PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Project Name Region Sector Project ID Borrower(s) Implementing Agency PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Environment Category Date PID Prepared May 9, 2007 Date of Appraisal April 6, 2003 Authorization Date of Board Approval July 7, Country and Sector Background Multisector HIV/AIDS Control Project Report No.: AB3121 AFRICA Other social services (44%); Central government administration (36%);Health (20%) P GOVERNMENT OF MAURITANIA National Executive HIV/AIDS Secretariat Ilot C No 519, BP 5161 Nouakchott Mauritania Tel: Fax: abhorma@senls.mr National Executive HIV/AIDS Secretariat Ilot C No 519, BP 5161 Nouakchott Mauritania Tel: Fax: abhorma@senls.mr [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) The Programme National de Lutte contre le SIDA (PNLS) was established in A Multisectoral National AIDS Coordinating Committee (NAC) was established in 2002 under the Prime Minister chairmanship. The NAC created the National HIV/AIDS Executive Secretariat (NAES) which is located within the Ministry of Health (MSAS). A UN Theme Group on AIDS was formed under the chairmanship of WHO, and a technical committee was created to address specific aspects of a national strategy using as a framework the UNGASS. 2. Government s Initial Response to HIV/AIDS The national program had a weak beginning but attitudes changed from 1999 to the present. The Government s response to the unfolding HIV/AIDS situation has been to focus primarily on its medical and health aspects under the leadership of the MSAS and PNLS. HIV drew limited attention from the national leadership because it was a taboo subject, there were virtually no visible signs that HIV/AIDS existed, and the widely held notion was that the national culture and behavior shielded the country from the epidemics. Under the leadership of the PNLS, with

2 WHO support and encouragement, an advocacy effort was launched to sensitize opinion makers. As a result, religious leaders became increasingly receptive to reaching out to their constituents with a message of tolerance for those infected, and recognition of the need to educate the population on the risks, and means to avoid its transmission. "Stop SIDA" was developed by an Imam.4.0. Community involvement proved fundamental for an effective campaign. Community, civil society, and private sector activities were needed to support prevention as well as care of those infected and affected. Such efforts helped empower communities at different levels to heighten the level of awareness of the general population, fight discrimination against individuals infected and/or affected by the HIV virus, and be an incentive for individuals to seek prevention and care services when needed. Strong emphasis was placed on counseling of both patients and families. 3. Rationale for Bank Involvement HIV prevalence rate in Mauritania is still low (below 1%) in the general population, but the current data (UNAIDS 2006) indicate that the epidemic is evolving. Mauritania s government budget alone would not be sufficient to prevent the spread of the pandemic. Further, if numerous donors are involved, their financial contribution remains modest. With project activities aiming at building structures and capacities for prevention and treatment of HIV infections, the project contributes - together with other interventions - to an improvement of the situation. 4. Rationale for project restructuring The project was designed during a period when the Bank was the principal financier resulting in a rather detailed project design which left little room for adaptation to the current situation in the country. Also, data collection and reporting situation were very poor at the time and did not permit targeting. Therefore, without changing the core activities of the project, the Government proposed a simplified project design better targeting high-risk and vulnerable groups, while at the same time continuing efforts at targeting the general population. The four project components are maintained; while the sub-components are reduced from 16 to 9. Also, the initial PDO (to maintain the level of human immunodeficiency virus (HIV) infection that causes the acquired immunodeficiency syndrome (AIDS) below the prevalence rate of 1 percent and reduce opportunistic infections) is recognized as unrealistic due to inclusion of HIV prevalence for several specific target groups. The KPIs are not realistic and need to be adapted to the changed PDO. To support implementation of the simplified Project reallocation of funds is needed to drop the activities that are not longer appropriate to achieve the project outcomes. 5. Objective The revised Project Development Objective is to increase the coverage and utilization of HIV prevention services, of medical treatment and social care, especially for high risk and vulnerable populations. 6. Description The Project has the following parts:

3 Part A: Institutional Capacity Strengthening and Project Management. Provide assistance to the Recipient to put in place and maintain the national HIV/AIDS apparatus through: (a) supporting NAC to: (i) ensure its capacity to perform its responsibility to oversee the National HIV/AIDS program, (ii) and reviewing its performance and approving the work programs and budgets; (iii) supporting the installation and the operation of the National HIV/AIDS Executive Secretariat (NAES) and the Regional HIV/AIDS Executive Secretariats (RAESs) to ensure their capacity to perform their mandates to provide secretariat services to the NAC and the RACs and be responsible for overall HIV/AIDS program administration, coordination, and facilitation; (b) helping build the capacity of all participating line ministries to prepare, implement, monitor, and evaluate HIV/AIDS sectoral action plans; (c) improving the institutional capacity of Beneficiaries to identify, prepare, and implement Sub-projects; (d) ensuring the program access to the less visible high-risk groups, stimulate community-based responses to include socially delicate HIV/AIDS-related issues through advocacy and awareness raising; (e) establishing and strengthening partnership with institutions, organizations and actors active in the sector to develop innovative activities targeting vulnerable/high risk regions or population groups; and (f) Supporting the installation and operation of an operational monitoring and evaluation system to an improved and balanced management and strategic decisions made by the NAC and all partners about priorities, contents, and approaches of the HIV/AIDS program, and Action Plans. Part B: Expand Public-Sector (non-health) Responses for Prevention and Care of HIV/AIDS Provide support to improve the capacity of non-health sector line ministries to respond to HIV/AIDS, emphasizing strengthening of the knowledge of the epidemics (transmission methods and prevention), testing and fight against discrimination of PLWHA through:

