Document of The World Bank Report No: ICR00001980 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-72510 IDA-39460 IDA-H1110) ON A LOAN/CREDIT/GRANT IN THE AMOUNT OF US$7.0 MILLION (US$3.5 MILLION LOAN; SDR1.25 MILLION CREDIT (US$1.75 MILLION EQUIVALENT); AND SDR1.25 MILLION GRANT (US$1.75 MILLION EQUIVALENT) TO SAINT VINCENT AND THE GRENADINES FOR AN HIV/AIDS PREVENTION AND CONTROL PROJECT IN SUPPORT OF THE THIRD PHASE OF THE MULTI-COUNTRY HIV/AIDS PREVENTION AND CONTROL PROGRAM FOR THE CARIBBEAN REGION October 31, 2011 Human Development Sector Unit Caribbean Country Management Unit Latin America and Caribbean Region CURRENCY EQUIVALENTS (Exchange Rate Effective October 6, 2011) Currency Unit = OECD Dollars (EC$) EC$ 1.00 = US$ 0.37 US$ 1.00 = EC$ 2.69 FISCAL YEAR 1 January – 31 December ABBREVIATIONS AND ACRONYMS AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral Therapy ARV Antiretroviral BCC Behavior Change Communication BoL Bread of Life BSS Behavioral Surveillance Survey CAS Country Assistance Strategy CCM Council of the Country Coordinating Mechanism CFR Case Fatality Rate: CHAA Caribbean HIV and AIDS Alliance CMIS Clinical Management Information System CSO Civil Society Organization FBO Faith-Based Organization FM Financial Management GOSVG Government of Saint Vincent and the Grenadines HMIS Health Management Information System HIV Human Immunodeficiency Virus ICR Implementation Completion Results Report IEC Information, Education, Communication IRR Internal Rate of Return ISR Implementation Status and Results Report KAP Knowledge, Attitudes, and Practices LM Line Ministry M&E Monitoring and Evaluation MAP Multi-Country HIV/AIDS Program MARP Most-at-Risk Population MOE Ministry of Education MOHE Ministry of Health and Environment MTR Mid-Term Review MSM Men who have Sex with Men NAC National AIDS Council NAS National AIDS Secretariat NPV Net Present Value NSP National Strategic Plan ii PAD Project Appraisal Document PANCAP Pan Caribbean Partnership Against HIV and AIDS PCU Project Coordination Unit PDO Project Development Objective PLWHA People Living with HIV/AIDS PSI Population Services International RF Results Framework STI Sexually Transmitted Infection SVG Saint Vincent and the Grenadines UNAIDS The Joint United Nations Programme on HIV and AIDS UNICEF United Nations Children‟s Fund VCT Voluntary Counseling and Testing WHO World Health Organization Vice President: Pamela Cox Country Director: Françoise Clottes Sector Manager: Joana Godinho Project and ICR Team Leader: Christine Lao Peña ICR Author: F. Brian Pascual iii SAINT VINCENT AND THE GRENADINES HIV/AIDS Prevention and Control Project TABLE OF CONTENTS DATA SHEET A. Basic Information...................................................................................................... vi B. Key Dates .................................................................................................................. vi C. Ratings Summary ...................................................................................................... vi D. Sector and Theme Codes ......................................................................................... vii E. Bank Staff ................................................................................................................. vii F. Results Framework Analysis .................................................................................... vii G. Ratings of Project Performance in ISRs .................................................................. xv H. Restructuring (if any) ............................................................................................... xv I. Disbursement Profile ............................................................................................... xvi 1. Project Context, Development Objectives and Design ............................................... 1 1.1 Context at Appraisal ............................................................................................. 1 1.2 Original Project Development Objective (PDO) and Key Indicators ................... 2 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification .............................................................................................. 2 1.4 Main Beneficiaries ................................................................................................ 3 1.5 Original Components ............................................................................................ 3 1.6 Revised Components ............................................................................................ 4 1.7 Other significant changes ...................................................................................... 4 2. Key Factors Affecting Implementation and Outcomes .............................................. 5 2.1 Project Preparation, Design and Quality at Entry ................................................. 5 2.2 Implementation ..................................................................................................... 6 2.3 M&E Design, Implementation and Utilization ..................................................... 7 2.4 Safeguard and Fiduciary Compliance ................................................................... 8 2.5 Post-completion Operation/Next Phase ................................................................ 9 3. Assessment of Outcomes .......................................................................................... 10 3.1 Relevance of Objectives, Design and Implementation ....................................... 10 3.2 Achievement of Project Development Objective................................................ 11 3.3 Efficiency ............................................................................................................ 13 3.4 Justification of Overall Outcome Rating ............................................................ 14 3.5 Overarching Themes, Other Outcomes and Impacts .......................................... 14 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops ... 15 4. Assessment of Risk to Development Outcome......................................................... 15 5. Assessment of Bank and Borrower Performance ..................................................... 15 5.1 Bank Performance ............................................................................................... 15 5.2 Borrower Performance ........................................................................................ 17 6. Lessons Learned ....................................................................................................... 19 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 20 iv Annex 1. Project Costs and Financing .......................................................................... 21 (a) Project Cost by Component (in USD Million equivalent) .................................. 21 (b) Financing ............................................................................................................. 21 Annex 2. Outputs by Component ................................................................................. 22 Annex 3. Economic and Financial Analysis ................................................................. 34 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 39 (a) Task Team members ............................................................................................ 39 (b) Staff Time and Cost ............................................................................................. 40 Annex 5. Beneficiary Survey Results ........................................................................... 41 Annex 6. Stakeholder Workshop Report and Results................................................... 42 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 43 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 56 Annex 9. List of Supporting Documents ...................................................................... 57 Annex 10. Country Background ................................................................................... 59 Annex 11. Key Outcome and Output Indicators........................................................... 60 Annex 12. Main MTR Findings and Recommendations .............................................. 61 MAP IBRD 33488 ........................................................................................................ 62 v A. Basic Information ST. VINCENT SNF THE St. Vincent and the GRENADINES HIV/AIDS Country: Project Name: Grenadines PREVENTION AND CONTROL IBRD-72510,IDA-39460, IDA- Project ID: P076799 L/C/TF Number(s): H1110 ICR Date: 10/31/2011 ICR Type: Core ICR Lending Instrument: APL Borrower: ST. VINCENT Original Total USD 7.0M Disbursed Amount: USD 6.51M1 Commitment: Environmental Revised Amount: USD 7.0M B Category: Implementing Agencies: Ministry of Health and the Environment B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 02/12/2004 Effectiveness: 01/14/2005 01/14/2005 06/17/2009 Appraisal: 05/03/2004 Restructuring(s): 12/23/2010 Approval: 07/06/2004 Mid-term Review: 06/11/2007 06/05/2007 Closing: 06/30/2009 04/30/2011 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Low Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Moderately Satisfactory Implementing Quality of Supervision: Moderately Satisfactory Moderately Satisfactory Agency/Agencies: Overall Bank Overall Borrower Moderately Satisfactory Moderately Satisfactory Performance: Performance: 1 Amount based on expenditure data as of August 31, 2011. vi C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Project Quality at Entry No None at any time (Yes/No): (QEA): Problem Project at any Quality of No None time (Yes/No): Supervision (QSA): DO rating before Satisfactory Closing/Inactive status: D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 61 61 Health 28 28 Other social services 11 11 Theme Code (as % of total Bank financing) HIV/AIDS 33 33 Nutrition and food security 16 16 Participation and civic engagement 17 17 Population and reproductive health 17 17 Tuberculosis 17 17 E. Bank Staff Positions At ICR At Approval Vice President: Pamela Cox David de Ferranti Country Director: Françoise Clottes Caroline D. Anstey Sector Manager: Joana Godinho Evangeline Javier Project Team Leader: Christine Lao Pena Mary T. Mulusa ICR Team Leader: Christine Lao Pena ICR Primary Author: F. Brian Pascual F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The objective of the Project was to assist the Government in controlling the spread of the HIV/AIDS epidemic through: (a) the scaling up of programs for the prevention of vii HIV/AIDS, targeting in particular both HIV/AIDS high-risk groups and the general population; (b) the scaling up of programs for the treatment and care of people living with HIV/AIDS; (c) the reduction of the degree of stigma and discrimination associated with HIV/AIDS; and (d) the strengthening of the institutional capacity of the Ministry of Health and Environment (MOHE), other related Government agencies and civil society organizations to ensure the effectiveness and the sustainability of the project. viii (a) PDO Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years Indicator 1: 108 less than 100; 10% 64; Reduction in the number of decrease 41 % decrease in 7 new HIV cases years Date achieved 27-May-2004 30-Apr-2011 31-Dec-2010 EXCEEDED: Enhanced prevention activities including increased condom Comments (incl. % distribution, voluntary counseling and testing, and educational campaigns likely achievement) contributed to surpassing this target. Indicator 2: 0% -15% -56% % of AIDS cases reduced Date achieved 27-May-2004 30-Apr-2011 31-Dec-2010 Comments (incl. % EXCEEDED: The number of AIDS cases decreased by 56% from 75 in 2004 to achievement) 33 in 2010. Indicator 3: Males: 15 years old; Males: 16 years; No BSS data; Median age by which 50% of Females: 16 years old Females: 17 years proxy data indicate young men and women aged progress 15-24 have first sexual contact Date achieved 27-May-2006 30-Apr-2011 31-Dec-2010 PROXY DATA INDICATE PROGRESS: No comparable BSS data, but Comments (incl. % UNICEF 2008 KAP survey of general population aged 14-17 years found only achievement) 42% have had sex, providing evidence of increased median age of first sexual encounter for a subset of target group. General population: Males 25-49 years: No BSS data; 85%; proxy data show Indicator 4: 25-49 years= 57% Females 25-49 years: progress Percentage of men and 65%; women using condoms at last Males 15-24 years: sexual encounter with non 78%; regular partner Females 15-24 years: 63%. Date achieved 27-May-2006 30-Apr-2011 31-Dec-2010 PROXY DATA INDICATE PROGRESS: No BSS data. UNICEF 2008 KAP Comments (incl. % survey among 14-17 years old found 85% used condoms. PSI 2007 survey of achievement) sexually active males 16-21 years old found 99% used condoms. These indicate positive behavior change in condom use. Indicator 5: General population: No applicable end-of- No BSS data; By 2008, at least 30% of project target set Proxy data show respondents demonstrate 25-49 years old= 89% since target was set sustained high knowledge of HIV and STI for 2008. knowledge level prevention methods 15-24 years old= 87% Date achieved 26-May-2006 30-Apr-2011 31-Dec-2010 PROXY DATA SHOW SUSTAINED KNOWLEDGE: No directly Comments (incl. % comparable BSS data, but UNICEF 2008 KAP survey found that 85% used achievement) condoms among those 14-17 years of age, with 73% stating most of the time or every time. Data indicate sustained high knowledge level. Indicator 6: With non-commercial No target set No data % of males and females 15+ partners: ix years old with more than one sex partner last year 15-24 years old= 38% 25-49 years= 6% Date achieved 31-May-2006 30-Apr-2011 31-Dec-2010 PROXY DATA SHOW INCREASE BUT OFFSET BY CONDOM USE: No Comments (incl. % BSS. PSI 2007 survey of sexually active males 16-21 years old found 81% had achievement) multiple partners in past year, indicating increase in sex partners for young males; however, 99% reported condom use. Indicator 7: No data 100% Proxy data show By 2008, all taxi drivers' progress associations implementing workplace prevention programs Date achieved 27-May-2004 30-Apr-2011 30-Apr-2011 PROXY DATA INDICATE PROGRESS: No data for taxi driver associations Comments (incl. % although taxi drivers received prevention training. Together with the achievement) Government‟s push to develop a National Workplace Policy, SVG is progressing towards reaching its taxi drivers. Condom use with non- 60% No data regular partner during last sexual encounter= Indicator 8: 59% Taxi drivers report protected sex practices Condom use with commercial partner at last sex= 93% Date achieved 27-May-2006 30-Apr-2011 31-Dec-2010 Comments (incl. % NO DATA: BSS data not available. achievement) Indicator 9: 22% 100% 100% By September 2008, 50% of all primary, secondary, and tertiary level students receive upgraded life skills and HIV and STI prevention instruction at least twice monthly Date achieved 30-Dec-2005 30-Apr-2011 31-Dec-2010 Comments (incl. % ACHIEVED: Target met for primary and secondary levels public schools. Data achievement) not available on private schools and tertiary level schools. Indicator 10: 36.00 180 204 Number of PLWHA receiving ARV treatment Date achieved 30-Dec-2004 30-Apr-2011 31-Dec-2010 EXCEEDED: Reaching and providing needed treatment to PLWHA contributed Comments (incl. % to significantly reduce the number of AIDS deaths from 63% to 13% in seven achievement) years. Actual data include private patients. Indicator 11: 63% 40% 13% Case Fatality Rate Date achieved 31-Dec-2003 30-Apr-2011 31-Dec-2010 Comments (incl. % ACHIEVED: Calculation based on 13 deaths in 2010 among 103 surviving AIDS x achievement) cases resulting in 13/103=13% CFR. Indicator 12: No data No target set 7 children Reduction in % of children under 15 years of age that have lost either father, mother or both parents Date achieved 30-Dec-2004 30-Apr-2011 31-Dec-2009 NO DATA: Baseline data not available at start of Project and no target was set, Comments (incl. % but number of children increased from 3 in 2007 to 7 in 2009. achievement) Indicator 13: No data 50% Proxy data show By 2008, at least 50% of progress businesses in the Tourism Industry with workplace programs for education among staff Date achieved 27-May-2004 30-Apr-2011 30-Apr-2011 AVAILABLE DATA INDICATE PROGRESS: No data on businesses but Comments (incl. % various trainings were conducted with Tourism industry workers. With achievement) Government‟s push to develop a National Workplace Policy, progress was made in providing workplace education programs. Indicator 14: 267 4,000 1,863 % of infected and affected individuals who received supportive counseling over the last 12 months Date achieved 31-Dec-2006 30-Dec-2009 31-Dec-2010 Comments (incl. % NOT ACHIEVED: 1,863 received services in 2010, but in 2009 there were 3,781 achievement) persons who received the services, close to meeting the target of 4,000. Indicator 15: No data No target set No data % of companies with non- discriminatory policies and practices in recruitment and benefits for employees infected with HIV Date achieved 31-Dec-2004 30-Apr-2011 29-Apr-2011 AVAILABLE DATA INDICATE PROGRESS: The Employer's Federation Comments (incl. % worked with 40 interested organizations to establish workplace policies. achievement) Workshops were conducted to reduce stigma & discrimination. SVG advanced in preparing its National Workplace Policy. Indicator 16: 15-24 years old= 4% No target set Proxy data show % of people surveyed significant progress expressing an accepting 25-49 years old= 6% attitude toward people with HIV Date achieved 31-May-2006 30-Apr-2011 31-Dec-2008 AVAILABLE DATA SHOW PROGRESS: No BSS. UNICEF 2008 KAP Comments (incl. % survey among 14-17 years old found 63% had accepting attitude towards HIV, achievement) saying that HIV+ students & teachers should not be barred from school, showing strong positive shift in accepting PLWHA. Indicator 17: No existing standards Standards of care Standards of care Standards of care reviewed reviewed and updated reviewed and and updated updated xi Date achieved 27-May-2004 30-Apr-2011 30-Apr-2011 Comments (incl. % ACHIEVED: Indicator met in late 2004 when SVG adopted the Clinical achievement) Guidelines for the Care and Treatment of HIV-infected persons in the Caribbean. Indicator 18: No existing protocols Treatment protocols Treatment Treatment protocols developed protocols developed developed Date achieved 27-May-2004 30Apr-2011 31-Dec-2010 ACHIEVED: Indicator met in late 2004 when SVG adopted the Clinical Comments (incl. % Guidelines for the Care and Treatment of HIV-infected persons in the Caribbean achievement) which included treatment protocols. Indicator 19: No existing system Referral and follow- Referral and Referral and follow-up up systems specified follow-up systems systems specified specified Date achieved 27-May-2004 30-Apr-2011 31-Dec-2010 ACHIEVED: Indicator met in late 2004 when SVG adopted the Clinical Comments (incl. % Guidelines for the Care and Treatment of HIV-infected persons in the Caribbean achievement) which included referral and follow-up systems. No existing legal and Legal and policy National policy Indicator 20: policy measures measures to guard the development Legal and policy measures to human rights of all process is ongoing guard the human rights of all PLWHA and their PLHWA and their significant significant others in others in place place Date achieved 27-May-2004 30-Apr-2011 30-Apr-2011 Comments (incl. % PARTIALLY ACHIEVED: A consultant is developing the workplace policy. achievement) Indicator 21: No existing programs Training programs for Training programs Training programs for providers, PLWHA, were conducted providers, PLHWAs and their and their families families developed by developed December 2004 Date achieved 27-May-2004 30-Apr-2011 31-Dec-2010 ACHIEVED: Training programs were conducted in a number of areas including Comments (incl. % VCT, HIV rapid testing, provider initiated testing and counseling, basic achievement) HIV/AIDS education. Indicator 22: 3 15 14 NGOs contracted to provide care for PLWHA and their families Date achieved 27-May-2004 30-Apr-2011 31-Dec-2010 ALMOST ACHIEVED: Indicator was included in PAD to reflect national Comments (incl. % commitment and did not have a specific target. Target of 15 was set during Project achievement) implementation. xii (b) Intermediate Outcome Indicator(s) Original Actual Value Target Values Formally Achieved at Baseline Indicator (from Revised Completion Value approval Target Values or Target documents) Years Indicator 1: 58% of 98% to 100% 99% Percentage of women counseled and pregnancies in (2,589/2,629) tested as part of ante-natal care 1999 and 2000 Date achieved 12-Dec-2002 31-Dec-2010 01-Dec-2010 ACHIEVED: PMTCT is well integrated in all health centers Comments (incl. % achievement) while HIV was part of routine antenatal testing and screening. 