Public Disclosure Authorized TRANSPORT AND HIV PORTFOLIO REVIEW & SITUATION ANALYSIS Public Disclosure Authorized NEPAL AND BANGLADESH Report No. 56848-SAS August 13, 2010 Lee-Nah Hsu Public Disclosure Authorized Sustainable Development Department Transport Unit South Asia Region Public Disclosure Authorized Document of the World Bank ABBREVIATIONS AND ACRONYMS AIDS Acquired Immuno-deficiency MOHFW Ministry of Health and Syndrome Family Welfare ART Anti-retroviral therapy MOPPW Ministry of Physical Planning and Works BCC Behavioral Change MSM Men having sex with men Communication DOR Department of Roads NCASC National Centre for AIDS and STD Control (Nepal) FHI Family Health International, a NASP National AIDS and STD USA-based non-governmental Program (Bangladesh) organization GESU Geo-environment and Social PLHIV People living with HIV Unit GFATM Global Fund to AIDS, PR Principle recipient of the Tuberculosis and Malaria Global Fund HIV Human Immunodeficiency Virus SAR South Asia Region HSS Health systems strengthening SR Sub-recipient of the Global Fund grants IEC Information, education and STI Sexually transmitted communication infections ICDDR,B International Centre for SWAp Sector-wide approach Diarrhoeal Disease Research, Bangladesh MARP Most at risk populations VCCT Voluntary counseling and confidential testing Vice President Isabel M. Guerrero Sector Director John Henry Stein Sector Manager Michel Audige Task Team Leader Jean-Noel Guillossou i ACKNOWLEDGEMENTS This report was prepared by a team led by Jean-Noel Guillossou, SAR co-focal point for HIV and Transport, Lead Transport Economist, SASDT with support from Comfort Olatunji, SAR co- focal point for HIV and Transport, SASDT. Ms. Lee-Nah Hsu, HIV AIDS specialist, consultant, is the main author of the report. The following World Bank team members contributed to the field work: Iffat Mahmud, Operations Analyst, SASHN, Dinesh Nair, Sr. Health Specialist, AFTHE, Marianne Kilpatrick, Sr. Transport Sepcialist, SASDT, Surendra Govinda Joshi, Sr. Transport Specialist, SASDT, Md. Tafazzal Hossain, Team Assistant, SACBD, Reefat Sultana, Project Analyst, SASDT, T.K. Barua, Social Development Specialist, Consultant, Albertus Voetberg, Lead Health Specialist, SASHN. The report was edited and formatted by Comfort Olatunji. The funding was provided by the HIV/AIDS Transport Incentive Fund under the UNAIDS Global AIDS Program unified budget and workplan (UBW). The work was carried out under the guidance of Mariam Claeson, HIV AIDS Program Coordinator, SASHN. The team benefited from comments from the peer reviewer: Julie Babinard (Environmental and Social Development Specialist, ETWTR). Additional comments were received from Iffat Mahmud, Operations Analyst, SASHN; Sandra Rosenhouse, Senior Health Specialist, SASHD, Luis Alberto Andres, Senior Economist, SASSD, and Tahseen Sayed, Operations Adviser, SACBD. The report also benefited greatly from inputs from Dr. Mohd Abdur Rahman, Line director, National AIDS/STD Program (NASP)/Safe Blood Transfusion Programme (SBTP), Bangladesh, Avra Saha, HIV/AIDS and Human Rights Advisor, UNAIDS, Dhaka, and Shaengjie Li, director, International Labour Organization (ILO), Nepal. ii EXECUTIVE SUMMARY This review report focuses on the HIV component of the World Bank Bangladesh and Nepal transport infrastructure projects as at the end of 2009. A separate literature review of gender, HIV and transport projects in the World Bank South Asia region was prepared in early 2009. This report is prepared with the following three objectives:  Knowledge improved and lessons learned from HIV and AIDS activities developed within the road projects financed by the World Bank in Bangladesh and Nepal as of the end of 2009.  Knowledge base built on current HIV and AIDS programs in the transport sector in Bangladesh and Nepal to serve as a reference for future World Bank projects in the transport sector in South Asia.  Guidance provided to the draft Regional Strategy for HIV Prevention in the Transport Sector of the Bank’s South Asia region. With regard to the first objective, this report indicates areas to enhance synergy and cost- effectiveness of HIV responses within road infrastructure projects in Bangladesh and Nepal financed by the World Bank. The report acknowledges efforts made by the World Bank transport sector to collaborate and obtain technical inputs from the Bank’s gender, health, and social sectors in the two countries. These were done during planning and monitoring of the HIV component of the road infrastructure projects. With regard to the second objective, the report identifies in these two countries, key stakeholders and potential partners to engage. Partnership with these key stakeholders can improve the selection of competent implementers, the application of evidence-informed responses, and the quality monitoring of implementers’ compliance with their terms of reference. With regard to the third objective, the report points out a need to broaden the scope of the World Bank’s draft strategy beyond India to be applicable to other South Asia countries. Specific suggestions are listed in the report. For example, conducting a pre-project mapping assessment would identify capable implementers and promote the development of an evidence-based strategy. Adopting a workplace HIV response in road transport projects can facilitate adherence to international labor standards, create an enabling worksite environment for HIV prevention and anti- discrimination, and reach out to workers’ families and communities surrounding the projects. The workplace approach encourages social dialogue among relevant ministerial officers, contractors’ project managers, workers, their families, and people in communities surrounding the projects. Such social dialogue can contribute to gender sensitivity and potential sustainability of responses beyond the life of the projects. The HIV component of the World Bank road infrastructure projects, by incorporating these dimensions in its South Asia regional HIV strategy, could pave the way to benefiting future road users, including vulnerable migrants. The World Bank has a comparative advantage in promoting the inclusion of a transport sector response within the new National AIDS Strategies being formulated for Bangladesh in 2010 and Nepal in 2011. The Bank may consider making the model HIV clause in the transport projects mandatory, consistent with other funders, such as the ADB and JICA, to improve aid effectiveness. iii The following are recommendations: HIV Components of Transport Projects in Bangladesh and Nepal 1. Implement a transport sector workplace HIV policy and program in Nepal, in view of interest expressed by staff of the Department of Roads (DOR) and representatives of construction companies. The workplace approach promotes sustainable HIV prevention and reduces the hit and miss, bi-annual visits made by the NGO implementers contracted by the Bank- supported road projects. 2. Use peer educators, because this has proven to be a cost- effective approach and experience shows that peer led interventions by non-state actors are most likely to be effective in reaching most at risk populations, thereby reducing HIV transmission compared to occasional visits by outside health educators. 3. Establish or use an existing technical HIV committee to select and monitor NGO implementers. The committee may consist of specialist and representatives from the National AIDS authority, UNAIDS, the principle recipients of the Global Fund to AIDS, Tuberculosis and Malaria, a government ministerial representative, and the World Bank. Such a committee can improve the transparency and quality of selection, facilitate joint monitoring, and share experiences and materials of the NGO implementers. 4. Strengthen monitoring of HIV responses within transport infrastructure projects, to gather knowledge and improve implementation. 5. Apply the World Bank practical guidelines on HIV interventions in the infrastructure sector for HIV responses that are part of future transport projects. The World Bank 6. During the pre-project feasibility assessment phase, use mapping information from National AIDS program to identify target populations, hot spots, available resources in communities affected by the road projects, and potential HIV response implementing partners. 7. Require that all contracts bid under transport infrastructure development projects include the model contractual clause on HIV. 8. To select an implementer for HIV components under Bank transport projects and to monitor the implementer’s performance, use an existing HIV technical committee. If none exists, set one up. 9. Include gender-sensitive HIV responses before, during and after construction. 10. Engage technical assistance to include transport workplace responses in formulating new National AIDS Strategies for Bangladesh and Nepal.1 1 Bangladesh is revising its National HIV AIDS strategy in 2010 and Nepal in 2011. It is an opportunity for the Banks’ South Asia Transport Unit to support the AIDS Strategy and Action Plan coordinator in accounting for transport sector workplace occupational safety and health. iv The Ministry of Physical Planning and Works, and the Transport Ministry 11. Assist the Ministries of Physical Planning, Works and Transport to establish an HIV workplace policy and program, thereby integrating HIV prevention into their road infrastructure projects and in the system for users and operators of roads. 12. When assessing a project’s feasibility, include HIV vulnerability mapping and gender impact analysis. A model Terms of Reference for mapping is included in the Annex 1 to the report. 13. Collaborate with labor inspectors who are trained on HIV workplace standards to monitor HIV workplace responses in the transport sector. HIV Prevention Implementers in the Transport Sector 14. Use evidence-informed responses such as peer-education and field-tested behavioral change communications. 15. Include monitoring and evaluation indicators and targets. Establish baseline, conduct a mid-term review, and end-of-project evaluation to improve knowledge, reporting and responses. Coordinate with other donors/implementers who are implementing interventions The NAC on National AIDS strategy 16. Engage transport sector institutions, including transport workers’ unions, to reduce the HIV vulnerabilities of mobile populations. 17. As part of HIV responses, develop strategy and partnership regionally among neighboring countries to cover the continuum of sending, transit and host communities of migrant workers. 18. To partner with other organizations e.g. International Labor organization (ILO) to scale up the workplace policies and programs and support the capacity of unions, employers and NGOs to design and manage workplace interventions. v Table of Contents ABBREVIATIONS AND ACRONYMS ............................................................................................. i  ACKNOWLEDGEMENTS ................................................................................................................ii  EXECUTIVE SUMMARY ............................................................................................................... iii  1.  INTRODUCTION ........................................................................................................................ 1  Objectives ......................................................................................................................................... 2  Scope ................................................................................................................................................. 