RFI_720656-2024-ESPERANCA English.pdf

SOLICITATION TYPE: REQUEST FOR INFORMATION (RFI)

RFI NUMBER: RFI- 720656-2024- ESPERANÇA

PROGRAM NAME: Ensuring Social Protection by Empowering and building

Resiliency for Adolescents, Nuclear families, Children, and caregivers affected by HIV/AIDS (ESPERANÇA)

ISSUANCE DATE: May 6, 2024 CLOSING DATE: May 30, 2024; 17:00 (Maputo Time)

TO: ALL INTERESTED PARTIES

Dear Potential Applicant/Offeror, This is a Request for Information (“RFI”) issued by the U.S. Agency for International Development (USAID) Mozambique for conducting market research in response to the questions provided in Attachment C. This RFI is issued solely for planning and information seeking purposes in accordance with FAR Part 10 and ADS 300. USAID will not pay for information submitted nor will it reimburse costs incurred by individuals or entities that elect to respond to this RFI.

USAID/Mozambique intends to design a new Activity - Ensuring Social Protection by Empowering and building Resiliency for Adolescents, Nuclear families, Children, and caregivers affected by HIV/AIDS (ESPERANÇA) - that will support and contribute to the Government of the Republic of Mozambique (GRM) to reach and sustain HIV epidemic control in three provinces - Sofala, Manica and Tete. This is anticipated to be a five (5) year award November - 2024 - 2029, with a total value of up to $40 million.

The purpose of this communication is to obtain industry comment and input on the above-mentioned activity. More specifically, the RFI intends to:

● Assess the interest of potential organizations in submitting applications/proposals for the new USAID/ ESPERANÇA Activity.

● Gain technical and organizational insights in the capacity of potential organizations.

● Explore innovative approaches to partnering with organizations working in the same area; and

● Collect inputs to contribute to the improvement of the proposed Program Description

(PD)/Scope of Work (SOW).

Attachment C presents the set of questions to which organizations should respond. Note that this is a RFI and not a Request for Applications (RFA) or a Request for Proposal (RFP). This RFI is not to be construed as a commitment by the U.S. Government to issue any solicitation or ultimately an award based on this RFI, or to pay for any information submitted as a result of this request. It should be noted that responding to this RFI will not give any advantage to any organization in the subsequent procurement.

USAID/Mozambique may use feedback and comments from this RFI to develop future programs. If a solicitation is issued for this activity, it is the organization’s responsibility to monitor the sites www.grants.gov or www.sam.gov and local newspapers for the release of any further information.

Please submit responses to this RFI to Patrice Lopez at patlopez@usaid.gov with a copy to jcaetano@usaid.gov and hcuambe@usaid.gov no later than May 30, 2024. Late submissions will not be accepted. The subject line of the e-mail must read “RFI – USAID/Mozambique ESPERANÇA Activity (2024 - 2029)”. Responses must include the organization's name, address, point of contact, phone number and email address. You will receive an electronic confirmation acknowledging receipt of your response. Hard copy responses will not be accepted and are discouraged.

Thank you for your interest in USAID/Mozambique programs.

Sincerely, Patrice Lopez Contracting/Agreement Officer

Attachments/Anexos

● Attachment A - Summary Proposed Activity

● Attachment B - Submission Requirements

● Attachment C – Response Requirements http://www.grants.gov/ http://www.sam.gov/ mailto:patlopez@usaid.gov mailto:jcaetano@usaid.gov mailto:hcuambe@usaid.gov

ATTACHMENT A - SUMMARY PROPOSED ACTIVITY

ANTICIPATED ACTIVITY NAME: Ensuring Social Protection by Empowering and building Resiliency for Adolescents, Nuclear families, Children, and caregivers affected by HIV/AIDS (ESPERANÇA)

ANTICIPATED MECHANISM TYPE: Assistance

ANTICIPATED TOTAL BUDGET: $40 Million

ANTICIPATED PERIOD OF PERFORMANCE: November 2024 - October 2029

Acronyms ABYM Adolescent boys and young men AGYW Adolescent girls and young women AJPE Associações Juvenis de Poupanca e Emprestimos ART Antiretroviral therapy C/ALHIV Children and adolescents living with HIV CDCS Country Development Cooperation Strategy CLA Collaborating, learning, and adapting CNCS National AIDS Council COP Country Operational Plan DREAMS Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe FSW Female sex worker FY Fiscal year GBV Gender-based violence GRM Government of the Republic of Mozambique HEI HIV exposed infants HES Household economic strengthening HTS HIV testing services IDP Internally displaced persons IIT Interruptions in treatment INAS Instituto Nacional de Acção Social MCH Maternal and child health MER Monitoring, Evaluation, and Reporting MGCAS Ministry of Gender, Children and Social Action MINEDH Ministry of Education and Human Development MISAU Ministry of Health MTCT Mother to child transmission (of HIV) OAA Office of Acquisition and Assistance OVC Orphans and vulnerable children PEP Post-exposure prophylaxis

PEPFAR U.S. President's Emergency Plan for AIDS Relief PLHIV People living with HIV PMTCT Prevention of mother to child transmission (of HIV) PrEP Pre-exposure prophylaxis PSS Psychosocial support SAAJ Serviços de Aconselhamento e Acompanhamento dos Jovens SDSMAS Servicos Distritais de Saúde Mulher Acção Social SRH Sexual and reproductive health UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme VMMC Voluntary medical male circumcision VSLA Village savings and loan associations WASH Water, sanitation and hygiene

I. JUSTIFICATION

Mozambique is ranked 185 of 191 countries in the 2022 United Nations Human Development Index, making it one of the least developed countries in the world1. At $440 USD (2022), the per capita gross national income is the third lowest in the world and has fallen 46 percent since 20142. In 2024, fifty-nine percent of the people in Mozambique live in extreme poverty, measured as living on less than $1.90 per day3. With an estimated HIV prevalence of 11.5 percent among adults 15 to 49 years and an estimated

2.4 million people living with HIV (PLHIV) in 2023, Mozambique has the third greatest number of PLHIV in the world4. Of these, around 304,000 are aged 15-245. While new HIV infections among this adolescent and young adult population has fallen steadily since it peaked at 56,000 in 20136, according to 2023 UNAIDS estimates, new HIV infections are estimated to be disproportionately higher among adolescent girls and young women (AGYW) at 24,763 as compared to their male age matched peers with 9,047 new infections per year. While there is some variance in HIV prevalence across provinces, Sofala is the province with the third highest number of PLHIV unaware of their status7 and combined, Sofala, Manica, and Tete provinces have an estimated more than 550,000 PLHIV8.

Children and youth represent a significant demographic group in Mozambique, where 44 percent of the population of 34.9 million9 are less than 15 years of age10. While in 2018, Mozambique made education compulsory for Grades 1 - 9 regardless of age11, primary school completion rates remain low at 42 percent12, with a 40 percent adult illiteracy rate13.

An estimated two million children in Mozambique are not living with their biological parents, with an additional 700,000 children at risk of being abandoned due to their caregivers’ old age, HIV in the family, and/or deteriorating socio-economic circumstances14. Currently, 23 percent of children are engaged in

1 United Nations Development Programme (UNDP). HDI by Country 2023. Accessed 14 March 2024.

2 The World Bank. GNI Mozambique 2021. Accessed 14 March 2024.

3 Statista. Share of population in extreme poverty in Mozambique from 2016 to 2025. Accessed 14 March 2024.

4 UNAIDS. HIV sub-national estimates viewer. HIV prevalence, 15-49, September 2023, Area level 1; Number of PLHIV, all ages, September 2023. Accessed 14 March 2024.

5 UNAIDS. HIV sub-national estimates viewer. Number of PLHIV, 15-24, September 2023, Area level 1. Accessed 14 March 2024.

6 AIDSInfo. Indicators: New HIV Infections: 15 - 24: Mozambique. Graphs. Accessed 14 March 2024.

7 UNAIDS. HIV sub-national estimates viewer. Number PLHIV unaware; All ages; September 2023; Area level 2.

Accessed 14 March 2024.

8 UNAIDS. HIV sub-national estimates viewer. PLHIV; All ages; September 2023; Area level 2. Accessed 14 March 2024.

9 Macrotrends. Population Data Mozambique. Accessed 14 March 2024.

10 Statista. Mozambique Age Structure. Accessed 14 March 2024.

11 UNICEF. Situation of the Children in Mozambique. Accessed 14 March 2024.

12 Ministério da Educação e Desenvolvimento Humano. Plano Estratégico da Educação 2020-2029. Accessed 11 January 2024.

13 World Bank. Literacy rate, adult total (% of people ages 15 and above) - Mozambique. Accessed 14 March 2024.

14 UNICEF Mozambique, Child Protection. Accessed 11 January 2024.

https://worldpopulationreview.com/country-rankings/hdi-by-country https://data.worldbank.org/indicator/NY.GNP.PCAP.CD?locations=MZ https://www.statista.com/statistics/1243825/extreme-poverty-rate-in-mozambique/ https://naomi-spectrum.unaids.org/ https://naomi-spectrum.unaids.org/ https://aidsinfo.unaids.org/ https://naomi-spectrum.unaids.org/ https://naomi-spectrum.unaids.org/ https://www.macrotrends.net/countries/MOZ/mozambique/population#:%7E:text=The%20current%20population%20of%20Mozambique,a%202.88%25%20increase%20from%202020 https://www.statista.com/statistics/507259/age-structure-in-mozambique/#:%7E:text=Age%20structure%20in%20Mozambique%202021&text=In%202021%2C%20about%2043.68%20percent,aged%200%20to%2014%20years https://www.unicef.org/mozambique/en/children-mozambique#:%7E:text=Child%20labour%20percentage%20in%20Mozambique%20is%2022%25%2052%25,children%20in%20Mozambique%20are%20living%20in%20absolute%20poverty https://planipolis.iiep.unesco.org/sites/default/files/ressources/2020-22-mozambique-esp.pdf https://data.worldbank.org/indicator/SE.ADT.LITR.ZS?locations=MZ https://www.unicef.org/mozambique/en/child-protection#:%7E:text=Orphans%20are%20also%20amongst%20the%20most%20vulnerable%20in,HIV%20in%20the%20family%20and%2For%20deteriorating%20socio-economic%20circumstances some form of child labor15, while the child marriage prevalence (<18 years) is 48 percent16 and 36 percent of girls 15 to 19 years have been pregnant17. Economic instability coupled with the large number of orphans precipitates an environment where children are susceptible to higher rates of child labor, disease, domestic violence, malnutrition, and future unemployment, which can perpetuate intergenerational poverty. Due to deep-rooted cultural attitudes, girls and children with disabilities are particularly vulnerable to exploitation and/or mistreatment. Fortunately, while the country has seen an increase in gender parity in secondary school enrollment (0.8 in 2010 to 0.93 in 2020)18, Mozambique still ranks 136 of 170 counties in the United Nations Development Program (UNDP) Gender Inequality Index19 due to high maternal health risks, pressure to marry young, limited economic prospects, high rates of illiteracy, and gender-based violence (GBV)20,21.

In Mozambique, HIV-related health services are delivered at the facility level, with significant support from community cadres in education, patient support and follow-up. In addition to promoting health seeking behaviors, community workers are critical in combating the HIV epidemic by supporting the holistic social and economic needs of the population, delivering preventative and adherence services.

The national health system relies heavily on community organizations to deliver the bulk of activities implemented at the community level, complimenting health services provided at the facility. This Activity will work through community cadres, social workers, and Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) mentors and facilitators, while complementing the Government of the Republic of Mozambique (GRM) and other donor efforts, including US government funded maternal and child health (MCH) and education programs.

This proposed Activity ties into USAID/Mozambique’s Country Development Cooperation Strategy (CDCS) Development Objective 1- Healthier and Better Educated Mozambicans, Especially the Young and Vulnerable, and is designed in line with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)’s 5x3 Strategy. Annual work plans will be guided by the Country Operational Plan (COP) to stay in line with PEPFAR goals, and activities will be data-driven and adapt based on program successes and challenges.

Adhering to best practices from PEPFAR DREAMS, orphans and vulnerable children (OVC), youth mentors and male championship strategies, this Activity will focus on reaching the most vulnerable AGYW and OVC; addressing harmful gender norms; increasing treatment adherence and viral load suppression among adolescents, youth, and men, while improving the system delivery for HIV prevention services.

15 United States Department of Labor. 2021 Findings on the Worst Forms of Child Labor: Mozambique. Accessed 14 March 2024.

16 UNICEF. Situation of the Children in Mozambique. Accessed 11 January 2024.

17 Demographic Health Survey (DHS) 2022-2023. Preliminary Results.

18 The World Bank. School Enrollment/Gender Parity. Accessed 14 March 2024.

19 United Nations Development Programme. Gender Inequality Index (GII) Dataset. Accessed 11 January 2024.

20 United States Agency for International Development. Gender Equality and Female Empowerment. Accessed 11 January 2024.

21 The World Bank. Literacy Rate. Accessed 11 January 2024.

https://www.dol.gov/sites/dolgov/files/ILAB/child_labor_reports/tda2021/Mozambique.pdf https://www.unicef.org/mozambique/en/children-mozambique#:%7E:text=Child%20labour%20percentage%20in%20Mozambique%20is%2022%25%2052%25,children%20in%20Mozambique%20are%20living%20in%20absolute%20poverty https://data.worldbank.org/indicator/SE.ENR.TERT.FM.ZS?locations=MZ https://hdr.undp.org/data-center/thematic-composite-indices/gender-inequality-index#/indicies/GII https://www.usaid.gov/mozambique/fact-sheet/gender-equality-female-empowerment#:%7E:text=USAID%2FMOZAMBIQUE&text=Low%20levels%20of%20education%2C%20high,women%20at%20a%20high%20disadvantage.

https://data.worldbank.org/indicator/SE.ADT.LITR.FE.ZS?locations=MZ

II. PURPOSE

The purpose of this Activity is to support GRM efforts to reduce HIV incidence and improve the health outcomes of households vulnerable to and/or impacted by HIV. The focus will be to identify and support AGYW highly vulnerable to HIV acquisition, children and adolescents living with HIV (C/ALHIV), and children impacted by HIV morbidity or mortality, by virtue of their relationship with one or more caregivers. This Activity will also work at the community-level to provide HIV prevention education and empowerment, link vulnerable populations to appropriate services and provide case management services and care to children and youth affected by HIV. In addition, the Activity will provide supportive services to increase treatment adherence and viral suppression among adolescents, youth, and men.

Services provided through this Activity will also work to improve the system delivery of HIV prevention services through building capacity of stakeholders in data management and use, empowering social affairs platforms and committees, and improving the economic resilience of youth and families affected by HIV.

III. DEVELOPMENT HYPOTHESIS

IF vulnerable AGYW and their partners are reached with HIV prevention services, including GBV prevention and response; and IF C/ALHIV OVC beneficiaries and households receive quality case management services tailored to their needs through appropriately trained community staff; and IF adolescents and youth PLHIV receive quality support in order to adhere to treatment and reach and maintain viral suppression; and IF systems for delivery of HIV prevention services are supported and strengthened to promote accountability, quality improvement, and ownership;

THEN there will be reduced HIV incidence and there will be an improvement in the health outcomes of households vulnerable to and/or impacted by HIV.

IV. RESULTS FRAMEWORK

Objective: Reduce HIV incidence and improve health outcomes of households vulnerable to and/or impacted by HIV

The results of this Activity are meant to align with the cascade of prevention, testing, linkage to treatment, and care and treatment, along with a final piece focused on overall strengthening of the systems for delivery of HIV prevention services for sustainability and maximized effort. This Activity will target children, adolescents, youth, caregivers, and men, making a concerted effort to reach the most vulnerable and hard-to-access within these populations.

To ensure complementarity of service provisions, recipient(s) of this award must be proactive in establishing and maintaining relationships with other stakeholders providing services to the same target population and within the same geographical regions. In addition, USAID will be intentional and encourage close collaboration across partners to ensure synergies in service provision and minimize any duplication.

Intermediate Result (IR) 1: Reduced HIV incidence among adolescents and youth - Routine HIV prevention activities have not been effective in reaching AGYW because activities are not responsive to the unique circumstances and lived experiences that often place AGYW at greater risk for HIV acquisition. Since the implementation of the DREAMS program in 2014, Mozambique has made significant strides to reach AGYW and reduce their risk of acquiring HIV. However, because of their disproportionate risk and vulnerability compared to their male peers, AGYW remain a priority population to target in order to reduce new HIV infections to reach HIV epidemic control. Although the DREAMS program requires the implementation of multiple interventions that target different risk factors and/or behaviors that may lead to HIV acquisition, the DREAMS program will continue to be a person-centered approach, whereby AGYW are always at the center. Utilizing behavior change theory, DREAMS activities and interventions will target different structural and individual factors that lead to an AGYW’s increased HIV risk. Implementing partners are encouraged to adopt gender transformative approaches throughout the intervention and incorporate positive youth development, as appropriate.

Over the course of the award, this activity must be flexible and adapt the program accordingly as geographic and population groups reach saturation.

Sub-intermediate Result (Sub-IR) 1.1: Empowered AGYW and reduced risk for HIV, unintended pregnancy, and violence - In order to achieve epidemic control, gender inequality, GBV, and sexual and reproductive health (SRH) must be addressed. Utilizing strategic interventions, the Activity will target AGYW (10-24 years) using different evidence-based/informed, age-appropriate packages of services depending on their risk factors. Core to this will be empowering AGYW and reducing their risk for HIV, unintended pregnancy, and violence through youth-friendly services. Interventions should include SRH related services, including condom promotion (demand creation, provision, and adherence); pre-exposure prophylaxis (PrEP) (promotion, provision and adherence); linkage to post violence care, including post-exposure prophylaxis (PEP); HIV testing services (HTS); expanding and improving access to voluntary, comprehensive family planning services; social asset building (such as mentoring, and HIV and violence prevention); and economic strengthening. Because AGYW at highest risk of HIV often lack strong social networks, DREAMS activities should include the creation of public or pre-determined safe spaces where AGYW can meet on a regular basis, with the hopes of allowing AGYW to make important connections, increase their agency and empower AGYW in order to prevent HIV infection. As a result of economic disparity related to gender inequity, activities will include economic strengthening (i.e. savings groups, financial literacy, youth savings and loan groups (AJPE- Associações Juvenis de Poupanca e Emprestimos), comprehensive vocational training (Siyakha), etc.) to decrease AGYW’s reliance on transactional sex and strengthen AGYW’s self-efficacy and decision-making power in relationships. Economic independence, via self-employment/entrepreneurship and wage employment, will include basic financial literacy training as well as the learning of new skills for DREAMS participants at highest risk of HIV acquisition. PEPFAR implementing partners must collaborate with MCH and family planning programs working in the same districts to ensure synergies in service provision and minimize duplication.

Sub-IR 1.2: Empowered and capacitated families through parenting programs and educational support - Having positive relationships with parents and/or caregivers is fundamentally necessary to protect AGYW from various negative health and social outcomes22.

Activities should include parent/caregiver programs that increase caregivers’ knowledge, skills, and comfort with talking to their children about sexual health, HIV, GBV, violence prevention and response as these interventions have shown promise in changing risky sexual behavior patterns among youth, including delayed sexual debut, condom use, and decreased exposure to negative outcomes such as violence and abuse23, 24. Parenting/caregiver programs should guide

22 Wang B SB, Deveaux L, Li X, Koci V, Lunn S. The impact of parent involvement in an effective adolescent risk reduction intervention on sexual risk communication and adolescent outcomes. AIDS Educ Prev. 2014;26(6):500–20.

Accessed 27 February 2024.

23 Wight D, Fullerton D. A review of interventions with parents to promote the sexual health of their children. J Adolesc Health. 2013;52(1):4–27. Accessed 27 February 2024.

24 Limaye RJ, Rimal RN, Mkandawire G, Kamath V. Tapping Into Traditional Norms for Preventing HIV and Unintended Pregnancy: Harnessing the Influence of Grandmothers (Agogos) in Malawi. Int Q Community Health Educ. 2015;36(1):53–70. Accessed 27 February 2024.

https://pubmed.ncbi.nlm.nih.gov/25490732/ https://pubmed.ncbi.nlm.nih.gov/25490732/ https://pubmed.ncbi.nlm.nih.gov/23260830/ https://pubmed.ncbi.nlm.nih.gov/26608074/ https://pubmed.ncbi.nlm.nih.gov/26608074/ parents/caregivers on how to best monitor children’s activities and increase positive parenting practices. In addition, because of the correlation between keeping girls in school and higher rates of HIV testing, decreased high-risk sexual behaviors, and the likelihood of early marriage, educational subsidies and material support should be provided for transitioning to and completing secondary school. While developing the work plan, PEPFAR implementing partners must work with other stakeholders to map all activities implemented in the geographic area in order to ensure synergies in service provision and minimize duplication. Throughout implementation, partners are expected to leverage these projects to ensure appropriate referrals and harmonization of service provision.

Sub-IR 1.3: Increased community engagement in HIV prevention initiatives - DREAMS activities include school-based HIV and violence prevention programs providing scientifically accurate information, referrals to health centers for services not provided in school, and skill-building related to prevention among young people in the community. Community mobilization programming should be strategically implemented to provide a support framework for HIV prevention programs by engaging boys, men, community leaders, and the broader community in addressing and impacting social and community norms and perceptions that increase HIV risk for AGYW. Interventions should target men and other community leaders and focus on HIV, gender norms, sexuality, relationships, violence prevention and response, joint decision-making, and alcohol use. Curricula should include a participatory learning component that focuses on building skills and community-level awareness and ownership of HIV risk reduction. Community mobilization efforts in related areas, such as GBV prevention, have impacted norms change, caused a decrease in violence25,26, and an increase in girls’ empowerment27. Activities must be innovative approaches that draw from evidence-based approaches and Applicants are encouraged to consider strategies and interventions that allow for youth-led prevention activities.

Sub-IR: 1.4 Reduced HIV risk among high risk youth and their sexual partners - DREAMS activities should have meaningful inclusion and engagement of male sexual partners of AGYW (including adolescents) in prevention, HIV testing, and refer male partners to risk reduction activities, including biomedical services such as voluntary medical male circumcision (VMMC) and antiretroviral therapy (ART) for men living with HIV to prevent transmission to their sexual partners. Because DREAMS is committed to a gender-equity approach, activities should reach out and enhance engagement of adolescent boys and young men (ABYM) through linkages with

25 Abramsky T, Devries K, Kiss L, Nakuti J, Kyegombe N, Starmann E, et al. Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda. BMC Med. 2014;12:122 10.1186/s12916-014-0122-5.

Accessed 27 February 2024.

26 Kyegombe N, Starmann E, Devries KM, Michau L, Nakuti J, Musuya T, et al. 'SASA! is the medicine that treats violence'. Qualitative findings on how a community mobilisation intervention to prevent violence against women created change in Kampala, Uganda. Glob Health Action. 2014;7(1):25082. Accessed 27 February 2024.

27 Limaye RJ, et al. Tapping Into Traditional Norms for Preventing HIV and Unintended Pregnancy: Harnessing the Influence of Grandmothers (Agogos) in Malawi. Accessed 27 February 2024.

https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0122-5 https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0122-5 https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0122-5 https://www.tandfonline.com/doi/full/10.3402/gha.v7.25082 https://www.tandfonline.com/doi/full/10.3402/gha.v7.25082 https://www.tandfonline.com/doi/full/10.3402/gha.v7.25082 https://journals.sagepub.com/doi/10.1177/0272684X15615446 https://journals.sagepub.com/doi/10.1177/0272684X15615446 other existing programs at the community, such as OVC, for complementarity of services both in school and out of school. Applicants should focus on raising beneficiaries’ awareness and social behavior change to reduce HIV risk; promote, distribute, and increase the uptake of HIV self-testing and condoms where applicable; and referring AGYW and AGYM to conventional HIV testing (at the community or facility level).

It is expected that applicants use the evidence-based pre-approved curriculum provided by USAID, translating materials as appropriate. While Mozambique's national HIV strategy is advancing combination prevention strategies, USAID welcomes partners to propose innovative strategies that reach AGYW with different HIV prevention services.

IR 2: Improved health, education, protection, and socio-economic outcomes among children and adolescents living with and affected by HIV, their caregivers, and families - With an estimated two million OVCs in Mozambique, PEPFAR Mozambique’s OVC program serves the dual purpose of mitigating the impact of HIV on children, adolescents, and their families as well as preventing HIV-related morbidity and mortality (among pediatrics and caregivers). There are currently an estimated 149,050 children under the age of 15 living with HIV in Mozambique; however, case identification remains low with only 75 percent of C/ALHIV under 15 knowing their HIV status28. Over the past few years, exceptional progress has been made in ensuring pediatrics are on optimized regimens, and viral load coverage is at 86 percent, with pediatric viral load suppression at 87 percent29. Thus, the largest hurdle still remains identifying HIV positive children that have not been diagnosed.

OVC programs must continue to evolve and focus on the key HIV challenges for children, including mother-to-child transmission (MTCT), the pediatric treatment gap, advanced disease, low viral load suppression, inadequate treatment literacy by caregivers, sexual violence against adolescent girls, and the risk of losing a caregiver due to adult interruptions in treatment (IIT). The OVC case management model must be client-centered and family-based, with the platform helping clients navigate stigma, access to health, social, legal, and economic support (including poverty alleviation). Case management will be used to build resilience and improve the well-being of families by increasing their access to social protection services and/or other OVC packages, such as village savings and loan associations (VSLA), positive parenting programs, nutritional support, and school support.

Sub-IR 2.1: Decreased risky sexual behaviors among adolescents - Activities within HIV prevention packages should be outcome-based and prevent sexual violence, delay sexual debut, and prevent HIV. Activities should also be gender-sensitive and age-segmented, targeting high-burden districts. Prevention activities should ensure that adolescents aged 10 to 14 years are reached with an evidence-based package of HIV primary prevention, which includes risk assessments and referrals to other relevant services. This includes referrals to OVC case management for adolescents meeting one or more of the eligibility criteria outlined by the PEPFAR OVC program, as well as any adolescent testing positive for HIV. The package of HIV

28 UNAIDS. HIV Sub-national Estimates Viewer: September 2023. Accessed 25 February 2024.

29 PEPFAR. Monitoring, Evaluation, and Reporting (MER) FY24 Quarter 1 Data.

https://naomi-spectrum.unaids.org/ primary prevention activities should align with the DREAMS primary prevention curriculum (i.e., OVC prevention activities should include age-appropriate activities that promote HIV prevention and support community norms and attitudes to reduce GBV, sexual violence, abuse, age appropriate sexual and reproductive health and the reduction of sexual exploitation of children and AGYW). For any priority districts that are also DREAMS program districts, primary prevention activities should be complementary, and OVC prevention activities should target males ages 10 to 14.

Sub-IR 2.2: Reduced socio-economic and HIV-related vulnerabilities of C/ALHIV, their families, and those affected - Children and adolescents at elevated risk for HIV acquisition, as well as those already living with HIV or significantly impacted by HIV in their household, require comprehensive, participatory OVC case management interventions to ensure they remain healthy, stable, educated, and protected from physical, emotional, or sexual violence/abuse. In collaboration with PEPFAR-supported facilities and partners, community-based activities will employ OVC Linkage Facilitators and use a bi-directional referral system. The referral system will increase the enrollment of C/ALHIV, HIV-exposed infants (HEI), children of female sex workers (FSWs) living with HIV, and other high-risk children, adolescents, and caregivers into the OVC comprehensive program. In PEPFAR-supported treatment sites in high-volume clinics within high-burden districts, implementing partners will then work to steadily improve coverage by assessing at least 95 percent of children (less than 18 years of age) for potential enrollment in the OVC Comprehensive program. Among those, at least 95 percent of C/ALHIV who are newly diagnosed and/or new on treatment (in the last 12 months), have no documented viral load, are not virally suppressed, and/or are less than five years of age will be offered enrollment in the OVC Comprehensive program. For HEI in particular, implementing partners should work closely with the prevention of mother to child transmission (PMTCT) program to identify districts with large numbers of adolescents and young mothers who have high rates of treatment interruptions and unsuppressed viral loads.

Once at-risk families are identified and enrolled in comprehensive OVC services, case managers will develop family-specific action plans (and the appropriate referrals) that deliver differentiated, age-appropriate OVC services for C/ALHIV, HEI, and their families that address the unique health, nutrition, education, protection, psychosocial, developmental, and economic challenges identified as part of the needs assessment. For HIV-positive children and their caregivers, this will include an assessment of knowledge gaps and other barriers to care, the provision of critical information for improved treatment literacy, support for pediatric transition to new medications, bi-directional linkages with the health facility, and skills-building to support treatment adherence and retention in care. OVC case managers will regularly monitor the health, nutritional, educational, and socio-economic status of beneficiaries. In addition, strategies must be tailored to meet the specific needs of early childhood and adolescent-focused programs, addressing the unique needs of the subpopulations at risk. Through targeted support, OVC case managers ensure progress is made against established ‘graduation benchmarks’ for each family (created to build resilience against risks in the long term and immediate timeframes).

Financial activities targeting HIV-positive households have been associated with improved health outcomes including increased ART adherence by addressing the barriers to access HIV treatment, and an increase in family income, reducing food insecurity, and creating and recovering assets. Considering the economic vulnerability of the OVC households, comprehensive household economic strengthening (HES) should be included where possible in order to build the ability for these households to meet their basic needs. Households most in need can benefit from VSLA, vocational training, cash transfer programs in the form of emergency funding for the most destitute families, and referrals to social protection programs.

In particular, in collaboration with the mentor mothers program, young mothers have been shown to benefit from these types of programs.

Sub-IR 2.3: Increased quality and effectiveness of OVC case management services - Front-line OVC providers and case managers must be carefully recruited, adequately trained, and well-supervised. Project data systems must be protected for confidentiality and subject to regular validity checks and data quality assessments, including reviews of primary source documents.

For each case-managed OVC beneficiary, an action plan must be developed that includes specific and measurable activities and goals and that can be verifiably monitored over time.

Activities should include monitoring of individual beneficiary-level progress, and wherever possible, data triangulation should take place to allow for comparing self-reported data and data extracted from the clinical setting. In addition, activities should include quantitative and qualitative anonymous feedback from OVC beneficiaries to ascertain whether the program is enhancing the lives of the beneficiaries as intended.

Activities must be innovative and have evidence-based training packages to improve the ability of program staff and community cadres to better deliver age-appropriate services to OVCs and their caregivers. More specifically, data-driven approaches should be used to identify gaps and determine adequate interventions to accelerate pediatric outcomes and increase economic and social protective factors to prevent HIV acquisition among OVCs. These packages should include:

1. Case management specific to the needs of each OVC sub-population

2. Innovative HIV primary prevention curricula

3. Positive parenting

4. Economic strengthening

5. Nutrition

6. Educational support

IR 3: Enhanced HIV clinical outcomes among adolescents, youth, and men - Based on the 2023 UNAIDS estimates, case finding gaps for children, youth, and men are disproportionately high with only 81 percent of male PLHIV 25- to 49-year-olds and 74 percent of 10- to 24-year-olds (male and female) on

ART30. In addition, as of December 2023, viral load coverage for HIV-positive men 25- to 49-years-old on treatment is 74 percent, while for 10- to 24-year-olds it is at 76 percent31.

As Mozambique approaches the first 95, HIV case identification must be strategic, identifying interventions that are person-centered and cost-effective. In addition, activities must promote linkages to care and treatment services through the various testing modalities, minimize care interruptions by providing psychosocial support to improve continuity of treatment and lead to viral suppression, especially among children and men who have higher rates of treatment interruptions.

Sub-IR 3.1: Improved adherence to ART - In order to ensure the provision of more personalized support for adolescents, youth, and men with the greatest needs, it is imperative that interventions be carried out in the health facility and community focusing on improving HIV literacy, including ART, and working with peers to educate beneficiaries about disclosing one’s HIV status, and the benefits and successes of ART. Furthermore, among men in particular, Activities must promote the participation of men as partners in women’s and children’s health care and encourage the creation of conversation circles among men and their peers.

Through adolescent and youth mentors and male champions strategies, implementing partners must train providers and program staff to align activities with the adolescent and youth, and male champion programs. To maximize effectiveness with limited resources, providers must limit enrollment to adolescents and youth aged 10 to 24 with fully disclosed HIV status. In addition, participants must fall under one of the following categories:

● Newly initiated or re-starting ART;

● Prescribed second-line ART and are not yet stable;

● First pregnancy and less than 20 years old;

● Viral load more than 1000 cp/ml;

● Non-adherence to treatment; and/or

● Active on ART and presenting a risk factor for adherence (i.e. psychosocial factors that affect adherence)

In addition, eligible participants for the youth mentor strategy can be HIV-negative adolescents and youth aged 10- to 24-year-olds who present a risk of contracting HIV infection and are on PrEP.

Implementing partners using the male champion approach must limit participation to HIV-positive men aged 25- to 49-years-old who are newly starting or restarting ART, those active on ART and presenting a risk factor for adherence, and/or men with an unsuppressed viral load.

Adolescent and youth programs should be specific to the needs of the target subpopulation.

30 UNAIDS. HIV Sub-national Estimates Viewer: September 2023. Accessed 14 March 2024.

31 PEPFAR. MER FY24 Quarter 1 Data: Mozambique.

https://naomi-spectrum.unaids.org/

Specific interventions and activities include demand creation for HIV testing including sexual partners; identification of signs and symptoms of Tuberculosis, malnutrition, and GBV; increased assess to self-testing kits for partners and peers; and informational sessions and referral to GBV services, PrEP, PEP, OVC, DREAMS, economic strengthening and other social services programs, as appropriate.

All implementation must be aligned with the national guidelines, which may shift depending on GRM recommendations and needs. In addition, adolescent and youth peer providers, and male champions allowances must comply with the incentives scale for community lay staff agreed between the Ministry of Health (MISAU) and PEPFAR.

Sub-IR 3.2: Expanded number of adolescents, youth, and men who achieve viral suppression - HIV adherence counseling must be reinforced both at the health facility and during home visits.

Clinical and community health providers, mentors, and supervisors must be trained on how to provide patient-centered care and support, and service providers must collaborate with each other to minimize any treatment interruptions and increase viral suppression among beneficiaries. In addition, service providers must work to educate adolescents, youth, and men about the importance of HIV disclosure to sexual partners and other family members, and supporting the strengthening of family resilience through viral load suppression.

To provide a safe place and increase the number of PLHIV virally suppressed, adolescent and youth mentors, and male champions should implement the following strategies:

● Welcome adolescents, youth, and men at the health facility;

● Through educational sessions, promote existing services available in the health facility;

● Provide peer support and literacy about HIV treatment;

● Support the organization and creation of facility support groups;

● Disseminate information about viral load to support the empowerment of adolescents, youth, and men in controlling their own viral load and achieving viral suppression;

● Identify individual psychosocial factors that affect a patient’s adherence to treatment and determine actions required to overcome these obstacles, including providing referrals to psychosocial support services;

● Regularly assess each patient’s ART adherence;

● Support the disclosure of one’s HIV disclosure status to other family members, including sexual partners and assist in the referring contacts for HIV testing;

● Refer patients to to OVC, DREAMS, economic strengthening, and social service programs, as appropriate;

● Conduct phone calls and home visits to beneficiaries;

● Perform reintegration phone calls and visits for eligible patients; and

● Support referral and counter-referral between different community partners to offer complementary services.

IR 4: Strengthened systems for delivering social protection services - Government stakeholders are key players in the national response, and thus in order to transition to a sustainable HIV response, activities must be designed to empower national stakeholders to oversee data management and the functionality of social affairs systems in order to address access barriers, contribute to improving the quality of services, and lead the HIV response.

Sub-IR 4.1: Enhanced capacity of stakeholders in data management and use - Community interventions, including DREAMS, OVC, and adolescent and youth mentor strategies, collect large amounts of data which PEPFAR implementing partners should share with GRM social affairs and health stakeholders. In addition to sharing data, partners are expected to support GRM in better managing, understanding, and utilizing data. Partners will work on strengthening program data from all areas by supporting data quality at the community level; ensuring that this feeds into a harmonized data management system; triangulating data from other sources;

and supporting MISAU, Ministry of Gender, Children and Social Action (MGCAS) counterparts, and other stakeholders in data use and interpretation. Activities must special focus to supporting the uptake of the eOVC data management system and other GRM shared systems as directed. Through Collaborating, Learning, and Adapting (CLA) activities and the annual planning process, Applicants must also support GRM in using data for decision-making and strategic planning. Data will also be used to routinely evaluate program implementation and inform strategic adjustments accordingly to ensure activities align with geographic and subpopulation needs for epidemic control.

Sub-IR 4.2: Improved functionality and capacity of social affairs platforms/ committees - Activities should ensure partnership with the GRM and other key stakeholders to build on PEPFAR investments in strengthening an HIV-sensitive and publicly-funded child protection, social work, and case management system for vulnerable children in Mozambique. PEPFAR implementing partners will coordinate closely with the GRM social affairs platforms to ensure that vulnerable children are identified, prioritized, and linked to social protection services (including psychosocial support) according to GRM guidelines. PEPFAR implementing partners should continue to support district- and community-level social workers in the implementation of HIV-sensitive case management and to strengthen the capacity of community-based organizations, local child protection and family welfare authorities (such as SDSMAS and INAS) to implement and manage core OVC interventions, with the ultimate goal of transferring ownership of HIV response activities to community and government stakeholders. In addition, PEPFAR will support the introduction and use of the eOVC data management system to improve case management of C/ALHIV OVC beneficiaries across the continuum of care.

V. GEOGRAPHIC AND POPULATION TARGETING

The selected recipient(s) for this Activity will initially work in Manica, Sofala, and Tete Provinces to continue to expand the achievements from the ongoing OVC Response (Manica) and OVC Response (Sofala) awards, with the possibility of expansion to other geographic regions, supporting the GRM’s response to HIV to provide comprehensive, high-quality, and cost-effective services. The Activity is envisioned to be solicited through an open competition, with eligibility restricted to local partners. The main populations projected under this Activity are: C/ALHIV; children, adolescents, and youth at high-risk of acquiring HIV; adolescent girls and young women, caregivers of C/ALHIV and caregivers who are HIV positive; local communities with high-HIV prevalence; and HIV-positive adolescents, youth, and men who require case management. The Activity will target sub-groups based on their specific needs and vulnerabilities, with the overall design to improve the health of children and adolescent youths highly vulnerable to and/or significantly impacted by HIV in Mozambique.

This Activity will also be inclusive and sensitive to the needs of internally displaced persons (IDPs), where appropriate. Factors that increase vulnerabilities among IDPs, the majority of which are youth, include sudden disruption from their families and livelihoods, premature/forced unions, sexual violence, difficulty to access youth-friendly services, and lack of social protection. As such, DREAMS and OVC implementing partners are required to facilitate access to basic HIV prevention services, post-GBV care, PrEP, SRH, and mental health services for IDPs, whenever possible and in coordination with other US government funded partners.

Additionally, this Activity will incorporate crisis modifier language into the final award in order to ensure the continuation of services in situations of unexpected shocks to programming, such as cyclones or flooding. With a crisis modifier, no additional interventions would be included, rather, flexible funds would be used to mitigate unexpected barriers to implementation resulting from a crisis.

VI. RISKS AND ASSUMPTIONS

This Activity assumes that HIV prevention and treatment services will continue to be delivered through government health facilities, with significant support for outreach and prevention from community organizations and cadres at the community-level. It is also assumed that MISAU, National AIDS Council (CNCS), Ministry of Education and Human Development (MINEDH), and MGCAS will continue to accept assistance from local and international partners. The Activity assumes that activities will continue to shift from key donors to the government, leading to a reduction in external funding, including PEPFAR allocations. Finally, the Activity assumes that the types of HIV prevention and response activities undertaken will continue to be accepted by community members, particularly social support services and programming supporting children, adolescents, and youth; and that GRM’s focus on adolescent and youth mentorship will only expand (and not reduce) over the period of implementation.

Potential risks to successful implementation include:

● Political environment for international assistance, including PEPFAR funding allocations - The political environment in the United States could lead to a decrease in international assistance, including PEPFAR programming, which would directly impact available funding for this award.

While GRM may be able to sustain some activities previously funded by PEPFAR, given limited financial resources, community-based services, such as those undertaken by this Award, would be difficult to assume.

● Climatic shocks, such as cyclones or drought - could increase poverty and drive displacement, disrupt service delivery including community cadres being affected by shocks, and could limit participation of target groups given competing priorities.

● Health system restructure or staff changes - PEPFAR implementing partners must cultivate relationships with new government leaders at district and/or provincial levels and may lose valuable allies/advocates within government; new bureaucratic hurdles could hinder implementation; and potential conflict and politics among government leadership or structures could make navigating key relationships more difficult and could impede the ability of PEPFAR implementing partners to work closely with key actors.

● Insecurity or social unrest - could limit program staff’s access and ability to deliver services and monitor implementation; restrict beneficiary and/or target population movements and seeking of services; and potentially cause supply chain disruptions, which would adversely impact HIV testing and treatment services.

● Disease outbreaks/global…