RFP 663-P-08-039

Issuance Date:

August 7, 2008 Deadline for Receipt of Questions: August 19, 2008 cob.

Closing Date:

Sept. 6, 2008 cob

SUBJECT:

Request for Proposal (RFP) No. 663-P-08-039 – Technical Assistance for

Food by Prescription for HIV/AIDS Care and Treatment Programs in Ethiopia Dear Prospective Offerors:

The United States Government, represented by the United States Agency for International Development in Addis Ababa, Ethiopia (USAID/Ethiopia), is seeking proposals from qualified organizations interested in providing the services described in the attached solicitation.

This is a full and open competition, under which any type of responsible organization (large or small commercial [for profit] firms, not-for-profit organizations or educational institution) is eligible to compete. The procedures set forth in FAR Part 15 shall apply. Such organizations may submit an offer for this contract, with or without a fee.

USAID plans to award a three years Cost Plus Fixed Fee (CPFF) completion type contract with one two years Option and a total estimated cost not to exceed $11 million for Base Period and $8 million for the Option Period. Offerors must propose costs that they believe are realistic and reasonable for the work. Cost proposals will be evaluated as part of a best value determination for contract award, including cost effective approaches to achieving the results.

This solicitation in no way obligates the USAID to award a contract, nor does it commit the USAID to pay any cost incurred in the preparation and submission of a proposal in response hereto. Furthermore the Government reserves the right to reject any and all offers, if such action is considered to be in the best interest of the Government.

USAID encourages the participation to the maximum extent possible of small business concerns, small disadvantaged business concerns and women-owned small business concerns in this activity as the prime Contractor or as sub-Contractors.

The authorized geographic code for procurement of goods and services under this contract is 935.

Potential Offerors may submit questions regarding this solicitation in writing at the addresses/numbers identified in Section L and via email to caddis@usaid.gov with a copy to mcsow@usaid.gov , hamenu@usaid.gov and fasfawossen@usaid.gov . The deadline for receipt of questions is specified on the top of the first page of this RFP Cover letter. Oral instructions, answers or guidance from any USAID source prior to the award of the contract shall not be binding. If substantive questions are received which affect the response to the solicitation, or if changes are made to the closing date and time, as well as other aspects of the RFP, this solicitation will be amended. Any amendments to this solicitation will be issued and posted on the Federal Business Opportunities website. Offerors are encouraged to check this website (http://www.fedbizopps.gov) periodically.

An Interested Vendor List is not included in this solicitation. Offerors can register and use the Interested Vendor List (IVL) on the FedBizOpps page, so that firms can contact one another for consideration of teaming arrangements and/or small business subcontracting opportunities in response to this solicitation.

U.S. Agency for International Development

Riverside Building off Olympia /Haile G.Selassie

P. O. Box 1014

Addis Ababa, Ethiopia Tel. : 251-11-5510088

Fax : 251-11-5510043

Website: www.usaidethiopia.org USA Address:

2030 Addis Ababa Place

Washington, DC 20521-2030

-2 – The details associated with the submission requirements and instructions are outlined under Section L of this solicitation. Late proposals will be handled in accordance with FAR 15.208.

The RFP, once issued, and subsequent amendments thereto, can be downloaded from the Federal Business Opportunities (“FBO”) web site. The worldwide Web address is http://www.fedbizopps.gov . It is the responsibility of the recipient of this solicitation document to ensure that it has been received from internet in its entirety and USAID bears no responsibility for date errors from transmission or conversion processes.

We extend our best wishes to all for a successful competition and than you for your interest in USAID/Ethiopia’s activities.

Sincerely, Marie-Claire Sow

Senior A&A Specialist

Attachments:

RFP 663-P-08-039

USAID/Ethiopia, Addis Ababa

Table of Contents Page

7PART I - THE SCHEDULE

7SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

7B.1 PURPOSE

7B.2 CONTRACT TYPE AND SERVICES

7B.3 ESTIMATED COST, FIXED FEE, AND OBLIGATED AMOUNT

8B.4 COST SCHEDULE

8B. 5 INDIRECT COSTS AND CEILING ON INDIRECT COSTS

9B.6. COST REIMBURSABLE

9B.7 LABOR

11SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

27SECTION D - PACKAGING – MARKING AND BRANDING

27D.1 AIDAR 752.7009 MARKING (JAN 1993)

27D.2 BRANDING POLICY AND STRATEGY

28SECTION E - INSPECTION AND ACCEPTANCE

28E.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

28E.2 INSPECTION AND ACCEPTANCE

29SECTION F - DELIVERIES OR PERFORMANCE

29F.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

29F.2 PLACE OF PERFORMANCE

29F.3 PERIOD OF PERFORMANCE

29F.4 PERFORMANCE STANDARDS

30F.5 REPORTS, DELIVERABLES AND OUTPUTS

33F.6 KEY PERSONNEL

33F.7 SUBMISSION REQUIREMENTS FOR DEVELOPMENT EXPERIENCE DOCUMENTS (JAN 2004)

35SECTION G - CONTRACT ADMINISTRATION DATA

35G.1 AIDAR 752.7003 DOCUMENTATION FOR PAYMENT (NOV 1998)

36G.2 ADMINISTRATIVE CONTRACTING OFFICE

36G.3 COGNIZANT TECHNICAL OFFICER (CTO)

36G.4 TECHNICAL DIRECTIONS/RELATIONSHIP WITH USAID

37G.5 752.7013 CONTRACTOR MISSION RELATIONSHIPS (OCT 1989)

38G.6 PAYING OFFICE

38G.7 ACCOUNTING AND APPROPRIATION DATA

39SECTION H - SPECIAL CONTRACT REQUIREMENTS

39H.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

39H.2.