2  Methodology .................................................................................................................................... 2  2.   HIV-AIDS AND TRANSPORT IN NEPAL .......................................................................... 4  Epidemiologic Situation .................................................................................................................. 4  The World Bank’s Transport Sector Projects ,............................................................................ 5  The World Bank Health Sector Projects .................................................................................... 13  Other Entities’ HIV Responses with Relevance to Transport or to Migrants ........................ 13  i.  Asian Development Bank (ADB) ....................................................................................... 13  ii.  USAID .................................................................................................................................. 15  iii.  European Community ........................................................................................................ 16  iv.  Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) ............................... 16  v.  International Labour Organization (ILO) ....................................................................... 18  vi.  The National Centre for AIDS, STI Control (NCASC)................................................... 18  3.   HIV, AIDS and Transport in BANGLADESH ................................................................... 19  Epidemiologic situation ................................................................................................................ 19  The World Banks’ Transport Projects in Bangladesh .............................................................. 21  World Bank Health Project ......................................................................................................... 21  4.  Other Organizations’ HIV Responses Relating to Transport Sector or Migrants............... 23  i.  ADB ...................................................................................................................................... 23  ii.  USAID .................................................................................................................................. 24  iii.  Social Marketing Company ............................................................................................... 24  iv.  International Transport Federation.................................................................................. 24  v.  GFATM ................................................................................................................................ 24  vi.  BRAC ................................................................................................................................... 24  vii.  National AIDS and STD Programme................................................................................ 24  vi 5.  RECOMMENDATIONS ........................................................................................................... 26  6.     SUGGESTIONS FOR THE DRAFT REGIONAL STRATEGY FOR HIV PREVENTION IN THE TRANSPORT SECTOR..................................................................................................... 28  ANNEX: 1: Sample Terms of Reference for an HIV and Health Vulnerability Mapping Assessment for a Transport Infrastructure Construction Project ................................................ 31  REFERENCES................................................................................................................................... 34  Maps MAP: 1. The World Bank-supported road upgrade segments in Nepal ....................................... 7  vii 1. INTRODUCTION 1. Within the World Bank’s South Asia Region (SAR), the Transport Unit began including HIV prevention in its road infrastructure projects in 2005. Currently (in 2010), 25 transport projects are under the supervision of the Bank’s SAR transport unit. Twelve of these projects have HIV prevention activities. An HIV component is being developed in six projects under preparation. All the transport projects with HIV responses are road projects2. HIV prevention in the Bank-supported transport projects so far targets construction workers and communities along or surrounding the project corridors. This report focuses on the HIV prevention components of road transport infrastructure projects in Bangladesh and Nepal. 2. Transport brings connectivity for people, goods, markets and other resources. A majority of people today engages in or use transport, even if they are not mobile populations. The World Bank SAR Transport Sector’s promotion of HIV prevention helps Bangladesh and Nepal to reach the Millennium Development Goals for poverty reduction and halving HIV, TB and malaria. 3. The transport sector can help reduce HIV vulnerability by applying HIV workplace policies and programs in its systems and by engaging public and private sector partners. However, the transport sector HIV responses should conform to the so-called “three-ones”3 and coordinate with the National AIDS authorities, the Global Fund grants, implementers of bilateral HIV projects, and the United Nations Task Teams on HIV. 4. On the other hand, the national AIDS strategies should consider the transport sector’s role in HIV vulnerability reduction as part of the national HIV and AIDS responses. For instance, improved transport infrastructure facilitates populations’ quest for employment. Greater connectivity strengthens linkages between migrants and their families at home. However, this connectivity also increases HIV vulnerabilities if HIV-preventive actions are not responsive to the vulnerabilities of the mobile population. Responsive actions must consider gender implications of transport projects before, during, and after the construction phase of such projects. 5. According to the 2009 UNAIDS and WHO epidemiologic trends report for Asia, at the end of 2008 4.7 million people were living with HIV, with 350,000 new infections. Except in Thailand, the overall HIV prevalence in Asia is under 1 percent. At present, in both Bangladesh and Nepal it is under 1 percent in the general population. However, the prevalence in Bangladesh is increasing4 and HIV prevalence is high among populations at risk. Nepal has integrated Biological and Behavioral Surveillance (IBBS) data for 2006 and 2008 on returned migrants in the Western to-far Western of Nepal on HIV prevalence specifically on returned migrants. 6. This review is initiated by the SAR Transport Unit to fill the following gaps identified by the sector in its HIV responses:  Cross-fertilization among transport projects with HIV components, by sharing lessons and methods.  Coordination with other sectors in and outside the Bank to reduce duplication. 2 Source: Terms of Reference from the World Bank 3 “Three ones” means one national AIDS authority, one national AIDS strategy and one HIV and AIDS monitoring and evaluation system. 4 Fact sheet on the latest epidemiological trends in Asia, 2009, UNAIDS and WHO. 1  Capacity of the Bank’s transport sector for cross-sectoral activities, as the Bank diversifies its portfolio. Objectives5 7. This review aims to:  improve knowledge on current HIV activities developed in Bank-financed road projects in Bangladesh and Nepal;  take advantage of the above knowledge in preparing new Bank-financed transport projects in SAR;  give guidance to the Bank’s draft South Asia Regional Strategy for HIV Prevention in the Transport Sector. Scope 8. This review focuses on Bangladesh and Nepal as a first step and expects to cover the remaining SAR countries in the near future. Specific Tasks a. Undertake a review of HIV prevention activities in road projects financed by the World Bank in Nepal and Bangladesh in 2009:  Review activities carried out in such projects;  Identify NGOs’ strategies and assess adequacy of NGOs’ capacity in carrying out the interventions;  Identify gaps, draw lessons learned from the current experience, and provide guidance for the preparation of future projects. b. Build a knowledge base on HIV interventions in the transport sector in these two countries:  Collect information on the risks related to HIV in the transport sector, review national AIDS programs and other programs (development partners, private sector, NGOs and others) in the transport sector and draw lessons;  Review relevant health sector strategies, policies and plans for the transport sector, if any, on HIV prevention. c. Provide guidance:  To strengthen future interventions in the sector;  To further strengthen effective collaboration and coordination with the National AIDS programs and other partners; and  To provide input to the draft Regional strategy for HIV prevention in the transport sector prepared by the Bank’s South Asia Transport Unit. Methodology 9. The review and situation analysis were conducted using the following two methods:  literature review of existing strategies, policies, plans, reports, surveys and research studies on HIV responses in the transport infrastructure construction sector of these two countries. 5 Refer to Terms of Reference 2  key stakeholder interviews with: o the Ministry of Health and Ministry of Transport; o the National AIDS and STI program; o project implementing agency (Department of Roads), contractors and NGOs that implement the Bank’s road project HIV component; o civil society (NGOs, CBOs, FBOs, research organizations operating in Bangladesh and Nepal on HIV, transport or mobility-related projects), and o development partners, transport associations, private sector and the International Transport Federation country affiliates. 3 2. HIV-AIDS AND TRANSPORT IN NEPAL Epidemiologic Situation6 10. Nepal reported its first AIDS case in 1988. By mid-2009, there were 14,320 reported HIV cases, of which 2,493 had AIDS7. The HIV prevalence in 2007 was 0.49 percent, representing 69,790 cases. Of these, 64,585 were between the ages of 15 to 498. 11. Unsafe sex and injecting drug use are the two main modes of HIV transmission. Many sex workers migrate to work in India and return with HIV. Research found certain migrants and men who have sex with men (MSM) are also vulnerable. Rural housewives have one of the highest cumulative-number of HIV cases9. 12. The HIV cases are concentrated in Kathmandu valley and districts along the highways. Approximately 30 percent of people living with HIV (PLHIV) are injecting drug users (IDUs). Nearly 20.7 percent of injecting drug users in Kathmandu are HIV positive, whereas the HIV prevalence among IDUs in other locations ranges from 12 to 32 percent. 13. The average HIV prevalence among sex workers is 1.6 percent. However, among street sex workers, the rate can be up to 17 percent. Only 2 percent of clients of sex workers use condoms. There are 34,000 sex workers estimated in Nepal. In addition, many young women or boys have been trafficked from rural areas to work in Mumbai, India, often engaging in sex work10. According to a Family Health International (FHI) study, nearly half of the Nepalese sex workers in Mumbai, India are HIV positive. 14. Approximately 60 percent of clients of sex workers are transport workers, migrants, policemen or military personnel. According to an estimate, 1.5 to 2 million Nepalese migrants are in India. A 2002 study found 8 percent HIV prevalence among Nepalese migrant workers returning from Mumbai. There are an estimated 193,000 MSM in Nepal. Among the MSM living in Kathmandu valley, the HIV prevalence is estimated at 3 percent. Based on these data, the most at- risk populations (MARP) in Nepal are female sex workers, injecting drug users, MSM, seasonal migrants and their spouses. 