RFI-695-17-000001.pdf

REQUEST FOR INFORMATION No: RFI-695-17-000001

Issuance Date: November 8, 2016

Comments Due Date: November 22, 2016

Subject: Input into USAID/Burundi’s PEPFAR Program Planning

The U.S. Agency for International Development in Burundi (USAID/Burundi) is in the process of designing its next phase of activities currently implemented by FHI 360 in furtherance of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). It is anticipated that these activities will be implemented over a period of approximately five years from 2017-2022 (beginning September 2017) across an estimated five provinces with multiple office locations, which could include Bujumbura and Ngozi. USAID seeks to incorporate feedback from a wide range of sources in its planning process with the aim of optimizing the resultant program designs for the greatest impact in curbing the epidemic. The anticipated budget for the activity is approximately $26 million to $29 million. The activity is anticipated to have five key personnel, one of whom could be an expatriate COP.

To that end, USAID requests input from all interested parties to provide evidence-based suggestions in support of USAID/Burundi's future HIV/AIDS care and treatment and HIV prevention programs funded by PEPFAR in Burundi. Background information on USAID's PEPFAR programming in Burundi to date, as well as some specific questions for which USAID seeks input, are provided in the attachment to this notice.

This request for information is issued solely for planning purposes and is published in accordance with FAR Part 10 and FAR 15.201(e).

This is not a solicitation or call for proposals. Any proposals submitted in response to this request will not be considered.

Responses to this notice must be received by no later than the due date and time stated in this notice. All information provided will become the property of USAID and will not be returned.

USAID reserves the right to use information provided by respondents for its purposes.

Proprietary information must not be sent.

USAID/Burundi seeks input into each of the three Program Areas described in the attached document. Specific questions have been identified for each Program Area. Individuals and organizations that wish to provide input to USAID must submit their responses in a MS Word file to zclarke@usaid.gov.

Responses to questions are optional and a respondent may select the questions to which it

USAID/Burundi PEPFAR Program Background Information and Questions

Epidemiology of Burundi’s HIV/AIDS Epidemic

Burundi is considered to have a low-prevalence mixed HIV epidemic, which continues to be a growing priority public health threat. As of 2015, 1.3% of the population was living with HIV with approximately 3,000 annual deaths attributed to AIDS.1 According to data estimates compiled by UNAIDS and the National AIDS Council (CNLS), approximately 68,000 adults and 9,100 children under 15 are living with HIV. Although Burundi is not a high prevalence country, the 2013 PLACE study estimated that the prevalence of HIV among key populations is significantly higher, with a prevalence of 21.3% among female sex workers and 4.8% among men having sex with men.2 Stigmatization and social/legal discrimination against key populations leads to unwillingness to self-identify, which makes them difficult to track in HIV/AIDS programs. No data is available on HIV prevalence in bisexual, transgender, or other marginalized populations including persons living with disabilities and injecting drug users.

The HIV/AIDS epidemic in Burundi is becoming increasingly feminized, with 56% of new infections in women and girls, and a 1.7% prevalence rate in women compared with 1% in men.3 Prevalent gender-based violence (GBV) is likely one explanation for the higher prevalence in women,4 with a 2014 study estimating almost one quarter of Burundian women having experienced GBV.5 Other factors contributing to the higher prevalence rate in women include early sexual debut and transactional sex.3 In addition, it is estimated that 89,000 children are orphaned due to HIV/AIDS in Burundi, placing these children at risk.

Burundi has had significant success with scale-up of antiretroviral therapy (ART) for pregnant and breastfeeding women, at 89% coverage, whereas coverage is generally low for the general population: at 58.4% for adults and 26.5 % for children under 15. Once on ART, survival rates among people with HIV are among the best in Africa: 90.1% at 12 months, 87.4% at 24 months and 83.9% at 36 months of treatment.

Epidemiology of Tuberculosis (TB)/HIV

Co-infection with HIV and tuberculosis (TB) is a potential major health challenge in Burundi.

Data is not available for TB rates in PLHIV, yet data for TB reveals poor linkages of TB and TB/HIV cases to care and treatment. Based on 2015 data from the World Health Organization’s Global TB Report,6 the estimated incidence rate of TB (including HIV-positive TB patients) is 122 per 100,000, with only 51% of those cases being notified to the National TB Program (6,892 new and relapse cases in total). Multidrug resistant TB (MDR-TB) is a concern in Burundi. The estimated burden of MDR-TB is 3.2% among new TB cases, and 14% among retreatment cases, yet only 22% of the 190 patients notified for MDR-TB in 2015 started treatment. Among TB patients, HIV incidence is 17%. There is no data available for the rate of diagnosis of HIV in TB

1 UNAIDS. "Burundi." Accessed August 26, 2016. http://www.unaids.org/en/regionscountries/countries/burundi.

2 Priorities for Local AIDS Control Efforts (PLACE) Study, 2013 3 Burundi DHS, 2010 4 Burundi Sexual Violence Assessment, Engender Health, 2011 5 Sexual Violence in Burundi (Households in Conflict Network, 2014) 6 WHO Global TB Report 2016: http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf?ua=1 patients, but once patients became aware of their HIV status, 94% were initiated on ART in 2015.

