20240424 AID-668-RFI-24-AHEC - Follow-on - Care and Treatment_ CO signed04242024.pdf

Embassy of the United States in South Sudan

Kololo Road, adjacent to the European Union's compound Juba, South Sudan Telephone: +211.912.105.107

Website: https://www.usaid.gov/south-sudan

REQUEST FOR INFORMATION

ISSUANCE DATE: April 24, 2024

REFERENCE NUMBER: Request For Information (RFI) Number AID-668-RFI-24-AHEC - Follow-on.

PRELIMINARY ACTIVITY TITLE: USAID/South Sudan Care and Treatment Activity

RESPONSE DUE DATE AND TIME: May 14, 2024, at 1700 Hours Juba Local Time

SUBMIT RESPONSE TO: Michael Loro, mloro@usaid.gov , and Juma Lutyo, jlutiyo@usaid.gov

Dear Interested Parties:

Pursuant to FAR 52.215-3 Request for Information (Oct. 1997), the United States Government, represented by The United States Agency for International Development (USAID) South Sudan Mission, is issuing the subject Request for Information (RFI) to all interested public and private entities on critical areas to support the delivery of integrated HIV care and treatment services for general and key populations including other disadvantaged populations such as people with disability and migrants.

The Purposes of the care and treatment activity are:

● Improve equitable access to and use of quality comprehensive HIV prevention, testing, care, and treatment services for all South Sudanese.

● Provide quality comprehensive services for key populations at the current locations and expand as needed.

● Develop local partner capacity and prepare local partners to manage direct awards.

This RFI is open for comments from any local Civil Society Organization (CSO), South Sudanese Organization, US, or non-US. Organization. This is an RFI, not a Request for Application (RFA). Do not submit any applications or proposals at this time; only the information requested per Attachment 1- RFI Questions for respondents and submission instructions- and all responses will be treated confidentially.

Responses to this RFI may be used to help determine critical areas to support the delivery of integrated HIV care and treatment services for general and key populations, including other disadvantaged populations such as people with disability and migrants. USAID may revise the structure and concept of the activity based on the comments received, but it is not obligated to do so.

All comments must be submitted electronically, with the subject of "RFI: USAID/South Sudan Care and Treatment Activity," no later than the date and time stated above.

mailto:mloro@usaid.gov mailto:jlutiyo@usaid.gov

RFI AID-668-RFI-24-AHEC

AHEC Follow-on - USAID/South Sudan Care and Treatment Activity

Please note: This is NOT a solicitation. This RFI is issued solely to gather information and innovative ideas for new design and planning purposes. This RFI does not constitute a Request for Applications (RFA), Request for Proposal (RFP), Notice of Funding Opportunity (NOFO), or a commitment to issue an RFA/RFP/NOFO in the future. USAID may release a full solicitation later through the US Government portal at beta.sam.gov or www.grants.gov.

Thank you for your interest in sharing your views and innovative ideas with the USAID/South Sudan Mission.

Sincerely, Lesley Stewart Contracting and Agreement Officer USAID/South Sudan

ATTACHMENTS:

1. Attachment 1 – RFI Questions for Respondents and Submission Instructions

2. Attachment 2 - Response Form

3. Attachment 3 - Draft Project Description http://www.grants.gov/ http://www.grants.gov/

ATTACHMENT 1 – RFI QUESTIONS FOR RESPONDENTS AND SUBMISSION INSTRUCTIONS

1) QUESTIONS FOR RESPONDENTS

a) Background and Information:

1) What concrete successes in South Sudan might a new activity replicate or scale?

2) What program gaps must be filled for equitable access to and quality comprehensive

HIV prevention, care, and treatment services for South Sudanese populations?

3) Are there private sector opportunities for engagement in HIV prevention, care, and treatment?

4) Are there better opportunities to reach key populations with community-based services or differentiated service delivery?

5) Identify opportunities to develop local partner capacity and prepare them to manage direct awards.

6) Are there opportunities to improve demand, access, and utilization of quality HIV prevention, testing, and treatment services for the general population in South Sudan?

7) Are there opportunities to improve HIV treatment literacy for the general population in

South Sudan?

8) Please attach reports, links, or summaries of reports that provide analyses and describe opportunities to build on current or past initiatives and lessons learned.

b) Objectives and Results:

1) Are the initial objectives and results proposed in the Draft Activity Description achievable and/or realistic? If not, why? Please be specific.