15. The national strategy for HIV and AIDS 2006-2011 consists of four components:  policy, legal reform and advocacy;  leadership and management;  strategic information system development (surveillance, monitoring and evaluation); and  financing and resource mobilization. 6 HIV/AIDS in Nepal, the World Bank, August 2008. 7 Data received from National Centre for AIDS and STD Control for cumulative data as of 15 July 2009. 8 Ibid. 9 Ibid. 10 National HIV/AIDS Strategy, 2006-2011, Ministry of Health and Populations, National Centre for AIDS and STD Control, Teku, Kathmandu, October, 2007, page 19 4 16. The national strategy plans to cover 70 to 80 percent of the most at-risk population to reduce new HIV infections. Two priorities of the national strategy applicable to the transport sector are listed below: Priority 3: facilitate and expand interventions for safe migration and mobility; and Priority 8: develop and implement workplace policies and programs. Therefore, the World Bank SAR Transport Unit’s HIV prevention initiative is consistent with the Nepalese National AIDS Strategic Plan. 17. The National Centre for AIDS and STD Control (NCASC) under the Ministry of Health and Populations is the government focal point on HIV matters. In addition, the HIV/AIDS and STI Control Board has been established to promote multi-sectoral engagement and HIV responses11. The Country Coordination Mechanism for the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) includes health and non-health ministries, civil society, United Nations and bilateral donors. Among the United Nations agencies in Nepal is the thematic group on HIV co-sponsored by UNAIDS. The International Labour Organization (ILO) chaired the group in 2009. 18. Political instability, poverty, the large volume of domestic and cross-border economic migration, culturally prescribed gender roles, and the taboo on discussing men having sex with men render HIV prevention a challenge in Nepal. Improvement of the road network facilitates rural to urban and cross-border movements. The reported high HIV prevalence among returning migrants from some high prevalence districts in India illustrate the critical role transport can play in HIV prevention. The World Bank’s Transport Sector Projects 12,13 (1) The Road Sector Development Project 19. At the time of this report, the Road Sector Development Project a World Bank-financed road project in Nepal has an HIV component.. The project became effective in March 2008 and will close in June 2012. The total project cost is $50.6 million and the Bank is financing $42.6 million. 20. The project aims to provide residents with all-season road access. It is anticipated that improved roads will help improve access to economic centers and social services. The project targets five hill districts which currently lack all-season road access. 21. The outcome indicators of this project are as follows:  6 percent increase in the number of people with all-season road access in the project districts (20 minutes walking or 2 km);  35 percent decrease in travel time for target populations to reach key economic centers and social services;  Department of Roads to provide effective road infrastructure services to users (measured through a user satisfaction survey); and  Roads Board to be fully functional and provide effective and sustainable funding for road maintenance (undertaking at least 500 km of periodic maintenance of the strategic road network annually and over 1,000 km of backlog periodic maintenance within the project period). 11 The Director of the Board was away during the Nepal mission and no one in that office was available to meet. 12 Refer to Project Appraisal Document, World Bank-Nepal (Reference 1) 13 Refer to FY09 SOPE Report, Nepal (accessed from WB website in October2009) 5 22. The project consists of two key components: road development; and institutional strengthening and policy reform. These are accompanied with raising HIV awareness among construction workers and surrounding community residents. 23. The project is implemented by the Department of Roads of the Ministry of Physical Planning and Works. The project covers five roads in the Mid-west and Far-west of Nepal (refer to Map 1 for the location of the road project packages). It is composed of 20 contract packages. According to the Department of Roads, at present 14 contractors have been engaged (see Table 1). The remaining six packages have now been awarded to construction contractors (SKM-3A, SKM-3B, SKM-06A (Re), SKM-06B (Re), KJC-11A (Re) and KJC-11B (Re)14). Table 1: Initial 14 Road Project Packages Awarded in 2009 Contract Package Road Contractor and Length JV-Sundar Nepal Sanstha & Development Nepal (Mid-west packages) as HIV component implementers Tallo Dhungeshwor - Dailekh (1) TSD 12 (8.2 km) M/s Lama Construction – Lohani & (from Tallo Dhungeshwor Brothers JV Bazar of Surkhet through (2) TSD 13 (11.9 km) M/s Kalika-Sapana Nirman Sewa JV Dailekh district) (3) TSD 14 (10.8 km) M/s Tamang – PS - Golden Good JV The Karnali Road – 128 km (4) SKM-4 (28.8 km) M/s Zhongding – Kanchanjunga - Bajra Surkhet-Khidkijhyula (from Guru JV Bangesimal of Surkhet to (5) SKM-05A (13.4 km) M/s Kanghajunga – United Builders JV Manma of Kalikot) (6) SKM-05B (13.9 km) M/s Tamang-Rasuwa JV Jv-Mitra Sang & Development Nepal (Far-west packages) as HIV component implementer Khodpe-Jotha-Chainpu (7) KJC-09 (19.9km) M/s Kalika - Sharma - Lama JV (8) KJC-10A (10.2km) M/s Kalika Construction Company Pvt Ltd. (9) KJC-10B (9.8km) M/s Tamang - P.S. - Golden Good JV Satbajh-Gokuleshwor (10) SG-07 (19km) M/s KNR & Nepal Adarsha JV (11) SG-08A (9.7km) (12) SG-08B (9.58km) M/s Zhongding - Lama Builders - Bajra Guru JV Satbajh-Tripurasundari- (13) STJ-01 (11.35km) M/s Tamang - Rasuwa JV Jhulaghat (14) STJ-02 (11.15km) M/s Swachchhanda - Mahalaxmi JV 14 Updated list as of September 2009 provided by Department of Roads. 6 MAP: 1.  The World Bank­Supported Road Upgrade Segments in Nepal15  Baitadi- Satbangha- Gokuleswo Road Upgrading r 15 Source: Department of Roads, Ministry of Physical Planning and Works. 7 HIV Component: 24. Description. This is the first World Bank-financed infrastructure development assistance project in Nepal’s transport sector which includes an HIV component. HIV awareness-raising is one of the intermediate project outcomes. This outcome aims at covering project construction workers and road users. There are indigenous ethnic minorities and other HIV vulnerable groups (construction workers, tea shop owners and transport workers) living in the project area or working on the project as construction workers. 25. The HIV component is being implemented by NGOs with the following scope of activities16:  prepare and distribute information, education and communication (IEC) materials to concerned stakeholders through frequent field visits;  conduct a one-day workshop for stakeholders - the contractor and supervising consultant at the start of the project and biannually during the project;  conduct awareness campaigns for construction workers at construction sites;  conduct awareness campaigns for transport workers, inhabitants, and businesses along the roads;  assist the District Development Committees, local road institutions, NGOs and CBOs in minimizing the negative social impact of HIV, AIDS and STIs during the short, medium and long term; and  assist internal monitoring by the Geo-environment and Social Unit of the Department of Roads and the Road Sector Development Project. 26. The Department of Roads manages the HIV component. The road project also request civil works contractors to ensure the health and safety of construction workers and their labor camps. 27. Strategy. According to the contracts issued by the Department of Roads, the awareness-raising activities implemented by the two NGO consortia shall be consistent with the guidelines of the NCASC. They shall make use of existing information, education and communication materials and collaborate with local public health centers and district health offices in delivering their services to construction workers, tea shop owners and transport workers during the construction phase. Four workshops were to be conducted over 24 months. The workshop participants shall be members of the district administration, health clinics and CBOs. 28. Implementation status. Two separate contracts were awarded to Development Nepal – an NGO based in Kathmandu valley to cover the 14 construction packages in Mid-west and Far-west regions (see Table 1). The HIV prevention activities began in November 2008 for 24 months ending in September 201017. Development Nepal formed two consortia: one with Jv-Mitra Sang for the Far-West road construction packages, the other with jv-Sundar Nepal Sanstha for the Mid-West road construction packages. The six new packages of civil works awarded after the project started are also covered by these two consortia. 16 Refer to the two contracts (Reference 9, 10) 17 Department of Roads contract document with Development Nepal consortia. 8 29. One consortium has delivered two progress reports (April and July 2009) and the other, one report (April 2009). The following information was obtained from the progress reports and from an interview with Development Nepal (the umbrella NGO):  Field assessment of awareness on health, safety, HIV, AIDS and STI was carried out through meetings with project management, consultants, contractors’ laborers, local residents, transport workers and others along the roads.  One consortium conducted an initial workshop and six awareness campaigns for each construction package, covering 258 workers, of which 19 percent were women;  28 awareness campaigns were planned for the Far-West region and 11 have been carried out. Four poster boards and 5,000 out of 10,000 brochures printed have been distributed. Thirty-one awareness campaigns were planned for the Mid-West region and 7 have been completed. The remaining awareness campaigns were planned for November 2009. 30. One NGO collected basic HIV information from the District AIDS Committee and prepared brochures, posters and a billboard as campaign materials. The first workshop was conducted by a staff of the District AIDS Committee, whereas the awareness campaigns were carried out by the NGO staff acting as social mobilizers (2 females and 3 males). 31. NGO capacity. These NGOs do not have prior HIV experience. Based on feedback from construction companies, the NGO social mobilizers are young, shy, lack group skills and basic knowledge for awareness campaigns. The text-only brochure is of limited use. Although a large number of the construction workers are from ethnic populations who are more familiar with their own languages, the brochure text is in Nepalese only. During the interviews, the workers, contractors and DOR staff requested communication materials and audio-visual aids more suitably relevant to the targeted populations18. 32. The text material produced by the NGO is inadequate. The same text has been printed as brochures, poster and a billboard. Basic behavioral change communication principles, however, suggest tailored messages for different types of media and for specific audiences. Graphical material would have been more appropriate because many workers are from rural villages, some of whom are of different ethnic origin and illiterate. 33. Lack of baseline, indicator, target and progress data. The Terms of Reference for the NGOs specified separate campaigns for local populations and for construction workers. The awareness campaigns that have been carried out so far are a mix of construction workers, local community, truckers and students. 34. The Terms of Reference for the NGO contracts also stated: “The training will focus on how the construction system can maintain and mitigate the negative impact in aspects of STDs, safety measures, health and hygiene of the laborers, compliance with labor law, rights of laborers and labor directives”. In addition, the NGO is expected to “conduct different levels of sensitization workshops so as to disseminate the information, including labor rights”. However, the campaigns carried out by the NGOs were not specific to the construction sector or the community. There are no mobility-related or labor rights messages in the campaign. 18 During this assessment mission, the Bank consultant collected attractive audio-visual and other pictorial, colored information material and training toolkits available in Nepal and provided them to the DOR for construction companies and the NGO implementers. 9 35. The Terms of Reference specified that “for each awareness-raising session it shall incorporate feedback and assessment of information by participants”19. Yet no such assessment has been done by the implementing NGOs, although there are many examples of such assessments available in Nepal. 36. There was no baseline survey of the target audiences’ prior HIV knowledge, behavior or attitudes. No indicators or targets were set for assessment of results, prior to the start of this HIV component. There is no information in the progress reports on the actual number of targeted populations reached per type. Although sex-disaggregated data on participants have been provided for some sessions, there is no information on the type of workers actually reached during these awareness campaigns. 37. The NGO progress reports are sketchy. It is not possible to ascertain the reach that IEC activities have on the intended audience, because there is no information in the progress reports on what audience was reached by which session; how many people from each proposed target group were covered; or what was the gender distribution for each group actually taking part. 38. The photos from the progress reports showed participants standing outside during an awareness campaign. According to Development Nepal, each session lasted less than 15 minutes because it was uncomfortable (hot, sunny, dusty and without chairs) and people did not stay long. It seemed the audience had difficulty hearing the social mobilizers, as the report stated that participants asked the mobilizers to use microphones. 39. Based on the progress reports, the number of people reached was small. The NGO indicated that peak construction work load and local festivals prevented them from reaching workers and target populations in the communities. 40. The activities for this HIV component began one year after the road project started. The NGO did not cover the awareness activities every 5 km along the road, as specified in the contract. 41. Contradictory information. According to the NGO there is total ignorance about HIV among target populations. Yet there is no information on the method used to reach such a conclusion. Furthermore the NGO did not provide concrete evidence to support this assertion. Consequently, it is not possible to ascertain the validity of this claim. On the contrary, both the Department of Roads' staff and construction contractors recalled an HIV component in the ADB-financed road project. They also indicated that their staff gained some knowledge about HIV on that occasion. They further acknowledged the relevance of having HIV prevention for their construction crews. 42. Lack of quality and appropriateness of the communication materials. The construction company representatives and the Department of Roads staff requested more attractive communication materials to better capture the attention of workers. For example, it would have been more effective to use pictorial, colored or audio-visual materials, instead of the text-only flier, poster and billboard distributed by the NGO. They suggested conducting the HIV information sessions at the camps in off-work hours (evenings), when workers are 19 Section 4.2 major task Item 4 of the Terms of Reference. 10 free but have no other form of entertainment. At present the NGOs have engaged young female social mobilizers who visit the construction site only once during working hours. 43. There are no workplace interventions and there is a lack of documentation in the progress reports. 44. Observations. Evaluation of HIV projects for construction workers in East Asia showed peer educators to be more cost-effective in raising awareness than occasional visits by outside educators. In Nepal, the construction companies rely on “gang leaders” from the rural villages to recruit both male and female workers. These leaders might be a potential source of peer educators. One might be able to recruit suitable workers and train them to be peer educators. The social mobilizers hired by the NGO implementers are inexperienced. This raises concern about the adequacy and effectiveness of their interventions so far. 45. A landslide on the way to the construction sites prevented site visits during this review mission. Only a representative from the umbrella NGO of the two consortia, Development Nepal, was present at the consultation. This representative stated he did not have information on the project implementation aside from the progress reports. This raises concern about local implementation monitoring. 46. Report quality. The progress reports were sketchy. The reports need strengthening to reflect implementation according to the Terms of Reference to facilitate monitoring and evaluation. A sample template of a progress report is shown in Table 2. (2) The Rural Access Improvement and Decentralization Project 47. The World Bank’s Rural Access Improvement and Decentralization Project were approved on June 21, 2005 with a closing date of December 31, 2010. A mid-term review was conducted between 10 November 2008 and March 2009. The Bank is providing $32.9 million funding. The project’s development objective is improved rural transport infrastructure and services for residents of participating districts, so that they can benefit from enhanced access to social services and economic opportunities. This project does not have any HIV component. It is unfortunate, because rural access creates an opportunity to reach migrants’ spouses and home communities to reduce their HIV vulnerabilities. 11 Table 2 Sample Progress Report with Indicators Target Audience Actual Numbers Date Location Planned It is preferable to make (per type of audience to facilitate Comments on Deviation from Target (give date (state exact Number age groupings (under 20, Type of Activity monitoring and tracking) -- and location for 20-50, over 50) example of type of audience listed month) each event) below M F Initial workshop Contractor management from valley from site (specify) GESU, DOR (specify) Local administration Local public health entities Local NGOs Local schools Local business (specify) Entertainment facilities Construction workers (specify, engineer, laborers or others) Awareness campaigns Distribution of IEC materials Posters Billboards Condoms Lubricants Others (specify) Showing video, Audio cassette distribution, etc 12 The World Bank Health Sector Projects 48. The World Bank is following a sector-wide approach by financing the Nepal Health Sector Program Project, which includes financing for HIV. The project was approved on September 9, 2004 and closed July 15, 2010.. A mid-term review was conducted in December 2007. An additional grant of $50 million was provided, bringing total support to $100 million. 49. The project’s development objective is to expand access to and increase the use of essential health care services, especially by underserved populations. This project is part of the health sector-wide approach for Nepal, with a pooling of resources from Government, World Bank, DfID and AusAID to finance annual national health sector work plans and budgets. 50. The Bank’s priority in the program is health system strengthening. The two key elements for the Ministry of Health include:  Setting up and strengthening the institutional framework for the health sector; and  Capacity building of institutions to contract out services for populations most at risk (MARP). 51. The structural framework for health in Nepal is weak. Multiple needs in the sector are unmet, such as nutrition (except micro-nutrients) or basic water and sanitation. The World Bank is assisting the Nepalese government to update its national AIDS strategic plan. The National Centre for AIDS and STD Control is the lead implementer of the National AIDS Prevention and Control Program. Nepalese National HIV AIDS and STI Board --a multi- sectoral, semi-autonomous entity-- was set up in 2007 with a few non-health ministries taking part. 52. The Bank’s health unit for Nepal provides inputs to the HIV component of the Road Sector Development Project by reviewing the NGO implementer’s terms of reference and progress reports. The Bank’s social unit in Nepal was planning a monitoring visit at the end of October 2009, which could be an opportunity to cover the HIV component. At the time of this review, no Bank monitoring visit to the HIV activities of the transport projects had been carried out yet. Other Entities’ HIV Responses with Relevance to Transport or to Migrants 53. Migrants have been identified in Nepal as one of the vulnerable populations. Several HIV projects target migrant workers and truck drivers. However, there are no country-level responses targeting road infrastructure construction workers. Nepal hosts several key international NGOs who work closely with local NGOs to help them build their capacities. Key entities working on HIV and migrants (including transport operators) are summarized below. i. Asian Development Bank (ADB) 54. The Asian Development Bank has instituted a mandatory HIV clause for all its road project contracts since early 2000. In Nepal, ADB supports Nepal’s 10th National Five-year 13 Development Plan. The Plan aims to improve the country’s sub-regional connectivity and economic integration. 55. The Roads Connectivity Sector Project was approved on August 10, 2006 for $55.2 million. It aims to connect district roads to district Headquarters, improve efficiency of the Department of Roads, build capacity of local construction and consulting services in road construction and management, and improve road safety. The objective is to promote economic growth and poverty reduction for isolated rural communities in northern Nepal. 56. The Project includes the following components:  Road connectivity improvement: Construct and upgrade 500 km of feeder roads to all-weather standards.  Capacity building of Department of Roads: Improve the efficiency and sustainability of the Department.  HIV prevention and anti-trafficking: Reduce the vulnerability of groups at risk to human trafficking, and increase access to HIV prevention services. 