Laboratory Services

The health system in Burundi is a three-tiered structure: central, intermediate and peripheral. The organization of the nation’s laboratories also follows this same configuration. The peripheral level comprises 46 laboratories within district hospitals, 430 laboratories in public health facilities, and additional structures in the private sector. The district laboratories also serve as referral centers for all health laboratories within the district, and are better equipped to perform more complex tests, such as hematology, biochemistry and CD4 cell count. The intermediate level comprises 17 provincial laboratories that serve as reference centers for the district hospitals.

These laboratories often resemble district laboratories in their capacity and equipment. The central level is comprised of two national laboratories which serve as reference laboratories for the country; the National Institute of Public Health, and the National Hospital Laboratory based in Bujumbura.

Strengthening the national laboratory system is a priority for the current National Health Development Plan for Burundi. While all health sectors will benefit from this commitment, there are also significant implications for HIV/AIDS and TB programming. Laboratory and sample transport systems are required for CD4 and viral load (VL) monitoring, as well as and early infant diagnosis (EID) for HIV-exposed infants. Diagnosis of infants requires significant attention, as undiagnosed infants have a high risk of death if not immediately placed on ART.

For a more detailed background on USG PEPFAR’s analysis of the HIV/AIDS epidemic, please refer to the USG PEPFAR Burundi Country Operational Plan 2016 (COP16), which can be found here: http://www.pepfar.gov/documents/organization/257659.pdf

USAID/Burundi’s Approach to Addressing the HIV/AIDS Epidemic in Burundi under PEPFAR

In accordance with the PEPFAR 3.0 strategy: Controlling the Epidemic: Delivering on the Promise of an AIDS-free Generation, USAID/Burundi works in collaboration with the Government of Burundi, civil society and other stakeholders to achieve greater impact on and control of the epidemic in Burundi. The PEPFAR 3.0 strategy in Burundi focuses financial resources and programmatic inputs into five provinces to improve the efficiency and effectiveness of technical assistance and direct service delivery. PEPFAR 3.0 seeks to support the Government of Burundi to achieve sustainable control of the HIV/AIDS epidemic in Burundi, where 90 percent of all people living with HIV know their status, 90 percent of all people diagnosed with HIV infection receive antiretroviral therapy, and 90 percent of all people receiving treatment have viral suppression. These targets are referred to as “90-90-90,” and are in line with the Joint United Nations Program on HIV/AIDS (UNAIDS) “90-90-90” targets. In addition, PEPFAR 3.0 focuses on improving linkages and program planning between prevention, treatment and orphans and vulnerable children activities at the community and facility levels.

The Government of Burundi has recently pledged to adopt the World Health Organization’s 2015 treatment guidelines for people living with HIV, to extend antiretroviral therapy to all people living with HIV and to support decentralized care and treatment.7 This new policy, also known as “Test and Start” or “Treat All”, supports ART initiation in all adults, adolescents, and children with HIV, regardless of their CD4 count or stage of disease. Innovations in the new guidelines include new approaches to HIV testing services (HTS), such as community-based, home testing, and self-testing approaches, the adoption of lifelong treatment for all PLHIV, considerations for differentiated care models, implementation of viral load testing as the preferred monitoring tool, and new point of care viral load technologies.

USAID/Burundi is prioritizing scaling up HIV/AIDS services through supporting the Government of Burundi in implementation of the new “Test and Start” policy for all persons living with HIV and in the transition from using CD4 to VL monitoring. Other priorities envisioned over the coming five years include: a focus on pediatric case finding; linkages for persons co-infected with HIV and TB to care and treatment; community-based ART services;

laboratory services for viral load and infant DNA-PCR tests; key populations (sex workers, men who have sex with men, and transgender people); closure of service gaps; addressing stigma and discrimination; and addressing GBV.

Priorities for PEPFAR programming will align to Burundi’s National Health Development Plan and Vision 2020, as well as to USG and Embassy Bujumbura strategic priorities.

For more about USAID/Burundi, refer to https://www.usaid.gov/burundi

The following outlines three program areas that USAID/Burundi proposes to include in the next five years of its activities, as well as questions related to each area for which USAID/Burundi seeks information and input.

USAID globally includes a focus on science, technology, innovation and partnerships (STIP);

responses in these areas, as well as local solutions, will be welcome. Recommendations to enhance program integration across these areas also would be welcome.

7 Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV (WHO, 2015)

Table 1: Results Framework for the New HIV Activity

Strategic Objective: Contribute towards HIV/AIDS epidemic control in PEPFAR target provinces.

Intermediate Results IR 1 Identify HIV-positive men, women and children through high quality, targeted HTS and link to ART services

IR 2 Increase ART coverage in men, women and children living with HIV.

IR 3 Ensure HIV+ men, women and children on ART are virally suppressed

Sub-Intermediate Results

Sub IR 1.1 Increase targeting of high quality HTS.

Sub IR 1.2 Ensure active linkage to ART of PLHIV identified through HTS.

Sub IR 1.3 Provide high quality DNA-PCR testing and HIV-exposed infant services.

Sub IR 1.4 Improve TB/HIV case-finding and linkage to care.

Sub IR 2.1 Increase ART enrollment in men, women and children living with HIV.

Sub IR 2.2 Improve ART adherence and retention in care by strengthening and sustaining linkages between site and community.

Sub IR 3.1 Ensure PLHIV on ART receive quality viral load monitoring and counseling.

Sub IR 3.2 Strengthen laboratory capacity and sample transport networks.

Intermediate Result 1: HIV Testing Services

USAID/Burundi’s anticipated goals and objectives for Intermediate Result 1: HIV Testing Services are:

Support the Government of Burundi to achieve the first “90” of the UNAIDS “90-90-90” targets by ensuring all HIV-positive men, women and children know their status and are actively linked to ART services; innovations in referrals including mHealth;

implementation of active case tracing strategies for individuals who are lost following linkage to ART services.

Provide technical assistance (TA) and/or direct service delivery (DSD) to improve the scale-up and quality of HTS delivered in healthcare facilities and in the community though health systems strengthening approaches, including facility and community health worker’s capacity building and deployment; decentralization; task-shifting; and ensuring services are delivered confidentially without stigma and discrimination.

Provide TA and/or DSD to ensure HTS strategies are evidence-based and targeted to certain populations, including the general population, men, pediatric, adolescent, pregnant and breastfeeding women, key populations; tuberculosis patients; OVC, and by high-yield entry points; in addition to supporting high-impact innovations in HTS such as self-testing.

Support the use of strategic information to inform HTS service delivery through accurate collection and use of data; providing TA to the Government of Burundi to scale up the Health Management Information System (HMIS); strengthening procurement and supply chain management for rapid diagnostic tests.

Desired results in target PEPFAR provinces:

1. 100% achievement of annual targets for HIV testing, including positivity yield disaggregated by entry points.

2. >90% of men, women, children and presumptive TB patients know their HIV status.

3. 95% of HTS providers have been trained in proficiency testing approaches.

4. >95% of facilities have zero HIV rapid test kit (RTK) stock outs due to requisitioning errors, including in TB clinics.

5. >90% of newly identified PLHIV, including those who are TB suspect or positive, are successfully linked to ART enrollment services within 1 week of diagnosis.

6. >80% of patients tracked are linked or returned to services.

7. >80% of family members of index cases are identified and linked to HIV testing and TB screening.

8. >95% of infants born to HIV+ mothers are linked to HIV-exposed infant care services, including EID testing, and are retained through final definitive outcome.

9. 100% of PLHIV suspected of having TB receive a GeneXpert test

10. 100% of PLHIV who test positive for TB (with GeneXpert) are referred for TB treatment

USAID/Burundi seeks input into the following questions related to Intermediate Result 1: HIV Testing Services:

1. What are the gaps in USAID/Burundi’s current HIV testing program? What areas might require additional investment to achieve the first “90”?

2. What are potential innovative interventions to identify and diagnose people living with HIV that could be supported at the national, provincial, colline, facility and community level?

3. What are potential strategies to increase the uptake of HIV testing services by men? Are there different strategies for different age groups?

4. How can key populations and priority populations, including OVC and victims of GBV, best be reached through HTS interventions and be successfully linked to prevention, testing, care and treatment services? What are the optimal approaches to ensure that services are supportive of these populations?

5. What may be the most efficient and effective approach to urgently address ineffective linkages to ART following diagnosis, including strengthening the health system?

6. Is TA or DSD the most effective approach to provide support for HIV testing services?

7. What components of the current USAID/Burundi HTS program should be maintained?

What components of the program should be eliminated? What components of the program should be replicated or expanded?

Intermediate Result 2: HIV Care and Treatment Services

USAID/Burundi’s anticipated goals and objectives for Intermediate Result 2: HIV Care and Treatment Services are:

Support the Government of Burundi to achieve the second “90” of the UNAIDS “90-90- 90” targets by ensuring all diagnosed HIV-positive men, women and children are immediately counselled and enrolled on lifelong ART services and receive the standard package of care and support services including prophylaxis and treatment for opportunistic infections and TB; retention on ART and regular clinical monitoring.

