Africa Transport Technical Note SSATP Note 35 May, 2003 Taming HIV/AIDS on Africa's Roads Antoine Lema, Stephen Brushett, Negede Lewi, John Riverson, Silue Siele Five issues are the focus of this note: (1) HIV/AIDS in Africa; (2) HIV/AIDS and the transport sector; (3) Challenges encountered in Transport ­ HIV/AIDS projects and Re- This note summarizes challenges, sponses provided by World Bank project teams; (4) Lessons learned. responses and lessons learned by two World Bank supported projects ad- dressing HIV/AIDS in the road sec- 1. HIV/AIDS in Africa tor. These are: The Joint Regional The HIV/AIDS challenges faced by the African continent are relentless. HIV/AIDS Project in the Abidjan ­ About 16,000 people in the world become infected with Lagos Transport Corridor hencefor- HIV each day. ward ("Corridor Project") and the Ethiopia Road Sector Development Out of the 40 million HIV/AIDS sufferers in the world, Program (RSDP). While the "Corri- 70% live in Africa. dor Project" is regional and addresses More than 20 million Africans have now died. HIV/AIDS on the road between Abidjan and Lagos, the RSDP is a Orphans of HIV/AIDS in Africa are estimated to be more country specific road construction than 12 million. program with an HIV/AIDS compo- HIV/AIDS has become the leading cause of adult deaths nent. Yet, the two projects share in Africa. The impacts are severe on the demographic, similarities and variations that dis- play valuable lessons. the economic and the social spheres. Demographic impacts: Increased child and adult mortality, especially in the produc- The purpose of this series is to share tive 20 ­ 40 year age group and reduced life expectancy. Economic Impacts: Reduction of information on issues raised by the labor force, erosion of productivity, increased sector costs induced by high labor turnover, studies and work of the SSATP. The increased recruitment and training costs and per capita growth reduced. Social Impacts: opinions expressed in the notes are breaking down of social cohesion, value systems, the social fabric and traditional coping those of the authors and do not nec- mechanisms, changes in household structure, increased dependency ratio and increased essarily reflect the views of the number of orphans. World Bank or any of its affiliated 2. HIV/AIDS and the Transport Sector organizations. For information on these notes, con- Findings of international studies of the HIV/AIDS pandemic at work places suggest that, tact the SSATP in the Africa Region the transport sector is a major vector for the disease. The reason is simple. People working of the World Bank at : in the transport sector are mobile, they spend weeks and months away from their families and their homes and many satisfy their sexual needs "on the road." Migration, short-term or long-term, increases opportunities for sexual relationships with multiple partners, trans- forming transport routes to critical links in the propagation of HIV/AIDS. International ssatp@worldbank.org studies also suggest that long haul truck drivers are the highest risk group in the road sec- tor.i Clearly, social capital is at risk. In Africa, studies assessing the relationship between transport and HIV/AIDS are still partial and embryonic. Yet, situational analyses undertaken to date suggest that HIV/AIDS has become a major threat to the social capital of the transport sector and to transport operations. Few, however, are the actions taken to address the insurgence of the pandemic. Nonetheless, investing adequately in combating HIV/AIDS in Africa is now a precondition for all other development investments to succeed. Sub-Saharan Africa Transport Policy Program (SSATP) UNECA and the World Bank 2 The transport sector faces four major challenges (2002), Ethiopia has one of the lowest density road networks in Reduction of social capital. Africa. To address the situation, the Bank assisted the Government Poor safeguard policies addressing HIV/AIDS at of Ethiopia to formulated a 10 ­ year road development program, work places. (1997 ­ 2007). The program is divided into two phases. In the first phase (1997 ­ 2002) the Bank financed the rehabilitation and up- Absence of standard HIV/AIDS clauses in grading of 10 national trunk roads and provided support for works contracts. strengthening the capacity of the Ethiopian Roads Authority Limited sector analytical work on HIV/AIDS. (ERA). In the second phase (2003 ­ 2008), the Bank's multi-phase support will contribute to rehabilitating and upgrading federal These challenges can be addressed. Committed leadership roads and regional rural roads. Also under this phase, the program continuous dialogue with clients and strategic partnerships aims at strengthening its poverty alleviating operations and thereby could make a difference. The HIV/AIDS pandemic is global, contribute to the realization of the Millennium Development but there is a growing consensus that solutions should be Goals. Over the two phase program, about 50,000 people are ex- thought out at the local level, therefore, there is a role for pected to be employed in the program, including many to be en- both local and national leaderships to fill. gaged by international contractors. Against this background, the Africa Region Transport Most of them will be short-term migrants, commuting from Group (AFTTR) acted to promote measures against project site to project site, and presumed to satisfy part of their HIV/AIDS, viz. (a) prepared an HIV/AIDS framework for sexual needs "on the road." This would most likely expose them the sector ­ AIDS and Transport in Africa-A Framework for and others to HIV/AIDS. Ethiopia has one of the highest number Meeting the Challenge; (b) drafted standard clauses for of people infected with HIV AIDS in Africa, about 10­11 % of the works contracts; (c) retrofitted transport projects, e.g., Ethio- 66 million population. pia; and (d) supported preparation of the "Corridor Project." Confronted with this challenge, the Bank Project Team initi- ated, together with the Ethiopian Roads Authority (ERA) through 2.1 The "Corridor Project" its Environmental Monitoring Branch (EMB), an HIV/AIDS strat- The objective of the project is to increase access, along the egy for the roads sector (including retrofitting of ongoing projects). transport corridor, to HIV/AIDS prevention, basic treatment, The target groups are ERA staff (about 16,000), project related support and care services, by underserved vulnerable groups. personnel including international contractors and consultants, and The project includes five countries (Nigeria, Benin, Togo, Ghana local communities at project camp sites. and Cote d'Ivoire) organized under one institutional framework. The strategy has three components: (i) information, education, The total cost is US$17.9 million of which US$ 16.6 million is communication (IEC); (ii) care and support; (iii) capacity building to be covered by a proposed IDA grant, the first of its kind. and policy development. The source of finance is the MAP. The The target groups are the migrant population along the estimated total cost of the sector program is about : US $ 1, 3 mil- corridor and in communities at the borders, particularly: lion. Linkages with the MAP are maintained through advisory and transport sector workers, commercial sex workers, travelers, financial support from the national HIV/AIDS program. civil servants at borders and the local populations at border towns. For the transport sector, this amounts to a significant 3. Challenges and Responses effort to protect social capital in the sector. Project compo- nents are three: (i) HIV/AIDS prevention; (ii) HIV/AIDS 3.1 Institutional Challenges treatment, care and support; (iii) Project coordination, capac- "The Corridor Project" -- A key challenge for the regional project ity building and policy development. was to create capacity where none previously had existed and ad- Component ii. (HIV/AIDS treatment), which is critical dress two key questions. To what extent could existing national for the quality of life of sufferers, consists of: (a) strengthen- capacities be harnessed to this end? Or would a preferred option ing, where possible, public and private health care facilities be through the involvement of a regional economic organization, along the corridor to provide services in the areas of Volun- and if so which one? tary Counseling and Testing (VCT), treatment of STIs, and Added to this was the challenge of finding the right financial treatment of HIV/AIDS opportunistic infections; (b) providing mechanisms for the Bank to support the preparation of the project. grants to Civil Society Organizations (CSOs) including NGOs It was not clear whether the Project Preparation Facility (PPF) used and to the private sector, to undertake community based ini- in standard credits, was applicable since the project was regional tiatives in HIV/AIDS care and support and; (c) supporting the and it was a grant. Who would be the recipient of the funds? Who disposal of medical waste related to project activities. would pay back the PPF should the project not be approved by Linkages with the Bank's Multi-Country HIV/AIDS Pro- Bank's Board? gram (MAP) were established by including in the project At client level, project countries were accustomed to dealing Governing Body, the heads of the national HIV/AIDS pro- with sector projects within their line ministries. Thus, an across grams and/or agencies (as well as representation from na- border project involving a number of sectors presented a challenge tional transport ministries). to their way of working, which was already new and not well en- 2.2. The Ethiopia Project (RSDP) trenched in their practices nor in their country experiences. The objective of the RSDP is to address road sector cons- The Ethiopia Project-- Bank policy towards funding of traints related to restricted road network coverage and low HIV/AIDS in transport operations is focused on the mitigation of standards. With a road density at 30 km per 1000 sq. km adverse social impacts. HIV/AIDS is an adverse social impact. 3 Yet, a transport HIV/AIDS sector strategy did not include not the case of HIV/AIDS in West Africa in spite of recent re- specific provisions for addressing that policy and all project search carried out under UNAIDS auspices funds had been committed. Funding was therefore a question mark in the process of establishing an elaborated operational The Ethiopia Project -- As in the "Corridor Project," the client strategy including a baseline study addressing risk behavior had no sector policy on transport ­ HIV/AIDS. Consequently, no and policy, there was a need for extra budgetary resources. ownership. Also, there was no previous analytical work addressing The establishment of the Ethiopia MAP was considered an the sectoral relationship between transport and HIV/AIDS. important opportunity for leveraging resources. The Response of the "Corridor Project" Team -- The Team At client level, the issue was how to find within the ERA, worked closely with the " transitional working group" to initiate relevant staff who could be assigned on a full time basis to and support a Common Declaration signed by the Presidents of the work on the HIV/AIDS strategy. There was a Medical project countries in April 2002, endorsing the basic principles of Branch within the organization but the branch was discon- the project: transport HIV/AIDS; regional, multi-sectoral under nected from any health work related to project