Report on the First Videoconference on HIV and Transport

Joint Initiative to Fight AIDS through Infrastructure

Report on the first Joint Initiative Video Conference, March 14, 2008

Background

Building on the Joint Initiative statement, the six development agencies came together for a videoconference on March 14th to exchange information and create a momentum for future collaboration. The discussion included how each partner had mainstreamed HIV/AIDS in infrastructure sectors in the past, what challenges had been encountered, and possibilities to capitalize upon synergies and scale-up cooperation.

The videoconference represented the first time all six signatories came together to discuss the Joint Initiative (JI). Although the focus of the JI is upon infrastructure in general, the focus of this dialogue was upon efforts in the transport sector in particular.

The following is a summary of the main messages presented by the development agencies and points of discussion of the event.

Japan Bank for International Cooperation (JBIC)

JBIC first piloted the incorporation of HIV/AIDS mitigation efforts in 2001. By 2005, mitigation clauses were incorporated into sample bidding documents for civil works funded by JBIC. Currently, HIV/AIDS mitigation components are included in about forty ongoing and approved transport projects. In the intervening years, JBIC learned to address the following obstacles: difficulty to obtain buy-in from infrastructure agencies, lack of a clearly defined role for each stakeholder; insufficient expertise, and precarious funding. Continuous dialogue lead to a catalytic environment by linking concerned ministries and other partners and aligning the interests and aptitudes of the various players.

The following lessons were learned:

•Support development and review of transport action plans on HIV/AIDS and mobility and provide necessary technical assistance

•Strengthen working relationships and coordination with existing authorities, especially National AIDS Councils, and local service providers

•Actively engage local/domestic parties in the process of development, implementation and monitoring of programs

•Explore public and private partnerships, including nongovernmental organizations

The pilot project in 2001 was funded by JBIC. Since then, there have been three sources of funding: loans, a special fund from the Japan Trust Fund of International Planned Parenthood Federation (a few projects) and the counterpart agency itself (e.g. The Delhi Metro Project).

JBIC is particularly interested in monitoring and evaluation. Specifically, contractors perform projects from the start to the end. However, construction workers and other temporary employees keep changing. Without a stable population to monitor, how does one track changes?

Other concerns include information-sharing and communication between field offices and HQ, expansion of services to move beyond prevention and include other health issues (e.g. TB), and the development of additional sources of funding.

JBIC would like to utilize the JI to harmonize efforts among the various partners. Specifically: a standardized process to define approaches and interventions, a minimum package of services, simple and standardized monitoring and evaluation tools, advocacy with governments, and resource mobilization (e.g. The Global Fund).

The World Bank (WB)

The transport group has been one of the most active in seeking to design andimplement sector-level programs to combat HIV/AIDS in the World Bank.

The World Bank is committed to ensure that all regions create an effective andappropriate response. Programs are most developed in the areas with thehighest HIV/AIDS prevalence (initially Sub-Saharan Africa and now to anincreasing extent in Asia).Projects have included the following components: IEC, retrofitting, construction, corridor/mobile populations, border crossing, treatment and care, regional strategies, capacity building and training, and research. Support provided by the sector include: regulartraining events to increase staff awareness and knowledge; highly visible programming during internal World AIDS Day events, a website through which staff and clients can access research materials andrelated resources.

In order to systematize the sector's response, explicit provisions forHIV/AIDS education have been embedded into standard bidding contract clauses for contracts over $10 million. A Full-time staff member in Africa and a consultant in India are dedicated to the issue of transport and HIV.

The Global HIV/AIDS Program (GHAP) recognizes that transport, along with education, have been the most effective sectors in mainstreaming an HIV/AIDS response into WB-supported projects. In this context, a transport incentive trust fund was created for FY 07to allow regions and the anchor unit tocreate a number of resources that will furtherfacilitate the mainstreaming process at the operational level (e.g. IECcampaign materials, clauses 'how-to', an overview paper on the issues and M&E instruments).

Whenever possible, the Bank seeks to mainstream via the assistance ofassociations of construction contractors, transport operators and theiremployees as key stakeholders with whom to cooperate in all countries. Theseefforts have been inspired in some measure by the good work of theInternational Transport Federation (ITF) and the International LaborOrganization (ILO).

There have been obstacles to scaling-up: funding, implementation, lack of supporting data and capacity for monitoring and evaluation. Bank financing is critical to mainstreaming. Without it, it is a challenge to generate interest and initiate programs or support clients’ requests. However, clients have tended to positively respond to AIDS activities originally funded by the Bank and have sustained programs and initiatives upon completion of the Bank activities. This was the case for example with IEC activities in China.

Lack of systematic data linking transport with HIV/AIDS transmission hinders action and commitment.Likewise, there is uneven commitment across regions, leaving a number of activities to be dependent upon the goodwill of Bank management, TTLs and clients. HIV/AIDS prevention receives low priority in sector strategies and interventions. Mandatory contract clauses in standard bidding documents are not always enforced. And capacity remains weak (among clients, the World Bank, and NGOs). This is evident in the area of monitoring and evaluation, particularly in the documentation of impacts and outcomes. As a result, sector-wide mainstreaming remains a challenge.

The World Bank agreed that it would be useful to determine to what extent the Initiative has measured up to the actions envisaged. Inparticular, it would like to carry out the “joint assessment of keyinterventions". Also the JI is seen as a practical way to share operational and analytical tools as well as to cooperate at the local level. It would be very helpful to delineate the criteria for implementation (qualifications and extent). It would also be fruitful to determine how to further share experiences in order to improve approaches and build upon synergies.

One step in this direction is the development of a website regarding the mitigation of the spread of HIV in the transport sector: ( This site developed through the Transport for Social Responsibility ThematicGroup provides resources on sector vulnerability and risk, interventions and stakeholders, surveillance and impact, sector contributions to World AIDS Day, the Joint Initiative, and regional and global responses.

The Asian Development Bank (ADB)

ADB’s focus is to support a government’s own efforts. However, a regional approach is also necessary due to cross-border mobility and reluctance on the part of national governments to invest in projects which benefit non-constituents. Another challenge is that many of the areas in which ADB works have low HIV prevalence. Economic arguments (what is the cost of inaction?) are used to garner support.Incentives matter yet they may not aligned very well. For example, a commercial contractor may see HIV interventions purely as a commercial cost and “downtime” while Ministries and JI partners are cognizant of the costs of inaction. Funding typically comes from loans. However some costs are accommodated by others (e.g. Ministry of Health, PEPFAR, The Global Fund).

ADB aligns its HIV mitigation efforts with other social risks (e.g. road safety, STIs, human trafficking). ADBstarts with a project-by-project approach and works toward national capacity development (particularly in monitoring and evaluation) to institutionalize implementation (i.e. moving from “add-on” to “built-in”). Environmental impact assessments can be a very useful tool to begin this process. (For example, projects can be designed to reduce vulnerability by minimizing population mobility.) Priority is given to those projects which are large, involve one or more JI partners, increase HIV risk, and/or display some regional characteristic. ADB shares its experience in the form of case studies, a toolkit, and an upcoming conference in the Mekong region.

At the level of HQ, ADB would like to see the JI verify and increase the scale, scope, and effectiveness of our efforts. It is a matter of accountability. ADB is particularly interested in joint assessments of impact, sustainability, and cost effectiveness. Measurement of outcomes and impact are of particular importance. In addition the JI should strengthen framework for sharing experience, enhance cooperation and expand to include other partners (UNAIDS, UNDP, etc).

ADB also has a vision of the JI operating at the regional level: “Focus on the operational activities on the ground, with an emphasis on supporting key resident missions throughout this region. After all, it isat the resident mission level in - country and at the specific project and program level that JI partners usually - or at least should - interface themost. We want to have a clear focus on practical effects in larger / higherrisk activities on the ground.”

The African Development Bank (AfDB)

HIV/AIDS activities have been mainstreamed into all education, agriculture, and infrastructure projects. The Infrastructure and Human Development Departments work together to ensure incorporation. Special emphasis is given to large-scale construction projects which mobilize numerous workers, as well as long-distance transport activities. AfDB currently has 15 transport projects, three of which are regional. IEC campaigns are the main interventions at this time. The target audience for these interventions is not only truckers and construction workers, but also those who use the roads.

In order to scale-up its efforts, AfDB will strengthen the relationship between the Infrastructure and Human Development departments. Two persons from each department will be designated to lead the effort. This partnership will: carry-out joint assessments in the early stages of new projects, includeimpact mitigation clauses in currentbidding documents used for large-scale civil works funded by the Bank, host workshops for both departments to garner internal support, and present one or two projects to their Board in 2008.

At the level of HQ, AfDB is currently undertaking a study to assess the effectiveness of its support to the prevention and control of HIV/AIDS in its Regional Member Countries. The study would aim to draw lessons and make recommendations to substantially improve the AfDB’s HIV/AIDS strategies and interventions to better address the challenges of the epidemic in Africa. At the present time, there is a need for transport engineers to be sensitized to enable them incorporate HIV into their work. There is a great deal of interest in sharing best practices.

KfW Entwicklungsbank (KfW)

KfW divides its mainstreaming efforts into two distinct areas: 1) FC-funded programs and 2) Institutional policy within the organization. In countries with a prevalence of 1% or greater, programs are evaluated for inclusion of HIV mitigation efforts. In making the assessment, three things are considered: the impact the project may have on the local HIV situation, the impact of HIV on the project, and what can be reasonably achieved given available resources. Interventions have typically consisted of IEC programs and the provision of condoms to program personnel, workers, and local community members. This has been achieved by the inclusion of mitigation clauses in tender documents and infrastructure contacts. Programmatic features have been carried out by local NGOs. This linkage with local partners has reduced program costs.

Since these efforts have been funded viagrants, it has been a challenge to secure similar support in low prevalence areas. In these areas, only those projects related to specific groups (e.g. CSW, drug users, and truckers) are appraised for impact mitigation.

To ensure that HIV remains an institutional priority within KfW, there is a designated focal point at the Sector and Policy Division Health. The purpose of the focal point is to advise and sensitize program managers, include HIV in FC instruments, contact external partners, and perform quality assurance and monitoring. Working with program managers is of particular importance: “Given the great variety of cross-cutting topics that need to be taken into consideration in addition to the topics that apply to the sector, it is important to regularly debate HIV/AIDS and to overcome reservations regarding the subject. After all, how seriously the issue is dealt with in FC projects and programs ultimately also depend on whether the program managers require this to be done in reports by executing agencies and consultants or bring-up the issue when they visit locations such as construction sites.”

KfW described both challenges and opportunities. One challenge is monitoring the effectiveness of its interventions. Sustaining momentum is another. Also, mainstreaming is not 100% in all activities, particularly in Africa. KfW would like to movefrom a project-to-project approach to a sector-wide approach with a sector-wide budget to ensure efficiency and consistency. The JI is an opportunity to share experiences on a regular basis as well as to raise the visibility of the issues. It would like to apply our communications to policy development.

UK Department for International Development(DFID)

DFID has for many years given high priority to the challenge of rolling-back HIV/AIDS to contribute to global programs and international agencies, support bilateral interventions, and encourage mainstreaming in relevant sectors. However, since the late 1990’s, the response has been restrained by reduced bilateral emphasis and greater support of multilateral activity in infrastructure. Poverty reduction strategies are used to provide an umbrella for incorporation of AIDS activities. The national strategy and epidemiological dynamics inform the specific interventions performed. DFID supports activities in five African countries by providing technical support and grants. DFID does not have standardized checklists for appraising infrastructure programs from an HIV/AIDS perspective. In addition, monitoring and evaluation measures need to be enhanced.

In terms of over-arching concerns, efforts among all agencies have focused on vulnerability reduction rather than impact mitigation. There is a need to identify good practices in this area. There is also concern about efforts to transfer skills by enhancing local capacity and making sure that the national context is set-up to accommodate and support these efforts.

The JI provides opportunities to be more systematic in designing infrastructure programs, taking into account how the sector exacerbates the HIV situation and how high levels of death and illness impact the effectiveness of the sector. A balance needs to be found between efforts: 1. to triage interventions to where they are most needed (addressing a short-term need) 2. to mainstream implementation (providing a long-term solution). DFID is particularly interested in working on the regional level.

Main common challenges

The discussion that took place following the presentations by each partner institution helped identify common challenges for mainstreaming HIV into infrastructure projects and in transport in particular.

Funding of HIV activities

JBIC raised the question about funding for HIV activities. Typically, HIV activities have been funded by grants as government clients are typically not supportive of paying for such activities through loans. This issue was also raised by ADB in the context of the regional Mekong cross border project involving several countries as well as mobile populations

The World Bank shared its positive experience on funding IEC activities where governments were not responsive in the beginning but then followed-up by sustaining the activities once they understood the importance and success of Bank-funded activities. Such was the case of the Shiman Highway IEC campaing activities in China.

ADB raised the argument that the cost of doing nothing should be presented to governments. It was also suggested by KfW and the WB that as much as possible activities have focused on prevention rather than provision of services and that they should be linked to locally available resources and programs (Pepfar, the Global Fund). Regional coordination could also facilitate cost-sharing and avoid duplication of activities.

How to use the JI to best serve country operations

ADB stressed that the energy devoted to the Joint Initiative should be utilized to serve country operations and needs. Analytical work (including cost-benefit analysis), capacity building and advocacy (including joint advocacy at the national level) are typically the domain of HQ since they are better positioned to engage in these efforts. Likewise, coordination at the level of headquarters is requisite to ensure that a standardized, well-defined, consistent approach is taken. However, as regions are in varying stages in their epidemics and their level of experience in responding to the epidemic differs, it is important that knowledge be shared within specific regions and to lead to greater cooperation. Experience from other regions should also be used.

Prioritizing AIDS interventions

The WB asked how to determine in which country and in what projects should resources be targeted in order to best use the little resources available for mainstreaming AIDS in infrastructure projects. Several options were discussed: 1) should activities be developed for countries with high HIV prevalence rates only?; 2) should a risk assessment methodology be used to prioritize among projects?; 3) should only cross border projects and those with mobile populations be given priority? .