Support community-based and CSO-led initiatives to ensure PLHIV receiving ART services are effectively referred, retained, and linked to other care services as needed.

Support community health worker interventions to enhance retention and ART adherence including mHealth and community adherence groups; implementation of active case tracing and return to care strategies for individuals who are lost following initiation of ART. This likely would use grants under contract mechanisms.

Provide technical assistance (TA) and/or direct service delivery (DSD) to improve the scale-up and quality of ART initiation and lifelong maintenance delivered in healthcare facilities and in the community though health systems strengthening approaches, including facility and community health worker’s capacity building and deployment;

decentralization; task-shifting; and innovations to decant services from the facility, including community-based drug delivery and multi-month prescribing for stable patients; costing of innovations for other patient populations.

Provide TA and/or DSD to ensure ART scale-up strategies are evidence-based and targeted to certain populations, including general populations, men, pediatric, adolescent, pregnant and breastfeeding women, key populations; tuberculosis patients; OVC.

Support the use of strategic information to inform ART service delivery through accurate collection and use of data; providing TA to the Government of Burundi to scale up the Health Management Information System (HMIS); strengthening procurement and supply chain management for ARVs and commodities for opportunistic infections (OI), such as

TB.

1. >90% of adults and adolescents and TB patients living with HIV receive ART.

2. >80% of children living with HIV receive ART.

3. 100% accuracy, completeness and timeliness of the documentation of ART and care services in registers and electronic health record systems

4. >95% of facilities have zero stockouts of ARVs and OI commodities

5. >90% of HIV-positive individuals receiving ART are retained in care at 12 months.

6. 100% achievement of annual targets for current on ART and retention on ART by population.

7. 100% of facility healthcare workers and community health workers receive training in community-site linkages.

USAID/Burundi seeks input into the following questions related to Intermediate Result 2: HIV Care and Treatment Services:

1. What are the gaps in USAID/Burundi’s strategies to provide ART for people living with HIV and HIV/TB? What areas might require additional investment to achieve the second “90”?

2. What are potential innovative community-based approaches to improve retention and adherence on ART? What strategies can be used to trace and return defaulted individuals to the health facility?

3. What are potential strategies to increase ART coverage for children?

4. What may be the most efficient and effective approach to urgently address ineffective linkages to ART following diagnosis, including strengthening the health system?

5. Is TA or DSD the most effective approach to provide support for ART scale-up?

6. What components of the current USAID/Burundi ART program should be maintained?

What components of the program should be eliminated? What components of the program should be replicated or expanded?

Intermediate Result 3: HIV Laboratory Services

USAID/Burundi’s anticipated goals and objectives for Intermediate Result 3: HIV Laboratory Services are:

Support the Government of Burundi to achieve the third “90” of the UNAIDS “90-90-90” targets by ensuring all HIV-positive men, women and children on ART have a suppressed viral load; demand creation for viral load tests; capacity building of healthcare providers to interpret results, and patient education and counseling.

Provide DSD to health facilities and CSOs to ensure that all HIV-exposed infants receive diagnostic EID tests as per national guidelines; developing strategies to retain mothers and infants in care along the PMTCT continuum, including active community-based case tracing, until a definitive infant final outcome.

Support the Government of Burundi, national laboratories, and supply chain in laboratory and logistics, including platforms, staffing and training, quality assurance, results return, sample transport, forecasting and procurement, and reagent storage and cold chain. It is not anticipated that the activity will include the purchase of laboratory diagnostic equipment or pharmaceuticals; however, transportation of pharmaceuticals may be required.

Provide TA to strengthen monitoring and evaluation systems to collect and report on laboratory services, including forms, registers, and health information systems; support the use of strategic information to inform VL and EID scale-up through accurate collection and use of data.

1. >90% PLHIV on ART have suppressed viral load within 12 months of ART.

2. >95% of laboratories and facilities implement the national laboratory strategy

3. >95% of laboratories implement a quality management system (QMS).

4. Turnaround time for 100% of EID samples is <20 days from collection to delivery of results to facility staff.

USAID/Burundi seeks input into the following questions related to Intermediate Result 3: HIV Laboratory Services:

1. What are the gaps in USAID/Burundi’s strategies to provide quality diagnostic tests and laboratory tests for men, women and children living with HIV and HIV/TB? What areas might require additional investment?

2. What are some possible strategies to create demand for VL tests?

3. What are potential national, facility, and community level approaches to ensure timely, expedited sample transport and results return to healthcare providers and to patients?

4. What may be the most efficient and effective approaches to urgently address EID testing for HIV-exposed infants?

5. What components of the current USAID/Burundi laboratory and sample transport program should be maintained? What components of the program should be eliminated?

What components of the program should be replicated or expanded?