Project Name. February 26, Country and Sector Background

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Project Name PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB531 THE PAN CARIBBEAN PARTNERSHIP AGAINST HIV/AIDS Region LATIN AMERICA AND CARIBBEAN Sector Health (100%) Project ID P Grant Recipient THE CARIBBEAN COMMUNITY AND COMMON MARKET (CARICOM) Implementing Agency Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Safeguard Classification Date PID Prepared February 17, 2004 Date of Appraisal Authorization Date of Board Approval March 25, Country and Sector Background [ ] S 1 [X ] S 2 [ ] S 3 [ ] S F [ ] TBD (to be determined) February 26, 2004 More than 500,000 persons in the Caribbean region are estimated to be infected with HIV/AIDS at the end of None of the Caribbean countries and territories has been spared from HIV/AIDS. The political leadership, the private sector, and civil society of these countries are keenly aware of the disastrous consequences of the pandemic in Sub-Saharan Africa countries and are committed to protect their economies and to safeguard the health and well being of their people through an aggressive regional program of support to prevention and treatment actions. The World Bank has been working intensively already with six of the fourteen eligible countries that include the six IDA countries (Guyana, Haiti, St. Lucia, St. Vincent and the Grenadines, Dominica and Grenada). The Multi-Country HIV/AIDS Prevention and Control Adaptable Program Lending (APL) for the Caribbean Region was approved by the World Bank Board of Directors in June 2001 with country loans, credits, and grants that amount to US$155 million. As of January 2004, US$ 86 million has been committed under the first two APL phases (the program treats specific country projects developed within the regional framework as phases of a horizontal APL; countries are grouped under each phase according to their readiness to undertake the initial set of activities aimed at establishing sustainable domestic structures for HIV/AIDS prevention and control). A regional approach was discussed and agreed on during APL preparation, and now the LAC Region has decided that the proposed project would be included as part of the third phase of the APL to help implement region-wide efforts. 2. Objectives The proposed project, in parallel with other international assistance, would help to establish, consolidate and effectively coordinate regional support to Caribbean countries in their efforts to reduce the impact of HIV/AIDS on the human and economic development of the Caribbean Region, especially in the context of the accelerated movement toward a Caribbean Single Market and Economy, and create a venue for knowledge sharing and exchange of country experiences to understand and respond to the epidemic.. The development objectives of the regional program are threefold: an effectiveness objective, by contributing to halting and beginning to reverse the spread of HIV/AIDS by 2015;

2 an efficiency objective, by providing the beneficiary countries/populations in the region with the knowledge and the tools for informing and mobilizing decision makers, promoting the rights of persons living with HIV/AIDS (PLWAS), combating stigmatisation and discrimination, managing and controlling opportunistic infections, sharing clinical laboratory capacity and diagnostic tools, strengthening surveillance and reporting, and supporting establishment and maintenance of reliable information systems; an equity objective, by ensuring that the benefits of the regional program are spread equitably across all countries, that benefits of the Grant would not accrue to any specific country or to the population of a specific country, and that special efforts be made to scale up the efforts of the poorer International Development Association (IDA) countries to keep stride with advances being made in more affluent countries. 3. Rationale for IDA Grant The Indivisibility Argument. Until today support for controlling HIV/AIDS has focused on national country-specific projects and it has become obvious that national programs are hindered in reaching their objectives because of: (i) the idiosyncratic make up of the region (multicultural, multilingual, multiracial, interdependent economies, common histories, unequal economic development, porous borders; (ii) tourism as the leading economic base with strong seasonal fluctuations and large fluid inter-country movement of workers and visitors; (iii) limited efforts by some countries to combat the spread of the virus; and (iv) the absence of a regional tracking and surveillance system documenting and reporting on how and where the virus is spreading and by whom. The proposed regional project therefore is based on evidence that national actions could be strengthened by a coordinated synergistic regional response, by sharing best practices, and by solidarity among the countries in arresting the epidemic, and that the regional impact in halting and beginning to reverse HIV/AIDS incidence and prevalence would be larger than the sum of the country-by-country outcomes. A coordinated regional response to the AIDS epidemic addresses the limited human resource capacity available in many of the smaller countries of the Caribbean and would help to bridge the gap between countries that have a strong response to HIV/AIDS and those that are struggling to respond. Successful previous experience with regional approaches, as well as clear economic analyses, point to regional integration as the best mechanism for achieving efficiency among small economies. A recent report from the Commonwealth Heads of Government also reinforces the economic justification for a regional approach particularly among small island economies. With a borderless epidemic such as HIV/AIDS and a highly mobile and fluid population such as that found in the Caribbean, political boundaries are obscured by the facto regionalization. The establishment of a Caribbean Single Market and Economy, expected to come into full force by 2005, would only increase population mobility and resource flows across the nations of the region. Previous experiences and successes of working cooperatively across the Region would be essential in addressing the HIV/AIDS epidemic in the Caribbean. The proposed regional program represents an initiative of the Pan Caribbean Partnership (PANCAP), a regional body coordinated by the Caribbean Community and Common Market (CARICOM) Secretariat the organization responsible for regional policy and cooperation among the Caribbean countries to put in place and implement a collective response to address the HIV/AIDS epidemic. PANCAP represents 24 member organizations from all 16 CARICOM nations. The regional program would primarily benefit the PANCAP member countries and territories of:

3 Antigua and Barbuda, The Bahamas, Barbados, Belize, Dominica, Dominican Republic (a CARIFORUM member), Grenada, Haiti, Jamaica, Montserrat, St. Lucia, Guyana, St. Kitts and Nevis, St. Vincent and the Grenadines, Trinidad and Tobago, and Suriname. The associated members of CARICOM who would benefit indirectly through information exchange related to the proposed regional activities include: Angilla, Bermuda, British Virgin Inlands, Cayman Islands, and Turks and Caicos. In addition, other states and territories in the Caribbean who would benefit indirectly include Aruba, Cuba, the Netherlands Antilles, Puerto Rico and US Virgin Islands. The proposed project was designed to support the implementation of the PANCAP regional program and builds upon an agreement in principle with the Financial Resources Management Unit (FRM) of the World Bank to provide an IDA Grant to partially finance region-wide and non-country specific HIV/AIDS prevention and control measures in the Caribbean. The benefits of the regional activities it would support would extend directly to several Caribbean countries that are members of the PANCAP but have different standing status with the World Bank. This include (i) IBRD-only countries (Belize, Dominican Republic, Jamaica, St. Kitts and Nevis, Suriname and Trinidad & Tobago); (ii) graduated IBRD-only countries (The Bahamas and Barbados); (iii) blend IDA borrowers (Antigua and Barbuda, Dominica, Grenada, St. Lucia, and St Vincent and the Grenadines); and (iv) IDA-only countries (Guyana and Haiti, which is currently in a non-accrual status). In addition, Montserrat is not a member of the Bank nor of IDA. Notwithstanding the above, IDA believes that proceeding with the proposed grant is fully justified in view of its regional focus and expected benefits and since grant-financed activities would not benefit or be attributable to any one country, but rather, to the Region as a whole. The proposed project builds on the strengths and history of Caribbean regional cooperation. Sharing knowledge and expertise across countries have been key features of Caribbean cooperation. So too has functional cooperation through institutions that work supra-nationally across the region. Recently, for example, countries in the Region have acted in concert on actions to adjust economies and regulations to accommodate climate change ( OECS Climate Change Project) and the GEF Climate Change Project (also managed through CARICOM). They have also acted collectively in dealing with the cruise line industry on solid waste disposal. Economic issues such as the access of Caribbean-produced bananas to European markets have also been addressed regionally. In the area of health, the Caribbean Cooperation for Health Charter, in existence since 1982 and coordinated by CARICOM and PAHO/WHO, facilitates information sharing and the implementation of health systems reform, including a special emphasis on HIV/AIDS. In addition, the Caribbean Epidemiologic Center (CAREC) located in Trinidad and Tobago provides services to all countries in the Region. In the area of drug supply and quality, the Pharmaceutical Procurement Service (PPS) located in St. Lucia has ensured the supply and availability of quality essential medicines to OECS member countries for the last 16 years using a regional pooled procurement mechanism. In addition, the Caribbean Drug Testing Laboratory in Jamaica provides essential services to Caribbean countries in the quality evaluation of medicines used in priority health programs. Most recently countries have entered regional negotiations with the pharmaceutical industry to reduce the price of antiretroviral drugs for the region. For these reasons, while HIV/AIDS by nature is a public health issue with substantial externalities cutting across geographic borders, it is even more so in the fluid Caribbean environment. Thus, HIV/AIDS prevention and control efforts in the Caribbean require not only individual national but also cross-border