752.225-70 SOURCE, ORIGIN AND NATIONALITY REQUIREMENTS (FEB 1997)

39H.3

AUTHORIZED GEOGRAPHIC CODE

39H.4.

LANGUAGE REQUIREMENTS

40H.5.

NON EXPENDABLE PROPERTY PURCHASES & INFORMATION TECHNOLOGY RESOURCES

40H.6

AIDAR 752.245.71 TITLE TO AND CARE OF PROPERTY

40H.7

LOGISTIC SUPPORT

40H.8

752.228-3 WORKER’S COMPENSATION INSURANCE (DEFENSE BASE ACT)

40H.9.

INSURANCE AND SERVICES

41H.10.

AIDAR 752.228-70 MEDICAL EVACUATION (MEDEVAC) SERVICES (JULY 2007)

41H.11.

AIDAR 752.7004 EMERGENCY LOCATOR INFORMATION (JUL 1997)

41H.12.

752.7007 PERSONNEL COMPENSATION (JULY 2007)

43H.13

722.170 EMPLOYMENT COSTS OF THIRD COUNTRY NATIONALS (TCNs) AND COOPERATING

44H.14 DIFFERENTIALS AND ALLOWANCES (July 1996)

46H.15 AIDAR 752.7032 INTERNATIONAL TRAVEL APPROVAL AND NOTIFICATION REQUIREMENTS (JAN 1990) AND AIDAR 752.7027 PERSONNEL (DEC 1990)

46H.16

FOREIGN GOVERNMENT DELEGATIONS TO INTERNATIONAL CONFERENCES (JAN 2002)

46H.17.

GOVERNMENT FURNISHED FACILITIES OR PROPERTY

47H.18.

SUBCONTRACTING PLAN AND THE SF 294 – SUBCONTRACTING REPORT FOR INDIVIDUAL CONTRACTS AND SF 295 – SUMMARY CONTRACTING REPORTS

47H.19.

SUBCONTRACTOR CONSENT

47H.20.

GRANTS UNDER CONTRACTS

47H.21.

CONFLICTS OF INTEREST

48H.22.

ORGANIZATIONS ELIGIBLE FOR ASSISTANCE (ACQUISITION) (JUNE 2005)

48H.23.

PERIODIC PROGRESS REPORTS (OCT 2007)

49H.24.

REPORTING OF FOREIGN TAXES (MAR 2006)

49H.25.

ENVIRONMENTAL COMPLIANCE AND MANAGEMENT

50H.26.

USAID DISABILITY POLICY - ACQUISITION (DECEMBER 2004)

51H.27.

DISCLOSURE OF INFORMATION

51H.28

USAID’S RIGHT OF USE AND SUBLICENSE OF MARKS

52H.29. EXECUTIVE ORDER ON TERRORISM FINANCING (FEB 2002)

52H.30.

HOMELAND SECURITY PRESIDENTIAL DIRECTIVE-12 (HSPD-12) (SEPT. 2006)

53H.31.

PROHIBITION OF ASSISTANCE TO DRUG TRAFFICKERS

53H.32.

CONDOMS (ACQUISITION) (JUNE 2005)

54H.33.

PROHIBITION ON THE PROMOTION OR ADVOCACY OF THE LEGALIZATION OR PRACTICE OF PROSTITUTION OR SEX TRAFFICKING (ACQUISITION) (OCTOBER 2007)

54H.34

752.7101 VOLUNTARY POPULATION PLANNING ACTIVITIES (JUNE 2008)

56PART II - CONTRACT CLAUSES

56SECTION I - CONTRACT CLAUSES

56I.1

NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

58I.2

FAR 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

58I.3

52.204-7 CENTRAL CONTRACTOR REGISTRATION (JUL 2006)

I.4

52.217-9 OPTION TO EXTEND THE TERMS OF THE CONTRACT (MAR 2000)

60I.5

52.222-39 NOTIFICATION OF EMPLOYEE RIGHTS CONCERNING PAYMENT OF UNION

60DUES OR FEES (DEC 2004)

61I.6

FAR 52.222-50 COMBATING TRAFFICKING IN PERSONS (APR 2006)

63I.7.

52.227-14 RIGHTS IN DATA-GENERAL (JUNE 1987)

66I.8

52.227-23 RIGHTS TO PROPOSAL DATA (TECHNICAL) (JUN 1987)

67I.9

52.232-25 PROMPT PAYMENT (OCT 2003)

69I.10

52.247-67 SUBMISSION OF TRANSPORTATION DOCUMENTS FOR AUDIT (FEB 2006)

70PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACHMENTS

70SECTION J - LIST OF ATTACHMENTS

71PART IV - REPRESENTATIONS AND INSTRUCTIONS

71SECTION K - REPRESENTATIONS, CERTIFICATIONS AND OTHER STATEMENTS OF OFFERORS

71K.1 NOTICE LISTING SOLICITATION PROVISIONS INCORPORATED BY REFERENCE

71K.2

52.204-3 TAXPAYER IDENTIFICATION (OCT 1998)

72K.3

52.204-6 DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER (JUNE 1999)

72K.4

52.204-8 ANNUAL REPRESENTATIONS AND CERTIFICATIONS (JAN 2006)

73K.5

52.230-1 COST ACCOUNTING STANDARDS NOTICES AND CERTIFICATION (JUNE 2000)

75K.6

52.230-7 PROPOSAL DISCLOSURE--COST ACCOUNTING PRACTICE CHANGES (APR 2005)

75K.7

752.226‑01 DISADVANTAGED ENTERPRISE REPRESENTATION (APR 1991)

76K.8

COMPLIANCE WITH VETERANS EMPLOYMENT REPORTING REQUIREMENTS

77K.9

INSURANCE - IMMUNITY FROM TORT LIABILITY

77K.10

SIGNATURE

78SECTION L - INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS

78L.1 NOTICE LISTING SOLICITATION PROVISIONS INCORPORATED BY REFERENCE

7852.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998)

