81596 TRANSPORT NOTES TRANSPORT & SOCIAL RESPONSIBILITY THEMATIC GROUP THE WORLD BANK, WASHINGTON, DC Transport Note No. TRN-42 September 2010 Addressing HIV/AIDS in South Caucasus Transport Projects Christopher R. Bennett, Julie Babinard, Satoshi Ishihara, and Robb Butler Transport has been identified as a sector that is particularly vulnerable to the HIV/AIDS epidemic. For this reason, explicit provisions for HIV prevention and awareness training are now embedded in the World Bank standard bidding documents for procurement of works in excess of US$10 million. These provisions were developed for countries with high national prevalence rates for HIV/AIDS. However, countries of Europe and Central Asia (ECA) have low prevalence rates of 1 percent or below, even in the worst affected countries of the region such as Ukraine, Russian Federation, Belarus, and Moldova. Using funds from the Transport and HIV/AIDS Incentive Trust Fund supported by the Global AIDS Program (GHAP), a study was undertaken on the viability of developing a risk-based approach for HIV/AIDS interventions to be applied in low prevalence countries. This note summarizes the findings of the work and presents an approach for addressing HIV/AIDS issues in transport projects in the South Caucasus. The findings, interpretations, and conclusions expressed here are those of the authors and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. HIV/AIDS in the Europe and Central Asia were linked to unprotected heterosexual Region intercourse. The number of IDU’s increased significantly between 2001 and 2006 in several The Europe and Central Asia Region (ECA) is countries, including Azerbaijan, Georgia, experiencing one of the world’s fastest-growing Tajikistan, Ukraine, and Uzbekistan. HIV/AIDS epidemics. 1 According to UNAIDS, the estimated number of people living with HIV in the There is a high increase in the number of newly region in 2007 rose to 1.5 million. Almost 90 HIV-infected women who have been infected as a percent of those infected live in either the Russian result of unprotected sex with an IDU partner. Federation (69 percent) or Ukraine (29 percent). 2 About 40 percent of newly registered HIV cases in the region in 2006 were women. Additionally, it is An estimated 110,000 people in the region estimated that some 35 percent of HIV-positive became infected with HIV in 2007 and some women were infected through intravenous drug 58,000 died of AIDS related illnesses. The annual use and a further 50 percent were estimated to numbers of newly reported HIV diagnoses are also have been infected by IDU partners. rising in Azerbaijan, Georgia, Kazakhstan, the Kyrgyz Republic, Moldova, Tajikistan, and HIV/AIDS in the South Caucasus Uzbekistan which now has the largest epidemic in Central Asia. There are increasing numbers of new HIV cases being reported in each of the South Caucasus The HIV epidemics in Eastern Europe and Central countries (Armenia, Azerbaijan and Georgia). Asia are concentrated mainly among intravenous While the information about HIV prevalence is drug users (IDU’s), sex workers and their various incomplete, it does shows a region with high sex partners. Of the new HIV cases reported in concentrations of HIV within specific sub- 2006 for which there was information on the populations rather than a more generalized mode of transmission, some 62 percent were infection profile. In all three countries, attributed to intravenous drug use and 37 percent transmission patterns follow similar patterns. IDU’s are reported as the leading group of HIV 1 ‘HIV/AIDS and Transport in the European and Central infection. The second most often reported mode of Asian Region’. J. Babinard. The World Bank, 2009. transmission is unprotected heterosexual activity, 2 ‘2008 Report on the Global AIDS Epidemic: Country typically with an IDU partner, a labor migrant, a Progress Indicators’. The Joint United Nations Programme on HIV/AIDS. Page 2 Transport NoteTRN-42 September 2010 commercial sex worker, or sexual contact with Condom availability across the region varies other partners at risk. significantly, as does the quality and affordability of quality condoms. Sexually transmitted infection In Armenia, HIV infections have been (STI) testing center coverage is poor, and severe predominantly among intravenous drug users, stigma regarding both usage of testing centers almost all of them men. Males constitute the (which are not always equipped to counsel users) majority of the total number of HIV cases, with and condoms is prominent. some 72 percent reported to be aged 20-39. There are an estimated 2,800 people living with The region is experiencing a dramatic increase in HIV in the country. During the past two years, the the volume of cross border traffic due to transport registered cases of HIV transmission through network development and regional economic sexual contacts have been higher than the cases integration. This can, in turn, lead to increased of HIV transmission through intravenous drug use. risk for HIV infection as an increasing number of All people infected through intravenous drug use people may be exposed to substance use and were men, while almost all women were infected risky sexual behavior. Four countries – Poland, through sexual contact. An HIV surveillance study Latvia, Lithuania and Estonia – are particularly at in 2007 reported that HIV prevalence