Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: 31772 Project Name VIET NAM HIV/AIDS PREVENTION Region EAST ASIA AND PACIFIC Sector Health (80%); Other social services (20%) Project ID P082604 Borrower(s) SOCIALIST REPUBLIC OF VIETNAM Implementing Agency State Bank of Vietnam Vietnam Ministry of Health 138A Giang Vo St. Vietnam Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Safeguard Classification [ ] S 1 [ ] S 2 [X] S 3 [ ] S F [ ] TBD (to be determined) Date PID Prepared February 25, 2005 (updated after appraisal) Date of Appraisal Authorization December 2, 2004 Date of Board Approval March 29, 2005 1. Country and Sector Background The global pandemic of human immunodeficiency virus (HIV) and the attendant epidemic of acquired immunodeficiency syndrome (AIDS) present one of the key public health challenges of our time. With no effective vaccine or cure likely to be available in the mid-term future, the priority responses of government remain prevention of HIV infection and, increasingly, treatment of AIDS. In Southeast Asia HIV/AIDS currently remains concentrated in particular vulnerable populations. Although effectively reaching these populations with prevention and treatment programs presents challenges, it also offers an opportunity to impact significantly on the progress of the HIV/AIDS epidemic. According to UNAIDS, in East Asia, the 50% increase in HIV infections from 2002-2004 is largely attributable to growing epidemics in China, Indonesia and Viet Nam. In Viet Nam in particular there is clear potential for the epidemic to spread from vulnerable groups through bridge populations to the general population. The major burden of disease is being borne by young people, with 62% of reported HIV cases aged 20-29 years. This implies serious economic consequences for the nation, with an epidemic among the most economically productive age group. Global experience has taught that national preventive programs targeting epidemiologically significant risk behaviors can control transmission amongst high-risk groups and stop the generalized spread of HIV. Viet Nam presents a clear example of a country in which the trajectory of a concentrated HIV/AIDS epidemic may be greatly curtailed by a highly focused program aimed at stopping HIV/AIDS transmission. Page 2 The anticipated success of such a program is based on comprehensive epidemiological data. Estimates and projections of HIV in Viet Nam have recently been prepared by The Viet Nam Technical Working Group and disseminated by the Ministry of Health (MOH). The report finds that the estimated number of people living with HIV in Viet Nam has been sharply increasing in the past 3-5 years - rising from approximately 96,000 to 245,000 during the four-year period between 1999 and 2003. HIV infection and deaths from AIDS have now been reported in all of Viet Nam’s 64 provinces. Although the population prevalence in the country as a whole remains less than half of one percent (0.44% in 2003), the prevalence of HIV is high among particular vulnerable populations. Injecting drug users (IDU) dominate the epidemic with males and youth being more at risk. IDUs have a national prevalence of approximately 33%, although this rate is much higher in areas such as Ho Chi Minh City (HCMC), Hai Phong and Quang Ninh. After IDUs, female sex workers (FSW) have the highest prevalence - approximately 3.1% nationally, again with higher rates in some cities including Hai Phong, HCMC, Hanoi and Can Tho. By 2005, it is estimated that there will have been a cumulative total of 60,000 AIDS deaths in Viet Nam. The overlap of risk behaviors is a critically important characteristic that is driving the HIV/AIDS epidemic in Viet Nam. In Hanoi and Ho Chi Minh City, 25% of commercial sex workers also inject drugs. The sharing of needles and syringes is widespread. Almost two-thirds of the IDUs in Hanoi (65.47%) and slightly fewer in Hai Phong (46.4%), Can Tho (51%), and HCMC (42.9%) reported 2 or more sexual partners in the past 12 months. With the exception of those surveyed in Ho Chi Minh City, IDUs do not consistently use condoms in a majority of their sexual encounters. The prevalence of HIV among male clients of sex workers is also steadily increasing. These and other findings from behavioral surveys are highly suggestive of the pathway the epidemic is taking from IDUs to Commercial Sex Workers (CSW), and other heterosexual partners. In many African and Asian countries the twin epidemics of HIV/AIDS and TB are closely linked – with the vulnerability of AIDS patients to TB infection threatening to reverse the gains in TB control of the last decade. Viet Nam is classified as a high TB burden country within the western pacific region. With the support of the WHO “STOP-TB” effort, the Viet Nam National TB Control Program institutes directly observed treatment (DOTS) in 100% of districts, with a high rate of diagnosis, notification and cure. All TB medications are procured and supplied through this national program. Despite this success however, there has yet to be any decrease in notification of new infections nationally. Multiple factors may contribute to this static pattern – including the masking of gains by active case identification and population mobility – however it is likely that the increasing prevalence of HIV is impacting on the picture of TB in Viet Nam. The National TB control program has recommended the establishment of a national TB/HIV coordinating committee and adoption of a TB/HIV framework. Policy and Regulatory Issues : The Prime Minister’s February 2003 directive designated functions by Ministry to strengthen HIV/AIDS prevention activities and coordination within government. The directive assigned MOH the key responsibilities of strengthening structures for HIV/AIDS Prevention from central to community levels, and key interventions, e.g. harm reduction, improving surveillance systems, promoting safe blood, prevention of mother to child Page 3 transmission (PMTCT). Four other ministries were given important roles as well. MPI and MOF were asked to arrange adequate and timely funding for HIV/AIDS prevention. Ministry of Public Security would develop mechanisms to support infected children, work with sex workers and drug users in rehabilitation centers, and develop and implement action plans for effective interventions to prevent transmission from high risk groups to the community. The Ministry of Culture and Information would collaborate with other Ministries and Peoples Committees in provinces and cities to strengthen responsibilities of all local levels of the Party and Government; improve understanding of HIV/AIDS; oppose discrimination towards PLWHAs and promote healthy lifestyles including practice of safe sex and safe injection. Other ministries were assigned more limited roles. In early 2004, the Prime Minister approved the National Strategy on HIV/AIDS Prevention and Control for the period 2004-2010, with a vision to 2020. The strategy specifies achievements to date and remaining challenges. The Strategy identifies the following nine action areas: 1) Information, Education and Behavioral Change Communication; 2) Harm Reduction and Prevention: 3) Treatment, Care and Support for People Living with HIV/AIDS; 4) HIV/AIDS surveillance; 5) Monitoring and Evaluation; 6) PMTCT; 7) STI Management and Treatment; 8) Safe Blood Transfusion; and 9) Capacity Building and International Cooperation Program. Donor Support to Viet Nam : Viet Nam is receiving assistance for a wide range of activities from a number of bilateral and multilateral donors, UN agencies and international NGOs. Some of the major programs include the Global Fund for AIDS, Tuberculosis and Malaria, DFID/NORAD (WHO/MOH implemented), USAID and the US Centers for Diseases Control (CDC). Since the commencement of this project preparation, the landscape of donor support has changed dramatically, with the announcement that Viet Nam has been designated the 15th focus country under the US President’s Emergency Plan for AIDS Relief (PEPFAR). Preliminary indications are that PEPFAR will be allocating on the order of $20 million per year for support to Viet Nam’s HIV/AIDS programs. There is consensus among the donor community of the need to work collaboratively and in ways responsive to the major innovations in Viet Nam’s National HIV/AIDS Strategy. Major strides are being taken towards strengthened donor coordination. Senior representatives of major development partners are collectively encouraging the government to intensify its national AIDS response, develop coordinated capacity to implement AIDS programs and prepare a unified M&E system. At a wider level, coordination is strengthened by the Community of Concerned Partners (CCP), which represents a wide range of multilateral and bilateral donors, UN agencies, foundations and non-government partners, working at both national and local levels and includes partners with extensive practical HIV/AIDS experience and skills. There are also numerous informal mechanisms to improve coordination. Key Constraints in the Implementation of national strategy targets: 1) Harm Reduction : The key constraint to the broad implementation of Harm Reduction Strategies remains the national legal environment. Clarification of the roles and responsibilities particularly of law-enforcement, the Ministry of Labor, Invalids and Social Affairs (MOLISA) are clearly needed. As well as a better understanding of factors that lead to drug use and addiction. 2) Monitoring and Evaluation : The national system for HIV/AIDS surveillance requires revision and upgrading. As Page 4 a particular priority, information should flow from this to a national monitoring structure, with evaluation linked to evidence based decision-making and planning. 3) Stigma and discrimination remains a pervasive issue in all discourse surrounding HIV/AIDS and risk behaviors. 4) Capacity constraints at both national and provincial levels, pose difficulties for the implementation of programs. 2. Objectives The overall goal of the proposed project is to reduce transmission of HIV/AIDS and to ensure that HIV prevalence remains below .3% -- this is a key objective of the Government of Viet Nam’s National HIV/AIDS Strategy. The Government of Viet Nam’s (GVN) strategy also seeks to increase awareness and change attitudes and behaviors, including among policy makers, of the risks and appropriate responses to HIV/AIDS. Achieving this objective will only be possible if Viet Nam is able to identify and interrupt the transmission dynamics that promote the spread of the epidemic. HIV transmission in Viet Nam is currently heavily concentrated among IDUs and CSWs. Experience in other countries shows that halting the spread of the infection among these groups significantly attenuates wider scale heterosexual transmission. Successfully reaching these populations is thus strategically vital, and requires action from multiple sectors and actors as well as locally driven programs and responses. The specific objective of this project is to support programs designed to halt transmission of HIV/AIDS among vulnerable populations (PLWHA, IDUs, CSWs, and their clients and sexual partners) and between these vulnerable populations and the general population. Key outcome indicators include 1 : · Percent of vulnerable groups in participating provinces reporting safer injection practices (from an estimated 20% at baseline to 70% at project end) · Percent of vulnerable groups in participating provinces reporting condom use in sexual intercourse (from an estimated 40% at baseline to 80% at project end) The World Bank's Country Assistance Strategy (CAS) Progress Report (2004) for Viet Nam calls for more effective policy responses to address the growing HIV/AIDS epidemic. Viet Nam’s National Strategy on HIV/AIDS Prevention and Control calls for the rapid scale up of action to address Viet Nam’s HIV/AIDS epidemic. The IDA Grant aims to reduce the transmission of HIV/AIDS, which is key for meeting the goal of the National Strategy and the CAS. 3. Rationale for Bank Involvement As one of the largest financiers of HIV/AIDS control programs in the world, the World Bank brings significant global and regional expertise and experience to the task of assisting Viet Nam to implement its National HIV/AIDS Strategy. The World Bank’s analytic work in Viet Nam – including the joint Government-Donor 2004 Public Expenditure Review to contribute to the decentralization of responsibilities for planning, budgeting and service delivery – enriches the project design and implementation strategy. The World Bank’s experience with HIV/AIDS investments in other countries has enriched its understanding of the utility of subgrant 1 Specific provincial targets to be set once baseline data is available. Page 5 management approaches in the fight against HIV/AIDS. In addition to considerable technical expertise in HIV/AIDS, the World Bank has built capacity, including in the financial management and procurement fields which can contribute to the successful implementation of the project. Key issues in Viet Nam include increasing coverage of programs and strengthening capacity. The project builds on ongoing initiatives and will complement support from other donor programs. For example, PEPFAR investments in prevention preclude support for needle exchange programs but can still provide much needed resources for other aspects of a comprehensive harm reduction program for IDUs. Similarly, PEPFAR will include major investments in treatment, while this project will focus more on prevention as well piloting of integrated approaches to prevention and treatment. 4. Description The project will support three main Components to be implemented at the National and Provincial Levels. COMPONENT ONE: Implementation of Provincial HIV/AIDS Action Plans (US$21.616 million) will provide sub-grants to 18 provinces (An Giang, Bac Giang, Ben Tre, Cao Bang, Dong Nai, Hau Giang, Khanh Hoa, Kien Giang, Lai Chau, Nam Dinh, Nghe An, Son La, Thai Binh, Thai Nguyen, Thanh Hoa, Tien Giang, Vinh Long, and Yen Bai) and two cities (Hai Phong and Ho Chi Minh City) to support the design and implementation of Annual Provincial Action Plans (PAPs). The provinces and cities will be allocated block grants based on specific criteria to determine the size of each year’s base allocation. The support from the project will complement and build on existing systems for allocating and monitoring the use of resources for HIV/AIDS, and will focus on supporting the process of preparing, reviewing, implementing and assessing the success of provincial specific plans. Proposed activities are expected to reflect the diversity of the province needs as well as diversity in appropriate response. Plans are to be prepared by October of each year for allocations to cover the period between January – December. Grants will be disbursed in tranches after the provincial plans are approved. Progress toward accomplishment of PAPs will be monitored. COMPONENT TWO: National HIV/AIDS Policy and Program (US$ 8.2 million): · Subcomponent 1: Policy and Program Development and Implementation will strengthen capacity at national and provincial levels and promote the development of innovative, effective prevention and treatment approaches and models among vulnerable groups through: (i) demonstration sites that will explore a community-based treatment model to integrate harm reduction with comprehensive HIV treatment and care; (ii) policy studies and research; (iii) knowledge sharing and training; and (iv) other innovations. · Subcomponent 2: Monitoring and Evaluation will support the development of a national monitoring and evaluation results framework, operational plan and system. · Subcomponent 3: Behavior Change Communication Focused on Reducing Stigma and Discrimination will support a 5-year nationwide BCC campaign to reduce stigma and discrimination against vulnerable groups. Page 6 COMPONENT THREE: Project Management (US$ 5.184 million) will provide support to the set up and management of the Central Project Management Unit (CPMU) as well as the Provincial Project Management Units (PPMUs) located in the 18 provinces and two cities. 5. Financing Source: ($m.) BORROWER/RECIPIENT 3.5 IDA GRANT FOR HIV/AIDS 35.0 Total 38.5 6. Implementation Institutional Arrangements. The main organizations involved in overseeing and implementing the HIV/AIDS Prevention Project is the Central Project Management Unit, in the General Department of Preventive Medicine and AIDS Control (GDPMAC), Ministry of Health; Provincial AIDS Steering Committees, Provincial Project Management Units in each project province and cities, and relevant implementing agencies such as NIHE at the national level, and the Pasteur Institute in Ho Chi Minh City, the Pasteur Institute in Nha Trang, and the Hygiene and Epidemiology Institute of Highland at the regional level. Central Project Management Unit (CPMU ). The role of the CPMU would be to: (i) manage the implementation of the National Component; (ii) provide technical support as needed to Provinces; (iii) evaluate and monitor the implementation of the Provincial Action Plans; (iv) coordinate with other central level line ministries; and (v) establish and maintain/update database and resources to be able to respond to requests for consultancy/advisory services, study tours etc. as articulated in Provincial Plans. Provincial Project Management Units . The PPMU will sit within the Department of Health at the provincial level and (i) facilitate the preparation of locally responsive HIV/AIDS Action Plans; (ii) monitor the implementation of the action plans; (iii) ensure timely disbursement of funds; and (iv) assemble reports on performance from implementing agencies. Provincial AIDS Steering Committee composed of senior officials from provincial People ’s Committee, provincial Health Service, HIV/AIDS Standing Bureau, DOLISA, Department of Public Security, Department Information and Culture, Department of Planning and Investment, Department of Finance and others as determined by People’s Committee. The Steering Committee is responsible for the overall direction of the project, reviewing and approving provincial action plan; coordinating to ensure the participation of multiple implementing agencies, including DOLISA, DPS, DOIC, various mass organizations (e.g. Women’s Union and Youth Union), and community-based groups of affected individuals and other elements of civil society in determining plan priorities and receiving resources to finance their contribution to implementing the Provincial Action Plan. Page 7 7. Sustainability The project’s sustainability is enhanced by several factors. At the level of political commitment , the Government of Viet Nam recognizes and is fully committed to responding decisively to AIDS. A major achievement was the approval of the National Strategy by the Prime Minister on March 17, 2004. The approved strategy elaborated specific activities for nine priority action plans. It also clearly defines the roles of both central and local levels of Government, ministries, mass organizations, the private sector, communities, families etc. The strategy is both forward- thinking (clearly supporting a comprehensive approach to harm reduction, including 100% condom use and needle exchange programs) and comprehensive. It envisions a multi-sectoral approach to implementing the strategy. It is a strategy that is welcomed by the international community and provides a clear framework for all partners to work in collaboration with the Government. At the policy level , the General Department of Preventive Medicine and AIDS Control is committed to working with political leaders to build a policy environment that supports a sustained and effective AIDS response. At the institutional level , the Government of Viet Nam is building the institutions required for a sustained and effective response to AIDS. It has strengthened the AIDS Department in the Ministry of Health. NIHE is developing an AIDS Unit. Provincial research institutions are strengthening their capacity as well. Above all, the Government of Viet Nam, supported by major development partners, including the World Bank, is building the provincial capacity for effective implementation of the strategy. It is also working with civil society to increase the capacity of mass organizations to contribute to the AIDS response. At the human resource level , Viet Nam has a senior tier of committed and dedicated AIDS professionals. This project will focus concertedly on training the next tier of professionals and on decentralized training, to develop a greater reservoir of expertise at the provincial level. With respect to financial sustainability, the Government of Viet Nam has already assigned significant personnel and resources from its own resources to the national response. It is committed to allocating further resources to HIV/AIDS. Growing revenues in an economy that is expanding by approximately 8% annually provide the government with a growing revenue stream, which will enable them to build a sustainable AIDS response. Its multi-sectoral approach means that resources from several sectors are devoted to AIDS. For example, MOLISA already assigns considerable resources to AIDS prevention, care and treatment. Similarly, resources are being mobilized at the local level, with major local government agencies such as Ho Chi Minh City (HCMC) assigning significant resources to AIDS. Thus, at several tiers – including the national, policy, institutional, human resource and financial levels – there is a sound foundation for sustainability. 8. Lessons Learned from Past Operations in the Country/Sector This project builds on key lessons learned in designing and implementing HIV/AIDS projects in the region and around the world. Many Asian epidemics, including Viet Nam’s, require a major emphasis on reducing HIV transmission among drug users, through comprehensive interventions encompassing supply reduction, demand reduction and harm reduction. A second lesson, evident in the World Bank’s experience with HIV/AIDS programs, in addition to strong national commitment, clearly evident in Viet Nam, project design and implementation Page 8 arrangements must sharply focus on removing implementation obstacles through capacity building that focuses on fiduciary issues and encourages a focus on managing for results. The project design, with its focus on block grants for provincial action plans with annual increments related to performance provides an incentive structure to focus attention on implementation and results. Third, stigma and discrimination against vulnerable populations, such as PLWHAs, IDUs and CSWs make the delivery of information and services especially challenging. Information campaigns directed at the general public have not been shown to be effective in reducing stigma and discrimination against vulnerable populations, and are of relatively low utility in settings where levels of awareness of the disease are relatively high, as in Viet Nam. The project thus supports an aggressive and carefully targeted behavioral change and communication effort designed to reduce stigma and discrimination against vulnerable populations, focusing in particular on the settings in which these groups are likely to seek information and services. 9. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment ( OP / BP / GP 4.01) [X] [ ] Natural Habitats ( OP / BP 4.04) [ ] [X] Pest Management ( OP 4.09 ) [ ] [X] Cultural Property ( OPN 11.03 , being revised as OP 4.11) [ ] [X] Involuntary Resettlement ( OP / BP 4.12) [ ] [X] Indigenous Peoples ( OD 4.20 , being revised as OP 4.10) [X] [ ] Forests ( OP / BP 4.36) [ ] [X] Safety of Dams ( OP / BP 4.37) [ ] [X] Projects in Disputed Areas ( OP / BP / GP 7.60) * [ ] [X] Projects on International Waterways ( OP / BP / GP 7.50) [ ] [X] 10. List of Factual Technical Documents ¾ The National Strategy on HIV/AIDS Prevention and Control in Vietnam with a Vision to 2020 ¾ Briefing Paper On Vietnam Estimates And Projections 2003 ¾ Operations Manual and Project Implementation Plan ¾ Report on the Institutional Assessment of the Ministry of Health and the HIV/AIDS System * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas Page 9 11. Contact point Contact: Maryam Salim Title: Sr. Human Development Specialist Tel: (202) 473-7846 Fax: (202) 522-7108 Email: Msalim1@worldbank.org 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 Web: http://www.worldbank.org/infoshop