78L.2 52.215-1 INSTRUCTIONS TO OFFERORS—COMPETITIVE ACQUISITION (JAN 2004)

81L.3 52.216-1 TYPE OF CONTRACT (APR 1984)

81L.4 52.233-2 SERVICE OF PROTEST (SEP 2006)

82L.5 52.215-20 REQUIREMENTS FOR COST OR PRICING DATA OR INFORMATION OTHER THAN COST OR PRICING DATA (OCT 1997)

82L.6

GENERAL INSTRUCTIONS TO OFFERORS

84L.7 INSTRUCTIONS FOR THE PREPARATION OF THE TECHNICAL PROPOSAL

88L.8 INSTRUCTIONS FOR THE PREPARATION OF THE COST PROPOSAL (CPFF)

92L.9 INSTRUCTIONS FOR THE PREPARATION OF THE BRANDING AND MARKING PLANS

94SECTION M - EVALUATION FACTORS FOR AWARD

94M.1 NOTICE LISTING SOLICITATION PROVISIONS INCORPORATED BY REFERENCE

94M.2 GENERAL INFORMATION

94M.3 EVALUATION CRITERIA

96M.4 COST EVALUATION

96M.5 DETERMINATION OF THE COMPETITVE RANGE AND CONTRACT AWARD

96M.6 CONTRACTING WITH SMALL BUSINESS CONCERNS AND DISADVANTAGED ENTERPRISES

97ATTACHMENT 1

97IDENTIFICATION OF PRINCIPAL GEOGRAPHIC CODE NUMBERS

98ATTACHMENT 2

98USAID FORM 1420-17 - CONTRACTOR BIOGRAPHICAL DATA SHEET

101ATTACHMENT 3 SF LLL - DISCLOSURE OF LOBBYING ACTIVITIES

105ATTACHMENT 4

105CERTIFICATE OF CURRENT COST OR PRICING DATA

106ATTACHMENT 5

106TEMPLATE FOR CONTRACTOR PERFORMANCE INFORMATION

LIST OF REFERENCED DOCUMENTS (separate documents to be found on www.fedbizopps.gov):

Annex 1 – FANTA Trip Report

Annex 2 – September 2007 Change in PEPFAR Policy

Annex 3 – September 2006 PEPFAR Policy on Food and Nutrition

PART I - THE SCHEDULE

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

B.1 PURPOSE

The purpose of this contract is to provide technical assistance and services as described in detail in Section C, Statement of Work for the implementation of the Food by Prescription (FBP) activities as part of the HIV/AIDS Care and Treatment Programs in Ethiopia.

B.2 CONTRACT TYPE AND SERVICES

This is a Cost-Plus-Fixed-Fee (CPFF) completion type contract. For the consideration set forth below, the Contractor shall provide the performance objectives and deliverables described in Section C and F in accordance with the performance standards specified in Section E.

B.3 ESTIMATED COST, FIXED FEE, AND OBLIGATED AMOUNT

(a) (a.1) The estimated cost for the performance of the work required during the Base Period (Years 1-3) hereunder, exclusive of fixed fee, if any, is $________. The fixed fee, if any, is $_______. The estimated cost plus fixed fee is $________.

(a.2) The estimated cost for the performance of the work required during Option Period (Years 3-4) hereunder, exclusive of fixed fee is $______. The fixed fee, if any, is $_______. The Estimated cost plus fixed fee is $__________.

(b) Within the estimated cost plus fixed fee (if any) specified in paragraph (a.1) above, the amount currently obligated and available for reimbursement of allowable costs incurred by the Contractor (and payment of fee, if any) for performance hereunder is $________. The Contractor shall not exceed the aforesaid obligated amount.

(c) Funds obligated hereunder are anticipated to be sufficient through _(to be determined at time of award)_.

Because the clauses entitled "Allowable Cost and Payment" (FAR 52.216-7) and "Fixed Fee" (FAR 52.216-8) are incorporated into this contract, the terms and conditions of these clauses apply after total payments of fixed fee reach eighty-five percent (85%) of the total fixed fee.

(d) Within two months from the Base Period completion date, the Government will activate the priced Option (see Section B.4.) by issuing a contract modification upon Contractor’s satisfactory implementation and submission and acceptance of the Base period deliverables (see Section E) by the Government. If contractor’s performance and deliverables are determined as not meeting the Government’s minimum requirements and expectations, it will automatically result in the contract self-expiry at the end of Base Period, and or with the effective date of the Contracting Officer’s written communication to this effect. Inclusion of options will not obligate the government to exercise the option(s). Exercising an option(s) is a unilateral right of the USG.

B.4 LINES ITEMS-COST SCHEDULE –

The below Cost Schedule will/may be modified at time of award:

Cost Line Item 1 – Cost Line Item 2

Total

Base Period

Option Period Labor

Equipment & Supplies

Training

Sub-awards

Other Direct Costs

Indirect Costs

Total Estimated Cost:

Fixed Fee:

TEC plus Fixed Fee:

Contract Base and Option Costs Plus Fixed Fee Contract Ceiling is: $____________

The specific work to be carried out by the Contractor in the Implementation of the Option Period is subject to final determination by USAID with the Contractor’s input when exercising each option, and must not exceed the TEC plus Fixed Fee $________ ceiling.

B. 5 INDIRECT COSTS AND CEILING ON INDIRECT COSTS

The contract clause entitled “Allowable Cost and Payment (DEC 2002)”, FAR Subpart 52.215-7 specifies that the indirect cost rates shall be established for each of the Contractor’s accounting periods which apply to this contract.

Pending establishment of revised provisional or final indirect cost rates, allowable indirect costs shall be reimbursed on the basis of the following negotiated provisional or predetermined rates and the appropriate bases:

Description

Rate

Base Type Period

1/ 1/ 1/

2/ 2/ 2/

3/ 3/ 3/ 1/Base of Application:

Type of Rate:

Period:

Source:

2/Base of Application:

Type of Rate:

Period:

Source:

3/Base of Application:

Type of Rate:

Period:

Source:

Note 1: Contractors are allowed to recover applicable indirect costs (i.e., overhead, G&A, etc.) on other direct costs (ODCs), if it is part of the contractor's usual accounting procedures, consistent with FAR Part 31, and Negotiated Indirect Cost Rate Agreement (NICRA).

Note 2: While Subcontractor indirect cost rates are not incorporated above, subcontractor indirect cost rates as indicated in Note 1 above shall be included in task order proposals, and are subject to approval of the TOCO in accordance with FAR 52.244-2, Subcontracts.

CEILING ON INDIRECT COSTS:

(1) Reimbursement for indirect costs shall be at the lower of the negotiated final (or predetermined rates) or the following ceiling rates:

Description

Rate

Base Type Period

1/ 2/ 3/

1/

2/

3/

(2) The Government will not be obligated to pay any additional amount should the final indirect cost rates exceed the negotiated ceiling rates. If the final indirect costs are less than the negotiated ceiling rates, the negotiated rates will be reduced to conform to the lower rates.

(3) This understanding shall not change any monetary ceiling, obligation, or specific cost allowance or disallowance. Any changes in classifying or allocating indirect costs required the prior written approval of the Contracting Officer

B.6. COST REIMBURSABLE

The U.S. dollar costs allowable shall be limited to reasonable, allocable and necessary costs determined in accordance with FAR 52.216-7, Allowable Cost and Payment, FAR 52.216-8, Fixed Fee, if any, and AIDAR 752.7003, Documentation for Payment.

In addition, the requirement and conditions concerning estimated cost and funding apply as detailed in: FAR 52.232-20, Limitation of Cost (applies while the contract is fully funded); and FAR 52.232-22, Limitation of Funds (applies while the contract is funded in an amount less than the ceiling price).

B.7 LABOR

Compensation of personnel under this contract or any resulting sub-contract must be in accordance with AIDAR 752.7007 Personnel Compensation, the full text of which is in section H.

END OF SECTION B

SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

Activity Title: Food by Prescription for HIV/AIDS Care and Treatment Programs

Acronyms:

ART

Anti-retroviral treatment

ARV

Anti-retroviral

BMI

Body Mass Index

CHAI

Clinton HIV/AIDS Initiative

CSMB

Corn-soy-milk blend

EDHS

Ethiopian Demographic and Health Survey

FANTA

Food And Nutrition Technical Assistance Project

FBP

Food by Prescription

GFATM

Global Fund to Fight AIDS, Tuberculosis and Malaria

GOE

Government of Ethiopia

HAPCO

HIV/AIDS Prevention and Control Office

HAPN

Health, AIDS, Population and Nutrition

MOH

Ministry of Health

MUAC

Mid-upper arm circumference

OGAC

Office of the Global AIDS Coordinator

OVC

Orphans and vulnerable children

PEPFAR

Presidential Emergency Plan for AIDS Relief

PFSA

Pharmaceuticals Fund and Supply Agency

PLMP

Pharmaceutical Logistics Master Plan

PLWHA

People living with HIV/AIDS

PMTCT

Prevention of mother-to-child transmission

RHB

Regional Health Bureau

RUTF

Ready-to-use therapeutic food

SCMS

Supply Chain Management System Project

USG

United States Government

WFP

World Food Program

W/H

Weight for height

WSMB

Wheat-soy-milk blend

STATEMENT OF WORK

C.1.

SUMMARY

USAID/Ethiopia’s Office of Health, AIDS, Population and Nutrition (HAPN) requests proposals for the implementation of a Food by Prescription (FBP) project under HIV/AIDS Care and Treatment programs.

Specifically, through this contract, USAID/Ethiopia is funding the delivery of therapeutic food products to HIV positive individuals who are moderately to severely malnourished. Referrals for other household members to long term supplementary feeding programs will also be a key element of the program.

The Contractor shall:

· Provide technical assistance in the delivery of therapeutic and supplementary food products

· Integrate clinical nutritional assessment and counseling services into public health facilities

· Build the capacity of the public sector to train health professionals including, case managers, persons living with HIV/AIDS/community agents and other cadre of health workers in nutrition counseling and therapeutic feeding

· Support pre-service nutrition programs at local colleges and universities.

· Support local production, marketing and distribution of therapeutic foods through local commercial organizations.

· Create economic opportunities for beneficiaries along the value change.

Selected Populations:

The specific target groups for this award are:

· Adults attending pre-ART and ART services.

· Pregnant and post-partum HIV positive women.

· Malnourished OVC (irrespective of HIV status).

Geographical focus:

This program shall be implemented in urban and peri-urban health facilities in multiple regions supported in a phased expansion of sites. These sites shall be located in high prevalence areas where there is a greater chance for employment opportunities for beneficiaries and where longer-term food security programs, including the World Food Program (WFP)-implemented Urban HIV/AIDS program, are available. USAID will be responsible for final approval of health facilities to receive support under this Contract.

C.2.

PROGRAM CONTEXT - BACKGROUND

In Ethiopia nearly 50 percent of the population consumes inadequate amounts of food daily, micronutrient deficiencies are highly prevalent, and rates of chronic and acute malnutrition in children are among the highest in Africa. According to the 2005 Ethiopian Demographic and Health Survey (EDHS), 47 percent of children under five are stunted, 38 percent of children in the specified age category are underweight, and more than 54 percent of Ethiopian children ages 6-59 months are anemic. The same report indicated that 27 percent of women are malnourished. In response to concerns about these macro-indicators Ethiopia was designated a Presidential Emergency Plan for AIDS Relief (PEPFAR) Food Focus Country.

PEPFAR/Ethiopia program recognizes the complexity of issues facing HIV positive and OVC populations. Comprehensively addressing issues of food insecurity in Ethiopia is beyond the scope of PEPFAR legislation. In response PEPFAR/Ethiopia has integrated specific and targeted nutrition interventions with HIV/AIDS treatment and care programs in an effort to improve clinical outcomes for PLWHA. In addition strengthening private sector responses, increasing cadres of health workers addressing nutrition and maximizing leverages with other partners that provide food assistance are also critical.

PEPFAR/Ethiopia will support the provision of food support to specifically identified target populations when such support directly contributes to meeting the prevention, treatment and care goals of the U.S. Five-Year Global HIV/AIDS Strategy; and when nutrition interventions are based on scientifically-established WHO assessment criteria and guidelines for nutritional care. To ensure integration of nutrition interventions PEPFAR/Ethiopia works closely with other bilateral and private donors and the Government of Ethiopia (GOE) to access food resources for therapeutic and supplementary feeding.

Research has established clinical malnutrition as a risk factor for HIV progression and mortality for pre-ART and ART patients, as well as for poor birth outcomes among HIV positive women, and morbidity and mortality among OVC, especially those under 5 years of age. As HIV infection progresses into AIDS, hyper metabolism, malabsorption of nutrients, diarrhea, and anorexia contributes to severe challenges to food intake and maintenance of adequate nutritional status. In addition, there is an extensive body of research recognizing that a strong correlation exists between nutritional care and the effectiveness and efficacy of HIV/AIDS anti-retroviral drugs. According to WHO, energy requirements are increased by 10% in asymptomatic adults, 20-30% in symptomatic adults and as much as 50-100% in infected children with growth faltering, while dietary protein levels should be maintained at 12-15% of total energy intake. The Food by Prescription (FBP) Program will be implemented in accordance with the PEPFAR Policy Guidance on the Use of Emergency Plan Funds to Address Food and Nutrition Needs (see Appendix D).

For ART patients, it is widely reported that highly nutritious foods – in small amounts consumed frequently – are critical to overcoming the side effects that accompany the introduction of anti-retrovirals (ARV). Unfortunately, in Ethiopia significant numbers of the population have difficulty accessing quality food in sufficient amounts needed during ART to combat the symptoms of the disease, as well as the effects of the medications.

In Ethiopia, there is a data gap on the prevalence of malnutrition among PLWHA. Some reports indicate that moderate to severe malnutrition rates can be as high as 25 to 35 percent among those enrolled in HIV/AIDS services at facilities and there are some estimates that 75% of HIV positive pregnant women in PMTCT are eligible for supplemental feeding programs. Clinically malnourished patients in care and treatment programs have an immediate need for energy/nutrient-dense foods that can be readily and safely prepared and consumed to improve their nutritional and immunological status, especially for ART patients.

In this context, the FBP Program will provide therapeutic and supplementary food support to moderate and severely malnourished patients within the context of specific eligibility and exit anthropometric criteria consistent with WHO and/or national guidelines. In time, moderate to severely malnourished patients will transition from time-limited therapeutic and supplementary feeding to leveraged food security programming so that PLWHA and their families can address their broader health, food security and livelihood needs.

Current Program Approach:

USAID’s Health and PEPFAR teams, together with its Food for Peace Office, the Ministry of Health, and other partners are developing HIV and nutrition programs for PLWHA and OVC.

Since 2004, PEPFAR/Ethiopia funded the Urban Nutrition Program for HIV/AIDS-Affected Children and Women. The urban gardening program supports OVC and low-income HIV infected and affected women, including those receiving home-based care (HBC) or ART. The objectives of the program are to improve the food security and nutritional status for low-income women and OVC affected and infected by HIV/AIDS by introducing low cost, low labor, intensive urban gardening systems to beneficiaries. Combined with appropriate training, organization and market linkages, urban gardening systems generate food for household consumption and improve household nutrition in addition to providing surplus for income generation. By June 30, 2008, 15,000 total households will be reached, with beneficiary numbers of at least 60,000 persons.

In 2007, PEPFAR/Ethiopia leveraged $12.4 million in food from Title II Food for Peace resources to provide nutritional support for PLWHA through the World Food Program (WFP) Urban HIV/AIDS Program. The program currently operates in 14 urban areas with high prevalence of HIV/AIDS and urban poverty. PEPFAR/Ethiopia resources support nutrition assessment, counseling and education within community and home-based care services, referral linkages with hospital and health center based pre-ART, ART and PMTCT services, capacity development of local HIV/AIDS committees and income generating activities support. The project also provides nutritional support to OVC. This activity supports 7,000 PLWHA, of which 70% are women, and assists an additional 110,000 beneficiaries, including OVC and household members of PLWHA.

PEPFAR/Ethiopia and Title II Food for Peace resources are utilized for care and support for PLWHA by Catholic Relief Services (CRS). PEPFAR/ Ethiopia has leveraged 9,442 MT of food worth $5,642,590 from Title II resources to work with Medical Missionaries of Mary, Organization for Social Services for AIDS and Missionaries of Charity to provide support to approximately 35,000 PLWHA in 18 urban communities in Ethiopia. Through this program, PEPFAR/Ethiopia implementing partners will provide nutritional support, hygiene education, counseling, psychosocial, spiritual and medical care, and preventive care to PLWHA both in their homes and hospices.

