INTEGRATED SAFEGUARDS DATA SHEET APPRAISAL STAGE Report No.: ISDSA721 Public Disclosure Copy Date ISDS Prepared/Updated: 11-Apr-2012 I. BASIC INFORMATION 1. Basic Project Data Country: India Project ID: P130299 Project Name: FOURTH NATIONAL HIV/AIDS CONTROL PROJECT (P130299) Task Team Leader: Mariam Claeson Estimated Appraisal Date: 16-Apr-2012 Estimated Board Date: 20-Nov-2012 Managing Unit: SASHN Lending Instrument: Specific Investment Loan Sector: Health (100%) Theme: HIV/AIDS (70%), Health system performance (10%), Population and reproductive health (10%), Other communicable diseases (5%), Child h ealth (5%) Financing (In USD Million) Financing Source Amount BORROWER/RECIPIENT 200.00 International Development Association (IDA) 250.00 FOREIGN SOURCES (UNIDENTIFIED) 0.00 Total 450.00 Environmental Category: B - Partial Assessment Is this a Repeater project? No 2. Project Objectives The Project Development Objective (PDO) is to increase safe behaviors among high risk groups, thus contributing to the national goal of reducing the incidence of HIV infections by 50%, by 2017. Public Disclosure Copy 3. Project Description 14. The Project will contribute to two of the four components of the national AIDS control program, the prevention component and a small share of the institutional strengthening and program management. The two other components, namely, the provision of care, treatment and support to people living with HIV and AIDS (PLWHA) and strategic information systems (SIMS), including disease surveillance, will be supported by the national budget, with some technical and financial support from other donors. The main support of the Project will go towards the scale up of HIV prevention interventions under NACP IV, with a focus on the high impact and cost-effective targeted prevention interventions for population groups at high risk, and related behavior change communications. The Project will also support NACO to further strengthen project management, especially the steering role of NACO, as the national program moves through a transition phase with integration and convergence of selected program elements such as treatment of sexually transmitted infections (STI), blood safety, facility-based integrated counseling and testing, treatment services and prevention of parent to child transmission (PPTCT), with the National Rural Health Mission and other health services and programs. The project has the following two components that include implementation at the national, state, and district levels: Component 1: Scaling Up Targeted Prevention Interventions (US$240 million) 15. This component will help support the scaling up of targeted interventions (TI) with the aim of reaching out to the hard to reach population groups who do not yet access and use the prevention services of the program, and saturate coverage among the HRG. In addition, this component will support other vulnerable population groups, such as migrants and truckers, and include activities that support the behavior change communications, primarily focusing on demand generation and stigma reduction. This component would include the following three subcomponents: 1.1 Scaling up coverage of Targeted Interventions among HRG : The project aims to reduce new HIV infections by expanding reach and coverage of quality targeted prevention interventions among HRGs over the next five years. This will be implemented through a large number of successfully proven targeted interventions (TIs) working with communities of female sex workers (FSW), men having sex with men (MSM), and injecting drug users (IDU), through the contracting of NGOs and CBOs. A definition of Targeted Interventions (TIs) are found in Annex 6 and the activities to be funded under this subcomponent are listed in Annex 2, and include: (i) mapping, size estimation and micro planning of TI for HRGs; (ii) provision of behavior change interventions to increase safe practices, testing and counseling, and adherence to treatment, and demand for other services; (iii) promotion and provision of condoms to HRG to promote their use in every sexual encounter; (iv) provision or referral for STI services including counseling at service provision centers to increase compliance of patients with treatment regimens, risk reduction training, and a focus on discordant couples and partner referral. 