The Guangxi Case
Step 15: Conducting external monitoring of site HIV prevention work
4 Adaptation and Expansion
4.4 Outstanding Issues
Although the TA team was able to make great strides in many areas, a few points of concern remained with regard to adoption of the proposed approaches, particularly in situations where no additional support is available through TA. These are briefly discussed.
Knowing Your Epidemic: How Accurate Is Behavioral Data?
To respond effectively to HIV/AIDS, it is important to understand the key risk factors that underpin the epidemic in different contexts. One way of getting additional information is through research studies. Some practitioners, however, question the value of such surveys. Mining company Anglo Gold, for example, which deals with many issues similar to those faced by construction companies, considers that one of the reasons for the success of its program is that it spent “less time and money on the risk assessment analysis, which is costly and can produce unreliable estimates, and more resources on acting.”30
Two specific concerns are the validity of self-administered questionnaires and the willingness of respondents to provide accurate information on their sexual behavior, a highly personal issue. Various research studies have found incompatible responses between construction workers and sex workers on the extent to which the construction workers visit sex workers and the degree to which they use condoms when they do so.31 Responses to questions on the extent of unprotected casual sex may also be understated in baseline studies due to embarrassment and also in endline studies as respondents know they are not supposed to be engaging in these behaviors.
It seems clear that well-administered surveys are much more likely to produce accurate information on knowledge and attitudes than on behaviors. Based on its experience, the project team considers that a short, simple survey on knowledge and awareness can be useful both in assessing key areas of focus for educational activities and materials, and also for measuring change over time. This can be complemented by other techniques
30 Anglo Gold. Quoted in J. Thomason and L. Richie. n.d. Mining Sector Public-Private Partnerships for Health.
JTA International. p. 3.
31 See, for example, Pact. 2011. Baseline HIV Risk on Highway 1A in Ca Mau, Vietnam: Knowledge, Attitudes and Practice Related to HIV Prevention Among Construction Workers, Female Sex Workers and General Residents. World Bank: Washington, DC.
Implementing the Framework: The Guangxi Case 41
such as focus group discussions and observation to provide insight into attitudes and behavior. (ADB’s More Safety manual provides a straightforward explanation of how to apply these techniques.)
This case study has highlighted how monitoring of activities, together with some form of quality assurance, can realistically be built into most HIV and transport responses.
This will help ensure that planned HIV prevention activities have taken place and that construction companies have complied with contractual obligations, where these exist.
This is very important, but it does not guarantee an impact of these activities on knowledge or, in particular, on behavior, which is the key determinant of the success of an HIV prevention program.
At a project level, changes in knowledge, attitudes, and behavior can potentially be assessed through baseline and follow-up surveys, as was done by the HIV/AIDS Prevention in the Transport Sector in Yunnan and Guangxi Project, ideally complemented by supporting information such as the number of condoms distributed or sold. As noted, however, collecting reliable information on highly sensitive topics, such as sexual behavior, is not easy. Trained researchers and data analysts are needed to improve the likelihood that such behavioral studies yield accurate results. This can be both difficult and expensive, particularly in remote areas.
An alternative, or complement, to the project-based approach is to further integrate HIV and transport programs into provincial and national evaluation systems and processes, such as second-generation surveillance surveys. These combine data on prevalence of HIV/AIDS and other STIs, with research on knowledge, attitudes, and behaviors among selected groups. Given the dearth of existing data throughout Asia on the specifics of the relationship between the AIDS epidemic and transport infrastructure, as well as on the relative effectiveness of different prevention programs, it is recommended that governments in the region consider identifying strategic transport development sites and incorporate these into national HIV surveillance systems. At the same time, on occasions when evaluation work is built into HIV and transport programs, aligning this work with national systems in terms of questions, indicators, and methodology can add to the overall knowledge base.
Adapting to Situations where Fewer Services Are Available
Two key components of an effective HIV prevention package are encouraging workers to seek prompt treatment for STIs, and promoting voluntary testing and counseling. In reality, however, these services are not always available, particularly in remote settings.
Even medical practitioners on the Baolong Expressway were found to have insufficient ability to accurately diagnose and treat STIs, for example. Privacy can also be an issue in both STI treatment and VCT. In these circumstances, it can be ineffective or even counterproductive to encourage workers to seek out these services.
Solutions to this problem are perhaps best found on a case-by-case basis. If health clinics exist close to key sites, for example, contractors could consider supporting training for
42 Implementing HIV Prevention in the Context of Road Construction
medical staff.32 Another option is to negotiate with health providers to strengthen STI and VCT services. In some circumstances the option of mobile STI and VCT teams, as successfully piloted in the HIV/AIDS Prevention in the Transport Sector in Yunnan and Guangxi Project, could be considered.
Technical Support project, the annual cost of implementing the activities proposed in this document would be in the order of
$5–$10 per worker, less than 1% of the total safety production budget for the road.33 However, technical support is required for effective implementation.
This is recognized in both the original International
Federation of Consulting Engineers (FIDIC) contract clauses, suggesting the involvement of an approved service provider, and in the steps developed under the TA. The TA team itself contained specialist HIV expertise and also benefited significantly from close cooperation with the Baise Center for Disease Control and Prevention in particular.
Such support is not always available, however, particularly given the competing priorities faced by many health service providers and the remoteness of many road construction sites. In Yunnan Province, the YPDOT was able to make good use of the in-house expertise available from its hospital. Departments without such expertise may consider bringing in expertise in the form of a small HIV/AIDS unit. These are likely to be economies of scale if the unit provides assistance across many different transport construction projects.
Dealing with Other HIV Risk Factors
This package of activities has been designed specifically to address risk factors faced by male migrant workers in relation to unsafe sex with non-regular partners. The TA team is confident that sound implementation of approaches outlined in this document will help reduce the HIV risk for those involved. At the same time, the team has strong doubts about whether the approaches outlined could be extended to address other aspects of
32 Even though building local capacity in this area appears outside the scope of the transport sector, the FIDIC guidelines require companies to “provide for STI and HIV/AIDS screening, diagnosis, counseling, and referral to a dedicated national STI and HIV/AIDS program.”
33 ADB and Marie Stopes International. 2008. More Safety: A Resource Manual for Health and Safety in Infrastructure. Manila. p. 35.
“I would like to say that we are very willing to work on this issue but are not professionals so we would like to request ongoing technical support.”
Transport company representative, Yunnan Province
“It’s hard to say what will happen when the ADB project finishes in future. At the beginning, workers were against learning about HIV/AIDS. They thought that they didn’t have the disease so wondered why they had to learn about it. Now it’s better when there is the project that is directed by Ms. Fu. Furthermore, this project is also very instructive for us. We may do it ourselves in future but may not get so good an effect.”
Xie Yan, Longbai Expressway project headquarters
Implementing the Framework: The Guangxi Case 43
the AIDS pandemic, notably the complex issue of drug use, which requires extremely specialized expertise, or the highly sensitive issue of men who have sex with men.34 The Post-Construction Period
The potential HIV/AIDS consequences of transport infrastructure do not end with the completion of construction. The HIV implications of transport operations can be significant, particularly where the new transport routes open up previously remote areas.
As noted, the growth of the sex trade following completion of a new road has already been documented in neighboring Lao People’s Democratic Republic, and long-distance truck drivers are frequently identified as being among the most at-risk populations (footnote 1). It is important for health authorities to be aware of the need to plan for these issues, which are generally accepted to fall outside the scope of transport construction companies. This is recognized by the World Bank, for example, which is removing from its HIV contract clauses reference to the defects notification period, which places obligations on contractors beyond the end of construction.