1. Project context, development objectives and design (this section is descriptive, taken from other documents, e.g., PAD/ISR, not evaluative).
The HIV/AIDS Prevention Project (HAPP) was appraised in June 1999. Although prevalence was low at the time of Appraisal, it was envisaged that HIV/AIDS was likely to become a major developmental challenge to Bangladesh, since there was some evidence that it was beginning to spread among vulnerable groups who were at high risk of contracting and spreading the disease. 1998-99 sero-surveillance data indicated that prevalence rates were still low among brothel-based female sex workers (FSWs) at 0.6%, but rising among injecting drug users (IDUs) at 2.5%. The risks of rapid spread among the IDUs were high due to widespread sharing of needles (96%).
The presence of other risk factors also suggested a possible general epidemic: (i) a large commercial sex industry involving an estimated 36,000 workers, with an average of 3-4 clients per day; (ii) high levels of sexually transmitted disease (STD), with syphilis rates ranging from 46% for brothel-based FSWs to nearly 57% for street-based FSWs; (iii) low levels of consistent condom use, varying from 4% for brothel workers to 27.8% among street workers; (iv) largely unscreened blood supply based on professional donors, of whom 20% had tested positive for syphilis and hepatitis; and (v) porous borders with countries with larger rates of HIV prevalence.
Awareness of the dangers of HIV and STDs was also low: in 1996/97, only 19% of ever-married women and 33% of men had heard of HIV, and condom use was extremely low. The lower status of Bangladesh women also made them more vulnerable to infection.
The overall assessment was that Bangladesh had a window of opportunity for making investments in key strategies to curtail the incidence of HIV infection even at such a nascent stage in the epidemic by: (i) promoting safe behavior through targeted interventions (TI) among groups most likely to contract and spread the disease; (ii) preventive measures for the general population, such as Information, Education, Communication (IEC) campaigns; (iii) strengthening government capacity to respond to HIV/AIDS in monitoring and evaluation (M&E), surveillance and operations research; and (iv) building up infrastructure for blood safety and STD treatment.
Government Strategy: Government of Bangladesh (GOB) had made efforts in partnership with bi-lateral and other donors to control the spread of HIV since the mid-1990s:
* A high level National AIDS Committee was formed and an STD/AIDS program was established within the Ministry of Health and Family Welfare (MOHFW) as part of the Essential Services Package (ESP). Action was taken to develop a National AIDS Policy, with an attempt to develop a multi-sectoral response to HIV. Specific action plans and guidelines for the National Program were also developed.
* A network of about 200 NGOs was formed, with about 50 NGOs actively engaged in HIVrelated activities among the most marginalized and hard-to-reach risk groups, supported by government and development partners.
* Multi- and bi-lateral development partners, such as UNAIDS, UNDP, WHO, USAID, and DfID, were financing a range of HIV prevention activities, often through NGOs.
While these early efforts formed a basis for comprehensive HIV programming, they faced significant challenges: implementation was slow; component-specific plans needed to be prioritized; quality needed to be strengthened; and the most effective interventions needed to be scaled up. Coverage of TIs among priority high risk groups was as low as 10%. It was feared that the scale of the response was insufficient to attenuate an epidemic given the widespread existence of risk factors.
The project was in keeping with the Bank's Country Assistance Strategy (CAS; Report No. 17453-BD; date of latest CAS discussion: 03/31/1998; Progress Report discussed on 07/20/1999), the over-riding objective of which was to assist Bangladesh to reduce poverty. The CAS highlighted promotion of human development (health, nutrition and population, as well as education) as a key priority of IDA's assistance strategy. The project was to help Bangladesh to scale-up the response to HIV, thereby promoting human development and directly supporting interventions that assist the poor.
The expected value-added of IDA support was: (i) IDA had already undertaken a key role in developing and coordinating the Health and Population Sector Project (HPSP), and as such was well situated to assist in developing the strategic links with other health investments in Bangladesh; (ii) The substantial cross-country experience that was available to IDA as financier of HIV/AIDS prevention and control projects globally would provide critical technical inputs to the project; and (iii) IDA investments in other sectors in Bangladesh, including education, would contribute to strengthening the necessary cross-sectoral linkages required for the HIV response.
1.2. Original Project Development Objectives (PDO) [as approved]:
To assist GOB to prevent HIV infection from gaining a larger foothold within high risk groups and to limit its spread into the general population, without stigmatizing high risk groups.