1.2 Scaling up of interventions among other vulnerable populations: Vulnerable population groups include clients of sex workers, migrants, and Page 1 of 4 long distance truckers moving between high and low prevalence areas and engaging in unsafe practices. The activities under this subcomponent will be guided by the information from the mapping of peer networks in order to influence the choices of the vulnerable populations and improve their access to prevention services, and might include: mapping and size estimation of migrant population groups at destination points, including truckers; behavior change communications (BCC) through peer led interventions of either individuals or groups to create awareness of their vulnerability and increase demand for products and services; promotion and provisioning of condoms through different channels including social marketing; development of linkages with local institutions, both public and NGO owned, for testing, counseling and STI treatment services, which will be an important area of public-private partnerships; creation of “peer support groups� and “safe spaces� for migrants at destination; and, Public Disclosure Copy strengthening networks of vulnerable populations with enhanced linkages to service centers and risk reduction interventions, specifically condom use. 1.3 Behavior Change Communications: BCC strategies related to TI, will take into account the specific structural amplifiers, risk factors and vulnerabilities of HRG and other vulnerable population groups including youth. This subcomponent will include the following activities: communication programs to increase demand and effective utilization of testing and counseling services; youth friendly services; and, effective communication programs including advocacy, social mobilization and BCC to integrate PLWHA and HRG into society at large and to encourage normative changes aimed at reducing stigma and discrimination in society at large, and in health facilities specifically. Component 2: Strengthening Institutional Capacity and Program Management (US$10 million) 16. In support of NACO’s national steering, coordination and managerial roles during the transformational phase of NACP IV, the Project will support innovations to enhance performance management including fiduciary management, such as the use of the computerized financial management system, at national and state levels. The support for institutional capacity will also help strengthen the procurement and financial management of the program at central and state levels, learning from the experiences of NACP III. This will help NACO to more effectively and efficiently manage the prevention component of the program, as well as the gradual integration of basic services and treatment over a transitional period. This component will also contribute to strengthening and institutionalizing the Technical Support Units’ (TSU) functions at national and state levels. In addition, this component will contribute to the oversight of the monitoring, evaluation and integrated bio behavioral surveillance systems, especially the effective use of available information in support of evidence-based planning and performance monitoring. See Annex 2 for more details. 4. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The national program will be implemented nationwide. The project focuses on targeted prevention interventions to high risk groups and their locations identified through mapping. NACP IV aims to focus specifically on the marginalized and hard-to-reach population groups not yet accessing HIV prevention, testing and treatment services, and therefore by design will benefit the most vulnerable populationm groups at highest risk, often marginalized and socially disadvantageous sections of society. No physical structures or facilities are planned to be undertaken in NACP-IV and therefore, the project will not generate any involuntary resettlement risks. NACP-IV will be implemented in high burden (category A and B districts) some of which are inhabited by tribal communities. 5. Environmental and Social Safeguards Specialists Ruma Tavorath (SASDI) Satya N. Mishra (SASDS) Public Disclosure Copy 6. Safeguard Policies Triggered? Explanation (Optional) Environmental Assessment OP/BP 4.01 Yes Natural Habitats OP/BP 4.04 No Forests OP/BP 4.36 No Pest Management OP 4.09 No Physical Cultural Resources OP/BP 4.11 No Indigenous Peoples OP/BP 4.10 Yes Op4.10 has been triggered in continuation of the safeguards approach adopted for the NACP III in view of the need to address vulnerability and risk of people in tribal districts Involuntary Resettlement OP/BP 4.12 No Safety of Dams OP/BP 4.37 No Projects on International Waterways OP/BP No 7.50 Projects in Disputed Areas OP/BP 7.60 No II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: The project is supporting the scale up of prevention with a focus on targeted interventions to population groups at high risk and related behavior change communications. While the project does not directly finance service delivery, it is important to ensure that risks associated with service delivery are well managed at a programmatic level. The project therefore continues to support NACO in instituting better infection control and waste management guidelines and systems. This is critical given that the primary environmental risks associated with the HIV-AIDS program relate to the handling and disposal of infectious wastes, such as sharps (infected needles and syringes, surgical equipment, IV sets) infected blood, pharmaceutical