Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB3643 Project Name Jamaica Second HIV/AIDS Project Region LATIN AMERICA AND CARIBBEAN Sector Health (80%); Other social services (20%) Project ID P106622 Borrower(s) GOVERNMENT OF JAMAICA Implementing Agency Ministry of Health and Environment Address: 2-4 King Street Oceana Building Kingston, Jamaica Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Updated March 13, 2008 Estimated Date of Appraisal Authorization March 12, 2008 Estimated Date of Board Approval May 8, 2008 1. Country and Sector Background Jamaica is the third largest island in the Caribbean with a population of 2.7 million. It is estimated that 25,000 (1.5%) of adults aged 15-49 years are infected with HIV. The gender difference has been narrowing and the infections are split almost evenly between men and women. The majority (65%) of reported AIDS cases fall within the 20-44 year old age group. The HIV epidemic in Jamaica has features of both a generalized and concentrated epidemic. The prevalence varies across population groups. In 2005, the HIV prevalence was 9% among female sex workers and 4.6% among sexually transmitted infections clinic attendees. In 2006, the prevalence among men who have sex with men (MSM) was between 20%-30% and 3.3% among prisoners. HIV infection is also high among substance abusers and people confirmed with tuberculosis. Between 1982 and 2005, the cumulative number of known AIDS cases was 11,004 with 6,437 reported AIDS deaths. Better access to antiretroviral (ARV) drugs has helped to extend the lives of people with AIDS and decreased the mortality rate in the past five years. By early 2007, just over 5,000 children under the age of 15 years had been orphaned by HIV/AIDS. All 14 parishes are affected by the HIV epidemic but the most urbanized parishes (Kingston, St. Andrew and St. James) have the highest number of AIDS cases. Heterosexual transmission is reported by 90% of persons with HIV. An intertwined set of cultural, economic, social, and behavioral factors are driving the epidemic. They include: risky behaviors as shown by the 2004 Knowledge Attitudes, Behavior and Practices (KABP) survey including multiple partners (50% of men); participation in commercial and transactional sex; failure to use condoms with non-regular partners (30% of men and 40% of women); and, early sexual activity among adolescents. Other factors fueling the epidemic include: poverty; gender inequity and gender roles; substance abuse population movement; and, stigma and discrimination which keep people from seeking prevention services. National Response to the Epidemic. Jamaica has confronted the HIV epidemic proactively for two decades. The National HIV/AIDS Program (NHP) was established in 1986 and the National Page 2 AIDS Committee (NAC) in 1988. The national response has been guided by a series of medium- term HIV/AIDS strategic plans, the latest of which covered the period, 2002-2006. The Government has recently completed the new National HIV/AIDS Strategic Plan (2007-2012). The Jamaica National HIV/AIDS Program has included prevention, treatment, care and support. Achievements in the response to the epidemic include: implementation of a major behavior change communication program aimed at encouraging adoption of safer sexual practices; condoms promotion and distribution; voluntary, counseling and testing (VCT) services; and, prevention of mother-to-child transmission (PMTCT). An estimated 75% of HIV-infected pregnant women and 85% of HIV-exposed infants accessed anti-retroviral therapy in 2006. There has also been a dramatic expansion of services for management of sexually transmitted infections, opportunistic infections and anti-retroviral therapy. In the legal context, achievements include the approval of the National HIV/AIDS Policy by Cabinet (2004) and Parliament (2005) and the Workplace Policy approved by Cabinet in 2007. The National HIV/AIDS Program has been financed by the Government and external resources of which the largest three were the Global Fund, the World Bank and the United States Government. It has been closely coordinated with all relevant regional institutions. Other bilateral donors and UN agencies have also provided technical assistance and funding as well. Challenges in the National Response to HIV/AIDS. Jamaica still faces a number of challenges. There is persistence of inaccurate perceptions about HIV/AIDS; 1 many people still engage in risky behavior; coverage is still insufficient for some services (e.g. only 34% coverage for antiretroviral treatment in 2006); and, there are delays in seeking and adhering to treatment. Building the national capacity is needed for: strengthening of the health care delivery system in the areas of human resources (shortage of doctors, nurses, laboratory staff, social workers and counselors), diagnostic capacity (equipment and skills) and technical management of programs including the need to integrate HIV/AIDS services into the existing health and family planning services. There is also need to strengthen institutional systems (management, monitoring and evaluation, procurement and financial management). Stigma and discrimination need to be reduced so as to foster an enabling environment to tackle the epidemic. Finally, there is need for additional funding to scale up the Government’s program to achieve universal access to HIV prevention, treatment and care for those who need them. The National