Since March 2007, USAID consulted with UNICEF and the Clinton HIV/AIDS Initiative (CHAI) to synchronize food and nutrition activities. UNICEF currently provides ready-to-use therapeutic food for malnourished patients. USAID envisions a link with UNICEF to address adult in-patients at locations where the UNICEF programs operate to expand the coverage and numbers of beneficiaries. CHAI supports therapeutic feeding for pediatric AIDS patients. USAID envisions a link with CHAI to address malnourished pediatric AIDS patients to expand the number of beneficiaries. Additional details of UNICEF and CHAI’s programs are located in Annex 2.

Additionally, USAID assisted Ethiopia’s Federal HIV/AIDS Prevention and Control Office (HAPCO) to establish a food and nutrition sub-working group to coordinate different HIV and nutrition related activities.

Figure 1 outlines program objectives and entry points for food and nutrition interventions for persons living with HIV/AIDS to enter and remain in the care continuum at health facilities.

C.3.

ACTIVITIES/COMPONENTS

Results Framework

Definitions:

· Therapeutic food/feeding targets severely malnourished individuals, (BMI <16 in adults and weight for height (W/H) z-score <-3 in children).

· Supplementary food/feeding targets mild-to-moderately malnourished individuals, (BMI 17-18.5 (mild) or 16-17 (moderate) in adults and W/H z-score <-2 in children).

· Supplemental food/feeding is provided to individuals based on vulnerability and an assessment that the diet is likely to be inadequate to meet basic energy and other nutrient needs, rather than strict anthropometric criteria – for example, supplemental rations to HIV-positive women during pregnancy and lactation and rations to early weaned infants up to 2 years of age.

· Clinical malnutrition refers to all patients with a BMI<18.5 (adults) or <-2 z-score (children); foods provided to those individuals might be therapeutic (severe malnutrition), supplementary (mild-to-moderate), or collectively known as feeding support.

USAID/Ethiopia envisions that a comprehensive package of four interventions will be provided through the Food by Prescription (FBP) Program, including:

· Nutrition assessment. Health providers will be trained in measuring body mass index (BMI) and mid-upper arm circumference (MUAC), and charts will be provided to determine malnutrition based on BMI and MUAC. MUAC will also be measured for clients whose height cannot be taken and for pregnant and lactating women. Additional equipment and materials to support anthropometric assessments may be provided, if needed.

· Nutrition counseling and education. Nurses and, where active, lay counselors and PLWHA volunteers will be trained to provide nutritional assessment, counseling and education and on preparation and consumption of the foods supplied. Nutrition counseling will be added to the other counseling topics that are currently covered and training materials will be provided, if needed.

· Provision of supplementary and therapeutic foods to moderate and severely malnourished HIV positive individuals, in particular pregnant and lactating women. Note: This program is not designed to address the issue of breastfeeding, and project foods shall not be given to infants under 6 months of age as this may interfere with exclusive breastfeeding, or not be nutritionally sufficient for infants on exclusive replacement feeding. Mixed feeding is never encouraged.

· Referral of HIV positive and at-risk individuals including OVC to household food assistance and livelihood support. The recipients can be linked to the WFP Urban HIV/AIDS Program that provides household food security rations. Other options include linkages to urban gardening programs and other livelihood assistance activities.

To ensure the success and sustainability of the nutrition intervention, it is important that the FBP program be linked to on-going household food security and livelihood assistance activities in Ethiopia.

The FBP program will be located in urban areas where longer-term food security programs, including the WFP-implemented Urban HIV/AIDS program, operates. Emphasis will be placed upon locations where there are enhance opportunities for income generation and linkages to organizations working in economic empowerment. The Contractor will coordinate support under the FBP program with other therapeutic and supplementary feeding activities for those HIV infected individuals and OVC that are moderate to severely malnourished. The linkages, envisioned with UNICEF’s ready-to-use therapeutic food (RUTF) services for pediatric and adult in-patients at targeted sites (regardless of HIV-status) and to CHAI’s therapeutic feeding of pediatric AIDS patients, are designed to draw from these experiences, complement rather than duplicate their food distribution, and expand the numbers of in-need patients who benefit from supplementary and therapeutic foods. In addition to wrap-around with other food security programs, efforts will be made to link beneficiaries with income generation activities. See Annex 2.

In the FBP program supplementary and therapeutic foods will be treated as a medicine. The targeted beneficiaries will receive a prescription for the food and will be instructed to consume the entire ration themselves in order to respond optimally to the treatment. The need for a prescription to receive the food will serve as a mechanism to draw beneficiaries into health facilities, where they can receive additional health and counseling services, improving adherence to clinical interventions. The FBP program is expected to provide moderate to severely malnourished PLWHA with time-limited access to therapeutic and supplementary foods and counseling services to reduce morbidity and mortality among adults and children enrolled in PMTCT, pre-ART and ART services.

During implementation, the Contractor will work closely with USG and non-USG partners under the coordination of the Ministry of Health (MOH) and Regional Health Bureaus (RHBs), to establish Standard Operating Procedures in selected health facilities and community organizations to:

1. Provide standardized nutritional assessment techniques for all pre-ART and ART clients receiving clinical services.

2. Ensure operational readiness of selected health facilities to participate in the FBP program.

3. Facilitate time-limited, individualized rations of supplementary and therapeutic foods for moderate and severely malnourished HIV positive individuals.

4. Monitor and evaluate the progress of moderately and severely malnourished HIV positive individuals enrolled in the FBP program.

5. Transition individuals receiving time-limited therapeutic food products to longer-term supplementary feeding programs and to economic strengthening activities in the community.

Implementation activities shall be organized around the achievement of specific expected results outlined below.

C.4

EXPECTED RESULTS

C.4.1 Result 1: Facilitated Access to Supplementary and Therapeutic Foods for Selected Populations through Public and Private Distribution Channels

The FBP program will support the development of a continuum of care for persons living with HIV/AIDS who require therapeutic and supplementary feeding products. This result outlines USAID’s expectations for the Contractor to integrate the FBP program into Ethiopia’s existing health network at health centers and hospitals which complement and actively support referrals to and from community-based palliative care services. In some instances, the Contractor will vary the mechanism of product delivery where USAID anticipates that 80 percent of beneficiaries will receive product through public sector sites and 20 percent of beneficiaries will receive product through nearby commercial outlets and utilize vouchers distributed at health facilities.

In 2007, USAID requested technical assistance from the Food and Nutrition Technical Assistance (FANTA) project to assess the country context. FANTA’s trip report and SCMS documentation is included as an annex for background information to the Contractor:

“The protocol for treatment of severe malnutrition is to provide foods that meet complete energy requirements. For clients with severe malnutrition, 276 g./client/day of Plumpy’nut equivalent and 400 g./client/day of CSMB will be provided. This will provide 3,000 kcal/day, which is close to 100% of caloric requirements for severely malnourished HIV-infected adults. Once clients are no longer severely malnourished and transition to being moderately malnourished, they will receive 92 g./client/day of Ready-to-use therapeutic food [RUTF] equivalent and 200 g/client/day of CSMB. This will provide 1300 kcal/day, which is approximately 50% of energy requirements for symptomatic HIV-infected adults who are not severely malnourished. For adult clients who enter the program with moderate or mild malnutrition, 92 g./client/day of RUTF and 200 g./client/day of CSMB will be provided.”

A combination of the two foods will be given because it is expected that adult clients will be better able and more likely to consume a variety of foods than consuming 100% energy requirement from RUTF alone. Experience has indicated that adults do not always like RUTF and consuming such a large quantity may be difficult. Secondly, maintaining a combination of two foods throughout treatment may encourage greater consumption and be easier for the client than abruptly transitioning from all of one food (RUTF) to all of another food (fortified blended food products). Lastly, providing a combination of RUTF equivalent and fortified blended food products is less likely to result in over-supplementation of micronutrients than providing 100% of energy from RUTF alone would. Depending on the situation, there may also be a need to procure a small quantity of F75 for adults with severe malnutrition who require Phase I treatment.

Transitioning clients who are no longer severely malnourished to a greater proportion of fortified blended food products is suggested because clients recovering from severe malnutrition require continued nutritional support, and greater proportions of supplementary food and smaller proportions of therapeutic food can be sufficient once moderate and mild malnutrition stages are reached in the recovery stages.”

Alternative formulations that meet nutrient and energy requirements may be considered based on availability and cost-effectiveness.

The remaining text in this Result 1 details the Contractor’s role and actions to be taken by the Contractor.

a. Sourcing and Procurement of Food Products It is important that the therapeutic and supplementary foods meet the specific nutritional and energy requirements for each of the specific targeted populations. Efforts shall be made to ensure that the food is culturally acceptable within an Ethiopian context. Also, the food must be quality assured and monitored on a regular basis to maintain hygienic standards, and in particular, eliminate risk of aflatoxin or other fungal or bacterial contamination.

The procurement of the Ready-to-use therapeutic food (RUTF) products for the FBP activities in Year 1-3 will be through the USAID mechanism entitled SCMS. For that reason, the FBP Contractor will have to collaborate with the SCMS contractor and other stakeholders providing food and nutritional support to ensure that the determination of requirements, quantification and sourcing of therapeutic food products have appropriate formulations under the FBP program.

The Contractor will procure fortified blended food products to complement RUTF at health facilities levels. Meanwhile the FBP Contractor shall provide technical assistance to engage local commercial organizations to: (a) support the production of the therapeutic and supplementary food products and (b) assist in business development including increasing local production capacity, quality and efficiency.

Developing local production capacity of both RUTF and fortified blended food products is important for Ethiopia. Current producers supply several multilateral organizations with RUTF and fortified blended food products. Therefore USAID envisions that some procurement will occur locally. As such technical assistance to support improvements in local production capacity and quality assurance of multiple local manufacturers is envisioned.

The FBP Contractor, in collaboration with the SCMS contractor, shall develop product packaging specifications, IEC materials and job aids, of the RUTF and fortified blended food products in accordance with pre-agreed specifications to minimize stigma and promote adherence (from USAID and the Government of Ethiopia).

b. Storage and Distribution of therapeutic and supplementary food products Timely distribution of therapeutic and supplementary foods to targeted health facilities is critical to the success of the FBP Program. While RUTF is smaller and can be accommodated in many pharmacy stores, the limited storage space in pharmacies makes it difficult to warehouse the larger fortified blended food products at health facilities.

The Contractor shall establish facility-level forecasted product needs, establish health facility level systems to track consumption and request replenishment, and will define options to bundle products for ease of use and transport in the Ethiopian context. The SCMS contractor, working alongside PFSA, will integrate RUTF and fortified blended food products into the HIV commodity system for standard distribution with one exception: Approximately 20 percent of the resources of the FBP in Year 1 shall be used by the FBP contractor for market assisted approaches which may include vouchers obtained from public health facilities to collect products from commercial outlets or other variations. Depending on the effectiveness of this approach the percentage allocated to this approach may increase in Year 2 – Year 5.

The Contractor shall coordinate with SCMS contractor to facilitate site level readiness and in some instances shall redistribute quantities of stock from regional storage points to sites or to provide stop-gap RUTF and fortified blended food products in the absence of available products.

The Contractor shall collaborate with SCMS and PFSA in defining site level storage requirements, to assess storage options at public health facilities and commercial outlets to develop options to manage product distribution and storage. Distribution to sites other than pharmacies needs to be explored, including coordinating with WFP, the use of private warehouses. Storage issues may be addressed on a site-specific basis.

Furthermore, the Contractor shall deliberately assess and create economic opportunities within local markets for beneficiaries and household members throughout the value chain of the manufacture and distribution of product. USAID envisions that greater participation in the production of inputs, processes in manufacture and distribution, and program implementation will build a more successful transition of FBP clients to sustained economic strengthening and household stabilization.

c. Provision of Safe Water

Since HIV-infected individuals are already nutritionally compromised, the quality and safety of food and water is of paramount importance. Where water is needed to prepare fortified blended food products its quality and safety should be improved using available point of use safe water to reduce the likelihood of morbidity. In addition, beneficiaries consuming RUTF should also be provided with safer water, possibly including a point-of-use household water treatment system.

The critical importance of water quality and safety suggests the need to incorporate water-quality/hygiene and point-of-use household water treatment components.

To ensure the completion of this project component, the Contractor is expected to:

· Conduct analyses to determine appropriate food combinations and formulations needed for selected populations including HIV positive children and adults including pregnant women.

· Monitor the quality, acceptable and culturally appropriateness of product.

· Implement voucher systems alongside distribution through commercial outlets

· Identify and propose economic strengthening activities for beneficiaries within the product’s value chain.

· Support adequate storage capacity and conditions for product.

· Integrate safer water systems with the FBP program.

These activities are also the performance indicators that USAID/E will use for measuring the completion of this program component:

C.4.2 Result 2: Provision of Technical Leadership for the Implementation of the Food by Prescription Program

a. Technical Assistance to Logistics Agents, Public Clinic and Commercial Sites to Support Distribution Systems, Inventory Control, Storage and Record Keeping Requirements

Public health providers in government-run facilities, the Government of Ethiopia and PEPFAR implementing partners require technical assistance to improve the likelihood that supplementary and therapeutic food products under this program are distributed, stored and utilized appropriately. This includes working with appropriate partners including PFSA, SCMS and RHBs to develop or adapt mechanisms to track the intake and distribution of RUTF and fortified blended food products. Local staffs (at hospitals, health centers and distribution warehouses) need to be aware of proper storage and reporting methods as no systems currently exist.

The Contractor shall provide training for storage, distribution, inventory monitoring and utilization reporting including voucher management for effective program implementation at the health facility and commercial outlet level.

To ensure the completion of this project component, the Contractor is expected to:

· Assess the necessary storage capacity to accommodate RUTF and fortified blended food products at health facilities or other storage facilities.

· Develop standards for proper storage and distribution.

· Train facility-level staff to maintain appropriate storage standards and maintain record keeping and inventory control.

· Adapt existing processes and systems to manage inventories of stock.

b. Initiate and Maintain Site-Level Operational Readiness in Collaboration with Regional Health Bureaus, District Health Offices and USG Partners through Site Assessment, Training and Monitoring in FBP Sites

Public health facilities providing HIV/AIDS services typically face a high client volume without adequate human resources or infrastructure. It is important that the Contractor provide technical assistance to FBP sites to ensure interventions are delivered, enrollment and transition mechanisms for clients are standardized and that reporting procedures are in place to support program management by health providers as a component of comprehensive HIV/AIDS services.

The Contractor shall assess and avail a standard package of equipment (e.g. scales, standiometers) necessary for anthropometric assessments. While determining site level readiness the Contractor shall provide equipment that is not available at health facilities. In addition on-site trainings, in collaboration with USG partners, in nutritional assessment utilizing BMI and MUAC, nutritional counseling and care, prescribing therapeutic and supplementary foods and monitoring adherence to both RUTF fortified blended food products and ART should be considered. Additional training topics that support the goals of the FBP program may be appropriate.

The Regional Health Bureaus and many health facilities lack expertise in nutrition and do not have focal persons who provide support to the planning, delivery and evaluation of nutrition-related activities. USAID envisions the FBP program to attach technical expertise to government offices as well as utilize training methodologies for physicians, clinical officers and nurses to scale-up rapidly and subsequently train a cadre of volunteer laypersons as nutrition counselors and helpers. Nutritionists shall work with existing PLWHA organizations to identify volunteers. USAID envisions that Nutritionists shall provide technical assistance and mentoring to nurses, health officers and case managers to triage, deliver services and support patients accordingly. Skills and knowledge transfer to appropriate personnel at facility level will be required.

The Contractor shall coordinate with USG implementing partners who train health workers and lay counselors, as needed, to support those persons diagnosed with HIV (asymptomatic and symptomatic) to integrate nutritional counseling in comprehensive training including subjects such as positive living, prevention and disclosure, infection prevention, family-referral for counseling, testing and care, referrals to testing and pediatric care for exposed children, HIV prevention of mother to child transmission including ANC and assisted delivery promotion and ART and family planning services. The Contractor shall focus on nutritional components of the comprehensive training as a mechanism to integrate HIV and nutrition into the broader training. Nutrition assessment and counseling is a core intervention in comprehensive HIV care and treatment programs and should be integrated at all stages of HIV care and treatment implementation, such as during routine clinical care workups, adherence counseling, and follow-up consultations and in PLWHA support groups. Health workers need to provide PLWHA with instructions on the appropriate use of RUTF and the importance of maintaining adherence to the FBP program. The FBP program shall build the capacity that this counseling and assessment occurs at appropriate points in the continuum of care.

In undertaking theses tasks, the Contractor is expected to:

· Support targeted sites to ensure that enrollment and graduation mechanisms are standardized and that reporting and evaluation procedures are in place to support program management.

· Collaborate with USG partners to train health personnel in nutritional assessment, counseling and care, prescribing therapeutic and supplementary foods and monitoring adherence.

· Provide the necessary anthropometric equipment at certain facilities, if needed.

· Train cadres of health providers and volunteer laypersons as counselors and helpers.

· Review and adapt existing training curricula and train health workers and partner organizations on nutrition, growth monitoring, BMI and MUAC assessment tools, RUTF and fortified blended food…