1.3. Revised PDO (as approved by original approving authority), and reasons/justification:
1.4. Main Beneficiaries, original and revised (briefly describe the "the primary target group" identified in the PAD and as captured in the PDO, as well as any other individuals and organizations expected to benefit from the project):
The project was to directly benefit: (i) groups at high risk of contracting and spreading HIV, such as FSWs and IDUs; and (ii) other vulnerable groups at risk of contracting HIV, such as clients of FSWs and men having sex with men. It was estimated that the project would reach about 750,000 individuals. About 40% of project costs were to be devoted to interventions to these groups.
In addition, the population of Bangladesh was expected to benefit from the preventive interventions, such as the IEC campaigns and blood safety component. Women would benefit from efforts to reduce their vulnerability to HIV and resulting additional marginalization. People living with HIV/AIDS (PLWHAs) would benefit from cost-effective care and support and drugs for STDs. Efforts to reduce the spread of disease, thus mitigating the social stigma and economic impact of HIV were to benefit the whole population as well.
1.5. Original Components (as approved):
Component 1 (US$22.68 million; 43.1% of total costs): High Risk Group Interventions
This component included TIs for four priority high risk groups: (i) FSWs; (ii) IDUs; (iii) Clients of sex workers (CLSW); and men having sex with men (MSM).
Component 2 (US$15.85 million; 30.1% of total costs): Communications and Advocacy
This component included interventions to create support for the HAPP by: (i) raising awareness, knowledge and understanding among the general population about HIV/AIDS/STDs; (ii) encouraging the mobilization of resources and commitment for implementation of the STD/AIDS program; and (iii) reducing stigmatization of AIDS affected people. Sub-components included (i) advocacy and (ii) public awareness.
Component 3 (US$5.01 million; 9.5% of total costs): Blood Safety
This component intended to facilitate the expansion of safe-blood initiatives, initially focusing on funding the continuation of UNDP's Safe Blood Transfusion Project (scheduled to end in 2001) for the provision of laboratory equipment and human resource capacity building for 97 district and tertiary facilities.
Component 4 (US$9.05 million; 17.2% of total costs): Project Support and Institutional Strengthening
This component included: (i) Program Management and Capacity Building by strengthening the National AIDS/STD Program (NASP) technical and managerial capacity; and (ii) M&E and Operations Research. The project also supported a package of policy and institutional reforms under this component, which included: (i) strengthening of the line Directorate, ESP and other critical MOHFW capacity in key technical areas such as procurement and financial management, M&E, and communications strategy development; (ii) developing a mechanism to facilitate the contracting and coordination of NGOs; and (iii) strengthening GOB's sentinel and behavioral surveillance and operational research capacity.
1.6. Revised Components:
There was no formal revision of the components.
1.7. Other significant changes (in design, scope and scale, implementation arrangements and schedule, and funding allocations):
Due to serious delays in start up, and slow implementation progress, the scale of the project was substantially reduced following re-structuring during the Mid-Term Review (MTR) (see section 2.2). The Development Credit Agreement (DCA) was amended and $15.4 million was canceled from the Credit on June 18, 2003, leaving $15.4 million remaining. In January 2006, a request was made to re-allocate the proceeds of the Credit between Categories (Reallocation Memo, January 2006); and it was agreed that funds would be reallocated from Categories 1 (Goods), 3 (Incremental Salaries and Operating Costs), and 4 (Unallocated) to Category 2 (NGOs, IEC Activities, Consultants' Services and Training).
The original project Closing Date was June 30, 2005. The first Extension to June 30, 2006 was granted based on the recommendation of the Joint Review Mission (April 11-21, 2005) to (i) give an opportunity for interventions to become fully established; (ii) to strengthen the capacity of NASP to effectively lead the national response to the epidemic; and (iii) to ensure a smooth transition into the Health, Nutrition and Population Sector Program (HNPSP). Subsequently a further extension of 18 months was requested (A-M, April 2006). This period was to (i) further strengthen management capacity at NASP; (ii) provide an opportunity to plan the mainstreaming of HAPP into HNPSP; and (iii) provide an opportunity for HNPSP to bring on board the Management Support Agency (MSA) which was to handle NGO contracting, and thus avoid any interruption of services after the merger. The new agreed Closing Date was December 31, 2007.