Transport is a social vector in the transmission of the disease similarly to other high risk behaviors such as injecting drug use and commercial sex which fuel the epidemic. Transport sector workers are twice as likely to acquire the HIV infection as workers in ‘low-risk’ occupations. Transport workers also serve as bridge populations linking with the general population. Because of this bi-directional relationship that transport has with the HIV epidemic, HIV AIDS programs for the transport sector are crucial to prevent a wider spread of the disease in South Asia.
The transport sector as a vector in the transmission of HIV AIDS
High risk practices tend to be common along the road ways.
Hot spots such as train stations, ports and airports serve as meeting points for other high-risk groups like injecting drug users, sex workers and as ‘cruising grounds’ for men who have sex with men.
The opening up of new transport routes also increases the risk of spreading the infection from one place to another as migrant
workers, mostly men, on the construction sites are separated from their families for prolonged periods, which increases the risk of transmitting the disease to the population living along the new routes or to their wives or other sexual partners.
Truckers present the same high-risk behavior. In Terai (Nepal), 70 percent of clients of sex workers are truckers. From various surveys in the South Asia region, the percentage of truckers visiting regularly sex workers ranges from 25 percent to 80 percent.
Why the transport workforce is at risk
Research by the International Transport Workers Federation, Report on the Global HIV/AIDS epidemic, 2002 UNAIDS, report that transport workers are twice as likely to acquire HIV as workers in ‘low-risk’ occupations.
With 6 million truck drivers in India and one million in Pakistan, the trucking industry represents a notable proportion of the labor force (2.5 percent) in these countries and the impact of HIV AIDS on the trucking industry has important social and economic implications on the rest of the country.
South Asia countries have also launched large infrastructure programs which cause significant migration of workers within countries. The same is true for workers who migrate outside the region to a number of countries which lack sufficient workforce for infrastructure projects.
The Rationale for Mainstreaming HIV/AIDS in Infrastructure
The HIV/AIDS epidemic impacts on the transport sector by reducing its performance and increasing its costs:
Reduced productivity due to AIDS-related illness (up to 6-8 percent reduction in profits has been seen in generalized epidemics): Given the high prevalence rate of HIV infection among transport workers and poor access to treatment, a significant number is likely to experience a drop in earnings and productivity as the epidemic prevails.
Increased costs of workers’ benefits and health expenses, a pattern seen in countries with mature epidemics: With increasing global advocacy for treatment, the need for more expensive health care benefits which provide coverage for treating AIDS-related illnesses and for anti-retroviral therapy (ART) will increase.
Increased costs of training and hiring replacements for workers lost to the disease: This occurs as a cumulative result of frequent turnover of employees due to increased illness and death from AIDS. There is also the risk of attrition in skills and expertise.
Transport sector’s role in combating HIV/AIDS
Reaching the transport workforce with focused interventions is one of the key strategies to reduce the spread of HIV/AIDS and to provide treatment, care and mitigation.
Some vulnerable groups lack of common sense knowledge on HIV and STDs and how to protect themselves. Therefore, changing attitude and practices by focused interventions is one of the key strategies in reducing the spread of HIV. Awareness on how to protect oneself from HIV is low in the region. In a recent 2007 survey of truckers in Pakistan, knowledge about two correct ways of HIV transmission was 40 percent only. 44 percent believed in efficacy of condoms in the prevention of HIV/STIs. 19 percent expressed the view that condom users were at high risk of HIV AIDS. In a 2007 survey in Bangladesh, 85 percent of truckers said that someone could be infected through touching another person. 82.5 percent never used condoms with commercial sex workers. 43 percent of rickshaw pullers in Dhaka said that HIV AIDS could not spread from husband to wife.
The transport industry faces a unique opportunity to combat against the HIV/AIDS. Key interventions include:
Disseminating information about HIV prevention. Awareness campaigns can deliver appropriate information by targeting champions within each vulnerable group. Information on HIV AIDS should be more specific and less ambiguous regarding the modes of transmission and the methods of protection.
Changing attitudes and practices among high risk groups. This includes targeting truck drivers, migrant laborers, and sex workers by promoting condoms at rest stops and terminals and on construction sites, and by setting up more convenient locations for condom purchase.
What the World Bank is doing
The World Bank has adopted a multi-sectoral approach to combating the HIV/AIDS epidemic. The South Asia Region is committed to mainstreaming HIV/AIDS in its new transport projects. This involves:
Screening all new transport projects under preparation to determine whether an HIV/AIDS prevention component could be mainstreamed into the project design.
