Page 1 INTEGRATED SAFEGUARDS DATA SHEET CONCEPT STAGE Report No.: AC4381 Date ISDS Prepared/Updated: 05/11/2010 I. BASIC INFORMATION A. Basic Project Data Country: Pakistan Project ID: P113484 Project Name: Pakistan - Second HIV/AIDS Prevention Task Team Leader: Cornelis P. Kostermans Estimated Appraisal Date: May 25, 2010 Estimated Board Date: September 28, 2010 Managing Unit: SASHN Lending Instrument: Specific Investment Loan Sector: Health (100%) Theme: HIV/AIDS (100%) IBRD Amount (US$m.): 0.00 IDA Amount (US$m.): 31.50 GEF Amount (US$m.): 0.00 PCF Amount (US$m.): 0.00 Other financing amounts by source: BORROWER/RECIPIENT 11.25 UK: British Department for International Development (DFID) 13.50 24.75 B. Project Objectives [from section 2 of PCN] The proposed project development objective is to support the Government of Pakistan to (a) contain the spread of the epidemic among most at risk groups and this way prevent its spread to the general population, and to (b) improve the health and wellbeing of those infected. The project seeks to prevent the spread of HIV by expanding coverage of HIV preventive services to high risk populations through province-wide service delivery packages for IDUs, male and female sex workers, transgender, jail inmates and truckers; and improving their quality by strengthening monitoring and evaluation of targeted interventions. Improving the health and well being of PLWA will be addressed by (i) improving access and effectiveness of testing, and care and treatment services; and (ii) reducing stigma. C. Project Description [from section 3 of PCN] Given the current dynamics of HIV in Pakistan, the proposed follow-on operation will focus financing on priority activities essential to preventing further spread of the epidemic and will have four components: These will include: i) expanding coverage of HIV preventive services to high risk group through province-wide service delivery packages; ii) improving treatment and care of people live with HIV through improving access and quality of treatment faculties; (iii) Page 2 and creating an enabling environment through the support of advocacy and communication activities; and vi) strengthening government capacity to respond through strengthened monitoring and evaluation of targeted interventions and treatment and care services. Component 1. Scaling up of Interventions for Most-at-Risk Populations This component would support the rapid and systematic expansion of programs aimed at providing most-at risk-populations (MARPs) with the services they need to prevent HIV. These services have been selected on the basis of the best available scientific and programmatic evidence and reflect global best practice. The Government would contract with NGOs to provide the following: (i) behavior change communication aimed at increasing knowledge about HIV prevention and increasing protective behaviors; (ii) promotion of effective condom use, increasing condom negotiation skills with sexual partners; (iii) voluntary counseling and HIV testing; (iv) proper management of STIs; (v) needle exchange and promotion of safe injection practices (among drug users); and (vi) empowering activities that allow members of the vulnerable populations to feel they have greater control of their lives. These activities would be defined by the beneficiaries themselves. This package of services would be provided to the populations that are at greatest risk of HIV including: including for IDUs, sex workers (male and female), transgender, jail inmates, and truckers. A detailed exercise to determine unit costs of the service delivery packages for different subgroups of MARPS has been undertaken by independent international experts in consultation with local consultants and implementing NGOs. Given the information NGOs would be selected through a competitive process. Component 2: Diagnosis, Care and Treatment Services At present there are a total of 12 treatment and care centers, three of which are located in private facilities. They are located in Islamabad, Peshawar, Lahore and Karachi. There are 1755 people enrolled in the program out of which 875 are receiving anti-retroviral treatment (ART). Care is provided free of charge except in private hospitals. The Government reimburses patient expenditures at private clinics. Four of the centers account for 80 percent of cases. The focus of this component would be to improve the quality and coverage of the care provided. Limited expansion of treatment centers is envisaged. At present, GFATM is financing ART. A prevention of mother to child transmission program has been launched. Vertical transmission is exceedingly low at present and rather than testing all women coming for ante-natal care, a risk scoring system is being piloted to reduce the number tested at four main hospitals. This scoring sheet will be fine-tuned to make it more effective. An assessment of the Care and Treatment program in being carried out to better define what will be financed under this component. Component 3: Generating a more Enabling Environment This component would comprise two sets of activities: (a) Communications activities to reduce stigma towards