NOFO 72067425RFA00002_DREAMS South.pdf

Funding Opportunity # 72067425RFA00002 HIV Prevention Among Adolescent Girls and Young Women and Other Vulnerable Youth

Populations - DREAMS South

Issue Date: December 20, 2024 Deadline for Questions: January 21, 2025 Closing Date for Concept Papers: February 18, 2025 Closing Time: 2pm South Africa time

Subject: Notice of Funding Opportunity Number (NOFO): # 72067425RFA00002 / Initial Announcement”

Program Title: HIV Prevention Among Adolescent Girls and Young Women and Other Vulnerable Youth Populations - DREAMS South

Federal Assistance Listing Number: CFDA 98.001 USAID Foreign Assistance for Programs Overseas

To All Interested Parties, The United States Agency for International Development (USAID) is seeking applications for one

(1) cooperative agreement from qualified entities to implement the “HIV Prevention Among Adolescent Girls and Young Women and Other Vulnerable Youth Populations - DREAMS South” program, which is expected to have a total estimated amount range between $52M-$58M.

Eligibility for this award is restricted to local entities (see Section B.1. of this Notice of Funding Opportunity (NOFO) for eligibility requirements of local entities).

USAID intends to make an award to the applicant who best meets the objectives of this funding opportunity based on the merit review criteria described in this NOFO, subject to a risk assessment. Eligible parties interested in submitting an application are encouraged to read this NOFO thoroughly to understand the type of program sought, application submission requirements, and selection process.

To be eligible for award, the applicant must provide all information as required in this NOFO and meet eligibility standards in Section B of this NOFO. This funding opportunity is posted on http://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 NOFO and to ensure that it has been downloaded from the internet in its entirety. USAID bears no responsibility for data errors resulting from transmission or conversion process. If you have difficulty registering on www.grants.gov or accessing the NOFO, please contact the Grants.gov Support Center at 1-800-518-4726 or via email at support@grants.gov for technical assistance or if you need assistive technology and are unable to access any material on this site.

http://www.grants.gov/ http://www.grants.gov/ mailto:support@grants.gov%20

Populations - DREAMS South

Applicants must comply with 2 CFR 25 requirements to obtain a Unique Entity Identifier (UEI) and register in the System for Award Management (SAM.gov), as applicable. See Section E, Submission Requirements and Deadlines, for more information. The registration process may take many weeks to complete. Therefore, applicants are encouraged to begin registration early.

Please send any questions to the point(s) of contact identified in Section A.4. 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 NOFO 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, /s/ Heather Wirick

Heather Wirick Agreement Officer

Populations - DREAMS South

NOFO TABLE OF CONTENTS

Section A – Basic Information

Section B – Eligibility

Section C – Program Description

Section D – Application Content and Format

Section E – Submission Requirements and Deadlines

Section F – Application Review Information

Section G – Award Notices

Section H – Post-Award Requirements and Administration

Section I – Other Information

Annex 1 - Summary Budget Template

Annex 2 - SF 424 Standard Forms

Annex 3 - Standard Provisions

Annex 4 - Abbreviations and Acronyms

Annex 5 – History of Performance Form

Annex 6 – Initial Environmental Evaluation (IEE)

Annex 7 – Gender Analysis

Populations - DREAMS South

SECTION A: BASIC INFORMATION

1. Executive Summary

The goal of the Activity is to: substantially lower HIV incidence among adolescent girls and young women (AGYW) ages 10-24 in the below geographic areas of highest HIV incidence and prevalence. It is envisioned that this goal will be achieved by improving AGYW access to a comprehensive package of evidence-based/informed, age-appropriate prevention interventions that address biological, behavioral, and socio-economic determinants of HIV risk, and by prioritizing the supply of contraception, STI treatment, and Post Exposure Prophylaxis (PEP).

The Activity will support the South African Government’s multi-sector strategies and priorities for HIV prevention and its efforts to achieve 95-95-95 goals along with near-universal HIV prevention and treatment coverage ending HIV by 2030. In line with GoSA and U.S. Government Partnership Framework Implementation Plan, the Activity’s priorities include long-term sustainability with health and social system strengthening to bolster an efficient, locally led response, including youth identified solutions. In addition, cornerstones of the Activity will be advancing equity for AGYW and human rights, meaningful youth engagement and participation, as well as maximizing community leadership to strengthen program responsiveness to clients’ priorities and improve service quality, acceptability, and impact.

Objectives and Results:

The Activity will consist of four (4) objectives which are as follows:

1. Strengthen community and youth leadership and participation in social and behavior change services;

2. Increase access to and utilization of biomedical HIV prevention services;

3. Improve access to social protection services; and

4. Increase technical assistance support to key GoSA departments to sustain and integrate

DREAMS interventions and approaches into GoSA priorities and plans.

The geographic focus is the South Region which will encompass four provinces: KwaZulu Natal (King Cetshwayo and Ugu), Free State (Lejweleputswa and Thabo Mofutsanyane), Eastern Cape (Alfred Nzo and Buffalo City), and Western Cape (City of Cape Town).

2. Estimate of Funds Available and Number of Awards Contemplated

USAID intends to award one (1) Cooperative Agreement pursuant to this Notice of Funding Opportunity (NOFO).

Subject to funding availability and at the discretion of the Agency, USAID expects to have a total estimated amount range between $52M-$58M in USAID funding over a five-year period.

Populations - DREAMS South

3. Start Date and Period of Performance for Federal Awards

The anticipated period of performance is five years. The estimated start date will be [to be determined].

4. Agency Point of Contact

Regional Office of Acquisition and Assistance USAID/Southern Africa Email: pretoriaapplications@usaid.gov

Name: Heather Wirick Title: Agreement Officer Email: hwirick@usaid.gov

Name: Alejandra Garcia Title: Senior Acquisition and Assistance Specialist Email: agarcia@usaid.gov

5. Acquisition and Assistance Ombudsman

The A&A Ombudsman helps ensure equitable treatment of all parties who participate in USAID’s acquisition and assistance process. The A&A Ombudsman serves as a resource for all organizations who are doing or wish to do business with USAID. Please visit this page for additional information: https://www.usaid.gov/work-usaid/acquisition-assistance-ombudsman.

The A&A Ombudsman may be contacted via: Ombudsman@usaid.gov.

For concerns related to FAR Subpart 33.103(e), the closing date for receipt of applications is the closing date of Phase 1 in accordance with the cover page.

6. Authorized Geographic Code

The geographic code for the procurement of commodities and services under this program is 935 any area or country including the recipient country, but excluding any country that is a prohibited source. Except as may be specifically approved in advance by the Agreement Officer, all commodities and services that will be reimbursed by USAID under this award must be from the authorized geographic code specified in this NOFO, and must meet the source and nationality requirements set forth in 22 CFR 228.

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mailto:pretoriaapplications@usaid.gov mailto:hwirick@usaid.gov mailto:agarcia@usaid.gov https://www.usaid.gov/work-usaid/acquisition-assistance-ombudsman https://www.usaid.gov/work-usaid/acquisition-assistance-ombudsman

Populations - DREAMS South

SECTION B: ELIGIBILITY

1. Eligible Applicants

Eligibility is restricted to local entities. Restricting eligibility to local South African organizations is the most responsive approach as the local organizations have the local knowledge of how to optimally tailor the technical approach that would allow for locally-developed and locally-led innovative and creative approaches to most effectively address development barriers and have the most efficient programmatic path to achieving epidemic control and development results.

Definition of local entities in accordance with ADS 303.6:

“As defined in Section 7077 of Public Law 112-74, the Consolidated Appropriations Act, 2012 (P.L. 112-74), as amended by Section 7028 of the Consolidated Appropriations Act, 2014 (P.L.

113-76), and included by reference in subsequent appropriations acts, local entity means an individual, a corporation, a nonprofit organization, or another body of persons that—

(1) Is legally organized under the laws of;

(2) Has as its principal place of business or operations in; and

(3) is:

(A) Majority owned by individuals who are citizens or lawful permanent residents of;

and

(B) Managed by a governing body the majority of who are citizens or lawful permanent residents of a country receiving assistance.

For purposes of this definition, “majority-owned’ and “-managed by” include, without limitation, beneficiary interests and the power, either directly or indirectly, whether exercised or 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.”

Faith-based organizations are eligible to apply for federal financial assistance on the same basis as any other organization and are subject to the protections and requirements of Federal law.

Additionally, USAID welcomes applications from organizations that have not previously received financial assistance from USAID.

Interested and eligible applicant entities may submit no more than one application under this

NOFO.

Applicants must have established financial management, monitoring and evaluation processes, internal control systems, and policies and procedures that comply with established U.S.

Government standards, laws, and regulations. The successful Applicant will be subject to a responsibility determination assessment by the Agreement Officer (AO).

The Recipient must be a responsible entity. The AO may determine a pre-award survey is required to conduct an examination that will determine whether the prospective Recipient has the https://www.usaid.gov/about-us/agency-policy/series-300/303

Populations - DREAMS South necessary organization, experience, accounting and operational controls, and technical skills – or ability to obtain them – in order to achieve the objectives of the Activity and comply with the terms and conditions of the award.

For-profit Applicants must note that USAID policy prohibits the payment of fee/profit for Recipients under assistance instruments. Forgone profit does not qualify as cost-share or leverage.

2. Cost Sharing

USAID has established a required minimum recipient cost share of 10% of the total estimated USAID amount for the award. Such funds may be provided directly by the recipient; other multilateral, bilateral, and foundation donors; host governments; and local organizations, communities and private businesses that contribute financially and in-kind to implementation of activities at the country level. This may include contribution of staff level of effort, office space or other facilities or equipment which may be used for the program, provided by the recipient. For guidance on cost sharing in federal financial assistance see 2 CFR 200.306. Applicants may refer to Section D, Application Content and Format, regarding requirements for the submission of letters or other documentation to verify commitments to meet cost-sharing requirements.

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Populations - DREAMS South

SECTION C: PROGRAM DESCRIPTION

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 H.

I. INTRODUCTION

USAID/South Africa is committed to supporting the South African Government (SAG) to achieve and sustain HIV epidemic control as well as enhance health security. The purpose of the HIV Prevention among Adolescent Girls and Young Women (AGYW) and Other Vulnerable Youth Populations Activity is to contribute to the achievement of the 95-95-95 goals by 2030 and reach and sustain epidemic control by: dramatically reducing new HIV infections, particularly among priority populations, including vulnerable youth, adolescent girls and young women (AGYW), and combating gender-based inequalities and gender-based violence (GBV) that place AGYW at increased risk for HIV infection.

The goal of the U.S. Agency for International Development (USAID) “HIV Prevention among Adolescent Girls and Young Women and Other Vulnerable Youth Populations” Activity (hereinafter referred to as the Activity) is to substantially lower HIV incidence among adolescent girls and young women (AGYW) aged 10-24 in areas of South Africa with highest HIV incidence and prevalence through a combination of prevention interventions that address biological, behavioral and socio-economic determinants of HIV risk.

This activity will be targeted in high HIV burden geographic areas across South Africa as per descriptions in Section III below and it is not designed to cover all AGYW in all areas.

The Activity will build upon lessons learnt from implementing the Determined, Resilient, Empowered, Aids-free, Mentored and Safe (DREAMS) Initiative package of evidence-based services in South Africa since 2016. This Activity will consolidate some of the DREAMS interventions and ensure the program has a more tailored strategic and technical focus. The anticipated result will be an improved implementation arrangement, with greater efficiencies, improved layering of the interventions and reporting, strengthened linkages between activity components, and a more standardized and simplified primary package of services. It is also envisioned that the Activity will create platforms through which youth can actively participate in the delivery of services, monitoring and leadership of activities, and provide opportunities for employment of DREAMS AGYW. The awardee will be expected to identify and enroll the most vulnerable AGYW and youth into the various interventions based on the vulnerability guidance included in the DREAMS NEXTGen Guidance.

Therefore, USAID anticipates that the prime partner applicants will have a demonstrated track record and strong working relationships with the South African Government (especially departments of health, social development and basic education) and a deep understanding of the community context within the targeted districts. Local partner leadership in developing and https://www.state.gov/pepfar-solutions/resources-and-tools/pepfar-dreams-nextgen-guidance/

Populations - DREAMS South implementing program models that can be adopted and replicated by the relevant SAG departments will advance equity and enable a sustainable response supporting vulnerable youth.

II. BACKGROUND

In 2014, The Joint United Nations Programme on HIV/AIDS (UNAIDS) launched the global 95-95-95 targets, with the aim to diagnose 95% of all individuals living with HIV, provide antiretroviral therapy (ART) for 95% of those diagnosed and achieve viral suppression for 95% of those treated by 2030. Given the rate of new infection, South Africa has yet to achieve “95-95-95” targets and the goal of HIV epidemic control.

While the HIV burden in South Africa continues to grow and the country continues to grapple with the challenge of achieving HIV epidemic control, other issues including gender inequalities and alarming high rates of gender-based violence continue to affect AGYW and undermine their ability to protect themselves against HIV. Addressing gender equalities and reducing South Africa’s rate of gender based violence (GBV), remains essential for ending the HIV epidemic.

According to a recent Gender Analysis, gender inequalities are systemic and deeply entrenched in institutions, cultures and traditions in South Africa. At the 2022 Presidential Summit on Gender Based Violence and Femicide (GBVF), President Ramaphosa described GBV as the first pandemic due to its alarming high rates in the country. GBV, which disproportionately affects adolescent girls and young women, remains a profound and widespread problem in South Africa.

Many AGYW across the country continue to face challenges in accessing health services, including heightened vulnerability to HIV, sexually transmitted infections (STIs), violence and abuse, unintended and unsafe pregnancies. Gender inequality and GBV restricts AGYW's mobility, access to resources, and limits their decision-making power―all of which impact their ability to act in ways that restrict access to healthy safe livelihoods. Gender inequality is one of the drivers of the HIV epidemic as well as a key challenge to the establishment of a wider culture of health-related attitudes.

The USG PEPFAR supported DREAMS program is currently implemented in 15 countries in partnership with the Bill and Melinda Gates Foundation, Girl Effect, Gilead Sciences, ViiV Healthcare, and Johnson & Johnson. DREAMS success depends on collaboration and coordination with national and local government officials at a multisectoral level, and other relevant stakeholders and community partners including AGYW themselves. DREAMS targets vulnerable AGYW (10-24 years) in communities with a high burden of HIV who are at an increased risk of acquiring HIV due to various demographic, geographic behavioral, and structural reasons. The DREAMS core package is an evidence-based/informed, age-appropriate, comprehensive package of biomedical, behavioral, and structural interventions across multiple sectors shown to mitigate the risk factors that may lead to HIV infection. Additionally, DREAMS provides contextual interventions to shift community norms and perceptions to create an enabling environment that supports HIV infection.

In South Africa the Bilateral Health Office has implemented DREAMS since 2016. Using a combination of prevention interventions that address biological, behavioral and socio-economic

Populations - DREAMS South determinants of HIV risk, the aim of the DREAMS Initiative investment was to substantially lower HIV incidence among adolescent girls and young women in areas of highest HIV incidence and prevalence. Some of the notable achievements of DREAMS in South Africa has included the provision of high quality technical support to the Department of Basic Education to integrate and scale HIV and Violence Prevention as part of the Comprehensive Sexuality Education in schools;

building robust clinical and community platforms to facilitate and promote the introduction of HIV prevention technologies including oral PrEP; and effectively implementing models for hybrid delivery of HIV prevention programming for AGYW during the COVID-19 crisis, demonstrating pathways for programmatic adaptation and resiliency and advancing the optimization of digital technologies for health.

Despite these achievements, continued implementation focusing on youth is needed to reach the UNAIDS 95-95-95 targets as part of epidemic control. While HIV prevention interventions have been concentrated in districts and provinces with the highest burden of disease and unmet need, to achieve epidemic control, South Africa will need to scale up and intensify targeted HIV prevention interventions nationally.

The latest Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM1 VI) HIV Prevalence Survey data shows that South Africa still continues to grapple with the challenge of achieving HIV epidemic control. HIV infections continue to be disproportionately higher among adolescent girls and young women (AGYW).

Annually, nearly one third of all new HIV infections in South Africa occur in youth ages 15-24 years, with adolescent girls being up to eight times more likely to be infected with HIV than their male counterparts, stigma and discrimination increases their HIV risk while keeping them away from services. While young people and especially AGYW face high HIV risks, the rates among older men and women are increasing as the epidemic matures, highlighting the need for age-specific and targeted interventions.

It is important to note that while the DREAMS package was designed to implement a specific set of high-quality, PEPFAR-approved activities and curricula, recent PEPFAR DREAMS NEXTGen Guidance allows for greater flexibility in programming and makes recommendations for a more standardized and simplified package of services. DREAMS NextGen is the next phase of DREAMS that will take a more nuanced approach that is more responsive to the current context within the country. In line with DREAMS NextGen guidance, implementation of the DREAMS core package will remain essential as South Africa still has a high HIV incidence (>1%) and high HIV burden among AGYW in many districts. However, it is anticipated that some activities and curricula will be consolidated, phased out while others are scaled up to achieve a more standardized and simplified DREAMS package to adequately respond to Government of South Africa (GoSA) and United States Government (USG) priorities.

A. Government of South Africa (SAG) Response

South Africa continues to benefit from high levels of political commitment from multiple Government of South Africa departments, including, but not limited to, the Departments of Social Development (DSD), Basic Education (DBE), Health (DoH) and Women, Youth and Persons with https://hsrc.ac.za/news/research-outputs/sabssm-vi-highlights-progress-and-ongoing-disparities-in-south-africas-hiv-epidemic/

Populations - DREAMS South

Disabilities. These departments have policies, guidelines and implementation strategies that prioritizes support for vulnerable youth. The South Africa’s National Strategic Plan for HIV, TB, and Sexually Transmitted Infections (NSP) 2023-2028 hereafter referred to as the NSP, outlines South Africa’s strategic framework for a multi-sectoral partnership to accelerate progress in reducing the morbidity and mortality associated with HIV, TB, and STIs and serves as the principal “blueprint” to operationalize the HIV response at the provincial, district, municipal, and local levels to achieve epidemic control in South Africa.

The recently revised NSP emphasizes a response that is people and communities centered, that aims to reduce inequalities, and increase access to health and social services. The NSP aims to reduce the barriers to accessing health and social services, building on lessons from the previous Strategy, promoting an urgent focus to reduce inequalities for all people living with HIV (PLHIV) who are not benefitting from treatment care and services. The 2023-2028 NSP also includes an emphasis on mental health services and social support, based on the strong association between HIV, TB, STIs, sexual and gender-based violence (SGBV), other forms of violations, inequalities, and mental health.

Goal 1 of the NSP, to “Break down barriers to achieving HIV, TB and STIs solutions”, Objective

1.4 focuses on addressing gender inequalities that increase AGYW vulnerability to both GBV and HIV. It calls for Enhancing gender-transformative community-led actions for HIV, TB, and Activity will support the NSP goals, with notable contributions expected for Goals 1 and Goal 2:

To maximize equitable and equal access to HIV, TB and STIs services.

The objectives and planned priority actions of the NSP are closely aligned with the National Development Plan: Vision for 2030, locating the fight against HIV, TB and STIs within the broader agenda for economic and social development. These are interlinked efforts as progress in reducing the burden of disease contributes to development, while faster development reduces social barriers and enhances equitable access to HIV, TB and STI services and solutions.

B. U.S. Government (USG) Response

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has made significant strides in reducing HIV infections, saving lives, and supporting many countries to achieve or approach epidemic control. The PEPFAR Strategy: Vision 2025 (closely coordinated with UNAIDS Global AIDS Strategy 2021-2026) aims to achieve sustained epidemic control of HIV by supporting equitable health services and solutions, enduring national health and social service systems and capabilities, and lasting collaborations. Key goals include reaching the global 95-95-95 treatment targets for all ages, genders, and population groups; dramatically reducing new HIV infections, particularly among priority populations, including children, AGYW, and key populations; and combating gender-based inequalities and GBV that place AGYW at increased risk for HIV infection.

In 2016 PEPFAR launched its DREAMS initiative in South Africa, specially targeting AGYW with a comprehensive portfolio of HIV prevention activities. This package of services comprises evidence-based/informed, age-appropriate, comprehensive biomedical, behavioral, and structural https://sanac.org.za/wp-content/uploads/2023/05/SANAC-NSP-2023-2028-Web-Version.pdf

Populations - DREAMS South interventions across multiple sectors and aims at achieving and sustaining epidemic control in the 27 priority districts. These represent the highest HIV burden districts in South Africa and comprise 82 percent of PLHIV in the country. PEPFAR has scaled up testing, treatment, and interventions to improve viral suppression among six priority age and sex bands to achieve full attainment in the 27 focus districts. In close coordination and collaboration with DSD, DOH, and DBE, PEPFAR has scaled up prevention interventions targeting AGYW to reduce new HIV and addressed the behavioral, biological, social and structural drivers of the HIV epidemic, which includes addressing gender inequalities and GBV.

This Activity will advance results set forth in the USAID/Southern Africa 2020-2025 Regional Development Cooperation Strategy’s (RDCS) and specifically links to the RDCS’s Regional Development Objective 3: “Resilience of People and Systems Strengthened” and Intermediate Result (IR) 3.2: “Equitable Provision of Quality Health and Other Services Improved”. In addition the Activity will align closely with the goals and objectives of the New PEPFAR Five Year Strategy Fulfilling America’s Promise to End the HIV/AIDS Pandemic by 2030 to “Close equity gaps for priority populations, including adolescent girls and young women, key populations, and children” link.

The USG has announced a new USAID Global Health Security strategy that aims to prevent, detect, and respond to global health pandemics. In South Africa, the Bilateral Health Office has started implementing the new strategy working in collaboration with the host government and other partners to address identified gaps and improve capacities in key global health security areas; support and sustain international capacity on surveillance and monitoring systems, including syndromic, pathogen, and events-based systems, needed to detect and regularly report known and new infectious diseases threats in humans, plants, and animals; support partner countries to develop, implement, and scale-up evidence-informed interventions at the community level to reduce zoonotic pathogen spillover; and increase demonstrated capacity in biosafety and biosecurity. This Activity may collaborate, and support interventions implemented under this strategy as needed and determined by USAID in the future.

USAID recognizes that climate change is a global crisis, disproportionately impacting people living in poverty and who are marginalized, including in South Africa. In the event of a crisis in the geographic areas of implementation, the Activity may collaborate and support shock responses interventions from other funding sources.

III. GEOGRAPHIC FOCUS

The geographic focus of the HIV Prevention among Adolescent Girls and Young Women (AGYW) and Other Vulnerable Youth Populations Activity - DREAMS South is 7 districts across 4 Provinces that have been identified as having significantly high rates of HIV incidence and prevalence.

This Activity is anticipated to encompass four provinces: KwaZulu Natal (King Cetshwayo and Ugu), Free State (Lejweleputswa and Thabo Mofutsanyane), Eastern Cape (Alfred Nzo and Buffalo City), and Western Cape (City of Cape Town).

https://www.state.gov/pepfar-five-year-strategy-2022/

Populations - DREAMS South

The anticipated geographic focus may shift in line with epidemiological changes and/or Government of South Africa (GoSA) and USG priorities. These shifts may result in the number of focus districts increasing or decreasing within the identified provinces or a shift to a new province and district(s) based on epidemiological changes in the outward years.

IV. ACTIVITY GOAL, OBJECTIVES, RESULTS & EXPECTED OUTCOMES

A. Goal

The goal of the Activity is to: substantially lower HIV incidence among vulnerable youth and adolescent girls and young women (AGYW) ages 10-24 in areas of highest HIV incidence and prevalence. It is envisioned that this goal will be achieved by improving access to a comprehensive package of evidence-based/informed, age-appropriate prevention interventions that address biological, behavioral, and socio-economic determinants of HIV risk. In collaboration with relevant government departments the Activity will prioritize the provision condoms and choice of contraceptives, prevention and treatment of sexually transmitted infections (STIs), provide post exposure prophylaxis (PEP) to survivors of gender based violence, provide pre-exposure prophylaxis (PrEP) and integrate the provision of new high impact HIV prevention technologies/injectables1 as they become approved by relevant authorities. The Activity will contribute to the core mandate of the Government of South Africa’s (GoSA) in strengthening the implementation of the Adolescent and Youth Health policy through strengthening of the Youth Zones and Adolescent and Youth Friendly Services to serve as key sites in target communities for sexual reproductive health (SRH) services.

The Activity will support the multi-sectoral strategies and priorities of GoSA for HIV prevention and its efforts to achieve 95-95-95 goals along with near-universal HIV prevention and treatment coverage ending HIV by 2030. In line with GoSA and U.S. partnerships, the Activity’s priorities include long-term sustainability with health and social system strengthening to bolster an efficient, locally led response, including youth identified solutions. In addition, the cornerstones of the Activity will be advancing equity for vulnerable youth and AGYW, ensuring meaningful youth engagement and participation, as well as maximizing community leadership to strengthen program responsiveness to clients’ priorities and improve service quality, acceptability, and impact.

Technical brief of Activity:

● Who: The target population will be vulnerable youth and AGYW (10-24 years) in communities with a high burden of HIV who are at an increased risk of acquiring HIV due to various demographic, geographic behavioral, and structural reasons.

● What: The Activity will draw upon the PEPFAR-approved HIV prevention core package of services that comprise evidence-based/informed, age-appropriate, comprehensive biomedical, behavioral, and structural interventions as per the DREAMS NEXTGen Guidance, 1 Injectables include cabotegravir (CAB-LA) and Lenacapavir (LEN) for PrEP

Populations - DREAMS South that are person-centered, are implemented across multiple sectors and have shown to mitigate the risk factors that may lead to HIV infection. The Activity will also implement HIV prevention contextual interventions that aim to shift community norms and perceptions in order to create an enabling environment that protects vulnerable youth and AGYW and supports the prevention of HIV infection. In alignment with USAID's localization policy and its goal to nurture youth leadership and advocacy skills, this Activity will support community-level monitoring efforts to help ensure services are maximally accessible and youth friendly.

● How: This Activity will focus on selected geographic regions, as described above, of high HIV burden. The programmatic approach will be multi‐level to ensure that risks are addressed at the individual level as well as influencing context, and that access to youth friendly health services and community-based interventions are increased; and layered to ensure that vulnerable youth and AGYW benefit from the synergistic effect of multiple interventions. USAID has identified uneven policy implementation as a critical disabler to the implementation of programmes, and it is anticipated that this Activity will provide the support needed to improve policy implementation.

USAID aims to reach the above goal by achieving the following four strategic objectives:

B. Objectives and Results

The Activity will consist of four (4) objectives which are as follows:

1. Strengthen community and youth leadership and participation in social and behavior change services;

2. Increase access to and utilization of biomedical HIV prevention services;

3. Improve access to social protection services; and

4. Increase technical assistance support to key GoSA departments to sustain and integrate

DREAMS interventions and approaches into GoSA priorities and plans.

The Conceptual Results Framework of the USAID/Southern Africa DREAMS Activities is included below:

Populations - DREAMS South

Five main results are expected from this Activity over the Five-Year Period of the Award (see targets below):

1. A reduction in new HIV infections amongst AGYW 10-24 years old.

2. Number of people in DREAMS SNUs completing an intervention pertaining to gender norms, that meets minimum criteria.

3. A reduction in new Gender Based Violence (GBV) cases amongst AGYW 10-24 years old.

4. Reach vulnerable youth and AGYW with PrEP interventions.

5. An increase in AGYW 15-24 years old in economically strengthened positions.

Populations - DREAMS South

The following describes in detail the four objectives and related intermediate results (IRs) to be achieved over the life of this Activity including tracking and reporting on PEPFAR Monitoring, Evaluation, and Reporting (MER) indicators below and activity specific custom indicators under Section V Monitoring, Reporting, and Quality Assurance.

OBJECTIVE 1: Strengthen Community and Youth Capacity to Lead and Participate in Social and Behavior Change Services:

IR1.1 Accelerate community HIV and violence prevention activities and improve capacity of AGYW, youth, and community leaders to lead and sustain activities to change norms, address structural barriers to HIV risk reduction, and advocate for uptake of HIV services.

This Activity will strengthen community mobilization activities for HIV prevention and expand the reach of evidence-based, culturally sound, person-centered HIV prevention and risk-reduction messages. In addition, the Activity aims to address negative attitudes, community stigma and discrimination against people living with HIV as this continues to be an impediment to HIV prevention. An important goal of the Activity is to advance community-led and youth identified solutions to HIV prevention and to leverage digital health innovations for HIV prevention education, such as platforms that include youth-friendly interactive content, virtual consultations, chatbots, and easy access to resources. Activities under Objective 1 will be developed and implemented in collaboration with local Community Based Organizations (CBOs), civil society organizations, and other PEPFAR-funded care and treatment, prevention and orphans and vulnerable children (OVC) partners, who support targeted youth sites such as health facilities, schools, churches, community-based organizations, and community structures.

Expected Outcomes

This activity will enhance community leadership and accountability in HIV and gender-based violence (GBV) prevention, leveraging digital technologies to expand education and strengthen referral networks for HIV and GBV response. By reducing GBV cases among AGYW in the DREAMS program and addressing stigma through standardized tools, communities will gain actionable insights to foster inclusion and drive change. The activity will empower HIV prevention beneficiaries as ambassadors and champions, while strengthening youth ownership of initiatives. Enhanced social media campaigns and community outreach will reduce HIV risk behaviors and increase service uptake, creating a supportive environment for sustainable prevention efforts.

Indicator 1.1.a.

● Number of community-based youth leaders trained on HIV prevention, advocacy, and social behavior change, in each focus sub-district.

Populations - DREAMS South o Target: Two (2) community-based youth leaders per sub-district.

o Target: 500,000 people in DREAMS SNUs completing an intervention pertaining to gender norms

Indicator 1.1.b.

● Percentage of youth-led HIV prevention initiatives implemented at the community level.

o Target: One (1) youth-led HIV prevention initiative per district.

Indicator 1.1.c.

● Number of young women serving as ambassadors (HIV and violence prevention) in each of the focus districts sub-districts (minimum 1 young women per sub-district).

o Target: Five (5) ambassadors per district.

IR1.2 Strengthen protective assets of AGYW to build enabling environments for HIV and GBV prevention.

The most vulnerable AGYW often lack strong social networks, such as relationships with peers and adults who can offer emotional support, information, and material assistance. This Activity will create opportunities for AGYW to build social skills that improve their ability to protect themselves by reducing their social isolation and providing them with social safety nets through mentors, peer groups, civic engagement, and access to HIV and health information and services.

Expected Outcomes

The activity is expected to increase the number of community Safe Spaces for AGYW, as well as dedicated spaces for other vulnerable youth and AGYW to access HIV and health information and services. It will enhance support for HIV prevention activities from caregivers, parents, partners, and community structures, while contributing to reduced rates of sexual violence among AGYW and vulnerable youth. Additionally, the activity will foster AGYW-led efforts to build supportive communities and strengthen social networks among and between AGYW, creating an environment that promotes safety, empowerment, and access to critical health services.

Indicator 1.2.a:

● Number of functional community Safe Spaces for vulnerable youth in each of the target sub-districts.

o Target: One community safe space in each target sub-district.

Populations - DREAMS South

Indicator 1.2.b:

● Number of AGYW completing the DREAMS primary package (HIV and Violence prevention intervention, Financial Literacy and Sexual Reproductive Health information and linkages) at safe spaces o Target: 250,000

OBJECTIVE 2: Increase Access to and Utilization of Biomedical HIV Prevention Services

IR2.1 Strengthen HIV Counseling and testing.

This Activity will increase the number of AGYW and other vulnerable youth who know their status. HIV testing remains the gateway to treatment and effective treatment is key to epidemic control. For reasons that include a general lack of awareness of why one should test, fear of knowing one’s status, and stigma, many young people including AGYW and vulnerable youth do not know their HIV status. Integrating HIV self-screening (HIVSS) as part of a broader biomedical intervention strategy is encouraged as this can increase early detection and linkage to care. Screening for HIV helps to detect the virus early and knowing one’s status and being connected to care if infected, will enable AGYW and other vulnerable youth to prevent spreading the virus to others.

Expected Outcomes

The activity seeks to significantly increase the number of AGYW and youth in the DREAMS program accessing HIV counseling and testing services, while promoting greater uptake of self-screening and ensuring effective linkage to care. It will ensure that at least 100% of high-risk AGYW and vulnerable youth in the program are aware of their HIV status and that all those diagnosed with HIV are promptly connected to comprehensive care and treatment services, reinforcing the program's commitment to holistic HIV prevention and support.

● Indicator 2.1.a: Number of individual HIV self-test kits distributed

○ Target: 35,156

● Indicator 2.1.b: Number of individuals who received HIV Testing Services (HTS) and received their test results

○ Target: 234,375

IR 2.2 Improve Access to Pre-Exposure Prophylaxis (PrEP), HIV Prevention New Technologies, Long-Term Injectables.

This Activity will increase the uptake of PrEP among eligible AGYW. In 2022, only an estimated 0.8% of sexually active people were taking PrEP (up from 0.1% in 2018)2. Among sexually active

2 Thembisa 4.6 2023 (April) model outputs as described in: Low M. (2023) HIV in graphs-latest figures confirm declining rates, but areas of concern. Daily Maverick; published online 31 May, 2023. https://www.dailymaverick.co.za https://www.dailymaverick.co.za

Populations - DREAMS South adolescent girls and young women, the number stood at 4% in 2022 – up from 0.1% in 2018 .

While these increases are a step in the right direction, uptake would have to be significantly higher for PrEP to start making a significant impact on the country’s infection rates. Integrating PrEP services with sexual and reproductive services, such as family planning, condoms, PEP, and STI services, can result in better PrEP continuation outcomes.

Expected Outcomes

The activity will enhance AGYW and vulnerable youth understanding and acceptance of HIV prevention technologies while increasing participation in adherence support services. It ensures all AGYW in DREAMS on PrEP have access to support services, with 100% of high-risk AGYW offered PrEP, 75% initiated, and sustained adherence after one year. Additionally, it will expand integrated services for PrEP, sexual and reproductive health, and other HIV prevention technologies.

Indicator 2.2.a.

● Number of people newly initiated on PrEP per year o Target:

- 225,000 vulnerable young women ages 15-24

- >90% of AGYW and other vulnerable youth initiated on PrEP have access to adherence support services.

Indicator 2.2.b.

● Percentage of eligible individuals accessing injectables or other long-acting PrEP options to prevent new HIV infections.

o Target:

- 100% of high-risk AGYW offered other long acting PrEP options;

- >60% of AGYW are initiated onto other long acting PrEP options.

IR 2.3 Post Exposure Prophylaxis (PEP)

This Activity will improve AGYW access to HIV post-exposure services. Preventing new HIV infections is crucial to attaining epidemic control. Despite the availability of prevention measures, exposures occur that pose the risk of transmission. Fortunately, with rapid initiation of PEP, infection can be blocked. After an exposure has occurred, HIV infection can be prevented with rapid administration of ARV medications that are formulated as PEP. The first dose of PEP should be administered within 2 hours of an exposure (ideal) and no later than 72 hours after an exposure to be effective in preventing infection.

Populations - DREAMS South

Expected Outcomes

The activity aims to enhance the understanding and acceptance of Post-Exposure Prophylaxis (PEP) among AGYW and other vulnerable youth, ensuring that 100% of those initiated on PEP complete the prescribed course. It targets providing more than 90% of AGYW survivors of GBV with timely access to PEP within the recommended timelines following exposure. Furthermore, the initiative seeks to ensure that over 90% of GBV survivors receive comprehensive clinical post-violence care services and support, addressing their immediate health needs and fostering long-term well-being.

Indicator 2.3.a.

● >95% of AGYW survivors of GBV have access to PEP within the prescribed timelines of an exposure.

o Target: 76,000 AGYW survivors of GBV

Indicator 2.3.b

● >95% of survivors of GBV access comprehensive clinical post violence care services and support.

o Targets: 95% of GBV survivors receive comprehensive clinical post-violence care services and 95% of those put on PEP complete the course.

IR 2.4 Improved Access to Post Violence Care Services

This Activity will advance critical services that respond to violence, especially gender-based violence. Comprehensive care for survivors of GBV, especially sexual violence, is an important part of any effective HIV response. USAID strongly supports strategies to increase the accessibility of integrated HIV and post-violence care services, including mobile services, hotlines, transportation assistance, virtual counseling, and first-line support. GBV case identification during HIV testing, initiation on ART, and routine HIV appointments are essential to identify people living with HIV who are survivors of violence and provide them with timely care, as well as support their linkage and adherence to and continuation of treatment.

Expected Outcomes

The activity will ensure that 100% of AGYW and vulnerable youth are aware of the locations and referral pathways to access post-violence care services. Additionally, it aims to increase the utilization of and support for these services, ensuring that survivors receive timely and effective care.

● 100% of AGYW and vulnerable youth have knowledge of location and referral pathways to access post violence care services.

● Increase utilization of and support for post-violence care services.

Populations - DREAMS South

Indicator 2.4.a.

● 100% of AGYW survivors of GBV have access to 100% of AGYW survivors of GBV access post violence care services.

o Target: 80,000

IR 2.5 Improved Access to Adolescent Youth Friendly Services

This Activity will decrease the barriers faced by AGYW and other vulnerable youth in accessing high-quality HIV and sexual and reproductive health (SRH) services. Vulnerable young people and especially other vulnerable youth, confront barriers at multiple levels including individual, structural, and socio-cultural that impede their ability to access high quality services that meet their needs. There is wide recognition that health facilities and providers need to do more to attract, serve, and retain young people as clients. This Activity will improve AGYW and vulnerable youth access to services that are well equipped to secure their health, especially in preventing HIV and unintended pregnancies, and that encourage future health-seeking behaviors among AGYW and youth.

Expected Outcomes

This activity will warrant that 100% of AGYW and vulnerable youth have access to services that offer privacy, are easily accessible, and provide a comfortable space for youth. It guarantees that all youth are served by providers who are trained in delivering adolescent- and youth-friendly services, allowing sufficient time for meaningful interactions. The activity will also enhance access to and satisfaction with HIV and SRH services for other vulnerable youth, while increasing the utilization of adolescent-friendly HIV and SRH services. Additionally, over 90% of sexually active young women will have access to comprehensive SRH services, including condoms and other contraceptive methods, and digital platforms will be utilized to monitor the reach and usage of these youth-friendly services.

Indicator: 2.5.a.

● 100% of program participants (AGYW and other vulnerable youth) have access to adolescent and youth friendly health services.

o Target: 225,000 (derived from the PrEP target).

Indicator 2.5.b.

● >90% sexually active young women have access to SRH services including condoms and other contraceptive methods.

o Target: 225,000

Populations - DREAMS South

IR 2.6 Improved Access to Mental Health and Psychosocial Support

This Activity will improve AGYW’s and other vulnerable youth’s access to mental health and psychosocial support services by integrating mental health into vulnerable youth’s prevention programming and standardizing the delivery and strategies to access advanced mental health services. As described in the Activity-level Gender Analysis undertaken by USAID/Southern Africa during the design phase of this Activity, there are many factors that undermine the emotional and psychological well-being of AGYW and vulnerable youth and contribute to their ongoing HIV risks and vulnerability3. Among these factors are exposure to or experiences of sexual, physical, or psychological violence that occur in homes, neighborhoods, or in and around schools, perpetrated as a result of gender norms and stereotypes and enforced by unequal power dynamics.