among IDUs risk due to the high prevalence rate in the is about 7 percent and less than 2 percent among neighboring countries and their geographical female sex workers. More than half the infections location at the cross roads of the main east-west to date have been in the capital, Yerevan. and north-south transport corridors.3 In Azerbaijan, intravenous drug use is widespread Other sub-groups of transport workers, such as and the majority of HIV infections reported to sailors, may also be at risk. Evidence from date have been attributed to exposure to non- Montenegro and Georgia suggests that sailors sterile drug injecting equipment. Almost half of may be at a higher risk of HIV infection. In the HIV infections reported were in the capital, Georgia, it was reported that 71 percent of Baku, where 13 percent of IDU’s tested HIV- Georgian sailors and 97 percent of foreign sailors positive in a 2003 survey. had a paid partner in the past year. 4 In Georgia, nearly 60 percent of the 1,156 Mobility and migration, which are occurring on a registered cases to date were reported in the past large scale throughout the region but are not well three years and the majority of people living with documented, could play a key role in the spread HIV reside in the capital, Tbilisi, and in the west of of HIV/AIDS through the transport sector. Data the country (especially in Batumi and Zugdidi). from Armenia shows that migrant workers have The rising numbers of newly reported infections lower levels of knowledge about HIV than other are associated with widespread intravenous drug key population groups and there is evidence of use and frequent cross-border movement of behavior that increases the risk of contracting persons to and from higher-prevalence countries HIV. Also, regional evidence suggests that such as the Russian Federation and Ukraine. heterosexual transmission across the region is driven by high flows of migrant workers. HIV/AIDS in the transport sector However, monitoring HIV transmission within In the ECA region there is much anecdotal migrant populations is very difficult as the evidence, but few studies exist, that link the majority of labor migration remains transport sector with HIV transmission. A study in undocumented. Evidence from other areas of the the Baltic countries, perhaps the first of its kind in world suggests that migrants are likely to engage the region, explored the practice of casual sex in risky sexual behaviors at their destination due among truck drivers and commercial sex workers to decreased social monitoring and attempts to in the border areas of the Baltic region and cope with the strains and stress of resettlement. 5 extrapolated the potential impact on the spread of Furthermore, access to medical services, condoms HIV/AIDS in these countries. 3 The review found and HIV testing is limited for these groups, that truckers often engage with multiple sex partners on the road with little awareness of the risks involved. 4 ‘Knowledge, Attitudes and Behavior Related to HIV/AIDS among Transport Sector Workers: A Case Study of Georgia. HIV/AIDS and Transport in Europe and Central Asia’. Europe and Central Asia Region. 3 ‘HIV/AIDS in the Western Baltics: Priorities for Early Washington, DC: The World Bank Group, 2008. 5 Prevention in a High-Risk Environment’. World Bank ‘Transport against HIV/AIDS: Synthesis of Experience Working Paper No. 68. Washington, DC: The World Bank and Best Practice Guidelines.’ Transport Papers TP-24. Group. Washington, DC: The World Bank Group, 2009. Page 3 Transport NoteTRN-42 September 2010 particularly if they are found to be HIV-positive and deported to their country of origin. 6 Box 1: World Bank Standard Bidding Documents: HIV/AIDS Clauses A recent survey of knowledge, attitudes, and Section VII. General Conditions behavior related to HIV/AIDS among transport sector workers in Georgia has identified their 6.7 Health and Safety unique needs with respect to HIV in the region. 7 The study revealed that HIV/AIDS awareness is (…) HIV-AIDS Prevention. The contractor shall high but that knowledge about transmission and conduct an HIV-AIDS awareness program via an prevention varies. As in other regions of the approved service provider, and shall undertake world, a key finding is that transport workers of such other measures as are specified in this the region are more likely to contract HIV through Contract to reduce the risk of the transfer of the sexual transmission than through intravenous HIV virus between and among the Contractor’s drug use. Personnel and the local community, to promote early diagnosis and to assist affected individuals. Compared with Africa, the ECA Region has low prevalence rates of the disease, with the majority The Contractor shall throughout the contract of infections sill concentrated in high-risk (including the Defects Notification Period): (i) populations. However, these figures also mask conduct Information, Education and Consultation differences in epidemic levels and patterns of Communication (IEC) campaigns, at least every transmission within the region. In countries where other month, addressed to all the Site staff and prevalence is much higher in certain areas and labor (including all the Contractor's employees, all among certain populations like in the ECA Region, Sub-Contractors and Consultants' employees, and HIV can move beyond its initial