2001 and 2006. · New AIDS cases declined by 46%. This refers only to AIDS cases, which have declined as a result of treatment. · Hospital admissions for treatment of opportunistic infections in PLHIV decreased by 42%. · Maternal transmission was kept at very low levels (below 2 cases per year). · Blood supply remained safe with 100% testing. · Share of people reporting positive attitudes towards PLHIV rose from less than 40% to nearly 80%. · The community voluntary counseling and testing program, including training of more than 100 new counselors, was launched and expanded. · A world-class testing laboratory was established at Ladymeade Reference Unit. · The pharmacy system was strengthened, with all necessary ARV available for all PLHIV who qualify. · The project was the first World Bank- financed project to support antiretroviral treatment. Remaining Challenges · Estimated HIV prevalence has not been reduced and the number of reported cases continues to rise. This refers only to HIV cases, not AIDS cases, which have declined as a result of treatment. · Feminization of the epidemic has been rapidly increasing; the male-to-female ratio now stands at 1. · Key groups at high risk of infection (sex workers, beach boys, men who have sex with men, prisoners and others) require better, more effective outreach activities. 20 · Social care of PLHIV needs to be strengthened. · Condom procurement and distribution to key groups at high risk should be improved. · M&E system should be fully functional. · Evidence and data should be a key factor in designing future programming. · Information flows and reporting should be more robust. · Multi-sector institutional roles and relations need to be clarified and solidified PDO 1: Reduce the rate of new HIV reported cases This objective was only partially achieved. The first case of HIV/AIDS was detected in Barbados in 1984, at a time when the epidemic was confined to men who have sex with men (MSM). However, the number of reported HIV cases continued to rise, particularly among self-reported heterosexual men and women of reproductive age. There are about 2,100 people known to be living with HIV (PLHIV) in Barbados, but MHNI estimates suggest that the total number of infected adults may be significantly higher. The reported HIV and AIDS cases represent the visible part of the epidemic. Studies estimate that approximately one-third of the HIV-positive population does not know their HIV status. Reported HIV and AIDS Cases and Deaths and PLHIV: 1984-2006 HIV AIDS Deaths PLHIV Total cumulative reported cases 3,241 2,025 1,329 1,912 The Caribbean Region continues to have the highest HIV prevalence among adults outside Sub-Saharan Africa. The estimated prevalence rate increased in Barbados from 1.3% in 2001 to 1.5% in 2006. The graph below shows that while new AIDS cases and AIDS mortality significantly declined (46% and 72%, respectively) since the advent of anti-retroviral treatment in 2001, estimated HIV prevalence continues to increase. Summary Profile of reported AIDS and HIV cases 1984 to 2006 250 2500 )sh 200 2000 eatD & )VIHLP( SDIA,VIH( 150 1500 ce en evalrp asesC 100 1000 detropeR edtroper VIH 50 500 0 0 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year AIDS HIV Deaths reported HIV prevalence (PLHIV) 21 In 2006, over 75% of reported infections occurred in the 15 to 49 years age group, and overall this group comprises 77% of all reported cases since 1983. In addition, the epidemic has been steadily feminizing (typical of an epidemic as it matures), with a male to female ratio of 1:1 in 2006. Until 2004, the highest proportion of AIDS cases was found in the 30 to 39 years age group, but since then the 40 to 49 age group has had a higher proportion of cases. The median age at HIV and AIDS diagnosis has risen overall, from 35 years of age in 2001 to 39 years in 2006 (28 in 1990 to 38 in 2006 in females and 31 to 42 in males). Trends in age at AIDS onset from 1983 to 2006 70 0 to 9 yrs 60 10 to 19 yrs 20 to 29 yrs 30 to 39 yrs 50 40 to 49 yrs 50 to 59 yrs asesc 40 over 60 SDIA Poly. (40 to 49 yrs ) of erb 30 m nula 20 nnuA 10 0 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 -10 Year However, maternal transmission was kept at very low levels with the number of infants born to HIV infected mothers kept below 2 per year in 2005 and 2006, and new AIDS cases declined by 46% (this refers only to AIDS cases, which have declined as a result of treatment). Maternal transmitted HIV has been substantially reduced, with only one child born HIV positive in the last two years. An evaluation study of the PMTCT program in Barbados revealed that there has been a major positive impact through intervention with prophylactic anti-retroviral drug therapy, with a significant decrease in transmission of HIV. 22 HIV Prevalence (percent) in Pregnant women 1.80% 1.67% 1.60% 1.63% 1.58% 1.40% 1.20% 1.19% 1.21% 1.13% 1.11% 1.00% 0.90% 0.90% 0.89% 0.89% 0.92% 0.89% 0.80% 0.81% 0.60% 0.54% 0.40% 0.28% 0.20% 0.00% 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 The blood supply is reported to be safe due to universal HIV screening of all blood and blood products. Epidemic-related knowledge, attitudes and practices (KAP) do not seem to have significantly changed among youth; and condom use, especially among most vulnerable groups, is low. The percent of youth able to correctly identify ways of preventing the sexual transmission of HIV, and who had no misconceptions about HIV transmission, increased only from 0.1% in 2001 to 1% in 2006. However, other evidence from the 2001, 2003 and 2005 youth KAP surveys indicate that educational messages have been successful in raising knowledge levels but less so in affecting changes in unsafe practices. The median age at first sex did not significantly change during the life of the project. Only about 27% of young men and 16% of young women report having used a condom the last time they had sex with a non-marital, non-cohabiting sexual partner in the last year. Data show that sex workers (SW) use condoms 80% of the time with clients, and condom use among men who have sex with men (MSM) is reported to have increased. However, the end-of-project targets for condom use of 85% use among men and women 15-24 years were too ambitious, considering the reported 2002 and 2005 percentage use among men and women 15-24 years. Studies estimate that approximately one-third of the HIV-positive population either does not know their HIV status or are not accessing the comprehensive treatment and support system of the National AIDS Program (NAP). The community voluntary counseling and testing program, including training of more than 100 new counselors, was launched and expanded. A world-class testing laboratory was established at Ladymeade Reference Unit. The percentage of people benefitting from VCT increased 17% from 2002 to 2006. However, a review of the National AIDS Program2 indicated that since the start of the 2National AIDS Program 2007. The HIV/AIDS Situation in Barbados 1984-2006. 23 program, the general population is not accessing VCT services significantly. This is especially true for people who engage in high risk practices. Surveys show that many have taken a test (46%) at one time for reasons such as pregnancy, insurance, loans or travel, but less than 10% of those who practice inconsistent condom use and have multiple partners seek testing. A behavior change communication strategy was approved under the first project, and implementation started under the first project and will be continued under the second one. PDO 2: Increase the life expectancy of persons living with HIV This objective was achieved by increasing HIV to AIDS survival and AIDS to death survival. The GOB has put in place a free, comprehensive treatment and care program for PLHIV. In 2007, there were 1,102 PLHIV registered at the LRU; of these 615 are receiving anti-retroviral treatment (all those who require ART)3. HIV-related deaths were reduced by 72% since the beginning of the project in 2001 and the end of 2006, as a result of the policy to provide antiretroviral treatment free of charge; 96% of infected pregnant women received a complete course of ART to reduce the risk of mother-to-child transmission, which kept infection among infants born to HIV+ mothers at very low levels (2.6%). About 85% of adults with advanced HIV infections received ART in 2005, and about 97% of diagnosed adults living with HIV were still alive 12 months after initiation of treatment in 2006. Median survival rates have risen steadily with 81% of those enrolled between 2002 (first full year of ART) and 2006 still alive by the end of 2006. One-year AIDS survival has risen from 65% in 2000 to 95% by the end of 2006. By the end of 2006, 65% of those diagnosed with AIDS years ago were still alive. The most likely reasons for this increase in survival are the improvement in early detection of HIV and advances and success in ART in prolonging lives of PLHIV. Trends in 12months survivial after AIDS Diagnosis by Gender 100.0% si 90.0% gnosa diretfa 80.0% sht 70.0% m 12 60.0% anht ero Male 50.0% m Female gnivirus 40.0% A WLP 30.0% of onit 20.0% oporrP 10.0% 0.0% 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year of AIDS Diagnosis 3MHNI 2008. HIV/AIDS Surveillance Report January-June 2007. 