57. This is the first ADB transport sector project in Nepal that incorporates an HIV component. The ADB used the following approach for this HIV component:  Step 1 - Preparatory phase: The social assessment included ascertaining HIV knowledge and behaviors of affected communities. At the time of the assessment there was low HIV awareness and risk perception in the project community, especially among women. There was wide-spread risk-behavior among mobile populations and sex workers. The Central Region of Nepal, which is the project location, is prone to human trafficking. Both male and female children from poor families are sent away by their parents to work as “domestic helpers”. They are females from 11-25 years of age and males 6 to 12 years of age. They have a tendency of being trafficked or forced to enter into sex work eventually20.  Step 2 - Design phase: The project HIV component was formulated during this phase. It targets road construction workers, transport operators, female sex workers, labor migrants and populations living along the road corridors. It also includes training of the Department of Roads staff.  Step 3 - Implementation phase: The project recruited a social development consultant with HIV and anti-trafficking experience for 36 months. The consultant supports the DOR to implement and monitor the HIV and anti-trafficking component. 58. The HIV and anti-trafficking component includes the following:  Identify risk groups for HIV and human trafficking, map geo-locations of sexual networks and intervention sites along the road corridors in partnership with NGOs;  Orient and sensitize project personnel on HIV and anti-trafficking;  Raise HIV awareness among contractors and construction workers;  Conduct public awareness campaigns for high-risk groups to change their behaviors;  Promote condom use and disseminate information on available testing, counseling and treatment services; and 20 National HIV/AIDS strategy, 2006-2011, Ministry of Health and Populations, National Centre for AIDS and STD Control, Teku, Kathmandu, October, 2007, page 19 14  Sensitize and build capacity of project personnel. 59. The Social Development Specialist has the following responsibilities:  sensitize the DOR and NGO staff on gender, focusing on the transport sector;  develop gender-responsive indicators to track progress;  participate in HIV and anti-trafficking theme groups;  determine appropriate IEC packages for transport operators, construction workers, female sex workers, tea-stall operators, women, school children, and mobile populations;  assist NGOs to identify risk and vulnerability factors by age and sex; and  implement HIV, AIDS and anti-trafficking activities addressing gender concerns. 60. The consultancy term ended in the summer of 2009 and the consultant had left Nepal at the time of this review and assessment in October 2009. 61. The DOR and contractor staff mentioned this HIV component, but it is not known to the NCASC, UNAIDS or the major HIV NGOs in the country. It may be due to it being within the transport sector and there is minimal exchange with the HIV partners. ADB will review this Nepal experience for adaptation to future HIV and anti-trafficking components for transport infrastructure projects. 62. ADB has also commissioned a review of linkages between gender, trafficking and HIV in Asia and published the report in August 200921. ADB, in collaboration with the World Bank, USAID, JICA, AusAID, ILO and the UN Regional Task Force on Mobility and HIV Vulnerability Reduction, has produced practical guidelines to harmonize lessons learned in HIV interventions for the infrastructure sector22. ii. USAID 63. Nepal’s key HIV funding is from bilateral and multi-lateral donors such as USAID, DFID, the Global Fund and the United Nations entities. 64. Family Health International (FHI) receives USAID funding for HIV activities in Nepal. Previously FHI worked for over 15 years along the East-West corridor linking Kathmandu to India focusing on truck drivers and their assistants. FHI’s present HIV portfolio includes building NGO capacities, particularly on responses to clients of sex workers and migrants. It conducts training workshops and supports 50 NGOs along the highways. 65. FHI, based on behavioral research findings, has developed behavior change communication packages. An example is audio tapes of songs by previous truck drivers who are now HIV-infected. There are also DVDs to complement printed brochures and information pamphlets. These BCC packages have been developed and field-tested with local 21 “Intersections – Gender, HIV and Infrastructure Operations: Lessons from Selected ADB-financed Transport Projects, ADB, August 2009 22 ADB, the World Bank, USAID, JICA, ILO, AusAID and the UN Regional Task Force on Mobility and HIV Vulnerability Reduction: “A Practical Guideline on Lessons in HIV Intervention for the Infrastructure Sector”, in press, 2010. 15 target populations and are popular among them. The materials are available in English and local dialects to facilitate access by ethnic groups.23 66. A national study found that the majority of clients of sex workers in Nepal are migrants and transport workers. FHI supports the National AIDS strategy by reaching sex workers and their clients who are migrants and transport workers. It operates 25 voluntary counseling and testing centers (VCT). 67. FHI has also been receiving DFID funding since 2006 for the project “Reaching across Borders with HIV Services for Migrant Workers”. This project targets Nepalese migrants and their families in Mumbai and Delhi, India to ensure service access on HIV prevention, AIDS treatment, care and support in India. 68. FHI, as part of its implementation of the USAID grant for the ASHA project24, disseminates their BCC materials. It offers to share for free all its BCC materials to the two Banks’ transport project HIV NGO implementers25. In addition, FHI would welcome Development Nepal, their consortia partners, the staff of DOR and contractors to its trainings. It is possible to coordinate with N-Mark, the Nepal social marketer for condom distribution, to extend their outlets close to the construction camps. iii. European Community 69. CARE-Nepal is implementing a European Community-funded HIV project called “Safe Passage” (2008-2012), targeting migrants and their families in rural villages of the Far West. The project provides savings and loans for villagers. Some villages are homes of the road project construction workers. The project has a network of local NGO partners. CARE has trained 540 peer educators in 3 districts among villagers and migrant peers. There are drop-in centers for HIV counseling with referral to local public VCT centers. 70. CARE-Nepal is using funds from the UK’s Big Brother lottery to carry out a regional migrant HIV project between Nepal, Bangladesh and India along the Bhimdatta highway - the Impath project (2009-2014). This cross-border project started in November 2009 to improve mobile populations’ access to HIV services through outreach, advocacy, and capacity building. CARE-Nepal produces many HIV informational materials in local languages and welcomes other NGOs to make use of the materials. iv. Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) 71. Nepal has received two GFATM HIV grants focusing on MARPs and implemented by NGOs. The three principle recipients (PRs) of GFATM HIV grants are Save the Children, UNDP and Family Planning Association of Nepal.  Round 2 grant was $10,365,995: The PRs were UNDP and Ministry of Health. This grant has ended.  Round 7 grant: Scaling up coverage and quality of HIV and AIDS prevention targeted to the most-at-risk population and treatment, care and support services to people living 23 The mission obtained two packages of various BCC materials from FHI. One set was given to the Department of Roads for them to share with their contractors. The other was forwarded by the Department of Roads to Development Nepal for possible use at the World Bank road project intervention sites. 24 ASHA project means Advancing Surveillance, policies, prevention, care and support to fight HIV/AIDS. 25 The FHI country director stated that the NGO implementers are welcome to put their own organization logos on these materials for dissemination. 16 with HIV. The grant is $12,321,512 for Phase I, and $36,620,119 for Phase II. The PRs are UNDP, Family Planning Association of Nepal, and Save the Children USA- Himalayan countries office. Phase I is from 16 November 2008 to 15 November 2010. Phase II is from 16 November 2010 to 15 November 2013. 72. Round 7 Global Fund HIV grant aims to fill the funding gaps of the national AIDS strategy. The goal of the grant is to reduce HIV transmission and enhance the quality of life of people living with HIV or AIDS. 73. The objectives are as follows:  Promote the adoption of safe behaviors among MARPs (especially labor migrants and their spouses, injecting drug users, MSM) through increased access and availability of prevention programs.  Expand access and coverage of quality HIV testing, counseling, STI diagnosis and treatment.  Strengthen health service capacity to provide quality care and treatment for people living with HIV and AIDS.  Increase access to quality care and support services for people living with HIV and AIDS.  Build the capacity of the Government of Nepal and civil society to manage and implement HIV and AIDS activities. 74. The grant provides VCT, condom, treatment of STI, and anti-retroviral therapies. The PRs and its sub-recipients train local NGOs. The PR regularly carry out monitoring visits of sub-recipients’ grant implementation. 75. The grant covers labor migrants in five districts: Doti, Acham, Ralpa, Pyuthan and Galmi. There are up to two sub-recipients for each district, for a total of 8 NGO implementers26. They have trained 720 peer educators to apply behavioral change communications. This represents 90 peer educators per sub-recipient NGO. 76. The sub-recipients are selected by a Technical Review Committee to ensure quality and transparency. The Committee is composed of NGOs, GO and United Nations representatives. 77. Save the Children would welcome construction workers, employees of contractors and other transport workers to use these services (VCCT, STI, condom distribution) provided by the GFATM grant in the geographic areas of the World Bank road project. It would also welcome the Bank’s HIV implementing NGOs to take part in their trainings. It could also provide technical assistance to the Bank’s road project NGOs to improve their capacities. Linking the Bank’s project NGOs to the existing HIV network could improve their HIV responses. 78. Family Planning Association of Nepal, the second PR of GFATM, operates 20 VCT service sites. UNDP, the third PR, operates an additional 37 VCT service sites. There are in total 123 VCT service sites in Nepal27. 26 The two existing sites will have just one each NGO implementer. The three new districts would have two NGOs per district, thus resulting in a total of 8 NGO implementers. 27 National Centre for AIDs and STD Control, July 2009. 17 v. International Labour Organization (ILO) 79. The ILO-Nepal, with funding from the United States Department of Labor (US- DOL), conducted HIV awareness raising with the Nepalese Transport Union. The union has 30,000 members including Kathmandu Drivers’ Union, Garbage Collectors’ Union, Nepal Taxi Drivers Union, and Public Sector Bus Drivers’ Union, Nepal Tourism Workers’ Union among others. It established drop-in centers at major bus depots for drivers. Although the project concluded in 2008, the union members continue to disseminate education materials. Members who are trained as peer educators continue to support their peers when needed. ILO also supported the government in its development and adoption of the National Policy on HIV and AIDS in the Work Place in 200928. vi. The National Centre for AIDS, STI Control (NCASC) 80. NCASC welcomes the World Bank’s initiative of HIV prevention and awareness raising in transport infrastructure projects. The Director noted that migrant workers are some of the most at-risk populations in Nepal. The office is not aware of the activities carried out by Development Nepal and its partners under the World Bank road project. However, the Director is pleased that the two Consortia coordinate their activities with the district AIDS coordinating committees. Recommendations 81. There is a need to improve contracting of HIV interventions and programs for Roads Project, with set criteria for selection of qualified NGO to ensure effectiveness of programs, beneficiaries will benefit from their output and there is value for money. 82. Capacity of selected NGOs will require some training to enable them carry out program effectively. Conclusions 83. In summary, in Nepal, aside from the Bank, ADB has a specific transport infrastructure sector HIV response. The FHI-produced BCC materials and peer educator approach used by other entities are useful references. It is possible to consider joining the GFATM PRs’ monitoring visits to cover the Bank’s road projects for synergy, sharing of experiences and efficiency. 28 “National Policy on HIV/AIDS in the Workplace”, adopted October 2007, Ministry of Labour and Transport Management, Singha Durbar, Kathmandu, Nepal 18 3. HIV, AIDS and Transport in BANGLADESH Epidemiologic situation29 84. The first Bangladesh HIV case was reported in 1989. Eight rounds of sero- surveillance and 6 rounds of bio-behavioral surveillance have been conducted in Bangladesh. The most at-risk populations identified by these surveys are sex workers and their clients, IDUs, hjiras (transgender), and men who have sex with men (MSM). Cross-border migrants and ethnic groups have also been identified as especially vulnerable. 85. Injecting drug users (IDUs). The number of IDUs is estimated at 40,000. The 8th sero-surveillance in 2007 reported IDU HIV prevalence at 1.2%. However, in one Dhaka neighborhood the rate has been 7% since 2006. Among the IDUs surveyed, 45 to 66 percent buy sex from sex workers. About 25 to 55 percent of them use condoms with sex workers. However, consistent condom use with sex workers was only14 to 43 percent. Female IDUs often sell sex to sustain their drug use. 86. Female sex workers. A 2004 study estimated 90,000 sex workers in the country. The number of sex workers has increased and is shifting from brothel-based operations to less regulated settings. There is high mobility among sex workers to different cities, districts and settings. Among clients interviewed, 80 percent use new sex workers at each encounter. There is a high number of clients per sex worker. For example, a hotel-based sex worker can have up to 44 clients a week. Their clients include internal migrants and rickshaw pullers. Unfortunately, condom use among clients is low at 15%. 87. The 8th survey in 2007 reported sex worker HIV prevalence as less than 1 percent except in Hili, a small town in Northwest Bangladesh at West Bengal, India border. HIV prevalence among sex workers in Hili was 2.7 percent. Active syphilis, a risk indicator for HIV, among sex workers in Dhaka and Chittagong, was 7 percent. Brothel-based sex workers’ condom use was 70 percent but 1 percent among hotel-based sex workers in Chittagong. Consistent with findings in other Asian countries, older (over 24 years of age) street-based female sex workers are more vulnerable to STIs compared to their younger peers. 88. Men who have sex with men (MSM). A 2006 study estimated the number of MSM as between 40,000 to 150,000. The 8th sero-surveillance estimated MSM HIV prevalence at 0.3 percent and active syphilis, 1 to 4 percent. MSM is a bridge population for HIV epidemics, because they tend to have sex with both sexes. MSM group-sex among 9 partners in a group is common. Most group sex acts are without condom use and often associated with violence. Although MSM is a taboo in Bangladesh, anecdotal evidence indicates that some long- distance truck operators at times engage in such behavior with their assistants. 89. Migrants. According to the Bureau of Manpower, Employment and Training of the Ministry of Expatriates’ Welfare and Overseas Employment, 900,000 migrants officially 29 Azim, T., et al, “20 Years of HIV in Bangladesh: Experience and Ways Forward. A Consolidated Review of Existing Information”, ICDDR, B to UNAIDS and the World Bank, March 2009 19 registered in 2007. Among these, 8 percent are females. The estimate is 13.6 percent females if considering both regular and irregular migration (i.e. not through official channels). The National STD and AIDS Program (NASP) in 2009 reported that nearly 64 percent of people living with HIV had previously worked abroad. Among husbands returned from previous migration, 56 percent reported having sex with sex workers while away. Only 13 percent among those reported using a condom in their last sex act with a sex worker. Among returnee husbands, 5 percent reported having sex with men while away. Among female migrants, 67 percent reported having done sex work while abroad30. 90. At border zones with India and Myanmar, many truckers, boatmen and sex workers cross the borders and engage in sex. For example, a study about boatmen who crossed over to Myanmar reported that 39 percent of the boatmen bought sex while away. The probability of engaging in sex while away is proportional to the length of time away from Bangladesh31. 91. Additional HIV vulnerabilities relating to migrant workers and transport have been identified. In the tea plantations, some of the day workers take on sex work by night. Due to traffic congestion, there is a city passage rule which restricts heavy truck transit within the city between 10 am and 4pm. Consequently, the drivers who did not make it through the city prior to 10 am stay idle at the outskirt of town waiting until after 4pm. The river passage is also congested with long ferry queues. The idle time increases the use of sex workers by boatmen and truck drivers. 92. Truck drivers and their helper32,33,34,35. Long-distance truck drivers and their helpers have high-risk sexual behaviors while on the road, as they spend long time away from home and families. Truck driver studies conducted from 1997 to 2006 consistently showed 42 to 54% of respondents having sex with sex workers. Among them 31 to 82% did not use a condom while engaging in paid sex. Up to 20% have existing STI symptoms, but many do not seek treatment. CARE-Bangladesh operates drop-in centers for truck drivers in collaboration with truckers’ unions. Truck drivers and their helpers have sex with male, female and transgender sex workers, thus may spread STI and potentially HIV. 93. General population- 15 to 24 years of age. Among the 15 to 24 years age group 90 percent have heard about HIV or AIDS. About 38 percent correctly identify modes of transmission and 40 percent identified means of HIV prevention36. More years of education, urban dwelling, better economic status, and access to TV contribute to improved HIV knowledge. Rural women and married youths have less HIV knowledge. Particularly, truckers (including helpers and cleaners), other transport workers, male migrants, international migrants, women in domestic work or garment workers are at high risk in Bangladesh. 30 T. Azim, et al, “20 years of HIV in Bangaldesh: Experiences and Ways Forward, a Consolidated Review of Existing Information”, ICDDR, B to UNAIDS and the World Bank, March 2009, p 55 31 Ibid, p 56 32 Barua PC, “Knowledge and Behaviour of Long-distance Truck Drivers on HIV/STD in Bangladesh,”, Institute of Child and Maternal Health study of 1997 presented at the International AIDS Conference, 2002; 33 Gibney L, Saquib N, Metzger J., “Behavioural Risk Factors for STD/HIV Transmission in Bangladesh’s Trucking Industry”, Elsevier Science Ltd. online journal, 2002 34 The Nation, 28 April 2007, UNESCO seminar based on a study by Life (an NGO) on truck drivers 35 Chowdhury, S.A.A., Chandra R.R., “Engaging Key Stakeholders Ensuring the Right to HIV/AIDS Education & Health Care Services”, New Tactics Project of the Centre for Victims of Torture, 2006 36 Ibid,p62 20 The World Banks’ Transport Projects in Bangladesh37 94. The Bank’s $190 million Rural Transport Improvement Project implemented by the Local Government Engineering Department (LGED) was planned from 2003 to 2009 and extended to 2011.There is no HIV component in the project. 95. The Government has asked the Bank to support railways reform with an investment operation. A separate project is also requested to finance the development of an Inland Container Depot to facilitate movement of containers along the Dhaka-Chittagong rail corridor. 96. In May 2009, the Bank approved the Clean Air and Sustainable Environment, a multi- year, multi-donor support project with JBIC and ADB. The project will support demonstration environmental investments in Dhaka’s urban transport. 97. The Government has also asked the Bank to support the inland water transport subsector. The project will include dredging of inland waterways, cover the country boat sector, and consider energy efficiency and river transport safety. 98. The Bank will support the construction of the Padma Bridge. The bridge will connect South-West Bangladesh with Dhaka and the East. The Bank will contribute $1.2 billion in partnership with JBIC, ADB and IDBA public health action plan was prepared which covers HIV AIDS. A public health action plan which also covers HIV AIDS was prepared for the project. World Bank Health Project 99. The World Bank is helping the Government carry out its Strategic Investment Plan in the sector-wide Health, Nutrition and Population Sector Program (HNPSP), 2003-2010. The program became effective in 2005 and will end in 2011. The SWAp is led by the Government of Bangladesh and costs $4.3 billion. $684 million is a pool-fund managed by the Bank. The fund includes an IDA credit of $300 million and multi-donor trust fund of $384 million. 100. The World Bank co-financed a project with DfID titled “HIV and AIDS Prevention Program” (HAPP), which ended in December 2007. After the closure of HAPP, the activities were integrated into HNPSP and the HIV component is called HIV/AIDS Targeted Intervention (HATI). Between January 2008 and March 2009, the Government contracted UNICEF to procure HATI NGO services. The National AIDS/STD Program (NASP), the Government agency for national HIV response, assumed management of the NGO contracts in March 2009 and anticipates resuming operations in December 2009. There are six packages in HATI, but less than $18 million of the budget has been secured38. 37 From the World Bank Bangladesh transport sector website. 38 http://www.bdnasp.net/index.php?option=com_content&view=article&id=67&Itemid=82 21 101. The NASP was initiated in July 1998, however HIV/AIDS related activities started since 1985, the program has limited capacity and frequent change of Line Director and Program Manager since its inception in 1985. A new Director was appointed for six months up to March 2010. Under HAPP, UNFPA supported NASP capacity building but the program no longer exists within NASP. Currently, Save the Children-USE provides technical Specialist as a part of their support to NASP. 102. The current National AIDS Strategic plan is 2004-2010. NASP has initiated the process for developing 3rd National Strategic plan for the period of 2011-2015. The World Bank coordinates technical assistance for the Bangladesh National AIDS Strategic Action Planning. 