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Annexes.

Annex 1. Project Costs and Financing

(a) Project Cost by Component (in USD Million equivalent)

Components Appraisal Actual/Latest Percentage
 Estimate Estimate of
 (USD millions) (USD millions) Appraisal
1 BEHAVIOR CHANGE
INTERVENTION AND STD 20.30 13.47 66
TREATMENT PROGRAMS AMONG
HIGH RISK GROUPS

2 DEVELOP AND UTILIZE
IEC CAPACITY TO SUPPORT
BEHAVIOR CHANGE, WHILE 15.85 2.60 16
MINIMIZING
STIGMATIZATIONAMONG HIGH
RISK GROUP

3 DEVELOP A BLOOD SAFETY 4.59 5.20 113
STRATEGY

4 STRENGTHEN GOB
CAPACITY TO IMPLEMENT,
MONITOR AND EVALUATE A 9.05 5.60 62
DECENTRALIZED HIV/AIDS
PREVENTION PROJECT

Total Baseline Cost 49.79 26.87 54

Physical Contingencies 1.01 0.00 0.00
Price Contingencies 1.79 0.00 0.00
Total Project Costs 52.59 26.87
Front-end fee PPF 0.00 0.00 .00
Front-end fee IBRD 0.00 0.00 .00
Total Financing Required 0.00 26.87

(b) Financing l/

Source of Funds Type of Appraisal Actual/ Percentage
 Cofinancing Estimate Latest of
 (USD Estimate Appraisal
 millions) (USD
 millions)

Borrower 2.59 0.03 1.16

UK: British 10.00 7.16 71.60
Department for
International
Development (DfID)

International 40.00 19.68 49.20
Development
Association (IDA)

1/US$21.7 and USD 7.3 disbursed from IDA Credit and DfID Trust fund
includes outstanding Designated Accounts advance of USD 2.02 and USD
0.14 million. Therefore, total IDA and DfID expenditures in above
tables are net of these outstanding advances.


Annex 2. Outputs by Component

1. High Risk Group Interventions

The objective of this component was to limit the transmission of HIV infection among those populations with the highest prevalence of risk behaviors and from those groups to the general population. Progress at end of project: 45 NGOs through 14 consortia were contracted out to implement 6 packages between 2004 and 2007. UNICEF was the management agency dealing with NGO contracts. The 6 packages were street-based sex worker, brothel-based sex worker, hotel and residence-based sex worker, drug users, transgender/ men who have sex with men, and clients of sex workers. A total of 145 drop in centers was established covering 46 districts of the country. The high risk intervention packages included condom promotion, STI management, needle/syringe exchange, detoxification, peer education, health education / counseling, resting/recreation facility, community awareness and local level advocacy. Supplies such as syringes, needles lubricants and condoms were delivered to NGOs as per the standard procurement plan agreed between NASP and UNICEF. There is some evidence to show that there was a drop in supply when there was interruption in the contracts due to piecemeal extensions (A-M; November 2007). STI management guidelines for high-risk groups were distributed to all NGOs by NASP in order to ensure harmonization of the treatment of STI. Training on STI management and record keeping was provided. Joint monitoring visits (GoB/NASP/UNICEF) were carried out to assess the functionality of the services and to identify need for support and areas for improvement.
Output by Intervention under HAPP

Consortium Condom Distribution Needle/Syringe
 Distribution

 Target Achieved Target Achieved

CARE 1,593,500 1,632,358 1,598,184 1,632,358
Padakhep 1,200,000 409,233 600,000 236,018
BWHC 2,644,500 1,905,434
DORP 648,291 648,291
PIACT 568,750 530,583
CDS 678,000 1,044,746
VARD 528,000 831,140
BRAC 380,160 285,617
HASAB 700,000 566,697
Badhan 24,447
BSWS 324,327
HASAB 14,182
Total 8,961,201 8,217,055 2,198,184 1,868,376

Consortium STI Treated VCTC Referral

 Target Achieved Target Achieved

CARE -- 5,298 -- 24
Padakhep 1,950 2,814 1,950 28
BWHC 18,320 4,553 544 167
DORP 4,544 200 190
PIACT 9,106 1,179
CDS 6,804 26
VARD 5,144 256
BRAC 3,242 421
HASAB 7,000 7,044 2,433
Badhan 25
BSWS 4,875 1,953 2,400 785
HASAB 17
Total

Source: Performance Audit of NGO Implemented Activities under HAPP.
PRDA; February 2008.


HIV/AIDS Intervention Fund (HAIF) was established to complement the NGO service component through a simpler mechanism of small grants of up to US$20,000 per proposed project. The component was managed by UNICEF. A total of 1185 proposals were screened and 74 of small grants were awarded under this fund. The selection process was time and human resource consuming but it resulted in a considerable capacity building of the small NGOs during the proposal approval phase. By June 2006, HAIF was discontinued because of the time consuming nature of its implementation and its poor targeting of interventions.. Effective interventions like MSM/Transgender and important lessons like involvement of PLWHA group / self help group of SW were integrated into TI packages.

An external review of HAPP TIs was undertaken in September 2007, which concluded that: (i) the population of greatest epidemiological concern is IDUs, especially in Central Dhaka, and NASP should focus on harm reduction strategies during 2008; (ii) TIs need to be intensified, with more regular and comprehensive coverage, lower peer to client ratio, greater efforts to involve Self-Help Groups, and greater involvement of the target groups in the planning, implementation and monitoring of interventions; (iii) capacity development had been ad hoc and needs to be more systematic and needs-based. The Performance Audit of TIs under HAPP (February 2008) also came to the same conclusions.

2. Communications and Advocacy

The objective of this component was to create support for HIV/AIDS prevention program by: (a) raising awareness, knowledge and understanding among the general population about HIV/AIDS/STD; (b) facilitating the adoption of safe practices across the whole society; (c) encouraging mobilization of resources and commitment for the implementation of the HIV/AIDS/STD Prevention Program; and, (d) reducing stigmatization of HIV/AIDS affected people. These objectives would be achieved through activities to be financed under two subcomponents: (1) Advocacy; and (2) Public awareness.

Progress at end of project: Strategic Communication Plan for the HIV/AIDS Prevention Project (HAPP) Advocacy and Communication Component (ACC) 2004-2005 was prepared but not implemented. A revised action plan was submitted in July 2007. However, the plan tries to cover too many activities, and is a mixture of advocacy and general awareness raising activities. The IDA review recommended that the plan focus on objective 1, which was "Provide support and services to the priority groups of people" and within that objective focus on IDUs and harm reduction strategies. Other advocacy materials included various flip charts and booklets that were distributed to the outreach workers in the field. Advocacy materials such as mugs, pins, card holders with the national HIV logo were also developed.

Capacity of implementing agencies to develop and implement effective advocacy and communication strategies was undertaken. Capacity building modules were developed: one for local level advocacy targeting the field level staff (DIC in charges) and the other on the use of folk and cultural media in HIV intervention. Tools for quantitative assessment of behavioral changes were developed and assessments conducted. However, UNICEF would need to expand their advocacy platform to be more inclusive of other stakeholders, increase advocacy capacity of NGOs and SHGs, as well as support greater networking among civil society organizations.

3. Blood Safety

This component would seek to facilitate the expansion of safe blood initiatives. It was agreed that the component's design and activities would be developed by the end of Year 1 of project implementation. It was expected, that, initially this component would focus on channeling funding for the continuation of UNDP's Safe Blood Transfusion Project for provision of laboratory equipment and human resource capacity building for 97 districts and tertiary care facilities.

Progress at end of project: The management of the Blood Safety component was transferred to WHO at the MTR, and was implemented through a network of 98 safe blood transfusion centers around the country, requiring civil 25 works and other inputs. This component commenced its activities in December 2004 and was managed by WHO. Screening kits for HIV, viral hepatitis B, C, malaria and syphilis were procured and distributed to 98 centers. However, the reconstruction of all centers has not been completed, and this and the absence of equipment maintenance plans are likely to cause problems down the road. Two training programs for Medical Technologists were completed covering several areas of blood safety. Two orientations program on Safe Blood were completed where experts and authority of 19 centers attended. Despite progress in the provision of inputs during the last three years of the project, a comprehensive vision of a safe, efficient and sustainable blood transfusion system was lacking. When this component is taken over by HNPSP, the challenges will be greater since there will be no technical assistance readily available; procurement of materials will go through the government system; and the flexibility available under the WHO will end.

Monitoring of the SBTP needs to be strengthened, with more accurate and regular measurement of indicators; and better use of the information for high level management decision-making. Available data indicate the following
Indicator Baseline 2005 Target 2006 Achieved 2007
 at 98 BTCs

Outcome

% of blood screened N/A 20% 100%
before transfusion
% of blood demand N/A 100% 100%
screened for 5 TTDs
% of blood demand 26% 50% 32%
donated by VNRBDs

Output

No. of BTC fully 20% 50% 100%
functional with full
equipment

No. of centers N/A
following SOPs for
blood screening
% of clinicians N/A 50% 100%
understanding
screening and rational
blood use
% of blood that is N/A
used as blood
component in each
center where blood
component equipment
has been provided
No. of community 1 40 100
mobilization sessions

Indicator Notes

Outcome

% of blood screened Using Rapidest kits
before transfusion
% of blood demand For 4 TTDs; malaria
screened for 5 TTDs not usually done
% of blood demand August 2007, from
donated by VNRBDs monthly reports

Output

No. of BTC fully Indicator separated
functional with full out with one shown
equipment below that is a better
 indicator of assessing
 safe blood screening
 practice
No. of centers
following SOPs for
blood screening
% of clinicians All trained now, and
understanding have basic
screening and rational understanding
blood use
% of blood that is Better indicator is
used as blood needed to assess
component in each practice
center where blood
component equipment
has been provided
No. of community Not clear whether this
mobilization sessions was a training session

Source: A-M; November 2007.


4. Project Support and Institutional Strengthening

This component would provide necessary foundations for the delivery of high-impact HIV prevention services through components 1, 2 and 3. It would do so through activities under the following sub-components:

I. Project Management and Capacity Building

The objective of this sub-component would be to strengthen the STD/AIDS Program's technical and 26 managerial capacities with the aim of facilitating the rapid scaling up of HIV/AIDS prevention activities. This would be achieved by securing adequate disbursement of funds and procurement of goods and services, including the contracting of NGOs and other partners; the provision of critical training activities to NGOs and other implementing partners; and effective supervision of project activities. These activities would be carried out in the context of the Health and Population Sector Program (HPSP).

II. Monitoring, Evaluation and Operational Research

The objective of this sub-component would be to provide critical information on the progress of the STD/AIDS program as a whole (regardless of the source of financing) as well as on the success of project activities, thereby facilitating feedback into project design. It would contribute to the development of regular nationwide behavioral and biological surveillance. It would also, through the surveys and research, contribute necessary technical information for continued project implementation and adjustments which could enhance the impact of the STD/AIDS program. It was agreed that the details of this sub-component would be prepared by the end of Year 1 of project implementation.

Progress at end of project: Institutional capacity of the program has been an on-going challenge throughout the life of the project. Frequent changes in leadership, the failure to procure and retain technically competent staff, and the reluctance to appoint the agreed consultants have all contributed to the management problems at NASP. Capacity for managing crucial NGO contracts was weak, and therefore delayed so much that at the MTR a decision was taken to transfer this responsibility to a partner agency--UNICEF. This relationship also did not proceed smoothly, leading to interruptions in service during the periods when project extensions were being sought. Currently the greatest challenge before the NASP is to coordinate the funding from multiple donors to ensure that there is no duplication in coverage, double-dipping by NGOs and wastage in resources. This is a daunting task, and one that requires that NASP's capacity be substantially strengthened with the appropriate technical and managerial personnel. NASP/MOHFW has embarked on this task with a meeting called in June 2007 of many of the DPs involved in implementing HIV/AIDS interventions; following this, NASP has started developing a database of their activities; they are also in the process of developing reporting arrangements.

UNFPA signed a contract with the Government in June 2003 for providing technical support to improve the capacity of the National AIDS/STD Program. Under the contract, UNFPA provided technical assistance (consultants) and other logistical support to NASP. The areas of Technical Assistance provided included program implementation; safe sex promotion; drug users interventions; advocacy/BCC; STI Management; monitoring and evaluation; financial and administrative management; and coordination of the TA. Various policy and program documents were developed with the help of the consultants and a resource center was established at NASP. An assessment of the performance of UNFPA is provided in the main text (Section 5.2(b)).

ICDDR,B was engaged for conducting the annual sero-surveillances. It completed 5th, 6th 7th and 8th round of surveillance. The serological surveillance collect data on high risk groups in sentinel sites in major urban centres with the highest concentration of particular risk groups. The geographical coverage has expanded over time from 5 sites in the first round to 23 in 64 districts currently. Coverage of high risk groups has also expanded from IDUs, brothel and street based sex workers in Dhaka to include other vulnerable populations including heroin smokers, hotel based sex workers and transgender. Data has also been collected in some rounds on bridging populations that are likely clients of sex workers including STI patients and transport workers as well as their regular partners.

A National AIDS Monitoring and Evaluation Framework and Operational Plan for 2006-2010, in line with the three "ones" has been developed with the assistance of UNAIDS.

Annex 3. Economic and Financial Analysis (including assumptions in the analysis)

Economic and financial analysis was not carried out at project appraisal or for the ICR.
Annex 4. Bank Lending and Implementation Support/Supervision Processes

(a) Task Team members

Names Title Unit Responsibility/
 Specialty
Lending (from Task Team in PAD Data Sheet)

William B. Herbert Social Sector Team SASHD Task Team Leader
 Leader
Frank Paulin Institutional SASHD Team Member
 Development
 Specialist
Anuschka Alvarex Operations Analyst SASHD Team Member
Rie Hiraoka Senior Social SASHD Team Member
 Development
 Specialist
Salim Habayeb Principal Public SASHD Team Member
 Health Specialist
J.S.Kang Senior Population SASHD Team Member
 Specialist
Jose P. Correia Senior Counsel SASHD Team Member
da Silva
Shahnaz Kazi Senior Economist SASHD Team Member
Nurul Alam Procurement SARPS Team Leader
 Specialist Procurement,
 Disbursement and
 Audit.
Nevine Sultana Research Analyst SASHD Team Member
Suraiya Zannath Finance Management SARFM Team Member
 Specialist
Mohammad Sayeed Disbursement Officer Team Member
A. Mead Over Senior Health Team Member
 Economist
Nilufar Ahmad Senior Social SASSD Team Member
 Scientist
Anthony Measham Consultant Team Member
Pradeep Kakkar Consultant (BCC/ Team Member
 NGO/IEC)
Ayur Kadihasanoglu Consultant (Project Team Member
 Management)
Mahesh Mahalingam Consultant (IEC) Team Member
Christine Ayash Consultant Team Member
Cheryl M. A. Powell Program Assistant SASHD Team Member
Shahadat H. Chowdhury Program Assistant SASHD Team Member
Maj-lis Voss Operations Analyst SASHD Team Member
Laura M. Kiang Operations Analyst SASHD Team Member
Virginia H. Jackson Senior Operations SASHD Team Member
 Officer

