Amend 04, N00244-19-S-F002 (PEPFAR Funded Countries).pdf

AMENDMENT 04

FUNDING OPPORTUNITY ANNOUNCEMENT (FOA)

Number N00244-19-S-F002

“FY19 – FY20 Department of Defense HIV/AIDS Prevention Program: Military

Specific HIV/AIDS Prevention, Care, and Treatment Program for PEPFAR (President’s Emergency Plan for AIDS Relief)

Funded Countries” The purpose of this Amendment 04 is to incorporate the following:

DHAPP is accepting “Concept Papers” for the following countries through 7 May 2019:

El Salvador, Honduras and Guatemala: DHAPP—Central America Regional Partnership for Sustainable HIV Epidemic Control in the Guatemalan, Honduran and Salvadoran Militaries;

Dominican Republic: DHAPP--FFAARD Partnership for Sustainable HIV Epidemic Control in Border Region;

Malawi: DHAPP--MDF Partnership for Sustainable HIV Epidemic Control

NOTE: Each narrative is a standalone effort and should not be combined with another narrative and all the program elements (tasks) in each specific narrative must be addressed in that concept paper submission.

E-mail address for submission of Concept Papers: usn.nhrc.dhapp@mail.mil

The full solicitation is available at: http://www.grants.gov/

Eligible Applicants are requested to submit Concept Papers following the guidelines and format provided in the N00244-19-S-F002, Section II, D.

All respondents must demonstrate the support of the in-country military and the DoD representative in the corresponding U.S. Embassy in the planning and execution of their proposals. The selected Grantee is the Implementing Partner and will be referred to as IP in this document.

mailto:usn.nhrc.dhapp@mail.mil http://www.grants.gov/

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for PEPFAR Funded Countries)

El Salvador, Honduras and Guatemala: DHAPP—Central America Regional Partnership for Sustainable HIV Epidemic Control in the Guatemalan, Honduran and Salvadoran Militaries

Introduction

The HIV/AIDS epidemic has been devastating and negatively affected many militaries and other uniformed organizations worldwide by reducing military readiness, limiting deployments, causing physical and emotional decline in infected individuals and their families, posing risks to military personnel and their extended communities, and impeding peacekeeping activities. As HIV management improves, many of these impacts are disappearing, however, militaries now need to sustain life-long HIV treatment for their HIV-infected beneficiaries in addition to other long-term chronic disease management issues.

The US Government has a long history of international collaboration and partnerships in the fight against HIV/AIDS, providing funding, technical assistance, and program support. These collaborations are all contributing to HIV epidemic control.

Over the years, the United States Department of Defense (DoD) HIV/AIDS Prevention Program (DHAPP) has successfully engaged over 80 countries in an effort to control the HIV epidemic among their respective military services. DHAPP is the DoD implementing agency collaborating with the US Department of State, the Health Resources and Services Administration, Peace Corps, US Agency for International Development (USAID), and the Centers for Disease Control and Prevention (CDC), in the US President’s Emergency Plan for AIDS Relief (PEPFAR).

DHAPP receives funding for its programs from two sources: a congressional plus-up to the Defense Health Program (DHP) and funding transfers from the Department of State for PEPFAR. Working closely with DoD, U.S. Unified Combatant Commanders, Joint United Nations Programme on HIV/AIDS (UNAIDS), university collaborators, and other nongovernmental organizations (NGOs), DHAPP’s mission is to build capable military partners through military-specific, culturally focused, HIV/AIDS cooperation and assistance.

In the Defense Security Cooperation Agency guidance, the US Secretary of Defense has identified HIV/AIDS in foreign militaries as a national security issue. Pursuing HIV/AIDS activities with foreign militaries is clearly tied to security interests, regional stability, humanitarian concerns, counterterrorism, and peacekeeping efforts due to the impact of HIV/AIDS as a destabilizing factor in developing societies. DHAPP employs an integrated bilateral and regional strategy for HIV/AIDS cooperation and security assistance. DHAPP implements bilateral and regional strategies in coordination with respective Combatant Commands (COCOMs) and Country Support Teams to offer military-to-military HIV/AIDS program assistance using country priorities set by the US Under Secretary of Defense for Policy and by the Office of the Global AIDS Coordinator. DHAPP provides strategic information and supports defense forces in HIV prevention, care, and treatment for HIV-infected individuals and their families.

On October 1, 2013, DoD established the Defense Health Agency (DHA) as part of the U.S.

Military Health System governance reform. DHA is a joint, integrated Combat Support Agency that enables the Army, Navy, and Air Force medical services to provide a medically ready force

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for and ready medical force to COCOMs in both peacetime and wartime. In July 2014, the Deputy Secretary of Defense approved the realignment of medical Executive Agent organizations to DHA, including DHAPP. The transition to DHA from the Secretary of the Navy was completed on August 20, 2017. DHAPP is now a division under the Research and Development (J-9) Directorate and continues to be cornerstone of the global health engagement portfolio delivering solutions to COCOMs. The DHAPP headquarters office remains at Naval Base Point Loma in San Diego, California.

In 2014, PEPFAR moved from an “emergency” response to a strategy focused on sustainable control of the HIV epidemic. In doing so, PEPFAR adopted the United Nations Programme on HIV/AIDS (UNAIDS) global 90-90-90 goals that state by 2020: 90% of people with HIV are diagnosed, 90% of them are on ART and 90% of them are virally suppressed. DHAPP shifted with PEPFAR in how Monitoring, Evaluation, and Reporting (MER) indicators are collected and reported to efficiently use data to drive decision-making and focus HIV programming in the right geographic areas. DHAPP collects MER indicator results on a quarterly and semi-annual basis, and data is reported at the site level. This data allows DHAPP to understand the gaps in programming and needs for shifts to reach our shared goals. Due to security sensitivities regarding military site locations and troop movement, all site-level data is analyzed at DHAPP headquarters and summary data is collected by the Office of the Global AIDS Coordinator so each USG country team can review military program results at the national level.

In fiscal year (FY) 2017, DHAPP supported 56 national HIV programs, mainly through direct military-to-military cooperation in addition to support from contracting external organizations and academic institutions to assist with specific aspects of proposed programs. Partners in FY17 included 54 NGOs and universities working in 55 countries.

Budget

Phase 1 Phase 2 Phase 3 Phase 4 Total Care & Treatment

$77,186 $77,186 $77,186 $77,186 308,744

HVCT- HIV

Testing Services HTXS- Adult Treatment

HVCT- 34,306

HTXS-

42,880

HVCT- 34,306

42,880

HVCT-

137,224

HTXS-

171,520

Health Systems Strengthening

169,814 169,814 169,814 169,814 679,256

OHSS- Health Systems Strengthening

HVSI-

Strategic Information

OHSS-

99,847

HVSI-70,327

OHSS-

99,847

HVSI-70,327

OHSS-

99,847

HVSI-70,327

OHSS-

99,847

HVSI-70,327

OHSS-

399,388

HVSI-281,308

247,000 247,000 247,000 247,000 988,000

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

Approaches to Reaching Sustainable Epidemic Control

Proposals are requested to support the Guatemalan, Honduran and Salvadoran Armed Forces to reach sustainable control of the HIV/AIDS epidemic through the pillars of transparency, accountability, and impact.

The TBD partner’s program should emphasize capacity building across all activities and technical areas. All proposals should detail how the partner will engage the partner military leadership as well as personnel at all levels in this work; and, specifically how the partner will utilize the organizational structure of the military to strengthen the internal capacity of the military to conduct these activities. Within the proposal the partner will need to demonstrate transition of programmatic capabilities and capacity to the military over the life of the grant.

The partner must work in complete coordination with the partner militaries’ HIV prevention and health services, as well as the DHAPP/DoD Program Manager based at the US Embassies in these countries, the DOD adult and pediatric treatment program manager based at the Military Health Department, other DHAPP supported implementing partners working in these countries, other bilateral and multilateral agencies with similar objectives and the DHAPP Headquarters Team. The Grantee is the Implementing Partner and will be referred to as IP in this document.

Targets

Progress towards epidemic control will be successfully measured, in part, through an effective strategic information framework that not only monitors program outputs, but also key outcomes and programmatic impact.

Collection and use of disaggregated data that characterizes the populations served in the lowest geographic areas where HIV services are being provided is critical in understanding current program performance and planning for future performance. Consequently, the Monitoring, Evaluation, and Reporting (MER) indicators continue to evolve in order to reflect the progression of U.S. government (USG) support and global HIV response guidelines.

Measuring the impact of support at national and regional above-site levels down to direct services at the site-level is paramount to DHAPP’s program implementation and monitoring approach.

MER indicators are not an exhaustive list of all metrics that should be monitored by DHAPP-supported programs. These programs should continually monitor and assess any acute programmatic issues and collect additional data to inform program improvement.

The indicators listed below strives to drive program monitoring to a more patient-centered approach. Per the 2017 WHO Consolidated Guidelines on Person-Centred HIV Patient Monitoring and Case Surveillance, person-centered monitoring refers to a shift from monitoring measuring services (e.g., the number of individuals tested or people on treatment) to monitoring people at the center of their access to linked HIV and health services. In essence, Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for this marks a shift to better support the clients accessing services by focusing more on their individual health outcomes.

The proposal will address approaches to reaching the following targets for military and civilian populations.

Testing

Technical Area Targets, Year 1 Indicator Label Military Only Civilian

HTS_INDEX

HTS_TST

HTS_TST_POS

Number of individuals who were identified and tested using Index testing services and received their results

Number of individuals who received HIV Testing Services (HTS) and received their test results

Number of individuals who received HIV Testing Services (HTS) and received their positive test results

TX_CURR

TX_NEW

Number of adults and children currently receiving antiretroviral therapy (ART)

Number of adults and children newly enrolled on antiretroviral therapy

(ART)

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

Technical Narrative

The IP will address the technical approach to each area. The IP will be responsible for providing the following in close collaboration with other DHAPP-funded implementing partners and the host military.

HIV Testing Services

Finding the remaining persons who are living with HIV infection is the first priority for reaching HIV epidemic control. Current data shows that the most effective strategy for case-finding is through testing of sexual partners of PLHIV as well as children of HIV+ mothers. The FAG HIV/AIDS program is strategically placed to initiate military index testing in Central America to reach these individuals through improving index testing services within the HIV testing centers and a focus on the centralized testing location at the Military Hospital in an effort to assist the MOH in achieving the “first 90”: 90% of all priority populations living with HIV know their status.

IP activity will focus specifically on index testing, especially for priority populations, to provide high yield testing to those most at risk for infection.

Ensuring that any positives identified are linked to HIV care and treatment is essential to the success of the FAG program. The IP should work to achieve 100% linkage to treatment of HIV+ individuals identified. The IP will monitor HIV index testing yield; modifying strategies that are not identifying and/or linking significant numbers of HIV positive persons to HIV care and treatment.

The IP will be responsible for:

• Technical Assistance for Index testing at both military hospitals o Train patient navigators, nurses and physicians to implement stigma-free and confidential index testing effectively at the Hospital Militar Central and provide monitoring and mentoring to ensure continued efficacy of program.

o Diagnose 60 new PLHIV through index testing with 100% of those diagnosed linked to HIV care and treatment services o Index-case testing for all sexual partners of HIV-infected military personnel and civilians diagnosed or treated at the hospital.

o Index-case testing for all children under 15 years of age with HIV- infected mothers.

• Directly link PLHIV from HTS to clinical care and treatment services, including documenting successful linkage both within and outside of the military hospital.

• Monthly reporting and review of index testing yield; modifying strategies that are not identifying and/or linking significant numbers of HIV positive persons to HIV care and treatment

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

HIV Treatment Dolutegravir (DTG)-containing regimens are the preferred first-line antiretroviral therapies (ART) due to superior efficacy, tolerability and higher threshold for resistance compared to efavirenz (EFV)-containing regimens. The fixed dose combination (FDC) of tenofovir disoproxil fumarate/lamivudine/dolutegravir (TLD) is currently priced as the least expensive FDC, and it is expected that prices will go down as generic manufacturing scales up. For these reasons, DHAPP now recommends TLD as the preferred option for ART, and further recommends that DHAPP-supported programs switch over to TLD as soon as possible in a coordinated fashion as supply becomes available.

Programs should carefully assess the risks and benefits of TLD in child-bearing age women.

See published updated from WHO and PEPFAR to further understand the high benefits in the face of a potential NTD signal.

Children (< 20kg) are not expected to be included in the initial roll-out of TLD. Development of pediatric DTG formulations and evaluation of appropriate DTG dosing in infants and children are underway.

A priority of HIV programs is to find, diagnose and treat people with tuberculosis (TB) disease and ensure that they become non-infectious. For all those who do not have active tuberculosis, prevention of TB is a priority using nationally approved TB preventive therapy.

TB preventive therapy (TPT) must be scaled up for all PLHIVs as an integral part of the clinical care package. IPs are expected to increase the use of TB diagnostic testing within DHAPP-supported HIV care and treatment facilities and promote the use of TPT as a routine part of HIV care. In short, all newly diagnosed HIV persons should be offered TB treatment or preventive therapy and all persons assessed for TB should be tested for HIV.

Programs should have clear policies and/or guidelines for the use of TPT, and should plan for programmatic and clinical trainings, procurement and supply management, adequate diagnostic capacity (including specimen transportation) and development of appropriate data collection systems. In Global Fund high-impact countries implementing joint TB/HIV grants, IPs should also seek opportunities to support effective joint program implementation.

Additionally, IPs should implement TB infection prevention and control activities to minimize the risk of TB transmission and provide safe health seeking environment. This is critical in DHAPP-supported settings where clients at high risk for TB and HIV often co-mingle. It also puts the health care workers at the highest risk of contracting TB disease. Activities aimed at preventing transmission at facility-level include administrative and environmental controls, and the availability and use of personal protective equipment.

Sustained viral suppression of all PLHIV is the key to HIV epidemic control. To this end, the IP will work closely with the XDF to scale-up viral load testing coverage and suppression in an effort to achieve 90-90-90 goals for military personnel. Targets for HIV/AIDS care and treatment will focus on generating significant progress towards the third 90: 90% viral suppression among PLHIV taking ART.

The IP should ensure the partner military has access to timely VL testing and that capacity exists to test at least 90% of persons currently on ART annually. To ensure this capacity the appropriate use of both plasma and dried blood spots (DBS) should be considered to increase access to routine viral load monitoring.

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

DBS are easy to collect and store under field conditions, no phlebotomist required, easy to transport to centralized laboratories, reduced cost associated with collection materials and transportation under ambient temperature. The DBS technology is applicable to both adult and pediatric populations and the small volume of blood required for preparing DBS makes it suitable for pediatric populations.

The IP will ensure that VL results are made available in a reasonable amount of time to both the health care provider and the client. These results should be used to ensure that those who are not virally suppressed are linked to adherence support and close follow-up leading to either suppression or ART modification as needed. Those who are suppressed should be encouraged to stay suppressed and should be offered differentiated models of care including multi-month supplies of ART and fast-tracking as an incentive and given the message that undetectable equals untransmittable (U=U).

These activities will address the 2nd 90 in the WHO 2020 goals (90% of diagnosed PLWHIV on ART treatment). The IP will achieve this through supporting the FAG and FAES in the following activities:

• Adherence: IP will support the FAG and FAES in designing and implementing strategies to improve adherence to treatment. Strategies should include but are not limited to:

o Improved patient tracking system including documentation tools o Development and execution of patient reintegration plan for all patients lost to follow up o Review of patient acceptability and impact on adherence of de-centralized follow up for multi-month scripting, program modification and follow-up training of patient navigators based on findings.

• Technical Assistance to support the FAG and FAES in quality assurance of treatment to include but not limited to the following activities:

o IP to guide monthly rounds to review significant morbidity or mortality outcomes, including improvement plans o Identify areas for improvement through rounds and tracking tool o IP to collaborate with FAG and FAES to train providers in identified areas for improvement.

o ART Monitoring and Evaluation and Reporting utilizing MOH and PEPFAR tools

• TA for commodities consumption forecasting and supply management including improving communication pathways with MOH and budget forecasting to ensure programs can adequately care for current patients and absorb new patients without strain to the healthcare system or detriment to quality of care.

Strategic Information

The IP will support the 3 militaries in improving the sustainability and efficacy of their programs through improving local capacity and standard practices for data use utilizing the following activities:

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

• HIV and STI Monitoring and Evaluation: Collection and analysis of military-wide data, adapting PEPFAR MER indicators to include data from non-PEPFAR sites for above-site analysis to inform strategic direction o IP will assist the militaries in assessing and modifying data collection tools to ensure all appropriate data points and disaggregates are collected.

o IP will assist the militaries analyzing and visualizing collected data to inform policy and planning decisions.

o Above-site assistance to militaries for the quarterly review of treatment cascade.

• M&E: Site-level monitoring and data analysis to ensure compliance with strategic plan and implement correction where needed.

o IP will assist the military in frequent, in-depth site visits to review data collection implementation and sight-level adherence to guidelines and best practices.

o IP will assist sites in determining success of sites in contributing to the 95-95-95 country goals through the monitoring of disaggregated testing yield, PLHIV starting and adhering to treatment, and patient health outcomes.

Health System Strengthening

The IP will support the FAES, FAH and FAG HIV Programs in each country at an above-site level to improve quality of care for all HIV services and removal of barriers to service uptake for all at-risk military as well as the communities served by the military health services.

The IP will achieve these goals through the following interventions:

• The IP will assist all 3 militaries with training and follow-up monitoring and evaluation for

DTA for HIV Rapid Test (Proficiency Test):

o IP will utilize MOH trainers to train MOD labs to perform QA/QI panels verifying the quality of HIV rapid tests as well as carry out one round of QA/QI. Expert trainers will be provided by MOH. IP will be responsible for all logistics and coordination of training and follow-up M&E.

o IP will coordinate with all 3 militaries to integrate QA/QI into policies as standard practice.

o IP will coordinate with all 3 militaries to provide improvement plans on a site-specific basis.

• S+D: IP will provide and execute comprehensive Stigma and Discrimination (S+D) reduction plan in collaboration with each country to focus specifically on training of military leaders and medical professionals in improving access and uptake of services through reducing Stigma and Discrimination. This plan should include a needs assessment, training development and execution, policy review and recommendations.

• Forecast ARV, Condoms and HIV Test needs: In Guatemala, IP will assist the military in aligning procurements with MOH procurements through planning and tracking commodity needs and provision, this will be done through training and mentoring, such that capacity is built for these activities within the MOD, and only minimal mentoring would be required after year 1.

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

Policy and Planning

The IP will assist all 3 militaries at an above-site level to improve policies as well as planning practices. The objective of these activities is to move the militaries towards sustainability of effective programs.

In each country the IP will organize at least one workshop with key stakeholders and decision-makers. The objectives to be met in each country are:

• Update of treatment policies to adhere to WHO and MOH guidelines, especially the inclusion of index testing, test and start, differentiated models of care such as multi-month scripting, transition to Dolutegravir and viral load testing.

• Detailed annual plan, including execution plan and indicators of success.

• Revision of 5-year plan.

Site Improvement through Monitoring System (SIMS)

The purpose of SIMS is to provide a standardized approach and set of tools for monitoring program quality at DHAPP-supported sites and entities that guide and support service delivery.

SIMS assessment results are used to strengthen alignment with global and national standards and facilitate program improvement as a component of an overall quality management strategy. SIMS is also used to identify performance issues that may impact patient outcomes or the integrity of reporting for MER targets or disaggregates. Low final scores (reds and yellows) from these core essential elements (CEEs) highlight potential issues with service delivery, site performance or oversight, and/or documentation of patient results. Site-level triangulation of MER and SIMS data can be used to contextualize performance and could be useful to determine if performance challenges at a site are due to issues related to the underlying quality of service provision.

Site Improvement through Monitoring System (SIMS) aims to: (1) facilitate improvement in the quality of DHAPP-supported services and technical assistance, (2) ensure accountability of U.S. government investments, and (3) maximize impact on the HIV epidemic.

The IP will train military health leadership to utilize the SIMS tool to perform their own SIMS-like analysis of their programs outside of the two sites receiving site-level support. The objective of this activity is to increase military capacity for efficient analysis of program quality, and agility in program improvement.

SIMS assessment results confirm compliance to minimum quality assurance standards and identify areas where improvements in DHAPP-supported programs can be made.

Programs should conduct SIMS assessments in accordance with DHAPP guidance and implementing partners are responsible for taking corrective action for items within the IP SOW and per discussion with DHAPP USG staff.

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

Data Monitoring

Successful tracking of patient level data is critical to the success of the partner military HIV program’s ability to monitor progress towards epidemic control. The Grantee will work with the respective partner militaries to support the collection of patient-level data, the clinical and programmatic use of data, and the reporting of site-level data to DHAPP HQ and the partner military leadership.

The IP will be responsible for:

• Staffing support and mentoring of existing partner military staff for data entry

• Ensuring confidentiality and security of data, in line with MOD, MOH, and national guidelines

• Timely, accurate reporting of all indicators required by the partner military and DHAPP.

• Securing all patient-level and site-level data from dissemination outside of the partner military and DHAPP without prior approval from the partner military.

• Support for data entry, cleaning, reporting, and use.

Data Quality

Measuring the success of HIV/AIDS initiatives requires strong monitoring and evaluation (M&E) systems that produce high quality data. Efforts to ensure data quality, therefore, are not singular events occurring randomly. Rather, these processes need to become institutionalized as part routine data management processes. Once achieved, data quality helps to ensure that limited resources are used effectively, progress toward established goals are accurately monitored, and that decisions are based on strong evidence. Attention to data quality ensures that target-setting and results reporting are informed by valid and sensitive information, and that all partners are thinking about and collecting and organizing this information in the same manner. In this way, attention to data quality leads to improved program performance and to more efficient resource management.

Data quality has always been a focus of global HIV monitoring and reporting efforts.

Specifically, all countries conducting programming supported by DHAPP are expected to have a data quality strategy in place. For example, data quality assessments should be conducted routinely and action should be taken as a result of these DQAs. If errors are identified in data, these should be remediated at the point of service delivery as well as in the DHAPP and host-country reporting systems as soon as possible. Standard operating procedures for routine data quality review should also be in place. Data should be routinely reviewed for errors before submission to ensure that the data passes the data quality checks outlined within the guidance and the Data Review Tool available in DATIM.

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

Work Plans

The Grantee must submit annual, programmatic and financial, work plans to the DHAPP Program Manager and DHAPP HQ (budget breakdown per activity and for program management is required). Work plans should include an activities implementation timeline as well as monitoring and evaluation timeline.

Reporting

• Quarterly Fiscal Reports: The grantee must submit quarterly programmatic and financial reports to DHAPP in order to monitor expenditures according to the program budget codes. The report template will be provided by DHAPP. Submit data within 30 calendar days following each reporting period (3/31, 6/30, 9/30, and 12/31).

• Interim Progress/Monitoring, Evaluation, and Reporting (MER) Report: This report shall summarize progress in relation to the approved work plan as well as monitor grant deliverables. The Grantee shall submit quarterly indicator reports in accordance with the format provided by the Program Office within 45 calendar days following the end of the reporting period: 12/31, 3/31, 6/30 and 9/30. The Grantee shall provide reports in accordance with the template provided by DHAPP

• Reports will follow DHAPP Headquarters and Country Team Templates

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

Dominican Republic: DHAPP--FFAARD Partnership for Sustainable HIV Epidemic Control in Border Region

Introduction

The HIV/AIDS epidemic has been devastating and negatively affected many militaries and other uniformed organizations worldwide by reducing military readiness, limiting deployments, causing physical and emotional decline in infected individuals and their families, posing risks to military personnel and their extended communities, and impeding peacekeeping activities. As HIV management improves, many of these impacts are disappearing, however, militaries now need to sustain life-long HIV treatment for their HIV-infected beneficiaries in addition to other long-term chronic disease management issues.

The US Government has a long history of international collaboration and partnerships in the fight against HIV/AIDS, providing funding, technical assistance, and program support. These collaborations are all contributing to HIV epidemic control.

Over the years, the United States Department of Defense (DoD) HIV/AIDS Prevention Program (DHAPP) has successfully engaged over 80 countries in an effort to control the HIV epidemic among their respective military services. DHAPP is the DoD implementing agency collaborating with the US Department of State, the Health Resources and Services Administration, Peace Corps, US Agency for International Development (USAID), and the Centers for Disease Control and Prevention (CDC), in the US President’s Emergency Plan for AIDS Relief (PEPFAR).

DHAPP receives funding for its programs from two sources: a congressional plus-up to the Defense Health Program (DHP) and funding transfers from the Department of State for PEPFAR. Working closely with DoD, U.S. Unified Combatant Commanders, Joint United Nations Programme on HIV/AIDS (UNAIDS), university collaborators, and other nongovernmental organizations (NGOs), DHAPP’s mission is to build capable military partners through military-specific, culturally focused, HIV/AIDS cooperation and assistance.

In the Defense Security Cooperation Agency guidance, the US Secretary of Defense has identified HIV/AIDS in foreign militaries as a national security issue. Pursuing HIV/AIDS activities with foreign militaries is clearly tied to security interests, regional stability, humanitarian concerns, counterterrorism, and peacekeeping efforts due to the impact of HIV/AIDS as a destabilizing factor in developing societies. DHAPP employs an integrated bilateral and regional strategy for HIV/AIDS cooperation and security assistance. DHAPP implements bilateral and regional strategies in coordination with respective Combatant Commands (COCOMs) and Country Support Teams to offer military-to-military HIV/AIDS program assistance using country priorities set by the US Under Secretary of Defense for Policy and by the Office of the Global AIDS Coordinator. DHAPP provides strategic information and supports defense forces in HIV prevention, care, and treatment for HIV-infected individuals and their families.

On October 1, 2013, DoD established the Defense Health Agency (DHA) as part of the U.S.

Military Health System governance reform. DHA is a joint, integrated Combat Support Agency that enables the Army, Navy, and Air Force medical services to provide a medically ready force and ready medical force to COCOMs in both peacetime and wartime. In July 2014, the Deputy

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

Secretary of Defense approved the realignment of medical Executive Agent organizations to DHA, including DHAPP. The transition to DHA from the Secretary of the Navy was completed on August 20, 2017. DHAPP is now a division under the Research and Development (J-9) Directorate and continues to be cornerstone of the global health engagement portfolio delivering solutions to COCOMs. The DHAPP headquarters office remains at Naval Base Point Loma in San Diego, California.

In 2014, PEPFAR moved from an “emergency” response to a strategy focused on sustainable control of the HIV epidemic. In doing so, PEPFAR adopted the United Nations Programme on HIV/AIDS (UNAIDS) global 90-90-90 goals that state by 2020: 90% of people with HIV are diagnosed, 90% of them are on ART and 90% of them are virally suppressed. DHAPP shifted with PEPFAR in how Monitoring, Evaluation, and Reporting (MER) indicators are collected and reported to efficiently use data to drive decision-making and focus HIV programming in the right geographic areas. DHAPP collects MER indicator results on a quarterly and semi-annual basis, and data is reported at the site level. This data allows DHAPP to understand the gaps in programming and needs for shifts to reach our shared goals. Due to security sensitivities regarding military site locations and troop movement, all site-level data is analyzed at DHAPP headquarters and summary data is collected by the Office of the Global AIDS Coordinator so each USG country team can review military program results at the national level.

In fiscal year (FY) 2017, DHAPP supported 56 national HIV programs, mainly through direct military-to-military cooperation in addition to support from contracting external organizations and academic institutions to assist with specific aspects of proposed programs. Partners in FY17 included 54 NGOs and universities working in 55 countries.

Budget

Phase 1 Phase 2 Phase 3 Phase 4 Total Care & Treatment 75,000 75,000 75,000 75,000 300,000 HTXS- Adult Treatment

75,000 75,000 75,000 75,000 300,000

Health Systems Strengthening

100,000 100,000 100,000 100,000 400,000

OHSS- Health Systems Strengthening HVSI- Strategic Information

75,000

25,000

75,000

25,000

75,000

25,000

75,000

25,000

75,000

25,000

TOTAL 175,000 175,000 175,000 175,000 700,000

Approaches to Reaching Sustainable Epidemic Control

Proposals are requested to support the Armed Forces of the Dominican Republic to reach sustainable control of the HIV/AIDS epidemic through the pillars of transparency, accountability, and impact.

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

The TBD partner’s program should emphasize capacity building across all activities and technical areas. All proposals should detail how the partner will engage the partner military leadership as well as personnel at all levels in this work; and, specifically how the partner will utilize the organizational structure of the military to strengthen the internal capacity of the these countries, the DOD adult and pediatric treatment program manager based at the Military Health Department, other DHAPP supported implementing partners working in these countries, other bilateral and multilateral agencies with similar objectives and the DHAPP

Targets

Progress towards epidemic control will be successfully measured, in part, through an effective strategic information framework that not only monitors program outputs, but also key outcomes and programmatic impact.

Collection and use of disaggregated data that characterizes the populations served in the lowest geographic areas where HIV services are being provided is critical in understanding current program performance and planning for future performance. Consequently, the Monitoring, Evaluation, and Reporting (MER) indicators continue to evolve in order to reflect the progression of U.S. government (USG) support and global HIV response guidelines.

Measuring the impact of support at national and regional above-site levels down to direct services at the site-level is paramount to DHAPP’s program implementation and monitoring approach.

MER indicators are not an exhaustive list of all metrics that should be monitored by DHAPP-supported programs. These programs should continually monitor and assess any acute programmatic issues and collect additional data to inform program improvement.

The indicators listed below strives to drive program monitoring to a more patient-centered approach. Per the 2017 WHO Consolidated Guidelines on Person-Centred HIV Patient Monitoring and Case Surveillance, person-centered monitoring refers to a shift from monitoring measuring services (e.g., the number of individuals tested or people on treatment) to monitoring people at the center of their access to linked HIV and health services. In essence, this marks a shift to better support the clients accessing services by focusing more on their individual health outcomes.

The proposal will address approaches to reaching the following targets for military and civilian populations.

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

Number of individuals who were identified and tested using Index testing services and received their results Number of individuals who received HIV Testing Services (HTS) and received their test results Number of individuals who received HIV Testing Services (HTS) and received their positive test results

Number of adults and children currently receiving antiretroviral therapy (ART) Number of adults and children newly enrolled on antiretroviral therapy

(ART)

Viral Suppression

TX_PVLS

Percentage of ART patients with a suppressed viral load (VL) result (<1000 copies/ml) documented in the medical or laboratory records/laboratory information systems (LIS) within the past 12 months

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

Technical Narrative The IP will address the technical approach to each area. The IP will be responsible for providing the following in close collaboration with other DHAPP-funded implementing partners and the host military.

HIV Testing Services

Finding the remaining persons who are living with HIV infection is the first priority for reaching HIV epidemic control. Current data shows that the most effective strategy for case-finding is through testing of sexual partners of PLHIV as well as children of HIV+ mothers. The FFAARD HIV/AIDS program is strategically placed to reach these individuals through improving index testing services within the HIV treatment centers at 2 Military Hospitals in an effort to assist the MOH in achieving the “first 90”: 90% of all priority populations living with HIV know their status.

HTS will focus primarily on index testing to provide high yield testing to those most at risk for infection. The local epidemiology and situational analysis should guide the use of other testing methodologies to identify those who are living with HIV.

Provider-Initiated Testing and Counseling (PITC) will continue in the fixed sites for both the military and civilian cohorts. PITC should focus in clinical areas that have shown a high yield such as TB and STI clinics.

Ensuring that any positives identified are linked to HIV care and treatment is essential to the success of the FFAARD program. The IP will monitor HIV index testing yield; modifying strategies or locations that are not identifying and/or linking significant numbers of HIV positive persons to HIV care and treatment.

The IP will be responsible for:

• Technical Assistance for Index testing at both military hospitals o Train testers to implement stigma-free and confidential index testing and provide monitoring and mentoring to ensure continued efficacy of program.

o Diagnosing 125 PLHIV through index testing with all of those diagnosed linked to

HIV care and treatment services and offered same day initiation on ART.

o Index-case testing for all sexual partners of HIV-infected military personnel and civilians o Index-case testing for all children under 15 years of age with HIV infected mothers.

o Appropriate confidential tools to accurately track new contacts

HIV Treatment Dolutegravir (DTG)-containing regimens are the preferred first-line antiretroviral therapies (ART) due to superior efficacy, tolerability and higher threshold for resistance compared to efavirenz (EFV)-containing regimens. The fixed dose combination (FDC) of tenofovir disoproxil fumarate/lamivudine/dolutegravir (TLD) is currently priced as the least expensive FDC, and it is expected that prices will go down as generic manufacturing scales up. For these reasons, DHAPP now recommends TLD as the preferred option for ART, and further recommends that

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for

DHAPP-supported programs switch over to TLD as soon as possible in a coordinated fashion as supply becomes available.

Programs should carefully assess the risks and benefits of TLD in child-bearing age women.

See published updated from WHO and PEPFAR to further understand the high benefits in the face of a potential NTD signal.

Children (< 20kg) are not expected to be included in the initial roll-out of TLD. Development of pediatric DTG formulations and evaluation of appropriate DTG dosing in infants and children are underway.

A priority of HIV programs is to find, diagnose and treat people with tuberculosis (TB) disease and ensure that they become non-infectious. For all those who do not have active tuberculosis, prevention of TB is a priority using nationally approved TB preventive therapy.

TB preventive therapy (TPT) must be scaled up for all PLHIVs as an integral part of the clinical care package. IPs are expected to increase the use of TB diagnostic testing within DHAPP-supported HIV care and treatment facilities and promote the use of TPT as a routine part of HIV care. In short, all newly diagnosed HIV persons should be offered TB treatment or preventive therapy and all persons assessed for TB should be tested for HIV.

Programs should have clear policies and/or guidelines for the use of TPT, and should plan for programmatic and clinical trainings, procurement and supply management, adequate diagnostic capacity (including specimen transportation) and development of appropriate data collection systems. In Global Fund high-impact countries implementing joint TB/HIV grants, IPs should also seek opportunities to support effective joint program implementation.

Additionally, IPs should implement TB infection prevention and control activities to minimize the risk of TB transmission and provide safe health seeking environment. This is critical in DHAPP-supported settings where clients at high risk for TB and HIV often co-mingle. It also puts the health care workers at the highest risk of contracting TB disease. Activities aimed at preventing transmission at facility-level include administrative and environmental controls, and the availability and use of personal protective equipment.

Sustained viral suppression of all PLHIV is the key to HIV epidemic control. To this end, the IP will work closely with the XDF to scale-up viral load testing coverage and suppression in an effort to achieve 90-90-90 goals for military personnel. Targets for HIV/AIDS care and treatment will focus on generating significant progress towards the third 90: 90% viral suppression among PLHIV taking ART.

The IP should ensure the partner military has access to timely VL testing and that capacity exists to test at least 90% of persons currently on ART annually. To ensure this capacity the appropriate use of both plasma and dried blood spots (DBS) should be considered to increase access to routine viral load monitoring.

DBS are easy to collect and store under field conditions, no phlebotomist required, easy to transport to centralized laboratories, reduced cost associated with collection materials and transportation under ambient temperature. The DBS technology is applicable to both adult and pediatric populations and the small volume of blood required for preparing DBS makes it suitable for pediatric populations.

The IP will ensure that VL results are made available in a reasonable amount of time to both

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for the health care provider and the client. These results should be used to ensure that those who are not virally suppressed are linked to adherence support and close follow-up leading to either suppression or ART modification as needed. Those who are suppressed should be encouraged to stay suppressed and should be offered differentiated models of care including multi-month supplies of ART and fast-tracking as an incentive and given the message that undetectable equals untransmittable (U=U).

• Adherence: IP will support the FFAARD in designing and implementing strategies to improve adherence to treatment and removing barriers to treatment, especially among the migrant population. Strategies should include but are not limited to:

o Improved patient tracking system including documentation tools o Development and execution of patient reintegration plan for all patients lost to follow up o Implementation of multi-month scripting and patient mentors to reduce loss to follow-up

• Technical Assistance to support the FFAARD in Quality Assurance of treatment to include but not limited to the following activities:

o IP to guide monthly rounds to review significant morbidity or mortality outcomes, including improvement plans o Identify areas for improvement through rounds and tracking tool o IP to collaborate with FFAARD MIHTP (Military International HIV Training

Program) graduates to train providers in identified areas for improvement.

o ART Monitoring and Evaluation and Reporting utilizing MOH and PEPFAR tools TA for commodities consumption forecasting and supply management including improving communication pathways with MOH and budget forecasting to ensure programs can adequately care for current patients and absorb new patients without strain to the healthcare system or detriment to quality of care.

Viral Load Scale-up

Sustained viral suppression of all PLHIV is the key to HIV epidemic control. To this end, the IP will work closely with the XDF to scale-up viral load testing coverage and suppression in an effort to achieve 90-90-90 goals for military personnel. Targets for HIV/AIDS care and treatment will focus on generating significant progress towards the third 90: 90% viral suppression among PLHIV taking ART.

The IP should ensure the partner military has access to timely VL testing and that capacity exists to test at least 90% of persons currently on ART annually. To ensure this capacity the appropriate use of both plasma and dried blood spots (DBS) should be considered to increase access to routine viral load monitoring.

DBS are easy to collect and store under field conditions, no phlebotomist required, easy to transportation under ambient temperature. The DBS technology is applicable to both adult and

Amendment #04, N00244-19-S-F002 (FY19 – FY20 DHAPP: Military Specific HIV/AIDS Prevention, Care, and Treatment Program for pediatric populations and the small volume of blood required for preparing DBS makes it suitable for pediatric populations.

The IP will ensure that VL results are made available in a reasonable amount of time to both the health care provider and the client. These results should be used to ensure that those who are not virally suppressed are linked to adherence support and close follow-up leading to either suppression or ART modification as needed.