FILOVC RFA-FINAL.pdf

U.S. Agency for International Development U.S.A. Postal Address Av. de Marginal 5467 Tel: (258) 84 095 8000 2330 Maputo Place P.O. Box 783 U.S. Department of State Maputo, Mozambique www.usaid.gov/mz Washington, D.C. 20521-

Issue Date: February 10, 2022

Deadline for Questions: February 17, 2022 at 17:00 pm (Maputo Time)

Closing Date & Time to submit applications: March 14, 2022 at 10:00 am (Maputo Time)

Subject: Notice of Funding Opportunity (NOFO)

Request For Application (RFA) Number:

72065622RFA00005

Program Title: USAID’s Facilitating Impact that Lasts for Orphans and

Vulnerable Children (FILOVC) Local Activity in Mozambique

Catalog of Federal Domestic Assistance (CFDA) Number: 98.001

Ladies/Gentlemen:

The United States Agency for International Development (USAID) is seeking applications for a Cooperative Agreement from qualified entities to improve the health of children and adolescents at risk to and/or significantly impacted by Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) in Mozambique in support of USAID/Mozambique’s Country Development Cooperation Strategy (CDCS) 2020-2025.

USAID intends to provide approximately $48,000,000.00 in total USAID funding over a 5 (five) year period.

Eligibility for this RFA is restricted to Local Mozambican Organizations (Local Entities) as defined below:

For the purpose of this section, local entity means an individual, a corporation, a nonprofit organization, or another body of persons that:

(1) is legally organized under the laws of Mozambique;

(2) has as its principal place of business or operations in Mozambique;

(3) is majority owned by individuals who are citizens or lawful permanent residents of;

and

(4) managed by a governing body, the majority of who are citizens or lawful permanent residents of a country receiving assistance from funds appropriated under title III of this Act. (c)

For purposes of this section, “majority-owned’ and “-managed by” include, without limitation, beneficiary interests and the power, either directly or indirectly, whether exercisable, to control the election, appointment, or tenure of the organization's managers or a majority of the organization's governing body by any means.

72065622RFA00003 USAID HIV Key & Priority Populations (KPP) Local Activity in Mozambique

These eligibility requirements apply only to the principal Applicant.

USAID intends to make one or multiple awards to the applicant(s) who best meets the objectives of this funding opportunity based on the merit review criteria described in this RFA subject to a risk assessment and funds availability. Eligible parties interested in submitting an application are encouraged to read this RFA thoroughly to understand the type of program sought, application submission requirements and selection processes.

To be eligible for award, the applicant must provide all information as required in this RFA and meet eligibility standards in Section C of this RFA. This funding opportunity is posted on www.grants.gov, and may be amended. It is the responsibility of the applicant to regularly check the website to ensure they have the latest information pertaining to this notice of funding opportunity and to ensure that the RFA has been received from the internet in its entirety. USAID bears no responsibility for data errors resulting from transmission or conversion processes. If you have difficulty registering on www.grants.gov or accessing the RFA, please contact the Grants.gov Helpdesk at 1-800-518-4726 or via email at support@grants.gov for technical assistance.

USAID may not award to an applicant unless the applicant has complied with all applicable unique entity identifiers and System for Award Management (SAM) requirements detailed in Section D.7.f. The registration process may take many weeks to complete. Therefore, applicants are encouraged to begin registration early in the process.

Please send any questions to the points of contact identified in Section D. The deadline for questions is shown above. Responses to questions received prior to the deadline will be furnished to all potential applicants through an amendment to this notice posted to www.grants.gov.

Issuance of this notice of funding opportunity does not constitute an award commitment on the part of the Government nor does it commit the Government to pay for any costs incurred in preparation or submission of comments/suggestions or an application. Applications are submitted at the risk of the applicant. All preparation and submission costs are at the applicant’s expense.

Thank you for your interest in USAID programs.

Sincerely, Patrice Lopez Agreement Officer

Attachment 1: MOZ Activity MEL Plan Template FINAL 08-30-21 http://www.grants.gov/ http://www.grants.gov/ mailto:support@grants.gov http://www.grants.gov/

72065622RFA00005 USAID’s Facilitating Impact that Lasts for Orphans and Vulnerable Children (FILOVC) Local Activity in Mozambique

Table of Content

SECTION A: PROGRAM DESCRIPTION 4

SECTION B: FEDERAL AWARD INFORMATION 51

SECTION C: ELIGIBILITY INFORMATION 53

SECTION D: APPLICATION AND SUBMISSION INFORMATION 54

SECTION E: APPLICATION REVIEW INFORMATION 77

SECTION F: FEDERAL AWARD ADMINISTRATION INFORMATION 81

SECTION G: FEDERAL AWARDING AGENCY CONTACTS 87

SECTION H: OTHER INFORMATION 88

ANNEX 1 - SUMMARY BUDGET TEMPLATE 89

ANNEX 2 - STANDARD PROVISIONS 90

ANNEX 3 - WORKPLAN TEMPLATE 93

ANNEX 4 – RFA WEBSITE LINKS 93

SECTION A: PROGRAM DESCRIPTION

Acronym List ADS Automated Directives System AGYW Adolescent Girls and Young Women AIDS Acquired Immunodeficiency Syndrome AO Agreement Officer AOR Agreement Officer’s Representative ART Antiretroviral Therapy C/ALHIV Children and Adolescents Living with HIV CA Cooperative Agreement CBO Community-based Organization CCPC Community Child Protection Committee CCS Centro de Colaboração em Saúde CDC U.S. Centers for Disease Control and Prevention CDCS Country Development Cooperation Strategy CLA Collaborating, Learning, and Adapting CNCS National AIDS Council (Conselho Nacional do Combate ao Sida) COP Country Operational Plan CoP Chief of Party CRC Convention on the Rights of the Child CRM Climate Risk Management CSO Civil Society Organization C-TIP Counter Trafficking in Persons DHS Demographic and Health Survey DO Development Objective DoD Department of Defense DoS Department of State DQA Data Quality Audit DREAMS Determined, Resilient, Educated, AIDS-Free, Mentored, and Safe DSD Direct Service Delivery EMMP Environmental Mitigation and Monitoring Plan

ENSSB National Strategy for Basic Social Security (Estratégia Nacional de Segurança Social Básica)

EO Executive Order EPTS Electronic Patient Tracking System FBO Faith-based Organization FDC Fundação para o Desenvolvimento da Comunidade

FFR Federal Financial Reporting Form FILOVC Facilitating Impact that Lasts for Orphans and Vulnerable Children FP Family Planning FY Fiscal Year FSW Female Sex Worker GBV Gender-based Violence GF Global Fund to Fight AIDS, Tuberculosis, and Malaria GRM Government of the Republic of Mozambique HCW Healthcare Worker HEI HIV-Exposed Infant HIV Human Immunodeficiency Virus HTS HIV Testing Services IC-HTS Index Case HIV Testing Services IEE Initial Environmental Examination IP Implementing Partner IR Intermediate Result J2SR Journey to Self-Reliance KP Key Population KPP Key and Priority Population LOE Level of Effort LTFU Loss to Follow-up M&E Monitoring and Evaluation MCH Maternal and Child Health MEL Monitoring, Evaluation, and Learning MELP Monitoring, Evaluation, and Learning Plan MER Monitoring, Evaluation, and Reporting MGCAS Ministry of Gender, Children, and Social Action MISAU Ministry of Health MOU Memorandum/Memoranda of Understanding MSM Men Who Have Sex with Men NGO Non-Governmental Organization OVC Orphans and Vulnerable Children PAD Project Appraisal Document PD Program Description PEN IV National Strategic Plan Against HIV/AIDS IV PEP Post-Exposure Prophylaxis

PEPFAR U.S. President’s Emergency Plan for AIDS Relief PLHIV People Living with HIV PMI Presidential Malaria Initiative PMTCT Prevention of Mother to Child Transmission PNAC II National Plan of Action for Children II PrEP Pre-Exposure Prophylaxis PWID Persons Who Inject Drugs Q Quarter RFA Request for Application RRF Rapid Response Fund SAAJ Adolescent and Youth-Friendly Services (Serviço Amigo do Adolescente e Jovem) SD Service Delivery SDG Sustainable Development Goal SOP Standard Operating Procedure SRH Sexual and Reproductive Health STI Sexually Transmitted Infection STIP Science, Technology, Innovation, and Partnership TB Tuberculosis TD Technical Director U.S. United States UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNICEF United Nations Children's Fund USAID United States Agency for International Development USG United States Government VAC Violence Against Children VL Viral Load VMMC Voluntary Medical Male Circumcision WASH Water, Sanitation, and Hygiene WHO World Health Organization

This funding opportunity is authorized under the Foreign Assistance Act (FAA) of 1961, as amended. The resulting award will be subject to 2 CFR 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, and USAID’s supplement, 2 CFR 700, as well as the additional requirements found in Section F.

1. Introduction

Alignment with USAID/Mozambique Development Goals

The purpose of this RFA is to solicit applications from eligible Applicants to award a five-year Cooperative Agreement (CA) for USAID’s Facilitating Impact that Lasts for Orphans and Vulnerable Children (FILOVC) Local Activity in Mozambique with a maximum ceiling of US$48,000,000. USAID requests that all Applicants use this activity name in their applications.

The overall goal of the activity is to “improve the health of children and adolescents highly vulnerable to and/or significantly impacted by Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) in Mozambique.” The focus of the program will be on identifying and supporting children highly vulnerable to HIV acquisition, children and adolescents living with HIV (C/ALHIV), and children impacted by HIV-related morbidity or mortality among one or more primary caregivers. Elevated vulnerability to HIV acquisition can result from geographic, socio-demographic, and/or specific risk behavior profiles, which merit tailored HIV prevention and/or mitigation interventions, in accordance with available epidemiologic evidence, implementation best practices, and national guidelines (see Section A.2. below for more details).

This goal directly supports the Results Framework for USAID/Mozambique’s Country Development Cooperation Strategy (CDCS) for the 2020-2025 period, as shown in Figure A.1 below. Specifically, the activity will address CDCS Development Objective (DO) 1:

“Healthier and better educated Mozambicans, especially the young and vulnerable” and intermediate results (IRs) 1.1 and 1.2 (quality and utilization of health and education services improved, focusing on youth and gender).1

Figure 1. USAID CDCS 2020-2025 Results Framework

Given the strong linkages between health, food security, nutrition, and water, sanitation, and hygiene (WASH), the FILOVC Local Activity will also coordinate with and, where

1 https://www.usaid.gov/sites/default/files/documents/CDCS-Mozambique-December-2025.pdf https://www.usaid.gov/sites/default/files/documents/CDCS-Mozambique-December-2025.pdf appropriate, layer and sequence upon, household nutrition and food security activities in support of DO 3; especially IR 3.1. Efforts in DO 1 will complement and benefit from DO 3 work to strengthen the resilience of vulnerable populations to economic, climate-related, or pandemic-related shocks.

The specific objective of the USAID FILOVC Local Activity is to “contribute to reduced pediatric HIV incidence and HIV-related child morbidity and mortality within FILOVC Local Activity-supported districts.”

The activity will aim to improve the coverage of highly vulnerable children and adolescents enrolled in OVC activities and will closely monitor the impact of these activities to ensure they translate into improved risk behaviors or HIV clinical outcomes for OVC beneficiaries.

Improving nutritional and educational outcomes will also be important, as they are precursors to improved health and HIV clinical outcomes, especially among HIV-positive OVC beneficiaries.

The selected Applicant(s) for this activity will work in nine provinces of Mozambique (Cabo Delgado, Gaza, Inhambane, Maputo City, Maputo Province, Nampula, Niassa, Sofala, and Tete). The Applicant(s) will support the Government of the Republic of Mozambique’s (GRM) national response to HIV and national action plans for child protection and social welfare while providing comprehensive, high quality, and cost-effective services and assistance to meet the Activity’s objectives.

The USAID FILOVC Local Activity will perform in priority districts within the provinces mentioned above, as per the guidance provided by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and in consultation with the GRM’s Ministry of Health (MISAU), National AIDS Council (CNCS), and Ministry of Gender, Children, and Social Action (MGCAS). Priority districts will be reviewed and revised based on available epidemiological evidence on an annual basis as part of the PEPFAR Country Operational Plan (COP) planning process.

The guiding theme for this award will be: “Engage, Prioritize, Support, & Sustain.” USAID envisions a combination of four integrated activity components:

a) Engage children and adolescents aged 9-14 in effective HIV prevention activities that reduce risky behaviors, referring those needing additional support to appropriate health and social services.

b) Prioritize (screen, assess, and/or test) highly vulnerable minors and their caregivers, as well as all eligible C/ALHIV, and enroll them in comprehensive OVC case management services tailored to address their unique needs, ensuring 81% or greater OVC coverage of C/ALHIV on antiretroviral therapy (ART) within activity-supported districts.2

c) Support and continually monitor and improve the quality and effectiveness of OVC case management services to ensure household-level resilience and beneficiary health outcomes improve.

2 PEPFAR Technical Guidance recommends that 90% of C/ALHIV enrolled in ART services within OVC program catchment areas also receive an offer for OVC service enrollment. In addition, PEPFAR aims for 90% acceptance/uptake among those C/ALHIV who receive an offer for OVC services. This translates into 81% coverage (90% x 90% = 81%).

d) Sustain gains in child health indicators and bolster household-level resilience by contributing to the strengthening of national child protection systems and institutions at all levels.

Orphans and Vulnerable Children Intervention Type Definitions

One of PEPFAR’s original mandates is to care for “children who have lost a parent to HIV/AIDS, who are otherwise directly affected by the disease, or who live in areas of high HIV prevalence and may be vulnerable to the disease or its socioeconomic effects.”3 To meet this mandate, PEPFAR’s OVC programming serves the dual purposes of mitigating the impact of HIV on children and adolescents and their families, as well as preventing HIV-related morbidity and mortality. Given these dual purposes, and given the dynamic epidemiological context in Mozambique, the FILOVC Local Activity will use three distinct intervention types. Each intervention type is designed for slightly different yet overlapping OVC beneficiary sub-groups. Individual OVC may participate in any or all intervention types at a given time.

Figure 2. OVC Intervention Types and Intended Beneficiaries

For the first OVC intervention type (Preventive), the definition of eligible OVC includes all male and female adolescents aged 9-14 who reside within FILOVC Local Activity-supported priority districts.

For the second OVC intervention type (Comprehensive), the age range is larger (0-17), but the definition of eligible beneficiaries is narrower. In addition to limiting this intervention to beneficiaries located in priority districts, only those children at elevated risk for HIV acquisition, at elevated risk of HIV-related morbidity or mortality, or those facing significant health or developmental challenges due to HIV-related impacts are eligible. This group includes any and all children who meet the following criteria:

● Children and adolescents living with HIV

● Children whose caregiver(s) are people living with HIV (PLHIV)

● HIV-exposed infants (HEI) who have ever interrupted treatment

3 PEPFAR 2009 Reauthorization Act. Reauthorization Act of 2008. “The Lantos-Hyde Act.”

Available at: https://www.congress.gov/110/plaws/publ293/PLAW-110publ293.pdf https://www.congress.gov/110/plaws/publ293/PLAW-110publ293.pdf

● Children with one or more deceased primary caregivers, regardless of cause of death

● Children living in child-headed households

● Children of female sex workers (FSW) and/or children of other key populations (KP)4

● Children who have experienced violence and/or are at risk of gender-based violence

(GBV)

● Children displaced by social or political instability, including civil unrest

Poverty and malnutrition continue to be significant contributing factors for myriad health and development challenges among children and families in Mozambique.5 The link between economic distress at the household or community-level and poor HIV-related health outcomes in Mozambique has been well established.6 However, neither individual nor household-level poverty alone is considered sufficient criteria for participation in the OVC Comprehensive intervention type. This marks a departure from previous OVC activities in the past, in which poverty-stricken families could receive OVC case management, even in the absence of elevated HIV prevalence in the area or HIV-specific risk factors in the home.

The rationale for this more epidemiologically driven focus on HIV-infected and HIV-affected children is grounded in Mozambique’s current urgent pediatric HIV crisis, which needs immediate attention and support.

