Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB2839 Project Name Afghanistan HIV/AIDS Prevention Project Region SOUTH ASIA Sector Health (70%);General education sector (15%);Media (10%);General public administration sector (5%) Project ID P101502 Borrower(s) GOVERNMENT OF AFGHANISTAN Implementing Agency Ministry of Public Health Afghanistan moph.tdd@gmail.com National AIDS Control Program Afghanistan saifurrehman.dr@gmail.com Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared April 27, 2007 Date of Appraisal Authorization April 15, 2007 Date of Board Approval July 31, 2007 Country and Sector Background 1.1 The HIV epidemic is at an early stage in Afghanistan, concentrated among high risk groups, mainly Injecting Drugs Users (IDU) and their partners. Although the HIV prevalence is low, HIV has a high potential for rapid spread due to the current increase in injecting drug use. A study among IDUs in Kabul city (2006) found that 3 percent of the IDUs were HIV positive. To date, the officially reported number of HIV cases is 71, most of them men, in Kabul alone. UNAIDS and WHO estimate a prevalence of between 1,000 to 2,000 HIV-positive cases. It is difficult to estimate the scale of spread of HIV associated with sex work (SW) or male-to-male sex (MSM). Evidence by ex-inmates suggests that injecting drug use takes place in Afghan prisons, a situation also found in many other countries. Long distance truck drivers and their helpers, and the many women who have lost husbands or provide care for severely disabled husbands or sons and the many abandoned street children are also vulnerable groups, potentially at risk for HIV infection. 1.2 Several factors contribute to the high risk for rapid spread, including war and conflict, migration, displacement and poverty. Approximately 7.8 million Afghans spent some time living abroad as refugees, in Pakistan (6.1 million) and Iran (1.7 million). Today, about 2 million widows, over 2 million orphans, 1.7 million returnees and 500,000 internally displaced persons reside in Afghanistan, while almost 4 million Afghan refugees still live in Pakistan and Iran. These countries have rapidly growing IDU driven HIV epidemics. In addition, the literacy rate in the general population is very low (36%) and lowest among women (21%), with little awareness Page 2 about HIV/AIDS and almost no condom use. Unsafe blood transfusion adds to the risk of spread to general population, with only 30 percent of transfused blood being tested for HIV. 1.3 To date, HIV/AIDS prevention programs have been fragmented and on a small scale. There are a few local and international NGOs and development partners that provide prevention services to high-risk and vulnerable populations, mainly HIV prevention interventions for IDUs, including harm reduction activities. A limited number of interventions have also been designed and launched among SWs, MSM, truck drivers, police and prison staff, mainly focusing on HIV/AIDS awareness, condom distribution and counseling. These activities utilize peer and community-based education but are limited in coverage and need to be expanded rapidly. 1.4 Included in one of the pillars of the Interim Afghanistan National Development Strategy is the goal to keep HIV prevalence in the general population at less than 0.5%. The national Millennium Development Goals include halting and reversing the spread of HIV by 2020, and scaling up the proportion of injecting drugs users in treatment by 2015. In addition, a national policy on harm reduction has been jointly prepared by the ministries of counter narcotics and public health providing a framework for effective interventions to break HIV transmission among IDUs and their partners. 1.5 The Ministry of Public Health (MOPH) has developed a national strategic plan, the Afghanistan National HIV/AIDS Strategic Framework 2006 – 2010 (ANASF) involving thematic working groups in the areas of capacity development; targeting of high-risk groups; health safety issues such as blood safety, Voluntary and Confidential Counseling and Testing (VCCT), co-infection with tuberculosis, reproductive health and, Information, Education and Communication (IEC). The goal of ANASF is to maintain a low prevalence of HIV-positive cases (less than 0.5 percent) in the population and to reduce mortality and morbidity associated with HIV/AIDS. A Program Operational Plan (POP) has been developed through a broad consultative process involving all key stakeholders including local and international NGOs, all relevant line ministries of the Government of Afghanistan (GoA) and development partners. The National Strategic Framework and the POP provide for a programmatic approach and harmonization among the many actors, through the oversight of the HIV/AIDS Coordinating Committee of Afghanistan (HACCA). 