Supervision (from Task Team Members in all archived ISRs)

William B. Herbert Social Sector Team SASHD TL
 Leader
Dinesh Nair Health Specialist SASHD TL (since
 02/01/2007)
Sandra Rosenhouse Sr. Population and SASHD TL
 Health Specialist
Md. Mahtab Alam Program Assistant SACBD Task team member
Cornelis P Kostermans Lead Public Health SASHD Task team member
 Specialist
Suraiya Zannath Senior Financial SASFM Task team member
 Management
 Specialist
Harvinder Singh Suri Consultant SASPR Task team member
Iffat Mahmud Research Analyst SASHD Task team member

Marghoob Bin Hussein Procurement SASPR Task team member
 Specialist
Md. Raziq Hossain Operations Analyst SASHD Task team member
Mariam Claeson Program Coordinator SASHD Task team member
Farzana Ishrat Nutrition Specialist SASHD Task team member
C Smit Sibinga Consultant SASHD Task team member
Peter Godwin Consultant SASHD Task team member
Shirin Jahangeer Consultant SASHD Task team member
Bina Valaydon Health Specialist SASHD Task team member
Mohammad Abdullah ET Consultant SASPR Task team member
Sadeque
Jagmohan S Kang Senior Population SASHD Team Leader
 Specialist
Frank Paulin Institutional SASHD Team Leader
 Development
 Specialist
Sundararajan Senior Health SASHD Team Leader
Srinavasa Gopalan Specialist
Jayshree Balachander Senior Health SASHD Team Leader
 Specialist

(b) Staff Time and Cost (from SAP)

(all fields are pre-populated by the system)

Stage of Project Cycle Staff Time and Cost (Bank Budget Only)

 No. of Staff Weeks US$ Thousands
 (including travel
 and consultant costs)
Lending
FY2000 35.17 137.16
FY2001 24.46 107.13
 TOTAL: 59.63 244.29

Supervision/ICR
FY2002 15.0 69.16
FY 2003 20.94 142.59
FY2004 17.46 76.62
FY 2005 13.62 85.00
FY 2006 15.86 92.34
FY 2007 10.17 115.87
FY 2008 4.50 47.52
 TOTAL 97.55 629.1


Annex 5. Beneficiary Survey Results (if any)

A beneficiary survey was not conducted as part of this core ICR. However, serological and behavioural surveys of the targeted population were undertaken during implementation. The key findings of these surveys are presented in Section 3.2.

Annex 6. Stakeholder Workshop Report and Results (if any)

Not conducted for this core ICR.

Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR

INTRODUCTION AND BACKGROUND

In response to HIV/AIDS situation in Bangladesh HIV/AIDS Prevention Project (HAPP) was conceived and approved in December 2000 by GoB and IDA/DFID. The project is financed through a credit from the International Development Association (IDA) and a DFID grant, along with a financial contribution from GOB. But due to its serious implementation problem till 2003, few progress were achieved. Since January 2003, GoB, World Bank with other development partners stepped up efforts to address the implementation problems. A problem solving mission was fielded in January 2003. The Problem Solving Mission followed in March 2003 by a Quality Enhancement Review (QER) in addition a Preparatory Technical Mission for the Mid Term Review was also held in June 2003.

HIV/AIDS Prevention Project (HAPP)

Effective date: February 1, 2001

Closing date: June 30, 2005

Revised closing date: December 31, 2005

Actual closing date: December 31, 2007

Original budget: US$ 52.59 million

Revised budget: US$ 26.23 million

Phase 1: September 2003--June 2005

Phase 2: July 2005--June 2006

Phase 3: July 2006--December 2007

The main causes for poor implementation identified by the Mid Term Review mission were a) inadequate preparation of the project before its approval, and non-completion of preparatory activities even after two years of the project's life; b) unclear implementation arrangements, resulting from the introduction of this project's activities into the Health and Population Sector Program (HPSP) and c) the lack of capacity and full-time personnel to manage this project.

As per the recommendations of the Mid Term Review Mission HAPP was restructured. The coverage and volume of activities were reduced. Activities were prioritized and implementation arrangements were simplified. The revised project was implemented with technical and management support from UN Agencies as follows: a) UNICEF; USD 5.5 million for target interventions covering most vulnerable groups (PNS Package), USD 2.5 million for small grant fund to NGOs, CBOs and other agencies (HAIF Package), and USD 3.5 million for communication and advocacy (ACC/BCC Package), b) UNFPA; Institutional capacity strengthening of NASP (USD 0.99 million for technical assistance) and condom procurement, and c) WHO for blood safety component (USD 3.09 million). In addition to the fund managed by UN agencies, the remaining 10.65 million USD was proposed to be managed by NASP for advocacy/ communication activities as well as institutional strengthening and capacity development.

[ILLUSTRATION OMITTED]

GOAL:

The goal of HIV/AIDS Prevention Project is to prevent and control the spread of HIV infection within high-risk behavior groups and to limit its spread to the general population, without discriminating and stigmatizing the high-risk groups including People Living With HIV/AIDS (PLWHA).

COMPONENTS OF HAPP:

High-risk group interventions, communications and advocacy, blood safety and project support and institutional strengthening are the four major components of this project.

Component 1: High-risk behavior group interventions

High-risk group interventions: It targeted vulnerable groups through procuring NGOs services (PNS) for implementation of HIV projects. This component initially covered five priority groups, i.e. women working as sex workers in the streets, brothels and hotel/residence, drug users and internal migrant workers. Later on MSM/Transgender package was added and internal migrant workers package was restructured to client of sex worker package. Agreement was signed between UNICEF & Ministry of Health & Family Welfare in October, 2003 for implementation of Procurement of NGOs services (PNS). Which was subsequently extended twice in 2005 and 2006.
Packages Lead Agencies Partner Agencies

Street-based sex workers DORP NUS-1
 Nari Moitree
 ACLAB
 PIACT Durjoy Nari Sangha
Brothel-based sex workers BWHC PSTC
 CHCP
 ICDDR,B
 GHARONI
Hotel and residence-based CDS Light House
sex workers AVAS
 VARD CRIS
 AID
 RPDO ORA
 ASARR
 CDWF

Clients of sex workers BRAC Hitaishi Bangladesh
 NUS
 VHSS
 HASAB JJS
 PSKP
Injecting drug users (IDU) CARE MSCS
 APOSH
 Light House
 PROYAS
 JJKS
 PROVA
 USS
 Padakkhep Moitree Bangladesh
 RRC

 KMSS
 SAS
Men having sex with men BADHAN
(MSM) and transgender sex BSWS ODPUP
workers SAS
 ICDDR,B
 Light House
 HASAB Shetu Bandhan

Packages Geographical Coverage

Street-based sex workers Barisal,
 Chittagong,
 Sylhet
 Dhaka, Rajshahi, Khulna
Brothel-based sex workers Dhaka,
 Barisal (8 brothels)

 Khulna (6 brothels)
Hotel and residence-based Chitagong (excluding Comilla),
sex workers Khulna, Barisal
 Sylhet,
 Comilla
 Rajshahi,
 Dhaka (excluding Dhaka City)

Clients of sex workers Sylhet,
 Barisal,
 Chittagong
 Dhaka, Rajshahi,
 Khulna
Injecting drug users (IDU) Dhaka,
 Rajshahi, Sylhet, Chittagong

 Barisal, Khulna

 (16 districts)

Men having sex with men
(MSM) and transgender sex
workers


Initially nine consortiums and two individual NGOs were contracted (34 NGOs in total) were contracted to implement the five packages of PNS. The process started on August 1, 2004. All the NGOs have established required infrastructure to provide services. In late 2006, other NGOs were contracted to implement newly added MSM / Transgender package. In totality 45 NGOs through 14 consortiums were contracted to implement 6 packages over 2004 to 2007. Two consortiums (RPDO & GHARONI) were terminated due to performance and irregularities.