22 4. Other Organizations’ HIV Responses Relating to Transport Sector or Migrants i. ADB 103. Road Network Improvement and Maintenance Project II. The total project cost is $187.1 million. ADB is providing a $126 million loan. The remaining $61.1 million is financed by the Government. There is an HIV prevention and anti-trafficking component. The project started in 2003 and will end by 31 December 2010. The project, except the HIV and trafficking component, is carried out by the Roads and Highways Department of the Bangladesh Road Transport Authority. 104. The HIV and AIDS component is executed by the Ministry of Women and Children’s Affairs. At present $500,000 has been provided. The objective of this component is to identify effective and viable modes of anti-trafficking operations, and improve awareness of vulnerable groups to HIV and AIDS. The following are activities of this component:  strengthen Government, NGOs and media capacity in awareness of HIV and trafficking of women at border area of Bangladesh and India;  provide capital investments for physical upgrading of innovative schemes (center for legal literacy/awareness of HIV, AIDS and trafficking in women) in two districts of Panchaghar and Dinaipur at the northern border of Bangladesh, and in one district in Chittagong. 105. A Steering Committee consisting of the Roads and Highways Department, the Ministry of Women and Children’s Affairs, Ministry of Health, Ministry of Home Affairs, NGO network on Action against Trafficking and Sexual Exploitation of Children, and ADB oversees the carrying out of the HIV component. 106. The Ministry of Women and Children’s Affairs engaged three local NGOs: Ashwash, Narimaitree and Rights Jessore from July 2007 to March 2008. The NGOs provide HIV and trafficking awareness-raising information, education and communication (IEC) activities. The contracts have been extended from April 2008 to 31st December 2009. This second phase focuses on the following:  Improvement and adoption of communication materials, suitable for literate, semi- literate and illiterate persons;  in-house capacity development for the three implementing NGOs;  awareness sessions at the subdivision and union levels for specific target populations;  courtyard meetings with vulnerable persons; and  development of a sustainability mechanism (exit strategy). The IEC targets adolescent boys and girls, bus/truck drivers, rickshaw pullers, potential migrant workers and commercial sex workers. 107. Other projects: There are two pipeline road projects. One will start in 2010; the other, 2011. Both pipeline projects may include an HIV component. In addition, ADB has an 23 Asia regional transport project39 which covers Bangladesh. It aims to develop HIV prevention capacities in urban local governments along the transport corridors by providing an HIV expert for 6 months. ii. USAID 108. FHI is receiving USAID funding from September 2009 to August 2013 to provide VCT, STI treatment for MSM, female sex workers, IDUs and clients of sex workers. Truck drivers are considered as clients of sex workers. FHI coordinates with the GFATM HIV Round 6 grant implementers and HATI to avoid duplication. The project works with religious leaders to reduce discrimination. It has a network of 21 NGOs to operate drop-in centers for the target populations. iii. Social Marketing Company 109. Condom promotion is an integral HIV prevention measure. The Social Marketing Company (SMC) has a boat operating along the river to Chittagong to promote condom use. If the World Bank’s inland waterway project starts and includes an HIV component, this entity could be a potential partner. iv. International Transport Federation 110. The International Transport Federation collaborated with CARE to work with air, rail and road transport workers between Bangladesh and India in 2008. The activities focused on IEC for HIV awareness-raising by producing and disseminating HIV prevention messages. v. GFATM 111. Save the Children-USA in Bangladesh, ICDDR,B and NASP are Principle Recipient of the GFATM HIV grant Rounds 2 and 6. Phase II will conclude by 2012. It includes GIS mapping of GFATM grant service locations. (Refer to Figure 2 map for the GFATM Rounds 2 and 6 coverage.) The maps provide information on available service locations. The Bank’s future transport project’s HIV component could take this information into account. vi. BRAC 112. BRAC has been working on HIV since 2002 in 14 districts with brothel-based sex workers, industry workers, migrants including unskilled factory workers, truck drivers and their associates collaborating with truckers’ unions. It operates 100 sites with peer educators who refer peers to VCT services. It is possible to utilize the materials developed by BRAC for awareness-raising for transport construction workers and surrounding communities. vii. National AIDS and STD Programme 113. Bangladesh is developing its 2011-2015 National HIV and AIDS strategy. This is an opportunity to include transport infrastructure sector workplace HIV responses to cover 39 ADB RETA 6321 is an Asia region-wide transport and HIV program. 24 railways, trucking, construction industry and hot spots such as bus terminals, railway stations and ports to reach mobile populations. 25 5. RECOMMENDATIONS 113. The following are recommendations: HIV components of Transport Projects in Bangladesh and Nepal  Implement a transport workplace HIV policy and program in Nepal, in view of the interest expressed by the Department of Roads’ staff and construction company representatives. The workplace approach promotes sustainable HIV preventive responses and reduces the hit-and-miss biannual visits of the Nepal NGO implementers.  Use peer educators, because it has proven to be cost-effective compared to occasional external health educator visits.  Establish (or use existing) technical committees to select and monitor NGO implementers. The committee may consist of representatives from the National AIDS authority, UNAIDS, the principle recipients of the Global Fund to fight AIDS, TB and malaria, government ministerial representative, and the World Bank. Such a committee can improve transparency and quality of selection, facilitate joint monitoring, and sharing of experiences and materials of the NGO implementers.  Strengthen monitoring to improve specific knowledge and implementation of transport infrastructure projects’ HIV responses.  Apply the World Bank joint practical guidelines on HIV interventions in the infrastructure sector for future transport projects’ HIV responses. The World Bank  Conduct situation mapping, during the pre-project feasibility assessment phase, to identify target populations, hot spots, available resources in communities affected by the road projects, and potential HIV response implementing partners.  Require that all transport infrastructure development projects include the model contractual clause on HIV in bidding.  Establish (or use existing) HIV technical committees for selecting and monitoring implementers of HIV components.  Engage technical assistance to include transport workplace responses in formulating new National AIDS Strategies for Bangladesh and Nepal.40  Include gender-sensitive features in HIV responses before, during and after construction. 40 Bangladesh is revising its National HIV AIDS strategy in 2010 and Nepal in 2011. It is an opportunity for the Banks’ South Asia Transport Unit to support the AIDS Strategy and Action Plan coordinator in accounting for transport sector workplace occupational safety and health. 26 The Ministry of Physical Planning and Works -Transport Ministry  Assist the Ministry to establish HIV workplace policies and programs thereby integrating HIV prevention into its road infrastructure projects, as well as users and operators of road systems.  As part of assessing project feasibility, include HIV vulnerability mapping and include gender impact analysis. A model term of reference is in the Annex.  Collaborate with labor inspectors who are trained on HIV workplace standards to monitor HIV workplace responses in the transport sector. The Transport Sector’s HIV Prevention Implementers  Use evidence-informed responses such as peer education and field-tested behavioral change communications.  Include monitoring and evaluation indicators and targets. Establish baseline, conduct mid- term review and end-of-project evaluations to improve knowledge, reporting and responses. The NAC – National AIDS strategy  Engage the transport sector, including transport workers’ unions, to reduce the HIV vulnerabilities of mobile populations.  In HIV responses develop strategies and partnerships regionally among neighboring countries to cover the continuum of sending, transit and host communities of migrant workers. 27 6. SUGGESTIONS FOR THE DRAFT REGIONAL STRATEGY FOR HIV PREVENTION IN THE TRANSPORT SECTOR 114. A draft strategy “Mainstreaming HIV/AIDS Interventions in the Road and Transport Sector Development Program” has been prepared by the transport unit of the South Asia Region. The document proposes a model program and management arrangements, identifies stakeholders, and provides models of service delivery for information, education and communication on HIV during the construction phase of a road project in India. 115. It is suggested that a strategy document on HIV responses in the road sector of the South Asia region should include the following framework: 1. Justification for the strategy This section should answer the question: Why should the transport sector integrate HIV preventive interventions into its infrastructure construction projects? It should also respond to the question of who are the target audiences of this strategy document. 2. Focus of the strategy This section should answer two inter-acting questions:  How can the transport sector contribute to reducing HIV vulnerability based on its unique mandate, expertise and network for connectivity?  How can the health sector and especially the national AIDS authority partner with the transport sector to mitigate the potential impact of HIV on the sector? 3. The strategic approaches This section should address what the transport sector can do for HIV vulnerability reduction and preventive interventions. Differentiated strategies need to be formulated for the entire cycle of the construction project. For instance, activities need to be undertaken at each of the following stages: a. Feasibility assessment phase Conduct HIV vulnerability mapping. This is an opportunity to ascertain the knowledge and HIV epidemic status among target communities along the transport corridors. It is suitable and feasible not only in the case of a road project, but also in the case of inland waterways or railway construction projects. b. Design phase During this phase, develop the HIV program component that can be integrated into the construction phases and schedules. The HIV component design should take into account spouses of workers, as well as gender considerations. c. Construction phase There are several approaches to selecting an appropriate organization or entity to implement the HIV component. This can be determined based on the findings of the mapping assessment. The current draft strategy provides some points on the HIV prevention element but lacks the development aspect. 