HIV and populations affected by HIV amongst the general population and (b) Advocacy to reduce barriers to program acceptance and effectiveness. Given pervasive social stigma associated with people living with HIV, sex work (male and female) and drug use, and widespread taboos associated with talking openly about sex and condom use, a solid communications strategy needs to be implemented to generate a more enabling environment. Page 3 Activities designed to reduce stigma under the current project were not effectively implemented as they lacked a strategy, resulting in ad hoc, poorly coordinated mass media events. Moreover, given existing taboos, prevention messages were vague and limited. Advocacy has often been equated with awareness-raising. The objective of advocacy would be to facilitate, remove barriers to the implementation of the program, whether through the development of AIDS related policies, enactment of laws, modification of school curricula or standards of care, changes in the attitudes of the judiciary system, or the media. Advocacy activities should not rely on mass media as they need to be very targeted. They might include workshops, seminars, one-on-one exchanges with key officials, etc. As part of project preparation, a clear strategy for advocacy and communications is being developed. The strategy would be informed by the implementation experience so far and in line with requirements of the Pakistan epidemic. For communication, the strategy will identify the target groups, medium and types of messages to be developed for each target group. In the case of advocacy, the strategy will identify the barriers to the generation and implementation of specific HIV/AIDS policies, and identify the solutions (the persons that would need to be targeted to remove barriers and activities that would need to be implemented). Communications activities would be subcontracted out to one firm but will be implemented in a decentralized manner. A decision regarding whether or not IDA would finance this component would be made at appraisal. Component 4: Strengthening Capacity to Respond 1. This component would aim to develop the capacity of the government to improve the effectiveness and quality of interventions through strengthened monitoring and evaluation of targeted interventions and treatment and care services and to strengthen overall program management. In order to recruit and maintain technical staff, market based salaries and a competitive selection process is envisaged. The National Program will engage the services of an independent firm for more systematic monitoring of all components of the Program. Payments to NGOs will be made subject to an independent validation of progress. The proposed operation will also support training in management, M&E and other related areas. D. Project location (if known) The project will be implemented all across the country, including the Northern Areas and Azad Jammu and Kashmir (AJK). E. Borrower’s Institutional Capacity for Safeguard Policies [from PCN] Currently, the borrower#s capacity to implement the safeguard aspects is weak, and some strengthening is needed in terms of a) assigning roles and responsibilities; and b) capacity building. F. Environmental and Social Safeguards Specialists Mr Javaid Afzal (SASDI) Mr Mohammad Omar Khalid (SASDI) Page 4 II. SAFEGUARD POLICIES THAT MIGHT APPLY Safeguard Policies Triggered Yes No TBD Environmental Assessment (OP/BP 4.01) X An Environmental Management Plan (EMP) exists for the on-going HIV/AIDS Prevention Project. For the proposed Second HIV/AIDS Prevention Project, this EMP needs to be upgraded to address some of the weaknesses that have been identified during the implementation of the existing EMP. Natural Habitats (OP/BP 4.04) X Forests (OP/BP 4.36) X Pest Management (OP 4.09) X Physical Cultural Resources (OP/BP 4.11) X Indigenous Peoples (OP/BP 4.10) X Involuntary Resettlement (OP/BP 4.12) X Safety of Dams (OP/BP 4.37) X Projects on International Waterways (OP/BP 7.50) X Projects in Disputed Areas (OP/BP 7.60) X The project is nation-wide including AJK Environmental Category: B - Partial Assessment III. SAFEGUARD PREPARATION PLAN A. Target date for the Quality Enhancement Review (QER), at which time the PAD-stage ISDS would be prepared: N/A B. For simple projects that will not require a QER, the target date for preparing the PAD-stage ISDS: 04/15/2010 C. Time frame for launching and completing the safeguard-related studies that may be needed. The specific studies and their timing 1 should be specified in the PAD-stage ISDS. The safeguard related study will be completed by April 15, 2010 IV. APPROVALS Signed and submitted by: Task Team Leader: Mr Cornelis P. Kostermans 04/01/2010 Approved by: Regional Safeguards Coordinator: Mr Sanjay Srivastava 04/06/2010 Comments: cleared Sector Manager: Ms Julie McLaughlin 05/05/2010 Comments: Cleared 1 Reminder: The Bank's Disclosure Policy requires that safeguard-related documents be disclosed before appraisal (i) at the InfoShop and (ii) in-country, at publicly accessible locations and in a form and language that are accessible to potentially affected persons. Page 5