2) Are there additional objectives or results that you believe would make this activity more effective in achieving the stated purpose of increasing demand for and access to HIV prevention and treatment services for the general population and key populations in South Sudan, given South Sudan's current context, and from your experiences in similar country contexts?

3) What opportunities or challenges do you anticipate in achieving sustainability of this activity given the fluid and evolving country context? Please describe and explain why.

c) Indicators, Milestones, and Targets:

1) Are there sufficient quality third-party indicators available to measure progress and achievement of the proposed objectives and results?

2) Can measurement gaps be addressed by custom indicators? Please be specific and reference exact objectives/results if describing measurement gaps.

3) Are there any challenges related to the indicator and measurement requirements that the design team should be aware of?

4) What aspects of the activity design require clarification and why?

d) Gender and Vulnerable Communities.

1) Are there any challenges, concerns, or recommended approaches to ensuring this activity addresses transparency and accountability issues related to women and vulnerable communities that USAID should consider?

e) Partnerships and Collaboration:

1) USAID is also hoping to gather information from South Sudanese civil societies, NGOs, think tanks and institutions, and other partners about potential collaboration with USAID to ensure equitable access to and quality comprehensive HIV prevention, care, and treatment services for South Sudanese, particularly young men and boys, women and girls, and children and key populations. What are the best ways to work with and empower local partners, systems, effective local partnerships, and initiatives?

2) RFI SUBMISSION REQUIREMENT

Responses should not exceed five (5) pages (not including cover page). Respondents must use size 12, Calibri font type single-spaced pages for all narrative documents, with each page numbered consecutively. If the respondent has developed relevant reports, these reports may be included, preferably as embedded links. If the reports are unavailable online, they may be submitted in the attachment(s). Respondents may respond to any or all the questions/requests for comments in attachment 1 above.

Responses will be held confidential. Proprietary information should not be submitted. RFI submissions will not be acknowledged, nor will we send any responses. USAID may use any information provided without incurring any obligation.

Please provide an electronic copy of your response in Microsoft Word format by no later than 1700 hours, Juba local time, to Michael Loro at mloro@usaid.gov, Juma Lutyo at jlutyo@usaid.gov

Include the below on the cover page, and complete Form Annex 1 - Response Form.

Reference: RFI: USAID/South Sudan Care and Treatment Activity Organization name:

Point of contact name and contact information:

Size and type of organization, including US small business or other status if applicable (optional, when applicable):

[End of Attachment 1 – RFI Questions for Respondents and Submission Instructions] mailto:mloro@usaid.gov mailto:jlutyo@usaid.gov

ATTACHMENT 2: RESPONSE FORM

REQUEST FOR INFORMATION (RFI) NO. USAID South Sudan

General Information

Name of Organization:

Small Business status:

Contact Person:

Name (POC):

Position Title:

Email Address:

Type of Organization:

● CSO. Local Civil Society Organization (CSO)

● Local South Sudanese Organization

● Other - Please indicate:

[End of Attachment 2: Response Form]

ATTACHMENT 3 - DRAFT PROJECT DESCRIPTION

1) General Overview

USAID is considering a new HIV care and treatment and key population activity to capitalize on and improve on the accomplishments of AHEC activity that ends in March 2025. The proposed activity for the design process should be known as USAID/South Sudan Care and Treatment Activity. USAID will select the final activity name with the successful applicant and key stakeholders.

This activity will work towards meeting the UNAIDS global framework of the three 95s by 2030: 95% of people who are living with HIV know their HIV status; 95% of the people who know that they are living with HIV are on lifesaving antiretroviral treatment; and 95% of people who are on treatment are virally suppressed. The purpose of this activity is to improve access to and use of comprehensive HIV prevention, care, and treatment services in South Sudan, particularly for people living with HIV (PLHIV) and people at high risk for HIV infection, including at-risk young men and boys, women and girls, children, and key populations, such as female sex workers (FSW) and their clients and men who have sex with men. Targeting the activity to these populations will help address equity gaps and ensure that all age groups and sub-populations advance toward HIV epidemic control.

The activity will contribute to the Mission's South Sudan Strategic Framework goals and development objectives (DOs), focusing on households and communities.