HIV/AIDS Strategic Plan (NSP), 2007-2012 . Confronting the HIV/AIDS epidemic is a still a high priority for the Government. It has recently updated the National HIV/AIDS Strategic Plan (NSP). The NSP (2007-2012) was developed through a participatory consultative process that involved civil society, the private sector, PLWHA, youth, representatives of marginalized groups, service providers, community leaders and policymakers. It outlines the vision, goal and guiding principles for the national response to the epidemic. The estimated cost of the National HIV/AIDS/STI Program for the period 2007 to 2012 is US$ 201.2 million. Taking into account available and planned resources, there is still an estimated funding gap of 67.3%. The NSP identifies four priority areas: (a) improving access to quality prevention services; (b) expanding treatment, care and support services; (c) fostering an enabling environment that protects human rights and empowers people to make healthy decisions; and, (d) promoting empowerment and governance, including institutionalizing of financing and management 1 Only 36% of young men and 40% of young women correctly identified ways of preventing the sexual transmission of HIV Knowledge attitudes practices and behavior (KAPB) 2004 survey. Page 3 arrangements for the program, operationalizing the “three ones” principle 2 ; and, expanding the involvement of all stakeholders in the public sector, civil society and private sector in the response to the epidemic. 2. Objectives The project development objectives are to contribute to the Government’s National HIV/AIDS Program through support to: (i) deepening prevention interventions targeted at high risk groups and for the general population (ii) increasing access to treatment, care and support services for infected and affected individuals; and (iii) strengthening program management and analysis to identify priorities for strengthening the health sector capacity to respond to the HIV/AIDS epidemic and other priority health problems. 3. Rationale for Bank Involvement Jamaica needs to sustain its response to the epidemic. The next 5-year program as outlined in the new National HIV/AIDS Strategic Plan (NSP) 2007-2012, will require a substantial amount of resources. The Government will obtain support from the Bank and the Global Fund as the two main sources of external funds to help it address the funding gap. The Bank funding will complement the Government’s own funding and that of other key external funding agencies principle among which is the Global Fund for AIDS, Tuberculosis and Malaria (GFATM). It will build on support provided under the ongoing Bank-funded project. 3 The project provided support for the Government’s program by supporting: prevention programs targeting high-risk groups and the general population; strengthening of treatment, care and support; and, strengthening of the country’s multi-sectoral capacity to respond to the epidemic. It will provide funding for key prevention, treatment and care not covered by the funding from the GFATM and complement initiatives supported by UN agencies which provide technical assistance and some limited funding. In particular, the Bank funding will strengthen institutional, program management capacity and strengthening of the health care delivery system as well as institutional strengthening for the multi-sectoral response to the epidemic through enhancing the role of non-health line ministries and Civil Society Organizations (CSOs) that reach particular vulnerable and/or high risk groups. Bank support is also critical for sustaining management and delivery of the national HIV/AIDS program. In particular, the ongoing Bank-financed project scheduled to close on May 31, 2007, funded critical positions at the National HIV/STI Control Program (NHP), in the regions and in selected line ministries due to previous budget constraints that limited establishment of new positions. The Government has initiated action to absorb the staff positions over a three-year period, starting with the new fiscal year in April, 2008. The new project will help with the transition by initially paying for some of the positions. The Bank also brings the accumulated technical experience in the Caribbean and the rest of the World in implementation of HIV/AIDS projects as well as lessons drawn from assessments of the 2 One national coordinating authority for HIV/AIDS, one national framework and one monitoring and evaluation system. 3 The Jamaica HIV/AIDS Prevention and Control Project due to close on May 31, 2008. Page 4 projects (including the multi-agency review of the Caribbean HIV/AIDS program led by the Bank in 2005). It has a comparative advantage in ensuring a multi-sectoral response through project funding, its overall cross-sectoral country dialogue and its role as a convener of donor and multi- lateral agencies. The Bank also contributes to strengthening implementation through its support for strengthening country systems for improved governance and accountability, transparent fiduciary management; and monitoring and evaluation. 4. Description The lending instrument proposed for the project would be a Specific Investment Loan (SIL) for US$ 10 million with co-financing from the Government. It would provide dedicated funds for a set of activities prioritized in the national strategic plan. Component 1: Prevention Activities. Prevention activities are a high priority of the National HIV/AIDS Program and need to be scaled up significantly to halt and reverse the spread of the epidemic. Three implementing agencies will scale up prevention activities: the Ministry of Health and Environment and the Regional Health Authorities; five non-health line ministries; and civil society including the private sector. Subcomponent 1(a): Prevention Activities by the Ministry of Health and Environment and Environment (MOHE) and the Regional Health Authorities (RHAs) . This subcomponent will strengthen the capacity of MOHE and of the RHAs to provide technical guidance for the national response to HIV/AIDS and to deliver HIV/AIDS related services for prevention through the health care system. Activities financed would include: (i) Support to behavior change communication (BCC) interventions targeting at-risk groups (commercial sex workers, men having sex with men, in and out of school youth, inmates, drug users) and the general population; (ii) Expansion of VCT for scaling up treatment and care and for preventing HIV transmission and expansion of PMTCT Services; (iii) Increased condom use; and (iv) Development of strategies and activities to promote the health of HIV positive persons: supportive environment for disclosure, promoting peer support groups within the health services, reproductive health services, and ensuring social support. Subcomponent 1. (b): Prevention Activities by the Non-Health Line Ministries. Strengthening Prevention Requires Scaling up the Contribution f the Non-Health Line Ministries . This aims to make the national response truly multi-sectoral. Five key line ministries: (a) Education; (b) Labor and Social Security; (c) Tourism; (d) Local Government, Community Development and Sports; and (e) National Security have been identified because they can reach important segments of vulnerable and/or at risk population groups through their official mandates. Activities would include implementing workplace HIV/AIDS policies; BCC; condom distribution and promotion; advocacy to reduce HIV/AIDS stigmatization and discrimination; training; and, technical and material support for focal points, and their respective ministerial HIV/AIDS Committees. Subcomponent 1. (c): Prevention Activities by Civil Society Organizations (CSOs ). The project would finance CSOs through demand- driven “subprojects” that would target interventions for: a) Youth that would include sexuality education, risk assessment, behavior modeling and leadership training; b) Commercial Sex workers (CSWs) interventions that include better access to counseling and health care, skills development for alternative income generation, referral to Page 5 agencies such as housing and drug addiction/prevention and support to increased involvement of club operators/ and the tourism services in risk reduction interventions including increased condom use; c) Men having sex with men by continuing training of trainers on risk reduction among the MSMs, referral to STI/HIV test and treatment along with adherence and positive prevention. Component 2: Treatment, Care and Support. This component would provide financing to support the strategy outlined in the NSP to enhance the following services: (a) Laboratory Services . The project would help strengthen HIV diagnostic services at the regional laboratories and the National Public Health Laboratory (NPLH). It would finance testing kits, reagents and supplies for HIV and syphilis. The project would also finance the training of staff, reviewing HIV testing algorithms and quality control mechanisms and a maintenance plan for equipment; (b) Blood Safety . All blood collected is screened for infectious markers including HIV at the National Blood Bank located in Kingston. Blood donations mainly come from replacement donors. The project will support blood safety including efforts to increase voluntary blood donations; (c) Treatment : antiretroviral therapy, PMTCT opportunistic infections (OIs) and sexually transmitted infections (STIs). The project would finance drugs including antiretroviral therapy drugs, nutritional supplements, substitution infant feeding formula, and training of health care workers in comprehensive management of HIV, STIs, OIs and PMTCT; and (d) Tuberculosis (TB). The project would support scaling up diagnosis and treatment for TB patients and the detection of HIV in this group through the financing of laboratory equipment and supplies to expand AFB smear in regional laboratories. It would also contribute to other supportive services. Component 3: Strengthening Institutional Capacity for Policy Formulation, Program Management and Monitoring and Evaluation. Subcomponent 3. (a) Policy Formulation for an Enabling Legal and Regulatory Environment and Human Rights. The project will provide technical assistance to support changes to the legislative framework that have been recommended by the legislative review including updating of the Public Health Act to deal with new health challenges such as HIV/AIDS and advocacy for further legislative and policy reform to address stigma and discrimination. Subcomponent 3. (b) Program Management . The project will also support staff costs required for the technical (reviewing work programs from line ministries and proposals from civil society implementing agencies; monitoring and evaluating program progress; and, training its staff and fiduciary functions of the PCU, Line Ministries and CSOs) and fiduciary functions of the PCU. Subcomponent 3. (c) Monitoring