24 Key stakeholders and studies attribute the dramatic reduction in mortality to the expanded response supported by the project, including the introduction of ART, and care and support service delivered through the centralized clinic services of the MHNI and the private sector. The project was the first World Bank-financed project to support antiretroviral treatment. The pharmacy system was strengthened, and is able to provide all necessary ARV to all patients who qualify, at reduced prices; and a world-class testing laboratory was established at Ladymeade Reference Unit. The percentage of lab testing increased 22% from 2002 to 2006. Laboratory capacity was built up, with the Ladymeade Reference Unit Lab being able to test all identified PLHIV for viral load and CD4. The LRU is making arrangements to initiate testing of viral resistance to ART drugs. All necessary equipment has been procured and installed. The government is currently seeking to provide laboratory services at a fee to other countries in the Caribbean. PDO 3: Improve quality of life of PLHIV This objective was achieved. More than 65% of the estimated number of PLHIV and over 90% of the diagnosed AIDS patients are accessing services. However, this data does not apply to the non-citizen residents of Barbados, who are not eligible for the NAP's care and treatment services. Also as a result of the ART policy, hospital admissions for treatment of opportunistic infections among HIV patients decreased by 42%, and the total number of hospital days fell by 59%. The share of people reporting positive attitudes towards PLHIV rose from less than 40% to nearly 80%. A Health and Social Services Utilization Study (HASSUS) showed that quality of life of patients receiving treatment and support increased by 14% in the first 18 months of the program. However, the study also showed that PLHIV receiving treatment and support continue to be marginalized from the workplace and from comprehensive health and supportive services as a result of self-stigma and discrimination. According to this study, while a PLHIV may not have been involved in sex work, there is a risk that he/she turns to this form of employment, formally or informally, as a means of generating economic sustainability within their household. A prospective study of women receiving PMTCT services showed that almost 25% of previous HIV positive mothers returned to the service pregnant within 2 years, with a different "father-to-be". Disclosure of HIV status in such situations is not common among HIV positive persons. Renovation of the Edgar Cochrane Polyclinic was completed by loan closing. Construction of the Food Bank by China State Corporation was 70% completed, with completion expected for March 2008. However, social care of PLHIV needs to be further developed under the second project. PDO 4: Build sustainable institutional arrangements for managing the HIV/AIDS epidemic. This objective was achieved. Extensive work has been done to put in place the UN "Three Ones" principles: there is (i) one agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners; (ii) one national AIDS coordinating authority (NHAC), with a broad-based multisectoral mandate; and (iii) a monitoring and evaluation system has been established. However, as mentioned before, 25 the M&E system remains the element of the "Three Ones" that most needs additional work, and institutional roles need to be further strengthened. A true multisectoral approach to HIV/AIDS prevention and control has been put in place. The HIV/AIDS Strategic Plan was prepared under the project, it was reviewed by UNAIDS and ASAP, and approved by the government shortly after loan closing. An HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners has been agreed under the project. A National AIDS Coordinating Authority, with a broad-based multisectoral mandate, is fully functional. The M&E system was established and strengthened. Of 18 Ministries, 15 report annually to NHAC on their respective HIV prevention programs. The number of AIDS-related CSO reporting annually to NHAC increased from 4 in 2002 to 11 in 2007. The percentage of enterprises targeted by the Project, which have HIV/AIDS policies and programs in the workplace, has increased from 5% in 2003 to 75% in 2007. All participant agencies have increased the awareness of their constituencies over the life of the project. NHAC has facilitated the coordination and implementation of the project through the implementing partners, managed the project resources, and has served as the main counterpart of all financing and technical assistance groups. The resulting "Barbados Model" successfully built sustainable institutional arrangements. The M&E system was established and strengthened. However, progress has been uneven across institutions and a number of shortcomings have emerged that challenge the long- term success of the system. Multi-sector institutional roles and relations, especially between NHAC and key ministries such as the Ministries of Health, Education, Social Transformation, Labor and Tourism, have to be further developed. NHAC continued supporting periodic meetings and technical working groups (TWG), but some TWGs have played only a minor role in the development of new initiatives and institutionalizing systems. In the context of project supervision and preparation of the follow on project, PDO and PDI were reviewed in depth, and the M&E framework was updated. The NHAC submitted an inventory of 32 surveys and other studies that were carried between 2001 and 2007. Project M&E was established during the first half of the project and the national M&E framework and operational plan, which includes the strategic flow of information and data, was finalized before loan closing to be implemented under the new project. In terms of staffing, NHAC has a program unit manager but no M&E officers, and the Department of Youth Affairs of the MES has a Research Officer and MES has a Planning and Research Unit. All HIV testing for the country has been carried out by the QEH, which is also the main source of information for sentinel surveillance. Sentinel surveillance data is being recorded manually at QEH and entered into a database at MH. NHAC, MH and the MES/Department of Youth Affairs have carried out a number of studies on HIV prevention practices, care and treatment and epidemiological trends. SHIP is a PLHIV database at the LRU, which includes patient information from the time of enrollment, as well as care and treatment. The MH does receive information from all health services, but has not structured a health management information system. With the assistance of CAREC and WHO/PAHO, the MH is strengthening the disease surveillance program to structure a robust and comprehensive information system. 26 Seroprevalence and KAP surveys will be carried out under the new project to enable NHAC to make strategic decisions based on robust evidence. Conclusions, recommendations and lessons learned Overall, the project had a dramatic impact on ultimate outcomes. The share of persons with advanced HIV infections who are receiving treatment has risen from 12% to more than 80%. Annual deaths from AIDS have declined by more than 70%. The share of people reporting positive attitudes toward persons living with AIDS has risen from less than 40% to nearly 80%. Equally important, Barbados has proven the feasibility of providing sustained HIV care and treatment and provided key lessons for its neighbors and other countries. Prevention programs have also grown substantially. Although not all intermediate project targets were reached, it is clear from today's greater knowledge of HIV/AIDS that some of these were unimportant to controlling the epidemic. Consequently, the project is regarded as having been successful. It also disbursed in full. The key challenges for the next phase will be to institutionalize better monitoring and evaluation practices, improve outreach to the groups at highest risk, and achieve safer sexual practices among young people. The new national strategy focuses on these areas, as will the next operation. HIV/AIDS prevention campaigns designed to reach key populations at higher risk have not significantly affected sexual practices. Part of the challenge lies with the fact that key populations at higher risk have to be better involved in the prevention and control work; and there has not been comprehensive training in behavior change communication (BCC). IEC contributed to the achievement of high levels of awareness among the general population; it is recommended that the program moves into the implementation of the comprehensive BCC strategy involving key groups at high risk of infection. Outreach for key populations at higher risk needs to be improved but this will be challenging. As a relatively small country, with close-knit family and social networks, people are often reluctant to identify themselves as being part of a vulnerable group, and may avoid government services and their perceived lack of confidentiality. The conservative nature of Barbadian society has also resulted in the social prohibition of