concentration in all truck drivers and crew making deliveries to the higher risk groups leading to an important Site for construction activities) and to the "tipping point" for each country. immediate local communities, concerning the risks, dangers and impact, and appropriate A risk-based approach to HIV/AIDS avoidance behavior with respect to of Sexually education Transmitted Diseases (STD)—or Sexually Transmitted Infections (STI) in general and The World Bank has provisions for HIV/AIDS HIV/AIDS in particular; (ii) provide male or female mitigation in its standard bidding documents condoms for all Site staff and labor as (SBD) for procurement of works in excess of appropriate; and (iii) provide for STI and US$10 million. The “Health and Safety” clauses HIV/AIDS screening, diagnosis, counseling and (Section 6.7) in the General Conditions of referral to a dedicated national STI and HIV/AIDS Contract include a model clause to implement an program, (unless otherwise agreed) of all Site HIV/AIDS awareness program via an approved staff and labor. (…) service provider such as an NGO, a health provider or a government body. The wording of Source: Standard Bidding Documents, these clauses is presented in Box 1. Procurement of Works, May 2006. Revised March and April 2007. The SBD clauses require that all contractors working on large World Bank transport projects implement HIV/AIDS programs encompassing Four practical challenges have been faced in prevention and awareness raising for their seeking to implement the SBD HIV/AIDS clauses: employees, sub-contractors, consultants, truck drivers and delivery crew as well as local i. obtaining support of the client for communities in the proximity of the project site. A undertaking an HIV/AIDS Information, non-discriminatory policy should be implemented Education and Consultation towards people found to be HIV/AIDS positive. Communication (IEC) or Behavior Change campaign; ii. ensuring that an appropriate campaign is conducted; 6 ‘HIV and AIDS in the Caucasus Region: A Socio- iii. monitoring the results and the impact of Cultural Approach’. UNESCO, Paris, France, 2005. the education provided; and, 7 ‘Knowledge, Attitudes and Behavior Related to HIV/AIDS among Transport Sector Workers: A Case Study of Georgia. HIV/AIDS and Transport in Europe iv. guidance on how to implement the and Central Asia’. World Bank report. clauses, particularly how implementation Page 4 Transport NoteTRN-42 September 2010 should vary depending on a country’s and activities cannot compensate for a epidemic level, the type of transport comprehensive situational assessment. Such project, the socio-economic context of the assessment-informed interventions are more project area and groups to be targeted by appropriate because they consider the the HIV education campaign. complexities of staff composition as well as the geographic coverage and vulnerability factors that These challenges have been compounded by the exist along a road section. These factors must be ‘one size fits all’ approach suggested by the SBD taken into account when designing the IEC clauses which were developed based on campaign. 11 experiences in countries with a high generalized prevalence of HIV/AIDS: a fundamentally different Every transport project involves the participation situation from much of the ECA Region. The view of workers who fall into three groups: low, is emerging 8 that it needs to be determined medium or high mobility, and road projects whether the SBD clauses should apply in all cases, invariably contain a mixture of all three mobility particularly in countries with low HIV prevalence groups. There are also managers and supervisors, like in the ECA region. skilled technical staff (for example equipment operators and surveyors), and laborers to The viability of adopting a risk-based approach to consider. develop an IEC campaign for the ECA Region was investigated in detail. The objective was to tailor In the majority of projects with international an IEC campaign based on; (i) the HIV prevalence contractors, managers, supervisors and other level of a country; and, (ii) the risk level of a skilled staff are migrant workers, often from other specific transport construction project. Such countries. Laborers may be migrant or locally tailoring would help distinguish interventions employed, but are usually seasonal workers from according to HIV epidemic levels. the country where the works are being undertaken. A conceptual framework was developed. 9 In this, the HIV epidemic level was classified as low (<1 Recent reviews of transport projects have percent in any sub-population), concentrated (<1 highlighted the increased HIV risk of the percent of general population and >5 percent managers, supervisors and the skilled staff high-risk groups) or generalized (>1 percent of groups, due to the fact that they are migrants, general population). Additionally, three levels of that they have expendable income as skilled staff, worker mobility were defined (low/medium/high). and that they have access to vehicles and drivers For each combination, target groups, intervention that enable them to visit local towns and cities and implementation levels, and specific outcomes regularly. from an IEC campaign were proposed. Staff who are classified as ‘local’ workers may in Field work was undertaken to investigate the fact engage in seasonal migration work viability of the proposed approach. 10 It was found themselves: in the Armenian Lifeline Road Project that the proposed framework had some it was found that many of those employed advantages, but that its widespread application is normally worked in the Russian Federation but questionable. The framework could assist in stayed in Armenia for the construction season due identifying the extent and budget required for an to the opportunites provided locally. IEC campaign, but the failure to carefully consider the specific local conditions could lead to The HIV and AIDS epidemics vary across and detrimental results. within countries. Furthermore, many road sections link areas where patterns of HIV transmission are Challenges with a risk-based approach different, risk factors vary, and where prevalence levels are different (higher or lower). Any risk- A key finding was that a risk-based approach based approach for IEC Campaigns would based on a matrix of suggested inputs, materials therefore need not only to consider the prevalence risk where the project was being conducted, but a 8 multi-dimensional risk profile, based on the ‘Review of the application of the HIV/AIDS contract origins of the different workers and their roles on clauses to date in the transport sector’. S. Brushett, et the project. al. Forthcoming World Bank report, to be published autumn 2010. 9 ‘A Risk-Based Framework for ECA HIV/AIDS 11 Interventions’. J. Babinard. The World Bank, 2009. These aspects have also been discussed in ‘Transport 10 ‘South Caucasus: Pilot testing of Guidelines for HIV against HIV/AIDS: Synthesis of Experience and Best Interventions in Transport Construction Projects’. R. Practice Guidelines’ Transport Paper TP-25. World Bank. Butler. Report to the World Bank, 2009. July 2009. Page 5 Transport NoteTRN-42 September 2010 A situational analysis at the time of project HIV/AIDS surveys which should include a variable preparation (i.e. before contracts are awarded) is concerning training session attendance. therefore essential to identify the type and extent of any IEC intervention to be undertaken. After The BoQ could also contain a lump sum for the awarding the contract, the campaign’s objectives operation of an IEC Campaign for the local and target groups would need to be refined to residents. The cost of this campaign, as well as meet the specific requirements of the contractor’s that for the workers, should be estimated from teams. the situational analysis done during project preparation and proposed as unit rates rather Improving the delivery of HIV/AIDS IEC than leaving the contractor to estimate them. The project assessed how the delivery of Using the BoQ in this capacity requires an HIV/AIDS IEC campaigns could be made more understanding and willingness to include HIV effective. The delivery of the HIV/AIDS IEC education by the client. campaigns should be done by an approved service provider—usually an NGO or government heath Standard Bidding Document Clauses agency—with experience in delivering IEC campaigns. The program should have support To further improve the delivery and effectiveness from a national HIV/AIDS commission/Ministry of of HIV/AIDS IEC Campaigns, Box 2 presents Health. The effectiveness of the efforts would be proposed new clauses to replace the standard improved by having (i) clearer payment clauses in Box 1. These could be included as mechanisms; and, (ii) guaranteed access to particular conditions of contract. workers in order to ensure that they will benefit from and attend HIV/AIDS training. The following • Para 1 (Unchanged). States an expectation sections propose how this should be achieved. that the contractor will sub-contract an approved service provider to conduct an HIV Payment through the Bill of Quantity awareness program; • Para 2 (Changed). The proposed changes seek A challenge faced in implementing HIV/AIDS IEC to: (i) ensure that actions are consistent with campaigns is to gain access to workers. the HIV/AIDS response of the country project, Contractors and construction sub-contractors at consistent with national activities, and any site are usually resistant to their workers established in relation to a situational taking time away from the workplace to take part assessment (i) ensure all staff have basic in educational activities on HIV/AIDS or in any HIV/AIDS awareness training; (ii) integrate type of health or social development training. One HIV/AIDS awareness activities to be part of way of addressing this is by including HIV/AIDS the regular health and safety training that all education in the Bill of Quantities (BoQ). The BoQ contractors should undertake; (iii) require is prepared early in the project, before contractors contractors to ensure that workers know of are hired and is the basis for payments to the the available VCT services and are actively contractor. encouraged to use them—as well; and, (iv) recognize the importance of access to quality Ensuring attendance to IEC training would affordable condoms for the workers and local constitute a first step to having an impact on community; 12 behavior change and for beginning to measure the • Para 3 (Changed). States that the components effectiveness of interventions through indicators should be priced and resources that are focused both on outputs and outcomes. required should be outlined; • Para 4 (Changed). Requires clear inclusion of Bill No.1, the ‘Preliminary’ and ‘Additional Items’ HIV/AIDS education in the BoQ. Bill, should include a pro-rata rate per employee training attendance. In other words, a rate should be set for each employee that undergoes HIV education through the lifetime of the project. This does not have to be a substantial rate per attendant, only sufficient to subsidize and offset some of the costs of the worker taking part in the session(s). Attendance could be easily verified by the list of attendees at the approved service 12 For high-risk groups and in areas where the known provider training sessions. Further verification factors of transmission are through IDUs, other should be undertaken during the post-intervention interventions, such as clean needle and syringe exchange programs, may be necessary. These would be identified by the situational analysis. Page 6 Transport NoteTRN-42 September 2010 pilot projects, a methodology for country-specific Box 2: Proposed new HIV/AIDS IEC clauses and regional application would be developed. The to replace the standard clauses (Box 1) pilot studies would provide guidance on HIV 6.7 Health and Safety responses, based on the mobility of workers as well as countrywide and regional HIV prevalence. (…) HIV-AIDS Prevention. The contractor shall In addition to IEC materials, the pilot projects conduct an HIV-AIDS awareness program via an would adapt other existing tools and materials to approved service provider, and shall undertake maximize benefits to workers, and build support such other measures as are specified in this and engagement of the ministries of transport and Contract to reduce the risk of the transfer of the transport authorities in HIV responses on the HIV virus between and among the Contractor’s Bank’s civil works activities. 13 Personnel and the local community, to promote early diagnosis and to assist affected individuals. The outcomes of the pilots would be: [No change] • To demonstrate the value of an HIV The contractor shall throughout the contract and component on transport project in the South with the assistance of an approved service Caucasus through shifts in worker’s basic provider: (i) ensure that all staff attend Induction HIV/AIDS awareness and knowledge, reduced Training programs which include an HIV/AIDS stigmatization, provision of access to quality education component, (ii) ensure that HIV/AIDS affordable condoms, and knowledge and topics are included in regular health and safety ability to access VCT. Impact will be measured sessions at civil work sites, (iii) conduct by comparing pre- and post-intervention rapid Information, Education and Consultation assessments on staff/labor/workers at work Communication (IEC) campaigns, addressed to all sites; the site staff and labor (including all the • To review the relevant sections of the ‘Road to contractor’s employees, all sub-contractors and Good Health Toolkit’ and make consultants employees, and all truck drivers and recommendations for future applicability in crew making deliveries to the site for construction the South Caucasus transport sector; activities) and to the immediate local communities • To build support in the transport sector for the concerning the risks, dangers and impact of STIs management of HIV/AIDS epidemic and HIV/AIDS in particular, and provide accurate prevention; and, referral information existing STI and HIV/AIDS • To actively disseminate and share experiences screening, diagnosis, and services as well as the within the South Caucasus public sector HIV National HIV/AIDS program; (iv) ensure access to response partnership to foster understanding quality, affordable condoms for all the and support future scaling up and aforementioned site staff and labor groups. mainstreaming of HIV/AIDS interventions in [Changed] the transport sector across the region of the South Caucasus - under the umbrella of a For each component, the program shall detail the regional (South Caucasus) program. resources to be provided or utilized and also include provision of detailed cost estimate. It is anticipated that funding will be secured in [Changed] 2010 to proceed with at least one country pilot project in one of the South Caucasus countries. There shall Items in the Bill of Quantities related to the engagement of all site staff and labor on HIV education training sessions. [Changed] Next Steps The next steps will be to pilot test the proposed approach. Approved local service providers with a track-record in HIV education would manage the HIV education activities on selected Bank-financed road sector projects in the South Caucasus countries. 13 Through the design, management and The project will adapt the existing IEC resources in dissemination of findings and experiences in HIV the ‘The Road to Good Health Toolkit’ which can be downloaded from: http://www.TheRoadToGoodHealth.org. Page 7 Transport NoteTRN-42 September 2010 For Further Information Christopher R. Bennett, Senior Transport Specialist (cbennett2@worldbank.org) Julie Babinard, Environmental and Social Development Specialist (jbabinard@worldbank.org) Satoshi Ishihara, Social Development Specialist (sishihara@worldbank.org) Robb Butler, HIV/AIDS Specialist (rbutler@rcgglobal.net) To learn more: World Bank Transport website: http://www.worldbank.org/transport Transport in Europe and Central Asia Region: http://go.worldbank.org/OTO14241H0