HIV/AIDS - Getting Results 46699 These reports describe activities, challenges and lessons learned during the World Bank Global World Bank's HI/AIDS work with countries and other partners. HIV/AIDS Program Working with Road Contractors to Prevent HIV Infection: Experience and Lessons from the Ethiopia Roads Sector Program Antoine Lema, John Riverson, Negede Lewi The Africa Region Transport Group (AFTTR) led the way in the World Bank when it included HIV/AIDS mitigating provisions within standard clauses for works contracts. Getting contractors to comply with the clauses has been challenging. The Ethiopian Road Sector Development Project (RSDP), implemented by the Ethiopian Roads Authority (ERA), was the first World Bank project to work closely with road contractors to include HIV prevention clauses into road contracts. The ERA implemented HIV prevention activities within its own workplaces and also reached out to contractors and communities near project worksites. These initiatives tested approaches to designing HIV prevention activities in road construction projects. Appropriate personnel, skills and funding are basic requirements for implementing HIV prevention activities. Village on the Nekempt ­ Mekenajo Road in Ethiopia Why HIV prevention needs to be mainstreamed into road investments operations. Some of the reasons for early inaction were the paucity of analytical data on the extent of the Studies of HIV prevalence and risks at work places problem, the lack of relevant expertise in the sector, and recognize that migration, short-term or long-term, absence of leadership to spur action and of guidelines increases opportunities for sexual relationships with on what to do and how to do it. multiple casual partners, transforming transport routes into "hotspot" corridors in the spread of HIV. Studies on Actions to include HIV prevention in road HIV and transport suggest that long-haul truck drivers transport operations in Africa are a high risk group. Recognizing the magnitude of the problem, the Africa Few studies have specifically investigated HIV Region Transport Group (AFTTR) took action, and prevalence and risks amongst road construction became the first Region within the World Bank to include workers. Yet people working in road construction are HIV prevention in its road operations. AFTTR pursued both short and long­term migrants, spending weeks, two main objectives in mainstreaming HIV prevention months or days away from their families and homes. If into road investments: i) to prevent road construction road construction workers satisfy their sexual needs "on projects from being vehicles of HIV infections, and ii) to the road", they too are an important risk group for HIV. help client countries to better define their HIV prevention strategies in the transport sector. Despite the gravity of the impact of AIDS on road and There are six main achievements: transport workers and on their partners, families and communities, as well its effects on company profits 1. "AIDS and Transport in Africa - A Framework for through higher absenteeism, illness, medical costs and Meeting the Challenge" (2003) was written to turnover, the transport sector was slow to incorporate provide guidance on how to incorporate HIV HIV prevention and AIDS mitigation and care into its prevention activities in the transport sector routinely. 2. Beginning with Ethiopia, existing road projects in 19 stigmatization of the subject. "This is something private, countries were retrofitted to incorporate HIV we don't talk about in our culture in Ethiopia", the Bank prevention activities. Work programs were prepared, project team was told. Just to utter the word "condom" and NGOs were recruited to implement the work crossed a cultural taboo. But repeated broaching of the programs. subject broke the silence and engaged the ERA in 3. Implementation of the first World Bank financed discussion. The change in communication and outlook Regional HIV and AIDS project -- the Abidjan-Lagos took about a year and half. Once ERA management Transport Corridor Project ­ has been completed. ownership was secured, progress followed. The next important step was to get the 12,000 ERA staff to start 4. Influenced by the experience in Ethiopia, an HIV changing attitudes towards the subject. Gradually, over prevention clause has been incorporated into the the next few years, people became willing to talk about World Bank Standard Bidding Document, requiring HIV/AIDS and socially sensitive matters like using all civil works contracts larger than ten million dollars condoms. Group discussions and meetings with to include HIV prevention activities for contract managers increased their awareness of the issues, workers. paving the way for workshops to discuss HIV/AIDS with 5. The World Bank Transport Unit in Africa has a full- employees and their families. Peer educators were time HIV coordinator who helps to ensure greater trained in units across the ERA to continue the application and effectiveness in implementing discussions beyond the workshops. HIV/AIDS interventions in the transport sector. No policy or strategy, and little institutional capacity: 6. A review of the lessons of experience in At the outset, there was of course no policy or strategy mainstreaming HIV into transport projects in Africa on HIV/AIDS within the Ethiopian road sector. When the was published in June 30 2008. Bank Team suggested that the ERA develop a policy document and a strategy on HIV prevention and control, Incorporating HIV Prevention in the Ethiopia the reply was: "We are engineers, what do you want us Road Sector Development Program to do, you want us to distribute condoms?" It was a legitimate concern. The ERA did not have the capacity to Starting in 2000, the Ethiopia Road Sector Development address HIV/AIDS related issues within its existing Program (RSDP) was the first Bank-funded roads institutional structure. program in the region to mainstream HIV prevention in its operations. The road has been bumpy, but many In response, the Bank project team proposed that the milestones have been reached, and much has been first thing to do was to include an HIV/AIDS clause into learned. construction work contracts. Second, the Team assisted the ERA Environmental Monitoring and Safety Branch There was very little experience to draw on - in early which normally addresses and monitors social issues 1990, some HIV/AIDS awareness activities had been and safeguards on road operations, to apply for funds implemented within the Feeder Roads Component of the from the Ethiopian Multisectoral HIV/AIDS project (one Uganda Transport Project (financed by the World Bank of the first projects approved under the Africa Multi- with co-financing from the Nordic Development Fund). Country HIV/AIDS Program, or MAP). The MAP funds Ethiopia "broke new ground" by taking a systematic were able to be used to hire consultants with relevant approach, and incorporating HIV in a new transport expertise to coordinate and facilitate the HIV/AIDS operation. Planning began in 1998, before the Bank's activities. large AIDS funding mechanism in Africa -- the Multi- Country AIDS Program (MAP) -- was conceived; when Once these first steps and decisions were taken, the MAP funding became available, it greatly facilitated the ERA prepared a concept note for an HIV prevention work. strategy. In the short term, they would do three things: include a clause requiring HIV prevention activities in A slow start road work contracts; start HIV prevention activities within It took three years to mainstream HIV prevention and the ERA; and develop a policy and a three-year strategy control activities within the Ethiopian Roads Authority and work plan. (ERA) and in the RSDP projects. There were three major obstacles to overcome: i) little initial client "buy in"; ii) the In November 2001, ERA received MAP funds of 461,875 absence of supportive policy and strategy; and iii) a lack Birr (US $ 53,000) to develop and implement its HIV of institutional capacity. prevention strategy. The MAP funds were given a budget line within ERA's financial management system. Client ownership: Initially, ERA management efforts to A nurse and a sociologist were hired as consultants, and tackle the issue within its institution were inadequate. began working within the ERA in mid-2002. Associated with the lack of ownership, was 2 Accomplishments activities as the first item on the meeting agenda. This is in stark contrast to the situation in 2000, when the Bank The work accomplished by the HIV consultants and the team were told that it was "just not in the culture" to talk Environmental Monitoring and Safety Branch with ERA about such private matters. staff, in the first three-and-a half years (July 2002 to December 2005, is summarized in the table below. In July 2004, the ERA HIV/AIDS policy and strategy documents were completed and published in English. An Summary of HIV/AIDS Prevention Activities Amharic (Ethiopian National language) version had been Conducted July 2002- December 2005 completed and published. The strategy included a three- year work plan (2004-2006). Activities No. Participants/beneficiaries Strengthen Institutional Female Male Total Care, treatment and involvement of people Capacity living with HIV Recruit 2 HIV/AIDS 2 1 1 2 prevention consultants As commitment to HIV prevention grew among the ERA management and staff, so did sensitivity to the need to Train peer educators 75 261 336 provide treatment and counseling, and to support people Set up 18 anti-AIDS 18 95 living with HIV. The ERA has offered jobs to older Committees, train members (working age) orphans to enable them to assist their VCT ­ Training course 1 12 3 15 young sisters and brothers. Managers have assigned people with AIDS to light duties, and transferred them to Analytical/policy Work work in the area nearest to their families. Workplace policy 1 Baseline Study 1 People living with HIV are actively involved in the 3-Year Strategic Plan 2 prevention program, teaching other staff about HIV IEC Sessions prevention. Some sero-positive ERA workers have Advocacy- managers 12 50 100 150 spoken out in a very visible and public way, the first notable occasion being at a big meeting to mark World Awareness raising - staff 37 1,500 10,500 12,000 AIDS