providing condoms to men in prison and an overwhelming public outcry against recommendations to decriminalize anal sex among consenting adults. The regional nature of the sex trade, with workers moving frequently among islands, further complicates attempts to reach them. By working more closely with CSO that have the trust of these vulnerable groups, services can be made more readily available to them. The Ministry of Education Youth Affairs activities have been considered by NHAC "star projects" for their consistent efforts in educating young people. The school curriculum on HIV has been institutionalized, as well as the work with the out-of-school populations. To move forward, the DYA staff indicated that they would like to expand prevention activities to include more youth groups; to focus more on counseling and to receive further training on BCC strategies. It is also recommended that the DYA continue implementing KAP studies standardizing the analysis, and complement these with in- 27 depth studies to assess the beliefs about modes of transmission of HIV, sexual practices and preventive behaviors in order to refine BCC strategies. While the National AIDS Program has engaged in voluntary counseling and testing (VCT), further collaboration with community groups and CSO will make VCT more available. Building capacity among CSO that work with key populations at higher risk such as men who have sex with men (MSM) and sex workers (SW) to perform VCT will greatly increase access, as well as referral to treatment and care, for these underserved groups. Implementing rapid testing could increase the number of organizations that can offer HIV testing services and further increase the number of people tested who return to get their results. The laboratory and blood bank should maintain their current activities and standards. Issues that still need to be addressed are improving the turn-around time of test results, implementing rapid tests (mainly in peripheral areas), engagement of more workplaces in HIV testing, and implementing the "opt-out" approach to testing within the health system. The LRU needs support to procure reagents and to purchase equipment for introducing rapid tests, and for carrying out sero-prevalence studies. While initial successes were many, effort will be required to sustain case management and treatment. Surveillance of drug resistance needs to be included in the overall M&E system. The number of patients requiring ARV will continue to grow, as the incidence of HIV may continue to increase in the short-term, and prevalence will continue to increase due to longer survival of PLHIV under treatment. The second project would continue to support ART and finance ARV, as these represent a relatively small percentage of the HIV/AIDS budget (less than 20%). Social care of people living with HIV (PLHIV) also needs strengthening. PLHIV are currently assigned to a social worker if necessary, but access to psychological support services or home care needs improvement. The Ministry of Health, National Insurance and Social Security (MH) reports a great need among PLHIV and high risk groups for counseling and support on drug use (alcohol, marijuana and cocaine). A study by the National Council on Substance Abuse reported that less than 4% of respondents (10 out of 278) in 2005 engaged in intravenous drug use. However, the lack of judgment brought on by drug use (intravenous or other) is often accompanied by high risk sexual behavior and/or sex being traded for drugs. In addition to improving the quality of life of PLHIV and key populations at higher risk, providing individual and group drug counseling can also contribute to reducing HIV transmission. Finally, multi-sector institutional roles and relations have to be further strengthened, especially between NHAC and key ministries such as the Ministries of Health, Social Care, Education, Labor and Tourism. Although the framework for the national HIV/AIDS strategy is multi-sectoral, the reality is that on the ground it has proven challenging to coordinate all of the Program's partners. Some institutions lack dedicated HIV coordinators, and in some instances resources to fully cooperate and share information with the NHAC. The MH is responsible for important essential public health 28 functions, some of which ­ for example, surveillance ­ also need strengthening. The Commission continued supporting periodic meetings and technical working groups; however, some TWGs have played only a minor role in the development of new initiatives and institutionalizing systems. The human resources constraint remained a problem during the life of the project. The recruitment and hiring process was extremely slow, and in some cases took more than two years. A human resources development policy is needed. 3.3 Efficiency An economic and financial analysis was not carried out before loan closing. However, the net present value of the benefits of the new project were estimated at US$295 million, with an internal rate of return of over 85 percent over ten years. These benefits would be due to savings in hospital, outpatient, and general treatment and support costs of prevented infections, as well as to the indirect gains of increased productivity due to improved health and longer lives. The assessment of the long term sustainability of the activities supported by the new Bank loan shows that, at the end of the project, the GOB would be assuming total new recurrent costs of less then 2 percent of the current public national health sector expenditure. Given the stability of the Barbados economy and its projected growth over the next five years, this increase in recurrent costs is sustainable. The first project also contributed to reduce human suffering and costs of AIDS for families, the health system and the economy. These effects allowed Barbados to significantly reduce the risk of losses in GDP, poverty rates, and erosion of social cohesion. As expected, the project allowed Barbados to continue to manage the epidemic through the longer term. However, due to the urgency caused by the epidemic, the NAP initiated activities without prioritizing interventions on the basis of cost-effectiveness. Also, as previously mentioned, the program favored care over prevention and had a limited understanding of the nature and drivers of the HIV epidemic, which meant that some activities did not target interventions on the basis of this information. Civil society organizations tended to focus on narrow aspects of health education, and it might have been possible to add other interventions such as BCC and condom promotion without significant marginal costs. Finally, the government's coordination of various HIV/AIDS resources and inputs from different sources could have been more robust, which would have made NHAC more efficient. 3.4 Justification of Overall Outcome Rating With a substantial rating for project relevance (4 out of 4); substantial for project efficacy (3 out of 4), and substantial for efficiency (3 out of 4), the overall outcome rating is satisfactory (10 out of 12). 29 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development. The project contributed to the reduction of human suffering and costs of AIDS for families, the health system and the economy, which allowed Barbados to significantly reduce the risk of losses in GDP, poverty rates, and erosion of social cohesion. The feminization of the epidemic has been rapidly increasing, with a male-to-female ratio which now stands at 1:1. The Ministry of Social Transformation works with single, unemployed and dependent women, who were identified as one of the key groups at higher risk of infection. HIV/AIDS is closely related to low socio-economic status and low level of education. The HASSUS quality of life component showed that employed PLHIV had been either fired or removed themselves from the workplace, and had the lowest mental health of all the groups observed, despite major increases in their physical well being. In addition, all members of the group that were fired from their jobs expressed that they did not want to return to the workforce and hence remained unemployed after 2 years of treatment. Under the project, the Division of Youth Affairs of the MES provided skills training to youth and helped them improve their economic conditions. Welfare Department identified PLHIV for additional support. Finally, the Food Bank was an initiative directly aimed at helping poor PLHIV. (b) Institutional Change/Strengthening. Institutional capacity to implement the national HIV/AIDS Program has been put in place under the project. The National HIV/AIDS Commission (NHAC) is responsible for overall coordination of the response to ensure complete coverage, without gaps and unnecessary duplication in the implementation of the National AIDS Strategic Plan. The National HIV/AIDS Commission's Secretariat performed the functions of Project Coordination Unit. Each ministry is responsible for the design, work plans, budgeting, procurement, implementation, and M&E of its own activities. The NHAC and MH provide technical assistance to ministries as needed. The ministries have the technical capacity to implement the national HIV/AIDS Strategic Plan through the designated HIV coordinators/focal points. Unlike some other parts of the world, in Barbados the fight against the HIV/AIDS epidemic is mainly led by the Government. However, CSO and private sector groups participated in the project. There are approximately 11 CSO working on AIDS-related issues in the country. The majority has been recently established and faces challenges in terms of their organizational and institutional capacities, staffing and resources. An important advance in recent years has been that the NHAC has managed to get faith-based organizations from different religions, considered a critical ally in the Barbadian context, engaged in prevention efforts. Parishes and communities have been mobilized and empowered to implement HIV/AIDS interventions. Led by the trade union movement and the International Labor Organization, approximately 11 private businesses now have workplace programs in place, and others finance and volunteer staff or are exploring possibilities for prevention programs through their corporate social responsibility programs. 30 (c) Other Unintended Outcomes and Impacts (positive or negative): As previously mentioned, this was the first project ever to involve Bank finance for ART. Although it stirred a fair share of controversy at inception, it has unquestionably proven a success, and enabled Barbados to establish an early and positive example that helped inspired later donors and new agencies to make HIV treatment a worldwide priority. As such, this could also be considered a demonstration project whose outcomes have far exceeded its own PDOs. Barbados and the Bank should take pride in having been catalysts for a global undertaking that has thus far saved more than two million lives. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops. A survey of beneficiary satisfaction and a stakeholder workshop were not carried out before loan closing. However, information about knowledge, attitudes and practices has been collected on a biennial basis among youth by the Ministry of Education's Division of Youth Affairs. Consultation meetings with implementing partners were held regularly during the preparation and implementation process of the new HIV/AIDS Strategic Plan. In addition, social and institutional assessments were carried out as part of the preparation of the new project to identify beneficiaries and their needs, assess the institutional arrangements in place to fill those needs, and identify necessary institutional changes for successful project implementation. In general, stakeholders are satisfied with their level of participation, especially during the preparation of the new Strategic Plan. 4. Assessment of Risk to Development Outcome The risk to the development outcome is negligible to low for the following reasons: Increased Prevention Capacity. The initial awareness campaigns were successful, and a BCC Strategy was approved and is under the initial stages of implementation. The second project would focus on prevention strategies better targeting the drivers of the epidemic and key groups at higher risk of HIV/AIDS. Limited increase in recurrent costs due to treatment. Barbados obtains ARVs at low cost, and their cost is about US $2 million a year, which is a small fraction of the MH budget (about $350.6 million in FY07). Financial support for the National AIDS Program. The Barbados Cabinet has already mainstreamed the annual budgets for most project interventions, and is able to finance about 70% of its activities. A follow-on project is currently under development, which would continue to provide technical and financial support to the program, and would address some persistent weaknesses in program activities, increasing the likelihood of sustainability. Increased institutional Capacity. NHAC main role was to institutionalize all of the program activities within line ministries and civil society organizations, work which achieved significant success during the project's implementation. The MH and MES were the main implementers of the project, and both have institutionalized the interventions into their regular program activities. 31 Improved M&E system. The improved M&E system will allow the NHAC to keep track of activities, measure results, address HIV in an ever increasingly efficient manner, and base on evidence further strategic development. Increased HR capacity. The project attempted to incorporate best practices from around the globe in project activities, and as such staff received training in M&E, BCC and other aspects of running a national HIV/AIDS program. It is highly likely that many of these trained professionals will continue to work in the NAP and will share knowledge with co-workers. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance: Satisfactory (a) Bank Performance in Ensuring Quality at Entry: Satisfactory Overall, the technical, institutional and financial aspects of the project design were appropriate. Project objectives were responsive to and supportive of the National HIV/AIDS strategy, and the project was structured in accordance with a standard Multi- Country AIDS Program (MAP) for the Caribbean Region. The design also followed lessons from other MAP Projects and other sectors. The project design team carried out consultations, and prepared detailed plans for project start-up. However, in hindsight, based on knowledge accumulated since the project was prepared, the design could have been strengthened by: (i) development of a prevention approach for key groups at higher risk of infection; (ii) closer relation between surveillance, monitoring and evaluation, prevention and treatment; (iii) early development of M&E, with more specific indicators; and (iv) inclusion of a capacity building program, particularly for CSO. (b) Quality of Supervision: Satisfactory As previously mentioned, a QAG Panel carried out in 2006 rated the overall quality of supervision of this project as Moderately Satisfactory (3 on the 6 point rating scale). It rated the Focus on Development Effectiveness and Adequacy of Supervision Inputs and Processes as Satisfactory (2) and the Supervision of Fiduciary/Safeguard Aspects and Candor and quality of ISR as Moderately Satisfactory (3). The Bank carried out regular supervision missions, with emphasis on the provision of health services, M&E and institutional arrangements. The Bank supervision team included sector, safeguards and fiduciary specialists, who provided technical support and assistance to the program's implementing partners, and identified and addressed critical fiduciary, safeguards and M&E issues in a timely manner. During the life of the project, task leadership changed twice. The first change occurred in the beginning of project implementation. When the second TTL took over in 2004, identified weaknesses were addressed, including implementation delays, safeguards concerns, procurement difficulties, and most importantly, development of a BCC strategy and M&E. The second change of TTL occurred less than six months before loan closing, as project activities were being evaluated and the follow-on project was being prepared. 32 (c) Justification of Rating for Overall Bank Performance Despite some weaknesses in project design and supervision, which were identified by MTR and corrected during project implementation, Bank financial and technical assistance has been contributing to the achievement of significant results in preventing and controlling the epidemic in Barbados. 5.2 Borrower Performance: Satisfactory (a) Government Performance: Satisfactory The Government of Barbados (GoB) is fully committed to containing the epidemic. Extensive work has been done to put in place the UN "Three Ones" principles: Counterpart funding was available as planned throughout the project. There are areas in which Government performance could, however, have been improved. In addition to the weak M&E framework, the QAG identified the failure of the Government to give priority to implementation of the prevention component and implement an appropriate medical waste management program, and weak arrangements for procurement on the part of the GOB and the Bank. These problems were inherent in the project design and were exacerbated by inadequate attention in early supervision efforts. Many of these issues were first fully recognized at the time of the MTR, which provided a roadmap for subsequent supervision. (b) Implementing Agencies Performance: Satisfactory The Program called for eight key line Ministries and Government Information Service to establish HIV/AIDS Core groups with responsibility for designing and implementing HIV/AIDS prevention and control activities within their constituencies. Results of the work of line ministries are significant, with the exception of better involvement of key groups at high risk; in addition, community health services and home care had not effectively begun by loan closing. (c) Justification of Rating for Overall Borrower Performance Despite its weaknesses, Barbados has an impressive National HIV/AIDS Program in place. Most deficiencies were corrected before loan closing (BCC Strategy, M&E Framework in place, etc), and the remaining ones (focus on key groups at higher risk, seroprevalence surveys, etc) will be addressed by a follow-on project. Implementing Agencies Performance 15 ministries report to NHAC on HIV/AIDS activities. IEC is well organized with several ministries being active. These agencies succeeded in increasing public awareness through mass media campaigns on various aspects of HIV/AIDS, including risks and protection measures, promotion of safer sex practices and risk reduction, advocacy for human rights protection, abolition of discrimination practices 33 and learning to live with PLHIV4. KAP surveys have confirmed this success5,6,7. The MHNI assumed responsibility for the procurement and distribution of condoms for the program. Condoms were distributed to all agencies involved in the fight against HIV that had trained educators. Prevention and control of STIs was developed and scaled up. The prevention of mother to child transmission has been successful, with a 80% reduction in HIV transmission from mother to child. There are no reported cases of infection through transfusions at present. VCT reached over 20,000 people by 2007. Laboratory and pharmacy services installed equipment and trained five laboratory technicians to perform HIV tests. Capacity now exceeds that required for Barbados' own use and may be available to assist programs in other Caribbean territories. The Barbados Drug Service (BDS) has been upgraded to provide a satellite pharmacy at the LRU for PLHIV. ART coverage is substantial. 6. Lessons Learned Lessons learned from the implementation of this first project, including the results of the QAG, and from other HIV and AIDS projects in the Caribbean and elsewhere were considered in the design of the second project. The QAG recommended that the NHAC put more emphasis on a strategic approach aiming at targeting the most critical problems rather than at comprehensive problem-solving. This would involve a focus on improving (i) project monitoring, (ii) prevention efforts, including VCT, BCC, condom distribution and fighting stigma; (iii) financial management; and (iv) capacity in these areas. In addition, the lessons below were taken into account. The countries that have been most successful in dealing with HIV/AIDS - Brazil, Thailand and Uganda in the 1990s - are those that have confronted the issue head- on, advocating safe sex without embarrassment. Barbados' approach to prevention has resulted in an unfinished agenda in creating dialogue on issues of sexual practice in general, sexual activities among key populations at higher risk and adolescents, and the position of women in society. Lessons learned in other countries indicate that this can be done in a manner that is culturally appropriate and respectful of local traditions. In Jamaica and elsewhere in the Caribbean, there has been an increasing awareness that enabling environments are critical to the reduction of transmission of HIV/AIDS and increased access to treatment and care. This includes policy and legislative changes and workplace and sector-specific policies and programs, to safeguard privacy, and confidentiality and address stigma and discrimination. 4Government of Barbados HIV/AIDS Prevention and Control Program. Mid-Term Review. Dr. Beverly Miller and Dr. Robert Crown 5MEYAS 2001. Report on the National KAPB Survey on HIV/AIDS. 6MEYAS 2004. Report on the Secondary School Behavioral Surveillance Survey. 7MEYAS 2006. Report on the Behavioral Surveillance Survey. 34 Popular figures, particularly those admired by adolescents, need to be engaged in speaking openly about the risk of HIV/AIDS, how to protect themselves, and the importance of knowing their status and seeking appropriate care. HIV/AIDS prevention campaigns designed to reach particular groups have not significantly affected sexual practices. Part of the challenge lies with the fact that key populations at higher risk have to be better involved in the prevention and control work; and a comprehensive training program in behavior change communication (BCC) was in place just before project closing. PAHO research on HIV/AIDS in the Caribbean indicates that for PLHIV, especially women, there are considerable barriers and delays (averaging 16 months) between time of diagnosis and treatment. Half of the women surveyed who were currently on ART were placed on treatment immediately following their first visit, further confirming the late presentation to care. In an effort to guarantee the highest quality of care for PLHIV in Barbados, these services were centralized in the Ladymeade Reference Unit. Although this centralized strategy resulted in high quality care, it also stigmatized the clinic to the extent that PLHIV are reported to avoid going there. The second project would decentralize HIV/AIDS care and build a quality assurance system to maintain high levels of quality of care. Barbados was the first country in the world in which the Bank financed ARV, and in hindsight this was a very positive decision. As the number of patients requiring ARV will continue to grow, as incidence of HIV in the short-term and survival will continue to increase, the second project would also finance ARV, as ARV represents a relatively small percentage of the NHAC budget (less than 20%). Separation of biomedical waste is an important public health issue and should be continuously supported. Capacity building on waste management should be continuous due to attrition and the difficulty of maintaining staff up to speed on the latest developments. NHAC deserves recognition for its effort developing a National M&E Framework. With the improved M&E from this project, there will be better epidemiological data to assist in determining and targeting key populations at higher risk. This will include a greater emphasis on the drivers of the epidemic, including unsafe sex with multiple partners, the role of women in society, adolescents' lack of access to correct information on sexuality and STIs, and the abuse of alcohol and marijuana. Three assessment strategies could help NHAC and its implementing agencies (IPs) to establish a vision of an even stronger and more robust HIV/AIDS program. First, the collection of quantitative and qualitative baseline information on various population groups would focus NHAC and IPs' attention on the needs of beneficiary populations. Second, an institutional and training needs assessment would determine whether the IPs had the technical skills and materials to respond to those needs. Third, an in-depth audit of financial and administrative systems would focus the attention on whether NHAC and IPs could sustain HIV prevention and control activities over the long term. These three assessments would help NHAC and IPs to identify project management capacities and 35 weaknesses, and findings could prompt planning of activities to enhance financial and administrative systems. The success of a program is often directly linked to the energy, thought, and hard work of the people and organizations working on the program. The core implementing partners have been the MH, MES, MST, MPW and MTI, each of which had specific functions and responsibilities vis-à-vis specific key groups at higher risk. Other agencies, which were mostly in charge of prevention, impact mitigation and working with special groups, have had a more hesitant participation style and worked with smaller populations. The process for selecting partners needs to be kept transparent. It is essential that there be a good fit between new technical interventions and the implementing partner mission and mandate. Each IP needs to be provided not only with information about the expectations, requirements, and resource commitments of the new technical programming (e.g., advocacy; BCC; etc), but also on the appropriate methodologies and technical support to accomplish the expected results. It is important to keep the process accountable by making available the technical guidelines and administrative criteria for quality of proposals, and also to monitor their achievements based on standardized indicators. A human resources development policy is needed. There are not enough human resources trained and working in M&E in Barbados. Comprehensive training programs in M&E need to be designed and implemented. Improved human resources would allow NHAC, MH, MES and other agencies to support and institutionalize the work that is being carried out by the implementing partners. In Barbados, it often can take a year or more for a new public position to be created and filled and the GOB often relies on consultants in the meantime. Measures have to be taken to make sure that the work of consultants is properly documented for future reference and that their knowledge is institutionalized. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies Comments from the Borrower indicate that the first project sought to scale up diagnosis, treatment and care with secondary emphasis on prevention efforts among key populations at higher risk, while the ICR assumes that the project should have focused on key populations since its inception. Although the ICR recognizes the achievements of the Barbados AIDS Program on diagnosis, treatment and care, the lack of focus in key populations at higher risk was considered a weakness in project design and implementation, which should have been corrected by mid-term. This will now be a major focus for the follow up operation. (b) Cofinanciers (c) Other partners and stakeholders 36 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Appraisal Estimate Actual/Latest Components Percentage of (USD millions) Estimate (USD millions) Appraisal Prevention and Control of HIV/AIDS Transmission 5.675 3.550 62.6 Diagnosis, Treatment and Care for HIV/AIDS 14.267 24.678 173 Management and Institutional Strenghtening 2.660 9.565 360 Total Baseline Cost 22.602 37.793 167.2 Total Project Costs 22.602 37.793 Front-end fee IBRD .150 0.151 Unallocated .891 Total Financing Required 23.643 37.944 160.5 (b) Financing Appraisal Actual/Latest Source of Funds Type of Estimate Estimate Percentage of Cofinancing (USD (USD Appraisal millions) millions) Borrower 8.50 22.8 268 International Bank for Reconstruction and Development 15.15 15.15 100 37 Annex 2. Outputs by PDO and by Component Achievements of Component 1: Prevention and Control of HIV/AIDS Transmission (i) Key Groups at high risk: Moderately Satisfactory. The MHNI has a project with sex workers, and CSO work with men who have sex with men and other key groups at higher risk of infection. However, there was limited involvement of key groups at higher risk of HIV on preventive interventions. In general, with regard to prevention, there was more focus on IEC for the general population than on outreach work with key groups at higher risk of HIV. (ii) Adolescents in and out of school: Moderately Satisfactory. The number of primary schools providing life skills training increased under the project. The Ministry of Education's Division of Youth Affairs (DYA) carried out outreach activities with the population of 15-29 years of age. Activities included (i) sports organized by Youth Commissioners; (ii) performing arts such as music, community theater and poetry; and (iii) skills development & training, geared to improve job opportunities and income. All outreach activities included a strong HIV education component and peer-to-peer support. At the school level, the Ministry facilitated HIV awareness sensitization sessions for primary and secondary school teachers as well as ancillary staff. The MES also developed and included age-appropriate "HIV Modules" in the primary and secondary school Health and Family Life Education curricula. The DYA conducted HIV Sensitization Session among Parent-Teacher Associations. The DYA carried out three Knowledge, Attitudes, Behavior and Practice (KABP) surveys in 2001, 2003 and 2005 on the 15-29, 10-18 and 15-24 population cohorts, respectively. The studies did not use the same questionnaires and the operational definitions of the indicators were not standardized, so assessment of trends over time of knowledge, attitudes and the adoption of protective behaviors are not consistent. Nevertheless, DYA staff indicate that knowledge of HIV has improved to levels of more than 95%, but practices such as initiation of sexual activity, condom use and multiple partners have not changed significantly. (iii) Information Education and Communication: Satisfactory. Attitudes towards PLHIV changed positively during the life of the project. Recognizing the need for a paradigm shift in HIV, a national Behavior Change Communication (BCC) Strategy for Barbados was developed with Bank assistance, and it was recently approved. The process itself helped raising awareness with the result that BCC strategy recommendations have been integrated into the National Strategic Plan, and the Government tripled its budget for BCC. Barbados is one of the few countries in the region with an explicit BCC strategy and the first with a BCC strategy that focuses on youth and women. The BCC strategy would be implemented under the new proposed project. IEC activities were mostly the responsibility of NHAC through sensitization and training workshops, electronic and print media campaigns, billboards, exhibitions, health fairs, "branding" events, press- relations, promotional materials, condom distribution, etc., in collaboration with public and private sectors, civil society, multilateral and bilateral institutions. 38 (iv) Condom Distribution and Use: Moderately Satisfactory. Condom use among MSM is reported to have increased during project implementation8. However; condom use, especially among most vulnerable groups, is low. Condom distribution through social marketing, peer groups and other means of free distribution are the main responsibility of the MH. Condom distribution through the public sector represents approximately 1% of the total condoms distribution through all sectors. This quantity does not satisfy the overall need for the key groups at high risk of infection and condom use promotion. Officers from the Division of Youth Affairs also indicated that condom availability to cover their programmatic and promotional needs is insufficient. It was also noted that the tourism industry has generally been reluctant to promote condom use in some hotels. (v) Prevention and Control of STI: Satisfactory. The MH has made an effort to have STI case management as a main component of disease prevention. STI surveillance, limited in the past, will be included as an important component of the overall disease surveillance strategy under revision. The MH developed and implemented STI case management protocols and guidelines in 2006, which are gradually being institutionalized in all health facilities. STI diagnosis is mostly done through laboratory tests. (vi) Prevention of Mother to Child Transmission (PMCT): Highly Satisfactory. Antenatal prevalence rates among pregnant women fluctuate below 2 cases per year. In 2006, 37 HIV positive pregnant women delivered newborns, but only one child was diagnosed as HIV positive. Ante-natal care service is close to 100% in Barbados, and HIV screening rates have been as high as 93% in 2000 and 83% in 2006. However, data that was previously available for both the public and private sectors is now only reliably available in the public sector. The successful program is currently being strengthened. PMTCT guidelines were drafted in 2006 with the assistance of CHART. With the PMCTCT guidelines, a Policy document on PMCT approved by the Cabinet in 2008, and a PMTCT training curricula, PMTCT training will be rolled out in 2008. (vii) Control of Laboratories and Blood Supply: Highly Satisfactory. No HIV cases have been reported due to blood transfusion. Achievements of Component 2: Diagnosis, Treatment, and Care for HIV/AIDS (i) Strengthening Voluntary Counseling and Confidential HIV Testing: Satisfactory. The percentage of VCT increased 17% from 2002 to 2006. The total number of people tested and counseled between 2001 and 2007 was over 20,000. The table below depicts the number of pre-and-post counseling, testing and those who received the test results carried out by the MH VCT program during the five years of the project. All polyclinics have VCT services, trained personnel and tests are carried out at 8NHAC (in preparation). The Barbados Men's Lifestyle Survey, 2007. 39 the QEH main laboratory facilities, also facilitating disease surveillance. The community voluntary counseling and testing program, including training of more than 100 new counselors, was launched and expanded; a testing laboratory was established at Ladymeade Reference Unit, and VCT training has been institutionalized. Activities Years Total 2001 2002 2003 2004 2005 2006 Persons trained in VCT - - - 40 47 28 115 VCT sites established - - 3 4 4 0 10 Total Counseled Male 1,446 1,813 1,419 4,678 and Tested (all Female - - - 2,559 2,652 3,265 2,652 program interventions) Total 4,005 4,465 4,684 13,154 HIV Positive Male 112 107 106 114 77 - 516 (with the VCT Female 80 62 72 78 68 - 360 program and Unknown 18 15 6 4 2 - 45 before) Total 210 184 184 196 147 - 921 Received Post- 1,381 1,754 1,376 4,511 test counseling Female - - - 2,536 2,625 3,238 8,399 and results Total 3,917 4,379 4,614 12,910 However, in spite of program efforts, the general population is not accessing VCT services significantly. This is of special concern for key groups at higher risk of infection, such as sex workers, beach boys, men who have sex with men and prisoners, where prevalence rates are expected to be much higher than among the general population. Behavioral surveys show that many Barbadians have taken a test (46%) at least once but less than 10% of those who practice inconsistent condom use and have multiple partners seek tests for their purpose of their health maintenance. Percentage of Male PLHIV with Simultaneous, Delayed and Deferred AIDS diagnosis by period of HIV diagnosis 60 56.6 Simultaneous Delayed Deferred 55.3 50.2 50 48.0 45.0 40 38.1 34.5 geat 32.1 30cenreP 20 11.3 11.7 10.2 10 7.0 0 87 to 1991 1992 to 1996 1997 to 2001 2002 to 2006 Note: Adding the simultaneous and Delayed bars represents the total proportion of PLHIV that were diagosed AIDS within 1 year of HIV Barbadian males access VCT services at a later stage than females, and this pattern has been maintained throughout the epidemic. In 2003, the median CD4 count of males was 40 40 cell/mm3 