4 (a) updating the existing HIV/AIDS and STI educational material, especially with regards to testing, treatment and non-discrimination; (b) focusing on high-risk and vulnerable groups, depending on the sector; (c) carrying out refresher course for the line ministry staff, their partners and dependents; and (d) strengthening the design, implementation, monitoring, and supervision of Line Ministry Action Plans. Part C: Health Sector Responses for Prevention, Treatment and Care of STI/HIV/AIDS Provision of medical and epidemiological information to promote safe sexual practices; offer quality preventive and medical services covering IST/HIV/AIDS; and prevent non-sexual transmission of HIV, through: (a) Surveillance and Epidemiological Research: Carrying out research on the evolution of the epidemic, using biological and behavioral surveillance and additional research among the general population and more particularly vulnerable groups. (b) Prevention and Voluntary Counseling and Testing (VCT): (i) (ii) (iii) (iv) Support to carry out HIV testing; Strengthening and progressive extension of mother to child transmission centers in the selected Regions of the Project; Strengthening the regional blood transfusion centers through more frequent and in-depth supervision and providing free confirmation testing; and Promotion of a safe working environment in medical facilities for a better hospital hygiene and prevention from iatrogenic infections through: (a) disposal of disinfection material, sterilization, protection; and (b) and generalization of protocols on exposure to blood. (c) Management of Bio-Medical Waste: Assist in setting up a system adapted to manage bio-medical waste and provide support for the implementation of the MWMP through providing goods such as incinerators where needed and technical assistance to assist the MOH to better manage medical waste. (d) Care and Treatment:

5 (i) (ii) (iii) Supporting the reinforcement of the Ambulatory Treatment Center (ATC) to upgrade the ACT as a center for national center of reference and for an improvement in-patient and out-patient treatment center; Re-starting the STIs treatment programs and promotion of voluntary HIV testing to patients with STIs and their partners; and Support in setting up a system to guarantee the regularity of the supply of reagents, consumables, and drugs in conformity with the international rules, quality control of imported goods, and quality of the storage of the drugs. Part D: Expansion of Private Sector Initiatives for HIV/AIDS Provision of resources for a broad spectrum of preventive and care activities that reach target Beneficiaries through: (a) expanding initiatives for HIV/AIDS by building AIDS competent communities for prevention, care, and social support carrying out Sub-projects of national, regional and local scope; and (b) development and expansion of private sector enterprise initiatives for HIV/AIDS to build awareness and capacity building within the private sector. 7. Financing Source: ($m.) BORROWER/RECIPIENT 2.4 IDA GRANT FOR HIV/AIDS 21 Total Implementation Agreements have been signed with eight line ministries for activities that focused on sensitization and distribution of contraceptives. The Ministry of Defense has introduced systematic testing of all new recruits. Also, with regards to the health sector response, the project has financed eight sentinel sites covering the majority of the country. An ambulatory treatment center was created thanks to a partnership among the Government, IDA, the French cooperation and French Red Cross. Furthermore, a center for prevention of Mother-To-Child- Transmission was opened based on collaboration among the Government, IDA, UNICEF, and AWARE. The project has also financed the establishment of three voluntary testing centers as well as for distribution of contraceptives. The Civil Society response has been important, and a private sector Coalition of Mauritanian Enterprises for HIV/AIDS control has been set up with the support of the project. Progress has been made to improve the M&E capacity with the identification of the need to institute a bio-behavioral surveillance survey for HIV, the development of the TOR for the study and the initiation of the study which is now in progress (with GAMET support). 9. Sustainability

6 The sustainability of the program will largely depend on the degree to which: (i) the present high-level commitment to fight the disease is maintained over time; (b) the coordinated multisector participatory approach is fully owned and appreciated by all stakeholders; (c) national HIV/AIDS mechanisms put in place are performing effectively; (d) key sectors engage in the fight against HIV/AIDS; and (e) efforts to inform all Mauritanians and change behavior are successful. As a result of this diagnosis, the project is focusing on: (i) capacity-building; (ii) demand-driven processes; (iii) ownership and accountability; (iv) communication strategies; and (v) M&E. With respect to financial sustainability, the Mauritanian fight against HIV/AIDS will require external financial support for an extended period and especially at community level. 10. Lessons Learned from Past Operations in the Country/Sector Key lessons learned and incorporated in the project design are: HIV/AIDS effort must be multisectoral and focused on development, focus that should be reflected by leadership; A multisectoral oversight body at the highest government level is needed; and Outsourced key management functions will improve procurement, efficiency, timeliness of funds transfer and other fiduciary tasks. 11. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.01) [x] [ ] Natural Habitats (OP/BP 4.04) [ ] [x] Pest Management (OP 4.09) [ ] [x] Cultural Property (OPN 11.03, being revised as OP 4.11) [ ] [x] Involuntary Resettlement (OP/BP 4.12) [ ] [x] Indigenous Peoples (OD 4.20, being revised as OP 4.10) [ ] [x] Forests (OP/BP 4.36) [ ] [x] Safety of Dams (OP/BP 4.37) [ ] [ ] Projects in Disputed Areas (OP/BP/GP 7.60) * [ ] [ ] Projects on International Waterways (OP/BP/GP 7.50) [ ] [ ] 12. Contact point Contact: Vincent Turbat Title: Sr Economist (Health) Tel: (202) * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties claims on the disputed areas

7 Fax: (202) For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C Telephone: (202) Fax: (202) pic@worldbank.org Web: