87100 IMPROVING THE RESPONSE TO HIV/AIDS IN SOUTH ASIA (P131032) BACKGROUND While overall national HIV prevalence in South Asian countries remains low, the size of the regional population means low prevalence translates into large absolute numbers of people living with HIV. Low national prevalence also masks higher HIV prevalence and incidence rates in certain geographical areas and among key populations at higher risk. The majority of new HIV infections are concentrated among population groups at higher risk including people who inject drugs, female and male sex workers and their clients, men who have sex with men and transgender people. The Bank is committed to achieving MDG Goal 6 of halting and beginning to reverse the spread of HIV by 2015. The Bank is also committed to helping countries achieve universal health coverage – including access to HIV treatment. Over the past two decades the Bank has harnessed its multi-sectoral reach to work across relevant sectors to improve health and reduce the risk of HIV. Recently, at the opening of the 2012 International AIDS Conference in DC, World Bank President Jim Kim pledged that "the World Bank will work tirelessly….to drive the AIDS fight forward until we win". Today the Bank supports HIV prevention activities in a stand-alone investment project in India (US$255 million) as well as through health sector programs in Nepal, Bangladesh, Pakistan and Afghanistan. As one of the ten cosponsoring organizations of UNAIDS, the Bank works together with other cosponsors and the UNAIDS Secretariat under the UNAIDS Unified Budget, Results, and Accountability Framework (UBRAF). The UBRAF is an instrument to catalyze country level action against AIDS within a broader development context while maximizing the coherence, coordination and impact of the UN’s response to AIDS. For CY2012-2013, the South Asia Region received US$531,000 of UBRAF funding to address our objective of “improving and accelerating the response to HIV, tailored to the epidemic dynamics of each country in the South Asia region by coordinating and supporting AAA, providing strategic TA to operations, fostering internal/external partnerships, and sharing knowledge and tools on HIV.” OUTPUTS A variety of activities were supported under this task over calendar years 2012-2013: i. Pakistan: The Naz Male Health Alliance (NHMA), Lahore implemented the project “Capacity building of MSM/TG Groups to Prevent HIV and Promote Sexual H ealth amongst MSM/TG in Pakistan”. The project aimed to develop the capacity of NMHA in the key and interlinked areas of rights’ awareness, promotion and empowerment. The assistance provided by the World Bank through this project helped to create a more sustainable and effective response to improving sexual and reproductive health and further reducing the spread of HIV among MSM and TG populations in Pakistan. The project had two components: 1) Strengthen technical support ability of NMHA staff and its partner organizations through participation in exposure visits, training programs and conferences in order to improve NMHA’s capacity to provide technical assistance. The trained staff were better able to provide technical support to groups funded under the Global Fund’s project DIVA; 2) Develop educational and technical ability of the trans- gender community. This component focused on basic literacy training for trans-gender (TG) people. TG specific training materials were developed in the local language. In total, 98 TG were trained. ii. India: The University of Manitoba and the Karnataka Health Promotion Trust implemented the Sabala project (ongoing) in the South Indian state of Karnataka. The goal of Sabala is to improve the quality of life of adolescent girls from vulnerable and marginalized communities in two districts of Karnataka by delaying their marriage, sexual debut, and entry into sex work. Project objectives include increasing the percentage of adolescent girls entering formal secondary education and increasing the percentage of adolescent girls that continue secondary education until Standard 10. The project addresses structural barriers and builds capacity of schools to positively influence gender socialization and roles. The project leveraged Government of India funds through the Rajiv Gandhi Scheme for Empowerment of Adolescent Girls. iii. India: The report “Charting a Programmatic Roadmap for Sexual Minority Groups in India” was drafted and disseminated. The report goes beyond the narrow confines of health problems confronting gender and sexual minorities and develops a fuller understanding of the barriers that confine their realization of civil liberties and inclusion in terms of ability, opportunity and dignity. The report has galvanized discussion within the Bank regarding rights and the economic cost of exclusion of sexual and gender minorities. Further work in that area is now being financed by the Nordic Trust Fund. iv. India: In an effort to learn from India’s success in preventing HIV among specific populations through the use of targeted interventions (TIs), the Bank undertook a case study. The study analyzes the process of adapting TIs for HIV prevention among female sex workers (FSWs) in the North and South states in response to changing contextual factors. The case study identifies the implementation “binding constraints” for prevention of HIV among FSWs in two sets of states, collects the evidence generated and used for the decision making that led to the adaptation of the TIs, describes the process of adaptation, including the role of different players, during implementation, and identifies the enabling factors and drivers as well as the lessons learned by comparing the implementation processes and results between the two sets of states. v. Afghanistan: In cooperation with the Ministry of Education, a vocational training program was developed for 194 injecting drug users (124 male and 70 female), most of whom were enrolled in a pilot program of opioid substitution therapy (OST) in Kabul. The trainees developed general life skills and specific vocational training in the areas of sewing, tailoring, carpet weaving, embroidery, beautician, house wiring, welding and plumbing. Unfortunately, due to lack of cooperation of the Ministry of Counter- Narcotics the OST pilot itself (not financed by UBRAF) could not be scaled up and instead was discontinued when its original financing dried up. vi. Nepal: The Sexual Orientation and Gender Identity (SOGI) project was implemented by the Blue Diamond Society (BDS). It addressed exclusion and bullying of LGBTI people in educational facilities. BDS developed and field tested a toolkit which was used for a training of trainers (TOT) of 176 teachers. Altogether 30 trainings were conducted for a total of 600 teachers trained from different districts of Nepal. vii. Regional: The Naz Male Health Alliance-Lahore organized the participation of 27 MSM/TG from seven South Asian countries in the 11th International Congress on AIDS in Asia and the Pacific (ICAAP 11) in Bangkok, November 2013. These participants contributed pro-actively to the success of ICAAP 11 through:  MSM preconference sessions  E-poster presentations  Oral presentations in various sessions to promote inclusion of sexual minorities in HIV programming across the region  Contributions and representation at LGBT booth organized by APCOM at the conference venue  Moderating the session of virtual participation of TG/MSM youth from Pakistan in a session organized by Youth Voices Count. The deliverables for each of the above-mentioned activities have been filed in WBDocs under P131032 and TF012430. They are also uploaded in the Operations Portal under P131032. LESSONS The key lessons learnt include:  There is significant variability in the capacity of national civil society organizations across the region. As these are the organizations that are closest to – and often members of – population groups at higher risk of HIV infection, it is important to note they may not have much experience or skill in proposal or report writing or monitoring and evaluation. Furthermore, they may face financial constraints that make it difficult for them to work on a fully reimbursable basis.  Stigma and discrimination remain important barriers to accessing treatment and services.  There are important cross-cutting areas and scope for inter-sector and inter- ministerial collaboration (Home Affairs/Prisons, Social Protection, Narcotics, etc.)  There is demand for south-south learning and collaboration within the region and with south-east Asia. These lessons are being incorporated into our work in various ways. In Nepal, an independent, third party firm was hired to provide monitoring and evaluation support and assistance to civil society organizations who are implementing HIV targeted interventions for key populations on behalf of the government. In India, the Bank is working together with the Ministry of Health and Family Welfare and the National AIDS Control Organization to establish a center that will coordinate the dissemination of knowledge generated by the national HIV program with an emphasis on south-south exchanges. In Pakistan, the recently approved Punjab Health Sector Reform Project has a subcomponent which finances the fight against HIV. The project will likely work with the NMHA for the implementation of this component. In Afghanistan, vocational training will become an integral part of all programs with groups at high risk of HIV infection. IMPACT It is still too early to assess impact in terms of outcomes of the activities supported under this task, and in some cases the work is still on-going (i.e. the Sabala project in India). However, in Pakistan our work with the Naz Male Health Alliance enhances the implementation of the GFATM funded DIVA project, which had no fund allocation for capacity building of Naz. The UBRAF funding for Afghanistan further incentivized the IDU to remain compliant with the OST, according to the implementing NGO (Médecins du Monde). COST AND TASK TEAM The total amount of the Trust Fund was US$531,000. The core task team included Kees Kostermans (Lead Public Health Specialist), Phoebe Folger (Operations Officer), and Alejandro Welch (Team Assistant). Country specific inputs were received from Sameh El-Saharty (Sr. Health Specialist), Amith Nagaraj (Operations Officer), Inaam Ul Haq (Lead Health Specialist), Manav Bhattarai (Health Specialist), Tawab Hashemi (Health Specialist), Iffat Mahmud (Operations Officer), Ghulam Sayed (Senior Health Specialist), and Aliya Kashif (Health Specialist).