and for females was 140 cells per mm3, while in 2007 it was 254 for men and 411 for women. However, the proportion of PLHIV that know their status more than one year before progression to AIDS is increasing steadily in both genders. A sign of slow yet steady success of the VCT program against the stigma of HIV testing is the rise in the proportion of males whose AIDS diagnoses is deferred from the diagnosis of HIV infection. However, the proportion of males (39%) whose first test is an AIDS diagnosis compared to females (25%) is still quite high. Percentage of Female PLHIV with Simultaneous, Delayed and Deferred AIDS diagnosis by period of HIV diagnosis 70 Simultaneous Delayed Deferred 65.0 61.4 60 51.4 50 48.8 42.7 40gea 37.2 entcr 30Pe 28.7 25.3 20 11.4 9.9 10 8.6 9.7 0 87 to 1991 1992 to 1996 1997 to 2001 2002 to 2006 Note: Adding the simultaneous and Delayed bars represents the total proportion of PLHIV that were diagosed AIDS within 1 year of HIV (ii) Strengthening Laboratory Capacity: Highly Satisfactory. Both staff and equipment were to be upgraded under the subcomponent. The percentage of lab testing increased 22% from 2002 to 2006. Laboratory capacity was built up, with the Ladymeade Reference Unit Lab being able to test all identified PLHIV for viral load and CD4. The LRU is making arrangements to initiate testing of viral resistance to ART drugs. The MH has installed equipment (flow cytometer for CD4, and a viral load machine and reagents for viral load testing), trained laboratory technicians for performing the tests and quality management (2 years diploma), and renovated workspaces. The project provided equipment and reagents. To date, the QEH, LRU and three private laboratories are fully functioning. All were evaluated in 2006 and are waiting for international accreditation. All laboratories have standardized their procedures through a procedures manual. (iii) Pharmacy Strengthening: Highly Satisfactory. The project aimed to introduce 11 ARV drugs. At loan closing, the drug dispensaries at LRU and QEH have more than 15 ARV drugs and a wide range of drugs for treating OIs. The MH has negotiated the prices of ARV and has been able to lower the cost of ART per patient. (iv) Strengthening Infrastructure for Community Health Services: Satisfactory. The MH trained more than 100 counselors to provide VCT services at the community level. However, the program is not fully integrated into the existing health system. 41 Follow-up rates and rates of patients tested who return for results still needs further strengthening. The MH plans to decentralize treatment to some polyclinics starting in 2008. (v) Expanding the Infrastructure for Treatment of Opportunistic Infections and Introduction of ART: Highly Satisfactory. In 2007, 1,102 patients were registered at the LRU and 615 were on ART. A group of PLHIV is treated in the private sector, and some of them are showing signs of virologic failure on second and third line therapies, which suggests viral resistance. The LRU provides care to PLHIV at all stages of the HIV and AIDS continuum. Care at the Unit is provided by a multidisciplinary team that includes: · Medical interventions focused on disease management, specifically the provision of ART. All approved drugs are free of charge to Barbadian citizens; · VCT to promote adherence to ART and other medications; · An in-house pharmacy that provides all medications needed; · A community outreach and domiciliary care component; · A case management information system that tracks individual patient progress and facilitates M&E. Achievements of Component 3: Management and Institutional Strengthening (i) Management Strengthening: Satisfactory. The Barbados project adopted a multi-sectoral approach that included line ministries, CSO and the private sector, which have increased the awareness and sensitization of their constituencies over the life of the project. NHAC has facilitated the coordination and implementation of the project through the various implementing partners, has managed the project resources, and has served as the main counterpart of all financing and technical assistance groups. NHAC's role as the nation's clearinghouse of information and training in the scaling-up of the multi-sectoral approach was strengthened. Of 18 Ministries, 15 report annually to NHAC on their respective HIV prevention programs. Each Ministry formed an HIV Core Group which is responsible for implementing HIV/AIDS prevention and control activities within their target populations. Some ministries had clearer roles, for example the Ministry of Education had very active roles with the youth both in and out of school, and carrying out population-based surveys. Also, the Ministry of Health has accomplished most of the activities that it committed to carry out in terms of prevention and care and treatment. The Ministry of Social Transformation scaled up its PLHIV social services programs. The National HIV/AIDS Commission has done considerable work with its civil society partners - CARE Barbados, United Gays and Lesbians Against AIDS Barbados, Barbados Evangelical Association, AIDS Society of Barbados - over the past two years with considerable results. As a result of these efforts, there has been greater civil society involvement and support from civil society for the National AIDS Program. The number 42 of AIDS-related COS reporting annually to NHAC increased from 4 in 2002 to 11 in 2007. The percentage of enterprises targeted by the Project, which have HIV/AIDS policies and programs in the workplace, has increased from 5% in 2003 to 75% in 2007. (ii) Project Monitoring and Evaluation: Moderately Satisfactory. Monitoring and evaluation systems were only partly established during the first project. Monitoring the epidemic in Barbados goes back to the mid 1980s. All HIV testing for the country has been carried out by the QEH, which is the main source of information for sentinel surveillance. Sentinel surveillance data is being recorded manually at QEH and entered into a database at MH. Epidemiological surveillance captures HIV cases through passive detection at ANC clinics and the blood-bank. SHIP is a PLHIV database at the LRU, which includes patient information from the time of enrollment, as well as care and treatment. The MH does receive information from all health services, but has not structured a health management information system. With the assistance of CAREC and WHO/PAHO, the MH is strengthening the disease surveillance program to structure a robust and comprehensive system. Seroprevalence and KAP surveys will be carried out under the new project to enable NHAC to make strategic decisions based on robust evidence. 43 Annex 3. Economic and Financial Analysis (including assumptions in the analysis) The initial economic analysis, which did not take into account the costs and benefits of ART, indicated that the expected rates of return were high (62.3% in the base scenario) and quite robust to changes in key parameters. In 2001, Barbados spent about US$8 million for drugs in the public sector, which represented 10% of public health expenditures. The estimated yearly cost of the ARV was expected to increase Barbados' expenditures for drugs by 30% or about US$2.6 million. A preliminary estimate of the impact of public sector financing of ARV drugs at negotiated prices would be to raise public expenditures by about 2%. The economic and financial analysis of the new project reaffirms these expectations. The net present value of the benefits of the new project were estimated at US$295 million, with an internal rate of return of over 85 percent over ten years. These benefits would be due to savings in hospital, outpatient, and general treatment and support costs of prevented infections, as well as to the indirect gains of increased productivity due to improved health and longer lives. The assessment of the long term sustainability of the activities supported by the Bank loan shows that, at the end of the project, the GOB would be assuming total new recurrent costs of less then 2 percent of the current public national health sector expenditure. Given the stability of the Barbados economy and its projected growth over the next five years, this increase in recurrent costs is sustainable. 44 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Names Title Unit Responsibility/ Specialty Lending Patricio Marquez Lead Health Specialist ECSHD Task Team Leader Supervision/ICR Joana Godinho Sr. Health Spec. LCSHH Task Team Leader Christoph Kurowski Sr. Health Specialist LCSHH Task Team Leader Marcelo Castrillo Health Specialist HDNGA M&E Juliana Victor-Ahuchogu Monitoring & Evaluation Spec. HDNGA M&E Gunars H. Platais Sr. Environmental Econ. LCSEN Safeguards Judith C. Morroy Procurement Analyst LCSPT Procurement Norma M. Rodriguez Procurement Analyst LCSPT Procurement Emmanuel N. Njomo Consultant LCSFM Financial Management Maria Lourdes Noel Sr. Program Assistant LCSHH TA Samia Benbouzid Program Assistant CESGM TA Que P. Bui Procurement Assistant LCSHH TA (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle No. of staff weeks USD Thousands (including travel and consultant costs) Lending FY02 1.78 FY03 1.74 FY04 7.20 FY05 1.17 FY06 2.12 Total: 14.01 Supervision/ICR FY02 3 55.47 FY03 2 25.88 FY04 9 54.59 FY05 11 56.43 FY06 21 87.88 FY07 18 94.35 FY08 13 76.78 Total: 77 451.38 45 Annex 5. Beneficiary Survey Results A survey of beneficiary satisfaction was not carried out before project closing. However, information about knowledge, attitudes and practices has been collected on a biennial basis among youth by the Division of Youth Affairs. Consultation meetings with implementing partners were held regularly during the preparation and implementation process of the new HIV/AIDS Strategic Plan. In addition, social and institutional assessments were carried out as part of the preparation of the new project to identify beneficiaries and their needs, assess the institutional arrangements in place to fill those needs, and identify necessary institutional changes for successful project implementation. In Barbados, key populations at higher risk include the groups indicated below. In addition, tourists, foreign sex workers visiting the island as tourists, and temporary foreign residents (owners of holiday houses, workers in outsourcing and regional trading companies, tourism and construction workers, exchange students, etc) make up a large percentage of the population living in the island. Estimates of size of Key Populations at Higher Risk in Barbados 2007 % HIV Highly Vulnerable Group Number Population Prevalence Female Sex Workers (estimate)9 400-1,600 0.6-2.24% NA Male Sex Workers NA NA NA MSM (estimate) 1,296 1% NA Prisoners 1,016 0.4 NA Substance users NA NA NA PLHIV 2,100 0.8 % 100% People with disabilities (2000) 13,142 4.6 NA Single, Unemployed and Dependent 4,200 1.5 NA Women (SUDW) Youth 15-24 years old 34,100 12.3 1.3 Work has started with some key populations, particularly SW, MSM and youth, but much needs to be done to extend preventive and treatment services to them. Available evidence shows that although some advances have been made in behavior change, the gap between knowledge and behavior is still large. There is a need to develop a more focused and systematic strategy to increase the levels of active and meaningful participation of vulnerable groups in design, implementation, monitoring and evaluation of prevention work through workshops, one-on-one meetings, focus groups or other appropriate methods. 9The project economic and financial analysis estimated the size of the female sex workers population as 0.6% of the female population 15-49 years, which probably underestimates the size of this group. 46 Key populations at higher risk and Government and Civil Society Partners Key Groups Government Partner Civil Society Partner SWs MH National Organization of Women Welfare Department UGLAAB Bureau of Gender Affairs MSM MH UGLAAB Welfare Department Bureau of Gender Affairs Ministry of Community Development and Culture Drug users National Council of Substance Abuse Centre for Counseling and Addiction MH Support Alternatives (CASA) Verdun House Prisoners Ministry of Home Affairs (education None and VCT) MH PLHIV MH CARE Barbados Ladymeade Reference Center Queen Elizabeth Hospital People with National Disabilities Unit BARNOD Disabilities Welfare Department MH Youth Ministry of Education HIV Community Committees Division of Youth Affairs and Sports Teachers' Union Single Bureau of Gender Affairs National Organization of Women unemployed Welfare Department women Ministry of Social Care, Constituency Empowerment and Urban Development Tourists and Ministry of Tourism Barbados Hotel and Tourism tourism staff Association To address the needs of the key populations at higher risk, the National HIV/AIDS Program will: Carry out studies to identify the size, HIV prevalence and behavior of each group, as well as gather other data and information about key populations at higher risk that can inform HIV planning and policy making. Carry out a continuous compilation and analysis of existing initiatives by governmental and non governmental organizations that work with key populations at higher risk. Continue to advocate for decriminalization of sex work and homosexuality, as existing discriminating laws have far reaching consequences in terms of identifying and reaching key populations at higher risk, learning about their behavior and determining prevalence, which prevents policy makers from formulating targeted programs and plans. Develop a strategy that encourages the active and meaningful participation of key populations at higher risk in design, implementation, M&E of prevention work to ensure a more structural and continuous participation of these groups. 47 Annex 6. Stakeholder Workshop Report and Results N/A 48 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR · The NHAC finds the original draft ICR prepared and submitted by Dr. Marcelo Castrillo to be an accurate and fair assessment of the Project. · There is a tendency within the document to re-interpret the original project description resulting in inaccurate statements. · There is a tendency to merge the facts about what occurred during the Project 1 with what occurred during post-project 1. Draft ICR frequently assesses Project 1 based on what is planned for Project 2. This negates the possibility of a truly fair assessment. For instance, project sought to scale up diagnosis, treatment and care with secondary emphasis on key populations, yet assessments seemed to based on the belief that Project 1 should at the inception focused on key populations instead of diagnosis, treatment and care. Unfortunately, it is not possible at this point to report on the Bank's performance during the initial Project negotiation stage as the original persons involved are no longer associated with the NAP. The type of assistance rendered by the Bank in the last three years of the Project was vastly different from what was received during the first three (3) years of the Project. In the latter three years of the Project, every effort was made to transfer knowledge and build capacity with Project Coordinating Unit staff and key partners in areas of need, i.e., building ownership at the country level. The National AIDS Program has found the Bank to be helpful particularly in assisting the Program with: · Disbursement challenges, resulting in the reformulation of the disbursement categories making it easier to access funds: · Provision of technical assistance in the areas of behavior change communication and monitoring and evaluation resulting in the strengthening of Project components; and · A one-year no cost extension to facilitate complete disbursement of all monies under the Project. Despite favorable performances by the Bank in some areas, there are some administrative issues which the Bank needs to resolve if it is to effectively assist countries with project implementation. In the case of Barbados, the NAP has flagged: · Lack of clarity with respect to satisfaction of Bank requirements related to project triggers, for example, the environmental safeguard policy (civil works component). · Late notification of mandatory Bank requirements in respect of environmental issues such as pesticide categories (civil works component). 49 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders 50 Annex 9. List of Supporting Documents Government of Barbados HIV/AIDS Prevention and Control Program. Mid-Term Review. Dr. Beverly Miller and Dr. Robert Crown. Barbados: Bridgetown Ministry of Education, Youth Affairs and Sports 2001. Report on the National KAPB Survey on HIV/AIDS. ISBN 976-8079-31-2. Barbados: Bridgetown. Ministry of Education, Youth Affairs and Sports 2003/2004. Report on the Secondary School Behavioral Surveillance Survey. Barbados: Bridgetown. Ministry of Education, Youth Affairs and Sports 2005/2006. Report on the Behavioral Surveillance Survey. Barbados: Bridgetown. MHNI 2008. HIV/AIDS Surveillance Report January-June 2007. NHAC 2007. The HIV/AIDS Situation in Barbados, 1984 to 2006. "Looking back to move forward." Barbados: Bridgetown. NHAC (under preparation). The Barbados Men's Lifestyle Survey 2007. The World Bank 2003. Barbados ­ Caribbean HIV/AIDS (P075220) - Seventh Quality of Supervision Assessment (QSA7). Draft Final Report. Washington DC. IBRD 33369 59°45' 59°30' BARBADOS SELECTED CITIES AND TOWNS NATIONAL CAPITAL RIVERS Archer'sBay North Point MAIN ROADS 13°30' 13°30' PARISH BOUNDARIES Crab Hill Spring Hall Harrison Point S T. L U C Y This map was produced by the Map Design Unit of The World Bank. Gay'sCove The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. Portland SixMen's Bay Greenland Speightstown S T. P E T E R S T. A N D R E W AT L A N T I C Bruce Vale O C E A N Westmoreland Mount Hillaby Bathsheba (336 m) S T. J A M E S Hillaby S T. J O S E P H CongorBay Holetown S T. T H O M A S Blackmans Coach Consett Bay Hill Bennetts S T. J O H N 13°15' Ragged Point 13°15' Thicket Payne'sBay Belair Prospect S T. G E O R G E Warrens Freshwater S T. P H I L I P Bay S T. M I C H A E L Bulkely Workhall Six Cross Turnpike ur Roads Crane Bay Crane BRIDGETOWN C H R I S T CarlisleBay C H U R C H Sargeant Needhams Point Saint Oistins Lawrence OistinsBay Long Bay South Point BARBADOS AT L A N T I C O C E A N 13°00' 13°00' 0 1 2 3 Kilometers 0 1 2 3 Miles 59°45' 59°30' DECEMBER 2004