A total of 145 Drop in Centers (DIC) covering 46 districts were established. Supplies such as syringes, needles lubricants and condoms were delivered to NGOs as per the standard procurement plan agreed between NASP and UNICEF. A STI management guideline for highrisk groups has been recommended, shared and distributed to all NGOs by NASP in order to ensure harmonization of the treatment of STI. Moreover training on STI management and record keeping has been provided. Joint monitoring visits (GoB/NASP/UNICEF) were carried out to assess the functionality of the services and to identify need for support and areas for improvement.

In general the high risk intervention packages included condom promotion, STI management, needle/syringe exchange, detoxification, peer education, health education / counseling, resting/recreation facility, community awareness and local level advocacy
Group Estimated Size Coverage (%)
 (Lower estimate)

Injecting drug user 20,000 10,082 51
Heroin Smokers 28,259
Brothels based sex workers 3,600 3,817 100
Streets based sex workers 37,000 6,708 18
Hotels/residences based sex 14,000 12,740 90
workers
Men buying sex (from male/ 1,882,080 100,559
females) (1)
MSM/MSW 40,000 6,175 15
Transgender 10,000 1,000 10


Based on surveillance results, the process to review the strategy to ensure expansion and consolidation of interventions to achieve full national coverage and strengthened services were initiated.

In paper the contract period of high-risk intervention was 51 months, stretched from September 2003 to December 2007, actual period comes down to 42 months as per signing date of contract. It further downed to 33 months or less, as actual implementation at field by the NGOs started from August 2004 and subsequent contract extension took 1-2 months for each time. So, in reality high risk intervention was in the field less than 33 months separated and interrupted in three phases.
Organization Component 1st Contract
 Date & Duration

UNICEF Procurement 21.10.03
 NGO service Sept 03-30 Jun 05
 21 months
 18 months)

Organization Component 2nd Contract 3rd Contract
 Date & Duration Date & Duration

UNICEF Procurement 11.08.05 16.10.06
 NGO service Jul 05-Jun 06 Jul 06-Dec 07
 12 months 18 months
 (10 months) (14 month)

Contract with implementing NGOs took couple of weeks to months after
contract with management agency


There were no structured baseline or end line assessments in the HAPP work plan. In absence of baseline and end line study, it was difficult to assess the impact of the high risk interventions. Successive sero and behavioral surveillances could be the best guess of changing situation of HIV epidemic within the high-risk population. Although other interventions impact and time factors have to be kept in mind. Fifth sero and behavioral surveillance conducted in 2003-04 could be used as baseline and 7th Sero and 6th Behavioral survey conducted in 2005-06 and 2007 respectively could show end line status of the epidemic.
Indicators 2003-04
 (5th Sero &
 Behavioural
 Surveillance)

% IDU lent needle/syringe last time in last 2 months
 Dhaka 90.2
 Rajshahi 21.9
 Chapinawabganj 74.2
 Chandpur 63.8

% SW used condom during last sex with new client
 Brothel-based 39.7
 Street-based 13.5-37.7
 Hotel-based 29.7-37.5

Prevalence of active syphilis among sex workers
 Brothel based 3.2-12.2
 Female Street based 1.5-11.9
 Hotel based 4.3-5.4
 Male MSW 6.2

Prevalence of HIV among sex workers
 Brothel based 0.0-0.6
 Female Street based 0.0-0.2
 Hotel based 0.5-1.6
 Male MSW 0.0

Prevalence of HIV among IDUs
 Central Dhaka 4.0
 Others 0.0

Indicators 2006-07 Remarks
 (7th Sero &
 6th
 Behavioural
 Surveillance)

% IDU lent needle/syringe last time in last 2 months
 Dhaka 60.4 P=0.00
 Rajshahi 56.6 P=0.00
 Chapinawabganj 78.6 P=ns
 Chandpur 64.1 P=ns

% SW used condom during last sex with new client
 Brothel-based 70.2 P=0.00
 Street-based 50.9-81.2 P=0.00
 Hotel-based 36.3-39.9

Prevalence of active syphilis among sex workers
 0.4-6.3
 Female 7.0-10.1
 4.2-8.3
 Male 4.9

Prevalence of HIV among sex workers
 0.2-0.7
 Female 0.0-0.3
 0.0
 Male 0.7

Prevalence of HIV among IDUs
 7.0
 0.0-1.8


HIV/AIDS Intervention Fund (HAIF): HAIF was established to complement the PNS component through a simpler mechanism of small grants of up to US$20,000 per proposed project. HAIF will be implemented through Government Organizations, Non Governmental Organizations, Community Based Organizations, and private sector initiatives. It is also envisaged that it will bring flexibility and innovation to the prevention of HIV and AIDS and make possible for necessary interventions to reach the general population in Bangladesh at the community level. The component was managed by UNICEF. The agreed tasks include were: (1) developing and disseminating the Operational Manual; (2) soliciting proposals and selecting qualified organizations against defined criteria; (3) disbursing funds; (4) monitoring the projects conducted by grantees; and (5) building capacities of participating service organizations.

A total of 1185 proposals were screened and 74 were awarded of small grants under this fund.

The selection process was time and human resource consuming but it resulted in a considerable capacity building of the small NGOs during the proposal approval phase. By the June 2006, HAIF was discontinued. Effective interventions like MSM/Transgender and important lessons like involvement of PLWHA group / self help group of SW were integrated in to TI packages. These 74 NGOs worked in 34 districts in all 6 divisions of Bangladesh.
 Intended beneficiaries # of NGOs Remarks
 involved

Industry laborers and 18 1 NGO working particularly
management with adolescent workers

Students and young people 17 Including club members

Ethnic population and 9 1 NGO working particularly
refugees with adolescent
External migrants 5

Leaders in the community 5 Including political,
 religious and social
Men having sex with men and 4 leaders
Hijra

Health service providers 4 Including 1 NGO working
 also with blood donors
People living with HIV and 3
AIDS

Women in sex work 3 Those not covered by PNS
Street children 2

Others 4 Journalists, tourists, slum
 dwellers, general
 population
TOTAL 74


Component 2: Communication and Advocacy

This component aims at expanding awareness and knowledge of the general population, civil society and policy makers. The Advocacy and Communication Component (ACC) was proposed to achieve the following objectives: (1) to raise awareness and develop understanding of HIV/AIDS prevention methods among the general population; (2) to encourage the mobilization of resources and commitment for the implementation of the STD/AIDS programme; (3) to reduce stigmatization of HIV/AIDS affected people; and (4) to provide interpersonal communication and counseling by health workers in public and private sectors to clients at health facilities. Thus, ACC was envisaged to "create support for the HIV/AIDS Programme" by involving general population and key groups who influence or are instrumental to the success of HAPP, such as key national, religious and opinion leaders while PNS and HAIF target the vulnerable groups. The component was managed by UNICEF in collaboration JHU/BCCP and valued worth US$ 3.5 million.