DO: Household resilience increased in targeted areas:

● Intermediate result (IR) 1: Household use of integrated health services increased.

○ Sub-IR 1.1: The capacity of healthcare workers to deliver community-level and facility-based integrated health services has improved.

● Intermediate result 2: Access to integrated health services improved.

○ Sub-IR 2.1: Quality integrated health services at the facility level are more available.

2) Background

According to the United Nations Development Program, South Sudan is categorized as low in the Human Development Index, ranking last at 191 among all countries in the 2022 Human Development Report1.

The country's basic health indicators are some of the worst in the world: WHO reports that the maternal mortality ratio is estimated at 1,223 per 100,000 live births, and neonatal and under-five mortality rates are 39.63 and 98.69 per 1,000 live births, respectively2. Most South Sudanese lack access to essential health services, safe water, and sanitation. Civil war and chronic under-investment in the health sector have hindered the development of South Sudan's public health system for decades. Since independence in 2011, substantial donor resources have been made available to South Sudan to develop the long-neglected health system.

1 Country Insights | Human Development Reports (undp.org) 2 World Health Organization, The Global Health Observatory. Available at https://www.who.int/data/gho/data/countries/country-details/GHO/south-sudan?countryProfileId=93615c01-a06a-4d9b-a4b0-a81142dc6aa6.

https://hdr.undp.org/data-center/country-insights#/ranks

The HIV epidemic in South Sudan is described as generalized with an adult prevalence of 1.9%3. The epidemic is geographically concentrated in the Equatoria States which comprise an estimated 46% of the national PLHIV estimate for 2022. The HIV prevalence rate, based on a 2022 routine antenatal care survey in these states, is 7.4% in Western Equatoria, 2.6% in Central Equatoria, 4.1% in Lake States, 0.6% in Western Bahr El Ghazal and 1.6% in Eastern Equatoria. Based on 2022 Spectrum estimates, there were 164,453 (102,778 female and 61,675 male) people living with HIV in South Sudan. Of this, only about 39% know their status and just about 32% (52,592/164,453) of the people living with HIV/AIDS are currently on treatment, out of which 84% are virally suppressed3.

The 2022 Spectrum study4 indicated that 80% of PLHIV are in 37 counties, of which 25 are PEPFAR-supported. Key populations and specifically female sex workers (FSWs) have the highest prevalence and are known to be the leading driver of the epidemic. A recent CDC study of 1,284 FSWs found HIV prevalence rates of 6.7% in Wau and 13.6% in Yambio; only 64.8% were aware of their HIV-positive status5. For men who have sex with men (MSM), the only study conducted was by the International Organization for Migration (IOM) in 2018 and was limited, as only 165 MSM were interviewed. The study estimated the MSM population size at 732. Of the 165 MSM who participated in the study, only 152 were tested for HIV, giving a prevalence of 3.3% (n=5)6. The HIV prevalence among sex workers' clients is unknown, as there have not been any studies conducted. The prevalence of HIV among different age brackets varies, with the highest among men aged 15-24 years old and women aged 25 and older having HIV prevalence of 3.68% and 2.08%, respectively, according to South Sudan spectrum estimates of 2022.

Table 1: PLHIV Estimates, 2022 Spectrum Data:

7National ART Data.

Priority Population PLHIV Estimate

PLHIV on ART

FY237

ART Coverage-

FY23

Infant <01 female 4,327 95 2.2% Infant <01 male 2,543 112 4.4% Children <15 female 2,930 1,266 43.2% Children <15 Male 4,950 1,099 23.9% Adolescent Girls and Young Women (15-24) 14,094 6,782 48.1% Adolescent Boys and Young Men (15-24) 7,299 1,371 18.8% Female (25-34) 27,558 14,367 52.1% Male (25-34) 14,286 5,485 38.4% Female (35 - 49) 40,321 9,289 23% Male (35 - 49) 24,275 6,963 32.7% Female 50+ 13,548 2,061 15.2% Male 50+ 8,322 2,061 24.8% Total 164,453 60,486 36.8%

Since 2015, the Mission has implemented several activities, including Strengthening the Provision of Primary Health Care for HIV services, LINKAGES, Evidence to Action, and the current AHEC activity, which are focused on HIV care and treatment and key populations programming. Under the AHEC activity, evidence has emerged showcasing the impact of community-based approaches, capacity building of local stakeholders, and targeted behavior change interventions on helping achieve activity objectives regarding HIV prevention and care and treatment. Successes and lessons learned from AHEC and broader PEPFAR South Sudan programming will inform the design of the new activity.

Insights from previous and ongoing activities will influence this project's goal and objectives by emphasizing the integration of services and strengthening community involvement. The envisioned activity seeks to not only deliver a targeted and evidence-based approach to provide comprehensive HIV services but also to address underlying structural barriers, particularly faced by key populations, ensuring a more sustainable and impactful response to address the evolving dynamics of the HIV epidemic and improve the overall health and well-being of South Sudanese communities.

The Health Pooled Fund (HPF) is USAID/South Sudan's flagship service delivery mechanism and the primary recipient of the Mission's maternal/child health funds. HPF3 supports integrated primary health care services in 7 of the 10 states. Although HPF3 is slated to end in July 2024, another multi-donor pooled fund activity led by the World Bank is planned to take over the project sites and activities and run from 2024-2027. USAID's technical support for HIV activities in 14 HPF sites across the country contributed to improved outcomes, including increased testing of people at risk for HIV and diagnosis and treatment of PLHIV.

3) Activity Overview

This activity addresses the UNAIDS 2030 95/95/95 targets for prevention, diagnosis, treatment, and retention in care. It will also speak to the USG Global Health Security and Diplomacy's PEPFAR 2022 Strategy, which comprises five pillars: supporting health equity for priority populations, sustaining the response, public health systems and security and transformative partnerships, and following the science8. South Sudan is substantially behind in meeting its 95/95/95 targets, as only 39% of PLHIV know their status, 32% of PLHIV who know their status are currently on treatment, and 84% of those on treatment are virally suppressed. This necessitates an accelerated national response. Additionally, a critical knowledge gap is that only 16.7% of women knew at least two ways in which HIV can be transmitted from infected mothers to their unborn children, compared to 17.2% of men and only 24.8% of women know at least two ways of how to prevent sexual transmission of HIV, compared to 35.9%

4 https://www.unaids.org/en/regionscountries/countries/southsudan 5 Bolo, A., Ochira, P., Hakim, A.J. et al. Limited awareness of HIV Status hinders uptake of treatment among female sex workers and sexually exploited adolescents in Wau and Yambio, South Sudan. BMC Public Health 23, 692 (2023).Available at https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-15593-z#:~:text=FSW%20in%20Juba%2C%20the%20capital,%2C%20and%20Kenyans%20(4.4%25).

6 Ministry of Health. 2018. Formative Assessment, Mapping and Integrated Biological and Behavioral Surveillance (IBBS) Survey among Men who have Sex with Men (MSM) in South Sudan.

7National ART Data.

8 PEPFAR 5-year Strategy, 2022: Fulfilling America’s Promise to End the HIV/AIDS Pandemic by 2030. Available at https://www.state.gov/pepfar-five-year-strategy-2022.

men9. This activity will address this gap through comprehensive education and awareness that is vital for successful prevention, testing, and treatment, aligning with the goals of reducing HIV transmission and improving health outcomes in South Sudan.

The new activity builds on and consolidates the work of AHEC under PEPFAR's local capacity development initiative, bolstering local organizations by improving organizational and technical capacity to implement HIV services. The new activity will build local organizations' capacity to promote future localization with a plan to issue transition awards to local partners in years four and five of the activity.

The Health Office will conduct the required activity design mandatory assessments as stipulated under ADS 201, as referenced below.

● Gender assessment: AHEC conducted a Gender Equality and Social Inclusion assessment in 2021, which will be reviewed for validity and to determine if new studies will be needed.

● Environment and climate risk assessments, where applicable.

4) Theory of Change IF access to comprehensive HIV prevention, care, and treatment services is provided for at-risk men, women, adolescent girls and boys, young women and men, and key populations in communities and health facilities; AND these services are demand-driven, integrated and accepted; THEN this will increase utilization of HIV services, and advance South Sudan's journey closer to achieving the 95/95/95 targets and HIV/AIDS epidemic control by 2030.

5) Strategic Linkages

The Mission's HIV/AIDS program addresses the health needs of the South Sudanese, which are articulated in key national and sector-specific policies and strategies. For example, the Revitalized Transitional Government of National Unity's (RTGoNU) Health Sector Strategic Plan 2023-27 identifies, among other key challenges, equity gaps with children having the lowest ART coverage (17%) as well as viral load suppression; loss of patients to care with as many as 50% of PLHIV no longer in care six months after initiation of ART; limited investments in other important components of HIV response such as primary prevention; and limited integration of HIV services with other health services.

In addition, the goals and objectives of the RTGoNU's Draft HIV National Strategic Plan 2024-2026 include scaling up combination prevention, improving coverage, and addressing rights and gender-related barriers to address equity gaps among vulnerable and key populations.

Below are some examples of strategies that this activity will align with:

● South Sudan Health Sector Strategic Plan 2023-2027

● South Sudan 2021-2023 HIV National Strategic Plan (NSP), Revised

This activity will address specific drivers of the HIV epidemic identified by the RTGoNU of South Sudan under the NSP, including lack of HIV knowledge and awareness; low uptake of HIV prevention methods;

9 Republic of South Sudan, National Household Health Survey 2020 table 29, page 48 https://docs.google.com/document/d/15ihaAWv5GB3p4DfEygcjz6MEo9zJJDXO/edit https://docs.google.com/document/d/1erJn581arVytb6vRX9tnOz5wuj0CJ0sOTGIjNNc9muM/edit https://docs.google.com/document/d/1YJwUEYm1zqQWI1X5LXdZiNT2rdNu40sfucs_CLJFRy8/edit https://docs.google.com/document/d/1vd8CwS316YAigAGpea3DIHYR_tuJEEBz/edit high rates of sexual and gender-based violence; elevated rated of transactional sex work; and high levels of HIV stigma and discrimination. The activity will also address additional challenges identified by the Ministry of Health, including low ART coverage and viral load suppression among children, high interruptions in treatment, the need for expanded primary HIV prevention, and limited integration of HIV and other health services.

Additionally, as laid out in the USAID South Sudan Strategic Framework10, this activity will contribute to "Intermediate Result 2.3: improved health of families". The activity will focus on community engagement, highlighting the person-centered nature of HIV prevention, care, and treatment; boost the capacity of local systems; support and coordinate with CSOs to enhance civic society capacity; improve household resilience through gender-sensitive programming; and strengthen data collection mechanisms to enable evidence-based decision making. The activity will engage with the RTGoNU where interests align, and engagement will boost the achievement of common long-term objectives.

6) illustrative Goals and Results

GOAL: Improve equitable access to and use of quality, comprehensive HIV prevention, testing, care, and treatment services for 'at-risk' South Sudanese and develop local partner capacity and prepare them for future prime funding

Result 1: Increased demand and access to quality comprehensive person-centered, clinical, and community-based HIV and TB services for the general population.

Result 2: Increased demand and access to equitable, comprehensive, community HIV services for key populations

Result 3: Technical and organizational capacity of local partners strengthened.

IR 1.1: Improved access to HIV services at community and health facilities.

IR 2.1: Improved access to evidence-based HIV prevention for key populations and their clients

IR 3.1: Improved local organizational capacity to manage USAID awards in compliance with regulations

IR 1.2: Ability and motivation for a sustained use of HIV services improved

IR 2.2: Reduced stigma, discrimination, and violence against key populations

IR 3.2: Improved technical capacity to directly manage PEPFAR programs.

IR 1.3: Reduced interruptions in treatment among the general population

IR 2.3: Expanded provision of non-discriminatory, Person- Centered HIV testing and treatment for KPs

IR 3.3 Improved monitoring and evaluation capacity to manage PEPFAR programs.

10 USAID South Sudan Strategic Framework, July 31, 2020-July 31, 2024; updated June 6, 2023. Available at www.usaid.gov/sites/default/files/2023-07/South%20Sudan%202020- 2024%20Strategic%20Framework%20REVISED%202023%20public-version_1.pdf.

