Combating HIV/AIDS in Transport

The World Banks Pilot Study of the HIV/AIDS Awareness Campaign: The Road to Good Health
Integration Report at the Completion of Phase I

Prepared by Research Communications Group For the World Banks East Asia and Pacific Region, Infrastructure Sector (EASIN)

August 2011

Acknowledgements
This project would not have been possible if not for the work of Christopher Bennett (World Bank) who spearheaded this initiative, secured funding, garnered government and stakeholder support, and has offered invaluable guidance and momentum to this work. Fei Deng and Maria Margarita Nunez (World Bank) were instrumental to program design and implementation. Their support and work for this initiative were crucial to the successful execution of this campaign to-date. This report was particularly informed by the work of the former Primary Consultant under this project, Mr. Robb Butler (Research Communications Group). Mr. Butler also performed the initial review and edits to the RTGH toolkit. He further laid the foundation for program implementation. Thanks to the advisors to this program, Julie Babinard and Janet Leno (World Bank) for their initial program review, and for their work collaborating with partners under the Joint Initiative. The work of Diane Gardsbane (EnCompass) was valuable in leading the original development of the Road to Good Health toolkit. With thanks to the following agencies who reviewed the toolkit in its initial phases: ADB, UNAIDS, JICA, CSEARHAP, Marie Stopes International, IOM, USAID. It is the goal of the World Bank task team to leave behind an impact more than a guide or tool. It is for this reason that we are grateful for the valuable stakeholder input we have received to inform this process. The local consultant teams of the Hubei Provincial Center for Disease Control, PACT Vietnam and PACT Cambodia demonstrated excellence in leadership, organization and reporting of results for this work. These team members were: Yang Fang, Li Ling and Song Wei (China); Hazel Simpson, Thuan Nguyen and Matthew Tiedemann (Vietnam); and Yut Sakara Phon, Eric Bergthold, Khunny Kheng, and Christian Leon (Cambodia). With thanks also to the World Bank task team leaders, local experts, data collectors who supported the data collection. In China, the following individuals were involved in reporting and translating the baseline data: Prof. Dr. Xiaoodng Tan, Dr. Yinxiu Hu, Dr. Juan Di, Dr. Qing Qing, Dr. Deyang Yu, Dr. Xiaolin Feng (School of Public Health at Wuhan University). In Vietnam, the Project Management Unit 1 (PMU1) and Ca Mau Provincial AIDS Committee (PAC) were closely involved in carrying out the baseline study. Mr. Simon Ellis and Mr. Dung Anh Hoang (World Bank) were both valuable supporters of this effort. In Cambodia, the survey was conducted by Advance Research Consultant Team led by Dr. Kem Ley (Team Leader), Boray Boraline, Nhim Dalen and Umakant Singh. We are also grateful to HE Dr. Tia Phalla, Deputy Chair of the NAA for his contributions to the survey. The support of Dr. Siele Silue and Mr. Ratha Sann (World Bank) was also valuable to carrying out the study.

For comments and enquiries, please contact Fei Deng at fdeng@worldbank.org

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Table of Contents
Overview ........................................................................................................................................vi I. II. III. IV. V. VI. VII. IX. Introduction........................................................................................................................... 1 Project Context...................................................................................................................... 5 Baseline Survey Results ......................................................................................................... 9 Overall Themes Arising from Baseline Survey ..................................................................... 24 Additional Activities on the YIBA Expressway ..................................................................... 27 Strategic Recommendations for Toolkit Improvements...................................................... 28 Final Workshop for Phase I.................................................................................................. 35 Overall Recommendations................................................................................................... 37

VIII. Next Steps............................................................................................................................ 37 Appendix 1: Joint Initiative Statement by Development Agencies (2006) ............................. 39 Appendix 2: Record of Phase I Final Workshop ........................................................................ 41 Appendix 3: Additional Comments on the RTGH Toolkit ......................................................... 51 Appendix 4: Summary of Phase 2 Works Associated with YIBA .............................................. 56 Appendix 5: Sample of General Survey Questionnaire for Baseline ....................................... 64

Annexes containing presentations from the Phase I workshop (24 May 2011, Phnom Penh) have not been included as part of this report but are available separately. A list of these Annexes is available in Appendix 2: Record of Phase I Final Workshop.

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Table of Figures
Figure 1. The link between sex work client infections and the spread of HIV/AIDS. ......................... 2 Figure 2. HIV/AIDS education requirement in contractor standard bidding documents, simplified and translated for Chinese contractors. .................................................................................... 2 Figure 3. World Bank-funded YIBA project components............................................................ 5 Figure 4. World Bank-funded components for the Mekong Delta Transport Infrastructure Development Project. The focus of this study, Highway 1A, is located in Ca Mau, in the south of Vietnam. ............. 7 Figure 5. World Bank-funded components under the Road Asset Management Project in Cambodia. The focus of this work is National Road 5, traveling north from Phnom Penh and depicted in red.............. 8 Figure 6. Breakdown of populations surveyed for HIV knowledge baseline................................... 10 Figure 7. Marital status of construction staff and workers. ..................................................... 11 Figure 8. Percentage of construction staff and workers living on construction sites. ...................... 11 Figure 9. Construction staff and workers who have visited a female entertainment worker in the past year. ....................................................................................................................... 12 Figure 10. Non-marital sexual activity by type of partner. ...................................................... 12 Figure 11. HIV knowledge by question. Results correspond to Chinas YIBA, Vietnam Hwy 1A, and Cambodias NR5. Emphasized values highlight questions where fewer than half of respondents provided the correct answer. ..................................................................................................... 13 Figure 12. Awareness of treatment services available for people living with HIV. .......................... 13 Figure 13. Percentage of construction staff and workers who have never been tested for HIV. ......... 14 Figure 14. Percentage of laborers who consider themselves at no risk for contracting HIV. ........... 14 Figure 15. Percentage of workers reporting access to HIV information on construction sites or through employers................................................................................................................. 15 Figure 16. Primary sources of HIV and AIDS information for construction staff and workers.............. 15 Figure 17. Marital status of female entertainment workers. .................................................... 16 Figure 18. Migratory status of female entertainment workers. ................................................. 16 Figure 19. Condom use in most recent sex (both paid and unpaid) among female entertainment workers.................................................................................................................... 16 Figure 20. Successful condom negotiation by client type........................................................ 17 Figure 21. Primary condom sources for female entertainment workers. ..................................... 18 Figure 22. HIV knowledge by question. Results correspond to Chinas YIBA, Vietnam Hwy 1A, and Cambodias NR5. Emphasized values highlight questions where fewer than half of respondents provided the correct answer. ..................................................................................................... 18 Figure 23. Percentage of female entertainment workers who have received formal HIV prevention education. ................................................................................................................ 19 Figure 24. Percentage of female entertainment workers who have been tested for HIV. ................. 19 Figure 25. Percentage of female entertainment workers who consider themselves at no risk for contracting HIV. ......................................................................................................... 20 Figure 26. Marital status of general residents located in the project area. .................................. 20 Figure 27. Percentage of general residents (men and women) with existing HIV knowledge. ............ 21 Figure 28. HIV knowledge by question. Results correspond to Chinas YIBA, Vietnam Hwy 1A, and Cambodias NR5. Emphasized values highlight questions where fewer than half of respondents provided the correct answer. ..................................................................................................... 22 Figure 29. Percentage of general residents who have received formal HIV prevention education. ...... 22 Figure 30. Condom use with spouse in the past month among general residents. .......................... 23 Figure 31. Percentage of general residents (men and women) who have never been tested for HIV.... 23 Figure 32. Percentage of general residents who consider themselves at no risk for contracting HIV.24

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Acronyms ADB CCE CDC EAP EASIN FEW FHI HBCDC HPTD IEC KAP M&E MARP MDTIDP MMP MPWT MRD NGO NR5 PAC PLHIV PMU1 RAMP RTGH Shiman STI TTL VCT WB YIBA Asian Development Bank Community Capacity Enhancement Center for Disease Control East Asia and Pacific East Asia and Pacific Region, Infrastructure Sector Female entertainment worker Family Health International Hubei Provincial Center for Disease Control Hubei Provincial Transport Department Information, education and communication Knowledge, attitude and practice Monitoring and evaluation Most at-risk population Mekong Delta Transportation Infrastructure and Development Project Mobile migrant population Ministry of Public Works and Transport Ministry of Rural Development Non-governmental organization National Road 5 Provincial AIDS Committee People living with HIV Project Management Unit 1 Road Asset Management Project Road to Good Health Shiyan-Manchuangan Expressway Sexually transmitted infection Task team leader Voluntary counseling and testing World Bank Yichang-Badong Expressway

Overview
The transport group of the World Banks East Asia and Pacific (EAP) region (the Bank) has taken a leading role in promoting the implementation of HIV/AIDS prevention campaigns in transport development and rehabilitation projects. These efforts are in response to the fact that mobile populations, including construction workers and long-distance truck drivers, as well as the groups that provide them services (from food to entertainment), are considered at increased risk for contracting and spreading HIV. With funding from the Global HIV/AIDS Program through their HIV/AIDS Transport Incentive Fund, the Bank has sought to facilitate HIV prevention activities through the development of a standardized yet flexible response to HIV transmission associated with the transport sector. The Road to Good Health toolkit (RTGH)1 seeks to provide interactive HIV/AIDS education to construction workers and managers, female entertainment workers and community residents who are affected by transportation project development2. Research from HIV awareness campaigns around the world has demonstrated that it is insufficient to simply provide information on how HIV/AIDS spreads and how it can be prevented. There are many reasons why a person may know about HIV/AIDS but continue to practice unsafe behavior. These range from not personalizing the risks to not being able to access or afford good quality condoms. The RTGH toolkit thus aims to go beyond the provision of basic information to support adoption and maintenance of safe behaviors. With this objective in mind, the RTGH provides specific short-term, intermediate and long-term outcomes for managers and supervisors, HIV trainers, and target populations. In order to evaluate the suitability of the RTGH for raising HIV awareness and encouraging behavior change, the Bank will pilot test the program on three transport development projects in three countries (China, Vietnam and Cambodia) with the goal of developing a methodology for both countryspecific and regional program implementation and monitoring. This program aims to provide information on the risk, transmission and prevention of HIV to the vulnerable populations identified above through delivery of organized training, distribution of information, education and communication (IEC) materials, and institutional capacity-building to support service availability and program sustainability in the future. The end goal is behavior change, supported through increased condom availability, improved counseling and testing services (either through increased education and information available, or improved accessibility of these centers), and personalization of HIV risks as appropriate. In order to develop an effective HIV/AIDS prevention program that is both useful and applicable throughout the region, the proposed program must be piloted, monitored and adapted as appropriate to each country context. The phases to be executed as part of this evaluation are presented below.

1 2

Available for download at www.TheRoadToGoodHealth.org As this effort is focused on reducing vulnerabilities in the construction phase of transport development projects, long-distance truck drivers are considered outside the scope of this effort.

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1: Develop a Program

Coordinate with the health sector Coordinate Review local, provincial and national strategies Review Conduct baseline surveys Conduct Develop or access appropriate educational materials Develop

2: Deliver a Program

Develop an effective intervention plan Develop Train educators in the health sector Train Improve quality and accessibility of Voluntary Counseling and Testing (VCT) centers Improve Conduct regular field visits and deliver intervention program Conduct

3: Monitor Results

Semi-annual monitoring annual Establish an HIV/AIDS strategy/operational manual for replication in similar projects Establish

This report summarizes the results out of the first phase of th project (Develop a Program), in which the Develop Program implementation is planned, current knowledge levels are assessed, and policy/program integration is performed.

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I.

Introduction

The Road to Good Health (RTGH) is an innovative HIV/AIDS prevention toolkit that details initiatives and practices for HIV/AIDS education and response in the transport sector. This Toolkit, which includes IEC materials, training curricula and a Monitoring and Evaluation (M&E) framework, is directed at two principal outcomes among target populations: Knowledge Transfer and Behavior Change. These are achieved through training sessions and the distribution of IEC materials. Monitoring and evaluation is intended throughout implementation in order to inform status of program activities and advise program adaptation as necessary. The purpose of this resource is to create and deploy educational activities that are simple, easily implemented, effective, low cost and that use readily-available resources. The RTGH was created with the goals of: reducing the incidence of HIV, reducing stigma and discrimination associated with HIV or AIDS, increasing the protection of human rights for people living with HIV and AIDS, and increasing gender equity. In order to achieve these goals, this campaign seeks to ensure access to, and increase knowledgeable use of: good, quality condoms; voluntary and confidential counseling and testing; diagnosis and treatment services for sexually transmitted infections; and HIV/AIDS treatment and care services. Relationship between HIV and Transport Development The World Banks clients continue to seek support for transportation development projects: the construction and rehabilitation of roads, highways and railways. These networks serve as corridors for the movement of people and trade, promoting economic development, increasing opportunities for members of the communities involved, and providing better access to health, education and other services. At the same time, improved transport infrastructure can contribute to negative developments such as facilitating the spread of communicable diseases like HIV/AIDS. In 2008, a comprehensive report prepared by the Independent Commission on AIDS in Asia indicated that, although HIV epidemics vary considerably from country to country, they share important characteristics. They are centered mainly around: unprotected paid sex, the sharing of contaminated needles and syringes by injecting drug users, and unprotected sex between men. In Asia, men who buy sex from women far outnumber drug injectors and men who have sex with men, so this group of men is probably the most important determinant of future rates of HIV".3 The Asian Epidemic Model (Figure 1 below) illustrates the proportion of new HIV infections in each most at-risk population (MARP) group. In this model while the epidemic typically begins among injecting drug users, sex worker client infections quickly take over as the leading cause of new HIV infections each year. Transport construction projects almost invariably increase the demand for sex work as they usually involve men who are away from their families and communities for long periods. Often these men have money and, particularly given the isolation of many sites, may see little to spend it on other than entertainment (alcohol and sex). Together, these factors serve to create an increased demand for sex work. The extent of this demand is such that some brothel owners are known to follow construction companies from site to site. Also relevant to the transport sector is the fact that long-distance truck drivers tend to show much higher rates of HIV infection than the general population.4

Commission on AIDS in Asia. 2008. Redefining AIDS in Asia: Crafting an Effective Response. New Delhi: Oxford University Press. p.5 4 ibid

Figure 1. The link between sex work client infections and the spread of HIV/AIDS.5

It is clear that, by reducing unsafe sex among men who have multiple sexual partners (including sex workers), the transport sector can make a strong contribution to reducing the spread of HIV/AIDS. Increased condom use is the most viable approach to a sustained response. Measures to reduce the demand for paid sex can also be considered, although it is important to note that women in local to communities can also be at risk from men seeking clean local girls. It is also important to note that investment in priority HIV/AIDS prevention programs makes economic sense. The AIDS Commission estimates that a $1 investment in appropriate prevention can save up to $8 in treatment costs for expanding epidemic countries.6 It is in response to the growing HIV/AIDS epidemic in the region (and the acknowledged risk of HIV/AIDS transmission associated with transportation development projects) that the World Bank issued in 2004 an HIV/AIDS education requirement associated with all transport projects with a significant civil works component (over US$10 million). This requirement is included as part of the World Banks Standa Standard Bidding Documents for Civil Works and focuses education on the contract workforce and affected communities. To encourage its use, these requirements were simplified, translated and distributed to contractors and project supervisors by the EAP transport team (Figure 2).

Figure 2. HIV/AIDS education requirement in contractor standard bidding documents, simplified and translated for Chinese contractors.

5 6

Independent Commission on AIDS, op cit. Independent Commission on AIDS, op cit.

This requirement has so far been met with marginal success in the field as World Bank Task Team Leaders (TTL) lack sufficient guidance on successful implementation of such programs, as well as how best to monitor progress, leading to inconsistent or incomplete programs absent measurable results. It is the goal of the RTGH toolkit to provide this guidance, as well as to encourage greater accountability among the World Bank, project management teams, and construction agencies for the health and safety of project-affected populations. Implementing HIV/AIDS education as part of transport development projects has encountered resistance from construction companies and government agencies who see their job as building roads, not providing condoms.7 Challenges have also been encountered on the implementation side as some leaders in the development community indicate a preference for project delivery and investment results rather than monitoring and addressing potential social impacts. With these challenges in mind, the RTGH toolkit has incorporated implementation solutions to garner agency and task leader support. These solutions include: Working with construction company leaders to ensure understanding of the relevance and importance of HIV prevention activities; Developing programs and activities that can be integrated into construction activities and timetables, thus minimizing disruption to the core work of road building; and Minimizing time commitments of highway agencies and World Bank task team leaders by hiring an approved service provider to deliver training. This is an attractive alternative for all parties as it eliminates the perhaps unrealistic requirement for road companies to become expert at designing and implementing HIV behavior change programs, and the involvement of approved service providers helps to ensure a consistent and appropriate standard of training throughout the project.

The RTGH toolkit represents part of the World Banks contribution to the Joint Initiative by Development Agencies for the Infrastructure Sectors to Mitigate the Spread of HIV/AIDS (2006) (Appendix 1). It further offers the opportunity to coordinate and cooperate with partner agencies undertaking similar efforts. These efforts include development of the Practice Guidelines for Harmonizing HIV Prevention Initiatives in the Infrastructure Sector, Greater Mekong Sub-region (regional response led by the Asian Development Bank [ADB]), and the Construction Workers Handbook: A resource manual for health and safety in infrastructure (Marie Stopes International/ADB). Status of the RTGH The Road to Good Health toolkit was developed in 2008 with funding from the World Banks Global HIV/AIDS Program through their HIV/AIDS Transport Incentive Fund. From 2008-2009, the guide underwent several reviews and revisions by World Bank professionals, as well as consultants and experts of partner organizations (Asian Development Bank, Japan International Cooperation Agency, UNAIDS, Canadian South East Asia Regional HIV/AIDS Programme, Marie Stopes International, the International Organization for Migration and the United States Agency for International Development). The RTGH was also revised according to information obtained during field visits, and further by on-site surveys, which include baseline studies and communication with local clients and stakeholders. The Bank plans to implement the Toolkit on transport development projects whose civil works are over US$10 million in value, in accordance with the World Banks Health and Safety requirements. In the East Asia and Pacific region, a toolkit pilot is planned to take place in China, Vietnam and Cambodia

This quote comes from a construction manager in China, though this sentiment has been echoed throughout the region.

from 2011-2012. The RTGH toolkit will be adapted to best meet the needs of each target group within each country context. Purpose of this Report The purpose of this report is to summarize results from the Baseline Data Collection phase of the Road to Good Health toolkit implementation project. This document reports on current HIV knowledge, highrisk behaviors and potential vulnerabilities of the communities targeted by this campaign: construction workers and managers, female entertainment workers, and general residents located in the area of the construction sites. In parallel with the data collection process, and taking account of the results, the local experts procured to facilitate data collection and program implementation made recommendations of improvements to the RTGH toolkit to improve its effectiveness. In so doing, they considered not only existing levels of knowledge and preferred media for communicating to target groups, but also the local social, political and epidemiological contexts of the project areas, as well as other existing materials and programs available locally. An additional purpose of this study is to share knowledge and experience between countries in the region, particularly those experiencing the epidemic in part through the movement of migrant laborers from neighboring countries. This report, therefore, provides country snapshots (including information on existing policies and programs) and offers implementation recommendations for each area. Results from this phase of the program were presented at a final workshop during which consultants from each studied country shared and discussed their findings, recommendations and challenges to work (24 May 2011, Phnom Penh Cambodia). Appendix 2 provides a summary of this workshop, including key outcomes.