wastes and HIV test kits generated from ICTCs, blood banks and laboratories. The overall context for health care waste management in India is provided by the revised Bio-Medical Rules (2011). The proposed project continues to be classified as Page 2 of 4 Category ‘B’ as per the World Bank’s Operational Policy (OP 4.01). Social: The project will primarily benefit population groups at high risk including female sex workers, injecting drug users, and men having sex with men, including transgender, through targeted interventions, including in the tribal areas. As the project will be implemented nation-wide including in the tribal districts, OP 4.10 is triggered. This is a continuation of the safeguards approach established for NACP-III based on a detailed Social Assessment which discussed specific impacts, concerns and issues relating to the tribal people, their vulnerability and needs with regard to HIV. NACO has established a Framework for preparing Tribal Action Plans (TAP), based on which TAPs have been prepared Public Disclosure Copy and implemented in 65 A and B category (high HIV prevalence) tribal districts across 13 states during NACP-III, which shall be continued for NACP-IV. In continuation of the process started during NACP-III, NACO will complete the vulnerability and need assessment study in category A and B tribal districts in the first year of implementation and incorporate measures required in the TAPs including targeted interventions as required. The Project shall not involve construction of any infrastructure facilities requiring land acquisition and therefore shall not require any involuntary resettlement, and will not have any potential large scale, significant and/or irreversible impacts. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: Improper knowledge and poor occupational practices by the healthcare workers puts them at potential risk for infection; including reuse of infected sharps. Therefore establishing the appropriate systems for sound management of infectious waste and ensuring good practices by healthcare workers involved in blood collections and HIV-AIDS prevention and treatment services is critical to manage the risks to public health and the environment. The project aims at facilitating behavior change among the high risks groups in order to reduce HIV incidence. A Social Assessment carried out for the Project discusses social issues and impacts on various beneficiary groups. It identifies adverse social and economic impacts of HIV infection on various population categories including women, children, sexual minorities, sex workers, migrants and other vulnerable groups. The Project will reduce transmission due to unsafe sex and sharing of needles and to reduce stigma and discrimination through BCC/IEC reaching the population groups most at risk and other vulnerable groups. The Project will have no long term or indirect adverse impacts. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. The Project was prepared based on learning gained from the implementation experience of the NACP-III and with the help of special working groups constituted to reflect on achievements made and lessons learned from NACP-III and accordingly advise on the design for the NACP-IV. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. Under NACP-IV, NACO has undertaken a situation and gap analysis based on which recommendations have been made to improve implementation under the program. The recommendations reiterate the need for a strong institutional framework both at the national and state levels, scaling up ICWM implementation in TI areas, intensifying capacity building activities and reducing the volume of infectious waste generated through effective segregation and waste management. These recommendations, which are synchronized with the revised BioMedical Rules (2011), now have to be detailed into an Action Plan with timelines and associated budgets. NACO is in process of uploading the draft Plan onto their website and will be organizing stakeholder consultations to discuss the recommendations, based on which it will finalize the Plan and re-disclose it before Negotiations. Social: The Social Assessment recommends policy and implementation measures for addressing the key social issues. NACO has already taken several policy and implementation measures to address these issues, which include: (i) national HIV/AIDS legislation; (ii) guidelines for mainstreaming women’s empowerment in HIV/AIDS intervention, (iii) draft policy on greater participation of people living with HIV; (iii) guidelines on HIV pediatrics and child rights; (iv) adolescent education program (AEP) for providing life skills education (already implemented in Public Disclosure Copy over 50,000 schools); (v) Operational Guidelines on tribal action plans. Elaborate implementation mechanisms have been established for NACP-IV, in continuation of systems and procedures established for NACP- III with improvements. NACO