The World Bank Report No: ISR3739 Implementation Status & Results Bhutan Public Disclosure Copy Bhutan - HIV/AIDS and STI Prevention and Control Project (P083169) Operation Name: Bhutan - HIV/AIDS and STI Prevention and Control Project Project Stage: Implementation Seq.No: 14 Status: ARCHIVED Last Modified Date: 15-Jun-2011 (P083169) Country: Bhutan Approval FY: 2004 Product Line: IBRD/IDA Region: SOUTH ASIA Lending Instrument: Specific Investment Loan Implementing Agency(ies): Ministry of Health Key Dates Board Approval Date 17-Jun-2004 Original Closing Date 31-Dec-2009 Planned Mid Term Review Date Last Archived ISR Date 15-Jan-2011 Effectiveness Date 18-Aug-2004 Revised Closing Date 30-Jun-2011 Actual Mid Term Review Date Project Development Objectives Project Development Objective (from Project Appraisal Document) The proposed project aims to reduce the risk of HIV and STI transmission among the general population, in particular among groups with high risk sexual behaviors. Has the Project Development Objective been changed since Board Approval of the Project? Yes No Component(s) Component Name Component Cost PREVENTING HIV/AIDS AND STIS 2.00 STRENGTHENING INSTITUTIONS 1.60 CARE AND TREATMENT OF AIDS AND STIS 1.00 Public Disclosure Copy STRATEGIC INFORMATION FOR HIV/AIDS AND STIS 1.10 Overall Ratings Previous Rating Current Rating Progress towards achievement of PDO Moderately Satisfactory Moderately Unsatisfactory Overall Implementation Progress (IP) Moderately Unsatisfactory Moderately Unsatisfactory Overall Risk Rating Implementation Status Overview This project is closing on June 30, 2011. The project development objectives (PDO) are measured by two key outcome indicators: (a) the percentage of persons reporting condom use with last non regular sex partner increased from less than 20 percent at project start to 30 percent among the general population and 60 percent amongst priority groups at project end; and (b) an increase in the percentage of patients with selected STIs at health care facilities who are appropriately treated according to the updated national guidelines Page 1 of 6 The World Bank Report No: ISR3739 from less than 20 percent at baseline to 60 percent at project end. The second indicator was included as evidence suggests presence of STIs increases vulnerability to HIV. The baseline figure included in the PAD is facility-based and refers to the proportion of family planning users using condoms and is thus not indicative of the proportion of the population Public Disclosure Copy using condoms to reduce risk of HIV transmission. The baseline for the second outcome indicator was an estimate as there were no data on the proportion appropriately treated. The project has met the first part of the first indicator as surveys have noted condom use with non regular partner was as high as 74 percent amongst the general population. Data on priority/risk groups of five male subpopulations and one female subpopulation focus on the most risky relationships, i.e. commercial sex, show an uneven situation. Consistent condom use ranges from 17 percent to 70 percent with half of all priority groups being under the 60 percent target. Moreover, 11 and 14 percent of respondents from two risk groups claiming 70 percent consistent condom use had had at least one STI symptom in the last year suggesting condom use is not as consistent as claimed. Given that most groups interviewed reported having limited or no contact with MOH HIV prevention efforts, and that minimal progress was made on implementing targeted interventions for high risk groups, achievement of the second part of the first indicator is not met. On balance, since emphasis on high-risk groups is the most effective approach to prevention, the overall achievement against the 1st PDO indicator is Moderately Unsatisfactory. With respect to the second PDO indicator (STI treatment), the proportion of STI patients appropriately treated was measured twice. The Health Facility Survey (HFS) of 2009 found that only 25 percent of district hospitals were treating urethral discharge correctly. The response was a combination of direct observation of practice and reported knowledge. A subset of the HFS was carried out in May 2011 to assess change with regards to STI treatment. It found 70 percent of those interviewed knew how to treat urethral discharge. Practice was not observed. Other data from the same survey note not only that reported practice significantly overstates observed practice, but that other aspects of STI treatment linked to HIV prevention are not being adhered to. For instance, the survey indicated that while 93 percent of respondents (health care workers) said they always gave STI patients condoms but a review of documentation at the same facilities noted only one third of patients received them. And although 68 percent of health workers said they referred STI patients for HIV testing, only 19 percent did in 2010, and 26 percent from January to April. Most importantly, identifying the correct treatment of male and female genital ulcers, the other two STI syndromes addressed through the new guidelines, continued to be low (23 percent for male patients and 28 percent for females). Thus, taking the second PDO indicator on face value, achievement of this PDO could be rated as Moderately Satisfactory. However, given the difficulties in comparing the two surveys, and triangulation with other indicators related to STI treatment, it is rated as Moderately Unsatisfactory. On balance, given that achievement against the two PDO indicators is Moderately Unsatisfactory, the overall rating for the PDO is also Moderately Unsatisfactory. This estimation is also based on the limited progress on efforts to increase among the high risk groups which was the crux of the project. Results Project Development Objective Indicators Public Disclosure Copy Page 2 of 6 The World Bank Report No: ISR3739 Indicator Baseline Current End Target Public Disclosure Copy Indicator Name Value Value Value Percentage of persons reporting condom use with last non regular sex <20% Bar girls: condom use with last 60% among priority groups and partner increased from <20% at project start to 60% among priority commercial sex last month: 30% among general population Date groups and 30% among the general population at project end 50-54% (needs to berevised) 01-Dec-2003 Last commercial sex last year Date Type Unit of Measure Comment Migrants: 17 to 50% 30-Jun-2010 Custom Indicator Text Estimate as no data were available Truckers: 37 to76% at the time. Taxi drivers: 68% Comment RBP: 38 to 70% RBA 63% 74% general pop Date 30-Jun-2006 Comment General Population Survey (2006) and Behavioral Surveillance Survey of identified risk groups (2009), sexual network studies (2010). Indicator Baseline Current End Target Indicator Name Value Value Value Percentage of patients with selected STIs at health facilities who are <20% 70% knew how to treat urethral 60% appropriately treated according to the updated national guidelines discharge Only 23% knew how to Date Date increased from <20% at baseline (yr 2) to 60% at project end treat male genital ulcers and 28% 01-Dec-2003 knew how to treat female genital 30-Jun-2010 Type Unit of Measure Comment ulcers. Comment Custom Indicator Text Date 20-May-2011 Public Disclosure Copy Comment subset of Health Facility Survey 2011. Data not comparable to earlier measurement of 25%. Other measures of STI treatment are still low. Intermediate Results Indicators Page 3 of 6 The World Bank Report No: ISR3739 Indicator Baseline Current End Target Public Disclosure Copy Indicator Name Value Value Value Percentage of general population and selected priority groups reporting 30% 75%-Gen pop, 2006 75% (specified in the PAD) easy access to condom supply increases Bar girls 65-87% Date Date Migrants 83-96% 01-Dec-2003 Police, army: 99-100% 30-Jun-2011 Type Unit of Measure Comment Truckers, taxi drivers: 100% Comment Custom Indicator Text Date 31-Mar-2010 Comment No new data: Data from General Population Survey (2006), Behavioral Surveillance Survey (2009) Indicator Baseline Current End Target Indicator Name Value Value Value Number of people receiving HIV testing and counseling through VCT none Grand Total: 7015 since 2005 2500 (HISC) centers (excl. hospital-based) Date Date Date 31-Dec-2004 31-Mar-2011 30-Jun-2011 Type Unit of Measure Comment Comment Comment Custom Indicator Text Includes those tested. Large increase resulted from peer interventions carried out in hot spots. Indicator Baseline Current End Target Indicator Name Value Value Value Proportion of blood donations that are Voluntary 2004 (25%, Thimphu) Thimphu 80% 2010 60% Thimphu Public Disclosure Copy Date Natl 46%. 45 % Natl 31-Dec-2004 Date Date Type Unit of Measure Comment 31-Dec-2010 31-Dec-2010 Custom Indicator Text Comment Comment Page 4 of 6 The World Bank Report No: ISR3739 Indicator Baseline Current End Target Public Disclosure Copy Indicator Name Value Value Value Percentage of labs meeting quality assurance standards never measured 80% Date Date Date 31-Dec-2004 31-Mar-2010 30-Jun-2011 Type Unit of Measure Comment Comment Comment Custom Indicator Text Has surpassed target of 80% Indicator Baseline Current End Target Indicator Name Value Value Value Number of priority group interventions (sex workers, drug users, MSM, 1 6 prisoners) Date Date Date 30-Jun-2004 31-Mar-2010 31-Dec-2009 Type Unit of Measure Comment Comment Comment Custom Indicator Text The two interventions in Thimphu and Phuentsholing were discontinued. Indicator Baseline Current End Target Indicator Name Value Value Value Percentage of known PLWA receiving CD4 every six months. no CD4 FACScount available until 100% 2005. So, value is 0. In 2005 there Date Date was one in Thimphu. 2006, one in Mongar. 21-Dec-2009 30-Jun-2011 Type Unit of Measure Date Comment Comment Custom Indicator Text 30-Jun-2004 This is calculated based on number of PlWA and CD4s carried Comment out in last year. Public Disclosure Copy Indicator Baseline Current End Target Indicator Name Value Value Value Adults and children with HIV receiving antiretroviral combination 0.00 36.00 therapy Date Date Date 31-Oct-2004 31-Mar-2010 30-Jun-2011 Type Unit of Measure Comment Comment Comment Core Indicator Number No ART available then. A total of 46 have been placed on Target difficult to estimate...should ART since epidemic began. 10 be 100% of those who need it. have died. Data on Financial Performance (as of 03-Jun-2011) Page 5 of 6 The World Bank Report No: ISR3739 Financial Agreement(s) Key Dates Public Disclosure Copy Project Loan No. Status Approval Date Signing Date Effectiveness Date Closing Date P083169 IDA-H1030 Effective 17-Jun-2004 01-Jul-2004 18-Aug-2004 30-Jun-2011 Disbursements (in Millions) Project Loan No. Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P083169 IDA-H1030 Effective XDR 4.00 3.96 0.04 3.58 0.38 90.00 Disbursement Graph Public Disclosure Copy Key Decisions Regarding Implementation There are no key issues for disclosure at this stage as this project is closing. Restructuring History There has been no restructuring to date. Related Projects Page 6 of 6