The third OVC intervention type (Determined, Resilient, Educated, AIDS-Free, Mentored, and Safe, or DREAMS) is focused on adolescent girls and young women (AGYW) aged 10-17 living in districts with highly elevated HIV incidence.

While OVC beneficiaries may participate in any and all of these intervention types, the recipient(s) of this FILOVC Local Activity award will be expected to assess, categorize, and prioritize OVC beneficiaries according to the intervention type that will result in the greatest overall health and development outcomes, for the greatest number of beneficiaries.

2. Development Context HIV Epidemic and Pediatric HIV Emergency

Mozambique, populated by approximately 32.5 million people, is challenged by a devastating generalized HIV epidemic.7 Current estimates from the Joint United Nations Programme on HIV/AIDS (UNAIDS) indicate that nearly 100,000 Mozambicans were newly infected with HIV in 2021, and 37,000 people died from an AIDS-related illness. National HIV prevalence is estimated to be 13.2%,8 with substantial geographic variation, ranging from less than 5% in

4 For the Mozambican context this includes female sex workers (FSW), men who have sex with men (MSM), persons who inject drugs (PWID), and people in enclosed settings (prisoners).

5 Rose ES, Blevins M, González-Calvo L, Ndatimana E, Green AF, Lopez M, Olupona O, Vermund SH, Moon TD. Determinants of undernutrition among children aged 6 to 59 months in rural Zambézia Province, Mozambique: Results of two population-based serial cross-sectional surveys. BMC Nutr.

2015;1:41. doi: 10.1186/s40795-015-0039-1. Epub 2015 Dec 17. PMID: 27182448; PMCID:

PMC4864006.

6Filimão DBC, Moon TD, Senise JF, Diaz, RS, Sidat M, Castelo A (2019). Individual factors associated with time to non-adherence to ART pick-up within HIV care and treatment services in three health facilities of Zambezia Province, Mozambique. PLoS ONE 14(3): e0213804.

https://doi.org/10.1371/journal.pone.0213804 7 Censo 2017 - http://www.ine.gov.mz/ 8UNAIDS Country Update, Mozambique. Based on updated Spectrum Estimates, 2020. Found at:

http://unaids.mio.guru/en/regionscountries/countries/mozambique https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4864006/pdf/nihms783424.pdf https://doi.org/10.1371/journal.pone.0213804 http://unaids.mio.guru/en/regionscountries/countries/mozambique

Tete Province to nearly 24% in Gaza Province.9 National HIV control strategies are focused on expanding testing and supporting linkage and adherence to life-saving ART. Nonetheless, nearly one-third of the estimated 2.1 million PLHIV in Mozambique are not accessing ART.

Low ART coverage leads to continued morbidity and mortality, as well as the continued spread of new infections.

The HIV epidemic has already contributed to a significant reduction in life expectancy among Mozambicans,10 and it has resulted in an estimated 920,000 orphaned children.11 Over the past two decades, the number of children who have lost one or both parents to an HIV-related death has steadily declined in most countries in sub-Saharan Africa, thanks to the widespread availability and uptake of life-saving ART. Unfortunately, as seen in Figure B.1 below, Mozambique stands out within the region as the country with the highest number of additional orphans each year due to HIV-related deaths.

Figure 3. Trends in Orphaning Due to HIV/AIDS12

There are currently an estimated 130,000 children and adolescents under the age of 18 living with HIV in Mozambique.13 Of these, approximately 84,000 (68%) are currently receiving ART medication. Every year, more than 6,000 children die due to AIDS-related complications, and thousands more are left orphaned by parents who succumb to the disease.

Viral load (VL) suppression rates, a measure of the real-life effectiveness of ART, remain at a critically low 47% among children and adolescents, reflecting an urgent need for improved ART regimens and dedicated, evidence-based pediatric retention programming that accounts for the unique needs of C/ALHIV in Mozambique.14

9 DHS Program - Mozambique AIS, 2015 - Final Report 10 World Health Organization (WHO) Mozambique. 2019 - https://www.who.int/countries/moz/en/ 11 UNAIDS. Mozambique 2019 - http://www.unaids.org/en/regionscountries/countries/mozambique 12 PEPFAR COP21 Technical Guidance, data from UNAIDS 2020 estimates.

13 UNAIDS 2020 estimates, adjusted for age to account for 18–20-year-olds using available ART modeling data.

14 PEPFAR. Mozambique Country Operational Plan 2021 (COP21).

Newer and more effective dolutegravir-based pediatric treatment regimens have demonstrated reductions on pediatric AIDS-related morbidity, and these are being quickly scaled-up in Mozambique.15 Nonetheless, additional efforts are needed to support caregivers and families in providing C/ALHIV with appropriate dosing regimens and the accompanying nutrition that these medications require.

Pediatric case finding, linkage, and retention remain central priorities for MISAU.16 PEPFAR and other donors actively support MISAU in accelerating and expanding pediatric HIV testing and treatment, yet current case-finding and referral programs are often not equipped to address the underlying barriers that prevent the most vulnerable children and caregivers from accessing and remaining engaged in effective HIV treatment. More comprehensive strategies are needed that can provide tailored support to the thousands of families currently underserved due to extreme poverty, limited access to health information or formal education, as well as social, cultural, or geospatial isolation.

Economic Vulnerability and the Youth Bulge

Mozambique’s economic vulnerability significantly impedes an effective response to the pediatric HIV crisis at the national, local, and household level. Mozambique is currently one of the poorest countries in the world, ranking 181 out of 189 countries on the United Nations (UN) Human Development Index in 2020. The adult (15-49 years) male literacy rate is 70%, while the adult female literacy rate is just 40%.17 With over 60% of Mozambicans living below or just above the poverty line, regular economic and environmental shocks leave most of the population at risk of either becoming poor or sinking deeper into poverty. Studies of the factors limiting ART adherence have identified economic obstacles, including financial barriers to procuring food and transportation, as among the most common and important drivers of treatment discontinuation.18 Multiple, successive waves of the COVID-19 pandemic in 2020 and 2021 brought death and economic devastation to communities throughout Mozambique, weakening an already vulnerable economy, with consequences that have yet to be fully realized or understood.

More than half of Mozambique’s overall population is estimated to be under 17 years of age.19 Of these, it is estimated that 48% (more than five million children) currently live in absolute poverty,20 and 2.1 million children are considered orphans, with one or more parents deceased.21,22 Another 700,000 children are estimated to be at risk of abandonment due to having elderly caregivers, HIV disease in the family, and/or deteriorating socioeconomic circumstances. A survey conducted in 2011 showed that 24% of children aged 5 to 14 years old worked in some form to generate income for themselves or their family.23 Recent census

15 Snedecor, S.J., Radford, M., Kratochvil, D. et al. Comparative efficacy and safety of dolutegravir relative to common core agents in treatment-naïve patients infected with HIV-1: a systematic review and network meta-analysis. BMC Infect Dis 19, 484 (2019). https://doi.org/10.1186/s12879-019- 3975-6 16 Ministry of Health. Annual HIV/AIDS Activity Report. 2018 17 UNDP. Human Development Indices and Indicators: 2018 Statistical Updates. 2011 18 Groh et al. BMC Public Health 2011, 11:650. http://www.biomedcentral.com/1471-2458/11/650 19 Censo 2017 - Available for download here.

20 https://www.unicef.org/mozambique/protec%C3%A7%C3%A3o-da-crian%C3%A7a 21 SOS Children’s Villages International, 2017 22 Ministry of Health. IMASIDA, 2015 23 https://www.unicef.org/mozambique/protec%C3%A7%C3%A3o-da-crian%C3%A7a https://doi.org/10.1186/s12879-019-3975-6 https://doi.org/10.1186/s12879-019-3975-6 http://www.biomedcentral.com/1471-2458/11/650 http://www.ine.gov.mz/iv-rgph-2017/mocambique/censo-2017-brochura-dos-resultados-definitivos-do-iv-rgph-nacional.pdf/view https://www.unicef.org/mozambique/protec%C3%A7%C3%A3o-da-crian%C3%A7a https://www.unicef.org/mozambique/protec%C3%A7%C3%A3o-da-crian%C3%A7a data reinforces this finding, indicating that 11,029 children aged 12 to 14 years old were the head of a household, intensifying an already challenging and vulnerable situation.24

Low contraceptive prevalence rates, driven by financial hardship and/or limited access to health care services, have left Mozambique with an exploding population. By the end of 2021, it is forecasted that Mozambique will have the largest youth bulge in the region.25 This sizable, growing youth population is both an opportunity and a challenge. If large segments of the emerging young generation do not have their basic needs met, then country-wide peace, progress, and prosperity may be jeopardized. Additionally, as youth become sexually active, the opportunity to achieve HIV epidemic control becomes elusive, unless comprehensive measures are taken immediately to reduce the pool of PLHIV who do not know their status or are not on HIV treatment and virally suppressed.

New HIV Infections among Children and Adolescents

Since the launch of the National Plan to Eliminate Vertical Transmission of HIV in 2012, Mozambique has made significant progress towards reducing the number of children who contract HIV from their mothers during pregnancy or breastfeeding (i.e., the prevention of mother-to-child transmission, or PMTCT.)26 Nonetheless, despite the successes in expanding HIV treatment for pregnant and lactating women, it is estimated that approximately 11,400 new HIV infections occurred through vertical transmission during 2020.27 Low ART uptake and poor treatment adherence among pregnant and lactating women, which results in poor viral suppression, has been identified as the primary source for these new vertical infections among infants.

Sexual transmission of HIV among adolescents and young people aged 10-24 in Mozambique also continues to present an urgent priority for epidemic control efforts. There were an estimated 50,000 new infections in 2021 among this age group, accounting for roughly 40% of all new infections in the country.28 AGYW aged 15-24 are particularly vulnerable, accounting for three times the number of new infections as compared to males of the same age. Sexual relationships with asymptomatic HIV-positive young men aged 20-29 who are either unaware of their HIV status or not accessing treatment are responsible for 66% of all new HIV infections among AGYW.

Often, these relationships are age-imbalanced, and recent evidence suggests that adolescents aged 10-17 are engaged in risky sexual behavior. A recent survey of nearly two thousand high-school students in Mozambique found that “more than half (57%) ever had sex (68% among boys and 46% among girls); and of these, 42% had early sexual debut (<14 years), 58% had multiple sexual partners, 42% had not used birth control at last sex, 25% had not used a condom at last sex, and 63.7% had engaged in multiple sexual risk behaviours.”29

24 National Statistics Institute (INE). Census. 2017 25Irish Aid. Prospects and Challenges: Mozambique’s Growth and Human Development Outlook to 2040. 2017 26 MISAU, 2020. Plano Nacional de Tripla Eliminação do HIV, Sífilis, Hepatite B em Moçambique, 2020-2024.Available for download here.

27 UNAIDS Spectrum Estimate, 2020. Spectrum Version 5.754.

28 UNAIDS Spectrum Estimate, 2020. Spectrum Version 6.06.

29 Supa Pengpid & Karl Peltzer (2021) Sexual risk behaviour and its correlates among adolescents in Mozambique: results from a national school survey in 2015, SAHARA-J: Journal of Social Aspects of https://www.misau.gov.mz/index.php/planos-estrategicos-do-hiv?download=571:plano-nacional-de-tripla-eliminacao-da-transmissao-vertical-do-hiv-sifilis-e-hepatite-b-em-mocambique-2020-2024

There is an urgent need for expanding primary prevention activities among adolescents living in high HIV prevalence areas, as well as among those with known risk factors for HIV acquisition. While poverty alone is not correlated with increased HIV risk, consumption of alcohol or drugs, as well as low school attendance, orphanhood, and weak family structures (e.g., child-headed families, displacement, etc.) are all associated with increased risk behaviors for HIV and early pregnancy. Expansion of comprehensive support programs is needed to assess, test, link, and retain more children and adolescents in HIV treatment programs. This includes addressing nutrition, school retention, family and peer support, and GBV prevention and mitigation activities for all at-risk adolescents.

Gender Imbalances and Gender-based Violence

Mozambique is ranked 138 of 155 countries in the Gender Inequality Index, with one of the highest child marriage rates in the world. Only 14 percent of women have at least some secondary-school education, compared to 20 percent of men.30 Age-imbalanced sexual relationships also contribute to unhealthy power differentials, which negatively affect female decision-making within the home and lead to differential health and development outcomes.

According to the 2011 Demographic and Health Survey (DHS) in Mozambique, 48% of women aged 20-24 were married or lived with their sexual partners before age 18 and 14% before age 15.31 The UN Children’s Fund (UNICEF) estimates that 40% of girls in Mozambique become mothers for the first time before age 18, while only 4% of boys become fathers by this same age.32 Child marriage endangers girls’ education and exposes these children to higher incidence of domestic violence, marital abuse (including physical, sexual, and/or psychological abuse), and abandonment. Early child marriage (i.e., formal and informal unions involving a minor less than 15 years of age) is a fundamental violation of human rights that denies children the right to health, education, and full social and emotional development. Early pregnancy carries increased risk of serious health complications prior to, during, or after birth, including fistula and infant and/or maternal mortality.

Sexual violence among minors is another gender-based factor that contributes to profound emotional and physical trauma and increases the risk of HIV acquisition among children and adolescents in Mozambique. The full extent of GBV in Mozambique is unknown, as service protocols and reporting procedures are not uniformly available. Further, episodes of GBV, including sexual, physical, and/or emotional violence, are woefully under-reported.

Numerous social and contextual factors contribute to poor uptake of post-exposure prophylaxis (PEP) among GBV survivors, who must receive this treatment during the 72-hour window after a known episode of sexual violence. Nonetheless, efforts are currently underway to launch new national data collection instruments, expand GBV service availability, and improve facility-based service standards countrywide.

Addressing violence against OVC and transforming social norms and practices that are potentially harmful for children requires engagement with and collaboration among a wide range of diverse actors: civil society, traditional and religious leaders, media, youth, and adolescents, including line Ministries and justice system actors. There exists a huge need to

HIV/AIDS, 18:1, 26-32, DOI: 10.1080/17290376.2020.1858947

30 Human Development Report 2020, Mozambique Country Profile, UNDP.

http://hdr.undp.org/en/countries/profiles/MOZ 31 https://www.unicef.org/mozambique/casamento-prematuro-em-mo%C3%A7ambique 32 UNICEF. Early Marriage and Pregnancy in Adolescents in Mozambique: Impact and Causes. 2015 http://hdr.undp.org/en/countries/profiles/MOZ https://www.unicef.org/mozambique/casamento-prematuro-em-mo%C3%A7ambique raise the awareness in communities about the prevalence of abuse and violence, as well as to empower families and children to report and address such violations in a timely manner.

3. Orphans and Vulnerable Children Initiatives and Lessons Learned to Date Government of the Republic of Mozambique’s Response to Orphans and Vulnerable Children

GRM’s OVC strategies and policies are based on international commitments and goals adopted by the host government such as the “Convention on the Rights of the Child” (CRC), the UNAIDS Fast-Track strategy to end the AIDS epidemic (2016-2021), and the UN Sustainable Development Goals (SDGs), as well as national priorities set out in key policy documents such as the National Strategic Plan Against HIV/AIDS IV (PEN IV) and the National Policy on Social Action. PEN V (2021-2025) provides the overall framework for the national response to HIV, identifying OVC and adolescents aged 10-14 as a vulnerable population and issuing MGCAS the mandate to establish standards of practice for any interventions targeting this disadvantaged demographic.

The GRM’s strategic response to the needs of OVC focuses on strengthening community-based efforts to provide better care, support, and protection for OVC. The main guiding document that outlines the GRM’s approach to addressing OVC is the National Plan of Action for Children II (PNAC II) 2013-2019, which outlines the main principles of intervention, targets, and priority actions that have been agreed upon by all major governmental sectors, civil society, and multilateral partners. PNAC II identifies four strategic objectives for the national response to OVC (child survival, development, protection, and participation) and is currently under development for updates.

The GRM’s National Strategy for Basic Social Security (“Estratégia Nacional de Segurança Social Básica,” ENSSB 2016-2024) ensures basic social protection programs for the poorest and most vulnerable groups in Mozambique. The ENSSB aims to reinforce the basic social security system; promote the development of human capital by improving nutrition and access to health and education services including child subsidies; prevent and respond to social risks that mainly affect children, women, the elderly, people with disabilities, and people affected by HIV; and strengthen institutional capacity to implement the first three goals at the central, provincial, and district level.

These strategies support the engagement and participation of communities and citizens, which is also promoted in the broader country development agenda through the decentralization process that foresees community and citizen participation at local, district, and provincial levels in health, humanization, and quality councils.

United States Government Response to Orphans and Vulnerable Children

The United States Government (USG) has funded OVC programs through USAID in Mozambique since the establishment of the PEPFAR in 2003. Multiple PEPFAR awards have driven OVC program innovation over the past 18 years, serving more than one million beneficiaries with nutritional, educational, and financial support, as well as HIV testing and referrals to essential health services. USAID/Mozambique currently supports OVC activities in all eleven provinces of the country, and these efforts are guided by USAID’s global Journey to Self-Reliance (J2SR) strategy document33, PEPFAR’s global COP21 Technical

33 USAID Journey to Self Reliance (J2SR). Strategy available at: https://www.usaid.gov/selfreliance https://www.usaid.gov/selfreliance

Guidance, USAID’s Mozambique-specific 2020-2025 CDCS34, and PEPFAR’s Mozambique-specific 2021 COP. OVC activities are also complemented by non-HIV USG programs such as the Presidential Malaria Initiative (PMI) and maternal and child health (MCH) and family planning (FP) programs.

In recent years, the OVC program in Mozambique has shifted towards greater HIV relevance, with a geographic footprint exclusively in districts with elevated HIV prevalence and a primary goal to enroll at least 80% of all C/ALHIV on ART into the OVC program in these districts by the end of FY2022. Working with in-country stakeholders, the OVC program continues to evolve, with increasing focus on the pediatric treatment gap, the high rate of sexual violence against adolescent girls, and the risk to children of losing a caregiver due to adult interruption in treatment and poor viral suppression. In addition, the OVC program continues to strengthen child protection systems by building the capacity of national institutions to monitor and implement OVC-aligned social safety net programs.

Currently, USAID partner FHI360 operates the flagship OVC program in Mozambique under the activity name COVIDA. This program was launched on June 23, 2016, and will end in September of 2022. The COVIDA program has been instrumental in shifting the OVC portfolio towards improved support for children and adolescents living with or affected directly by HIV. COVIDA has been successful in strengthening systems for monitoring OVC health and development outcomes, as well as standardizing management approaches for front-line OVC case managers and local partners. Some of the key lessons from the COVIDA program to date include a need to:

● Manage and monitor OVC caseloads carefully to avoid case manager burnout

● Train OVC case managers regularly on new pediatric drug regimens and effective support approaches to improve pediatric ART adherence

● Embed professional counseling skills among case managers and front-line OVC workers to facilitate appropriate coaching and support for behavioral interventions

● Incorporate community-based index case HIV testing services (IC-HTS) into community OVC programs to facilitate identification and linkage of HIV-positive children and adolescents

● Incorporate effective economic strengthening activities to address underlying barriers to HIV care, including food insecurity and the high costs of transportation

● Incorporate flexible “social emergency funds” to address acute shocks and financial insecurity at the household level, which can derail health and development gains

DREAMS

In 2015, PEPFAR, the Nike Foundation, and the Bill & Melinda Gates Foundation launched the DREAMS Partnership. This US$210,000,000 partnership is an ambitious effort to decrease the rates of HIV incidence and to mitigate risk to AGYW ages 10-24 years old by 25% in at least ten sub-Saharan African countries, including Mozambique. The PEPFAR/Mozambique DREAMS program has significantly expanded from nine to 32 districts in FY 2021, with a focus on increasing coverage and saturation.

The DREAMS core package of evidence-based interventions aims to reduce new infections in adolescent girls. This includes activities that OVC programs can support and implement, such as education, psychosocial support, and other combinations of socio-economic

34 USAID|Mozambique CDCS. Available at: https://www.usaid.gov/mozambique/cdcs https://www.usaid.gov/mozambique/cdcs approaches. The FILOVC Local Activity shall proactively identify subgroups of girls at high risk of HIV infection in the targeted districts, including out-of-school girls, and incorporate a primary prevention package aligned with the existing DREAMS intervention, which benefits these groups and reduces the risk of exposure to HIV. Lessons learned during the collaboration between the DREAMS and OVC programs to date include the need to:

● Establish formal cross-referral mechanisms with child welfare and protection services, which are essential to identify children at high risk of abuse, neglect, and HIV infection, including children living outside of family care and/or child survivors of abuse; and

● Align and automate data systems to better track OVC and DREAMS participants, including with the national electronic patient tracking system (EPTS) for patients accessing HIV clinical services.

PEPFAR-Supported Clinical Partners

Within each epidemiologically priority district in Mozambique, PEPFAR has identified high-volume health facilities that require significant technical and financial support to provide adequate HIV-related services. PEPFAR, through the U.S. Centers for Disease Control and Prevention (CDC) and USAID, contracts non-governmental implementing partners with clinical expertise to work hand-in-hand with these health facilities. These clinical partners provide seconded human resources and offer direct service delivery (DSD) at most sites, as well as logistical, monitoring and evaluation (M&E), and laboratory support and clinical mentorship for front-line providers. The FILOVC Local Activity Recipient(s) are expected to work closely and in collaboration with the designated PEPFAR-supported clinical partners in all OVC activity districts and health facilities to jointly support the pediatric and adult care and treatment cascade (including retention and viral suppression) for all highly vulnerable individuals identified as eligible for enrollment in comprehensive OVC case management.

Lessons learned to date as part of this ongoing collaboration with PEPFAR-supported clinical partners include:

● Establish Memoranda of Understanding (MOU) with each clinical partner, MISAU at the provincial and district levels, and each health facility; and

● MOUs with PEPFAR clinical partners and MISAU should detail referral procedures, roles, and responsibilities of each party to ensure strong linkage and tailored ART adherence support for vulnerable children, adolescents, and their caregivers.

Mentor Mothers Program

The Mentor Mothers program aims to improve HIV treatment adherence among pregnant and lactating women and children 0-5 years old through the use of highly trained community workers who provide a structured series of household visits to all HIV-positive women within the catchment area. The program also conducts health talks within health facilities and serves as the primary contact for all community work with pregnant and lactating HIV positive women. USAID expects the FILOVC Local Activity Awardee(s) to coordinate closely with Mentor Mothers to ensure all eligible women and children receive this essential support.

Mentor Mothers and OVC activities not only refer to each other, but also collaborate while working in the community together. Community health workers, activists, and Mentor Mothers already have sustained positive, therapeutic relationships with many of the OVC-eligible families. Lessons learned from the collaboration with Mentor Mothers to date include the need for:

● Clear bi-directional referral systems to ensure all C/ALHIV receive the tailored prevention and ART adherence support they need;

● Clear community-based mapping of catchment areas to understand Mentor Mothers and OVC program coverage gaps; and

● Joint planning and regular updates of health facility leadership and community leaders to ensure that all stakeholders understand the roles of Mentor Mothers and OVC case managers thoroughly.

Integrated HIV Prevention and Health Services for Key and Priority Populations

USAID currently supports the implementation of a comprehensive HIV prevention program with key and priority populations (KPP) in all eleven provinces of Mozambique. FHI360 currently implements this program, and a follow-on project will begin starting in September of 2022. Close coordination with the KPP program and the FILOVC Local Activity will be essential considering that children of KP, especially FSWs, are one of the target groups for the comprehensive case management intervention type. Lessons learned as part of this collaboration with the KPP program to date include the need to:

● Support the KP program with risk assessments and goal setting for children of FSWs;

● Coordinate at the national level to understand KP program catchment areas and ensure strong coverage with OVC enrollment for case management activities; and

● Coordinate economic strengthening and other activities with FSWs as caretakers of

OVC within the comprehensive case management intervention.

Non-United States Government Response to Orphans and Vulnerable Children

The Global Fund to Fight AIDS, Tuberculosis, and Malaria

On February 5, 2021, GRM and the Global Fund to Fight AIDS, Tuberculosis (TB), and Malaria (GF) launched six new grants worth US$773,913,181 to fight HIV, TB, and malaria and build resilient and sustainable systems for health. The new grants represent a 49% increase in funding from the previous allocation cycle and will run from 2021-2023. The new grants aim to expand access to HIV, TB, and malaria prevention services, with a focus on key and vulnerable populations, including vulnerable children and youth. The grants will be implemented by MISAU, Fundação para o Desenvolvimento da Comunidade (FDC), Centro de Colaboração em Saúde (CCS), and World Vision International. Targets and activities are already established and include new HIV prevention and testing initiatives for adolescents and young people aged 15-29. Recipient(s) of this FILOVC Local Activity will be expected to coordinate all planning with Global Fund implementing partners closely to avoid duplication and align with MISAU priorities.

UNICEF

Guided by the PNAC II, USAID works in close collaboration with UNICEF, MGCAS, and other actors to ensure effective referral systems are in place to ensure support for vulnerable children who fall outside of any care or support systems. In collaboration with other international and national stakeholders, UNICEF supports the GRM to implement a holistic social and child protection system, including integrated case management that links community-based and statutory structures. Recently, UNICEF partnered with the GRM to develop the National Social Protection Strategy, which contributes to “reducing poverty and vulnerability, ensuring that the results of the growth of the Mozambican economy benefit all citizens, particularly those living in situations of poverty.”

UNAIDS

UNAIDS recently released social protection fast-track guidance, where it describes how social protection can address the multiple social determinants of HIV, including poverty, income inequality, gender inequalities, stigma and discrimination, and social exclusion, and thus contributes to efforts to reduce new HIV infections, AIDS-related deaths, and HIV-related discrimination. This UNAIDS strategy also highlights how social protection can address demand-side barriers to accessing HIV services, with the potential to improve HIV prevention, treatment, care, and outcomes. The strategy also highlights how HIV-sensitive social protection helps mitigate the social and economic impacts of HIV on people, including people living with, at risk of, or affected by HIV.

4. Activity Description

Theory of Change and Results Framework

The proposed FILOVC Local Activity’s ultimate goal is to improve the health of children and adolescents highly vulnerable to and/or significantly impacted by HIV in Mozambique, with the programmatic objective to contribute to reduced pediatric HIV incidence and HIV-related child morbidity and mortality within Activity-supported districts.

Implicit in this stated programmatic objective is the need for continuous monitoring of risk behaviors, new HIV infections, and HIV clinical outcomes (e.g., viral suppression, treatment failure, etc.) among children, adolescents, and caregivers enrolled in OVC programs within Activity-supported districts. The FILOVC Local Activity recipient(s) must work closely with USAID and other PEPFAR and GRM stakeholders to understand the universe of need for each target population within each Activity district.