Day in 2004. ERA workers decided at this meeting Condom distribution 265,000 to contribute one percent of their monthly salary for a year, to be used to buy antiretroviral drugs for ERA Awareness raising activities started with 150 managers workers with AIDS. This was to be start-up or "seed across the institution, discussing the impact of HIV and funding" which would need to be complemented by other AIDS and how preventive activities could be sources. Treatment began ­ although for only five incorporated into the work of the ERA. Next, discussions people ­ at the end of 2005. The numbers were began with staff. Over the next three years, about expanded as more funding became available through 12,000 workers participated in 37 workshops to discuss broader treatment programs. how HIV is transmitted, and how to prevent infection. About 15,000 leaflets, 5,000 posters and 500 T-shirts One area where achievements lagged far behind plans were distributed. in the first years was in voluntary counseling and testing (VCT). In a 2003 baseline survey of 861 ERA and Stickers used to hold the annual vehicle inspection contractor workers and members of communities near license were provided for all ERA vehicles, a constant road work projects, only 30.5% of workers and 7.5% of reminder to drivers to "stop stigma and discrimination" local community respondents said they had access to a and "protect women and girls against HIV/AIDS". In VCT service. In 2004, the ERA trained 15 people to headquarters, staff began to wear their ID cards hanging provide counseling and testing, and bought the reagents from cords printed with the HIV/AIDS ribbon and an anti- and other materials needed to perform tests. However, it stigma and discrimination message. took more than a year before permission was received from the Health Bureau to start the service. Eighteen Anti-AIDS Committees with a total of 95 members were set up in units across the ERA. Working Working with Road Contractors on HIV with the Committees, 336 peer educators were trained. Prevention Over time, people became more interested in serving as In addition to the work with its own staff, the ERA committee members and peer educators, and HIV/AIDS prevention strategy also focused on road discussions about HIV and AIDS became commonplace. construction companies contracted under the Road Nor is HIV discussed only in special meetings. At various Sector Development Program, and local communities at progress meetings and annual meetings, ERA has construction project camp sites. An initial study on developed a tradition of discussing HIV prevention sexual behavior and HIV awareness among 1,050 3 workers in 12 road projects being constructed by 8 primarily hired to build roads and not to distribute international contractors and 4 of ERA's "own force" staff condoms or to organize education, information, and was carried out in 2001. Over 700 of the workers communication (IEC) sessions on HIV prevention. surveyed were aged 18-30, more than half were single and most of the others were working far from their Contract clauses need corresponding budgets: spouse. Awareness of HIV was very limited, and very Although clauses were included in works contracts, HIV few reported taking measures to prevent HIV infection. prevention activities were not incorporated in the bills of The survey underscored the clear need to work with quantity ­ the budgets ­ of the first generation of RDSP road contractors to reach their staff. contracts. This gave a signal of low priority. Also, from the contractors' perspective, this was a disincentive, In late 2003, another survey of knowledge, attitudes and because it was as if they had to pay for the activities behaviors was carried out among 487 workers (ERA themselves, unlike the civil works which they were being "Own Force" and contractors) and 380 community paid to do. This lesson was quickly learned and easily members living in the road corridor areas, supplemented corrected in the next set of contracts, which required by 25 focus group discussions and in-depth interviews contractors to include a lump sum for HIV prevention with 33 key informants. All the workers and most activities. community members had heard about HIV and AIDS, and over 80% gave correct answers to questions about Ignorance about HIV/AIDS, and language barriers how HIV is transmitted and how to prevent infection. In addition, many contractors were from China and However, about 70% of respondents perceived their own South Korea and few had heard anything much about risk of infection as low, but the qualitative data indicated HIV and AIDS or its impact in Africa. Their staff did not that sexual intercourse with non-regular partners was speak English or local Ethiopian languages and they had widespread, and condom use low: only 33% of the very few interpreters ­ typically one or two for 30­100 workers and 12% of the local community reported ever expatriate staff. And the contractors who had heard having used a condom. While the surveys in 2001 and about HIV and AIDS didn't know what to do about it. Nor 2003 are not fully comparable, they suggest that there did they know how to report on the preventive activities has been progress in increasing knowledge and in they were supposed to undertake in their monthly changing attitudes, but that much more remained to be progress reports. done to change behaviors. Specific Oversight of Contractors' HIV prevention plans and activities In addition to Engineers and other technical staff, the Bank supervision teams included a sociologist, with specific responsibility for reviewing the contractors' HIV prevention activities. The sociologist`s Terms of Reference included the following tasks: "Review the Contractor's proposed work programs and associated work method statements, resource analysis and requirements, and approve or reject the proposals. Identify any changes or additional resources required. Make sure that the program submitted for the execution of the Works shall, in addition to the program for pure construction activities, include an alleviation program for Site staff. In consultation with ERA's responsible environmental office, advise the contractors of new developments and additional needs in respect of STDs and HIV-AIDS as and when they occur." HIV Drama during Awareness Workshop, Alamata - Betemariam Road Project, Ethiopia Clarifying what to do and reporting During supervision mission discussions, the ERA and Contract clauses on HIV are not enough. The Bank team raised consultants' and contractors' approach taken with contractors was to include a clause HIV/AIDS awareness, and reminded them of their in the works contract, requiring certain actions to be contractual obligation to carry out and report on taken on HIV. It was relatively easy to include the clause activities. The ERA HIV prevention team also began in the contract, but much more difficult to enforce it. providing technical assistance to the consultant Supervising engineers and contractors either ignored the engineers and contractors, and worked with local health clauses, or gave them low priority. After all, they were 4 centers to carry out awareness raising activities at Although it is impossible to know how reliable the project sites. numbers are, the contractors reported that a total of nearly 2 million condoms were distributed to projects Two main areas of HIV prevention activities were carried collectively employing about 27,000 people. Nearly out: IEC and distribution of condoms. The ERA and 41,000 brochures/posters were distributed in 527 Bank team developed a simple form for contractors to sessions in World Bank financed road projects, during use to report on their HIV prevention activities, as part of the years 2001 to 2005. Female condoms were their regular contract monthly progress reports (see demonstrated in some work areas. Some contractors below). However, some contractors repeated, in each recruited health personnel to work full time on HIV monthly progress report, the same number of condoms prevention and control activities. distributed each month. The supervision missions repeatedly had to remind them of their contractual obligations to adequately carry out and report on their activities. Contractor's Monthly Report on HIV Prevention Activities Month / Year: ______________ Project: _________________ Population (Total) Distribution of Total No. of Total No. of No Working M F T Condoms Brochures information people at Section /Posters sessions information sessions 1 Base Camp Office 2 Base-Camp 3 Laboratory 4 Site 1a 5 Site -1 6 Site -2 7 Site-3 8 A/Plant 9 Paving 10 Culvert -1 11 Culvert -2 12 Work Shop 13 C/Plant 14 Sub-Contractor 15 Engineer Camp Total this month Total to date Condom Distribution Points Distribution Distribution Location Points Location Points Base Camp Toilet Workshop Clinic Base Camp Clinic Workshop Restaurant Base Camp Restaurant Foremen Engineer's Office Working with local health care facilities in team to establish strategic partnerships between roadside communities contractors and their host communities' health clinics. IEC and condoms were made available to both A recurrent question encountered during the supervision contractors' workers and to the host communities. missions was: "What other HIV prevention activities, Likewise, the VCT services of the host community clinics beside IEC and condom distribution, could the were made available to contractors and their workers. contractors offer their workers?" The question was This increased workers' exposure to HIV prevention after addressed in part by getting the ERA's HIV prevention 5 working hours, in their homes, and also gave them mainstreaming HIV prevention in the transport access to counseling outside their workplace. However, sector. The workshop was held in Addis Ababa, in the question of how to provide effective HIV prevention July, 2004 in partnership with the ERA. In addition to services to a mobile work force of road builders remains Ethiopia, five eastern and southern African countries to be fully addressed, and becomes even more critical in attended: Lesotho, Kenya, Malawi, Uganda and the context of providing access to anti-retroviral Zambia. The objective of the workshop was to help treatment. participating countries to start preparing transport HIV prevention polices and strategies. At the end of Main Outcomes the workshop, each participating country had drafted an HIV/AIDS policy and strategy, which they took The HIV prevention strategy of the Ethiopia RSDP is home to finalize. The drafts were the basis for considered a model of "best practice", both by the retrofitting their transport projects to incorporate HIV Bank's Ethiopia MAP Team and by the Ethiopian prevention. HIV/AIDS Prevention Control Office (HAPCO). Six achievements stand out especially. Lessons Learned High Level of Awareness: The 2003 study commissioned by the ERA to assess sexual Institutional level of the transport authority behavior and HIV and AIDS awareness within the MAP funds were critical for taking the ERA HIV organization concluded that awareness was high: prevention activities forward. Initially, the institution 85% of road construction workers and 90% of ERA did not have capacity, expertise or funding for HIV staff knew about HIV and AIDS and how HIV is prevention activities, and the MAP funds made it transmitted. possible to hire experts and begin developing capacity. Change of Attitudes: Both the ERA staff and the contractors' changed their attitudes towards HIV Management and workers within the institution need prevention in contract clauses. The sensitization and to be persuaded of the importance of HIV increased awareness within the ERA decreased awareness and prevention; this ownership is stigma and silence. When the HIV prevention necessary for successful and sustained efforts. consultants began working at the ERA, few staff Change takes time and requires repeated and would talk to them. Some thought they had been persistent efforts not only to sensitize people and hired because they were HIV-positive; others provide access to condoms, but ultimately to thought that being seen with them would make establish a larger vision that includes both colleagues think that they were HIV-positive. These prevention and treatment. Transport Ministries need fears no longer exist. not do this alone; they can make strategic alliances HIV status being acknowledged: Some ERA staff with NGOs, local health clinics, VCT centers, etc., in have come forward and spoken openly about being order to achieve their goals. HIV-positive. Condoms are widely available: Condoms are now found in every toilet at consultants' and contractors' camps and even in the offices. They are also found in male and female toilets at ERA headquarters and ERA district offices. The replenishment rate of condoms accelerated over time, suggesting increasing use. Improved Contract Documents: HIV prevention clauses in works contract documents were strengthened by requiring that their costs be included in the contract, by adding a lump sum in the bills of quantities (budget). A reporting form helps guide contractors' performance and provides adequate information on the activities to be monitored. Information has been shared with other Peer educators in training, engaged in group work countries: The Ethiopian policy and the strategy documents were used as primary work materials in a World Bank sub-regional workshop on 6 Shared responsibility for HIV prevention Still room to improve The HIV/AIDS pandemic is global, but solutions On September 23- 26, 2008, the ERA held its annual have to be local. The HIV/AIDS pandemic is global, Road Sector Development workshop Two of the four but solutions have to be local. It is at the local and days were dedicated to issues around safeguards. The individual level that behavior change and treatment effectiveness of compliance with environmental and take place. Therefore, there is a clear role for the social safeguards clauses, including HIV, and the management of national roads authorities and difficulties of ensuring consistent supportive supervision contractors, and World Bank project teams to were discussed. The latest ERA assessment of progress address HIV and AIDS in their work. concluded that there is still room for improvement. Consequently, a committee has been set up to look into Committed World Bank team leaders engaged in the issue, and develop specific recommendations. Two continuous dialogue with clients and strategic initial proposals were put on the table: impose monetary partners make a difference. penalties for noncompliance, and/or make compliance a Operational level condition of project completion hand-over. Condom distribution needs to be complemented by information and education. A survey carried out in the RSDP for Ethiopia suggested that condoms distributed to workers were used in interactions with professional sex workers but not with regular partners. This prompted some stakeholders to object to the distribution of condoms, as they were (mis)perceived as encouraging promiscuity. Careful communication is needed, and also to get across the message that there may be risk of infection even with regular sexual partners if one or both people have other sexual partners. Questions remain concerning HIV/AIDS prevention activities in road construction projects: What is the best HIV/AIDS prevention approach when dealing Condom Demonstration at Jijiga - Degehabur Road with a mobile population of road workers? What kind Project, Ethiopia of HIV prevention activities should be provided besides condoms and IEC? Is it feasible to include access to treatment? About the authors: Including HIV prevention clauses in works contracts Antoine Lema (Alema@worldbank.org) is a Social does not ensure the implementation of activities. Scientist, John Riverson Jriverson@worldbank.org) There is a need for more guidance on is a Retired Lead Highway Engineer, and now implementation, supervision and monthly reporting Senior Consultant, and Negede Lewi mechanisms as well. A Social Scientist has been (Nlewi@worldbank.org) is a Senior Highway included in the Supervising Engineers' team to Engineer in the World Bank. follow up implementation of HIV prevention as well as other social safeguards and mitigation measures. Photographs were taken by Antoine Lema HIV prevention is part of the social mitigation measures of any project. Those measures need to For further information, or feed-back, please be included in the bills of quantity and in the contact: specifications in order to be given proper funding The authors for information on the Ethiopia project. and attention by consultants and contractors. Contractors and the Supervising Consulting Jocelyne do Sacramento, Transport and HIV/AIDS Engineers often interact with community Specialist, Africa Transport Unit, World Bank (for more representatives in the construction area, and on the Africa Transport Mainstreaming Work), respond to local community needs. Many companies Jsosacramento@worldbank.org are trying to do more to fulfill corporate social responsibilities and address HIV prevention and Joy de Beyer, Global HIV/AIDS Program (for feedback other important issues. Working with local NGOs, on the series), jdebeyer@worldbank.org health and social workers can greatly facilitate this. October 2008 7 HIV Prevention Clauses in Civil Works Contracts Over the entire contract period, the Contractor is required to: Civil works construction contracts have long included (i) conduct Information, Education and Communication provisions to safeguard worker safety and to ensure (IEC) campaigns, at least every other month, reasonable access to health. For example, the World addressed to all Site staff and labor (including all Bank Standard Bidding Document for Works, General employees of the Contractor, Sub-Contractors and Conditions, Section 6.7 on the Health and Safety of Staff Consultants, all truck drivers and crew making and Labor, require the Contractor to: deliveries to Site for construction activities) and to the immediate local communities, on the risks, "take all reasonable precautions to maintain the health dangers and impact, and appropriate avoidance and safety of the Contractor's Personnel. In behavior of Sexually Transmitted Diseases or collaboration with local health authorities, the Infections (STI) in general and HIV/AIDS in Contractor shall ensure that medical staff, first aid particular; facilities, sick bay and ambulance service are available at all times at the Site and at any accommodation for (ii) provide male or female condoms for all Site staff and Contractor's and Employer's Personnel, and that labor; and suitable arrangements are made for all necessary (iii) provide for STI and HIV/AIDS screening, diagnosis, welfare and hygiene requirements and for the counseling and referral to a dedicated national STI prevention of epidemics." and HIV/AIDS program, (unless otherwise agreed) of all Site staff and labor. The revised version of the World Bank Standard Bidding Document for Works published in May 2007 included The Contractor shall include in the program to be new clauses specifically establishing contractors' submitted for the execution of the Works under Sub- obligations to implement and fund activities to prevent Clause 8.3 an alleviation program for Site staff and HIV. It defines the actions that contractors must take to labour and their families in respect of Sexually prevent HIV among their workers and the communities Transmitted Infections (STI) and Sexually Transmitted with which they interact. Diseases (STD) including HIV/AIDS. The STI, STD and HIV/AIDS alleviation program shall indicate when, how "HIV-AIDS Prevention. The Contractor shall conduct and at what cost the Contractor plans to satisfy the an HIV-AIDS awareness program via an approved requirements of this Sub-Clause and the related service provider, and shall undertake such other specification. For each component, the program shall measures as are specified in this Contract to reduce detail the resources to be provided or utilized and any the risk of the transfer of the HIV virus between and related sub-contracting proposed. The program shall among the Contractor's Personnel and the local also include provision of a detailed cost estimate with community, to promote early diagnosis and to assist supporting documentation. affected individuals. Discussions with contractors on strengthening HIV prevention activities in RSDP I Projects Please visit www.worldbank.org/aids to read about other topics in the "HIV/AIDS - Getting Results" series 8