operations. one institutional framework. This resulted in the conversion of the Supervision of the implementation of health clauses in pro- group into a Governing Body for the project which has now a ject contracts was carried out by the Environmental Monitor- strong political mandate to act. It also confirmed that Benin would ing Branch and the Contract Division composed of engi- receive the IDA grant assistance on behalf of the other countries neers, lawyers, financial analysts and other technicians. and could request a PPF in their name. At the same time, constitu- The Response of the "Corridor Project" Team --To secure ency building workshops were organized to strengthen project project preparation funding, the Team applied for the Japa- ownership and the multi-sectoral understanding of HIV/AIDS. nese PHRD fund to cover costs for the various studies to be The Team helped to draft terms of reference for seven basic conducted. In addition, the Project Team also applied for studies conducted in the process of establishing the project work resources from the Norwegian trust fund to cover costs such program, funded through a Japanese PHRD Grant. At client level, as, hiring of vehicle, purchase of laptops, fuel, secretariat the project countries contributed through the recruitment of re- services. This was to enable preparation to start in parallel to gional and national consultants to execute the studies and provided the definition and agreement of country roles. a forum in November 2002 where the study conclusions could be At client level, The Bank helped to facilitate the creation reviewed and recommendations adopted. of a "transitional working group" representing the five coun- The Response of the Ethiopia Project Team -- The Team advised tries to spearhead preparation. A number of options for an the ERA to carry out a baseline study focusing on risk behavior organizational structure were reviewed before it was decided and needs assessment within the sector. Assisted the client to draft to create a small dedicated organization under a "conference the TORs and continued the HIV/AIDS dialogue. Also, the Team of ministers". At the same conference, roles of the different assisted the ERA to develop a road HIV/AIDS strategy framework. countries were defined which resulted, inter alia, in the iden- At client level, ERA management included HIV/AIDS as a tification of a grant recipient, i.e., the financial partner for the permanent subject in its yearly meetings with staff. HIV/AIDS Bank, that was Benin. committees were created to guide the Environmental Monitoring The Response of the Ethiopia Project Team --First, the Branch and the HIV/AIDS consultants recruited. Team advised the ERA to include HIV/AIDS clauses into the works contracts. Second, the Team assisted the ERA to apply Table 1: Studies Conducted for funds from the Ethiopian MAP. -- At client level, the Project Studies Team advised and agreed with ERA to hire consultants to "Corridor Project" Baseline Survey and Beneficiary Assessment prepare the strategy and an NGO to implement the work un- Common Policy Framework der the supervision of the Environmental Monitoring Branch Analysis of Elements Impeding the Smooth Circulation of Traffic in collaboration with the Medical Branch. Medical Waste Management Plan Gender Study 3.2 Policy Challenges Project Implementation Manual "The Corridor Project" -- None of the project countries of Baseline Survey, Risk Behavior and Needs the "corridor project" had a transport HIV/AIDS sector pol- Ethiopia RSDP Assessment icy, let alone policies for work places. Likewise, there were no regulations governing the rights of HIV/AIDS infected 3.3 Some Operational Challenges persons in the sector. In addition, although useful, analytical works conducted by UNAIDS to provide a regional situ- For both projects, a key operational challenge was how best to ational analysis, were in need of updates. This did not pro- address social capital deficiencies. Generally speaking in the min- vide a strong basis for the development of common policies istries of transport and in road sector agencies, HIV/AIDS was which was an essential objective of the project. considered a soft issue. Although some engineers and technical Associated with the absence of policies was the initial staff are conversant with the social issues, they cannot be expected weak and diffuse ownership of the project. This is not un- to execute social scientific tasks, e.g., conduct base line studies or common, however, for regional projects in Africa, unless the prepare a concept paper on HIV/AIDS, because they don't have issues at stake are perceived as of vital and immediate impor- the appropriate training or experience. tance to the project countries. Paradoxically, perhaps this was At the ministries of health, HIV/AIDS was seen primarily a health issue, yet thousands of new infections arise daily and thou- 4 sands of people are dying despite the health care provided. (ii) The social capital of the transport sector is mobile. People To convince transport sector stakeholders that HIV/AIDS is a spend weeks and months away from their families and homes, and multi-sectoral issue was and still is a daily challenge, even where tend to satisfy their sexual needs "on the road." Through this, they in most countries multi-sectoral HIV/AIDS commissions are become both victims and propagators of both STIs and HIV/AIDS either established or in the process of being established. ­ transport sector workers are a key group to influence and involve Relevant personnel trained to address the pandemic from in controlling the pandemic. a multi-sectoral perspective are still limited. In addition, the subject still makes people uncomfortable as, HIV/AIDS is (iii) Analytical work linking transport and HIV/AIDS is still partial considered a private issue or a stigma. Model interventions and embryonic. Future projects would benefit from conducting more in the transport sector need to be developed, taking account comprehensive analyses, including baseline and impact surveys. of parallel experiences in other sectors, first to get people (iv) Policies and regulations governing the HIV/AIDS pandemic comfortable in discussing the subject, and then to work out in the transport sector are still sketchy. The Bank could make a programs to combat HIV and its causal factors difference in assisting African ministries of transport in developing At the level of the contracting industry, the problem was harmonized policies, in the context of regional collaborative pro- similar, even with international contractors. The Bank's lev- grams like the "Corridor Project". erage in the struggle against HIV/AIDS in transport project operations is presumed to be strongest at design level. That (v.) HIV/AIDS belong to the category of problems that are experi- is, to include HIV/AIDS clauses in bid documents. However, enced but not expressed (because the disease embodies high risk for the Ethiopian experience has shown that, international road social stigma), or, that are neither experienced nor expressed consultants and contractors do not necessarily have the social because symptoms may take time to manifest. This raises a funda- capital to implement the clauses or the know how to hire mental question for all HIV/AIDS projects in the transport sector or appropriate subcontractors to conduct the work. otherwise: How do we address problems that are experienced but not expressed and problems that are neither experienced nor expressed? The Response of the Corridor Project" Team -- The "Cor- ridor Project" is not yet fully operational. However, together 4.2 Operational Findings with the project countries, UNAIDS and other donors, the (vi) The HIV/AIDS pandemic has global impacts, but experience Team has assisted in establishing an executive secretariat suggests that, solutions should be thought out and applied at the supported by a Bank financed consultant. The secretariat is in local level. The guidance of both local and national leaderships to the process of putting together an initial operational plan to champion interventions is vital for success ­ for the transport sec- start in 2003. tor, this means that not only national ministries, but sector agen- To strengthen social capital, recurrent training of project cies, transport unions and other groups have a role to play. stakeholders in issues related to transport and HIV/AIDS, is included as part of the project work program. For the trans- (vii) Contractors and consultants are not necessarily cognizant of port sector this is likely to have two principal elements: de- the HIV/AIDS pandemic in the country of their work. Experience veloping HIV/AIDS prevention strategies in the transport from Ethiopia shows that they may benefit from technical assistance in sector which will be national but also coordinated across order to deliver and consistently implement HIV/AIDS programs. borders; and facilitating the smooth flow of traffic in cross (viii) The Bank's leverage in the struggle against HIV/AIDS in border areas to contribute to the reduction of risk. transport project operations, is presumed to be largely at design phase. The Response of the Ethiopian Project Team -- The Team But the inclusion of HIV/AIDS clauses in the bidding documents advised and assisted the ERA in including HIV/AIDS reports only does not ensure their implementation. Bank's leverage would benefit from project designs that take into account HIV/AIDS issues into road project consultants' monthly project progress re- during both the design and the implementation phases. ports. Also at client level, the Team assisted the ERA to re- Also, strengthening the social capital of the client to ensure cruit two national long-term consultants (a sociologist and a adequate monitoring/supervision of HIV/AIDS clauses in con- nurse) to start IEC work within the ERA while other consult- tracts, has emerged to be the key to successful implementation. ants were executing the baseline study. (ix) The lead role of the Bank Teams in initiating transport -- 4. Lessons Learned HIV/AIDS dialogues with the clients has made a difference in raising awareness and creating the possibilities for a higher priority A number of lessons were learned from the experience of the to be given to HIV/AIDS and for establishing the basis of an World Bank's project teams. They are here presented under operational response. First, it helped create a social space that en- two main categories: study/analytical findings and opera- courages the client to break the silence and the associated stigma, tional findings. and take ownership in addressing the issue. Second, clients' own- 4.1 Study/Analytical Findings ership of transport HIV/AIDS initiative encouraged other donors and stakeholders to commit their support to the work. (i) Migration, short-term or long-term, increases opportuni- ties for sexual relationships with multiple partners ­ and iSee Giraud, P. (1993), The Impact of AIDS at the Sectoral Level, in Blom, DE and while transport, and in particular roads, are an important vec- Lyons JV (eds), The Economics of the Implications of AIDS in Asia, UNDP, New tor for HIV/AIDS transmission the sector may also be seen as Delhi, and Marcus T. (1997), Interpreting the risk of AIDS: A Case Study of Long an asset in the dissemination of HIV/AIDS information. Distance Truck Driver's, in Development Southern Africa, Vol. 14, No.3. See also the series AIDS BRIEF for Sectoral Planners and Managers.