218,900 2 million 2,017,335 Indicator 2: (cumulative) (cumulative); No of condoms distributed island-wide 100,625 in 2010 Date achieved 31-Dec-2004 31-Dec-2010 01-Dec-2010 EXCEEDED: Planned Parenthood, MOH, and the AIDS Alliance Comments (incl. % achievement) distributed condoms. Indicator 3: NA 2,000 8,927 Number of individuals who were tested for HIV Date achieved 31-Dec-2004 30-Jun-2009 30-Sep-2010 EXCEEDED: SVG continues to strengthen its capacity for HIV Comments (incl. % achievement) testing as reflected in having trained 60 persons on rapid testing and 164 on counseling in the last year. Indicator 4: 115 375 474 Number of HIV/AIDS positive people under treatment Date achieved 27-May-2004 31-Dec-2010 30-Dec-2010 EXCEEDED: A total of 474 cases were reached and received Comments (incl. % achievement) treatment, of whom 146 dropped out (died, transferred, losst to follow-up), leaving 328 currently on treatment. Indicator 5: 95% 100% 82.4% (14/17) Percentage of pregnant women who are HIV+ who are provided with treatment and care Date achieved 27-May-2004 31-Dec-2010 30-Dec-2010 PARTIALLY ACHIEVED: Three missing cases: one premature Comments (incl. % achievement) delivery who never received ARVs, and two women who never attended antenatal care clinics. Indicator 6: 33 100 127 Number of orphans and vulnerable children receiving psychosocial support Date achieved 27-May-2004 31-Dec-2010 12-Mar-2010 Comments (incl. % achievement) EXCEEDED: OVCs received several types of services. Indicator 7: 18 39 39 Number of public facilities staffed by trained counselors providing specialized HIV counseling and testing Date achieved 30-Dec-2004 31-Dec-2010 01-Dec-2010 Comments (incl. % achievement) ACHIEVED: 39 public facilities provide counseling and delayed xiii testing, while 19 provide rapid testing. Indicator 8: 2 9 10 including the No. of line ministries that have MOHE implemented work plans according to the National HIV/AIDS Strategic Plan Date achieved 31-Dec-2005 31-Dec-2010 01-Dec-2010 EXCEEDED: Success in establishing implementable work plans Comments (incl. % achievement) in key ministries helps consolidate national commitment. Indicator 9: 0 21 23 No. of health facilities rehabilitated using project funds Date achieved 31-Dec-2006 31-Dec-2010 01-Dec-2010 EXCEEDED: This included rehabilitation and provision of Comments (incl. % achievement) equipment to strengthen SVG‟s capacity to conduct rapid testing. Indicator 10: 1 3 1 Number of health care facilities that have the capacity to deliver palliative care, treatment and referral for HIV infected patients according to national guidelines Date achieved 27-May-2004 30-Apr-2011 29-Apr-2011 NOT ACHIEVED: Services presently only offered at Main Hospital, but counseling services currently being offered at the Comments (incl. % achievement) Stubbs, Marriaqua, and Clare Valley health facilities and will be rolled out to the Buccament Polyclinic later this year. Indicator 11: 1 3 1 Number of health facilities providing Highly Active Antiretroviral Therapy Date achieved 27-May-2004 30-Apr-2011 29-Apr-2011 NOT ACHIEVED: Services only offered at the Main Hospital. Counseling offered at Stubbs, Marriaqua, and Clare Valley Comments (incl. % achievement) facilities and will be rolled out to the Buccament Polyclinic by this year. Treatment training underway at the four additional sites. xiv G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 10/28/2004 Satisfactory Satisfactory 0.00 2 03/25/2005 Satisfactory Satisfactory 0.32 3 08/08/2005 Satisfactory Satisfactory 0.32 4 06/09/2006 Satisfactory Satisfactory 0.47 5 12/21/2006 Moderately Satisfactory Moderately Satisfactory 1.19 6 03/22/2007 Moderately Satisfactory Moderately Satisfactory 1.41 7 08/14/2007 Moderately Satisfactory Moderately Satisfactory 1.80 8 04/19/2008 Moderately Satisfactory Satisfactory 2.28 9 10/16/2008 Moderately Satisfactory Moderately Satisfactory 2.73 10 04/03/2009 Moderately Satisfactory Moderately Satisfactory 3.36 11 08/28/2009 Satisfactory Satisfactory 3.52 12 12/11/2009 Satisfactory Satisfactory 4.08 13 06/23/2010 Satisfactory Moderately Satisfactory 4.91 14 02/23/2011 Satisfactory Moderately Satisfactory 6.13 15 09/07/2011 Moderately Satisfactory Moderately Satisfactory 6.51 H. Restructuring (if any) Board ISR Ratings at Amount Restructuring Approved Restructuring Disbursed at Reason for Restructuring & Key Date(s) PDO Restructuring Changes Made DO IP Change in USD millions It did not appear that the Project would meet some targets by the original closing date. Changes included extending the closing date to provide additional time to allow the project to successfully 06/17/2009 N MS MS 3.48 complete the planned activities in order to achieve the PDO; reallocating funds as a result of increased costs of certain activities; aligning the Legal Agreements with the PAD. The Project was hampered as a result of the Government‟s financial burden from addressing damages from the hurricane and unforeseen delays in the aftermath of national elections. The closing date was 12/23/2010 N S MS 5.78 extended to create an additional window of time to allow the Project to disburse from the loan and provide sufficient time to receive the final set of equipment and supplies needed. xv I. Disbursement Profile xvi 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Saint Vincent and the Grenadines (SVG) in the Eastern Caribbean consists of 32 islands with a total land area of 150 square miles and an estimated population of 103,330 in 2004 [see Annex 10 for additional country background]. HIV was first diagnosed in SVG in 1984 (Figure 1). By 2004, a total of 796 HIV cases had been reported, reaching an annual high of 108 cases. Among the reported total cases, 63% were males and 37% were females. A majority (64%) of the 796 cases were between 25-49 years of age, while 20% were among young adults between 15-25 years of age and 10% were among children under 15 years of age. Heterosexual sex was documented as the main mode of transmission (68%) followed by homosexual/bisexual contact (12%) and vertical transmission (8%). At the time of project appraisal, 54% (431 cases) of the HIV+ cases had developed AIDS-related diseases and experienced a case fatality rate (CFR) of 51% (405 cases), leaving 391 persons living with HIV/AIDS. Among AIDS cases, the fatality rate was 94% (405/431). Figure 1. Number of reported cases of HIV, AIDS, and AIDS-related deaths in Saint Vincent and the Grenadines, 1984-2004. HIV AIDS Deaths 120 100 Number of cases 80 60 40 20 0 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Year Source: NAS, 2011 2. Following the identification of the first HIV/AIDS case in 1984, the Government of Saint Vincent and the Grenadines (GOSVG) established a response program, which eventually led to the development of the National HIV/AIDS and Sexually Transmitted Infections (STIs) Strategic Plan 2001-2006. Despite the high level of HIV/AIDS awareness in the country, positive behavior change remained a challenge. Soon after, the Strategic Plan evolved into the National HIV/AIDS Strategic Plan 2004-2009.2 The Strategic Plan was consistent with the Caribbean Regional Plan 2 The National HIV/AIDS Strategic Plan proposed five strategies: (i) strengthen inter-sectoral structures and institutional capacity; (ii) develop HIV/AIDS/STI Prevention and Control programs with priority given to youth and high risk/vulnerable groups; (iii) strengthen care, support, and treatment programs for people living with AIDS and their families; (iv) conduct research; and (v) upgrade surveillance systems. 1 of Action that came about in 2000 that endorsed National Strategic Plans (NSPs) focused on a comprehensive approach. During the same time, the World Bank initiated financing for the Multi-Country HIV/AIDS Program (MAP) for the Caribbean Region, pledging US$155 million on a multi-country effort to engage many countries, raise political awareness, and provide the first significant financial resources to combat the disease.3 3. The Saint Vincent and the Grenadines HIV/AIDS Prevention and Control Project was to be implemented in four and a half years (Jan 2005 – June 2009) as part of the third phase of the MAP Adaptable Program Lending for the Caribbean Region, which established guidelines for giving equal importance to prevention, treatment, and care. While led by the public sector, the strategy aimed to involve wide participation of civil society through the non-Governmental Organizations, Faith-based Organizations (FBOs), and Community-based Organizations. The Project remained consistent with the findings of the Country Assistance Strategy (CAS) in 2001 for the Eastern Caribbean Sub-Region, which highlighted the need to urgently address HIV/AIDS in SVG, as well as to support building human and institutional capacity. 4. The World Bank involvement was considered valuable given the Bank‟s likely contributions to (i) financing immediate scale-up of ongoing initiatives; (ii) strengthening extant antiretroviral treatment program; (iii) sharing lessons learned from other ongoing HIV/AIDS projects, including those under the multi-country and multisectoral programs in Africa, the Caribbean, and Brazil; (iv) supporting technical guidance; and (v) helping ensure that key policy issues at the national, regional, and global levels are addressed. 1.2 Original Project Development Objective (PDO) and Key Indicators 5. The objective of the Project was to assist the Government in controlling the spread of the HIV/AIDS epidemic through: (a) the scaling up of programs for the prevention of HIV/AIDS, targeting in particular both HIV/AIDS high-risk groups and the general population; (b) the scaling up of programs for the treatment and care of people living with HIV/AIDS (PLWHA); (c) the reduction of the degree of stigma and discrimination associated with HIV/AIDS; and (d) the strengthening of the institutional capacity of the Ministry of Health and Environment (MOHE), other related Government agencies and civil society organizations (CSOs) to ensure the effectiveness and the sustainability of the Project [see Annex 11 for key outcome and output indicators]. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 6. The PDO remained unchanged. However, the Project and the Government teams agreed on a simplified, shorter list of indicators to be monitored during the course of project 3 Between FY01-FY05, one regional project and nine country projects were approved and received a total funding amount of US$ 117.65 million. 2 implementation. This involved adding two new PDO indicators to monitor HIV prevention knowledge and efficacy of treatment: (1) people who can correctly identify two ways of preventing HIV infections and (2) survival rate of people with HIV/AIDS under antiretroviral (ARV) treatment. These two PDO indicators were monitored in the Implementation Status and Results Reports (ISRs) along with four other PDO indicators that were taken as a subset out of the original 22 PDO indicators approved in the Project Appraisal Document (PAD). Since these indicators represented a subset of data already being collected by the Government, the Bank team and the country did not consider requesting a formal restructuring of the Project indicators. Given the decision to focus on six indicators to monitor progress, a formal restructuring should have been undertaken to revise the PDO indicators. For this Implementation Completion Results Report (ICR), since there was no formal restructuring of the results matrix, the original indicators as approved in the PAD were reviewed to assess how well the Project met its objective. 1.4 Main Beneficiaries 7. The Project supported targeted interventions for high risk groups and non-targeted interventions for the general population. It was expected that the implementation of the Project would lead to: (i) increased awareness of HIV/AIDS and use of prevention services; (ii) increased support for PLWHA and their families who were receiving care and support; and (iii) strengthened capacity of both public sector and civil society to respond to HIV/AIDS. 1.5 Original Components Component 1: Scaling up HIV/AIDS response by CSOs (US$0.98 million; actual expenditure US$0.33 million). The Project will empower communities to respond effectively to the HIV/AIDS epidemic. Civil society groups such as Non-Governmental Organizations, Community-Based Organizations, FBOs, and the private sector have access to different groups including difficult-to-reach groups that are particularly high risk (commercial sex workers, men having sex with men, prisoners, and truck drivers) and vulnerable groups (orphans and youth). Activities to be implemented by these organizations included: behavior change communication (BCC); support to orphans; provision of care for PLWHA; and distribution of condoms. The Project will also finance capacity building for the CSOs. Component 2: Scaling up the response by line ministries (LMs) (US$1.60 million; actual expenditure US$0.51 million). The Project will support LMs to expand initiatives in accordance with priorities in the National Strategic Plan for AIDS 2004-2009. The Project will support cross-cutting activities focusing on prevention of HIV/AIDS and STIs through: training, information, Information, Education and Communication/Behavioral Change Communication (IEC/BCC); condom distribution; treatment and care for the infected and affected families; work place policy formulation including reduction of stigma and discrimination; and, HIV/AIDS impact assessments. There are also HIV/AIDS related interventions that are specific to each ministry‟s external clients, for example, students, teachers and parents for the Ministry of Education (MOE), the hotel and restaurant industry for the Ministry of Tourism, and PLWHA, 3 orphans and school drop outs for the Ministry of Social Development. Interventions will be tailored by each of the Ministries to their respective clients. Component 3: Expanding Health Sector Prevention, Treatment and Care Services for HIV/AIDS (US$3.48 million; actual expenditure US$5.43 million). The Project will support strengthening, upgrading and expansion of prevention, treatment and care services through the health care system. This will include upgrading of laboratories, voluntary counseling and testing (VCT) rooms, training health care workers and counselors and provision of equipment, drugs, supplies, testing kits, condoms, and technical assistance in key areas: IEC/BCC; VCT; condoms distribution; Treatment (sexually transmitted diseases and opportunistic infections treatment, including ARV treatment); laboratory services; and biomedical waste management. Component 4: Institutional Capacity Strengthening, Monitoring, Evaluation and Research (US$2.55 million; actual expenditure US$2.38 million). The Project will support institutional capacity building for scaling up the response through financing of technical advisory services, training, staffing, equipment, goods, and general operating costs for strengthening institutional capacity for coordinating and managing the Government‟s National HIV/AIDS Program through the National AIDS Council (NAC) and its operating arm, the National AIDS Secretariat (NAS); and strengthening monitoring and evaluation (M&E), including support for monitoring program implementation, epidemiological surveillance, and establishing the HIV/AIDS/STI clinical management information system (CMIS) and required information technology platform for the main public hospital and for 18 VCT selected health centers. 1.6 Revised Components N/A 1.7 Other significant changes 8. Level II Restructuring approved on June 17, 2009. Although the Project was on track to meet most of its targets, it did not appear that it would meet some targets by the original closing date of June 30, 2009. The Project was restructured based on the GOSVG‟s requests on January 7, 2009 and March 17, 2009. The PDO and associated outcome targets remained relevant and were not amended. The economic, financial, environmental, technical, and social aspects of the Project as appraised were still valid as well. Amendments to the Agreements included:  Aligning the Legal Agreement with the PAD and Agreements with Government made during the Project Implementation. The PAD did not include certain civil works, such as the construction of the Bread of Life (BoL) orphanage, renovation of an HIV/AIDS Resource Center at the MOE, upgrading of the Stubbs Health Center into a polyclinic, and renovation of the NAS building. Moreover, the refurbishment of 18 VCT rooms mentioned in the PAD was not incorporated into the Legal Agreements (Loan/Credit/Grant). To permit the financing of these activities under the Loan, Credit, and Grant proceeds, and to ensure 4 consistency among the Project documents and the Legal Agreements, the Legal Agreements were amended accordingly.  Adding the financing of “works� under subprojects on the disbursement table in Paragraph 1 of Schedule 1 of the Loan Agreements. The amendment supported new construction of the BoL orphanage. Because the PAD indicated that Component 1 of the Project supported eligible CSOs to respond to the epidemic through financing of subprojects only and did not contemplate the financing of works, Category 6 set forth in the disbursement table was modified accordingly. The Operations Manual was modified accordingly.  Reallocation of proceeds. Loan, Credit, and Grant funds were reallocated among disbursement categories of eligible expenditures to address increased project costs, such as expenses already incurred in upgrading health clinics and the NAS building, and future project needs, such as civil works related to the BoL construction.  Extending the closing date from June 30, 2009 to December 31, 2010. The 18-month extension was needed to complete remaining project activities, including civil works; installation of the information technology platform; and CSO proposals and LM work plan activities recently approved at the time. 9. Level II Restructuring approved on Dec. 23, 2010. The Project was restructured to extend the closing date from December 31, 2010 to April 30, 2011. Given the financial strain the Government experienced in addressing the damages caused by Hurricane Tomas, the restructuring provided the Government an additional window of time to use Bank funds, rather than its own funds, to support the delivery of remaining items: goods for the Stubbs Polyclinic; supplies for the biomedical waste management; and hardware equipment for the Health Information System (HMIS). At the time of the restructuring‟s approval, 10% (US$0.35 million) of the loan amount remained uncommitted. The new extension also gave the Government‟s Central Tender Board time to review and approve the contract for the HMIS hardware equipment, which had been delayed due to the December 2010 national elections, and enabled the Project to receive the final delivery of equipment and supplies. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 10. Soundness of the background analysis: The Bank adopted lessons learned from other HIV/AIDS projects in the Caribbean and the Africa Region for the design and implementation of this Project, including the need for: (i) high level political commitment and leadership; (ii) a comprehensive approach to prevention, treatment, care and support; (iii) awareness of rapidly changing prices and technology of HIV/AIDS-related items; (iv) M&E to provide timely information for scaling up the national response; (v) attentiveness to slow start up within projects; (vi) recognition of all stakeholders; and (vii) building a strong fiduciary architecture. These aspects addressed many of the issues that the Project needed to overcome to succeed. In 5 addition, project design took into account the challenge of working in small countries in the region with limited human resources as highlighted in the Country Assistance Strategy for the Eastern Caribbean Sub-Region in 2001. For example, the need for training and intensive implementation support was identified. Also, instead of establishing a separate Project Coordinating Unit (PCU), the Bank team decided to use the same PCU responsible for managing two existing WB financed projects. 11. Assessment of the project design: The design of the Project established a NAC that determined the HIV/AIDS program‟s strategic content and direction, and was jointly presided by the Prime Minister and Minister of Health with the intent of providing political visibility and accountability. The NAC was composed of appointed representatives from the private and public sectors, including Government and civil society. The NAC oversaw the NAS, its operating arm for all its decisions, and appointed a Director to coordinate the Project and provide technical guidance to implementing agencies. The Council of the Country Coordinating Mechanism (CCM) for the Global Fund, created in 2003 with broad representation from all sectors, was designated to evaluate the anticipated demand-driven CSO proposals and recommend qualified proposals to the NAS for approval and to the NAC for ratification. An existing PCU located in the Ministry of Finance, Planning and Development managed the financial and procurement aspects of the Project. A critical aspect of the design entailed structuring the Project components around implementing agencies. This created a division of labor between the implementing agents (CSOs, LMs, MOHE, and NAS/PCU) that made specific agencies responsible for particular activities with corresponding financial resources. In the past, projects that were driven by thematic components created confusion related to who was responsible for achieving which results. In addition, the participation of the various implementing agents addressed the Government‟s strategy of recognizing that all stakeholders are important in the fight against HIV/AIDS and in delivering a coordinated multisectoral response as indicated in its NSP. As mentioned in the PAD, the arrangement took advantage of the available resources in the country by drawing on existing expertise in Bank-financed projects. In this case, the PCU had been managing fiduciary aspects through its involvement with the Emergency Recovery (US$3.2 million) and Disaster Management (US$5.9 million) projects, both of which required rapid implementation. For such a small country with limited human resources, it was appropriate not to set up another PCU. The Project team considered two alternative design options but rejected them because it either precluded a multisectoral approach that sufficiently confronted the varied socio-economic factors that fuel the epidemic (health sector investment option); or neglected the concept that HIV/AIDS could rapidly move from specific groups to the general population in a country with a highly concentrated epidemic located in a region that is highly mobile (targeted option focused only on high-risk/vulnerable groups). 2.2 Implementation 12. Coordination arrangement between the NAS and PCU: Although institutional mechanisms had been put in place, the Project suffered initial delays, mostly due to the steep learning curve experienced by SVG in implementing a multi-sector project that involved various stakeholders, which it had never done in the past. Initial coordination issues between the NAS 6 and PCU also surfaced. Despite these issues, country management eventually learned and, as highlighted in the ISRs, progressively resolved coordination issues. The fiduciary and technical units began working well together. The NAS and PCU also started to hold periodic meetings with the LMs and CSOs. 13. Mid-Term Review (MTR): Few activities had been implemented at the time of the MTR in mid-June 2007; only 23% (US$1.6 million) of the funds had been disbursed, resulting in a disbursement lag of 58%. The MTR found that M&E remained inadequate; PCU capacity was insufficient; CSO and LM engagement were weak and inconsistent; and the health sector response was progressing and strong, but suffered from poor coordination [see Annex 12 for detailed description of main findings and recommendations from the MTR]. The MTR concluded that the PDO and overall design remained relevant. The PDO focused on interventions targeting both the general population and the high-risk groups. For a small country with high levels of stigma and discrimination, it was important to remain committed to educating the general public about HIV/AIDS while at the same time reaching out to those most-at-risk who could have the potential of spreading the virus across a small population. The lag in disbursement and implementation required a number of adjustments in the project cost tables, the procurement plan, and Schedule 1 of the Legal Agreements. The Government agreed to review the proposed changes discussed during the MTR and submit an updated procurement plan and a request for reallocations in Schedule 1 of the Legal Agreements by June 30, 2007. However, other events (Hurricane Tomas and national elections that were held earlier than expected) affected and further delayed implementation. 2.3 M&E Design, Implementation and Utilization 14. M&E design: SVG identified 22 indicators to monitor its progress toward achieving the PDOs. Indicators for which baseline data were available used information gathered from SVG‟s routine surveillance reporting or through the Behavioral Surveillance Survey (BSS) conducted in 2005. While the PAD notes that additional data from a Knowledge, Attitudes, Practices (KAP) survey among the youth, workplace discrimination surveys, and key informant interviews would be used to provide additional baseline data, there was no indication that these surveys were completed or used at the outset. These surveys could have provided more information regarding the HIV/AIDS situation in SVG, including providing baseline data for four of the 22 PDO indicators (see Results Framework (RF) in Datasheet). The RF had more indicators than is usually included in a typical Bank lending project (i.e., 22 PDO indicators rather than just five). While many of these were part of SVG‟s National Strategic Plan, and thus included in the RF, the Bank could have used fewer indicators to assess progress in achieving Project objectives. 15. M&E implementation: An electronic patient monitoring system was launched in 2007 at the Care and Treatment Center in the country‟s main hospital. The system provided data critical to keep track of patient progress and help manage ongoing patient care. In addition, the HMIS that was developed by MOHE with Project support4 has already been rolled out in 36 out 4 Project funding for the HMIS (design, equipment, and staffing) amounted to approximately US$1.1 million. 7 of 39 health clinics located all over the country. The system includes administrative data, financial data, clinical data, physician orders, electronic health records, and laboratory results. The HMIS is intended to (i) provide electronic personal identification codes and records for every patient; (ii) improve health through availability of reliable and timely health information; (iii) improve monitoring of national, regional, and international indicators; and (iv) enhance accountability and support evidence-base decision making. It will be a comprehensive system that is among the first in the region. Throughout the Project, SVG remained thorough in collecting data in no small part due to dedicated and dynamic staff. Despite the progress achieved within the last years, SVG‟s capacity needs to be further strengthened. This was evident in its PDO reporting of AIDS CFR in which SVG documented a 42% rate for 2010, indicating that SVG did not surpass the 40% end-of-project target. During the ICR preparation, however, Bank team recalculations resulted in a 13% CFR, a figure much lower than originally reported, indicating that the country was actually doing better in reducing CFR than it had been reporting. Another weakness was the failure to conduct a follow-up BSS, which was contemplated as part of the Project, resulting in an inability to monitor key behavioral changes and progress as planned. 16. M&E utilization: Epidemiological data were compiled on a monthly basis into a central unit, including data from private laboratories, then analyzed and shared with MOHE and NAS. This helped SVG respond to various reporting requirements, including the United Nations General Assembly Special Session and the World Bank, as well as produce and disseminate semi-annual and annual national reports. With the development and use of the M&E Manual during project implementation, data collection and reporting improved considerably especially for the health sector. The next critical step is to continue to improve data collection from other participating sectors and to use data for programmatic monitoring, outcome evaluation, and decision making. The M&E function was transferred from NAS to MOHE in June 2009. The M&E unit is now also responsible for disease surveillance and works in a complementary function with the Epidemiology Unit. Presently, the epidemiologist has taken on the task of M&E while, previously, the NAS had an M&E Coordinator/Advisor who was contracted through the Project, a position that has not been filled since the retirement of the previous M&E Coordinator/Advisor due to budget and human resource constraints. The workload to do both M&E and disease surveillance efficiently is not sustainable. In addition, the expertise needed to perform each task effectively is quite different, thus requiring two staff with different set of skills. 2.4 Safeguard and Fiduciary Compliance 17. Safeguard: The only safeguard policy triggered by the Project was the Environmental Assessment (OP/BP 4.01). The Project received a Category B environmental rating at the appraisal phase and was not expected to not generate adverse environmental effects. Prior to launching the Project, a biomedical waste management assessment and a plan for its implementation were prepared in 2001 under a World Bank-funded program to address the problem of solid and ship-generated wastes. The plan recommended a number of priority actions for dealing with biomedical waste, including strengthening the regulatory framework; enhancing medical waste disposal management; and purchasing and installing disposal equipment. When 8 the Project started, SVG was already in the process of acquiring new incineration technology to dispose of medical waste in an environmentally acceptable manner. The Biomedical Waste Management segment of the Project was implemented by the MOHE. The Government financed training while the Project funds financed some training and biomedical waste management supplies. As planned under the Bank‟s environmental safeguard requirement, biomedical waste was prepared at the hospital and health center sites following strict procedures, after which the waste was transported to a landfill site for incineration. The design for the incineration and implementation of civil works, as well as health worker training on comprehensive biomedical waste disposal, were completed. The Project received a Satisfactory rating for both safeguard compliance with the Environmental Assessment and for Overall Safeguard Compliance. 18. Fiduciary: During the life of the Project, the PCU experienced the following challenges: delays in receiving bank statements and other documents required to prepare the Financial Management Report and Financial Statements; poor oversight and accountability in preparing monthly bank account reconciliations and in making direct payments; lack of staff to cover workload; and poor file management. An external audit in 2007 found the project risk level as Substantial. Similar findings were observed through the Bank missions. To help improve financial management (FM) performance, the Bank recommended improving data management by ensuring that entries used formula to avoid data entry errors, hiring an assistant to help with FM, and adjusting its workflow and internal controls arrangements. The Bank made itself available for technical support and training as needed. FM gradually improved over the remaining life of the Project, although the Bank mission‟s FM review in December 2010 still found inconsistencies and indicated that there is still need for improvement. While the Project, in general, had no issues with regard to counterpart funding over the course of project implementation, the budget challenges posed by Hurricane Tomas in 2010 and the worldwide economic downturn, resulted in delayed payments to the contractors of the BoL Orphanage and the Stubbs Polyclinic. 2.5 Post-completion Operation/Next Phase 19. The Cabinet approved and is currently implementing the National Strategic Plan 2010- 2014. Moreover, key successes include NAS staff moving to the permanent MOHE structure to promote continuity of key program interventions; the HMIS system is in the process of being installed in 39 health clinics in districts all over the country; an important study on Men who have Sex with Men (MSM) was completed that provides data useful for moving forward in tackling this target group. This study is unique in the Caribbean region given the high level of stigma and discrimination that pervades the region. However, there is general consensus that more work needs to be done to minimize stigma and discrimination in the country. More effort would also be required to ensure that gains made via multisectoral interventions through the non- health LMs and CSOs are sustained, at the very least, through training, provision of technical assistance from the MOHE/NAS, and regular opportunities for networking and coordination. 9 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation Relevance of PDO and design/implementation (combined rating): Moderately satisfactory. 20. Relevance of PDO: Satisfactory. The objectives were consistent with the Country Assistance Strategy for the Eastern Caribbean Sub-Region (2001) where the Bank aimed to help reduce poverty by building human and institutional capacity, including direct provision of services to the population, such as HIV/AIDS services. The Interim Poverty Reduction Strategy and Action Plan for SVG in 2003 underscored the country‟s efforts at poverty reduction, which included mitigating potentially negative social impacts resulting from HIV/AIDS and other issues related to economic development. More recently, the World Bank‟s Regional Partnership Strategy for the OECS for the Period 2010-2014 emphasized the importance of continued effort to improve health services and systems, including those that involve HIV/AIDS. In addition, SVG is already implementing its NSP for 2010-2014, which continues to implement the multi- sector strategy that the National HIV/AIDS Program began in 2005. 21. Relevance of design and implementation: Moderately satisfactory. The Project achieved most of what it set out to accomplish as evident from its project indicators. Specifically, it decreased the number of new positive HIV and AIDS cases, decreased the AIDS CFR, increased the number of patients receiving ARV, and established much needed guidelines and protocols for managing the National HIV/AIDS Program effectively. 22. The Project came close to meeting targets for a few other indicators such as increasing the percentage of pregnant HIV+ women who were provided with treatment and care, as well as establishing legal and policy measures that guard human rights of all PLHWA and their significant others. A critical factor behind what the Project accomplished was the selection of relevant partners to implement the Project. Moreover, separating them into components ensured that all implementing agencies had room to operate and accomplish their respective tasks. The intervention mix indicated the importance of the health sector in the HIV/AIDS response, receiving as much as 40% (US$3.48 million) of the total Project allocation (US$8.61 million). In contrast, the CSO component received the smallest allocation at 11% (US$0.98 million) of the total Project allocation. Given that the CSOs were designated to implement prevention programs as well as reach Most-at-Risk Population (MARP) such as commercial sex workers, MSM, prisoners, and vulnerable groups (orphans and youth), it might have been more appropriate to funnel additional funds to CSOs, especially in light of findings during the Project life that MARPs within SVG exhibited a much higher rate of HIV/AIDS than the general population.5 Given the limited capacity of most CSOs in SVG, a larger proportion of funds could have been allocated to strengthen the capacity of the CSOs instead of focusing mainly on financing specific CSO sub-projects, so that the CSOs themselves could better carry out targeted activities towards MARPs. 5 Data from sero-surveys found a prevalence rate of 4.1% among the prison population and 29% among MSMs. 10 23. Although the project design was appropriate in terms of using existing resources in the country and matching the comprehensive multisectoral approach mandated by the country‟s NSP, SVG struggled to implement project activities. Some of the obstacles faced by the Project included the initial coordination issues between the NAS and PCU, as well as challenges faced by the Government (NAS/PCU/FM) in managing non-health sector participation that turned out to be more transactions-intensive because of the multiple stakeholders involved. 24. One of the drawbacks of the Project was its inability to complete certain key activities even through the 22-month extension period. For example, a follow-up BSS would have provided valuable evidence on results of SVG‟s six and a half year effort. Although various surveys were completed during the life of the Project (MSM study, condom study among young population), their findings could not be directly compared to the baseline values from the 2005 BSS of the general population. However, these recent studies provide insight into behavior patterns of certain segments of the population, offering potential strategic avenues to develop future HIV/AIDS prevention and treatment programs. 3.2 Achievement of Project Development Objective 25. Rating: Moderately satisfactory. The development objective of the Project was to assist the Government in controlling the spread of the HIV/AIDS epidemic. The Project was successful in supporting the National Program in controlling HIV/AIDS in the population as reflected in the downward trend of reported HIV and AIDS cases since the start of the Project (Figure 2). The number of new HIV positive cases declined by 41% from a baseline of 108 cases in 2004 to 64 in 2010, thus exceeding the Project‟s target of reducing the baseline value to less than 100 cases. Concomitantly, the number of new AIDS cases declined by 38% from 40 cases to 25 during the same time period, exceeding the 15% reduction target. Of the 22 total PDO indicators, nine were exceeded or achieved, two were nearly achieved, one was not, and ten could not be measured with directly comparable data although data from other surveys and reports demonstrated progress in a majority of them. Figure 2. Reported cases of HIV, AIDS, and AIDS Deaths, St. Vincent and the Grenadines 2004-2010 HIV Cases AIDS Cases AIDS Deaths 120 100 Number of cases 80 60 40 20 0 2004 2005 2006 2007 2008 2009 2010 Year Source: NAS, 2011 11 26. The scale-up of prevention programs was evident from the increased distribution of condoms (target=2,000,000; actual=2,017,335), counseling and testing of virtually all pregnant women, and increase in the number of those in the general population tested for HIV (target=2,000; actual=8,927). Moreover, project implementation involved active mass campaigns and provision of HIV lessons in primary- and secondary-level classes. Studies conducted during project implementation point to likely contribution of these enhanced prevention activities to changes in behavior. For example, a Knowledge, Attitudes, and Practices (KAP) survey in 2008 by the United Nations Children‟s Fund (UNICEF) found that among the youth, which is considered a high risk group, condom use was 85%, up from 60% in 2004 (BSS). In another survey by Population Service International (PSI, 2007), 99% of youths aged 16-21 years responded using condoms within the last month. Among MSM, condom use was recorded at 80% (MOHE-SVG, 2010). SVG‟s success was also evident in the scale-up of treatment and care programs, which was led by the MOHE. By the end of the Project, MOHE succeeded in dramatically decreasing the CFR (target=40%; actual=13%) and increasing the number of patients who received treatment (target= 375; actual= 474). Given the expansion in the number of clinics staffed with trained counselors, such positive trends may indicate progress in catching patients early in the disease and enhanced quality of treatment. Beyond the life of the Project, these improvements in institutional capacity will have lasting effects. SVG has also set itself to continue its gains by assuring that guidelines on standards of care, treatment, referrals were in place. In the end, all of these contributed to the observed 41% decrease in newly reported HIV cases and the 38% decline in new AIDS cases since the start of the Project. Moreover, HIV prevalence among reported cases remains at around 1% or less. Although the Bank was only one of several development partners in SVG, its involvement largely solidified SVG‟s National Response Program and allowed many complementary prevention and treatment activities from other organizations and synergies to materialize. 27. The PDO indicator whose target was not met, was the percentage of infected and affected individuals receiving supportive counseling over the last 12 months (target=4,000; actual=1,863). While 2010 fell short of reaching its target, previous years fared much better; for example, 3,781 individuals in 2009 received counseling, nearly reaching the target of 4,000. 28. Of the ten PDO indicators that could not be measured, six behavioral indicators with baseline data from the 2004 BSS could not be directly assessed because of the absence of a follow-up BSS, although other surveys and studies were conducted that provide useful information. Of these indicators, the most important one is the percentage of men and women using condoms since it would be directly correlated to decreasing the spread of disease and would have provided further proof of an important behavioral change. While directly comparable BSS data were not available for this indicator, previously mentioned findings from other surveys and studies reveal elevated levels of condom use among high risk groups: 99% among sexually active males 16-21 years old within the survey month (PSI, 2007); 85% among population aged 14 to 17 years old used a condom at their last sexual encounter with a nonregular partner (UNICEF, 2008); and 80% among MSM (MOHE-SVG, 2010). These condom use rates exceed the end of Project targets for young males (78%) and females (63%) aged 15 to 24 years old. Moreover, median age for first sexual encounter appears to have risen as well based on UNICEF 12 (2008) findings that only 42% of youths aged 14-17 have had sex, compared to 2005 BSS findings where 50% of 15 year old males and 16 year old females have had sex. And even though comparable data for two other prevention related indicators (the number of taxi drivers‟ associations that implemented workplace prevention programs and the percentage of businesses in the Tourism Industry with workplace programs for education among staff) were not available, training sessions on prevention were provided to taxi driver associations and to Tourism Industry workers during Project implementation. Additional impact will likely be observed once the Government implements its National Workplace Policy, which is currently under preparation. 29. While there is a general consensus in the country that stigma and discrimination remain high, efforts to implement HIV lessons in public schools, as well as the scaled-up IEC campaigns, may have contributed to reducing stigma and discrimination among the young. Although no follow-up BSS was conducted at the end of the Project to allow for a direct comparison, the 2008 KAP survey (UNICEF) indicated an increase among those surveyed regarding accepting attitudes toward people with HIV (target=10% in the general population, actual=63% among younger population). The baseline reference point was 5% among those aged 15-49 years at the start of the Project.6 Aside from organizing workshops on reducing stigma and discrimination, the Government has also been working on two important initiatives: a Community Stigma Baseline Survey developed by the Pan Caribbean Partnership Against HIV and AIDS (PANCAP) and a National Policy that would protect the rights of PLWHA and their families. The Employer‟s Federation in SVG has also worked with 40 interested organizations to establish workplace policies and staff education. 30. Thus, surveys and studies conducted during the implementation period provide evidence of positive shifts in attitudes and behaviors that may reflect the impact of SVG‟s actions as implemented through the Project. Moreover the significant reductions in the reported new cases of HIV and AIDS could also be interpreted to reflect positive changes in preventive behavior [see Annex 2 for detailed analysis of Achievement of PDOs]. 3.3 Efficiency 31. Rating: Satisfactory. A cost benefit analysis was carried out comparing scenarios with- and without the Project (Annex 3). The analysis estimated the HIV infections averted, resulting in quantifiable benefits of averted productivity losses and savings on in-patient care and on treatment of opportunistic illnesses. The stream of costs and benefits from the Project yielded an internal rate of return (IRR) of 41.3% and a net present value (NPV) of US$ 9.48 million (based on a 10% discount rate), 7 demonstrating the Project‟s significant added value to curbing the spread of HIV/AIDS. 6 The BSS (2005) found that 4% among those aged 15-24 years and 6% among those aged 25-49 years (or 5% overall) had expressed an accepting attitude toward people with HIV. 7 Due to data availability, estimates were based on reported HIV cases rather than true incidence. 13 3.4 Justification of Overall Outcome Rating 32. Rating: Moderately satisfactory. The overall rating is based on the following sub- ratings: (i) Relevance of the objectives and design/implementation: Moderately Satisfactory; (ii) Achievement of PDOs - Moderately Satisfactory; and (iii) Efficiency – Satisfactory. 3.5 Overarching Themes, Other Outcomes and Impacts 33. Poverty Impacts, Gender Aspects, and Social Development: While the Project did well in reaching the general population through mass campaigns, pregnant women through the Prevention of Mother-to-Child Transmission program, and Orphaned and Vulnerable Children, it remains unclear what impact the Project had on high-risk groups such as MSMs. Moreover, available data could not discern changes in levels of stigma and discrimination that could be attributed to the Project. 34. Institutional Change/Strengthening: The NAS was responsible for supporting, coordinating, and overseeing project implementation by all implementing agencies; the NAS carried out their technical functions satisfactorily. By the end of the Project, staff members of implementing agencies, including key staff at the NAS and MOHE, gained valuable skills and experience that could be utilized by the MOHE on HIV/AIDS and other disease areas. Moving forward, enhanced capacity in these agencies places SVG in a better position to respond to, and implement, future development projects. Throughout the Project, Bank support such as training opportunities for fiduciary and technical staff enhanced SVG‟s institutional capacity. For example, the Bank team organized two major regional workshops: a 2006 five-day HIV/AIDS MAP Consultation and Training workshop for the 10 Caribbean projects and a 2008 two-day Policy Forum that brought together all the Caribbean countries involved in the MAP Adaptable Program Lending for the Caribbean Region. These workshops provided the Bank team an opportunity to discuss relevant issues with all the Governments in the region, thus gaining a better sense of how projects were progressing. It also provided a venue for the Governments to learn best practices from each other and voice concerns to the Bank. Procurement and FM specialists were brought in to provide training as needed, as well as to respond to requests from the Government for technical support. In addition, periodic fiduciary training workshops were also held in Washington, DC for Project Coordination staff. As a result, both procurement and FM improved in SVG over time despite delays as a result of a difficult work environment and limited human resources. 35. Other Unintended Outcomes and Impacts: Implementation of the HMIS under the Project will impact general health systems strengthening and create broader benefits down the road since the system was designed for use beyond just for HIV/AIDS. In particular, it supports epidemiological surveillance, documents patient health information, and monitors SVG‟s indicators in a timely fashion with the view of strengthening evidence-based decision making. It could serve as a model system for other countries in the region interested in building a comprehensive system. 14 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops N/A 4. Assessment of Risk to Development Outcome 36. Rating: Low. The Project reflects the country‟s priorities and commitment to fighting HIV/AIDS as reflected in SVG‟s recently approved NSP. In addition, efforts made since the Program began in 2005 have increased awareness significantly in the general population. As described earlier, much has been done to strengthen institutional capacity in SVG through numerous technical training and the development of a comprehensive HMIS. After the Project closed, SVG continued to benefit from technical and financial assistance from the United States President‟s Emergency Plan for AIDS Relief to support laboratory and health systems strengthening, strategic information, and prevention programs, as well as from the Global Fund to support care and treatment programs. Moreover, the Government has actively transitioned key staff into its permanent structure. Given the high staff turnover rates experienced by other Caribbean countries involved in the same program, the challenge now is retaining key technical staff to manage, coordinate, and implement the program. Additional challenges remain in continuing to build on and strengthen CSOs and LMs involvement in working on such a multi- sector program. Increasing likelihood of sustainability would entail strengthening links with CSO, as well as in all procedures that relate to their involvement. The NAS/MOHE must also find ways to continue to engage LMs, especially those whose external clients provide access to high- risk groups. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry 37. Rating: Moderately satisfactory. The Bank designed a project aligned with the Caribbean and SVG‟s priority of halting and controlling the spread of HIV/AIDS in a comprehensive manner. This was clearly defined in the PDOs. The design also considered the environmental impact of the Project and incorporated a waste management system. The Bank utilized a multi-sector design common to other Caribbean and African multi-sector MAP projects at the time. Furthermore, the Bank utilized resources already available in the country to support the Project, namely, incorporating the existing PCU into this program. The Bank also ensured that stakeholders including some LMs and CSOs were involved in the process of developing and launching the Project. 38. When the Project started in 2005, the multi-sector approach aligned the Project to the country‟s strategy as well as how other Bank HIV/AIDS Projects were designed. It involved numerous stakeholders and brought to bear everyone‟s contribution in implementing a comprehensive program. While the idea behind the design remains intact, the experience from project implementation now indicates that a more focused approach, wherein only LMs that 15 reach the key high risk groups could be involved for example, might have been more efficient. The whole Program, while still multisectoral in nature, would have centered on stakeholders who had high organizational interests in pursuing HIV/AIDS-related activities. This modified approach would have put more weight on the participation of the health sector and MOHE, as well as focusing on a few other key LMs, such as the MOE and the Ministry of Tourism. In 2005, other existing multisector HIV/AIDS projects in the Caribbean could have better informed the SVG project design. 39. The Project could have benefitted from a more streamlined M&E design typical of other Bank lending projects, rather than incorporating a list of 22 PDO indicators to monitor. Including more indicators than needed inevitably requires more resources to properly track them. Also, a few indicators have no baseline value or no target. (b) Quality of Supervision 40. Rating: Moderately satisfactory. The Project‟s Task Team Leader changed three times over the life of the Project. However, each one of the Team Leaders had years of experience managing Bank-funded development projects. Also, there was no indication that these transitions had any negative effect on the supervision of the Project. Throughout the Project, the Bank team frequently followed up on project activities and a team of Bank specialists carried out regular implementation support missions. A review of the Bank‟s supervision budget (Annex 4) indicates that the Bank team remained engaged in the Project, allocating 123 staff weeks and US$580,339 to supervise project implementation that amounted to US$89,300 per year. 41. As evident from the ISRs, the team was candid in highlighting potential obstacles and offering solutions on how they could be resolved. In addition to the workshops and Policy Forum mentioned earlier, the Bank team remained proactive throughout the life of the Project to ensure implementation progressed. Prior to June 2009, when the first restructuring was approved, the Bank team had proposed a number of key actions during and beyond the MTR that, while not requiring a formal restructuring, resulted in positive changes in the Project.8 The Bank team was also pro-active in following up on the MTR actions. As a result, combined disbursements and commitments doubled from 23% to 46% between the Project MTR in June 2007 and December 2007. During this period, several activities advanced, especially those that were non-technical in nature, as well as smaller works. Moving the main civil works activities, which comprised approximately 30% of project funds, remained a challenge. 42. The Bank team in collaboration with the Government counterparts also followed up on the recommendations of the 2005 Caribbean MAP review. In particular, the National Strategy 8 Proposed action steps included (i) formally appointing the NAC subcommittee to review CSO proposals in order to make the review and approval processes more efficient; (ii) recruiting the CSO field officer to support the CSO/LM Coordinator; (iii) providing CSOs and LMs training on procurement and proposal writing and work plan preparation to enhance their understanding of the Bank‟s project requirements and procedures; and (iv) periodically convening LMs and CSOs to network and share experiences. 16 was reviewed to ensure a balance between prevention and support; Bank funds were reallocated to take into account GF support; supervision ensured clarification of roles and responsibilities, procedures and processes; and the Bank‟s Global Monitoring and Evaluation Team provided assistance in developing a simplified and workable M&E data collection and reporting process. While joint donor missions were not conducted, efforts were made to coordinate with The Joint United Nations Programme on HIV and AIDS (UNAIDS) and the GF in supporting the NSP. The AIDS Strategy and Action Plan team housed within Global HIV/AIDS Program also provided critical support by reviewing and helping draft the country‟s 2010-2014 NSP, which was completed and approved by the Cabinet. 43. The Bank team tried to move the follow-up BSS forward with prompt Terms of Reference reviews and regularly following-up on the process, including expediting its approval of a contract award and proposal even before the Central Tenders Board provided its approval as normally required. Unfortunately, the BSS could not be undertaken before the Project closed because of in-country procedures and events (e.g., elections and Hurricane Tomas), which delayed the Central Tender Board‟s review and approval of the proposed contract award. In the end, the Board rejected the proposal to award the BSS contract even though the Bank team felt that the organization was well qualified to do the BSS. By this time, there was no time left in the project implementation period to restart the whole firm selection process. Although the first restructuring focused on pressing implementation issues and resulted in reallocation of funds based on the country‟s priorities and situation, it did not change the RF. SVG continued to report adequately on many of the indicators from the original RF in the PAD and the revised RF used in the ISR. However, the Bank team missed an opportunity to formally revise the RF that would have simplified and streamlined Project‟s monitoring and evaluation, formally aligned the RF with the ISR matrix, and eliminated indicators that could not be measured. Thus, although a Satisfactory rating was initially contemplated for Bank Supervision, the M&E shortcoming resulted in downgrading the rating to Moderately Satisfactory (c) Justification of Rating for Overall Bank Performance 44. Rating: Moderately Satisfactory. The overall rating is based on the following sub- ratings: (i) Bank Performance in Ensuring Quality at Entry: Moderately Satisfactory; and (ii) Quality of Supervision: Moderately Satisfactory. 5.2 Borrower Performance (a) Government Performance 45. Rating: Moderately Satisfactory. The Government is to be commended for establishing a true national program in the face of a resource constrained environment. The success achieved in SVG would not have been possible without the continued commitment of the Government and its agencies to reduce HIV/AIDS and mitigate the impact among its population. In the end, SVG saw a reduction in the number of new HIV/AIDS cases, decreased CFR, enhanced institutional capacity, and the development of its comprehensive HMIS that is among the first in the region. 17 Moving forward, SVG also took several steps to ensure sustainability by absorbing NAS operations into the MOHE, hiring key project staff after the Project closed, and approving the costed NSP 2010-2014. 46. While the Government was committed to controlling the impact of HIV/AIDS, participation of the NAC seemed to have been uneven during the life of the Project, for example, it strongly supported the preparation and review of the NSP 2010-2014 but it seemed relatively slow in handling certain implementation issues. It did not meet regularly, resulting in delays in responding to CSO proposals. The Government could have also addressed the lack of capacity at the beginning of Project implementation among the various implementing agencies, including the LMs and CSOs. The Government could have also provided the necessary Project orientation, as well as proposal and work plan for preparation and training up-front. These steps could have created a smoother transition and improved internal working relationships between the NAS and PCU; it could have also modified the Operational Manual to reduce implementation delays that took place as a result of lack of understanding of certain procedures and roles and responsibilities. (b) Implementing Agency or Agencies Performance 47. Rating: Moderately Satisfactory. The MOHE accomplished much in the six and a half years of the Project, from increasing VCT, dramatically reducing AIDS mortality rate, harmonizing the list of indicators, producing and disseminating reports, finalizing the IEC strategy and increasing health facilities staffed with trained counselors. In addition to increased technical capacity, the newly established M&E System will have a lasting impact beyond the life of the Project. The commitment from the MOHE Permanent Secretary in advancing these activities remained consistent throughout the Project. The MOHE also completed an MSM study, one of very few coming out of the Caribbean region given the strong stigma and discrimination that pervades the region; the study will help SVG develop prevention, treatment, and mitigation strategies for one of its highest HIV/AIDS risk groups. As for non-health LM‟s, engagement was difficult throughout the Project, mainly due to: (i) the small size of ministries with a limited number of civil servants (some as few as 12 to 15 staff); and (ii) a belief that HIV/AIDS is a health problem and therefore should be handled by the MOHE which has a large staff. Exceptions were the MOE; Ministry of Tourism, Youth, and Sports; and Ministry of Labor which had a better understanding of the multi-sector character of the epidemic. Despite this, participation improved over the course of the project implementation, with 9 non-health LMs actively engaged in raising awareness and sensitizing their internal and external clients to the potential development and health risks posed by a spread of the HIV epidemic. The CSO component also faced challenges at Project start-up, though for different reasons. First, the number of CSOs in a small country is few and many are FBOs. Second, there was a bottleneck in getting proposals approved. Third, CSOs are often used to reach out to MARPs in larger countries; however the religious orientation of many CSOs in SVG and the punitive laws on homosexuality and commercial sex work are serious impediments to approaching or working with high risk groups. With enhanced support from the NAS and the PCU throughout the Project, the CSO component and participation progressively improved. The concern now is to what extent CSOs can remain actively engaged once they experience 18 decreased financial and technical support after the Project closure and, given fiscal constraints, whether the Government can find creative and innovative ways to keep CSOs engaged. (c) Justification of Rating for Overall Borrower Performance 48. Rating: Moderately Satisfactory. The overall rating is based on the following sub- ratings: (i) Government Performance: Moderately Satisfactory and (ii) Implementing Agencies: Moderately Satisfactory. 6. Lessons Learned 49. Selective Targeting of Implementing Agencies. The Project design clearly identified implementing agencies and assigned specific tasks to each one, resulting in a clear implementation plan. Such a design had been shown to work well in other similar projects, namely in Saint Lucia and Guyana. SVG‟s experience, however, also illustrated varying levels of interest from various stakeholders throughout the Project. In moving forward, as it builds its capacity to coordinate multiple stakeholders with varying levels of interest and institutional capacity, the Government is advised to focus on choosing a few select partners that can reach the greatest number of key targets and MARPs. 50. Selecting Key, Measurable Indicators. The country would also benefit from a more focused and shorter list of indicators that need to be tracked. While SVG has been generally able to report on key indicators, other countries with weak M&E capacity and culture often have difficulties in collecting large sets of data, which may in fact hinder progress. Projects need to also pay more attention upstream to the need for completing follow-up surveys and formally revising indicators when needed. It may be worthwhile to establish a team of experts whose main function is to oversee M&E progress. Given that M&E has traditionally been weak in the region, such a group could help provide a focused approach to improve M&E and use data to drive programming needs. For groups of countries that lack in-country M&E expertise, this may require having a regional team of experts. 51. Supporting Broader Health Systems Strengthening. SVG‟s HMIS, financed through this Project, has a broader impact beyond HIV/AIDS. Aside from supporting the development and rollout of the HIV/AIDS/STI CMIS as part of the HMIS, the Project also provided inputs to program implementation monitoring and epidemiological surveillance. This demonstrates that disease-specific projects can and should support broader health sector activities such as the development and implementation of a HMIS which also contributes to overall health system strengthening, evidence-based policy, and decision-making. 52. Transitioning Staff for Sustainability. Within the Government infrastructure, the ability to retain technical staff after Project closure is a necessary requirement to guarantee operational sustainability, as well as to solidify the gains achieved under the Project. Because of the timely preparation and eventual approval of the NSP 2010-2014, and the proactive approach adopted by the MOHE in requesting key personnel to be financed by the Government budget, the Project 19 was able to begin transitioning staff into the Government well before the Project closed [see Annex 2 for detailed discussion of Lessons Learned]. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies. The Borrower‟s ICR with Project feedback is in Annex 7. (b) Cofinanciers. N/A (c) Other partners and stakeholders. N/A 20 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions) Scaling-up HIV/AIDS Response by 0.980 0.325 33% Civil Society Organizations Scaling-up HIV/AIDS Response by 1.600 0.506 32% Line Ministries Strengthening the Health Sector 3.480 5.434 156% Response to HIV/AIDS Strengthening Institutional Capacity for Program Management and 2.550 2.378 93% Monitoring & Evaluation Total Baseline Cost 8.610 8.643 100% Physical Contingencies 0.000 0.00 0.00 Price Contingencies 0.105 0.00 0.00 Total Project Costs 8.715 8.643 99% Front-end fee PPF 0.00 0.00 0.00 Front-end fee IBRD 0.035 0.018 51% Total Financing Required 8.750 8.661 99% (b) Financing Appraisal Actual/Latest Type of Percentage of Source of Funds Estimate Estimate Cofinancing Appraisal (USD millions) (USD millions) Borrower 1.75 1.87 107% International Bank for Reconstruction 3.50 2.69 77% and Development International Development Association 1.75 1.95 111% (IDA) IDA GRANT FOR HIV/AIDS 1.75 1.87 107% 21 Annex 2. Outputs by Component COMPONENT 1: Scaling-up HIV/AIDS Response by CSOs (input provided by NAS) 1. A total of fourteen CSOs received funding throughout the life of the project to implement HIV/AIDS care and support activities. The total re-allocation to the CSO component was US$ 603,750.00. 2. The fourteen CSOs that received funding were BoL, Lauders Sports and Cultural Club, Diamonites, VINSAVE, House of Hope, Marion House, St. Vincent Employers‟ Federation, Indigenous Awareness Movement, St. Vincent Planned Parenthood Association, St. Vincent Red Cross Society, St. George‟s Cathedral/ St. Mary‟s Health Guild, Casper/Maria Marshall Centre, St. Vincent and the Grenadines Cadet Force and the St. Vincent and the Grenadines Seventh-Day Adventist Churches. 3. The CSOs have conducted sensitization, education, and awareness activities, primarily targeting youth. The BoL Orphanage was supported by the project to construct a new orphanage in Georgetown. This construction was one of the main activities that resulted in the extension of the project‟s closing date by 18 months. Two CSOs received vehicles under the project. 4. Some of the activities undertaken by the CSOs included: development of „How to training manual‟ for all pre-school centers; development and airing of radio drama and jingles on HIV/AIDS; development of coloring books for pre-schools; HIV/AIDS awareness activities such as camps & workshops targeting the youth; activities addressing stigma and discrimination including rallies; and several workshops and training programmes targeting the church. All of these activities contributed to the overall development objective of the project and the outcome of creating a supportive environment with accepting and non discriminatory attitudes toward PLWHA, their families and orphans, as well as, reducing the prevalence of HIV in the general population. 5. The Programme underestimated the capacity of the CSOs to deliver the services required under this component. A number of smaller community-based organizations did not have the required staff to run their organizations and to apply the procurement processes required by the project. The procurement and financial management capacity of CSOs were strengthened through training conducted by the PCU. In terms of future projects, CSOs should be objectively identified during project design, whereby their capacity can be assessed and weaknesses identified and addressed before project implementation commences. This will also result in early commitment to the overall objective of the project and responsibilities of CSOs. 22 COMPONENT 2: Scaling-up the Response by LMs (input provided by NAS) 6. A total of nine LMs had assigned focal points and received funding throughout the life of the project to implement HIV/AIDS prevention, control, and support activities. The total re- allocation to the LMs was US$666,762.00. 7. The LMs included Education; Tourism; National Security; Finance and Economic Planning; Urban Development, Culture, Labor & Electoral Matters; and National Mobilization. LMs have contributed to the achievement of the project‟s objectives by reaching individuals in their sectors. The project was able to draw on the managerial experience and institutional positioning of key line ministries to achieve its outcomes. Highlights from the LMs work include:  the introduction of HIV workplace policies in five enterprises  education and sensitization activities through key tourism and national events such as a calypso competition & carnival mas bands  training and workshops targeting hospitality workers, construction workers based at resorts, and security personnel  training of school counselors, teachers and peer educators at secondary schools  training of adult learners on the basic facts of HIV and AIDS  provision of financial support for PLHWHA, orphans and vulnerable children COMPONENT 3: Strengthening the Health Sector Response to HIV/AIDS (input provided by NAS) 8. Most activities earmarked under this component of the project were successfully implemented. The inputs and outputs have led to a number of commendable outcomes including the improved quality of life of PLWHA, no longer is a diagnosis of HIV synonymous with death as persons are able to access treatment and care for HIV and opportunistic infections. Although, there is no scientific data, anecdotal data suggest that the attitude towards PLWHA is more accepting and non discriminatory. This was demonstrated during recent community outreach activities geared towards addressing stigma and discrimination, as well as the increasing number of persons being tested for HIV and accessing care and treatment. Some of the achievements by specific areas: Information, Education and Communication/Behavior Change Communication (IEC/BCC)  Recruited an IEC/BCC Communication Specialist  Developed and disseminated IEC/BCC materials  Installed two electronic billboards to further strengthen and sustain the HIV/AIDS awareness campaign  Developed a draft BCC strategy  Convened primary schools public speaking competitions on HIV/AIDS themes  Produced and aired media programmes using television, radio and newspapers to disseminate messages 23  Acquired promotion items imprinted with HIV/AIDS messages  Participated in a Health and Wellness Week with messages on HIV/AIDS, the correct use of condoms  Convened discussion to address public and private workplace issues.  Organized a number of activities for World AIDS Day  Launched several awareness campaigns to reduce stigma and discrimination, to inform, educate and communicate behavioral change messages 9. The strategies have ranged from the use of cultural activities, peer to peer interventions, various print and electronic media materials and mass media campaigns. Alliances and several collaborative efforts have been strengthened with the non-governmental organizations including FBOs, and government organizations. During the collaboration with these organizations, the technical capacity of the agencies was improved to deliver more effective behavior change interventions. 10. Provision and distribution of condoms The Project was able to exceed the target of distributing 2 million condoms over the life of the project. Partners that were involved in the distribution of condoms included St. Vincent Planned Parenthood Association, PSI and the Caribbean HIV and AIDS Alliance (CHAA). PSI provided condom social marketing to promote the increased establishment of non-traditional condom outlets with the 'Got it? Get it.' Campaign, while CHAA distributed condoms and other commodities to most-at-risk groups including men who have sex with men. Nineteen condom dispensing machines were installed island-wide, at bars targeting most at risk population groups. Condoms are priced at one Eastern Caribbean dollar for a pack of three. 11. Ensuring safety of blood supplies The national laboratory continued 100% testing of all donated blood according to World Health Organization (WHO) guidelines. 12. Voluntary Counseling and Testing (VCT) As a result of the Project, the VCT programme was expanded to offer VCT services in all 39 health centers in SVG. Eighteen health centers were refurbished and equipped to provide HIV rapid testing. HIV rapid testing is also offered during outreach activities (wellness week, national day of testing, prisons, community intervention). Audiovisual equipment were purchased and distributed to health centers to support continuous education and VCT programmes. 13. The number of people tested since the implementation of the programme is 8927; exceeding the target of 2,000 people to be tested by the end of the project. The increase in the number of people tested is due to increased accessibility to the service. Treatment care and support of PLWHA The project supported the following services  Treatment of opportunistic infections  Provision of second line anti-retroviral drugs 24  Support of nutritional interventions for PLWHA  Procurement, storage and distribution of pharmaceuticals, equipment and supplies required for effective management of HIV/AIDS  Strengthening of the laboratory capacity to assist in the diagnosis, treatment and care of PLWHA through training of staff, purchasing of equipment, rapid test kits and laboratory reagents as well as recruitment of a laboratory technologist and an inventory clerk to support the laboratory service  Training of health care workers on the HIV treatment protocols for management of HIV/AIDS and sensitization to reduce stigma and discrimination of HIV/AIDS patients; and, care and support initiatives including home-based care and nutritional support 14. At the end of March 2011, there were 313 patients in active follow-up at the lone clinic currently in the public sector. There were 204 patients on antiretroviral treatment (including 3 children) both in the public and private sectors. 15. Over the life of the Project, PLWHA received social support in collaboration with the Department of Family Affairs of the Ministry of National Mobilization, Social Development etc.; and Orphans and Vulnerable Children (OVC) received psycho-social support. 16. Central Medical Stores procured pharmaceuticals for the programme; including condoms and drugs. The Health Information System will improve the management of pharmaceutical supplies through computerizing the inventory control at the Central Medical Stores. 17. Prevention of mother to child transmission All pregnant women were counseled and screened for their HIV status, thereby achieving the target of 100%. HIV positive pregnant women were offered antiretroviral drugs to prevent transmission of the virus to their babies. Mothers were counseled about feeding options and provided with infant formula. The dry blood spot test to diagnose infants was introduced in 2008 with the assistance of the Clinton HIV/AIDS Initiative and samples were sent to South Africa for testing. Testing is now being done by Lady Meade Reference Clinic Laboratory in Barbados. 18. Nutrition Activities The Nutrition Unit of the MOHWE provided individual nutrition assessments and care for PLWHA who were referred from the infectious clinic of the Milton Cato Memorial Hospital or from VCT centers; trained health workers and community workers. These interventions promoted proper nutrition in persons living with and affected by HIV/AIDS; measured and monitored the eating habits and nutritional status of children and adults living with or affected by HIV/AIDS; and built the institutional capacity in nutrition care and service to PLWHA. This Unit purchased anthropometric equipment, updated records and conducted workshops. 19. Policy Formulation With the assistance of the PANCAP, a law, ethics and human rights national assessment was undertaken in the country and two reports were prepared. The first report was a desk review of the laws and policies as they pertain to HIV/AIDS human rights issues. The second report was 25 prepared following community consultations addressing the findings of the legal consultant. PANCAP developed model policy and legislation. The national policy development process has started and is ongoing. A consultant has been recruited to develop the workplace policy. 20. Biomedical Waste Management The primary contribution of the project in biomedical waste management was training for comprehensive biomedical waste disposal at the hospital and the health centers. Biomedical waste is prepared at the hospital and health centre sites, following strict procedures and then transported to a landfill site. Biomedical waste handling supplies were also purchased for the hospital. COMPONENT 4: Strengthening Institutional capacity for Program Management and Monitoring & Evaluation (input provided by NAS) 21. Institutional capacity for coordinating and managing the HIV/AIDS Project The project supported the newly-established NAC and its operating arm, the NAS which was an expansion of the HIV/AIDS Prevention and Control Programme in the MOHWE. It also provided support to the CCM responsible for evaluating the CSO proposals. The NAC was established in February 2004 and co-chaired by the Prime Minister and the Minister of Health and the Environment. Officers from the PCU and the MOHE benefited from training workshops financed by the World Bank on HIV/AIDS programme implementation and fiduciary matters. A notable training exercise was the attendance of eight officers at the International AIDS Conference in Mexico, 2008. Attendees included four focal points representing the Non-Health LMs, one PLWHA and staff of the NAS. 22. Specialized skills were added to the NAS to coordinate and oversee project implementation. An already existing PCU for externally financed projects located in the Ministry of Finance and Economic Planning supported the financial management and procurement activities of the project. A building to house the NAS was refurbished and equipped. 23. Strengthening programme monitoring and evaluation (M&E) The Project supported: (a) programme implementation monitoring; (b) epidemiological surveillance; and (c) HIV/AIDS/STI Clinical Management Information System as part of the Health Management Information System (HMIS) for the main public hospital and for health centers. The HMIS generates information for decision making at the point of service through online electronic medical records, pharmaceutical supply chain management and other modules. Project support included technical assistance, training, acquisition of hardware and software, and equipment and supplies to enable the production and analysis of valid and reliable data. 24. During the life of the project, the HIV/AIDS M&E functions were carried out by an Advisor, who collected and aggregated data, generated reports, gave feed back to stakeholders and contributed to the further development of M&E capacity of various stakeholders. The data collection and analysis were based on process, outcome and impact indicators developed to track and evaluate the national HIV/AIDS response. An M&E Plan was drafted in accordance with the National Strategic plan with technical assistance provided by the Global Monitoring and 26 Evaluation Team. A Monitoring and Evaluation Reference Group was formed which provided a forum for stakeholder discussion of project implementation based on indicators. 25. Under the World Bank project, materials required for output reporting were printed. These included revised forms. The 2005 and 2008 United Nations General Assembly Special Session reports, annual reports for 2006, 2007 and 2008 were published for distribution to stakeholders. Other reports were generated, including reports for donor agencies and quarterly bulletins. In an effort to sustain the progress made with the monitoring and evaluation system, the functions have been integrated into the Health Information Unit. EVIDENCE IN SUPPORT OF THE ACHIEVEMENT OF THE PDO. The scaling up of programs for the prevention of HIV/AIDS, targeting in particular both HIV/AIDS high-risk groups and the general population. 26. The number of new HIV positive cases declined by 41% from a baseline of 108 cases in 2004 to 64 in 2010 (Figure 2), thus exceeding the Project‟s target of reducing the baseline value to less than 100 cases. Concomitantly, the number of new AIDS cases declined by 38% from 40 cases to 25 during the same time period, exceeding the 15% reduction target. A key element of SVG‟s program involved the promotion of prevention messages. To this end, the program focused on early intervention and education by successfully advancing life skills and HIV and STI prevention instructions to 100% of primary (ages 5-9 years) and secondary (ages 10-19 years) level public schools, exceeding the target by 100% (target=50%, actual=100%). Among the older population, the BSS in 2005 provided evidence of the general population‟s high awareness level of relevant HIV/AIDS-related knowledge and practices 9 at the outset of the Project. Joint efforts by the National Program and CSOs to deliver prevention messages may have contributed to sustained and improved knowledge. The declining numbers of bacterial STIs between 2007 and 2010 lend further support to changes in behavior and practices (Figure 3). Gonorrhea decreased by 53%, syphilis by 24%, and chlamydia by 84%. Because STIs share the same transmission pattern as HIV, STIs can be prevented using the same safe behavioral practices to prevent the spread of HIV. Since bacterial STIs are curable, they provide a more recent indication of sexual risk behaviors. Moreover, the number of newly reported cases of HIV began to decline in 2007, despite an increasing number of individuals tested annually for HIV that surpassed the Project‟s target (target=8,927, actual=2,000). Testing was most successful among pregnant women, among whom 99% were screened for HIV status (target=98%-100%, actual=99%). All babies born from HIV positive mothers were provided testing and treatment. 9 BSS (2005) revealed that 83% of people could correctly identify two ways of preventing HIV infections, while 49% of men and women used condoms at last sexual encounter with non-regular partners. 27 Figure 3. Burden of STI, 2007-2010 2007 2008 2009 2010 200 Number of cases 150 100 50 0 Gonorrhoea Syphilis Chlamydia Sexually Transmitted Infection Source: MOHE, 2011 27. Several project activity outputs likely contributed to the observed decline. For example, the Project was successful in its condom distribution activities, which resulted in surpassing the targeted number of dispensed condoms (target=2,000,000, actual=2,017,335). The majority of the condoms distributed were funded through the National HIV/AIDS Program (88%), although a substantial amount of condoms were from another source (12%, Caribbean HIV/AIDS Alliance). While the 2005 BSS revealed that 60% among those aged 15-24 years and 65% among those aged 25-49 years used condoms during the last sexual encounter with a non-regular partner, more recent surveys among high risk groups (youth and MSM) may reflect an overall uptick in condom utilization:  Among sexually active males aged 16-21 years, 99% used condoms within the last month, while a subset of 67% of these males consistently used condoms (PSI, 2007).  Among the general population aged 14-17 years, 85% used condoms (UNICEF, 2008).  Among MSM population, 80% used condoms (MOHE-SVG, 2010). 28. Comparable end-of-project data on six behavioral indicators designed to verify progress in the scale-up of prevention programs (see datasheet) were not available. These indicators included baseline data collected during the 2004 BSS; however, a second BSS that was envisaged to provide follow-up data was not completed. Of these six, comparable end-of-project data showing an increase in the percentage of men and women using condoms at last sexual encounter was the most important as it would have provided strong evidence for explaining the decline seen in the number of reported HIV cases, as well as corroborated the increased demand and distribution of condoms. Although not meant as a follow-up to the 2004 BSS data, a 2008 KAP Survey by UNICEF found that among the younger population 14-17 years of age, 85% used condoms, representing an increase from the 2005 BSS wherein 60% stated they used condoms. The other five behavioral indicators were less directly correlated to the observed decline in cases. 28 The scaling up of programs for the treatment and care of PLWHA. 29. The Project scaled-up treatment and care successfully, which helped prolong and improve the quality of life of PLWHA. As demonstrated in the PDO indicators below, the AIDS mortality rate dropped significantly during the life of the Project (Figure 4), while the number of advanced HIV cases on ARV surpassed the project target. (Figure 5). Figure 4. AIDS Mortality Rate among AIDS Patients, 1984-2010 100% 90% 100% 99% 98% 97% 93% 80% 88% 70% 80% Percentage 60% 69% 50% 40% 30% 38% 20% 10% 0% 1984-1986 1987-1989 1990-1992 1993-1995 1996-1998 1999-2001 2002-2004 2005-2007 2008-2010 Year Source: NAS, 2011 Figure 5. Number and percentage of all eligible persons with advanced HIV infection receiving ARV, 2003-2010 Number receiving ART Percentage of all eligible cases on ART 100% 200 90% 88% 86% 89% 80% Number on ARV 85% 84% 150 70% Percentage 60% 50% 100 40% 30% 50 20% 10% 0 0% 2003 2004 2005 2006 2007 2008 2009 2010 Year Source: NAS, 2011 30. As a result of the enhanced National Response to HIV/AIDS supported through the Project and the availability of ART in 2003, SVG also succeeded in providing access to treatment and care. Figure 6 depicts the continued and increased demand for such services. Over the life of the Project, 474 cases received care, among whom 146 dropped out due to a death, transfer, or loss to follow-up. While the Project contributed to activities that helped bring the CFR down to 13% at the end of the Project, the challenge for SVG moving forward will be to 29 continue enhancing quality of treatment and reducing patient loss to follow-up. Moreover, in combination with CFR data, it may have been more informative to keep track of the percentage of living PLWHA under treatment and care. Figure 6. Cumulative Number of PLWHA Enrolled in Treatment and Care, 2003-2010 Actively Enrolled Dropouts Total Enrolled 474 500 450 397 400 343 146 Number of clients 350 284 101 300 85 224 250 65 182 200 44 122 27 328 150 7 296 258 100 219 56 2 155 180 50 115 54 0 2003 2004 2005 2006 2007 2008 2009 2010 Year Source: NAS, 2011 31. Other output measures of progress in the provision of treatment and care included delivering psychosocial support to 127 orphans and vulnerable children (target=100, actual=127) and providing treatment and care to 82% (14/17) of HIV+ pregnant women (target=100%, actual=82%). The three missing pregnant women included one case who had a premature birth and never received ARV since treatment is provided in the last trimester; and two cases who never went to an antenatal clinic prior to giving birth. Despite not reaching 100% of HIV+ pregnant women in 2010, the Project has had success in previous years during the Project (100% in 2007 and 95% in 2008). Given the small number of HIV+ pregnant women and because of the very few that will be invariably missed due to similar reasons stated above, missing one or two cases drastically reduces the percentage rate and potential success in reaching the Program‟s target. It is important to look at this finding in light of the success the Program has had in offering testing to all infants born to HIV+ mothers and maintaining a transmission rate to infants of 0%. 32. One PDO indicator – percentage of children under 15 years of age that have lost either or both parents – could not be properly assessed because baseline and target values were not assigned. However, available data indicate that the number of children falling under this category increased from 3 in 2007 to 7 in 2009. 30 Reduction of the degree of stigma and discrimination with HIV/AIDS. 33. Stigma and discrimination remain a challenge in SVG, as in other countries in the region. The PAD included two PDO indicators useful for tracking progress in these areas, both of which could not be directly verified with available data. The first relates to the percentage of people surveyed expressing an accepting attitude toward people with HIV (target=10% in the general population, actual=63% among younger population). The baseline reference point was 5% among those aged 15-49 years at the start of the Project.10 Given that no follow-up BSS was conducted at the end of the Project, a direct comparison was not possible. Other studies that were completed during the life of the Project, however, surveyed a subset of the population and provided an indication of how perceptions and attitudes have changed since 2005. A 2008 KAP survey of the general population aged 14-17 years conducted by UNICEF found that 63% of respondents had an accepting attitude towards HIV, measured by those who said that HIV+ students should be allowed to attend school while HIV+ teachers should be allowed to continue teaching. Clearly, efforts to implement HIV lessons in public schools, as well as the scaled-up IEC campaigns, have had an impact in reducing stigma and discrimination among the young. Indications to support such progress among the older population could not be discerned as data were not available. 34. The other PDO indicator presented in the PAD to monitor stigma and discrimination focused on the percentage of companies with non-discriminatory policies and practices in recruitment and benefits for employees infected with HIV. The plan to conduct workplace surveys at the beginning, middle, and end of the Project as a means of verification never came to fruition. Moreover, baseline and target values were never established. Thus, evaluating this indicator to assess its contribution to changing attitudes and perceptions about HIV/AIDS could not be performed; no data could be found that could serve as a proxy for measuring such change. It must be noted however that the Employer‟s Federation had worked with 40 interested organizations to establish workplace policies. Also, the program supported workshops focused on reducing stigma and discrimination, and were well attended. Strengthening institutional capacity of the MOHE, other related Government agencies, and CSOs to ensure the effectiveness and the sustainability of the Project. 35. The PDO indicators included in the original RF of the PAD highlighted several conditions that must be met to attest to SVG‟s national commitment to the HIV/AIDS response. The Project succeeded in achieving almost all of its PDO indicators under this objective, with one considered almost achieved and another still in progress. Of these, the Project achieved its target of completing the following: an updated guideline on standards of care; treatment protocols; referral and follow-up systems; and training programs for providers, PLWHA and their families. Project outputs that were fully realized, while at the same time ensuring that the national commitment raised by the recent achievements mentioned above will be sustained, 10 The BSS (2005) found that 4% among those aged 15-24 years and 6% among those aged 25-49 years (or 5% overall) had expressed an accepting attitude toward people with HIV. 31 included the number of public facilities staffed by trained counselors (target=39, actual=39); number of LMs that have implementable work plans (target=9, actual=10); and number of rehabilitated health facilities (target=21, actual=23). 36. SVG is in progress of establishing legal and policy measures that guard human rights of all PLWHA and their significant others. Currently, SVG is in the process of developing its national policy and a more focused workplace policy; the national policy will be based on PANCAP‟s recently developed model policy and legislation. SVG also collaborated with PANCAP on a newly published review of laws and policies in SVG as they relate to HIV/AIDS human rights issues; a report on community consultations addressing the findings from the first report has been prepared but not yet published. 37. Two intermediate outcome indicators that would have signaled increased institutional capacity but were not achieved were related to the number of health facilities with the capacity to deliver palliative care, treatment, and referral services (target=3; actual=1) and to the number of health facilities providing Highly Active Antiretroviral Therapy (target=3; actual=1). Despite this, the Program‟s commitment never missed a step as evident from the increased number of ARV patients. Ensuring that all the treatment and referral guidelines were in place and the counselors in clinics throughout the country were adequately trained helped alleviate any negative impacts from not providing services from all three facilities. Budget constraints within the country resulting from the financial economic crisis prevented the Government from fully pushing forward its plan for all three centers. Currently, Milton Cato Memorial Hospital, the SVG‟s main hospital is providing comprehensive services, while the Stubbs Polyclinic has recently been renovated and is expected to provide similar comprehensive services to HIV/AIDS patients. LESSONS LEARNED 38. Selective Targeting of Implementing Agencies. Project design should clearly identify the different implementing agencies. The components corresponded to the four implementing agencies reflecting the comprehensive approach by the country. This model makes it easier for implementers and coordinating bodies alike to plan and budget around specific activities. Clear boundaries and an agreement of who is responsible for which activities with what resources need to be set at the design stage. This design was a strength of this Project and has been shown to work well in other similar projects as well, namely in Saint Lucia and Guyana. The experience from SVG, however, illustrated varying interest from various stakeholders throughout the Project, as well as declining assistance provided to CSOs and LMs once the Project ended due to fiscal constraints. Implementation challenges included bottlenecks in the proposal and approval process, conflict of interest between the development agenda and mandate of the organization, and the broader issue of integration into the health sector and its sustainability. Part of the problem may have also been the wide array of stakeholders that participated in the program and the country‟s capacity to coordinate multiple stakeholders. In moving forward, the Government is advised to focus on choosing few select partners who can reach the widest number among the key targets and MARPs. This approach not only helps simplify and decrease the number of interactions the Government needs to deal with, but also gets partners involved who are vested 32 and have institutional interests to seeing development agenda through. A united bond between collaborators makes it easier to build a sustainable environment. 39. Selecting Key, Measurable Indicators. Projects would benefit from a more focused and shorter list of indicators that they need to track. While SVG did well in gathering the required data, it should be noted that small countries with weak M&E capacity and culture may have difficulties in collecting large sets of data and may in fact hinder progress. Projects need to also pay more attention upstream to the need for completing follow-up surveys and formally revise indicators when needed. It may be worthwhile to establish a team of experts whose main function is to oversee M&E progress. Other countries benefitted from such a Task Force as was implemented in Saint Lucia. The strength of this group came from bringing individuals who had a practical understanding of M&E and viewed M&E with different lenses as a result of each member‟s expertise. Given that M&E has traditionally been a weakness in the region, such a group could help provide a focused approach to improve M&E and use data to drive programming needs. For groups of countries that lack in-country M&E expertise, this may require having a regional team of experts. 40. Supporting Broader Health Systems Strengthening. Aside from supporting the development and rollout of the HIV/AIDS/STI CMIS as part of the HMIS, the Project also provided inputs to program implementation monitoring and epidemiological surveillance. As the experience in SVG illustrates, disease-specific projects can and should support broader health sector activities, such as the development and implementation of a HMIS which not only supports HIV/AIDS monitoring, but contributes to the overall strengthening of the country‟s health system. It will provide inputs to program implementation monitoring and epidemiological surveillance and contribute towards evidence-based policy and decision-making in the health sector that goes well beyond this Project. The Bank‟s approach in the Caribbean has been to use HIV/AIDS projects to contribute to health systems strengthening, such as the financing of HMIS in which broader health components could later be built on top of initial HIV modules. 41. Transitioning Staff for Sustainability. The ability to retain technical staff after Project closure is a necessary requirement to guarantee operational sustainability. In SVG, key project staff already trained with the necessary skills to carry on the task of controlling the spread of the HIV/AIDS virus and mitigating its impact have been offered permanent employment with the Government. Such actions solidify the gains achieved under the Project. By focusing on completing the NSP and getting Cabinet approval as in this case, the Government has shown its commitment to continue the HIV/AIDS Program, as well as convey the message that HIV/AIDS prevention, treatment, and care remains a high priority. Because of the timely preparation and eventual approval of the NSP 2010-2014, and the proactive approach adopted by the MOHE in requesting key personnel to be financed by the Government budget, the Project was able to begin transitioning staff into the Government well before the Project closed. 33 Annex 3. Economic and Financial Analysis 1. The Caribbean region, to which SVG belongs, is the second-most HIV/AIDS affected region in the world, after sub-Saharan Africa, and is the most affected in the Americas. Calculations from UNAIDS estimated that the prevalence in SVG was 1% based on reported cases, compared with 1%-2% prevalence in Barbados, Dominical Republic and Jamaica, or 2%- 4% in Bahamas, Haiti, and Trinidad and Tobago (UNAIDS 2006). Therefore, SVG has an opportunity to prevent the epidemic from escalating and posing a significant problem to its socio-economic development as it has in other Caribbean regions. 2. The St. Vincent and the Grenadines HIV/AIDS Prevention & Control Project originally allocated a total of US$8.75 million (including government loans). Disbursement was US$6.51 million over a period of seven years. The first three components, which were focused on CSOs, LMs, and the Health Sector, accounted for over two thirds of total budget and directly targeted HIV/AIDS prevention, treatment, and care delivered through the healthcare system. The economic and financial analysis in this annex aimed to evaluate the cost-effectiveness of the Project‟s HIV/AIDS prevention and treatment activities. 3. As commonly recommended in evaluating project benefits and as widely used in cost- benefit analysis for healthcare investment projects, two scenarios were analyzed to determine the net benefit associated with the Project: (1) a without-project scenario that calculated key HIV indicators if Project had not been implemented, and (2) a with-project scenario that estimated the Project‟s actual impact. As in many areas of project evaluation, assessing the without-project scenario in estimating the magnitude of Project benefits and costs was not easy because it was impossible to measure the number of persons infected with HIV in the absence of the Project. Difficulties also arose from the fact that SVG, like other Caribbean countries, has a small population in which HIV and AIDS remain highly stigmatized, which made HIV incidence data hard to collect; thus, data also rarely existed especially among high-risk population even under the with-project scenario. We relied on reported cases to calculate the annual incidence rate. However, using reported surveillance data may have largely underestimated the HIV prevalence or incidence rate due to insufficient data availability. Similarly, project benefits will be also largely underestimated as a result of underreporting of HIV cases. In fact, the United States Agency for International Development and MEASURE estimated that reported cases may only represent approximately one third of the “true� number. 4. Figure 1 (Number of reported cases of HIV, AIDS, and AIDS-related deaths, Saint Vincent and the Grenadines, 1984-2004, in main text) shows the total number of reported cases of HIV, AIDS and AIDS-related deaths in SVG between 1984 and 2004, the period before the implementation of the HIV/AIDS Prevention & Control Project. Although statistics of the adult population (age 15-49), the age group our analysis primarily focused on, was slightly lower than the numbers shown in the figure, the overall trend was identical. Case reporting suggested that annual HIV cases since 1984 had increased substantially, especially between 2000 and 2004 right before the Project. If this trend had continued without policy interventions, HIV cases in 34 2011 would have been double the reported number of cases in 2000 (projected based on historical 1984 and 2004 data). 5. Figure 2 (Reported cases of HIV, AIDS, and AIDS Deaths, SVG, 2004-2010, in main text) shows the total number of reported cases of HIV, AIDS and AIDS-related deaths in SVG between 2005 and 2010, the period of the HIV/AIDS Prevention & Control Project implementation. HIV cases still show an increasing trend during 2005 and 2007 (but lower than 2004 and before), largely due to the introduction of the new plan and VCT strategies in 2005 that increased numbers being tested as a result of expanded responses and scale up of VCT campaigns and testing access points. The declining trend after 2007 suggests that the Project had effectively contributed to averting HIV infections. 6. The cost-effectiveness calculation in this annex used assumptions and simulation when appropriate. The assumptions used in this annex are described as follows:  HIV cases data for with-project scenario between 2005 and 2010 came from NAS. The 2011 data were linearly projected based on 2005-2010 statistics.  Under without-project scenario, HIV cases data were projected based on historical HIV case reporting from the NAS during 1984-2004. Quadratic year functional forms were used to account for possible nonlinearity of the time trend.  An averted infection provided an individual with thirty-three more years of productive life, which was simply the pension age (60) minus average HIV infectious age 27.  Average working individual productivity was estimated to be $2199 per year, which was assumed to be equivalent to the World Development Indicator of per capita household final consumption in 2004.  An infected patient will live for 10 years after infection with adequate care.  The average annual cost of care per patient after infection with adequate care was assumed to be $1,000.  Benefits accrued five years after the infection had been averted, restricting the disease from progressing and translating into productivity losses and health care costs for the individual. 7. The economic analysis focused on averted infections only, since that was the only data we observed or can project during the study period. The computation of financial benefit of HIV Project was based on life of years saved. It would have been ideal to do separate analysis for treatment effect on productivity, decreased health service utilization and HIV transmission. However, we simply did not have such data available to do a thorough examination. In addition, it was not possible to break down project cost into small pieces that was specifically used for each component. For countries within the Caribbean region, data availability remains the primary challenge in undertaking rigorous economic analyses and thorough research. 8. We restricted this economic and financial analysis to the adult (ages 15-49) group. Table 1 shows the estimated number of newly infected adults in the with-project scenario. Based on the assumption described above, the incidence rate for the adult population would have reached 2.54/1000 in 2011 if the Project had not been implemented, a 50% increase relative to 2005. 35 Table 1. Without-Project Scenario 2005-2011 Population Number newly of age 15- Incidence infected with Year 491 Rate per 1000 HIV 2005 53,724 1.69 91 2006 53,497 1.83 98 2007 53,480 1.96 105 2008 53,567 2.09 112 2009 53,567 2.24 120 2010 53,567 2.39 128 2011 53,567 2.54 136 1 SVG MOHE 9. With-project scenario indicators are listed in Table 2. In the PAD, the goal of reducing incidence of HIV/AIDS or new HIV positive cases was 10% by the end of the Project. In this sense, the Project contributed to significantly reducing the HIV/AIDS incidence rate. In 2005, the incidence rate was 1.69/1000 in the without-project scenario, while this number decreased by more than 50% in 2011 to 0.60/1000. Table 2. With-Project Scenario Population Number newly of age 15- Incidence infected with Year 491 Rate per 1000 HIV 2005 53,724 1.02 55 2006 53,497 1.22 65 2007 53,480 1.42 76 2008 53,567 1.01 54 2009 53,567 0.97 52 2010 53,567 0.78 42 2011 53,567 0.60 32 1 SVG MOHE 10. The averted HIV infections and years of life saved are summarized in Table 3. Infections averted attributable to the Project was the difference between newly infected cases under the without-project scenario and the with-project scenario. Years of life saved was number of infections averted multiplied by increased productive life caused by the Project, which was assumed to be 33 years. From these averted infections, the project benefits can be calculated for the cost benefit analysis. The total benefit of the Project included the averted productivity loss by remaining in the labor force and the medical savings on in-patient care and treatment of opportunistic illnesses. 36 Table 3. Project Cost and Benefits Infections Years of life Productivity Averted cost Year averted saved Year losses averted of care Total benefits 2005 36 1,188 2010 2,612,412 360,000 2,972,412 2006 33 1,089 2011 2,394,711 330,000 2,724,711 2007 29 957 2012 2,104,443 290,000 2,394,443 2008 58 1,914 2013 4,208,886 580,000 4,788,886 2009 68 2,244 2014 4,934,556 680,000 5,614,556 2010 86 2,838 2,015 6,240,762 860,000 7,100,762 2011 104 3,432 2016 7,546,968 1,040,000 8,586,968 Total 414 13,662 24,127,092 4,384,260 28,511,352 11. The Project annual cost data was obtained from the Project monthly disbursement record. Although we focused the analysis on the Project‟s prevention and treatment components, the total Project disbursement was used in calculating cost-effectiveness indicators due to the fact that it was difficult to disaggregate Project costs and expenditures. This would have overestimated the prevention and treatment costs and, therefore, underestimated the Project IRR and NPV. Table 4. Project Stream of Cost and Benefit Year Costs2 Benefits Net Benefits 2005 317,500 0 (317,500) 2006 278,225 0 (278,225) 2007 1,168,621 0 (1,168,621) 2008 634,081 0 (634,081) 2009 1,080,667 0 (1,080,667) 2010 1,429,265 2,972,412 1,543,147 2011 1,602,144 2,724,711 1,122,567 2012 0 2,394,443 2,394,443 2013 0 4,788,886 4,788,886 2014 0 5,614,556 5,614,556 2015 0 7,100,762 7,100,762 2016 0 8,586,968 8,586,968 2 Project monthly disbursement record 12. Four key Project cost and effectiveness indicators were calculated based on the previous Project benefit estimate. The cost-benefit stream yielded an IRR of 41.3% and NPV of $9.48 million assuming a 10% discount rate. The measure of cost effectiveness in this analysis was the ratio of project costs to a health-related outcome that can be attributed to the Project: HIV infections averted and years of life saved. The numerator was the total cost of delivering the Project and the denominator was the accumulated health outcomes during the project implementation period. The calculation yielded $15,725 for each HIV infection averted and $476 for each year of life saved. 37 Table 5. Key Project Cost and Benefit Indicator Indicator Value Description IRR 41.3% Internal rate of return NPV (million) $9.48 Net present value in US 2004 million dollars CE ratio 1 $15,725 Dollar cost of each infection averted CE ratio 2 $476 Dollar cost of each year of life saved 38 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Mary Mulusa Senior Operations Specialist LCSHH Team Leader Mariana Montiel Legal Counsel LEGLA Legal Counsel Edward Daoud Sr. Loan Officer LOAG Loan Officer John Stephen Osika Sr. Health Specialist AFTTR Health Specialist Financial Fabienne Mroczka Financial Management Specialist LCOAA Management Specialist Procurement Guido Paolucci Sr. Procurement Specialist LCOPR Specialist Institutional Willy De Geyndt Consultant Consultant Management Specialist Patricio Marquez Lead Health Specialist LCSHH Health Specialist Information Alberto Gonima Information Technology Specialist Consultant Technology Social Development Yaa P.A. Oppong Social Anthropologist PRMGE Specialist Samia Benhouzid Language Program Assistant LCSHD Program Assistant Supervision/ICR Christine Lao Pena Sr. Human Development Economist LCSHH Team Leader Shiyan Chao Sr Economist (Health) LCSHH Team Leader Financial Svetlana V. Klimenko Sr. Financial Management Specialist LCSFM Management Financial Emmanuel N. Njomo Consultant AFTFM Management Procurement Marta G. Ospina Consultant LCSPT Specialist Financial Maritza Rodriguez Sr. Financial Management Specialist LCSFM Management Procurement Norma M. Rodriguez Procurement Specialist LCSPT Specialist Procurement Judith C. Morroy Consultant LCSPT Specialist Luis Tineo Senior Operations Officer GPOBA Operations Officer Jean Rutabanzibwa-Ngaiza Consultant AFTHV Social Scientist Mario E. Bravo Sr. Communications Officer EXTOC Communication 39 Specialist John Stephen Osika Consultant LCSHH Health Specialist Carmen Carpio Health Specialist LCSHH Health Specialist Marcelo H. Castrillo Consultant HDNGA M&E Specialist Institutional Willy L. De Geyndt Consultant HRSSC Management Specialist Harry Toews Wiebe Consultant AFTED Architect Zukhra Shaabdullaeva Consultant LCSHH Program Support Samia Benbouzid Program Assistant AFTHE Program Assistant Maria Elena Paz Gutzalenko Program Assistant LCSHE Program Assistant Judith Marcano Williams E T Temporary LCSHH Program Assistant Viviana A. Gonzalez Program Assistant LCSHH Program Assistant Yuyan Shi Consultant LCSHH Economist F. Brian Pascual Operations Analyst HDNHE ICR Author Robert Oelrichs Sr. Health Specialist HDNHE Peer Reviewer Nadeem Mohammad Sr. Operations Officer OPCRX Peer Reviewer (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY04 14 99.43 FY05 0.00 FY06 0.00 FY07 0.00 FY08 3.64 FY09 0.00 Total: 14 103.07 Supervision/ICR FY04 0.00 FY05 20 95.10 FY06 18 77.86 FY07 14 76.34 FY08 18 91.62 FY09 17 84.95 FY10 21 76.81 FY11 15 77.66 Total: 123 580.34 40 Annex 5. Beneficiary Survey Results N/A 41 Annex 6. Stakeholder Workshop Report and Results (Not available) 42 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Borrower ICR submitted by NAS on Sept 29, 20011. HIV/AIDS PREVENTION AND CONTROL PROJECT IMPLEMENTATION COMPLETION REPORT St. Vincent and the Grenadines 2011 43 OVERVIEW 1. The Government of St. Vincent and the Grenadines (SVG) was proactive in trying to avert the potential negative impact of an HIV/AIDS epidemic on the country. With the first case of HIV diagnosed in SVG in 1984, the government‟s response has been swift, recognizing the fact that this epidemic has serious developmental implications. The HIV epidemic in SVG is driven by a number of factors including cultural, behavioural and socio-economic. 2. The HIV/AIDS/STI Prevention and Control Programme in the Ministry of Health, Wellness and the Environment has coordinated the Government‟s response to the HIV epidemic since 2001. The human resource capacity of the programme was strengthened in 2005 through the St. Vincent and the Grenadines HIV/AIDS Prevention and Control Project. The programme has three main goals: reducing the transmission of new HIV infections; mitigating the impact of HIV/AIDS on the people of SVG; and achieving a sustained, effective multi-sectoral infrastructure to support the national response to HIV and AIDS. 3. The Government of SVG in its mission to scale up the HIV/AIDS prevention and control programme began negotiations with the World Bank in 2003 to finance the programme. The World Bank funded project necessitated the development of an updated strategic plan to encompass a multi-sectoral implementation approach. The implementing agencies involved in the national response included government ministries, civil society organizations such as non- governmental organizations, faith-based entities and the private sector. THE OBJECTIVES, DESIGN, IMPLEMENTATION AND OPERATIONAL EXPERIENCE OF THE PROJECT 4. The Government of St. Vincent and the Grenadines signed Loan, Credit and Grant Agreements with the International Bank for Reconstruction and Development (IBRD) and the International Development Association (IDA) on August 17, 2004. These agreements financed the HIV/AIDS Prevention and Control Project over the period February 8th 2005 (Date of Effectiveness) to April 30th 2011. An amount of US$7,000,000.00 was provided in the proportion of 50% - 25% - 25% for the loan – credit - grant respectively. 5. The development objective of the project was to support the national programme that aimed to prevent and control the spread of HIV/AIDS and to mitigate the socio-economic impact of the disease on the population. The project had proposed to use a two-pronged strategy: - targeting interventions at high risk groups - and implementing non-targeted activities for the general population. 6. It was believed that the successful achievement of the development objective will: (a) have high risk groups use safe sexual practices; (b) enhance knowledge in the general population of the negative societal and family impact of the disease; (c) prolong the lives of infected persons and provide care and support to their families; and (d) reduce the degree of stigma and discrimination associated with the disease. 45 7. The project was able to achieve its overall development objective. High risk groups such as youth, prisoners and mini bus drivers were reached through the various Civil Society Organizations implementing prevention activities. The Caribbean HIV/AIDS Alliance, although not funded by this project, has set up a country office and has been working with men who have sex with men (MSM), sex workers and people living with HIV for the past four years. The general population was targeted through a number of interventions including the print and electronic media; electronic and non-electronic billboards, community outreach, provision of condoms and other commodities; distribution of information brochures and training sessions on HIV 101. 8. The Project Appraisal Document (PAD), Loan/Credit/Grant Agreements and the Operations Manual were the documents which governed the operations of the Project. The project design was satisfactory. The project design provided an excellent opportunity for the government to engage line ministries and civil society organizations in the HIV response which may not have occurred outside of the project. These stakeholders were able to appreciate their roles and responsibilities in the national response which hitherto was seen as the responsibility of the health sector. At mid-term review, a number of project activities were unavoidably not implemented and a reallocation exercise was undertaken for the following reasons: - Funds allocated to purchase antiretroviral drugs remained unspent because the country received antiretroviral drugs through the OECS Global Fund project and donations from the Government of Brazil. - The uptake of funds by the Civil Society Organizations and Line Ministries was much lower than anticipated. - There were a number of unforeseen activities that were necessary for the successful implementation of a comprehensive HIV/AIDS response, namely, the refurbishment of the Stubbs Polyclinic, construction of the Bread of life orphanage and procurement of laboratory equipment. DESCRIPTION OF PROJECT ACTIVITIES, OUTPUTS AND OUTCOMES Scaling up HIV/AIDS Response by Civil Society Organizations 9. A total of fourteen Civil Society Organizations (CSOs) received funding throughout the life of the project to implement HIV/AIDS care and support activities. The total re-allocation to the CSO component was US$ 603,750.00 of which US$275,307.00 (46%) was utilized. 10. The fourteen CSOs that received funding were Bread of Life, Lauders Sports and Cultural Club, Diamonites, VINSAVE, House of Hope, Marion House, St. Vincent Employers‟ Federation, Indigenous Awareness Movement, St. Vincent Planned Parenthood Association, St. Vincent Red Cross Society, St. George‟s Cathedral/ St. Mary‟s Health Guild, Casper/Maria Marshall Centre, St. Vincent and the Grenadines Cadet Force and the St. Vincent and the Grenadines Seventh-Day Adventist Churches. 11. The CSOs have conducted sensitization, education, and awareness activities, primarily targeting youth. The Bread of Life Orphanage was supported by the project to construct a new 46 orphanage in Georgetown. This construction was one of the main activities that resulted in the extension of the project‟s closing date by 18 months. Two CSOs received vehicles under the project. 12. Some of the activities undertaken by the CSOs included: development of „How to training manual‟ for all pre-school centers; development and airing of radio drama & jingles on HIV/AIDS; development of coloring books for pre-schools; HIV/AIDS awareness activities such as camps & workshops targeting the youth; activities addressing stigma and discrimination including rallies; and several workshops and training programmes targeting the church. All of these activities contributed to the overall development objective of the project and the outcome of creating a supportive environment with accepting and non discriminatory attitudes toward PLHIV, their families and orphans, as well as, reducing the prevalence of HIV in the general population. 13. The Programme underestimated the capacity of the CSOs to deliver the services required under this component. A number of smaller community-based organizations did not have the required staff to run their organizations and to apply the procurement processes required by the project. The procurement and financial management capacity of CSOs were strengthened through training conducted by the PCU. In terms of future projects, CSOs should be objectively identified during project design, whereby their capacity can be assessed and weaknesses identified and addressed before project implementation commences. This will also result in early commitment to the overall objective of the project and responsibilities of CSOs. Scaling up HIV/AIDS Response by Non-Health Line Ministries 14. A total of nine Line Ministries (LMs) had assigned focal points and received funding throughout the life of the project to implement HIV/AIDS prevention, control, and support activities. The total re-allocation to the LMs was US$666,762.00 of which $506,307.00 (76%) was spent. 15. The Line Ministries included Education; Tourism; National Security; Finance and Economic Planning; Urban Development, Culture, Labor & Electoral Matters; and National Mobilization. Line ministries have contributed to the achievement of the project‟s objectives by reaching individuals in their sectors. The project was able to draw on the managerial experience and institutional positioning of key line ministries to achieve its outcomes. Highlights from the Line Ministry work include: - the introduction of HIV workplace policies in five enterprises - education and sensitization activities through key tourism and national events such as a calypso competition & carnival mas bands - training and workshops targeting hospitality workers, construction workers based at resorts, and security personnel - training of school counselors, teachers and peer educators at secondary schools - training of adult learners on the basic facts of HIV and AIDS - provision of financial support for PLHIV, orphans and vulnerable children 47 Strengthening the Health Sector Response to HIV/AIDS 16. Most activities earmarked under this component of the project were successfully implemented. The inputs and outputs have led to a number of commendable outcomes including the improved quality of life of PLHIV, no longer is a diagnosis of HIV synonymous with death as persons are able to access treatment and care for HIV and opportunistic infections. Although, there is no scientific data, anecdotal data suggest that the attitude towards PLHIV is more accepting and non discriminatory. This was demonstrated during recent community outreach activities geared towards addressing stigma and discrimination, as well as the increasing number of persons being tested for HIV and accessing care and treatment. Some of the achievements by specific areas: Information, Education and Communication/Behavior Change Communication (IEC/BCC) - Recruited an IEC/BCC Communication Specialist - Developed and disseminated IEC/BCC materials - Installed two electronic billboards to further strengthen and sustain the HIV/AIDS awareness campaign - Developed a draft BCC strategy - Convened primary schools public speaking competitions on HIV/AIDS themes, - Produced and aired media programmes using television, radio and newspapers to disseminate messages - Acquired promotion items imprinted with HIV/AIDS messages - Participated in a Health and Wellness Week with messages on HIV/AIDS, the correct use of condoms - Convened discussion to address public and private workplace issues. - Organized a number of activities for World AIDS Day - Launched several awareness campaigns to reduce stigma and discrimination, to inform, educate and communicate behavioral change messages 17. The strategies have ranged from the use of cultural activities, peer to peer interventions, various print and electronic media materials and mass media campaigns. Alliances and several collaborative efforts have been strengthened with the non-governmental organizations (NGOs) including faith-based (FBOs), and government organizations. During the collaboration with these organizations, the technical capacity of the agencies were improved to deliver more effective behavior change interventions Provision and distribution of condoms 18. The project was able to exceed the target of distributing 2 million condoms over the life of the project. Partners that were involved in the distribution of condoms included St. Vincent Planned Parenthood Association, Population Services International (PSI) and Caribbean HIV and AIDS Alliance (CHAA). PSI provided condom social marketing to promote the increased establishment of non-traditional condom outlets with the 'Got it? Get it.' Campaign, while CHAA distributed condoms and other commodities to most-at-risk groups including men who have sex with men. Nineteen condom dispensing machines were installed island-wide, at bars targeting most at risk population groups. Condoms are priced at one EC dollar for a pack of three. 48 Ensuring safety of blood supplies 19. The national laboratory continued 100% testing of all donated blood according to WHO guidelines. Voluntary Counseling and Testing (VCT) 20. As a result of the project, the VCT programme was expanded to offer VCT services in all 39 health centers in St. Vincent and the Grenadines. Eighteen health centers were refurbished and equipped to provide HIV rapid testing. HIV rapid testing is also offered during outreach activities (wellness week, national day of testing, prisons, community intervention). Audiovisual equipment were purchased and distributed to health centers to support continuous education and VCT programmes. 21. The number of people tested since the implementation of the programme is 8927; exceeding the target of 2,000 people to be tested by the end of the project. The increase in the number of people tested is due to increased accessibility to the service. Treatment care and support of PLHIV The project supported the following services - Treatment of opportunistic infections - Provision of second line anti-retroviral drugs - Support of nutritional interventions for PLHIV - Procurement, storage and distribution of pharmaceuticals, equipment and supplies required for effective management of HIV/AIDS - Strengthening of the laboratory capacity to assist in the diagnosis, treatment and care of PLHIV through training of staff, purchasing of equipment, rapid test kits and laboratory reagents as well as recruitment of a laboratory technologist and an inventory clerk to support the laboratory service - Training of health care workers on the HIV treatment protocols for management of HIV/AIDS and sensitization to reduce stigma and discrimination of HIV/AIDS patients; and, care and support initiatives including home-based care and nutritional support 22. At the end of March 2011 there were 313 patients in active follow-up at the lone clinic currently in the public sector. There were 204 patients on antiretroviral treatment (including 3 children) both in the public and private sectors. 23. Over the life of the project, PLHIV received social support in collaboration with the Department of Family Affairs of the Ministry of National Mobilization, Social Development etc.; and Orphans and Vulnerable Children (OVC) received psycho-social support. 24. Central Medical Stores (CMS) procured pharmaceuticals for the programme; including condoms and drugs. The Health Information System will improve the management of pharmaceutical supplies through computerizing the inventory control at the Central Medical Stores. 49 Prevention of mother to child transmission (PMTCT) 25. All pregnant women were counseled and screened for their HIV status, thereby achieving the target of 100%. HIV positive pregnant women were offered antiretroviral drugs to prevent transmission of the virus to their babies. Mothers were counseled about feeding options and provided with infant formula. The dry blood spot (DBS) test to diagnose infants was introduced in 2008 with the assistance of the Clinton HIV/AIDS Initiative and samples were sent to South Africa for testing. Testing is now being done by Lady Meade Reference Clinic Laboratory in Barbados. Nutrition Activities 26. The Nutrition Unit of the MOHWE provided individual nutrition assessments and care for PLHIV who were referred from the infectious clinic of the Milton Cato Memorial Hospital (MCMH) or from VCT centers; trained health workers and community workers. These interventions promoted proper nutrition in persons living with and affected by HIV/AIDS; measured and monitored the eating habits and nutritional status of children and adults living with or affected by HIV/AIDS; and built the institutional capacity in nutrition care and service to PLHIV. This Unit purchased anthropometric equipment, updated records and conducted workshops. Policy formulation 27. With the assistance of the Pan Caribbean Partnership against HIV/AIDS (PANCAP), a law, ethics and human rights national assessment was undertaken in the country and two reports were prepared. The first report was a desk review of the laws and policies as they pertain to HIV/AIDS human rights issues. The second report was prepared following community consultations addressing the findings of the legal consultant. PANCAP developed model policy and legislation. The national policy development process has started and is ongoing. A consultant has been recruited to develop the workplace policy. Biomedical Waste Management 28. The primary contribution of the project in biomedical waste management was training for comprehensive biomedical waste disposal at the hospital and the health centers. Biomedical waste is prepared at the hospital and health centre sites, following strict procedures and then transported to a landfill site. Biomedical waste handling supplies were also purchased for the hospital. Strengthening Institutional Capacity for Program Management and Monitoring & Evaluation Institutional capacity for coordinating and managing the HIV/AIDS Project 29. The project supported the newly-established National AIDS Council (NAC) and its operating arm, the National AIDS Secretariat (NAS) which was an expansion of the HIV/AIDS Prevention and Control Programme in the MOHWE. It also provided support to the Country Coordination Mechanism Council (CCM) responsible for evaluating the CSO proposals. The NAC was established in February 2004 and co-chaired by the Prime Minister and the Minister of Health and the Environment. Officers from the PCU and the MOHE benefited from training workshops financed by the World Bank on HIV/AIDS programme implementation and fiduciary 50 matters. A notable training exercise was the attendance of eight officers at the International AIDS Conference in Mexico, 2008. Attendees included four focal points representing the Non- Health Line Ministries, one PLHIV and staff of the NAS. 30. Specialized skills were added to the NAS to coordinate and oversee project implementation. An already existing Project Coordination Unit (PCU) for externally financed projects located in the Ministry of Finance and Economic Planning supported the financial management and procurement activities of the project. A building to house the NAS was refurbished and equipped Strengthening programme monitoring and evaluation (M&E) 31. The project supported: (a) programme implementation monitoring; (b) epidemiological surveillance; and (c) HIV/AIDS/STI clinical management information system (CMIS) as part of the Health Information System for the main public hospital and for Health Centers. The HIS generates information for decision making at the point of service through online electronic medical records, pharmaceutical supply chain management and other modules. Project support included technical assistance, training, acquisition of hardware and software, and equipment and supplies to enable the production and analysis of valid and reliable data. 32. During the life of the project, the HIV/AIDS M&E functions were carried out by an Advisor, who collected and aggregated data, generated reports, gave feed back to stakeholders and contributed to the further development of M&E capacity of various stakeholders. The data collection and analysis were based on process, outcome and impact indicators developed to track and evaluate the national HIV/AIDS response. An M&E Plan was drafted in accordance with the National Strategic plan with TA provided by the GAMET group. A Monitoring and Evaluation Reference Group was formed which provided a forum for stakeholder discussion of project implementation based on indicators. 33. Under the World Bank project, materials required for output reporting were printed. These included revised forms. The 2005 and 2008 UNGASS reports, annual reports for 2006, 2007 and 2008 were published for distribution to stakeholders. Other reports were generated, including reports for donor agencies and quarterly bulletins. In an effort to sustain the progress made with the monitoring and evaluation system, the functions have been integrated into the Health Information Unit. EVALUATION OF THE BORROWER'S PERFORMANCE 34. Project coordination and management were shared between two ministries; the Ministry of Finance and Economic Planning and the Ministry of Health and the Environment. The Project Coordination Unit (PCU) within the Ministry of Finance and Economic Planning carried out the fiduciary management of the Project. The PCU was staffed with a Project Coordinator, Procurement Specialists, Financial Management Specialists, Administrative Assistant, Junior Clerk, and an Office Attendant. This Unit had already acquired some experience in applying the World Bank procedures since it was intimately involved in the implementation of previous IRBD funded Projects such as the Emergency Recovery and Disaster Management Project and the Emergency Recovery Project. 51 35. Further, the PCU fulfilled all fiduciary responsibilities as stipulated in the Loan Agreement. A financial management system was maintained; including records, accounts and financial statements in the format acceptable to the Bank to reflect the operations, resources used and expenditures related to Project activities. Financial Monitoring Reports (FMRs) were submitted on a quarterly basis and annual audits were conducted. The Ministry of Health was responsible for technical matters and collaborated with the relevant stakeholders in fulfilling the requirements of the Project. 36. During the early stages of the Project, the execution of activities occurred at a very slow pace thus resulting in a low disbursement of loan funds. This was partly due to the unfamiliarity with the Bank procedures by the technical officers in the ministries, the uncertainty regarding the responsibilities of key players. 37. Overall, the Government of St. Vincent and the Grenadines was able to accomplish the objectives of the project. Therefore, the general performance can be considered satisfactory. EVALUATION OF THE BANK'S PERFORMANCE 38. Over the life of the project, there have been three (3) Task Team Leaders. The changes did not negatively affect the Bank-Government of St. Vincent and the Grenadines coordination as it appeared that there was an efficient handing over process. All task teams made a significant impact in terms of project implementation and management. At midterm review, the team recognized the need for the reallocation exercise and worked diligently and in close collaboration with the Ministries of Health, Wellness and the Environment, and Finance and Economic Planning in the completion of this process. 39. The teams conducted biannual comprehensive supervision missions resulting in the development of a valuable working relationship and improved project implementation over time. During the missions, all stakeholders were engaged in meaningful discussions which provided greater understanding of issues. This constant involvement of stakeholders resulted in an increased ownership by most stakeholders. 40. Easy access to Bank staff and the availability of Bank staff to assist during critical periods have contributed in part to the overall accomplishment of project objectives. In general, the World Bank‟s performance can be rated as satisfactory. LESSONS LEARNT 41. Lessons learned from the implementation experience of the CSOs include the importance of regular meetings to support coordinated efforts and knowledge-sharing among the CSOs. 42. Lessons learned from the LM experience include the need to continue with monthly meetings to allow LMs to explore synergies across their activities and for targeted fiduciary training to be provided at a much earlier stage of project implementation, to help LMs understand and work within Bank policies. 52 43. As far as possible, flexibility must be built into the project design to facilitate unexpected events which can delay project implementation. 44. Where technical deficiencies are noted in country, particularly in relation to bids/proposals, evaluation and development of appropriate specifications and terms of reference, resources should be provided from the project to recruit competent short-term consultants to assist where necessary. 45. Knowledge of the procurement procedures of the World Bank should not be confined to the officers at the PCU but should be extended to the personnel of the implementing technical agency and other stakeholders. This would aid in expediting the implementation of the project activities. 46. Having the same officers on the Bank and Beneficiary‟s team, as far as possible, during the tenure of the Project can assist with continuity, consistency and avoid delays in Project implementation. Where this is not possible, efforts should be made to establish formal handing over procedures to improve project specific knowledge within the team at any given point. 47. The successful implementation of the Programme is dependent on human capital. With respect to the Line Ministries response, some focal points were overburdened which impacted the roll out of the Programme in some Ministries. 48. The National AIDS Programme has begun the process of strategically integrating the programme into mechanisms already in existence, so as to eliminate the perception that the programme is an added burden. Thus, areas such as integration of HIV data on forms already in use in the health care sector; care, treatment and support services; counseling and psychological services have already begun. SUSTAINABILITY 49. The HIV/AIDS Prevention and Control Project has built a strong foundation on which the strengthening of the national HIV/AIDS programme can take place. The multi-sectoral response which the project fostered will be strengthened with the recruitment of Programme Offices to coordinate the prevention, care, treatment and support services within government institutions and civil society. The Officers will also serve as advocates for the incorporation of HIV activities in line ministries annual budgets. 50. The construction of polyclinics, where care and treatment for people living with HIV will take place in an integrated manner, reducing the stigma associated with the disease will be expanded. Project funds were utilized to construct the first polyclinic at Stubbs and the Government has mobilized resources from the European Development Fund to construct the additional polyclinics which could not have been constructed under this project. 51. The project highlighted the importance of an organized monitoring and evaluation system. The monitoring and evaluation component of the project has been integrated into the Health Information Unit and the M&E system is currently being expanded to include the other ministry 53 programmes. The health system has also been strengthened with the implementation of an electronic health information system that will greatly improve patient management. 52. The great interest shown by the Bank to fund HIV/AIDS programmes in the region provided the impetus for other donors to become involved. The additional funds have assisted the Government to sustain and strengthen its national response to HIV/AIDS. 53. The most recently completed, costed and approved National Strategic Plan covers the period 2010 - 2014; and acknowledges the challenge of sustaining and managing existing programmes in light of reduced financial resources. The plan intends to address this issue by utilizing the strategies of decentralization/integration of care and treatment services, strengthening the multisectoral ownership and implementation, and ensuring that the response is more evidence-informed. The plan outlines a resource mobilization strategy that will involve fund raising activities with development partners, the Government and the private sector. The government is currently a recipient of donor technical assistance/funds from the United States President‟s Emergency Plan for AIDS Relief, for laboratory and health systems strengthening, strategic information and prevention targeting key populations through the work of the Caribbean HIV and AIDS Alliance. Through the PANCAP‟s Global Fund Round 9 grant, the country is receiving assistance to continue its care and treatment programme. The country is also part of the OECS RCM that intends to submit a proposal to Global Fund Round 11 in December 2011. SUMMARY OF PDO ACHIEVEMENTS AND SHORTFALLS PDO ACHIEVEMENTS SHORTFALLS Scaling up of programs for the  Voluntary Counseling and Testing programme including  Repeat KABP prevention of HIV/AIDS, refurbishment and furnishing of counseling rooms and survey targeting in particular both HIV rapid testing HIV/AIDS high-risk groups and  Prevention of Mother to Child Transmission programme the general population including early infant diagnosis  Increased condom distribution including condom vending machines  NGOs dedicated to targeting MSM, SW and Youth  Multisectoral approach to implementing prevention programmes including Line Ministries and CSOs  Reduction in the number of HIV reported cases  Behavioral and sero-prevalence survey among MSM  High knowledge regarding HIV transmission and prevention strategies in general population Scaling up of programs for the  Relocation of the clinic to a more acceptable environment  Limited treatment and care of people  Increasing number of persons accessing treatment and care nutritional living with HIV/AIDS  Provision of equipment – laboratory, nutrition counseling  Reduction in the number of AIDS-related deaths  Care and treatment team including psychologist, social worker and counselor  Development and implementation of adherence strategy The reduction of the degree of  Conducted law, ethic and human rights assessment stigma and discrimination  Developing workplace policies associated with HIV/AIDS  Training of relevant stakeholders  Stigma and discrimination (SCOR B) survey ongoing 54 The strengthening of the  Electronic Health Information System institutional capacity of the  Construction of Stubbs Polyclinic Ministry of Health and  Training of Health Care Workers in the various aspects of Environment, other related HIV management Government agencies and civil  Training of Line Ministries and CSOs society organizations to ensure effectiveness and sustainability of the project 55 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders N/A 56 Annex 9. List of Supporting Documents DFID, WHO/PAHO, GFATM, UNAIDS Secretariat, and the World Bank. HIV/AIDS in the Caribbean Region: A Multi-Organization Review: Final Report. November 2005. Government of St.Vincent and the Grenadines. National HIV/AIDS Programme Report 2008. Ministry of Health and the Environment, Kingstown, April 2009. Government of St.Vincent and the Grenadines. National HIV/AIDS Programme Report 2007. Ministry of Health and the Environment, Kingstown, February 2008. Government of Saint Vincent and the Grenadines. HIV/AIDS Prevention and Control Project, Project Operations Manual (POM). Undated. Government of Saint Vincent and the Grenadines. HIV/AIDS Prevention and Control Project, Project Appraisal Document (PAD). April 26, 2004. Government of Saint Vincent and the Grenadines. Men Who Have Sex with Men Behavioral and HIV Sero-prevalence Pilot Study conducted in St. Vincent and the Grenadines 2010. Ministry of Health and the Environment, Kingstown, August 2011 (DRAFT). Government of Saint Vincent and the Grenadines. St. Vincent and the Grenadines Country Poverty Assessment 2007/2008: Report on the Institutional Assessment, Vol 3. Ministry of Finance and Planning, Kingstown, UNDATED. Government of St. Vincent and the Grenadines. HIV and AIDS National Strategic Plan 2010- 2014. Ministry of Health and the Environment. Project Coordinating Unit. St. Vincent and the Grenadines HIV/AIDS Prevention and Control Project Financial Monitoring Report. November 30, 2010. PSI. Caribbean (2007): Price as a Barrier to Condom Use: A Randomized Controlled Trial in Trinidad and Tobago and St. Vincent and the Grenadines. PSI Research & Metrics, Trinidad & Tobago, October 2007. The World Bank. Country Assistance Strategy of the World Bank Group for the Eastern Caribbean Sub-Region. Caribbean Country Management Unit, Latin America and the Caribbean Region. Memorandum of the President of the International Bank for Reconstruction and Development, the International Development Association, and the International Finance Corporation to the Executive Directors. Report No. 2205-LAC. June 14, 2001. The World Bank. Regional Partnership Strategy for the Organization of Eastern Caribbean States (OECS) for the Period 2010-2014. Caribbean Country Management Unit, Latin America and the Caribbean Region and the International Finance Corporation, Latin America and the Caribbean Region. Report No. 53762-LAC. May 3, 2010. 57 UNAIDS, Barbados and, Eastern Caribbean. Mapping of Punitive Laws which Impede Universal Access to HIV Prevention, Treatment, Care and Support in the OECS and Barbados. November 2010. UNAIDS. UNGASS Report: Saint Vincent and the Grenadines, 2010. UNAIDS. UNGASS 2006: Country Progress Report, St. Vincent and the Grenadines, 2009. UNAIDS. UNGASS 2008: Country Progress Report, St. Vincent and the Grenadines (Reporting Period: January 2006-December 2007), January 31, 2008. UNICEF. The Response of Caribbean Youth to HIV/AIDS Prevention Messages & Campaigns: A Study Designed to Measure their Knowledge of HIV/AIDS & How They Are Acting on that Knowledge. November 2008. USAID, FHI, PAHO (2007). Behavioral surveillance surveys (BSS) in six countries of the Organization of Eastern Caribbean States, 2005–2006. Final Report. May. Port of Spain. 58 Annex 10. Country Background 1. SVG‟s largest island is St. Vincent, which serves as the commercial and political center where 90 % of the country‟s population resides. Moreover, SVG is a member of regional political and economic organizations such as the Organization of Eastern Caribbean States, the Caribbean Community, and the Pan Caribbean Partnership Against HIV and AIDS (PANCAP). Its economy relies heavily on banana production, which employs up to 60% of the country‟s work force and accounts for 50% of its merchandise exports. Tourism, however, also represents an important segment of the economy and has become the chief earner of foreign exchange. As such, SVG‟s economic growth is largely influenced by seasonal variations in the agricultural and tourism sectors. For example, tropical storms in 1994, 1995, and 2002 wiped out substantial portions of crops, while a post-September 11, 2001 recession hurt the tourism industry. Other important sectors include banking, insurance, electricity and water, and manufacturing. Table 6 presents SVG‟s economic indicators at project appraisal. Table 6. Saint Vincent and the Grenadines’ Economic Indicators, 2004 GDP per capita $3,512 Exports Merchandise $37 million Commercial Services Imports Merchandise $225 million Commercial Services Debt (external) $223 million Economic aid received EU $34.5 million Unemployment 12% Poverty level 30% Adult literacy 88% Source: World Development Indicators 59 Annex 11. Key Outcome and Output Indicators 1. Key impact and outcome indicators included: (i) Prevalence and incidence rates of HIV/AIDS in the general population and in high risk groups; (ii) Access to ART and to treatment for opportunistic infections (OIs) by infected persons; (iii) Support for affected households and orphans; and (iv) Accepting and non-discriminatory attitudes by the population towards victims of the disease in the workplace and in the community. 2. Expected outputs included: (i) Positive HIV cases identified, counseled and treated; (ii) STI cases traced and treated; (iii) Condoms distributed; (iv) Pregnant women testing positive and receiving ART; (v) Blood units screened before transfusion; (vi) Physicians and nurses trained in managing HIV/AIDS patients; (vii) Orphans identified and cared for; (viii) HIV/AIDS Information, Education, Communication (IEC) messages aired in the mass media; and (ix) CSOs actively engaged in the national HIV/AIDS response. 60 Annex 12. Main MTR Findings and Recommendations Table 7. MTR Findings and Recommendations, June 2007 Main Findings Recommendations M&E. Country capacity remained extremely Contract services of M&E Advisor; recruit weak; operationalizing the National M&E Plan biostatistician and data entry clerk; develop HIV had not progressed; inadequate infrastructure M&E operations manual; cost and disseminate resulted in poor data access, quality, and flow. National HIV M&E Plan; develop national HIV database; standardize set of process measures to monitor CSO and LM progress; develop concept paper describing vision and approach for M&E in health in general. Procurement. Insufficient PCU; LMs had not PCU should hire additional staff to establish and undertaken their share of responsibility in maintain procurement tracking system, as well as preparing Terms of Reference and technical handle procurement filing; LMs should actively specifications for procurement of goods and participate in the procurement process. services; CSOs. Inefficient vetting process delayed CSO Create a small participatory committee to replace participation in the National Response; NAC CCM Council in evaluating CSO proposals; ensure met infrequently while CCM Council had that approved activities match CSO‟s area of difficulty reaching a quorum, both of which expertise; develop a realistic estimate of how much held up decision-making process; quality of funds CSOs can absorb before project closing date; CSO participation needs to be improved. create a CSO website link to inform organizations; finalize contract for CSO/LM Coordinator; recruit field officer to support CSO/LM Coordinator. LMs. While LMs provided sensitization and Encourage outreach to external clients by key awareness training to own staff, involvement ministries (Education; Tourism, Youth, and Sports; with their external clients varied widely; degree Social Development; and Labor); enable focal points and intensity of effort by focal points varied to focus more on coordinating activities and less on widely and depended in part on their personal implementing them; provide local and/or regional commitment and their workload; certain LMs training for focal points in key ministries; and experienced staff turnover; and execution of develop a realistic estimate of how much funds LMs activities delayed due to: 1) procurement can absorb before project closing date. process and procedures; 2) delay in paying suppliers; and 3) late approval of budgets. Health Sector. While each of the health sector Expedite recruitment of new Clinical Care technical components made progress, there was Coordinator; review other existing sources of funding a lack of clarity on the coordination for first line ARV drugs and reduce corresponding arrangements within the sector. Bank allocation; quickly advance procurement of laboratory equipment and Laboratory Technologist; accelerate refurbishing remaining VCT sites; NAS should liaise with other development agencies regarding patterns of condom usage in the country; IEC/BCC Specialist and the Health Promotion Unit in MOHE need to collaborate more closely to ensure a coherent national approach to HIV/AIDS IEC/BCC; coordinate with technical heads and staff to develop a revised health sector training plan based on needs that have been identified. 61 IBRD 33488 61°15'W 61°00'W SAINT VINCENT and Saint Vincent Channel Fancy the GRENADINES Soufriere SELECTED CITIES AND TOWNS SAINT (1234 m) DAVID PARISH CAPITALS Orange Hill TTE Richmond NATIONAL CAPITAL RLO Chateaubelair RIVERS Georgetown SAINT CHA MAIN ROADS Cumberland PARISH BOUNDARIES 13°15'N PATRICK Saint 13°15'N Barrouallie INTERNATIONAL BOUNDARIES Vincent Layou Biabou 61°15'W SAINT Mespotamia This map was produced by the Map Design Unit of The World Bank. ANDREW The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank KINGSTOWN Stubbs Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. Calliaqua SAINT Caribbean GEORGE 0 2 4 6 Kilometers Sea Bequia Channel 0 2 4 6 Miles Bequia 13°00'N Port Elizabeth 13°00'N Derrick Petit Nevis Battowia Isla á Quatre Pigeon Baliceaux ries S Pillo All Awash The E I N Dovers Mustique Caribbean D Sea Petit GRENADINES Mustique A N Savan E Petit Canouan R G 12°45'N 12°45'N Canouan Canouan E North Mayreau Channel H Tobago T Mayreau Cays Nor th Mayr ST. VINCENT & eau C the GRENADINES hann el Ashton Union Clifton Palm I. (Prune I.) Mar tiniq ue C hann el Petit St. Vincent 12°30'N GR ENAD A 61°15'W 61°00'W JANUARY 2005