1.6 To support the implementation of parts of the POP, a national Project Implementation Plan (PIP) has been prepared by the National AIDS Control program (NACP) of the Ministry of Public Health with a focus on four priority areas: strengthening communications and advocacy; strengthening surveillance; providing targeted interventions for people at highest risk; and, building program management capacity. The PIP will also provide support to multi sector action plans though an innovation fund. Objectives 2.1 The objectives of the project are to contribute to the national development goals of maintaining the HIV prevalence below 0.5 per cent in the general population and below 5% among the vulnerable groups at high risk. The project’s development objectives are to: (i) achieve behavior change by scaling up prevention of new infections in high risk groups; and (ii) Page 3 improve knowledge of HIV prevention and modifying attitudes of stigma, in the general population. The key performance indicators that will be used to track the project development objectives are: (i) percent of injecting drug users who have adopted behaviors that reduce transmission of HIV, that is, who use clean injecting equipment at last time injecting AND who report using a condom with their most recent sexual partner; (ii) percent of sex workers who report using a condom with their most recent client; and (iii) percent of young people aged 15 - 24 who correctly identify ways of preventing HIV transmission. Rationale for Bank Involvement 1.1 The main rationale for Bank involvement in the national HIV/AIDS response is the lack of sufficient financial support to HIV/AIDS programming from other sources. The French Cooperation is supporting safe blood supplies. It is expected that Afghanistan will receive GFTAM funds for some aspects of the US$30 million POP in the next round. The Bank would fill a critical financial gap, by supporting a third of the budgeted national program over a three year period of an emergency operation, and help leverage support from GFATM and other donor partners. 1.2 A comparative advantage is the Bank’s track-record working on HIV prevention in neighboring Central and South Asia countries which brings valuable design inputs to the program and help foster regional and inter-regional exchange of knowledge and experience. The Bank has tailored its response to the epidemic dynamics in the South Asia Region, supporting scaling up of targeted interventions for high risk groups – a strategy that is achieving results. The Bank also supports a programmatic approach, the “three ones”, strategic multi sector involvement in one national program, one national authority and one monitoring and evaluation framework. In addition, the Bank would contribute to the necessary economic sector work, impact evaluation and operations research and engage in high level advocacy to inform policy. Description To achieve the above objectives the project would comprise the following four components: 1.3 Component 1: Communications and advocacy to increase knowledge, change attitudes, and reduce stigma and discrimination, among vulnerable groups, opinion and community leaders and the population in general. Activities will include (a) audience baseline, (b) appropriate communication or advocacy activity such as meeting, materials development, media, training, (c) audience survey, and (d) reporting. 1.4 Component 2: Strengthening surveillance of HIV prevalence through biological and behavioral surveys (second generation surveillance (SGS) and KAP studies. This component will map and estimate the sizes of groups engaged in high risk. Rounds of HIV prevalence and behavioral surveys will be done every second year in 4 major cities and as more data becomes available, surveillance may be extended to other areas. The SGS will be implemented by an organization selected by international competitive bidding. This organization will work with the NACP, HACCA and the Surveillance Working Group, do training on surveillance, obtain all necessary test kits and other materials, provide timely reports, and disseminate findings. Page 4 1.5 Component 3: Targeted interventions for people engaged in high risk behaviors, including injecting drug use and unsafe sex. The vulnerable groups at high risk include IDUs, sex workers and their clients, truckers and prisoners and others. This component will support implementation of effective HIV prevention programs through NGOs, building on their experiences and ability to reach and work with vulnerable groups at high risk, often both highly stigmatized and marginalized. This component will also support innovative approaches and delivery strategies through operations research to evaluate feasibility of substitution therapy. 