Providing seed money to clients for HIV prevention: this also involves contacting the relevant National and State Aids Control Programs during project preparation.
Monitoring program impacts and evaluating intervention information.
As a result of the decision to mainstream HIV/AIDS interventions in transport projects financed by the World Bank in the South Asia Region HIV/AIDS interventions are ongoing currently in eleven projects under supervision out of a portfolio of twenty one projects, and five projects under preparation out of a portfolio of seven road projects have an HIV/AIDS component:
Projects under Supervision
Punjab State Road Sector Project in India.
Mizoram State Roads Project in India.
Road Sector Assistance Project in Sri Lanka.
Rural Access Project II in Bhutan.
Tamil Nadu Road Sector Project in India.
Uttar Pradesh State Roads Project in India.
Road Sector Assistance Project in Sri Lanka.
Highways Rehabilitation Project in Pakistan.
Transport Sector Development Project in Nepal.
Grand Trunk Road Improvement Project in India.
Lucknow-Muzaffarpur National Highway Project.
Projects under preparation
Himachal Pradesh State Roads Project in India.
Orissa State Roads Project in India.
Road Sector Reform Project in Bangladesh.
Orissa State Roads Project in India.
Andhra Pradesh State Highways Project in India.
The World Bank has developed standard clauses in civil works contracts to mitigate the impact of HIV AIDS caused by high-risk behavior from migrant workers. The Clauses require the contractors to arrange for its employees, its sub-contractor’s employees and others to attend an HIV awareness program. The contractor is also required to undertake the necessary actions to reduce the risk of the transfer of the HIV virus between and among the Contractor’s Personnel and the local community, to promote early diagnosis and to assist affected individuals.
The Transport Sector in South Asia region currently has recruited an HIV AIDS specialist who supports mainstreaming of HIV AIDS activities in the transport portfolio. The consultant is based in New Delhi. His responsibilities are to supervise the HIV AIDS components of the transport projects financed by the World Bank; support transport staff in the design of HIV activities/ components in new WB supported transport projects; update and disseminate HIV/AIDS information to transport sector staff in all countries in the region.
The sector carried out a study to strengthen Monitoring and Evaluation of HIV/AIDS Components in road projects. The objective of the study was to:
Assess the extent of M&E in HIV AIDS and Transport components in the portfolio;
Review the literature to identify core indicators for measuring results of HIV/AIDS and transport related activities;
Propose a menu of HIV/AIDS outcomes and indicators;
Develop a model Results Framework
Design strategies to strengthen M&E in HIV/AIDS components of projects;
Make recommendations on how to strengthen capacity for effective and integrated M&E systems on HIV/AIDS projects in the focus countries of South Asia Region.
A gender-related study is being launched targeted at wives of migrant workers and truckers in India and Bangladesh. A methodology will be established to identify wives of migrants and carry out specific intervention programs.
Government and Private Company Efforts inSouth Asia
Some government and individual companies in South Asia have taken the initiative in developing and implementing their own HIV/AIDS programs for their workforces. Examples are listed below:
The National Highway Authority of India (NHAI):NHAI recently acknowledged HIV/AIDS as a corporate social responsibility and has taken the lead in association with the WB, ADB & NGOs on HIV/AIDS awareness programs to truckers and migrant workers. NHAI launched an awareness program called "Pathik Mela" on two national highways. The program will progressively cover other highways that NHAI is improving. Several programs are similarly underway targeted at truck drivers, commercial sex workers and the communities surrounding the truckers.
Pakistan National HIV/AIDS Control Program:The program provides HIV preventive services designed to reduce the prevalence of HIV and other sexually transmitted infections among truck drivers and their sexual partners, including strategic behavioral communication, health education programs, counseling and testing, and service delivery and referral.
Transport Corporation of India (TCI):TCI has intervention programs focused on Long-distance truckers (LDT) with clinical management of sexually transmitted infections and related counseling through condom promotion and social marketing; social marketing and community mobilization.
Delhi Metro Corporation (DMC):DMC targets migrant workers - owing to building the metro rail system in Delhi, their program focuses mainly on increasing HIV/AIDS awareness and improved sexual behaviors, attitudes and practices; and promoting the use of condom.
The ILO Code of Practice on HIV/AIDSThis is a framework for action related to the workplace and contains key principles for policy development as well as practical guidelines for programs at company, community and national levels.