And Evaluation. The project will finance technical assistance, equipment and training to strengthen the M&E system and the decision- making process through: staffing; training; preparation of a costed M&E Operational Plan and Map; harmonizing the information flow from multiple data sources for impact, outcomes, outputs and inputs; i.e., biological HIV surveillance; behavioral HIV surveillance; studies on special populations and other small surveys; conducting surveys and surveillance; integrating the five national and sub-national HIV databases; and, prioritizing the evaluation and research agenda. Component 4: Health Sector Development Support . Sub-component 4 (a) Biomedical Waste Management . The project will support upgrading and improved management of the biomedical waste management system. This will include: technical assistance for drafting new national medical waste management regulations; upgrading medical waste treatment facilities; equipment and capacity building activities: develop and disseminate medical waste management training Page 6 material; train healthcare workers in medical waste management and post exposure prophylaxis, including regional ‘Training of Trainers’ workshops; share best practices; and train staff for operation and maintenance of new equipment. Sub-component 4 9( b)Diagnostic Capacity Assessment for the Health Sector . This sub-component will also finance an assessment of the obstacles that limit the capacity of the health sector to deliver quality health care efficiently. It would prioritize cost effective interventions and finance those that would be most helpful to the NHP to reach its objectives. Activities to be financed could include technical assistance, consultant services, medical equipment and supplies, minor civil works to upgrade and renovate health care facilities, and training of health care personnel. 5. Financing: Source: ($million) Borrower 1.00 International Bank for Reconstruction and Development 10.00 Total 11.00 6. Implementation Institutional and Implementation Arrangements . The project will be managed by the Project Coordination Unit of the National HIV/STI Program (NHP) within the Ministry of Health and Environment. Implementation will be carried out by the MOHE and the RHAs; selected non- health line ministries, civil society organizations and the private sector. The NHP will report to Cabinet through the Minister of Health and Environment. The National AIDS Council will provide policy advice to the Cabinet and the NHP. The Government Ministries implementing project activities will prepare annual work plans which are aligned to the Government annual budgets. CSOs will be funded through a demand-driven process based on the system that has been put in place under the ongoing Bank-financed project. Financial Management Arrangements. The overall financial management responsibility under the Project will be coordinated and guided by the Project Coordinating Unit (PCU). The Ministry of Finance and Public Service will issue warrants covering the budget for the project for each fiscal year. Expenditures incurred that would be financed out of the World Bank loan proceeds will be funded out of the designated account to be established at the PCU. The main designated account under the project would be managed by the PCU. The RHAs would maintain individual designated accounts that would be replenished periodically from PCU’s account. Expenditures by the Line Ministries and Civil Society Organizations would be funded out the PCU’s designated account. Procurement Arrangements . Procurement for the proposed project would be carried out in accordance with the World Bank’s ‘Guidelines: Procurement Under IBRD Loans and IDA Credits’ dated May, 2004 revised October 1, 2006; and ‘Guidelines: Selection and Employment of Consultants by World Bank Borrowers’ dated May 2004 revised October 1, 2006, and the provisions stipulated in the Legal Agreement. A procurement plan will be prepared and updated Page 7 regularly (at least annually or as required) to reflect the actual project implementation needs and improvements in institutional capacity. Procurement procedures and Standard Bidding Documents to be used for each procurement method as well as model contracts for works and goods procured, are presented in the project operations manual. Safeguard Assessments. One safeguard policy, Environmental Assessment (OP/BP/GP 4.01) is triggered due to the biomedical waste that will be generated in the course treatment. The Government has a bio-medical waste management system in place. A number of investments including upgrading of biomedical waste equipment and staff training have been financed under the ongoing Bank-financed project. The assessment under the ongoing project has been updated and a number of areas identified for further strengthening of health care waste management. Some of the priority actions will be financed under the new project. EA has been prepared and is disclosed in the Bank's Infoshop and on the Government’s website. 