ACC component was planned to achieve three overall outputs:

1. Updated HIV and AIDS advocacy and communication strategy and materials in place

2. Motivated policy makers, national and local leaders taking actions to foster and support the HAPP goals

3. Motivated citizenry who understand their roles in HIV and AIDS prevention and who provide care and support for people living with HIV and AIDS

The first output of the HAPP ACC was the Strategic Communication Plan for the HIV/AIDS

Prevention Project (HAPP) Advocacy and Communication Component (ACC) 2004-2005. As the primary objective of ACC was to create support for the HIV/AIDS prevention programme, the Plan was developed to set forth a detailed plan of actions for HAPP ACC so that an enabling environment for HIV and AIDS prevention can be created in this country.

Another accomplishment was collect necessary information and develop the National HIV and AIDS Communication Strategy 2005-2010. As for other communication materials, flip charts and booklets that were developed and distributed to the implementing agencies at the field level so that all peer educators and outreach workers have adequate communication materials to help their work. Advocacy materials such as mugs, pins, card holders with the national HIV logo were developed.

Capacity of implementing agencies to develop and implement effective advocacy and communication strategies were done. Capacity building training was developed: one for local level advocacy targeting the field level staff (DIC in charges) and the other on the use of folk and cultural media in HIV intervention. Tools for quantitative assessment of behavioral changes were developed and assessments conducted.

Component 3: Blood Safety:

Blood Safety component was implemented through a network of 98 safe blood transfusion centers around the country. Strategies to motivate and educate blood donors, select and retain safe donors, maintain records and management information, training staff in the centers, quality assurance and monitoring and evaluation were all part of this comprehensive safe blood transfusion package.

The component was managed by WHO, an agreement between Ministry of Health and WHO was signed on 4 September, 2004 with a total value of US$ 3.08 million.

This component has been designed to upgrade 19 centers of excellence for blood transfusion including national and teaching hospitals and some hospitals in the private sector to ensure mandatory blood screening including quality assurance, the rational use of blood and to increase voluntary blood donation. The GOB has identified 6 states of art Blood Banks & 13 blood banks for upgrading.

Based on the objective the implementation of activities within this component commenced in December 2004 and a work-plan was developed through consultation between national authorities and WHO. National Coordinator, National consultants, and other technical and administrative staff were recruited.

The screening kits for HIV, viral hepatitis B, C, Malaria and syphilis were procured and distributed to 98 centres . The two training programmes for Medical Technologists were completed covering several areas of blood safety. Two orientations programme on Safe Blood were completed where experts and authority of 19 centres attended.

Component 4: Project support and institutional strengthening

National AIDS/STD Program (NASP) has mandated as an oversight and stewardship body to address the national response to HIV /AIDS. In order to carry out the national mandate, UNFPA and the Government signed a contract in June 2003 for providing technical support to improve the capacity of the National AIDS/STD Program to play an appropriate role in the national response to HIV/AIDS. The component was comprised of consultant and other logistical support.

Through this component, consultants provided Technical Assistance to NASP. The TA concentrated on strengthening NASP's capacity with the following objectives:

* Strengthened institutional response within MOHFW and NASP to lead and co-ordinate national efforts in HIV/AIDS and supporting multi-sectoral initiatives.

* Improved institutional capacity within other key ministries (Home Affairs, Religious affairs, Education, information, Youth, Women and Child Affairs) for an expanded and sustainable response to HIV/AIDS.

* Boarder based of technical expertise available in Bangladesh addressing different dimension of HIV/AIDS

The areas of Technical Assistance provided were:

* Programme Implementation

* Safe Sex Promotion

* Drug Users Interventions

* Advocacy/BCC (2 positions)

* STI Management (2 positions)

* Monitoring and Evaluation

* Financial and Administrative Management

* Coordination of the TA

Through this component following policy / programme documents were developed ; National Strategic Plan for HIV/AIDS for 2004-2010, HIV/AIDS Module for Health Managers, National Harm Reduction Strategy, National Guidelines for ART, National STI management guideline, Nurses' manual on HIV/AIDS, Media workshop guideline, HNPSP Operational Plan for HIV/AIDS (2006-2010), Conceptual framework of the National HIV/AIDS Monitoring and Evaluation, Monitoring indicators for different high-risk interventions, Monitoring tools. A resource center was established at NASP.

Sero and Behavior surveillance: ICDDR,B was engaged for conducting the annual sero-surveillances. It completed 5th, 6th and 7th round surveillance. Surveillances covered MARG such as injecting drug users, heroin smokers, brothel, street and hotel based female sex workers, male sex workers, MSM and transgender population. In certain rounds bridging population like rickshaw pullers, truckers, part time casual female sex workers were included in study population. Approximately 10368 and 7167 samples were used for 7th round sero-surveillance. To improve the design of surveillance, a piloting of "Respondent Driven Sampling" methodology was done.

Constraint faced:

1.Preparatory:

* Adequate preparations were not done before launching the formal implementation of the project. There were lacks of human and physical infrastructure at NASP to effectively implement the project. NASP was not prepared to handle large number of NGO selection, contract, manage and monitoring. Human resources were in adequate and implementation mechanism was not clear.

2.Implementation:

* Due to administrative process and bottlenecks in MOHFW, DGHS, MOHFW, World Bank and UNICEF, there were delays in fund disbursement from donor to implementing NGOs.

* The implementation periods were stretched in to three short phases of 12 -18 months. This made the administrative process of proposal development and approval, contract signing, repetitive and time consuming which further shortens the actual time of implementation. This resulted frustration within the project beneficiaries and loss of trained manpower from implementing agencies.

* There were delays in reporting by Management Agencies specially the financial reports. This made difficult for NASP to compile the report and have a clear look of the situation. It also delayed the process of submission of report to different relevant authorities.

* In the HAPP plan there were no provision for operation research, so it was difficult to test out different strategies of the ongoing interventions.

3.Evaluation:

* In the project plan there was no plan for structured baseline and end line assessments. In absence of that implementing NGOs did rapid situation assessment by their own, which was not well coordinated by management agency and methodologically not sound. The data could not be compiled and used. End line survey was also not planned; there was confusion that who will responsible for the assessment. In absence of that the opportunities will be missed to find out the impact of the project and return of resource investment.

Lesson learned:

* A large programme like HAPP needs adequate pre-implementation preparation before formal launching. This involves time duration and physical and human infrastructure. In absence of these required pre factors, actual implementation hampers and activities slows down. NASP did not have the requisite human and physical infrastructure at the beginning of the programme launching.

* There should be a clear under standing of implementation modalities. Role of coordinating, implementing agencies should be clear to all agencies.

* For effective implementation a simple M & E system need to be established. Data need of different level have to be identified and process of compilation and dissemination established.

* Interventions in the high risk behavior groups need support of local law enforcing agencies from the very beginning. Adequate planning and advocacy needed in this regard.

* Greater impact of programme needs involvement of certain key ministries like home, education, youth and employment.

* Repeated disruption and short phases hampers the project outcomes. It creates loss of credibility to the at risk population, loss of trained manpower. For effective output intervention should have minimum duration of 3 years.

* Capacity development of NGO and GO should be a continuous and institutional process

* Involvement of Self Help Group (SHG) of vulnerable population in the implementation brings greater and sustainable results.