II.

Project Context

In order to assess the quality and appropriateness of the RTGH campaign, this program will be tested as this part of the health and safety component of three transport construction and rehabilitation projects located in three countries in the region: China, Vietnam and Cambodia. The section below presents tries details of the associated projects as well as current HIV epidemic and response. Information about the baseline data collection, which looks at current levels HIV knowledge among target groups associated with these three transport projects, is also provided in order to give context to existing conditions (including any gaps in HIV knowledge) and offer a framework within which to develop these programs. Country-specific recommendations of enhancements to the RTGH toolkit based on the social, political ons and epidemiological context of each pilot country, as well as the responses to the baseline survey, are presented in Appendix 3 to inform improvements to the RTGH before local local-level implementation. lementation.

China
The Yichang-Badong Expressway project ( Badong (YIBA) involves a 173.6 km highway construction located in Hubei Province (Figure 3) and managed by the Hubei Provincial Transport Department (HPTD). It is anticipated that this project will take six and a half years to complete and affect four counties and six townships. The construction timeline is particularly long because of the extensive civil work e works component: over 100 km of bridges and tunnels will be constructed in order to traverse the Three Gorges National Geological Park. Populations living in the area of construction may be impacted . on because of the proximity of construction camps, which brings opportunities to make money by camps, providing services to workers: cooking, cleaning, entertainment. Laborers in China are often migrant workers coming from elsewhere in the country who live on site in construction camps between 48 and 50 weeks per year. This extended period away from home and family, the accessibility to female entertainment and paid sex, the pressure to drink, as well as often limited access to information, make information mobile and migrant populations (MMP) particularly vulnerable to HIV. The risk is further spread as these MMPs return home to their wives and communities. With more than 120 million migrant workers throughout China, the risks associated with th population have serious implications for the country as this a whole.

Figure 3. World Bank-funded YIBA project components. .

HIV prevalence in China is currently estimated at 0.1%. By the end of 2007, an estimated 700,000 adults and children were living with HIV. Cases of HIV have been found in all 34 provinces (including municipalities/minority autonomous regions). The epidemic is not distributed evenly throughout the country, however, as 80% of known cases come from just six provinces. (In some areas of western Yunnan Province, HIV prevalence already exceeds 1% among pregnant women, which indicates that the 8 province may be moving to what UNAIDS defines as a generalized epidemic. ) The extent of this epidemic in Yunnan compared to other parts of China highlights the importance of the transport sector in ensuring that road developments and migrant workers do not facilitate the spread of HIV from high prevalence to low prevalence areas. The Government of China has taken a strong stance against HIV/AIDS, guided by Chinas Action Plan for Reducing and Preventing the Spread of HIV/AIDS (2006-2010), which seeks to adopt the Three Ones principle: one national plan, one coordinating mechanism, and one monitoring and evaluation system. Part of this plan involves the Four Frees and One Care policy: 1) free ARV drugs to HIV patients who are rural residents or people with financial difficulties living in urban areas; 2) free Voluntary Counseling and Testing (VCT); 3) free drugs to HIV-infected pregnant women to prevent parent-to-child transmission, and HIV testing of newborn babies; 4) free schooling for children orphaned by AIDS; and 5) care and economic assistance to the households of people living with HIV & AIDS. The Banks experience implementing HIV awareness programming in China has also evolved over time, at first being met with resistance (in the words of some construction managers, road construction is my business, not promoting condoms.9) and later being accepted as part of the Banks social safeguard programming on projects. The Shiyan-Manchuanguan Expressway (Shiman) project in Hubei Province was the first program of its kind undertaken by a Provincial Transport Department in China.10 By providing financial resources (a US$50,000 grant from the Banks Global HIV Program) and technical expertise (trained HIV service providers), the Bank reinforced its commitment to HIV prevention on projects and the Client was able to observe the value of HIV education to worker health and safety. For the baseline data collection on the current YIBA Expressway project, assessing current HIV knowledge and understanding, surveys were taken over the entire length of the road construction: within the six townships of the four affected counties, and within the 31 construction camps. It is important to note that at the time of the baseline data collection survey, workers had already been mobilized for more than a year so many of the relationships between workers and service providers were already established.

Vietnam
The Mekong Delta Transportation Infrastructure and Development Project (MDTIDP) is a multi-modal transport investment program with three main components: I) Investments in main supply corridors to improve the standard and connectivity of trunk road and canal networks (including major landing stages) concentrating on links in northern and southern corridors serving the two cities (Ca Mau and Can Tho), and eleven provinces of the Mekong River Delta Region (Long An, Tien Giang, Ben Tre, Tra Vinh, Vinh Long, Dong Thap, An Giang, Kien Gang, Hau Giang, Soc Trang and Bac Lieu); 2) Investments to connect the poor to the supply corridors through feeder waterways and roads at the commune and provincial levels in order to link poorer and more distant producer communities to the above-mentioned corridors; and
8

In 2010 the Cangyuan CDC reported rates of 2.06% in youth tested before marriage (Phil Marshall, pers. comm.) This area is dominated by the Wa ethnic minority with significant levels of injecting drug use.
9

Bennett, Chris. 2005. Transport Against AIDS in China. World Bank. Presentation available for download at lpcb.org. 10 At the time, Provincial Transport Departments were known as Communications Departments. They changed their names in 2009.

3) Institutional support to the Ministry of Transport. The HIV epidemic in Vietnam has shown signs of stabilizing as prevalence among MARPs is on the decline; for example, the number of injecti drug users living with HIV decreased from 29% in 2004 to injecting 18% in 2009.11 The statistics also indicate that people living with HIV are getting younger and heterosexual transmission is becoming more significant At the same time, antiretroviral therapy significant. ntiretroviral coverage has increased which indicates improved access to treatment among affected populations.12 Pact Vietnam conducted the baseline study along Highway 1A in Ca Mau province, where t national the Highway 1A was being extended from its southern terminus in Ca Mau City to the outlying Nam Can district (Figure 4). Works were already underway for this project and due for completion in April 2010. . PACT carried out the baseline study from January to February 2010, in close collaboration with Project Management Unit 1 (PMU1) and the Ca Mau Provincial AIDS Committee (PAC).

Figure 4. World Bank Bank-funded components for the Mekong Delta Transport Infrastructure Development Project. The focus of this study, Highway 1A, is located in C Mau, in the south of Vietnam. Ca

Cambodia
The Road Asset Management Project (RAMP) is a road rehabilitation program that will maintain and repair roadways throughout the country, beginning in southeast Cambodia and passing through Kampong Chhnang, Phnom Penh, Prey Veng, and Svay Rieng Provinces (Figure 5). The Project , Figure Implementing Agency for this work is the Royal Government of Cambodias Ministry of Public Works and Ministry Transport (MPWT); the Ministry of Rural Development (MRD) is managing rural road rehabilitation. The objective of RAMP is to ensure continued effective use of the rehabilitated national and provincial road network in support of the economic development in Cambodia. It will do so by improving the institutional and technical capacity of the MPWT for road maintenance planning, budgeting and operations, and by expanding and strengthening maintenance activities.
11

The Socialist Republic of Viet Nam. 2010. The fourth country report on following up the implementation to the declaration of commitment on HIV and AIDS AIDS. 12 UNAIDS Viet Nam. 2008. HIV in Viet Nam Nam. http://www.unaids.org.vn/sitee/index.php?option=com_content&task=blogsection&id=4&Itemid=26 (Accessed: 25 w.unaids.org.vn/sitee/index.php?option=com_content&task=blogsection&id=4&Itemid=26 March 2011).

The HIV epidemic in Cambodia is at present on the decline, with HIV prevalence dropping from 2.1% to 0.7% from 1998 to 2010. In addition to this decline, over 90% of eligible people living with HIV (PLHIV) receive treatment. According to PACT Cambodias baseline report, these successes are a result of high levels of political support behind HIV/AIDS initiatives, including the 100% condom policy in brothels. Indeed, Cambodia is one of the few countries in the world that has achieved its Millennium Development Goals related to HIV. Despite the decline in HIV prevalence, there are fears that the epidemic could worsen in coming years. Numerous factors account for the possible reversal in current trends. These factors include: (i) highly mobile populations, moving among provinces, across borders and between rural and urban areas; (ii) the persistent stigmatization and fear of HIV/AIDS at household and community levels; (iii) recent behavioral surveys indicating that more men are now visiting sex workers; and (iv) changes in the nature of commercial sex with less brothel-based prostitution (making it more difficult for HIV prevention efforts to reach sex workers).

Figure 5. World Bank-funded components under the Road Asset Management Project in Cambodia. The focus of this work is National Road 5, traveling north from Phnom Penh and depicted in red.

Critical to reducing the epidemic in Cambodia are measures that intensify prevention efforts and target vulnerable groups. The Royal Government of Cambodia has taken a number of key steps towards addressing HIV/AIDS, particularly with two of the more vulnerable groups: drug users and sex workers. More recently, initial efforts to address another vulnerable group - construction workers - has been the focus of HIV/AIDS and sexually transmitted infections (STI) education campaigns. Because of the extended periods they are away from their families and their close interactions with local communities, construction workers are an increasingly targeted population for controlling the spread of HIV/AIDS in Cambodia. The focus of the Cambodia study is National Road 5 (NR5), a component of RAMP where construction activities have begun and workers have been mobilized. NR5 (407.45 km) connects Cambodias capital, Phnom Penh, with Thailand. As noted above, it passes through four other provinces: Kampong Chhanang, Pursat, Battambang, and Bantey Meanchey (see Figure 5).

III.

Baseline Survey Results

In order to develop an understanding of current HIV knowledge among target populations associated with each of these three projects, and ultimately to adapt the HIV awareness program to the needs of these groups, a baseline survey was performed by the local consultants in each countrys project area (as defined in Section II above). Data for this baseline survey effort was obtained through use of standard sampling approaches, applied to ensure representative and reliable analysis of the baseline research data. The methodology involved one-on-one interviews with selected members of the target population, generally acknowledged as much more reliable than self-administered written questionnaires. The information gathered was largely quantitative with a view to establishing clear baselines and allowing measurement of progress on key indicators over time. A sample of the general survey questionnaire used to collect data on all target populations is included in Appendix 4. The questionnaires were adapted to each county with question detail and organization modified locally to better fit the needs and comfort level of individuals interviewed. In Cambodia, the local consultant team, PACT Cambodia, expressed concern about the length of the survey. PACT worked with the Primary Consultant to shorten the survey by eliminating questions deemed of lower relevance and also those regarded as too personal thus being unlikely to yield reliable responses and also potentially creating discomfort that might affect other questions in the survey. A number of challenges were faced during data collection, including access to target populations. In addition to the common problem of identifying and interviewing entertainment workers, local consultant teams in all countries struggled to identify and interview sufficient numbers of construction workers, who were often on site or otherwise unavailable during interview times. Further, the personal nature of many of the questions presented issues in capturing data that is both accurate and reflective rather than responses perceived as correct. This was particularly notable with regard to drug use, an illegal activity in all countries. Despite known drug use within the target population, personal drug was not acknowledged by any respondents, a result believed by the researchers to be unlikely. In the future, it may be worth considering the utility of attempting to collect behavioral information on illicit drugs using one-to-one interviews, given questions over data accuracy and the already long survey instruments. Further, research in Vietnam noted discrepancies in the responses on condom use between construction workers and sex workers. Survey respondents were encouraged to give no response to questions they felt uncomfortable answering. A label of no data in the figures below means that either an insufficient number of respondents chose to answer the question, or that surveyors failed to collect data associated with that question. An additional issue relates to the use and analysis of the data, in particular cross-tabulation of data that is, analysis looking at more than one variable. Some of the responses are not particularly useful in and of themselves, and require cross-tabulation with other data before conclusions can be drawn. One example relates to questions on self-analysis of risk. Without comparing this to an individuals behavior, it is unclear whether a low-risk perception reflects an accurate assessment of low risk (positive) or an inaccurate assessment of higher risk. It may be better, therefore, to reduce the number of questions that do not relate to the project objectives (such as age at first sex) and those that arent being analyzed (such as income levels) and strengthen cross-tabulation of key data as these yield more usable results. Notwithstanding these constraints, the baseline survey results proved to be illuminating and instructive, providing valuable data for shaping a focused response to HIV transmission on transport projects. Results of this study are organized here among the three target populations with comparison offered between sites in order to identify opportunities for country-specific improvements to the RTGH.

Results are organized as follows: Demographics HIV Knowledge o HIV Transmission and Prevention o HIV Risk o Reducing vulnerability to HIV Stigma/Discrimination (Attitudes) Behavior o Sexual Activities o Condom Use o Alcohol Consumption o Drug Use Miscellaneous knowledge, attitude and practice ( (KAP) Factors o Awareness and Use of Voluntary Counseling and Testing Services o Access to Information o Gender Equity

In the study overall, more than 2,200 individuals were interviewed across the three countries. In China, associated with the YIBA project, 1,382 persons were surveyed (though only about half of the 725 construction staff and workers interviewed reported on their sexual behavior); in Vietnam associated reported with Highway 1A, 347 individuals were surveyed (a shortfall of construction staff and worker interviews resulting from the number on site during survey times); in Cambodia associated with NR5, 537 individuals were surveyed (Figure 6). The variability in the proportion of different populations Figure interviewed between countries result from the availability of target populations during data results y collection.

Figure 6. Breakdown of populations surveyed for HIV knowledge baseline.

Construction Staff and Workers Figure 7 indicates that, except for the sample group associated with Vietnams Highway 1A project, more than half of construction staff and workers are married. In their home communities in the presence of family and social norms, this status may reduce multiple partnerships (extramarital sex partnerships

10

with sweethearts13, casual or paid partners). Away from home, as on construction sites, workers may seek entertainment during off-work hours and may engage in risky sexual behavior. Risk is further work compounded when men return hom to their wives and engage in unprotected sex. STIs and HIV can be home STI brought with migrant workers home to their families and communities where they may continue to spread. The wives of migrant workers are particularly vulnerable as experience suggests that encouraging widespread condom use within marriage for reasons other than birth control is not really viable as an HIV prevention strategy.14

Figure 7. Marital status of construction staff and workers. .

The percentage of workers living on site in temporary worker camps is also important. The combination important of living away from home, having a disposable income, and being surrounded by other young men can increase risk-taking behavior. Loneliness and depression may result from living in construction camps, taking away from family for long periods and with limited access to entertainment. Workers sometimes engage in alcohol, illicit drugs or paid sex to offset these depressive feelings and/or as a consequence of boredom. Further, peer pressure can play a major role, and lead to the establishment of unhealthy eer norms around alcohol, drugs and transactional sex.15 As Figure 8 illustrates, nearly all laborers on the YIBA project in China live on the project site; in China, these migrant laborers are known to spend ; more than 48 weeks away from their home communities and their families.

Figure 8. Percentage of construction staff and workers living on construction sites.

13

Used in this context to refer to a regular sexual partner that is not cohabitating and may also have other regular partners. 14 This is found to be true except in some individual cases where one partner is known to be HIV positive and the other HIV negative. 15 It is possible that the large proportion of men on construction sites, particularly in remote areas, may also lead to an increase in men having sex with men (such as is found in prisons). Little information is available on this and it is suggested as an important area for research.

11

In-depth interviews and local information from district health staff suggest that many construction depth workers visit sex workers as often as their income allows. Figure 9 below shows the percentage of construction staff and workers interviewed who indicated that they visited a female entertainment worker for paid sex in the past 12 months. The reliability of this data is unclear, however, as some construction workers chose not to respond and others may have concealed the frequency of their visits to sex workers. This is also an issue for consideration in follow follow-surveys as, following implementation of , HIV/AIDS prevention activities, workers may be more conscious that sex with entertainment workers is frowned upon by management and health professionals professionals.

Figure 9. Construction staff and workers who have visited a female entertainment worker in the past year. workers

Figure 10 identifies the types of partners that construction staff and workers were involved with in were non-marital sexual relationships in the last 12 months. For the purposes of this survey, a casual partner is defined as someone other than a wife, regular mistress or steady girlfriend; a regular partner is someone with whom there is an ongoing sexual relationship, absent marriage or cohabitation. When investigating sexual activity by type of partner, surveyors found that most construction staff and workers had regular partners, with paid sex being the next most common partner next type. Data for the YIBA project in China was not available.

Figure 10. Non . Non-marital sexual activity by type of partner.

In terms of HIV knowledge, surveys found that across all projects, knowledge is poorest surrounding availability of a cure for HIV and abstinence as a method to reduce risk (Figure 11). The responses on . abstinence are consistent with information found on other HIV projects in China and Cambodia. It is not ormation clear whether this reflects a lack of understanding of the potential role of abstinence or simply a view that this is not a realistic behavioral option for reducing HIV transmission through sexual means. ugh means

12

Question (with correct answer) 1. Can a pregnant woman pass HIV to her unborn baby? (yes) 2. Can a mother pass HIV to her baby by breastfeeding? (yes) 3. Is a cure available for people with HIV? (no) 4. Can HIV risk be reduced by properly using condoms during every sexual contact? (yes) 5. Does having one faithful, uninfected sexual partner protect against HIV? (yes) 6. Does avoiding sexual contact protect against HIV? (yes) 7. Can a person get HIV from food or drink that contains someone else's saliva? (no) 8. Can a person get HIV by using a needle or syringe already used by someone else? (yes) 9. Can a healthy-looking person have HIV? (yes)
a

YIBA N % 587 81.6 493 67.3 97 15.7 570 77.6

Hwy 1A N % 115 86.5 72 54.5 64 48.5 92 70.2

NR5 N %
a a

29 87.9
a a

32 88.9

514 67.9 512 66.9 320 42.5

81 61.8 38 29.5 98 74.2

19 57.6 23 63.9 27 79.4

635 86.6 380 55.0

125 94.0 91 68.4

36 97.3 34 94.4

Either this question was not asked or results were not reported.

Figure 11. HIV knowledge by question. Results correspond to Chinas YIBA, Vietnam Hwy 1A, and Cambodias NR5. , Emphasized values highlight questions where fewer than half of respondents provided the correct answer.

Surveys found that knowledge of treatment services for PLHIV is also limited (Figure 12). Familiarity nowledge (Figure with these services is beneficial for con construction staff and workers so they can obtain treatment and have a resource with whom to consult in the case of HIV transmission.

Figure 12. Awareness of treatment services available for people living with HIV. .

HIV testing among construction staff and workers was somewhat variable. As knowledge of HIV status is not a requirement for work and construction companies do not test employees, HIV testing would have

13

had to be done outside of this work, either voluntaril on the part of the worker or as a requirement of voluntarily another job.16 On the YIBA project in China, fewer than 10% of construction workers were tested for HIV; on the Highway 1A project in Vietnam, less than one-quarter received testing (data was not available for NR5 in Cambodia) (Figure 13). Surveys found that, in general, these tests were completed Figure n voluntarily, though in some cases, past employers required HIV testing before hiring. The relatively low . percentage of workers who have been tested in China indicates a need to promote testing among target populations. By learning their HIV status, construction staff and workers can seek out treatment y and protect their families.

Figure 13. Percentage of construction staff and workers who have never been tested for HIV.

Many construction workers do not see themselves at risk for contracting HIV (Figure 14). When given (Figure the choice, more than 2/3 of both Chinese and Vietnamese respondents, and over half of Cambodian respondents, indicated they are at no risk of contracting HIV. Reasons given include: I have only one Reasons partner, my partner is generally trusted, my partner is faithful, and I always use a condom. It was not possible from the research reports to ascertain the relationship between the perceived risk of workers and their actual risk. As noted previously, cross-tabulation of such factors is essential if risk assessment data is to be meaningful.

Figure 14. Percentage of laborers who consider themselves at no risk for contracting HIV. .

Interestingly, many construction workers across all projects reported never having received formal HIV education or training as part of their job. Few indicated access to HIV information at construction sites or through their employer, particularly on the Highway 1A project in Vietnam (Figure 15). The project ( availability and accessibility of HIV/AIDS information is important to protecting the health and safety of workers on site and at home. It also shows the commitment of government and construction companies to the health and safety of their workers.
16

It is worth noting that China does test all workers leaving the country to

14

Figure 15. Percentage of workers repo . reporting access to HIV information on construction sites or thro through employers.

On both the YIBA project and Highway 1A (China and Vietnam, respectively), television appears to be the primary means to communicate HIV health information ( (Figure 16). In Cambodia, construction staff ). and workers report that friends are their primary source for information on HIV and STIs, with the radio STI coming in second. This information may be useful in planning the delivery of valuable HIV/AIDS information to this target group, while noting that television is an expensive and one-way medium that , one may also not be available on construction sites.

Figure 16. Primary sources of HIV and AIDS information for construction staff and workers. .

Female Entertainment Workers According to data reported in the baseline survey, most female entertainment workers (FEW) are unmarried (either single, divorced or widowed (Figure 17). As these workers dont always use condoms widowed) ). with their spouse, there may be a risk of HIV transmission to the families and home communities of FEWs.

15

Figure 17. Marital status of female entertainment workers. .

The migratory status of female entertainment workers is important as it indicates whether a worker is surrounded by her family and community, or living and working on her own. This data also gives an idea of how HIV spread might be affected by the mobility of entertainment workers (Figure 18). The proportion of entertainment workers from close to the project area was particularly high in Vietnam. from

Figure 18. Migratory status of female entertainment workers.

When interviewed about their most recent sexual encounter (both paid and unpaid), female entertainment workers indicated they generally used condoms with their partners (Figure 19). Condom orkers (Figure usage in their most recent sexual encounter was highest associated with NR5 in Cambodia; this is likely a result of the 100% condom initiative in brothels in the country.

Figure 19. Condom use in most re recent sex (both paid and unpaid) among female entertainment workers.

16

Successful condom negotiation by female entertainment workers, organized by client type, is , presented in Figure 20 below. Data reported in the baseline survey indicates that local men and construction workers (including construction company staff and drivers) are among the most frequent condom users where female entertainment workers request them. There was, however, a discrepancy ndom in Vietnam where all construction workers who said they had sex with sex workers claimed they used condoms, yet sex workers reported only a 56% success rate in negotiating condom use with construction negotiating workers. As evident by this survey, the clientele of female entertainment workers extend beyond construction workers and local residents (the target populations of this study) HIV education, particularly study). education surrounding condom negotiation, is therefore particularly useful to FEWs so that they can protect themselves during all sexual interactions not just with construction workers. Although the differences interactions, are small, it is notable that, in both Vietnam and Cambodia, business travelers are the population least , likely to use condoms at the request of female entertainment workers (Figure 20). HIV prevention training would provide an opportunity to empower FEWs with all client types. In doing so, there is the potential to apply the concept of positive deviance by seeking to identify the factors that allow some women to negotiate condoms more successfully than others. For example, highlighting the HIV risks to successfully families of clients has proved to be an effective strategy in Vietnam, and is something that can be Vietnam, supported by educational materials on construction sites.17

Figure 20 Successful condom negotiation by client type. 20.

Drug stores are the primary venue for female entertainment workers to obtain condoms (approximately 50% across all projects) with health stations coming in second for Hwy 1A (Vietnam) and NR5 (Cambodia) (Figure 21). That female entertainment workers visit these locations is potentially beneficial as these facilities often house medically medically-trained personnel useful for consultation regarding sexual health and condom usage.

17

see www.positivedeviance.org for more discussion of this concept.

17

Figure 21. Primary condom sources for female entertainment workers.

Surveying existing HIV knowledge among female entertainment workers indicated that knowledge was most limited surrounding questions on HIV transmission misconceptions (you can get HIV by sharing a you meal with an HIV-infected person) and on whether there is a cure ( ) (Figure 22). Unfortunately, responses ). to these questions were not reported for NR5 in Cambodia.

YIBA Question (with correct answer) N % 1. Can a person get HIV by having a meal with someone that has 61 40.4 HIV? (no) 2. Can a person get HIV by sharing a syringe with someone 140 92.7 that has HIV? (yes) 3. Can a pregnant woman pass 125 82.8 HIV to her unborn baby? (yes) 4. Can a mother pass HIV ot her 89 58.9 baby by breastfeeding? (yes) 5. Is a cure available for people 48 31.8 with HIV? (no) 6. Does avoiding sexual contact 105 69.5 protect against HIV? (yes) 7. Does having one faithful, uninfected sexual partner protect against HIV? (yes) 8. Can HIV risk be reduced by properly using condoms during every sexual contact? (yes)
a

Hwy 1A N % 63 66.3

N
a

NR5 %
a

94 98.9 90 94.7 74 77.9 31 33.0 58 61.1 53 55.8

78 96.3 56 70.9 75 94.9

a a

44 56.4 41 55.4

111 73.5

133 88.1

63 66.3

75 96.2

Either this question was not asked or results were not reported. Figure 22. HIV knowledge by question. Results correspond to Chinas YIBA, Vietnam Hwy 1A, and Cambodias NR5. Emphasized values highlight questions where fewer than half of respondents provided the correct answer.

Fewer than 20% of FEWs associated with the YIBA and Highway 1A projects (China and Vietnam, respectively) have received formal HIV prevention education, though more than 50% of FEWs associated

18

with NR5 in Cambodia have received training (Figure 23). The disparity in HIV education is a result of . Cambodias national program to education FEWs on condom usage and negotiation throughout the country (the 100% condom in brothels initiative)18.

Figure 23. Percentage of female entertainment workers who have received formal HIV prevention education.

There is a relationship between those who know of the availability of testing services and those who were tested (Figure 24). Of the female entertainment workers tested, most were tested voluntarily, particularly those in Cambodia who received additional HIV training as part of the 100% condom policy in brothels.

Figure 24. Percentage of female entertainment workers who have been tested for HIV. entertainment

Surveys indicate that, in Cambodia, more female entertainment workers identify themselves as having no risk of HIV transmission (Figure 25). This is perhaps because of the national policies and programs Figure ). in place to reduce their risk (as with the 100% Condom Campaign). as

18

In China, the situation is currently complicated by a crackdown on the sex trade, pushing sex work underground and making it more difficult to access sex workers. It is unclear how long this crackdown will last. s

19

Figure 25. Percentage of female entertainment workers who consider themselves at no risk for contracting HIV.

Future HIV prevention campaigns may be able to take advantage of the media most often enjoyed by FEWs. Surveys found that more than 90% of female entertainment workers watched television several times per week, while fewer than 21% listened to the radio. Popular forms of entertainment can be an er opportunity to transmit basic HIV knowledge to target groups, particularly where reaching individuals in person is not possible. However, it is important also to note that television is a costly medium that only provides one-way communication and the nature of the medium may be partly responsible for gaps way g in understanding highlighted throughout this section. Specially designed and carefully developed television programs can nonetheless contribution to both increased knowledge and less discriminatory ograms attitudes (such as through character modeling). The sort of education to encourage behavior change (personalizing individuals risk for HIV, for example) generally requires inter-personal communication, personal communication however. General Residents The marital status of general residents located in the project areas surrounding YIBA, Highway1A and NR5 is reported in Figure 26 below. Notable is the high number of single residents along the Highway1A . project in Vietnam. It seems likely that single people in project area communities would be more at project-area risk of HIV through multiple partners. In addition, single women may be particularly vulnerable to being gh approached by construction workers for unsafe sex, due to perceptions that they are unlikely to be erceptions infected with HIV.

Figure 26. Marital sta status of general residents located in the project area.

Existing HIV knowledge among general residents (both men and women) is reported to be very high (more than 75% of the populations across all projects; Figure 27). Of note is the disparity in HIV ). knowledge among men and women in YIBA, Hubei and Highway 1A, Vietnam. This may result from the .

20

additional education most men receive in these areas (men more often report receiving secondary education while women tend to complete up to primary). On NR5 in Cambodia, by contrast, women report higher HIV knowledge than men; this most likely results from the emphasis the Kingdom of m Cambodia has placed on HIV prevention education among women throughout the country.

Figure 27. Percentage of general residents (men and women) with existing HIV knowledge.

Demonstrated HIV knowledge, as reported through correctly answering several questions on HIV transmission and treatment, was observed as relatively high among general residents ( (Figure 28). Areas where knowledge was lowest surrounded HIV transmission (avoiding sexual contact can protect against (avoiding HIV, and you cannot get HIV from the saliva of an infected person An understanding of the ways that person). HIV is not spread is important in reducing stigma and discrimination based on fear. HIV transmission and non-transmission methods are therefore worth focusing on in training activities of general transmission residents, particularly associated with YIBA and Highway 1A (in China and Vietnam, respectively).

21

Question (with correct answer) 1. Can a pregnant woman pass HIV to her unborn baby? (yes) 2. Can a mother pass HIV to her baby by breastfeeding? (yes) 3. Is a cure available for people with HIV? (no) 4. Can HIV risk be reduced by properly using condoms during every sexual contact? (yes)

YIBA N % 461 91.1 403 79.6

a a

Hwy 1A N % 102 93.6 86 78.9 55 50.5 79 72.5

NR5 N % 304 79.6 359 92.5

a a

400 79.5

356 89.9

5. Does having one faithful, uninfected sexual partner 355 70.2 protect against HIV? (yes) 6. Does avoiding sexual contact 361 71.3 protect against HIV? (yes) 7. Can a person get HIV from food or drink that contains someone 202 39.9 else's saliva? (no) 8. Can a person get HIV by using a needle or syringe already used 453 89.5 by someone else? (yes) 9. Can a healthy-looking person have HIV? (yes)
a

76 69.7 44 40.7 68 62.4

217 55.5 238 60.7 341 86.8

104 95.4 75 69.4

398 98.8 241 64.1

255 50.4

Either this question was not asked or results were not reported.

Figure 28. HIV knowledge by question. Results correspond to Chinas YIBA, Vietnam Hwy 1A, and Cambodias NR5. , Emphasized values highlight questions where fewer than half of respondents provided the c correct answer.

Formal HIV prevention education was generally limited across all projects, with fewer than 11% of the residents associated with YIBA and H Highway 1A projects having received training (Figure 29). On NR5 in Figure Cambodia, more than 30% reported receiving formal training, most often from non-governmental organizations (NGO). Many of these training activities were associated with other development projects . deve in the region, and higher levels of HIV knowledge were observed in this area.

Figure 29 Percentage of general residents who have 29. received formal HIV prevention education.

22

Figure 30 below shows the percentage of general residents (men and women) who report using a condom with their spouse in the past month. Interesting here is the discrepancy between men and womens reported condom usage with their spouse. Vietnam in particular (with 46% of men saying they used a condom with their wife and only 9% of women reported condom use with their husband) shows a wide gap between mens and womens reported condom use.

Figure 30. Condom use with spouse in the past month among general residents.

Figure 31 below indicates that HIV testing among general residents is evenly split for both men and g women (fewer than 15% have been tested on H Highway 1A in Vietnam, while close to 50% have been tested on NR5 in Cambodia); results were not reported for YIBA in China. The national level response to HIV in Cambodia, as well as the additional HIV education provided by NGOs, have encouraged the n amount of HIV testing among general residents here.

Figure 31. Percentage of general residents (men and women) who have never been tested for HIV.

In Figure 32 below, general residents report their self perceived risk to becoming infected with HIV. self-perceived Results indicate that Cambodian residents, who receive the most HIV prevention education, are more residents, able to identify their own risky behavior. It seems that, by learning more about HIV, Cambodian residents are more conscious of the risk of HIV. Interestingly, though, Cambodian residents appear to HIV. be less familiar with HIV testing and relatively few have been tested ( (Figure 31). Vietnamese residents, ). by contrast, have less self-perceived risk and more of them have been tested for HIV. It is possible that perceived and they are reporting low self-perceived risk because of a negative HIV test result. perceived

23

Figure 32 Percentage of general residents who consider 32. themselves at no risk for contracting HIV.

The media source most often consulted by general residents along YIBA and H Highway 1A (in China and y Vietnam, respectively) is television with more than 90% of surveyed residents reporting regular use of television, a TV. On NR5 in Cambodia, by contrast, general residents report relatively equal uses of both television contrast, and radio, with newspaper (print journalism) falling not far behind at almost 40%.

IV.

Overall Themes Arising from Baseline Survey

In this section, the main themes arising from the baseline survey are condensed into actionable conclusions. Country-specific recommendations are incorporated into the recommendations included in Section VI while general recommendations have been included under overall recommendations in Section IX. It is important to note that research results on individual road projects cannot be generalized to other road projects and certainly not to each country as a whole. A range of variables affect the existing HIV/AIDS knowledge, attitudes and practices including the extent of existing coverage of HIV/AIDS including: education programs; access to good quality affordable condoms; contextual factors, such as size and condoms; nature of the sex trade and existence of injectable drugs and existing and emerging cultural practices, drugs; including among ethnic minority groups which may increase or mitigate HIV/AIDS risk factors. At the groups, same time, the work of the local consultants on baseline studies has generated considerable information of wider relevance, including in regard to existing HIV/AIDS response. These are summarized below. Research issues Several issues arose during the baseline study that should be taken into account going forward. First, t the questionnaires are extremely long and not all the information collected appears essential for the purposes of the project. Second, the usefulness of the analysis is limited by a lack of cross , cross-tabulation of data collected, for example, risk self ample, self-perception compared to actual risk behavior, or the relationship between misconceptions on HIV spread and discriminatory attitudes. An overall recommendation for the RTGH toolkit is therefore that the core questionnaires be shortened and a also accompanied by a section providing straight straight-forward guidance on data analysis. Third, there are questions over the accuracy of responses to the more sensitive questions, notably drug use (based on background knowledge of the target population) and condom use (based on discrepancies condom in responses of female entertainment workers and clients). Alternative research methods, probably emphasizing qualitative approaches, may be needed to provide an assessment of the reality in regard to these factors. A final issue relates to access to target populations. In particular, this reinforces the importance of timing project activities to match construction schedules and work routines, something which affects

24

all aspects of the HIV/AIDS prevention package, not just research. Worker mobility and impact on local communities Significant differences were noted in relation to the proportion of workers living away from home. On the YIBA expressway in Hubei, all workers lived away from home in temporary construction camps, while in Cambodia the figure was less than 60%. Where a proportion of construction workers live in local communities, this offers the opportunity to link construction site and community education programs, though use of locally-based construction workers. In terms of female entertainment workers, the research in Vietnam found a significant proportion of workers from local communities. On the one hand, this may mean that local females are vulnerable to being drawn into the sex trade. On the other, it may mean less turnover, which will assist in HIV prevention efforts. On a related note, the research found significantly lower levels of HIV knowledge in local communities among women than men, except in Cambodia, where knowledge levels were very high for both groups. Since local women are more likely than men to engage in casual sexual encounters, paid or unpaid, with mobile construction workers and the workers may perceive local women as being unlikely to be infected with HIV and therefore be reluctant to use condoms close attention should be paid to this group. Access to information versus knowledge Access to HIV information in the workplace was highest in Hubei, with more than half of the workers reporting access compared to one-third in Cambodia and around 20% in Vietnam. Despite this, knowledge levels among workers in Hubei the lowest of the three sites surveyed. Further, while the ability of respondents to answer basic questions about HIV transmission and prevention was quite high, there remain major misconceptions about other aspects of HIV 85% of workers in Hubei and 52% in Vietnam incorrectly stated there was a cure for HIV, while only 42.5% of people in Hubei and fewer than 80% in the other sites knew that HIV could not be spread by casual contact. The results for construction workers were mirrored by those for female entertainment workers and community members. They are typical where people access information primarily from sources such as the mass media, as reported in the survey results, and/or one-way information sources such as posters. This highlights a need to provide ongoing, practical and interactive HIV/AIDS education, including a focus on how HIV is not transmitted, the lack of a cure but the availability of treatment, and whether a healthy looking person can have HIV. The conveying of messages on non-transmission can be challenging. A message such as HIV is not transmitted by mosquitoes, for example, can actually be counter-productive in creating a mental association between HIV and mosquitoes. Knowledge versus behavior On all sites, and across all populations, the large majority of those surveyed were able to identify that HIV could be prevented by consistent use of condoms. However, this was not fully reflected in reported condom use. The most concerning information came from Vietnam where only 60% of female entertainment workers reported condom use during most recent sex. Research in Cambodia also highlighted concerns about low levels of condom use with regular but not necessarily monogamous sexual partners (sweethearts). These findings reinforce once again the importance of moving beyond knowledge provision to address issues around adoption and maintenance of safe behaviors, including access to affordable good quality condoms, negotiating skills around their use, and strategies to deal with diminished risk perception due to drunkenness. Voluntary Testing and Counseling According to baseline study results, most construction staff and workers have not been tested for HIV, either as a requirement for work or voluntarily. This is the case particularly in Hubei where more than

25

90% of construction staff on the YIBA project reported never having received an HIV test. The results are similar for other populations in both Hubei and Vietnam. The greatest awareness and uptake of testing services was available in Cambodia, where there is widespread promotion of VCT. These results indicate that, where VCT services are available and promoted, people will utilize these services. Knowing ones HIV status is important to mitigating risk as the more informed people are, the better decisions they can make about their behavior. This includes people who have HIV being able to access treatment. As highlighted in Figure 12 above, knowledge levels on treatment were low in all countries. Thus, efforts to promote VCT should also aim to increase knowledge of the availability of treatment for people with HIV, increasing the incentives for people at risk to undertake testing. In summary, a focus on educating workers as to the importance of HIV testing should be emphasized in all project countries. It is expected that this will give workers a better measure of their true level of risk which, according to the baseline survey, may be distorted (lack of cross-tabulation of data means it is not possible to be sure about this). While direct provision of VCT and other services such as STI prevention and treatment appear outside the role of the World Bank, two points are worth noting. First, the World Bank may consider supporting the provision of mobile services to construction workers who may otherwise not be able to access these. Second, it is important to note that workers should not be referred to services that are not confirmed as satisfactory. This covers issues such as technical competence of service, attitude of service providers to clients particularly female entertainment workers and privacy/ confidentiality. Referral of people to poor services will quickly backfire, making it much more difficult to encourage people to take up services in future. Building on Local Contexts There remain significant differences in the context between different countries. In Cambodia, the HIV/AIDS response is particularly well advanced, reflecting strong recognition by the Royal Government of Cambodia (RGC) of the threat presented by HIV/AIDS to the countrys health system and economic development. A central feature of this work, unique among the countries studied, is implementation of the 100% Condom Use Programme in establishments selling sex. This was initiated in 1998 by the World Health Organization at the request of the Ministry of Health and has been effective in reducing the spread of HIV by increasing condom use in commercial sex, focused on educating FEWs, providing condom supplies, and increasing accessibility of STI treatment. At the same time, there are signs that the nature of sex work is changing in Cambodia partly as a result of crackdowns on sex venues resulting from questionable interpretations by authorities of a new law against trafficking in persons. The level of indirect sex work where women work in venues such as karaoke bars and massage parlors is increasing in relation to direct brothel-based sex work. This is generally beneficial for the women involved as it gives them more than one incomes source and a higher degree of choice over clients, but means the women are not as accessible to health service providers, complicating HIV/AIDS prevention efforts. This is something that will need to be considered by future programs. The Cambodian example is singled out here as it highlights both the importance of building on existing efforts and the fact that contextual issues will change over time, including of course in relation to the road construction process itself. However, major HIV/AIDS responses in China and Vietnam are also in place and feature a range of tried and tested prevention approaches that can be drawn on to complement the approaches presented in the RTGH toolkit (see Section VI for more information on this point). An important issue to consider for the RTGH in relation to expanding to other countries or in more remote locations, is how to deal with situations in which there are limited or unsatisfactory existing services, such as a lack of VCT or STI facilities, a lack of trained health workers, or limited condom availability. While it is not the role of a HIV/AIDS and transport response to substitute for an overall HIV/AIDS response, a program without supporting services is unlikely to be successful and this is reflected in feedback from local consultants. This issue is discussed further in Appendix 3.

26

V.

Additional Activities on the YIBA Expressway

Unlike the projects in Cambodia and Vietnam, the YIBA Expressway in Hubei Province of China has already completed implementation of the RTGH program. It is comprised of three phases: (1) Baseline Survey, (2) Program Pilot Activities and (3) Monitoring and Evaluation, which overlaps to some extent with the second phase but has as its main focus an endline study to be compared with the results of baseline survey. These results are summarized in the preceding two sections and this section focuses on the pilot activities being undertaken as part of phase two. The Hubei Provincial Center for Disease Control (HBCDC) is undertaking prevention activities in three counties affected by the Expressway: ZiGui, BaDong and XinSha as well as YiLing district. This work is not only promoting HIV prevention along the expressway but also providing an opportunity to pilot the Toolkit. Further, research for the baseline and endline surveys is being carried out both on sites that have been the focus of Toolkit-led HIV prevention activities and on sites where no activities have taken place. This will provide a strong indication of the impact of prevention activities implemented based on the RTGH toolkit. As well as the RTGH toolkit, the HBCDCs work on the YIBA expressway is being informed by experience on a previous World Bank-funded HIV/AIDS prevention project on the Shiyan-Manchuangan Expressway (Shiman) in Hubei. Personnel working on the Shiman project were invited to participate in the initial preparatory workshop for the YIBA project and provide input on activities and appropriate IEC materials. This workshop was held in Wuhan, China (Hubei Province) in October 2010 with experts from the HBCDC AIDS Center, Health Bureau, and the Yunxi CDC (from the Shiman project). In this workshop, plans for developing a viable second phase of the Road to Good Health project were discussed, suitable information, education, and communication (IEC) materials were identified, and the form and content of information resources were agreed upon. A reporting system and implementation schedule were also developed as part of this workshop. Shortly after this preparatory workshop, phase two was launched with an HIV/AIDS intervention seminar. The seminar involved officers from the Provincial Health Office and the Provincial Department of Transportation, as well as four project county leaders and main staff. Discussions in this seminar focused on ensuring the quality and results of Phase 2 programming considering the needs and availability of target populations. Several follow-up meetings were to discuss and refine toolkit approaches and finalize appropriate IEC materials. Experience in China highlights a preference for IEC materials that are useful such as playing cards and calendars and a range of different materials were developed with this in mind. To educate the trainers in use of the Toolkit and accompanying materials, the HBCDC then carried out special training sessions in each of the project counties ten individuals from each of the three counties and YiLing district. A key aspect of YIBA activities is the inclusion of an HIV/AIDS component in the regular safety management training course for project managers and supervisors. Much attention is now being paid to safety issues in China, and the inclusion of HIV/AIDS within this system offers the chance to capitalize on existing structures for implementing and monitoring of activities. This approach was reflected in a major meeting in December 2011 involving a total of 120 people, including the contractors project managers and directors. The meeting was successful in increasing understanding of HIV/AIDS, raising issues around stigma and discrimination and the rights of people with HIV/AIDS, and generating support for project activities. It also allowed project staff to build relationships with site managers, facilitating later communication. After these preparatory steps, the HBCDC team launched a series of participatory education activities with the three target groups: construction workers, female entertainment workers, and local residents. These activities, based on the Toolkit, commenced on World AIDS Day, 1 December 2010 and are to continue until September 2011. A range of different interactive approaches have been used, including

27

singing and dancing competitions, and exercises from the toolkit tailored to local situations. Voluntary testing for HIV and other STIs has also been made available on site for construction workers. This is an important service as construction workers often find it difficult to access local health services due to the location of work sites. To facilitate smooth project implementation and ensure the quality of training activities under this invention, the HBCDC invited three graduate students from the Wuhan University of Science and Technology to observe implementation activities. These students are attending all of the training sessions in one implementation location over the duration of Phase 2, and providing independent monitoring of project activities. This assists HBCDC to improve the quality of program planning and implementation. In addition, the HBCDC has established a regular reporting system requiring all project counties to report project activities and results every two months. These data are collected and analyzed before being reported to the Bank. The first report, summarizing results out of Phase 2 from November 2010 to April 2011, is provided in Table 1 below.
Table 1. Monitoring and Evaluation Reporting for November 2010 to April 2011

Activity Attended training The number of peer education members who received training Condoms distributed HIV educational brochures distributed Individuals who sought voluntary counseling and testing following intervention activities HIV Testing Results Syphilis Hepatitis B

Construction Managers 14 12 1,935 1,473 163 65 65 65

Construction Workers 21 16 9,986 6,574 591 313 313 313

Female Entertainment Workers 15 26 3,834 1,709 78 139 139 139

Area Residents 17 57 5,192 8,140 421 217 217 217

Total 67 111 20,947 17,896 1,253 734 734 734

Further information on activities performed under Phase 2 of the Road to Good Health on the YIBA project is provided in Appendix 4 to this report.

VI.

Strategic Recommendations for Toolkit Improvements

The Local Consultants, serving as area experts in planning for implementation of the RTGH within the target communities of their country, made several recommendations for adaptation of the Toolkit to enhance its accessibility, appropriateness and effectiveness for behavior change. This section summarizes the major themes raised by the consultants in each studied country, drawing on supplementary information where directly relevant. This is followed by an itemized list of recommendations by country. Additional comments prepared independently by the Primary Consultant have been included as Appendix 3.

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 The Toolkit addresses a very important area The importance of an HIV response in relation to the transport sector was agreed by all consultants. In particular, the HBCDC (the local consultants in China) would like to see the standard HIV clauses under the World Bank projects extended to all construction projects in China. In Cambodia, a number of suggestions were made to secure endorsement of the Toolkit as part of the national HIV/AIDS response. The Toolkit must prioritize behavior change communication Evidence from HIV prevention programs worldwide indicates that providing only information on HIV/AIDS is rarely sufficient to trigger the adoption and/or maintenance of safe behavior. Research from a road construction project in Yunnan Province of China (2005 2008), for example, revealed that the most risky behaviors for HIV were found among managers and supervisors, those with the highest levels of education and the highest knowledge about HIV/AIDS.19 There are many reasons why people may know about an issue such as HIV without taking action to protect themselves. This may include a failure to personalize risk; lack of access to condoms; reluctance to use condoms due to perceived loss of feeling; and diminished sense of danger due to alcohol. Behavior change communication involves working with members of the target group to identify barriers to safe behaviors and help to address them. This necessarily requires interactive face-toface communication, rather than simply the one-way transmission of messages (as through television programming or billboards). Consultants in all countries highlighted the importance of a strong focus on behavior change, and suggested that the Toolkits content on risk perception and internalization could be strengthened. PACT Cambodia emphasized the need for ongoing programs that allowed reinforcement of messages, and specifically recommended more focus on the proactive engagement of program participants. The HBCDC in China commented along similar lines, suggesting that the crucial focus on skills-building is somewhat diluted by the overwhelming level of information provided. PACT Vietnam made a number of recommendations on the specific skills to be built, including: avoiding peer pressure, seeking health lifestyle alternatives accessing VCT and STI treatment, and negotiating condom use. Peer education is important but must take high turnover into account Given the central role of interpersonal communication, all consultants agreed on the importance of peer education as a core component of an HIV/AIDS prevention package. It was also noted that, in addition to working with peers on HIV education and promoting safe behaviors, which includes endorsement of STI treatment and VCT services, the peer educators could play a role in distributing condoms and educational materials. The HBCDC in China raised the issue of compensation for peer educators.20 They also highlighted the high turnover rates among construction workers and FEWs, which may limit a sustained HIV prevention response among these groups. This issue requires careful consideration. Two ADB projects in China have had to revise the peer education model due to high turnover; the projects found success in using foreman and site supervisors as peer leaders for construction sites, and brothel owners as educators for FEWs. Further discussion on peer education is included the discussion on issues raised in the final workshop (Section VII below). IEC materials must be well-targeted but dont necessarily have to be original As highlighted in the RTGH toolkit, an IEC campaign cannot be effective alone. It is, however, an important component of an HIV prevention strategy. Messages should not be overly preoccupied with the medical/scientific aspects of HIV, but instead focus more on behavioral and attitudinal issues, such as social norms and stigma. Projects by the World Bank and others, for example, have produced IEC materials linking use of helmets for safety during work time now commonly
19 20

ADB TA4142. 2008. Preventing HIV/AIDS on Road Project in Yunnan Province: Final Project Report. Allowing peer educators to sell condoms at a low price and keep a percentage may be one way of doing this.

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accepted practice with use of condoms for safety after hours. Road construction projects in China and Mongolia have developed materials aimed at reminding workers of their responsibilities to their families back home. Local consultant responses also highlight the availability of existing local materials, implicitly questioning the Toolkits current stance that use of existing materials is a second-best option. The RTGH toolkit highlights the preference of most target populations for IEC materials that are inherently useful, such as playing cards and calendars. It also underscores the importance of language-appropriate materials, a point reinforced by Cambodia. This is relevant not just for internationally migrating workers but also for local ethnic minority groups.21 The RTGH was originally designed with low literate audiences in mind notably through high use of graphical resources. The local consultants of PACT Vietnam would like to see this aspect of the Toolkit strengthened further. Cooperation and dialogue between key partners is essential An effective HIV response in the transport sector requires strong cooperation and dialogue between all key partners. The types of approaches included in the RTGH will involve transport and health authorities, local hospitals and health centers, construction companies, local government agencies and committees, and entertainment venues. All consultants highlighted the need for close collaboration, with the HBCDC team in China emphasizing the importance of clearly defined responsibilities for contractors and other partners. It is important that, for example, transport sector operators understand the importance of HIV/AIDS and the need to go beyond basic information provision, while health educators need to understand the realities of working in a construction setting, including both time constraints and the opportunities provided by existing health and safety processes, such as induction training. Project must build on and complement existing activities, where these exist Consultants from all countries highlighted the importance of linking with and building on existing initiatives, noting a range of potential partners, such as provincial and district AIDS committees. However, they also all identified the need to strengthen existing services, particularly in the area of VCT and STI diagnosis and treatment. The treatment of STIs is a crucial aspect of HIV/AIDS programs, both because the presence of STI sores greatly increases the potential for HIV transmission and because STIs indicate the existence of risk behaviors and provide openings for education and counseling services. Yet, because most infrastructure projects are in remote areas, local capacity in VCT and STI treatment often does not exist. The local consultants in China and Vietnam also raised the issue of accessibility of services for migrant workers and recommended that mobile STI and VCT services be considered where appropriate. Other comments The consultants made a number of other comments and recommendations worth highlighting. HBCDC in China noted the importance of locating condoms in accessible places (including possibly vending machines22). PACT Cambodia suggested that the RTGH explore topics such as the perception of risk, relations with sweethearts, drug use, and health-seeking behavior in more detail. PACT Vietnam raised the possibility of organizing toolkit delivery into two phases, first focusing on urgent risk factors such as unsafe sex and access to condoms and VCT/STI services, and then delving into underlying risk factors, such as money management, stigma and discrimination. This issue of money management highlights that there are other possibilities for HIV prevention beyond the most obvious solutions of condom use, abstinence and STI treatment. For example, workers who are paid all their money directly on site may end up with a lot of cash in their pocket
21

Research in both Cambodia and China has highlighted the failure of IEC materials produced in, or directly translated from national languages. 22 This is sometimes problematic on construction sites as the location needs to be private but safe and, as noted by the China team, the machines need to be regularly restocked

30

and little to spend it on apart from alcohol and entertainment. An alternative whereby employers send part of their pay directly home to families would offset this temptation as well as benefiting the families. Another possibility comes from Yunnan in China where construction companies are encouraging workers to bring their families, increasing trips home for those unable to do so, and putting a special focus on foremen, who often act as role models for their teams. The increased presence of family in the lives of construction staff and workers serves to reduce their risky behavior over the long term. Finally, the importance of both Monitoring and Evaluation was highlighted by all consultants. In terms of monitoring, there is a need to set practical indicators for monitoring implementation of activities in line with the HIV contract clauses in order to assist Task Team Leaders and road management to hold construction companies accountable for program delivery. Evaluating changes in knowledge, attitudes and behaviors can be measured using baseline and follow-up studies. Attitudes and behaviors do not tend to change overnight so there is a need for realistic timeframes between surveys. Additional comments on Monitoring and Evaluation are included in Section VIII on next steps.

Country-Specific Recommendations for Toolkit Enhancements This section provides the full list of country-specific recommendations for the Toolkit and next steps for RTGH as provided by the local consultants working in each country. These recommendations take into account both the baseline research findings (Sections IV and V) and Toolkit review. It is anticipated that, prior to the start of Phase II of this project (Deliver a Program), these countryspecific recommendations would be incorporated into the RTGH toolkit in order to maximize the effectiveness of the campaign in each target country.

China
Establish a Network of Departments and Encourage Joint Participation in Program Implementation Extend the Banks initiative on HIV/AIDS interventions through standard clauses to all construction projects in China. Clearly define responsibilities and obligations of the contractors to ensure that they are active participants of the program. With the coordination of the district government and the cooperation of the Health Department and Transportation Department, encourage community groups (such as the Womens Committee, rural hospitals, etc.) to participate in the intervention work; the Women's Committee is encouraged to fully participate in the intervention and propaganda work of sex workers. Work with the Transport Department to encourage construction workers to participate in the project. Employ the Health Department to lead the implementation and coordination of the intervention. Work with area hospitals to set up VCT that is accessible and convenient for the target groups, and promote correct and regular use of condoms. Work with the Radio and Television Department to strengthen the spread of HIV/AIDS knowledge. Strengthen provincial supervision and cross-sectoral support in order to identify and solve problems in a timely fashion. Provide additional training to the primary project staff for better results. Promote HIV/AIDS Knowledge through Media and Dissemination of IEC Materials Focus on anti-discrimination efforts in media propaganda campaigns. Advance development and dissemination of IEC materials (i.e. brochures, CDs, playing cards, and calendars). Grow knowledge through face-to-face meetings with road workers and managers.

31

Promote Voluntary Counseling and Testing Consider establishing a fixed voluntary counseling and testing center, as well as providing door-to-door group consultation service for ease of access to services. Promote Condom Use Locate HIV/AIDS educational materials and condom distribution sites in locations other than the managers offices, to provide better accessibility to the construction workers. Make condoms available at VCT centers; also provide information on when and how to use condoms correctly at these locations. Locate site condom vending machines in private and secure locations on construction sites; ensure these machines are regularly restocked. Standardize STI Treatment Identify solutions to support training of STI and HIV doctors and counselors to strengthen initial diagnosis and treatment of these diseases. Develop a strategy to work with STI patients in order to provide treatment and get a handle on their risks in order to prevent future STI outbreaks or contraction of HIV. Support Peer Education Develop peer education among the workers with appropriate compensation, and make the workers in charge of the distribution of condoms and educational materials. Identify and train peer educators in each target group (considering turnover rates among Construction Workers and FEWs, if appropriate). Gain Support from FEWs and Entertainment Venue Owners for this Campaign The nationwide crackdown on paid sex work may make FEWs more hidden, and may cause entertainment owners and FEWs unwilling to accept or participate in the intervention. Strengthening and supporting the cooperation with these groups is therefore important in order to garner support and advance program implementation.

Vietnam
Pilot-test the Toolkit with Construction Managers and FEWs Work with PAC Ca Mau to establish program with the sex worker network, and work also with construction companies and staff still operating in the area in order to pilot-test the Road to Good Health. Modify the Toolkit with consideration for low-literate audiences, with wording, methodologies and training of trainers adapted to the needs of the target populations. Focus on Building Awareness of Risks and Developing Skills The Toolkit should be adapted to select the contents and methodologies that facilitate increased knowledge and internalization of participants risk as many already have an established knowledge base. For construction workers, given their dominance in sexual relations and womens limited empowerment, it is important to integrate perceptions of risk for both male construction workers and their female sex partners. The Toolkit pilot should also facilitate skills-building, which is currently diluted by the overwhelming level of information provided. For construction workers, essential skills include: - Avoiding peer pressure - Seeking healthy lifestyle alternatives such as sport and other cultural activities that do not involve risk behaviors - Talking to service providers and using STI and VCT services. For FEWs, skills to negotiate condom use and seek HIV testing and STI services are particularly important. Building Local Capacity through Provincial AIDS Committee (PAC) is Crucial for Toolkit Delivery Because most infrastructure projects are in remote areas, building local capacity is key. A training agency can be identified to initiate the Toolkit revision and deliver it based on the above recommendations. Throughout this process the agency should coach the local PAC or

32

a local NGO to deliver the Toolkit so they can continue to offer it effectively for future projects. In a central support and monitoring role, the Ministry of Construction should also involve its Social, Environmental and Safety Unit, which is responsible for monitoring environmental impacts and the welfare of workers and affected communities. Toolkit Delivery Should be Organized into Phases Given the challenges of limited local capacity and resources, the Toolkit should be piloted in two phases to optimize behavior change among the target groups: Phase 1. Address urgent risk factors such as unsafe sex and lack of access to STI and VCT services. The objective of this phase is to ensure that construction workers, sex workers and general residents receive an essential package to protect themselves from HIV. The educator should be aware that supplying these basic services is challenging in underserved areas. Setting up a peer education program, community-based education and links with existing services are major tasks requiring significant resources. Phase 2. Address underlying causes of risk. Targeted behavior change communication should also address underlying risk factors. The current toolkit already lays out a strategy to address these underlying risks through sessions on topics including money management, alcohol and risk, stigma and discrimination, and personal future plans. These issues require multidisciplinary collaboration such as advocacy with managers and policymakers above the construction site level, to support the longer-term process of developing non-discriminatory workplaces. This strategic scale-up is especially important when adopting a peer education approach to toolkit delivery. Peer educators are construction workers, sex workers or community youth that have pre-existing work priorities, and focused, strategic messages will help them be more effective. Enhance Monitoring and Evaluation Component Baseline findings can be used to evaluate KAP changes; the Toolkits monitoring and evaluation tool should be adapted to reflect the recommendations above. Build on Existing Programs and Services The project should mobilize peer educators and specialists from existing FEW programs within the local PAC. Work to ensure existing VCT and STI services are not overloaded; coordinate and plan for service growth with local PAC early and establish financial assistance where needed for set up costs. One challenge is to ensure that services are accessible during migrant workers limited free time. Past experience shows that, by advocating with PAC, mobile services for workers can be organized at reasonable cost.

Cambodia
Present Study Results to Relevant Institutions Submit the proposed Road to Good Health program to the Ethical Committee for Research of Ministry of Health and to Monitoring and Evaluation Advisory Group in order to obtain a formal endorsement for work. Absent this endorsement, the Ministry of Public Work and Transport (MPWT) will be in difficult position to present the findings and the recommendations of this study to interested institutions/groups including the National Technical Board of the National AIDS Authority. The World Bank and MPWT should therefore find alternative methods to lobby with the National AIDS Authority to disseminate the study findings and results to concerned institutions, Civil Society Organizations and local authorities along the affected road. Seek support for target communities in order to encourage involvement and effectively implement the campaign.

33

Integrate the Road to Good Health Initiative with Existing Efforts The Road to Good Health initiative should not be considered an isolated effort; indeed, this program can only be implemented smoothly and successfully if linked closely to the existing efforts, service deliveries and behavior change communication of the relevant stakeholders working with other sectors. Provincial and district AIDS committees must be involved at every stage of the education program in order to facilitate coordination and collaboration among sectors, and promote sustainability of initiative. The MPWT should introduce the Road to Good Health initiative to the Mobility Technical Working Group, which is the national coordination body of all government, nongovernmental organizations working on mobility for consideration. Subsequently the RTGH initiative could capitalize on the existing multi-sectoral efforts of government, civil society and the network of FEWs, MSM and PLHIV. For Construction Workers, it is recommended that the existing successful methods provided under the Uniform Services (Peer Education Program) be combined with the adapted RTGH program in order to best educate and inform this group as to the risks and prevention of HIV/AIDS. Entertainment Workers are already receiving some HIV/AIDS education under the SOP on Continuum of Prevention to Care and Treatment for Women Entertainment Workers, where peer education is currently run by NGOs, including FHI, KHANA and PSI. Besides the current efforts to expand education for the MARPs, Community Partnership is currently creating an enabling environment to facilitate interventions surrounding HIV and AIDS, Anti-Trafficking and Drug Use. For the Community Residents, it may be useful to combine elements of the successfully implemented Community Capacity Enhancement (CCE) Module (UNDP) that focuses on participation and underscores values related to health and family. Community Conversation as part of CCE further allows community members to interact and to come up with local solutions to deal with the emerging problems related to HIV and AIDS in their community.

Utilize existing IEC materials and methodology to inform Construction Workers and Entertainment Workers living on or near construction sites; for example, print and audio media developed for Overseas Migrants Workers (CWPD, CSEARHAP, CARAM), and the Smart Girls Program concept (FHI). Learning Methodology The facilitator-oriented approach of the RTGH education campaign may not be appropriate considering the demonstrated value of participant involvement and support. Also, where target populations are being required to attend these trainings, there may be less buy-in and therefore less acceptance of training. The learning methodology for implementation of the Toolkit should be focused around interaction and proactive involvement in the learning process. Participants should own the program rather than the facilitators. HIV-prevention activities should be carried out with the same intensity from the beginning to the end of the project, and should be repeated to reinforce behavior change messages. Innovative IEC approaches should include multilingual materials (For Chinese, Thai and Vietnamese) and multimedia (especially videos). Additional Topics for Inclusion in the Road to Good Health Some topics are missing are not developed completely enough in the RTGH toolkit: description of the current HIV/AIDS situation in Cambodia, perception of risk, relations with sweethearts, drug use, health-seeking behavior.

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VII.

Final Workshop for Phase I

The final workshop for Phase I of RTGH project took place in Phnom Penh on 24 May 2011. It was attended by: Mr. Ratha Sann, World Bank, Cambodia; Mr. Yut Sakara Phon, PACT, Cambodia; Ms. Yang Fang, HBCDC, Hubei, PRC; Ms. Li Ling, HBCDC, Hubei, PRC; Mr. Phil Marshall, RCG, Primary Consultant and Mr. Alan Shi Guanghui, Interpreter. Ms. Emily Dubin, formerly World Bank, Washington participated in the morning session by Skype. The workshop commenced with a review of project status, followed by presentations on the results of the baseline study in China, Cambodia and Vietnam. Participants then presented and discussed their recommendations on the Toolkit, including implementation challenges. The remainder of the workshop comprised a discussion about possible next steps, noting that World Bank funding to support further work had yet to be secured. The section below highlights three important discussion points during the workshop: primary users of the Toolkit; peer education; and PACT Cambodias suggestion for an amended approach to working with community residents. The other issues covered in the workshop discussion are largely reflected in the recommendations (Section IX) or covered elsewhere in this paper. The full meeting record is contained in Appendix 2. Primary Users of the Toolkit The workshop revealed differences of understanding as to who the primary audience was for the Toolkit. Some participants expressed the view that the Toolkit was primarily to guide those in the transport sector as to how to develop effective HIV programs. Others considered that only people with considerable HIV experience could use the Toolkit. The HBCDC team noted that it looks simple but it isnt. If you want to use this Manual, you have to have some basic skills. Even commune doctors would have difficulty using it. Participants did agree that involvement of health education personnel was essential in the early stages, such as running initial trainings. Some, but certainly not all, work could be done by the transport companies themselves. This lack of consensus among organizations that have worked extensively with the Toolkit as to its primary purpose is a potential concern. The workshop discussed and agreed with the Primary Consultants recommendation that the World Bank consider different overview sections for different audiences. For health personnel, this could include information on how to work most effectively in a transport setting. The importance of close cooperation between the health and transport sectors was again emphasized by all partners. For transport personnel, this would include evidence of the need to go beyond simple provision of information. Peer Education Issues During the workshop, it became apparent that the term peer education is used differently in Cambodia and China. In Cambodia, peer education refers to the use of people who are strictly peers as educators. For example, sex workers to train other sex workers, laborers to train other laborers. This approach was seen as very effective in Cambodia in general terms, although there can be problems when turnover is very high. The key issue is how to select educators effectively. In contrast, peer education in Hubei could involve the use of managers of entertainment venues (mommies) as educators for sex workers, and the use of foreman or even higher level employees as educators for laborers on construction sites. This is also the situation in Guangxi and Yunnan, where as noted in Section VI, ADB project staff coined the term peer leaders to differentiate from strict peer educators. This form of education is seen as successful in China and helps address the turnover issues. In Vietnam, peer education is generally understood in the same way as in Cambodia. The Primary Consultant noted that experience from HIV prevention work on other construction sites in Vietnam

35

suggests some problems with peer education. Some companies had shown resistance because they saw it as having the potential to interrupt normal work practices. Further, in a culture where formal education and educators attract a lot more respect and attention, seeking behavior change communication outcomes can often be more effective through formal programs than through peer education.23 PACT Vietnam was consulted on this topic following the workshop and noted that they did see an important role for peer education but highlighted the importance of this being part of a packaged approach. In particular, they stressed that it was important to emphasize referral to existing services for VCT, and STI check-ups and treatment. Community Capacity Enhancement Approach In its report on the RTGH Toolkit, PACT Cambodia expressed concern that the facilitator-oriented approach of the RTGH education campaign may not be appropriate considering the demonstrated value of participant involvement and support. Also, where target populations are being required to attend these trainings, there may be less buy-in and therefore less acceptance of training. The learning methodology for implementation of the Toolkit should be focused around interaction and proactive involvement in the learning process. Participants should own the program rather than the facilitators. PACT further noted that for community residents it may be useful to combine elements of the successfully implemented Community Capacity Enhancement (CCE) Module that focuses on participation and underscores values related to health and family. CCE is a participatory methodology in which a process of Community Conversation allows community members to interact and to come up with local solutions to deal with the emerging problems related to HIV and AIDS in their community. This includes reviewing existing community norms and practices that may have a positive or negative impact on HIV transmission.24 One example of a community coming up with its own solution is negotiated safety, a term first used in Australia in the early 1990s to describe a practice among gay men in a stable but non-monogamous relationship of having unprotected sex within that relationship while using condoms consistently with other partners.25 Although many HIV prevention messages focus on either mutual fidelity or use of a condom in every sexual episode, the strategy of using a condom when someone has sex outside their stable relationship is essentially what is being promoted for mobile workers. Examples were also given in the previous Section of this paper of solutions developed locally on another HIV and transport project in Yunnan. As indicated by PACT Cambodia, it may be possible to incorporate elements of the CCE approach into the RTGH, particularly through integrating some of the exercises that emphasize communities coming up with their own solutions, solutions being imposed from the outside, such as a focus on adoption of ABC messages (Abstinence, Be Faithful, Use Condoms). This is something that should be considered in terms of finalization of the Toolkit.

23

Pers. Comm. from staff involved in SMARTWork (Strategically Managing AIDS Responses Together), a workplace HIV/AIDS prevention education project in 14 provinces in Vietnam.
24 25

UNDP, 2005. Community Capacity Enhancement Handbook, New York. Kippax S et al., 1993. Sustaining safe sex: A longitudinal study of homosexual men. AIDS 7:257-263.

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VIII.

Next Steps

Project activities in Hubei are continuing until September 2011. This includes a continuation of pilot prevention activities, ongoing monitoring and reporting, and an endline survey. As noted in Section III, the survey will enable comparison of the situation at the beginning and end of pilot project activities. Further, it will also enable comparison of sites in which HIV prevention activities were undertaken, based on the RTGH Toolkit, and sites where no activities were undertaken. This should provide a clear picture of the effectiveness of project activities. The World Bank is currently seeking funding for a continuation of the very important work initiated under Phase I of this project. A proposal is under consideration for Phase II which would take forward the process of adaptation and implementation of the Road to Good Health approach with a view to creating a basic minimum response for combating HIV/AIDS in the transport sector, thus meeting World Bank HIV/AIDS education requirements on transport development projects. The first task under Phase II of the project would involve adaptation of the RTGH Toolkit for each country followed by implementation in the form of pilot testing in China, Cambodia and Vietnam. Phase III would involve Monitoring and Evaluation of program activities and outcomes. Under this component, a standard set of indicators would be developed before implementation of the campaign, which will allow outcomes under each project to be measured against each other. It is strongly recommended that the World Bank break this component into separate Monitoring and Evaluation sub-components. Monitoring is essentially about answering the question did we do what we intended to do? It should be grouped with reporting and can readily be undertaken by non-HIV specialists, based on simple checklists, which can be derived from the Toolkit. Evaluation is essentially about answering the question did we achieve what we wanted to achieve? It generally requires the involvement of external parties and usually involves the creation of a baseline against which progress can be measured towards clearly defined targets. To be effective, evaluation must go beyond the assessment of outputs produced. These primarily address the monitoring question above that is, did we do what we intended to do?

IX.

Overall Recommendations

The overall recommendations from the final workshop are set out below. Those that link to the strategic recommendations for toolkit improvements discussed in Section VI are highlighted in bold. The recommendations are not in order of priority. Proposed Approach 1. 2. 3. 4. 5. 6. Priority must be placed on behavior change and capacity building not just knowledge transfer. The proposed approach should build on and complement existing activities. In this regard, while customised IEC materials are needed, existing materials should be reviewed first for suitability before new materials are developed. The proposed approach is too facilitator-focused. More participatory approaches should be considered. Cooperation and dialogue is essential, especially between health and transport partners. There should be more focus on how to build HIV work into existing systems and structures, such as health and safety processes, monitoring systems and contract management systems (including potential incorporation in the Bill of Quantity).

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7.

Adequate supporting services in VCT and STI are essential to an effective HIV prevention response. The World Bank should give consideration to how to proceed with prevention programs in locations where such services are not in place.

RTGH Toolkit 8. 9. 10. 11. 12. The RTGH Toolkit addresses a very important area and should form the basis of future HIV and transport work for the World Bank. In line with the central importance of behavior change, the Toolkit should be further strengthened in this area. The importance of ongoing access to affordable, good quality condoms in supporting safe behaviors should be further emphasised. The Toolkit should include a stronger focus on other sexually transmitted infections, which are easier to identify and act as an indicator of risk behavior. The Toolkit should include more discussion of advantages and disadvantages of peer education approaches and note differences between countries as to how peer education is conceptualised to avoid confusion and misunderstandings. Different sections should be considered to address the differing needs of transport companies, project supervisors and health educators. More discussion should be included on the roles and responsibilities of different actors. Shorter survey forms should be included, incorporating the crucial questions needed and providing guidance of how the data should be analysed, including the need for genderdisaggregated data, which was well addressed in the existing research, and the need for crosstabulation of data, which was not. Alternative methods may be needed to get information on particularly sensitive topics such as injecting drug use. The Toolkit should be translated into the relevant national languages. An onsite training-of-trainers for local contractors conducted by external trainers should be considered. This could possibly be a regional training for all local contractors.

13. 14. 15.

16. 17.

Funding Options 18. In China, future budget allocations should be split between the transport companies and Department of Health/CDC (rather than have companies pay CDC). 19. In Cambodia, the World Bank should consider flexible funding options. Government policy is that 1% of civil work contracts should be allocated for HIV/AIDS work. This level is probably too high but could be a good starting point for negotiation.

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Appendix 1: Joint Initiative Statement by Development Agencies (2006)

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Appendix 2: Record of Phase I Final Workshop Workshop to Review Results from Phase I of the World Banks Program Combating HIV/AIDS in the Transport Sector Phnom Penh, 24 May 2011 World Bank Cambodia Country Office Summary Record - Final Participants
Mr. Ratha Sann, World Bank, Cambodia Mr. Yut Sakara Phon, PACT, Cambodia Ms. Yang Fang, HBCDC, Hubei Ms. Li Ling, HBCDC, Hubei Mr. Phil Marshall, RCG, Primary Consultant Ms. Emily Dubin, formerly World Bank, Washington (morning, by Skype) Mr. Alan Shi Guanghui, Interpreter Apologies: Ms. Fei Deng, World Bank, Washington Mr. Eric Bergthold, PACT, Cambodia Dr. Thuan Nguyen, PACT, Vietnam

Session 1: Review of Project Status to-date, Baseline Study Results and Toolkit Recommendations
1. Welcome and Introductions

Mr. Ratha Sann (World Bank, Cambodia) welcomed all delegates and presented apologies from Ms. Fei Deng and Dr. Thuan Nguyen (Local Contractor, Vietnam). He explained that for over a decade, the World Bank has offered long-term financial and specialized technical support and knowledge to countries for effective prevention of new HIV infections, care and treatment for People Living with HIV/AIDS, and alleviation of social and economic consequences for affected communities. The Bank plays a global leadership role in three key areas: 1. 2. 3. Supporting HIV strategic planning by helping countries to develop well-prioritized, evidencebased national AIDS strategies and action plans; Preventing sexual transmission of HIV; Strengthening social protection for people affected by HIV.

The Road to Good Health (RTGH) program is the first effort by the World Bank's transport group to develop an organized response to the spread of HIV associated with project construction. The longterm goals of the RTGH are to: Reduce incidence of HIV; Reduce stigma and discrimination;

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Increase protection of rights for people living with HIV or AIDS; and Increase gender equity.

On behalf of the World Bank, Mr. Sann expressed appreciation for the work of the teams in China, Cambodia and Vietnam, as well as the coordination that has been ongoing with the respective Ministries of Transport and Health. The RTGH program had made great strides since its beginning in 2008 and the workshop was an important step leading onto the next phase of work, updating the Road to Good Health Toolkit (the Toolkit) according to overall and country-focused suggestions, and beginning to implement its approaches. The full version of Mr. Sanns comments is included as Annex 1. All participants then introduced themselves. Mr. Yut Sakara Phon (PACT Cambodia) added the apologies of Mr. Eric Bergthold (PACT Cambodia) who had a prior engagement but wanted to emphasize that PACT remains very interested in this work. Mr. Phil Marshall (RCG) then briefly outlined the workshop program. 2. Project Chronology: Status of work, challenges and opportunities for next steps Ms. Emily Dubin (formerly World Bank) provided an overview of the history of the Road to Good Health project. The project followed from earlier initiatives in China, (Shiman Highway, Jiangxi III Highway, Inland Waterways V, Liaoning Urban Transport Projects), Cambodia (Provincial and Rural Infrastructure Project), and Indonesia (Eastern Indonesia Regional Transport Project II). Groups at risk from transport sector developments include: construction workers away from home, people living along transport routes, sex workers and employees of long-distance transport. The World Banks focus is on the first three groups. The East Asia and Pacific Transport Division has adopted a regional HIV/AIDS strategy with a vision that every project have an effective HIV/AIDS response. Within the Bank, Task Team Leaders now have responsibility to ensure HIV/AIDS education programs are undertaken. The RTGH Toolkit was developed with a view to developing a standard approach and education materials that could be adapted to each country. China, Cambodia and Vietnam were selected to pilot test this Toolkit. The World Bank has sought funding to support the next phase and is awaiting the outcome. Ultimately, the two key outcomes of this program are: knowledge transfer and behavior change. Knowledge transfer includes communicating information on HIV transmission and prevention to target groups. Behavior change includes setting up condom distribution sites, providing training on proper usage and improving access to Voluntary Counseling and Testing. The program also seeks to build capacity in the transport sector for HIV responses. Ms. Dubins presentation is included as Annex 2. 3. Baseline Study Results: Report from each project area and summary of overall results This session involved presentations of both the research findings and preliminary recommendations on the RTGH Toolkit. China Research and Toolkit Findings Ms. Yang Fang, Deputy Chief of the HBCDC, explained that the HBCDC has been working on HIV prevention on the Yichang Badong (YIBA) Expressway since 2008. The HBCDC has the lead on this project and has good cooperation from a range of other players. Road construction in YIBA is located far from urban areas and the road is complex from an engineering point of view, requiring many bridges and tunnels. Unlike Cambodia and Vietnam, work in China also includes an intervention component, involving trial use of the Toolkit. The baseline survey was conducted in 2009 before application of Toolkit commenced in 2010. Toolkit application activities will continue until September 2011. The baseline survey aimed to establish HIV/AIDS-related knowledge, attitudes and behaviors to inform interventions

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and allow later evaluation. The survey questionnaires were tested before the survey and modifications made to improve understanding. Six sites were chosen for the survey, four where Toolkit-based activities were taking place and two other sites where only IEC materials were provided. In all, 725 construction workers were interviewed, comprising 604 laborers and 121 supervisors. A total of 506 community residents and 151 sex workers were also surveyed. Simple HIV/AIDS knowledge among all groups was relatively high but respondents lacked in-depth of understanding. For example, while around 80% of people identified condom use as a form or prevention, around half thought that HIV was spread by mosquito bites and sharing of food. The survey found that construction workers and supervisors spent long periods of time away from their homes and families, were thus likely to seek other sexual partners and were able to afford commercial sex. Consistent condom use among sex workers was low, with only 52% saying they used condoms all the time. It appeared that competition for clients was a significant factor in low condom use. Few members of any group surveyed had received HIV tests and the research noted high demand for testing among construction workers. It seemed people would prefer to be tested when away from their home communities so the possibility of on-site voluntary testing should be considered. Ms. Yang emphasized that the results of the baseline survey represent HIV related knowledge levels in relation to the six construction sites. The results could not be taken to represent the overall situation in China or even Hubei Province. Future plans are: 1. 2. 3. 4. 5. Completion of report on mid-term assessment of the effects of Toolkit implementation (May 2011); Continue Toolkit application and assessment, including development of more gifts (JuneSeptember 2011); Final survey initiated, final survey report and toolkit application assessment completed (September 2011); Joint convention and press conference summarizing project by Health and Transport Departments (October 2011); and Submit key outcomes of the Toolkit to the Peoples Government of Hubei Province (November December 2011).

Recommendations included: Ensure multiple departments involved in implementation; Include a focus on advocacy; Support peer education approaches; Standardize STI diagnosis and treatment; Promote voluntary counseling and testing; Place strong emphasis on condom use; and Strengthen information programs with an emphasis on anti-discrimination.

Ms. Fang concluded her presentation by reinforcing the importance of the World Banks support for HIV and transport initiatives in China. The Bank has a key role in actively promoting international exchanges and learning, developing the intervention toolkit and supporting adaptation to national and local conditions. She recommended enlarging the project scope and extending to other high-speed roads. She also requested the Bank consider exploring the adaptation of the Toolkit for other target groups (e.g. men who have sex with men, students, and other migrant workers). In response to a question from Mr. Sann, Ms. Fang said that the HBCDC consulted regularly with the transport sector contacts. In order for these approaches to expand to other places, the Department of

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Transport has to take the lead. At present, HIV is not part of the core system. The HBCDCs counterpart within the Department of Transportation is the World Bank office. In Hubei, the HBCDC is best placed working with site doctors, who can have doctors, however, especially repeated training, not just one-off. to provide technical assistance. In some instances, this can involve also distribute/sell condoms and promote HIV testing. Not all sites in remote areas. It is important also to emphasis the need for Ms. Fangs presentation is included as Annex 3.

Cambodia Research and Toolkit Findings Mr. Sakara presented the findings of the baseline survey in Cambodia. To undertake the survey, PACT worked through a local research agency. The research combined: document review, key informant interviews and a KAP survey along Road 5 in Cambodia. A total of 537 people were interviewed: 38 construction workers; 92 female entertainment workers (FEW) and 407 local community members. The research among construction workers found that awareness and knowledge of the HIV and AIDS was very high, with 97% having basic knowledge. Risks related to having multiple partners was not clearly understood, however, and only 58% believed that having a faithful and regular partner could help avoid HIV infection. Consistent condom use with FEWs was low and alcohol consumption which can increase risk was significant. Access to HIV information at construction sites was low (32%). The majority of construction workers sought out HIV information from friends, clinics, the internet and radio. It seems that that radio is source of general information on HIV, but friends and internet are source of specific information on HIV and AIDS. There is high mobility among FEWs, with only 14% stayed in the same place for more than one year and 52% of those interviewed were migrants. The knowledge level with regard to prevention was very high (95-96%) in the areas of consistent condom use, transmission of HIV to baby during breastfeeding and HIV transmission through needle/syringe already used by someone else. Basic HIV awareness among community residents was also generally high. However, their knowledge level in some areas is still low. For example, although 98% male and all female community respondents reported having heard of HIV and AIDS, only 64% believed that a person who looks healthy can be infected with HIV. A high level of consistent condom use was reported by male respondents during last sex with their sex workers (83%). The main sources of HIV information were television (76%), radio (66%) and health centre/health staff (58%). Recommendations from Cambodia were as follows: Ensure formal endorsement and buy-in from relevant stakeholders; Advocate for HIV/AIDS interventions in the public works and transport sector; Conduct further research on HIV/AIDS among the public works and transport sector to advocate for the routine application of its 1% policy (see discussion under this point in part 5 below); Integrate the Road to Good Health initiative into existing efforts; Draw lessons from uniform services to implement HIV education for construction workers; and Draw lessons from Community Capacity Enhancement programs to implement HIV education for community residents.

With specific regard to the RTGH Toolkit: Efforts should be made to integrate updated epidemiological and underlying socio-economic determinants that fuel HIV and AIDS infection in Cambodia into the curriculum; Additional topics should be added including alcohol consumption, low condom use, possible combination of other risk with the drug uses, risk perception and low health seeking behavior;

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Female Entertainment Workers need to be aware and be fully involved with Community Enablers team of the MARPs Community Partnership and the local stakeholders who are implementing the Partnership; and HIV-prevention activities should be carried out with the same intensity from the beginning to the end of the project, and should be repeated to reinforce behavior change messages.

Mr. Sakaras presentation is included as Annex 3. Vietnam Research and Toolkit Findings Prior to providing an overall research summary, Mr. Marshall briefly described the work undertaken by PACT Vietnam on Highway 1A in Ca Mau Province in the Mekong Delta. The research involved 133 construction staff and workers, 97 sex workers, 112 general residents and 5 HIV service providers. Among the interesting findings were discrepancies in the responses on condom use between construction workers and sex workers. While all construction workers who said they had sex with sex workers claimed they used condoms, sex workers reported only a 56% success rate in negotiating condom use with construction workers. Further, one-third of all unmarried men said they had had sex with a sex worker, but only one respondent with a regular partner reported sex with a sex worker and none with non-paid casual partners. Responses on drug use questions were also universally negative despite considerable known drug use in the area. These answers call into question the accuracy of information being received on sensitive topics. Another notable aspect of the research in Vietnam was the discovery that houses have moved nearer the road to sell snacks and tobacco. Mr. Marshall noted that in northern Lao PDR, this was the first step in a process which saw shops move onto selling beer and whiskey, noting that the shops with young women sold more, employing more young women and then seeing the growth of paid sex. There appears to be similar potential in Vietnam. PACT found that most of the female sex workers are local women, not migrant women as elsewhere, and further that 19% of local women had never heard of HIV/AIDS. This suggests that local women may be at extremely high risk. Other risk factors noted in communities were high alcohol consumption, low risk perception and attitudes to gender 35% or men and women think domestic violence is acceptable. Among construction workers, recommendations included: challenging ungrounded trust in partners behavior; increasing condom use; reducing multiple partnerships; dispelling myths about HIV spread; increasing awareness and usage of VCT and strengthening knowledge of STIs, including symptoms. For entertainment workers, the report found a need to support changes to attitudes of powerlessness in negotiating violence and unwanted sex. There should be a strong focus on consistent condom use, even when clients offered to pay more to not use condoms. With regard to the Toolkit, the main recommendations were: The Toolkit should be piloted in Ca Mau with construction managers and female sex workers; The Toolkit should focus on building awareness of risks and skills; Building capacity through Provincial Aids Committees is crucial for Toolkit delivery; Toolkit delivery should be organized in phases. Phase I should address urgent risk factors such as unsafe sex and lack of access to STI and VCT services. Phase II should address underlying causes of risk, including stigma and discrimination; The M&E tools in the Toolkit should be adapted to reflect the above recommendations; and Building on existing programs and services is essential.

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Overall Research Summary Mr. Marshall then provided an overview of the research across the three countries. In each country there had been issues with accessing the target group. In Cambodia, road construction was not fully underway meaning it was difficult to access construction workers while crackdowns on the sex trade in China made accessing sex workers a challenge, although the Hubei team had still managed to interview 151 people. There were also different contexts in each country. In China, where the road is remote and the work technical because of the terrain, all workers lived on site, while in Cambodia, this figure was less 60%. Access to information on site was limited, ranging from less than 20% in Vietnam to around 60% in China, where YIBA project activities were underway. No analysis was done comparing access to on-site information with HIV knowledge levels. Access to HIV education among sex workers was also low, less than 20% in both China and Vietnam, though over 50% in Cambodia. Despite this, HIV levels were reasonably high in China as well as Cambodia. In Vietnam, however, only 66% of sex workers identified condoms as a way to prevent HIV (compared to 88% in China and 96% in Cambodia) and only 33% knew there was no cure (similar to China). The misconceptions on whether there is a cure for HIV and whether HIV could be spread through food and drink were also found among construction workers in China and Vietnam. Misconceptions as to how HIV spreads can be a key factor in stigma and discrimination. Again no cross-analysis was done with regard to knowledge and discriminatory attitudes. Mr. Marshall noted that the lack of cross-tabulation/multivariate analysis meant that the value of asking many of the questions was lost. For example, it was impossible to make sense of risk perception data without knowing actual risk levels. Also, data on issues ranging from income levels to age at first sex to alcohol consumption did not appear to have practical usage for the purposes of this research. HIV knowledge levels among communities were again high in Cambodia but considerably lower in Vietnam and China, where only around 10% of the population had received HIV education. This reinforces the importance of context. It seems that relatively more attention on HIV knowledge would need to be paid to communities in China and Vietnam than Cambodia. As noted by Mr. Sakara, mass media such as television and radio may be useful for promoting general awareness and understanding but not so useful in terms of in-depth understanding and support for behavior change. In most settings surveyed, television was noted as a primary source of HIV information. This may help explain why many respondents had no more than basic HIV/AIDS knowledge. Mr. Marshalls presentation on the overall research findings, including Vietnam, is included as Annex 5. Discussion on Research The discussion on research results centered on two main issues: the length of the questionnaires and the reliability of the data. As noted by Mr. Marshall, not all of the data collected had been used and participants agreed it may be better to have fewer questions and increase focus on analysis. Greater cross-tabulation might also help assess the accuracy of responses, as noted in the example in Vietnam comparing responses by sex workers and construction workers. With regard to drug use, Mr. Sakara suggested using less direct questions to gather information on this topic. The possibility was also raised of linking with existing sentinel surveillance systems (both sero surveillance and behavioral surveillance).

Session 2: Discussion of Next Steps

4. Toolkit Review/Implementation Challenges and Opportunities:

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It was agreed to combine the discussion on the Toolkit with that on implementation challenges and opportunities because of the overlap between the two topics. Mr. Marshall made a brief presentation, commencing with an overview of the key themes of the Toolkit review, several of which had already been raised in discussion. These included: the need for such a Toolkit in this area; the importance of focusing on behaviors; the need for cooperation and key dialogue between health and transport sector actors; and the desirability of building on and complementing existing activities. He also stressed the importance of clarity as to the main primary audience for the Toolkit. In terms of implementation, flexibility was obviously important. No two roads are the same. Across the region it is possible to find great variations in terms of factors such as: whether the road is opening up a new route or replacing an old road; the location and accessibility of the construction sites in relation to local communities; and the complexity of the road and the composition of the labor force, including local workers. All of these factors have potential implications for HIV projects. Further, HIV situations and responses also vary. It is obviously easier to establish an HIV program in a transport setting where appropriate surrounding services already exist. Within the transport sector, opportunities often exist for building HIV education into routine health and safety work and/or other existing systems and processes, such as induction trainings. The enforcement of HIV contract clauses can make health service providers key partners for transport companies. This may be further enhanced if service providers can incorporate other health issues into their training of interest to the companies and workers. This has been successfully done in Yunnan province (China), for example, where issues ranging from heart problems to alcohol to dental care have been incorporated into HIV trainings at the request of participants. Another point to note is that the transport sector resources often dwarf those of the health sector so there is certainly potential for contributions in terms of resources. In terms of constraints, transport companies are often reluctant to accept the need for HIV programs. Further, many managers struggle to understand the importance of going beyond awareness in these programs. Comments such as our job is to build roads and why cant be just show them a video are common. Similarly health providers can be reluctant to be involved in work with the transport sector. Our health staff dont have time to travel to sites. HIV work in construction and entertainment sites can be further complicated by high turnover of workers. Further, as indicated by the report from Vietnam, local communities are often affected after construction as well as during operation. This highlights the importance of building local capacity and ensuring ongoing activities. Mr. Marshall concluded by raising questions about peer education, evaluating impact, men having sex with men and responses in areas where surrounding services such as STI diagnosis and treatment were inadequate. This led onto in-depth discussions on the key issues and next steps, which is summarized in the next section. Mr. Marshalls presentation is included as Annex 6. 5. Discussion on the Toolkit and Next Steps The issues raised with regard to the RTGH Toolkit were largely similar to those that the local contractors had raised in their reporting and presentations. It was, however, notable that there were differences of opinion as to who the primary audience was for the Toolkit. Mr. Sann and Mr. Sakara expressed the view that the Toolkit was primarily to guide those in the transport sector as to how to develop effective HIV programs. Mr. Sann believed that, with the Toolkit, transport companies could develop and implement their own programs. On the other hand, the delegation from Hubei Province considered that only people with considerable HIV experience could use the Toolkit. It looks simple but it isnt. If you want to use this Manual, you have to have some basic skills. Even commune doctors would have difficulty using it. Mr. Sakara

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suggested that involvement of the health sector was important in the early stages, such as running initial trainings, but that some work could be done by the transport companies. Mr. Marshall agreed. This lack of consensus among organizations that have worked extensively with the Toolkit as to its primary purpose is a potential concern. Mr. Marshall noted that, as flagged in his presentation, he had recommended that the World Bank consider different overview sections for different audiences. Participants agreed this would be a good idea. Mr. Sann took up this point and suggested that it would be preferable if HIV work could be incorporated into existing processes, such as safety systems. The possibility of making provision for HIV activities in the Bill of Quantity should also be explored. Time on site was limited and he noted that transport companies were very experienced at scheduling and could work to tailor activities accordingly. Mr. Sann also highlighted that the Toolkit would be very valuable in avoiding the need to re-invent the wheel on every project. The Toolkit opened up the possibility of setting common standards, broken down into step-by-step processes. Ms. Fang raised the strong importance of evaluation. Mr. Marshall agreed and noted that accurate and affordable collection and analysis of data for evaluation can be costly. Participants considered that the models for implementing the Toolkit in each country are likely to differ. In Hubei, cooperation between the transport and health authorities, particularly CDC, should be sufficient. In Cambodia, NGOs were seen as having a role in working with the transport sector. Participants agreed that, in either model, close communication between the transport sector and health service providers was essential. Toolkit Methodology Mr. Sakara explained the PACT and the research team in Cambodia suggested the Toolkit was currently too facilitator-focused and that there should be more emphasis on community capacity enhancement methods. These involved supporting the identification of issues and solutions by communities themselves. Mr. Sakara agreed to provide materials on this after the meeting. He subsequently forwarded two documents: UNDPs Community Capacity Enhancement Handbook and an Evaluation of Community Capacity Enhancement Project, 2003-2006. Soft copies of these documents are included as Annexes 7 and 8. Peer Education There was a discussion about the effectiveness of peer education. During the discussion it became apparent that the term peer education is used differently in Cambodia and China. This is a very important issue. In Cambodia, peer education refers to the use of people who are strictly peers as educators. For example, sex workers to train other sex workers, laborers to train other laborers. This approach was seen as very effective in Cambodia in general terms, although there can be problems when turnover is very high. The key issue is how to select educators effectively. In contrast, peer education in Hubei could involve the use of managers of entertainment venues (mommies) as educators for sex workers and the use of foreman or even higher-level employees as educators for laborers on construction sites. This is also the situation in Guangxi and Yunnan, where ADB project staff coined the term peer leaders to differentiate from strict peer educators. This form of education is seen as successful in China and helps address the turnover issues. In respect of Vietnam, Mr. Marshall noted that he was aware of work suggesting such programs in construction settings were not always successful. It seems that in some instances the informal nature of peer education programs may lead to them not being taken seriously. (PACT Vietnam was consulted on this following the workshop and noted that they did see an important role for peer education but highlighted the importance of this being part of a packaged approach. In particular, they emphasized

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that it was important to emphasize referral to existing services for VCT, and STI check-ups and treatment. These services are already widely available in Vietnam). Evaluating Impact Participants agreed that, once a clear set of activities had been set out, monitoring the implementation of these activities was relatively straight-forward. The Toolkit already provides considerable guidance in this area. Ms. Fang suggested that monitoring should be done by an external agency, linked to the key indicators and forms provided in the Toolkit. Evaluation on the other hand is more complicated. The approach favored by the Toolkit involves baseline and follow-up surveys. As highlighted in the discussion on research, the forms provided for these surveys are extremely long and not all of the data is used. Further, not all the information appears reliable. It was thus agreed that more consideration should be given to how the evaluation process could be made more straightforward and less costly. IEC Materials All participants agreed there was a need for IEC materials that were tailored to the local context, including language and education levels. However, many materials already exist and participants considered that use should be made of these wherever possible, especially for communities and female sex workers (the Toolkit currently paints this as a second-best option to new materials). Other There was limited discussion on the issue of men having sex with men in male-dominated construction settings other than an acknowledgement that there was very little data on this issue. On the remaining discussion point, dealing with situations where surrounding services were lacking, participants expressed the view that this was something the World Bank needed to consider, in terms of its willingness and ability to address such problems, and the consequences of not doing so. 6. Workshop Recommendations Mr. Marshall compiled a list of recommendations based on the discussions. All participants then reviewed the recommendations and made adjustments as appropriate. The final agreed set of recommendations are set out below. The recommendations are not in order of priority. Proposed Approach 1. Priority must be placed on behavior change and capacity building not just knowledge transfer. 2. 3. 4. 5. 6. The proposed approach should build on and complement existing activities. In this regard, while customised IEC materials are needed, existing materials should be reviewed first for suitability before new materials are developed The proposed approach is too facilitator-focused. More participatory approaches should be considered. Cooperation and dialogue is essential, especially between health and transport. There should be more focus on how to build HIV work into existing systems and structures, such as health and safety processes, monitoring systems and contract management systems (including potential incorporation in the Bill of Quantity).

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RTGH Toolkit 7. 8. 9. The RTGH Toolkit addresses a very important area and should form the basis of future HIV and transport work for the World Bank. In line with the central importance of behavior change, the Toolkit should be further strengthened in this area. The importance of ongoing access to affordable, good quality condoms in supporting safe behaviors should be further emphasised.

10. The Toolkit should include a stronger focus on other sexually transmitted infections, which are easier to identify and act as a sign of risk behavior. 11. The Toolkit should include more discussion of advantages and disadvantages of peer education approaches and note differences between countries as to how peer education is conceptualised to avoid confusion and misunderstandings. 12. Different sections should be considered to address the differing needs of transport companies, project supervisors and health educators. 13. More discussion should be included on the responsibilities of different actors and who does what. 14. Shorter survey forms should be included, incorporating the crucial questions needed and providing guidance of how the data should be analysed, including cross-tabulation. 15. The Toolkit should be translated into the relevant national languages. 16. An onsite TOT training for local contractors conducted by external trainers should be considered. This could possibly be a regional training for all local contractors. Funding Options 17. In China, future budget allocations should be split between the Department of Health/CDC (rather than have companies pay CDC) transport companies and

18. In Cambodia, the World Bank should consider flexible funding options. Government policy is that 1% of civil work contracts should be allocated for HIV/AIDS work. This level is probably too high but could be a good starting point for negotiation.

Annexes (not included in the Final Report but available separately)

1. Opening remarks by Mr. Ratha Sann 2. Presentation by Ms. Emily Dubin, The Road to Good Health: Training Strategies, Curricula and Resources for HIV Education 3. Presentation by Ms Yang Fang, Hubei Province YIBA Expressway HIV/AIDS the Road to Good Health Toolkit: Exemplary Project 4. Presentation by Mr. Yut Sakara Phon, Key Findings: Baseline Survey for HIV and AIDS Education and Capacity Building for Transport Project 5. Presentation by Mr. Phil Marshall, Summary of Research Findings 6. Presentation by Mr. Phil Marshall, Road to Good Health Toolkit Challenges and Opportunities 7. UNDPs Community Capacity Enhancement Handbook 8. Evaluation of Community Capacity Enhancement Project, 2003-2006.

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Appendix 3: Additional Comments on the RTGH Toolkit

In this addendum to the Road to Good Healths (RTGH) Final Integration Report, some additional questions and comments are provided for consideration by the transport team of the World Banks East Asia and Pacific Region (the designers and programmers of HIV/AIDS education initiative associated with transport projects in the region, henceforth known as the Bank). These comments are based on the Primary Consultants experience on the implementation of HIV programs on road construction projects in China, Lao PDR, Mongolia and Vietnam. At the same time, the Primary Consultant has come onto the project late in its design and planned implementation so some comments may simply reflect gaps in understanding. The RTGH (the toolkit) is clearly highly regarded by all local contractors involved in the project. It contains a wide range of excellent tools relevant to HIV responses in a transport context. At this point, however, it does not appear entirely clear how these tools are intended to be used and by whom. The toolkit, as it is designed, also requires adaptation to reflect the needs of different target groups, much of which is addressed by local consultants in the Integration Report. Specific questions and comments with regard to toolkit content and proposed implementation are set out below. 1. Toolkit Objectives and Target Groups

The introduction to the toolkit identifies several different intended audiences: World Bank managers responsible for integrating HIV into sector projects; contractors seeking to provide HIV education to workers; and HIV educators looking for promising approaches for working with construction workers, sex workers, and community members. These intended audiences have different needs in terms of HIV and transport. Those in the transport sector without a background in HIV need to know, for example: Why HIV is important and relevant to their work; Why providing information on HIV/AIDS is not enough; The key components of an effective HIV/AIDS program; and In the case of construction companies, what is required of them.

Those involved in managing programs need to know, for example: The key steps in designing and implementing HIV/AIDS programs; Who should be doing what, e.g. role of approved service providers; and How to monitor programs, in line with HIV contract clauses.

Those with a background in health education but not transport construction need to understand the opportunities and constraints of working in the transport sector context, for example: High turnover of workers and how this impacts HIV programs. In particular, how potentially high turnover of peer educators can present problems for the peer education programs that are highly favored in the toolkit, and possible alternative approaches to address this; The possibility of building HIV into existing health and safety systems and monitoring processes. This might include incorporating HIV into induction training for construction workers and managers, including HIV topics in health and safety briefings, etc.; The importance of understanding construction schedules and time constraints, including how workers travel to sites, when they eat, holiday periods, which may increase risk behavior. (Also, the time commitment for some of the trainings currently suggested in the Toolkit may be unrealistic and require adjustment); The nature of different groups on the construction sites. The present segmentation of transport sector workers into just two groups managers and laborers may be somewhat

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simplistic. Foremen and truck drivers, for example, are two distinct target groups that are not at present distinguished. Foremen in particular can play a key function as role models among workers and in labor camps. It is also important to understand the links between issues such as access to vehicles and HIV risk; and Alternative strategies to reduce risk behavior, such as part-paying wages into home bank accounts, which reduces the amount of cash that workers have available for entertainment as well as providing obvious benefits in terms of savings.

The information needs for health educators and transport sector specialists are thus quite different. If the toolkit is intended to serve both groups, it is suggested that separate sections be demarcated in the toolkit for each. It is particularly important to ensure the realities of working in the transport sector are addressed. Locating HIV prevention activities in the context of the transport sector is a key area of value added for the toolkit. In its current form, however, it does not appear to be sufficiently distinguished from the plethora of generic HIV toolkits already in existence. Recommendation: Separate sections could be developed for the key target groups for the Toolkit. These could be brief, addressing the key points of relevance for each group. In particular, health practitioners/HIV educators reading the toolkit would benefit from more information about the realities and specifics of implementing HIV/AIDS programs in a construction setting. This could include a sample list of question to ask work supervisors in order to assist with their HIV program design. 2. Role of the Approved Service Provider

The toolkit refers to approved service providers (ASPs) and this model has been very used effectively on World Bank HIV projects. However, the intended role of the ASP is not currently clear from the Toolkit. There would appear to be three options for involvement of ASPs: 1. Delegation of entire program implementation to one or more approved service providers.26 This has the advantage of ensuring work is done by those with training in the area, specifically contracted to do so. A disadvantage is that it can be more costly and have the effect of reducing ownership by companies. A partnership involving one or more ASPs, construction companies and local authorities. This would involve ASP input at key parts in the program with other partners assigned specific responsibilities. For example, the ASP may train HIV prevention teams in each company who would then organize activities on site. Similarly, they could train community members as peer educators; the local CDC/AIDS committee, if not already the ASP, could provide programs for entertainment workers. (This may already be part of their existing responsibilities and may just require some additional resources to cater to a likely increase in this target group). No involvement of an ASP. This option is not recommended. Just as one would not give a construction plan to a health professional and ask them to build a road, it is unrealistic to expect road contractors to implement effective HIV programs without outside assistance.

2.

3.

Recommendation: The involvement of an ASP is strongly favored. The toolkit could set out options for ASP involvement in HIV prevention programs. 3.
26

A Template for Action

A list of service providers can be agreed by the World Bank and local authorities, based on clearly defined requirements. In some cases, it may be preferable to have one service provider for the whole road (to provide economies of scale or because only one agency is qualified). However, in others, including where different agenicies are located at different points along the road, it may be preferable to provide a choice.

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The toolkit at present is strong on how to implement specific activities, but does not clearly locate these activities as part of an overall package. It also appears unclear on who specific training is for, notably the Training of Trainers workshop. As such, it does not appear to fully address the goal of providing guidance to Task Team Leaders in implementing the required HIV education component on their projects. While the precise details of an HIV prevention package are likely to differ from place to place, the toolkit might benefit from providing a sample outline of activities. An example is included in Table 1 below:27 Table 1: Sample of HIV Program for Construction Sites 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Activity Include HIV/AIDS prevention clauses in project bidding contract document Including HIV/AIDS prevention indicators in project monitoring and supervision system Advocacy meeting for site HIV/AIDS prevention work Establish HIV Prevention Team (HPT) on each section and agree their responsibilities Training for HPT members on HIV/AIDS prevention knowledge Baseline survey Develop site HIV/AIDS prevention work plan Formulate site HIV/AIDS prevention policy HIV/AIDS prevention induction training for site management staff HIV/AIDS prevention induction training for site laborers Training for site peer/field educator on the site Initiate HIV prevention activities on the site (IEC distribution, HIV talks, small training exercises, one-on-one contacts by field educators) Develop system for condom distribution Reports regularly on HIV/AIDS prevention activities Monitoring visits to sites Ongoing activities with focus on behavior change End-line survey Responsibility World Bank/Client Client Client/ASP Construction companies ASP Research entity HPTs HPTs ASP ASP or HPTs depending on budget (may use DVD) ASP HPTs/field educators HPTs HPTs Client (possibly with ASP assistance) HPTs/field educators Research entity

Recommendation: The toolkit includes samples of an HIV program and sets out more clearly where the exercises currently in the toolkit would fit. 4. setting? A transport sector response to HIV or a comprehensive HIV approach in a transport

At present, it is not clear whether the toolkit is focused on developing a response to HIV that can reasonably be undertaken by the transport sector, or whether it is focused on developing a comprehensive HIV response in a transport setting. The former would focus on what could reasonably be achieved by the transport sector. Likely this would look primarily at addressing the linkage between transport sector workers and casual sex (particularly paid/transactional sex) and focus on behavior change communication, including the encouragement of health-seeking behavior, and ensuring access to good quality, affordable condoms (usually either through making these available at no cost or through social marketing). With the
27

Sample adapted from ADB Project TA6321-7, HIV in the Transport Sector in Yunnan and Guangxi

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assistance of an approved service provider, including for supporting activities in nearby communities and entertainment sites, this appears a realistic goal for the transport sector. The latter, more comprehensive approach, essentially needs to be led by the health sector with the transport sector as a secondary player. It would address not just behavioral issues with regard to mobile men and entertainment workers, but also issues such as injecting drug use and men having sex with men (MSM), which are almost certainly too complex to be built into a transport sector response (and would likely not gain much support from clients, construction companies and task team leaders). Both approaches have their advantages and disadvantages. An HIV and transport response has the potential for wider adaptability beyond projects funded by the World Bank or other external donors. However, it is more limited, particularly in very remote areas where there is a lack of existing services with which to link, or in situations where injecting drug use plays a major role in the epidemic. For example, it is no use referring people to STI treatment if there are no available medical facilities, or if health staff are not properly trained in diagnosis and treatment of STIs as well as privacy/ confidentiality. The advantages of a more comprehensive approach are clear; however, such an approach is unlikely to be applicable beyond Bank-funded projects. Recommendation: The World Bank should clarify the nature of the intended HIV programs. If the Bank wishes to support both of the above approaches, depending on context, these should be distinguished in the toolkit. 5. Monitoring of Activities

Monitoring of activity implementation is relatively straight-forward. Once a basic template for action is established, the monitoring of HIV activities can be built into the road contract monitoring system. This is very important. Experience from ADB projects in China suggests that, while a crucial first step, the HIV clauses in construction contracts are largely ineffectual unless linked to a monitoring system that carries potential penalties for non-compliance. As well as increasing the likelihood of compliance with HIV contract clauses, the inclusion of HIV requirements in monitoring systems has the potential to transform the relationship between transport companies and approved service providers, who become a key ally in helping the companies fulfill their contractual requirements rather than an interruption to their core work. Recommendation: Include a monitoring form for overall adherence to implementation of HIV contract clauses in the toolkit. 6. Evaluation of Outcomes and Impact

While monitoring will provide information on whether activities have taken place, assessing whether these activities have any effect is more complicated. Usually research is required to evaluate changes in knowledge, attitudes and behavior among target groups. This generally involves one-on-one interviews, where possible, supplemented by information such as changes in the level of condom sales. The Toolkit provides extremely detailed questionnaires that seek to collect perhaps more information than is essential, and may also be difficult to implement. The extent of data collection should consider not just the resources involved in gathering the data, but also the resources required to analyze it. There is very limited value, for example, in collecting information on respondents self-assessment of risk if this is not going to be cross-tabulated with their responses on behavior. The current research findings appear to assume that low self-assessment of risk is a negative thing, whereas low selfassessment of risk, related to low actual risk, should be a goal. An additional issue is the reliability of data on sensitive issues such as drug use and, depending on context, STI symptoms. As noted in the integration report, the responses on drug use in Vietnam do not

54

appear to be consistent with known drug-use patterns. It may be worth developing a much shorter core questionnaire, accompanied by instructions for mandatory cross-tabulations of responses.28 In each country, this should be linked to the questions asked in their national HIV surveillance surveys. This could be augmented by a longer list of sample questions that could be added to individual questionnaires on a case-by-case basis as appropriate. Recommendation: Include a streamlined questionnaire focusing on core questions and indicators, accompanied by a template for data analysis in the toolkit. This should be adapted on a countryby-country basis according to national HIV systems. It may also be possible in some instances to have transport corridors added into existing sentinel surveillance systems. Training on HIV in Transport for WB Task Team Leaders The toolkit has the potential to be a reference guide for Task Team Leaders but is probably not suitable as a basis on which to provide training to this group. A separate 2-4 hour interactive training package could easily be developed for this group focusing on why HIV is important in relation to the transport sector, why this must go beyond information provision and what kinds of activities are needed.

28

ADBs Practice Guidelines has a simplified indicator list around condom use. This could be expanded to cover basic questions around HIV knowledge and stigma.

55

Appendix 4: Summary of Phase 2 Works Associated with YIBA

Progress Report Summarizing Phase 2 of the Road to Good Health Project on the YiBa Expressway
Hubei Provincial Center for Disease Control and Prevention (HBCDC) China
The transport team of the World Banks East Asia and Pacific Region (the Bank) is working to pilot test an HIV/AIDS education program targeted at construction workers and managers, female entertainment workers, and community residents working or living near Bank-funded transport development projects. To support their effort in China, the Bank secured the Hubei Provincial Center for Disease Control and Prevention (HBCDC) as a local consultant to oversee program implementation associated with the Yichang-Badong (YiBa) Expressway project in three phases: Phase 1 Baseline study Phase 2 Program Pilot Phase 3 Monitoring and Evaluation

In March 2011, the baseline survey in the YiBa project area (YiLing District, ZiGui County, BaDong County, and XinShan County) was completed. The second phase (implementation of the Road to Good Health Toolkit [Toolkit] in order to pilot the program) began in December 2010, together with the data collection and Toolkit review effort of Phase 1, and continued through March 2011. This document serves as a progress report for activities under Phase 2 of this program. Monitoring and evaluation (M&E) information detailing results out of this phase are provided at the end of this report.

Program Development
A programmatic workshop to discuss implementation of the Toolkit was held in Wuhan, China (Hubei Province) on October 9, 2010 with experts from the HBCDC AIDS Center, Health Bureau, and the Yunxi CDC (who supported a similar HIV education campaign on the Bank-funded ShiMan Expressway Project in 2006) in attendance. In this workshop, plans for developing a viable second phase of the Road to Good Health project were discussed, suitable information, education, and communication (IEC) materials were identified, and the form and content of information resources and giveaways were agreed upon. A reporting system and implementation schedule were also developed as part of this workshop. Figures 1 and 2 below show the workshop where program logistics and outcomes were discussed.

Figures 1 and 2. Program development workshop, October 9, 2010.

56

The Launch of the Second Phase

To inform each project county of activities under Phase 2 of this program and to garner their support, the HBCDC held an HIV/AIDS intervention seminar at the Wuhan Foreign Language Training Center on October 22, 2010. A total of 20 participants attended this seminar, including officers from the Provincial Health Office and the Provincial Department of Transportation, as well as four project county leaders and main staff. The seminar was divided into three parts: a summary of the first phase of the project, launch of the second phase, and discussion of activities planned for the second phase. Discussions in this seminar focused on ensuring the quality and results of Phase 2 programming considering the needs and availability of target populations. Figure 3 below is a photo from that meeting.

Figure 3. Launch of Phase 2 with county leaders.

Improving the Toolkit

The HBCDC believes that developing a useful and effective Toolkit is the most important step to success in program implementation. To enhance the quality of the Toolkit and make it more suitable to the needs of the target populations associated with the YiBa project, considering particularly the local conditions and context of the YiBa project, the HBCDC held several seminars and discussions with the Health Bureau and met with the project management organization, the Hubei Provincial Transportation Department (HPTD) to discuss opportunities to improve effectiveness of HIV education curricula and materials. Figures 4 - 6 below show some of the IEC materials included in the Toolkit to educate target populations about HIV transmission and prevention.

57

Figure 4. Playing cards for Spin the Bottle risk game (IEC materials)

Figures 5 and 6. Set of risk cards (IEC materials)

Capacity Building
Training of Trainers
To educate the trainers in use of the Toolkit and accompanying materials, the HBCDC carried out special training sessions in each of the project counties from November 22 23, 2010. In each county, as well as YiLing district, 10 people received this interactive training. Figures 7 - 10 show highlights from these training sessions, including use of the IEC materials (risk cards, handouts) and the interactive games to communicate valuable messages on HIV/AIDS transmission.

58

Figure 7. Training of trainers opening session.

Photo5: study how to use risk cards

Figure 8. Trainers learn how to use risk cards.

Figure 9. Playing the Web game, an HIV education game.

59

Figure 10. Playing an educational game.

Safety Training for Contractors and Project Managers

The education and support of construction managers is crucial to the success of this effort, particularly in terms of access to the site, access to workers, and sustainability of the program message. A meeting in December 2010 focused on providing information for this program, which included introducing the Toolkit and describing the operational requirements of the Road to Good Health program, and also provided an opportunity to introduce the project managers to each other in order to facilitate communication across the project. This meeting also confirmed the safety benefits of allowing the county CDC and township hospital staff to work with construction managers to perform intervention activities and organize workers to participate in training. Finally, presenters in this training spoke to stigma and discrimination issues for people living with HIV/AIDS (PLWHA), focusing on safety concerns for construction workers and managers when disease or its sufferers are not understood. A total of 120 people were in attendance, including the contractors project managers and directors. Figures 11 and 12 below show this meeting and the number of construction staff and representatives in attendance.

Figure 11. An expert from the HBCDC reports on the Road to Good Health program.

60

Figure 12. Contractor managers and directors at the training and information session.

Intervention Activities in Each Project County

Intervention in each project county began on World AIDS Day, in December, 2010. Construction workers were the main target of these initial campaigns until March 2011; implementation of the program among female entertainment workers and project-area residents followed soon after. Figures 13 - 15 highlight some of these intervention activities for construction workers in several of the project counties during the winter of 2011.

Figure 13. Large singing and dancing competition in Zigui County, World AIDS Day 2010.

61

Figure 14. Trainers play risk cards with a construction worker.

Figure 15. HBCDC staff performing HIV and STI testing for construction workers in XinShan County.

Project Organization and Management

To facilitate smooth project implementation and ensure the quality of training activities under this invention, the HBCDC invited three graduate students from the Wuhan University of Science and Technology to attend the implementation activities. These students, who will be attending all of the training sessions in one implementation location over the duration of Phase 2, will engage in discussion and program planning with the HBCDC in order to improve the quality of these efforts and their outcomes. In addition, the HBCDC has established a regular reporting system requiring all project counties to report project activities and results every two months. These data are collected and analyzed before being reported to the Bank. The first report, summarizing results out of Phase 2 from November 2010 to April 2011, is provided in Table 1 below.

62

Table 1. Monitoring and Evaluation Reporting for November 2010 to April 2011

Activity Attended training The number of peer education members who received training Condoms distributed HIV educational brochures distributed Individuals who sought voluntary counseling and testing following intervention activities HIV Testing Results Syphilis Hepatitis B

Construction Managers 14 12 1,935 1,473 163 65 65 65

Construction Workers 21 16 9,986 6,574 591 313 313 313

Female Entertainment Workers 15 26 3,834 1,709 78 139 139 139

Area Residents 17 57 5,192 8,140 421 217 217 217

Total 67 111 20,947 17,896 1,253 734 734 734

63

Appendix 5: Sample of General Survey Questionnaire for Baseline CONSTRUCTION WORKERS SURVEY QUESTIONNAIRE HIV/AIDS TRANSPORT STUDY Part 1. Interview information Questionnaire number Interviewer Identification number Date of interview Time of interview Supervisor Identification number Supervisor Signature Part 2. Demographic Characteristics N Q201 Q202 Q203 Questions Sex of correspondent How old are you? What is your education? Responses Male Female . Years old Never been to school Primary (1-5) High school (6-12) Vocational school, college University or higher 1 2 3 4 5 Code 1 2 Go to

Date.month.year 2010 From.to..

Q204

What is your marital status?

Single Married Divorced/Separated Widowed Not married but living with partners Yes No

1 2 3 4 5 1 2

Go to Q 301 for drivers. Go to Q401 for others

Q205

Do you have a child?

Part 3. Drivers and Driver Assistants Only N Q301 Questions What is your occupation? Responses Truck driver/assistant Crane/excavator driver Driver for Manager/Supervisor Suppliers driver 64 Code 1 2 3 4 Go to

N Q302

Questions What is your average monthly earning? If the respondent has seasonal earnings, please ask them to estimate an average monthly income for the past year

Responses Other ________________ Less than 1 million VND 1 - 3 million VND 3 5 million VND 5 - 10 million VND More than 10 million VND Dont remember Refuse to answer

Code 95 1 2 3 4 5 96 98

Go to

Q303

Please estimate about how many days in a year do you spend at a location that is not your place of permanent residence?

Q304

Q305

Q306

Q307

Less than 7 days 12 weeks 36 weeks 23 months 4-6 months More than 6 months per year Dont remember And about how many nights of the nights past month did you spend away Dont remember from home? Refuse to answer In what type of places do you Stay in truck/parking sleep when you stop for the night? Motels/hotels Construction Labor Camp 1= Yes 2= No Partner/girlfriends home #2 Companys office Other .................................... Refuse to answer Bar/Pub When you stop for the night, what kind of place do you go for Night club Restaurant relaxation? Casino Brothel 1= Yes 2= No Massage Not stop for relaxation/ stayed in truck Other_____________________ Refuse to answer The last trip before this one, what Bar/Pub kind of place did you go for Night club relaxation. Restaurant Casino 1= Yes 2= No Brothel Massage Not stop for relaxation/ stayed in truck Other_______________ 65

1 2 3 4 5 6 97 . 97 98 . . . . 95 98 . . . . . . 95 98 . . . . . . 95

Questions

Responses Refuse to answer

Code 98 1 2 97 98 1 2 3 4 95 98 .. 95 98 1 2 96 98 1 2 96 98 .. .. 95 96 98 1 2 98 1 2 3 95 98

Go to

Q308

Do you listen to the cassette/CD player while you are driving?

Q309

Q310

Q311

Q312

Q313

Q314

Q315

Yes No Dont remember Refuse to answer What types of music do you Comedy usually listen to? Music Traditional music Southern Soap opera (cai luong) Other. .. No answer Wait until I return home When you are travelling and Visit a doctor have a problem with your health, what do you usually do? Visit a public clinic 1= Yes 2= No See the doctor at worksite Other_________________ #4 No answer Are you an employee of one Company company or do you work Independent independently? Dont know No answer Does your company provide any Yes medical services for you? No Dont know No answer (If Yes) What type of services? Health insurance Regular medical check-ups Doctor at loading or drop-off points, or at company headquarters Other_______________________ Dont know No answer Do you usually keep a condom Yes when travelling? No No answer Where do you keep your condom? In the purse At home With key bunch Other .. No answer

Go to Q310

Go to Q 314

Go to Q 314

Go to Q401

Part 4. Migrant Workers and Migrant Supervisors

N Q401

Questions Please estimate how many days in a year do you spend at a location

Responses Less than 1 month 13 months 66

Code 1 2

Go to

Q402

Q403

Q404

Q405

Q406

Q407

Q408

Questions Responses that is not your place of permanent 36 months residence? More than 6 months 1 year Dont remember No answer In your current work where do you Motels/hotels sleep? Construction Labor Camp Rented apartment/room/flat Partner/girlfriend s house 1= Yes 2= No Companys office Other ............................................ No answer What kind of place do you go to Vendors Karaoke for relaxation? I will read a list Restaurant of places and please tell me Casino whether you visit such places. Brothel 1= Yes 2= No Pub Not go out for relaxation Other_____________________ No answer What kind of entertainment mean TV do you mostly prefer? Radio Cassette player CD player Other.. No answer When you have a problem with Wait until I return home your health, what do you usually Visit a private doctor in the nearest town/city do? Visit a public clinic in the nearby area 1=Yes 2= No See the doctor at the worksite Buy medicine by yourself Other_________________ No answer Are you an employee of one One company company or do you work Independent independently? Dont know No answer Does your company provide any Yes medical care for you? No Dont know No answer (If Yes) What type of care? Health insurance Regular medical check-ups Doctor at loading or drop-off 1= Yes 2= No points Other_______________________ 67

Code 3 4 97 98 . .. .. .. .. 95 98 .. .. .. .. . . 95 98 .. .. .. .. 95 98 . .. . .. .. 95 98 1 2 96 98 1 2 96 98 .. .. 95 96

Go to

Go to Q 501

Go to Q501

Questions

Responses Dont know No answer

Code 98

Go to

Part 5. Sexual behavior

N Questions Q501 How old were you when you first had sex?

Q502 About regular sexual partners (i.e., spouse or permanent sexual partner that you do not pay), how many person do you have? Q503 Did you have sex with your regular partners last month?

Responses Years old Not have sex yet Dont remember No answer No persons No answer

Code Go to . 1 97 98 0 Go to Q507 _______ 98

Q504

Q505

Q506

Q507

Q508

Yes No Dont remember No answer Do you usually use a condom Always when having sex with regular Sometimes sexual partners? No Dont remember No answer Why didn't you use condoms? Want to have a child Was not available Too expensive Partner refused 1= Yes 2= No Dont like it Apply safer sex (massage) Didnt think of it Dont know how to use it Other (specify) ______________ No answer Who made the decision to use a Myself condom? My partner Both of us Dont remember No answer Have you ever had sex with sex No workers? Once per week If so, how often? Several times per week Once per month 2 3 times per month Dont remember No answer What kind of sex did you have Vaginal sex 68

1 2 97 98 1 2 3 97 98 . . . .. .. . 95 98 1 2 3 97 98 0 1 2 3 4 97 98 .

Go to Q507

Go to Q506

After this question, go to Q507

Go to Q516

Responses Code Go to Oral sex . Anal sex .. Combined . No answer 98 Q509 Do you use condom with sex Always workers? Mostly .... Sometimes Never No answer 98 Q510 Did you pay a sex worker a Yes 1 higher price to not use condom? No 2 No answer 98 Q511 How many paid sex partners do person . you have in the last month? Dont remember 97 No answer 98 Q512 Last time when you had sex Yes 1 Go to Q514 with your paid-for sexual No 2 partner, did you use a condom? Dont remember 97 No answer 98 Q513 Why didn't you and your paid- Was not available/Did not have it . for sexual partner use condoms Too expensive .. at that time? Partner refused .. Dont like it . Apply safer sex (massage) 1= Yes 2=No Didnt think of it Dont know how to use it . Other (specify) ______________ 95 No answer 98 Q514 Whose initiative was it to use Mine 1 Go to Q516 condoms at that time (you or Partners 2 your paid-for sexual partners)? Mutual 3 Dont remember 97 No answer 98 Q515 If you want to use condoms Yes 1 with your paid-for sexual No 2 partner, can you ask her to do Dont know 96 so? No answer 98 I will ask you about your casual sexual partners. A casual sexual partner is someone who you are not married to, never lived together, and have never paid money or exchanged drugs for sex. Q516 Did you have a sexual contact Yes 1 with a casual sexual partner No 2 Go to Q523 over the last 12 months? Dont remember 97 No answer 98 Q517 What kind of sex did you have Vaginal sex . with your casual sexual partner Oral sex . last time? Anal sex .. Combined . 1= Yes 2= No No answer 98 69

Questions with sex workers last time? 1= Yes 2= No

N Questions Q518 Last time when you had a sexual contact with your casual sexual partner, did you use condoms? Q519 Why didn't you and your casual sexual partner use condoms at that time?

Responses Yes No Dont remember No answer Was not available/Did not have it Too expensive Partner refused Dont like it Apply safer sex (massage) 1= Yes 2= No Trust partner Didnt think of it Other (specify) ______________ No answer Q520 Whose initiative was it to use Mine condoms at that time (yours or Partners your casual sexual partners)? Mutual Dont remember No answer Q521 If you want to use condoms Yes with your casual sexual partner, No can you ask her to do so? Dont know No answer Q522 Do you know where to get/buy Yes condoms? No No answer STI Q523 Have you heard of diseases that Yes are transmitted sexually? No Dont remember No answer Q524 Can you describe STI symptoms Abdominal ache that are observed among Vaginal release women? Odorous release Burning pain while urinating Vaginal ulcer 1= Yes; 2= No Swollen vulva Itching Other: _________(specify ) Dont know No answer Q525 Can you describe STI symptoms Genital release that are observed among men? Burning while urinating Genital ulcer Swollen penis 1= Yes; 2= No Other: _________(specify ) Dont know No answer Q526 Have you observed genital Yes 70

Code 1 2 97 98 . . . . . . 95 98 1 2 3 97 98 1 2 96 98 1 2 98 1 2 97 98 95 96 98 95 96 98 1

Go to Go to Q520

After this question, go to Q521

Go to Q522

Questions release/genital ulcer/rash or burning pain while urinating during the last 12 months? Q527 Whom did you apply for medical treatment? 1= Yes 2= No

Responses No Dont remember No answer STI Clinic Private doctor/clinic Traditional healer Drugstore Friend Nobody Other (specify)_____________ Dont know No answer

Code 2 96 98 95 96 98 1 2 97 98 1 2 3 95 98 1 2 97 98

Go to Go to Q528 for Male, Q601 for Female

Sexuality with men: MEN only Q528 Have you ever had sex with men?

Yes No Dont remember No answer Q529 What kind of sex did you have? Cuddling, fondling Oral sex 1 = Yes; 2 = No Anal sex Other (specify________________ No answer Q530 Did you use a condom last Yes time? No Dont remember No answer Part 6. Knowledge and attitude on HIV/AIDS Q601 Have you heard of HIV or Yes AIDS? (Please explain: HIV is a No human immunodeficiency virus Dont know which causes AIDS. No answer Make sure that the respondent understood what HIV is. You may use additional definitions too) Q602 In your opinion, is HIV a Very serious serious problem in Vietnam? Somewhat serious Would you say it was very Only a minor problem serious, somewhat serious, only Not a problem at all a minor problem, or not a Dont know problem at all? No answer Q603 Do you believe that an Yes HIV/AIDS-infected pregnant No woman can transfer the virus to Dont know her fetus? No answer Q605 Can a mother transfer the HIV Yes to her baby through No 71

Go to Q601

1 2 96 98

1 2 3 4 96 98 1 2 96 98 1 2

Questions breastfeeding?

Q606 How can a pregnant or breastfeeding woman reduce the risk of transferring the infection to fetus and baby? 1= Yes 2= No

Q607 If a person is infected with HIV, is there any cure available?

Q608 If a worker were infected with HIV would his/her employer be required to provide treatment for him/her? Q609 How likely is it for you to contract HIV? Which level of risk that you might get HIV? One answer

Q610 Why do you think you have a low risk of contracting HIV? 1= Yes; 2= No

Q611 Why do you think you are at risk of contracting HIV? 1= Yes; 2= No

Responses Dont know No answer Taking medication (anti-retroviral) Sexual abstinence Stop breastfeeding Delivering baby by operation Other ____________________ Dont know No answer Yes No Dont know No answer Yes No Dont know No answer No risk A slight risk Some risk High risk Dont know No answer I do not have sexual relations I only have one partner I trust my partner My partner is faithful I do not have suspicious partners I do not go to sex workers I always use a condom I always use a condom when I have sex with people I do not know very well I avoid intravenous injections I do not use injectable drugs I do not accept blood transfusions I have no contact with PWH Dont know No answer I have many partners My partner has other partners I have been with suspicious partners I have been with a sex worker I do not always use a condom I may have had unsafe intravenous injections 72

Code 96 98 . . . 95 96 98 1 2 96 98 1 2 96 98 1 2 3 4 96 98

Go to

Go to Q611 Go to Q611

After this question, Go to Q612

. 96 98 .

Q612

Q613

Q614

Q615 Q616

Q617

Q618

Responses I may have had unsafe blood transfusions I have been in contact with PWH Dont know No answer Do you know about voluntary Yes and confidential HIV test? No No answer I don't want to know about the Yes test results but have you ever No taken an HIV test? Dont know No answer It was voluntary Was it your initiative to take I had to the HIV test or you had to? No answer Who required you to take the Employer Other___________________ test? Yes Don't tell me the test result, No but do you know it? No answer If yes, did you tell anybody Yes your test result? No No answer If you told anybody your test Spouse result, please tell me, whom did Regular partner you tell? Family members Friends 1= Yes ; 2= No Nobody #23 Other.. No answer

Questions

Code . . 96 98 1 2 98 1 2 96 98 1 2 98 1 2 1 2 98 1 2 98 95 98 Yes No

Go to

Go to Q619

Go to Q616

Go to Q619

DK

RTA

Circle the choice Q619 Q620 Q621 Q622 Q623 Would you be comfortable having a meal with a person who is diseased with HIV or AIDS? If your relative were infected with HIV would you like to take care of him at your place? If a student is infected with HIV, but not diseased should he be permitted to continue studying? If a teacher is infected with HIV, but not diseased should he be permitted to continue teaching at school? If a food salesman you are acquainted with is infected with HIV, will you buy food from him/her? 73 1 1 1 1 1 2 2 2 2 2 96 96 96 96 96 98 98 98 98 98

Yes Circle the choice Q624 Q625 Q626 Q627 Q628 Q629 Q630 Q631 If a member of your family were infected with HIV would you like it to keep this in secret? Can one reduce the HIV risk if one properly uses condoms during every sexual contact? Can one get HIV as a result of an mosquito's bite? 1 Do you believe that one may protect oneself from HIV by having one uninfected and reliable sexual partner? Do you believe that one can protect oneself from HIV by keeping away from (avoiding) sexual contact? Do you believe that one can get HIV by taking food or drink that contains someone elses saliva? Do you believe that one may be infected with HIV by using a needle/syringe already used by someone else? Do you believe that a person who looks healthy can be infected with HIV, which causes AIDS? 1 1 1 1 1 1 1

No

DK

RTA

2 2 2 2 2 2 2 2

96 96 96 96 96 96 96 96

98 98 98 98 98 98 98 98

N Q632

Q633

Questions Is there any information about HIV/AIDS available at your workplace? For construction/transport workers this is the work site or camp, for truckers this is the place they load/unload. Has training been offered to you about HIV? If yes, did it include information about: 1 = Yes, 2 = No

Responses Yes No Dont know No answer

Code 1 2 96 98

Go to

Q634

No HIV transmission Condom Use Counseling, testing for HIV Care and treatment of HIV Human rights issues Stigma and discrimination Dont remember Is a peer-education program in Yes No place that you have been No answer involved in (either as a peer educator or as a participant in peer education sessions)? Who organized this peer education program? 74

0 . 97 1 2 98

N Q635

Questions Have you ever sought out information about HIV/AIDS? If yes, where did you seek out such information? 1= Yes; 2= No

Q636

Q637

To your knowledge are there care services available in Vietnam for people who have AIDS?

Responses Yes No No answer Sexual partner Educators/volunteers Family Private doctor Clinic Internet TV Radio Other...................................... Dont know No answer Yes Dont know No answer

Code 1 2 98 95 96 98 1 2 98

Go to Go to Q637

Part 7. Alcohol/Drug Knowledge and Behavior Q701 How many times did you drink Times alcohol over past 4 months? Dont remember No answer Q702 Have you ever used anything Energy drinks Amphetamines/ of the following drugs ? 1 = Yes; 2 = No Methamphetamine Heroin Opium Other No answer Q703 Have you ever injected drugs? Yes No No answer Q704 How long have you been/did year.month Dont remember you injecting drugs? No No answer matter whether you do it yourself or somebody else makes injections for you. (Please indicate only number of years, or months, or both) Q705 Have you ever used a Yes No needle/syringe that was used No answer by somebody else before? Q706 When you last injected did you Used one New one use a needle/syringe that was used by somebody else before? No answer Q707 Can you actually get new and Yes No unused needles and syringes 75

. 97 98 .. .. .. .. 95 98 1 2 98 97 98

Go to Q709

1 2 98 1 2 98 1 2

Go to Q707

N Q708

Questions whenever you need them? Where can you get/buy new needles/syringes? 1= Yes; 2= No

Responses No answer Drug store Medical staff Wholesale drug store/salesperson Family/Relatives Sexual partner Friends Other injection drug user Syringe exchange program Bought in the street Other _______________ Dont remember Yes, currently taking a medical treatment Used to take a medical treatment, but later quit it Never have been treated No answer Consultations at a health centre Self-treatment groups Substitution with Methadone Detoxification with other drugs Detoxification without drugs Psycho-social rehabilitation centre Other. Dont know No answer Stopped myself Treatment not available Could not afford Did not need treatment Did not want treatment Other________________ Dont know No answer

Code 98 .....

Go to

95 98 1 2 3 98 . . . . Go to Q711

Q709

Q710

Do you currently get any medical treatment (or assistance), or have you ever taken such a treatment (or assistance) because you are a drug user? (Please read out the options below) What kind of medical treatment or assistance have you taken? 1= Yes; 2= No

End of interview

Q819

Why did you not receive treatment for your drug addiction? 1= Yes; 2= No

95 96 98 . . . 95 96 98

Thank you very much for your time.

76