7. Sustainability The following factors will contribute to program sustainability after project completion: (a) An enabling policy and legal environment with strong political support and leadership for dealing with HIV/AIDS; (b) Government’s willingness and ability to sustain public awareness of HIV/AIDS issues; (c) Implementation sustainability: development of broad ownership and a strong institutional coordination mechanism for the expanded response to the pandemic and the involvement of other key stakeholders (line ministries, NGOs, FBOs, local communities, etc.) in implementation; (d) Converting some of the PCU positions into permanent establishment posts to create an institutionalized and sustainable core group of professionals to coordinate and support the implementation of the national HIV/AIDS Program; and (e) Financial sustainability would include Government budget allocations to finance the national HIV/AIDS program and continued support from external sources especially the Global Fund. 8. Lessons Learned from Past Operations in the Country/Sector There are a number of lessons learned from implementing the ongoing Bank-financed project, The Jamaica HIV/AIDS Prevention and Control Project, as well as from other Bank and donor- financed projects throughout the Caribbean 4 . (a) Prevention . The number one issue posited by the NSP is increasing prevention activities and improving strategic focus. This is consistent with the experience in other Caribbean countries and globally. Activities that lead to behavior change need to be more skillfully designed and intensified to respond to the complex socio-economic factors that are driving the epidemic such as multiple partners, commercial and transactional sex and poverty. This project will contribute 4 The Bank led a multi-agency review of the Caribbean HIV/AIDS Program in 2005. Page 8 through a two pronged strategy: targeting interventions at high risk groups and implementing non- targeted activities for the general population. (b) Stigma and discrimination in Jamaica as in most Caribbean countries, is still a major impediment to the response to the epidemic as it prevents people from seeking care and caregivers from giving appropriate care. (c) The fight against HIV/AIDS requires a multi-sector response with buy-in from leadership in Government, key non-health line ministries, the private sector and participation of a cross-cutting range of stakeholders: CSOs, community level and household levels, religious groups, professionals groups and PLWHA. The project will scale up the role and capacity of non-health line ministries as well as CSOs. (d) The health system still requires considerable strengthening to enable it to cope with the increased demands for prevention, treatment and care brought on by the HIV/AIDS epidemic: improving physical facilities; diagnostic capacity; and, increasing the number and skills of staff. Based on the experience of the first project, it is important to identify and solve the most urgent bottlenecks in service delivery. (e) The fight against HIV/AIDS is expensive and Jamaica needs additional resources to sustain the momentum it has built. Along with this, it is critical for the NHP to be institutionalized through the establishment of staff positions on the regular public payroll. The Government needs to continue to keep HIV/AIDS as a priority in its expenditure plans as it has done in the past to ensure that HIV/AIDS response is not compromised when the Government faces budget shortfalls. (f) Finally, it is important to note that t here is no proven “production function” in responding to HIV/AIDS in a complex epidemic such as Jamaica’s. Research will be important to continue to identify those areas that contribute the most to addressing the epidemic. 9. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment ( OP / BP 4.01) [X ] [ ] Natural Habitats ( OP / BP 4.04) [ ] [X] Pest Management ( OP 4.09 ) [ ] [X] Physical Cultural Resources ( OP/BP 4.11 ) [ ] [X] Involuntary Resettlement ( OP / BP 4.12) [ ] [X] Indigenous Peoples ( OP / BP 4.10) [ ] [X] Forests ( OP / BP 4.36) [ ] [X] Safety of Dams ( OP / BP 4.37) [ ] [X] Projects in Disputed Areas ( OP / BP 7.60) * [ ] [X] Projects on International Waterways ( OP / BP 7.50) [ ] [X] * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas Page 9 10. List of Factual Technical Documents Draft National Strategic Plan 2007-2012 (September, 2007 Version) Jamaica HIV/AIDS World Bank Follow on Project Concept Paper and Project Overview Jamaica HIV/AIDS Prevention and Control Project Appraisal Document (PAD) Jamaica Second HIV/AIDS Project –Project Concept Note Jamaica Second HIV/AIDS Project. Decision Note of the PCN Review Meeting Project Concept Supplementary Note Aide-memoire of the mid-Term Review Mission, April 25-29, 2005 Aide-Memoire of the Supervision Mission and Identification of the Second Jamaica HIV/AIDS Project, October 1-5, 2005 HIV/AIDS in the Caribbean Region: A multi-organization Review. World Bank. 2005. Jamaica UNGASS Report January 2003-December 2006 HIV/AIDS WORKPLACE Survey Report on HIV/AIDS Second Generation Surveillance Survey (BSS) Among Female Sex Workers, Jamaica, 2005. Report of National Knowledge, Attitudes, Behaviour and Practices (KABP) Survey, 2004 HIV Epidemic Update 2006 Jamaica Second HIV/AIDS Project assessments: Medical Waste Management Assessment. Jamaica Second HIV/AIDS Project assessments: Social Assessment. Jamaica Second HIV/AIDS Project assessments: Health Sector Response Assessment. Jamaica Second HIV/AIDS Project assessments: Legal Issues Affecting HIV/AIDS Assessment. 11. Contact point Contact: Mary T. Mulusa Page 10 Title: Senior Public Health Specialist Tel: (202) 473-1937 Fax: (202) 614-6054 Email: mmulusa@worldbank.org 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: pic@worldbank.org Web: http://www.worldbank.org/infoshop