and SACS have established special cells for “mainstreaming�, which handles issues of social inclusion, gender equity, and tribal action plans in coordination with other agencies. The targeted interventions (TI) for specific beneficiary /high risk groups will be implemented in partnership with the CSOs and CBOs having skills and experience , local understanding, and sensitivity to social issues. Capacity building measures have been highlighted in the draft SA, based on which the NACO will plan and implement demand driven training programs for various stakeholders. Further details of the implementation strategy will be finalized during Appraisal. NACO will roll out TIs in tribal areas, where required, based on the vulnerability and need assessment study to be completed in the first year of implementation. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. As per World Bank's Disclosure Policy, NACO has uploaded the draft revised IC-WM Plan on its website and also will be organize stakeholder consultations with some SACS, and a selected sample of administrators and key staff working in health facilities to discuss the recommendations and revised IC-WM Plan before it is finalized. The stakeholders for the Project include: targeted beneficiary groups (sex workers, IDUs, men having sex with men, including transgender groups) and other vulnerable groups, such as migrants, truckers and tribal groups. CSOs work with them and on relevant issues, research institutions , government departments, and donor agencies. NACO and SACS work closely with all the stakeholders including CSOs, associations, and advocacy groups representing various stakeholders and affected groups in designing and implementing various activities. They work with different government departments to mainstream HIV interventions within various development and welfare schemes. NACO and SACS have adopted a highly consultative approach in planning and implementing NACP activities in recognition of the socio-cultural sensitivities and awareness needs of the people and to encourage participation of various stakeholders including CSOs. The Social Assessment documents consultations held so far and will provide a framework for future consultations. During NACP-III grievance redress mechanisms have been established to respond to reported cases of stigma and discrimination, which will be reviewed and strengthened as required for NACP-IV. The draft Social Assessment has been disclosed on the NACO website seeking stakeholder feedback and shall be finalized incorporating Bank’s comments and feedback from consultation with the key stakeholders, including CSOs working with tribal people during Appraisal. B. Disclosure Requirements Date Environmental Assessment/Audit/Management Plan/Other Page 3 of 4 Date of receipt by the Bank 04-Apr-2012 Date of "in-country" disclosure 05-Apr-2012 Date of submission to InfoShop 05-Apr-2012 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors Public Disclosure Copy Indigenous Peoples Development Plan/Framework Date of receipt by the Bank 04-Apr-2012 Date of "in-country" disclosure 05-Apr-2012 Date of submission to InfoShop 05-Apr-2012 If the project triggers the Pest Management and/or Physical Cultural Resources policies, the respective issues are to be addressed and disclosed as part of the Environmental Assessment/Audit/or EMP. If in-country disclosure of any of the above documents is not expected, please explain why: C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) OP/BP/GP 4.01 - Environment Assessment Are the cost and the accountabilities for the EMP incorporated in the credit/loan? Yes [ ] No [ ] NA [ ] OP/BP 4.10 - Indigenous Peoples If the whole project is designed to benefit IP, has the design been reviewed and approved by Yes [ ] No [ ] NA [ ] the Regional Social Development Unit or Sector Manager? The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank's Infoshop? Yes [ ] No [ ] NA [ ] Have relevant documents been disclosed in-country in a public place in a form and language Yes [ ] No [ ] NA [ ] that are understandable and accessible to project-affected groups and local NGOs? All Safeguard Policies Have satisfactory calendar, budget and clear institutional responsibilities been prepared for Yes [ ] No [ ] NA [ ] the implementation of measures related to safeguard policies? Have costs related to safeguard policy measures been included in the project cost? Yes [ ] No [ ] NA [ ] Does the Monitoring and Evaluation system of the project include the monitoring of safeguard Yes [ ] No [ ] NA [ ] impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed with the borrower and the same Yes [ ] No [ ] NA [ ] Public Disclosure Copy been adequately reflected in the project legal documents? III. APPROVALS Task Team Leader: Mariam Claeson Approved By: Regional Safeguards Coordinator: Name: Sanjay Srivastava (RSA) Date: 15-May-2012 Sector Manager: Name Julie McLaughlin (SM) Date: 12-Apr-2012 Page 4 of 4