28 d. Post-construction phase41 To make sure the strategy and interventions contribute to the Bank’s socio-economic development and poverty-reduction goals for transport infrastructure improvement, the transport sector interventions can best be achieved by taking on roles that are in its sectoral mandate and where the transport sector has comparative advantages. An example is to facilitate market access for affected communities. Identify and include interventions based on improved access to resources and technologies with strengthened connectivity from improved transport infrastructure that ensure gender equality in access42. An impact assessment could also be carried out in the post-construction phase. 4. Region, country and sector-specific considerations A regional strategy is an opportunity to provide a regional perspective. Country-specific administrative structures and systems could be provided in an annex. Where feasible, identify opportunities or mechanisms where partnerships and linkages with existing national processes could be built or strengthened. For example, provide the anticipated schedules of national AIDS strategy revisions by countries in the region. 5. Resource requirements This section could provide options for financing the HIV component in the transport infrastructure construction sector. The model contractual clause has been an effective instrument to date. The development banks which have included such a clause usually provide funding for the HIV component as a grant. There are several co-financing and partnering opportunities in countries in South Asia from multilateral grants (especially under the one-UN context), bilateral sources, and the Global Fund to Fight AIDS, TB and Malaria. 6. Workplace model The ILO Code of Practice for the world of work on HIV and AIDS is an instrument recognized by workers’ unions, employers’ organizations and member States internationally. It could be applied to construction companies. An International Standard is currently under review for potential adoption by the International Labour Conference in June 2010. The Standard will provide the guiding framework for workplace HIV programs, and could be considered in this strategy document. It is worth noting that, by applying the principles of the Code of Practice, gender considerations, anti-discrimination and protection of workers’ rights would be covered. This is pertinent, as many construction workers are migrant workers. This is also relevant as the labor inspection would ensure occupational safety and health for construction workers. In some countries in South Asia, labor inspectors have been trained to incorporate HIV considerations in their inspection, to ensure compliance by construction companies. 7. Sustainability Promote the integration of workplace and transport sector responses as part of the National AIDS Strategy and regionally through SAARC. It would be relevant for the strategy document to consider building the sustainability of HIV interventions in the transport sector. 41 Guest, P. , du Guerny J., and Hsu, L-N, “From Early Warning to Development Sector Responses against HIV/AIDS Epidemics,”, May 2003, www.hivdevelopment.org, pages 10-11 42 Gender equality of access interventions will reduce women’s trading sex for transportation. 29 8. Monitoring and evaluation It is critical to make sure there is a baseline and the interventions will be properly monitored and evaluated to draw lessons for future refinement. Setting realistic indicators and targets is critical. Identifying partners for joint monitoring in the strategy could build synergy with other HIV stakeholders in the country. In summary, the current draft strategy document has several useful elements that could be incorporated in an implementation guide. However, in view of the expanding road network between the countries of the region, it could be complemented by a regional perspective as it is specific only to India. In addition, there are several major gaps to be filled as identified above. A revised strategy document would also benefit from clear section headings that reflect the content discussed. Use of concise wording, information and diagrams or flow charts could aid in readability, thus improving user-friendliness. 30 ANNEX: 1: Sample Terms of Reference for an HIV and Health Vulnerability Mapping Assessment for a Transport Infrastructure Construction Project 1. Transport infrastructure construction and improvements contribute to improved connectivity for people, goods, markets, information and communications. The anticipated increase of traffic flow will bring more people in contact with communities along the corridors. It would also facilitate residents from rural communities to reach urban cities. It is an opportunity to reach populations which otherwise might not have access to certain information or services. It is relevant, as with environmental and social assessments prior to a construction project, to have a health and HIV vulnerability assessment. 2. The sample Terms of Reference is for conducting an HIV and health vulnerability mapping during the feasibility phase of a transport infrastructure construction project. It is not limited to road construction but can be applied to waterways, railway or port construction. Ideally such an assessment should be conducted prior to the start of a project. Such timing could maximize preparedness for the project and timely incorporation of appropriate HIV interventions in the project. However, in the event a project has already started, it is still feasible to conduct the HIV and health vulnerability mapping. In such circumstances, the mapping could ascertain remedial HIV and health interventions to be provided as part of the occupational safety and health enforcement for the construction workforce. It could also support awareness-raising for the surrounding communities. 3. The assessment aims to ascertain the potential influence the transport project might have on HIV and health vulnerabilities, both positive and negative, on the populations of surrounding communities and the construction workforce. It also aims to identify available local resources for HIV prevention and wellness promotion. The tasks for the assessment may encompass the following: 1. Literature Review and Second-hand Data Analysis  Epidemiologic and behavioral surveillance reports 4. Obtain from the National AIDS authority, UNAIDS, local research institutions and NGOs available health, HIV and TB epidemiologic and bio-behavioral surveillance reports of the country. In particular, obtain data on the specific area where the project is being proposed. These include studies on vulnerable populations, the pattern of transmission with sex- disaggregation of data. Map the HIV, TB and health statistics to compare the prevalence of HIV, TB and other diseases of the project-specific communities with that of communities to be connected through the construction projects.  Project- or program-specific studies and reports 5. Obtain and review operations research and other available published and unpublished studies relevant to HIV, TB and the health situation of the country, with particular focus on the geographic area of the proposed project and of migrant and ethnic populations to be affected by the project. The findings from these studies could shed light on the relevant approaches and socio-economic or cultural factors to be taken into account in designing the HIV component of a project. 31  Map resources and services available along the proposed project corridors or sites 6. Identify the relevant organizations, governmental, private, the United Nations entities and civil society organizations with a presence in the country, particularly those with a presence along the project corridors or sites. Map them as to location and services they provide. Consult the project implementing agencies to match potential workers’ camps with the location of these services. Develop an inventory of available resources and services (such as STI treatment clinics, VCT sites, pharmacies, vendors of condoms, etc. if these inventories are not already available). During this step, it is feasible to ascertain the potential pool of eligible implementers for the HIV component.  Map patterns of population movements 7. Identify current pattern of population flow related to the project (source communities, transit hubs, and direction and destination communities). Place as a layer of the map.  Identify gender disparities 2. Primary Data Collection 8. Based on the review of literature and analysis of second-hand data, identify gaps in knowledge and information. Conduct a rapid assessment with key stakeholders to fill the gaps. The rapid situation assessment could normally be accomplished in 5 to 10 days, depending on the size and scope of the proposed transport infrastructure construction projects.  Interview key stakeholders 9. This includes local government and planning authorities to ascertain their knowledge, understanding and support to the project, as well as any other planned major infrastructure projects in their communities during the timeframe of the proposed transport project43. Also include local NGOs, health authorities and businesses to be interviewed. 10. Find out from transport unions whether they already have HIV programs. Identify whether the existing certified labor inspectors (for occupational safety and health) have already been trained on the HIV component of inspections. From potential construction contractors active in the country for the type of construction projects, find out whether they already have HIV workplace programs or policies.  Map entertainment and other service sector sites 11. Along the transport project corridors or sites, identify entertainment or service industry entities and map their locations to be over-laid with the HIV and health status map. Include local health authorities, NGOs (not limited to HIV NGOs), private businesses, service industries and tourism sectors (hotel, restaurants, bus depot, car park, guest houses, rest stops, etc.)  Random sample interview of local residents, transport operators and passengers 43 The local government usually has an economic planning calendar and could advise on whether other major infrastructure, such as a dam, is being planned, the time frame, location and scope of these other projects, if any. 32 12. A standard questionnaire for each of the target populations could be utilized to ensure completeness of information to be collected by field data collectors. 3. Analysis of Primary and Secondary Data 4. Produce a Synthesis Mapping Report 13. The report should provide visual maps that reflect the physical locations and proximity among health, HIV and other services, service industry and entertainment facilities overlaid with HIV prevalence data. The report should provide specific recommendations to the approach and proposed elements of an HIV intervention, as well as the type of set-up for entities to carry out the HIV component. For example, it could be an add-on to a local organization which already has good rapport with the local community by providing technical assistance to them. 14. In some instances, one of the outputs of the mapping assessment could be terms of reference for a potential HIV component implementer. In other instances, one of the outputs from the mapping assessment could be a proposed HIV/health program for the transport project. 15. Note that the Terms of Reference for a transport project HIV and health vulnerability assessment should be adapted to the specificity of each country and locality where the project will take place. This will ensure that the Terms of Reference respond to the local cultural, social and economic context, as well as the availability of resources. 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