Role of stakeholders

UNICEF

Three agreements were signed between UNICEF & Ministry of Health & Family Welfare in October, 2003 for implementation of following interventions; a) Procurement of NGOs services (PNS-US$ 5.5 m), b) HIV and AIDS Intervention Fund (HAIF-US$ 2.5) and c) Advocacy and Communication Component (ACC- US$ 3.5) with a total value of US$11.5 m. UNICEF was the largest stakeholder of HAPP. They were involved in large group NGOs selection, contracting, managing and monitoring. Their contribution in this regard is commendable. Initially the coordination mechanism with UNICEF was weak and irregular. It took considerable time and efforts to improve the situation. The internal administrative process of UNICEF some times slowed down the implementation process. Few efforts were made to tap UNICEF's international expertise and resources.

UNFPA

UNFPA was responsible for managing part of the fourth component--Institutional Strengthening and Capacity Building worth US$ 0.99 m. There contribution came in the form of recruiting and managing consultants and logistics supply. This improved human capacity and physical environment of NASP. The understanding of institutional strengthening and capacity building was not clear and no formal plan was agreed upon. Which caused lack of coordination between NASP and UNFPA and resulted in only providing consultants and logistics. Some institutional assessments were done which were not adequately followed up.

WHO

WHO managed the blood safety component in providing support for procurement of equipment and reagents and facilitating training and facilitating continuous on-site technical support. This was in major part continuation of UNDP supported earlier activities.

World Bank

WB as a whole facilitated the project implementation. Through local WB office and regular Joint Monitoring Mission, supports were provided. WB helped NASP to progress the project in every phase. WB helped to restructure the project and redefining implementation mechanisms. Initially the administrative and decision making process within WB was time consuming which was simplified later on.

Conclusion

HAPP was an unique experience of NASP to run a multi-stakeholder project, where three UN agencies acted as management agency and with more that 100 implementing NGOs. Successful completion of HAPP increased the capacity of NASP. The project enabled GoB to expand critical high risk intervention nationally and develop national strategies and guidelines. With the experience of HAPP, NASP/GoB will be able to expand and manage nation wide HIV/AIDS intervention.

Annex 8: Comments of Cofinanciers and Others Partners/Stakeholders

DFID Project Completion Report (PCR)

Relevant sections of DFID Project Completion Report are reproduced below:

Purpose to Goal

HIV and AIDS in Bangladesh remains low prevalence. To date evidence suggests that it remains predominantly within most at risk groups particularly IDUs, Female Sex Workers and MSM. With the exception of IDUs, prevalence also remains low within these groups (overall 0.9%). The project has contributed to this continued low prevalence. This means that the spread of HIV infection has been controlled sufficiently so that it has not impacted on poverty reduction or accelerated human development in Bangladesh. There are some concerns in Bangladesh about the numbers of returning migrant workers who are HIV positive however there is currently limited evidence to support this. The GoB is planning to improve this evidence base and design interventions accordingly.

Project Purpose Rating- General /Overall progress assessment 3-Likely to be partly achieved Justification

This project suffered major problems in it's early years (2001-2004) and little had been implemented or achieved by 2004. This early slow progress was due to the project not having been fully planned before it was launched, weak capacity within the MoHFW to manage or implement the project and insufficient support provided by the World Bank or DFID to drive the project forward. In 2003, the IDA Credit and DFID grant to the project were cut by a half due to this slow disbursement and implementation. At this time, 3 UN agencies were invited to implement different parts of the project on behalf of NASP; UNICEF to procure NGO services to implement high-risk intervention and innovative approaches, together with communication and advocacy; UNFPA for capacity building, and WHO for blood safety. Agreeing the contract details between UN agencies and government took time. Project activities only really got underway in August 2004 and the project was originally due to end in 2005. In 2005 a one year extension was granted, and in 2006 a further 18 month extension was agreed (to December 2007).

During project supervision and reviews, the UN agencies have been criticised for their performance in implementing the project, and it is clear that there were some shortfalls, particularly with UNFPA and WHO in fulfilling their terms of reference. However, they were asked to participate in the project as an 'emergency measure' in a failing project and none of the agencies (except for WHO) was implementing an activity that is considered to be within its area of expertise. Additionally, the three short contracts that they were given meant that their ability to develop and sustain their capacity to support NASP and project activities was compromised. These short contracts (and the funding gaps that took place between them) also impacted on the quality of services provided by the NGOs to deliver targeted interventions and on their ability to have the sustained engagement with beneficiaries needed to change behaviours.

Despite these delays and gaps in maintaining project funding and activities, since 2004 and largely through the NGO interventions progress has been made in half of the purpose-level indicators. The things that have been achieved include the major objective of keeping HIV prevalence below 5% among all categories of female sex workers, men who have sex with men, and transgendered persons (hijras). Furthermore, active syphilis is significantly declining or at least being kept in check among all FSWs, IDUs, MSM and transgendered persons. Hepatitis C among IDUs in Central A has significantly declined over several rounds of measurement. A rating higher than "3" is not justified because, on the down side, HIV prevalence amongst IDUs has risen over the life of the project to 7% in Central-A, with one neighbourhood as high as 10.5%. Hepatitis C among IDUs outside of Central A is a mix of some decline and some increase. There has been some limited impact on the policy environment, including the development and approval of some important strategies. The challenge has been and will continue to be the need for sustained capacity within the MoHFW to ensure effective implementation of these and other policies.

Project Outputs Rating-General/Overall progress assessment 3-Likely to be partly achieved Justification

Overall, the outputs are likely to be partly achieved by the end of the project as highlighted above. Three out of four Outputs are scored "3" and one is "4" leading to this composite score.

There has been an impact on some high risk behaviours in most at risk populations. Whilst the results across geographical areas and population groups are mixed, in the most vulnerable geographical area--'Central A', condom use amongst female sex workers has increased significantly and needle sharing amongst IDUs has decreased. This is important and significant for controlling the epidemic. The quality of the interventions could undoubtedly be improved, but the short term contracts and lack of systematised capacity building given to the NGOs limited their ability to focus on quality. The component of the project focussed on interventions with high risk populations has been undoubtedly the most important and successful of the project and has had the most impact. Under HNPSP and GFATM funding, it is essential that the focus is on improving the quality and coverage of interventions particularly with IDUs.

Other components have been less successful. The blood component has been subject to significant delays and setbacks and there have only been patchy improvements in parts of the Blood Transfusion System. Under HNPSP it has been recommended to the GoB that blood safety is given higher priority, and that high quality technical support is available. Institutional strengthening of NASP has been, and remains a challenge, largely due to frequent transfers of staff, the relatively low priority given to HIV and AIDS within the MoHFW, and a lack of strong long term technical support focussed on institution building. Advocacy plans and strategies have been developed, but advocacy and awareness raising efforts remain somewhat ad hoc and not well monitored. It is difficult to gauge how far the project has contributed any increases in awareness about HIV and AIDS in the general population. It has been recommended to NASP that they rationalise their tasks and functions, develop a technical assistance framework, and for the medium term contract consultants to support their priority roles and functions.

Purpose Attribution

Any achievement of the project purpose may be attributed to the first two outputs. Limiting the spread of HIV through successful targeted interventions that hold HIV low in high risk groups is likely to help limit the spread in the general population. This is not necessarily dependent upon success in achieving the third output of developing a blood safety strategy. Nor is it dependent upon the NASP technical and managerial capacity during the life of the project.

The project has relied upon the high quality National Surveillance date (behavioural and serological) to assess its impact. Whilst there is no doubt that the project has contributed to the gains made in behaviour change and to keeping HIV prevalence low, there have also been interventions (smaller and limited in their scope) funded by USAID through Family Health International which will also have contributed to progress made.

Risk Management

Risk Category A | Medium Has the Risk Category changed since the last review? If so explain why. No. Key Risks How successful was the action taken to monitor / manage these risks

The main risks initially identified that have occurred were inadequate leadership, institutional and management capacity in NASP and frequent changes of staff, delays in operationalising GoB/NGO collaboration, and insufficient NGO capacity. The first two of these risks could have been monitored and managed more proactively in the early years of the project. Radical measures were taken in 2003 to manage them by 'outsourcing' the project components to UN agencies.

The plan to manage the latter was to phase in NGOs and initially sole-source NGOs that had proven capacity and experience. This did not happen in practice and some NGOs that were awarded contracts had gaps in their capacity to deliver high quality interventions. This could have been managed with strategic and planned technical support (perhaps contracted out), but this support only come after some time when UNICEF (the managing agent) developed it's own capacity.

Measures to monitor and manage other risks were largely successful.

Lessons Learned

Lessons learned, and suggested dissemination.

1. Working with Partners

* In a low HIV prevalence setting, stakeholders (Government, development partners and NGOs) need to be constantly reminded of the evidence that should drive the priorities for the National response. In Bangladesh there are clear epidemiological indications that the focus of the response should be on most at risk populations particularly harm reduction with IDUs. Whilst this project was focused on the right issues, efforts can easily be distorted by particular institutional interests, misinformation or global directives from the International Community (such as 'Universal Access' or pushes to ensure a multisectoral response)..

* Funding through the World Bank does not necessarily mean reduced transaction costs for DFID. Early reviews indicate that the transaction costs to DFID to get the project on track were high.

2. Best Practice / Innovation

* Participation by most at risk populations in programming decisions and implementation was limited in this project but where it happened, it proved important for programme success and sustainability.

3. Project / Programme Management

* Funding for HIV prevention efforts with most at risk populations must be uninterrupted and long term (e.g. at least 3 years).

* Whilst it ensures transparency, contracting out of NGOs through an open tendering process may not always get the best results particularly when working with stigmatised or marginalised groups. These processes are also open to interference and rent seeking.

* There needs to be a clear understanding at all levels about the difference between advocacy and awareness raising.

Key Issues / Points of information

Two no-cost extensions were granted to the project at the GoB's request. These were largely to ease the transition from HAPP funding to funding under HNPSP as the planned institutional mechanisms were not in place to contract NGOs. The bureaucracies of the GoB as well as development partners meant that there were gaps in funding between these phases. This was far from ideal and undoubtedly impacted on the quality of the interventions.

If appropriate, please comment on the effectiveness of the institutional relationships involved with the project (eg comment on processes and how relationships have evolved)

DFID and the World Bank developed strong relationships with the NASP through interactions on the project, particularly its reviews. The supervision missions have been a critical point for discussing the national HIV and AIDS programme in Bangladesh and bringing together key stakeholders. They have also allowed DFID and the World Bank to provide strategic TA support in a timely and demand driven way. Once the project activities are subsumed under HNPSP there will not be the same opportunities to monitor them. Efforts are underway to ensure that there is a joint HIV and AIDS annual review which will draw in all funders and stakeholders and ensure a space is created for strategic discussions.

Annex 9: Project Outcome and Intermediate Indicators

Outcome indicators to measure progress toward the development objective were changed several times over the course of the project. According to the PAD, the indicators to measure achievement of PDOs were: (i) reductions in behavioral, biological (STD, HepC) and social indicators listed in the evaluation framework; (ii) prevalence of HIV infection among sex workers and injecting drug users remains below 5%; and (iii) AIDS Program Effort Index. Of these (iii) was never defined or used and (i) was translated in the first PSR into the following specific indicators:

* Reductions in behavioral indicators: (a) % sex workers who used condom with last client; (b) % IDU who shared no needle last week;

* Reductions in biological indicators: percentage of sex workers with positive test for active syphilis;

* Reductions in social indicators: (a) # IDU and sex workers beaten by police last year; (b) # IDU and sex worker forced into sex by police last year.

While baseline values were available for the above indicators, no targets were set and many of them were very difficult to collect in a consistent manner over time. At the MTR, a new logical framework was agreed, which retained the same objective, with two PDO indicators: 1) % of HIV infected people among CSWs, MSM and IDUs; 2) Prevalence of syphilis among CSWs and IDUs. Actual values at the MTR for these two indicators were reported in the PSR (#08), and end-of-project targets were recorded. Of these, the first indicator has been tracked till the end of the project, albeit with a change in targets while the second one was dropped in May 2005. No explanation was offered in the ISR or relevant Aide-Memoire for either of these changes.

A large number of intermediate and output indicators were also included in the results framework of the PAD and were subsequently dropped in the MTR. These included indicators of: knowledge and attitudes of the general population; advocacy such as number of workshops conducted; blood safety; and institutional capacity. At the same time several new indicators were included during the MTR and dropped in May 2005. These included: behavioural indicators of high risk populations such as passive sharing of needles/syringes among IDUs, consistent use of condoms by FSWs, use of condoms by clients of FSWs; rephrased questions on knowledge of HIV transmission among the general population; a new set of indicators of blood safety; and of institutional capacity.
(a) PDO Indicator(s)

 Original Target
Indicator Baseline Value Values (from approval
 documents)

Indicator 1 : Reduction in Biological indicators-a) Prevalence
 of HIV infection among sex workers and IDUs
 remain below 5% (PAD)

Value IDU: 0.2%; Brothel <5% for all HRG
quantitative or Based Sex Workers: 0%;
Qualitative) Street Sex Worker
 Dhaka: 0.3%; MSM: 0.2%

Date achieved 4/15/2001 4/15/2001

Comments The indicator was reworded at the MTR to refer to
(incl. % commercial sex workers, MSM and IDUs. The targets
achievement) for the first two groups was revised to < 1
 percent at the MTR and was changed back to < 5
 percent in the May 15, 2005 ISR.

Indicator 2 : Reductions in biological indicators (STD, Hep C)-
 b) sex worker: test positive for syphilis

Value IDUs: 10.4 %; Brothel No target values
quantitative or Based Sex Worker: specified
Qualitative) 32.3%; Street Based Sex
 Worker Dhaka: 24.2%;
 MSM: 41.6%

Date achieved 4/15/2001

Comments This was included in the PAD but changed at the
(incl. % MTR to prevalence of syphilis among CSWs and
achievement) IDUs. It was dropped in the ISR of May 15, 2005.

Indicator 3 : Reductions in behavioural indicators-a) Percent
 of IDUs who did not share needles in the last
 week

Value Dhaka: 16%, Rajshahi: No target specified
quantitative or 38%
Qualitative)

Date achieved 4/15/2001

Comments This was a PDO indicator in the PAD but was
(incl. % classified as an IO indicator at the MTR.
achievement) Subsequently the target date was extended along
 with project extensions.

Indicator 4 : Reduction in behavioural indicators-b) % of CSWs
 using condoms (condom use in last sex with new
 clients)

Value Brothel: 20%, Street
quantitative or based workers (SBSW)
Qualitative) Dhaka: 29% SBSW
 Chittagong: 19%.

Date achieved 4/15/2001

Comments This was a PDO indicator in the PAD but
(incl. % classified as IO indicator at the MTR.
achievement)

Indicator 5 : Reductions in social indicators -a) % of IDU, sex
 workers beaten by police in the last year

Value IDU: n/a; Street sex No data
quantitative or worker: n/a; Brothel
Qualitative) sex worker: n/a; MSM
 (Central): 16.3%

Date achieved 4/15/2001

Comments This was a PDO indicator in the PAD, no target
(incl. % values were specified. No follow-up surveys were
achievement) undertaken and it was dropped at the MTR

Indicator 6 : Reductions in social indicators-b)% of IDUs and
 sex workers forced into sex by police last year
 Street sex worker

Value (Dhaka): 60.2%; Brothel No data
quantitative or sex worker (National):
Qualitative) 6.8%; MSM (Dhaka):
 15.1%

Date achieved 4/15/2001

Comments
(incl. % No target values specified and dropped at the MTR
achievement)

Indicator 7 : AIDS Program Effort Index

Value No data No data
quantitative or
Qualitative)

Date achieved No data No data

Comments This was included as a PDO indicator in the
(incl. % results framework of the PAD. The indicator was
achievement) not defined and dropped in the first PSR of
 January

(b) Intermediate Outcome Indicator(s)

Indicator Baseline Value Original Target Values
 (from approval
 documents)

Indicator 1 : Percentage of estimated total high risk
 population in Bangladesh reached by NGOs
 contracted by the project

Value SBSW Dhaka: 41%; SBSW
quantitative or Chittagong: 6%;
Qualitative) Rickshaw Drivers Dhaka:
 0%; Truckers Dhaka:
 <1%; MSW Dhaka: 42%;
 MSM Dhaka: 32%; MSM
 Sylhet: <2%, IDU Dhaka:
 46%, IDU Rajshahi: 68%

Date achieved 2/1/2001

Comments Source: Behavioural Surveillance Surveys (BSS).
(incl. % The BSS does not provide country level
achievement) information but includes reported coverage in
 select cities. This indicator was included in the
 PAD, dropped in the MTR and again included with
 target in May 2005.

 Formally Actual Value Achieved
Indicator Revised Target at Completion or Target
 Values Years

Indicator 1 : Reduction in Biological indicators-a) Prevalence
 of HIV infection among sex workers and IDUs
 remain below 5% (PAD)

Value <1% in all groups FSW
quantitative or <1%, MSM 0.6%
Qualitative)

Date achieved 12/31/2007

Comments The indicator was reworded at the MTR to refer to
(incl. % commercial sex workers, MSM and IDUs. The targets
achievement) for the first two groups was revised to < 1
 percent at the MTR and was changed back to < 5
 percent in the May 15, 2005 ISR.

Indicator 2 : Reductions in biological indicators (STD, Hep C)-
 b) sex worker: test positive for syphilis

Value CSWs: <10%; IDUs: <10% CSWs: <10%; IDUs: <10%
quantitative or
Qualitative)

Date achieved 06/30/2005 01/09/2007

Comments This was included in the PAD but changed at the
(incl. % MTR to prevalence of syphilis among CSWs and
achievement) IDUs. It was dropped in the ISR of May 15, 2005.

Indicator 3 : Reductions in behavioural indicators-a) Percent
 of IDUs who did not share needles in the last
 week

Value >95 percent Dhaka: 45%;
quantitative or Rajshahi: 51%;
Qualitative) Chapinawabganj: 26%;
 Chandhpur: 37%

Date achieved 12/31/2007 01/09/2007

Comments This was a PDO indicator in the PAD but was
(incl. % classified as an IO indicator at the MTR.
achievement) Subsequently the target date was extended along
 with project extensions.

Indicator 4 : Reduction in behavioural indicators-b) % of CSWs
 using condoms (condom use in last sex with new
 clients)

Value >50% Brothel workers:
quantitative or 70%; SBSW
Qualitative) Dhaka: 81%;
 SBSW Chittagong:
 91%; SBSW
 Khulna: 51; Hotel based
 sex workers (HBSW)
 Dhaka: 40%; HBSW
 Chittagong: 36%; HBSW
 Sylhet: 71%

Date achieved 06/30/2005 01/09/2007

Comments This was a PDO indicator in the PAD but
(incl. % classified as IO indicator at the MTR.
achievement)

Indicator 5 : Reductions in social indicators -a) % of IDU, sex
 workers beaten by police in the last year

Value No data No data
quantitative or
Qualitative)

Date achieved

Comments This was a PDO indicator in the PAD, no target
(incl. % values were specified. No follow-up surveys were
achievement) undertaken and it was dropped at the MTR

Indicator 6 : Reductions in social indicators-b)% of IDUs and
 sex workers forced into sex by police last year
 Street sex worker

Value No data No data
quantitative or
Qualitative)

Date achieved

Comments
(incl. % No target values specified and dropped at the MTR
achievement)

Indicator 7 :

Value No data No data
quantitative or
Qualitative)

Date achieved No data No data

Comments This was included as a PDO indicator in the
(incl. % results framework of the PAD. The indicator was
achievement) not defined and dropped in the first PSR of
 January

(b) Intermediate Outcome Indicator(s)

Indicator Formally Revised Target Actual Value Achieved
 Values at Completion or Target
 Years

Indicator 1 : Percentage of estimated total high risk
 population in Bangladesh reached by NGOs
 contracted by the project

Value 100 percent Brothel workers
quantitative or national: 75%; SBSW
Qualitative) Dhaka 56%; SBSW
 Chittagong: 87%; SBSW
 Khulna: 53%; HBSW: 20%;
 HBSW Chittagong: 9%;
 HBSW Sylhet: 37%;
 Rickshaw 3%; Truckers:
 3%; MSW Dhaka: 48%; MSM
 Dhaka: 15%; MSM Sylhet:
 11%; IDUs Dhaka: 80%;
 IDUs Rajshai: 51%

Date achieved 12/31/2007 1/9/2007

Comments Source: Behavioural Surveillance Surveys (BSS).
(incl. % The BSS does not provide country level
achievement) information but includes reported coverage in
 select cities. This indicator was included in the
 PAD, dropped in the MTR and again included with
 target in May 2005.


Annex 10. List of Supporting Documents

1. Bondurant Tony et al. (2007) Towards a Coordinated National Response for Targeted Interventions in Bangladesh

2. Care Bangladesh Consortium, (2007) Project Completion Report, HIV/AIDS Prevention Program (Injecting Drug Users)

3. Family Health International (April 2007) Bangladesh: An Epidemic in Transition

4. Foss, Anna M. et al. (2006) Could the Shakti Care Intervetiont for Injecting Drug Users be maintaining low HIV prevalence in Dhaka, Research Report

5. HLSP (2008) Performance Audit of NGO Implemented Activities under the HIV/AIDS Prevention Project

6. ICDDR,B: Centre for Health and Population Research, (2006) Serological Surveillance for

HIV in Bangladesh Round VII

7. National AIDS/STD Program (2008) Behavioural Surveillance Survey, Sixth Round Technical Report

8. Reddy, Amala et al. (2008) HIV Transmission in Bangladesh: An Analysis of IDU Programme Coverage, The International Journal of Drug Policy

9. Sibinga, Smit (2006), Institutional Assessment of the Safe Blood Transfusion Program Bangladesh

10. UNICEF (2007) Interim Report-HIV/AIDS Prevention Project

11. World Bank, (2007), Final Assessment of the UNFPA Capacity Building Contract

12. World Bank (2000), Bangladesh HIV-AIDS Prevention Project, Project Appraisal Document.

13. World Bank (2000-2007), Bangladesh HIV-AIDS Prevention Project: Aides-memoire

14. World Bank (2000-2007), Bangladesh HIV-AIDS Prevention Project: Implementation Status and Results (ISR) Reports

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