Report No. PID11503 ST. KITTS AND NEVIS-KN: HIV/AIDS... PREVENTION AND CONTROL PROJECT. Latin America and Caribbean Region. Sector Health (100%)

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1 Report No. PID11503 Project Name ST. KITTS AND NEVIS-KN: HIV/AIDS... PREVENTION AND CONTROL PROJECT Region Latin America and Caribbean Region Sector Health (100%) Project ID P Borrower(s) ST. KITTS & NIVES Implementing Agency MINISTRY OF HEALTH Address: Church Street, Bassaterre, St. Kitts Contact Person: Dr. Earl Martin Tel: (869) Fax: (869) Environment Category B Date PID Prepared October 30, 2002 Auth Appr/Negs Date December 15, 2002 Bank Approval Date May 15, Country and Sector Background Main sector issues As with all Caribbean countries, the first case of HIV/AIDS in St. Kitts/Nevis was discovered in the mid 1980s. Since then, the country has seen a significant rise in HIV/AIDS and it has started to affect the population as a whole. As of third quarter 2001, St. Kitts and Nevis reported 195 cumulative HIV cases, 75 AIDS cases and 58 deaths because of AIDS. Of these, 36 cumulative HIV/AIDS cases belong to Nevis, of which, 1 has AIDS, and 18 have died due to AIDS. Despite the absence of a sentinel surveillance system, HIV prevalence among people aged is estimated at about %, which means that about people are already infected by HIV. Furthermore, it is estimated that 5% of pregnant women are HIV positive, which represents 50 HIV positive pregnant women. Without any intervention, this can produce about new HIV positive newborns a year. The majority of reported cases were among persons years of age, with a sex ratio of 2 males to 1 female. These figures indicate that St.Kitts/Nevis are in the process of changing from a concentrated to a generalized epidemic, if effective action is not taken now. Worse, a 1.5-2% prevalence in a small population such as that of St. Kitts/Nevis is far more serious than in larger populations, because its impact in the productive population is felt more severely. Overall, CAREC estimates that there may be up to 40% under-reporting Communication from CAREC though PAHO Regional Office, Barbados. MSM cases account for about 3%, which is also considered to be seriously under-reported due to the stigma attached to homosexuality in the country. St. Kitts/Nevis responded to the outbreak of HIV/AIDS in the mid-eighties

2 by setting up a National AIDS Program within the Ministry of Health, which depended essentially on external assistance (e.g. CAREC) to initiate testing, surveillance and research, protect blood supplies, and carry out communication and behavioral interventions. With the situation worsening in the mid nineties, the GOSK took a more proactive approach and set up an AIDS Coordination Unit within the Ministry of Health, staffed with a coordinator and two professional staff. The Coordination Unit has, since then, been very dynamic in mobilizing NGOs, community groups and other ministries of government with the goal of raising public awareness and changing behavior. The Ministry of Health has also begun a more concerted effort to fight HIV/AIDS by strengthening STI management and condom programs. Condom distribution has become a more common practice at festivals, carnival and other public gatherings. The issue to be addressed is how to scale up other effective interventions and sustain the momentum over the longer term. Recognizing the challenges ahead, the Government has adopted the Caribbean Regional Strategic Plan of Action for HIV/AIDS, to which it contributed. Within the framework of this Regional Plan and after wide consultations among stakeholders in the country, the Ministry of Health has formulated the "Strategic Plan for the National Response to HIV/AIDS in St. Kitts/Nevis" with the goals of reducing: (i) the spread of HIV infections and (ii) the impacts of HIV/AIDS on individuals, families and communities. The Plan identifies the five priority areas for intervention: 1. Prevention 2. Treatment, Care and Support 3. Advocacy 4. Surveillance, Epidemiology and Research 5. Program Coordination and management 2. Objectives St. Kitts/Nevis has met the eligibility criteria for country participation in the Multi-Country HIV/AIDS Prevention and Control Adaptable Program Lending (APL) for the Caribbean Region, which provides loans and/or credits to governments in the Region to finance their HIV/AIDS prevention Programs. The project aims to support selected activities of St. Kitts/Nevis' Strategic Plan for the National Response to HIV/AIDS (SPNR). It would assist the Government of St. Kitts/Nevis (GOSK) to control the spread of HIV/AIDS through: (a) scaling up prevention programs targeting high-risk groups as well as the general population; (b) strengthening treatment, care and support for persons living with HIV/AIDS (PLWA); and (c) strengthening of St. Kitts/Nevis' multi-sectoral institutional capacity to better respond to the epidemic. 3. Rationale for Bank's Involvement Through its participation, the Bank would re-enforce GOSK's adoption of institutional arrangements for sustaining the HIV/AIDS prevention and control project, and would provide necessary incremental resources to invest in this development. It would also re-enforce St. Kitts/Nevis' policy to introduce HAART by assisting to meet requirements in the infrastructure of the health system for a successful program. The Bank would also strengthen the partnerships that St. Kitts/Nevis has built with PAHO/CAREC, UNAIDS, OECS/PPS and in the dialogue with suppliers of ARV -2 -

3 drugs. 4. Description 1. Project components (see Annex 2): A. Advocacy and Behavior Change Advocacy. The Project would assist the government to create a favorable legal and policy environment that protects the rights of PLWA. This work would begin as part of project preparation, including identification of strategic partners (media, local celebrities, religious, business and community leaders) to mobilize their support in public information campaigns against stigma and mobilization. PLWA will be involved in these advocacy activities. Information Education and Communication - IEC. Aiming at maintain people's awareness of HIV/AIDS and prevention measures, promote behavior changes for safe sex practices and risk reduction. It will be done through national and community campaigns. B. Prevention in high-risk groups and general population This component would finance activities to identify high-risk groups (CSW, MSM, uniformed personnel, migrant workers, and hotel and tourism workers) and their informal networks (e.g. through participatory mapping), in order to target them with prevention and behavioral change interventions. For both, target groups and the general population, the project would support IEC and awareness campaigns, Voluntary Counseling and Testing services, condom distribution, prevention of MTCT, and STI management. A strong emphasis will be laid on youths (both in and out of school). Improved Management of Biomedical Wastes: Although the size and type of services provided by the project do not pose threat to health personnel, patients, or the community, the project would finance the strengthening of the biomedical waste management system in public health facilities, including equipment, training, technical assistance and new facilities for the treatment and disposal of bio-medical wastes. C. Access to Treatment, Care and Support for PLWA The project would support capacity strengthening and upgrading current services available for providing treatment, care and support for PLWA, through: a) management of opportunistic infections and palliative care; b) introduction of HAART; c) strengthening heath facilities/laboratory capacity; d) pharmacy strengthening; and d) home and community-based care for PLWA. D. Surveillance, Epidemiology and Research The project would support a new information system, which would: (i) protect the confidentiality of medical records assuring patient privacy through encrypted technology; (ii) improve the quality of the information allowing for cross reference analysis from multiple databases being implemented; and (iii) support decision making in case management, particularly for ART but also for STIs in general, by providing secured online real time clinical information. The project would provide system design, adaptation of available software and procurement of hardware, installation, provision of IT support and the training for practitioners, laboratory staff and MOH researchers required to use the system. It would support second-generation surveillance that - 3 -

4 monitors both HIV infection and risk behaviors to inform the trends of the epidemic. A monitoring and evaluation system will be put in place with quantifiable indicators. E. Sustainable Management Response The project would support the creation and the initial operations of a "National Council on HIV/AIDS (NCHA)", whose mandate would be to provide policy guidance to the Prime Minister and his Cabinet, and oversee implementation and resources mobilization for HIV/AIDS. The Project would also support the operation of a virtual PCU under the leadership of a Steering Committee, which would be responsible for project implementation and periodic briefing to the Cabinet and the NCHA on project implementation activities (see Implementation Arrangements, below). Ministries and agencies with operational responsibilities for the program would designate a "focal point" staff to be responsible for implementing the agencies' program components. 5. Financing Total ( US$m) BORROWER $0.28 IBRD $2.60 IDA Total Project Cost $ Implementation The project would be implemented following annual work programs according to a calendar that mirrors the preparation of the Government's annual budget. They would be designed to account for the results obtained in the prior year's work, the further refinement of needs assessed in vulnerable groups, an new opportunities and knowledge. The project Operations Manual would contain guidelines for annual work program preparation and implementation and would be a condition for effectiveness. As the impacts of many proposed project activities, especially those that are directed at changing behavior and attitudes, is difficult to predict, project activities would be reviewed, added, dropped and modified as lessons are learned during implementation. Annual progress reviews would contribute to the use of rolling annual work plans and a mid-term review will be an important project management tool. Of particular concern would be St. Kitts/Nevis' ability to introduce and scale up HAART from its present base. A period of preparation of the necessary infrastructure, human resources and management platforms would be necessary for this to occur. The project would provide resources to support this preparation. 7. Sustainability Achieving project sustainability would eventually be an outcome of the development of a sound structure of the NCHA. Once formed, the NCHA would continue to draw on the Ministry of Finance on financial and administrative matters and the Ministry of Health on technical matters thus providing a sustainable framework for the Response. Mainstreaming of HIV/AIDS prevention and control actions within the regular work programs of relevant government agencies would be re-enforced through the GOSK budget process. Results of the assessment on longer-term financial sustainability of the policy for ART have been very positive

5 8. Lessons learned from past operations in the country/sector The project adopts the design features that underpin the Multi-country HIV/AIDS Prevention and Control Adaptable Lending Program for the Caribbean region and takes into account lessons that have proven successful in other countries. These include the following: n demonstrating a high level of government commitment and providing clear national leadership for a project, embodied in a new National Council for HIV/AIDS; n building collaboration networks with NGOs and community groups as a complement to public sector agencies; n incorporating other public and private partners in the implementation of the project; n including the focus on treatment and care as a continuum with advocacy and prevention within the project; n providing focus on behavior change of specific groups practicing risky life-styles as a key element of prevention and control; and n adopting implementation measures that provide flexibility and responsiveness to the epidemic as it evolves. 9. Environment Aspects (including any public consultation) Issues : Category B. See Annex on Environmental aspects. 10. Contact Point: Task Manager Patricio V. Marquez The World Bank 1818 H Street, NW Washington D.C Telephone: (202) Fax: (202) For information on other project related documents contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C Telephone: (202) Fax: (202) Web: Note: This is information on an evolving project. Certain components may not be necessarily included in the final project. This PID was processed by the InfoShop during the week ending November 8,