1.6 Component 4: Program management and coordination , capacity development, monitoring and evaluation, and Innovation fund for multi sector activities in support of project objectives. The NACP core functions will be supported though national consultants, the program manager, and an international advisor. The project will support NACP office operations, monitoring and supervision, including transport to activity sites throughout the country on a monthly basis. This component will also support the multi sector HIV coordination through HACCA. Activities include exposure visits, short term TA, trainings, and conferences leading up to policy development and review. The Innovation Fund for the HIV Response will invite proposals in support of program objectives from other sectors. Financing Source: ($m.) BORROWER/RECIPIENT 0 IDA Grant 10.0 Total 10.0 Implementation 6.1 The project will be implemented over a three year period by the MOPH, the lead implementation agency of the proposed project. Technical coordination will be provided by the NACP and financial coordination by the GCMU, both of the MOPH. GCMU (Grants and Contracts Management Unit) of the MOPH will handle all procurement and financial management under AHAPP. GCMU will carry out daily financial management operations of the Project, preparation of payment forms, coordination with line ministries, donors, and selected NGOs. Table 1: Responsibility for Implementation and Supervision Component Implementer Supervisor 1. Communication and Advocacy Contracted agencies NACP and GCMU, MOPH 2. HIV Surveillance Contracted agency NACP and GCMU, MOPH 3. Targeted Interventions Contracted agencies NACP and GCMU, MOPH 4. Project management, coordination, and monitoring NACP HACCA Innovation Fund Contracted agencies NACP and GCMU, MOPH 6.2 A Public Financial Management (PFM) performance rating system has been recently developed for Afghanistan by the Public Expenditure and Financial Accountability (PEFA) Page 5 multi-agency partnership program, which includes the World Bank, IMF, EC, and other agencies. Afgh anistan’s ratings against the PFM performance indicators portray a public sector where financial resources are, by and large, being used for their intended purposes as authorized by a budget that is processed with transparency and has contributed to aggregate fiscal discipline. Sustainability 7.1 The Project will be financed as a specific investment operation for Emergency Recovery Assistance. The economic and financial analysis carried out for the project estimate that the burden of recurrent government expenditures generated by the proposed project will equal US$2,976,000 per year after project completion. The uses of recurrent expenditures falling to the central government include the continuing activities of communications, HIV surveillance and the continuation of harm reduction activities and other targetd interventions forn high risk groups. This amount is relatively small (2.1 percent) in comparison with the total health sector Government spending, which is currently 140.0 million USD per year (including donor support) and expected to increase substantially in the coming years. Real GDP growth is projected at 12 percent in 2007/08 and 10 percent from 2008/09 onwards. In addition the share of government health expenditures in total GDP is expect to increase 40 percent by 2009/10 (IMF, 2006). This anticipated growth implies that the inherited recurrent spending will total only 1.2 percent of the public sector health budget by 2009/10. 7.2 The Bank project will support a third of the budgeted national Program Operational Plan over a three year period, and help leverage support from GFATM and other donor partners. Lessons Learned from Past Operations in the Country/Sector 8.1 The implementation of the Health Sector Emergency Reconstruction and Development Project provides useful lessons learned for the implementation, financing, procurement and monitoring arrangements of the proposed project. Independent evaluation of the health project provides important clues for how to increase coverage of services among difficult to reach populations in a post conflict, resource constrained setting. The model of NGO contracting to deliver services that has worked in the Afghanistan is being applied to the targeted interventions component of this project. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment ( OP / BP 4.01) X [ ] Natural Habitats ( OP / BP 4.04) [ ] [X ] Pest Management ( OP 4.09 ) [ ] X Physical Cultural Resources ( OP/BP 4.11 ) [ ] X Involuntary Resettlement ( OP / BP 4.12) [ ] X Indigenous Peoples ( OP / BP 4.10) [ ] X Forests ( OP / BP 4.36) [ ] X Safety of Dams ( OP / BP 4.37) [ ] X Projects in Disputed Areas ( OP / BP 7.60) * [ ] X * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas Page 6 Projects on International Waterways ( OP / BP 7.50) [ ] X List of Factual Technical Documents Contact point Contact: Mariam Claeson Title: HIV/AIDS Program Coordinator, South Asia Region Tel: 5770+136 / 977-1-422-6792 Fax: (202) 522-2955 Email: mclaeson@worldbank.org Location: Washington, D. C. (IBRD) 1. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: pic@worldbank.org Web: http://www.worldbank.org/infoshop