4 actions that would reduce the risks of gaps in knowledge, strategy, the prevention and control of the pandemic that might exist if countries did not move in a coordinated manner. Regional institutions such as CARICOM, CAREC, CRN+, UWI, and UNAIDS, who are part of the PANCAP and to be supported under the proposed program, play a pivotal role in monitoring the social conditions of the Caribbean people and in developing institutional responses to emerging challenges. As a whole, these institutions are now promoting and coordinating a range of health promotion and disease prevention and control programs to address the HIV/AIDS epidemic in the Caribbean Region. These organizations therefore truly serve the Caribbean region as a whole and not a particular country. The grant would finance actions grouped in four components: COMPONENT 1: Advocacy and Policy Development (US$:1.4 million equivalent) Under this component, support would be provided to develop tools and best practices and their adoption at country levels to help reduce stigma and discrimination against persons living with HIV/AIDS (PLWHA) and their families, including the review of legal frameworks in the countries and the development of regional model policies, guidelines and legislation. Mechanisms would also be developed to monitor human rights violations and to enable those whose rights have been violated to seek redress and services to address individual- or country-specific concerns. Countries would be supported to establish National Registries while the Pan Caribbean Partnership Against HIV/AIDS (PANCAP) would maintain a Regional Registry to keep track of incidence of violations reported and the way they are addressed at national levels. A regional multimedia campaign related to HIV/AIDS-related stigma and discrimination would support human rights advocacy activities and information, education, and communication (IEC) campaigns. A regional multimedia campaign would ensure Caribbean people are exposed to consistent messages wherever they travel in the region. Common approaches and messages in national and regional programs would ensure a higher degree of success for initiatives addressing stigma and discrimination. Support would also be provided to PANCAP to ensure advocacy on law, ethics and human rights issues at the highest political levels by briefing and informing the political leadership during regional meetings. Additionally, the project would support the Health Economics Unit (HEU) of the University of the West Indies (UWI) to execute research activities with a view to providing information and mobilizing policy makers at the highest level with evidence-based information on the evolution, consequences and costs of the epidemic. The project would finance under this component consultant services, IEC campaigns, travel and subsistence, materials and supplies, and the costs related to publication and dissemination of policies, studies and best practices, including the organization of meetings, seminars, and workshops. COMPONENT 2: Prevention of the Spread of HIV/AIDS (US$1.1 million equivalent) The support that would be provided under this component is geared to assist in the coordination of regional and subregional HIV/AIDS prevention efforts to ensure that key populations have access to HIV/AIDS prevention services that are culturally, linguistically, and logistically appropriate. The proposed activities would focus upon mobile populations, a large share of which are women as they dominate the major migration streams in the Caribbean Region, as well as youth, and regional employers. The interventions that would be supported under the project in conjunction with other partners such as the Global Fund include:

5 A study to identify conditions that increase HIV risk for mobile populations and development of measures to reduce such risk conditions, particularly IEC campaigns. Assistance for the development of comprehensive prevention services at regional tertiary level educational institutions, including the provision of grants to student organizations on the campuses to conduct peer-designated-and-delivered HIV/AIDS activities. Support to national expatriate associations to deliver comprehensive HIV/AIDS prevention services to its constituents Support the involvement of regional employers in the development and dissemination of IEC materials at key transport and lodging spots and cultural events. Support of the implementation of the CARICOM Youth Ambassadors Mini-Grant Program that is geared to support interventions designed and implemented by youth and community groups to increase awareness around the social and health-related aspects of HIV, and facilitate the implementation of peer education initiatives. Support for the development of a regional condom social marketing program, including mass media campaigns, to promote safer sexual practices among youth and other vulnerable groups by increasing access to affordable condoms, decreasing barriers to consistent condom use, and enhancing local capacity for sustainable HIV/AIDS prevention. Partnerships with local distributors would be built to develop a means to track condom sales in order to measure growth in the overall condom market and collect accurate annual sales data by country. Economies of scale would be achieved through shared promotional materials and enhanced collaboration with regional condom distributors. Support of the development of behavior change communication activities tailored to youth and mobile populations, including the printing of materials to provide information and messages to target groups. Promoting increased corporate responsibility on HIV/AIDS issues by supporting the development of workplace policies and the implementation of programs at the workplace, including training for staff. The project would finance under this component consultant services, IEC campaigns and behavior modification activities, travel and subsistence, materials and supplies, and the costs related to publication and dissemination of policies, studies and best practices, including the organization of meetings, seminars, and workshops. COMPONENT 3: Strengthening Regional Laboratory Services To Support Scaling-Up Treatment and Care (US$2.5 million equivalent) Laboratory capacity and services are fundamental to providing diagnosis/identification of the HIV infection and continuing HIV care and treatment (e.g., anti-retroviral drugs (ARV) monitoring, diagnosis of opportunistic infections such as TB, and diagnosis of STIs). Laboratory services are also required for the provision of VCT services for the general population and surveillance and tracking of the epidemic and of drug resistance. CAREC acts as a regional reference and referral center for laboratory diagnostic and reference testing for all its member countries and also reviews new laboratory procedures and provides advisory services on their suitability. Under this component, therefore, the goal is to support the strengthening of regional laboratory services for HIV/AIDS care and treatment and opportunistic infections such as TB. Physical infrastructure rehabilitation and expansion, equipment, consultant services and institutional operating costs would be provided to CAREC for upgrading its laboratory system in support of expanded Voluntary Testing and Counseling (VCT), and treatment monitoring, surveillance and research activities as a region-wide network.

6 The project would also support the strengthening of related laboratory information systems and the connectivity between CAREC and country laboratories (clinical and public health) by extending CAREC s Laboratory Information System (LABIS) to up to six new country sites, with emphasis given to IDA-eligible countries. In addition, resources would be allocated to strengthen the biomedical waste management system at the CAREC regional laboratory. Project support to strengthen the CAREC laboratories capacity to respond to the HIV/AIDS epidemic would contribute significantly to the region s implementation of the World Health Organization s (WHO) global 3x5 initiative to scale up treatment of HIV-infected persons. This initiative has become an international priority as five to six million people infected with HIV in the developing world need access to antiretroviral therapy (ART) to survive. Only 300, 000 have this access. The failure to deliver ARVs to the millions of people who need them is now consider a global emergency as WHO declared at the September 22, 2003 UN General Assembly meeting on HIV/AIDS. Indeed, the vision for the Caribbean is for a 3x5 plus approach, to diagnose and bring into programs of care and preventive services, a high percentage of persons living with HIV/AIDS, including those who need ARVs. By achieving high coverage (75% PLHA in care by end 2007) with an agreed package of quality care and preventive services, the twin goals of the Regional plan against HIV/AIDS will be advanced: to decrease spread of HIV and to decrease impact (reduce deaths and sickness due to AIDS). COMPONENT 4: Strengthening Regional Response Capacity (US$4.0 million equivalent) The project would finance civil works construction and rehabilitation, equipment, management information systems, consultant services, and operating expenditures to: i) strengthen the management and operation capacity of key regional institutions (Caribbean Regional Network of People Living with HIV/AIDS CRN, UWI, and the United Nations Program for HIV/AIDS --UNAIDS) that support countries efforts against HIV/AIDS; and ii) ensure effective and efficient coordination of the regional response to provide a favorable environment for further scaling up of country efforts. Each of these agencies would be strengthen under this component to fulfill their regional roles as follows: a) CRN+ The Caribbean Regional Network of People living with HIV/AIDS (CRN+) was established in 1996, with its Secretariat based in Trinidad and Tobago. Organizational Development: This would entail a review and redesign of several areas of CRN+ s present operations. Firstly, CRN+ would seek to redevelop its vision, mission and constitution, so that it can more effectively reflect where the organization is today, but more importantly where it needs to be. Secondly, a great deal of emphasis would also be placed on reviewing the organization structure and human resource strategy. This area would seek to balance the need of the organization with the welfare of the PLWHA. This strategy would also lead to a more appropriate internal utilization policy for personnel with respect to recruitment and selection, orientation and training, management and assessment of performance, reward and compensation and modes of separation from the organization. The strategy would also address issues pertaining to non-plwha and in so doing would seek to establish the criteria for their participation in the organization. Communication and Marketing: This strategy would begin with a focus on the image enhancement of CRN+ and it would serve to initiate the process of establishing a positive and sustainable organizational profile for CRN+. It would then be developed to include management of stakeholder satisfaction with the

7 organization through the use of appropriate communication stimuli. Key to this entire process would be the development of a Marketing and Communications Department. Resource Mobilization: CRN+ has in the past been able to mobilize resources from several strategic partners. With the finalization of its five-year strategic plan it has become critical for the organization to continue along these lines and seek funding from both internal and external sources. Strengthening CRN + Monitoring and Evaluation (M&E( and Informational Technology (IT) Platform In addition, under this component, support would be provided to CRN+ to ensure that there is appropriate monitoring, evaluation and control while promoting the growth and development necessary for the organization to realize its mandate. In addition, the project would finance the development of the Information Technology (IT) Support Plan and the development of Human Resources Database, including the linking of CRN+ Regional Secretariat Office in Trinidad and Tobago with CRN+ Country Networks. b) UWI The Health Economics Unit (HEU) of the University of the West Indies (UWI) provides university education and community support to its member countries. Over the past few years it has emphasized the urgency of meeting the demand for policy advice based on quantitative and qualitative analysis. Through its work in the region, partners in the region have observed the demand for strong technical support in the areas of health economics and health administration. The project would assist HEU/UWI to position itself to provide technical support and training to countries in the region in key areas related to policy and planning especially program costing, program planning, implementation, administration and monitoring, health services management, and public administration. c) UNAIDS The Regional UNAIDS Team would provide support for most activities undertaken through PANCAP. Of specific importance would be the provision of support for national monitoring and evaluation mechanisms which has been identified as a priority area for action in the countries national strategic plans. The goal under this component, therefore, would be to support UNAIDS to provide technical assistance to countries, placing particular emphasis on capacity building at the country level, complementing the national efforts supported under the World Bank Multi-Country AIDS Prevention and Control APL, and by the Caribbean Epidemiology Center (CAREC) and the Caribbean Health Research Council (CHRC). Under this component, the project would also support the undertaking of (i) undertaking of an assessment of the patent system for drugs and the drug registration system of the Caricom countries from the standpoint of the promotion of public health, particularly in light of the WTO and Free Trade Agreements; and (ii) sponsorship of the care and treatment meetings to facilitate cross-fertilization arrangements among care and treatment country units and staff to set national targets and share responsibilities to achieve these goals/targets and to monitor progress accomplished on a yearly basis. This annual platform would also be used to share success stories and plan for some TCC (south-south cooperation activities).

8 4. Financing Source: ($m.) GRANT RECEPIENT 0.90 INTERNATIONAL DEVELOPMENT ASSOCIATION (IDA) GRANT 9.00 Total Implementation The CARICOM Secretariat located in Georgetown, Guyana, has been charged by PANCAP wit the responsibility to establish a small unit to coordinate and facilitate PANCAP s activities. CARICOM would be the recipient of the Grant, along with CAREC, CRN+, the HEU of the UWI, and UNAIDS. PANCAP would assist these institutions to carry out project activities. For said purpose, an internal arrangement between CARICOM and PANCAP (through the designation of a representative of the defacto partnership) would need to be signed in order stipulate the rights and obligations of the parties (such as the obligation to maintain an executive committee and a project coordinating unit, reporting, disbursement and procurement requirements). The execution of said arrangement would be a condition of effectiveness. 6. Sustainability PANCAP is built on a shared commitment to reduce the risks of the spread of HIV/AIDS in the Caribbean, and is expected to be a sustainable institutional arrangement for as long as the epidemic presents risks. PANCAP s success in meeting its goals will justify further financial contributions from the donor community to continue its program initiatives. CARICOM itself is a well-sustained regional body that has served its members and is expected to continue to do so. This project would increase the sustainability of other actions such as (i) national projects, through the transfer of additional information, technology, access to laboratory services, support for PLWAS; (ii) regional institutions such as CRN+, UWI, UNAIDS and CAREC through support for their institution building and modification efforts, that would provide a platform for continuing their regional HIV/AIDS prevention and control work; and (iii) PANCAP itself by providing a basis for its initial development as an operational factor in region-wide HIV/AIDS management. 7. Lessons Learned from Past Operations in the Country/Sector Broad lessons have been learned in the organization and management of an effective national HIV/AIDS national prevention and control projects that have been financed to date. The following lessons have been key: The need to build strong national constituencies advocating for HIV/AIDS prevention and control, protection of the needs of PLWAs, policies addressing drug cost control, recognizing the needs of specific vulnerable groups in society; The importance of national political leadership and advocacy of these needs, supported with multi-sectoral government action and adequate budgets; The relevance of bringing the private sector into the efforts to control the epidemic; The need to share information and coordinate actions to backstop and complement purely national actions; The finding and training of professionals to alleviate the key constraint of human resources The desirability of sharing facilities, infrastructure and specialized services and sources of professional expertise that would be beyond the means of individual countries.

9 Experience in the Caribbean in such areas as negotiation with pharmaceutical suppliers and addressing common tariff and fees issues in the management of ship-generated solid waste, have also shown that collective and common actions can yield scale economies and assure that each country adopts a coherent approach to issues. This project has incorporated these lessons. 8. 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) [ ] [x ] Projects in Disputed Areas (OP/BP/GP 7.60) * [ ] [x] Projects on International Waterways (OP/BP/GP 7.50) [ ] [x ] 9. List of Factual Technical Documents World Bank HIV/AIDS in the Caribbean: Issues and Option. World Bank Project Appraisal Document for the Multi-Country HIV/AIDS Prevention and Control Adaptable Program Lending for the Caribbean Region. 10. Contact point Contact: Patricio V. Marquez Title: Lead Health Specialist Tel: (202) Fax: Pmarquez@worldbank.org 11. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C Telephone: (202) Fax: (202) Web: * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas