Success on the Road: Reversing the Spread of HIV/AIDS In West Africa

This 49-page report shares the experience and five key factors identified as important to the success of the Abidjan-Lagos Corridor HIV/AIDS Joint Regional Project. According to the report, long-range ground transport is a major route for the spread of HIV in Africa. Drivers and their assistants overnight along their way and can spend days at border crossings waiting to clear customs and other border formalities. These rest stops and delays provide multiple opportunities for sexual encounters that can transmit HIV and other sexually transmitted infections (STIs). This puts truck drivers, other mobile workers, sex workers, and the people who live along the route at increased risk for HIV. The report states that the project reduced HIV risk among these vulnerable populations, and therefore provides a good model for beginning to reverse the spread of HIV/AIDS in Africa and maximising opportunities for and the benefits of care and treatment of those living with HIV.

Financed through the World Bank's Multi-country HIV/AIDS Program (MAP), the report suggests that the Corridor Project achieved solid results: better knowledge of how to prevent HIV, more diagnosis and treatment of STIs, greater condom availability and use, and greatly increased voluntary HIV counselling and testing (VCT). The project accomplished this through careful planning and effective monitoring, strong government commitment, cooperation among local government authorities and the health and transport sectors, community participation and ownership, and targeted technical support. The Corridor project brought together five countries, working with different stakeholders in various locations to benefit truck drivers, sex workers, travellers, border communities, and military and customs officials.

According to the evaluation, knowledge of how to prevent HIV increased in primary target populations from 50-68% pre-intervention to 83-88% post-intervention. Reported use of a condom at last encounter with a client or non-regular partner increased from less than 60% to over 70% for sex workers and to 79% for truck drivers. By 2007, nearly 28,000 people along the corridor had accessed VCT services, and 8.8 million condoms had been distributed. Very substantial progress was made towards the ambitious outcome targets. The project also had a contraception benefit — the condoms distributed through the social marketing component over two-and-a half years were enough to provide 109,319 couple years of protection (CYP) compared to 9,778 CYP for condoms distributed in 2003, prior to the project.

The report outlines five critical success factors. They are:

• Shared Ownership: The report states that perhaps the single most important factor in the project's success is that it was able to engender and maintain a deep and broad sense of ownership among its constituents. Project management and the approach to coordination were highly participatory at all stages from project concept inception to the project completion. In October 2001, the Abidjan-Lagos Corridor Organisation (ALCO) was established to implement the project. Creating a new organisation helped ensure shared ownership among the five participating countries. Civil society organisations (community organisations, NGOs, and the private sector) were key implementing partners for the project. The commercial drivers set up a coordination body supported by ALCO including the various unions along the corridor to undertake HIV/AIDS awareness campaigns to sensitise their truckers who are the most vulnerable people.
• Strengthening Health Systems and Harmonising the Continuum of Care: In the context of the Corridor project, harmonisation entailed building the capacity of health centers serving the corridor to provide a minimum level of HIV/AIDS prevention and care that is easily accessible to people living and traveling along the corridor, no matter which partner country they find themselves in. A reference guide was developed with the five countries to harmonise their approach to the continuum of prevention, treatment, care, and support services along the corridor. In the end, the project conducted facility assessments and substantially improved capacity at 36 public and private health facilities. It financed staff training, equipment, furniture, supplies, and reagents and drugs to diagnose and treat STIs, opportunistic infections, and common ailments. Health center staff received training to improve the quality of service provision. In addition to the basics, training paid particular attention to making sex workers feel welcome at the centers so that they would not avoid seeking treatment.
• A Harmonised Communication Strategy: An integrated regional information education and communication (IEC)/behaviour change communication (BCC) strategy was developed, validated by the five countries and widely disseminated. The Corridor project's BCC strategy provided a common BCC framework for the five project countries. It enabled partners at all levels to help meet the HIV/AIDS-related needs of border communities and mobile populations through a coherent, coordinated, and harmonised approach. The project’s communication strategy is founded on qualitative and quantitative research that identified audience demographic and socio-cultural characteristics; their knowledge, attitudes, and practices relevant to HIV/AIDS; and where they get information and services. It lays out communication objectives, communication channels, message concepts, M&E indicators, and partnership mechanisms for implementing the strategy. It takes into consideration the social and cultural context of the different countries, the changes desired in each segment of the population, and the appropriate use of various communication approaches. The communication interventions developed under the project contributed to strengthening health centers and promoted access to quality prevention and treatment services. The project also provided training and technical support to implementing partners to strengthen their strategic planning skills as well as the technical skills required to implement and monitor communication activities.
• Facilitation Committees Played a Crucial Role: During and after project development, transport workers, police, customs agents, and communities identified the need for a mechanism to address complaints about border crossing and to inform travellers of what is required to cross borders. Drivers complained about the number of checkpoints (up to 36 per 100 kilometers, versus the recommended three per 100km), long delays (typically four hours for passenger vehicles and two or more days for vehicles carrying goods), and inconsistency of demands at different times and different posts. After the project was approved, two workshops were held in Lomé, Togo — one with representatives of transport workers and another with border control agents from each of the border areas. The third workshop brought the two groups together. The committees’ overall charge was to eliminate hindrances to crossing the borders and to sensitise border employees and others on behaviours that put them at risk of HIV infection. During the project, waiting times at borders decreased, as had the number of checkpoints between borders. Awareness of border crossing requirements increased significantly.
• Managing to Effect: Making this project work required an enormous number of people and a clear organisational framework. The inherent complexity of a multi-country, cross-border HIV/AIDS project demanded that institutional arrangements be as straightforward as possible. Given the size and complexity of the project, institutional arrangements and management models also had to be lean and flexible. The project management structure within the Bank was typical of other projects except that at the regional level a single team of specialists (financial management, health, and procurement), based in Benin, provided technical support instead of having a team in each country. This proved to be cost-efficient and ensured a broad view of the entire project instead of a primarily country-level perspective. Like the creation of ALCO, having a single team for the five countries fostered progress toward an overall objective instead of individual objectives (and success) for each country. Project coordination was highly labour intensive with significant diplomatic and political risk. Coordination among five countries (1022km of corridor) was difficult due to two national languages, multiple cultures and local languages, multiple religious beliefs and beliefs on traditional and spiritual healing, and engagement of five Ministries of health, transport, and uniformed services.

This study highlights the following as lessons learned from this and other projects:

• Mainstreaming in the Transport Sector: The project provides an impressive example of mainstreaming HIV/AIDS in the transport sector in World Bank operations. It has significantly raised awareness of the impact of HIV on the sector’s development and of the sector’s contribution to the spread of the epidemic.
• Easing the flow of persons and goods across borders: While this project provided an excellent example of mainstreaming HIV/AIDS in the transport sector, accelerating border clearing formalities may not be sufficient to reduce significantly the time spent by trucks in front of a border (a major contributor to risky behaviour); addressing the root causes of the chaotic conditions prevailing at some borders requires a comprehensive programme combining physical investment and regulatory and behaviour change.
• Complementing national AIDS programmes: Regional HIV/AIDS programmes are most useful when they complement national programmes, focus on border areas, and target vulnerable groups associated with the trucking industry. The Governing Board greatly facilitated the process of developing synergies between the five national AIDS programmes and the regional programme. A programme combining the fight against HIV/AIDS with trade facilitation offers strong opportunities for synergy, though it is easier to reach a consensus among governments on the former than on the latter.
• Project design: The project incorporated strong commitment to regional co-operation, objectives matching regional capacity, clear delineation and coordination of the roles of national and regional institutions, accountable governance arrangements, and planning for sustainability of outcomes. The project design was innovative and relied heavily on a participatory process that engaged a variety of stakeholders. This approach resulted in strong ownership from the heads of state to the community level.
• Sustainability: Planning and implementation must take place with sustainability in mind. Knowing that the project grant had a real end-date, project partners worked quickly to demonstrate the value of the approach and begin to identify potential new partners and donors.
• The Project Development Objective (PDO), Strategic Alignment and Focus: The PDO was realistic, simple, and developed based on evidence and recognition of the complexity of the challenge to address HIV/AIDS in the mobile settled populations along the Abidjan-Lagos corridor, especially at the border areas. The PDO was based on assessments done in 2001 at the border areas that estimated about 300,000 HIV positive persons traveling across the borders annually and the time to clear cargo trucks at the border areas that resulted in delays from a few days to months, in some cases.
• Monitoring and evaluation across borders: Bringing five countries to agreement on the M&E standards, software, data collection, and reporting took time in the beginning. It also was very challenging to conduct surveillance of mobile populations. With mobile groups, it is even more difficult to have absolute data.
• Behaviour change among mobile populations: Border areas are estimated to have prevalence as high as twice the national figures. Changing behaviour in the mobile population is more difficult than the settled population.
• Building capacity where little capacity exists: Building grassroots capacities required very large amounts of human and financial resources. The cost and time needed should not be underestimated.

The report concludes that the Abidjan-Lagos Transport Corridor HIV/AIDS Joint Regional Project made considerable progress toward reducing the risk of transmitting HIV/AIDS and other STIs along this major West African highway. The project documented notable improvements in knowledge about STI/HIV/AIDS prevention. Access to VCT services increased many-fold. This project has made a real and lasting difference along the Corridor. Such major gains would have been unlikely if not impossible without joint ownership by all five countries and the other project stakeholders. A comprehensive approach to systems strengthening and harmonisation of health services in some ways laid the foundation for change — adequate services must be available to encourage, reinforce, and support behaviour change.