Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB2200 Project Name HIV/AIDS Multi-sectoral AIDS Project Region AFRICA Sector ` Other social services (40%); Health (30%); General information and communications sector (20%); General education sector (10%) Project ID P098031 Borrower(s) GOVERNMENT OF ETHIOPIA Implementing Agency: HIV/AIDS Prevention and Control Office Environment Category [ ] A [X] B [ ] C [ ] FI [ Date PID Prepared September 6, 2006 Estimated Date of appraisal Authorization September 8, 2006 Estimated Date of Board Approval December 21, 2006 1. Key development issues and rationale for Bank involvement 1. The Ethiopia Multi-Sectoral HIV/AIDS Credit (EMSAP) for US$ 59.7 million became effective in January 2001 with the aim of accelerating the implementation of the Federal and Regional Multi-Sectoral HIV/AIDS Strategic Plans through the Provision of HIV/AIDS prevention, care and treatment services at all levels and in a number of sectors. HIV/AIDS is recognized as a threat to development in the current PASDEP (PRSP) and indicated a financial need of about U$ 6 billion over the next 5 years for HIV/AIDS interventions in Ethiopia. The World Bank was the major funding agency of HIV/AIDS program initially, but at present there are a number of multilateral and bilateral organizations supporting HIV/AIDS prevention and control programs. At present, the Global Fund and PEPFAR have allocated enormous resources (more than USD 500 million) to support the HIV/AIDS program in Ethiopia. However, the major portion (>75%) of these allocations are earmarked for ART and related activities, leaving a major financing gap for preventive activities. In view of this, there is a compelling reason for supporting HIV/AIDS program in Ethiopia. 2. The available data on the HIV epidemic that allow for an interpretation of the historical trends are from ante-natal surveillance and from Voluntary Counseling and Testing services in Addis Ababa. The evidence, interpretation and modeling (through the Epidemic Projection Package) of these data suggest that the epidemic in Ethiopia is generalized and expanding with a rising trend in the rural areas (modeled prevalence and a stable incidence). The overall result of a rising prevalence is a result of a mixed pattern of rising prevalence in rural areas, a declining prevalence in Addis Ababa and leveling off of the prevalence in other urban areas. With more tha n 80% of Ethiopia’s population living in rural areas, these findings indicate a potential explosive situation unless drastic steps are taken to scale up the response to HIV/AIDS in rural areas . 3. The indicated trends are confirmed when examining the prevalence among the 14 to 19 year olds as a proxy for recent infections. The number of recent infections is leveling off in Addis Ababa but still increasing in other urban areas and even more so in rural areas. In addition, preliminary findings of the 2005 Demographic Health Survey Page 2 show a significant difference in infection rates between men and women and especially young women are much more likely to be HIV infected than their male counterparts. The combination of epidemiological data in Ethiopia seems to suggest that the HIV epidemic is driven by the vulnerability of young girls. 4. Population-based surveys such as the DHS and BSS have been carried out once and consequently don’t provide a historical perspective of the epidemiological trends. Data from the second BSS (2005) will be available soon and may provide further insight in the historical trends of some of the determinants of HIV infection. 5. No data exists that directly link specific intervention to declining HIV incidence and/or prevalence. However, there are surveys, studies and assessments that document significant linkages between specific interventions and those factors that are believed to be determinants of (vulnerability to) HIV infection. The evidence base to guide prevention related interventions is therefore based on interventions that have a reasonably well documented influence on factors such as awareness, knowledge, behavior and exposure to risk, either at individual, corporate, or community level. Justification for preparation of EMSAP II 6. The terminal evaluation, the identification mission findings and the ICR indicate the project has successfully achieved its DO and recommended the preparation of the follow-up operation to achieve the ultimate objective of reducing the HIV infections. The preparation of EMSAP II is in line with the long-term support envisioned during the preparation of the first MAP projects. Since the year 2000, and under the Bank financing, Ethiopia has shown a major change in the way the country is responding to the epidemic and there is a compelling reason to continue supporting HIV/AIDS prevention and control activities in Ethiopia. 2. Proposed Development Objectives 7. The project will support the government of Ethiopia’s long-term objectives of reducing the HIV incidence rate and achieving universal access to prevention and treatment. 8. Consequently, the Project Development Objective will be: To support a multisectoral enabling environment, especially in the rural areas, for prevention, care, mitigation, and treatment in Ethiopia by: (i) improving access to HIV/AIDS services to priority target groups including commercial sex workers in market towns; (ii) increasing community level interventions to reduce stigma, and expanding care and support for PLWHA & orphans; iii) enhancing prevention for girls between 15-24 years of age; and (iv) complementing other donor supported programs. 3. Preliminary Project Description 9. Many current support programs in Ethiopia have a rather short timeframe for their financial commitments. The risk of abrupt changes in the resource envelope, both positive and negative, could be mitigated to some extent by a flexible EMSAP-II design and a project period of not less than five years. EMSAP-II will be financed with Page 3 about US$30 million of preferably Grant Funding. EMSAP II would be implemented according to the “three ones,” namely: one national policy framework, one national coordinating authority, and one national M&E system. 10. The available data and information suggest that the epidemic in Ethiopia is expanding with a rising trend in the rural areas and among females aged 15 to 24 years. EMSAP II will support prevention activities in rural areas and market towns and will target young females, currently the highest risk population. Priorities and Components 11. EMSAP II is proposed to be a three to five-year project with three components namely: (i) National Program Coordination and Institutional Strengthening, (ii) Strengthening Government Multi-Sectoral Response in priority line ministries; (iii) Improving and scaling-up civil society response in the priority areas and for priority groups. 12. The priority activities to be supported by EMSAP II will be community mobilization ( Local Response), rural HIV/AIDS interventions, Commercial Sex Workers in urban and rural market towns , emphasis on programs addressing the youth and particularly young females aged 15-24 years, support to M&E development and capacity building of institutions. Indicators 13. The following are some of the results expected at the end of five years; · Increase in the number of VCT and PMTCT centers in rural areas · Increase in the use of condoms during the last sexual intercourse among the youth · Increase in the number of people seeking VCT and PMTCT services · Reduction of traditional practices that increase the risk of HIV infection · Reduced incidence of HIV infections among 15-19 year old girls · Increase in the number of AIDS cases under treatment and levels adherence to treatment · Establishment of a functional M&E to regularly monitor and evaluate the success and failures of various interventions 4. Safeguard policies that might apply This project will be rated as an Environmental Category B project, for its concerns regarding medical waste hazards for which the Ministry of Health has prepared Medical Waste Disposal and Handling Guideline which has been implemented since September 1997 and Infection Prevention Guideline for Health Care Facilities in Ethiopia ( February 2005). Furthermore, the health institution structural designs provide facilities for medical waste disposal. In addition Injection Safety Guidelines are at the final stage of preparation. The implementation of the available guidelines will help mitigate the hazards emanating from inept medical waste handling. Page 4 Plans for proper supervision by environmental health experts should be developed to ensure that guidelines are properly implemented. 5. Tentative financing : DFID has indicated an interest in co-financing the project with complementary financing. BORROWER/RECIPIENT: US$3 million IDA Grant: US$ 30 million 6. Contact point Gebre S. Okubagzhi Title: Senior Health Specialist. Tel: 5358+352 Fax: 251 1 011 662 77 17 Email: Gokubagzhi1@worldbank.org Location: Addis Ababa, Ethiopia (IBRD)