Final_RFI_HIVAIDS_01262018.pdf

Issuance Date: January 26, 2018

Response Due Date and Time: February 16, 2018 at 8:00 a.m. Burma Local Time.

Subject: Request for Information on USAID/Burma’s HIV-AIDS Program Planning (RFI_HIV-AIDS_Activity)

The U.S. Agency for International Development's Mission to Burma (USAID/Burma) is in the process of finalizing the design of a new activity to support the country’s efforts to achieve HIV epidemic control.

To that end, USAID requests comments and information about interests, capabilities, and market information related to the attached document contained in this file and the set of specific questions included therein, to inform the design of a future mechanism.

This Request for Information (RFI) is issued solely for planning purposes and is open for comments from any interested US and Non-US Organizations.

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

Please do not submit applications, proposals, resumes or promotional materials, as they will be discarded. The submission shall be written in English with each page numbered consecutively.

Responses to this RFI should be submitted to USAID via email to BurmaOAA@usaid.gov with subject line “RFI

- USAID/Burma’s HIV-AIDS Program Planning”, no later than the date and time stated above. Only electronic submissions will be accepted.

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. The issuance of this request will not restrict the Government's ultimate approach, if any. Respondents are advised that USAID is under no obligation to acknowledge receipt of the information, answer questions or provide feedback to respondents with respect to any information submitted. Any information submitted in response to this notice is voluntary. Not responding to this request does not preclude participation in any future solicitation, if any is issued.

Thank you for your assistance and interest in USAID/Burma programming.

Sincerely, /s/ R. Brian Aaron Agreement Officer USAID/Burma mailto:BurmaOAA@usaid.gov

USAID/Burma’s HIV-AIDS Program Planning Background Information and Questions

(RFI_HIV-AIDS_Activity)

USAID/Burma HIV/AIDS Program Background Information and Questions

I. Introduction

The latest sub-national HIV estimates for Myanmar, as of December 2017, indicate prevalence among men who have sex with men (MSM) and female sex workers (FSW) in Yangon is higher than in Thailand (30% and 20%, respectively), and in Kachin State prevalence now varies between 40% to 80%. HIV infections in Kachin State are bridging from persons who inject drugs (PWID) to the general population where HIV prevalence now constitutes a generalized epidemic in this state. The general population prevalence for the rest of the country is 0.6 percent. These new data provide evidence that Myanmar requires a path to epidemic control that is balanced between prevention and treatment. USAID can serve a catalytic role to alleviate obstructions and relieve bottlenecks that are hampering progress to 90-90-90. The PWID epidemic in Kachin is raging and is spreading to the general population, as well as geographically to nearby states. This portends the spread of a much wider global drug use emergency. Myanmar provides a unique opportunity to incubate and innovate on controlling a PWID fueled HIV epidemic, providing interventions and results that can be used in other countries, perhaps including the USA. The persistence of high prevalence in the PWID population, despite available harm reduction (HR) and anti-retroviral therapy (ART) solutions, and rising rates in the urban MSM and FSW communities warrant the introduction of pre-exposure prophylaxis (PrEP). Myanmar is poised to begin working with PrEP as a prevention tool to knock down rising rates, yet it needs a champion to lead and guide its introduction. Yet, Myanmar is the world’s fastest-growing economy, according to the IMF World Economic Outlook. The country’s Gross Domestic Product is projected to grow by 7.5% this year. Myanmar has great economic potential. It has reserves of natural resources, including gold, silver, platinum, coal, tin, tungsten, zinc, copper and gemstones, and it has a wide range of climatic conditions that allows for the growing of everything from tropical fruits to vegetables. USAID is well-positioned to assist Myanmar assume financial responsibility for its own HIV/AIDS activities. Key structural investments right now can contribute to financial sustainability in a relatively short time.

The vision for USAID’s program under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Initiative in Myanmar is to support the country’s efforts to achieve epidemic control using the “90-90-90” global targets as a framework for HIV program planning and prioritization. USAID in Myanmar supports focus on technical assistance and targeted support to improve the cascade of HIV prevention, testing and treatment, especially for key populations (KP) affected by high HIV prevalence and limited access to and low coverage of HIV services. USAID/Burma’s overarching HIV program goals aim to achieve high yield of HIV testing among KP, as well as early enrollment and high rates of retention in treatment services for those who are HIV infected.

These goals place particular emphasis on scaling up harm reduction services and medication-assisted therapy (MAT), as well as improving case detection and linkage to treatment PWID.

The USAID program in Myanmar is strategically structured to capitalize on site-level incubator innovations and service delivery models, in order to inform broader policy and guideline shifts that support scale-up and impact of HIV programming and more efficient use of country resources. To this end, through close collaboration with all key in-country actors, including the government, civil society, the community and other stakeholders such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and its partners, U.S. Government resources are intended to be used to identify cutting-edge solutions to national epidemic control challenges, invest in these ideas, test them and work to scale the solutions that promise the greatest impact using other domestic and international resources.

Question:

What are the HIV/AIDS strategies, fine-tuned for Myanmar at this time in its development, which will provide the boost that gets the country through its structural obstacles and prevention-treatment imbalance and on-track for epidemic control by 2022?

II. Background

Myanmar, a sovereign nation bordered by Bangladesh, China, India, Laos and Thailand, is made up of one Union Territory, 14 states and regions, 74 districts, 330 townships and 13,602 village tracts. It has a population of 51,486,253 people and comprises at least 138 ethnic groups. About 89 percent of the population is Buddhist.

Myanmar is one of 35 countries that account for 90% of new HIV infections globally (UNAIDS Fast Track Update on Investments, 2015). Myanmar has an estimated 224,794 people living with HIV (PLHIV) (AEM, Spectrum 2016). The HIV epidemic in Myanmar was at its height in 2005, when HIV prevalence reached 0.73% of the general population. In 2015, HIV prevalence declined to 0.59%. The HIV epidemic in Myanmar remains concentrated among KP, with HIV transmission primarily occurring among PWID, MSM, TG and FSW and their clients.

Currently available KP size estimates are 66,000 FSW and 252,000 MSM. Based on the results of the Integrated Bio-Behavioral Survey (IBBS) of PWID, which was completed in 2014, there are an estimated 83,000 PWID in Myanmar. National HIV prevalence is 28.5% among PWID (NSP III, AEM, 2014 PWID IBBS); 14.6% among FSW (NSP III, 2015 FSW IBBS draft report); and 11.6% among MSM (NSP III, 2015 MSM IBBS draft report).

Prevalence varies geographically: For example, in the north and north-eastern parts of Myanmar, such as in Muse (Shan State) and in Waingmaw and Bamaw (Kachin State), nearly one in two PWID who participated in the IBBS in 2014 tested HIV-positive, which is the 5th highest HIV prevalence level among PWID in the Asia/Pacific region. Similarly, HIV prevalence among MSM was 27% in Yangon and 22% in Mandalay; HIV prevalence among MSM in Yangon is the highest in a specific geographical site in the Asia/Pacific region.

Incidence rates for KP are not available, though estimates and projections of incidence, i.e., new infections, are generated by the AIDS Epidemic Model (AEM). A large proportion of new infections (29%) are attributable to PWID. USAID is concerned about potential future increases of HIV transmission through injection drug use and sharing of needles and syringes, should service provision for PWID remain inadequate or decrease further; a significant drop in donor funding to support prevention programs for KP has already been observed.

According to the Government of Myanmar’s ART report, at the end of 2016, 127,402 persons were receiving ART. This represented 57 percent of all those in need of treatment as specified by national treatment guidelines.

The national program has ambitious treatment targets, including having 196,743 individuals on ART by 2020 (NSP III, 2016 NAP). However, there are a wide range of health system constraints that need to be overcome to ensure scale-up of services that are accessible to all target populations. These include fiscal and financial barriers, shortages of human resources, gaps in public sector supply chain and laboratory systems supporting scale-up, lack of regular monitoring of results and performance at all levels, and sub-optimal coordination and leverage of resources and capacities across both the public and private sectors.

Despite the very high HIV prevalence estimates for PWID, the number of PWID who accessed HIV Testing and Counseling (HTC) services was low: a reported 27,802 PWID were tested and received their results in 2015, with

33.5 percent of that group having HTC uptake. The number was also low for the number of PWID receiving MAT with methadone (12,488 in 2016). A reported total of 18.5 million needles and syringes were distributed in 2015.

This lack of services for PWID is likely based on the geographical politics of Myanmar, as HIV services have been focused on the Burmese heartland, while ethnic peripheral areas such as Kachin and Shan states, where the majority of PWID reside, have historically received less attention. Needle and syringe exchange programs

(NSEP), MAT and ART are known to result in HIV incidence reduction among PWID, yet accelerated rollout of these services in geographical areas where injection drug use is most prevalent have significant challenges.

III. USAID Programming Strategy and role in PEPFAR

USAID/Burma, in its role as a PEPFAR STAR country, works on the "innovate-adopt-amplify" model that drives responses that are effective, sustainable and scalable. USAID/Burma is poised to provide a catalytic burst to the mature FSW and MSM programs, as well as to the nascent TG activities in country. USAID/Burma is pivoting to an approach that taps into the broader public health system and promotes sustainability through community-led initiatives informed by a total market approach that utilizes novel financing schemes that include strategic purchasing by government and user fees by clients with the ability to pay. USAID/Burma is also working on strengthening the systems that will allow for more efficient monitoring, procurement, and supply chain systems.

Presently, USAID concentrates on improving service delivery for KP in the four highest burden catchment areas through NGOs and private and public sector settings to enhance services and accelerate HIV diagnosis yield, treatment uptake and retention of KP. The four priority catchment areas are:

• Yangon: All KP.

• Mandalay: All KP.

• Kachin: New PWID support, other existing KP support maintained.

• Shan: New PWID support, other existing KP support maintained.

At the national level, PEPFAR and USAID will continue to provide technical assistance to strengthen ART decentralization and strategic information, laboratory and supply chain systems.

The latest PEPFAR Burma Country Operational Plan can be found at https://www.pepfar.gov/documents/organization/272003.pdf

IV. Questions

USAID Myanmar proposes to include in the next five years of its activities three broad program areas to support the national goals of 90-90-90: (1) HIV Prevention, (2) HIV Testing and AIDS Treatment, and (3) Health Systems Strengthening.

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.

USAID/Burma seeks input into the following questions.

A. HIV Prevention

1. What are the most optimal innovations that may be successfully implemented in the Myanmar context, including effective behavior change communication strategies? What could be game-changers for prevention?

2. How could key and priority populations best be reached through prevention interventions and successfully linked to testing, care and treatment services?

3. What may be the most effective strategies to focus on and elevate human rights and gender issues?

4. How might structural interventions be scalable and sustainable?

5. How might biomedical interventions be introduced and scaled up (e.g., Pre-exposure prophylaxis, or

PrEP, and others)?

6. What service delivery gaps need to be filled in responding effectively to GBV, especially sexual violence?

7. What innovative community approaches can be used to help prevention in key populations?

B. HIV Testing and AIDS Treatment

1. What are potential game-changing interventions that could be supported at the national, State/Division, township, facility and community level?

2. What may be the most optimal way to ensure service delivery (through TA and/or direct service delivery) at all levels of facilities, including public and private sectors?

3. What may be the most efficient and effective modalities to urgently address leakages (particularly with PWID) in the HIV cascade, including strengthening the health system?

4. Are there are any new components or innovative game-changers that would be of significant benefit to USAID/Burma to support the attainment of the “90-90-90” targets among key populations that should be introduced in future care and treatment activities?

C. Health Systems Strengthening:

1. What national/provincial interventions should be prioritized by USAID/Burma to advance an AIDS-free generation?

2. What national/provincial human resources for health (HRH) interventions (e.g., human resource development, human resource planning, human resource information systems) should be prioritized by USAID/Burma to enable Myanmar to better implement Test and Treat and new models of service delivery (e.g., Adherence Clubs; Pick-Up Points; General Practitioner Contracting)?

3. What national/provincial strategic information interventions (e.g., Health Information Systems, Routine Monitoring, Research) should be prioritized by USAID/Burma to facilitate adaptive management of the HIV response by the government and USAID/Burma?

4. Are there opportunities with the rapid scale up of electronic data systems and mobile technology that the HIV program could test, that would also work in the public sector?

5. What are the long term plans for supporting ART programs? What strategies could be developed to ensure sustainable quality services are being developed that build local capacity and decentralize services?

- End of Request for Information -

Acronyms and Abbreviations

AEM AIDS Epidemic Model

ART Antiretroviral Treatment

FSW Female Sex Workers

GBV Gender-based Violence

HTC HIV Testing and Counseling

HR Harm Reduction

IBBS Integrated Bio-Behavioral Survey

KP Key Populations

MAT Medication-Assisted Therapy

MSM Men Who Have Sex with Men

NAP National AIDS Program

NSEP Needle and Syringe Exchange Programs

NSP III National Strategic Plan for HIV: 2016-2020

PEPFAR U.S. President’s Emergency Plan for AIDS Relief

PWID Persons Who Inject Drugs

PrEP Pre-Exposure Prophylaxis

TG Transgender

USAID United States Agency for International Development

- End of Acronyms and Abbreviations -