IR 2.4: Improved adherence and treatment continuity for KPs

7) Development Landscape

South Sudan is a country in a protracted crisis, plagued by conflict, flooding, corruption, poor governance, economic mismanagement, and increasing dependency on donor assistance since its independence in 2011. RTGoNU funds just two percent of the country's health care needs, shifting critical training, medicine, and service responsibilities onto donors. The United States Government has been a strong supporter of South Sudan, providing over $6.6 billion in humanitarian aid and development assistance since 2011 and helping broker peace agreements. South Sudan is facing several challenges, including those mentioned above, making it difficult for the country to recover from the conflict and build a stable and prosperous future. Broader systemic issues continually upend the efforts and investments into the public health landscape of the country, such as high poverty levels, lack of or deteriorating infrastructure, and sexual and gender-based violence directed at women and girls. The major donors for HIV programming are the USG and the Global Fund (GF).

At the highest level, the USG coordinates with the GF, the Ministry of Health (MOH), and the South Sudan AIDS Commission through regular meetings, annual planning cycles, and program reviews to ensure alignment with key government HIV policies, strategies, and priorities and to mitigate any duplication of investment. USAID implementing partners (IPs) also coordinate with other stakeholders through regular technical meetings, which include GF participation. Additionally, GF and IPs participate in the PEPFAR annual country operational plan (COP) process. This allows for a better alignment of activities so they do not overlap with those provided through GF support.

USAID collaborates with the larger PEPFAR team (CDC and DOD) as these interagency entities provide complementary care and treatment activities in Juba, Yambio, Rumbek, Wau, and Magwi Counties. To ensure that there is no duplication of services, PEPFAR will continue to coordinate with other donors and ensure this activity complements existing activities in Juba County and six other counties of Tambura, Yambio, Wau, Nimule, Rumbek, and Bor.

One significant hurdle in implementing this activity is a weakening enabling environment for key populations. Key populations such as FSWs and MSM face increasingly hostile environments. FSWs have faced arbitrary arrests and inhuman treatment over the past year. This new activity will seek to expand on the existing advocacy work done by AHEC, continuing engagement with law enforcement officials and improving coordination with GF, IPs, CSOs, and parliamentarians.

8) Targeted Beneficiaries and Geographical Area

The South Sudan Care and Treatment Activity will provide HIV prevention, care, and treatment services for South Sudanese broadly and will specifically focus on at-risk young men and boys, women and girls, children, and key populations, including female sex workers. The geographic focus will stay the same as the current activity (AHEC)11 , with the possibility of expanding based on annual COP discussions.

9) Risks and Issues

Working with the RTGoNU presents programmatic challenges and barriers to long-term activity sustainability. Communication and participation from MOH leadership are often lacking, given that PEPFAR does not provide any incentives to RTGoNU staff, which is the practice for non-USG donors. As a result, training for MOH staff at state and county levels is often difficult to implement. At times, officials from the South Sudan AIDS Commission demand incentives at project sites. There is low morale among MOH-employed staff due to low salaries, which leads to a high staff turnover, especially at the sub-national and facility level. Sustaining this investment will be challenging as the RTGoNU does not allocate funds towards HIV services.

The operating environment of South Sudan contains significant challenges, including ongoing conflict, widespread food insecurity, economic crisis, and high numbers of internally displaced persons in point-of-care sites. A hazardous physical operating environment, especially outside of Juba, adversely impacts program implementation for clients and service providers. The IP of this new activity will need to demonstrate a capacity for resilient programming that ensures the quality of care under possible disruptive risks, including pandemics, physical insecurity, the potential of political violence due to upcoming general elections, and providing services to mobile communities, including cattle-herders. The IP must demonstrate the ability to manage program implementation in conflict or complex emergency environments.

The criminalization of sex work complicates key population health service provision in South Sudan and creates a harsh and unfriendly operating environment. Female sex workers face recurrent harassment and financial extortion by security agents, coupled with arbitrary arrests. This may include arrests of service providers in crucial population hot spots.

[End of Attachment 3 - Draft Project Description]

[END OF NUMBER AID-668-RFI-24-AHEC - FOLLOW-ON]

11 Juba County: Gurei, Kator, Nyakuron, Kimu, Gumbo, Malakia Juba PoC, Aru Junction, Lutheran and Munuki PHCCs.

Terekeka County: Terekeka PHCC.

Tambura County: Tambura, Source Yubu and Mupoi PHCCs Nagero County: Nagero PHCC Bor South County: Bor Hospital Towns: Wau, Rumbek, Magwi, Yambio, Juba and Bor KP sites